Early intervention using written exposure therapy for PTSD and AUD symptoms following sexual assault: Description of design and methodology

Abstract

The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common following sexual assault and associated with more severe symptomology and increased likelihood of sexual revictimization. Integrated interventions aimed at reducing PTSD and AUD symptoms following recent sexual assault are needed and should address barriers to care and early treatment termination. The proposed study will test a novel, brief (5 to 7 sessions) intervention that integrates Written Exposure Therapy for PTSD and Cognitive Behavioral Therapy for AUD, and is initiated within the first six weeks post-assault. In Phase 1, qualitative analysis of content gathered during focus groups with treatment providers will be conducted to inform intervention development. In Phase 2, a proof-of-concept pilot study (n = 10) of the intervention, Substance Use Skills Training and Exposure Post-Sexual Assault (STEPS), will be conducted. In Phase 3, a pilot randomized controlled trial (RCT) among 54 recent sexual assault survivors will be implemented using the updated manualized STEPS intervention to evaluate feasibility and preliminary efficacy in reducing PTSD and AUD symptoms. Ecological momentary assessments will be used to assess daily alcohol use, craving, affect, intrusions and avoidance. The effects of STEPS on commonly associated symptoms (e.g., depression, substance use) will be examined. The proposed study has the potential to make a significant public health impact by advancing knowledge on the link between sexual assault and co-occurring PTSD and AUD and informing early intervention efforts for this high-risk population.

1. Introduction

One in three women will experience sexual assault (SA) in their lifetime¹ and approximately 75% of SA survivors met diagnostic criteria for posttraumatic stress disorder (PTSD) one month following SA². Half of women who received a SA medical forensic exam reported heavy drinking in the past year (i.e., more than 3 drinks in a day and 7 drinks in a week for women³), which is a risk factor for harmful drinking related consequences and an indicator of alcohol use disorder (AUD)^3,4. One-third met criteria for AUD within six months following the SA⁵. Despite high rates of co-occurring PTSD and AUD among SA survivors, there is a paucity of interventions targeting the reduction of symptoms recently following SA (i.e., early intervention)⁶.

In co-occurring PTSD and AUD, cyclic associations may develop between the symptoms of each disorder such that stress-related symptoms trigger alcohol cravings and use because of alcohol’s ability to dampen aversive emotional states, and in turn alcohol use may further increase PTSD symptoms because it interferes with emotional processing of the traumatic event and fear extinction^7–9. Research using ecological momentary assessment (EMA), which involves repeatedly assessing symptoms in real time while someone is in their natural environment, is an innovative way to understand associations between PTSD and AUD symptoms. EMA research has generally supported that on days when people report greater PTSD symptoms, they also report greater alcohol craving and use^10–12. In a sample of SA survivors, intrusions and avoidance had the strongest association with same-day alcohol craving and use. The association between PTSD and AUD symptoms among SA survivors highlights the importance of integrated treatment that address both PTSD and substance misuse concurrently.

Integrated Treatments for PTSD and AUD

Treatments that solely address AUD or PTSD following trauma exposure may not adequately address co-occurring symptoms^13–15. In a recent RCT comparing gold standard treatments for PTSD, heavy drinking and drug use among veterans with military-related PTSD did not significantly reduce after treatment¹⁶. The treatment literature indicates that integrated interventions result in significant reductions in both PTSD symptoms and substance use^17,18. Fortunately, existing integrated interventions for PTSD and AUD have empirical evidence of efficacy, safety, feasibility, and patient preference over non-integrated approaches to treatment^19–24. Integrated interventions exist in both trauma-focused (e.g., Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure Therapy [COPE])²³ and non-trauma-focused (e.g., Seeking Safety) forms²⁴. However, in their present form, integrated interventions are too time intensive (i.e., 12 to 25 sessions). There is a need for briefer treatments that can be easily administered in the weeks following SA to help reduce the worsening of PTSD and AUD symptoms⁶.

Early Interventions for SA Survivors

Remarkably, there is a paucity of research on early interventions aimed at reducing PTSD and AUD symptoms following SA⁶. Rothbaum and colleagues (2012) reported a greater reduction in PTSD symptoms relative to an assessment only control condition when using a three-session modified Prolonged Exposure therapy for people presenting to an emergency department within 72 hours following a traumatic event (41%, n = 47, of which had experienced SA).²⁵ Abbreviated Cognitive Processing Therapy significantly reduced PTSD symptoms in women who received it within the first month of experiencing SA, though it did not significantly differ from a standard care condition²⁶. Although these studies provide promising preliminary evidence for intervening early for PTSD following SA, they are limited by their exclusion of individuals with AUD symptoms.

