The Meadows Blog

Monday, 19 March 2012 20:00

What Caused Sgt. Bales to Snap?

A group I facilitate for Vietnam Veterans struggled with this question even before the name of the accused sergeant was released. Violence, injury, death and war stir intense emotions in all, particularly among veterans who have been up close and personal. The issue of atrocity and slaughter of civilians is, naturally, an incredibly intense and sensitive subject.

My group members wrestled with this for 90 minutes; most had extreme empathy for the cumulative damage war has upon warriors. They could not even begin to grasp the immense pressure put upon younger soldiers, some of whom serve three, four, and up to nine tours. They/we are humbled by shocking reports of soldiers committing sudden violence, some of which is toward family, but more often towards self. They embraced the contributing factors that need be considered: alcoholism, traumatic brain injury, post traumatic stress disorder (PTSD), financial problems, issues of unemployment, possible relationship problems, a passed over promotion, an unwanted next tour, recent injury, and experiencing the wounding or killing of fellow warriors.

Reports indicated that Sgt. Bales was suffering from many of these factors; he was also reported to be highly decorated, a model soldier, and has saved lives of civilians and Americans in some of the hottest conflicts in Iraq. How could a highly trained soldier, a member of an elite unit, trained sniper and leader of men possibly commit such an atrocity? Our group struggled with this question and did not come to a clear explanation. They had empathy and contempt; some launched into politics of the current wars, some blamed the military for too many rotations, some defended the military, others discussed the role of combat, loss of recent friends, PTSD, alcohol, and tbi (traumatic brain injury). The discussions were intense and a few favored certain factors, but no consensus or full explanation was derived.

One thing we did derive: in certain situations our usual narratives fall apart. If the conditions are right, we are all capable of sudden violence or extreme behavior. The media will no doubt speculate on which factor(s) were critical in this current horror. Forensic experts will attempt to definitively opine, but we may never fully know why this particular soldier "snapped" in such a dramatic and horrific fashion. Thousands of soldiers carry the burdens of war. Most struggle in silence and harm no one, and if they do injure anyone, they hurt or punish themselves.

We may never know the full explanation of what went wrong. My personal speculation is that alcohol played a large factor. It is the most common variable in violence: domestic, self or toward others. It also works in tandem with PTSD and traumatic brain injury. What will probably emerge is a complex picture of a determined and accomplished soldier worn down by many variables, military and domestic. Early reports suggest Sgt. Bales and others were drinking heavily that evening, against military rules. Those early reports also suggested drinking to levels of blackout. Sgt. Bales allegedly had a drunk driving hit and run episode while stateside. Whereas not the sole factor, alcohol might have been the "tipping point". Alcohol is a common way of "self-medicating" or "de-stressing", but it can have an almost "evil" impact in unleashing primitive emotions. In fact, it is a common but often understated factor in the surging suicide numbers in young soldiers. Alcohol has a long history of violence in so many settings, especially the home. Unfortunately, we continue to deny alcohol's power or even its presence. Mr. Bale's attorney alleged his client had not been drinking.

We will know more as facts emerge, but we may never fully grasp what went wrong or why. We do know that war is ugly; it changes people and distorts mind, body and soul. The results of war can make you feel "untouchable" and unique. My hope is that veterans or military personnel reading this blog will recognize that their worst fears are not reflected in the rare disasters. Most people, even civilians, have a fear of "snapping". Exposure to the horrors of war intensify that fear beyond that which most observers can express or comprehend. The vast majority of those who develop PTSD do not snap. Instead, they suffer quietly and deconstruct their lives. PTSD, especially with co-occurring addiction, is complicated and destructive, but highly treatable. Recovery requires Sleep, Safety and Sobriety, the three "S's" that are the first steps in separating you from the demons of war.

Jerry Boriskin, Ph.D, has been at the forefront of the treatment of PTSD, addiction, and co-occurring disorders for more than 30 years. He is the author of several books, including PTSD and Addiction: A Practical Guide for Clinicians and Counselors and At Wit's End: What Families Need to Know When a Loved One is Diagnosed With Addiction and Mental Illness.

For more about The Meadows' innovative treatment program for PTSD and other disorders, see or call The Meadows at 800-244-4949.

