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In a lamp lit room, a group of six casually dressed people sit in chairs which are arranged in a circle.  All, but one, seem to be engaged in two or three different conversations as a more formally dressed woman enters the room. She sits in one of the vacant seats of the circle as the people in the room gradually turn their eyes toward her. “Good morning,” she says, “you guys are a bubbly group this morning.” She smiles wryly as a tall gray-haired man in the group says, “Well, Amy started it.” He turns his gaze onto a thirty-year-old blonde woman sitting to his left who smiles as she begins to explain, “I picked up my six-month chip last night. It’s the longest I have been sober since I started drinking fifteen years ago.” Members of the group all offer her their congratulations in various ways. John, the quiet one, glances up quickly and says in a flat voice, “Keep up the good work, Amy.” “You don’t seem yourself today, John. What is going on with you,” asks the more formally dressed woman, a therapist facilitating this relapse prevention therapy group. Looking down at the floor, John reveals to the group that he used yesterday.

Like everyone else in this therapy group, John is an addict. Most of the people in the room have at least 90 days clean and are now working on relapse prevention skills. If they are not actively using drugs or alcohol, why are they still in treatment? What are relapse prevention skills? And, what is a “relapse”?

One reason to remain in treatment after discontinuing the use of substances is because the physiological addiction is only part of the challenge. Long after the individual has ceased substance use, the psychological and behavioral elements of addiction remain. Many addicts struggle with how to cope with stress, celebrate, socialize, or even go to sleep without relying on a substance.    These elements of addiction need to be addressed or most addicts slip right back into substance use.

Another aspect to consider is that “withdrawal symptoms” can actually last for up to two years after cessation of use. While the acute symptoms may alleviate within a few weeks, there are “post acute” withdrawal symptoms that follow. During this time, changes that occur in the brain, as the brain is adjusting to no longer having the effects of the substance use, can trigger a person to want to use. It can even cause them to have very vivid dreams of using that are so real, the individual may have trouble telling the difference between the dream and reality.

This is what happened to John mentioned earlier. He awoke one morning having had a “using dream.” It felt real, as if he had used his drug of choice and actually felt high. Realizing this was a dream, he tried to put it out of his mind, but he just kept thinking about it. He didn’t share his struggles with anyone, feeling like a dream was a silly thing with which to trouble his sponsor and other friends. Later that day, he received a call from an old using buddy whose car had broken down and who needed a ride. John picked up his friend, and when he dropped that friend off, the friend repaid him for his help with his drug of choice. John tried to decline, but his friend left the drugs on the seat of the car and waved goodbye. John returned home to an empty apartment and used.

The bottom line is, getting sober is different from staying sober. To recover from substance addiction requires learning a new lifestyle, developing a support system that will help you maintain that lifestyle, and learning how to cope with life on life’s terms… without using. The relapse prevention phase of treatment focuses on achieving these goals. While someone, like John, might slip up and use while in the process of learning such skills, they can remain connected with support and treatment, using the experience as a learning tool, and preventing a complete return to his/her former way of life.

After John shared with the group, they offered him support. Amy said, “John, I know how hard it was to come in here and say that. I know I’d be worried that people would judge me, so thank you for sharing and showing us that it is safe to do so.” Others chimed in and echoed Amy’s commendation. One group member shared, “When I feel like I  want to use, I call someone from our group and call my sponsor. I keep calling numbers until I get someone on the phone.” Another said, “When I am craving, I get out of wherever I am and go somewhere safe. I like to walk on the beach. It clears my mind and calms me down.” Then, the therapist facilitated a discussion around the various elements of John’s story and the skills that any group member could use should any of them face similar things in the future.

  • I am a Psychologist and Clinical Addictions Specialist at the Chrysalis Center. I have successfully treated individuals who struggle with addiction for eight years. I also treat individuals with binge eating, anxiety, depression, and trauma challenges. To schedule an appointment to see me, please call the Chrysalis Center at 910.790.9500. ~Lillian Hood, LPA, LCAS

*John and Amy are fictional characters used to demonstrate the real experience that individuals under these circumstances tend to face.



This posts shares some information about a supportive, evidence based treatment for trauma and PTSD symptoms: Prolonged Exposure.

What is PTSD?

Post traumatic stress disorder is a common mental health problem following trauma. Individuals with PTSD often have difficulties with emotion regulation, managing symptoms of arousal, and other related symptoms. Co-occurring problems such as eating disorders, substance use disorders, depression, and self-injury are also common. You can read more about PTSD in my prior Chrysalis blog about PTSD.

