Post a (200 word APA Format) brief description of the natural disaster you chose. Then provide three PTSD-related early interventions that might contribute to the stabilization of survivors in the specific natural disaster you chose. Explain how and why t

During a Crisis—Early Interventions

Early crisis intervention requires rapid responses, assessment, and intervention. Your crisis plan should include information about the demographics of the region, including numbers of people with mental health and physical considerations, approximate number of children and elderly, and information on other special populations. With this information in hand, the initial assessment during a crisis is focused on immediate client needs and physical safety. A survivor’s previous crisis experience or other pre-existing psychological or physical conditions should be included. Aspects of crisis intervention that differ from therapy include short or brief interventions or therapy involving problem-solving techniques. Gathering information about a client’s social systems is important for the client’s safety and support for problem-solving. Also, in most types of crises, interventions taken by counselors are more directive than they would normally be with individual clients. Referrals may be made for housing, clothing, food, and other basic essentials for living. Other early interventions, such case management, include needs assessment, care planning (such as housing), implementation, and regular review. These referral issues are crucial because, depending upon the scope of the crisis, survivors may not be able to return to work or to their homes for an extended period of time.

Choose a natural disaster other than Hurricane Katrina, and research the demographics for the area where the disaster occurred. Think about the populations affected by the natural disaster you chose as you review the following materials.

To prepare for this Discussion:

Review Chapters 5, 8, and 13 in your course text, Crisis Intervention Strategies, paying particular attention to the various types of interventions associated with different populations.

Review the article, “Integrating Treatment of Posttraumatic Stress Disorder and Substance Use Disorder,” focusing on the methods of and rational for integrating PTSD and substance use disorder interventions.

Review the article, “The Monsters in My Head: Posttraumatic Stress Disorder and the Child Survivor of Sexual Abuse,” and think about the complications and dynamics added to a recent crisis when childhood sexual abuse is in the client’s history.

Review the article, “Validity of the Suicide Assessment Checklist in an Emergency Crisis Center” and consider how assessing for suicide is made even more complex during and after a crisis situation.

Review the article, “Risk Factors for Suicidality Among Clients with Schizophrenia,” and again think about how mental illness might contribute to suicidality during and after a crisis situation.

Review the article, “Predictors of Depression and Anxiety Among International Students,” and consider additional stress factors for this population.

Now concentrate more closely on the natural disaster you chose and think about early interventions related to PTSD in children, adults, and special populations and how they might contribute to stabilization of survivors.

With these thoughts in mind:

Post a (200 Word APA Format) brief description of the natural disaster you chose. Then provide three PTSD-related early interventions that might contribute to the stabilization of survivors in the specific natural disaster you chose. Explain how and why they might work.

Course Text: James, R. K. & Gilliland, B.E. (2017). Crisis intervention strategies (8th ed.). Boston, MA: Cengage Learning. 

Chapter 5

https://bookshelf.vitalsource.com/books/9781305888081/pageid/117

Copy

Chapter 8

https://bookshelf.vitalsource.com/books/9781305888081/pageid/224

Chapter 13

https://bookshelf.vitalsource.com/books/9781305888081/pageid/450

Journal of Counseling & Development  ■  Fall 2007  ■  Volume 85 475

Assessment & Diagnosis

© 2007 by the American Counseling Association. All rights reserved.

Historically, administrators and clinicians have been hesitant 
to address posttraumatic stress disorder (PTSD) in the treat-
ment of substance use disorders (SUDs). However, a growing 
body  of  research  literature  provides  support  for  integrating 
PTSD and SUD treatment. PTSD is prevalent among individu-
als with SUDs (Chilcoat & Menard, 2003; Dansky, Saladin, 
Brady,  Kilpatrick,  &  Resnick,  1995;  Fullilove  et  al.,  1993; 
Najavits et al., 1998), and SUDs are prevalent among adults 
with PTSD (Chilcoat & Menard, 2003; Jacobsen, Southwick, 
& Kosten, 2001). Specifically, epidemiologic studies indicate 
that adults with SUDs (particularly involving opiates or co-
caine) are 2.6 to 10.8 times more likely to have PTSD than 
adults  who  do  not  have  SUDs  (Chilcoat  &  Menard,  2003). 
Comparable findings were reported in epidemiologic studies 
with adolescents, with alcohol, marijuana, and hard-drug (e.g., 
heroin, cocaine) abuse or dependence associated with a 1.6 to 
2.9 times increased risk of PTSD. When the focus is shifted 
to the risk of SUD conferred by PTSD, studies indicate that 
adults with PTSD are between 1.4 and 4.5 times more likely 
to have an SUD (including alcohol or other drugs) than adults 
who do not have PTSD. Among adolescents, PTSD is associ-
ated with a 3.2 to 14.1 times greater risk of SUD (Chilcoat 
& Menard, 2003). 

A history of exposure to traumatic violence, such as physical 
or sexual assault in childhood, is common and such a history 
often leads to PTSD (i.e., 30%–59% prevalence) among women 
with chronic SUDs (Najavits, Weiss, & Shaw, 1997). Exposure 
to recent violence also is prevalent among women with comor-
bid PTSD–SUD. More than 50% of women seeking treatment 
for  comorbid  PTSD–SUD  reported  having  been  exposed  to   
and/or having engaged in physically assaultive behavior with a 

primary partner in the past year, and 45% reported having been 
exposed to sexual coercion by a partner (Najavits, Sonn, Walsh, 
& Weiss, 2004). In community epidemiological studies of men 
and women, traumatic violence was associated with substan-
tially greater risk of developing PTSD (e.g., 46%-65%) than 
were other forms of trauma (e.g., nonviolent traumas; 8%–20% 
risk of PTSD; Chilcoat & Menard, 2003). PTSD and SUD also 
often co-occur after traumatic violence (Fullilove et al., 1993). 
For example, women in a national survey of crime victims were 
3 times more likely to have an SUD if they had PTSD than if 
they did not have PTSD (Dansky et al., 1995). 

Across  both  gender  and  diverse  ethnocultural  background, 
as many as 90% of SUD treatment recipients report a history of 
sexual or physical assault, and as many as 59% have PTSD (Chil-
coat & Menard, 2003; Dansky et al., 1996; Najavits et al., 1997). 
Moreover, comorbid PTSD–SUD may result from particularly 
severe trauma exposure and may cause particularly severe PTSD 
symptoms. For example, women seeking SUD treatment who 
had comorbid PTSD–SUD had more extensive trauma histories 
and severe PTSD symptoms (particularly avoidance, emotional 
numbing,  and  sleep  difficulties)  than  did  women  with  PTSD 
alone (Saladin, Brady, Dansky, & Kilpatrick, 1995). 

Several  hypotheses  have  been  advanced  to  explain  why 
PTSD and SUD co-occur, with the strongest empirical support 
accrued  by  the  self-medication  hypothesis,  which  proposes 
that SUDs are the result of attempts by people with PTSD to 
use substances to cope with PTSD symptoms such as intrusive 
memories, hypervigilance, sleep disturbance, irritability, and 
physical reactivity. Both epidemiological (Chilcoat & Menard, 
2003) and SUD treatment (Stewart & Conrod, 2003) studies 
indicate that PTSD more often (i.e., in 53% to 85% of cases) 

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Julian D. Ford, Department of Psychiatry, University of Connecticut School of Medicine; Eileen M. Russo, private practice, Water-
bury, Connecticut; Sharon D. Mallon, Connecticut Department of Mental Health and Addiction Services, Hartford. The writing of this
article was supported by a National Institute of Mental Health K23 career development grant, MH01889-01A1, Julian D. Ford, principal
investigator. The authors thank Rocio Chang for her valuable input concerning the clinical issues and safety planning. Correspondence
concerning this article should be addressed to Julian D. Ford, Department of Psychiatry, MC1410, University of Connecticut Health
Center, 263 Farmington Avenue, Farmington CT 06030 (e-mail�� Ford�Psychiatry.uchc.edu�e-mail�� Ford�Psychiatry.uchc.edu�.

Integrating Treatment of Posttraumatic
Stress Disorder and Substance Use Disorder
Julian D. Ford, Eileen M. Russo, and Sharon D. Mallon

Historically, administrators and clinicians have been hesitant to address posttraumatic stress disorder (PTSD� in the
treatment of substance use disorders (SUDs�. However, research shows that SUD treatment recruitment and outcomes
may be adversely affected if co-occurring PTSD is left untreated. The authors provide guidelines for screening and as-
sessment, treatment services, and workforce and organizational development that are designed to facilitate integrated
PTSD–SUD treatment. Case examples illustrate the necessary precautions related to and the potential benefits of
integrating treatment of PTSD and SUD.

Journal of Counseling & Development  ■  Fall 2007  ■  Volume 85476

Ford, Russo, & Mallon

predates  SUD  than  vice  versa,  with  only  one  exception  in 
which 18-year-olds were slightly more likely (54%) to report 
that alcohol dependence preceded PTSD than vice versa (46%; 
Giaconia et al., 2000). A prospective study of primarily White, 
middle-class adults in a health maintenance organization (ages 
21–35 years) found that having PTSD led to a fourfold increased 
risk of developing an SUD independent of the influence of prior 
conduct problems or depression, but having an SUD did not 
increase  the  risk  of  either  exposure  to  trauma  or  developing 
PTSD (Chilcoat & Menard, 2003). The strongest relationship 
between PTSD and SUD was with abuse of or dependence on 
prescription drugs but not street drugs (i.e., drugs obtained il-
licitly or illegally), which is consistent with the higher levels of 
use of prescription drugs versus street drugs by this particular 
subgroup  of  young  adults.  Similar  findings  of  SUD  leading 
to an increased risk of PTSD (but not of trauma exposure per 
se) have been reported with alcohol and street drugs in studies 
of women, military veterans, and disaster victims (Stewart & 
Conrod, 2003). Thus, SUD may predate PTSD, but it is more 
likely that SUDs develop or are worsened as a result of attempts 
to cope with PTSD. 

PTSD and SUD also may exacerbate and sustain each other 
over time. Men and women with alcohol- or cocaine-related 
SUDs who also had PTSD were more likely than those without 
PTSD to report a craving for substances if reminded of past 
trauma or substance use (Saladin et al., 2003). Accident survi-
vors or women who have been raped were more likely to have 
persistent PTSD if they had prior alcohol disorders than were 
those with no alcohol disorder (Stewart & Conrod, 2003).

Despite these consistent and disturbing findings of PTSD–
SUD  comorbidity,  most  adults  receiving  SUD  treatment  are 
neither evaluated for PTSD nor offered PTSD treatment, or PTSD 
services are provided only after lengthy periods of substance use 
abstinence (Ouimette et al., 2003). Yet, adults with co-occurring 
PTSD and SUD often want to receive treatment for both PTSD 
and SUD and to do so in an integrated manner rather than ad-
dressing one disorder at a time (Brown, Read, & Kahler, 2003). 
Moreover, SUD treatment recruitment, retention (Brown et al., 
2003), and outcomes (Ouimette et al., 2003; Palacios, Urmann, 
Newel, & Hamilton, 1999) may be adversely affected if co-oc-
curring PTSD is undetected and untreated. 

On the positive side, PTSD treatment has been shown to 
reduce not only immediate but also long-term risk of SUD re-
lapse if provided during the transitional period beginning soon 
after discharge from inpatient SUD treatment and during the 
long-term recovery period (Ouimette et al., 2003). Although 
they did not provide integrated PTSD–SUD treatment in their 
study, Ouimette et al.’s findings suggest that SUD and PTSD 
recovery  and  treatment  are  not  incompatible—indeed  they 
may be essential to each other (see also Dansky et al., 1996). 
Although several models of PTSD treatment have been em-
pirically validated in the past 2 decades, most PTSD therapies 
have  not  been  adapted  to  address  co-occurring  SUD  (Ford, 
Courtois, van der Hart, Nijenhuis, & Steele, 2005). Recently, 

however, several integrated PTSD–SUD therapies have been 
developed  (see  Donovan,  Padin-Rivera,  &  Kowaliw,  2001; 
Ford  et  al.,  2005;  Najavits,  2002; Triffleman,  2003)  with 
promising although preliminary outcome evaluations (Coffey, 
Dansky, & Brady, 2003; Donovan et al., 2001; Frisman, Ford, 
& Lin, 2004; Hien, Cohen, Miele, Litt, & Capstick, 2004). 

Clinical Strategies for Integrated
PTSD–SUD Treatment

Although promising intervention models are in development for 
integrated PTSD–SUD treatment, at this early stage in the devel-
opment of evidence-based practices for integrated PTSD–SUD 
treatment, clinicians need pragmatic strategies for handling the 
clinical issues that arise during this complex endeavor (Sullivan 
& Evans, 1994). Shavelson (2001) has noted: 

I  am  certain  of  one  thing: When  an  addict,  no  matter  how 
together he or she seems, works vigorously to get into rehab, 
persists in the program with clear and sincere intentions of 
overcoming addiction, and yet still repeatedly relapses to drug 
use, there is invariably an additional psychological disturbance 
underlying that failure to stay clean. (p. 300)

When  PTSD  is  the  additional  psychological  disturbance, 
the  challenge  is  to  treat  PTSD  without  exacerbating  SUD 
and  precipitating  relapse  or  safety  crises. We  discuss  les-
sons learned in the course of implementing and evaluating 
(Frisman et al., 2004) an approach to integrated PTSD–SUD 
treatment  called  “TARGET”  (Trauma Adaptive  Recovery 
Group  Education  and  Therapy  (Ford  &  Russo,  2006). 
TARGET teaches a sequential skill set for recognizing and 
managing PTSD, SUD, and affect dysregulation that is sum-
marized by a readily remembered acronym: FREEDOM. For 
example, the letter f represents the first step in responding 
effectively to stress reactions, focusing. The focusing step 
involves three skills, which are also summarized in a simple 
and  memorable  mnemonic,  SOS  (i.e.,  slow  down;  orient 
yourself; self-check your current level of distress, positive 
personal control, and urges to engage in maladaptive coping 
behaviors such as using substances). TARGET also uses a 
creative  arts  exercise  in  which,  over  the  course  of  several 
treatment sessions, each client uses such techniques as col-
lage, drawing, writing poetry, crafts, or music, to develop a 
representation of significant life experiences and the meaning 
(e.g., feelings, beliefs, goals, changes in self-concept, hopes, 
and relationships) that these experiences had for them in the 
past and continue to have in the present. 

In  the  following  sections,  we  frame  the  lessons  learned 
from our work with TARGET in general terms applicable to 
any approach to integrated PTSD–SUD treatment. Through-
out,  we  refer  to  two  composite  clinical  scenarios  (Case  1 
and  Case  2,  disguised  to  ensure  confidentiality)  as  a  basis 
for discussing clinical dilemmas and potential solutions for 
clinicians treating co-occurring SUD and PTSD. 

Journal of Counseling & Development  ■  Fall 2007  ■  Volume 85 477

Integrating Treatment of Posttraumatic Stress Disorder and Substance Use Disorder

Case 1

Susan  is  a  34-year-old African American  woman  who  began 
using marijuana and alcohol, with her mother’s encouragement, 
at age 11. Susan was also being prostituted by her mother and 
her mother’s boyfriend. Susan had been able to put together three 
periods of abstinence since the death of her boyfriend from a drug 
overdose 5 years previously and when threatened with the loss of 
her parental rights (of her two young daughters), but each time 
she relapsed after a few months. She keeps returning to treatment, 
using both inpatient and intensive outpatient levels of care. Susan 
typically is very reserved and suspicious, but she has begun to 
connect with other women in a sobriety support group. Overall, 
she has done well in the group sessions, but if she talks about her 
childhood sexual abuse, the group leaders tell her to wait to deal 
with trauma until after she has been sober for 1 year. Meanwhile, 
she is experiencing nightmares, anxiety, and exaggerated startle 
responses (e.g., “I feel like I’m going to jump out of my skin”). 
Susan diligently works on a family reunification plan mandated 
by the Department of Children and Families, often visiting her 
daughters  in  a  foster  home. This  is  Susan’s  fifth  admission  to 
outpatient treatment. She fears another relapse and wonders what 
to do to break the cycle of partial recovery. 

Case 2

Edward is a 44-year-old Caucasian man who was referred to 
an outpatient jail diversion program after being arrested for 
burglary while high on heroin and crack cocaine. As a child, 
Edward saw his father beat his mother on a regular basis. His 
mother alternately treated Edward as her “perfect little man” or 
as “having the devil in him, a little monster who never should 
have  been born.” Edward describes his mother in idealized 
terms  and continues to seek her approval. He also longs to 
be a husband and father in what he calls a “perfect family.” 
When he was 15, he began drinking alcohol and quickly pro-
gressed to snorting and shooting heroin and smoking crack 
cocaine. Edward witnessed the killing of two friends during 
a drug deal, but he says, “that’s life on the streets, nothing in 
the past bothers me.” Edward is easily angered, has bouts of 
depression  (particularly  when  relationships  are  conflicted), 
and trusts no one “except my mother.” He is hypervigilant and 
has cognitive impairment consistent with chronic drug use. 
Edward does not seem to retain or use the skills he has been 
taught in sobriety support and anger management groups. He 
says, “I like group but I don’t remember nothing from it.” His 
care coordinator fears that a PTSD group will destabilize him 
and precipitate a relapse.

Reconsidering Common Assumptions
Concerning the Treatment of Trauma,
PTSD, and SUD

A  key  underlying  philosophy  of  early  addiction  treatment 
programs was “if it don’t itch, don’t scratch” (White, 1998, 
p. 203). Addiction treatment was assumed to work best by ad-

dressing only obvious SUD behavior patterns because delving 
into  psychological  issues  was  viewed  as  colluding  with  the 
client’s avoidance of taking responsibility for sobriety or (as in 
Edward’s case) as opening Pandora’s box and precipitating a 
relapse. In addition, 12-step groups often recommended that no 
one in early recovery should make major changes for a year (as 
in Susan’s case) in order to avoid impulsive or poorly considered 
life choices. Even in later stages of recovery, addressing issues 
other than SUD symptoms is often assumed to interfere with 
12-step  recovery  or  to  trigger  relapses.  Several  myths  about 
trauma survivors and PTSD treatment perpetuate the philosophy 
of don’t tell, don’t treat with co-occurring PTSD–SUD. 

A common myth is that prior to attaining sobriety and be-
coming psychosocially stable, an individual (such as Susan) 
is  too  fragile,  impulsive,  and  reactive  to  deal  with  trauma. 
Another  myth  portrays  addiction  treatment  clients  such  as 
Edward as feeling revictimized and falling to pieces if trauma 
issues or memories are opened up. The corollary to this myth 
is that trauma recovery requires dredging up awful feelings 
and  traumatic  memories  for  detailed  examination. A  third 
myth is that sobriety requires a distinct set of commitments 
and skills that differ fundamentally from those involved in the 
treatment of other psychological disorders, including PTSD. 
A fourth myth is that traumatic events are all in the past, and 
therefore  there  is  no  need  to  reopen  old  wounds  and  cause 
the individual to experience further distress or to be preoc-
cupied with memories that are better treated as water under 
the bridge. A final myth is that there is no cure for PTSD, so 
it is best not to set clients up for failure by giving them hope 
that treatment can eliminate PTSD.

We propose several alternative views to such myths based 
on the research literature and on observations by clinicians 
and  case  managers  who  have  been  trained  to  conduct  an 
integrated  PTSD–SUD  treatment.  Recovery  from  PTSD  is 
complementary  with  recovery  from  SUD  because  recovery 
from  PTSD  involves  learning  how  to  deal  with  unfinished 
emotional business resulting from trauma without denial and 
with personal responsibility (i.e., sobriety). Trauma survivors 
with PTSD are not fragile but rather are highly resilient be-
cause they have had to develop ways of coping with extreme 
stressors.  If  this  were  not  true,  they  would  not  be  seeking 
sobriety. Trauma survivors with PTSD have developed highly 
reactive  stress  response  systems  in  their  bodies  that,  if  not 
modified  therapeutically,  can  precipitate  SUD  (Jacobsen  et 
al., 2001). With awareness of and skills for managing PTSD 
symptoms, trauma survivors such as Susan or Edward may 
be able to face rather than avoid the symptoms, just as they 
manage SUD symptoms by acknowledging them and learning 
constructive skills to manage them. 

