SAFETY AND STABILIZATION FOR THE ADDICTED
SURVIVOR OF TRAUMA
Eric Gentry Ph.D., LMHC, D.A.A.E.T.S.
Amy Menna, LCSW
Marjie Scofield, MSW
In order to fully resolve traumatic material, feelings of empowerment must mitigate the victim role. These skills are meant to be suggestive and may not work for every survivor. It is important that the client be able to identify what works for them. Some clients experience a feeling of failure if they attempt to lower their SUDS scale and it does not work. It is important that we as clinicians normalize trial and error and instill hope in the trauma survivor.
Remember that the goal of these skills is to take the client out of the fight or flight option and back into intentionality where they control their internal and external world. It is helpful to use the term staying “intentional” vs. being rendered “reactive.” When we are intentional, we have the ability to act out our intentions. When we are in a reactive state of mind, we react to situations without thought or insight. A reactive state is fear driven and impulsive.
In her excellent book, “The Body Remembers” Rothschild (2000) encourages clinicians to teach clients how to put the “brakes” on when beginning trauma therapy. She uses the analogy of teaching a new driver to be really comfortable with the braking system in a car before “accelerating”. In the same manner, she finds methods for teaching client’s how to “brake” before becoming deeply involved in trauma work. In this way, the client moderates the trauma work. A client can begin to work beyond the fear once they have learned that they need not be stuck in fear forever. Once an individual learns that they can touch just the surface of their experience and then return to a safe or neutral ground it is empowering and affords them the knowledge that they can master their own discomfort.
Ehrenreich (1999) provides a simple script for Progressive Relaxation that can be expanded or contracted with just a minimum of effort. Begin this exercise by instructing the individual to focus on lengthening and deepening the breath. Focus on the inhalation and exhalation making the breath smooth and deep.
Now tighten both fists, and tighten your forearms and biceps … Hold the tension for five or six seconds … Now relax the muscles. When you relax the tension, do it suddenly, as if you are turning off a light … Concentrate on the feelings of relaxation in your arms for 15 or 20 seconds … Now tense the muscles of your face and tense your jaw … Hold it for five or six seconds … now relax and concentrate on the relaxation for fifteen or twenty seconds … Now arch your back and press out your stomach as you take a deep breath … Hold it … and relax … Now tense your thighs and calves and buttocks … Hold … and now relax. Concentrate on the feelings of relaxation throughout your body, breathing slowly and deeply (Ehrenreich, 1999, Appendix B).)
A favorite script for Autogenic Relaxation comes from “Mastering Chronic Pain” (Jamison, 1996). Although written for a different audience, it is applicable to the addicted survivor. Autogenics is a process of using internal dialogue to self-soothe. It is NOT hypnosis. The client is in control the entire time. It begins by encouraging the client to find a relaxing place and position. Focusing on their breath allows it to soften, lengthen, and deepen. The internal dialogue can then begin.
Jamieson (1996) begins with:
“Now slowly, in your mind, repeat to yourself each of the phrases I say to you. Focus on each phrase as you repeat it to yourself” (p. 73).
I am beginning to feel calm and quiet
I am beginning to feel quite relaxed.
My right foot feels heavy and relaxed.
My left foot feels heavy and relaxed.
My ankles, knees, and hips feel heavy, relaxed, and comfortable.
My stomach, chest, and back feel heavy and relaxed.
My neck, jaw, and forehead feel completely relaxed.
All of my muscles feel comfortable and smooth.
My right arm feels heavy and relaxed.
My left arm feels heavy and relaxed.
My right hand feels heavy and relaxed
My left hand feels heavy and relaxed
Both my hands feel heavy and relaxed.
My breathing is slow and regular.
I feel very quiet.
My whole body is relaxed and comfortable.
My heartbeat is calm and regular.
I can feel warmth going down into my right hand.
It is warm and relaxed.
My hands are warm and heavy.
It would be very difficult to raise my hands at this moment.
I feel very heavy.
My breathing is slow and deep.
My breathing is getting deeper and deeper
I am feeling calm.
My whole body is heavy, warm, and relaxed.
My whole body feels very quiet and comfortable.
My mind is still, calm, and cool.
My body is warm and relaxed.
My breathing is deeper and deeper.
I feel secure and still.
I am completely at ease.
I feel an inner peace.
I am breathing more and more deeply (Jamieson, 1999, p.73-74).
Now encourage the client to bring their attention back into the room in which they are relaxing. Suggest that they can bring feelings of relaxation into their regular waking day simply by focusing in the same manner as they have during this exercise.
