Monthly Archives: August 2012

Trauma, Addiction and Ouroboros

Therapists are often reluctant to see clients who just kicked their addiction. We know therapy can be wrenchingly difficult. We worry we’ll trigger a relapse if we see someone before they’re firmly grounded in sobriety. Maybe we shouldn’t.

A new study from University of South Wales researcher Katherine L Mills  and her team tested their program, COPE: Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure. As the name makes clear, COPE combines addiction treatment with prolonged exposure therapy for post-traumatic stress disorder. Most would fear the grueling exposure process would cause the clients to relapse. It didn’t. After nine months, the COPE  group and an addiction-treatment-only control group both saw the same decline in substance dependence. Among those who were still addicted, both groups’ members saw their addiction grow less intense by roughly the same amount.  The only statistically significant difference between groups? Those in the COPE group had significantly lower rates of post-traumatic symptoms.

Ouroboros, in a medieval engraving.

Critics have rapped the study for comparatively small effect-sizes. One would suggest they’ve missed the point. Dually-diagnosed clients can feel like Ouroboros – the mythical serpent forever swallowing its’ own tail.  Alcohol and other drugs might be their only way to cope with emotional problems, even while their addiction makes those problems worse.  Emotional pain and the struggles of recovery may be the right choice, but it’s a hard choice when the option is to get wasted one more time.  In this study, even those clients who weren’t fully abstinent saw their PTSD symptoms dwindle.

Ouroboros, as experienced by many dually-diagnosed clients.

The authors are clear that a client can’t get blotto every day and still get somewhere in therapy. They do say:

“These findings challenge the widely held view that patients need to be abstinent before any trauma work, let alone prolonged exposure therapy, is commenced. Although we agree that patients need to show some improvement in their substance use and an ability to use alternative coping strategies before prolonged exposure therapy is initiated, findings from the present study demonstrate that abstinence is not required.”

The fact these clients improved without firmly-established sobriety, some without even being fully abstinent, is more significant than the extent to which they recovered.  More studies on therapy with the recently-sober, please.


Mills KL, Teesson M, Back SE, Brady KT, Baker AL, Hopwood S, Sannibale C, Barrett EL, Merz S, Rosenfeld J, Ewer PL  Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: a randomized controlled trial. [Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov’t] JAMA 2012 Aug 15; 308(7):690-9.

@ 2012 Jonathan Miller All Rights Reserved

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Filed under Post-Traumatic Stress Disorder

Where Borderlines Excel

If you’ve worked with clients who have borderline personality disorder (BPD), you’ve probably had a conversation like this:

Therapist: How did that make you feel?

Client: I dunno.

Therapist: How do you think that might have made someone else feel?

Client: I dunno.

Therapist: Take a look at that list of feeling words and see if there’s anything that fits.

Client: Oh God. I can’t face that list today.

Therapist: Well… hm.

Client: You’re getting worried. You’re thinking about referring me, aren’t you?

Can people really be so oblivious to their emotions when they’re so well-attuned to yours?

Carina Frick, Simone Lang, et al answer at least half of that question in their  new study. They asked clients with BPD to receive an MRI while guessing the emotions others displayed in photographs.  The BPD clients out-guessed the control group of healthy subjects. The fMRIs showed they actually used different parts of the brain.  They were so skilled at identifying what others feel that the mentalization term ‘mind-reading’ seems eerily appropriate.

The researchers suggest this serves as empirical evidence for Alan Krohn’s 1974 paradoxical theory. Krohn noted people with these issues usually grew up with unpredictable parents and inconsistent rules; what Marsha Linehan would later dub the invalidating environment.  The clients he studied had to hide their feelings and read their guardian’s mood quickly to avoid punishment. Clients with BPD are often alert to your emotions and blind to their own, because that kept them safe through childhood.

Neurologists will be titillated by the differences in the brain activity. The fMRIs showed BPD clients’ amygdala, medial frontal gyrus, left temporal pole and the middle temporal gyrus were more active when guessing others’ emotions. The members of the control group lit up in the insula and the superior temporal gyri.  Therapists will be excited that even very low-functioning clients with these issues have a common strength to build on. Two possibilities:

  1. Clients with BPD often feel hopeless about their abilities. We can validate and encourage them by reminding them of this skill, and how useful it is in the work world.
  2. When clients talk about times where it was obvious what someone else felt, I’m going to ask just what they saw. What posture did that person take? How did their face look? What tone was in their voice? What happens in the client’s throat and mouth when they reproduce that tone?

Here’s to the hope these ‘mind-reading’ abilities can be reverse-engineered towards greater self-awareness.

n.b.: If you’d like to test yourself on ‘mind-reading’,  Simon Baron-Cohen‘s “Reading the Mind in the Eyes” test is available here.


Frick C, Lang S, Kotchoubey B, Sieswerda S, Dinu-Biringer R, et al. (2012) Hypersensitivity in Borderline Personality Disorder during Mindreading. PLoS ONE 7(8) e41650. doi:10.1371/journal.pone.0041650

@ 2012 Jonathan Miller All Rights Reserved


Filed under Borderline Personality Disorder

“It’s All in Your Head”

LicensedMentalHealthCounselor has a thoughtful post on parents’ denial of their children’s mental health problems. It reminded me of a pet peeve: family members who ask clients, “What wrong with you?” then dismiss the answer with, “That’s all in your head.”

What does “It’s all in your head” mean? “You’re incorrect”? “You’re making excuses”? “You’re lying”?  It might mean, “Please don’t talk about this.” Talk about mental health problems can trigger others many ways. For example,

1. Not everyone with problems is in treatment. If a client admits they are vulnerable to emotion, others remember they’re vulnerable,  too.

2. “I can’t,” isn’t in our vocabulary. Our culture values hard work, personal responsibility and triumph over adversity.  Only the most severe mental health issues are visible to others.  Most skeptics have long experience with The Jitters and The Blahs. They can have a hard time understanding what separates those from Panic Disorder or Major Depressive Disorder.

3. As a culture, we don’t talk about emotional problems. If we talk about them at all, we do so in an understated, hesitating way. When someone explains they have mental health issues, the other person is left to guess how much understatement just occurred. Does, “My nerves make it hard to go outside,” mean they have a moderate case of agoraphobia? Or does it mean the entire family will be murdered in their sleep? Much easier to sweep the entire topic aside by saying, “That’s all in your head.”

In fairness, “It’s all in your head,” often means, “You can do it.” It can come from the same well-meaning and wholly-useless intentions as, “Don’t worry about it,” “Relax,” and, “Just cheer up.” It can also channel condemnation those other tips don’t. Clients say this disregard is worse than insensitive – it’s invalidating. Even when their family hopes they’ll feel empowered, the client is often to wonder, “Do I actually have problems, or am I just a lazy coward?”

Different clients have handled dismissive relatives differently.  Shrill didactic lectures haven’t always been the answer. When a pithy conversation-ender seems appropriate, I’ve suggested, “Sure it’s all in my head. And your diabetes is all in your pancreas.”

@ 2012 Jonathan Miller All Rights Reserved

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Filed under The Client's Side