Trauma Work When Drinking Is Still in the Room
Dana, 41, was referred after a sexual assault three years ago. She meets criteria for PTSD with a PCL-5 of 58 and for moderate-severe alcohol use disorder with an AUDIT of 24: four to five drinks nightly for two years, two blackouts, one fall. She has been abstinent 14 days and reports mild tremor and night sweats but no seizure history. She sleeps four to five hours, has nightmares three nights a week, and avoids the bus and the six blocks around the assault. Her partner is supportive. She asks to "start the trauma work now" and says she is afraid you will make her do six months of "drinking stuff" first. No current suicidal ideation.
1. How do you decide the sequencing, and what do you assess before agreeing to begin trauma-focused work?
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The evidence supports integrated, concurrent treatment - not a mandatory abstinence waiting period. Requiring months of sobriety before trauma work is an old habit, not a standard of care, and it often functions as avoidance.
Before starting:
- Withdrawal safety. 14 days out with tremor and night sweats but no seizure history is reassuring; confirm she has been medically evaluated, and refer if symptoms escalate. Document it.
- Function of drinking. If alcohol is her main tool for suppressing intrusions, treating only one problem undermines the other. Integrated protocols (e.g., COPE) were built for this.
- Current safety and stabilization - housing, partner support, suicide risk, and a coping plan that does not depend on alcohol.
- Session sobriety contract - a stated expectation that she arrive able to participate, framed as protecting the work, not as a punishment.
Answer her fear directly: "We are not parking the trauma for six months. We start now, and we keep an eye on the drinking at the same time."
2. At session 4 she arrives having drunk two glasses of wine, apologizes, and says the nightmares were unbearable. What do you do?
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Treat it as data, not as a contract violation.
- Do not run exposure while she is intoxicated - she cannot encode or process the material, and the session would reinforce drinking as a coping strategy.
- Assess: how much, when, and what preceded it. "The nightmares were unbearable" is the functional link you need - alcohol is doing the job of a coping skill.
- Do a brief safety check (self-harm, driving, intoxication level), then shorten the session to stabilization and rescheduling. Do not terminate or deliver a lecture.
- Name the pattern without shame: "The drinking is doing the job the nightmares create. Let's build a second tool so it doesn't have to."
- Re-contract explicitly on the session expectation, add between-session coping (imagery rehearsal, sleep hygiene, urge surfing), and increase contact frequency briefly.
- Document the lapse, your assessment, your actions, and the plan. Distinguish lapse from relapse in your note and in what you tell her.
3. What do you measure, how often, and how do you use the numbers?
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Measurement here serves two masters: symptom change and drinking change.
- PCL-5 every 2–4 sessions. Roughly a 10-point drop is commonly used as a marker of reliable change; track the trend, not a single score.
- TLFB for drinking days and quantity, plus AUDIT-C at intervals or a craving rating each session.
- Sleep diary - nightmares and hours slept are the fastest-moving indicators and the ones she cares about.
- Suicide risk screen at each phase transition, especially when trauma processing begins.
Use the numbers to make decisions you would otherwise make on impression: if the PCL-5 is flat at session 12 with no drinking increase, change the protocol or the dose of exposure; if drinking is climbing as trauma symptoms drop, the alcohol needs its own focus. Share the scores with her - this is a client who will disengage if she thinks the drinking agenda is secret.