Self-medication and PTSD: A Path to Greater Complexity and Addiction?
Readers familiar with their own journeys or observing the struggles that loved ones endure know that PTSD symptoms sometimes demand immediate relief. Mood-altering chemicals, especially alcohol and marijuana, often provide temporary relief from anxiety, anger, depression, and other "limbic" surges. For many, alcohol and marijuana "take the edge off." They numb intense feelings, appear to quiet repetitive thinking, and afford some sleep and relief from the aftermath of trauma. In fact, in Western culture, alcohol has been a favored method of "recovering" among warriors, firefighters, and others who engage in vital but dangerous missions. Temporary relief usually comes in the form of "feeling no pain."
Actually, for a small but significant percentage of survivors, alcohol and other chemicals permit relief from the absence of feeling. In other words, getting drunk or high permits some feeling - any feeling - to break through the numbing produced by PTSD. Self-medicating is a devilishly seductive way of managing trauma. Self-medication provides temporary relief - a shortcut with the illusion of healing - but, oh, the price you pay! Alcohol, for example, will add to depression, confuse thinking, poison core relationships and, for some, set off violent behavior. For many, self-medicating will become a full-blown addictive disorder. Instead of one problem (PTSD), they now have two! Self-medication can involve food, sex, and the usual suspects: cocaine, opiates, amphetamines, cigarettes, alcohol and marijuana.
Academics and clinicians differentiate drugs from medicines: Drugs are self-administered without controls for dose, purity, etc. Medicines are taken only as prescribed (but often abused by active addicts). It's an oversimplification to say that all medicines are good, and all self-medication is evil. Many medicines cause harm; benzodiazepines and some sleep medicines can become addictive. However, in the hands of a skilled practitioner, medicines can provide much-needed symptom relief while the patient masters natural techniques that are highly effective in managing PTSD's multidimensional symptoms.
Recovery takes hard work and support. Re-stabilizing one's body and soul requires more than simple, singular solutions, sayings or insights; it is a process we know works. Self-medicating is not only risky, it is often tragic. Too many soldiers and civilians have been further injured by self-medicating. Simplistic, seductive, addictive, compulsive, and self-administered "treatments" too often result in broken marriages, broken careers and broken bodies. Life is hard enough without trauma, and trauma is hard enough outside of addiction.
The path to healing takes work, and work sometimes requires peer and professional support. John Barleycorn and Jack Daniels are not healthy supports or tools for recovery. If you are new on the journey of healing, do not be seduced by the temporary fixes offered by alcohol, drugs or other self-medicating behaviors. Recovery requires new skills. It's a process of integrating and healing, achieving and connecting - not masking, numbing or avoiding. Keep it simple and do not be intimidated, distracted or seduced by the siren song of medicating oneself.
In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness
The Meadows presents Peter Levine, PhD
December 3, 2010 Austin, Texas
Trauma is neither a disease nor a disorder, but is rather an injury caused by paralyzing fright, helplessness and loss. If we enlist the wisdom of the living, sensing body and engage our innate capacity to self-regulate high states of arousal and intense emotion, we can transform trauma and be healed. We will explore the roots of addiction in unresolved trauma, insecure attachment and habitual childhood frustration. Drawing on more than 40 years as a pioneering body-oriented clinician, as well as a parallel study of stress, biology, child development and discoveries in the neurosciences, Dr. Levine shows that it is possible to live life robustly with pleasure and creativity, even in the face of the most painful assaults to our humanity- and in the face of deceptively trivial ones. From an evolutionary understanding of the source of trauma, to a spiritual dimension of how we as human beings can be strengthened by traumatic healing, this journey unfolds- if we learn to attend to the "unspoken voice of the body."
This presentation will teach participants the following:
• To recognize the biological and naturalistic roots of trauma and their implications for treatment.
• To explain how sensate awareness is an important vehicle for regulating high arousal states and intense emotions in transforming trauma.
• To describe the relationship between developmental issues, unresolved trauma and addictive processes.
