COMPLEX PTSD AND ADDICTIVE DISORDERS: WHY SIMPLISTIC SOLUTIONS DO NOT WORK
By Jerry Boriksin, PhD
The logic is easy but seems to elude the most brilliant of minds: Some complicated conditions require multiple approaches delivered skillfully and in the proper sequence. A single solution, no matter how powerful, tends to fail when up against sufficient intensity and complexity. To put this into simpler language: If a tornado leveled your home, you wouldn't rebuild by simply calling a plumber. You would need to call in a team of craftspeople - in the right sequence - in order to repair the damage. Calling in the roofer before restoring the walls would be absurd.
Individuals who have sustained severe emotional damage or multiple traumas, or who had their foundations damaged by early childhood neglect or abuse, tend not to do well with singular, well-intended, or even well-delivered therapeutic approaches. Repeated attempts and failures reinforce the hopelessness and futility that are central to the inner beliefs of those who suffer. Essentially, they believe they are broken beyond repair. This is what we refer to as nihilism (i.e., "I am hopeless and there is no meaning, no escape... nothing will work"). The result is often a resumption of self-medicating: indulging in drugs, alcohol, risky sexual behavior, bad relationships, etc. Addiction is a frequent cohort of pain, futility, and hopelessness.
Researchers have been trying for decades to develop singular, powerful treatments for the cure of PTSD. Whereas the treatments are better, even the best treatment techniques fail when facing complex PTSD with co-occurring conditions. Very often, immersion in a safe, sane environment is needed in order to gain some traction. This is why we often need a higher level of care to start the process of rebuilding.
The very first foundations are:
2. Restored sleep cycle. Once this foundation is secure, additional techniques can be employed. However, it is important to recognize that we are dealing with complex problems. We need multiple approaches - delivered skillfully, cooperatively, and rationally - with several specialty artists who can work comfortably with the necessary complexity, honesty, and skill.
While science has helped and will help us further, no magic, medicine, or technique will rebuild the damage inflicted by severe childhood abuse, war, and subsequent disasters. We need to utilize a team with a wide range of tools and skills. We need to embrace the complexity, rather than deny its reality. So, sobriety first, sleep second; then the rebuilding can begin. Do not minimize how much structural work is needed; almost any building can be rebuilt, but it requires a team with many disciplines and several tools, all used in a synthetic, not simplistic, fashion.
Spoken Agreements and Silent Arrangements
Debra L. Kaplan
M.A., CSAT-3, EMDR-II
During a particularly tense session of couple's therapy, Kelly turned to Robert, her partner of eight years, and said, "You agreed that you would work at paying down your debt, but I don't see you doing that!" Robert, clearly offended, sprang forth with anger: "What right do you have to accuse me when I work hard everyday, just as hard as you do?" Kelly was about to go for his therapeutic jugular when I interrupted her.
"Kelly, when you met Robert, what information did you have about his financial situation, and what information did you choose to ignore?" I understood the situation, as this was a topic often addressed in couple's therapy.
When they met and started dating, Robert was dealing with a recent bankruptcy, and his financial situation was fragile. As Kelly described it, "Robert was reeling from a business deal gone awry, and he was doing the best he could to get back on his feet." Robert promised Kelly that, due to his business acumen, his situation would be short-lived. He maintained that he would bounce back from his mounting debts.
Although Robert's promise of financial rebound didn't materialize, the two moved in together early in their relationship. Before long, they started arguing about finances. Every few months, they came to resolve their issues in therapy - only to back away from the most obvious of issues between them. Kelly had agreed to move in with Robert based on what she knew, and she had chosen to avoid asking questions that would have helped her make a healthier decision.
This relationship, and many others like it, operates on two levels of understanding: The first level speaks to agreements based on information we know, and the second level speaks to the silent arrangements we make based on information we ignore.
Kelly knew about Robert's financial situation but chose to ignore the fact that he was struggling to make ends meet. Kelly also chose to ignore the fact that, rather than paying off his debts, Robert continued spending his money and building financial stress.
