PTSD and Addiction: A Cognitive Restructuring Approach

January 11, 2014
By Terence T. Gorski, Author
June 22, 2013

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.


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.


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.


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.


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.


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.


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).


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.


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?


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.


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.


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.


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.


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.


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.


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.


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 …


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

Transformational Experiences

April 12, 2012

hope (1)By Terence T. GorskiAuthor
GORSKI BOOKS available from

Many people have told me that we can recover from anything and everything that happens to us. I wish that were true, I really do, but if we define recovery as returning to the kind of person we had been before the trauma, I don’t believe it.

We cannot totally recover from all of the things that we experience. Once we know something we cannot unknown it. Once we see something, we cannot unsee it. Once innocence and the naive idealism of inexperience are lost they cannot be regained.

Some things change us. Even if we are resilient, when we bounce back we are difference. This is because some of what happens to us in life are TRANSFORMATIONAL EXPERIENCES. The most common transformational experience for most women is childbirth. You don’t just have a baby and go on with your life unchanged. Childbirth transforms most women.

Combat is a transformational experience. You don’t train and then put yourself in harm’s way knowing you are at risk of being maimed or killed or being called upon to maim or kill others without the experience transforming you on a deep level.

The are POSITIVE TRANSFORMATIONAL EXPERIENCES that build us up and give us hope: our first love; the birth of a new child; the hug of a loved one; meeting a new friend; falling in love again when we never though we could; a spiritual experience that opens us with joy and reverence to the beauty around and within us. These powerful experiences change us, because as we make sense of what has happened our view of ourselves, others, and the world opens us to new possibilities.

There are also TRAUMATIC TRANSFORMATIONAL EXPERIENCES that wound us deeply, crash our dreams on the jagged rocks of harsh reality, and shake the very foundations if our faith human goodness.

We all experience them from time-to-time. As unpleasant as they may be, maturity teaches us that they are a part of life. We will all experience: the death of a loved one, the loss of a true love; the violation of trust by a close friend; or the personal confrontation with violence and brutality. Most of us will face serious injury or illness. We will all grow old suffering the loss of youthful ambition.

Most of us will survive even the worst of these experiences, recover from the trauma, and then start making sense out of what happened to us, why, and it means. The traumatic moment unbundles the deepest part of our spirit. Our will to live pushes us to move on step by step.

We assign meaning to he experience. We do an in inventory noting the parts of ourselves we have lost in the experience and the new parts of ourselves we have gained. We realize we are the same person, yet somehow we are fundamentally different. Our conscious awareness of ourselves, others, and the world has changed and it can never be put back the way it was.

Transformational experiences change us. We are no longer the same people we were before the experience. We have changed, either for the better or the worse. And the change is governed by the choices we make in interpreting and responding to the trauma. That is the choice we have to make – how will I allow this trauma to affect me?

In the aftermath of a trauma we can make decisions to adapt and grow in ways that strengthen us and make us better people; or we can make decisions to adapt in a way that weakens us, blocks our growth, and makes us bitter and miserable people. That choice is always ours.

If you’re feeling sorry for yourself think of Christopher Reeves. In spite of staggering losses, he made massive contributions to all around him and left a legacy for us all to follow.

Why did he do it? He chose each day to struggle to hold the emotional high ground — and I am sure it wasn’t easy. I am also sure he didn’t stay on the high ground all day every day, but he was resilient. He always bounced back to the best of his ability. This is all any of us can do.

Trust in yourself. Do the best you can in the moment. Believe that will be enough because it usually is.

In the aftermath of a transformation life experience, it is best to move slowly and carefully. We are on new ground and need to regain our footing. How we choose to move forward will set the stage for what we will do next in our lives.

The most important thing, however, is to know that you can stand up again, even if you are afraid you might fall; to be willing to try again even if you are afraid you might fail; to know that you still have a life to be lived and that there are still people you love and who love you.

Bill White has an excellent article describing recovery from addiction as a process of transformational change:



Straight Talk About Addiction by Terence T. Gorski

All of the books of Terence T. Gorski
are available from

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