Peter A. Levine, PhD, Clinical Consultant of The Meadows and Mellody House, has a background in medical biophysics, stress and psychology. He is the originator of Somatic Experiencing®, which he has developed during the past 40 years. He teaches this method throughout the world. Levine is the author of the best-selling book Waking the Tiger and the book/CD Healing Trauma. He is also the co-author, with Maggie Kline, of Trauma Through a Child's Eyes: Awakening the Ordinary Miracle of Healing.
Sheraton Austin Hotel
at the Capitol
701 East 11th Street
Austin, Texas 78701
Self-parking at hotel is included.
5.5 Continuing Education Credits
To Register: http://www.themeadows.org/events/index.php?rm=event_details¶m1=show¶m2=135&
Note: This article was originally published in the Winter 2007 edition of MeadowLark, the magazine for The Meadows alumni.
Techniques for Managing Post-Traumatic Stress Disorder
By Lara Rosenberg
This article is based on a workshop that Lara gave February 13 - 14, 2006, in Sri Lanka hosted by the INGO RedR. The workshop is focused on staff working with individuals, families, and communities that have experienced or continue to experience traumatic events. It was an introductory workshop of particular value for staff having community experience, but limited or no psychological training. It was assumed that participants had prior knowledge of stress.
Stress affects us in many ways: cognitively, affectively, physiologically, and behaviorally. "Stress" is a broad term. It's part of all of our lives; each individual has his own ideas of how to define it. There are many definitions given to stress, but the important underlying factor is that stress results from a change in one's environment and requires an adjustment. The environmental changes that require us to adapt and adjust are known as "stressors" they can include anything out of the ordinary. Many think of stress as only negative, but it can be positive and necessary to our healthy development. The ways in which we adapt to our environments leave some stimulated and others with feelings of fear, nervousness, and confusion, which lead us to either solve or avoid a problem. Change always brings extra pressure, as individuals have to adapt to new circumstances.
Humans and animals are born with the capacity to react to threatening situations in adaptive ways; the "fight or flight response" allows individuals to experience resilience in response to danger. Bessel van der Kolk (1994) describes the fight response as hyper-arousal or protest and the flight response as freezing or numbing sensations, which allow individuals to avoid consciously experiencing the event.
Trauma is caused by a stressful occurrence "that is outside the range of usual human experience, and that would be markedly distressing to almost anyone" (Peter Levine, 1997). Post-traumatic stress disorder (PTSD) causes one to experience a prolonged or delayed reaction to an intensely stressful event. According to The DSM-IV Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, PTSD occurs when an individual experiences a threat (actual or perceived) of death or serious injury to self or others with a response of "intense fear, helplessness, or horror." PTSD can occur in adults and children from all socio-economic backgrounds. Most people who are exposed to a traumatic, stressful event experience some symptoms of PTSD in the days and weeks following exposure. According to the National Center for PTSD, data suggest that approximately 8 percent of men and 20 percent of women exposed to trauma develop PTSD; of that group, 30 percent develop a chronic form that persists throughout their lifetimes.
The World Health Organization (WHO) states that the prevalence of mild and moderate common mental disorders in the general population is 10% and can increase to 20% after a disaster. As stated by Dr. Daya Somasundaram from the Department of Psychiatry at the University of Jaffna, Sri Lanka (WHO, 2005), "WHO estimated that 50% may have problems and 5-10% have serious problems needing treatment. One [non-WHO] survey found 40% post-traumatic stress disorder (PTSD) in children," referring to people in Sri Lanka. Other data suggest that the mental health burden in Sri Lanka is even higher. Dr. Roy Lubit (2006), as well as Pia Mellody, a pioneer on the effects of childhood trauma, stresses that the full impact of trauma may not be experienced until a child reaches adulthood, engages in adult relationships and responsibilities, and develops more sophisticated cognitive capabilities.
The National Center for PTSD states that one of every three disaster survivors experiences some or all of the severe stress symptoms that may lead to lasting PTSD, anxiety disorders, or depression. Severe stress symptoms are extreme attempts to avoid memories and feelings. In order to numb their emotional pain, individuals will stay unusually busy, withdraw, and exhibit addictive behaviors. Violent behaviors often become prevalent.
