WEBVTT
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Hi, I'm Dr.
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David Gross, psychiatrist.
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And I'm Dr.
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Andrew Rosen, psychologist, and this is Two Shrinks in a Mike.
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I got the idea for an important topic for us to discuss today after watching a uh series on one of the streaming channels.
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It was a science fiction uh series about the first uh expedition to Mars, but the subplot was uh very different.
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The subplot was about the daughter of one of the main astronauts who had a drug addiction problem.
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And she ended up going into a number of rehabs and uh ended up still being in trouble.
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Uh what they didn't really focus on uh in in the need for treatment was the fact that she had witnessed her mother walk into the big lake where they lived, not big, big river where they lived to kill herself and successfully killed herself.
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So the d this daughter who at the time was probably about 20 years old witnessed this horrible trauma.
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Um basically had most of her upbringing with her mother because her father, the astronaut, was busy much of the time, uh, either training or going to the moon.
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Um and so this was a horrendous traumatic event.
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And the f theories focused on, you know, the fact that maybe she needs to go to another rehab, which raised a sensitive topic in my mind that I've been concerned about for years, which is the fact that uh trauma is ubiquitous.
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Uh it's much more common than people realize, and it it includes uh we've talked about that before, we talked about post-traumatic stress disorder, everything from um having a major illness and being in the hospital and dealing with uh IVs and noises and not sleeping to uh you know horrendous experiences.
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Um and so when you think about rehabs and what goes on in rehabs, for the most part they do an excellent job dealing with substance abuse.
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Uh many of the rehabs are are uh staffed by individuals who are in recovery themselves and have recovered successfully, so they understand recovery.
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But in my experience, there's never been enough of uh attention to the psychological, psychiatric aspects of addiction.
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And in fact, um being an addict itself is a traumatic experience from having to get the next uh heroin shot to uh being with the community of addicts, which uh oftentimes is dangerous and scary and f and fearful.
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So um I thought we'd spend some time today talking about the concept of trauma and addiction and how uh uh rehabilitation in the traditional sense doesn't necessarily address the problem.
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That's a great idea, Dave.
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You know, uh when I moved moved to Florida in 1984, I went into a practice in Fort Lauderdale that was primarily involved in uh addiction, alcoholism and addiction.
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And I learned a lot about addiction then, be and the and the strength of it and the power of it.
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Uh and also attended uh so I could get familiar with the concept, the twelve step programs.
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AANA and so uh so on.
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And one of the things that struck me was that um you know there was like in everything, uh there's a curve, and on one end of the curve, which was pretty popular at that time, uh addiction or alcoholism was considered to be freestanding entity.
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That is if you were an addict or you were an alcoholic, that is the problem.
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And basically that is the only problem.
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And so if a person who was going to AA or NA um was was looking to get into recovery and get sober, they were really uh discouraged and sometimes actually not permitted to go to meetings if they also were seeing psychological psychiatric help and on medicine.
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It was frowned upon for anybody to be on medicine, thinking like, that's really not your problem, that's a cop out, your problem is addiction.
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And that that model was not unusual and it's kind of worked its way through in different forms even to the present, so that many rehabs, many drug and alcohol rehabs, even if they do recognize a dual diagnosis, meaning that there's uh uh other psychiatric problems that might occur, including trauma, they really are very is secondary or even tertiary in terms of the attention that the program gives to those problems.
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And uh so they focus on the addiction as if uh it's freestanding and there there aren't any other issues.
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So they don't typically ask for uh things like what's happened in your life and you know, do you have a uh history?
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Uh is there anything that's happened in your life including trauma?
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Now it's changed.
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So, and I think, you know, partially for clinical reasons and partially for getting people into the programs, uh it's changed enough so that uh a lot of the programs do recognize dual diagnosis and they do ask questions about trauma.
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Uh, but I don't think that they're uh uh reinforced enough.
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And um that's partially why there's such recidivism and such a turnaround where a person goes into a 28-day program or longer and uh you know they do well when they're in there and they come out and they're left to their own devices again, including dealing with their own depression or trauma.