One prevention study tested a 17-minute video for women presenting for a SA medical forensic exam at the emergency department. The video reviewed psychoeducation on common reactions, the use of exposure, and the negative impact of substance use on recovery following SA ^27–29. Compared with treatment as usual, the video intervention was associated with reduced alcohol use among women and girls who engaged in binge drinking prior to the assault, but not among women who did not binge drink pre-assault. Although prevention in the acute period after a traumatic event is extremely important, there is a need to also have more intensive treatment options for survivors to treat symptoms in the weeks following SA. Furher, important treatment considerations unique to SA survivors are also needed in integrated interventions.

Treatment Considerations for SA Survivors

SA along with other violent crimes occur more frequently in under-resourced and low-income communities^30,31, which experience pre-existing barriers to accessing care (e.g., irregular/inflexible work hours, childcare and transportation needs)³². Remote treatment delivery platforms offer a vehicle for delivering interventions that circumvents many of these treatment obstacles and increase the accessibility of treatment. As such, the development and testing of telehealth interventions is particularly important following SA.

In addition to access barriers, there is also a problem with high attrition among those who receive existing PTSD treatments³³. This points to the need to develop more tolerable interventions that target mechanisms of change with streamlined approaches. Written Exposure Therapy (WET), a 5-session exposure-based protocol that involves 30 minutes of exposure via writing assignments, was developed to address the limitations of trauma-focused treatments. WET³⁴ may be particularly effective at retaining patients because it (i) involves writing rather than divulging details of the traumatic event directly to the therapist, (ii) initiates exposure in the first session, mitigating anticipatory anxiety, and (iii) does not involve homework assignments. In addition, since patients often drop out of trauma-focused treatment before or at mid-treatment³⁵, patients may be more willing to initiate and complete a briefer treatment. Three RCTs involving WET attest to its efficacy in reducing PTSD symptoms, with one trial showing WET was non-inferior to Cognitive Processing Therapy (CPT) in reducing PTSD symptoms^35,36. Significantly more participants who received WET completed treatment compared with those who received CPT (94% vs. 68%). WET may be an ideal treatment to integrate with content focused on AUD because it is brief, low burden and yields excellent retention³⁴.

Cognitive Behavioral Therapy (CBT) for AUD is an evidence-based approach³⁷. CBT Coping Skills Therapy Manual for AUD was developed in Project Match and demonstrated efficacy in reducing alcohol use severity and has been successfully used in more lengthy integrated protocols (e.g., COPE²³) to reduce co-occurring AUD and PTSD³⁸. The CBT Coping Skills Therapy Manual may be an ideal treatment for recent SA survivors because it includes skills that can be applied to the continuum of misuse to AUD (e.g., motivational interviewing), managing cravings that occur in response to SA related distress, and planning for high-risk situations, such as upcoming court cases. Further, it includes effective drinking refusal skills and assertiveness which may be particularly important for this patient population to protect against future revictimization.

Research objectives and hypotheses

We herein describe the design and methodology of a Stage 1A/1B study³⁹ that aims to establish feasibility, acceptability, safety, and preliminary efficacy of a new efficient, early integrated intervention for reducing PTSD and AUD symptom severity among women who experienced recent SA and report current symptoms. The intervention is called Substance use Skills Training and Exposure for Post-SA (STEPS) and integrates two evidence-based treatments: WET³⁴ and CBT for AUD³⁸. The study involves three phases of treatment development and testing of STEPS³⁹. In Phase 1, feedback on STEPS will be obtained from providers and experts in PTSD and AUD and integrated into the therapy manual/handouts to make it more specific to the needs of SA survivors. The goal of Phase 2 is to make final modifications to the STEPS intervention in a proof-of-concept pilot trial of 10 women. Phase 2 will provide an opportunity to personalize care to recent SA survivors by collecting feedback from participants that can improve the content, timing, examples, and language used in STEPS. Finally, in Phase 3, we will conduct an intent-to-treat pilot RCT in which participants will be randomly assigned to receive either STEPS or an exposure-only condition (WET³⁴) delivered primarily via video teleconferencing software. Further, we will collect daily EMAs on women’s alcohol use, craving, mood, trauma-related intrusions and avoidance during the treatment phase of the RCT.