The Meadows, a world-class trauma and addiction center in Wickenburg, Arizona, is a gold sponsor of The American Foundation for Suicide Prevention (AFSP) Out of the Darkness Campus Walk at Arizona State University in Tempe, Arizona, on Saturday, March 31 from 10:00am to noon. A team from The Meadows will also be participating in the walk.

Last spring, AFSP launched its inaugural Out of the Darkness Campus Walk campaign. The Campus Walk, patterned after AFSP's highly successful Community Walk will take place again in 2012 at colleges and high schools across the country. Suicide is the third leading cause of death for people ages 15-24, only accidents and homicides are higher. For college students specifically, suicide is the second leading cause of death, just behind accidents.

The goal of the ASU Walk is to create awareness and raise more funds for aggressive mental health research and programs for college and high school students within the local community. The ASU Walk hopes to raise $20,000.

"We are pleased to support this very important event," said Jim Dredge, The Meadows CEO. "The Out of the Darkness Campus Walk campaign helps bring attention to the need for more suicide prevention education."

Steve Schiro, the AFSP Field Advocate in Arizona, became involved with the organization after his son, who was a senior at ASU, took his life last year. "My wife and I are both educators and we didn't see the signs. We needed to learn more and we found AFSP," Schiro said. Both he and his wife now serve on the board of the Arizona Chapter." Schiro added that awareness for students to see the signs of depression and suicide will bring the subject out into the open so people can talk about it and realize that there isn't a stigma and there are alternatives.

For more information on how to participate in the walk, please call 480-227-4230 or visit

A body of research indicates that there is a correlation between trauma and suicidal behaviors. The Meadows is the industry leader in treating trauma through its inpatient and workshop programs. To learn more about The Meadows' work with trauma and addiction contact an intake coordinator at (866) 807-3778 or visit

AFSP is the leading not-for-profit organization exclusively dedicated to understanding and preventing suicide through research and education, and to reaching out to people with mood disorders and those impacted by suicide. Since 1987, AFSP has invested over $10 million in new studies, as well as provided education and information through public workshops, trainings, our adolescent and college educational films, publications and public service announcements addressing teen depression.

For over 35 years, The Meadows has been a leading trauma and addiction treatment center. In that time, they have helped more than 20,000 patients in one of their three centers or in national
workshops. The Meadows world-class team of Senior Fellows, Psychiatrists, Therapists and Counselors treat the symptoms of addiction and the underlying issues that cause lifelong patterns of self-destructive behavior. The Meadows is a Level 1 psychiatric hospital that is accredited by the Joint Commission.

Attachment Theory in Action: Feeling Attachment Security in the Body

Several months ago, as I sat waiting to board a flight, my attention was captivated by an active toddler sitting (for the most part) on her mother's lap. Beneath naturally curly locks of hair, her eyes, bright and curious, darted about the busy terminal, feasting on the smorgasbord of novel stimuli. When a scruffy-looking man passed by in a wheelchair and offered a gnarled hand to the young child, she fearfully buried her face in her mother's loose-fitting sweater. The girl's mother instinctively pulled her close and whispered softly in her ear while giving the grizzled man an apologetic smile. As the man pushed on, his course laugh still lingering in the air, the girl gingerly emerged from her safe, sweater-cocoon to survey the scene. Still within her mother's secure embrace, the girl stood-up and ventured an inquisitive glance in the direction of the retreating man. Her fear had been down-regulated and she was able to explore the environment once again.

Interactions like this between a parent and child are repeated on a regular basis throughout early development. From the perspective of attachment theory, these dyadic experiences are the foundation for all social-emotional development. It is noteworthy that, from the earliest moments of life, attachment experiences are interactions between two minds and two bodies. As illustrated by the example above, the mother sensitively responded to the nonverbal intentions and emotions of the child by communicating safety and security through an embodied interaction with her child. In this way, attachment experiences, whether secure or insecure (as in the case of relational trauma and abuse), are incorporated into the body's self-regulatory systems, and as a result, can play an important role in how the body reacts and responds in close relationships later in life.

This article is part of a series on attachment theory and relational trauma (see the first article for an overview) and is meant to illustrate how attachment theory can guide a therapeutic approach that incorporates working with emotions and the body. To ensure patient confidentiality and anonymity, the clinical example in this article is a fictional account based on many different patient histories and various treatment experiences. Although the following clinical information isn't associated with one particular person, it is representative of many people who have experienced relational trauma.

