Canada Drug Rehab

Modern war and major disasters such as 9/11 and Hurricane Katrina have highlighted the horrendous effects of psychological trauma. Here are some rates of post-traumatic stress disorder (PTSD): 23 percent in regions in Israel that have been shelled, 40-70 percent in Gaza, 17 percent of US military personnel, 44 percent in high school seniors in Kosovo five years after hostilities ended, and 30 percent in New Orleans after the hurricane.

Many of these poor souls have turned to alcohol and other drugs to deal with the impact. New research is helping us develop new ways to treat these clients with co-occurring disorders.

The Impact of Trauma on the Brain

Trauma imprints itself in the brain’s memory system. Stress hormones that accompany the emotional intensity of trauma activate the amygdala, which in turn activates other subcortical structures in the limbic system, the primitive, ‘non-thinking’, part of the brain. In other words, emotion mediates how memories are consolidated. The precise mechanisms involved are still debated, but neuroscientist James McGaugh says everyone agrees that “Stronger emotional experiences make for stronger, more reliable memories” (2003, p. 327). Memories of a wartime fire-fight or a collapsed building may intrude repeatedly in a survivor’s daily life or lead to nightmares. Survivors appear to be sensitized that even a door slamming or an image on television can trigger the intense experience. As psychologist David Myers says, “It is as if they [the memories] were burned in” (2010, p. 342). Even months or years later, traumatic memories are so clear that victims recall the event with remarkable detail.

To understand the power of trauma on the memory, think back to 9/11. Chances are that you remember what you were doing on September 11, 2001. But do you remember what you were doing September 11, 1999? Myers reports a study in which victims of car accidents, rape, and other traumatic incidents were given either a placebo or propranolol, a drug that blunts memories. Three months later, half the placebo group and none of the propranolol group experienced stress disorder. “Weaker emotion means weaker memories” (Myers, 2010, p. 342).

Trauma and Drug Use

Statistically, there is an association between addiction and trauma, though much more work is needed to discover what the precise link is. Some say that those suffering from trauma are more vulnerable to addiction; the earlier the trauma, the stronger the association. This may be due to the impact of early trauma on the brain’s development. Others say that the addicted brain makes people more vulnerable to PTSD. Some suggest that traumatized people are more vulnerable to addiction because they want to medicate their condition. Still others say that those with trauma who are addicted to substances are not medicating their pain, but using substances as any addict does—to relieve boredom, despair, guilt, loneliness, and a lack of a sense of belonging. And so on.

Treatment

Traditionally, scientific treatment for trauma and addiction has relied on cognitive-behavioral therapy (CBT). Among the most the most famous for co-occurring additions and trauma is Lisa Najavits’ Seeking Safety (2002) program. But many are questioning whether CBT and traditional psychotherapy are enough. One of the more controversial figures advocating a new clinical approach is Bessel van der Kolk (2005). He has suggested that because trauma affects structures in the brain’s limbic system and inhibits key functioning in the ‘thinking’ brain, that body-oriented and self-regulation therapies may be more effective than traditional talk therapies alone.

Based on brain-imaging techniques that show traumatic memories appear to be mediated or moderated by the limbic system, some trauma experts are using techniques that integrate the mind and the body. James Gordon (2010), head of the college of mind-body medicine at Saybrook University, works with US soldiers and local residents in Gaza, Bosnia, Afghanistan, and elsewhere. Gordon’s mind-body approach focuses on client strengths, builds resiliency, and balances the sympathetic nervous system’s fight or flight response with the parasympathetic nervous system’s relaxation response. Initially, after creating a safe environment, he follows a three-step process: shake, breathe, and move to music. Strange as the idea may first appear, this body-work frees participants sufficiently to deal with the trauma. They often break down sobbing during this somatic process, able to talk about what happened to them. Othre clinicians use EMDR and OEI, various types of body-work, forms of psychodrama, and other cutting-edge techniques.

Today, little of this trauma work is applied in the addiction field. But there is great hope that as addictions clinicians become more familiar with trauma, that their traumatized clients will fare better.

References

Gordon, J. S. (2010, Jan 19). Trauma and transformation: Healing the wounds of war and other disasters. [Workshop]. College of Mind-Body Medicine, Saybrook University, San Franciso, CA.

McGaugh, J. I. (2003). Memory and emotion: The making of lasting memories. New York, NY: Columbia University Press.

Myers, D. G.. (2010). Psychology. New York, NY: Worth Publishers.

Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY: The Guilford Press.

van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18(5), 389-399.