What is prolonged exposure?

Prolonged exposure (PE) is a well established evidence based treatment for PTSD. It has been shown to yield long term improvement in PTSD symptoms.  PE can be applied with individuals who have co-occurring problems as part of a comprehensive treatment plan.

PE s a form of Cognitive-Behavioral Therapy (CBT) for PTSD, developed by Edna Foa, PhD. PE typically takes 8-12 sessions with at home practice in between sessions. Before working on traumatic memories, the PE therapist teaches the patient various safe techniques for relaxation from anxiety and arousal.  After the patient learns theses techniques, the PE therapist helps the client begin to work on traumatic memories. As part of this process, the trauma survivor intentionally recalls a traumatic memory that is contributing to PTSD symptoms. This is done through the use of verbal or written narratives while under the careful supervision of the PE therapist. These memories are recalled and then the safe relaxation techniques are employed. This is done long enough and often enough to experience a reduction in PTSD symptoms.

Working in this careful manner with a PE therapist, the patient learns new ways for the brain and body to respond to traumatic reminders. This allows the traumatic memories to lose their power to elicit PTSD symptoms. To be successful, PE needs to target the traumatic memories that are most related to PTSD symptoms. However, individuals can experience improvement  without discussing every trauma or all aspects of their trauma.

How does prolonged exposure work?

PTSD can be seen the inability of the brain to stop the fight-or-flight response. Reminders of the trauma trigger distressing thoughts, feelings, and harmful behaviors, even when there is no current danger. Escape and avoidance behaviors develop to provide temporary relief; unfortunately, over time they can lead to PTSD and co-occurring problems.

By intentionally approaching traumatic reminders safely under the therapeutic guidance of a PE trained therapist, new learning can happen to decrease PTSD symptoms. Over the course of PE, the brain starts to learn that traumatic memories and reminders are not dangerous, that anxiety does not last forever and that it is possible to have some power and control over traumatic memories.

What if I feel too afraid to start prolonged exposure?

It is natural to feel afraid at the start of PE. It is common not to feel quite to start PE or even feel afraid. All of that is totally okay. In fact, the first steps of PE address these concerns and give patients tools to decrease these anxious feelings, relax and regain control before working on traumatic memories.

PE should only be done in the context of a strong therapeutic relationship with a licensed clinician who has received formal training in PE. PE is a gradual process where the patient is in control and works collaboratively with the PE therapist. As part of this collaboration, fears about PE should be discussed about openly with your PE clinician throughout the process. This should help decrease initial fears and keep later fears manageable. It is okay to feel afraid and PE will help you gain strength and confidence.

What if I am ready to start prolonged exposure?

If you think you may have PTSD and that PE might be helpful, talk with your primary clinician or  contact Chrysalis to set up an initial evaluation. PE is compatible with ongoing therapy for other difficulties. PE can be added for 8-12 weeks in conjunction with your primary therapist in a collaborative approach to your treatment. At Chrysalis, we offer PE by a licensed psychologist who has been intensively trained in PE.  You can contact Chrysalis for more information about getting started. Recovery from PTSD is possible and within reach!

Dr. Kate Brody Nooner is a licensed clinical psychologist and associate professor of psychology at UNCW. She also holds an adjunct appointment at Duke University and is the principal investigator of NIH-funded grants aimed at reducing child and adolescent trauma and preventing alcoholism.



Michael*, a 52-year-old man who has recently reconciled with his wife, walks in his front door shortly after 9:00pm on a Monday evening. His wife is sitting on the sofa watching Law & Order on Netflix. She looks over at him suspiciously, “Did you work late today?” “No,” he says,” I went to a meeting.” “You go to your meetings on Tuesdays and Thursdays…” she says with a “gotcha” tone.  Michael, fighting becoming exasperated, looks her in the eye and says, “I’m going to have to work late tomorrow and I’ll end up missing that meeting, so I went today to keep up my routine of two meetings a week.”  Michael’s wife still looks discontented. Looking away, she says, “Fine.” Then she mutters, “Are you going to go to two of those meetings a week for the rest of your life? And, aren’t you still doing therapy too? I thought we’d eventually get our life back.”

Michael is an alcoholic and has been attending AA meetings for about nine months now, and has been in therapy for just as long. Why does he do both? How long will this go on?  First, AA or Alcoholics Anonymous is a self help group, and it’s not the only self help group out there for individuals struggling with an addiction. Let’s start by looking at what self help groups are and then we can look at what role therapy plays in a person’s recovery.