Trauma recovery neither requires nor necessarily includes 
dredging  up  or  repetitively  recalling  trauma  memories  but, 
instead, can be accomplished by helping the survivor to man-
age and even gain control over the unwanted trauma memories 
that are core symptoms of PTSD. Skills for managing PTSD 

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provide a foundation for trauma survivors to make thoughtful 
choices  about  if,  how,  when,  and  with  whom  to  reexamine 
trauma memories, so that this is an informed choice rather than 
a  retraumatizing  or  destabilizing  experience. When  trauma 
survivors with PTSD are helped to examine stressful here-and-
now experiences and to recognize PTSD symptoms as self-
protective responses (Harris & Fallot, 2001), they can manage 
unwanted trauma memories in the same way that they manage 
SUD urges. Susan specifically asked her counselor for help 
with flashbacks to incidents of sexual abuse because these in-
trusive memories often appeared to trigger relapses. Although 
there is no way to eradicate memories of traumatic experiences 
nor any total permanent cure for PTSD, this situation is no 
different than it is for SUD. Most survivors never completely 
eliminate PTSD symptoms, but they can reduce the distress 
caused by these symptoms by learning how to manage them 
rather than feeling powerless in the face of unwanted trauma 
memories and the associated stress reactions. The solution is 
not to develop such a thick skin that trauma memories are not 
upsetting but, instead, to learn to deal with trauma memories 
and PTSD symptoms thoughtfully and effectively. For many 
people, full recovery from SUD is not possible without ad-
dressing trauma recovery in this manner.

Case 1

Susan introduced herself in her first trauma recovery group by 
interrupting  another  group  member  and  saying,  “maybe  this 
isn’t the right group for me because I was raped by my mother’s 
boyfriend  and  then  made  into  a  ‘ho’  by  them.”  She  became 
agitated and said she needed to leave. One of the group leaders 
immediately  went  to  sit  next  to  Susan  and  quietly  reassured 
Susan that she could be in the group without having to go back 
to those painful experiences. The leader helped Susan to ground 
herself and gradually come back from the dissociative state she 
had slipped into. Simultaneously, the other group leader softly 
spoke with the rest of the group. The counselor let them know 
that  Susan’s  pain  might  be  frightening  or  disturbing,  but  the 
group would be able to help her and themselves by learning 
new ways to deal with bad memories so they would not get lost 
in them. Several group members expressed skepticism (e.g., 
“That’s what they tell you in every group, but it hasn’t helped 
me yet!”). The group leader acknowledged that members’ past 
experiences could make this seem impossible, adding that the 
group  could  test  this  immediately  by  using  a TARGET  skill 
right at that moment to see if it would be helpful to Susan and 
to other members. The leader modeled and coached the group 
members, with a special emphasis on Susan, in using the first 
TARGET skill for trauma recovery, that is, focusing. Susan and 
other group members gradually became more present-focused 
and calmer, and the group leaders were able to explain why these 
PTSD reactions occur and how the FREEDOM skills could help 
them to reset a survival alarm in their brains. 

The group leader helped the group discuss how their intense 
reactions could be healthy self-protective responses that their 
bodies  had  learned  as  a  means  to  help  them  survive  terrible 

experiences.  Susan  asked  if  this  meant  that  she  had  to  talk 
about the abuse in order to get over these alarm reactions. The 
group leader clarified that this was not the case, and that during 
the group sessions, the leaders would teach skills to help them 
decide when they were ready and if they needed to talk about 
past traumas. When Susan asked if this meant she had “messed 
up” by “saying too much and upsetting the group,” the group 
leader responded that this was not a “mess” but instead was a 
courageous way for her to let the group know how hard she 
has been working on her own recovery from very painful past 
experiences. The group leader also commented that Susan had 
used the focusing skills effectively in group, despite learning 
them for the first time while having an alarm reaction.

The group leaders chose to get to know Susan and other group 
members better in subsequent group sessions before addressing 
several possible treatment issues that were raised by Susan’s spon-
taneous disclosure of her past sexual abuse. For example, Susan 
may have been replaying a personal script of being exposed in 
her past experiences of sexual abuse and forced prostitution. She 
may also have been testing the leaders and the group by exposing 
them to her traumatic past and to her intense distress, either to 
see if they would reject her or to learn if they were strong enough 
to tolerate her intense distress and terrible memories. The group 
leaders’ use of the education concepts regarding the body’s alarm 
system provided a way to reframe Susan’s impulsive disclosure 
as an expression of the core dilemma that the group would help 
each member to address. This dilemma is the question of how 
to  recover  from  traumatic  experiences  and  to  manage  intense 
stress reactions without escalating into a state of crisis or shutting 
down emotionally, isolating from other people, avoiding healthy 
activities, or lapsing into substance use. Susan was particularly 
interested in the idea that she might have used drugs to try to 
turn off the stress alarm in her brain, and she expressed a sense 
of new hope because she believed that learning how to adjust 
this inner alarm might reduce or give her greater control over 
her urges to use substances.

Case 2

Edward participated very little in the first two trauma group 
sessions, except to say that nothing really bothered him since 
he had learned in another group to just forget the past. In the 
third group session, Edward said he did not think this group 
was helping him because he had gotten in trouble for yelling 
at another patient in his program, and none of the skills had 
helped  once  he  “lost  it.”  Group  leaders  helped  Edward  to 
reexamine that incident, beginning with what he was feeling 
and thinking about earlier that day that might have affected 
his reaction to the other patient. Then Edward was helped to 
identify specific triggers for his alarm reaction. Edward said 
the first trigger was that “he was disrespecting me,” and with 
further thought and therapeutic guidance he was able to pin-
point a facial expression and tone of voice that “was just like 
my mother did when she told me I was the devil and beat me.” 
Edward expressed anger toward the group leaders for “making 
me think about things I don’t want to remember” and got up 

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Integrating Treatment of Posttraumatic Stress Disorder and Substance Use Disorder

as if to storm out of the room. Rather than focusing on the 
content of this trauma memory, the leaders gently but firmly 
asked Edward to see if they could work this out without his 
leaving, while also giving him permission to leave if he felt he 
needed a time out (this was done to prevent emotional escala-
tion by inadvertently leading Edward to feel trapped). 

Edward stopped and angrily said, “I don’t need a time out, 
I  need  to  be  left  alone,  and  you’re  not  leaving  me  alone  with 
this  therapy  stuff.” The  group  leaders  responded  by  empathi-
cally validating his goal of being able to put the bad memories 
behind  him  and  have  a  good  life  and  good  relationships  now 
and in the future. They said that anger often was a very positive 
sign of a strong commitment to a very important goal, and that 
participation in the group sessions might be able to help Edward 
channel his anger in a way that would allow him to achieve his 
goals. As Edward began to de-escalate, the leaders commented 
supportively that that was what Edward was doing right at that 
moment by recovering his focus but also holding firmly to his 
personal goals. Rather than assuming that Edward was too early 
in his recovery or too cognitively impaired to deal with PTSD, 
they helped Edward understand and manage his PTSD reaction 
in the session. The leaders emphasized that the group’s goal was 
to help each participant move forward and not dwell on the past 
by strengthening each group member’s skills for dealing with this 
type of alarm reaction and refocusing on positive steps toward 
their personal goals. The leaders asked other group members if 
they felt that Edward’s success in recovering his focus despite 
his anger alarm was a helpful example for them. Several group 
members  thanked  Edward  for  handling  the  situation  well  and 
giving them hope that they could do the same at times in the 
future when they felt triggered into an alarm reaction. 

Edward was surprised and then seemed not only calmer 
but  also  proud  to  be  receiving  the  genuinely  supportive 
acknowledgements. At  the  close  of  the  session,  when  the 
group leaders went round the group circle to get a self-check 
from each member, Edward reported feeling a lower level of 
distress and little urge to use substances as well as a higher 
level of personal control than he had described earlier in the 
session or in the past two sessions. The group leaders asked 
him if he thought that the work he had done in that session 
to  strengthen  his  focusing  skills  might  actually  help  him 
with  his  sobriety  and  his  ability  to  manage  anger,  and  for 
the first time he paused (instead of simply saying no) and 
said he would “think about that.” As illustrated by the case 
examples,  the  myths  that  trauma  and  addiction  recovery 
are  disconnected,  or  even  mutually  incompatible,  are  not 
borne  out  by  clinical  experience  that  involves  integrated 
PTSD–SUD treatment.

Meta-Models of PTSD and SUD
Fundamental to integrated PTSD–SUD treatment is address-
ing  how  PTSD  and  SUD  are  understood  by  the  clinician 
and the client, that is, their meta-models for conceptualizing 
PTSD and SUD. 

Disease Models of PTSD and SUD

The  disease  model  views  PTSD  and  SUD  as  conditions 
requiring  cure  or  correction,  similar  to  the  situation  with  a 
medical illness. PTSD and SUD may also be seen as chronic 
disabilities that cannot be eliminated but can be managed bio-
logically and behaviorally like other persistent health problems 
or “handicaps.” Although there is ample scientific evidence 
that  PTSD  and  SUD  are  potentially  chronic  and  disabling 
conditions  that  involve  dysregulation  in  several  biological 
systems, there also is evidence that both psychological and 
biological  therapies  can  improve  each  disorder  and  at  least 
partially  restore  healthy  bodily  self-regulation  (Ford  et  al., 
2005; Jacobsen et al., 2001). 

Cognitive–Behavioral Models of PTSD and SUD

From a cognitive–behavioral standpoint, PTSD and SUD are 
the result of dysfunctional (i.e., threat-based or addiction-based) 
beliefs, cognitive biases, and reactive behavior patterns that 
lead  to  an  escalating  sense  of  anxiety,  anger,  and  helpless-
ness  (Brewin  &  Holmes,  2003).  From  a  stress  and  coping 
perspective,  PTSD  and  SUD  involve  maladaptive  coping 
in response to stressors that range in intensity from mild to 
traumatic (Stewart & Conrod, 2003). From an empowerment 
or strengths-based perspective, PTSD and SUD involve a loss 
or a breakdown of the person’s psychological and interpersonal 
resources (e.g., sense of safety, self-efficacy, motivation; Ford 
et  al.,  2005).  The  newer  interventions  for  co-occurring 
PTSD–SUD, therefore, consistently teach complementary 
cognitive  and  behavioral  skills  for  building  or  acquiring 
personal strengths or interpersonal resources and for cop-
ing  with  the  effects  of  both  current  and  past  stressors  or 
threats to sobriety. 

Developmental and Cultural Models of PTSD and SUD

In  a  developmental  framework,  PTSD  and  SUD  involve 
disrupted learning and maturation, such that the person does 
not  develop  self-regulatory  capacities  and  healthy  attach-
ments (Ford et al., 2005). When a stable sense of self is not 
achieved by people experiencing multiple adversities, identity 
confusion may exacerbate posttraumatic stress (Asner-Self 
& Marotta, 2005). Although traumatic stressors in adulthood 
may be factors in the etiology or course of either PTSD or 
SUD,  traumatic  stressors  experienced  in  childhood  (par-
ticularly traumas involving a betrayal of trust) can alter core 
psychological  or  biological  development  in  ways  that  lead 
to complex and chronic forms of PTSD or SUD (Ford et al., 
2005; Jacobsen et al., 2001). 

Finally, from a cultural perspective, PTSD and SUD involve 
larger  sociocultural  forces,  barriers,  and  norms  that  influence 
the impact that traumatic events have on entire communities or 
societies and on people’s core beliefs and on their ways of life. 
Similarly,  from  a  spiritual  viewpoint,  PTSD  and  SUD  can  be 
seen as crises of faith, hope, and moral values (Manson, 1996). 
Each individual experiences and responds to trauma, addiction, 
and  recovery  in  unique  ways  that  require  an  idiographic  (i.e., 

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Ford, Russo, & Mallon

person-centered  rather  than  purely  standardized)  approach  to 
counseling (Lee & Tracey, 2005). Treatments for co-occurring 
PTSD–SUD tend to address the cultural and spiritual dimensions 
of trauma or addiction by focusing on these issues as important 
but not primary aspects of the individual’s psychological adjust-
ment  and  recovery. Approaches  to  conceptualizing  SUD  and 
PTSD and the recovery process that place culture or spirituality 
in a central position are rare. For example, Hardy and Laszloffy 
(1995)  have  described  the  impact  of  racial  oppression  on  the 
therapeutic issues involved in the treatment of African American 
families. Also, Brende (1993) has developed a 12-step recovery 
model that focuses specifically on spiritual and cultural healing 
and growth in recovery from co-occurring PTSD–SUD. 

Synthesis of Meta-Models: Memory and
Emotion Regulation in PTSD and SUD

The meta-models of PTSD and SUD just described are not 
mutually exclusive but are often treated as such. All of these 
meta-models  intersect  in  two  core  domains,  memory and 
emotion regulation, which provide a basis for understand-
ing  co-occurring  PTSD–SUD  that  can  guide  integrated 
PTSD–SUD treatment. 

PTSD  and  SUD  involve  a  loss  of  control  over  one’s  own 
memory  (Harvey,  1996).  In  PTSD,  this  takes  the  form  of 
unwanted, persistent, and fragmented memories of traumatic 
experiences. In SUD, memory tends to be fragmented, over-
whelmingly painful, and, at times, frustratingly elusive. There-
fore, integrated PTSD–SUD treatment must enable survivors to 
regain mastery of memory (Harvey, 1996). Traditionally, this 
has involved telling the personal story of trauma or addiction 
in order to gain the emotional and moral support of significant 
others (Harvey, 1996). This can be done either in the context of 
a variety of culturally sanctioned rituals or in formal counsel-
ing settings (Herman, 1992). Reclaiming mastery of memory 
involves a fundamental developmental shift in personal identity 
that includes but goes well beyond the resolution of traumatic 
memories. In a qualitative study of seven women who had ex-
perienced childhood sexual abuse, Phillips and Daniluk (2004) 
identified the following crucial recovery themes: “[gaining] an 
increasing sense of visibility, congruence, and connection, an 
emerging sense of self-definition and self-acceptance, a shift 
in worldview, a sense of regret over what has been lost, and a 
sense of resiliency and growth” (p. 179). Reclaiming memory 
thus involves clarifying and integrating both memories of the 
past and new memories that are created in the present, and this 
process leads to fundamental shifts in how the person views 
herself (e.g., from viewing self as a victim, to a survivor, to a 
woman). In cases such as Edward’s in which memory may also 
be compromised by chronic substance use or organic problems, 
the  development  of  the  psychological  capacity  to  enhance 
memory coherence is a crucial prerequisite to any form of PTSD 
treatment that involves recalling trauma memories. 

In the 12-step tradition, the fourth step involves accurately 
recalling past experiences and actions that are often painful. 

Rejoining a community of peers and honestly facing and telling 
one’s story of addiction and recovery (the fifth step) is another 
core element in the 12-step approach to treatment of SUD. Al-
though Brende (1993) has adapted the 12-step model to PTSD, 
there is no integrated model to guide the simultaneous telling 
of the personal story of SUD and PTSD. For clients such as 
Susan, for whom PTSD and SUD are intimately intertwined, 
treatment must provide a basis for reclaiming a life story without 
compartmentalizing PTSD and SUD experiences.

Although  trauma  and  addiction  are  painful  to  remember, 
the major barrier to memory is not the events themselves but 
the extreme emotion dysregulation that traumatic memories or 
reminders evoke (Cloitre, Scarvalone, & Difede, 1997). Chronic 
PTSD and SUD both involve mood shifts that encompass in-
tense rage, grief, fear, despair, guilt, and shame, as well as pro-
found emotional cut-offs such as dissociation, alexithymia, and 
numbing. Integrated PTSD–SUD treatment, therefore, focuses 
on enhancing emotional regulation to increase clients’ ability 
to recognize and manage both SUD and PTSD symptoms and 
the often complex interplay of these symptoms (e.g., intense 
denial, rage, and urges to use substances when experiencing 
painful unwanted memories or hypervigilance). 

Case 1

Susan  initially  was  restless  and  fidgety  during  the  trauma 
group sessions, stating that she was trying to keep her mind 
empty by distracting herself. As Susan practiced the TARGET 
focusing skills in each group session and as she learned ways 
to identify manageable emotions, thoughts, and personal goals 
using  the  FREEDOM  skill  set,  she  experienced  moments 
in  which  she  could  consciously  choose  to  pay  attention  to 
thoughts, feelings, and memories rather than avoiding them. 
Correspondingly,  Susan  began  to  recall  and  draw  on  very 
basic goals and values that had once been important to her 
but that she had forgotten or given up on (e.g., “to be smart 
enough to figure out problems” and “to be able to speak my 
mind  without  being  rejected  or  punished”). A  creative  arts 
exercise  (the  lifeline;  Ford  &  Russo,  2006,  p.  347)  helped 
Susan to see in a tangible way how these goals had been an 
integral part of her development in childhood but were lost 
when trauma became the defining force in her life in her ado-
lescence. In this way, Susan learned that she had the ability to 
remember what she chose to remember and when she chose 
to  remember  it,  and,  consequently,  she  became  less  phobic 
about her memory.

Case 2

Edward  was  able  to  use  focusing  and  trigger  identification 
skills  during  the  group  sessions,  but  said  that  he  could  not 
remember  these  skills  outside  of  the  group  setting;  he  also 
stated that if he was already angry, it was too late to focus on 
himself anyway. However, while doing the lifeline exercise, 
Edward disclosed that he used to write rap lyrics and had kept 
a personal notepad full of them until his stepfather had torn 
it  up  to  punish  him. A  group  leader  asked  if  he  would  like 

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Integrating Treatment of Posttraumatic Stress Disorder and Substance Use Disorder

to experiment with writing rap-style entries on the personal 
practice  worksheets  that  were  used  in  the  group  sessions 
to  help  members  break  down  stressful  experiences  into  the 
FREEDOM steps. Edward found that this gave him a struc-
tured and safe way to re-access his knack for pithy phrases 
and rhymes. He created a series of “FREEDOM Raps” that he 
illustrated with drawings and a collage on his lifeline to show 
visually how he was using the FREEDOM steps to reexamine 
and make sense of important current and past experiences in 
his life. Edward reframed his actions into choices that he made 
in an effort to live up to the values he expressed in his raps. 
He  found  that  creating  the  FREEDOM  raps  was  especially 
helpful and productive when he started to feel angry because 
he  could  use  the  energy  and  determination  from  his  anger 
to  “speak  truth  to  the  powers  that  be,”  instead  of  reacting 
impulsively or shutting down emotionally. 

Edward surprised the group in a session near the end of the 
treatment by spontaneously telling the leaders that he now was 
able to remember things that used to “go in and out of my mind 
like a sieve when I started this group.” He remembered the 
leaders saying in the first session that he could learn to channel 
and use his anger but that, at that time, he had thought that was 
impossible. Now, he said, “my raps are proof that I can do it!” 
The group leaders and members responded that the raps also 
were proof that Edward could use his inner alarm to harness 
the power of creativity and truth. This vignette illustrates how 
PTSD–SUD skills can enable clients both to gain mastery of 
memory and to achieve emotion regulation even when they 
have begun treatment with doubt and distress. 

Preliminary Best Practices Guidelines for
Integrated PTSD–SUD Treatment

With the goals of facilitating mastery of memory and emo-
tional self-regulation, we next suggest best practices guide-
lines for integrated PTSD–SUD treatment in three domains: 
screening and assessment, treatment services, and workforce 
and organizational development.

Screening and Assessment

Screening as motivational enhancement. For  most  clients, 
PTSD symptoms are strongly and problematically linked to 
SUD symptoms, but treatment providers rarely, if ever, discuss 
this relationship; thus, the two sets of symptoms have been 
treated as totally separate concerns. In addition to providing 
information about clients’ current functioning and treatment 
needs,  initial  trauma  screening  provides  an  opportunity  to 
begin  educating  the  client  about  the  treatment  model.  For 
example, during the screening interaction, the counselor can 
briefly  explain,  using  a  statement  like  the  following,  that 
unwanted PTSD memories are actually signs that the brain’s 
survival system is being activated:

These unwanted memories and the feeling of being tense and 
in danger all the time actually are your body’s alarm system 

trying  to  protect  you,  but  the  problem  is  that  you’re  not  in 
control of the alarm because you don’t know how to turn it 
off when you really are safe. The treatment will help you learn 
some skills for controlling your body’s alarm reactions without 
slipping up and using alcohol to try to turn off the alarm.

Such empathic and practical psychoeducation can motivate 
the client to engage in treatment by giving the client a new 
way to think of her or his PTSD and SUD symptoms, which 
has immediate practical relevance and resonates with clients’ 
personal experiences and goals. The assessor can also discuss 
how urges to use substances may stem, in part, from an internal 
response to turn down the brain’s inner alarm system. 