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And within 30 days, 60 days, 90 days, they're back into the program or another program, a residential program.
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So it's our job really to make sure that that uh kind of ends and that there's a much healthier respect for some of the issues that get a person to end up over involved with drugs and alcohol.
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It's not always just somebody who dabbled in drinking or dabbled in a drug and then got hooked on it.
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You know, the other aspect of of uh substance abuse is that if you think about uh access to care, um you have to recognize that if there's a trauma or major psychiatric component that's part of the substance use, uh a lot of individuals self-medicate anxiety disorders, panic attacks, underlying depression, um, but it's the addiction that becomes so visible, especially to the family and to the individual who's has the substance use problem.
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So the family just focuses on how frightened and scared they are because of their loved one putting themselves in harm's way because of the addiction and the drug use and this era of fentanyl and super powerful fentanyl now on the market.
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Um so getting somebody to recognize there's more to the puzzle is part of the challenge.
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And families get scared, and so they they they put all their hopes in somebody going to a rehab and uh when they come out and they don't do as well as they hoped they would do, um, well, the next step is to go into another rehab, et cetera, et cetera.
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And um the the the core issues uh related to trauma need to get addressed because what we now know about trauma, as we've discussed in previous podcasts, is that traumatic life experiences get stored uh tenaciously in a part of the brain called the amygdala.
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And the amygdala is a primitive part of the brain that uh is responsible for survival.
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It it creates fear response, it uh helps you survive in uh in the jungle when you're surrounded by dangerous things, but it stores the traumatic experiences and doesn't let it go.
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So if you talk to folks who are Vietnam vets to this day, which is how many years ago?
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A long time ago, they'll still be uh terrorized by traumatic experiences that in intrude into their consciousness.
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Um, because it's part of the brain, it releases it various times.
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And so if you're um walking along the street and and you're a Vietnam vet who was in combat and dealt with a mortifier and bombs exploding, et cetera, and a car backfires, it's going to signal that part of the brain, the amygdala, to release the sensory information and the experience of what it was like to be in the foxhole and have bombs exploding around you.
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So um that part of the brain is a major, major obstacle to recover from the trauma.
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The good news is that there are treatments now that uh appear to help empty out the the those memories and those experiences and the painful emotions from the amygdala um uh fairly effectively.
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But it takes time and it takes specialized care.
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And these the individuals who are trauma clinicians have had uh years of training and experience to deal with this this area.
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Um uh th there are a lot of tr courses on trauma that people can go for a weekend course, but that doesn't make you a trauma expert at all.
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Um so um getting somebody to to recognize within the family structure that their loved one has more to it to the picture than just substance abuse is the challenge.
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And that's part of what a good evaluation is all about.
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Um and it's something that uh uh I'm gonna talk about a bit later that has to do with what I call systems theory.
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And it's it's very complicated because uh let's say you know a person has had trauma, and uh that would be uh helped a lot if they were receiving trauma treatment.
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But part of the problem with that is if a person's actively using a drug or actively drinking heavily, uh you really can't treat the trauma until they start to clean out a little bit.
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Uh so what do you do?
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Do you do you focus on the drug and drinking issue primarily and just kind of make note of the fact that once you are able to have a period of time, an interval where your brain is starting to clean out and you're starting to feel things, we need to move over to dealing with the trauma work and at the same time make sure that you're in recovery.
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It's a delicate process, a a back and forth kind of a thing.
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And you know, just the other day I was talking with a parent of an 18-year-old who uh has had alcohol and and uh mainly alcohol abuse, but um realizes that there's also other psychological disorders in there, including maybe bipolar.
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And it was totally overwhelming to think, now my God, now it's not just a drug and alcohol problem on top of it or underneath of it.
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There's other things it's overwhelming.
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So naturally, what do people want to do?
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They want to simplify and go, well, let me just hope and think that maybe if they stop drinking and drugging, everything else will get better.
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But it doesn't necessarily work that way.