Individuals can experience severe depression as part of PTSD, suffering a complete loss of hope, self-worth, motivation, and purpose. Some might experience disassociation, feeling outside of oneself as if living in a dream, or may become vacant for periods of time. Intrusive re-experiencing can occur through terrifying memories, nightmares, or flashbacks. For some, hyper-arousal manifests in panic attacks, rage, extreme irritability, or intense agitation. Other manifestations include severe anxiety, paralyzing worry, extreme helplessness, obsessive and compulsive behaviors, and feeling responsible for the event. Children often re-experience traumatic or stressful events through recurrent memories, nightmares, and play. Some children become very aroused, exhibiting nervousness, irritability, anger, disorganization, or agitation. Children also shun thoughts, feelings, or places that evoke memories of the event. Occasionally, they experience a loss of developmental patterns or skills, separation anxiety, bed-wetting, and learning difficulties. An 8-year old boy in Sri Lanka could not see for 10 weeks after enduring the terrifying experience of the tsunami, in which he lost his mother and home. This example of physical impairment demonstrates the freezing response described by Bessel van der Kolk (1996), as well as Peter Levine (1997) in his Somatic Experiencing® work.
Disaster stress may revive memories of prior trauma; pre-existing social, economic, spiritual, psychological, or medical problems can intensify. Individuals at higher risk for severe stress symptoms and lasting PTSD include those who have been exposed to other traumas, such as abuse, assault, or combat. Chronic poverty, homelessness, unemployment, or discrimination will often intensify the traumatic event, as can chronic illness and psychological disorders.
Most likely to develop PTSD are those who experience stress at a greater intensity, with unpredictability, uncontrollability, and real or perceived responsibility. Factors such as genetics, early-onset and longer-lasting childhood trauma, lack of functional social support, and concurrent stressful life events also contribute to the disorder. Those who report a greater perceived threat, suffering, terror, and fear are at risk for developing PTSD, and a social environment that produces shame, guilt, stigmatization, or self-hatred can affect sufferers as well.
Individuals experiencing PTSD face an increased likelihood of co-occurring disorders such as alcohol/drug abuse and dependence, major depressive episodes, conduct disorders, and social phobias. According to the National Center for PTSD, "In a large-scale study, it was found that 88% of men and 79% of women with PTSD met the criteria for another psychiatric disorder." Some experience difficulty in their psychosocial functioning, with profound problems in their daily lives. Concurrent prevalent physical problems include headaches, dizziness, chest pain, and other aches and pains. Often medical doctors treat only the symptoms, without considering PSTD development.
At the same time, stressful or traumatic experiences can facilitate personal growth. In treating sufferers, it is most important to restore safety in their lives, build coping strategies, and reduce pain. It is necessary to find out how they are coping with the situation and stress. Healthy coping mechanisms should be slowly introduced if behavior patterns reflect unhealthy habits such as smoking, drinking, or staying unusually busy. When dealing with disclosure, it is important that a secure and confidential environment is maintained. Humanitarian aid workers should teach survivors of trauma that they are not alone in order to help reduce a sense of isolation and rebuild trust. The aid worker should acknowledge and validate the person's feelings and experiences by offering comfort and support.
Aid workers should assume people are doing their best to cope and should empower them to feel as in-control as possible. Victims should not be asked to reveal emotional information, but if they volunteer it, helpers should listen. Access to mental and physical health services should be provided. In addition to reducing anxiety and depression, valued and meaningful goals help individuals regain hope and purpose. Improved access to education and employment opportunities encourages achievement. It is important to restore individual dignity and value, create opportunities for pleasure, and foster connections by maintaining or re-establishing communication with family and the community. Expressing oneself through journaling, reading, or becoming aware of experiences helps to release stress. Eliminating self-blame for what is occurring allows people to grow. Relaxation methods such as walking, breathing, meditation, yoga, prayer, and listening to music also promote healing, as do self-care behaviors such as brushing teeth, showering, and taking care of one's living environment. Small goals should gradually lead to a focus on the big picture.