How many times do we venture forth in romantic relationships, despite our "our gut instinct" telling us that it isn't right? How many relationships begin with the ominous belief that "I don't care for her/his friends, but once we're together, s/he will change?" If we remain committed to blind hope or desire, we ensure relational demise.
We treat our relationships with ourselves as less important than relationships with others. We allow our hopes and/or desires to push us forward, "eyes wide shut." We risk losing our true selves as well as our potential for enduring positive change.
We often know more than we think we do when we make decisions regarding relationships and life choices. Because we cannot come to grips with the outcome, we often tune out important knowledge in lieu of walking away or sticking to what we know is right. At times, the very information we need in order to have a solid relationship is the very information that we neglect, even when it is in plain sight.
In the case of Kelly and Robert, his bankruptcy resulted from a less-than-stellar work ethic and poor choices. This did not change when he moved into Kelly's house, but she chose to ignore this vital information. Her need to have Robert move in was stronger than her need to ask for more information. Had she asked questions, Kelly may not have moved forward in the relationship. While that would have been painful for her, it would have been less painful than eight years of emotional turmoil, financial ups and downs, and unresolved relationship cycles.
The act of recovery means living life on life's terms and, at times, this means disappointing ourselves and/or another. Recovery demands that we be willing to disappoint ourselves and others in order to live healthy, fulfilled lives. Meeting the demands of life on life's terms is a formidable challenge for many of us. More difficult yet is the challenge to set and meet our own demands while being honest with ourselves. This rigorous honesty is no less necessary in a relationship. We must ask the tough questions and act upon reality as it is, rather than how we wish it to be.
Isn't the term"sex addiction" just an excuse for bad behavior?
By Maureen Canning
News stories about celebrities struggling with sexual addiction have raised questions about the legitimacy of sexual addiction as a disorder. Many say the diagnosis is an excuse for bad behavior. But assessing someone's behavior from afar is not an effective tool for understanding another's reality. Some may use sex addiction as an excuse, but it is important to understand it as a viable disorder that, when left untreated, can have serious consequences.
Sexual addiction is a progressive disorder; if not treated, it will become worse over time. Consequences will build up and wreak havoc in one's life. As the disease progresses, so do the consequences: depression, sexually transmitted disease, financial loss, relational conflict, isolation, low self-esteem, and suicidal thoughts or gesturesThe individual spirals out of control to the point where the need to act-out sexually becomes his/her only priority.
Sex addicts have tunnel focus; they are hypervigilant when seeking another "hit." Meeting a friend at local restaurant is not about connecting emotionally, sharing, or catching up. It turns into an opportunity to objectify others or flirt with the server or attractive patrons. Addicts becomes frustrated when expected to be present in the conversation. They feel trapped and limited by their inability to catch another glimpse or slip their phone number to a possible hookup.
As the addiction progresses, it takes more time, energy, and resources. It may drain bank accounts, cause marriages to end in divorce, cost opportunities at the work place, and rob hobbies of interest. Despite obvious changes, addicts are experts at believing their own lies. They minimize their behaviors, believing they still have control. They distort reality to justify continuing the addiction.
Typically addicts don't seek treatment until the pain of their behaviors outweighs the gain. Self-motivation is crucial. An intervention with stiff consequences may be necessary to create the motivation. Most important is the knowledge that treatment is available for the sexually addicted individual. Within the context of a healing environment, addicts are able to break through the denial and begin a restorative process.
LEGALIZATION OF MARIJUANA IN ARIZONA
by Jerry Boriskin, PhD
Arizona Legalizes Medical Marijuana: www.cbsnews.com/8301-504763_162-20022928-10391704.html
The following Time Magazine article, "How Marijuana Got Mainstreamed" looks at the issue from a national perspective: http://www.time.com/time/nation/article/0,8599,2030768,00.html
As a professional who treats individuals with PTSD and other co-occurring conditions, I want to encourage you to be careful in separating hype, culture, science, and fact in making decisions about using marijuana as a tool, distraction, or method of coping with emotional and/or physical discomfort. Perhaps the most important thing to know is the difference between a drug and a medicine. Cannabis may in fact have some medicinal ingredients; separating the medicine from cannabis" 400 other chemicals will require additional science, some of which is already under way. I list below my key concerns:
1. You might feel mellow when you smoke or consume cannabis, but your ability to learn, drive a car, or function in a relationship may become more impaired than you would ever dream. There is evidence that young brains, not fully developed, may be permanently injured or altered by marijuana use.