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So it does require, for those out there who are listening and and you know, involved in trying to figure out how to help people, it does involve making sure that the clinician or clinicians that you are involved with for your loved one or if it's for you yourself, has a good balance point between knowing as much as possible about addiction and at the same time knows a lot about, for example, trauma and how to ameliorate both problems.
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You know, that's where the uh the evaluation becomes so important and also raises the question as to who does the evaluation.
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You want somebody who is broadly trained and can provide what I call critical thinking.
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In medical school, we were trained with critical thinking.
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For example, if if you're uh 60 years old and um you need to have a hip replaced, uh, but on top of that you have uh anemia, your blood count is low, um, and you have heart disease that uh would put you potentially at risk for uh the surgery.
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Um both a combination of the heart disease and uh anemia uh could increase the risks of surgery, and therefore you need to prioritize the problems, and that's where systems theory becomes important.
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Uh dividing things into the parts that we have to pay attention to.
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It's almost like drawing a big pizza pie and deciding how we're gonna divide it into slices.
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So even though this individual has lots of severe pain because of the bad hip and wants to get this hip replaced as soon as possible, uh you have to prioritize.
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And and the the doctor is going to let them know that we need to uh address your anemia, we need to address your heart problems and make sure your heart is stable, and then we can proceed with the hip so that you can have a successful, healthy outcome.
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So in in the field of mental health, system theory becomes very, very important uh because we need to get all the information and decide what are the various problems and how to prioritize them.
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So as as as you said, Andy, if somebody is actively uh using uh substances, whether alcohol, marijuana, cocaine, or opiates, uh, and they have a significant trauma history, their brain is not going to benefit from trauma therapy until their brain recovers from the effects of those drugs.
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And that's the top priority.
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And so um being able to set up a several-step uh treatment plan makes the most sense.
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So the family and the individual patient understands that, well, this is what you need to do first.
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You need to get your brain clean.
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And then we need to address the trauma, and it may be it need to be addressed in a different kind of treatment modality than in the rehab, that we may need to have you see a trauma specialist afterwards for com continual care to try address the trauma while you continue to pursue, you know, a good treatment recovery program for your substance use.
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Because you just don't stop pursuing recovery for substance use, it has to be continued because it takes a while to really get out of the woods and to be in a relatively safe uh level of recovery.
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A lot of folks you talk to who have been in AA for years will tell you that you're never really out of the woods, that you always have to work a program.
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I'm not sure I agree with that, but for a lot of people it may be the case, and for some people it may not be necessary.
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Uh but at the same time, um you need to make sure that you continue to work that program after initially getting clean to maintain the sobriety so that you can sexually produce the uh pr pursue the trauma therapy.
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And the other challenge is to help the family recognize that, you know, this this trauma experience in the case of this young lady in the in the series I was watching on television, uh, this young lady's substance abuse was clearly driven by her trauma.
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The pain of of watching her mother die and the and and the missing her mother and et cetera, et cetera, was so intense that she was doing anything she could do to numb herself.
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Um and there were the scenes in the in the show where her trauma got triggered by doing something simple.
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She was an artist and she was uh actually trying to make a portrait of her mother and she could never get it right.
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And I'm sure this kept reawakening the emotional pain of the loss and the suicide uh and led her to r repeat uh substance use and and getting into trouble.
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And so um uh systems theory is important, putting together a list of the problems and how to approach them.
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Uh A, B, C, and D, and this is the direction we have to go in, is what uh oftentimes is necessary as part of the treatment plan.
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And you know, I think a lot of times uh we like to think that we can cure things uh but in reality in life I think it's not often that we cure emotional or behavioral problems.
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We uh in my in my thoughts, I think what I try to do with somebody who let's say has been involved with addiction and uh if there's antecedent traumas is let's see how long we can go with you b being able to not be involved with drugs and alcohol and sustain you know good functioning and not let those old traumas uh defeat you.
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Uh for example, if a person has had a particular trauma or loss in in in youth, um they we try to help them overcome the effects of that and not rely on drugs and alcohol and sustain good, healthy living.