The majority of trauma survivors will prove resilient; their feelings of fear and anxiety, along with urges to avoid or relive the experience, will decrease over time. Everyone handles life experiences differently, and it is necessary to allow each individual to heal at his or her own pace. The experience will always be a part of this person's life; however, the possibility of growing from the experience becomes more attainable when anxiety is reduced.
Note: This article was originally published in the Summer 2008 issue of MeadowLark, the alumni magazine of The Meadows.
Science and Ancient Wisdom: Treatment Here-and-Now
Before reading further, take 20 to 30 seconds to do this exercise: Let your gaze leave this article and let your eyes look around wherever, and at whatever, they want - just 20 seconds or so. (Really, try it, and then come back to reading.) People in my Somatic Experiencing® (SE) Trauma Treatment courses who try this are surprised that, in a very short time, they feel noticeably more relaxed, peaceful, and in the "here-and-now." Some say they should do this all the time!
Thanks to the forward-thinking people at The Meadows, the connection between trauma and addiction is better understood and more effectively treated. Part of this treatment at The Meadows' extended-care facilities consists of working with the trauma-resolution skills of Peter Levine’s Somatic Experiencing®. The relationship between trauma and the exercise you just tried is that, according to Bessel van der Kolk, post-traumatic stress is fundamentally a disorder in the ability to be in the here-and-now. This means that the state of- the-art in trauma therapy is no longer intense regressive or cathartic therapy. Instead, state-of-the-art therapy is the process of becoming alive to the moment.
For those I train in SE, like those at The Meadows, working in the here-and-now is a cornerstone of clinical theory and practice. When doing his dissertation decades ago, Peter Levine met Stephen Porges and explored his research. Porges' "Polyvagal Theory" (Porges, 2001) shows how one pathway of the nervous system engages freeze and another relates to social engagement. Levine discovered how to work with the transition of the nervous system through these phases (freeze and engagement), as well as the phases of fight and flight. This is SE. This article’s focus is on the engagement phase, which must be integrated into all other nervous system phases.
While Porges' emphasis is based on single linear phase transitions, in SE we work with non-linear and rapid cycling states, for instance, freeze and fight, or flight and orientation. Traumatic symptomology such as intrusion of fight, flight and freeze means that the past has become the present. Flashbacks are the classic example of such disorientation - innocuous cues can trigger an all-out response. In other words, the person temporarily experiences a state that is disconnected from the actual here-and-now environment. One of the antidotes to this traumatic recollection is orientation. I provisionally define orientation as "connecting to the environment through the senses" - in other words, coming back to our senses. This is a broader understanding of engagement than social engagement, per se. For clients whose early life experiences were marked by trauma and abuse, social engagement is actually a trigger for fight, flight and freeze. In this process of orientation, rather than being inundated with a cycle of feelings, thoughts, and sensations associated with unresolved trauma, the client's attention can be directed to the reality of the environment that is available through the senses. Typically we see decreased blood pressure and decreased heart rate, as well as the subjective experience of greater relaxation and interest. In other words, it is the difference between stopping to smell the roses and reliving getting stuck by a thorn!
With many severely disoriented clients, much of the initial therapeutic work (in addition to establishing rapport) consists of the stabilization that comes from establishing better cognitive pathways or habits of here-and-now sensory attention. In attending to the sensory experiences of the external world, physiological mechanisms for assessing safety are allowed to occur without undue influence from traumatic memory. The mechanisms of this assessment are far too important, in a survival sense, for the slow processing of linear thought or conscious effort. Porges aptly names this subconscious process of safety assessment "neuroception" (Porges, 2004). Thus, a natural orientation to the external environment via the senses facilitates the neuroception of safety.