2. Self-medicating with drugs, alcohol, and/or marijuana can make things much worse, not better. We know that alcohol increases depression and the risk of violence. The negative impact of cannabis is more subtle for most, and dramatic for a few. For some individuals, anxiety is relieved temporarily but increases over time. Some long-term users develop full-blown panic attacks.
3. Regular use of cannabis can increase the risk of schizophrenia, a serious psychiatric disorder. Modern marijuana tends to contain higher levels of hallucinogens than did the pot of the 1960s. We also believe that marijuana increases the risk of the onset of bipolar disorder. We do not fully understand all the causative factors for these serious illnesses, but genetic and environmental risk factors do exist. The use of marijuana appears to increase the risks.
4. Cannabis is addictive. There are some disputes regarding the formal definition of "addiction," but recent evidence indicates that cannabis meets the criteria of an addictive substance. Those of us who treat addictions have seen many older and sober patients who have been addicted to marijuana for decades; one of the most common observations is "I don't know how I lost the last 20 years. I got nothing done."
5. Smoking marijuana may mask symptoms of PTSD - delaying treatment, recovery, and natural mastery of powerful symptoms.
6. Self-medicating is not the same as treatment. When you self-medicate, you cannot control the content, quality, or dose of what you consume, and you are at great risk of becoming impaired, addicted, or out of control in ways you might not see for a long time.
Bottom line: If you are a trauma survivor, you should be aware that self-medicating for PTSD and other psychiatric disorders is risky. I am an advocate of your good physical, emotional, and interpersonal health. I urge you to avoid self-medicating with alcohol as well as cannabis; staying sober and clear-headed will help you recover from the symptoms that bring you to our doors.
I can't tell anybody about what I do sexually. I'm too ashamed.
Shame about addictive sexual behavior is normal, but when certain behaviors - such as voyeurism or exhibitionism - fall far from the cultural norm, there can be a profound sense of judgment, shame, and stigma. When an addict's behaviors are out of the ordinary, he is often seen as perverted, deviant, and a nuisance. But the acting-out behavior is not based in "perversion." Rather, it's based in an event that affected the individual's sexual development.
When a child or adolescent experiences a disruption in his or her psychosexual development, it creates a template or memory. The child can be so disturbed by the event that he may become preoccupied or obsessed with it. For example, a child who comes from a family that leaves the door open while using the bathroom, bathing, or dressing may witness images that are confusing and overwhelming. A little girl who sees her father urinating can be upset by this, but, at the same time, she may be curious. She may find it exciting, scary, or intriguing. She may feel shame about her interest as she tries to sneak peeks of her father in the bathroom. Before she knows it, she is online, looking at sites about urination. When she becomes sexually active, she acts out with men who urinate on her.
Her resulting feelings are identical to what she felt at the initial upset: excitement, fear, disgust, shame, curiosity, and danger. She has become obsessed, and that obsession has progressed over the years.
In another scenario, a heterosexual adolescent boy sees his mom getting dressed for a night out. As he watches his mother putting on lacy undergarments, he becomes aroused. The arousal is confusing, because he knows it is wrong to have sexual feelings toward his mother, but his body automatically and naturally reacts to the images. He feels a tremendous amount of shame. But, at the same time, he is excited, anxious, intrigued, and confused. He starts to sneak more peeks - not only at his mother, but at his sister and her girlfriends as well. He becomes obsessed with their movements, anticipating when he can get another glimpse of the forbidden. Eventually he hides a Web cam in the bathroom so he can spy on his family and friends.
