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European Journal of Psychotraumatology logoLink to European Journal of Psychotraumatology
. 2025 Jun 5;16(1):2509385. doi: 10.1080/20008066.2025.2509385

Difficulties in emotion regulation among patients with substance use disorder and a history of exposure to traumatic events: the role of PTSD symptoms, emotional avoidance, shame, and guilt

Dificultades en la regulación emocional en pacientes con trastorno por uso de sustancias e historia de exposición a eventos traumáticos: el papel de los síntomas de TEPT, la evitación emocional, la vergüenza y la culpa

Johanna Vigfusdottir a,b,CONTACT, Edvard Breivik a,b, Bjorn Olav Henden a, Egil Jonsbu a,b, Lars Lien c,d, Hakon Stenmark e, Erlend Mork f
PMCID: PMC12143005  PMID: 40470803

ABSTRACT

Introduction: Individuals with substance use disorder (SUD) often struggle significantly with regulating their emotions and there is a high prevalence of a history of exposure to traumatic events. Difficulties in emotion regulation and PTSD symptom severity contribute to elevated psychological burden, higher dropout rates, and increased risk of relapse. Currently, we still lack a precise understanding of the psychological mechanisms associated with difficulties in emotion regulation in SUD.

Objectives: The objective of this study was to examine the magnitude and correlates of difficulties in emotion regulation among patients with SUD who have a history of exposure to traumatic events. We assessed the association between difficulties in emotion regulation and PTSD symptoms, emotional avoidance, shame, guilt, and substance use-related problems.

Methods: This cross-sectional observational study was conducted in a naturalistic setting with 74 adult patients in long-term inpatient SUD treatment in Norway, including both sexes. A clinical interview measuring PTSD symptom severity was conducted and participants completed questionnaires about emotion regulation, emotional avoidance, shame, guilt, and substance use-related problems. Additional demographical and descriptive data were collected.

Results: The patients reported substantial difficulties in emotion regulation, severe PTSD symptoms, severe emotional avoidance, and strong shame and guilt. Emotional avoidance and shame but not guilt or alcohol or substance use-related problems were associated with greater difficulties in emotion regulation beyond the difficulties contributed by PTSD symptom severity.

Conclusions: Difficulties in emotion regulation were highly prevalent in this sample. The findings support targeting difficulties in emotion regulation, emotional avoidance, and shame especially in long-term SUD treatment for patients with a history of exposure to traumatic events. Reducing these factors may help potentially improve treatment outcomes and reduce suffering for this difficult-to-treat patient population.

KEYWORDS: Trauma experience, post-traumatic stress disorder (PTSD), substance use disorder (SUD), emotion regulation, emotional avoidance, shame, guilt

HIGHLIGHTS

  • Patients in inpatient long-term treatment for SUD with a history of exposure to traumatic events experienced substantial difficulties in emotion regulation, severe PTSD symptoms, severe emotional avoidance, and strong shame and guilt.

  • These individuals were prone to using emotional avoidance to manage difficult emotions, both trauma-related and in general.

  • Targeting emotional avoidance and shame while working with emotion regulation could be important to prioritise in long-term SUD treatment for patients with a history of exposure to traumatic events.

1. Introduction

More than a quarter of one billion people worldwide use drugs and over 35 million people suffer from alcohol and substance use disorders (SUDs) (United Nations Office on Drugs and Crime, 2024). A history of exposure to traumatic events is prevalent among people with SUD (Karsberg et al., 2024; Mandavia et al., 2016). The psychological aspects underlying this widespread health problem are complex; the patients are heterogeneous and different explanatory models are emerging (Ayres, 2021; María-Ríos & Morrow, 2020).

Recent years have seen an increased focus on the role of difficulties in emotion regulation (DER) (Stellern et al., 2023; Weiss et al., 2022) in substance abuse. Substance use can alleviate aversive, distressing emotions (Westphal et al., 2017) and may therefore serve as an immediate and short-term way to regulate or distract from strong, unpleasant emotions (Cooper et al., 2016; Stellern et al., 2023). This could be especially relevant in the case of individuals with SUD and a history of exposure to traumatic events, as reminders of traumatic events can elicit strong emotional responses that are difficult to regulate (Roberts et al., 2022).