Given that the primary purpose is to establish feasibility, acceptability, and safety, we offer the following preliminary hypotheses regarding the efficacy of STEPS (to be evaluated more rigorously in a subsequent fully powered efficacy trial). In line with previous research that non-integrated, trauma-focused treatments do not result in reduction of alcohol misuse¹⁶ and integrated treatments reduce co-occurring PTSD and AUD symptoms among women²², we expect that STEPS participants will report greater reductions in alcohol use and cravings relative to participants who received the WET³⁴ only comparison condition at the end of treatment. Since untreated alcohol misuse may maintain and exacerbate PTSD symptoms^6–9, we expect that STEPS participants will report greater reductions in PTSD symptoms and co-occurring conditions and associated features of PTSD (e.g., depression, anxiety, emotion regulation, post-traumatic cognitions) relative to WET³⁴-only participants at the end of treatment.

2. Materials and methods

2.1. Participants

Phase 1 participants will be victim advocates and mental health service providers who have experience working with survivors of SA. Phases 2 and 3 participants are adult women (aged 18–65) who report SA in the past six weeks, current heavy drinking (defined as a score of 3 or higher on the the AUDIT-C⁴⁰) and traumatic stress symptoms related to the recent SA at baseline (defined as a score of 31 or higher on the PCL-5⁴¹). Delivering early intervention 6 weeks after SA capitalizes on a period of time when distress is high and may bolster emotional recovery in the subsequent months when trajectories for PTSD symptoms among SA survivors tends to become established.² We use a cut-off of 31 on the PCL-5⁴¹, rather than requiring a PTSD diagnosis because participants can be included at any point within the six weeks following SA. Inclusion criteria also include having some memory of the SA and ability to read and write in English. Exclusion criteria include current symptoms of psychosis, mania, or an active eating disorder, significant alcohol withdrawal symptoms, and suicidal ideation with intention. Participants taking psychotropic medications are required to have 2 weeks of no changes in drugs or dosages prior to study start. We will consent and screen up to 90 women to obtain data for analyses from 54 participants.

2.2. Study Design and Procedures

This study was reviewed and approved by the Institutional Review Board (IRB). For focus groups, service providers will be recruited via email from PTSD and substance use mental health clinics and rape crisis agencies. Focus groups will be 90 minutes in length and guided by a structured discussion that solicits participants’ opinions about potential modifications of the intervention to be more specific, helpful, and relevant to recent SA. Focus groups will be conducted in-person and via video conferencing, audio recorded and transcribed. In consultation with a team of six experts in PTSD and AUD, the PI will review recommendations from participants to make final decisions about the therapy manual/handouts.

Participants in Phases 2 and 3 will be recruited from online sources, flyers in community hubs and mental health agencies, rape crisis agencies, and the emergency department. All study visits are planned to be conducted via telehealth, however if requested participants will have the option to attend visits in-person in a private space at an academic medical center. The baseline visit will include a self-report survey and clinical interviews. Participants deemed eligible at the baseline study visit will then be enrolled into the study until target recruitment is met (n = 10 for the open-label trial; n = 54 for the RCT). For the RCT, participants who are eligible based on baseline assessments will be randomized in a 2:1 manner to receive the STEPS or WET using a computer-generated randomization scheme⁴² (see Figure 1). A 2:1 randomization was selected to aid in adapting and refining the intervention protocol³⁹. Once a participant is randomized they will be included in the intent-to-treat analysis plan.

Figure 1.

Study flow for pilot RCT

2.3. STEPS Intervention Protocol

The integrated intervention, STEPS, combines WET³⁴ and CBT for AUD³⁸ to address the bidirectional association between PTSD and AUD symptoms in five to seven sessions (see Table 2). Each session in STEPS includes a focus on PTSD and AUD, and examples of how SA and PTSD relate to alcohol are provided for each CBT skill. STEPS includes repeated in-session writing about the details and impact of the traumatic event and is conducted in the same manner as WET such that participants write for 30 minutes each session, following the same prompts. Subjective Units of Distress (SUD) are collected pre- and post-writing. Pre- and post-ratings of cravings for alcohol are collected. Further, after writing is completed, participants are asked how the writing assignment went. It is recommended that if SUDs have not decreased during sessions 1 and 2, the initial writing prompt is repeated up to two times. Participants complete written exposure in relation to their most recent SA.

Table 2.

