PTSD, Complex PTSD, Addictions and Treatment
Learning to make the connection and finding out that treatments have been developed can provide hope for healing and a better life. Here we provide some basic information about different types of trauma, post-traumatic reactions and disorders, and treatment approaches and options. Promises programs are designed to incorporate attention to trauma in all facets of treatment.
Abuse as a child, witnessing a violent event, being the victim of a crime, experiencing an accident or a human-made or natural disaster, having a debilitating illness, experiencing the sudden death of a loved one, being a veteran or currently serving in a combat zone -- all of these are examples of traumatic events and experiences. These are identified as “traumatic stressors” or “potentially traumatic exposures or events” that can result in a wide range of aftereffects and debilitating symptoms up to and including those that make up post-traumatic stress disorder (PTSD).
Because each traumatic event or experience is unique and because individuals differ in their outlook and capacity to cope, not all have the same reactions, even if they have experienced the same trauma. Most go on to develop post-traumatic reactions that resolve in a fairly natural way with rest, the support of others and some adaptation to the event. However, if the trauma is avoided and memories and emotions associated with it are not processed so they become like other memories, they can develop into more painful emotions and symptoms. This can occur fairly soon after the trauma or emerge later in what is known as delayed onset.
What Is PTSD?
PTSD is a mental health condition made up of a set of symptoms that develop after a trauma experience. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the trigger for PTSD is “exposure to actual or threatened death, serious injury or sexual violation.” It results from an overwhelmed emotional state and extreme physiological stress reactions. Exposure can result from one or more of these scenarios, in which the individual:
• Directly experiences the traumatic event
• Witnesses the traumatic event in person
• Learns that a traumatic event occurred to a close family member or friend (with the actual or threatened death being either violent or accidental)
• Experiences first-hand extreme or repeated exposure to aversive details of the traumatic event (not through media, pictures, TV or movies, unless work-related).
Regardless of the trigger, the traumatic event causes clinically significant impairment or distress in the individual’s capacity for healthy relationships with others, in work and social interactions, and/or other important functional areas. The classic symptoms of PTSD include:
1) Re-experiencing of the trauma in forms such as dreams and nightmares, flashbacks and upsetting memories in response to re-exposure of some sort;
2) Emotional numbness, disconnection and dissociation, often in response to the pain of the re-experiencing;
3) Attempts at avoidance of feelings and external reminders of the trauma; and
4) Physiological hyperarousal and hypervigilance.
Those who suffer from PTSD may also have symptoms of depression, anxiety and anger, medical concerns and difficulties in their intimate, social and work relationships, among a host of other problems. It is not unusual for them to have thoughts of suicide or to make attempts, to engage in self-harm and other risky behavior, and to have a variety of addictions and compulsions. These behaviors, initially used to cope with the aftereffects, then become problems in addition to the PTSD symptoms.
Although it is easy to assume that PTSD is usually the response to trauma, researchers have discovered that it is not the typical response in traumatized adults since about 25% of them develop PTSD after a severe trauma. In contrast, it is much more common and may be the typical response for traumatized children who, due to their immaturity, dependence on adults and increased vulnerability, develop PTSD at much higher rates.
Defining Complex Trauma
In recent years, disturbed and disrupted attachment to primary caregivers, child abuse of all sorts (i.e., physical, sexual, emotional, and neglect/abandonment), and ongoing violence, whether in the family (i.e., domestic violence) or the community, have been recognized as complex forms of trauma due to a number of factors. They often involve complicated family dynamics, are committed by someone related to or known to the child on whom he or she relies for nurturance and protection, and involves trauma bonding.
Complex trauma is typically not a one-time or time-limited occurrence. It usually occurs repeatedly, becoming chronic and progressively more severe as perpetrators act in an increasingly compulsive manner or feel emboldened and entitled to their demands. It usually spans developmentally vulnerable time periods, especially early childhood or adolescence, compromising the child’s security and development. It can also occur later in life in any form of chronic exposure.
Because complex trauma is interpersonal and relational, it involves conditions of betrayal-trauma. Moreover, when those who are in positions to intervene or protect do not, it causes trauma of another sort, secondary trauma. And finally, when agencies whose mission it is to intervene and provide assistance do not respond in ways that are helpful or intensify the problems, another form, known as institutional or sanctuary trauma, can result.
Understandably, these additional interpersonal traumatizations result in a profound mistrust of others, sometimes leading to a paradoxical inability to identify dangerous people or situations in what has recently been termed betrayal blindness. This dynamic seems related to the fact that complex trauma, especially when it occurs in childhood, is associated with increased vulnerability to revictimization and retraumatization over the entire lifespan. Taken together, all of these effects and vulnerabilities result in layered and cumulative trauma and impact.