It can be very empowering for the client to develop their own script which they can then read when they are feeling overwhelmed or in need of self-rescue. This can also assist the client in becoming more creative and proactive in resolving their traumatic material.
If we watch an infant sleep, we will see the rhythmical movement of deep belly breathing. This is the ideal breathing for relaxation and the nourishing of the body with the breath. Again, it is important for the addicted survivor to recognize when they are in need of an exercise to self-soothe. For instance, many addicted survivors can relate feelings of anxiety to a “lump in their throat” or a “pain in their chest.” These somatic experiences will act as a cue that feelings of safety may need to be addressed.
When we feel upset or anxious about something our breathing is often the first thing to change. It is likely to become shallow, rapid and jagged or raspy. If on the other hand, we were to practice an intentional diaphragmatic breathing, we would be more able to consciously regulate our breathing when we became upset.
Find a comfortable, unrestricting position to sit or lie in. Place your hands on your belly as a guide to the breath. Begin to consciously slow and smooth out the breath. Just noticing the rhythm of the breath through the inhalation and exhalation. Is it smooth, deep and full or jagged, shallow and slight? Now focus on bringing a deeper breath into the belly. Let a full breath be released on the exhalation. Inhale fully, not holding the breath at any time. On the exhalation release completely and pause, counting to 3 after the exhalation is complete. Then inhale slow full and deep. Continue to focus in this manner on the breath.
Gentry (2002), suggests placing one’s clasped hands behind the neck. This opens the chest through the lifting and spreading of the elbows. As this occurs, breath moves much more freely deep into the belly, thus allowing an excellent alternative (to hands on the belly) for those just learning deep breathing exercises.
At first, the individual is taught to deep breath in sets of 5. Then this is increased to 10 inhalations and exhalations. Finally, an instruction is given to practice 2 times each day for 5 minutes per day. In this way, the individual is learning to relax through deep breathing.
This technique assists the trauma survivor in developing the capacity to “self-rescue” from the obsessive, hypnotic and numinous power of the traumatic intrusions/flashbacks. It is based on the assumption that if the survivor is able to break his/her absorbed internal attention on the traumatic images, thoughts and feelings by instead focusing on and connecting with their current external surroundings through their senses (here-and-now), the accompanying fight/flight arousal will diminish. This technique will assist the survivor in understanding that they are perfectly safe in their present context and the value of using their sensory skills (sight, touch, smell, hearing, and even taste) to “ground” them to this safety in the present empirical reality.
Postural grounding is a technique drawn from practice with clients who have dissociative symptoms. As a trauma survivor begins to experience the images and feelings associated with a flashback, they can often be observed to migrate into a constricted and fetal posture of protection. In addition, the clinician can usually notice psychomotor agitation in the form of shaking legs, tremors, either fixated or scanning eyes, and shallow breathing.
When the client begins exhibiting these signs of re-experiencing and arousal, ask them “Would you like some help in getting out of there [those images and feeling]?” If the client says, “yes,” follow the script below to help them develop the capacity for self-rescue from flashbacks.
This exercise is an anchoring process that enables the individual to gain access to a safety state without the use of “hypnosis” type exercises.
The next exercise, although NOT hypnosis is a technique that does utilize some elements that are like “hypnotherapy”. It is therefore limited for use by those who have had formal training and appropriate educational background to offer that type of work.
This next exercise is adapted from the Treatment Manual for Accelerated Recovery from Compassion Fatigue (Gentry & Baranowsky, 1999).
Find a place and position where you can relax. This should be a place where you can be assured of minimal interruptions. Take the time to set the space for your maximum benefit. Once you are satisfied with the environment and feel it will be one that is safe and relaxing we will be ready to begin.
During this exercise you will have the opportunity to enjoy a sense of deep relaxation through a guided exercise. Through the exercise you will be instructed in the inner imagining of a Safe Place that may be a place you have been to before or one entirely made up in your imagination.
It is important to remember that this is NOT hypnosis but instead a guided relaxation and imagery exercise in which you are in control while being deeply relaxed. You CAN stop at any time if you need to BUT we recommend that you experience the entire exercise without interruptions to enjoy the greatest benefit and insight.