Patients with co-occurring PTSD and SUD experience more significant health problems (Yarvis & Schiess, 2008), stronger drug cravings (Sinha, 2009), more severe substance use (Najavits, 2014), and a higher risk of treatment dropout (Tull et al., 2013). The presence of PTSD symptoms in these patients appears to result in lower distress tolerance and greater DER (Tull et al., 2013). Being exposed to a traumatic event in itself can lead to clinically significant difficulties and reduced functioning (Grubaugh et al., 2005). Recent studies indicate that 77%–95% of individuals with SUD have been exposed to traumatic events in their lifetime (Karsberg et al., 2024; Mandavia et al., 2016) and 36%–50% have comorbid PTSD (Roberts et al., 2022).

Currently, we still lack a precise understanding of the psychological mechanisms that may play a role in DER among people with SUD and a history of exposure to traumatic events (Roberts et al., 2022). Emotional avoidance, shame, and guilt may be important variables associated with DER among this population. A better understanding of these mechanisms could potentially increase our understanding of SUD and influence treatment.

DER as measured by the Difficulties in Emotion Regulation Scale (DERS) focuses on six domains of potential DER when the emotions is experienced: non-acceptance of emotional responses, difficulty engaging in goal-directed behaviour when emotionally activated, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity (Gratz & Roemer, 2004). If one has, the tendency to avoid difficult emotions it can affect the ability to regulate difficult emotions effectively. Emotional avoidance can hinder development of effective strategies to manage situations that activate difficult emotions (Linehan, 1993). Emotional avoidance as measured by the Emotional Avoidance Questionnaire (EAQ; Taylor et al., 2004) refers to avoidance of both positive and negative emotions by leaving situations or actively distracting from thoughts that activate strong emotions. Emotional avoidance also refers to negative beliefs about experiencing emotions and avoiding showing emotions in social settings (Taylor et al., 2004). DER and emotional avoidance both focus on how one deals with emotions. While DERS measures reactions (emotional, cognitive and behavioural) when the emotion is experienced (Gratz & Roemer, 2004), the EAQ measures attempts (cognitive and behavioural) to avoid experiencing emotions at all (Taylor et al., 2004). Emotional avoidance hinders the possibility of being aware of, understanding, and accepting emotional responses, and it limits opportunities to use other more adaptive strategies to regulate emotions than avoidance (Foa et al., 2006). Substance use can be an effective way to avoid emotions in the short term (Weiss et al., 2022). With a lack of opportunities to experience difficult emotions and thus possibilities to practice managing these emotions effectively, one likely increases DER (Linehan, 1993).

Strong feelings of shame and guilt are feelings that can be difficult to regulate. Shame and guilt can be briefly defined as a painful set of affective and cognitive states characterised by self-judgment due to breaking perceived social and cultural norms or expectations (Lewis, 1987; Tangney et al., 1996). Shame and guilt are similar, as similar situations can elicit them both, and it may be difficult to discriminate between them. An established model to differentiate between shame and guilt has a focus on self-versus-behaviour (Lewis, 1971). According to Lewis’s model, shame condemns the self (i.e. ‘I have done an awful thing’, therefore ‘I am an awful person’). Guilt, conversely, is an emotional reaction to a negative judgement of one's behaviour (‘I have done an awful thing’) (Lewis, 1971; Tangney et al., 1996). Shame is typically the more painful feeling, characterised by negative self-evaluation and fear of rejection, thus evoking the impulse to hide and avoid situations that could trigger shame (Tracy & Robins, 2007). Guilt appears less disruptive (Saraiya & Lopez-Castro, 2016), where rumination and regret for one’s actions are central, as is the need to make amends or seek punishment (Lewis, 1971; Tangney et al., 1996). People with greater PTSD symptoms are more prone to feelings of shame and guilt (Saraiya & Lopez-Castro, 2016). Shame especially can be a significant barrier in the treatment of PTSD (Saraiya & Lopez-Castro, 2016) and a factor in emotional avoidance (Roemer et al., 2001).

