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When Trauma Poses a Treatment Challenge

May 1, 2006
by Kathleen Parrish, LPC and Jeffrey C. Friedman, LISAC
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PTSD clients' recovery plan should focus on adaptive coping

The instinctive response to trauma is to cover it over, to bar memories of it from consciousness. Yet even with the mind-numbing effects of drugs and alcohol—used in a desperate effort to soothe the painful emotional legacy of past violence or neglect—these memories refuse to stay buried. Like restless ghosts, emotional and somatic recollections of trauma stir at the edges of awareness, imploring the traumatized to tell their terrible, long-buried truths.

To help the process of acknowledging, giving voice to, and managing these memories in a way that does not jeopardize the fragile process of early recovery represents a critical challenge facing the clinician working with trauma clients. In the therapeutic setting, a carefully crafted and skillfully executed treatment plan can be a key component of a recovery effort for those suffering from co-occurring addiction and post-traumatic stress disorder (PTSD).

Treatment of PTSD in chemically dependent patients can be a perplexing task for clinicians. Not only must therapists appreciate the role PTSD can play in the addictive process, but they also must be cognizant of possible personality-level dynamics, while skillfully addressing the patient's distressful feelings and often self-defeating behavior patterns. These patterns can linger well into the treatment experience, despite the clinician's best efforts.

Optimal therapeutic strategies used in the care of traumatized chemical dependency patients address not just the trauma itself, but also any trauma-driven behavior that might sabotage recovery. Clinicians are well-advised to focus the recovery plan on helping the client develop more adaptive ways of coping with the challenge of traumatic memories (i.e., self-soothing skills) and helping the client restructure the negative core beliefs that result from the memories.

Addiction and PTSD

The relationship between trauma and addiction is complex and even synergistic. Some therapists ask whether substance abuse in the traumatized patient is not just a symbolic reenactment of the initial abuse.1Whether or not this is true, it is well-understood that adult victims of childhood trauma, while in active addiction, often live in a world of violence and exploitation. Exposure to environmental stressors such as these can trigger distressful PTSD symptoms, resulting in an accelerating downward spiral into ever more compulsive use of drugs and alcohol.2Research also suggests that trauma can produce in some people an enduring dysregulation of endorphin activity in the brain, creating a plausible neurophysiologic predisposition to opiate abuse.3

Research has shown high levels of comorbidity in the chemically dependent population in regard to PTSD. Najavits and colleagues report that patients with current PTSD comprise 30 to 59% of substance abuse treatment sample populations.4 They also note that among women with PTSD, substance use disorders are 1.4 to 5.5 times more prevalent than among women without PTSD.

The exact causes of PTSD are not yet known, although researchers are investigating a possible genetic predisposition, environmental factors, and gender-specific predisposing traits. PTSD rates tend to be higher in women. Men typically present with PTSD resulting from combat- or accident-related trauma, while women with PTSD more often report significant, chronic sexual/physical abuse.

There also appears to be a link between early childhood trauma and the development of borderline personality disorder (BPD). Zimmerman and Mattia confirmed the presence of early developmental stage trauma in 85% of individuals who meet clinical criteria for BPD.5

Treatment challenges

The high correlation between childhood trauma and BPD warns of a possibly complicated therapeutic process, and guarded prognosis for a positive treatment outcome. Many chemical dependency patients with trauma and BPD will find significant difficulty functioning in the therapeutic environment. Profound fears of abandonment, as well as frequent mood instability coupled with an often unpredictable vacillation between idealization and devaluation of the clinician, can reduce the efficacy of the therapeutic dyad. These interfering behaviors can spike during family sessions and trauma therapy, as painful memories are rekindled and clients process intense and often uncomfortable feelings.

Studies indicate that use of containment skills to address treatment-interfering behaviors can help reduce occurrences of maladaptive self-soothing through the use of drugs and alcohol while increasing clients' awareness of their own body, mind, and emotions, as well as their innate potential for wellness. One example of a containment skill involves the use of diaphragmatic breathing, which can help in the development of body awareness and the overall reduction of anxiety associated with trauma recollections. Linehan also suggests that Dialectical Behavioral Therapy strategies be incorporated to reduce self-harming behaviors and impulse control problems.6