Focus on the sense of relaxation now in the muscles in the back of your eyes and notice how this relaxation can spread. Now as your eyelids softly rest over your eyes notice how you are able to soften your facial muscles — first those that are closest to your eyes but then more and more as you sense a smoothing, soothing, warming sensation spread across your face. Notice this warming, soothing sensation spread greatly across your forehead — across your eyes — through your hairline. Notice as it warms and softens the lines of your face. Just notice and let the gentle warmth calm your face. This calming sensation moves down your face … your nose … lips … chin … until your whole face becomes a numb mast of relaxation. Even the mind takes on a soothing a mellow position … until the mind feels very quiet. Listen to the sound of my voice and any other sounds without doing anything. Let these sounds be signals to let you know that you are safe, here in this room. Allowing you now to pay even closer attention to the INSIDE world. Simply let the sounds assure you that you are in a safe place in this room. Feeling that safety allow yourself to relax and slowly let the soothing warmth spread through to your neck muscles helping you to release any tensions. The warmth now moves down through your arms all the way to your fingertips. As it does you can release tension in your upper body by imagining it spilling out through the tips of your fingers and into the ground below. Allow the warmth to spread through to your chest and fill up your lungs … relaxing your muscles, relaxing your stomach, softening the muscles of the back and warming and releasing any tensions there. Continue to pay attention to my voice. Notice any points of tension and bring the soothing warmth to those points so they too can soften and relax. Bring the warmth through to your lower back, thigh, calves, feet, and toes. Become aware now that you can release even more tension from your lower body by imagining it spilling down through all the way to the tips of your toes and spilling out and into the ground. Just let your body relax as deeply as it wants letting your conscious mind stray where it might … and while your body relaxes it brings a feeling of calm detachment … and a feeling that time doesn’t matter, time is not important … you feel calm and emotionally detached.
Now allow your mind to find a relaxed and soothing space — a safe place. This is a place from the past that you have been to before or one from your imagination. Either way is OK, because it all belongs to you. Begin to develop a picture as a Polaroid film would develop. Watch as the safe place develops exposing itself to you. Notice how the lights, colors, textures, that surround you are now soothing to you. Notice what is above and below you. Walk around this place taking notice of all the sounds of relaxation … those that are close and those sounds that are far away. Notice the soothing fragrances in this safe place … those that are distinct and those that seem subtle. Be aware of all the safe fragrances. Now notice the temperature and quality of the air…reach out and touch some of the objects in this place of safety…notice all the textures. Be aware that anything that is safe can be imported into this place by you. If anything seems unsafe or threatening, allow yourself to send it out and notice how you are able to do this. Feel and appreciate all the relaxing sounds … assuring smells… and the sight of safety … feel it, appreciate it. Take it all in and memorize it so that if someone asked you to draw it at a later date you could do this in great detail … or can call it up at any time (5-10 seconds of silence). Also notice how you can begin to move about…moving about with the feeling of relaxed joyfulness … relaxed joyfulness …this is our natural state. Remember what it feels like to be relaxed…and joyful. Take a moment now to give yourself permission…full permission to enjoy this state of comfort…of relaxation…of peace (be silent for about 10 seconds).
Slowly begin to bring your awareness back into this room realizing that shortly but not just yet you will open your eyes. Before you do this realize that you will feel more relaxed and better able to get on with the rest of your day. Make small movements in your fingers and toes … make small movements in your arms and legs. Whenever you are ready slowly begin to bring your awareness fully into this room – opening your eyes when you are ready.
The following journal format is useful as a functional analysis of triggers and symptoms. It allows the survivor to chart their progress and identify some of the most effective ways of coping. Thoughts of using and impulses can also be included in this journal.
Ritualistic methods for safety and stabilization can vary widely. The key is to create a form of practice or ceremony that reinforces the individual’s sense of reassurance, safety or security. One lovely ritual is to have a “marriage” ceremony with oneself. This effectively strengthens the internal tie – the person is now responsible for themselves and fully empowered to act on their best behalf. If things are not going well or goals have been set, they must look to themselves to move their lives forward in the direction that is desired. This takes an act of will but it is much more likely that one will achieve ones greatest hopes and dreams if we take full responsibility for these dreams. After all, who else is as fully informed of what we truly wish from life if not ourselves.
The ceremony is to be orchestrated in the vision of the individual. This can be completed alone or in the company of trusted counselors or friends/family. In one example, the individual chose to complete the ritual alone. Candles were lit, paint and paper was available for creative expression, a colorful silk robe was worn and meaningful music was played. The individual wrote their wishes for the future and their commitment to themselves. They wrote a “self-marriage” ceremony in which they made a strong and earnest vow to “care for themselves in a manner that met their inner desires, hope and dreams”. In effect, this ceremony was a joyous occasion one of personal commitment to future and self-support. The individual came to the conclusion that if they treated themselves in this manner they would have nothing to feel disappointed about and if they did not they would have no one to “blame” other than themselves.