DER and emotional avoidance are related constructs as both focus on strategies used to manage difficult emotions, such as strong shame and guilt. Avoiding emotions, thoughts, and memories and feeling shame and guilt about specific traumatic events are also a core part of PTSD. A lack of emotion regulation, strong emotional avoidance, shame, and guilt can be disruptive factors in the treatment of co-occurring PTSD and SUD (Roberts et al., 2022). As far as we know, no previous study had focused on the severity and associations of DER, PTSD symptoms, emotional avoidance, shame, and guilt among patients in inpatient SUD treatment with a history of exposure to traumatic events. By understanding these mechanisms better, one might more effectively identify possible treatment targets to increase the effectiveness of SUD treatment for these patients.

The objective of this study was to examine the presence and correlates of DER among patients in long-term inpatient treatment for SUD with a history of exposure to traumatic events. Specifically, we hypothesised that (a) inpatients with SUD and a history of exposure to traumatic events experience high levels of DER and (b) higher scores of PTSD symptoms, emotional avoidance, shame, guilt, and severity of substance abuse-related problems are positively associated with greater DER. Furthermore, we predicted that emotional avoidance, shame, and guilt would be associated with DER beyond the contribution of severity of PTSD symptoms and other factors associated with DER, including demographics.

2. Materials and methods

2.1. Study design

This was a cross-sectional observational study in a naturalistic setting in a long-term inpatient SUD treatment programme at the Molde Treatment Centre (MBS). MBS is a treatment option for people with severe and long-lasting SUD who were evaluated to need the structure of an inpatient treatment. The average treatment period was 6–9 months and detoxification was required (when needed) prior to admission. Data were collected 5 weeks after admission. All participants had been drug-free a minimum of 7 weeks at the point of data collection. All patients admitted to MBS in the period from May 2021 to May 2024 (N = 86) were evaluated for inclusion. Patients that (1) spoke a Scandinavian language (Norwegian, Danish, or Swedish); (2) were willing to give informed written consent; and (3) be able to read and understand Norwegian (and who did not have a clinically significant low intelligence; IQ ≤ 65 or limited linguistic functioning) were invited to participate in this study. Finally, to be included in the final sample, respondents had to have a history of being exposed to a traumatic event as defined by Criterion A for PTSD in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V; APA, 2013). One person was excluded due to Scandinavian language difficulties and two declined to participate in the study. Of all patients who consented to participate (N = 83), six dropped out from treatment shortly after giving written consent, which left 77 potential participants. All but three (n = 74, 96%) met PTSD Criterion A for exposure to a traumatic event (APA, 2013), leaving a final sample of 74 participants. Everybody that participated in the study provided complete datasets, so there were no missing values.

2.2. Outcome measurements

2.2.1. Demographic information

Participants provided basic demographic information, including age, gender, and nationality, level of education, employment/support status, and marital status.

2.2.2. Traumatic experiences and PTSD symptoms

The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) is a 30-item structured interview based on the diagnostic criteria for PTSD in the DSM-5 (APA, 2013). The CAPS-5 can be used to make a current (past month) diagnosis of PTSD and to assess current PTSD symptom severity (Weathers et al., 2014). Total severity scores range from 0–80; scores of 22 and under are considered mild, scores between 23 and 34 are considered moderate, and 35 and above indicate severe symptoms of PTSD (Weathers et al., 2018). The CAPS-5 has sound psychometric properties regarding the measurement of PTSD symptom severity and is considered the gold standard in diagnosing PTSD (Hunt et al., 2018). The CAPS-5 interviews were conducted and scored by licensed clinicians with training and experience in assessment and the treatment of PTSD.

