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| Another Chance: Treating Early Life Trauma Issues in Adolescents Suffering from Addictive Disorders |
| Feature Articles - Adolescents | |||||
| Wednesday, 31 March 2004 | |||||
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“It is a sad reality that for many children, the most nurturing, predictable and unconditional exp- eriences come from animals — dogs or cats. Children with abusive and unpredictable adults caring for them put their hopes and dreams and faith in relationships with non-humans.” (Perry in Bank, 1996) Gina was 6 years old the first time her father sexually abused her. The abuse continued until she was 10. Around this time, she started drinking and smoking both cigarettes and marijuana. It was not long before she was stealing Valium® and Vicodin® from her mother. At age 17 she was admitted into treatment after cutting her wrists. Gina met criteria for depression along with her substance-related disorders. Everyone thought 15-year-old Eric was a great football player because he was so tough and played with aggressive abandon. What people didn’t know about Eric was that his father physically abused him until he became big enough and tough enough that his father no longer messed with him. Eric had a lot of drinking buddies and sometimes they would get high on methamphetamine. The drug made his behavior more out of control. He had been arrested for physically assaulting one of his male teachers. Eric was mandated into treatment because of his combative behavior and alcohol/drug abuse. Children who are maltreated (neglected, physically, sexually or emotionally abused) have a greater incidence of developing numerous problems during their preadolescent and adolescent years:
These same children will have a higher incidence of numerous psychiatric disorders, including substance abuse:
The truth is, early life trauma can prime the brain for a later PTSD presentation. The presence of depressive symptoms is the rule and not the exception for adolescents with a history of early life trauma.
Roots of substance use For teens like Gina and Eric, drugs worked very well (Table 1 lists the most common drugs of abuse). Gina’s use of painkillers, tranquilizers, and alcohol helped her dissociate from the pain she felt. Gina said, “The drugs helped me ‘check out’ when things started to feel to heavy.” Eric’s approach to dealing with his pain was very different. He especially loved methamphetamine because it “made me feel invincible and no one could hurt me and I could take care of anyone who got in my way.” Table 1
These types of responses are not uncommon in people like Eric and Gina. Gina would “numb off” or dissociate when sensory stimuli reminded her of the early hurt. She would sit in her room with her dog Checkers because she was “the only one who understood me and was there when everyone else didn’t care.” Eric would go into “fight or flight” or hyperarousal. He loved to fight. To make matters worse, the brain changes associated with early life trauma can cause survivors to misread sensory cues and to overreact to no or minimal threat. For example, they may misinterpret sadness in another as anger and respond in kind. When this happens, the cognitive and behavioral recovery techniques and strategies learned in treatment cannot be accessed. In response to their subjective distress, the adolescent will often turn to the therapist or other relationship. If this doesn’t alleviate their stress they will use alcohol, drugs, food, or engage in self-destructive behavior such as cutting themselves. These adolescents lack the ability to successfully manage their early recovery from addiction when confronted with sensory reminders of early trauma. Based on Perry (2002), Table 2 presents characteristics commonly found in those individuals that hyperarouse or have dissociative symptoms secondary to reminders of the trauma. Hyperarousal is a fear response controlled by lower (reactive) parts of the brain. Dissociation involves the endogenous opioid system and is very much like a narcotic experience — recall Gina’s experience with the Vicodin® she stole from her mother. Table 2
Treating early life trauma issues Since there are no medications that specifically treat trauma, medications are used to treat symptoms. Table 3 lists symptoms and medications commonly used to treat them. The FDA has approved paroxetine and sertraline for the treatment of PTSD and these medications (SSRI’s) are considered first-line treatment (Feldman et al., 2003). Table 3
Behavioral techniques can also be helpful during stabilization. Structure is important and client schedules and treatment plans help provide this. Other techniques, such as a safety plan, can help the client deal with difficult times. A safety plan is developed using a 3x5-inch index card. On the card are reminders of behaviors that one can perform when starting to feel stressed. The following is an example of Gina’s plan, which she kept with her at all times:
1. Call Maria 299-2990
Working with hyperarousal and dissociation One helpful cognitive technique is to ask the client to keep a log or journal. They are to write down what they are feeling when they feel under stress. Then they are to write down who they were with, what was being talked about, where they were, etc. This information is to be brought to treatment and discussed with a therapist who can help them make the link between what they are feeling and what is happening in their environment. With this understanding, hopefully the client can learn to better tolerate feelings that in the past were intolerable and lead to self-destructive behaviors. Eric started to understand that he experienced the feeling of anger and sometimes became aggressive in the presence of male authority figures like his father. His aggressive act toward a male teacher is a good example of his acting-out. Clients like Gina often have difficulty remembering what happened in-group. The stress of group can cause dissociative symptoms although the client seems to actively participate. To assist, the therapist had Gina write a synopsis of her participation and a list of her assignments at the end of each group. At the beginning of the next group, the therapist summarized the previous group and reviewed assignments. Gina used to say, “I forgot to do the assignment when, in fact, she had little or no recollection. Utilizing this cognitive strategy, she was able to better participate in-group.