Here, in the Wilmington, NC area, we have a few different self-help/self-empowerment groups for those seeking self help for addiction. I’m going to talk about AA (Alcoholics Anonymous), NA (Narcotics Anonymous), CR (Celebrate Recovery), and SMART Recovery (Self Management And Recovery Training).  Most people have at least heard of AA and NA. These two groups are aimed at helping people in similar ways. The major difference is that AA is specifically geared toward alcoholics and NA is open to a variety of chemical dependency addictions. These two groups provide a support network and guidance for individuals who have a desire to live a clean and sober lifestyle. Individuals are encouraged to get a sponsor, someone who has experience in recovery and the AA/NA “program,” otherwise known as the 12-step program.  A sponsor guides the addict through working the steps and provides support for recovery and a lifestyle free of addictive behaviors. This program asks members to acknowledge a “higher power” to whom they will give over their will and in whom they trust to help them with their addiction. Although this program originally began based on biblical principles and Christianity, currently the wording is changed to include all forms of belief in a power greater than yourself.

Celebrate Recovery, on the other hand, is strictly a Christian self help group. This group covers all addictions, habits, and hang-ups that a person wants to change and can include everything from alcohol to sex, co-dependency and gambling. This program is similar to AA/NA in many other ways including a 12-step program and sponsorship.

SMART Recovery is not based in any form of spiritual belief system. It is specifically based on scientific research and the principles of cognitive-behavioral therapy. They teach the “4-Points” which include working on motivation, learning how to deal with urges, managing thoughts, feelings and behaviors, and living a balanced life. In SMART Recovery, there are usually fewer meetings offered in a community, and there is not as broad of a community of support as tends to be available through AA/NA and CR. Which one should you choose? Anecdotally, I know of success stories from individuals who have used each of these programs. I’m a firm believer in doing what works for you!

Why should a person do therapy and engage in self help? Self-help groups offer a level of support that is just not available through meeting with a therapist. However, a trained professional is able to identify and treat problematic behaviors and mental health issues. This is not something that self help groups are truly able to do. For example, individuals who have survived a trauma are especially vulnerable in a way that is best addressed by someone who is trained to do so. I have seen many trauma survivors relapse because someone well meaning addressed the individual’s trauma in a way that triggered nightmares or flashbacks that the trauma survivor was not skilled enough to handle yet. Issues related to mental health and trauma frequently rise to the surface once the addiction isn’t masking them. This is why many of the individuals who are successful at managing an addiction often attend therapy in addition to participating in self-help groups. It allows an individual to benefit from the strengths of both methods and increase the likelihood of success in reaching recovery goals.

Michael, mentioned in the outset, is a trauma survivor. He attends AA meetings to address his addiction, develop a new lifestyle, and gain support from those who understand his journey. He participates in therapy for all of those reasons and also to address his trauma and develop the skills he needs to deal with trauma symptoms without drinking. He will attend some kind of 12-step meeting for the rest of his life as part of his program of recovery. When his sponsor agrees that he is ready, he will sponsor those who need help and request his guidance. He will provide support for other members of AA and for “new comers” for years to come. Michael attended 90 meetings in the first 90 days of his sobriety, as suggested by his sponsor, and has now reduced down to twice per week. His personal goal is to always attend at least one meeting per week. However, if he finds himself struggling for whatever reason, he will attend as many meetings as he can, and he will call members of his support system for help. As far as therapy goes, when he started nine months ago, he attended intensive outpatient therapy for the first 90 days of his sobriety. This means that he attended nine hours of group therapy and one session of individual therapy per week. Upon completion of intensive outpatient therapy, he began attending two individual therapy sessions per week and is still doing so six months later. As he accomplishes therapy goals related to addiction and trauma, he will reduce down to attending one session per week, then one session every other week, then once per month, and then at some point, he will no longer need to participate in therapy. In the mean time, he also faces the challenge of helping his loved ones understand what he needs to do to be a healthy person. He will probably discuss this with his therapist and his sponsor before addressing the issue with family members who are struggling to understand how he spends his time and what it takes for him to stay in recovery. With support and the application of what he learns through AA and therapy, he has a good chance of succeeding!

*Michael is a fictional character used to demonstrate the real experience that individuals under these circumstances tend to face.

