Integrated treatment for trauma and addictive disorders

Many people with traumatic histories have co-occurring addictions, which present a complex tangle of challenges for treatment providers. Until very recently, the prevailing wisdom among addiction professionals held that addicts needed to experience a period of abstinence before addressing the underlying trauma. The dilemma has been that abstinence was frequently unachievable or that even when addicts could remain abstinent, the symptoms of untreated post-traumatic stress would often surface, causing suicidal thoughts and attempts; self-injury; immobilizing depression; and often correlated loss of support networks, livelihood and loved ones.

Or, as one addiction went into remission, another would become more acute, as with the young female crack addict who stops using, begins to gain weight and sees symptoms of anorexia emerging, or with the alcoholic male who gets sober, leaves his long-term relationship and begins to act out sexually with multiple partners.

Conversely, in the mental health field, the belief has historically existed that addictive behaviors were “medicators” for the traumatic symptoms, and that if the trauma were treated, the maladaptive attempts to self-soothe would be alleviated. This approach did not recognize the primary nature of addictive disorders.

This linear, either/or conceptualization has limited our ability to recognize the need for a radical paradigm shift until recently, when brain research has begun to tell us why our traumatized clients can’t remain clean and sober, or abstain from sexually compulsive behaviors, or adhere to a meal plan and maintain weight gain. We have begun to ask the right questions: How can we accurately assess and match treatment needs for clients experiencing a wide range of shifting clinical symptoms? What is the hierarchy for the client’s needs? And, most saliently, what is the synergistic interplay of trauma and addiction?

The dilemma of treating co-occurring addiction and trauma has been confounding. Advances in neurobiology have given helping professionals the data to evidence what we’ve known anecdotally: People who suffer from addiction and trauma have neurological, interpersonal, cognitive and affective deficits that are compounded by the synergy that occurs with dual disorders.

Trauma and addiction both generate belief structures associated with being an outcast, not belonging, being inherently damaged. The world is experienced as a dangerous place, trust is too risky, and on a deep intrapsychic level a chronic chasm is formed between self and others. Defenses are constructed to protect the split, and survival depends on hiding the true self and its needs, causing impenetrable isolation and loneliness. It is into this living tomb that we are invited when we begin working with the synergy of addiction and trauma.

In addition, the categories currently in use (post-traumatic stress, which is a natural and predictable response to a traumatic event, and post-traumatic stress disorder, which is the cluster of symptoms that occur when trauma has not been adequately resolved) have been expanded to include complex PTSD through the work of Christine Courtois and her identification of the far more challenging client who presents with multiple traumatic exposures and a resulting labyrinthine clinical presentation. These clients are often acute and chronic, presenting for repeated treatment episodes over the course of their lives. The comorbid disorders and the paucity of internal and external resources for these clients contribute to the preponderance of treatment challenges.

Clients with addictive disorders and trauma often present with a constellation of diagnoses that have become treatment-resistant over time. In addition to drug and alcohol addiction, sex addiction, eating disorders and self-injury (one, several or all of which may be present in varying levels of intensity at different times), there is frequently the presence of a co-occurring mood disorder, anxiety disorder, and often features of or possibly a fully developed personality disorder.

Trauma creates an abiding belief that “I do not belong” and “My needs can’t be met.” The cycle of mistrust, self-protection organized around rejection of others, and the profound internalized rejection of the self forge an almost impenetrable defensive structure that in turn embeds the cycle ever more deeply.

Illustrative case study

I first met Ramona at a treatment center she’d been referred to that specialized in residential extended care for trauma and co-occurring disorders. She came to us from a primary facility, where she had completed treatment for addiction, an eating disorder and complex PTSD.

We met for our first session in my small and narrow office, which I had been using temporarily. My chair was placed between Ramona and the door. I remember spending our first hour together feeling as though I was in an enclosed place with a trapped, wild animal. Ramona kept her eyes on the floor and glanced furtively at the door once or twice. She answered questions with three-word sentences and flew out of the office when the session ended.

It was early 1999, and I knew nothing about the biology of trauma, fight, flight, the freeze response or tonic immobility, but I remember talking in a consistently low and even voice, making slow and measured movements only when absolutely necessary and wondering afterwards who I had actually been trying to reassure, Ramona or myself.

