An assault on trauma and addiction: PTSD treatment

Recent articles indicate that 15 percent of American and 6.1 percent of Canadian military personnel return home from conflicts such as Iraq and Afghanistan with symptoms of post-traumatic stress disorder (PTSD) or major depressive disorder (MDD), and that hospitalizations for mental disorders like PTSD now surpass those for battle injuries in the U.S. military. 1,2 Unfortunately, many of these traumatized individuals become addicted to alcohol or drugs in an attempt to control their trauma-related symptoms. One U.S. study showed that between 60 and 80 percent of combat veterans with PTSD also met the criteria for alcohol or drug abuse. 3

PTSD is not new, though methods for its treatment have evolved, notably during World War II and the postwar period. At that time, Dr. Gordon Bell, a pioneer in addiction treatment in Canada and co-founder of Bellwood Health Services (Toronto, Canada), was asked to prepare emotionally disabled veterans-many of whom suffered from what we now call PTSD-for a return to civilian life.4 Since 1984, Bellwood has continued his work with military personnel and veterans facing addiction problems and, in many cases, PTSD. In 2000, Bellwood began offering a treatment program for co-occurring PTSD and addiction to military and other clients involved in hazardous occupations (i.e., police, firefighters, and disaster teams).

Understanding PTSD

Judith Herman observed that “the common denominator of trauma is a feeling of intense fear, helplessness, loss of control and threat of annihilation.”5 Bessel Van Der Kolk adds that a person's coping mechanism becomes overwhelmed because the stressful event is inescapable.6

The diagnosis of PTSD incorporates experiencing, witnessing, or hearing about an extremely stressful event that involves actual or threatened death or serious injury. PTSD, created by the raw, intense feelings of terror, helplessness, and loss of control that are triggered by an event, can occur at any age. Symptoms can be divided into three categories: persistent re-experiencing symptoms, persistent avoidance and numbing symptoms, and persistent hyper-arousal.7 Examples of these symptoms may help to convey the complexity of treatment required:

• Re-experiencing of the traumatic event through recurrent and intrusive thoughts, perceptions, and images, and terrifying nightmares and flashbacks.

• Avoidance of people, places, and activities reminiscent of the trauma, along with diminished interest, feelings of detachment from others, and an inability to plan ahead.

• Increased arousal, seen in irritability, anger, rage, hyper-vigilance, or an exaggerated startle response.

The “living hell” of PTSD, in which an individual feels trapped by memories and doomed to relive the trauma again and again, poses huge challenges in everyday life. It increases stress in marital and parental relationships. It can cause memory and concentration problems, issues in employment and finances, as well as legal difficulties. It can result in low self-esteem, feelings of hopelessness, and a sense of failure.

Essentials of PTSD treatment

Upon entering treatment, PTSD/trauma and addiction clients present with complex clinical issues related both to the trauma they have experienced and to the substance abuse that has served as a maladaptive coping strategy. Compared to non-affected substance dependent clients, those with comorbid PTSD/trauma must also engage in a treatment plan designed to help them manage the symptoms associated with their psychiatric disorder.

Treatment for PTSD, along with recovery, must be ongoing, involving the whole person: body, emotions, mind, and spirit. While the traumatic experience cannot be erased, it is possible to treat trauma symptoms and help clients manage them with new coping skills. Often, treatment must help clients address spiritual or existential issues: the meaning of life, the reality of human suffering and death, the darkness of the human heart, and human powerlessness in the face of natural forces.

Treatment programs for PTSD and addiction must address four components:

Individual problems. Empathy and gentleness is essential in creating the sense of safety that is needed for clients to overcome defensive avoidance and talk about their trauma with others. Clients often withdraw into a “safe” due to deep feelings of shame, distrust, and the fear of being judged by others.

Because PTSD has both psychological and physiological components, trauma recovery also needs to address and heal the connections between mind and body. At the outset of treatment, it is important to teach clients how to “down regulate” the hyper-arousal of their nervous system. Mastering methods for soothing and calming themselves helps clients create the sense of safety and self-control needed to begin trauma processing. Bellwood staff has observed that clients respond well to acupuncture treatment, which appears to promote relaxation and diminish substance cravings. Massage therapy is also integral to treatment, since it counteracts a common PTSD symptom-numbing or decrease in body sensations and feelings-while releasing muscle tension and promoting relaxation. In the words of Dr. Steven Melemis, “Relax your body and your mind will follow.”8

Psycho-education about PTSD is another important aspect of the treatment program, with elements that may include:

• Learning about the neuroscience of PTSD symptoms in order to understand the effects of trauma on the brain.

• Development of strategies to reduce or change the content of recurrent nightmares and learning about sleep hygiene to assist with the difficulty falling or staying asleep.

• Methods of acupressure tapping, a technique that combines physical distraction with systematic desensitization to reduce the impact of stressful thoughts and feelings.

• Somatic experiencing or sensorimotor psychotherapy.9,10

• Weekly, two-hour PTSD group therapy sessions open only to military/hazardous occupation clients, which provide a tight-knit forum where clients can realistically and safely share violent experiences, including those involving civilians, without fear of misunderstanding or judgment.