Karen, as I will call her, was a 37 year-old divorced female who entered treatment after becoming depressed and suicidal following a breakup with a boyfriend. She reported that symptoms of depression and anxiety had been a problem for most of her life, but they always got much worse during periods of relationship turmoil. Similar to previous episodes, when the most recent relationship ended, she turned to alcohol and binge eating to numb the pain.

Karen reported that whenever a romantic relationship ended, she felt a profound sense of emptiness and loss. After her partner left, she couldn't stop thinking about what she might have done wrong and she feared that she would never have a healthy relationship. She fantasized incessantly about getting back together and about how she would "fix" herself to make the relationship work.  These kinds of thoughts plagued her day and night until the helplessness and despair were overwhelming.

As a child, Karen's mother struggled with alcoholism and her father with workaholism; she remembered feeling like she was constantly hungry for their attention and love. In fact, as a young girl she was certain that her father had a trap-door in his office where he would disappear and carry out his "secret life". Even when her parents were available, she often worried that she was "annoying" and she feared that her desire for attention actually drove them away.

Karen's parents divorced when she was nine-years-old and their separation only intensified her father's distance and her mother's alcoholism. The pain and loneliness associated with her parents" divorce was partially ameliorated by a warm and loving relationship with her maternal aunt, who had been a stable figure throughout her life. However, at thirteen-years-old, her aunt died, and not long after that, Karen began using food and alcohol in excess to alter her mood.

Karen's childhood history indicated that she likely had insecure attachment relationships with both parents that could be categorized as ambivalent/preoccupied. In other words, her early development was marked by implicit feelings of insecurity because she was unsure whether or not her parents could consistently provide a safe and secure presence in her times of need. Additionally, she believed that this lack of security was her own fault, which led to a pervasive fear of abandonment and a preoccupation with maintaining closeness. These patterns of thinking and feeling seemed to carry-over into adulthood where her romantic relationships were characterized by an anxious attachment style and showed clear signs of love addiction (as described in Pia Mellody's work).

This kind of assessment of Karen's attachment relationships was very helpful in formulating her treatment plan at The Meadows. Recognizing that she would likely harbor tremendous fear and anxiety about rejection and abandonment, treatment providers were careful to establish a secure therapeutic environment with clear limits/boundaries and a consistent, warm, and responsive presence (elements that were missing from her early attachment relationships). Through various forms of treatment (including highly experiential inner-child work), she was able to acknowledge and process long-held feelings of pain, fear, anger, and shame regarding her early attachment relationships.

Although Karen strongly identified with the concept of love addiction, halfway through her treatment she was still struggling with intense thoughts and emotions regarding the unhealthy relationship that preceded treatment. During a session when she was particularly emotional about this subject, the therapist asked Karen to close her eyes and imagine what it would feel like to finally end the relationship and say goodbye to the relationship partner. Karen said, "It would feel like saying goodbye to a part of me... there would be a hole in there." She pointed to her chest. The therapist asked, "As you imagine that hole in your chest, what does it feel like in your body?" Karen's face winced and her eyes shut tight as she responded, "It's like a sharp, stabbing sensation."

The therapist inquired further, "As you are feeling the stabbing sensation in your chest, do you notice any other thoughts or emotions?" Karen paused, her hand over her chest now, "I worry that the hole will never be filled - that I will never find anyone else." The therapist tenderly implored, "How does it feel in your body as you say that?" Her breathing increased and her shoulders tensed upwards, "Now I feel tightness in my chest and throat." Knowing that the tightness was likely defending against something even more vulnerable, the therapist deepened the approach, "What would happen if you never found anyone else? What would that say about you?" Karen's shoulders released, she bent over slightly and began to cry, "Maybe it's me... maybe I'm just unlovable." The therapist gently asked, "How does that feel in your body?" Through streaming tears, Karen replied, "There's a deep ache in the pit of my stomach - that's where the hole leads - that's where it ends. It really hurts."