Another approach is to make a concrete commitment or contract in writing to move toward healing. This can serve as a mantra for the client as s/he makes a commitment to healing and moving through her the part of the self that has been holding him/her back. Some of these commitments take place as affirmations, songs, mission statements, and the like. Again, this is an opportunity for the client to become creative in her/his healing process.
Below is an example of a commitment contract. The contract may be used between clinical sessions or by the survivor independently. uBy operationally defining what their goals are, their progress can be easily identified and they begin to recognize their own capacity for healing.
Safety Goal Area: (My goal)
I care about myself and am committed to my healing. I realize that to do this I have to make changes in my life and the way I live it. By making these changes, no matter how small, I am affirming my choice to become the person I want to be.
I want to: (My goal)
I will prove to myself that I am committed to becoming my best self by completing the following behavioral objectives (tiny achievable steps):
Connection with Others: _
Self-soothing Skills Acquisition:
I will complete these affirmations of myself on or before:
This is an awareness technique to assist clients by improving their understanding of the necessity for processing time and the level of energy required for suppression. Many people who have been exposed to traumatic events attempt to “push bad thoughts out of their minds.” It is also not uncommon for addicted survivors to have thoughts of using while in early, or even late recovery. Again, the thoughts are met with judgement and feelings of inferiority or failure. In significant numbers, this approach tends to result in the unfortunate outcome of post-trauma symptoms (i.e., intrusive thoughts, poor sleep, anxious feelings, avoidance). By refusing to think about difficult events we fail to establish a complete narrative, make sense of our experiences, desensitize through exposure and recognize that we are now safe. Baer (2001) provides an excellent illustration of this technique in his publication the Imp of the Mind (p. 95-99).
When we are feeling very badly about something that has occurred or that we worry might occur, we sometimes make a big effort to “suppress” our thoughts, feelings, memories associated with the disturbing recollection. Many research studies show that this type of thought suppression does not work. In addition, it uses a lot of energy to keep thoughts out of our mind and is therefore exhausting. It also increases the fear factor – as we are hiding this thing from our thoughts, reducing our ability to review and resolve our feelings and thus making it seem even more unbearable than it is. Recall someone saying to you that something terrible has happened and then not telling you right away what it is … your mind arrives at a conclusion that is even worse than the actual reality, in most cases.
Instruct the individual to think of a “Stone Buddha” for 1 minute keeping their mind as focused as possible during this time. If at any time, they lose their focus they are to lift a finger alerting both themselves and you that they have lost their focus. Now discuss what this exercise was like, what they observed and how much energy it took to keep their mind focused.
Next, the individual is instructed to keep “Stone Buddha’s” out of their mind for a full minute. Again, they are to lift a finger every time “Stone Buddha” comes into the mind. When the minute is over they are given time to reflect on the difficulty of this exercise and the amount of energy it takes to keep the mind focused.
Now they are asked to notice if “Stone Buddha’s” come to mind at an even greater rate than prior to thought suppression. This is called the rebound effect and is noted in a number of research studies. The studies show that the object of suppression surfaces more often and more vigorously than prior to suppression.
Explain this phenomenon to the individual so they understand the importance of reflection and resolution as opposed to the tendency to want to suppress our negative thoughts, feelings, memories or fears.
This is an extremely useful approach when preparing the individual for trauma review and reducing treatment resistance as the individual begins to recognize that suppression does not work efficiently and is likely the reason for ongoing feelings of distress. This exercise is also a practical clarification as to why “Thought Stopping” is frequently unsatisfying for individuals seeking relief from trauma-related thoughts.
This exercise springs from the increasingly familiar work on “mindfulness” or reflection and acceptance. Or as Jon Kabat-Zinn (1990) explains in his grounded breaking book Full Catastrophe living, “Mindfulness is cultivated by assuming the stance of an impartial witness to your own experience” (p.33). He goes on to state that as we begin to pay attention to the internal dialogue “it is common to discover and to be surprised by the fact that we are constantly generating judgments about our experience” (p. 33).
The next important piece of mindfulness is “acceptance”. Without this we will make no progress, as we cannot live peacefully within our own bodies if we are unable to gracefully accept its natural fragility along with its strength. If we are plagued with chronic headaches following a traumatic event we will certainly be worse off if we grow angry and frustrated every time we have a headache. Our anger and frustration will fuel our headache feeding it into a much worse bodily felt experience.
