Parents of young addicts suffer the aftershocks of trauma long after the addict has entered REHAB and begun recovery. The Family Member PTSD Scale © Note1 which assesses family members of drug addicts for SHOCK, ISOLATION, VICTIMIZATION, SHAME, OVER-RESPONSIBILITY, LACK OF HOPE, and GRIEF, as well as for other symptoms of Post-Traumatic Stress Disorder (PTSD) or Complex Post-Traumatic Stress Disorder (C-PTSD), is the first tool to use when starting to work with families of addicts. The scale was designed to determine the degree of trauma and the residual effects that trauma has had on parents and siblings. There are stages of unresolved trauma which must be known before beginning family reconciliation.
Examples of some of the typical SHOCK questions on the scale that parents of addicts endorse include: "I am numb from dealing with the crisis of addiction" or "I am shut down emotionally and do not respond like I used to" or "I have flashbacks of incidents that happened in our family when we were dealing with active addiction" or "When the phone rings late at night, I sometimes still experience startle, fear and vivid memories."
Most families have some form of PTSD. A parent who found their child collapsed in the bed or bath nearly dead from an overdose, who experienced a surge of adrenalin to handle the emergency, and never processed the crisis, is frequently haunted by vivid recollection, and nightmares. The nightmares can last for years. For many parents, the long battle with trying to save their teenager's life has resulted in C-PTSD. C-PTSD was first described in 1992 by Judith Herman in her book Trauma & Recovery. It is a psychological injury that results from protracted exposure to prolonged interpersonal trauma with "loss of feeling in control", "disempowerment", or "feeling trapped," which parents suffer knowing they are responsible for underage children in grave danger. The key difference between PTSD and C-PTSD is the concept of "protracted exposure."
All previous family models for working with addiction have approached the family system from the point of view as if addiction began with adults and was passed down generationally. Today we are seeing a very high percentage of first-generation addicts, and the devastation to relatively normal parents when their children turn to drugs is incomprehensible. We have begun to work with families using a different model from the traditional model of family systems theorists of 20 years ago. Once the addict is admitted to REHAB, an immediate assessment for Post Traumatic Stress (PTS) of parents and siblings of these young addicts is begun. Some form of relief from the PTS symptoms is the most immediate need of family members. For some parents, the admonition to just "start working on your own issues" feels like a slap in the face. When the very first advice parents get from treatment center staff are things like "look at your enabling" or "look at your codependency" or "go find an ALANON group and work on your own stuff", some are offended and further traumatized by the lack of empathy for their current state of SHOCK.
"The most painful thing that we see parents dealing with," says April Lain, M.Ed, L.L.S.A.C, who has facilitated over 360 family workshop sessions integrating young adults back into their family of origin, "is the confusion of being told to disengage and leave the addict on their own - the concept of ALANON of "detach with love" is healthy but can be confusing. Parents are sometimes even made to feel guilty for continuing to seek help for their adult children who are caught in the grip of addiction, when intervention is required." She goes on to say, "I tell these parents not to feel guilty for seeking help. If you saw a stranger standing out on the ledge of a 14-story building about to jump off, wouldn't you at least call 911 and try to save their life? If you would do that for a stranger, why not for your own son or daughter who is standing on the proverbial window ledge and their life is in great danger from drug and alcohol use?" For parents who are in the trenches strategizing interventions, they are still on the battle ground. The adrenalin is still pumping. Lives are at stake.
The PTSD/C-PTSD approach to dealing with families is cutting-edge and compassionate. Without fail, along the way, the family members have suffered severe abuse from the addict. Abuse comes in several forms: Overt, Covert, Stealth, Structured, and Impulsive.
Overt abuse is clear-cut and easily recognizable and easy to describe. Cursing, name-calling, fighting, and verbal threats are overt and obvious. If your beloved son or daughter is standing in your kitchen threatening you with a knife, it is obviously abuse and is easily describable to others. If your teenager is throwing things or kicking holes in doors, you have evident visible damage. If you have bruises, broken lamps and you've started to put locks on your bedroom door out of fear, you are dealing with overt, tangible abuse.
