Rural Center of Excellence on SUD Treatment
UVM CORA Co-occurring PTSD and OUD Toolkit

Treatment Manuals

Manualized trauma-focused therapy is the first-line treatment for posttraumatic stress disorder (PTSD). VA/DoD Clinical Practice Guidelines – Management of Posttraumatic Stress Disorder and Acute Stress Disorder 2023 recommend Prolonged Exposure Therapy (PE), Cognitive Processing Therapy (CPT), and Eye Movement Desensitization and Reprocessing (EMDR) as the most effective treatments for PTSD. In addition, Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (known as COPE) integrates PE for PTSD with relapse prevention for substance use disorder (SUD) and may be particularly useful when working with individuals with co-occurring PTSD and opioid use disorder (OUD). Although EMDR has been identified as an effective treatment for PTSD, we do not have expertise in providing this treatment. Accordingly, this toolkit focuses on PE, CPT, and COPE. Providers who are interested in EMDR resources and training can visit the EMDR International Association.

A manualized therapy is one in which the provider uses a manual to assist in care delivery, ensuring that all important related topics are addressed. Use of a manual to guide and structure therapy with a patient is associated with improved attendance, adherence, and symptom reduction compared to therapy that does not use a manualized approach. This approach does not limit the therapist or reduce their expertise. Rather, manualized treatment provides a scaffold that addresses core issues related to trauma and PTSD in a systematic way and provides evidence-based work for the patient to complete outside of therapy sessions.

Evidence-based interventions for PTSD are time-intensive and require training to deliver. However, recent studies suggest that the results are well worth the effort. For individuals with co-occurring PTSD and SUD, trauma-focused treatments such as PE and CPT are consistently more likely to lead to improvements by the end of treatment.1 For example, a recent study by our group evaluating a novel prolonged exposure therapy protocol found that a large majority of patients receiving MOUD who completed PE achieved diagnostic remission and no longer met criteria for PTSD. There is also no evidence that PE is associated with any increase in substance use.2 Furthermore, there are very few reasons why someone with PTSD should not receive PE. Accordingly, patients with most co-occurring conditions (e.g., SUDs, dissociative symptoms, moderate-to-severe depression, mild borderline personality disorder) can benefit from these treatments, particularly when the patient is receiving integrated or concurrent treatment for the co-occurring condition.3, 4

In rural communities where distance, costs associated with travel, unreliable transportation, limited childcare, and limited availability of mental health treatment providers may prevent or delay individuals’ ability to seek PTSD treatment, the delivery of these interventions via telehealth may be a particularly helpful option. Fortunately, the delivery of these interventions via telehealth has been studied and found to be effective.5–8 Our group also recently demonstrated the feasibility and initial efficacy of delivering PE via telehealth to individuals receiving MOUD.9, 2

UVM CORA can provide rural treatment providers with physical copies of the PTSD treatment manuals below. Click here to submit a request for these materials.

  • Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences – Therapist Guide (2nd Edition) – by Foa et al., Oxford Academic. This therapist guide to prolonged exposure (PE) treatment is accompanied by the patient workbook, Reclaiming Your Life from a Traumatic Experience. The therapist guide instructs therapists to implement this brief cognitive behavioral therapy program that emphasizes helping patients confront safe but anxiety-evoking trauma-related memories, feelings, and situations to overcome their unrealistic and excessive fear and anxiety. This treatment is intended for individuals who are diagnosed with PTSD or who manifest PTSD symptoms that cause distress and/or dysfunction following various types of trauma. The overall aim of the treatment is to help trauma survivors emotionally process their traumatic experiences to diminish or eliminate PTSD and other trauma-related symptoms.
  • Cognitive Processing Therapy for PTSD (2nd Edition) – A Comprehensive Therapist Manual – by Resick et al., Guilford Press. Written by the developers of Cognitive Processing Therapy (CPT), this manual explains the theoretical and empirical underpinnings of CPT and ways to work effectively with specific populations, such as combat veterans and sexual assault survivors. This manual includes session-by-session implementation guidelines and extensive sample dialogues that address upsetting and unhelpful thinking patterns associated with traumatic experiences that maintain PTSD symptoms. Patient handouts can be photocopied from the large-size book or downloaded from the companion webpage.
  • Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE): Therapist Guide – by Back et al., Oxford Academic. COPE is an integrated cognitive-behavioral psychotherapy program designed for patients who have PTSD and a co-occurring alcohol or drug use disorder. COPE represents an integration of two evidence-based treatments: PE for PTSD and Relapse Prevention for SUD, where both the PTSD and SUD are addressed concurrently in therapy by the same clinician, and patients can experience substantial reductions in both PTSD symptoms and substance use severity. The program includes information about how PTSD symptoms and substance use interact with one another; information about the most common reactions to trauma; techniques to help the patient manage cravings and thoughts about using alcohol or drugs; coping skills to help the patient prevent a return to substance use; a breathing retraining relaxation exercise; and in vivo (real life) and imaginal exposures to target the patient’s PTSD symptoms.