Karen was invited to stay in-touch with the deep ache in her stomach while the therapist guided her in some breathing exercises. Once Karen's emotions were more regulated, the therapist asked her to think about a relationship in childhood where she felt unconditional acceptance and love. Karen immediately identified her deceased aunt and tears welled-up in her eyes once again. The therapist queried, "If your aunt were here right now, how would she respond to the deep ache you are feeling?" Karen was still crying, but a faint smile came across her face, "She would give me a big hug and then she would just stay here with me." The therapist asked, "When you think about your aunt's response, how does that feel in your body?" Her frame straightened and her smile broadened, "It feels warm all over... more open and free inside my body." After a few moments of quiet introspection, she spontaneously added, "The ache is gone."

Relying on the wisdom of her body (and with help from the therapist), Karen was able to drop below the habitual thoughts and feelings associated with love addiction and actually experience the pain associated with early attachment insecurity (i.e., "I'm unlovable"). More importantly, she was able to contrast, and even dissolve, this deep pain through an embodied experience of secure attachment (i.e., "unconditional acceptance and love"). Later she had great difficulty describing this therapeutic process in words, but it proved to be an "emotionally corrective experience" that she carried with her throughout her treatment. Gradually, by bringing awareness to feelings in her body, and the associated thought processes, Karen learned more about her love addiction patterns and she developed tools to tap into a hidden wellspring of compassion and positive regard for herself.

Like most people, Karen's childhood experiences with attachment figures profoundly influenced how she felt about herself and her relationship partners. Indeed, the mental and emotional scripts associated with early attachment relationships are written into the neurobiology of the developing child and, often without conscious awareness, are acted out on the stage of romantic relationships. Fortunately, meaningful and lasting alterations to these scripts can be facilitated by a variety of therapeutic techniques, particularly those that are experiential in nature and involve working with emotions and the body.

ADHD, Income Taxes, and Unopened Envelopes

by Bonnie A. DenDooven, MC, LAC

Many Americans have a visceral, gut-wrenching reaction to the terms "IRS" and "taxes". It is a response quite similar to the way certain war veterans with PTSD over-react to the sound of a car backfiring. For those who suffer from financial disorders, fear of unopened envelopes and misplaced financial records is the norm, but at this time of the year, the fear of the IRS combined with ADHD and unprocessed trauma from childhood could exacerbate the problems. Research now shows that 67 percent of adults who are diagnosed with ADHD have problems with money management (1). The additional mental concentration required to gather and process tax forms sends many reeling into a spiral of shame and panic.

Managing finances is a unique challenge for an individual with ADHD. The major features of procrastination, disorganization, and impulsivity can wreak havoc. Surveys have shown that when compared with their non-ADHD peers, adults with ADHD may be three times more likely to be currently unemployed and forty-seven percent more likely to have trouble saving money to pay bills. Financial disorders follow ADHD adults.

Evidence is starting to show that for some, it is more than ADHD causing problems. Childhood financial trauma is frequently at the root of financial mismanagement. This helps to understand why purely behavioral solutions such as creating budgets, making spending plans, writing down all expenditures, or even putting money into envelopes has not worked for certain people. When emotions are involved in finances and fear dominates, cognitive behavioral remedies must be preceded by affective and somatic therapy to bring resolution to the fear.

The greater effort some people exert at changing their money behaviors by focusing on them, the more chaos they encounter. It may be like hearing a car backfire every time they think about money.

What happens to make a mature adult reduced to feeling powerless over finances and afraid like a helpless child? Peter Levine says in a video interview, "ADHD is a very complex . . . but when I work with kids who have ADHD they look like kids who had trauma." He goes on to say, "When we work with ADHD from a trauma model the symptoms appear to go away. The hyper-arousal, hyper-vigilance, inability to attend to the here-and-now, the inability to focus, those are key elements of trauma."(2) Psychological trauma is a violation of the person's belief that their world is safe and secure. A highly charged and emotional argument between caregivers over money can create extreme emotional confusion and insecurity for a child who may not understand the details of their parents' conversations, but do understand the powerful emotions at a deep limbic level. Children understand the power of money in an argument, just as they understand the power of alcohol over an alcoholic parent. In the world of financial disorders, we are treating many Adult-Children-of-Money-Trauma-Families.

Fighting over money is the one disagreement over all other disagreements that can predict divorce. A 2009 study(3) by Jeffrey Dew, a faculty fellow at the National Marriage Project, Utah State University, showed that couples who disagree about finances were over 30 percent more likely to divorce than those who did not. For women, arguments about sex ranked second with money arguments first as a precursor for divorce, but for men, financial disagreements stood alone at the top for breaking up a marriage. Nothing strikes fear and creates trauma in the heart of a child as severely as the fear of losing a parent. Divorce means a loss. In the eyes of a child, an argument between Mom and Dad can be scary enough, but a resulting divorce co-mingled with the topic of finances can create a situation where any future conversation about money is trauma-bonded to the panic of survival and loss.