On the other hand, covert abuse by an addict revolves around the addict's need to assert and maintain control over his/her parents or brothers and sisters. Covert abuse may not be visible to others such as to the non-custodial parent in divorced families, or with grandparents or schools and even police or coaches who continue to see the addict as charming. These "outsiders" will say, "Oh, you are making a big deal out of nothing." Or, "They will grow out of it, quit nagging them." Covert abuse is emotional and manipulative. It takes advantage of trust and costs parents their self esteem and confidence. Covert abuse is made all the more painful because others do not see the emotional damage - they only see a seemingly "crazy person" who is dealing with the aftermath of addiction.
Stealth abuse such as gaslighting is a form of abuse where the truth gets denied so often and so convincingly that the parent starts to believe they are going crazy. It is the deliberate use of false information to make others doubt his or her own reality, doubt their own memory, and not trust their own perceptions. (The term gaslighting comes from a 1944 film called "Gaslight" starring Ingrid Bergman. Her charming new husband deliberately attempts to drive her crazy, i.e., gaslighting.) Many parents report a feeling "like I was losing my mind".
Sometimes addicts manifest what is known as a patterned (or structured) abuse. That is someone who abuses everyone around them, not just parents but other children, friends, authority figures. The abuse is predictable- everyone gets a fair share. Other addicts are more unpredictable and impulsive with their abuse - they are nice at times and then they strike "out of the blue" in a flurry of chaos. One never knows when the rage fit will hit.
Bessel van der Kolk, in his "Assessing and Treatment of Complex PTSD" identified depression, lack of self worth, problems with intimacy, inability to experience pleasure, satisfaction, or to have fun, as symptoms of C-PTSD. There are no reliable statistics of the number of marriages that do not survive dealing with a child addict, but it appears it could be as high as 20 percent. It is complicated because other factors might have impacted the marriages. The emotional toll is very high on the family.
Drugs and alcohol have taken a foothold on our younger generations on an epidemic scale. Validating the stress that the families have endured is the first step for starting to work with the family. Helping the family to recognize the PTSD characteristics of their reactions, helping them to heal and finally, helping the addict to feel and show empathy for how the trauma has impacted those who love them- that is the work of a REHAB Family Counselor.
Bonnie A. DenDooven
Bonnie A. DenDooven, MC, LAC, a family workshop therapist at Gatehouse Academy, is a former business owner-turned-therapist. The author of the MAWASI© for therapy and healing of financial disorders and work behaviors. She is a former primary and family counselor and assistant clinical director for Dr. Patrick Carnes at The Meadows. Bonnie was schooled in Gestalt therapy and is a member of Silvan Tomkins Institute of Affect Script Psychology, an advocate of Martin Seligman Positive Psychology, and a champion for the initiative for VIA Classification of Strengths and Virtues (jokingly referred to as the "un-DSM").
As Humans, we are intensely social creatures. Close relationships with other people are often the source of our greatest joy in life, but they can also be associated with tremendous pain and suffering. Early relationships with caregivers, siblings, and extended family are not merely a static backdrop to a mechanistic unfolding of human development - these relational experiences have profound effects on biological and psychological processes, for better or for worse. We now know that children come into the world with sophisticated neurobiological systems that are keenly attuned to the social environment and in turn these systems are shaped by the social milieu. This means that the narrative of the early social experience is written into the biology of the developing child, or in other words, nurture actually becomes nature.
Unfortunately, overt forms of childhood abuse and neglect are all too common and can result in serious long-term physical and psychological consequences. In fact, large research studies have shown that adverse childhood experiences can lead to serious health risks, including many forms of chronic illness and even shortened length of life. However, it is increasingly recognized that covert forms of relational trauma and emotional abuse can also lead to deleterious outcomes, particularly in the area of social-emotional development.
While the term "relational trauma" often connotes overt forms of maltreatment such as physical and sexual abuse, it can also be used to describe covert forms of maltreatment such as abandonment, enmeshment, parent-child role reversal, verbal abuse, love-withdrawal, and many other forms of emotional abuse. Relational trauma can be difficult for children, caregivers and outside observers to recognize, which means it can persist throughout much of childhood and even into adulthood. For this reason, relational trauma can have insidious effects on development through persistent, maladaptive interaction patterns. These social interaction patterns occur while the brain is developing and can therefore shape the way that individuals think and feel about themselves, others, and the world around them.