In  addition,  as  a  result  of  chronic  SUD,  many  individu-
als with extensive trauma histories are not able to gauge the 
severity of their PTSD symptoms and, thus, may unintention-
ally under- or overreport PTSD symptoms. Education about 
PTSD and SUD in the screening process can facilitate a more 
accurate identification and estimation of PTSD symptoms. If 
this appears to be the case, the assessor can explain that trying 
to suppress or ignore emotional and bodily alarm reactions 
such as anger or craving for substances is an understandable 
attempt to cope with these reactions that provides short-term 
relief (i.e., “helps you get through the day, or the night”) but 
unfortunately makes the alarm reactions more frequent and 
disruptive  in  the  long  run. The  assessor  can  then  ask  if  the 
client has observed that feelings of being unsafe or angry or 
being tempted to use substances can build up and become a 
problem if they are ignored and not dealt with. The assessor 
can then offer the client an encouraging new perspective by 
explaining that the PTSD–SUD treatment is designed to teach 
new skills for giving the client more control over the body’s 
stress alarm system so that the client can escape this vicious 
cycle of feeling distressed, avoiding or denying these alarm 
signals, and then feeling worse in the long run. This approach 
provides the client with an opening to disclose symptoms that 
may initially have been denied or minimized and to engage 
in treatment. 

Containment-focused screening. A thorough review of PTSD 
and associated traumatic stress symptoms can be upsetting or 
demoralizing for some clients. Screening does not automatically 
involve obtaining a detailed trauma history. Many PTSD–SUD 
clients do not feel ready to disclose more than small amounts 
of  information  about  traumatic  experiences  until  they  have 
established a trusting therapeutic alliance. In some cases, the 
client may not be able to tolerate the intensity of his or her own 
reactions to disclosing the details of terrible personal memo-
ries. For other clients, this is merely a fairly rote recitation of 
a familiar list of problems that they believe will never change. 
Still other clients feel compelled to tell all, either to justify their 
distress and their right to treatment or because they do not know 
how to select manageable amounts of past memories. Screening 
should not focus singularly on past traumatic events but on the 
way in which stressful past experiences have interfered with 
the client’s current relationships and life goals—and the way 

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in which treatment can help to enhance current relationships 
and  achieve  life  goals. A  containment-focused  approach  to 
screening demonstrates that it is possible to examine trauma 
and addiction in a carefully structured and titrated manner, and 
this can become a model for managing unwanted memories or 
emotional distress. 

Prescreening: Safety planning and follow-up. Questioning 
the client about past traumas, even when done with caution and 
sensitivity, is stressful. Therefore, the first step in the screening 
and assessment process should be the development of a safety 
plan for the client. Safety planning is appropriate for any dis-
cussion of traumatic past experiences, and it can be valuable to 
help prepare clients for a screening or assessment interview. In 
our experience, safety planning takes as little as 2 to 3 minutes, 
and  it  is  a  useful  way  to  let  clients  know  that  their  difficult 
experiences are heard with compassion and to begin to help 
them attend to their own safety in healthy ways. The purpose of 
safety planning is to begin to teach clients that it is possible to 
enhance their own safety, especially if their lives have been or 
still are unsafe in some ways as the result of trauma (Najavits, 
2002). Safety planning is a skill that will be developed over 
the course of treatment, not a one-time intervention applicable 
only to an initial screening or assessment. The safety plan itself 
should include a practical list of steps to follow should the client 
become distressed after the screening or assessment interview 
has concluded. (See Appendix for a sample client safety plan.) 
The plan can include names and telephone numbers of support 
persons, such as family members, friends, sponsors, or a trusted 
therapist or case manager. It should also include the agency’s 
telephone numbers for during and after business hours, and, if 
possible, a specific contact person. Some clients find it helpful 
to have a list of self-reported stress management strategies or 
activities that they find relaxing or soothing on their safety plan. 
Every safety plan should include simple directions on what to 
do in a crisis, such as call a friend, therapist, sponsor, hotline, 
or mobile crisis team or go to the nearest hospital emergency 
department. The  plan  should  have  a  readable  list  of  names, 
places, and telephone numbers because, in a crisis, people often 
cannot recall such basics, especially if they are experiencing 
PTSD symptoms. Safety planning should address the client’s 
emotional  and  physical  safety,  including  distress  related  to 
assessment  and  treatment,  but  should  also  take  into  account 
objective danger related to domestic or community violence. 

Susan took safety planning a creative step further and 
wrote  a  script  that  she  gave  to  the  mobile  crisis  team  at 
the  agency  where  she  was  in  treatment. The  script  was  a 
verbatim  statement  she  wanted  the  mobile  crisis  hotline 
staff to read to her if she called them in a state of crisis, 
and it included several key thoughts that she had formulated 
based  on  what  she  was  learning  in  PTSD–SUD  therapy. 
Susan came up with the idea of the script in a group session 
devoted to safety planning and using the SOS skills to deal 
with extreme alarm reactions such as feeling suicidal. She 
wrote the script on her own and shared it with the group 
members  and  leaders  by  reading  it  out  loud  as  a  part  of 

her  check-in  during  the  next  group  session.  The  mobile 
crisis team was surprised, having never before had a client 
script his or her response. Ultimately, the team was very 
appreciative when they found that using the script was very 
calming for Susan and actually helped to prevent hospital-
izations on several occasions when she made crisis calls to 
the team. In the past, virtually every hotline call by Susan 
had led to involuntary hospitalizations because the crisis 
team could not sufficiently help her modulate her intense 
agitation and distress.

Stepwise screening and assessment.  Screening  leads  to 
assessment in four sequential stages. Stages 2 and 3, although 
helpful,  may  be  bypassed  or  postponed  when  time  and  re-
sources are limited.

Stage 1 involves identifying PTSD symptoms from data 
routinely gathered in assessment services (e.g., psychosocial 
and  family  history  intake,  progress  monitoring).  However, 
counselors  should  guard  against  both  false  positives  and 
false  negatives  when  using  existing  clinical  data  in  PTSD 
screening, for two reasons. First, there are no symptoms that 
definitively indicate that a traumatic experience has occurred. 
Many symptoms that appear to reflect PTSD may actually be 
due to other disorders or current stressors. It is important for 
the counselor to give careful consideration to other possible 
diagnoses rather than to assume that stresslike symptoms are 
always  due  to  PTSD.  Second,  many  traumatic  experiences 
and PTSD symptoms are not disclosed by clients without the 
counselor’s careful and sensitive interviewing to assist the cli-
ent in recognizing trauma and PTSD. Many clients assume that 
traumas and symptoms either are the norm or are too shameful 
or stigmatizing to be divulged. Therefore, Stage 1 screening 
involves the formulation of tentative clinical hypotheses about 
trauma history and PTSD. Further structured diagnostic as-
sessment is necessary for definite clinical conclusions.

In  Stage  2,  when  resources  and  time  permit,  a  brief 
screening instrument can be used to identify potential past or 
current traumatic experiences and PTSD symptoms. Several 
brief validated questionnaires or interviews are available for 
focused  trauma  screening  (see  http://www.ncptsd.va.gov/
ncmain/assessment/). The goal is to identify key events and 
“traumagenic dynamics” (i.e., powerlessness, stigmatization, 
sexualization, isolation; Browne & Finkelhor, 1986, p. 66), 
as  well  as  the  PTSD–SUD  symptoms  that  most  interfere 
with current functioning. At this stage, education about how 
PTSD–SUD symptoms have made sense as adaptive survival 
reactions but now must be managed to prevent interference 
with daily living can bolster the client’s sense of safety and 
engagement in treatment. It is important to conduct screen-
ing for trauma history and PTSD symptoms in a gentle and 
respectful manner, with very specific behaviorally anchored 
descriptions of types of potentially traumatic experiences.

It  can  be  helpful  for  counselors  to  prepare  clients  for 
Stage  2  screening  with  a  brief  introduction  during  which 
clients are informed about the types of questions they will 
be asked. For example, 

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Integrating Treatment of Posttraumatic Stress Disorder and Substance Use Disorder

Now I’d like to ask you about stressful experiences that may 
have happened to you at any time in your life. All that I need 
to know is if each type of experience ever happened to you, 
if  it  was  very  upsetting  to  you  at  the  time  (because  not  all 
stressful experiences are upsetting at the time they happen), 
and how old you were when it happened. Please let me know 
if you’d like to pause or stop at any time. 

It is also essential to give clients the option of declining to ac-
knowledge or discuss any experience they do not feel ready or 
able to disclose or of stopping the process altogether. Providers 
must be prepared to sensitively validate clients’ often intense 
feelings  evoked  by  disclosing  and  thinking  about  traumatic 
experiences and to assist clients in managing these feelings and 
reactions during and after the screening (e.g., by using a safety 
plan protocol). Providers also should assist clients in limiting 
the extent and detail of memory disclosures so that screening 
is a therapeutic as opposed to an overwhelming experience for 
clients. The goal of Stage 2 screening is not only to learn about 
the client but to help the client begin to learn that she or he 
can choose to recall and disclose a limited amount about past 
traumas  (and  current  symptoms)  in  a  personally  meaningful 
way, while managing the often intense feelings and reactions 
that are triggered. Successful screening or assessment, thus, can 
demonstrate to the client that, with therapeutic guidance, he or 
she has the personal resources to deal with PTSD. 

Following an initial screening, Stage 3 involves a diagnostic 
assessment of PTSD–SUD and co-occurring disorders (Read, 
Bollinger,  &  Sharkansky,  2003).  PTSD  occurs  in  several 
forms that may require different treatment strategies. If trauma 
occurred within the past month, the individual may experi-
ence PTSD symptoms complicated by acute stress reactions 
in the form of an acute stress disorder that is distinct from 
PTSD (American Psychiatric Association, 1994; see Ehlers 
& Clarke, 2003, for treatment strategies). If PTSD symptoms 
are not sufficient to constitute a PTSD diagnosis, they may 
warrant  clinical  attention  as  subthreshold  PTSD  (Mylle  & 
Maes, 2004). If co-occurring PTSD–SUD is complicated by 
co-occurring psychiatric or personality disorders, treatment 
must  address  symptoms  across  the  full  array  of  disorders 
rather than just PTSD and SUD (Ford, 1999).

Finally,  Stage  4  involves  identifying  specific  traumatic 
experiences  and  posttraumatic  stress  symptoms.  Trauma-
specific assessment tends to be most helpful to clients, and 
most complete and accurate, when it is done on an ongoing 
basis. Treatment  and  other  services  can  build  in  periodic 
assessments of relevant past experiences and reviews of the 
clients’ current or recent symptoms. This can improve the 
client’s  ability  to  recognize  and  manage  their  symptoms. 
Brief questionnaires (see http://www.ncptsd.va.gov/ncmain/
assessment/) can be useful for monitoring change and fine-
tuning ongoing services. Creative arts exercises such as the 
lifeline (Ford & Russo, 2006, p. 347) can provide a vehicle 
for safe and therapeutic disclosure of trauma memories in the 
context of enhancing the client’s full set of life memories.

Treatment Services

Establishing the therapeutic frame. Before  or  during  the 
screening and assessment process, client engagement is maxi-
mized if an orientation is provided that describes the treatment 
and reassures the client that he or she will not have to disclose 
painful memories or situations. Orientation is particularly well 
received when the presenters include clients who are actively 
involved in or have completed the integrated treatment model. 
Such peer mentors can speak to the personal fears and ques-
tions that prospective clients have about PTSD treatment and 
about the benefits of engaging in PTSD–SUD treatment. 

Individual counseling or case management. Although  it 
can be difficult logistically, we recommend that each client 
involved in PTSD–SUD treatment has a primary counselor, 
clinician,  or  case  manager  guiding  their  PTSD–SUD  treat-
ment and ensuring that this is complementary with all other 
aspects  of  the  treatment  plan.  The  frequency  of  contacts 
with a primary provider can be individualized and may vary 
depending on the stage of treatment. For example, more fre-
quent,  regular  individual  visits  or  telephone  check-ins  may 
be  helpful  at  the  beginning  of  treatment  or  at  times  during 
treatment when the client is experiencing intense symptoms. 
The goal of individual counseling or case management is to 
provide clients with enough therapeutic structure and support 
to enable them to focus on recovery and life management in 
an organized manner despite the interference caused by PTSD 
and SUD (Ford et al., 2005).

Group treatment. Ideally,  PTSD–SUD  therapy  groups 
will have coleaders in order to provide immediate back-up if 
one leader is unable to attend or if one of the leaders needs 
to assist a group member privately because of severe stress 
or dissociative reactions (as illustrated previously by the case 
of  Susan).  Clients  in  PTSD–SUD  treatment  occasionally 
experience flashbacks, affective flooding, or suicidality in a 
group session, and, although this is rare, when it occurs it is 
essential that the group leader provides intensive one-to-one 
intervention until the client has stabilized. Often this can be 
done in the group setting, and, if so, the coleader can assist 
other group members in managing their own strong feelings 
while supporting the group member who is in crisis. In some 
cases, it is best for one coleader to leave the group and assist 
the client in a more private location while the other coleader 
actively  helps  the  remaining  group  members  discuss  and 
process their reactions and feelings about the crisis. 

If a formal coleader pairing is not possible, we have found 
that it can be sufficient to designate another on-site clinician 
or case manager to be on call during group sessions and to 
be available to come into the group to assist in the event of a 
crisis. If there is only one group leader, we recommend keep-
ing the group size small (e.g., 4 to 5 clients). In addition to the 
many obvious advantages of having coleaders involved in any 
approach to group therapy, in PTSD–SUD groups, coleaders 
also provide a level of safety and shared responsibility that 
sets a positive example for clients who are in recovery from 

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PTSD and SUD and who, therefore, often tend to expect that 
they must face life alone.

In most cases, PTSD–SUD groups should be gender spe-
cific, at least in the initial phases of treatment. In our experi-
ence,  female  clients  have  been  more  vocal  than  men  about 
this,  but  the  principal  advantage  is  no  different  for  either 
gender. Many trauma survivors have never (or only rarely or 
intermittently)  had  the  opportunity  to  reflect  on  the  impact 
that traumatic stress has had in their lives or the chance to give 
and receive support with others of their gender. There are as 
many differences as there are similarities among same-gender 
trauma survivors, but a key similarity not shared with members 
of the opposite sex is the impact that the trauma has had on 
each person’s sense of self, whether that person is a woman 
or  a  man.  Same-gender  groups  provide  an  opportunity  for 
men as well as for women to experience counseling in ways 
that  add  depth  and  richness  to  recovery  both  from  trauma 
and addiction, which Williams (2005, p. 280) has described 
as including “community building, self-determination, com-
passion, and empowerment through interpersonal connection 
as  key  modes  of  resistance  to  oppression.” Although  these 
experiences  may  be  of  particular  importance  to  women  of 
color, we have found that they can be life-transforming for 
clients  of  all  backgrounds.  Clients  often  move  from  same-
gender groups to mixed-gender groups with a greater sense 
of self-confidence and readiness to engage in honest dialogue 
after having benefited from their preliminary recovery work 
in a gender-specific PTSD–SUD group. 

The gender of the group leaders also warrants careful con-
sideration. The leader’s gender can symbolically evoke transfer-
ence reactions and may also be an inadvertent reminder of past 
traumas. This is most often seen in a situation in which there 
are male leaders and female clients. However, it is interesting 
to note that in the later developmental stages of some groups, 
group members have requested opposite gender coleaders for 
occasional sessions or on an ongoing basis in a new cycle of 
the group. Such requests can be fruitfully discussed in group 
sessions in order to help the clients decide if having a group 
leader of the opposite gender is likely to help them to address 
gender-related PTSD–SUD issues at this stage.

Here-and-now self-regulation focus. Prior  to,  or  instead 
of, delving in great detail into specific traumatic memories 
or situations, PTSD–SUD clients benefit from learning skills 
that enhance their mastery of memory and emotion regulation 
in their current lives. These skills can be applied to incidents 
in  which  they  are  troubled  by  unwanted  trauma  memories 
or PTSD symptoms. Focusing on helping clients make, and 
successfully implement, self-enhancing choices when faced 
with trauma’s unfinished emotional business (i.e., disrupted 
memory; dysregulated emotions) in current stressful situations 
is  consistent  with  all  meta-models  of  PTSD. As  previously 
noted, we recommend reframing PTSD as a sensitization of 
the self-protective bodily alarm system that requires regula-
tion in current stressful experiences. This enables clients to 
make connections between current stress reactions and past 

traumatic experiences while maintaining an adaptive here-and-
now focus on current functioning, symptom management, and 
personal goals. Using this approach, we have found that few 
clients choose to tell their trauma memories at length. Instead, 
they tend to disclose key portions of traumatic memories us-
ing the self-regulation skill-set. The self-regulation skill-set 
involves clients reorganizing their recollection with a focus 
on their inner experience and the personal resources they were 
able to access to survive at the time. 

When a client does disclose aspects of a trauma memory, 
it is important for clinicians to guide the disclosure so that 
the  client  safely,  consciously,  and  voluntarily  experiences 
stress  reactions  in  the  present  moment.  This  is  in  contrast 
to past experiences of these self-protective reactions, which 
would have occurred largely without protection, awareness, 
or  choice  during  or  after  traumas. We  have  found  that  this 
type of therapeutic reexperiencing is best done with a focus 
on  current  alarm  reactions  (rather  than  on  exploration  of 
detailed memories) and with the client explicitly in control 
of how much, how fast, and how deeply these reactions are 
experienced. This process can be done in several ways. One 
way is to help the client focus not only on the impact of the 
traumatic experience but also on the core personal goals that 
she or he was pursuing during times of trauma and that she 
or he continues to pursue right up to the present. Another way 
to control therapeutic reexperiencing is to regularly shift the 
client’s frame of reference from past experiences to the im-
pact that memories of these experiences have on the client’s 
current life and functioning in order to retain a here-and-now 
focus  as  a  counterbalance  to  the  tendency  for  people  with 
PTSD  to  ruminate  about  or  feel  lost  in  trauma  memories. 
The here-and-now focus also offers opportunities to shift the 
therapeutic focus from the memory to what the client and the 
counselor can do right now to help the client to manage and 
channel her or his alarm reactions as they are occurring in the 
counseling session. The goal is to help the client to experience 
a better paced and focused exploration of what otherwise can 
be overwhelmingly complex stress reactions. Another goal is 
to safely use very specific self-regulation skills and to invest 
memories  with  current  relevance  and  meaning,  rather  than 
merely automatically regurgitating memory fragments without 
a sense of control and meaning. 

When treatment is mandated. PTSD–SUD treatment may 
occur in a context of SUD services that are legally mandated 
and monitored. The requirements imposed on clients by the 
legal system can be valuable tools to enforce behavior change 
for  the  sake  of  the  client’s  and  society’s  safety.  However, 
these mandates may also inadvertently replicate coercive or 
punitive  aspects  of  the  client’s  past  traumatic  experiences 
and  can  thereby  be  counterproductive  to  trauma  recovery. 
In such cases, integrating PTSD–SUD services actually can 
strengthen clients’ engagement by providing assistance with 
stress reactions and emotion dysregulation that could other-
wise contribute to legal problems. When a client must report 
to probation officers, courts, or child protective services for 

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legal purposes of tracking and enforcing compliance, this of-
ten exacerbates anxiety and reluctance to engage in treatment. 
However, external mandates cannot be ignored because to do 
so would collude with the client’s wish to be free from  ac-
countability and with the punitive aspects of the legal system. 
We have found that PTSD–SUD treatment is most successful 
in providing skills that enable clients to achieve responsibility 
and accountability if the provider is not in a dual relationship 
of being both the counselor and the compliance monitor. Other 
types of services, such as addiction education, may be more 
appropriate  for  compliance  reporting.  If  PTSD–SUD  treat-
ment provides a place for clients to examine their posttrau-
matic dilemmas and develop the ability to respond effectively 
to the here-and-now challenges posed by legal mandates, this 
simultaneously supports the legal system’s objectives and the 
client’s trauma recovery. 

