Illustrating the connection among addiction, psychiatric illness and trauma

Addiction commonly co-occurs with psychiatric disorders and trauma, and integrated treatment is considered a standard of care.¹ More importantly, addressing comorbid psychiatric illness and trauma in substance abuse treatment settings leads to improved client outcomes.² Yet despite considerable attention to making integrated treatment a standard of care, too much of treatment today is still provided in a sequential or parallel fashion. The Center for Substance Abuse Treatment (CSAT) estimates that fewer than 2% of clients receive truly integrated care.³

One obstacle to integrated treatment is the lack of a visual framework or “heuristic.” Heuristics are valuable learning tools, and those of us who have been in the field for many years can recall the importance of Vernon Johnson’s illustration of the feelings continuum to show how one moves through pain, normal, and euphoria in the progression of alcoholism.⁴ Another classic in the area of alcoholism research was the Jellinek Curve.⁵ Aspects of self as it pertains to recovery and group dynamics were often illustrated using the Johari Window.⁶ Where have the heuristics that allow us to illustrate complex topics in addiction recovery gone?

Integrated treatment for co-occurring disorders and trauma also needs a heuristic. A visual way to capture these co-occurring conditions as it pertains to the individual client’s narrative seems critical. It is difficult for me as a clinician to retain my conceptualization of each client who presents with multiple brain disorders over the course of our work together. This is complicated by working with multiple clients simultaneously. In addition to this, clinicians have diagnostic bias, favor certain topics in therapy, and lose sight of the key themes that need to be addressed.

The high degree of avoidance among our clients only serves to compound the journey further. Imagine the difficulty from the client’s perspective. The story has been lost, distorted, confabulated over the course of years, in large part because the cleint is at the mercy of brain disorders that adversely affect cognitive processes, feelings, behaviors, and capacity for relationships with a Higher Power, self, and others.

Many years ago, I developed a Venn diagram (see figure below) heuristic to guide my clinical work.⁷ I see it as a tool that:

• Provides a visual reference for the client to increase her/his literacy about how addiction, psychiatric comorbidity and trauma interact—I refer to this as integrated.

• Affords me a concrete way to show the client the rationale for what we are doing in therapy in terms of skill building and where in the personal Venn diagram the effective strategy can be helpful for his/her own recovery management—I refer to this as the intentionality of treatment.

• Keeps me focused on delivering on the treatment that we negotiated, and is tailored for the circumstances of the person sitting in front of me—I refer to this as individualized.

What follows is a description of the Venn diagram and the way I use the heuristic to understand my client’s life story and to identify the issues that must be addressed as part of an integrated treatment plan. For me, the Venn diagram simplifies the daunting task of providing integrated, intentional and individualized treatment for my client. No two clients would have a similar Venn diagram. It is a framework that helps guide the delivery of treatment for co-occurring disorders and trauma at each stage of treatment—be it assessment, diagnosis, treatment or aftercare.

Description of the Venn diagram

Each circle in the Venn diagram (see below) is made up of two parts. These components can be considered as the unique aspects (unshaded area) and the shared aspects (shaded area), which represent how the disorders may interact with another disorder. It is important to note that when these disorders co-occur, the brain is under considerable assault that affects the individual's thinking, emotional functioning, behaviors and capacity for relationships. Consequently, prolonged periods in Area D of the Venn diagram lead to demoralization, disconnectedness and being death welcoming.

The dotted line around the Venn diagram denotes the defense mechanisms, personality features and personality disorders that are described in the DSM-5.⁸ When working with a client, I usually take this same order to understand the issues that concern her/him. That is, we start with addiction, move toward psychiatric illness, discuss trauma, and explore personality features and defenses.

The relevant components then are not only the unique features of each area (Addiction, Psychiatric Illness, etc.), but also the areas of overlap (Area A, B, C and D). These overlapping areas are particularly important, since these brain-based disorders can commingle at a level outside of the patient’s awareness.

As an example, Area B represents the relationship between addiction and trauma. A very common issue in early recovery is being at high risk for relapse when approaching a one-year anniversary. This is not surprising. Outward success and accolades are at odds with the individual's sense of self as being wretched, a fraud, and doomed to fail and disappoint those around him/her. This disparity between the outside world and one's internal sense of self creates cognitive and emotional dissonance. Consequently, the familiar pattern of chaos and destruction can often follow. This is simply one way of using the Venn to explore these overlapping areas. Clients often surprise me with their insights when prompted to think about their recovery in this integrated manner.