  1. Hien, D. A., Morgan-López, A. A., Saavedra, L. M., Ruglass, L. M., Ye, A., López-Castro, T., Fitzpatrick, S., Killeen, T. K., Norman, S. B., Ebrahimi, C. T., & Back, S. E. (2023). Project Harmony: A meta-analysis with individual patient data on behavioral and pharmacologic trials for comorbid posttraumatic stress and alcohol or other drug use disorders. The American Journal of Psychiatry, 180(2), 155–166.
  2. Peck, K. R., Giannini, J., Badger, G. J., Cole, R., & Sigmon, S. C. (2025). A novel prolonged exposure therapy protocol for improving therapy session attendance and PTSD symptoms among adults receiving buprenorphine or methadone treatment. Drug and Alcohol Dependence, 266, 112507.
  3. Foa, E. B., Hembree, E. A., Rothbaum, B. O., & Rauch, S. A. M. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences (2nd ed.). Oxford University Press.
  4. van Minnen, A., Harned, M. S., Zoellner, L., & Mills, K. (2012). Examining potential contraindications for prolonged exposure therapy for PTSD. European Journal of Psychotraumatology, 3, 10.3402/ejpt.v3i0.18805.
  5. Acierno, R., Knapp, R., Tuerk, P., Gilmore, A. K., Lejuez, C., Ruggiero, K., Muzzy, W., Egede, L., Hernandez-Tejada, M. A., & Foa, E. B. (2017). A non-inferiority trial of Prolonged Exposure for posttraumatic stress disorder: In person versus home-based telehealth. Behaviour Research and Therapy, 89, 57–65.
  6. Morland, L. A., Mackintosh, M. A., Greene, C. J., Rosen, C. S., Chard, K. M., Resick, P., & Frueh, B. C. (2014). Cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: A randomized noninferiority clinical trial. The Journal of Clinical Psychiatry, 75(5), 470–476.
  7. Morland, L. A., Mackintosh, M. A., Rosen, C. S., Willis, E., Resick, P., Chard, K., & Frueh, B. C. (2015). Telemedicine versus in-person delivery of cognitive processing therapy for women with posttraumatic stress disorder: A randomized noninferiority trial. Depression and Anxiety, 32(11), 811–820.
  8. Morland, L. A., Mackintosh, M. A., Glassman, L. H., Wells, S. Y., Thorp, S. R., Rauch, S. A. M., Cunningham, P. B., Tuerk, P. W., Grubbs, K. M., Golshan, S., Sohn, M. J., & Acierno, R. (2019). Home-based delivery of variable length prolonged exposure therapy: A comparison of clinical efficacy between service modalities. Depression and Anxiety, 37(4), 346–355.
  9. Peck, K. R., Badger, G. J., Cole, R., Higgins, S. T., Moxley-Kelly, N., & Sigmon, S. C. (2023). Prolonged exposure therapy for PTSD in individuals with opioid use disorder: A randomized pilot study. Addictive Behaviors, 143, 107688.