PTSD and Addiction: A Cognitive Restructuring Approach

By Terence T. Gorski, Author
June 22, 2013
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Recovery Is Possible With
Cognitive Restructuring

 WHEN  TREATING PTSD AND ADDICTION, I don’t use a single approach – I use a consistent set of principles and practices. I strive to be sensitive and adaptive to the emerging needs of patients in the moment. The key seems to be a balance of flexibility and consistency.  Everyone responds in a uniquely personal way in learning to understand and manage PTSD. I like the idea that and the PTSD recovery process results in Post Traumatic Growth. People don’t just overcome their symptoms. They grow and change in positive ways.

PTSD ASSESSSMENT – A CRITICAL FIRST STEP

First I do a comprehensive assessment of PTSD. This includes an analysis of presenting problems, a life history, and a history of treatment and recovery. I include efforts at self-help to be important. Most people try everything they know to get a handle on their PTSD before seeking any formal or professional help.

ADDICTION ASSESSMENT – NOT A LUXURY, A NECESSITY

If the assessment provides confirmation of active PTSD symptoms, I do a comprehensive addiction assessment because addiction is so common in patients with PTSD. If the addiction is not identified and treated concurrently, the PTSD treatment can make the addiction symptoms worse, and the addiction symptoms can prevent patients from benefiting from the treatment/recovery of PTSD.

PSYCHO-EDUCATION – TEACHING A LANGUAGE OF RECOVERY

Then I use psycho-education to give people a new cognitive frame of reference about PTSD. This is extremely important because, although most people are familiar with the general idea of PTSD, most lack accurate information or a useful way of understanding the symptoms and the pathways to recovery.

SURVIVORS – NOT VICTIMS

The most important thing I want to teach is that patients are trauma survivors, not trauma victims. I also want to be sure that the trauma is over. You work differently with PTSD if the trauma is still ongoing It makes a difference if: a soldier needs to return to combat or is home from the war; if a battered child is still living under the control of violent parent and will have to go home; if the abused spouse is out of the marriage or still involved due to children or financial issues; if the person is in prison and going back to the cell block or if they have been released. If they are actively involved in an ongoing trauma teach survival and coping skills, safety plans, and ways to responsible get out and get safe.

GET PATIENTS SOME INITIAL RELIEF FROM PAIN

The first goal is to provide relief for the most painful mediate symptoms. This often involves referral for EMDR. I am not skilled with this method, but many patients find it helpful. This also involves basic training in relaxation, diet, and exercise as a part of overall stress management.

THE LIFE AND SYMPTOMS HISTORY – A COLLABORATIVE APPROACH

Then I do a guided life and symptom history so people can see how symptoms have affected their life negatively through pain, problems, and losses; and positively through a process of making decisions that lead to positive change, growth, and development. This is a positive psychology intervention called Post Traumatic Growth (PSG).

THE COMPREHENSIVE SYMPTOM LIST

I develop a comprehensive list of the PTSD symptoms that patients are struggling with. This often involves showing them a list of symptoms because they lack the words or language to describe what they are experiencing. It is easy for me to forget how important it is to give patients a language of recovery so they can identify and communicate their experiences.

Once I have a comprehensive symptom list, I ask patients to evaluate the frequency (how often) and severity (how disruptive) the symptoms tend to be.  Then explore each symptom. First I want them to tell me real-life stories about what happened when they experienced each symptoms. I like to get at least two stories about each – one story in which they managed it pretty well, and one story in which they managed it poorly. This helps them to take ownership of their symptoms and get a feel for the new language they are learning. I get stress enough how important I feel this process by relating symptoms to actual lived experiences is for most patients.

I look for patterns of symptoms. Many symptoms appear in clusters that are activated by the same trigger event and once they appear, they mutual reinforce and intensify each other. I treat these symptom clusters as a single symptom and help patients to find a meaningful name it.

STRENGTH-BASED – WHAT ARE YOU DOING RIGHT

I make it a point to discuss how patients have managed to survive up to this point. I want to find periods of time when they have successfully managed their symptoms or been symptoms free. What were they doing at those times. What was going on or not going in their lives. What thoughts, feelings, behaviors, and social styles are associated with successfully coping with the symptoms?

THE IDEA OF PTSD SYMPTOM EPISODES

I also like to introduce the concept of PTSD symptoms episodes – moments in time when the symptoms get turned on by triggers and turned off by things like rest and safe environments. The idea is that the symptoms are not always there. Most patients believe that they are, but they are usually wrong. The symptoms are usually turned on some of the time and turned off at other times. Once a symptoms episode is activated by a trigger, it starts, runs a cycle, and then ends or significantly diminishes in intensity. Know that it will end gives strength in facing the symptoms. Naming the symptoms identifies the enemies or the monsters to be dealt with. At the very least, at some times the symptoms are less severe and more manageable than at other times.

