Tag Archives: PTSD

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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Trauma Treatment: Tetris

This seemed too good to be true, but by Godfrey, the results have been duplicated:

Researchers are now corroborating what some trauma sufferers have happened upon by chance: Focusing on a highly engaging visual-spatial task, such as playing video games, may significantly reduce the occurrence of flashbacks, the mental images concerning the trauma that intrude on the sufferer afterwards.

Video game play immediately after a traumatic incident may prevent flashbacks by keeping the brain's visual circuits busy.

When clients call in panic after a traumatic experience,  this could be an immediate it’s-worth-a-try intervention to recommend. One with no wait time, no need for insurance company panels, and virtually no risk of harm. The researchers don’t claim  Tetris should be recommended above other games, but it’s worth noting the game is cheap or free for smart phones and other platforms.  It’s an abstract geometry game unlikely to trigger emotional memories. Compared with some, it’s downright pacifying – one would hardly recommend Call of Duty to a client who just witnessed a shooting.

One point of fascination:

To test their idea, researchers asked subjects to view a disturbing film — an admittedly poor but sufficient simulation of real trauma. Within six hours of viewing this film, the period during which memories are thought to be consolidated for long-term storage , test subjects were randomly assigned to one of three tasks: answering trivia; playing Tetris, a 1980s video game that involves optimizing visual-spatial cues; or engaging in nothing in particular. Over the following week, subjects who had played Tetris reported experiencing significantly fewer flashbacks of the film than the others did. (For reasons that are unclear, those who answered trivia actually had the most flashbacks.) (emphasis added)

Neurologists have suggested traumatization may work as a memory problem, in that the traumatic memories can’t be remembered well enough to be filed and stored correctly.  The researchers in this study believe the game occupied the visual and spatial circuits of the subjects’ brains, and kept them from consolidating the traumatic images. Could  it be that recalling bits of trivia hampered the hippocampus‘  ability to cope with the memory of the film?

Promising first-aid for trauma: video games.  Asterisk: Tetris, yes. You Don’t Know Jack, no.

@ 2012 Jonathan Miller All Rights Reserved

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Can Trauma Make Us Stronger?

Stephen Joseph, PhD, professor of psychology at University of Nottingham, UK. (Photo credit: Maria Tanner at Lace Market Photography)

Great – another f***ing growth opportunity,” reads the classic bumper sticker. “Classic” here means, “old”, especially given that ‘personal growth’ seems as outdated as Esalen, hot tubs and encounter sessions. In his new book, “What Doesn’t Kill Us”, Stephen Joseph, PhD pries the concept free from associations with self-indulgence by linking it to Grandpa’s good, old-fashioned ‘character building’ – finding strength through suffering.

In 1990, Joseph conducted three-year follow-up interviews with survivors of the Herald of Free Enterprise sinking. Those who lived through the tragedy reported all of the pain, guilt and sleeplessness researchers expected. Yet, surprisingly, 43% also made comments like, “I live everyday to the fullest now,” and “I am more determined to succeed in life now.” Joseph, professor of psychology at the University of Nottingham, UK, used these findings to develop his Changes in Outlook Questionaire (CiOQ), and found it repeatedly confirmed such signs of personal growth in hundreds of trauma survivors.   Like Viktor Frankl, Joseph “… saw two sides of suffering, noting that while there might be nothing inherently good in misfortune, it might be possible to extract something good out of misfortune.” He argues against Freud’s view that therapy’s role is to get clients back to common unhappiness. Rather, the therapist’s job should be to help people lift themselves above their pre-trauma level of functioning – to grow.

"... 'terror'... 'torment'... 'tragedy' .... here it is, 'trauma'."

Every trauma survivor seeks information. They’re filled with questions such as, “ What happened? Why can’t I put it behind me? Why did this have to happen at all?” Joseph presents PTSD as an information-processing problem. To be traumatized is to be blasted with unbearable knowledge at an intolerable volume.  So much, so fast, creates an overload that destroys neurons in the hippocampus and hampers one’s ability to process the memory. These ‘uncategorizable’ recollections drift about the mind in the form of flashbacks and nightmares, like so many piles of paperwork on a desk. To file such memories away properly, the survivor’s understanding of the world must grow. A new file folder with a new category, (one that makes sense of the memory), must be labeled.  Unanswerable “Why me?” questions aren’t resistance or self-pity – they are the start of the search for meaning. 

None of Joseph’s ideas fit on a bumper sticker, and all are ripe for misinterpretation. One can sense his desire for a rubber stamp reading, “OF COURSE”.  Of course trauma survivors suffer, he says. Of course no one would choose trauma for the benefits of post-traumatic growth. Of coursePositive Psychology” doesn’t mean clients censor their pain with smiley-face stickers. He makes it clear that growth is not a guaranteed result of trauma, and lack of growth is not evidence of poor character. First, Ryan and Deci’s basic needs (such as acceptance and belonging) must be met. A client must choose to engage in the growth process before that process can begin. When a person is traumatized enough to meet criteria for post-traumatic stress disorder, growth won’t happen until those symptoms ease in treatment. A more specific, less marketable title might have been, “What Doesn’t Kill Us or Give Us PTSD.”