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Uh, but there may be another loss down the road that will reignite the original trauma in that person's life and make them more vulnerable to relapsing and and relying on the same things that they relied on before.
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So forewarned is forearmed.
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And part of what I do with patients is help them realize there are gonna be some new speed bumps out there.
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There will be some new, maybe very horrible traumas, or maybe, you know, the small T types of traumas that everybody encounters in life.
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And we need to do whatever we can do to lighten the effects of the original traumas, but also give you the tools to cope better and not have a relapse into uh addiction.
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It's not easy.
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And uh I remember there's a book that was written by um one of the gurus and pioneers in uh mindfulness, and one of the books that he wrote was called Full Catastrophe Living.
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And I I always love the title of it because basically it acknowledges that we all have lots of catastrophes in life.
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Normal life has catastrophes.
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Some of them are small, some of them are big, but if one has had uh an accumulation of the small type traumas or even uh one or two of the big ones, it does leave you vulnerable to wanting to get out of the pain and then rely on things like alcohol and drugs and go right back to the bottom of the shoots and ladders game of life.
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So it's uh it it's hard for male health professionals to kind of do that balancing act, but I think more and more people are aware of that, uh need to do that balancing.
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And look, there are plenty of people who can't afford treatment, they don't go for treatment, and maybe the only thing they have available to them is the AAA model.
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And uh what I have always tried to do, and I know you have as well, is when we have the chance, is to educate people who do go to meetings or or run meetings to let them know not everybody is addicted and doesn't have other issues.
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I'm gonna have to remember that uh great analogy, the chutes and ladders of life.
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If you don't mind, I'll quote you from time to time.
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It's really true.
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But you're absolutely right.
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There's no absolute answer.
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I mean, uh both you and I, as we've gotten older, have learned that we have to cope with the aches and pains and limitations of getting older.
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So there's nothing nobody has a hundred percent um recovery of anything.
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Um it's a matter of quality of life and functional capability.
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Um and so, for example, uh an individual who has been traumatized will not forget the nature of the nature of the trauma, but the goal would be so that the the the trauma nightmares and the flashbacks and the emotional reactivity and the intrusive thinking is no longer there.
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They they still will from time to time uh be traumatized, so to speak, by the memory of what they went through.
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Um but um if if their functional capabilities and their quality of life has improved, uh that's a good goal to reach for.
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You know, one of the classic models of of trauma and substance abuse is the uh the war veteran, you know, the soldier who's been in combat.
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Uh most most uh veterans will tell you that you you go into combat and you come back a different person.
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Um and for many of them it's been traumatic.
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Uh and they def m a certain number develop PTSD, a certain number develop uh subclinical trauma syndromes.
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But the the reason why it becomes a model that's a classic model is the incidence of substance use in veterans is pretty high.
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Um and clearly it's it's part of the the desire to to self-medicate and deal with the pain.
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Um and um I think it's only relatively recently that the Veterans Administration has has demon recognized that they have to really spend a fair amount of money on trauma therapy to help their uh their veterans.
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Um trauma therapies have evolved over the years.
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In in the early days, um the idea was if somebody goes through a horrendous traumatic episode like a a car crash or a bombing is you you do a rehash of the event right after w it happens, right there and then, until people studied it carefully and realized it made people worse, not better.
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Um so uh trauma therapy has come a long way.
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But like I said, coming up with a list of priorities and a treatment plan is absolutely critical.
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The other aspect of the of the veteran who's been in combat, we're now learning, unfortunately, is uh closed head injury.
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Um being exposed to the blast effects um um uh can can lead to, over time, something similar to CTE, chronic traumatic encephalopathy, which is what we're seeing in football players.
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And they're raising concerns about uh the effects of concussive effects from uh bomb blasts and from even firing off a howitzer when you're um the the uh soldier who's press pressing the button that fires the howitzer, there's a blast of uh pressure that hits you.
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It's not just the noise.