The first 30 days of each year, most people receive important tax documents in the mail. Individuals stuck in the FREEZE arousal state of PTSD will fail to open the envelopes for several more weeks and will procrastinate, sometimes until the last minute or after. The "unopened envelope" stack is a familiar phenomenon to speakers at a Debtors Anonymous or Business Owners Debtors Anonymous meeting. Some 12-steppers need to get help to just sit with them while they open the envelopes - to help them unfreeze from the panic.

Many people respond to the perceived financial danger with FLIGHT. While some have a desire to flee any financial discussion, the tendency is never more pronounced, obvious, and identifiable than in the weeks leading up to April 15th. The angst of having to deal with records, receipts, statements, forms, and most of all, submitting to financial authority, becomes a secret horror. Those stuck in the FLIGHT are likely to misplace documents, checks, forms, receipts and writing utensils in an unconscious attempt to flee and get some distance from the task itself - out of sight, out of mind.

Those stuck in the FIGHT arousal state can be expected to take extraordinary risk by literally cheating on their taxes - creating their own private battle and attempting to win at any cost. It is an emotional, fearful fight to end all fights. The fear of having cheated on ones taxes creates ongoing fear of getting caught. It is trauma repetition every time an envelope comes from the IRS.

The most common recommendations of money management do not work for some because each budget, each bill, each envelope re-traumatizes. The therapy required is to resolve the unprocessed trauma and become free from emotions of the past.

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").

(1) 2003 - 2004 UMASS study



Tuesday, 21 February 2012 19:00

The Meadows Survivors Workshop Experience

The Meadows Survivors Workshop Experience

Testimonial from Scott E - a 20 year-old participant in February 2012

I recently had the chance to attend the Meadows Survivors Workshop. Upon completion, I was asked to describe the experience and I wrote the following thoughts.
The Meadows was the most eye opening experience of my life. It has left me in awe; the program was a godsend for me. I was able to go places inside of myself that I was unaware of. Places that would be forbidden to go; and that I would unconsciously avoid. I was able to go there and break down walls from within. I love this workshop and the facility and staff because they made me capable of loving myself.

I had compassion for others and was able to share my emotions with others. I was able to cry when I needed to cry, and laugh when I needed to laugh.

Most importantly I'm leaving with a smile and love for myself. I'm content with me and I know that I am a gift to this world. I leave intrigued with myself, with a respect and love for others and ready to take on life on life's terms. My slogan for the Meadows is that shit gets real, real fast. I am 20 years old...

Thursday, 16 February 2012 19:00

Whitney Houston, a Tragic Loss

We are all mourning the tragic loss of Whitney Houston. While there are no definitive answers regarding the cause of death, her battle with addiction was played out in the media for many years.

Interventionist Brad Lamm has written an informative article about Whitney Houston and addiction in the Huffington Post entitled "The Rules Are Different." In the article Lamm discusses how the addicts' rules are different.

As he describes, "I'm like Whitney. I drank, coked, and smoked and swallowed Xanax to cope, then there was calm. I tried to live in the middle where moderate drinking and pills wouldn't get the best of me - while keeping coke and crystal meth on the shelf. It didn't work."

To read the rest of the article, visit

Long before I was a psychiatrist, I worked at a golf course rummaging through thorny shrubbery and dense pockets of oak trees to find golf balls that had strayed from their masters. As an eight-year-old boy, this hardly seemed like work - it was more like a treasure hunting adventure, complete with the threat of poison ivy and villainous snakes. After a couple of cycles in the ball-cleaner, a relatively unscathed Titleist could fetch a dime, and a bucket of similar balls could finance an extravagant trip to the candy store.

Occasionally I would come across a ball that looked as though it had been mauled by a wild animal (or, more likely, a large lawnmower); the ball's hard shell filleted open, allowing the mangled elastics to protrude through the untidy gash. Such a ball had no monetary value at the time - but these many years later, the image of the ruptured golf ball has become a meaningful metaphor in my work with individuals who have experienced trauma.