STEPS Intervention Session Content

Treatment Session	Intervention Content	Time Estimates
Session 1	Psychoeducation on AUD and PTSD following SA	20 minutes
	Motivational interviewing to enhance treatment engagement	10 minutes
	Exposure-writing about details of the SA	30 minutes
Session 2	Managing alcohol-related cravings and urges to drink	30 minutes
	Exposure-writing about details of the SA	30 minutes
Session 3	Managing high risk thoughts about alcohol	30 minutes
	Exposure-writing about most distressing part of the SA and perceived impact on life	30 minutes
Session 4	Problem solving, Assertiveness, or Drink Refusal Skills	30 minutes
	Exposure-writing about most distressing part of the SA and perceived impact on life	30 minutes
Session 5	Managing high risk situations related to alcohol	20 minutes
	Exposure-writing about impact of SA and future	30 minutes
	Review progress, next steps, and termination	10 minutes
Additional 1–2	Exposure-writing about details of the SA;	30 minutes
Sessions	Sessions added after Session 2

2.3.1. Fidelity Monitoring

Therapy sessions will be recorded and 20% randomly selected for evaluation of fidelity to the respective treatment manual using a modified Yale Adherence and Competence Scale⁴³. In Phase 2, the PI will provide STEPS. In Phase 3, masters-level study therapists will conduct the sessions. Study therapists will complete a training workshop in WET and STEPS. Study therapists will meet weekly with the PI for supervision and review digitial recordings of sessions.

2.4. Compensation

Participants will receive up to $365 for the RCT, with compensation for baseline and follow-up visits ranging from $50-$75, $20 for treatment sessions, $10 for additional treatment sessions, and a bonus $10 for attending all treatment sessions. Participants will be compensated $1.00 for each EMA that is completed during the treatment phase and an extra $5.00 for each week they complete a minimum of 80% of assessments.

2.5. Measures

2.5.1. Primary outcome measures

Table 1 includes primary and secondary assessments for all study visits. Primary clinical outcomes for AUD include level and frequency of alcohol consumption assessed by the Timeline Follow Back⁴⁴ (percent days using and number of standard drinks per drinking day). The Timeline Follow Back⁴⁴ is a retrospective self-report measure of alcohol use quantity over the past 30 days that uses a calendar to prompt participants’ memory.

Table 1.

Assessments and Timeline across Study Visits

Assessment	Domain	Baseline	Treatment Phase	Post-Treatment	Follow-Up
Alcohol Use
Timeline Follow Back44	Alcohol consumption	X	X	X	X
Visual Analogue Scale	Cravings	X	X	X	X
Alcohol Use Disorder Identification Test61	Hazardous drinking	X		X	X
CIWA-AR62	Alcohol Withdrawal	X
Drinking Motives Questionnaire63	Drinking motives	X		X	X
Saliva test strips for alcohol	Alcohol use	X	X	X	X
Urine analysis for EtG	Alcohol use	X		X	X
Trauma and PTSD
Clinician-Administered PTSD Scale45	PTSD	X		X	X
PTSD Checklist for the DSM-541	PTSD Symptoms	X	X	X	X
Life Experiences Checklist for the DSM-564	Lifetime traumatic events	X
Associated Areas of Functioning
Patient Health Questionnaire-965	Depression symptoms	X	X	X	X
Beck Anxiety Inventory-II66	Anxiety symptoms	X		X	X
Difficulties with Emotion Regulation Scale67	Emotion regulation	X		X	X
Post-Traumatic Cognitions Inventory67	Posttraumatic cognitions	X		X	X
Process Measures
Helping Alliance Questionnaire68	Therapeutic alliance			X
Treatment Expectancy Questionnaire69	Treatment credibility	X		X
Client Satisfaction Questionnaire46	Satisfaction with treatment			X
Acceptability of Intervention	Treatment acceptability			X
Measure47
Treatment Services Review71	Treatment engagement	X	X	X	X

The primary clinical outcomes of PTSD symptom severity include the weekly Clinician-Administered PTSD Scale (CAPS-5⁴⁵) and the PTSD Checklist for DSM-5 (PCL-5⁴¹). PTSD measures will be completed in relation to the most recent SA that participants experienced. The weekly CAPS-5⁴² is a structured interview used to assess PTSD symptoms in the past week and diagnostic status. Participant responses to clinician-administered questions are scored on a 5-point scale ranging from 0 (absent) to 4 (extreme/incapacitating). The weekly CAPS-5⁴⁵ will be administered by masters- or doctoral-level independent evaluators who complete training in administering CAPS-5⁴⁵, establish inter-rater reliability to audio-recorded interviews that will be rated by an expert evaluator, and attend a CAPS-5⁴⁵ supervision group. We will measure inter-rater reliability to audio-recorded interviews by generating a kappa coefficient based on the presence or absence of 20 PTSD symptoms and correlation coefficient of CAPS-5⁴⁵ severity scores. Inter-rater reliability for co-rated interviews for each independent evaluator will be established at the onset of the study and annually. The PCL-5⁴¹ is a 20-item self-report measure in which respondents rate the severity of 20 symptoms on a 5-point scale ranging from 0 (Not at all) to 4 (Extremely).