This approach is receiving increasing scientific and popular attention (Time Magazine: Mind & Body Special Issue, January 27, 2007, pp. 55ff). Whether incorporated into CBT, DBT or meditation, the role of the observer is crucial. The process of orientation is fundamental to this cognitive activity. However, many traditions that recommend observation may not adequately reinforce with clients the importance of orientation to the outer versus the inner environment. For those with significant disorientation, it is nearly impossible to track the interior landscape without being involuntarily drawn into what SE terms the "Trauma Vortex." The involuntary and repetitive attraction to this "vortex" is the disruption of the approach-avoidance system, and it is one of the dynamics that underlies addiction and compulsive behaviors in general. Although somatically informed therapists draw from Levine's work, they often make the mistake of inviting clients' attention to the inward sensate experience, without consideration to the vital criteria that indicate whether a client can negotiate such attention without reactivating and reinforcing trauma states. For instance, one of the most common beginner's mistakes is when a therapist asks an anxious client to focus on that sensation in the body. For some clients, this can work well and provide a sense of relief and transition to a more relaxed state; for others, this can lead to further discomfort and other states of disintegration. It is vital for the therapist to immediately and accurately assess the client's capacity in order to determine the appropriate intervention. Without such assessment skill, the safer route is to begin with external orientation, which can stimulate the innate orienting response and build stability.
Once relative stability is attained, a balance of interior and exterior attention can be facilitated. Then a more neutral and practiced observation of the range of experiences can be enjoyed, as the attention can shift naturally between affective experiences, both positive and negative. (This fundamental process at the heart of SE is known as "pendulation," which I discussed briefly in the Summer 2006 edition of The Cutting Edge) This natural swing between polarities is the normal condition of the balanced nervous system. And interestingly, the resulting integration that comes from this innate oscillation is a broader and more nuanced life in the here-and-now. The experience brings awareness, presence, and a greater ability to experience life on its own terms, without undue constriction or elation. Obtained after significant work of attending, this resulting state can yield an expanse of awareness with an increasing ease of relation and a connectedness to everything that is. This state, known among meditative adepts, is simply our human mind freed of its overlay of conditioning hewn by survival networks related to approach-avoidance. Freed from the dominance of an ill-conditioned approachavoidance paradigm, one enjoys engagement with what is now, new and alive. And so, as clinicians, we can orient to the fact that we live in a time of opportunity, when mind and body are becoming reacquainted, and when science can shake hands with ancient wisdom.
Hoskinson, S. (2006) "SE's Systemic View of Functional Reward Systems." The Cutting Edge, Summer 2006. See TheMeadows.org.
Porges S. W. (2001) "The polyvagal theory: phylogenetic substrates of a social nervous system." International Journal of Psychophysiology, 42, 123-146.
Porges, S. (2004) "Neuroception: A subconscious system for detecting threats and safety." Zero to Three [Online] National Center for Infants, Toddlers and Families. No. 5, May. See zerotothree.org.
Stengel, R. (Ed.). (2007). The brain: A user's guide [Mind and body special issue]. TIME, 169 (5).
ABOUT THE AUTHOR
STEVEN HOSKINSON, MA, MAT
Under the auspices of Hoskinson Consulting in Encinitas, California, Steven Hoskinson, MA, MAT, is an international consultant and trainer for clinicians and trauma treatment providers. Steven is a Senior International Instructor for the Foundation for Human Enrichment and has done research in creativity, myth and spirituality. His perspectives include evolutionary, developmental, cognitive-behavioral and systems approaches within a mindfulness framework. Other major influences include personal mentoring with Peter Levine, PhD, more than 20 years of experience in the contemplative arts, and a decade as a practicing aikidoist. www.HoskinsonConsulting.org
Note: This article was originally published in the CuttingEdge Spring/Summer 2009 Newsletter
By Debra L. Kaplan, MA, LAC, LISAC
Not too long ago, a client who I was treating for prescription drug abuse, looked at me and said, "It's my desperate need to silence my feelings that drives me to want to use." She went on to describe what it felt like to live in her skin. "It's as if the people in my life are at the controls of this rollercoaster called my life and I'm trapped and I can't get off. I like or hate the ride based on how I feel about them at that moment; in my mind you're either with me or against me. But I can't fire them from the controls!"