Enhancing the creative process. Creativity and flexibility 
are crucial to effective PTSD–SUD services and to evaluat-
ing their success. Clients in recovery from PTSD often feel 
powerless and, therefore, may develop nontraditional ways to 
empower themselves within the group process. For example, 
initially  during  the  group  sessions,  Susan  felt  best  able  to 
talk if she could keep her back partially turned to the group. 
Edward  spent  many  group  sessions  writing  in  a  personal 
journal, which he said was not meant to show disrespect for 
other  clients  or  the  group  leaders  but  because  this  helped 
him  to  avoid  feeling  overwhelmed. Also,  Edward  often  got 
up and walked around the room during the group sessions. 
These  behaviors  would  be  frowned  on  in  traditional  group 
settings and viewed as indicating a lack of involvement in the 
process. However, we view these behaviors as self-protective 
and as an opportunity for leaders to empathically help clients 
to  become  more  aware  of  their  behavior  and  what  they  are 
attempting to accomplish, such as managing stress reactions. 
If a client’s feelings, thoughts, and goals in relation to these 
behaviors  can  be  sensitively  discussed  and  clarified  in  the 
therapeutic dialogue, rather than leading to disruption during 
the group session, this fosters therapeutic awareness and group 
cohesion. Similarly, the outcomes of PTSD–SUD treatment 
are highly variable in form and timing. It is not good to set 
the standard, explicitly or implicitly, that clients must report 
reduced  distress  and  increased  self-efficacy  consistently  as 
treatment proceeds. Instead, if leaders help clients track their 
internal levels of reactivity (distress), efficacy (personal con-
trol), and relapse risk (urges), it is important to consistently 
emphasize that it is the act of responsible self-monitoring and 
the use of good judgment in coping with stressors or distress
that are more important than always feeling better or doing 
well. Therefore, clients are encouraged to notice when self-
check ratings reflect higher levels of distress or lower levels 
of personal control, as well as improvement, in order to foster 
the expectation that increases in distress and decreases in per-
sonal control are to be expected and are not signs of failure. 
Detecting early warning signs also provides an opportunity 
for relapse prevention. As PTSD–SUD treatment proceeds, 

most clients gradually shift their self-ratings, both within and 
across sessions, toward reduced distress and weaker urges to 
use substances and toward greater self-efficacy—but this is 
highly variable. Rather than setting the unattainable expecta-
tion that all clients should change in a positive direction on 
every outcome measure, it is best to help each client recognize 
and develop ways to manage positive and negative fluctuations 
throughout the recovery process.

Tangible transitional objects and learning generalizers. It 
is axiomatic that PTSD–SUD treatment must be done in an 
atmosphere of safety, nurturance, and respect for each person’s 
unique experience and strengths. This can be done in several 
tangible  ways.  For  example,  we  give  each  client  a  journal 
with  personal  practice  worksheets  in  which  to  record  how 
the FREEDOM skills are used outside the group setting. We 
encourage clients to choose what they feel ready to share from 
this journal in individual and group therapy. This provides an 
implicit statement that each client’s emotions, thoughts, goals, 
and observations are of importance and potentially helpful if 
shared with others but are also the client’s private business. 
We have also used laminated letters from the acronyms used 
as  memory  aids  for  skills  sets  (e.g.,  FREEDOM),  so  that 
clients have a colorful immediate reminder of the skills they 
are learning. Having the treatment room and materials ready 
ahead of time sets a tone of planful proactive organization. 
These are good practices in any counseling process but are 
especially useful when working with trauma survivors who 
are  poised  to  react  to  small  changes  and  disruptions  with 
hypervigilance.

Workforce and Organizational Development

Organizational or systematic “buy-in.” When  introducing 
integrated  PTSD–SUD  treatment  into  an  agency  or  a  prac-
tice group, key participants (e.g., colleagues, administrators) 
must  be  committed  to  this  approach  to  treatment  from  the 
outset. This requires taking the time to discuss concerns and 
to actively seek input from everyone involved. It is critical to 
know if anyone has had any negative experiences with trauma 
treatment and, if so, to address their concerns immediately. 
Moreover,  a  plan  should  be  established  to  ensure  that  such 
past  negative  experiences  are  not  repeated  in  the  current 
implementation of PTSD–SUD treatment. Open discussion 
and  brainstorming  tend  to  enhance  buy-in  even  among  the 
skeptical or wary, who often join in only when satisfied that 
PTSD–SUD services not only are helpful to their clients but 
also  do  not  cause  problems  or  increase  the  already  heavy 
workloads of the staff.

Clinician personal buy-in. Integrated PTSD–SUD services 
are most sustainable when clinicians are interested in doing 
this type of work both professionally and personally. This does 
not mean that only trauma survivors can provide PTSD–SUD 
services. Health care providers who take seriously the frame 
of reference of people who have experienced traumatic shock 
and loss can be highly effective. Three qualities distinguish 
effective PTSD–SUD clinicians. The first quality is genuine 

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respect  for  the  courage  and  resilience  of  trauma  survivors. 
The  second  is  a  commitment  to  a  developmental  treatment 
model  that  is  based  on  strengths,  regardless  of  theoretical 
orientation. The third quality is openness to using skills and 
concepts from PTSD–SUD treatment models along with those 
from other psychotherapy, counseling, and health promotion 
interventions. The least successful clinicians are those who 
view  trauma  survivors  as  “disabled,”  troublesome,  overly 
demanding or dependent, or in need of corrective education 
(e.g., “borderlines”). Clinicians who accept only one treatment 
philosophy or model as correct, or who simply are not commit-
ted to PTSD–SUD treatment and are doing the work largely 
for economic reasons or because of professional necessity or 
convenience, are also unlikely to be effective. 

Blended rather than compartmentalized treatment menus.
PTSD–SUD services are not necessarily the best modality for 
a given client at any particular point in her or his treatment 
and  recovery,  even  if  PTSD  is  a  key  issue  for  that  client. 
Trauma recovery takes many forms and can occur in many 
types  of  treatment.  Therefore,  we  recommend  establishing 
PTSD–SUD treatment as one item in a menu of recovery ser-
vices and encouraging clients and clinicians to consider how 
other complementary services may equally or better address a 
client’s recovery goals and stage of change. Also, PTSD–SUD 
concepts and skills can be infused into many other services 
(e.g., relapse prevention; stress, pain, or anger management; 
social/leisure  skills;  art  therapy;  body  therapy)  rather  than 
used as a completely separate treatment regimen.

Training.  Not  only  clinicians  but  also  case  managers, 
social services providers, health care providers, clergy, and 
support staff should receive training in integrated PTSD–SUD 
services. All of these individuals have valuable informal inter-
actions with clients that can support or detract from the treat-
ment model, depending on whether they are knowledgeable 
about and invested in PTSD–SUD treatment. Such training 
can  familiarize  every  staff  member  with  key  concepts  and 
skills and enable them to apply relevant portions to their own 
stress  experiences.  This  approach  also  conveys  the  crucial 
message that every helper is a valued professional colleague. 
Clinicians  who  specialize  in  PTSD–SUD  treatment  should 
also  be  included  because  they  often  discover  that  they  can 
adapt elements of the integrated treatment model within the 
groups  or  other  services  they  provide.  Inclusiveness  also 
supports truly multidisciplinary services, takes the mystery 
out  of  trauma  work,  and  amplifies  the  support  given  to  the 
clients and clinicians who are involved in specific PTSD–SUD 
treatment services.

It  is  very  important  that  treatment  for  PTSD–SUD  not 
be done on an ad hoc basis without the treatment providers 
receiving adequate training and consultation. However, it is 
equally  important  to  help  providers  who  are  not  specialists 
in PTSD treatment to learn about PTSD–SUD concepts and 
tools and to incorporate them into their practice—especially 
if they treat clients who are involved in formal PTSD–SUD 
treatment. If only certain providers are authorized to assist cli-

ents with trauma-related issues or to use the treatment model, 
both clients and staff can come to view PTSD treatment as 
a  separate  domain  apart  from  other  services. This  artificial 
split also leaves openings for staff to use other PTSD treat-
ment  models  or  their  own  idiosyncratic  methods  for  doing 
trauma work in ways that set up a false competition between 
the approaches. An inclusive approach provides a forum for 
clinicians to discuss views about PTSD–SUD treatment and 
its pros and cons, rather than avoiding it. 

Ongoing consultation.  Clinical  consultation  groups  for 
staff members are essential because training alone does not 
lead to sustained changes in counseling practice. Often, clini-
cians attend training, become excited about it, but then lose 
enthusiasm because lack of time, peer support, and admin-
istrative buy-in make it difficult to implement new services. 
Clinical  consultation  ideally  occurs  on  a  weekly  basis  in  a 
group setting that encourages both the primary PTSD–SUD 
staff and other interested staff to discuss treatment issues. If 
the focus is on the challenges immediately facing counselors 
with their current clients and groups, PTSD–SUD treatment 
concepts,  skills,  and  techniques  can  support  constructive 
clinical  problem  solving  and  mutual  peer  support  among 
staff. Having a regular time and place to step back from the 
pressures  of  providing  services  to  highly  stressed  clients 
while working in demanding organizations sets a model for 
staff self-care and reflective processing that is professionally 
and personally rejuvenating. We have found that the optimal 
combination is that of an external expert facilitator, who is a 
skilled clinical consultant and knowledgeable in the applica-
tion of the treatment model, and an internal local champion, 
who serves as the leader in the agency for the treatment model 
and the staff using it. 

However,  depending  on  how  they  are  actually  conducted, 
consultation groups can be inclusive or divisive and can sup-
port or detract from the personal well-being and professional 
development of participating counselors. The potential down-
side occurs if a consultation group is set up to involve only a 
few select staff members who can come to view themselves 
as the only trauma experts in an agency. The second potential 
pitfall in consultation groups is to focus mainly on technical 
or administrative discussions of case management. The staff 
then miss the valuable opportunity to debrief with other clini-
cians, gain support, and engage in personal and professional 
self-reflection and self-care. In our experience, the best way to 
prevent or reduce the potential negative effects of conducting 
PTSD treatment (e.g., burnout, vicarious traumatization) is to 
provide an open forum through ongoing consultation groups in 
which counselors can discuss personal reactions and dilemmas 
raised by providing services as well as professional, technical, 
or operational issues. 

Ideally, the skills and process for trauma recovery taught 
in the treatment model will be mirrored in the facilitation of 
the clinical consultation group. If this parallel process occurs, 
participating counselors gain an understanding of and develop 
constructive  ways  to  address  their  own  stress  reactions  in 

Journal of Counseling & Development  ■  Fall 2007  ■  Volume 85 487

Integrating Treatment of Posttraumatic Stress Disorder and Substance Use Disorder

the  consultation  group  discussion. This  does  not  mean  that 
counselors can or should “do therapy” with one another or that 
the consultation group facilitator(s) should treat participants 
as if they were clients receiving personal therapy. Instead, by 
staying within the boundaries of respectful interprofessional 
relationships,  consultation  group  participants  can  examine 
their  own  reactions  using  the  framework  provided  by  the 
treatment model as a guide. Staff can also work together to 
develop creative approaches to addressing clinical challenges 
and to ensuring their own personal self-care.

Vicarious traumatization (VT). Also referred to as “second-
ary traumatization” or “compassion fatigue,” VT refers to the 
emotional impact counselors experience from clients’ intense 
traumatic  stress  reactions  (Trippany,  Kress,  &  Wilcoxon, 
2004). VT is intensified if PTSD counseling involves detailed 
trauma  memory  disclosure—this  is  an  additional  reason  for 
considering adopting a here-and-now rather than a there-and-
then approach to PTSD–SUD counseling. VT may be related 
to the clinician’s degree of sympathy for client suffering, yet 
empathic attunement does not appear related to VT. Empathy, 
the ability to take another person’s internal frame of reference 
seriously, involves personal and professional boundaries that 
do not prevent a clinician from feeling the impact of client suf-
fering but do help the clinician reflect on and work through that 
impact, rather than just absorbing it as inchoate distress (Kohut 
& Wolf, 1978). On the other hand, sympathy, while laudable 
and probably inevitable unless the clinician is overly detached 
(which, paradoxically, can result from excess sympathy), in-
volves  excessively  permeable  emotional  boundaries  that  can 
lead to overidentification or enmeshment with clients. In our 
experience,  sustained  empathy  requires  reflective  processing 
and  open  dialogue  with  peers.  Empathy  may  protect  against 
extreme VT, but it is not an antidote for VT. Intense sympathy 
(e.g., feeling a need to rescue a client) may intensify VT and is 
best addressed by regaining an empathic balance of involvement 
and separateness in relation to clients and clinical work.

VT  is  more  likely  to  occur  and  to  be  heightened  if  a 
clinician’s personal issues are activated (affectively or sym-
bolically) by clients’ current suffering or traumatic memories. 
Working through personal issues is the responsibility of every 
helping professional, as is deciding when it is necessary to 
place limits on the amount or type of therapeutic work being 
done  for  the  sake  of  the  clinician’s  self-care  and  the  well-
being of clients. We have found that VT is minimized when 
agencies and clinicians carefully apply their PTSD treatment 
model’s core principles to themselves. For example, the agency 
whose  administrators  support  a  thorough  organizational 
self-examination on a regular basis to maintain a genuinely 
trauma-informed and growth-oriented milieu, for staff as well 
as for clients (Harris & Fallot, 2001), is likely to maximize 
clinical effectiveness of the staff. 

Conclusion
Integrated PTSD–SUD treatment requires a shift from ask-
ing “whether” to treat to asking “how best” to treat PTSD in 

an effective and integrated manner with clients in recovery 
from SUD. The principal pitfall, therefore, is not choosing the 
wrong integrated PTSD–SUD treatment model or technical 
approach. Each evolving model has strengths and limitations 
that  can  be  considered  in  developing  an  approach  that  best 
suits one’s clients, milieu, and approach (Ford et al., 2005). 
Equally  or  more  important  than  specific  PTSD–SUD  treat-
ment  models  is  the  development  of  practice  guidelines  for 
PTSD–SUD  treatment  that  reflect  the  scientific  literature 
and clinicians’ practical knowledge and experience (Westen, 
Novotny, & Thompson-Brenner, 2004) as well as the diverse 
types  and  levels  of  organizational  and  workforce  readiness 
to undertake and sustain a paradigm shift (Simpson, 2002). 
This article is an attempt to contribute to the paradigm shift 
that  is  occurring  in  the  mental  health  and  substance  abuse 
counseling  fields  (Harris  &  Fallot,  2001)  by  outlining  key 
issues  that  counselors,  administrators,  and  researchers  face 
as  they  contemplate  or  engage  in  a  shift  to  an  integrated 
PTSD–SUD treatment.

We  believe  that  the  principal  pitfall  is  to  provide  PTSD 
treatment  without  addressing  addiction  recovery  or  SUD 
treatment without addressing trauma recovery. Blending these 
treatment  agendas  is  a  complex  but  attainable  goal  that  will 
require  careful  planning  and  evaluation  simultaneously  per-
formed by individual practitioners, by treatment agencies and 
organizations,  and  by  the  counseling  field  at  large. We  have 
not addressed the fiscal or political issues that are involved in 
the transfer of science and technology to the field (Simpson, 
2002) but have focused instead on describing a conceptual and 
clinical paradigm that we hope can be a model not only for the 
practitioner and the agency but also for the larger behavioral 
health systems in which PTSD–SUD treatment can be provided 
in an integrated manner. 

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APPENDIX

Sample Client Safety Plan

Personal Safety Plan

It is natural that during times of extreme stress, we all need support. Having people available to talk to about our feelings and needs
can help. Here are some steps to help you feel safe and be safe.

Step 1:
➢ Talk with a support person with whom you feel safe.

Names of Support Persons Telephone Numbers

Step 2:
➢ Do something right now that gives you a feeling of safety and enjoyment.

Activities or Programs You Can Get Involved With First Step to Start the Activity

Step 3:
➢ If you feel you need more help, contact your therapist, case manager, or treatment team.

Names of therapist, case manager, treatment team members Telephone Numbers

Step 4:
➢ If you need help right away and can’t contact a therapist or case manager, you can call the Mobile Crisis Team 24-hours a

day, 7-days-a-week to talk or have them come help you.

Mobile Crisis Team (860� XXX-YYYY

I agree to use this guide, to the best of my ability, to keep myself safe and to build the life I want.

Participant’s signature Witness Date

Other Resources to Learn More About Healthy Recovery:
➢ To learn more about trauma, contact The Connecticut Trauma Coalition 1-800-XXX-YYYY or visit a Trauma Internet Web site��

http��//www.trauma-pages.com/index.htm
➢ To learn more about addiction and trauma recovery, visit the Connecticut Clearinghouse Web site��

http��//www.ctclearinghouse.org

Journal of Counseling & Development  ■  Fall 2007  ■  Volume 85490

Ford, Russo, & Mallon

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Examination Questions
 1.  One hypothesis advanced by the authors to explain why 

posttraumatic stress disorder (PTSD) and substance 
use disorder (SUD) can co-occur suggests that SUD 
results  from  attempts  by  people  with  PTSD  to  use 
substances to cope with PTSD symptoms.

   a.  True
   b.  False

 2.  In  the  integrated  approach,  which  of  the  following 
outcomes  can  be  achieved  if  treatment  is  provided 
during  the  transitional  period  beginning  soon  after 
discharge from inpatient SUD treatment and during 
the long-term recovery period?

   a.  Reduction in immediate risk of SUD relapse
   b.  Reduction in long-term risk of SUD relapse
   c.  Reduction in not only immediate, but also long- 

    term risk of SUD relapse
   d.  No effect on SUD relapse

 3.  Vicarious traumatization, as discussed in this profes-
sional article, can best be defined as:

   a.  The emotional dilemmas experienced by family  
    and  friends  of  clients  engaged  in  PTSD-SUD  
    treatment

   b.  Client reactions when there is an imbalance in  
    PTSD and SUD treatments

   c.  The  emotional  impact  counselors  experience  
    from clients’ intense traumatic stress reactions

   d.  None of the above

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Journal of Counseling & Development  ■  Winter 2009  ■  Volume 8780

Qualitative Research

© 2009 by the American Counseling Association. All rights reserved.

A child awakens in the middle of the night, the nightmare still 
fresh in her mind of “him” on top of her. Her breath comes 
in short, quick gasps as she struggles to determine whether 
what she has just experienced was real or only a dream. She 
strains to hear if the footsteps coming down the hall are real or 
imagined. She pushes the thoughts out of her head. Perhaps if 
she sleeps under the bed, he will not find her. She wishes her 
mother would come in and comfort her, but she feels discon-
nected from her family, as if she is a stranger living in her own 
house. No one understands. No one cares. She prays for the 
morning to come so the dreams will stop, but she knows that 
the morning brings nightmares of its own: the looks from her 
sister, the speeches from her teacher about her lack of con-
centration in class. Her day is spent alternately trying to recall 
what happened and trying to forget. She finds no pleasure in 
the activities that she once loved. The night comes again, and 
the cycle continues. The monster that was once in her bed has 
now been replaced by monsters in her head.

There has been a growing body of literature on the subject of 
posttraumatic stress disorder (PTSD) in children. The literature 
consistently points to children’s vulnerability to the development 
of PTSD after severe trauma, particularly child sexual victimiza-
tion. (Note. In this article, both the terms child sexual victimiza-
tion and child sexual abuse are used. Child sexual victimization 
refers to the symptomatology experienced by the person being 
victimized. This term assumes the perspective of the victim. Child
sexual abuse refers to the overall experience and nature of sexual 
abuse, including the criminal component.) When children’s bod-
ies are used to meet adult needs, there is enormous potential for 
physical  and  psychological  trauma  (Monahon,  1993).  Many 

clinicians differ on the applicability of a diagnosis of PTSD for 
children  who  have  been  sexually  victimized. Although  many 
authors believe that PTSD is a logical outcome following child 
sexual victimization, others (e.g., Finkelhor, 1990) object to 
using the diagnosis of PTSD as a way of always conceptualiz-
ing the sequence of events and symptoms that children who are 
sexually abused often face after the trauma. This article does 
not seek to resolve this debate, but rather seeks to shed light on 
the controversy. This article examines the nature and scope of the 
problem, proper assessment and diagnosis of PTSD in children, 
treatment strategies known to be effective, and implications for 
counselors treating this population. In the interest of time and 
space, this article only addresses PTSD as it specifically relates 
to child and adolescent survivors of child sexual victimization, 
while acknowledging that adult survivors of child sexual abuse 
may also experience the effects of PTSD.

Nature and Scope of the Problem
PTSD has long been associated with the aftereffects of war 
and  natural  disasters.  This  disorder  was  brought  to  main-
stream attention with the return of soldiers from the Vietnam 
War. Many of these returning soldiers experienced recurrent 
nightmares,  suddenly  feeling  or  acting  as  if  the  event  were 
recurring, restricted range of affect, and hypervigilance (Da-
vidson & Foa, 1993). It is now recognized that PTSD is not 
limited to wartime but may arise from a variety of traumatic 
events that can occur throughout the life cycle of men, women, 
and children. It is estimated that 4 out of 10 Americans have 
experienced major trauma, and the disorder may be present 

Stacie E. Putman, Counseling, Educational Psychology, and Reseach, The University of Memphis. Stacie E. Putman is now at
Department of Psychology, Tennessee State University. The author thanks Jeri Lee, Ronnie Priest, and Nancy Nishimura for their
thoughtful review and comments on earlier versions of this article. This article is based on research conducted for the author’s
doctoral residency project at The University of Memphis. Correspondence concerning this article should be addressed to Stacie
E. Putman, Department of Psychology, Tennessee State University, 3500 John A. Merritt Boulevard, Nashville, TN 37209 (e-mail:
sputman@tnstate.edu).