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Um they're beginning to recognize that fighter pilots who uh uh are are blasted off of the deck of an aircraft carrier, the G-force is so uh impressive and so powerful, you do that repetitively enough, and it has an impact upon the brain.
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So um we're learning a lot more uh in many respects, unfortunately, as to how we've uh had an impact on the brain.
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And uh trauma needs to be needs to be identified and treated, as well as uh the the aspects of of head injury and recognizing that that's uh a component.
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And that's where the systems approach becomes.
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So important because you can almost make a list of what are the factors that are interfering with this individual's ability to pursue a higher quality of life, and let's prioritize them and work on each one one at a time to maximize the chance to have as good a life as they can.
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Now let's also remember that um I I I remember when I was in my original training and uh particularly in the in psychoanalysis and in those days we'd put somebody on the couch who was drinking a lot and or alcoholic and and uh or drug addicted.
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And um you know, the kind of the focus of the treatment was let's figure out what happened earlier in your life, you know, what your disappointments were, whatever, whatever.
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And and if we can if we can get insight into that, then it's likely that you won't drink anymore or w you won't drink excessively.
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And so, you know, treatment would go on for a long time until we maybe found out what some of those little traumas were, you know, whether it'd be parenting, etc.
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And then we realized, well, wait a minute, you know, uh maybe maybe that's kind of like even enabling the problem.
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Uh you can drink for the next few years while we work on the problem.
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So uh the enabling aspect of that kind of flipped over into no we don't care what your reasons for drinking are.
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You drink because you drink.
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Or you drug because you drug.
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There's no reasons.
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There's no there's no need to go look at that stuff because all that does is give you an excuse to drink or drug.
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And it's the answer is probably somewhere in between, is why we're talking about the role, for example, of trauma, because we can't say it's uh the reason why you drink and drug as if it's an excuse and permission.
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But we do have to acknowledge that if you've had trauma, there's an increase in likelihood that you will turn to substances to deal with that psychic pain that the trauma gave you.
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So uh it's just it's really important to see it as for those who are thinking, well, if you're looking for causes, then you're g you're enabling.
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No.
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We're trying to do all we can do to reduce the opportunities for uh continuation of of drinking and drugging and or relapse.
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And if you ignore certain things, you're just leaving that person very, very vulnerable to uh to a relapse.
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Just like in general medicine, if you ignore certain things, uh maybe that you're leaving that pre uh person very vulnerable to some bad event.
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So it's it's important to know the whole picture.
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And you and I have always talked about that uh human behavior and the human mind and brain is the most complicated thing there is on the planet, and to know a little bit of it just is not right.
00:24:50.000 --> 00:24:57.599
We have to know a lot of it and know it well, and and uh maybe that gives us a chance to help people a little bit better.
00:24:58.079 --> 00:25:00.480
And that's why critical thinking is so important.
00:25:00.720 --> 00:25:08.880
And you as you described, the the individuals who say you d drink because you drink and drug because you drug, et cetera, that's that's not critical thinking.
00:25:09.039 --> 00:25:14.400
That's the that's really uh believing in a model without uh trying to better understand it.
00:25:14.480 --> 00:25:27.839
And that raises the other issue that's always been a problem, and I think it's an inherent in a lot of mental health uh thinking and treatment, which is that if somebody is not improving in treatment, it's because they're resistant or because they're not improving.
00:25:27.920 --> 00:25:39.680
And so if the drug addict is not getting better, it's it's i the responsibility is put on their shoulders rather than saying, well, let's take step back a treatment team and put get back into a huddle and try to rethink what's going on here.
00:25:39.839 --> 00:25:43.680
Maybe they're not getting better because we didn't pay attention to the underlying trauma.
00:25:43.839 --> 00:25:47.440
Um, maybe they're not getting better because the brain hasn't hasn't recovered yet.
00:25:47.599 --> 00:25:48.799
We haven't given them enough time.
00:25:49.039 --> 00:25:53.599
Many of these 28-day programs uh don't give the brain enough chance to recover.