Lillian Hood, LPA, LCAS
Psychologist and Clinical Addictions Specialist
At the Chrysalis Center, I specialize in treating individuals with co-occurring disorders. This includes working with individuals who have trauma, depression, bipolar, anxiety, and/or eating disorders along with an addiction. I use evidence-based practices to help patients develop skills for successfully facing this unique challenge.

References:

Alcoholics Anonymous  www.aa.org

Celebrate Recovery       www.cr-inside.com

Narcotics Anonymous   www.na.org

SMART Recovery  http://www.smartrecovery.org



Image credit: dreamstime.com

What is traumatic stress?

Traumatic stress and posttraumatic stress disorder (PTSD) are unique mental health problems in that they have a known cause – a traumatic event. Life is filled with stressors. There are typical daily stressors such as a car breaking down or a large bill to pay. There are also bigger stressors such as getting divorced, losing your job, or the death of a grandparent. Even positive events can be stressful including buying a home or getting married. However, none of these positive or negative daily stressors are considered traumatic events.

Traumatic events are different in that they are events in which someone believes that their life or the life of others is being threatened. Traumatic events can be witnessed, such as watching a friend get mugged, or experienced directly, such as being sexually assaulted, fighting in a war, experiencing a serious accident or natural disaster, or being abused as a child. These are the types of traumatic events that can lead to PTSD.

How common are traumatic events?

Unfortunately, traumatic events are common. Statistics from the National Center for PTSD show that more than 60% of men and 50% of women have had at least one traumatic event in their lives. This means that most people have experienced a traumatic event at some point. However, among the people who have experienced a traumatic event, most do not develop PTSD. While about 7% of people develop PTSD in their lifetime, this is actually a substantial number, representing 1 out of every 15 people. So, it is likely that your or someone you know may have experienced PTSD at some point.

What happens after a traumatic event?

After people experience a traumatic event, it is useful to have a strong reaction. Remembering what was dangerous and staying away from that can help you stay safe after a traumatic event. However, once that threat has been removed, it is healthiest for our brains and bodies, if our strong reactions decrease to pre-trauma levels. For most people, this happens within about a month after a traumatic event. But, for people with traumatic stress and PTSD, these strong reactions do not disappear and they start negatively impacting daily life. In fact, if the traumatic stress or PTSD symptoms do not return to pre-trauma levels within a year, it is highly unlikely that they will go away without evidence-based treatment from a professional.

How do I know if I have PTSD?

If you have experienced a traumatic event and are having difficulty in areas of your life or find that you are coping with behaviors that are unhealthy, such has drinking heavily or drug use, self-injury, significant changes in eating or sleeping, or other high-risk activities, you may have PTSD.

To diagnose PTSD, individuals need to consult with a licensed mental health professional who specializes in PTSD. Symptoms of PTSD include experiencing a traumatic event and having specific symptoms that cause significant distress or impairment for more than one month including:

1) intrusion of traumatic memories or uncontrollable reminders of traumatic events

2) avoidance of safe people, places, activities, or behaviors that are in some way associated with the traumatic event

3) negative changes in thinking or mood

4) alterations in arousal or reactivity, which include feeling numb, also called dissociation, or feeling on edge, also called hyperarousal

What should I do if I think I have traumatic stress or PTSD?

It is not a good idea to “self-diagnose” if you think you have PTSD. Self-diagnosis can lead to increase in trauma symptoms and other problematic behaviors. The best course of action if you think you may have PTSD is to seek an evaluation from a licensed mental health professional who specializes in treating traumatic stress and PTSD.

How can I get help for traumatic stress or PTSD?

The Chrysalis Center for Counseling offers compressive treatment for traumatic stress, PTSD, and many co-occurring problems. At Chrysalis we have licensed professionals, who used evidence-based treatments to decrease trauma symptoms and help people live their best lives following trauma.

Future blog posts will describe the specific evidence-based traumatic stress and PTSD treatments offered at Chrysalis. However, you can call at any time to hear about these treatments and to schedule a time to talk with one of our licensed professionals.

You can also find out more about evidence-based treatment for PTSD at the National Center for PTSD: www.ptsd.va.gov. This site has useful posts and videos on PTSD treatment, including many of the treatments we offer at Chrysalis.

Dr. Kate Brody Nooner is a licensed clinical psychologist and associate professor of psychology at UNCW. She also holds an adjunct appointment at Duke University and is the principal investigator of NIH-funded grants aimed at reducing child and adolescent trauma and preventing alcoholism.