Attachment theory is a very useful framework for understanding how differences in the quality of close interpersonal relationships, particularly parent-child bonds and adult romantic bonds, influence health and well-being throughout the lifespan. In the mid-nineteen hundreds, John Bowlby proposed that an attachment behavioral system evolved in humans (and other animals) because it improved the chances of offspring survival and successful reproduction by fostering proximity to caregivers, protection and safety, and sense of security for the developing child. Bowlby argued that a secure attachment relationship between a parent and child doesn't lead to dependency, which was the contention of his psychoanalytic colleagues at the time, but instead creates a secure base for the child. In fact, he postulated that attachment security, and specifically a secure base, actually facilitates exploration and learning in childhood and ultimately leads to greater autonomy and social competence later in life.
According to attachment theory, when a child experiences conditions such as pain, sickness, loneliness, or fear, the attachment system is activated and there is a natural, even biological, drive to seek comfort and safety from an attachment partner. In a secure attachment relationship, the attachment figure is sensitive and responsive to the child's desire for closeness and safety. Moreover, a secure attachment relationship provides a safe haven where intense emotional states are co-regulated and the child is able to return to engaging openly with the environment. This cycle of attachment system activation, proximity and support seeking behavior, interpersonal interaction (with the possibility of co-regulation of affect), and a return to environmental exploration occurs repeatedly in the day-to-day exchanges between attachment partners. It is in the context of this repeated "dyadic dance" that patterns of attachment behavior take shape. In turn, these attachment-related patterns contribute to the organization of biological pathways in the brain and body that underlie emotion regulation capacities and mental representations of the self and others (i.e., internal working models).
Due to the attachment system's critical role in human development, it remains active even in adverse conditions, such as relational trauma, emotional abuse, neglect, and maltreatment. As suggested by Pia Mellody in her model of development, children are born "valuable, vulnerable, imperfect, dependent, and spontaneous". This precarious natural state of the child necessitates that he or she seek comfort and support from an attachment figure, even if that caregiver is ill-equipped to consistently provide a safe haven or a secure base. The child can't simply choose to not to attach - like the physiological drive to drink when thirsty, children are compelled to seek closeness and security when feeling threatened in some way. Thus, in the context of relational trauma, the child experiences an instinctive drive to find support and safety in an attachment figure who, often without malicious intent, may also be a source of fear, anger, shame, and pain.
This "double-bind" situation is emotionally and mentally confusing - the child is torn between the attachment-related drive to seek security and love, and the self-protective impulse to avoid pain and fear. It is no wonder that relational trauma often leads to an insecure attachment pattern where the child unwittingly adopts various mental and emotional strategies aimed at obtaining or maintaining a sense of relationship security, while also protecting against loss, pain, and fear. In this light, insecure attachment patterns represent the child's best efforts to negotiate incredibly complex relational circumstances and, at least in the short-term, can be seen as a successful adaptation to environmental adversity. However, in the long-run, the distorted mental representations and emotional processes that are often associated with insecure attachment relationships can have significant effects on core areas of development.
The elegant theoretical model used at The Meadows treatment centers, which is based on extensive clinical work by Pia Mellody and her colleagues, indicates that relational trauma leads to developmental immaturity by causing an individual to become polarized along five core dimensions of development: 1) self esteem (less than versus better than), 2) boundaries (too vulnerable versus invulnerable), 3) reality issues (bad/rebellious versus good/perfect), 4) dependency (too dependent versus needless/wantless), and 5) moderation (too little versus too much self-control). The model goes on to predict that relational trauma and the subsequent distortions of the core issues result in higher rates of addiction, mental health disturbances, and spiritual disconnection. Finally, the model describes how these cascading variables almost invariably lead to problems with intimacy and romantic relationships in adulthood.
While relational trauma can have direct effects on these core dimensions of development, it may be helpful to also consider the indirect effects that are mediated by the attachment relationship. For example, when a child experiences abandonment and neglect, it may be adaptive for the child to amplify or "hyperactivate" the attachment system to get proximity and support from an elusive caregiver. Under these conditions, the child may engage in energetic and insistent attempts to remain close to the caregiver out of a fear that separation will bring abandonment, loneliness, and insecurity.