For humans, trauma can take a myriad of forms, yet the immediate response is surprisingly predictable. Like most animals, trauma in humans evokes an automatic and primitive instinct to survive. The traumatic stress response has little need for logic or reason, but instead relies on the unconscious reflexes of fight, flight and freeze. Therefore, out of necessity, the tender and vulnerable aspects of trauma are often swallowed up and pushed away. Survival is the goal.

Actually, this universal response to trauma is remarkably successful... at least in the short-term. By in large, people do survive. After experiencing trauma, most people get up and they face family and friends, they go back to school and work, they re-engage in life. Often, there is no other option. Life keeps moving - it doesn't pause for trauma processing. People do survive, but the trauma is still there.

In many cases, the thoughts and emotions attached to the trauma are too tangled and messy to be processed openly, so they get pushed to the back, into a dark corner of the psyche. But trauma has tentacles, like rubber bands, that reach out from the darkest corners and pull at the mind and body, threatening implosion and utter collapse. So, frequently the traumatized individual unwittingly severs the rubber bands - disconnects from the trauma - letting the frayed elastics retreat into the dark where they twist and turn into a ball.

This ball of elastics is ripe with potential energy - wrapped tight with anger, fear, shame, and self-blame. Often, there is tremendous anxiety that the quivering ball will unravel and all that pain will burst into awareness, wreaking havoc from the inside. So, like the shell of a golf ball that contains its elastic core, the traumatized individual applies an analogous hard, protective coating over the reactive ball of trauma. This resilient shell is meant to encapsulate the energized elastics of trauma and allow the individual to bounce back into life.

For some individuals, the trauma is walled-off with layers and layers of denial and repression. In fact, the protective coating of repression can be so effective that, over time, the person may not have any conscious recollection of the traumatic event. For others, the trauma is encapsulated with the help of alcohol, drugs, work, food, or sex. However, the protective effects of these practices are often short-lived and eventually, the addictive behavior contributes more pain to the process than it does protection.

The layers of repression and addiction can be applied for years, sometimes even decades. However, keeping the loaded bands of trauma sequestered and contained taxes the mind and the body. As a result, defensive barriers can be unexpectedly breached by a subsequent trauma or loss later in life, such as infidelity or divorce, children leaving home, retirement, financial insecurity, or the death of a loved-one. Sometimes the protective layers are peeled back by more subtle insults: a random encounter with a person from childhood, a television program or newsworthy incident, or a body-oriented experience like massage or surgery.

When the trauma finally breaks through the ruptured shell, there can be tremendous fear, anxiety, pain, anger, and confusion. Many individuals feel like they are losing their mind - they doubt their own inner experience or blame themselves for not keeping the painful emotions under tighter control. Often, desperate attempts are made to stem the emotional hemorrhage using familiar defensive tactics, like avoidance and addiction. However, much like a ruptured golf ball, it may be impossible to repair the untidy gash in the protective coating and push the traumatic content back under the shell.

In this vulnerable position, where old defenses are no longer effective, the traumatized individual may benefit from clinical treatment. With the supportive guidance of treatment professionals, a safe therapeutic environment can be co-created so that habitual defenses can be relaxed and the traumatic material can be acknowledged. Through a variety of treatment techniques, the intense thoughts and emotions associated with the trauma can emerge from dark corners, into the soft light of awareness. The tender aspects of trauma that were pushed away in the service of survival are finally allowed to come forth and are the very seeds that will give rise to a growing inner strength.

As recovery progresses, there can be an inexplicable movement towards wholeness - a genuine desire to open oneself to what has long been walled-off. For most people, the trauma doesn't necessarily go away. However, out of the wreckage of ruptured defenses, one-by-one, the tangled bands of trauma can become an integrated part of a person's life. Indeed, many people have discovered that the experience of trauma can become a pathway to profound tenderheartedness and compassion for oneself and others. In the poetic words of Rashani Réa, "There is a brokenness out of which comes the unbroken, a shatteredness out of which blooms the unshatterable."

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 well being. 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.

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.

Free Lecture Series - Houston, Texas, August 2, 2011


The Council on Alcohol and Drugs Houston
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Houston, Texas 77007
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please contact Melanie Shelnutt, Houston Community Relations Representative, at 877-733-7930 (713-702-7784 local) or email

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