Article – Treatment of Complex Post-Traumatic Stress Disorder

FOR PURPOSES OF PRIVACY THE INDIVIDUAL CASE STUDY HAS BEEN REMOVED, IT WILL ONLY BE USED FOR TEACHING PURPOSES

Taken from ECOTS2007 presentation June 2007

by Judy McLaughlin-Ryan from USA 310-209-0740 

Research suggests that, when treating post-traumatic stress disorder (PTSD), which is at the core of symptomatology of complex post-traumatic stress disorder (CPTSD) and co-morbid addictions, participation in a twelve-step program early in the treatment process decreases the likelihood of relapse. Quimette, Moos, and Finney (2003) found that patients with substance use disorders and PTSD who received focused treatment for PTSD immediately following treatment for the substance use disorder, along with participation in a twelve-step program during the first year of treatment, were more likely to experience long-term (five-year) remission from the substance use disorder.

Because research reflects significant co-morbidity rates between PTSD and addictions, the parallel treatment of both conditions is key to resolving the disorders. Donovan, Padin-Rivera, and Kowaliw (2001) estimated the rate of substance abuse among persons with PTSD to be as high as 60-80%. Jacobson, Southwick, and Kosten (2001) studied the pathophysiology of PTSD and substance abuse, finding that both are functionally related to one another, with high rates of comorbidity.

Research also suggests that, with PTSD, positive group support is the strongest predictive factor significantly related to a decrease in the severity of the PTSD symptoms (Guay, Billette, & Marchand, 2006). The constellation of similarities between CPTSD and addictions (CPTSD/A), supported by research findings, points to the necessity of integrating social support into the treatment. The twelve-step model, as an adjunctive, offers reparative experiences in the areas of regulation, attachment, brain functioning and altruistic service to others.

As an adjunctive to psychotherapy, the utilization of a twelve-step program provides individual and group support for the patient. The twelve-step group provides remedial experiences for the patient that increase the likelihood of ameliorating the symptoms of both disorders. Although utilizing a twelve-step program as an adjunctive to the treatment is not a panacea, and is not appropriate for all patients, participation in the twelve-step program increases the likelihood of addressing the following confounding issues of treatment with this population: maintaining abstinence from drugs/ alcohol or other addictive behaviors, while simultaneously treating PTSD, and increasing the patient’s tolerance for secure attachments, tolerance for social support, mindfulness regarding the integrated interoceptive experiences of body and mind, and opportunities for interactive assistance with regulatory responses that mobilize activation responses that result in a safe place to which the patient can turn. Van der Kolk’s (2006) research suggests that this mobilization, based on awareness, is vital for those with complex trauma and/or PTSD. Overall, the twelve-step model is an action-oriented program that offers a “safe place to go or run to” when in distress.

Symptoms of PTSD are at the core of CPTSD/A; therefore, research findings for PTSD and complex trauma overlap. CPTSD includes diagnostic PTSD symptoms, as well as problems with attachment, cognition, and self-concept. Additionally, CPTSD and addictions have many symptoms in common, especially in the areas of dysregulation and attachment. With CPTSD, not only are the classic PTSD symptoms of dysregulation of affect and state present, but also the patient typically suffers from prolonged interpersonal trauma and abuse, which results in the loss of a sense of trust, safety, self-worth, coherency, and one’s systems of meaning (Cook, Blaustein, Spinazzola, & van der Kolk, 2003). Patients with CPTSD also have disturbances in the areas of attachment, resulting in distrust, loss of faith, searching for a rescuer, social isolation, difficulty attuning to other people’s emotional states and views, disturbances on neurobiological development effecting physiologic and neuroendocrinologic responses as well as maturation of specific brain structures, hypersensitivity to physical contact, analgesia, somatization, numerous medical problems, depersonalization and derealization, poor modulation of impulses, aggressive behavior, substance abuse, eating disorders, learning difficulties, language development problems, a general sense of being ineffective in dealing with one’s own environment, believing that one is permanently damaged, difficulty describing feelings, a sense of emptiness, feelings of dread, suicidal ideation, and an inability to read internal states (Cook et al., 2003, van der Kolk, 2006; van der Kolk, Pelcovitz, Mandel, McFarlane, & Herman, 1996).