As a way of making sense of a caregiver's repeated failures to be emotionally and physically present, the child often develops a deep sense of personal unworthiness - a belief that "something is wrong with me" - thereby assuming a "one-down" position. Additionally, the child may resort to mental rumination, perseveration, and fantasy about the attachment relationship as a way of keeping it alive and filling the internal void associated with its absence. These individuals often experience their own self-worth as being highly dependent on the actions of others. So, naturally they are hypervigilant and hypersensitive to possible relationship threats and can experience intense negative emotions when threatened with loss or separation. This "anxious" or "preoccupied" behavioral pattern represents one dimension of attachment insecurity and accurately describes some of the socioemotional challenges for individuals who have been exposed to relational trauma.
Another form of relational trauma is enmeshment or parent-child role-reversal, which paradoxically involves abandonment. Often, the enmeshed caregiver isn't able to meet the attachment needs of the child because he or she is getting their own needs met through the child. In contrast to attachment-related anxiety, under conditions of enmeshment, the child may find it most adaptive to suppress or "deactivate" their own attachment system so that he or she can effectively meet the caregiver's needs and thereby maintain closeness and support. In fact, over time, the child may tacitly learn that his or her own bids for proximity and security elicit disapproval, frustration, and anger from the caregiver, and actually threaten the attachment relationship.
Therefore, when the attachment relationship is marked by enmeshment, the child dutifully meets the caregiver's interpersonal demands by suppressing, avoiding, and down-playing their own attachment-related desires. This role-reversal can create a sense of false empowerment for the child and a "one-up" position. However, it can also foster an undercurrent of resentment and rebellion as the child yearns to be free of the expectations and roles given to him or her by the caregiver. Often these individuals feel unable to depend or rely on others to meet their attachment needs, so they avoid interdependence and instead resort to rugged self-reliance and a commitment to deal with adversity alone. This "avoidant" behavioral pattern represents the other main dimension of attachment insecurity. Like its counterpart, it is often associated with relational trauma and is thought to have long-term consequences for socioemotional functioning.
It should be noted that abandonment and neglect are not always associated with attachment-related anxiety, and enmeshment is not always associated with attachment-related avoidance. Certainly the reverse can be true for both types of relational trauma, and in some cases, individuals who have experienced relational trauma can show elements of both attachment-related anxiety and avoidance. Also, even though these two dimensions of attachment behavior are considered insecure, they are nevertheless organized patterns of mental and emotional strategies aimed at maintaining intra- and inter-personal equilibrium within the context of a suboptimal attachment relationship.
However, in recent decades it has been discovered that some children who are exposed to relational trauma exhibit disorganized attachment patterns involving contradictory approach-avoidance behaviors toward the caregiver. Disorganized attachment can involve various un-integrated elements of the anxious and avoidant dimensions, as well as more ominous signs such as "freezing" or trance-like expressions and coercive or controlling interpersonal behaviors. Of importance to clinicians, disorganized attachment in early childhood has been linked to later deficits in mentalization (i.e., understanding one's own and other's mental and emotional states), dissociation, and mental health disturbances.
The effects of relational trauma on the attachment system and on subsequent developmental trajectories are moderated by a number of contextual factors. For example, evidence suggests that genetic and temperamental factors play a role in how susceptible a person is to traumatic experiences. Children with the DRD4 variant of the dopamine receptor gene are more negatively affected by relational trauma than those children without the genetic susceptibility. Also, in light of the growing awareness of critical or sensitive periods in development, it stands to reason that the timing and type of relational trauma are important variables. In some cases, the negative consequences associated with an insecure attachment to a particular caregiver can be buffered to some degree by a warm and loving relationship with a different caregiver. The family system as a whole, with its intricate dynamics and various roles, is an important, but frequently overlooked moderating variable. Finally, it is important to remember that the child is an active agent in their own development, so how he or she perceives and formulates the experience of relational trauma will have considerable bearing on its developmental consequences.