2.5.2. Acceptability and satisfaction measures

Participants will complete the Acceptability of Intervention Measure⁴⁶ and Client Satisfaction Questionnaire⁴⁷ at post-treatment. Feedback regarding helpfulness of each coping skills will be collected during the therapy phase of the study by asking “Did the following skill help you deal more effectively with your problems?” with five response choices, ranging from “It helped a great deal” to “No, it seemed to make things worse”, and the option to select “I didn’t try to use the skill.” Three open-ended questions will be used to elicit feedback on STEPS and inform if further adaptation is needed to personalize the therapy to recent SA survivors.

2.6. Ecological momentary assessment procedures

During the intervention phase of the RCT, patients will receive daily phone prompts to complete brief assessments. At the baseline assessment visit, participants will be instructed to download a software application on their smart phone that uploads data to REDCap⁴⁸ in real time. Those without a smartphone of their own are supplied one for the duration of the study. All participants will be trained by study personnel on how to use the application and engage in a practice assessment. One scheduled reminder notification will be sent to the smartphones at 9 AM and one random assessment will be sent between 4:00pm and 9:00pm. All EMAs are time stamped and will continue for 5-weeks. These assessments consist of rating their craving to drink alcohol on a 100 point visual analog scale with anchors of none and extreme. Daily, participants are also asked to report on “How many standard drinks have you had in the past 24 hours?” and “How stressed do you feel right now?” (measured on a seven-point Likert scale). The mood form^49,50 will be used to elicit state affect across nine items (e.g., “Happy,” “Frustrated”) on a seven-point Likert scale with a higher number indicating stronger affect. Every three days six items created by the study team and adapted from the PCL-5⁴¹ will be used to assess intrusions (e.g., “Today how much were you bothered by thoughts, images, and feelings related to the SA”) and avoidance (e.g., “Today, how much have you allowed yourself to stay around people, places, conversations, activities, objects or situations that remind you of the SA”) on an seven-point Likert scale. Intrusions and avoidance were selected due to their associations with alcohol craving and use¹², and items will be administered every three days for brevity.

2.6. Data Analytic Plan

2.6.1. Qualitative Analysis

For Phase 1 and 2, data derived from focus groups and open-ended questions will be analyzed using content analysis⁵¹ informed by grounded theory to systematically identify themes and patterns in the qualitative data⁵³. This will entail a three-step inductive approach in which participants’ responses will be initially reviewed to develop a codebook of possible themes in the data. Two independent coders will then use the codebook to ascribe one or more codes to each participant’s responses⁴⁶. Inter-rater discrepancies will be discussed and resolved by the coders. Finally, themes will be merged and/or subdivided into sub-themes via discussion in multiple in-person meetings until a final comprehensive codebook is developed. NVivo Version 11.1 software will be used for data management and analysis⁵⁴.

2.6.2. Feasibility, Acceptability, and Satisfaction Outcomes

Feasibility outcomes will include enrollment (% of approached and eligible subjects who are successfully recruited), randomization success (% of participants successfully randomized to condition), retention (>70% of participants attend all sessions and assessment visits), and adherence to protocol (adherence to fidelity recording protocol on >90% of sessions evaluated). Proportions of participants who are approached and successfully recruited, randomized, and retained will be computed. Between-subject t-tests will be conducted to compare satisfaction and acceptability total scores in the experimental and control condition. Descriptive statistics will be used to report participant perceptions of helpfulness of each AUD coping skills.

Sample Sizes

The samples sizes selected for Phase 1 and 2 are designed to inform decisions on revisions of the adapted treatment because of a relatively homogenous sample and STEPS is based on already developed treatment manuals³⁹. A power analysis was conducted on Query Advisor 7.0⁵⁵ based on effect sizes from similar clinical studies and an assumed attrition rate of 33%²². Our sample size provides 80% power to detect moderate changes from baseline within each treatment arm (effect sizes of 0.9 and 0.6 in the STEPS and WET³⁴ groups, respectively) for alcohol use and PTSD symptoms, and allows relatively precise estimates of group means (i.e., with 95% confidence intervals extending ± 0.4 to 0.6 standard deviation units) and group-specific proportions (i.e., with 95% CIs extending ±12% to 30% depending on the proportion estimate). Detection of small to moderate effect sizes within the STEPS group for alcohol use and PTSD symptoms will support further study of STEPS in a fully powered RCT.