In an attempt to make sense of the session, I contacted Ramona's therapist from the primary treatment program she had just completed. During my conversation with this therapist, whom I knew well, I had the distinct impression that we had gotten tangled up about which client I actually was working with, since my colleague described Ramona as an aggressive, bullying woman who had intimidated other patients and staff. When we finally established that we were talking about the same person, we expressed surprise at the depth of the split that this client presented.

Over the next several months, Ramona and I painstakingly unraveled her history. She began drinking around age 10, using drugs by her mid-teens. She was chemically dependent by the time she entered college at 17. She had gotten into recovery when she was in her early 20s and experienced more than a decade clean and sober in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Eventually, she began using pills for pain, which eventually led her back to illegal drugs and alcohol. At 38 years old, she had been trying to stop using without success for more than two years, despite regular counseling and 12-Step meeting attendance, and she decided to admit herself to an inpatient program.

Her bulimia began when she was in her early teens and had continued unabated throughout her years in recovery from substance dependence as well as during the seven weeks she spent in primary treatment. She purged with vomiting and over-exercise. She also had used drugs to suppress her appetite and had lost a great deal of weight prior to entering treatment. She then experienced intense panic as she began to eat and gain weight.

Ramona’s history of trauma was so extensive, and she was often in such a significantly dissociative state, that it required months and many sessions to begin to assess the extent of what she had experienced. Beginning in infancy, both of her parents had abused her physically and sexually. She was the youngest of three children and although all three were abused, it was most severe for Ramona.

She responded wonderfully to art therapy; she was highly creative and loved working with charcoal, paints, clay and felt tip markers. Through these pieces, which spanned the first several years of her therapy, a sinister and tragic tableau unfolded.

Ramona’s parents had shunned her entirely. She was not allowed to take meals with the family, could not enter the living room when her father was present, and could listen to the television only while hiding behind the sofa. If her father noticed her, he’d beat her. Her mother took every opportunity to humiliate her in front of the rest of the family as well as neighbors. She often was locked in the cellar, sometimes for days.

The sexual abuse she had experienced from her parents left her with permanent physical problems that complicated the work she did later in her therapy, particularly with her eating disorder.

After Ramona left home at 17, gaining early entry to college, she found herself unable to maintain the school fees and lived on the streets, homeless, for several years. During that time, she was raped, beaten and robbed repeatedly, and survived by finding a homeless man who offered her some protection but in turn sexually abused her.

She married in her early 20s and completed her education, entering into a career and excelling at this while she mothered three sons and got into recovery from her alcohol and drug addiction through AA. She had more than 12 years clean and sober when the PTSD finally became overwhelming. In addition to dealing with the active bulimia, she began using prescription medications for back pain and when she entered primary treatment toward the end of 1998, she had been binge drinking, blacking out and using illicit drugs and prescription drugs regularly.

Throughout the five years that she and I worked together, Ramona relapsed to alcohol use every 16 to 24 weeks. At times during these episodes, she would contact me to say she felt like killing herself. I contacted the police on at least three of those occasions, and went to her house on another.

She was arrested for driving under the influence. The severity of her use precipitated a referral back into primary treatment in early 2002, which she completed. She relapsed three more times that year.

Ramona’s purging stopped in 2003, but her hatred of her body and disgust with food and eating remained a problem that did not abate with the abstinence.

In early 2004, Ramona decided to leave therapy and focus her attention on her two sons, who at the time were teenagers. She had several one-day relapses and then returned to 12-Step meetings and had maintained her abstinence for several years when we last checked in with each other in 2007. She told me she was doing well in her life, and was managing the stressors of a complex divorce and a career change without relapsing with the addictions or eating disorder.

One of the clear advantages that Ramona and I had from the beginning of her treatment was that she had accessed a treatment environment rich in resources. She saw the staff psychiatrist, a nutritionist and an eating disorders specialist, and she and her sons had family therapy, as well as her daily group and twice-weekly individual therapy. After seven weeks in primary and four months in extended-care treatment, she transitioned into outpatient services.