The Monsters in My Head:
Posttraumatic Stress Disorder and the
Child Survivor of Sexual Abuse
Stacie E. Putman

Posttraumatic stress disorder (PTSD) is 1 of several possible outcomes of child sexual victimization. There is a growing body of
literature regarding the prevalence of PTSD among children who have been sexually victimized. Using specific case examples,
this article looks at the nature and scope of the problem, diagnostic criteria according to the Diagnostic and Statistical Manual
of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) symptomatology of children presenting with this
disorder, assessment and diagnosis, treatment interventions, and implications for counselors treating this population.

Journal of Counseling & Development  ■  Winter 2009  ■  Volume 87 81

Posttraumatic Stress Disorder and the Child Survivor of Sexual Abuse

in  9%  of  the  U.S.  population  (Breslau  &  Davis,  1987). A 
growing number of Americans with PTSD are children who 
have  been  sexually  abused. According  to  the  U.S.  Depart-
ment  of  Health  and  Human  Services  (2000),  11.5%  of  the 
903,000 children who were victimized in 1998 were victims 
of sexual abuse. According to Browne and Finkelhor (1986), 
it is estimated that between 46% and 66% of children who are 
sexually abused exhibit significant psychological impairment. 
McLeer, Deblinger, Atkins, Foa, and Ralphe (1988) studied 
the  prevalence  of  PTSD  in  31  children  who  were  sexually 
abused and found that in 48% of their sample, a diagnosis of 
PTSD was warranted. Many children who did not meet PTSD 
criteria nevertheless experienced PTSD symptoms. 

Another study by Briere, Cotman, Harris, and Smiljanich 
(as cited in Briere, 1992) found that “both clinical and non 
clinical  groups  of  sexual  abuse  survivors  report  intrusive, 
avoidant, and arousal symptoms of PTSD” (p. 20). According 
to Briere, survivors of sexual abuse are prone to displaying 
PTSD-related intrusive symptoms. Other symptoms survivors 
of  sexual  abuse  may  experience  include  mood  disorders, 
somatization, sexual difficulties, anger and frustration, self-
injurious behaviors, and a pervasive distrust of others (Naugle, 
Bell,  &  Polusny,  2003).  These  symptoms  often  manifest 
themselves  in  the  form  of  flashbacks,  when  the  survivor  is 
flooded  with  intrusive  sensory  memories  that  may  include 
visual, auditory, tactile, or olfactory sensations (Briere, 1992). 
Many of these flashbacks may be triggered by abuse-related 
stimuli or interactions. 

I worked with a young girl who became physically ill when she 
encountered the smell of chlorine, particularly prevalent around 
swimming pools. During the course of therapy, it was discovered 
that the client had been repeatedly sexually assaulted one summer 
by one of her older brother’s friends at a local swimming pool. 
The perpetrator would take the client behind the pool’s storage 
shed and repeatedly assault her. The smell of the chlorine would 
inevitably return her to that place, and she would “feel” his hands 
on her. Often, disclosing the abuse experience can be the only 
stimulus needed to trigger flashbacks. 

In  a  survey  of  six  separate  studies  by  McNally  (1993), 
which  involved  the  application  of  PTSD  criteria  to  cases  of 
child sexual abuse, four of these studies reported no cases of 
PTSD,  whereas  the  other  two  studies  reported  rates  of  48% 
and 90%, respectively. As McNally noted, “Clearly, there is no 
uniform outcome associated with child sexual abuse” (p. 69). 
The clinician working with this population should consider a 
diagnosis of PTSD as a possible outcome of child sexual abuse 
but recognize that such a diagnosis is not always a given in cases 
in which child sexual abuse has been reported. 

Symptomatology
It is important for the clinician dealing with survivors of child 
sexual  victimization  to  be  aware  of  how  these  clients  will 
present upon entering counseling. The clinician who suspects 

that a child is experiencing PTSD should be cognizant of the 
signs  and  symptoms  that  are  possible  indicators  of  PTSD. 
Frequently,  fearfulness  and  anxiety-related  symptoms  have 
been  described  as  sequelae  of  sexual  abuse.  Green  (1985) 
described anxiety states, sleep disturbances, nightmares, and 
psychosomatic complaints in children who were sexually as-
saulted. Sgroi (1982) observed fear reactions in children who 
had been sexually abused extending to a phobic avoidance of 
all males (when the perpetrator is male). Kiser et al. (1988) 
documented PTSD in 9 out of 10 children between the ages 
of 2 and 6 years who were molested in a day-care setting. The 
most frequently observed symptoms were acting as if the trau-
matic event were reoccurring, avoiding activities reminiscent 
of  the  traumatic  event,  and  intensification  of  symptoms  on 
exposure to events resembling the molestation, all of which 
satisfied criteria for a diagnosis of PTSD. 

According to Koverola and Foy (1993), one of the ongoing 
controversies in the diagnosis of PTSD in children who have 
been sexually victimized lies in the issue of whether children 
manifest PTSD symptoms in the same way that adults do. As 
Koverola and Foy noted, “One way in which PTSD in children 
may differ from PTSD in adults is in the nature of the traumatic 
reexperiencing” (p. 120). It is argued that children are more 
likely to experience nightmares as opposed to the dissociative 
flashbacks  that  adults  experience  (Koverola  &  Foy,  1993). 
These nightmares can be classified into two types of PTSD 
according to Terr (1989). Type I can be classified as a graphic 
representation of the original trauma and that results from a 
single  incident. Type  II  can  be  classified  as  more  symbolic 
representation of the event and is often classified by denial, 
dissociation,  and  numbing. Type  I  nightmares  often  appear 
soon after the abuse and usually decrease over time. Type II 
nightmares seem to be both a short- and long-term sequel of 
trauma,  often  surpassing Type  I  nightmares  as  the  survivor 
grows older (Terr, 1989).

Dissociation,  or  an  alteration  in  consciousness  resulting 
in an impairment of memory or identity, has also been ob-
served in children traumatized by sexual abuse (Kluft, 1985). 
Signs of early dissociation in children are “forgetfulness with 
periods of amnesia, excessive fantasizing and daydreaming, 
trancelike states, somnabulism, the presence of an imaginary 
companion, sleepwalking, and blackouts” (Wilson & Raphael, 
1993, p. 578). There seems to be a close relationship between 
dissociation and PTSD. Liner (1989) found that children who 
were physically and sexually abused who were referred for 
outpatient treatment exhibited significantly more dissociation 
than did a comparison group of nonabused children who at-
tended a child psychiatry outpatient clinic. Sexual abuse and 
physical abuse are the most frequent background factors in the 
etiology of dissociative identity disorder in adults (Wilson & 
Raphael, 1993). It is quite possible that the child who has been 
sexually victimized who presents with dissociative symptoms 
began the dissociation process during the course of the trauma 
as a way of coping. Just as the dissociation served a purpose 

Journal of Counseling & Development  ■  Winter 2009  ■  Volume 8782

Putman

during the trauma, the clinician needs to be ever mindful of 
the purpose that dissociation may serve after the trauma.

An  essential  feature  of  PTSD  is  the  avoidance  of  situa-
tions and stimuli that are associated with the traumatic event 
(American Psychiatric Association [APA], 2000). Survivors 
of child sexual abuse invariably make conscious attempts to 
avoid thoughts, feelings, or activities that bring back recol-
lections of the abuse. Cognitive suppression and distraction 
are particularly common, as is behavioral avoidance (Jackson 
&  March,  1995).  Children  who  use  these  survival  strate-
gies  pay  a  high  price  because  these  strategies  inevitably 
spill  over  into  other  domains  of  functioning. According  to 
Jackson and March, “children with PTSD often show mark-
edly diminished interest in previously enjoyed activities and 
sometimes lose previously acquired skills, leaving them less 
verbal  or  regressed  to  behaviors  such  as  thumb  sucking  or 
enuresis” (p. 283).

Child survivors of sexual victimization experiencing PTSD 
also  may  show  evidence  of  restricted  affect,  accompanied  by 
feelings of detachment or estrangement from others (APA, 2000). 
Children who have been sexually victimized who begin to talk 
about their experiences may do so with blunted affect and with a 
detached demeanor. The clinician should not take this restricted 
affect as a sign of dishonesty regarding whether the abuse oc-
curred, but rather as a possible sign that abuse has occurred. 

Children  often  reexperience  or  reenact  part  or  all  of  the 
traumatic event. The traumatic event of sexual abuse can be 
reexperienced in the form of distressing, intrusive thoughts 
or memories, dreams, or flashbacks. McNamara (2002) stated 
that reenactment is the rule in children who have been trauma-
tized. Reexperiencing symptoms set PTSD apart from other 
psychiatric syndromes; in no other symptom are portions of 
the traumatic event recapitulated (Jackson & March, 1995). 
Reexperiencing occurs both spontaneously and in response 
to traumatic reminders, as noted earlier. 

Traumatic  play  is  often  an  essential  feature  of  PTSD  in 
children who have been sexually victimized. Traumatic play 
refers to “the repetitive acting out of specific themes of the 
trauma” (Jackson & March, 1995, p. 282). According to Py-
noos  and  Nader  (1993),  when  children  incorporate  rescues 
that lead to a happy ending, otherwise known as intervention
fantasies, play may represent an attempt at mastery. The child 
who  has  been  sexually  victimized  may  reenact  aspects  of 
the abuse in his or her play; however, in the child’s version, 
perhaps the “victim” becomes empowered by a magic wand 
and he or she is therefore able to make the abuser disappear. 
According to Jackson and March, “traumatic play is clearly 
maladaptive when it interferes with play’s normative uses or 
leads to risky or aggressive behaviors” (p. 282). 

Child survivors of sexual victimization are said to develop a 
“sense of foreshortened future” (APA, 2000, p. 468), believing 
that they may never grow up or fulfill other adult tasks (Terr, 
1990).  Many  survivors  often  possess  a  self-image  of  “bad-
ness,” implying that they are not worthy of having a future in 

which there is happiness, marriage, and children. According 
to Jackson and March (1995), there is little empirical literature 
that supports this element as a necessary element of the PTSD 
symptom picture.

Hyperalertness and hypervigilance are also common fea-
tures of PTSD associated with increased physiological arousal. 
Children with PTSD who have been sexually abused may show 
symptoms of increased arousal, such as sleep disturbances, ir-
ritability, difficulty concentrating, exaggerated startle respons-
es, and outbursts of aggression (Friedman, 1991). According 
to McNamara (2002), these symptoms persist for more than 
a month. A study by Chaffin, Wherry, and Dykman (1997) 
looked at the coping strategies used by 84 children, ages 7 to 
12 years, who had been sexually abused. These authors found 
that internalized coping strategies used by children who had 
been sexually abused were strongly associated with increased 
guilt and PTSD hyperarousal symptoms. 

The stress and coping literature generally concludes that 
males are more vulnerable than females to the negative effects 
of stress (Hetherington, 1984); however, it is unclear whether 
this  gender  difference  holds  for  all  stressors,  particularly 
child  sexual  abuse.  Kempe  and  Kempe  (1978)  concluded 
that the impact of sexual abuse was usually more severe for 
males than for females; however, they provided no empirical 
evidence for this conclusion. Do males, then, have a higher 
rate of PTSD from sexual abuse than do females? Kiser et al. 
(1988) found gender differences in the PTSD presentations 
of ten 2- to 6-year-old children who were sexually abused in 
a day-care setting. The boys in the study initially presented 
more clinically significant symptoms than did the girls. A 
partial follow-up 1 year later suggested that the girls were 
more symptomatic at that time than were the boys. A similar 
study by Burke, Moccia, Borus, and Burns (1986) looked at 
the behavioral reactions of boys and girls to a traumatic event 
and found that boys reacted more intensely and their symp-
toms resolved slowly, whereas in girls a recurrence of symptoms 
developed at a later time.

Friedrich and Reams (1987) further found gender differ-
ences among children between the ages of 3 and 12 years who 
had been sexually abused. These authors concluded that girls 
display greater internalization and boys greater externalization 
when dealing with the trauma of child sexual victimization. It 
is clear, however, that there is no consensus on whether there 
is a higher incidence of PTSD in males or females who have 
been  sexually  victimized;  however,  the  literature  seems  to 
suggest that girls who are victims of father–daughter incest 
frequently  become  symptomatic  and  meet  the  diagnostic 
criteria for PTSD (Wilson & Raphael, 1993).

Assessment and Diagnosis
The type, duration, and frequency of trauma determines the 
likelihood  of  PTSD  development,  and  as  such  PTSD  may 
result  from  a  single  or  repeated  traumatic  event  exposure 

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Posttraumatic Stress Disorder and the Child Survivor of Sexual Abuse

(Famularo, Fenton, Kinscherff, & Augustyn, 1996). Children 
who are sexually abused seem to develop PTSD at a higher 
rate than do children who have been physically maltreated or 
who  have  experienced  parental  neglect  (Famularo,  Fenton, 
Kinscherff,  1993).  How,  then,  does  the  clinician  properly 
assess,  diagnose,  and  treat  those  child  survivors  of  sexual 
victimization experiencing PTSD?

Evaluating  children  who  have  been  sexually  victimized 
and assessing their treatment needs requires thoughtful and 
purposeful planning. As with any client, it is important that an 
assessment is made of all resources available to the clinician. 
These  resources  may  include  reports  from  outside  sources, 
such as physicians, teachers, social workers, family, clergy, 
and legal services. Assessment instruments are also helpful in 
diagnosing PTSD in children who have been sexually victim-
ized. Miller and Veltkamp (1995) researched various measures 
designed to aid the clinician in diagnosing PTSD. Instruments 
such as the Children’s Post-Traumatic Stress Disorder Inven-
tory (Saigh, 1994), the Childhood PTSD Interview (Fletcher, 
1991), When Bad Things Happen (Miller & Veltkamp, 1995), 
and the Trauma Symptom Checklist for Children (Wolpaw, 
Ford, Newman, Davis, & Briere, 2005) are all designed to aid 
the clinician in properly assessing and diagnosing PTSD in 
children who have been sexually victimized. 

The role of play and drawing in the assessment and treat-
ment of posttraumatic stress goes beyond the simple idea that 
drawing permits an easy access to children who might other-
wise find it difficult to speak about their abuse experiences. 
According  to  Nader  and  Pynoos  (1990),  in  the  specialized 
treatment  of  children  experiencing  PTSD,  drawing  is  more 
than just a window into the child’s mental representation of 
traumatic material. Nader and Pynoos contended that visual 
and other perceptual experiences of the event become embed-
ded and transformed in a child’s play and drawings. “Thus, 
play and drawings serve as an ongoing indicator of both the 
child’s processing and his or her resolution of traumatic ele-
ments” (Pynoos & Nader, 1993, p. 538). 

As with any disorder, the criteria for PTSD in the Diagnos-
tic and Statistical Manual of Mental Disorders (4th ed., text 
rev.; DSM-IV-TR; APA, 2000) must be met before an accurate 
diagnosis  can  be  made.  PTSD  must  often  be  differentiated 
from other  DSM-IV-TR diagnostic categories. According  to 
Peterson,  Prout,  and  Schwarz  (1991),  common  diagnostic 
differentials include anxiety disorders, depressive disorders, 
adjustment disorders, antisocial personality disorders, schizo-
phrenia, factitious PTSD, and malingering. Because of a wide 
array of potential clinical symptoms following severe trauma, 
errors  in  diagnosis,  particularly  differential  diagnosis,  are 
common among patients with PTSD. 

Children  who  have  been  traumatized  frequently  exhibit 
symptoms of disorders other than PTSD, and children with 
other disorders not uncommonly have PTSD as an intercurrent 
diagnosis. Famularo et al. (1996) conducted a study in which 
PTSD in children who had been maltreated was found to be 

statistically  related  to  other  formal  psychiatric  diagnoses. 
The  results  of  their  study  suggest  that  “children  diagnosed 
as  PTSD  demonstrate  concurrent ADHD  [attention-deficit/
hyperactivity  disorder],  anxiety  disorders  (panic,  phobic, 
overanxious,  simple  phobia),  and  a  tendency  toward  mood 
disorders  (major  depression,  dysthymic)”  (Famularo  et  al., 
1996, p. 959). Borderline personality disorder has also been 
etiologically linked to PTSD (Bemporad, Smith, Hanson, & 
Cicchetti,  1982).  Famularo  et  al.  (1996)  also  found  a  high 
correlation between childhood diagnosis of PTSD and at least 
transient suicidal ideation. These findings suggest that when 
a diagnosis of PTSD in children who have been sexually vic-
timized is made, it is highly probable that another disorder is 
also present, as well as suicidal thoughts, for which a suicide 
risk assessment should be administered. 

Treatment Interventions
According to Friedrich (1990), “although the PTSD diagnosis 
seems to be relevant for some sexually abused children, its 
greatest utility is probably that it identifies the existence of 
specific  behaviors  that  should  be  addressed  in  therapy”  (p. 
24).  Likewise,  “assessment  for  PTSD  in  children  who  are 
believed to have been sexually abused can be useful both for 
intervention as well as forensic purposes” (Walker, 1993, p. 
131).  Walker  further  stated  that  the  treatment  of  PTSD  in 
children must contain some of the same components as those 
for the treatment of PTSD in adults, which includes empow-
erment. It is essential that the child becomes empowered to 
take back that which has been taken from him or her through 
the violation of sexual abuse. It is important to recognize that 
children have limited control over their surroundings and over 
situations, but by allowing them to make decisions that are 
within  parental  limits,  the  child  can  begin  to  regain  power 
over his or her life and future (Walker, 1993).

According  to  the  International  Society  for  Traumatic 
Stress  Studies,  “cognitive-behavioral  approaches  have  the 
strongest empirical evidence for efficacy in resolving PTSD 
symptoms in children” (Ovaert, Cashell, & Sewell, 2003, p. 
294). Peterson et al. (1991) contended that from a behavioral 
perspective, it is the child’s response to memories of traumatic 
events that produces the primary manifestations of PTSD. It 
is  further  assumed  that  secondary  features  of  the  disorder 
are also, directly or indirectly, caused by the child’s reactions 
to his or her memories; therefore, the primary focus of a be-
haviorally oriented approach to PTSD is the child’s memory 
of  the  original  trauma  (Meiser-Stedman,  2002;  Peterson  et 
al., 1991).

For adults or children, almost all therapeutic approaches 
to  PTSD  incorporate  some  review  and  reprocessing  of  the 
traumatic events. The emotional meaning the child attaches 
to the abuse, as well as the personal impact, is embedded in 
the details of the experience, and the therapist must be pre-
pared to hear everything, however horrifying or sad. Special 

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interview techniques may be necessary to assist children to 
explore thoroughly their subjective experiences and to help 
them understand the meaning of their responses (Pynoos & 
Eth,  1986).  By  encouraging  children’s  expression  through 
drawing, play, dramatization, and metaphor, the therapist at-
tempts to understand the traumatic links and looks for ways to 
recruit children’s fantasy and play actively into communication 
about their abuse experiences. 

One treatment goal is to bolster children’s observing ego 
and reality-testing functions, thereby dispelling cognitive con-
fusions and encouraging active coping with the abuse experi-
ence. A second goal is to help children anticipate, understand, 
and manage everyday reminders, so that the intensity of these 
reminders and their ability to disrupt daily functioning recede 
over time (Wilson & Raphael, 1993). 

Another  goal  is  to  assist  the  child  in  making  distinctions 
among current trauma, ongoing life stresses, and previous trauma 
and to decrease the impact of the recent trauma on present expe-
rience (Walker, 1993). Helping children recover from the most 
immediate  posttraumatic  reactions  may  directly  increase  their 
ability to address the posttraumatic changes in their lives.

Ovaert et al. (2003) found that group therapy was valuable 
in decreasing PTSD symptoms in children. Patients participat-
ing in the study said that by being able to share their traumatic 
experiences with those who could sympathize with them was 
an  important  part  of  their  treatment.  Being  able  to  express 
feelings verbally helped patients to better able to deal with 
emotions elicited by the traumatic experience. According to 
Foy,  Erickson,  and Trice  (2001),  “it  [group  therapy]  offers 
advantages over individual therapy in providing a safe, shared 
therapeutic environment where children who have survived 
terrible experiences can normalize their reactions and provide 
support  for  each  other  while  processing  their  traumas”  (p. 
250). Group therapy helps children to build trusting relation-
ships with those involved in therapy. The hope is that children 
will integrate these skills into their everyday lives and begin to 
repair the damage to trust relationships caused by the sexual 
abuse experience. 