Both of these individuals have become sexually addicted. A disturbing yet intriguing disruption set off a self-destructive, repetitive cycle. Through repetition and fixation, the individual attempts to gain control over the original trauma. "If I can gain control over this experience, it will go away, and I will feel better about myself." This is not a conscious thought, but rather an unconscious attempt to "undo" the original experience.
Getting to the Truth of "Body, Mind, and Spirit"
By Shelley Uram, MD
I've been a psychiatrist for more than 20 years, and I've heard the phrase "body, mind, spirit" many, many times. I was very pleased with this newly emerging holistic concept when I was a psychiatrist-in-training. It captured the concept of the spirit, which was usually ignored in American medicine, and the phrase included the mind, whose influence on the body had also been minimized.
I consider myself a holistic psychiatrist, but that is not the "bottom line" of my interest. The inclusion of these three aspects of the self provides a far more accurate description of each of us, when compared to traditional American medicine's interest in addressing the physical body. If you are searching for a deeper level of truth, I would like to share my perspective with you.
Ultimately, before passing from this earth in death, most people become serious about reflecting upon their lives. They usually want to know if they have lived as they should have, and they want to know more deeply who they "really" are. This is the final reckoning. Our lives boil down to these and a few other questions.
So what does this have to do with "body, mind, spirit"?
The real powerhouse of the three is spirit. It is our soul, or essence, that can ultimately bring us peace in our minds, emotions, and body. Ignoring or choking our essence brings pain and suffering. Our American culture is not imbued with respect for, or recognition of, this most basic essence in every one of us. We suffer the consequences of this individually and as a nation.
So what is the truth about "body, mind, spirit"?
They are not equal.
They are all very important, but they are not equal.
Peace, at the level of the spirit/soul, can generate peace in the body and mind. Even if the body is ill or impaired, we can experience ongoing peace if that is what we feel deep within. The corollary is that, no matter how healthy the body is, it does not bring long-lasting peace to the mind/emotions/spirit.
Therefore, the more a therapeutic intervention addresses our essence, or spirit, the greater impact it will have on the mind/emotions and body. For many years, I have been a big fan of Pia Mellody's treatment model. By addressing what are called "core issues," I have seen many people settle into a centered, respectful, moderate, and calmer place within. From this space, a portal opens to soul-knowingness. When people come to honor this inner knowing, the payoff is remarkable.
A continued "cleaning up" in the five core issue areas is needed in order for the portal to remain open and grow a larger connection with the essence of the person, or soul. When the wisdom and peace of the spirit are tapped into, the mind and body usually quickly follow its lead with healing and a sense of great relief.
Bessel van der Kolk, Clinical Consultant for The Meadows, was recently mentioned in an article on PsychCentral. On her blog Healing Together for Couples, Suzanne Phillips cites Dr. van der Kolk's classic text, The Body Keeps Score:
"In his famous work on traumatic memories, Bessel van der Kolk (1994) reminds us that "The Body Keeps Score". Essentially he is referring to the fact that because traumatic memory is registered and stored in the emotional sensory centers of the brain as images, feelings and sensations rather than in the language areas of the brain, the use of mind and body strategies will help in the integration of traumatic memories.
As a couple the more mastery and control you have over your body states - be it through yoga, jogging, gym sessions, walking, etc. the more you change the body memories of trauma. Modeling this, inviting your partner, finding opportunities to feel differently together is part of the process."
The post discusses how traumatic memories differ from ordinary memories and how couples can help each other transform traumatic memories. To read more from the article Handling Traumatic Memories in Your Relationship, see the PsychCentral website. To learn more about Dr. van der Kolk's work and his role with The Meadows, please visit see www.themeadows.com.
