The Relationship between PTSD And Substances Like Alcohol and Opioids
June is Post-traumatic Stress Disorder (PTSD) Awareness Month, and in this podcast addiction specialist, Clare Waismann, RAS/SUDCC and psychotherapist David Livingston, LMFT are discussing the relationship between PTSD and substances like alcohol and opioids.
Listen as they discuss the causes of trauma, symptoms, available treatments, and when alternate coping mechanisms such as substance use come into play. Learn what you can do if you or a loved one is struggling with PTSD or addiction.
Dwight Hurst, LPC: Welcome back to Addiction, Recovery and Mental Health, a podcast by Waismann Method Opioid Treatment Specialists. I’m your co-host Dwight Hurst and joined as always by Clare Waismann and David Livingston. We were talking about PTSD and addiction. Today with it, June is amongst the various there’s there’s different months it’s pride month I just learned it’s also men’s mental health month. But one of the things that’s commemorated in June is PTSD and PTSD awareness. And so that’s right up our alley here on the show is to talk about that. We do talk about the relationship between trauma and with mental health and PTSD is kind of got its own wrinkles to it as well. How is everyone feeling on this topic? Where should we start today?
Clare Waismann, RAS/SUDCC: David, I’m going to let you open this door today.
David Livingston, LMFT: Okay. You got it. So. So maybe PTSD, I think was maybe a good place to start is with just a little information about it for if anybody isn’t sure of what it is, it is post-traumatic stress disorder. So it was first, I think, created as a disorder for for combat veterans or people who went through really chaotic experiences. Often that had to do with death or dying was one of the major attributes that tended to be associated with it, with the diagnosis. So it is in essence being exposed to something traumatic. And it’s and it and it also can be can happen when people are sort of thrown into a level of chaos that overwhelms their sense of how they’re organized, either internally, externally or probably in some ways both. One of the things they’ve learned, particularly with PTSD, because we see a fair amount of of people associated with military veterans and so forth who come through and who we work with. One of the things that’s correlated to PTSD, and I’ve seen this in people I’ve worked with, is the perception that people bring into. So if you go to war, the people who are expecting it to be, for lack of a better word, hell, tend to get less PTSD. If you’re naive about it, you tend to it overwhelms you and surprises you at a level and can be more disorganized. So that’s one of the attributes to it. So some of the things that are associated with it are nightmares, high levels of anxiety, depression, depersonalization and disassociation, hyper responses to noises and sounds. And so some of those are more characteristic of the diagnosis. So maybe that’s a place to start.
Clare Waismann, RAS/SUDCC: That. Um. Um. David, would you describe it as somebody is in constant alert-mode?
David Livingston, LMFT: For sure. It’s as if the nervous system is on high alert and the ability to relax. Because we’re at ultimately work we’re adaptive. So if you’re in a prolonged state or period of vigilance, your nervous system actually can begin to adapt to that and make that more of the baseline. So you’ll see that with combat veterans who have had especially if they’ve had a lot of time in combat, especially, you know, highly in dangerous and intensive situations. So there’s they’re nervous systems adapt and so so yes.
Dwight Hurst, LPC: Yeah. And it’s interesting because some of the research that’s been done shows different causes. I mean, like you said, it used to be from the development of the diagnosis, it was just kind of used as a combat thing, something more scientific than saying shell shocked, which they used to say. Right. And then it sort of branched out to say, oh, I guess I guess the research shows life threatening experiences. And then it seems like it’s gone a step further to say, oh, actually there’s a lot of people who maybe weren’t in danger of death, like those who are physically or sexually abused or had other events that also show the same symptoms and that qualify now for PTSD. And so we’ve seen kind of different gradients and different causes of trauma, but they seem to have a lot of the same dynamics, right?
David Livingston, LMFT: Exactly. There are different ways to approach it. And there’s a high correlation to you know, you can imagine why we see a fair amount of people who’ve been on opioids to try to help calm their nervous systems or who get addicted while they’re in combat and then come back and are trying to find a way to, you know, to lower their hyper arousal state and through opioid use, which tends to work for a period and then actually makes it worse, and then it causes all kinds of other problems eventually. So it doesn’t lead to what you need over time. But, you know, so so we certainly see people and help and work with veterans coming off of opioids.