To describe the patient population, the participants were divided into three groups: PTSD, sub-threshold PTSD, and no PTSD. The PTSD criteria included A: been exposed to a traumatic event; B: re-experiencing intrusive symptoms related to the traumatic event; C: avoiding trauma-related thoughts, feelings, or reminders; D: experiencing negative alterations in cognition or mood related to the traumatic event; and E: experiencing alternations in arousal and reactivity (APA, 2013). Sub-threshold PTSD as used in prior research (Grubaugh et al., 2005) was defined as having experienced a traumatic event and re-experiencing symptoms for 1 month or longer and experiencing significant distress or functioning impairment, and experiencing either avoidance symptoms or arousal symptoms.

2.2.3. Emotion regulation

The DERS is a self-report instrument consisting of 36 items meant to measure an individual’s typical level of difficulties in emotion regulation across six domains: non-acceptance of emotional responses, difficulty engaging in goal-directed behaviour, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and a lack of emotional clarity (Gratz & Roemer, 2004). The DERS has high internal consistency (α = .93) (Gratz & Roemer, 2004) and has demonstrated good test-retest reliability (ρ1 = .88, p < .01) and adequate construct and predictive validity (Bemmouna et al., 2022). DERS items are recorded so that higher scores ranging from 36–144 indicate greater difficulties in emotion regulation (Gratz & Roemer, 2004). A mean score of 97 or higher indicates severe difficulties in emotion regulation (Bemmouna et al., 2022; Neacsiu et al., 2014).

The Emotional Avoidance Questionnaire (EAQ) is a 20-item self-report instrument designed to measure the overall tendency to engage in emotional avoidance; a higher score indicates greater emotional avoidance (Taylor et al., 2004). The EAQ measures four components of emotional avoidance: avoidance of positive emotions, negative beliefs about emotion, social concerns about displaying emotion, and avoidance of negative emotions. All four components display good internal consistency, α = .74–.83 (Taylor et al., 2004). There is no standardised cutoff available for the EAQ, but patient populations in which severe emotional avoidance is a known factor (avoidant personality disorder) have a mean score of 56. The instrument has been shown to possess good psychometric properties among different populations.

The Norwegian version of the Personal Feelings Questionnaire (PFQ-2) is a 22-item self-report instrument designed to measure proneness to guilt and shame (Vigfusdottir et al., 2024). It consists of two subscales – shame (nine items, α = .808) and guilt (seven items, α = .834), with higher scores indicating stronger feelings of shame and guilt. There are six filler items that name other emotions like sadness and joy that are not included in the calculations of the scores. The Norwegian version of the PFQ-2 has good psychometric properties (Vigfusdottir et al., 2024). There is no standardised cutoff score available for the PFQ-2. A clinical population of psychiatric patients in Norway had a mean score of 18 for shame and a mean score of 18 for guilt (Vigfusdottir et al., 2024).

2.2.4. Substance abuse

Information about ICD-10 drug diagnoses (F10–F19, indicating substances used) was collected from the patient's hospital journal. Also, the Alcohol Use Disorders Identification Test (AUDIT) is a 10-item screening instrument that was used to assess the severity of alcohol consumption, drinking behaviours, and alcohol-related problems. AUDIT scores range from 0–40, with higher scores indicating greater problems related to alcohol consumption (Bohn et al., 1995). This instrument has sound psychometric properties, with high internal reliability (α = 0.93), and has been used and assessed for variety of different populations, for instance to assess the extent and risk of alcohol-related problems in a hospital setting in Norway (Bohn et al., 1995).

The Drug Use Disorder Identification Test (DUDIT) is an 11-item self-report instrument developed for the identification of individuals with drug-related problems. DUDIT scores range 0–44, with higher scores indicating more drug use and drug-related problems (Berman et al., 2007). The DUDIT has sound psychometric properties, with good internal reliability (α = .88–.95), and has been used and assessed for a variety of different populations, like patients in a hospital setting in Sweden (Berman et al., 2007) and patients in a psychiatric emergency ward in Norway (Gundersen et al., 2013).