I am suggesting that treating both disorders on a parallel track, while utilizing the twelve-step social context to strengthen and develop the patient’s interpersonal relationships, is key to successful treatment. Both disorders, dysregulating in origin and causing significant disturbances in overall functioning, need to be treated simultaneously, with overarching social support. If the patient builds interactive, attuned social relationships that address difficulties with dysregulated emotional responses, the patient will have longer term, readily available options when in distress.

PTSD (Semple et al.,1992) and alcoholism (Adams et al., 1995) both show evidence of structural impairments in orbitofrontal activity. Schore’s (2003) work suggests that “these functional vulnerabilities reflect structural weaknesses and defects in the organization of the orbitofrontal cortex, the neurobiological regulatory structure that is centrally involved in the adjustment or correction of emotional responses” (p. 24).

When treating the CPTSD/A population, if one condition is treated, while the other is ignored, the treatment often becomes chronically sabotaged. If patients seek regulatory mediation utilizing drug abuse or alcohol, a cascade of relapse events occur, interfering with the potential for self-regulatory functioning. Additionally, these relapses usually disrupt the development of potentially secure attachments. If the addiction is treated, while ignoring or dismissing the CPTSD, triggering events can lead to the fight, flight, or freeze response. After a triggering event, the patient may respond by isolating him or herself, becoming aggressive, or dissociating, to name a few responses. Again, this response may disrupt the potential for self-regulatory functioning, as well as the development of potentially secure attachments. However, if the patient has access to a broader socially supportive community of attuned others, such as a twelve-step program, during these times of distress, he or she has options for potentially reparative experiences in the areas of both regulation and attachment.

Research abounds linking symptoms of dysregulation with disorganized attachment patterns (Main & Solomon, 1986, 1990), especially with CPTSD and addictions. This research has expanded our understanding of the attachment patterns of secure, insecure-avoidant, and insecure-resistant (Ainsworth, Blehar, Waters, & Wall, 1978). Bowlby (1973) looked at the link between attachment processes and dissociative psychopathology. He referred to internal working models (IWM), which are formulated as a result of care-seeking interactions with primary caregivers. The formation of multiple IWMs serves to regulate emotions and cognitions in a way that is alien to the self (Bowlby, 1973). He further described patient’s symptoms as the outcome of attachment figures that induced the child to disown personal, firsthand experiences (Bowlby, 1978, 1979).

In more recent literature, this observation of Bowlby’s is now referred to as dissociation and disorganizing attachment patterns. Grotstein (1986) recognized that early-forming psychopathology results in disorders of attachment that manifest in neurobiological impairments and result in failures of self and/or interaction regulation. Schore (2003) asserts that “the functional indicators of this adaptive limitation are specifically manifest in recovery deficits of internal reparative mechanisms” (p. 24). As a result, there are deficits in coping with negative affect and deficits in adaptive responses to socioemotional stress. Van der Kolk and Fisler (1994) recognize this inability to regulate intense feelings as the most far-reaching effect of early trauma. The two can barely be separated, as it is currently understood that both regulation responses and attachment patterns can either complement one another in treatment or implicate one another.

I believe that, along with the formation of a therapeutically developed secure attachment, which assists with regulatory responses for the patient, the twelve-step experience may offer an additional socially-driven support system, in which exposure to secure attachments and self and other interactive regulatory experiences can be developed. Liotti’s ( 2006) theory suggests the need in psychotherapy for a phase-oriented process focused primarily on achieving attachment security and, secondarily, on the trauma work. Along with others, I am suggesting that achieving a secure therapeutic relationship, as well as developing other significant interpersonal relationships in treatment, is of primary importance (Gold et al., 2001). Further, the exposure to potentially long-term interactive experiences with members of their twelve-step group can provide remarkable reparative experiences. For example, an Alcoholic Anonymous (A.A.) survey taken in 2004 found that 36% of the members were sober over a ten-year period, 70% had a sponsor (a person who shares their experiences and provides strength) within 90 days of attending their first meeting, and meeting attendance averaged over two meetings per week. Additionally, 8% of the members indicated that they were referred to A.A. by a healthcare professional, 31% were referred through a treatment facility (Alcoholics Anonymous, 2004).

The twelve-step model, although primarily for the treatment of the addictive disorder, offers regulating and mediating reparative experiences that address CPTSD as well. Not only does the twelve-step program assist the patient in mediating experiences, but it also assists in developing and modeling secure attachments that not only help the patient, but help others at the same time. This altruistic basic tenet of the twelve-step program, helping others, is grounded in an action-oriented approach, accomplished through interactive, action-oriented directives between members.