Dwight Hurst, LPC: And that does seem to be a theme we see with a lot of dynamics and opiates. Right. Even with pain to an extent. It works for a while and then doesn’t and then aggravates.
David Livingston, LMFT: Right? Well, yes. And similarly, pain throws a system into some level of chaos and disorganization. Because if you’re in enough pain, it will disorganize your system. Because the pain, it’s like instead of living in feeling relaxed inside, now you’re living in two worlds. You’re trying to organize the external world and the internal world and then there are all kinds of other feelings that get associated – anxieties, you know, disruptions in sleep, all kinds of things that often occur.
Clare Waismann, RAS/SUDCC: So, David, I, I think it’s important for us to talk because we see, you know, um, a lot, a lot of, um, patients struggling with PTSD that we treat and then they go through the detox. Now, you know, you have a person that feels raw and all these symptoms that at one point were masked by the opioids are surfacing at full force. Um, what, what are the treatments? What is first, how do you deal with it as soon as they get detoxed? And what are the risks of them not having the appropriate care post-detox? So if you can talk a little about, you know, how you handle those patients that wake up and do not know how to relax, do not know how to feel safe within, you know, their own boundaries. So yeah, just talk a bit about it, please.
David Livingston, LMFT: So because we often see people who’ve been on opioids for a very long time, so they the, because the course of opioids is they tend to regulate in the beginning they help they help anxiety depression for many people they help pain but that ramps up and is the dosage ramps up it comes to a plateau and then you tend to plateau and then it goes down the other side. And we see people very often who are coming down the other side. So ironically, even though, yeah, they’re feeling their feelings more directly off the opioids, they’re not going through the severe dysregulation that the opioids are causing because at that level, as they’re metabolizing the opioids quickly, as it’s just regulating their sleep as it is, is affecting their mood and their ability to and their lives, frankly, just start to shut down. They do less. They’re less involved with other people. So all the regulating forces that actually tend to elevate mood. So yeah, you come off and you’re feeling your own feelings more directly, but those feelings are not, you know, I mean, maybe in the most severe cases of people with PTSD, you know, it can vary where that can be a lot. But in general, people feel better because it’s our feelings and our sense of values and perceptions that begin to re-regulate and not only regulate but create a sense of well-being again. Right. So all of a sudden, it’s fun to listen to music again and you actually want to see your friend and the people you’ve been avoiding, who you realize you’re missing, you want to talk to them. And so all these aspects of life that actually create meaning and a sense of value, again, are better.
David Livingston, LMFT: And so, yes, you’re you’re dealing with your feelings more acutely, but not just negatively after a period of time. And so one of the things that I see a lot is that people have been on opiates for a long time because they just needed the space, the distance between the trauma and the and getting off the opioids. And then as the opioids are worse in their life, they went off of them. We see them a lot then and then actually they’re better off. So that’s not 100% the case. And often they have to go into and get the continued treatment and tthere are different treatments that are known to be effective. EMDR is one that’s been known to sort of help with the nervous system. I think massage is actually, a therapeutic massage can be very helpful just to help people’s nervous systems and then being able to slowly move into feelings. You know, as I say to the patients, you know, the goal is to you talk about things in here as you need to and then you shut it down and then you walk out the door and you shut things down. And and and so what happens is, is you there’s a mechanism that can be put back into a place where you can repress, you can repress, you deal with them enough, and then you repress them because you can’t keep things open all the time. So you open the door and you shut it. And that combination can get put in place through effective therapy over time, something like that.
Dwight Hurst, LPC: It’s emotional regulation, right?
David Livingston, LMFT: Very much.
Dwight Hurst, LPC: And as we talk a lot on the show about the self-medication and that dynamic. And so I think what I’m hearing is you’re talking about that is that there’s there would be a certain amount of irresponsibility to help somebody get off of drug use and then not have anything there to replace that solution. Because we forget sometimes that drug abuse is a solution more than it is a problem. In other words, it’s a bad solution.