Psychopharmacology may be indicated in those children 
whose  PTSD  arousal  symptoms  and/or  sleep  disturbances 
have  increased  to  the  extent  that  additional  impairment  in 
other areas of functioning is experienced, including  altered 
self-concept  and  personality.  In  cases  of  severe  anxiety  or 
depression, psychopharmacology may be necessary to bring 
the child to a stable level of functioning before other treatment 
interventions can be used. 

A wide range of psychotherapeutic and educational tech-
niques have been proved successful in alleviating the PTSD 
symptoms and distress experienced by children who have been 
sexually abused. Individual psychoanalytically oriented play 
therapy and psychotherapy have been used effectively with 
youngsters who have been sexually abused, as well as group 
therapy, whereas family treatment modalities have been used 
with some families that are dysfunctional and abusive (Coons, 

Bowman,  Pellow,  &  Schneider,  1989).  According  to Yule 
(1989), group counseling affords the opportunity to reinforce 
the normative nature of the children’s reactions and recovery, 
to share mutual concerns and traumatic reminders, to address 
common fears and avoidant behavior, to increase tolerance for 
disturbing affects, to provide early attention to depressive 
reactions,  and  to  aid  recovery  through  age-appropriate 
and situation-specific problem solving. Ultimately, the clini-
cian  must  help  the  child  to  see  that  his  or  her  pathological 
defenses,  personality  traits,  and  distorted  object  relations 
that  have  served  to  master  the  abusive  experience  and  to 
control or ward off further assault are not serving him or her 
in nontraumatic, nonabusive environments. This can only be 
accomplished when the counselor helps the child to link these 
PTSD symptoms and defenses back to the original traumatic 
experiences,  which  are  uncovered,  remembered,  reframed, 
and assimilated in the safety of the counseling setting. Family 
therapy, when warranted, can also help the family understand 
the manifestations of the symptomatology of PTSD, the mean-
ing the child has attached to the abuse experience, and how 
to effectively intervene to help the child return to a healthy 
level of functioning. 

Case Examples
These case examples serve to help clinicians understand the 
etiology  and  manifestation  of  PTSD  in  children  who  have 
been  sexually  victimized. Although  the  diagnostic  criteria 
remain the same for each case, treatment interventions used 
and the implications for counselors treating this population 
are  as  unique  as  the  children  who  present  for  treatment. 
Without  sufficient  understanding  in  how  to  treat  PTSD  in 
these  children,  counselors  will  only  feed  the  monsters  that 
live inside these children’s heads. The names of the children 
cited have been changed and all identifying information left 
out to protect confidentiality.

Andrea

Andrea  is  a  15-year-old,  White  female  adolescent  who 
presented to a residential treatment facility for treatment of 
behavioral issues related to sexual abuse. Andrea presented to 
treatment with a long history of physical and sexual abuse at 
the hands of her uncle and several of her mother’s boyfriends. 
Andrea’s abuse started at the age of 5 years and continued until 
she was finally removed from her mother’s custody and placed 
in the custody of the Department of Children’s Services at the 
age of 6 years. Andrea meets the diagnostic criteria for PTSD 
in the following ways. 

Andrea seems to have regressed to the developmental level 
that she was at when the abuse occurred. Andrea sucks on a 
pacifier, insists on drinking out of a sippy cup, and talks in “baby 
talk” when addressed. Andrea often has intense psychological 
distress whenever another child goes into crisis or is aggressive 
or if adults raise their voice around her. Andrea’s response to 

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Posttraumatic Stress Disorder and the Child Survivor of Sexual Abuse

these external cues include her becoming physically aggressive, 
attempts to flee out of the cottage, and Andrea reliving her own 
abuse experience through the form of flashbacks. Andrea at-
tempts to avoid all discussion regarding her thoughts, feelings, 
or experiences related to her sexual abuse. Andrea often creates 
crises at bedtime to avoid going to bed because of the intrusive 
nightmares she experiences. She has a profound fear of the dark. 
She  has  impaired  memory  regarding  her  abuse  experience, 
including the most recent episodes of abuse. Andrea has dif-
ficulty concentrating and falling asleep and often has explosive 
fits of anger. She is hypervigilant and possesses an acute sense 
of her surroundings. Andrea often experiences anxiety-related 
symptoms, such as a chronic headache and stomachache (these 
somatic complaints intensify when faced with participating in 
therapy related to discussing her abuse experience). She shuts 
down emotionally and refuses to talk about her abuse. When 
asked about her future, Andrea does not seem to project much 
beyond the next few weeks.

Andrea’s physical appearance resembles that of a 16- or 
17-year-old. She is physically mature; however, she is perpetu-
ally stuck in the world of a 5- to 7-year-old. Andrea’s tone of 
voice is often loud and inappropriate. Further exploration of 
this issue resulted in the discovery that Andrea had a hearing 
loss as a result of the physical abuse that she suffered at the 
hands of her perpetrators.

Andrea has continued problems with interpersonal relation-
ships, often making relationships with staff and her counselor 
(the author) into more intimate relationships than they are in 
reality, often calling some female staff members “Mommy.” She 
has no contact with her biological family, including her younger 
brother, who was adopted by a foster family. Andrea justifies 
the use of the pacifier and sippy cup as being the last physical 
links she has to her younger brother. She attempts to identify 
with him by imitating her brother’s developmental level. She has 
abandonment issues and has a difficult time when people (even 
those she dislikes) move on. Her placement following treatment 
is uncertain, and Andrea experiences a high level of anxiety 
when faced with the possibility of returning to another foster 
home. Andrea lacks impulse control and often says whatever 
comes to mind. In this way, she is refreshingly honest. 

Andrea’s treatment interventions have included helping her 
to recall aspects of the abuse, normalizing her reactions to the 
abuse, exploring the meaning she has attached to the abuse, 
and attempting to have Andrea use developmentally appropri-
ate coping skills for dealing with her abuse experience.

Ben

Ben is a 13-year-old, White male adolescent who presented 
to residential treatment for issues related to sexually offend-
ing his 2- and 6-year-old nieces. Ben also presented with his 
own sexual abuse history, having been placed in the custody 
of  his  older  brother  by  his  mother  a  few  years  earlier. This 
brother had been convicted and served time as an adolescent 
for sexually offending Ben. Ben reciprocated by sexually of-

fending his brother’s children. Ben was also sexually abused 
by a friend of his brother and, according to Ben, carried on a 
“relationship” with this 35-year-old man. Ben was diagnosed 
with  PTSD  as  a  result  of  his  own  sexual  abuse,  as  well  as 
diagnosed with having sexually abused a child. Ben met the 
criteria for PTSD in the following ways.

Ben had experienced repeated sexual abuse at the hands 
of one of his brothers, while experiencing physical abuse at 
the hands of his other brother. Ben had no contact with his 
biological father or mother at the onset of treatment; however, 
5 months into treatment, Ben’s mother began making contact 
by phone and letter, indicating that she wanted to be in Ben’s 
life. His mother never followed through with her promises of 
contact and eventually moved and changed her number, ter-
minating all contact with Ben. Ben felt helpless and powerless 
to change his circumstances, choosing to sexually offend as 
a way to “empower” himself. 

Ben  often  experienced  flashbacks  and  visual  hallucina-
tions in which he saw men in black trench coats. During these 
episodes, Ben would feel as if the sexual abuse was recurring. 
Ben would tremble, cry, and often crawl into a corner, pulling 
himself up into a ball. Ben experienced physiological reactions 
to external cues, often becoming nauseous or vomiting after 
witnessing a peer become angry or aggressive or when faced 
with discussions related to sexual behavior or sexuality. In the 
beginning of therapy, Ben would avoid discussing his feelings, 
thoughts, or experiences related to his own abuse. He was un-
comfortable discussing his own sexually deviant behaviors but 
was often more comfortable discussing his sexual offenses than 
he was his own sexual abuse. Ben felt detached from his family 
and others, becoming more estranged from his family of origin 
as his treatment progressed. Ben vacillated between wanting 
to be with his family and wanting to avoid any contact with 
them, given that they reminded him of his own abuse. Although 
Ben had goals for the future, he often felt as if he would never 
achieve them and viewed himself as a “failure.” 

Ben  was  plagued  with  nightmares  during  his  stay  in 
residential  treatment.  He  often  had  difficulty  falling  asleep 
and  concentrating.  Ben’s  outbursts  of  anger  and  irritability 
seemed  to  be  more  acute  following  individual  therapy  ses-
sions in which both his sexual offenses and personal sexual 
abuse  history  were  addressed.  Ben  startled  easily  and  was 
hypervigilant regarding his surroundings. 

Treatment interventions focused on addressing Ben’s feel-
ings of helplessness and powerlessness by helping him feel 
more empowered and in control without his having power and 
control over others. Other interventions included helping Ben 
address his cognitive distortions related to his own abuse and 
the abuse he perpetrated and teaching him more appropriate 
coping skills. Interventions regarding healthy sexual relation-
ships and impulse control were central to helping Ben suc-
cessfully  transition  back  into  his  community.  Psychotropic 
medication was used to help Ben reduce his anxiety level, as 
well as help him sleep at night. 

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Gerry
Gerry is a 10-year-old, White boy who presented to residential 
treatment with a history of sexual abuse by his older brother. 
Gerry is small in stature, physically resembling a 6- or 7-year-
old  child.  Gerry  presented  with  a  history  of  inappropriate 
sexual behaviors directed toward his younger siblings. Gerry 
is a quiet child who often blends into the crowd. Gerry met 
the criteria for PTSD in the following ways.

Gerry’s history of sexual abuse by his brother lasted for 
over  a  year.  Given  his  small  stature  and  the  fact  that  his 
brother  used  threats  of  physical  force  to  keep  Gerry  quiet, 
Gerry stated that he often felt powerless to stop his brother 
from abusing him. Gerry’s reexperience of the traumatic event 
manifested in his sexualized play with his younger siblings. 
Gerry complained of nightmares and became visibly shaken 
when discussing his sexual abuse history. 

Gerry’s affect was blunt and flat, and he presented to therapy 
with  a  detachment  from  his  surroundings  and  his  family. 
Gerry  lacked  the  ability  to  emotionally  bond  to  his  family, 
stating that he felt unable to love them. Gerry refused to talk 
about  his  own  abuse  and  the  inappropriate  sexualized  play 
with his siblings. Gerry initially presented to treatment with a 
diminished interest in activities that he once enjoyed, such as 
organized sports. Gerry preferred to play video games alone 
rather than socialize with others. 

Gerry had difficulty falling asleep and difficulty concen-
trating in school. He was hypervigilant and became agitated 
whenever changes in his environment occurred. Gerry’s family 
presented as highly disorganized, with his father placing Gerry 
in an infant role, while his mother placed him in a parentified 
role. This role confusion contributed to Gerry’s anxiety, and 
he  responded  by  further  withdrawing  emotionally  from  his 
family, increasing the estrangement. 

Treatment  interventions  focused  on  helping  Gerry  bond 
with his family by increasing the amount of therapeutic one-
to-one time with both his mother and father. Gerry’s attempt 
to control his own feelings of helplessness were re-created in 
his sexualized play with his siblings, in which he attempted 
to gain control by placing them in the role of victim. Inter-
ventions focused on helping Gerry normalize his feelings of 
helplessness  and  powerlessness.  Because  of  Gerry’s  small 
stature, other interventions focused on ways that Gerry could 
protect himself from future abuse, given that his perpetrator 
would eventually return to the home. 

Communication  issues  were  a  common  theme  in  both 
individual and family therapy. The use of bibliotherapy and 
creative expression, such as drawing and writing, helped 
Gerry express his feelings about his abuse to his counselor 
(the author) and his family. Gerry was placed in a leader-
ship role among his peers to facilitate the development of 
feelings of healthy power. 

Other  interventions  focused  on  Gerry’s  inappropriate 
sexual behaviors with his siblings. Developing empathy for his 
siblings was crucial in increasing the affective bond between 

Gerry and his family of origin. Gerry’s ability to dissociate 
from  his  surroundings  and  his  family  was  addressed,  and 
alternative coping skills were explored. 

Counselor Implications
Counselor  implications  for  working  with  someone  who 
presents with issues similar to those of Andrea include care-
fully considering and accounting for Andrea’s desire to stay 
stuck at the developmental level of a 5- to 7-year-old, while 
attempting to facilitate developmentally appropriate coping 
skills. Further implications include helping Andrea find ad-
equate support resources, given her lack of familial contact, 
as  well  as  working  through  the  issues  of  abandonment  and 
loss regarding her brother. Although Andrea desired to stay at 
the developmental level she was in when she was victimized, 
she  also  presented  as  highly  sexualized  and  often  dressed 
inappropriately  for  her  age.  She  often  talked  suggestively 
toward others, yet when approached by anyone in what could 
be construed as a sexual way, she reacted within her PTSD 
diagnosis by having outbursts of anger, crying, and experienc-
ing memory lapses. 

Green  (1980)  described  the  tendency  of  some  women 
physically abused as girls to reenact their “victim” status by 
ultimately choosing physically abusive mates. This tendency 
toward  revictimization  may  be  regarded  as  evidence  of  the 
PTSD symptom of reenacting the trauma. The future possibil-
ity  of  revictimization  may  increase  the  child’s  likelihood  of 
experiencing PTSD as an adult survivor. Furthermore, Russell 
(1986) found that between 33% and 68% of the women who 
were sexually abused as children (depending on the seriousness 
of the abuse they experienced) were subsequently raped, com-
pared with an incidence of rape in 17% of nonabused women, 
supporting Green’s position that children such as Andrea may 
grow up and seek out sexually abusive partners. Naugle et al. 
(2003)  discussed  several  risk  factors,  including  situational 
factors and personal characteristics of both the victim and the 
perpetrator, that increase the risk that child survivors of sexual 
abuse will be revictimized as adults. Therefore, it is important 
for counselors working with someone like Andrea to educate her 
on developing and maintaining healthy sexual relationships into 
adulthood. The counselor dealing with this population should 
be aware of the risk of revictimization and help to prepare his 
or her child clients in an attempt to lower that risk.

Working with Ben’s presenting issues of PTSD was further 
complicated by his sexual offending. This counselor (the au-
thor) often had to balance having Ben review and reprocess 
his own sexual abuse experience with the inevitable sexual 
arousal  and  subsequent  deviant  sexual  fantasies  that  would 
arise following such a discussion. Responsibility for his own 
offenses versus lack of responsibility for his own abuse was 
often a tightrope this counselor walked. The meaning that Ben 
attached to his own abuse experience was integral to helping 
Ben develop empathy for his victims. Given that Ben’s fam-

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Posttraumatic Stress Disorder and the Child Survivor of Sexual Abuse

ily life and subsequent placement following treatment was so 
unstable, much intervention was directed toward helping Ben 
cope  with  this  lack  of  stability,  without  sexually  offending 
others, and helping him incorporate developmentally appro-
priate coping skills to cope with his own sexual abuse, while 
interrupting his sexual assault cycle. Furthermore, Ben also 
manifested  psychotic  symptomatology  when  he  felt  threat-
ened, either physically or sexually by others. Ben used this 
pathological defense as a way to protect himself. Interventions 
focused  on  helping  Ben  feel  empowered  to  protect  himself 
from future assault using appropriate strategies. 

Like Andrea, Ben needed help in understanding the nature 
of healthy sexual relationships. Ben viewed his last abuser as a 
“lover” and a partner in a meaningful relationship rather than 
as what he was: a sexual predator. This distorted perception 
of what constitutes a healthy sexual relationship can be traced 
back to Ben’s sexual victimization by his older brother. Not 
only was Ben’s perception of romantic relationships skewed 
by his trauma, but his perception of appropriate sibling rela-
tionships was altered as well. Ben’s PTSD symptomatology, 
which  included  visual  and  auditory  hallucinations  (such  as 
flashbacks of his own victimization), complicated interven-
tions to help him process his sexual abuse history, given that 
such discussions often triggered these symptoms. 

Implications  for  counselors  working  with  a  child  who  is 
diagnosed with both PTSD and sexually deviant behaviors face 
unique challenges. Reliving the abuse experience in someone 
who has sexually deviant behaviors may send that child into a 
cycle of sexual perpetration, increasing the likelihood that the 
child will seek to feel power over his or her own abuse by abus-
ing others. Often, it is the child’s own sexual abuse history that 
initially motivates the sexual offending behaviors, as was the case 
with Ben. The feelings of powerlessness and helplessness Ben 
experienced as a victim were compensated for by his attempts 
to have power over others sexually. The counselor working with 
someone like Ben should help empower the survivor of sexual 
abuse by helping him or her to understand how to protect himself 
or herself from future victimization without hurting others. 

Implications for counselors treating a child who presents 
with issues similar to those of Gerry are threefold. The first 
implication deals with Gerry’s dissociative symptoms. It is im-
portant that counselors trace back the origin of such dissocia-
tion to target the purpose such dissociation may serve. In this 
case, Gerry’s dissociation and subsequent detachment from 
his abuse experiences and his family served to protect him 
from the feelings he experienced during and after the trauma. 
His efforts to avoid the feelings, thoughts, or conversations 
regarding his sexual abuse experience only served to deepen 
his dissociation and detachment. Facilitating affective bond-
ing with his family often acted as a trigger to Gerry’s anxiety 
arousal. The counselor addressing dissociation in a child with 
PTSD must be careful to be prepared to help the child cope 
with the feelings that may arise once the child begins to recon-
nect with the abuse experience and significant others.

Second, because Gerry’s traumatic experience was reexperi-
enced through his sexualized play with his siblings, it is important 
for the counselor to address the potential for Gerry to become 
an adolescent or adult sex offender in the future should he not 
find more appropriate ways to cope with future feelings of pow-
erlessness and hopelessness. Gerry’s sexualized behaviors were 
manifested more out of a reaction to his own sexual abuse rather 
than as a motivation to control others. Unlike Ben, Gerry had 
not yet crossed the line from sexual victim to sexual perpetrator. 
Counselors should understand the distinction between trauma-
specific reenactment and sexual offending behaviors. 

Third, Gerry’s family of origin presented with complicated 
issues. The tendency for his father to “baby” him, while his 
mother often looked to him as a peer, triggered more anxiety 
in Gerry. Empowering Gerry to facilitate discussion and ask 
his father to treat him in a developmentally appropriate role 
increased  Gerry’s  confidence  to  disclose  future  abuse  and 
communicate with his parents. It was important for the coun-
selor (the author) to educate and model for Gerry’s parents 
developmentally  appropriate  roles  in  which  to  place  Gerry 
and his siblings. A large portion of Gerry’s therapy focused on 
empowering his parents to protect him and his siblings from 
future abuse and providing them with basic parenting skills. 

In all three of these cases, each child was diagnosed with 
PTSD; however, the interventions and implications for coun-
selors  differed,  given  how  each  child  presented  to  therapy. 
Although  these  interventions  were  case  specific,  there  are 
some implications for counselors treating this population that 
are not case specific but also warrant discussion.

There are legal implications for the counselor treating a child 
who has been sexually victimized who is experiencing PTSD. 
According to Walker (1993), “in forensic cases, a diagnosis of 
PTSD sometimes makes the difference in whether a case can 
proceed to trial or not, especially when the alleged perpetrator 
denies the abusive behavior” (p. 131). Walker was quick to add 
that a diagnosis of PTSD in and of itself does not prove beyond 
a reasonable doubt that a child was sexually victimized.

A diagnosis of PTSD may help to explain the denial and 
retraction of the abuse experience by children who have been 
sexually victimized (Dutton, 1993). The avoidance phase of 
PTSD  is  often  characterized  by  the  child’s  repeated  denial 
of the abuse experience. This may even occur after the child 
has  disclosed  the  abuse,  in  the  form  of  retraction  (Bradley 
& Wood,  1996).  By  articulating  to  the  court  the  avoidance 
phase of PTSD, the counselor can help to bolster the child’s 
credibility in a legal hearing. 

Another implication for counselors has to do with the re-
viewing of the abuse experience, especially if the counselor 
uses implosive therapy or flooding. Flooding the child with 
memories  of  the  abuse  experience  may  only  intensify  the 
PTSD symptoms, particularly avoidance, and therefore hin-
der treatment. The counselor who uses this technique should 
proceed with caution and be prepared to deal with the possible 
flood of emotions this technique might release. 

Journal of Counseling & Development  ■  Winter 2009  ■  Volume 8788

Putman

Diehl and Prout (2002) found that PTSD symptomatology 
in  children  who  have  been  sexually  abused  can  negatively 
affect  survivors’  self-efficacy.  The  abuse  experience  alone 
can leave the child survivor feeling that he or she has little 
to no control over his or her actions, emotions, thoughts, and 
behaviors. Counselors should keep in mind that by helping 
the child survivor effectively cope with and manage the effects 
of PTSD, they may in turn help increase that child’s feeling of 
power over his or her own destiny. In other words, although 
the  child  survivor  had  no  control  over  the  abuse,  he  or  she 
does have control over how that abuse affects and/or defines 
his or her sense of self. 