When members in the twelve-step program are in distress, they are encouraged by other members to reach out for help. Whether the member is in a CPTSD-triggered response or an addiction triggered response, he or she has the option to interact with others in order to mediate painful affective/state experiences, using the tools of the twelve-step program. The members are encouraged by other members, and the program’s literature, to share their distress with each other in order to help themselves, as well as each other. Members are encouraged to reach out and share with others through going to group meetings, making service commitments at the group meetings, making telephone calls to other suffering members, actively helping others in distress, having a relationship with a sponsor, doing writing assignments, and learning about and working the twelve steps, twelve traditions, and twelve concepts (Appendix). Overall, in the twelve-step program, the act of sharing each other’s experiences, strength, and hope is what unifies the members. Helping one another is the primary tenet and is believed to be paramount to recovery (Alcoholics Anonymous, 2005).

Many clinicians working with CPTSD/A have firsthand clinical experience of just how difficult taking action can be for this CPTSD/A population. When patients experience dysregulating symptoms, sometimes another person must literally be present to activate the patients’ initiating responses. If a patient has a flashback, is dissociated or immobilized in the freeze response, in a reactive fight response, or obsessed with using alcohol or drugs, proactive behavior may be improbable and/or neurobiologically impossible without an interaction with another. Patients with CPTSD/A are frequently unable to read their bodily cues or alarms, and when misread, may take life extinguishing actions in response to an internal cue, when, in fact, the cue was telling the patient to reach out for help, receive comfort from another, or something about his or her bodily needs.

Interoception, defined by Cameron (2001), is the psychosomatic process of the brain’s influence on bodily functions and afferent sensory input to the central nervous system. It affects behavior, cognitive function and emotions. It is the mechanism of visceral sensory psychobiology, including internal organs in the abdominal cavity, and affects the viscera, resulting in an intuitive experience. As seen above, interoception is short circuited in patients with CPTSD/A. The basic tenet of interoception is that it is the interchange between the body and the brain. As Cameron states: Bodily changes follow directly the perception of the exciting fact, and that our feeling of the same changes as they occur IS the emotion . . . Without the bodily states following on the perception, the latter would be purely cognitive in form, pale, colorless, destitute of emotional warmth. We might then see the bear, and judge it best to run, receive the insult and deem it right to strike, but we should not actually feel afraid or angry. (p. 698)

With those who have CPTSD/A, emotions are often not read at all, reacted upon appropriately, or often not utilized for life supportive, action-oriented behavior out of the context of a traumatic interpretation.

Van der Kolk (2006) discussed the necessity for the patient with PTSD to learn how to take effective action. For example, after one is stressed, the reaction to run towards a loved one for comfort and safety is a predictable response. With those who suffer from PTSD, this mobilization response may be impossible. Because many with PTSD experience chronically overwhelming emotions, they often lose their capacity to use emotions as guides for effective action. “Unable to gauge and modulate their own internal states, they habitually collapse in the face of threat or lash out in response to minor irritations. Futility becomes the hallmark of daily life” (p. 282). He described the necessity in treatment to address and pay sufficient attention to “the experience and interpretation of disturbed physical sensations and preprogrammed physical action patterns (p. 282). In other words, before one can take an effective action, one must have a sense of what is going on inside of his or her body and develop the capacity to act upon these sensations appropriately and not only from the perspective of the traumatic response. This awareness is a precursor to subsequent life supportive, action-oriented responses.

Those with CPTSD/A may not be aware of typical affective and state bodily functions such as hunger, tiredness, physical illness, loneliness, and many others. This awareness is a precursor to life supportive action taking. Many patients with PTSD are overwhelmed by focusing on internal sensations and deny having an inner sense of themselves. Self-awareness may initially result in a retraumatizing experience (van der Kolk, 2006). The patient may leave the here and now in response to the self-awareness and interpret the sensation or awareness as the trauma reoccurring once again. This reading of the awareness aborts the proactive response that needs to be taken. Experiences that reorient and refocus the sensory awareness into interpretive proactive experiences are needed for effective action to occur.

Ogden and Minton’s (2000) work in the Sensorimotor Psychotherapy Institute addresses approaches that are focused on physiological elements of trauma that are somatically based. Their work suggests the integration of sensorimotor processing with cognitive emotional processing in the treatment of trauma, with the therapist interactively regulating clients’ dysregulated states as clients build their awareness and understanding of their inner bodily sensations. For this awareness or interoceptive experience to occur, patients need to learn to identify their physical sensations and translate their emotions and experiences into communicable language (van der Kolk, 2006).