By Daniel Jordan

One of the benefits of being the marketing person at Sunshine Coast Health Center is that I get to sit in on presentations led by some of the top experts in psychotherapy. Basically, I set up my exhibit, hand out some brochures during the break, and spend the rest of my time sitting in the back of the room taking notes. At Sunshine Coast, we are always trying to figure out ways to make our alcohol & drug treatment center better so I have a particular listening when I hear these presenters. Typically, the questions I am asking myself are typically “how does this apply to addiction?”, “have we already incorporated some of the presenters ideas in our program?”, “is this better than the programming we are already providing?”, etc. So, in other words, I have a particular agenda but almost without exception there is something to be learned from every presenter regardless of whether the topic is addiction- or adult-focused.

For the past two days, I have been in a hotel in Northeast Calgary with Dr. Donald Michenbaum, Ph.D., presented by Jack Hirose & Associates. Dr. Michenbaum is one of the leading experts on Post-Traumatic Stress Disorder (PTSD) and is well-known for his work in both Canada and the United States. Dr. Meichenbaum was one of the founders of Cognitive Behaviour Therapy and in the American Psychologist magazine, North American clinicians voted Dr. Meichenbaum to be “one of the ten most influential psychotherapists of the century.” Dr. Meichenbaum is also the Research Director of the Melissa Institute for Violence Prevention and Treatment of Victims in Miami, Florida.

When you spend a little time with Dr. Meichenbaum, it doesn’t take long to realize that trauma has long tentacles that extends into our schools, homes, and workplaces - particularly with special populations such as First Nations and military veterans. At our treatment center, trauma often seems to go hand-in-hand with addiction so it’s an important consideration in our work with clients.

Probably the biggest statistic that Dr. Meichenbaum mentioned was one that showed that while more than half of Americans report having at least one traumatic event in their life, only a fraction (10 - 20%) who experience a traumatic event will actually develop persistent PTSD.

I. THE CAUSES OF PTSD

So how are 90% resilient to these traumatic events while 10% develop PTSD? Dr. Meichenbaum has identified four factors that influence the development of PTSD:

1. The Traumatic Event (objective and subjective features)

There are two sides to a traumatic event: (1) What actually happened to the survivor and (2) what the survivor thought happened.

Details of Actual Event

- extent, severity, duration of stressors (were survivors exposed to grotesque sights, smells, sounds or did they witness others being traumatized?)
- type of stressor - (50% of POWs develop PTSD while only 4% of natural disaster survivors develop PTSD)
- proximity to traumatic event, suddenness, unexpectedness, lack of preparedness

According to Dr. Meichenbaum, rape, sexual molestation, and childhood physical abuse most commonly produce PTSD.

What Survivor Thought Happened

-perception of threat (whether the perceived threat was perceived as deserved or simply an accident)
-sense of responsibility (survival guilt, blame, shame, what survivor feels could have been done to avoid the event)
-attibution of deliberateness, intentionality and self-blame (intentional harm is more distressing than impersonal harm)
-belief about future dangers, about helplessness, about emotions, persistent attention to attribution of cause

Marilyn Laura Bowman states that “pre-event individual differences in emotionality, beliefs, actions, disorders and intelligence account for more of post-event distress syndromes than do the event characteristics.” Source: Bowman M.L., Individual Differences in Posttraumatic Distress: Problems with the DSM-IV Model (February 1999) Canadian Journal of Psychiatry, Volume 44.

2. How the Survivor Reacted to the Traumatic Event

- How did the survivor react at the time of the event? Did he/she space out (dissociate)?
- How is the survivor dealing with the traumatic event today? Is he/she drinking/drugging to self-medicate? Isolating? Prone to angry outbursts?
- Is he/she functioning in other areas? Still working? Maintaining close ties with family and friends? Eating right and exercising?

The degree to which a survivor’s social network (friends, family, work colleagues such as military) were also traumatized can also play a part in a survivor’s reaction to a traumatic event.

3. Pre-Existing Characteristics of Survivor

Individuals can be more vulnerable to trauma based on factors such as:

-Prior victimization - repeated trauma (cumulative) increases the incidence of PTSD
-Premorbid stability - those with pre-existing anxiety and depression are 3x more likely to develop PTSD)
-Trait emotionality - how emotional one is in response to trauma
-Vulnerability due to family factors - family history of mood disorders, substance abuse, antisocial behavour
-Intergenerational victimization - if parents have PTSD their children can develop PTSD with less traumatic events (divorce, death of loved one)
-Socialization factors - childhood separation, harsh discipline, neglect, family instability
-Age and gender factors - more vulnerable at a younger age

4. Recovery Environment

A survivor’s recovery environment following the event and current environment can also be a factor in the development of PTSD:

- Current Stressors - marital status, trouble with the law, financial struggles, etc.
- Nature of recovery environment - availability and convenience of services, absence of stigmatization, absence of revictimization

II. WHAT YOU NEED TO DO TO DEVELOP PTSD

Dr. Meichenbaum also presented a tongue-in-cheek list of what individuals need to do (and not do) to develop persistent Posttraumatic Stress Disorder:

1. Engage in self-focused thoughts that have a “victim” theme
-see self as being continually vulnerable
-see self as being mentally defeated
-dwell on negative implications
-be preoccupied with others’ views
-imagine and ruminate about what might have happened

2. Hold the belief that:
-changes are permanent
-the world is unsafe, unpredictable, untrustworthy
-the future is going to be worse than the present
-life has lost its meaning

3. Blame
-others with accompanying anger
-self with accompanying guilt, shame, humiliation

4. Engage in comparisons
-self versus others
-before versus now
-now versus what might have been

5. Thing to do
-be continually hypervigilant
-avoidant thoughts - suppress unwanted thoughts, dissociate
-avoidant behaviours - use substances, withdraw, abandon normal routines
-ruminate and engage in distorted (contra-factual) thinking
-engage in delaying change behviours
-keep secrets by failing to share trauma story
-put self at risk for revictimization

6. What not to do
-don’t believe that anything positive could result from trauma experience
-fail to accept or retrieve date of positive self-identity
-fail to seek social support
-experience negative, unsupportive environments (indifferent, critical people or people that aren’t interested in you “moving on”)
-fail to use faith and religion as a means of coping

III. THE TREATMENT OF PTSD

Dr. Meichenbaum is best known for his work with Cognitive Behavioral Therapy (CBT) so it is not surprising that he recommends CBT-based intervientions such as Prolonged Exposure Therapy, Cognitive Processing Therapy, and Coping Skills Training (anxiety management, anger management, stress inoculation).

Dr. Meichenbaum is skeptical of many approaches to the treatment of PTSD. This is especially true of Eye Movement Desensitization and Reprocessing (EMDR), Thought Field Therapy developed by Roger Callahan, and Critical Incident Stress Debriefing (CISD). In fact, according to Meichenbaum, CISD may actually exacerbate PTSD. Furthermore, pharmacotherapy for PTSD has, at best, modest effectiveness.

In the treatment of PTSD, Dr. Meichenbaum recommends that treatment focus on “here and now” issues, as well as “then and there issues.” Present-oriented interventions that teach coping skills, bolster self-efficacy and nurture a new more adaptive narrative (”story telling”) are as important as the cognitive and emotional reprocessing of the client’s “trauma story.”

Finally, Dr. Meichenbaum cautions that any therapist working with PTSD-affected clients be both culturally-sensitive and developmentally-sensitive. Consultants should be engaged that are familiar with specific cultures (such as Elders with First Nation groups). Each age group responds differently to traumatic events so treatments must factor in the developmental stage of the client.

IV. SUMMARY

Dr. Meichenbaum presented a brief overview of PTSD and and, since this was a workshop for therapists,  spent the better part of two days discussing the treatment of PTSD. Suffice to say that Dr. Michenbaum’s opinions on the effectiveness of some PTSD treatment approaches are often controversial and not welcome by many therapists with alternative approaches.

To conclude this summary here are some interesting points and statistics:

1. It’s not only the traumatic event that is important but how the event was interpreted by the person impacted by the event (”the story they tell”) and pre-existing characteristics of the survivor
2. short-term interventions immediately after the traumatic event can reduce the incidence of PTSD
3. Religion and prayer is one of the leading ways PTSD-affected individuals cope
4. Spiritual injury (”God shouldn’t have let this happen”), not just psychological injuries contribute to PTSD

Statistics

1. in the US, more than half of the population (61% of men, 51% of women) report exposure to at least 1 traumatic event
2. of these, only a fraction (10 - 20%) who experienced trauma will develop persistent PTSD
3. in the US, 1-3% of the general population in the US suffer PTSD
4. 30%-50% of men and 25%-30% of women with lifetime PTSD also have substance use disorders (SUDs)

V. FOR ADDITIONAL INFORMATION

For those interested in learning more about Dr. Meichenbaum or additional trauma-related resources visit the website for the Melissa Institute, a non-profit research and training group founded by the parents of Melissa Aptman, a student attending Washington University who was murdered in 1995.

ABOUT THE AUTHOR

Daniel Jordan is the General Manager of Sunshine Coast Health Center and hopes that these postings will help  take away some of the mystery often associated with addiction and its treatment.