"In desperate love, we always invent the characters of our partners, demanding they be what we need of them, and then feeling devastated when they refuse to perform the role we created in the first place." - Elizabeth Gilbert (Eat, Pray, Love)
In Facing Love Addiction, Pia Mellody outlines how childhood trauma creates relational patterns of love addiction and love avoidance in adulthood. Love addicts "invent the characters of our partners." We enter relationships from a wounded child ego state, believing that we are less-than and making up a fantasy about our partners. We make ourselves completely vulnerable, we tell ourselves that we are "bad" when our partner pulls away from us, we become needy, and we act out-of-control. We demand that our partners become what we "need." Often, we look at them to give us the love that our parents did not. As a love avoidant in relationship, we become the "character" that is expected of us. We enter relationships from a better-than position, we act invulnerable, we demand perfection, we are needless, and we attempt to seek control by creating intensity to feel alive. We get our sense of worth from taking care of someone we perceive as needy, but we resent him or her for it.
At The Meadows, patients often ask me what a "normal"relationship looks like. Of course, this is relative to the individual's experience of what is "normal." And it begs the question: What do functional adults do in relationships? What do recovering love addicts and love avoidants do? How do we date again? In order to address these important questions more completely, we are introducing a new workshop. It will help patients explore what a healthy relationship looks like by first tracing their own relationship histories and then considering what they want in potential partners.
First things first, sobriety must be established from any addiction that is present. Patients also must begin to examine their childhood traumas and identify whether they were abandoned or enmeshed in their families of origin and how this impacts their current relationships. Then we identify how they operate from a love-addiction or love-avoidant relational cycle. Often patients will tell me about how their partners have wronged them. In this process, participants begin to discover how they have re-created their own families of origin in their relationships and can understand what they bring to those relationships. Before someone can be intimate, he must begin the process of loving himself and knowing who he is. In our dating workshop, we will start by studying an individual's value system. In active addiction, people live outside of their values, so we want to remind them to reflect on their values. This way, they can begin to live in integrity and choose partners who have shared values. Next we have a patient define what is non-negotiable, negotiable, and "gee, it would be nice if..." about a future partner. For example, if you are a sober person, a non-negotiable may be drug use and "gee, it would be nice if he was 6 feet tall." Examining values and what is non-negotiable is important because love addicts are notorious for abandoning themselves to be with partners. This exercise helps them gain understanding of who they are and what they want.
The next step is to clearly define the impact that sobriety has on dating. Just like we define our sobriety when we get sober, we must have a plan when we enter the single world. This plan should include specifics, such as how many dates per week, how much phone/text contact, when physical contact is okay, how to discuss sobriety, social networking contact, etc. In essence, we are establishing boundaries. It may be helpful to have the patients set an intention for their dating experiences and future relationships. For example, they may say, "It is my intention to be myself while dating."
The goal is to be a functional adult when dating. This means entering relationships from a position of equality, with realistic expectations. We are authentic, we maintain our lives outside of the relationship, and we are mindful of our partner's walls in addition to our own. As the relationship progresses, we acknowledge our disappointments and feelings of overwhelm, and we communicate. The goals are to resolve conflict, negotiate, and repair disharmony while acknowledging our own childhood woundings that may be surfacing. We also bring our sober living skills into our relationships. The idea is that we enter relationships with self-esteem, boundaries, reality, willingness to express needs and wants, and a commitment to moderation.
Lastly let us remember love and respect. To quote Pia Mellody's book The Intimacy Factor, "Love is a continuum that ranges all the way from respect to very warm regard, the latter of which most people call "love." For many years, I mistakenly thought that if I loved someone, all I needed to do was to continually have a deep sense of warmth for him. Although that deep sense of warmth is basic, there are also other degrees of love that have to do with the condition of the relationship. As we experience the truth of another person, that person may be difficult- human. We might naturally feel fear, pain, and shame - not exactly pleasant. I had the idea that if I felt these unpleasant emotions, I was not loving the other person. And early on I actually wasn't, but as I got into recovery, I began to feel something healthy in its place. I learned to recognize another ingredient, and that was respect."
First we respect and love ourselves, then we practice respecting and loving others.