However, Ramona and I both knew that as she transitioned to a lower level of care, she needed to continue to have a multidisciplinary, strongly woven system of support. For several years, she consistently refused to attend any 12-Step meetings except for Overeaters Anonymous (OA), which she would attend only intermittently. I contacted a colleague who specialized in working with eating disorders, and she agreed reluctantly to meet with Ramona twice a week, saying she was not used to seeing clients who were seeing other providers. I reassured her that she would not want to see Ramona as a solo practitioner.

I committed to once-weekly sessions as well as acting as Ramona’s care coordinator. She continued seeing the same psychiatrist she had seen in extended care. The psychiatrist worked tirelessly over nearly four years to adjust her medications, which included several courses of selective serotonin reuptake inhibitor (SSRI) antidepressants, two trials on mood stabilizers, and long-term use of several medications including clonidine and a low dose of risperidone, which were just beginning to be used to manage the more florid symptoms of PTSD.

At this psychiatrist’s recommendation and everyone’s assent, Ramona also completed two six-month modules of Dialectical Behavior Therapy (DBT), which she said was one of the most helpful elements of her treatment. Given her intelligence and need to understand, this elegant cognitive-behavioral approach, with its embedded Buddhist wisdom, served as a very effective way of internalizing a wide range of skills for Ramona.

Eventually, she was able to tolerate Rosen body work from a licensed massage therapist who became another key member of her integrated team. There also was a nutritionist who provided several sessions at necessary junctures, and a women’s healthcare provider available as needed. Regular consultation among providers was vital, and without consistent communication and conjoint sessions, Ramona could not have received the scope or quality of care that she required.

We all took our turns being dismissed when she would become hurt or angry, and we learned to function as a tolerant, kind and skilled attachment structure, soothing her wounds and keeping one another well-informed on Ramona's most recent treatment challenges and gains. It was exhausting, it was exhilarating, and she often told us that we were saving her life.

Hard therapeutic work

The ability to comprehensively assess and treat clients with this type of continually shifting clinical picture, particularly for a sole practitioner, can be daunting at best, and overwhelming and a recipe for burnout at worst.

For therapists skilled at working with trauma, working with concomitant addictions and experiencing a client’s repeated relapses or shifts into other addictive disorders can cause irreparable ruptures in the therapeutic alliance, leaving the therapist feeling demoralized. For addiction specialists, even those who have had advanced training and experience working with dual diagnosis, the interpersonal deficits caused by developmental trauma may hinder or prevent the formation of a working alliance that is essential to the philosophical foundations of addiction treatment. This may evoke a client-blaming stance for therapy failures. This may manifest as an attribution of failure to client resistance, or a rejection of a client’s traumatic material as having been exaggerated or fabricated.

Another exacerbating factor is the 12-Step community’s historical stance on people coming into recovery with more than one primary issue. How often has the professional community heard stories from our clients about sponsors advising them to come off psychotropic medications, terminate therapy, leave treatment and just go to more meetings, do more service work, read the Big Book and “get off the pity pot?” This punitive and uninformed reaction merely adds to the shame, sense of failure, marginalization, and feelings of being intrinsically flawed or contaminated that are clearly already present. In a 12-Step culture based on shared suffering, hope and mutual support, this type of rejection is particularly devastating.

The mind/body dualism upon which the field of psychology was founded, originating from early Greek thought and later expanded upon by Rene Descartes, contributes to the linear and confining way in which we often think about our clients and our work. Inherent in the Gordian knot of working with trauma and addictive disorders is an invitation, a challenge: to expand our framework, our preferred ways of working, our beliefs.

We are being called to discover new ways of working with clients. Trauma, addictive disorders and co-occurring disorders are, by the very nature of the synergy among them, profoundly alienating and daunting, both for the client and the practitioner. An integrative framework is the essence of the expanding paradigm: one that embraces the body, the thinking and feeling mind, early developmental needs, attachment issues, neurochemistry, nutrition, relational and spiritual development, establishment and maintenance of a well-chosen and evolving network of helping professionals, and our own recognition that it does indeed take a village to heal trauma and addiction.

Liz Cervio, LMFT, SEP, serves as an adjunct faculty member at Santa Fe Community College and as clinical supervisor at Solutions Treatment Center in Santa Fe, N.M. Her more than 27 years of experience as a supervisor, mentor, psychotherapist and educator has informed her work with others in the liminal territory of change. Her e-mail address is orbspidersdancing@gmail.com.