Thich Nhat Hanh (1990) explains a five-step process for centering that opens a dialogue between the individual and their own internal bodily felt experiences. He recommends that we allow ourselves to get to know and reflect on our internal processes whether it is fear, pain, sadness, confusion, irritation, etc. The first step is to just notice what comes up leaving judgment aside.
The second step is to greet the internal experience (i.e., Hello sadness. What is happening with you today? Why are you here?). This is in contrast to the common response which may be “hey, get out of here sadness, you have no place inside of me, who invited you!” In this way we are no longer battling with ourselves. It becomes acceptable to for us to feel whatever surfaces. The mindfulness is present and can moderate our internal experience of sadness – we are to just watch and let our attachment to judgment drop. Conscious breathing is an integral component to centering.
In the third step, you coax an inner calmness just as you would soothe a young child who is feeling sadness or pain. You might say, “I am here sadness and I will not abandon you. I am breathing into my sadness with calm cooling breath.” Being one with the feeling allows it the space and time to be nurtured, explored, expressed, acknowledged and provides the opportunity for respectful recovery.
The fourth step begins the process of releasing the feeling. You have faced the fearful emotion living in your body. It is now time to recognize that as you add a calm mindfulness the sadness begins to transform. You have taught your body to feel ease even in the presence of deep sadness. You have sent a new message to your body – that you are ready to remain present and care for yourself even when faced with disturbing internal messages. Make a conscious decision to soften the feeling even more noticing that it can become a gentler expression. Imagine yourself smiling calmly at your feeling and letting it go with willingness to release.
The fifth step involves a deeper look. Bring your mindfulness to the source of the discomfort. Even if it has fully dissipated, the body will have a memory of its existence. Ask, “What is this feeling about? Where did it come from? What internal or external causes form this experience?” With questions like this, we can better understand ourselves. With understanding we can find the source of our internal distress. We can offer our own wise counsel, offering words of kindness and support, self-acceptance and transformation.
This self-directed exercise can add to the richness of anyone’s life. The ability to be compassionate and patient with one’s self when learning these techniques is helpful. The key to mastering these techniques is practice and self-acceptance. Lingering feelings of distress may be met as continued invitations for practice and growth vs. signs that you are not getting any better or that the self-soothing techniques are not working.
Previously, this article introduced two individuals, Brad and Erica, both struggling with trauma and addiction. For individuals confronting the dual challenge of trauma and addiction, there is an even greater need for the ability to develop a feeling of safety. Trauma-related triggers for the addictive behaviors are often not identified until after the behavior occurs and the damage is done. For Brad and Erica, an awareness of how their desire or compulsion to use substances to cope was connected to past trauma may have enabled them to find alternative ways of coping. With greater understanding and more resources for coping at their disposal, each may have been able to respond with healthier means of self-regulation. Based on a foundation of safety and stabilization, traumatic material can be resolved and the continuation of self-destructive behaviors will gradually dissipate.
With the ability to self-regulate anxiety, impulsive behavior and traumatic material can be mastered and addicted survivors can move to the next phase of trauma resolution. However, without a strong foundation of safety, addicted survivors often resort to old patterns of coping and self-soothing, i.e., addiction–as these behaviors were at one time a means of survival. By offering new coping strategies, addicted survivors of trauma can learn to live life without the use of mood altering substances or behaviors and still manage the traumatic symptoms that may resurface in their absence.
Treating the addicted survivor of trauma can be debilitating for the clinician as well as the system that provides this treatment. Individuals with co-occurring unresolved trauma and addiction tend to have more conflicts and act out more often when attempting to address the trauma or to maintain abstinence. Without an understanding of how trauma and addiction are interrelated and an integrated treatment approach, the cycle of retraumatization and relapse will likely continue. For an optimal outcome when treating addicted survivors of trauma, it is essential that treatment begin with a strong foundation of safety. With this foundation solidly in place, the chances of a sustained recovery increases and the individual can lead life free from traumatic memories and addiction–TraumAddition become recovery.
Vice President of Arizona Trauma Institute, LLC
J. Eric Gentry, Ph.D., LMHC, D.A.A.E.T.S. is a board-certified and internationally recognized leader in the study and treatment of traumatic stress and compassion fatigue. His doctorate is from Florida State University where he studied with Professor Charles Figley—a pioneer of these two fields. In 1997, he co-developed the Accelerated Recovery Program (ARP) for Compassion Fatigue—the world’s only evidence-based treatment protocol for compassion fatigue.