00:25:53.759 --> 00:26:18.000
And so the this whole concept of resistance, which was part of your training and my training in the early days of learning psychotherapy and learning how to treat mental health problems, was uh a big part of it, which was unfortunate, because um i there is a resistance there, but our job is to help the individual understand why they're scared of making progress, why they're scared of opening up, while their defenses are so strong and where they come from.
00:26:18.079 --> 00:26:33.839
And maybe their defenses are there for a good reason, that if they came from a painful, abusive childhood, uh they they keep things close to the chest and for for a good reason, and therefore it's going to take time and trust for them to be able to believe that uh things can change and they can open up.
00:26:34.000 --> 00:26:43.519
And so um it's it's like the end of that wonderful movie Goodwill Hunting, when uh uh they tell uh Damon that it's it's not your fault.
00:26:43.680 --> 00:26:55.039
He spent his entire life w unconsciously and consciously believing that it was his fault for the terrors that occurred within his life until finally says to uh somebody, I think it was Robin Williams, who says to him, it's not your fault.
00:26:55.200 --> 00:26:59.279
And the reality is that that uh we need to have critical thinking.
00:26:59.359 --> 00:27:08.319
We need to be able to prioritize, put together the list of the variables and the problems that have to be addressed, and then tackle them oftentimes one at a time.
00:27:08.559 --> 00:27:11.359
And so I hope I hope this discussion has been helpful.
00:27:11.519 --> 00:27:15.359
Um we're happy to hear from you all if you have comments or interests in this.
00:27:15.440 --> 00:27:17.920
Uh, we're open to uh emails, etc.
00:27:18.240 --> 00:27:19.119
But I'm Dr.
00:27:19.200 --> 00:27:20.559
David Gross, a psychiatrist.
00:27:20.880 --> 00:27:21.200
And Dr.
00:27:21.279 --> 00:27:24.480
Andrew Rosen, psychologist, and this has been Two Shrinks in a Mic.
00:27:24.720 --> 00:27:27.039
And Shrink and Hooks and Ladders of Life.
00:27:27.599 --> 00:27:32.480
The Two Shrinks in a Mic podcast is for informational and entertainment purposes only.
00:27:32.640 --> 00:27:38.799
The views expressed are those of the host and guests and do not constitute medical, legal, or professional advice.
00:00:08.240 --> 00:00:08.960
Hi, I'm Dr.
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David Gross, psychiatrist.
00:00:10.800 --> 00:00:11.279
And I'm Dr.
00:00:11.359 --> 00:00:14.880
Andrew Rosen, psychologist, and this is Two Shrinks in a Mike.
00:00:15.439 --> 00:00:22.160
I got the idea for an important topic for us to discuss today after watching a uh series on one of the streaming channels.
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It was a science fiction uh series about the first uh expedition to Mars, but the subplot was uh very different.
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The subplot was about the daughter of one of the main astronauts who had a drug addiction problem.
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And she ended up going into a number of rehabs and uh ended up still being in trouble.
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Uh what they didn't really focus on uh in in the need for treatment was the fact that she had witnessed her mother walk into the big lake where they lived, not big, big river where they lived to kill herself and successfully killed herself.
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So the d this daughter who at the time was probably about 20 years old witnessed this horrible trauma.
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Um basically had most of her upbringing with her mother because her father, the astronaut, was busy much of the time, uh, either training or going to the moon.
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Um and so this was a horrendous traumatic event.
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And the f theories focused on, you know, the fact that maybe she needs to go to another rehab, which raised a sensitive topic in my mind that I've been concerned about for years, which is the fact that uh trauma is ubiquitous.
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Uh it's much more common than people realize, and it it includes uh we've talked about that before, we talked about post-traumatic stress disorder, everything from um having a major illness and being in the hospital and dealing with uh IVs and noises and not sleeping to uh you know horrendous experiences.
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Um and so when you think about rehabs and what goes on in rehabs, for the most part they do an excellent job dealing with substance abuse.
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Uh many of the rehabs are are uh staffed by individuals who are in recovery themselves and have recovered successfully, so they understand recovery.