Mindfulness heightens the capacity to become filled by the senses of the moment and attuned to our own state of being. As we also become aware of our awareness, we can sharpen our present focus on the present, enabling us to feel our feet as we travel the path of our lives. (Siegel, 2007, pp. 14-15)

Patients’ increasing internal awareness, while learning to understand themselves, metabolizes the activation of the capacity to look for and/or find a safe place to go (van der Kolk, 2006).

Assuming that the development of mindfulness and interoceptive life supportive actions are being developed in the treatment, provisions for a safe place to go are critical. Without a safe place, the patient could experience further reenactment of the original trauma, where one was left unprotected, without any reregulating interactive experience. The point of cultivating this internal understanding in the patient is to assist the patient in the process of engaging, or as Siegel (2007) stated, a process of enhancing compassion and empathy, while experiencing authentic connections with consideration and more reflection.

Providing the patient with a safe harbor and interactive figures that serve as interoceptionists is vital to the treatment of CPTSD, and increasing a community experience should be a part of the treatment goals. The exclusive therapeutic relationship can provide only a piece of the therapeutic puzzle, especially because the therapist cannot be available at all times to all of his or her patients, when they are having a triggered reaction or the compulsion to use drugs or alcohol in a destructive manner as a means to mediate their tension.

Those who have CPTSD, when in a fight, flight, and/or freeze response, in regard to a triggering event, need “a place to go,” “a place to run to,” “a place of hope.” This running towards hope metabolizes a reparative primitive response to the traumatic experience or traumatic memory. The twelve-step program offers that place to go for hope. Meetings are available worldwide, and there are 24-hour phone lines, on-line meetings, and on-line discussion groups. “A.A. can be found almost everywhere almost all the time–in more than 105,000 groups throughout the world” (Alcoholics Anonymous 2005, p. 48). A.A. is a fellowship of men and women who share their experience, strength, and hope with each other so that they may solve their common problem and help others to recover from alcoholism. A.A. is not allied with any sect, denomination, politics, organization, or institution. Our primary purpose is to stay sober and help other alcoholics achieve sobriety” (Anonymous, 1970, p.1).

Members are encouraged to make contact when in distress and not to wait to do so. Many members offer telephone numbers for outreach calls and remind one another that these outreach calls help both parties involved, not simply the person in distress. Most clinicians and psychotherapeutic support groups do not offer this type of broad range availability all hours of the day, seven days a week. Therefore, while the patient is in treatment, developing the security of a place to go when in distress any time of day offers the potential for the patient to build secure attachments, learn to self-regulate, and learn to help others, which subsequently develops the potential for the patient to have the experience of compassion and attunement through identification.

A confounding treatment problem with CPTSD/A is that the dysregulatory response of flight, fight, or freeze, with added emotionally reactive responses of compulsivity and obsession, may disrupt the patient’s capacity to automatically and autonomously initiate life supportive, healthy action responses to distress. One cannot assume that the patient has had sufficient interactive attuned experiences to be independently aware of his or her own dysregulated state. Sometimes, the patient may require another’s input to make a down or up regulating response. In other words, for the patient experiencing massive dysregulatory responses, including the compulsive need for addictive behavior to mediate the stress, the execution of a plan of positive action may sometimes not be simple or even possible.

Most clinicians who have had experience working with those who have a traumatically-driven addictive responses understand how therapeutic interventions and cognitive-intellectual understanding can be massively limited for the patient when it comes to actually putting these life supportive responses into action. Because reflective thought is incompatible with the traumatic reaction, sometimes an attuned interactive experience is necessary at the time of the traumatic reaction. Again, the therapist and/or family members may not be available during these perturbations of symptomatology. However, if the patient is developing a community of others in the twelve-step program, instructions on socially-driven action-oriented responses are more likely to be developed via the attuned interactive experiences and the availability of a safe place.

The experience of having access to another member of the program and the development of an internalized working model of a social community that models awareness of self, secure attachment bonds to mitigate states of dysregulation, the reliance on others, identifying the cause of the problem, and then taking the appropriate action to solve that problem helps the patient become aware of his or her own internal states. This development occurs through the reliance on others by seeking identifying experiences with fellow members and through faith in some power greater than oneself. Schore (2003) discusses how a regulating attachment of another not only helps regulate the dysregulated patient, but literally develops a more regulated neurobiological brain and thus a more regulated reaction. In other words, during times of this type of distress, interaction is vital. The twelve-step program members practice sharing how the program has worked in their lives, which generally involves self-regulating experiences. Members share how they found solutions to distress and/or their dysregulating experiences.

