Recent articles indicate that 15 percent of American and 6.1 percent of Canadian military personnel return home from conflicts such as Iraq and Afghanistan with symptoms of post-traumatic stress disorder (PTSD) or major depressive disorder (MDD), and that hospitalizations for mental disorders like PTSD now surpass those for battle injuries in the U.S. military. 1,2 Unfortunately, many of these traumatized individuals become addicted to alcohol or drugs in an attempt to control their trauma-related symptoms. One U.S. study showed that between 60 and 80 percent of combat veterans with PTSD also met the criteria for alcohol or drug abuse. 3
PTSD is not new, though methods for its treatment have evolved, notably during World War II and the postwar period. At that time, Dr. Gordon Bell, a pioneer in addiction treatment in Canada and co-founder of Bellwood Health Services (Toronto, Canada), was asked to prepare emotionally disabled veterans-many of whom suffered from what we now call PTSD-for a return to civilian life.4 Since 1984, Bellwood has continued his work with military personnel and veterans facing addiction problems and, in many cases, PTSD. In 2000, Bellwood began offering a treatment program for co-occurring PTSD and addiction to military and other clients involved in hazardous occupations (i.e., police, firefighters, and disaster teams).
Judith Herman observed that “the common denominator of trauma is a feeling of intense fear, helplessness, loss of control and threat of annihilation.”5 Bessel Van Der Kolk adds that a person's coping mechanism becomes overwhelmed because the stressful event is inescapable.6
The diagnosis of PTSD incorporates experiencing, witnessing, or hearing about an extremely stressful event that involves actual or threatened death or serious injury. PTSD, created by the raw, intense feelings of terror, helplessness, and loss of control that are triggered by an event, can occur at any age. Symptoms can be divided into three categories: persistent re-experiencing symptoms, persistent avoidance and numbing symptoms, and persistent hyper-arousal.7 Examples of these symptoms may help to convey the complexity of treatment required:
Re-experiencing of the traumatic event through recurrent and intrusive thoughts, perceptions, and images, and terrifying nightmares and flashbacks.
Avoidance of people, places, and activities reminiscent of the trauma, along with diminished interest, feelings of detachment from others, and an inability to plan ahead.
Increased arousal, seen in irritability, anger, rage, hyper-vigilance, or an exaggerated startle response.
The “living hell” of PTSD, in which an individual feels trapped by memories and doomed to relive the trauma again and again, poses huge challenges in everyday life. It increases stress in marital and parental relationships. It can cause memory and concentration problems, issues in employment and finances, as well as legal difficulties. It can result in low self-esteem, feelings of hopelessness, and a sense of failure.
Essentials of PTSD treatment
Upon entering treatment, PTSD/trauma and addiction clients present with complex clinical issues related both to the trauma they have experienced and to the substance abuse that has served as a maladaptive coping strategy. Compared to non-affected substance dependent clients, those with comorbid PTSD/trauma must also engage in a treatment plan designed to help them manage the symptoms associated with their psychiatric disorder.
Treatment for PTSD, along with recovery, must be ongoing, involving the whole person: body, emotions, mind, and spirit. While the traumatic experience cannot be erased, it is possible to treat trauma symptoms and help clients manage them with new coping skills. Often, treatment must help clients address spiritual or existential issues: the meaning of life, the reality of human suffering and death, the darkness of the human heart, and human powerlessness in the face of natural forces.
Treatment programs for PTSD and addiction must address four components:
Individual problems. Empathy and gentleness is essential in creating the sense of safety that is needed for clients to overcome defensive avoidance and talk about their trauma with others. Clients often withdraw into a “safe” due to deep feelings of shame, distrust, and the fear of being judged by others.
Because PTSD has both psychological and physiological components, trauma recovery also needs to address and heal the connections between mind and body. At the outset of treatment, it is important to teach clients how to “down regulate” the hyper-arousal of their nervous system. Mastering methods for soothing and calming themselves helps clients create the sense of safety and self-control needed to begin trauma processing. Bellwood staff has observed that clients respond well to acupuncture treatment, which appears to promote relaxation and diminish substance cravings. Massage therapy is also integral to treatment, since it counteracts a common PTSD symptom-numbing or decrease in body sensations and feelings-while releasing muscle tension and promoting relaxation. In the words of Dr. Steven Melemis, “Relax your body and your mind will follow.”8