2.3. Ethical considerations

Participating in the study was voluntary and required informed written consent. Refusing participation did not affect the patient’s access to treatment. Answering questions about traumatic experiences could potentially cause discomfort. A therapist was available to help patients regulate a possible transitory increase in PTSD symptoms. The Helsinki Declaration was followed and relevant permissions were obtained from the Regional Ethics Committee (REC; 03 428/2020) and Data Protection Services (DPS; 2021/6844).

2.4. Statistical analysis

We used SPSS 29.0.1 for statistical analysis. Descriptive statistics for demographic and psychological variables (age, emotional avoidance, shame, guilt, DER, PTSD symptom severity, severity of alcohol use-related problems, and severity of drug use-related problems) measured on a continuous scale were reported in terms of means and standard deviations. In contrast, the distribution of categorical variables (gender, PTSD, sub-threshold PTSD diagnosis, substance disorder diagnosis) was reported in terms of proportions and percentages. Pearson’s correlation coefficient and multiple regression with hierarchical linear regression analyses were conducted to analyse the association between DER (dependent variable) and PTSD symptom severity, emotional avoidance, shame, and guilt (independent variables). We conducted analyses to examine the association between DER and severity of substance and alcohol use-related problems for the last year. To identify possible covariates, we also examined the association between DER and demographic variables such as gender, age, employment (unemployed/employed), education (10th grade or lower/finished 10th grade or higher), and relationship status (in a relationship/single).

3. Results

3.1. Demographic and clinical characteristics

Sixty-nine percent of the participants were male (n = 51) and ranged in age from 20 to 44 years (M age = 32.3, SD = 10.693). Most of the participants were unemployed (n = 65, 91.9%); about half (n = 34, 54%) had no education higher than 10th grade. Participants were predominantly single (n = 58, 78%). Seventy-four percent (n = 55) of participants met the criteria for PTSD. In addition, 19% (n = 14) met the criteria for sub-threshold PTSD, meaning only 7% (n = 5) did not meet the criteria for either diagnosis (no PTSD). Most patients had more than one SUD diagnosis (n = 51, 69%). Forty-one percent (n = 31) were diagnosed with polysubstance drug use (indiscriminate drug use). Fifty-two percent had alcohol dependency (n = 38), although most of them (n = 29, 76%) had alcohol dependency in combination with other SUD diagnoses.

3.2. Descriptive statistics

Psychological factors and substance use-related problems as measured on a continuous scale are provided in Table 1. They show participants had severe DER (M = 111.351, SD = 24.534), severe symptoms of PTSD (M = 50.260, SD = 19.211), severe emotional avoidance (M = 58.459, SD = 14.304), experienced great feelings of shame (M = 16.432, SD = 6.684) and guilt (M = 17.554, SD = 5.208), and they had severe drug-related problems (M = 26.878, SD = 15.028).

Table 1.

Age, alcohol use-related problems (Alcohol Use Disorders Identification Test), drug use-related problems (Drug Use Disorder Identification Test), difficulties in emotion regulation (Difficulties in Emotion Regulation Scale), PTSD symptom severity (Clinician-Administered PTSD Scale), emotional avoidance (Emotional Avoidance Questionnaire), shame and guilt (Personal Feelings Questionnaire, Shame–Guilt). Means, standard deviations, and bivariate correlations between the variables, N = 74.