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But in my experience, there's never been enough of uh attention to the psychological, psychiatric aspects of addiction.
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And in fact, um being an addict itself is a traumatic experience from having to get the next uh heroin shot to uh being with the community of addicts, which uh oftentimes is dangerous and scary and f and fearful.
00:02:33.360 --> 00:02:45.199
So um I thought we'd spend some time today talking about the concept of trauma and addiction and how uh uh rehabilitation in the traditional sense doesn't necessarily address the problem.
00:02:45.680 --> 00:02:46.800
That's a great idea, Dave.
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You know, uh when I moved moved to Florida in 1984, I went into a practice in Fort Lauderdale that was primarily involved in uh addiction, alcoholism and addiction.
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And I learned a lot about addiction then, be and the and the strength of it and the power of it.
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Uh and also attended uh so I could get familiar with the concept, the twelve step programs.
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AANA and so uh so on.
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And one of the things that struck me was that um you know there was like in everything, uh there's a curve, and on one end of the curve, which was pretty popular at that time, uh addiction or alcoholism was considered to be freestanding entity.
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That is if you were an addict or you were an alcoholic, that is the problem.
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And basically that is the only problem.
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And so if a person who was going to AA or NA um was was looking to get into recovery and get sober, they were really uh discouraged and sometimes actually not permitted to go to meetings if they also were seeing psychological psychiatric help and on medicine.
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It was frowned upon for anybody to be on medicine, thinking like, that's really not your problem, that's a cop out, your problem is addiction.
00:04:04.400 --> 00:04:33.040
And that that model was not unusual and it's kind of worked its way through in different forms even to the present, so that many rehabs, many drug and alcohol rehabs, even if they do recognize a dual diagnosis, meaning that there's uh uh other psychiatric problems that might occur, including trauma, they really are very is secondary or even tertiary in terms of the attention that the program gives to those problems.
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And uh so they focus on the addiction as if uh it's freestanding and there there aren't any other issues.
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So they don't typically ask for uh things like what's happened in your life and you know, do you have a uh history?
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Uh is there anything that's happened in your life including trauma?
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Now it's changed.
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So, and I think, you know, partially for clinical reasons and partially for getting people into the programs, uh it's changed enough so that uh a lot of the programs do recognize dual diagnosis and they do ask questions about trauma.
00:05:08.879 --> 00:05:13.600
Uh, but I don't think that they're uh uh reinforced enough.
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And um that's partially why there's such recidivism and such a turnaround where a person goes into a 28-day program or longer and uh you know they do well when they're in there and they come out and they're left to their own devices again, including dealing with their own depression or trauma.
00:05:32.959 --> 00:05:39.120
And within 30 days, 60 days, 90 days, they're back into the program or another program, a residential program.
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So it's our job really to make sure that that uh kind of ends and that there's a much healthier respect for some of the issues that get a person to end up over involved with drugs and alcohol.
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It's not always just somebody who dabbled in drinking or dabbled in a drug and then got hooked on it.
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You know, the other aspect of of uh substance abuse is that if you think about uh access to care, um you have to recognize that if there's a trauma or major psychiatric component that's part of the substance use, uh a lot of individuals self-medicate anxiety disorders, panic attacks, underlying depression, um, but it's the addiction that becomes so visible, especially to the family and to the individual who's has the substance use problem.
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So the family just focuses on how frightened and scared they are because of their loved one putting themselves in harm's way because of the addiction and the drug use and this era of fentanyl and super powerful fentanyl now on the market.
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Um so getting somebody to recognize there's more to the puzzle is part of the challenge.
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And families get scared, and so they they they put all their hopes in somebody going to a rehab and uh when they come out and they don't do as well as they hoped they would do, um, well, the next step is to go into another rehab, et cetera, et cetera.
00:07:03.519 --> 00:07:20.720
And um the the the core issues uh related to trauma need to get addressed because what we now know about trauma, as we've discussed in previous podcasts, is that traumatic life experiences get stored uh tenaciously in a part of the brain called the amygdala.