The accuracy of the diagnosis of PTSD has serious implica-
tions for counselors. It is crucial that the DSM-IV-TR (APA, 
2000) criteria be met for a diagnosis of PTSD. The counselor 
must  also  be  cognizant  of  the  likelihood  of  psychiatric  co-
morbidity in childhood PTSD. Differential diagnosis is criti-
cal, given that a child may manifest symptoms of numerous 
disorders, never meeting the full criteria for any one specific 
disorder. The accuracy of assessment and diagnosis is crucial 
when formulating a treatment plan. If the diagnosis itself is 
not accurate, then how beneficial will the subsequent treat-
ment be to the child?

Finally, the likelihood and severity of PTSD in victims of 
child  sexual  abuse  depends  on  several  variables:  (a)  the  age 
and developmental level of the child; (b) the child’s preexisting 
personality; (c) the onset, duration, and frequency of the abuse; 
(d) the severity of the sexual abuse; (e) the relationship between 
the child and the perpetrator; (f) the family’s response to the 
disclosure; (g) the institutional response (e.g., police, social 
workers, attorneys); and (h) the availability and quality of the 
therapeutic intervention (Friedrich, 1990; Salter, 1995). 

PTSD can strike at any time in the lives of children who 
have  been  sexually  victimized.  The  intrusiveness  of  the 
memories of the abuse is more than their young minds can 
handle, and they are constantly trying to find a way to escape 
the monsters in their heads. 

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9

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One of the most important goals of U.S. higher education is to 
encourage the enrollment of international students for academic, 
economic, and cultural purposes. The successful recruitment of 
these students comes with the responsibility to welcome, serve, 
and maintain the well-being of international students, and also 
to create an environment for multicultural interaction with stu-
dents in the United States (hereinafter referred to as American 
students; Peterson, 

B

riggs, Dreasher, Horner, & Nelson, 1999). 
Marion  (1986)  suggested  that  international  students  may  act 
as great resources for increasing global understanding and the 
perspectives  of American  students.  Peterson  et  al.  found  that 
American students learned about different cultures, their histo-
ries, and international issues from foreign students. In addition, 
they learned to acknowledge and respect cultural and individual 
differences and broaden their perspectives, thereby preventing 
stereotypical thinking. Marion also suggested that international 
students play an important role in providing technological knowl-
edge to less developed countries. In the United States, enrollment 
of international students has been encouraged for the economic 
contribution of nearly $13.5 billion every year that they spend 
on tuition, living expenses, and related costs (Institute of Inter-
national Education, 2007).

The United States has the largest number of international 
students who represent many countries. During the academic 
year of 2005–2006, there were approximately 600,000 inter-
national  students  from  several  nations,  with Asian  students 
representing  58%  of  all  international  students,  followed  by 
students  from  Europe  (15%),  Latin America  (11%), Africa 
(6%), the Middle East (4%), and 6% from North America and 
Oceania (Institute of International Education, 2007).

Adjustment to a new educational and social environment can 
be  a  stressful  process.  Most  college  students  experience  stress 
throughout this process. However, many international students ex-
perience even more serious stress because of the additional culture 
shock factor (Church, 1982) and various sociocultural factors that 
are involved in the adjustment process of international students 
(Luzio-Lockett, 1998). It is not surprising that international stu-
dents often face language barriers, immigration difficulties, culture 

shock, social adjustment, and homesickness. During this period 
of adjustment, international students may experience isolation and 
loneliness. Mori (2000) reported that these negative experiences 
can cause the students to feel hopeless, and an intensive sense of 
hopelessness may be the manifestation of depression. Consider-
ing  the  cultural  differences  and  misunderstandings  of  the  new 
and diverse experiences, it is likely that international students will 
experience feelings of estrangement, anxiety, and depression as a 
part of their adjustment process (Adler, 1975). Spielberger (1966) 
reported  that  anxiety  is  related  to  stress,  and  Furukawa  (1997) 
reported  that  people  who  are  exposed  to  foreign  cultures  may 
become depressed or anxious and display maladaptive behaviors 
as a result of this acculturative stress.

Understanding the experiences of international students has 
important implications for creating and implementing programs 
that provide academic and personal support. Therefore, it is cru-
cial to increase awareness about international students’ problems 
and to recognize the students’ individual perspectives regarding 
the  factors  that  are  involved  in  the  adjustment  and  adaptation 
process  (Luzio-Lockett,  1998).  Because  of  these  concerns,  a 
number of studies have focused on the academic, psychological 
and social effects on international students of studying and liv-
ing in the United States (Marion, 1986). In one of these studies, 
Kilinc and Granello (2003) found that students who were less 
acculturated  experienced  significantly  more  difficulty  in  their 
academic life, with language, and with medical/physical health 
than did the students with higher levels of acculturation.

A close examination of the literature reveals that although 
depression and anxiety are frequently manifested symptoms of 
stress (Arthur, 1998), these symptoms were not studied among 
the international student population in the United States. Con-
sidering the fact that there is limited research on depression and 
anxiety among international students in the United States, the 
purpose of our study is to contribute further to the literature 
by examining these variables in relation to a set of other vari-
ables retrieved from the literature: gender, age, race/ethnicity, 
proficiency  in  English,  pattern  of  social  contact,  academic 
achievement, social support, and length of stay in the country. 

Predictors of Depression and Anxiety
Among International Students
Seda Sümer, Senel Poyrazli, and Kamini Grahame

The role of gender, age, race/ethnicity, length of stay, social support, and proficiency in English in the variance in depres-
sion and anxiety among international students revealed that social support was a significant predictor of depression
and anxiety among international students. Age significantly contributed to the variance in anxiety, and self-rated English
proficiency uniquely contributed to the variance in both depression and anxiety. Latino/a students had significantly
higher levels of depression than did Asian students.

Seda Sümer, Department of Counseling and Psychological Services, Georgia State University; Senel Poyrazli and Kamini
Grahame, School of Behavioral Sciences and Education, Penn State Capital College. Correspondence concerning this article should
be addressed to Senel Poyrazli, School of Behavioral Sciences and Education, Penn State Capital College, 777 West Harrisburg
Pike, W157 Olmstead Building, Middletown, PA 17057 (e-mail: poyrazli@psu.edu).

Journal of Counseling & Development  ■  Fall 2008  ■  Volume 86430

Sümer, Poyrazli, & Grahame

This study also attempted to integrate some of these variables 
in the accurate prediction of depression and anxiety levels of 
international  students.  In  the  following  sections,  a  literature 
review that is focused on certain variables  (i.e., gender, age, 
race/ethnicity, social support, English proficiency, and length 
of stay) in relation to depression and anxiety and international 
students’ adjustment experiences is presented.

Gender
Literature about gender supported a relation between social 
support and American female college students’ anxiety and 
depressive  symptoms.  Swift  and  Wright  (2000)  found  that 
social support was negatively correlated with female students’ 
anxiety and depression levels. Hawkins (1995), on the other 
hand, found that female students with higher levels of social 
support experienced lower levels of anxiety and depressive 
symptoms, whereas male students’ anxiety levels did not cor-
relate with social support.

Other studies that examined international students showed 
that  female  students  had  higher  emotional,  physiological, 
and behavioral reactions to stressors (Misra, Crist, & Burant, 
2003) and also were more likely to feel homesick and lonely 
than  were  male  students  (Rajapaksa  &  Dundes,  2002).  In 
contrast,  Poyrazli, Arbona,  Nora,  McPherson,  and  Pisecco 
(2002) reported that male international students scored higher 
on the UCLA Loneliness Scale than did female international 
students. In the same study, there were no differences among 
men and women regarding general adjustment. A reason for 
the discrepant findings of these two studies might be that the 
former study used a snowballing technique, whereas the latter 
used  a  random  sample  approach.  In  addition,  these  studies 
used different scales to measure loneliness. 

Furthermore, the gender differences reported in previous 
research could be a result of international students’ cultural 
background  and  the  socialization  process  both  genders  go 
through.  Therefore,  it  is  important  to  study  international 
students from different ethnicities to see if gender is related 
to their experiences of anxiety and depression. 

Age
Oei and Notowidjojo (1990) studied the impact of life change 
on  adjustment  of  international  students  and  found  that  age 
was a significant predictor of depressive symptoms. In par-
ticular, older international students in Australia scored higher 
on  depressive  symptoms  than  younger  students.  However, 
Furukawa’s (1997) study with Japanese teenage exchange stu-
dents, who were enrolled in 1-year placements with volunteer 
host families in various countries, showed that age was not 
a predictor of depressive symptoms among this international 
student group. The discrepancy between the findings of Oei 
and Notowidjojo’s and Furukawa’s studies could be a result 
of researchers using a different scale to measure depression 
and  including  students  from  different  educational  levels. 

Therefore, it is important to conduct additional studies with 
international college students to see if age is related to anxi-
ety and depression levels of students attending college in a 
foreign country. 

Race/Ethnicity
Research on the effects of race/ethnicity and the adjustment to 
a new culture indicated that the adjustment process becomes 
more  stressful  as  the  differences  between  the  two  cultures 
increase  (Kinoshita  &  Bowman,  1998;  Surdam  &  Collins, 
1984; Yang & Clum, 1994). Yang and Clum suggested that 
for a foreigner, entering into a new culture might cause stress 
if  that  individual  lacks  information  regarding  appropriate 
behavior in that culture. 

Tafarodi and Smith (2001) conducted a study that compared 
Malaysian and British students at a British university. This study 
addressed individualism-collectivism as a dimension of cultural 
factors that produced differential sensitivity to life events. The 
results of the study showed that Malaysian students displayed 
higher levels of depressive symptoms than did British students. 
For Malaysian students, positive social life events were inversely 
related,  and  negative  social  life  events  were  directly  related 
to increased levels of depression. On the other hand, positive 
achievement-related events indicated a smaller increase in de-
pression among British students, but there was no association 
between negative achievement-related events and depression. 
Overall,  collectivist  cultural  orientation  was  associated  with 
greater vulnerability to social experiences, whereas individualist 
cultural orientation was associated with greater sensitivity to 
personal achievement-related experiences. Other research about 
the impact of collectivist and individualist cultural orientations 
on international students’ adaptation, satisfaction with life, and 
anxiety levels showed similar results, indicating that students 
from collectivist cultural orientations had lower levels of adap-
tation and satisfaction with life and higher levels of anxiety as 
compared with students from individualist cultures (Kinoshita 
& Bowman, 1998; Sam, 2001; Surdam & Collins, 1984). These 
studies  indicated  that  when  an  international  student  from  a 
collectivist culture attends college in an individualist culture, 
he or she might experience higher levels of anxiety because of 
cultural dissimilarities. 

Social Support
Huang  (1977)  suggested  that  it  may  be  difficult  for  inter-
national  students  to  replace  the  social  network  of  family, 
neighbors, and friends that they had in their home country. 
Research in this area has shown that stressful life situations 
might  lead  individuals  to  evaluate  their  social  support.  In 
those circumstances, individuals with poor support might pay 
more attention to the weakness of their support. Rudd (1990) 
suggested that this might lead to increased hopelessness; indi-
viduals with poor support may be more sensitive to life stress 
and, therefore, experience higher levels of distress.

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Predictors of Depression and Anxiety Among International Students

Several  studies  (Furukawa,  1997;  Jou  &  Fukada,  1995; 
Misra et al., 2003; Rajapaksa & Dundes, 2002; Wethington & 
Kessler, 1986; Yang & Clum, 1994; Yeh & Inose, 2003) have 
shown that social support and related variables such as social 
network  satisfaction,  perceived  social  network,  and  needed 
support are related to international students’ adjustment levels, 
life satisfaction, acculturative stress, reactions to stressors, and 
depressive symptoms. In particular, students with higher social 
support tended to experience higher adjustment levels and lower 
levels of depression and acculturative stress. Results suggest 
that social support might serve as a buffer and help students 
cope more effectively with challenges they encounter. 

English Proficiency
Language difficulties, in particular, appear to be a challenge 
for the majority of international students. According to Mori 
(2000), the lack of English language skills is likely to affect in-
ternational students’ academic and social performances, which, 
in turn, may affect their psychological adjustment to the new 
culture (p. 138). Surdam and Collins (1984) studied the adapta-
tion of international students upon their arrival in the United 
States in relation to their English language skills. Their results 
showed that the students who believed that their English was 
adequate on arrival were significantly better adapted than those 
who believed that it was inadequate. In support of this finding, 
Yeh and Inose (2003) reported that English language fluency 
was a significant predictor of acculturative stress. In particular, 
participants  who  reported  higher  levels  of  English  fluency, 
higher  frequency  of  English  use,  and  higher  comfort  level 
in  communicating  in  English  experienced  less  acculturative 
stress. Proficiency in English was also found to be significant 
in predicting adjustment among international students (Poyrazli 
et  al.,  2002).  Findings  from  Poyrazli  et  al.’s  study  suggested 
that English proficiency affects international students’ ability 
to discuss educational issues and to form social relationships 
with Americans. Therefore, lower levels of English proficiency 
were associated with lower levels of adjustment. 

Length of Stay
The  relation  of  length  of  stay  to  international  students’  ad-
justment  experiences  has  been  the  focus  of  a  major  theory 
developed by Lysgaard (1955). He indicated that the adjust-
ment  processes  of  international  students  in  a  host  culture 
follow a U-shaped curve over time. Initially, the adjustment 
process starts with excitement about being abroad and seeing 
new  things.  However,  during  this  period,  the  person  is  not 
involved  in  any  special  friendship  group. After  some  time, 
the excitement of the first stage loses its attraction when the 
need for more intimate personal contact and interaction with 
friendship  groups  becomes  important.  If  this  need  is  not 
satisfied, the individual might experience feelings of loneli-
ness and depression. In time, however, foreigners may learn 
to resolve the adjustment difficulties they experience in this 

“loneliness” stage (Lysgaard, 1955). They may get involved 
with other individuals at a more intimate level, make friends, 
and have a satisfactory social life.

Literature about the impact of length of stay on interna-
tional  students’  adaptation  and  depression  levels  supported 
the U-curve hypothesis (Oei & Notowidjojo, 1990; Surdam 
& Collins, 1984). Specifically, international students staying 
in another country for more than 1 year were more depressed 
than were native-born students; those with less than 1 year 
in  another  country  did  not  become  frustrated  as  easily  and 
were less worried about future misfortunes when compared 
with  native-born  students. Also,  international  students  who 
had been in the United States from 2 to 4 years showed lower 
adaptation than those who had been in the United States more 
than 4 years. 

In summary, the literature indicates that several variables 
affect  adjustment  and  acculturation  levels  of  international 
students  to  a  new  culture. Among  these  variables,  gender, 
age,  race/ethnicity,  social  support,  pattern  of  social  contact 
(i.e.,  with  whom  do  students  socialize  mostly?),  English 
proficiency, and length of stay have been studied in relation 
to students’ general adjustment experiences or level of accul-
turative stress, but not in relation to depression and anxiety. 
However, there is some evidence in the literature indicating 
that gender is related to anxiety and depression among non-
international college students. Therefore, the purpose of this 
study  was  to  fill  a  gap  in  the  literature  by  examining  these 
variables and their relation to the depression and anxiety levels 
of international students. We were specifically interested in 
the following research questions. 

 1.  What are the correlations among gender, age, length of 
stay, academic achievement, social support, pattern of 
social contact, English proficiency, and international 
students’ depression and anxiety levels?

 2.  What are the contributions of gender, age, length of 
stay,  social  support,  English  proficiency,  and  race/
ethnicity  to  the  variance  in  international  students’ 
depression and anxiety levels?

Method
Participants

A total of 440 international students who held either F-1 or J-1 
student visas participated in the study. They were studying at 
two different college campuses located in the eastern portion 
of the United States. Fifty-seven percent of the participants 
were  men  and  43%  were  women.  The  age  of  the  students 
ranged from 18 to 49 years, with an average of 26.15 (SD = 
4.78).  Educational  levels  represented  by  the  students  were 
doctoral  (50%),  master’s  (28%),  undergraduate  (21%),  and 
other (1%). Students’ grade point averages ranged from 1.50 
to 4.00 (M = 3.60, SD = .37). Regarding race/ethnicity, 68% 
of the participants were Asian, followed by 16% White/non-
Latino/a,  4%  Latino/a,  3%  Middle  Eastern,  2%  Black,  and 

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Sümer, Poyrazli, & Grahame

7%  who  identified  themselves  as  “other.” A  breakdown  of 
Asian students by region was as follows: India, 38%; China, 
28%; Korea, 13%; Taiwan, 8%; Japan, 3%; Singapore, 3%; 
Thailand, 2%; 1% each from Malaysia, Nepal, Pakistan, and 
Sri Lanka; and less than 1% each from Indonesia, Philippines, 
and students who did not indicate their country of origin. 

Only 26% of the participants were married. Among those 
who were married, 49% reported residing with their spouse 
in the United States. Seventy-three percent of the participants 
were single and 1% were divorced. Participants’ length of stay 
in the United States ranged from 2 months to 10 years, with 
an average of 2.9 years (SD = 1.82).

Variables

Depression. The Goldberg Depression Scale (GDS; Goldberg, 
1993; Holm, Holm, & Bech, 2001) was used to measure depres-
sion. Participants respond to this 18-item measure using a 6-point 
Likert-type rating scale; responses range from 0 (not at all) to 
5 (very much). The highest score on this scale, 90, indicates the 
most  severe  depression,  and  the  lowest  score,  which  is  zero, 
indicates the complete absence of depressive symptoms. Factor 
analysis was used to measure the internal validity of this scale; 
one general factor was identified, which explained 50% of the 
variance. The results indicated that the 18 items on the GDS have 
a  valid  rank  order  and  structure.  In  addition,  external  validity 
was measured by comparing the responsiveness of GDS with 
the  Hamilton  Depression  Scale  (HAM-D). The  correlation  of 
the total GDS and HAM-D scores was .74 (p < .001; Holm et  al., 2001). The internal reliability, measured by Cronbach’s alpha,  of the scale for the sample used in this study was .93, indicating  that GDS was a reliable measure for our sample.

Anxiety. The State Anxiety scale (Form Y-1) of the State-
Trait Anxiety Inventory (STAI; Spielberger, 1983) was used 
to measure anxiety. This scale is a 20-item, 4-point self-report 
scale.  Responses  range  from  1  (not at all)  to  4  (very much
so). The  items  on  the  scale  measure  a  temporary  condition 
of anxiety, called state anxiety, which consists of feelings of 
tension,  nervousness,  and  worry  that  vary  in  intensity  and 
fluctuate over time according to perceived threat (Spielberger, 
Sydeman, Owen, & Marsh, 1999). High scores indicate high 
levels of state anxiety. The stability coefficients for the State 
Anxiety scale were low, with a median of .33. However, Spiel-
berger et al. reported that this lack of stability was expected 
and  considered  essential  because  a  valid  measure  of  state 
anxiety should reflect the influence of situational factors at 
the time of testing. On the other hand, internal consistency 
of the State Anxiety scale was .93 (Spielberger et al., 1999). 
Spielberger (1983) reported that the construct validity of the 
State Anxiety scale was demonstrated when college students 
were administered the scale following a classroom examina-
tion. Participants’ scores were higher at that time than when 
they were tested during a relatively nonstressful class period. 
Cronbach’s  alpha  reliability  coefficient  of  this  subscale  for 
the current sample was .94. 

Social support. The Social Provisions Scale (SPS; Cutrona 
& Russell, 1987) was used to measure social support. This scale 
consists of 24 questions, 4 for each of the following variables: 
attachment, social integration, reassurance of worth, reliable 
alliance, guidance, and opportunity for nurturance. The items 
are rated on a 4-point Likert-type scale, with responses ranging 
from 1 (strongly disagree) to 4 (strongly agree). A high score 
indicates a greater degree of perceived support. Test–retest reli-
ability coefficients for this scale were reported to range from 
.37  to  .66  (Cutrona  &  Russell,  1987).  However,  because  the 
scale consists of items that measure the individual’s mood, the 
time of testing might have influenced the test–retest reliability 
analysis. On the other hand, internal consistency reliability for 
this scale was reported to be excellent (α = .93). The convergent 
validity of this scale was measured by comparing the scores 
on the Social Integration, Reassurance of Worth, and Guidance 
provisions on the SPS with scores on the UCLA Loneliness 
Scale for the same sample. The results of this comparison in-
dicated that the deficits in the social provisions explained 66% 
of the variance in the UCLA Loneliness scores. Cutrona and 
Russell  reported  that  the  predictive  validity  measure  of  SPS 
indicated that social provisions scores were predictive of loneli-
ness, depression, and health status among teachers. In addition, 
discriminant validity measure showed that the intercorrelations 
among the six provisions ranged from .10 to .51, with a mean 
intercorrelation of .27. The internal reliability of the instrument 
in the current study was .94.