Clinical application of the Venn

To illustrate the use of the Venn diagram more broadly, we will consider a fictional client. Recall that the starting point would be to examine the factors related to the client’s addiction presentation. This is often the presenting problem, and clients are usually able to outline the progression of their addiction and related consequences (depending on where they are with acceptance). I usually make my notes during the intake under these headings: Addiction, Psychiatric Illness, Trauma, and Personality Features/Defenses/Disorders. I also make note of health concerns and other relevant psychosocial factors.

Beginning with Addiction, our fictional client has the following relevant factors:

• There is a family history of alcoholism going back three generations.

• The client’s first use of alcohol was at age 11, he is 45.

• The client has had two detox admissions within the past couple of years.

• He has had a DUI (mid-December, three years ago).

• There is no evidence of illicit or prescription drug abuse by history, collateral interviews or urine drug testing (including EtG testing).

• There is no prior treatment history.

• He attended AA as part of his DUI sentencing requirement.

Moving on to Psychiatric Illness:

• There is a maternal history of depression.

• He scored in the severe range of a depression inventory.

• The client has never had contact with a mental health professional.

Examining the Trauma issues we know:

• The client reported a history of being bullied in his formative years.

• His parents divorced when he was 7.

• The divorce resulted in a move to another state.

• He admitted to military sexual trauma while serving in the Navy in his early 20s, and at times has some re-experiencing in the form of nightmares.

• He has been divorced twice. He shared that his ex-wives expressed concern about his depression for several years.

Exploring Personality Features, Defenses and Disorders, we know that:

• The client shared being mostly fearful and anxious in early life.

• During sobriety he is mostly avoidant about issues/conflicts.

• He has a deep sense of shame and failure about being a screw-up.

• He recognized that drinking made him feel normal from the first drink.

• Under the influence he describes himself as morose and reflective about his life, and tends to go to dark places.

In addition to examining these areas of the Venn diagram, it is important to examine anniversary issues. What I look for here are patterns in the individual’s life. When did he go to treatment? When was he arrested? When was he admitted to detox? In this case, each detox occurred between Thanksgiving and Christmas. We are having our first appointment on Dec. 10. And the patient was born in mid-November.

Area D of the Venn diagram is when a patient is most demoralized, dejected and perhaps death welcoming. This very state can be fertile for opportunity. There is always a relationship between one’s decision to make a change and how bad things are at that time.

For me, this is a wonderful moment to describe the nature of the problem(s) and, more importantly, some possible solutions. After the interview, I invite the client to draw in closer toward my desk and we get out a copy of the Venn diagram. On a hardcopy image, I begin to draft out the clinical information I gathered, placing it in the relevant areas of the diagram. I pay particular attention to the overlapping areas and highlight the bidirectional relationship between areas. I also highlight relevant biopsychosocial aspects in our understanding of these issues and their treatment.

Once I have sketched out the material in the various areas, I thank the client for helping me to understand the nature of these problems in such detail. I then ask if there is anything else she/he would add, and proceed with my assessment of the clinical picture and the process of laying out some options for treatment.

In the case of our fictional client, I shared with him that alcoholism is a disease and that genetics accounts for 50% of the risk for developing it. In his case, the genetic salience was particularly strong, in light of several generations of alcoholism. I was able to share that there are many approved medications for alcoholism that could aid in his early sobriety, and that he was a good candidate to meet with an addiction psychiatrist. I also shared my concerns surrounding the time of year based on his history, and the need for him to be in a safe, sober and contained environment. This made sense to him when I showed him his pattern of decompensating. Finally, I shared that joining a fellowship of fellow alcoholics in AA could go a long way toward reducing his shame and sense of defectiveness about having the disease of alcoholism.

Moving on to his psychiatric condition, I educated him on the genetics of depression and the course of the illness without effective treatment. I reviewed potential treatments from a pharmacological and psychological perspective, including evidence-based therapies such as cognitive-behavioral therapy (CBT). We discussed the progression of his depression and alcoholism and talked about the bidirectional influence each of these disorders has on the other. He was able to reflect back on when he made the connection between the two.