2.6.3. Clinical Outcomes

Descriptive analyses will be used to characterize the sample. To address the hypotheses of efficacy, generalized linear mixed models will be constructed to estimate the between- and within-group changes in primary and secondary outcomes over time, along with their variance estimates. To examine the course of AUD symptoms following SA and their change between sessions, EMA data will be analyzed with similar generalized linear mixed models to examine intervention effects on alcohol use, craving, affect, stress, intrusions and avoidance ratings.

3. Discussion

SA is associated with increased risk to develop PTSD compared to other types of traumatic events. A substantial portion of survivors report alcohol misuse both before and after SA^4,5. Following SA, women may cope with distress by drinking and might be particularly motivated to address alcohol misuse. PTSD and AUD symptoms have several negative impacts on survivors of SA, ranging from increased risk for sexual revictimization to suicide^8,56,57. There is a substantial need for an evidence-based integrated intervention for PTSD and AUD post-SA. Further, due to barriers to care^30–32 and high rates of treatment drop out³³ integrated early interventions need to be brief and personalized to the needs of recent SA survivors.

This project will result in one of the first exposure-based, early interventions that aims to reduce AUD symptoms tailored for recent SA survivors and will increase knowledge on the co-occurrence of PTSD and AUD among women in the months following a SA. Developing and testing STEPS closes many existing gaps in the literature. The use of a phase-based approach will inform how to personalize integrated treatment to the unique needs of recent SA survivors. Previous clinical trial research with recent survivors of SA has generally been limited to individuals without occurring AUD and/or in college populations¹³. Further, PTSD prevention research has often been conducted in acute care settings; however, over two-thirds of victims of SA do not receive emergency care⁵⁸. Testing STEPS among a community sample may increase reach of early interventions for SA survivors. STEPS has the potential to be efficient and sustainable because it can be offered in five to seven 60-minute sessions, does not require homework, and the exposure content is written which has the potential to be more readily implemented by clinicians with fidelity than traditional trauma-focused interventions. The proposed intervention has the potential to accelerate recovery following SA by reducing the association between PTSD and AUD symptoms.

Exposure-based treatments have support for being safe and decreasing PTSD symptoms among people who reported substance misuse^59,60. Yet, PTSD treatments have not been compared to integrated treatments that include components of both exposure and CBT for AUD among adults. The proposed study will advance the field by testing if adding CBT-based skills for AUD is more effective than providing exposure for PTSD alone. If the proposed hypotheses are supported by the data, it will have important implications for integrating PTSD and AUD components into brief protocols. If reductions in PTSD and AUD are comparable across conditions, this would point to the possibility of offering trauma-focused-only or integrated treatments to patients based on preference or other potential clinical indicators that one treatment may be effective for certain individuals.

This study will advance translational PTSD and AUD research by using EMA to test temporal and proximal associations between affect, alcohol craving, consumption, intrusions and avoidance during the weeks immediately following SA, when self-medication may be starting to develop. Results will inform how associations between alcohol craving and use, affect, and intrusions/avoidance relate to treatment outcomes. Further, it may encourage future just-in-time interventions that can target trauma-related symptoms when SA survivors are at high risk to further increase drinking.

This is among the first studies to address PTSD/AUD using an exposure-based integrated intervention among women recently exposed to SA. Results from this study will add to the growing literature on the efficacy of integrated interventions for PTSD and AUD, and the mechanisms that lead to and maintain the PTSD-AUD link. Importantly, this study has the potential to advance the goal of developing and evaluating treatments for SA that are more accessible and acceptable/tolerable than extant PTSD and AUD treatments.

Abbreviations:

SA

sexual assault

PTSD

post-traumatic stress disorder

AUD

alcohol use disorder

EMA

Ecological Momentary 1ymptoms1t

RCT

randomized controlled trial

CBT

cognitive behavioral therapy

WET

written exposure therapy

NIAAA

National Institute on Alcohol Abuse and Alcoholism

STEPS

Substance Use Skills Training and Exposure Post-Sexual Assault