Trauma, Alcohol and Substance Use

If you have been drinking or using more since something overwhelming happened, or you are worried about someone who has, this page is not here to judge that. It sets out what official sources and research say about trauma and substance use, and where help is available in Massachusetts.

Most of the research below concerns posttraumatic stress disorder (PTSD), and much of it comes from veterans. Only a clinician can assess whether PTSD or a substance use disorder is present. PTSD symptoms: what clinicians look for explains what that assessment covers.

How often do PTSD and substance use problems occur together?

Often. The VA's National Center for PTSD says: "In the U.S., over 4 out of 10 adults (or 45%) who have PTSD also have problems with drug or alcohol use." Its page for clinicians gives the figure from a large national epidemiologic study: 44.6% of people with lifetime PTSD also met criteria for an alcohol use disorder or another substance use disorder. Those are lifetime diagnoses, so the two were not necessarily present at the same time.

In the same study, the VA says, veterans who had PTSD at some point in their life were 2 times more likely to have problems with alcohol use and 3 times more likely to have problems with drug use than veterans who did not have PTSD.

These figures describe people with a PTSD diagnosis as a group. They are not a prediction for any one person. The sources for this guide give no comparable figure for people who lived through a traumatic event and did not develop PTSD.

Which usually comes first?

Usually PTSD, according to the VA: "Research suggests that for most people who have both PTSD and problems with alcohol or drug use, PTSD develops first. Some people use drugs or alcohol to try to deal with PTSD symptoms."

It can also run the other way. The VA notes that using drugs or alcohol can impair people's judgment, which can put them at risk for traumatic events.

Read that way, drinking or using can be an attempt to cope with symptoms that are hard to live with. This guide treats it as a health matter, not a moral one.

How can alcohol or drugs affect PTSD symptoms?

The VA says: "Using drugs or alcohol can make PTSD symptoms worse." Its example is sleep. Some people use alcohol to help them sleep, but in the VA's words, "alcohol can make sleep less restful." How trauma affects the body has more on sleep.

The VA also says that people with both PTSD and a substance use disorder "have a higher risk of depression, anxiety, and suicide." If you are having thoughts of suicide, call or text 988, or call 911 in an emergency.

Do you have to stop drinking or using before PTSD treatment?

The 2023 guideline from the Departments of Veterans Affairs and Defense (VA/DoD) says substance use should not rule treatment out. Its wording, a weak recommendation: "We suggest that the presence of co-occurring substance use disorder and/or other disorder(s) not preclude treatments in Recommendation 8 and Recommendation 9 for PTSD." Those two recommendations list the psychotherapies the guideline recommends or suggests for PTSD. Its discussion adds that "the presence of comorbidities should not delay PTSD treatment."

The United Kingdom's guideline body, NICE, makes the same point in its guidance for UK services: "Do not exclude people with PTSD from treatment based solely on comorbid drug or alcohol misuse."

The guideline was written for the VA and military health systems and says it is not intended to define a standard of care. So ask any therapist or program how they work with people who are still drinking or using.

What does treating both look like?

The VA says: "Research shows that treating PTSD and substance use at the same time works to treat both conditions. This is called "concurrent treatment."" It describes two ways to get it:

• Two therapies at once, one for each problem, usually with different therapists.
• One integrated therapy that addresses both.

On the PTSD side, the VA says: "For treatment of PTSD, trauma-focused psychotherapies are the most effective. This is true for people with and without substance use disorders." The American Psychological Association's 2025 guideline strongly recommends offering trauma-focused treatment plus usual substance use treatment over usual substance use treatment alone. It names a therapy called Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE). Types of trauma therapy and what the research says explains the trauma-focused therapies.

Psychodynamic therapy has been studied much less for PTSD. The VA/DoD guideline lists it among therapies with insufficient evidence to recommend for or against. That means too little good research, not proof that it fails.

How strong is the evidence?

It is modest, and two research reviews read it somewhat differently.

A 2022 systematic review of 27 studies (Roberts and colleagues) found modest benefits for PTSD symptoms after treatment when a trauma-focused intervention was added to substance use treatment (standardized mean difference -0.36), and at 6 to 13 months for PTSD (-0.48) and for alcohol use (-0.23). It found no benefits for present-focused approaches aimed at improving coping skills beyond those of substance-use-only interventions. Overall, the authors found "little evidence of any added benefit on substance use, beyond that of standard addiction treatments, for any included intervention." Dropout was relatively high across studies, and the authors wrote that "Most findings were of very low quality."