SYMPTOM SELF-MONITORING

I encourage patients to do conscious self-monitoring o their symptoms at least four times per day (breakfast, lunch, dinner, and before bed) and note the specific symptoms experienced, how severe the symptom is, what is happening that is making it more severe, and what could be done to make it a little bit less severe. This starts patients on a journey of Post Traumatic Growth by showing them they are not totally at the mercy of these symptoms — that they can choose to do things to make their symptoms a little bit better or a little worse.

FLASHBACKS – TEACHING PATIENT TO GET OUT SAFELY

I find that many patients are fearful of the flashback and dissociative states that they get into that are often a part of PTSD. They fear that if they get into these states they will fall into a bottomless black pit and never be able to crawl out again. This is why a believe so many people are afraid to start talking about past experiences or the triggers that activate symptoms. They are afraid that once the symptoms start they won’t stop.

FINDING A SAFE PLACE INSIDE YOURSELF

To counter this, I like to have patients find a safe-memory or fantasy that they can go to and practice going there when they are feeling pretty good. I want them to learn and practice relaxation exercises that work for them. I give them a smorgasbord of relaxation methods to choose from. Giving choices, it seems, reduces resistance. I also avoid “one size fits all” methods of relaxation — but no methods really do work for everyone. I avoid using guided imagery at first because I find it unpredictable. Once patients relax and engage their imagery processes, they often are vulnerable to intrusive thoughts, feelings, and flashbacks.

IMMEDIATE RELAXATION METHODS – CHOICE AND SAFETY

I like to teach centering, deep-breathing, and mindful (detached) awareness, I want to be sure that patients learn how to get back into the here and now and stop intrusive symptoms as soon as they start.

I avoid what I call “big bang catharsis techniques” which take the patients quickly into deeply re-experiencing the memories of trauma. I have just had too many b ad experiences with patients regressing and getting worse as a result of these techniques. I personally don’t find using them worth the risk.

I would rather take patients into the memories as they emerge in the assessment and recovery skills training process. I want to be sure that patients have the ability to stop and crawl out of the experience and get back into a tight anchor with here-and-now-reality.

SUPPORT NETWORKS 0 CRITICALLY IMPORTANT

I also focus on building support networks of people, places, and things that can be used when things get tough. Simple things like: Who can you call if you need to talk? Who should you avoid if your symptoms are bad in the moment? What can you do that will help? What should you avoid doing because it will make things worse? I am especially concerned about having a support systems that can be used during the night. This is when the symptoms tend to be more intense and the support less available.

COGNITIVE RESTRUCTURING – TFUAR MANAGEMENT

The general structure I wrap these general principles of cognitive restructuring. I use the word cognitive to mean total information processing with the brain and the mind. This involves Thoughts (T), Feelings (F), Urges (U), actions (A), and relationships. It also involves subtle intuitions and openness to spiritual experiences which seem to be very common in people who survive trauma. using a cognitive restructuring process. I ask patients to complete these sentence stems, or I turn them into open-ended questions. Using active listing is critical. Patients must feel listened to, understood, taken seriously and affirmed as a person. This process turns a sterile and “objective” assessment into a highly personalized and collaborative self-assessment.

COGNITIVE RESTRUCTURING FOR PTSD

Here is a general structure for the process:

1.  The symptom that I am experiencing is …

2.  When I experience this symptom I tend to think …

  • A more helpful way of thinking might be ….

3.   When I experience this symptom I tend to feel …

  • A more helpful way of managing those feelings might be ….

4.  When I experience this symptom I tend to manage it by doing the following things …

  • A more helpful behavioral strategy for managing this symptom might be ….

5.  When I experience this symptom what I do to try to get help from other important people in my life is …

  • A more helpful strategy for getting the help and support if others in managing this symptom might be ….

6.   he overall daily plan I have for managing my PTSD recovery is …

  • Some ways of making my recovery plan more helpful for me might be …

A SIMPLISTIC SKELETON OF A COMPLEX PROCESS 

This is a simplistic skeleton of the basic principles and practices of a cognitive restructuring approach for PTSD. This sketch, of course, just covers some of the steps on the critical path to recovery and relapse prevention. It also presents my preferences as a therapist based upon my past experiences with clients. I am sharing this as a personal report on lessons learned.

 Gorski Books

16 Responses to PTSD and Addiction: A Cognitive Restructuring Approach

  1. Guy Lamunyon says:

    Hypnosis can also be effective. I am not a hypnotherapist however have been able to use hypnotherapy by providing recordings:

    http://www.potentialsunlimited.com/product-details.cfm?sku=240MS

    • Terry Gorski says:

      Hypnosis: Basic Principles

      I operationally define hypnosis as “a state of heightened suggestibility.” There is no consensus on what it is. Many people believe in it and others don’t. The research is difficult to pull together because of the lack of standard language. Here is my best understanding:

      Individuals different in levels of hypnotic suggestibility ranging from high to low. Therefore, hypnosis itself cannot be said to be said to be effective or ineffective. There are four factors that must be considered:

      (1) The skill if the hypnotist (some are better at inducing trance than others).