Demographics. We developed a questionnaire to ascertain 
students’ age, gender, race/ethnicity, and length of stay in the 
United States. We added four more questions to the question-
naire to measure students’ English proficiency. Students were 
asked to rate their skills in the areas of speaking, reading, under-
standing, and writing; responses ranged from poor to excellent 
on a 4-point Likert-type scale. Another item measured students’ 
pattern of social contact by asking them to state with whom 
they socialized most—Americans or non-Americans (i.e., other 
international students or people from their own country).

Procedure
The participants were recruited from two different campuses of 
a university located in the eastern portion of the United States. 
Approximately  3,000  international  students  were  contacted  via 
e-mail through International Student Office representatives. This 
e-mail included information about the purpose of the study and 
the compensation for participation. Students were asked to go to a 
designated Web site address to complete the surveys. Of the 3,000 
students who were e-mailed, we could not determine how many 
actually received the information. However, we received a total of 
440 responses, which represented a return rate of 15%. Although 
this rate is low for a traditional mailed survey, we cannot determine 
what this number represents for a Web-based survey.

Web-based data collection procedures must take into con-
sideration  Internet  accessibility  by  the  targeted  population 

Journal of Counseling & Development  ■  Fall 2008  ■  Volume 86 433

Predictors of Depression and Anxiety Among International Students

(Gosling, Vazire, Srivastava, & John, 2004). However, because 
international students are often frequent users of the Internet 
for communicating with their family and friends in their home 
countries and have easy access to the Internet on their cam-
puses (e.g., in computer labs, libraries), this concern might not 
be as significant, particularly, for the current sample. 

To minimize the effects of repeat responders, we matched 
consecutive  responses  on  key  demographic  characteristics 
such as age, gender, degree sought, and race/ethnicity (Gos-
ling et al., 2004). We also compared the set of item responses 
to identify duplicate or near-duplicate entries. When such a 
match was detected, we kept only the first entry. 

Data Analysis
This project was a cross-sectional, exploratory study in which 
depression and anxiety were measured among international 
students. Cronbach’s alpha was calculated to determine the in-
ternal reliability of the measures for the current sample. Pear-
son product–moment correlational analyses were performed 
to examine the relationship between interval variables. 

Gender, age, length of stay, social support, English profi-
ciency, and race/ethnicity were investigated for their contribu-
tions  to  both  depression  and  anxiety  levels  of  international 
students. Two hierarchical multiple regression analyses were 
used  to  explore  the  contributions  of  these  variables. To  en-
ter  the  race/ethnicity  variable  into  regression  analyses,  we 
dummy-coded this variable. 

Results
Correlational Analyses

Pearson  product–moment  correlation  analyses  were  per-
formed  to  look  at  the  relation  between  the  interval  vari-
ables used in the study (see Table 1). The means, standard 
deviations, and range of scores for these variables are also 

presented  in  Table  1.  Analyses  indicated  that  depression 
was  negatively  correlated  with  social  support  (r =  –.57,  p
< .01) and English proficiency (r = –.24, p < .01). Students  with higher levels of social support and English proficiency  reported lower levels of depression. Similarly, anxiety was  found  to  be  negatively  correlated  with  social  support  (r  =  –.59, p < .01) and English proficiency (r = –.25, p < .01). Stu- dents who had lower levels of social support and proficiency  in English reported higher levels of anxiety. It was also found  that depression and anxiety were intercorrelated (r = .76, p  < .01). Students who scored high on the GDS, which was  used to measure depression, also scored high on the State  Anxiety scale, which was used to measure anxiety. 

English proficiency was negatively correlated with age (r = 
–.24, p < .01) and pattern of social contact (r = –.25, p < .01), and  positively correlated with social support (r = .29, p < .01). In other  words, younger students reported higher English proficiency than  did older students, and students who socialized primarily with  non-American students reported lower English proficiency than  did students who socialized primarily with American students. It  was also found that students with higher levels of social support  reported higher levels of proficiency in English.

Finally,  length  of  stay  correlated  with  pattern  of  social 
contact (r = –.10, p < .05). As the students’ length of stay in  the United States increased, so did their level of socialization  with Americans. The  relationship,  however,  was  too  low  to  reach any practical significance. 

Multiple Regression Analyses

Two hierarchical regression analyses were performed using 
the  following  predictor  variables  in  the  first  block:  gender, 
age, length of stay, social support, and English proficiency. In 
the second block, race/ethnicity was entered as dummy-coded 
variables for European, Middle Eastern, Latino/a, African, and 
Other. The Asian group served as the reference group. 

Table 1

bivariate Correlations, Means, Standard Deviations, and Range of Scores

Variable

1. Gender
2. Age
3. Grade point average
4. Pattern of social

contacta

5. Depression
6. Anxiety
7. Social support
8. English proficiency
9. Length of stay

M
SD
Range

—

9

aStudents’ pattern of social contact was dummy coded and entered into the correlational anaysis. Thus, means, standard deviations, and
range of scores are not reported here.
*p < .05. **p < .01.

87654321

–.03
—

26.15
4.78

18–49

–.12*
.32**

—

3.60
0.37
1.50–4.00

.03
.04
.09

—

.02
.05
–.12*

.06
—

14.26
13.47

0–90

–.05
.08
–.06

.09
.76**

—

39.23
12.09

20–80

–.06
.00
.01

–.15**
–.57**
–.59**

—

77.90
11.61

24–96

–.01
–.24**
–.02

–.25**
–.24**
–.25**
.29**

—

13.11
2.75

4–16

–.01
.25**
–.04

–.10*
.03
.01
.09
.05

—

2.90
1.82

.17–10

Journal of Counseling & Development  ■  Fall 2008  ■  Volume 86434

Sümer, Poyrazli, & Grahame

Depression. When the first set of variables were regressed 
on depression, results indicated that this model accounted for 
35% (R² = .35) of the variance in depression (see Table 2). The 
F value for the model in predicting depression was significant, 
F(5,  380)  =  40.56,  p  <  .01.  However,  among  the  predictor  variables,  only  length  of  stay,  social  support,  and  English  proficiency  had  significant  standardized  beta  coefficients.  When  race/ethnicity  variables  were  added  to  the  model,  R²  increased to .36, F(10, 373) = 21.16, p < .01. Interestingly,  although length of stay significantly contributed to students’  level of depression in the first model, with the addition of race/ ethnicity variables, the contribution became nonsignificant.  This indicated that race/ethnicity groups differed from each  other based on their length of stay in the United States. An  examination of means for length of stay showed that Africans  had been in United States longer than any other group (M =  3.61), whereas Asians had been here for a shorter time than  the  other  groups  (M  =  2.74  years). The  second  model  also  indicated that Latino/a students had higher levels of depression  than Asians. However, these findings are tentative because of  the small number of Latino/a students in our sample. Overall,  the  findings  showed  that  lower  levels  of  social  support  and  English proficiency and being Latino/a were associated with  higher levels of depression. 

Anxiety. When the first set of variables were regressed on 
anxiety, the R² value of this model was .38, indicating that the 
combination of these variables accounted for 38% of the vari-
ance in anxiety (see Table 3). It was found that these variables 
significantly  predicted  anxiety,  F(5,  361)  =  44.66,  p  <  .01.  The  standardized  beta  coefficients,  however,  indicated  that  only age, social support, and English proficiency significantly 

contributed to the variance in anxiety. The signs of the stan-
dardized beta coefficients showed that higher social support 
and better English skills were associated with lower anxiety, 
whereas older age was associated with higher levels of anxiety. 
When race/ethnicity variables were entered into the equation 
as  the  second  block,  the  R²  of  the  model  increased  to  .39, 
F(10, 356) = 22.84, p < .01. Age, social support, and English  proficiency remained significant. Gender, length of stay, and  race/ethnicity were not significant in predicting anxiety. 

Discussion
In this study, international students were examined in terms 
of  the  depression  and  anxiety  levels  they  might  experience 
as a result of their adjustment to living and studying in the 
United  States. We  investigated  the  contribution  of  a  model 
for explaining the variance in depression and anxiety. Results 
showed that social support had a significant contribution to 
the model in predicting depression. Students with lower levels 
of social support reported higher levels of depression. This 
result is consistent with the results of several studies that in-
vestigated reactions to stressors, adjustment, and depressive 
symptoms of international students (Furukawa, 1997; Jou & 
Fukada, 1995; Misra et al., 2003; Wethington & Kessler, 1986; 
Yang & Clum, 1994; Yeh & Inose, 2003). Besides depression, 
social support also contributed significantly to the variance 
in anxiety. In particular, students with lower levels of social 
support  were  more  likely  to  have  higher  levels  of  anxiety, 
suggesting that higher levels of social support might enable 
international students to be more socially active and interact 
with people more often and, as a result, reduce the feelings 
of depression and anxiety.

Table 2

Summary of Hierarchical Regression analysis for
Variables Predicting Depression (N = 385)

Variable

Step 1
Gender
Age
Length of stay in U.S.
Social support
English proficiency

Step 2
Gender
Age
Length of stay in U.S.
Social support
English proficiency
Race/ethnicity
European
Middle Eastern
Latino/a
African
Other

b

–0.95
0.11
0.67
–0.64
–0.50

–0.84
0.10
0.57
–0.66
–0.60

2.33
0.58
6.15
2.30
3.47

1.14
0.13
0.32
0.05
0.22

1.15
0.13
0.32
0.05
0.23

1.68
3.39
2.72
4.03
2.47

–.03
.04
.09*
–.55**
–.10*

–.03
.03
.08
–.57**
–.12**

.06
.01
.10*
.02
.06

SE

B

Note. R 2 = .35 for Step 1; DR 2 = .36 for Step 2. Reference group for
race/ethnicity variables = Asian.
*p < .05. **p < .01.

B

Table 3

Summary of Hierarchical Regression analysis for
Variables Predicting anxiety (N = 366)

Variable
Step 1
Gender
Age
Length of stay in U.S.
Social support
English proficiency
Step 2
Gender
Age
Length of stay in U.S.
Social support
English proficiency
Race/ethnicity
European
Middle Eastern
Latino/a
African
Other
b

–1.59
0.28
0.23
–0.60
–0.44

–1.60
0.27
0.23
–0.61
–0.47

5.13
1.63
–2.58
–0.62
2.07

1.03
0.12
0.29
0.05
0.20

1.03
0.12
0.29
0.05
0.21

3.49
2.46
3.55
2.28
1.52

–.06
.10*
.03
–.57**
–.10*

–.06
.10*
.03
–.59**
–.11*

.06
.03
–.03
–.01
.06

SE B

Note. R 2 = .38 for Step 1; DR 2 = .39 for Step 2. Reference group for
race/ethnicity variables = Asian.
*p < .05. **p < .01.

B

Journal of Counseling & Development  ■  Fall 2008  ■  Volume 86 435

Predictors of Depression and Anxiety Among International Students

The age variable contributed uniquely to the variance in 
anxiety. Older students were more likely to report higher levels 
of anxiety. This finding suggests that younger students may be 
more open and flexible to a new culture and to environmental 
differences. This might be due to globalization, which gives 
younger students the opportunity to have more exposure than 
older students to American culture through media. As a re-
sult, they may feel more familiar with American culture, and, 
therefore, might experience less anxiety toward the cultural, 
educational,  and  social  changes,  making  their  adjustment 
easier. However, older students may be more traditional, more 
resistant to change, and have more difficulties in accepting 
the host culture’s norms and values and, therefore, experience 
higher levels of anxiety during their adjustment period.

Results showed that students with lower levels of Eng-
lish  proficiency  reported  higher  levels  of  depression  and 
anxiety. This finding supports the findings of previous stud-
ies (Poyrazli et al., 2002; Surdam & Collins, 1984; Yeh & 
Inose, 2003) indicating that English proficiency is related 
to acculturation, adaptation, and adjustment of international 
students. However, this result contradicted the finding of 
Furukawa’s (1997) study, in which no relation was found 
between English fluency and depressive symptoms among 
Japanese high school exchange students. One explanation 
for this discrepant finding might be that the experiences of 
high school exchange students might be different from the 
experiences of international college students. Other results 
of the current study showed that English proficiency was 
negatively correlated with age and pattern of social con-
tact. Specifically, younger students reported higher levels 
of English proficiency, and students with higher levels of 
English skills reported socializing mostly with Americans, 
not with their conationals or other international students. 
These  results  imply  that  younger  students  might  have  an 
easier  time  learning  another  language  as  compared  with 
older  students;  having  better  English  skills  might  help 
students  to  form  relationships  with Americans,  which  in 
turn might further improve these students’ English skills. 
Another finding indicated that Latino/a students had higher 
levels  of  depression  than Asian  students.  However,  these 
findings  are  tentative  because  we  had  a  small  number  of 
Latino/a  students  in  our  sample;  thus,  there  is  a  strong 
likelihood of chance variation.

The  results  of  our  study  do  not  support  the  findings  of 
previous  studies  regarding  international  students’  length  of 
stay in the host culture and their adaptation and depression 
levels (Oei & Notowidjojo, 1990; Surdam & Collins, 1984). 
Previous literature, which investigated length of stay in rela-
tion to adjustment and adaptation levels among international 
students, found significant differences among groups. On the 
contrary, our findings showed no group differences in terms of 
length of stay for international students’ levels of depression 
and anxiety. There might be two reasons for this discrepant 
finding. First, some of the previous studies used samples that 

included  only  one  race/ethnic  group  and  examined  differ-
ences  among  these  students.  Second,  the  remaining  studies 
included sufficient numbers of students from different cultural 
and ethnic backgrounds and investigated the impact of length 
of stay for various ethnic groups. However, in our study, the 
percentage  of  students  representing  different  race/ethnic 
groups was not equal. 

Unlike  the  studies  that  showed  significant  gender  dif-
ferences for anxiety, reactions to stressors, and feelings of 
loneliness (Hawkins, 1995; Poyrazli et al., 2002; Rajapaksa 
&  Dundes,  2002;  Swift  &  Wright,  2000)  among  college 
students, in this study no relation was found between gender 
and  international  students’  depression  and  anxiety  levels. 
Research studies examining American college students’ anxi-
ety in relation to their gender (e.g., Hawkins, 1995) found 
that social support was related to female students’ anxiety 
levels. The  reason  that  we  did  not  find  a  relation  between 
gender  and  levels  of  depression  and  anxiety  among  inter-
national students might first reflect the fact that we studied 
a  non-American  sample.  Second,  even  though  female  and 
male students react differently to stressors or feel different 
levels of loneliness (Misra et al., 2003; Rajapaksa & Dundes, 
2002), the level of their depression and anxiety might not 
differ because of many other factors that contribute to de-
pression and anxiety.

Implications
In  this  study,  we  found  that  social  support  was  related  to 
depression and anxiety; students who scored higher on the 
social support measure scored lower on the depression and 
anxiety measures. Regarding counseling services that can be 
provided, a social support group for international students 
might be offered to serve as a buffer against depression and 
anxiety. Students in such a group may be taught to utilize 
stress-management  techniques  to  release  the  tension  and 
anxiety  that  they  might  experience.  Counseling  centers 
might  also  assign  bilingual  or  international  counselors  to 
work  with  students  whose  English  proficiency  levels  are 
not  adequate.  This  approach  may  promote  more  frequent 
and easier use of counseling services among international 
students,  while  helping  these  students  learn  how  to  cope 
with depression or anxiety.

Implementing programs like “host family,” or programs 
that  match  international  students  with  more  experienced 
international students, can help the students have smoother 
adjustments by providing social support upon their arrival 
to the United States. Peer programs, in which an American 
student  is  paired  up  with  an  international  student,  might 
also  serve  as  a  great  resource  to  promote  international 
students’  interaction  with American  students,  thus  helping 
them expand their social support network. It is important to 
have American students become an essential part of these 
programs  for  international  students  because  socializing 

Journal of Counseling & Development  ■  Fall 2008  ■  Volume 86436

Sümer, Poyrazli, & Grahame

with  American  students  also  positively  affects  English 
proficiency of international students.

Limitations and Suggestions for
Further Research

The data for this study were collected online. Although the 
current  sample  represents  the  total  international  student 
population  at  the  university  where  the  data  were  collected, 
the  return  rate  was  only  15%. As  a  result  of  the  policy  of 
the international student office, we were unable to send out 
a reminder e-mail to the international students to participate 
in the study, and this might have contributed to not having a 
higher return rate. However, because of a lack of information 
on Internet surveys and return rate, we could not determine 
if our return rate was low or normal. Also, most of the data 
were collected just before students began their spring break, 
a time when they were possibly stressed, working on class as-
signments, and taking tests. During that period, the students’ 
perceptions  of  their  anxiety  levels  might  have  been  higher 
than they would normally have been.

The results of this study were correlational in nature and, 
as a result, no causal conclusions can be drawn about depres-
sion and anxiety. We also need to interpret the results of this 
study in light of the average level of depression and anxiety 
students reported. For the depression measure (i.e., the GDS), 
our sample, on  average, answered 2 on a 0- to 5-point scale, 
and also responded with 2 on a 4-point scale for anxiety (i.e., 
STAI State Anxiety Scale). These numbers indicate that stu-
dents did not experience high levels of depression or anxiety. 
However, this might also indicate that less depressed students 
might be more likely to volunteer for a research project on the 
Internet; it could also be that the students with high depres-
sion or anxiety might have chosen not to participate. Although 
the internal reliability level for the GDS in the current study 
indicated that this scale was a reliable measure for our sample, 
previous research did not specify the racial/ethnic background 
of  the  participants  studied,  making  it  difficult  to  show  that 
this  scale  has  been  used  with  other  cultures  effectively. To 
measure anxiety, we used the State Anxiety scale of the STAI, 
which measures a temporary condition of anxiety. The Trait 
Anxiety scale was excluded because this scale measures an 
individual’s  anxiety-proneness,  and  we  were  interested  in 
measuring temporary anxiety that could be caused by being 
in a new culture or unfamiliar environment. However, future 
research  could  examine  trait  anxiety  before  students  leave 
their country and examine the effects of this type of anxiety 
on students’ experiences while abroad. 

Moreover,  the  race/ethnicity  groups  in  our  sample  did  not 
have  an  equal  number  of  students. Therefore,  future  research 
could include equal numbers of participants in each category and 
examine the group differences in terms of depression and anxiety. 
Further research might also attempt to examine depression and 
anxiety levels of international students in a longitudinal study. 

Measuring the depression and anxiety levels of students prior 
to their arrival in the United States and following them up with 
periodic assessments after their arrival would provide a better 
understanding of the impact of cultural change and the accultura-
tion process. The small number of married students who reported 
residing with their spouses did not allow us to determine whether 
living with a spouse in the United States contributed to the levels 
of depression and anxiety among international students. There-
fore, further research could be conducted with married students 
with and without their spouses in the United States to determine 
how these students’ psychological well-being is affected by the 
presence or absence of the spouse. 

Although  we  had  a  large  sample  of  students,  it  was  a 
highly self-selected group. Future research could replicate 
this study or compare the results with another college sample. 
Future research could also examine depression and anxiety 
among international students with an ecological perspective 
that emphasizes the impact of the interaction between inter-
national  students  and  their  environment  (Bronfenbrenner, 
1979; Kelly, Ryan, Altman, & Stelzner, 2000). This approach 
is based on the assumption that an individual’s behavior and 
psychosocial health are influenced by his or her social and 
physical  contexts  (Kelly,  1990). Therefore,  examining  the 
community  context  and  physical  setting  of  international 
students  might  play  an  important  role  in  understanding 
the environmental factors that contribute to these students’ 
depression  and  anxiety  levels. The  way  that  international 
students (or foreigners, in general) are welcomed and treated 
in the community and the lack of important resources (e.g., 
transportation, financial support) might be factors in inter-
national students’ depression and anxiety levels. Therefore, 
in order to understand underlying factors of depression and 
anxiety among international students, it might be useful to 
assess attitudes of American students and others in the local 
community  toward  different  cultures  and  countries  and  to 
examine the resources provided to this population. Finally, 
depression  and  anxiety  might  negatively  affect  academic 
achievements of international students. This concern could 
be  addressed  through  a  longitudinal  study  that  examined 
whether or not depression and anxiety are related to academic 
success among international students.

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