Effect of Complex Trauma: Complex PTSD
These layered or compounded effects of complex trauma are “above and beyond” the classic symptoms of PTSD. They include a range of developmental aftereffects including neurophysiological changes, difficulties with emotional regulation, unstable self-structure and a negative sense of self, a lack of personal integration and integrity, insecurity with others including relational mistrust and instability, somatic problems and medical conditions, and skewed beliefs, cognitions and learning patterns, among the most common. As in classic PTSD, the coping mechanisms used to manage the unresolved effects become adaptations to the trauma that frequently cause later problems.
These varied problems and symptoms may emerge in different ways and at different times, according to the individual and his or her circumstance. Most commonly, medical and mental health practitioners have treated them as free-standing conditions, diagnoses and personality/relational difficulties and have not identified them as post-traumatic or as related to one another in any way. Complex PTSD was proposed as an overarching and inclusive way to understand them and their origin and as an aid to treatment planning.
Treating Complex Trauma, Complex PTSD
Due to the fact that a tiered set of problems (i.e., the primary effects of the original trauma, the means used to cope at the time and later, developmental deficits and interruptions, attachment problems, additional victimization) must be treated, complex PTSD can be a challenge for practitioners. Treatment is complicated due to the sheer number of issues for which the client might seek help and the lack of emotional regulation or life skills with which to address them.
Therapists are advised to start with a primary focus on personal and environmental safety and with education about trauma and its effects as a foundation for the remainder of treatment. Once clients are safe and engaged in treatment, they can be taught skills for identifying and regulating their emotions.
In recent years, treatment for PTSD has increasingly emphasized the use of cognitive-behavioral interventions, including such techniques as prolonged exposure (PE), cognitive restructuring (CR), cognitive processing therapy (CPT), and eye movement desensitization and reprocessing (EMDR), all of which have empirical research support. At present, it is still unclear if these same techniques are equally applicable to complex PTSD and a sequenced treatment with a hierarchy of treatment tasks is recommended. The cognitive behavioral interventions (especially those involving exposure) are usually introduced later, after the client has achieved some stability. The rationale is that without the ability to feel safe or regulate strong emotions, exposing complex trauma clients too directly to their trauma history can lead to retraumatization, associated decompensation and inability to function.
The treatment sequence includes three main stages, along with pre-treatment and involves the following main tasks, selected according to the needs of the client:
• Pre-treatment assessment and treatment planning, education about therapy, motivation enhancement, and the decrease of any therapy-interfering behavior. Determining the need for detox.
• Early stage: safety, detox as needed, early sobriety, education, stabilization, skill-building and development of the treatment alliance. Skills to be developed include healthy boundaries, safety planning, assertiveness, self-nurturing and self-soothing, physical relaxation, mindfulness, emotional modulation, and strategies to cope with spontaneous flashbacks and dissociative episodes. Attention to wellness, stress management, and any medical or somatic concerns is also needed at this stage. Medications, including antidepressants and anti-anxiety drugs, are often helpful to target PTSD symptoms and those associated with depression, anxiety and sleep disorders.
• Middle stage: ongoing sobriety and deliberate trauma exposure (gradual or prolonged) for emotional processing and resolution. Bereavement and mourning. Meaning-making and existential/spiritual issues and development. Considering courses of action with perpetrators and others.
• Late stage: ongoing sobriety, self and relational development no longer limited by the trauma response. Personal choice and life course.
Each stage builds upon the previous one, with the trauma survivor acquiring growing control and mastery, which directly counteract the powerlessness of victimization and its continuing aftereffects. Throughout the stages, there is overlap in therapeutic work. Often a need exists to rework stabilization skills over the entire course of the treatment.
Treating Trauma and Substance Abuse
Treatment for trauma and addiction are best conducted concurrently and in the same sequence. The treatment of one should reinforce the other. It is important to note that sobriety alone, although important, does not resolve trauma. In fact, it can create risk for relapse as memories of trauma emerge along with post-traumatic symptoms. The addicted trauma survivor needs specialized education and skills for managing emotions without the use of substances in order to cope. In this way, trauma can be resolved and sobriety maintained.
The course and length of treatment can vary dramatically and might involve the use of a variety of treatment strategies across the stages. Some clients are in therapy for years and never move past the early stage, especially those with extensive trauma histories, limited personal resources and those with insecure attachment styles. Other trauma survivors, however, move through the treatment stages in much less time. Still others engage in treatment only episodically, as needed. Shorter-term approaches are in development.
What is most important to know about getting treatment for complex trauma or complex PTSD and addictions is that new and different approaches are now available and effective. As a trauma survivor who was once confused by your symptoms or hopeless about getting help, you now have the opportunity to get effective treatment, to heal, and to get your life back and on track.