      (2) The hypnotic method of induction (which vary in effectiveness)

      (3) Individual characteristics related to hypnotic suggestibility (not everyone is equally susceptible or capable of entering trance states).

      (4) The setting in which the hypnotic trance induction is attempted (some settings are conducive to trance induction and some are not.

      Volumes of research have been done since I studied hypnosis.

      Here is the MUST PLAIN ENGLISH OVERVIEW ARTICLE ON HYPNOSIS: The Trouble With Hypnosis: Psychology Today: http://m.psychologytoday.com/articles/200910/the-trouble-hypnosis

      This one gives the position of the American Psychological Association (APA): https://www.apa.org/monitor/2011/01/hypnosis.aspx

      Here are some interesting links:

      1. Hypnotic Susceptibility.
      Hilgard, Ernest R.
      Oxford, England: Harcourt, Brace & World. (1965). xiii 434 pp.
      http://psycnet.apa.org/psycinfo/1965-15730-000

      2. Stanford Hypnotic Suggestibility Scale: http://ist-socrates.berkeley.edu/~kihlstrm/PDFfiles/Hypnotizability/SHSSC%20Script.pdf

      • Guy Lamunyon says:

        I have also considered ‘guided meditation’ to be states of heightened suggestibility. If your eyes are closed and someone is telling you what to think or believe I call that hypnosis. Many advocates of ‘mindfulness’ are actually using guided meditations of this sort.

        As with many things, there is research either way – pick the research you like to support your position. We cannot discount the placebo effect in any of our methods:

        Mark 5 – Your faith has made you well (healed you):

        25 A woman who had had a hemorrhage for twelve years, 26 and had endured much at the hands of many physicians, and had spent all that she had and was not helped at all, but rather had grown worse— 27 after hearing about Jesus, she came up in the crowd behind Him and touched His [i]cloak. 28 For she [j]thought, “If I just touch His garments, I will [k]get well.” 29 Immediately the flow of her blood was dried up; and she felt in her body that she was healed of her affliction. 30 Immediately Jesus, perceiving in Himself that the power proceeding from Him had gone forth, turned around in the crowd and said, “Who touched My garments?” 31 And His disciples said to Him, “You see the crowd pressing in on You, and You say, ‘Who touched Me?’” 32 And He looked around to see the woman who had done this. 33 But the woman fearing and trembling, aware of what had happened to her, came and fell down before Him and told Him the whole truth. 34 And He said to her, “Daughter, your faith has [l]made you well; go in peace and be healed of your affliction.”

      • Terry Gorski says:

        I agree. We are not as smart as we think we are. A big problem is the lack of uniform language and systematic concept formation in the general population and specifically among counselors and therapists.

  2. Guy Lamunyon says:

    Here is a documentary video showing dramatic results using hypnotherapy with WWII combat veterans:

  3. Terry Gorski says:

    I wish my father, a WW II Vet with severe combat-related PTSD had the chance to experience some effective therapy. Click here to read: Show Me A Hero which has a part of his story.
    https://terrygorski.wordpress.com/2013/12/12/show-me-a-hero/

  4. Terry Gorski says:

    The mind is a powerful thing. It is not infinitely powerful and the very intelligence we are given that to help us discover who we really are, often works against us. The truth is hard to find. The potential of the human mind for self deception seems nearly infinite.

  5. Tertia says:

    Thanks for your perspectives and your awareness of the prevalence of PTSD issues in recovery. One thing I find helpful to recommend, especially for folks in early recovery dealing with a lot of PAWS as well, are grounding techniques such as those found in Marsha Linehan’s Dialectical Behavioral Therapy. These can improve distress tolerance and help an addict in recovery hang on long enough to make use of some deeper healing.
    P.S. Thanks for visiting my dual diagnosis blog, Not This Song.

  6. I often worry how we will help my husband cope after having been wrongfully imprisoned, and most recently put in isolation for standing up for human rights. How do we begin to help inmates decompress once they are back in society? Thanks

  7. gpen says:

    What’s up to all, as I am actually eager of reading this web site’s post to be updated daily.
    It consists of good information.

  8. Jano says:

    Thanks for sharing your experience.

  9. Terry Gorski says:

    Reblogged this on Terry Gorski's Blog and commented:

    The relationship of PTSD, ADDICTION, AND RELAPSE has been one of the most talked about areas on my blog. As a result I am reposting information on this very important topic.

  10. Tommie says:

    I love reading through an article that can make men and women think.
    Also, thank you for allowing for me to comment!

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