The last issue is particularly relevant, given Salon.com’s try at shoehorning the author’s ideas into an “over-diagnosis” narrative.  Joseph straddles the diagnosis debate. He observes that a PTSD diagnosis validates a client’s story. It’s undoubtedly a good thing  survivors have been moved from the file marked, “Malingering coward,” into the one labeled, “Someone with an understandable, treatable illness who is deserving of our compassion.” He’s troubled, though, that the same redefinition moves trauma from the, “I will survive this and grow stronger,” category  to the, “This is something the doctor needs to fix,” file.  In his view, our current understanding can file trauma survival under stiff-lipped perseverance or a treatable illness, but not the process of becoming someone new.

Friedrich Wilhelm Nietzsche (1844-1900). Personal-growth pioneer - not actually to blame for WWII.

Perhaps this critique of the medical model explains why the book is weakest when it addresses treatments for post-traumatic symptoms. It’s clear Joseph’s focus is to break up our thinking about trauma. He encourages therapists to speak in the disease model’s terms long enough to engage the client in the process of growth, but rushes past descriptions of how specific symptoms can be eased so growth can begin. With all of the book’s valuable advice for clients on coping with stress and finding professional help, one wishes the author spent more time on why, how, and how well different treatments work.

In “What Doesn’t Kill Us”, the author wire-walks his way between the fact-free fluff of self-help and the rigid, symptom-focused empiricism of insurance panels, to show how Nietzche‘s maxim can apply to leading a fulfilling life, not just survival in a vicious world. What doesn’t kill us provides the opportunity to nurture changes in our thoughts, behaviors and understanding of how life works. We can grow enough from adversity that the answer to, “Why did this have to happen?” becomes, “So I could be a stronger, more compassionate, more fully-alive person.”

(The New York Times has an excellent article about post-traumatic growth among members of the U.S. military here.)

@ 2012 Jonathan Miller All Rights Reserved

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PTSD is overdiagnosed – unless maybe it’s not

Salon.com ran an interview with Stephen Joseph, professor of psychology, health and social care at the University of Nottingham,U.K., and author of, “What Doesn’t Kill Us: The New Psychology of Posttraumatic Growth”. The headline? “How PTSD took over America”.  The subtitle? “The diagnosis is now being applied to everything from muggings to childbirth. An expert explains why it’s bad news.”  Interviewer Alice Karekesi asks questions like, “Do you believe that PTSD is over-diagnosed?”, “Is the emotional pain overblown in such cases?” and “Are there some cultures that are more prone to post-traumatic growth?”  One quick scan and I was ready to ask Dr. Joseph blistering questions such as, “How long does a client need to suffer before they can skip the ‘growth’ and actually get some help?”

Until I re-read his answers. And noticed that Salon and Joseph were talking about different things. Joseph doesn’t claim post-traumatic stress disorder is over-diagnosed. He explains the definition of PTSD has expanded, but doesn’t argue that’s a bad thing. He notes some say the DSM over-medicalizes the human experience, but doesn’t take a stand on whether it does or not.  The only “bad news” he explains in the interview?  People who have a normal reaction to an upsetting event may believe they have PTSD.

I’ll be reading Joseph’s book in the near future. Blurbs for the book suggest it’s not about diagnosis, but the way one can grow during recovery from trauma, and emerge stronger and healthier than before. If there are meaty chapters claiming that PTSD is over-diagnosed, you’ll read the full update here.

Political observers note media coverage is often driven by pre-established narratives – storylines and stereotypes that journalists (overworked, underpaid, overstressed and under-respected, by definition) fall into. Why did Candidate X get labeled as a flip-flopper when Candidate Y changed positions, too? Because it fit a storyline, including people’s perceptions of X’s character. The narrative here seems to be that if you say you have PTSD (or any other DSM diagnosis), it’s more likely you’ve inflated mild symptoms into a mental disorder because you’re weak.

DSM-V comes out next year. Watch for more of this narrative as May, 2013 approaches.

@ 2012 Jonathan Miller All Rights Reserved


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Can police peers prevent PTSD?

The DSM-IV-TR defines traumatic events (TE’s) as  “events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.” That’s a  fair description of  situations police officers might find themselves in every day. In Quebec, the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST) has found that police officers are less vulnerable to Post-Traumatic Stress Disorder than previously thought. Per the IRSST, they’re actually no more likely to develop PTSD than any one else.

The American Medical Network reports:

“Providing police officers with interventional support shortly after and in the weeks following a TE improves the chances of preventing PTSD,” explained André Marchand, lead author of the study, researcher at the Fernand-Seguin Research Centre of Louis-H. Lafontaine Hospital and Associate Professor at Université de Montréal’s.”

What is intriguing here is how much “interventional support” sounds  like Critical Incident Stress Management. With CISM,  emergency service personnel and accident victims meet mental-health professionals for information and support immediately after a traumatic event. It’s an intervention that seems logical, but can actually increase the risk of developing PTSD. So what’s the difference?

…  the police officers stated that talking to their colleagues, obtaining peer support and taking part in leisure activities are particularly helpful after a TE. “The police offers involved in this study even advise their colleagues who experience this kind of event to consult a psychologist and are themselves open to the idea of receiving psychological support if need be,” said Mélissa Martin, co-author and psychologist at the Trauma Study Centre at Louis-H. Lafontaine Hospital.

This is a tantalizing hint of two key differences:

  • support from friends and family, rather than a stranger with a psychology degree
  • choosing to meet with clinical staff, rather than being presented with them

The original study has not been translated into English. Man, I wish I spoke French.

@ 2011 Jonathan Miller All Rights Reserved

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