The concept of "wellness" has gained popularity in today's media and has played a major role in the treatment of trauma and addictions. The word suggests a state of well-being, a balance in the social, emotional, occupational, spiritual, physical, and intellectual aspects of life. At The Meadows, the newly renovated Wellness Program is structured to help patients make choices to build a more successful lifestyle.
Frequently, those suffering the effects of trauma and addictions make poor choices that result in an imbalance in one or more areas of life. Addressing this imbalance has been an integral part of The Meadows' treatment program for the past 34 years. Developed by Pia Mellody, The Meadows' model focuses on the interplay of core issues throughout our development that have culminated in unmanageable symptoms or an imbalance in our lives. The five core issues - self-esteem, boundaries, reality, dependency, and moderation - form the foundation for the treatment program. If patients learn to make good choices in their lives, they will learn to esteem themselves, establish appropriate boundaries in relationships, live lives of moderation, accept their imperfections, and take responsibility for their needs and wants. They will be in a state of wellness.
Wellness Coordinator Courtney Berg will initiate the program by conducting an individual interview with each patient during his or her first week. A wellness questionnaire will be completed, and a medical doctor will be consulted in constructing a wellness plan consistent with the patient's treatment plan and physical condition. The Wellness Coordinator will monitor the wellness plan for each patient through regularly scheduled meetings and progress reports at weekly treatment team meetings.
Patients will begin each day with a walk around campus on a newly marked walking path. Monitored by the Wellness staff, this activity will serve to start the day "on the right foot." The walk itself is low-impact and appropriate for all levels of fitness. Those who are very fit will gain from the camaraderie and team building. Those who are not so fit will begin to build confidence and physical fitness.
The Meadows has historically offered tai chi and yoga. New offerings will include water aerobics, pilates, deeper forms of meditation, and expanded expressive arts activities. Saturday mornings will feature animal and equine therapy.
New programming will include a weekend Grief Workshop, Dating in Sobriety Workshop, Mindfulness in Recovery Workshop, 12 Steps in Recovery, Expressive Arts Experiences, and specialized lectures on the Brain and Trauma, Mind-Body-Spirit Connections, and The Role of Meditation in Treatment.
In a series of brief articles, beginning below, Pia Mellody illustrates how living The Meadows' model has brought balance to her life.
In beginning the draft of my fifth book, I find myself continuously re-examining the relationship between body, mind, and spirit. In doing so, I have become even more acutely aware of the spiritual battle that rages between the ego and the soul. This topic becomes more poignant as I watch The Meadows' treatment model continue to gain worldwide recognition as the "spiritual model for the treatment of trauma and addictions."
Treatment at The Meadows has always been all-encompassing, addressing the body, mind, and spirit. Treating the body through our Wellness Program contributes to the healing process. Treating the mind through readings, lectures, workshops, and group interactions leads to healing through a shift in cognition's role in our lives. Treating the spirit is about treating spiritual impoverishment; different forms of spiritual practice include, but are not limited to: meditation, tai chi, yoga, and following 12 Step practices. These, in effect, engage the patient in spiritual balance.
Looking at the role of ego in the spiritual battle, I see it as attached to "I," "me," and "my." Self-examination can reveal how the ego has been destructive in life processes. If the ego is too powerful, the individual cannot see how it's creating misery. Our treatment goal in this scenario is to get the patient to self-examine what he's doing via his own self-destructiveness. The ego is attached to the body and naturally seeks pleasure. Our senses lead us to addictive processes and compulsions to seek pleasure and thereby medicate ourselves. When we use substances (alcohol, drugs), processes (sex, gambling), or people (love addiction), ultimately we will experience misery, as we are self-medicating.
When we cover our soul with our ego, we lay the foundation for spiritual impoverishment. We have buried our value, power, and abundance. The soul, in this scenario, plays a pivotal role; it remembers that we - and others - have inherent worth.
As I work on the new book, I will continue to share my thoughts on the rich connections between mind, body, and spirit, as well as show how value, power, and abundance affect individuals and the greater world. In the next article, I will illustrate how to truly heal through the understanding and application of the five core issues.