    Bivariate correlation
Measures M (SD) Age AUDIT DUDIT DERS CAPS EAQ PFQ Shame
Age 35.53 (8.547)              
Alcohol Use Disorders Identification Test (AUDIT) 19.283 (13.125) .240*            
Drug Use Disorder Identification Test (DUDIT) 26.878 (15.028) −.363** −.286*          
Difficulties in Emotion Regulation Scale (DERS) 111.351 (24.534) −.282* 0.009 0.207        
Clinician-Administered PTSD Scale (CAPS) 50.260 (19.211) −.241* −0.032 .272* .612**      
Emotional Avoidance Questionnaire (EAQ) 58.459 (14.304) −0.106 0.121 0.096 .738** .529**    
Personal Feelings Questionnaire, Shame (PFQ-Shame) 16.432 (6.684) −0.193 0.045 .302** .724** .617** .506**  
Personal Feelings Questionnaire, Guilt (PFQ-Guilt) 17.554 (5.208) 0.043 0.068 0.156 .543** .486** .449** .727**
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Note. *p < .05. **p < .001.

We observed a significant association between DER and age (r = −.282, p = .015) and gender, F(1.74) = 8.411, p = .005, where women had significantly more DER than men. Age and gender were therefore included in further analyses as a covariate. We found no significant association between DER and the other demographic variables such as education, F(1.72) = 1.540, p = .219, employment, F(1.72) = 2.275, p = .136, or relationship status, F(1.72) = 3.278, p = .074. These were therefore not included in further analysis. We found no significant association between DER and severity of drug use-related problems in the last year (r = .207, p = .077) nor the severity of alcohol use-related problems in the last year (r = −.021, p = .853). They were therefore not included in further analysis.

3.3. Association between DER, PTSD symptom severity, emotional avoidance, shame, and guilt

The results of the multiple regression analysis with hierarchical linear regression appear in Table 2. The basic model, including the covariate variables gender and age, was significant, F(2.70) = 7.047, p = .002, indicating that greater DER was associated with younger age and being a woman, accounting for 14.4% of the variance. By adding PTSD symptom severity to the model, the model was still significant, F(3.69) = 17.074, p  = < .001, with greater DER being associated with more severe symptoms of PTSD now accounting for 40.1% of the variance. Including PTSD symptom severity to the model, gender and age lost their statistical significance. In the next step, emotional avoidance was entered, where greater emotional avoidance (β = .552) was associated with greater DER beyond the influence of PTSD symptom severity, F(4.68) = 30.685, p < .001, R2adj = .222. In the fourth step, we included shame (β = .403), which was positively associated with DER beyond the influence of PTSD symptom severity and emotional avoidance, F(5.67) = 29.669, p < .001, R2adj = .086. When emotional avoidance and shame were added to the model, PTSD symptom severity lost its statistical significance. Finally, we tried a fifth and final step, including both guilt and shame. Guilt (β = .016) was not significantly (p = .973) related to DER beyond the influence of PTSD symptom severity and emotional avoidance and did not significantly increase the accountancy of variance (R2adj = −.004). Guilt was therefore excluded from the final model. The final model accounted for 70.6% of the variance in DER.

Table 2.

Hierarchical regression analysis of difficulties in emotion regulation as a function of PTSD symptom severity, emotional avoidance, and shame (n = 74).

Predictor variables B SE B β p R²adj F p
Model 1         .144 (2.70) 7.047 .002*
 Gender 14.318 5.773 .274 .016      
 Age −.754 .317 −.263 .020      
Model 2         .401 (3.69) 17.074 <.001**
 Gender 8.451 4.941 .162 .092      
 Age −.437 .271 −.152 .111      
 Clinician-Administered PTSD Scale .682 .122 .536 <.001      
Model 3         .623 (4.68) 30.685 <.001**
 Gender 6.191 3.939 .118 .121      
 Age −.427 .215 −.149 .051      
 Clinician-Administered PTSD Scale .325 .112 .256 .005      
 Emotional Avoidance Questionnaire .961 .149 .552 <.001      
Model 4         .709 (5.67) 29.669 <.001**
 Gender 1.273 3.617 .024 .726      
 Age −.360 .189 −.126 .061      
 Clinician-Administered PTSD Scale .096 .110 .075 .386      
 Emotional Avoidance Questionnaire .829 .134 .476 <.001      
 Personal Feelings Questionnaire, Shame 1.501 .325 .403 <.001      
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Note. Significant change in variance explained by the model. *p < .05. **p < .001.