Clare Waismann, RAS/SUDCC: Healthy it’s a consequence instead of a solution. No.
David Livingston, LMFT: But what I would say is it in the very beginning it may. It may be a solution, but not over time actually.
Dwight Hurst, LPC: It becomes its own problem, right? Yes, exactly.
David Livingston, LMFT: Right. But in terms of the feelings, in terms of what the person experiences internally, the solution part of it is long past, I mean and truly and so. So when they come off of it, yeah. You’ve, you know, like and then then, you know, if I say one of the most difficult things is getting people getting is helping them trust enough to want to get reestablished in a relationship that can be therapeutic. And my hope is that they have a good enough experience here and with the care they get that that will instill some hopefulness that can be carried forward.
Clare Waismann, RAS/SUDCC: And I think that is so incredibly important. David because, um, Dwight, like you said right now, that is irresponsible, to treat somebody and not have a replacement for the drugs in place, as great as it sounds, is not realistic. A, because you can’t have, you know, a treatment protocol that is going to fit everybody’s needs or that everybody’s going to follow. The second issue is, I believe that when you make someone that especially PTSD that is so scary to commit to any treatment, you know, they are so scared to open themselves and get completely stabilized. Um. It’s really, really important, as David was saying, that they have a good experience, so they start trusting again. So they feel comfortable within their realm to actually open up to someone and start working on that. But we need to be very careful with, you know, pre-deciding people’s solution without really understanding their makeup. And what they can’t withstand.
Dwight Hurst, LPC: Isn’t trust and lack or loss of trust, one of the symptoms that we would run into with PTSD?
David Livingston, LMFT: 100%. Because then there’s with the loss of trust, there is, you know, values and relationships, which is one of the most valuable things I think there is maybe the most if you can’t trust and you can’t let people in and you can’t sort of form reciprocal, loving relationships, then the value system is skewed and then then there’s you’re in a certain amount of chaos and that is a part of PTSD.
Dwight Hurst, LPC: I know that they’ve updated also a little bit when they used to talk about PTSD and it activates the panic system and you go into survival mode. I remember going to school and they’d always talk about the fight or flight response. And now they’re talking in treatment circles about fight, flight or freeze. And just the other day, I’d heard a fourth response pattern. They say fight, flight, freeze or fawn, which oftentimes in violent and toxic relationships, someone will fawn or try to, you know, gain the approval of someone to protect themselves. So that mainly is referring to domestic violence and toxic situations there. But I think we may underestimate the presence of that freeze response. And sometimes if someone’s not raging or those types of things, we think, well, they’re okay. They’re just kind of quiet after these traumatic experiences but then we start to get upset with them. Sometimes caretakers or family members will get frustrated that the person’s not making decisions or that maybe they’re not taking healthy choices. And then, of course, sometimes then the drug use or abuse starts and. Do. We don’t realize there’s that freezing shutdown response when someone is being triggered. Right.
David Livingston, LMFT: So. Right, right. You see that in animals and in nature. And it’s in us, too. There’s a protective mechanism. And, you know, and at times it’s the most adaptive. But ultimately, you’ve got to you need to know that that health is like we talk about is the ability to move as you need to and you want to. So but. Yes.
Dwight Hurst, LPC: What about the element of shame that that plays in PTSD when you see people who’ve gone through trauma, and especially if drug use has then become a part of their coping or their attempt to cope. It seems like shame and the hesitancy to become vulnerable would be a big part of it. I mean, you see people hiding addiction. Do you see people, you know, having… How strong of a relationship is there between shame and PTSD?
Clare Waismann, RAS/SUDCC: If things a combination of shame and fear they’re hiding, sometimes even more feared than shame.