Rules and trust Establishing a trusting relationship is the key. Think of this as creating an environment where the client can depend on the rules being consistently interpreted — in other words, a safe environment that allows for risk taking. A family experience very much unlike the environment they came from. Without the creation of this type of trusting environment, psychotherapy will be ineffective and staff members will spend all of their energy putting out one crisis after another.
Psychotherapy There are two fundamental problems with this approach. First, the client with early life trauma issues rarely makes it clean for one year. Second, the therapist is always working with early life issues by nature of transference and often countertransference. There are clients in early recovery that should not participate in treatment of early life traumatic events. Those that suffer from severe co-occurring disorders such as schizophrenia and bipolar disorder are not candidates for emotionally charged clinical technique. Also, those adolescents who are still in an abusive environment might be put into a position of retaliation if these issues are raised with the family. In order to go through the process, the adolescent needs a good support program (it is advisable to intensify contact with sponsors and go to even more self-help meetings). Remember that the client must tell the story — no words should be put in their mouths and clinicians should not jump to conclusions based on symptoms often associated with early life trauma. The client should be assessed for safety prior to any consideration of trauma-related treatment. The axiom ALWAYS DO NO HARM should be the guiding principle. If conditions are appropriate, the question becomes, “What type of therapy is effective with this population?’’ According to the treatment guidelines developed by the International Society for Traumatic Stress Studies, behavioral exposure therapy is the most empirically supported treatment for PTSD (Foa et al., 2003). Psycho-education along with relaxation and cognitive therapy are valuable adjuncts. PTSD can be considered a conditioned phobia. As with any phobia, exposure therapy is designed to help clients confront fearful memories and images. This form of therapy involves imaginal exposure (repeated recalling of the traumatic memory) and, when possible, adds an in-vivo (actual confrontation of trauma-related situations) component. The effectiveness of therapies such as Eye Movement Desensitization and Reprocessing (EMDR) may well be related to behavioral exposure. Gina’s therapist used an exposure technique, asking her to do the following:
Between 7 and 8 p.m. tonight I want you to write a letter to the perpetrator (her father). In the letter, I want you to write what you remember about what happened to you, how it has impacted your life, and how you feel about this now. If things get “heavy” while you are writing, I will be available by phone to talk with you. You may have to leave a message for me but I will get back to you tonight. Bring the letter into our session at 9 a.m. tomorrow morning. After a while her therapist said the following: You are very courageous. This is very difficult to do and you did it. You should be proud of yourself. But you left out some things in the letter and I want you to go back tonight and between 7 and 8 p.m. rewrite the letter adding those things that you will remember. Bring the letter with you tomorrow. The therapist asked Gina to rewrite the letter three times adding more detail each time. On the fourth reading of the letter, Gina read it as if she were reading a newspaper. She displayed no emotion and exhibited little or no dissociative symptoms. At this point, Gina had moved from subjectivity (reacting through the eyes of a 6 year old) to objectivity (seeing things through the eyes of a 17 year old). In other words, when she is around situations, images, and other stimuli that remind her of the old hurt, she used to react like she did as a fearful 6 year old and “numb” or dissociate. Now she can act — not react — to situations. In the past, the old reactions were part of her relapse dynamic, as she would use drugs or cut herself to relieve negative-feeling states. Several months later Gina told her therapist that she had received a wedding invitation from her father whom she had not seen in five years. She said to her therapist, “Should I go?” After carefully analyzing the situation it was decided that Gina would go to the wedding. When she returned she said to her therapist, “It is the first time I can remember being around my father and not being fearful but actually wishing him well.” She did not experience the dissociative symptoms as before.
Another chance to live There is something sacred about the experience of working with clients with a history of early life hurt. The clinician is often the first person that the adolescent has trusted enough to share their personal, painful story. They try so hard only to end up relapsing if the old hurt is not addressed. Sometimes when clients come to treatment the odds seem slim that they will experience personal positive recovery. However, sometimes you see them several years later and they are “all grown up.” This amazing and energizing experience is a constant reminder of the power of the human spirit. Cardwell C. Nuckols, PhD, ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) is grateful for the many clinicians who work so hard to help change lives. His passion is taking the current research and translating it into relevant hands-on techniques and strategies to assist clinicians in their work.
References
Note This article is published in Counselor,The Magazine for Addiction Professionals, April 2004, v.5, n.2, pp. 48-52.              |
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