4. Discussion

The objective of this study was to examine the presence and correlates of DER among patients in long-term inpatient treatment for SUD with a history of exposure to traumatic events. This study focused on the association between DER and PTSD symptom severity, emotional avoidance, shame, guilt, and the severity of substance use-related problems.

The results supported our hypothesis that inpatients with SUD and a history of exposure to traumatic events experience high levels of DER. The results also supported that higher scores of PTSD symptoms, emotional avoidance, shame, and guilt are positively associated with greater DER. The patients had severe substance use-related problems which were not associated with greater DER. One prediction was partially supported: Emotional avoidance and shame were associated with DER beyond the contribution of severity of PTSD symptoms and demographic factors, but guilt was not.

Almost all included patients (74 of 77) in the long-term inpatient treatment for SUD had been exposed to traumatic events. In addition to severe DER, they also experienced severe PTSD symptoms, severe emotional avoidance, and strong feelings of shame and guilt. Most of the participants had either PTSD or sub-threshold PTSD. The participants showed similar or even greater emotional avoidance than patients with co-occurring generalised social phobia and avoidant personality disorder (Taylor et al., 2004). The experience of shame and guilt observed in this study was similar to what was found in a clinical population of patients in an outpatient psychiatric hospital (Vigfusdottir et al., 2024).

Severe emotional avoidance, shame, and guilt could be a disruptive factor in SUD treatment for patients with a history of exposure to traumatic events. A narrative review of the literature on DER and co-occurring PTSD and SUD supported the theory that patients with PTSD symptoms may use substances to cope with difficult trauma-related emotional responses, and that the use of substances to avoid strong emotions may maintain the substance abuse and interfere with psychological treatment (Westphal et al., 2017). This suggests targeting emotional avoidance in treatment for co-occurring PTSD and SUD.

Emotional avoidance and shame were both associated with greater DER beyond the difficulties contributed by PTSD symptom severity, but that did not apply to guilt. The results showed that gender, age, and PTSD accounted for 40.1% of the variance in DER; adding emotional avoidance and shame to the model, the explained variance in DER increased to 70.9%. When emotional avoidance and shame were taken into consideration, the effect of PTSD symptom severity on DER was reduced and became statistically nonsignificant. This indicates that emotion avoidance and shame predict DER beyond what can be solely attributed to PTSD symptom severity. The results suggest that patients in SUD treatment exposed to traumatic events may be prone to use emotional avoidance in general as a strategy to manage difficult emotions, not only in association with PTSD symptoms.

4.1. Potential clinical implications

The findings of this study support that in addition to targeting trauma symptoms in SUD treatment there could be grounds to specifically target emotional avoidance and shame in long-term SUD treatment for patients with a history of exposure to traumatic events. Shame has previously been identified as a significant treatment target for those with SUD and a history of traumatic exposure to interpersonal violence (Bhuptani et al., 2024). Previous research indicated that individuals who use substances to avoid emotional responses may benefit more from emotional exposure interventions aimed at addressing emotional avoidance compared to traditional SUD treatment (Otto et al., 2005). Reducing these factors may help reduce DER and PTSD symptom severity, thus potentially improving treatment outcomes and reducing suffering for this difficult-to-treat patient population.

Within SUD treatment, it could be of value to incorporate a combination of interventions targeting DER, including emotional avoidance and shame, such as dialectical behaviour therapy (DBT; Linehan, 1993) and trauma exposure-focused therapies like trauma focused cognitive behaviour therapy (TF-CBT), narrative exposure therapy (NET), or EMDR (APA, 2017). Trauma-focused therapies target DER, PTSD symptoms, emotional avoidance, and shame by safely confronting reminders of trauma (APA, 2017; Foa et al., 2006). In line with the findings of this study and previous research, it might be important to teach strategies to regulate difficult emotions in general (Westphal et al., 2017) beyond trauma-related suffering. It is important to increase the ability to regulate one’s emotions with adaptive strategies likely to increase distress tolerance, thus increasing one’s ability to reach one’s goals and reduce suffering in the long run (Linehan, 1993).