David Livingston, LMFT: And often one of the things I think they’re afraid of and maybe even ashamed of is how angry they are that there’s that with a loss of trust is a feeling of, you lose a sense of humanity because PTSD is associated with experiences of either seeing someone die or death in some capacity. You know, that’s something we as human beings repress all the time. I think it was Freud who accurately said that, you know, within our unconscious is everybody thinks that they’re immortal. So once that has been when you see this with combat vets, they don’t think that or feel that and they can’t repress that the way we all do. We all forget about it and thank goodness because then we go on and we live our lives more fully. But what happens is, is when you can’t forget about that in the same way, you know, and so there’s there are techniques in ways to help you begin to forget. And it may sound funny. I mean, it’s no wonder that opioid use is correlated because it is a way of dampening and trying to forget. So that that like I was saying in therapy, it’s a great, you know, one of the things I, I do when I’m talking with people who are dealing with PTSD is I make it crystal clear that we’ve done the work for today and you need to forget about everything until the next time we talk. And it’s easier said than done, there’s no question. Sometimes it’ll come out in dreams, sometimes it comes out other ways. And this is why you need a long runway. So when successful treatments, from my experience, what happens is, is there’s a rhythm you get into where you deal with things and you repress things and shut them down. You open them up, you shut them down. And that as that gets re-established, it’s part of the treatment for it because then the person can actually deal with some of these things. There’s a place to do it, and then they begin to really learn how to shut things down again, which is critical.
Dwight Hurst, LPC: And that’s a big part of a lot of the trauma therapies I know with EMDR. It’s all about triggering and processing responses differently, but they typically also have a start up and slow down, as my understanding so does. I don’t know if they call it. It’s not exactly a terminology, but it’s kind of a relaxation and decrease of that because otherwise, you find that it actually kicks things up and people need to be able to regulate that. And, you know, in a way it’s interesting because practicing being able to do that naturally with our own psychology and our own physiology sort of then reduces hopefully the need to ingest a psychoactive substance or to abuse drugs to try to get that result. Because in a way, that’s what we’re trying to do with drug abuse, is we’re trying to take an unnatural or a what we think is an unnatural level of control over our feelings.
David Livingston, LMFT: I’m just going to say this. It’s one of my biggest complaints about the standard treatments in our field is that it’s eight or 10 hours of as of group therapies and this and that it just overwhelms people. It’s way too much. People are wanting to. Are needing to learn how to lower and shut things down. And you have to find a balance. It’s so the idea of more and more treatment, more treatment, more treatment is a terrible idea. It’s really finding what it allows that person to deal with things enough for that that actually there’s a titration and then they can stay regulated for a period of time and forget for a period and then deal again. That’s really the far more of my idea of it, but it’s not so, you know, and look, there can be a lot of in-between socializing, you know, going for walks, doing other things, talking with people. But just that stuff is all great. That can be that can really help to just kind of, you know, be some in-between ground.
Dwight Hurst, LPC: Well, and I feel like that’s a more research-based that’s a more modern approach is if you’re talking about like in a residential treatment or kind of an inpatient or an intensive outpatient to say we’re going to do therapy groups every hour, I think is being replaced in the more progressive programs by saying, let’s, yeah, take a walk, let’s get to know people, let’s talk about how to have healthy relationships or healthy dietary things that are meant to be positive, things that are replacing the negative behaviors and not just talking about the negative behaviors over and over and over and over.
David Livingston, LMFT: 100% and time to just let your imagination and yourself just relax and trip around, not have to be accountable to somebody for something all the time.
Dwight Hurst, LPC: And we’re going to leave it there for today with the focus and awareness available to talk about PTSD. I want to encourage everyone to get out there and look for those signs in individuals, loved ones. Make sure that you’re paying attention to those who may have suffered trauma and whether you’re aware of it or not, that there are those that are hurting and need help and support. Sometimes something as simple as forwarding things on the Internet and social media that are healthy and useful can be a powerful way to do that. You can follow us as well @opiates on Twitter or email us info at opiates and see some of the things that we are putting out there and that we’re spreading about awareness, about addiction, recovery and of course, trauma and PTSD is a big part of that. Big thanks to Clare Waismann and David Livingston, as always, for being here to put this episode together. This show is produced by Popped Collar Productions. You can learn more about them at Popped Collor.net and our music is the song Medical by Clean Mind Sounds. Remember to keep asking questions because if you ask the right questions, you will be able to find answers. And when you find answers, you can find hope. Bye-bye for now from Waismann Method opioid treatment specialists. We’ll be here again soon.