The Untold Secret

By Dr. Jerry A. Boriskin, Ph.D.

Actually, it is not a secret but more like an aspect of addiction hidden in plain sight. For decades we’ve split off mental health from addiction and alcoholism. The history of how this happened is interesting but not relevant to those newly sober. More vital is the now accepted notion that the majority of addicts suffer from co-occurring mental health issues. Do not be intimidated by the language; mental illness is an awkward- and often misleading – term that gets in the way of information you and your family need in order to increase the likelihood of sustained sobriety. We now recognize that up to 80% of those who are dealing with addiction also deal with depression, anxiety disorders, Attention-Deficit Disorder, Bipolar Disorder, and a whole range of cognitive, emotional and mood problems that make sustained recovery much more difficult. For those who want to read more detail I suggest At Wit’s End: What You Need to Know if A Loved One is Diagnosed with Addiction and Mental Illness (Jay and Boriskin, 2007). It is not easy navigating two systems- mental health and recovery work – but getting help with your depression or anxiety can be a lifesaver.

My personal area of interest and expertise is the role of trauma in addiction, recovery and relapse prevention. Most readers are familiar with what was once an obscure term- PTSD. Post-traumatic Stress Disorder was actually recognized a mere thirty years ago (though it was known by other labels in the past, such as ‘shell shock’.) Most people associateit with war-related trauma. Indeed, the overwhelming stress of combat, horrors of death, helplessness, rage, etc. are widely depicted in movies and mentioned in news stories. What many do not realize is that PTSD is a condition that affects civilians as well. In fact, those who have active PTSD are at a much higher risk of developing an addictive disorder, and about 25% to 30% of those in addiction recovery treatment programs meet diagnostic criteria for PTSD. Whether it is a result of self-medication for physical or emotional pain, or a way of feeling once you have become numb, alcoholism and addiction co-occur with startling frequency.

What is interesting is that both conditions follow similar patterns- they are intrusive, obvious in hindsight but often misdiagnosed or misunderstood by those who treat as well as those who suffer. Adding to the challenge is the fact that many individuals do not connect their trauma issues with their addiction- they separate them and often obscure one or either of these conditions. Denial is symptomatic of PTSD as well as alcoholism/ addiction. Even more vexing is the fact that drug and alcohol use can be the source of traumatic exposure. Far too many young people have been sexually violated when using MDMA, Ecstasy often in combination with alcohol and other drugs.. Tragically, there is a bit of publicity suggesting MDMA as a treatment for PTSD. While the science will sort this out, I am willing to predict it will join the dustbin of false treatment and in the process might damage those who try to self-treat. So, what do you need to know in order to treat the trauma and reduce chances of relapse?

SEQUENCE: WHICH COMES FIRST?

It should be noted that the sequence of whether the trauma came first and the addiction after is not relevant. However, the sequence of treatment is important. Sobriety must come first. You cannot get sober by simply addressing PTSD- unless you were not a full genetic addict. The vast majority of clients we see need to become solidly sober and preferably involved in active 12 step support/treatment. So, sobriety first followed immediately by focus on the trauma. Ideally, treatment for PTSD should begin in early recovery- well before the six month sober mark.

HOW DO YOU WORK ON THE PTSD AND WHAT SHOULD I LOOK FOR IN TREATMENT?

Not everyone exposed to traumatic events develops PTSD. It is estimated that perhaps 25% do develop the condition. However, if you develop PTSD it is something you need to learn to manage, not eliminate. The work that you do in trauma therapy should be focused on building your understanding, acceptance and management of PTSD symptoms. There is no ‘magic’ and there is no ‘cure’, but there are multiple things you can do to dramatically improve your life and protect your sobriety. I strongly encourage you to find a credentialed mental health professional with whom you can develop some trust. The goal is not the perfect clinician, but one who you feel can listen and guide; the best clinicians are great listeners, not task masters or fixers. The goal of therapy is not like you see in the movies. It is not a simple “exposing’ of the trauma or remembering things you have worked to forget. Sure, feeling some of the pain and remembering some of the trauma almost always happens, but it is part of the process, not the goal of treatment. The best treatment providers teach you how to think differently. They help you recognize triggers. They help you realize that you are normal, not mentally ill. In fact, a simple definition of PTSD is: “A sane reaction to insane events”.

I like to encourage clinicians and clients to see recovery as a multidimensional challenge. You need to work on the four main factors:

1) Psychological- understanding how you think and how you speak to yourself; 2) Biological: managing the surges in impulse and multiple false alarms that push you to overreact to harmless situations. Sleep, diet, and exercise are key features that need attention. Many clients with PTSD need one or more medications to help provide the safety and sleep you need to recover. Naturally, do your best to find a trauma-informed physician who can manage these medications without risking relapse or over medicating. The optimal goal is as few meds as needed and use of natural techniques whenever possible; 3)  Interpersonal: isolation is a common pattern with trauma survivors. Nobody feels trustworthy. “I would feel better if I was simply left alone” is a common statement. However, your chances for improvement are much better if you can build a few key supports. You can do this while attending AA/NA and working the steps with a sponsor. A solidly run therapy group for trauma survivors can be a great adjunct. Simply knowing you are neither alone nor unique can make a great difference; 4) Spiritual: this is more about outlook than religion. Those who develop PTSD often have trouble with fairness, the future and hope. They struggle with ‘nihilism’ -sense that nothing will ever be right. Skilled clinicians often address this; many sponsors in AA and NA also assist with this. I strongly recommend reading Man’s Search for Meaning, Vicktor Frankl’s classic book that helps readers identify this part of the challenge. His main theme is helping you look forward with a sense of meaning and purpose. Finding meaning going forward can be vital in keeping you sober as well as far healthier in terms of PTSD.

It is important that trauma survivors work on building strength and resilience. It is not a matter of a clinician or treatment program ‘fixing what is broken’. It is more a matter of rediscovering your strength. Recovery from both PTSD and Addiction requires a sense of safety and restored balance as well as a core of self-forgiveness and acceptance. Much of this is covered within the 12 steps but you may need additional assistance in learning to better manage the impact of PTSD. One final caveat- whichever group or program you choose, remember that you are the consumer and you must go at a pace that is comfortable for you. You may feel some intense emotions but the goal is to keep you from feeling overwhelmed or ‘flooded’. Also, remember that what you do in therapy is only a beginning; building confidence, strength and sobriety requires considerable attention to your overall health and wellbeing. The untold secret of sustained sobriety is that you must work on all four dimensions outlined above. It requires learning new skills and becoming your own observer, staying away from guilt, harm, helplessness and dealing with triggers with the help of others. The secret of recovery is perseverance with a focus on building strength, balance and resilience. It is not mystical; it involves hard work.

Dr. Boriskin is an author, lecturer, and clinician widely known for his ground
breaking work in the fields of trauma, PTSD, and addictive disorders. He
is a Senior Fellow for the Meadows of Wickenburg Arizona as well as a
psychologist for the Northern California Veterans Health Care System.
He was a pioneer in extending the continuum of care and developed two
extended residential treatment programs for co-occurring disorders. A
passionate advocate for integrated treatment, he possessed a vision
that predated the ongoing movement toward specialized and integrated
treatment for co-occurring disorders, particularly those involving trauma.
In addition to his groundbreaking clinical work Dr. Boriskin is the author of
“PTSD and Addiction: A Practical Guide for Clinicians and Counselors.” and
co-authored, “At Wit’s End: What Families Need to Know When A Loved
One is Diagnosed with Addiction and Mental Illness.”