Emotional avoidance can significantly impact PTSD treatment by hindering emotional exposure (Foa et al., 2006) and affecting the processing of complex emotions in general (Roemer et al., 2001). One way to target emotional avoidance is to practise mindfully naming and feeling an emotion (thoughts, bodily sensations, and impulses) without distraction (Linehan, 1993). Strong feelings of shame could be explicitly addressed in the treatment of DER and comorbid PTSD and SUD as excessive shame increases self-judgment and increases lack of self-worth and can thus maintain emotional avoidance and negative, destructive thought patterns and destructive behaviour (Rahim & Patton, 2015). One way to reduce strong feelings of shame is to practice self-validation and self-acceptance and to share with others in a safe environment what one is ashamed of (Linehan, 1993).

4.2. Strengths and limitations

Due to this being a cross-sectional study, we could not determine causal relationships between DER, PTSD symptoms, emotional avoidance, and/or shame and guilt. It is important to note that PTSD symptoms, DER, emotional avoidance, shame, and guilt are intertwined and their association dynamic. PTSD symptom severity affects emotional avoidance and shame and thus increases DER. It is also possible that DER affects the effect PTSD symptom severity has on emotional avoidance and shame – greater difficulties in emotion regulation increase the influence of PTSD symptom severity on emotional avoidance and shame. Regardless of the direction of the association of DER, PTSD symptoms, emotional avoidance, and shame, the results indicate that, as mentioned, emotional avoidance and shame could be important treatment targets in SUD treatment of patients with a history of exposure to traumatic events.

One of the strengths of this study was that we collected a broad spectrum of data from a difficult-to-treat population of patients in long-term inpatient treatment for severe substance abuse and addiction, most using multiple substances prior to entering treatment. This is a population often excluded from research and thus understudied and undertreated. However, these findings must be interpreted with caution. Importantly, the correlational and cross-sectional data prevent the identification of the precise nature and direction of the association between these variables. Longitudinal data are needed to identify causal effects. Also, our small sample size limited the number of variables for possible inclusion in the regression analysis and limited the generalisability of the findings. Future research should further assess the relationship between DER and PTSD symptom severity, emotional avoidance, and shame and its effect on substance abuse, such as substance craving, dropout from treatment, and relapse into substance abuse.

5. Conclusions

This study’s findings indicate that patients in long-term inpatient treatment for SUD with a history of exposure to traumatic events have severe difficulties in emotion regulation, a high level of PTSD symptoms, severe emotional avoidance, and strong shame and guilt. They are prone to avoid difficult emotions in general and have difficulties regulating shame beyond what can be attributed to PTSD symptom severity. The association between these factors supports targeting DER and specifically emotional avoidance and shame in long-term SUD treatment. Targeting these factors in the treatment of co-existing PTSD and SUD has the potential to reduce the suffering of a vulnerable and difficult-to-treat patient population.

Acknowledgments

We thank the leadership and the staff of Molde Treatment Centre and More and Romsdal Hospital Trust for their contribution to the project.

Funding Statement

This work was supported by the Central Norway Regional Health Authority – Helse Midt Norge RHF and the Norwegian University of Science and Technology NTNU under Grant 2020/7923-17.

CRediT authorship contribution statement

All authors contributed to the study conception and design. Johanna Vigfusdottir and Edvard Breivik performed the material preparation, data collection, and analysis. Johanna Vigfusdottir wrote the first draft of the manuscript, and all authors commented on previous versions of the manuscript. Edvard Breivik, Egil Jonsbu, Erlend Mork, Lars Lien, and Håkon Stenmark critically reviewed the method design, choice of measurements, and analytic methods. Bjorn Olav Henden was responsible for the review and editing of the manuscript. All authors read and approved the final manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available from the corresponding author, JV, upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, JV, upon reasonable request.

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