We examined the trauma circle and he could clearly identify how difficult the holidays were for him, starting with his birthday and through the holiday season. The sense of brokenness and abandonment were most pronounced during these times. He could connect how his military sexual trauma exacerbated his sense of worthlessness. I was able to discuss special services at the VA medical center for veterans who had encountered this, including males. Since he admitted to using alcohol at bedtime to pass out, we discussed therapies (e.g., EMDR) and medications (non-addictive) that could assist with his nightmares.

After I shared my concerns and thoughts, I invited him to work through the Venn diagram and share any thoughts he had. He was able to point out some additional items that enhanced our understanding of his suffering. I reiterated that integrated treatment for addiction, psychiatric illness and trauma is the recognized standard of care, and I compared it to the simultaneous treatment of medical conditions (e.g., diabetes, high cholesterol and hypertension) that is fairly common in general medicine. He agreed to go to a residential treatment center that specialized in integrated treatment for addiction, psychiatric illness and trauma.

Recovery roadmap

Teaching our clients to develop an understanding of their conditions and methods for recovery from addiction, psychiatric illness and trauma is both necessary and possible. The Venn diagram has been a useful tool toward this end. Clients and clinicians both report that this simple heuristic can serve as a visual roadmap in recovery. The path to recovery from addiction, psychiatric illness and trauma is indeed difficult, and having a visual framework can assist in the process.

The diagram is atheoretical in terms of a necessary or preferred clinical approach, but I have found Motivational Interviewing (MI) to be the most helpful strategy. I am especially fond of the FRAMES acronym, which stands for specific Feedback, Responsibility for change, Advice, Menu of options, Empathy, and Supporting self-efficacy.⁹

Understanding the nature of how addiction, psychiatric illness, trauma and personality features all interact within a particular client is essential to delivering integrated treatment. The challenge to us as addiction professionals is to find both time and opportunities to increase our knowledge about disorders that commonly co-occur with addiction. This does not require that we become experts in every disorder, but at a minimum we must recognize when consultation may be needed to clarify a diagnosis.

Not all clients will have the same severity in each of the circles. Not all clients will come to an acceptance of these disorders in parallel fashion. For each of these circles the client will go through his/her stages of change, but we can educate and inspire the client with accurate information and options for what comes next. We must make every effort possible as clinicians and treatment programs to provide hope that we understand how these conditions interact and that we have a framework to help our clients navigate these chronic, complex conditions while building a more fulfilling life.

Julio I. Rojas, PhD, is a licensed health service psychologist and licensed alcohol and drug counselor in Oklahoma. He is an Associate Professor in the Department of Psychiatry and Behavioral Sciences, College of Medicine at the University of Oklahoma Health Sciences Center. Rojas also is a program consultant and staff psychologist at VizOwn, a private residential treatment program for women outside of Norman, Okla., that specializes in integrated addiction treatment, where he uses the Venn diagram to guide clinical care.

References

1. Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. Rockville, Md.: Substance Abuse and Mental Health Services Administration; 2005.

2. Morrissey JP, Jackson EW, Ellis AR, et al. Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatr Serv 2005;56:1213-22.

3. Van Hoof-Haines K. Dual diagnosis: the state of treating co-occurring disorders in the U.S. Retrieved from www.drugfree.org.

4. Johnson VE. I’ll Quit Tomorrow: A Practical Guide to Alcoholism Treatment (revised ed.) San Francisco: HarperCollins; 1980.

5. Page PB. E.M. Jellinek and the evolution of alcohol studies: a critical essay. Addiction 1997;92:1619-37.

6. Luft J, Ingham H. The Johari Window: a graphic model of interpersonal awareness. Proceedings of the Western Training Laboratory in Group Development, UCLA.

7. Rojas JI. A Venn diagram heuristic for working with co-occurring disorders and trauma. J Mental Health Subst Abuse 2013;6:262-71.

8. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, D.C.: American Psychiatric Association; 2013.

9. Miller WR, Sanchez VC. Motivating young adults in treatment and lifestyle change. In Howard G, Nathan PE (eds.). Alcohol Use and Misuse by Young Adults. Notre Dame, Ind.: University of Notre Dame Press; 1994.