The CPTSD/A condition can interfere with some of the most basic areas of life supportive daily actions and daily functioning, such as eating, sleeping, and mood, as well as other states and affective experiences. Van der Kolk (2006) describes the basic problems that those with PTSD have with interoceptive experiences. He suggests that the therapist’s functions include being an interoceptionist or one who facilitates the patient’s learning to tolerate, understand, and finally react to internal feelings and sensations. Van der kolk (2006) describes the difficulties that traumatized individuals have focusing on internal sensations. When traumatized individuals try to mediate these trauma-related perceptions, emotions, and sensations, they often deny the bodily experience or feel overwhelmed by it. Thus, taking any action as a result of a bodily sensation is impossible.

As noted above, traumatic experiences often have an impact on the patient’s interpretation of bodily states and affects, including awareness of his or her own body in relationship to others.

Case study deleted for privacy purposes, used for teaching only. Some of case study included without privacy disclosed. (see the following)

HALT is one example of how the twelve-step program addresses problems with interactive experiences of mindfulness regarding interoception and basic bodily physical functions, develops secure and attuned attachments, and helps regulate terrifying affective/state experiences. Jack’s directed reading was taken from Courage to Be Me (Alanon World Service Literature, 1996 ). “We can watch for the need to HALT and give ourselves special attention when we are feeling Hungry or Angry or Lonely or Tired” (p. 139). His sponsor shared with Jack how this concept of HALT was applied to his own life, and he shared his experiences. His sponsor explained that the daily readings are from A.A.’s World Service Conference approved literature (governing body through group conscious decision making) and provides a daily guide to concepts of recovery. It was recommended that he read “Hope for Today,” a daily reflection book for Al-Anon Family Groups, providing hope for families and friends of alcoholics. On April 5, it states:
HALT. Don’t get too hungry, angry, lonely, or tired. I use this reminder to help me set healthy limits for myself, which I never learned as a child of an alcoholic. In the past, I often believed I should be able to go for days without food or sleep. I also tested the limits of my ability to handle enormous doses of stress and isolation without tending to my own emotional needs.

Al-Anon has taught me a gentler, simpler way of caring for myself. I find it of great benefit to have a brief list of the most basic areas in which I neglect my own well-being: nourishment, emotional wellness, fellowship, and physical rest. First, is my stomach rumbling? Then I need to stop what I am doing and eat some food. Am I too angry about the trivial details of my life? If so I can take a break and punch a pillow or engage in some physical exercise. Am I lonely? I could go to a meeting or call my sponsor. Finally, am I so tired that I can’t keep my eyes open? Then it’s time to lie down for a nap or a good night’s sleep.

Thought for the Day:
When I feel stressed, I’ll stop to check whether my basic needs are being met (Anonymous, 2002, p. 96).
(The book also is available in French, German, Japanese, and Spanish.)

When Jack met his sponsor that evening at the coffee shop, as the sponsor drank his herbal tea, Jack read his writing on the first three steps of A.A. to him. He wrote out each step and then they discussed his thoughts, feelings, and behavior. The first step is “We admitted we were powerless over alcohol, that our life had become unmanageable.” The second step is “Came to believe a power greater than myself could restore me to sanity.” The third step is “Became willing to turn my will and my life over to the care of God as I understand God, praying only for his will for me and the power to carry that out” (Anonymous, 2001, p. 59).

Although Jack had no belief in God, he and his sponsor agreed that Jack would use his love for animals as his belief system, in order to find a sense of faith, peace, and hope. Jack felt that he was always able to rely on the animal world and it became an internalized working model for Jack. When Jack discussed the unmanageability of his mood and behavior with his sponsor, he was able to turn to his belief in the animal kingdom as a source of comfort. When he felt this sense of comfort from images of animals whom he loved, he felt his sane behavior and regulated mood return.

Subsequently, Jack and his sponsor had many such meetings together. Instead of drinking alcohol, Jack experienced an interactive relationship with an empathic other, a secure attachment, had the immediacy of a place to go for hope, and most importantly learned about tools of self -regulation.