A 2021 meta-analysis of 28 randomized trials with 3,247 participants (Simpson and colleagues) found that trauma-focused treatments outperformed all comparators on PTSD outcomes at post-treatment, and non-trauma-focused treatments did not. Neither kind outperformed manualized substance use treatments on PTSD outcomes. Its authors concluded that all three "are sound options" for people with both conditions. The VA/DoD guideline is less favorable to non-trauma-focused integrated therapies. It says they did not improve PTSD symptoms more than substance use treatment alone or treatment as usual.

One trial shows the pattern. In 2019, 81 military veterans (90.1% male) with both conditions were randomly assigned to 12 sessions of COPE or of relapse prevention. Participants attended 8 out of 12 sessions. COPE led to significantly greater reductions on a clinician-rated PTSD scale (d = 1.4), and both groups showed significant and comparable reductions in the severity of substance use. It was a small trial of mostly male veterans.

Where can you find help in Massachusetts?

• Massachusetts Substance Use Helpline: call or text "HOPE" to 800-327-5050. Its site describes it as "a statewide, public resource for finding substance use harm reduction, treatment, recovery, and problem gambling services." It is free, confidential and available 24/7. More at helplinema.org.
• SAMHSA's National Helpline: 1-800-662-HELP (4357), or TTY 1-800-487-4889. It is a confidential, free information service that runs 24 hours a day, 365 days a year, in English and Spanish, for individuals and family members facing mental or substance use disorders. Its site says it does not provide counseling: trained information specialists transfer callers to state services and connect them with local assistance and support.
• Massachusetts Behavioral Health Help Line: call or text 833-773-2445, 24/7. Mass.gov says it is available for all residents of Massachusetts and connects people to treatment services for mental health and substance use, "including outpatient, urgent, and immediate crisis care." The help line's own site says: "It's free, confidential, and no health insurance is required."
• 988 Suicide and Crisis Lifeline: call or text 988 if you are having thoughts of suicide. The 988 Lifeline says it is available 24/7/365 and that conversations are free and confidential. In an emergency, call 911.

This guide does not state that Dr. Rabin treats substance use disorders. Her trauma therapy page describes an approach that is psychodynamic, attachment-based, trauma-informed and mindfulness-based. If alcohol or drug use is part of what you are dealing with, say so when you request the free consultation of about 15 minutes through the contact page. Ask whether her practice is the right place to start or whether another service would suit you better. She is a psychologist and does not prescribe, and she can coordinate with a prescriber. Medication, therapy or both for PTSD? covers who prescribes.

Keep reading

• How to Choose a Trauma Therapist
• Trauma-Informed vs. Trauma-Focused Therapy: What the Labels Mean
• What to Expect in Trauma Therapy
• All trauma guides

Sources

• VA National Center for PTSD, Substance Use and PTSD (last updated September 25, 2026)
• VA National Center for PTSD, Treatment of Co-Occurring PTSD and Substance Use Disorder in VA (last updated October 15, 2025)
• U.S. Department of Veterans Affairs and Department of Defense, VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder (June 2023)
• American Psychological Association, Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults (2025)
• Roberts NP, Lotzin A, Schäfer I, A systematic review and meta-analysis of psychological interventions for comorbid post-traumatic stress disorder and substance use disorder. Eur J Psychotraumatol (2022)
• Simpson TL, Goldberg SB, Louden DKN et al., Efficacy and acceptability of interventions for co-occurring PTSD and SUD: A meta-analysis. J Anxiety Disord (2021)
• Back SE, Killeen T, Badour CL et al., Concurrent treatment of substance use disorders and PTSD using prolonged exposure: A randomized clinical trial in military veterans. Addict Behav (2019)
• Massachusetts Substance Use Helpline, home page (accessed 2026)
• SAMHSA, SAMHSA's National Helpline (accessed 2026)
• Commonwealth of Massachusetts, Behavioral Health Help Line (BHHL) FAQ (accessed 2026)
• NICE (UK), Post-traumatic stress disorder, NG116, Recommendations (2018)
• Massachusetts Behavioral Health Help Line, home page (accessed 2026)
• 988 Suicide and Crisis Lifeline, home page (accessed 2026)

Last reviewed October 2026. This guide is general information, not medical advice or a diagnosis. If you are in crisis or thinking about harming yourself, call or text 988, or call 911 in an emergency.