Addiction commonly co-occurs with psychiatric disorders and trauma, and integrated treatment is considered a standard of care.1 More importantly, addressing comorbid psychiatric illness and trauma in substance abuse treatment settings leads to improved client outcomes.2 Yet despite considerable attention to making integrated treatment a standard of care, too much of treatment today is still provided in a sequential or parallel fashion. The Center for Substance Abuse Treatment (CSAT) estimates that fewer than 2% of clients receive truly integrated care.3
One obstacle to integrated treatment is the lack of a visual framework or “heuristic.” Heuristics are valuable learning tools, and those of us who have been in the field for many years can recall the importance of Vernon Johnson’s illustration of the feelings continuum to show how one moves through pain, normal, and euphoria in the progression of alcoholism.4 Another classic in the area of alcoholism research was the Jellinek Curve.5 Aspects of self as it pertains to recovery and group dynamics were often illustrated using the Johari Window.6 Where have the heuristics that allow us to illustrate complex topics in addiction recovery gone?
Integrated treatment for co-occurring disorders and trauma also needs a heuristic. A visual way to capture these co-occurring conditions as it pertains to the individual client’s narrative seems critical. It is difficult for me as a clinician to retain my conceptualization of each client who presents with multiple brain disorders over the course of our work together. This is complicated by working with multiple clients simultaneously. In addition to this, clinicians have diagnostic bias, favor certain topics in therapy, and lose sight of the key themes that need to be addressed.
The high degree of avoidance among our clients only serves to compound the journey further. Imagine the difficulty from the client’s perspective. The story has been lost, distorted, confabulated over the course of years, in large part because the cleint is at the mercy of brain disorders that adversely affect cognitive processes, feelings, behaviors, and capacity for relationships with a Higher Power, self, and others.
Many years ago, I developed a Venn diagram (see figure below) heuristic to guide my clinical work.7 I see it as a tool that:
Provides a visual reference for the client to increase her/his literacy about how addiction, psychiatric comorbidity and trauma interact—I refer to this as integrated.
Affords me a concrete way to show the client the rationale for what we are doing in therapy in terms of skill building and where in the personal Venn diagram the effective strategy can be helpful for his/her own recovery management—I refer to this as the intentionality of treatment.
Keeps me focused on delivering on the treatment that we negotiated, and is tailored for the circumstances of the person sitting in front of me—I refer to this as individualized.
What follows is a description of the Venn diagram and the way I use the heuristic to understand my client’s life story and to identify the issues that must be addressed as part of an integrated treatment plan. For me, the Venn diagram simplifies the daunting task of providing integrated, intentional and individualized treatment for my client. No two clients would have a similar Venn diagram. It is a framework that helps guide the delivery of treatment for co-occurring disorders and trauma at each stage of treatment—be it assessment, diagnosis, treatment or aftercare.
Description of the Venn diagram
Each circle in the Venn diagram (see below) is made up of two parts. These components can be considered as the unique aspects (unshaded area) and the shared aspects (shaded area), which represent how the disorders may interact with another disorder. It is important to note that when these disorders co-occur, the brain is under considerable assault that affects the individual's thinking, emotional functioning, behaviors and capacity for relationships. Consequently, prolonged periods in Area D of the Venn diagram lead to demoralization, disconnectedness and being death welcoming.
The dotted line around the Venn diagram denotes the defense mechanisms, personality features and personality disorders that are described in the DSM-5.8 When working with a client, I usually take this same order to understand the issues that concern her/him. That is, we start with addiction, move toward psychiatric illness, discuss trauma, and explore personality features and defenses.
The relevant components then are not only the unique features of each area (Addiction, Psychiatric Illness, etc.), but also the areas of overlap (Area A, B, C and D). These overlapping areas are particularly important, since these brain-based disorders can commingle at a level outside of the patient’s awareness.
As an example, Area B represents the relationship between addiction and trauma. A very common issue in early recovery is being at high risk for relapse when approaching a one-year anniversary. This is not surprising. Outward success and accolades are at odds with the individual's sense of self as being wretched, a fraud, and doomed to fail and disappoint those around him/her. This disparity between the outside world and one's internal sense of self creates cognitive and emotional dissonance. Consequently, the familiar pattern of chaos and destruction can often follow. This is simply one way of using the Venn to explore these overlapping areas. Clients often surprise me with their insights when prompted to think about their recovery in this integrated manner.