There is mounting evidence that the effects of early relational trauma and attachment insecurity can reverberate across generations. Bowlby hypothesized that the attachment behavioral system remains active throughout the lifespan and that attachment-related patterns of thinking and feeling influence adult romantic relationships and parent-child relationships. It should be noted that attachment insecurity in childhood doesn't guarantee that an individual will experience significant problems in being able to bond with romantic partners or children in adulthood. However, consistent with the clinical model used at The Meadows treatment center, longitudinal research has shown that relational trauma and attachment insecurity in childhood are associated with disturbances in core developmental areas, which are in-turn related to higher rates of mental and emotional problems, addiction to mood altering substances and behaviors, and challenges in negotiating adult relationships. For practitioners who recognize and routinely encounter the intergenerational effects of relational trauma in their clinical practice, attachment theory provides an elegant framework that connects childhood attachment experiences to adult pair-bonding and parenting.
Adult attachment orientations, whether assessed by a semi-structured interview or a self-report questionnaire, generally fall on the previously noted dimensions of attachment-related anxiety and avoidance. In a series of research studies, my colleagues and I showed that adults with a history of childhood maltreatment, particularly emotional abuse, were more likely to have problems with emotion dysregulation (especially when facing fear), addictions, depression, and adult attachment-related anxiety and avoidance. Importantly, these two attachment dimensions are remarkably similar to the constructs of Love Addiction and Love Avoidance, which are an integral part of Pia Mellody's model and the clinical work at The Meadows. While more research is needed to understand how these two perspectives interface with each other, they are both extremely useful frameworks for understanding how early relational experiences influence cognitions, emotions, and behavior in adult relationships. Adult attachment will be discussed in greater detail in future articles.
Fortunately, individuals who have experienced relational trauma and attachment insecurity can receive treatment that leads to a path of true and lasting recovery. Certainly, early intervention with at-risk parents and children is ideal, but there is also much hope for adults who have experienced trauma in childhood or adult relationships. Indeed, recent findings indicate that the brain is more "plastic" or malleable than we once thought. In fact, research has shown that social experience, including therapeutic experiences, can have meaningful effects on gene expression, physiological processes, and brain function. This means that the neurobiological pathways that were sub-optimally organized in the context of relational trauma and attachment insecurity can be re-organized by the application of appropriate treatment techniques. Similar to a secure attachment relationship, effective treatment generally involves the creation of a secure therapeutic environment where raw, painful thoughts and emotions associated with past trauma can be safely explored and metabolized so that personal and interpersonal well-being can be restored. The Meadows has been offering this kind of treatment for decades and remains a world-leader in the treatment of trauma and addiction.
Jon G. Caldwell, D.O., is a board certified psychiatrist who specializes in the treatment of adults with relational trauma histories and addictive behaviors. He currently works full-time as a psychiatrist at The Meadows treatment center in Wickenburg Arizona. For a number of years he has been teaching students, interns, residents, and professionals in medicine and mental health about how childhood adversity influences health and wellbeing. His theoretical perspective is heavily influenced by his PhD graduate work at the University of California at Davis where he has been researching how early childhood maltreatment and insecure attachment relationships affect cognitive, emotional, and social functioning later in life. His clinical approach has become increasingly flavored by the timeless teachings of the contemplative traditions and the practice of mindfulness meditation.
The Spring/Summer 2009 edition of The Cutting Edge, The Meadows' official newsletter, has just been published. Highlights of the issue include three feature articles and information on upcoming events offered by The Meadows.
Claudia Black, a Clinical Consultant for The Meadows, is the author of Deceived: Facing Sexual Betrayal, Lies, and Secrets. Says Claudia, "Nearly a decade ago, I began to work with women confronting sexual betrayal. It was this professional experience that inspired me to write Deceived: Facing Sexual Betrayal, Lies and Secrets, a book for female partners of sex addicts. Much of this article is excerpted from that book, published by Hazelden in April 2009."
Another Meadows author, John Bradshaw, discusses his new book, Reclaiming Virtue, in Author to Reader. According to John, "Reclaiming Virtue is a very ambitious book. I originally conceived of it as part of my own Stage Four recovery work, but I later came to the realization that the book is more like a record of my own struggle over the past 50 years."
In Twisters & Roller Coasters: Living with Complex Post-Traumatic Stress Disorder, Arizona licensed therapist Debra L. Kaplan discusses her work with CPTSD patients, its history, treatment options and prognosis.
You'll also find information on The Meadows' new Integrated Evaluation program; a list of upcoming workshops and seminars and symposiums; and details on The Meadows' free lecture series. The Cutting Edge is available in both HTML and PDF formats.