Lisa*, a 41-year-old woman, wakes up at 5:45am to the screeching sound of an alarm clock. She rolls over and slaps it furiously to silence the brain piercing sound. She sighs and says in a determined whisper, “Thirty-six days.” As she begins her daily routine, worries swirl around her mind…”Did I forget to wash my coffee cup before I went to bed last night? If I left it out again, I will get fined by the recovery house manager. What if the bus is running late this morning… they’ll fire me if I’m late again. How am I going to make it to my therapy appointment today? I think my roommate hates me. She’s always so mad that I have to be up before she wants to get up when I work a morning shift. Am I going to have enough money to pay my rent?” Her chest feels tight, and she is filled with dread before the day even begins. Lisa lives in a recovery house. A recovery house is a place where addicts live with other addicts who are working on recovery from addiction. The recovery house provides structure, accountability, and support to those who are willing to comply with the rules of that recovery house’s program and who are actively pursuing recovery. Lisa shares a room with another woman who is in recovery from heroin. She has been sober from heroin for 31 days, and Lisa has been sober from alcohol for 36 days. However, Lisa faces a challenge in her recovery that her roommate does not. Lisa has Generalized Anxiety Disorder in addition to her addiction.

The National Institute on Drug Abuse (NIDA) states that individuals diagnosed with a substance use disorder are twice as likely as a member of the general population to be diagnosed with a co-occurring mental health disorder. In addiction, when an individual stops using a substance such as alcohol or another drug, the body goes through a period of time, called withdrawal, where it is adjusting to the absence of the substance. During this time, it is particularly difficult for an individual to refrain from using since using is the easiest way to stop withdrawal symptoms. These symptoms vary depending on the substance(s) used by the individual and can include extraordinary pain, depression, sweats, goose flesh, vomiting, diarrhea, and seizures. This is considered “acute” withdrawal. Depending on the amount and duration of substance use, this can last for a few weeks. After these symptoms subside, a person will go through “post acute withdrawals” which can include forgetfulness, inability to focus, confusion, emotional disregulation, sleep disturbance, emotional numbness, depression, anxiety and more. This can last up to two years after completely ceasing use and generally lessens over time. During post acute withdrawal, the extreme experience of emotions, depression, anxiety, and feelings of boredom are major triggers to use.

So, as you think about Lisa’s story, imagine what it is like to have used alcohol to cope with anxiety, only to have become addicted to alcohol. Having realized that her life had become unmanageable, she sought help at a recovery house and at a clinic where they treat people who have co-occurring mental health and substance use disorders. She is motivated to “get her life back” and tries hard to follow the advice given by those who know more than she knows about the road to recovery, but she still struggles daily with overwhelming feelings of anxiety, all the while her brain is begging her to fix it the old way… with alcohol. She is also not immune to the emotional effects of post acute withdrawal symptoms that are common at this point in her recovery, and her anxiety can be exacerbated by these symptoms. She can seek medical attention for her anxiety but is afraid of becoming reliant on a pill to cope with anxiety. She only considers this as an option because the symptoms of her generalized anxiety are so severe that she is afraid she will relapse on alcohol if she doesn’t stabilize her mental health.

Individuals who suffer from co-occurring mental health and substance use disorders face the challenge of staying sober while not being able to lean on the substance that they have used for so long to medicate their mental health disorder. They also face the challenge of coping with mental health symptoms complicated by post acute withdrawal symptoms. Structure, accountability and support is often not enough to help them overcome this special challenge. Frequently, medication and psychotherapy are necessary to stabilize their mental health disorder symptoms while they build the skills for living a sober lifestyle. Programs that include this combination offer hope to those who are determined to make a change and willing to work hard to begin a new life.

*Lisa is a fictional character created to represent real circumstances and challenges faced by those who suffer from co-occurring mental health and substance use disorders.

Lillian Hood, LPA, LCAS
Psychologist and Clinical Addictions Specialist
At the Chrysalis Center, I specialize in treating individuals with co-occurring disorders. This includes working with individuals who have trauma, depression, bipolar, anxiety, and/or eating disorders along with an addiction. I use evidence-based practices to help patients develop skills for successfully facing this unique challenge.

Reference:
National Institute on Drug Abuse www.drugabuse.gov
National Association for Alcoholism and Drug Abuse Counselors www.naadac.org


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At Chrysalis, we believe that a supportive, healing environment is essential in order for change and growth to occur. We seek to offer such an environment to clients and help them create that in their lives and relationships. Read More

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