Unbeknownst to this woman, she was verbalizing her underlying issue: Complex Post-Traumatic Stress Disorder (CPTSD). For the uninitiated, CPTSD is classified as a long-term traumatic stress disorder that may impact a healthy person's self-concept and adaptation. Exhibited symptoms include mood disorders (depression, manic-depression, anxiety); fear of real or imagined rejection or abandonment; and addictive, self-defeating behaviors including bulimia, anorexia, compulsive spending, sexual compulsivity, and perhaps self-injury.
In an effort to differentiate between psychosis and neurosis, the condition first was branded Borderline Personality Disorder (BPD). New research and advances in studying chronic trauma’s effects on self-concept and psychological organization have yielded a more accurate approach to characterize exhibited symptoms.
Recurring bouts of emotional instability wreak havoc on the life of an individual struggling with this issue. Along with the ups and downs of the emotional roller coaster comes confusion about one's identity. An individual with CPTSD often wrestles with a persistently unstable self-image; like in a house of mirrors, one's identity is rendered illusive and distorted.
Those who are familiar with CPTSD know all too well the chaos and havoc brought to bear upon relationships. In working with trauma complicated by emotional dysregulation, I have often likened the displays of impulsive rage to a cluster bomb. From one furious mass come multiple smaller submunitions. These emotional explosions neutralize any threat of real or imagined relational rejection, abandonment or disapproval. Loved ones who are idealized one day are devalued and rejected the next, relegated to the role of enemy - perhaps simply because an act of parting was interpreted as an act of betrayal. Some who struggle with CPTSD have co-occurring mood disorders that exacerbate internal stressors to the point of brief psychotic episodes.
Individuals with CPTSD often verbalize feeling wronged, misunderstood and empty. As is often the case, the trigger - be it internal or external - prompts attempts to self-medicate overwhelming emotions with alcohol or chemical dependence, acts of self- mutilation (cutting, burning, wrist-slashing), and even suicide attempts.
Historically speaking, the prognosis for CPTSD has been poor. Within the therapeutic community, clients who present with these symptoms have been branded unmotivated, hard to treat or, worse, noncompliant. The current belief - and one that I genuinely embrace - posits that a consistently supportive therapeutic relationship can become a healthy foundation that allows a client to begin to experience trust and safety. Much is still unknown about the post-traumatic condition, but continued advances in neurobiological, genetic, and social research have led to new treatments and psychopharmacological interventions that have proven successful in generating enduring, positive change.
The path out of the CPTSD maze begins with a gradual acknowledgement of the problem and a willingness to accept oneself. But what happens when one does not acknowledge the presence of a problem? Clearly, such denial undermines progress toward positive change. An individual's need to shield himself from unacknowledged and overwhelming feelings exists until he is psychologically ready to see himself as he really is - and not who he wants to be.
Support for an individual's attempts to break through denial is necessary for enduring progress to be made. The presence of a psychological struggle does not designate a bad or defective person. He's done nothing to deserve it, much like a child does nothing to deserve the onset of juvenile diabetes. However, the individual is now living a reality of roller coaster emotions, unstable relationships, addictions, and feelings of emptiness. The cold, harsh fact is that the self-defeating behaviors and unstable self-worth are not likely to change until the person changes.
As with all physical and emotional distresses, there comes a moment when the status quo is no longer acceptable. The chaos or unmanageability of a situation necessitates asking for help and taking action. Perhaps the adage "being brought to one's knees" applies here. An ensuing adjustment period, in which one comes to terms with a new reality, may not be immediate. However, a new perspective might arrive with a sobering blow to the denial - or with the quiet realization that life is eroding beyond one’s grasp. Self-acceptance can be attained perhaps only through small, sometimes imperceptible steps. In recovery speak, it is progress rather than perfection that guides us: "I am not a problem, but my behavior has become problematic!" I ask my clients, "Which would you prefer to be: resolutely right or resolutely happy?"
When one is living a life that, despite great efforts, no longer results in satisfying outcomes, it is time to look inward and ask the hard questions: "What am I doing that is no longer working? Harder yet, what am I prepared to do about it?"
Until that moment of introspection and committed motivation, little if any enduring change will occur. But the path out of the house of mirrors, and away from the emotional roller coaster, is the path to a new life.