It is essential that any program be led by a therapist with experience and knowledge of PTSD treatment. The therapist must be able to address clients' most severe symptoms while assessing their stability and the appropriateness of treatment. Clients frequently arrive in a hyper-aroused state, often with a history of suicidal ideation or attempts, anger-control problems, or aggressive behavior. Yet, in their desperation for treatment, they know that their acceptance of treatment offers hope.

One key issue for military clients is anger management. While anger is often part of psychological preparation for combat, it makes the adjustment to civilian life difficult upon returning home. At home, as they confront combat-related emotions-grief, sadness, fear, anxiety, powerlessness, and lack of control-clients must learn to turn away from the anger that gives them power and control on the battlefield. They must learn methods for mastering angry impulses to eliminate the threat of violence against others, at home or in the community. At Bellwood, clients participate in an intensive, small-group anger management program, spanning 12 hours over a four-week period.

Impact on the family. Children can be severely affected by the PTSD symptoms of a parent, who returns from service a changed person. They may hear their father waking up at night, screaming, or they might feel restricted by day because his hyper-vigilance and fear for their safety means they cannot walk, visit, or play in the community as they used to. Spouses, too, are puzzled, living with an unpredictable, sometimes violent individual that they no longer know and seemingly cannot help or comfort. Family members need education about the trauma and addiction their loved ones face in the treatment program. Often, they require ongoing therapy themselves.

Stigma in the workplace. Because only a minority of returning soldiers (or others involved in hazardous professions) develop PTSD, it can be very difficult to acknowledge. Many clients, feeling institutional and societal stigma, express fear and shame: “Why me, when the others are fine?” They feel weak, vulnerable, or as if they have let others down. Until quite recently, acknowledging a PTSD diagnosis was feared as a cause for early discharge, an end to advancement, or a form of “career suicide.”

Fear and stigma often lead traumatized active-duty personnel and veterans to feel angry at the military, which was once the focus of their loyalty. Treatment providers must address this and help the client to regain a sense of trust, a feeling that it is OK for them to pursue and use the treatment and support that is available to them in the military system. Ongoing education among those involved in the military and other hazardous occupations is another vital factor in reducing this harmful stigma.

In Canada, the Operational Stress Injury Social Support Program (OSISS), developed by Lieutenant Colonel Stephane Grenier, offers traumatized personnel peer support from recovering veterans, military members, and relatives who have suffered the effects of PTSD (now referred to by the Canadian Forces as an operational stress injury or OSI). OSISS peer leaders have been invaluable to staff and clients in articulating and resolving the trust and relationship issues that occur between traumatized clients and the military.

Transition to continuing care. Addiction treatment providers know about the importance of continuing care. In addition to ongoing supports such as 12-Step attendance and aftercare groups, clients with co-morbid PTSD and addiction require specialized therapy in their home community to continue the recovery process. These clients also benefit from periodic visits to their treatment center for refresher treatment programs, which give them a chance to reconnect with the staff and facility where they learned the necessary self-management techniques to begin their journey of recovery.

Although the co-morbid diagnosis of PTSD and addiction presents a “more severe clinical profile than those with just one of these disorders,” inpatient treatment-followed by ongoing care in the home community-offers the opportunity to create a secure foundation for ongoing recovery. 11

ABOUT THE AUTHORS

Janice M. Hambley, PhD, CPsych, (left) is a clinical psychologist and Anne Pepper, MEd, CCC, (right) is the PTSD/Trauma and Addiction program supervisor at Bellwood Health Services in Toronto, Canada.

References

1. Baird D.The Enemy Inside. The Walrus. July/August 2010. Available at: https://www.walrusmagazine.com/articles/2010.07-health-the-enemy-inside.
2. Zoroya G.Mental Illness Costing Military Soldiers. USA Today. Available at: https://www.usatoday.com/news/military/2010-07-23-1Amentaldischarge23_ST_N.htm.
3. Meisler AW. Trauma, PTSD and Substance Abuse. PTSD Research Quarterly. 1996; 7 (4): 1-8.
4. Bell RG. A Special Calling: My Life in Addiction, Treatment and Care. Toronto Ontario:Stoddart; 1989.
5. Herman J. Trauma and Recovery. New York NY:Basic Books; 1992:33.
6. Van der Kolk BA, McFarlene AC, Weisaeth L. Traumatic Stress. New York NY:Guilford; 2007.
7. Diagnostic Statistical Manual of Mental Disorders (4th Ed.). Washington DC:American Psychiatric Association; 1994.
8. Melemis S. I Want to Change My Life: How to Overcome Anxiety, Depression and Addiction. Toronto Ontario:Modern Therapies; 2010:43
9. Levine P. Healing Trauma. Boulder Colorado:Sounds True; 2005.
10. Ogden P, Minton K, Pain C. Trauma and the Body. New York NY:Norton; 2006.
11. Najavits LM. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York NY:The Guilford Press; 2002:2.

Behavioral Healthcare 2010 October;30(9):28-30