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And the amygdala is a primitive part of the brain that uh is responsible for survival.
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It it creates fear response, it uh helps you survive in uh in the jungle when you're surrounded by dangerous things, but it stores the traumatic experiences and doesn't let it go.
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So if you talk to folks who are Vietnam vets to this day, which is how many years ago?
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A long time ago, they'll still be uh terrorized by traumatic experiences that in intrude into their consciousness.
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Um, because it's part of the brain, it releases it various times.
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And so if you're um walking along the street and and you're a Vietnam vet who was in combat and dealt with a mortifier and bombs exploding, et cetera, and a car backfires, it's going to signal that part of the brain, the amygdala, to release the sensory information and the experience of what it was like to be in the foxhole and have bombs exploding around you.
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So um that part of the brain is a major, major obstacle to recover from the trauma.
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The good news is that there are treatments now that uh appear to help empty out the the those memories and those experiences and the painful emotions from the amygdala um uh fairly effectively.
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But it takes time and it takes specialized care.
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And these the individuals who are trauma clinicians have had uh years of training and experience to deal with this this area.
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Um uh th there are a lot of tr courses on trauma that people can go for a weekend course, but that doesn't make you a trauma expert at all.
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Um so um getting somebody to to recognize within the family structure that their loved one has more to it to the picture than just substance abuse is the challenge.
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And that's part of what a good evaluation is all about.
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Um and it's something that uh uh I'm gonna talk about a bit later that has to do with what I call systems theory.
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And it's it's very complicated because uh let's say you know a person has had trauma, and uh that would be uh helped a lot if they were receiving trauma treatment.
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But part of the problem with that is if a person's actively using a drug or actively drinking heavily, uh you really can't treat the trauma until they start to clean out a little bit.
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Uh so what do you do?
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Do you do you focus on the drug and drinking issue primarily and just kind of make note of the fact that once you are able to have a period of time, an interval where your brain is starting to clean out and you're starting to feel things, we need to move over to dealing with the trauma work and at the same time make sure that you're in recovery.
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It's a delicate process, a a back and forth kind of a thing.
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And you know, just the other day I was talking with a parent of an 18-year-old who uh has had alcohol and and uh mainly alcohol abuse, but um realizes that there's also other psychological disorders in there, including maybe bipolar.
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And it was totally overwhelming to think, now my God, now it's not just a drug and alcohol problem on top of it or underneath of it.
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There's other things it's overwhelming.
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So naturally, what do people want to do?
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They want to simplify and go, well, let me just hope and think that maybe if they stop drinking and drugging, everything else will get better.
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But it doesn't necessarily work that way.
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So it does require, for those out there who are listening and and you know, involved in trying to figure out how to help people, it does involve making sure that the clinician or clinicians that you are involved with for your loved one or if it's for you yourself, has a good balance point between knowing as much as possible about addiction and at the same time knows a lot about, for example, trauma and how to ameliorate both problems.
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You know, that's where the uh the evaluation becomes so important and also raises the question as to who does the evaluation.
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You want somebody who is broadly trained and can provide what I call critical thinking.
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In medical school, we were trained with critical thinking.
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For example, if if you're uh 60 years old and um you need to have a hip replaced, uh, but on top of that you have uh anemia, your blood count is low, um, and you have heart disease that uh would put you potentially at risk for uh the surgery.
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Um both a combination of the heart disease and uh anemia uh could increase the risks of surgery, and therefore you need to prioritize the problems, and that's where systems theory becomes important.
00:12:07.919 --> 00:12:11.840
Uh dividing things into the parts that we have to pay attention to.
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It's almost like drawing a big pizza pie and deciding how we're gonna divide it into slices.
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So even though this individual has lots of severe pain because of the bad hip and wants to get this hip replaced as soon as possible, uh you have to prioritize.
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And and the the doctor is going to let them know that we need to uh address your anemia, we need to address your heart problems and make sure your heart is stable, and then we can proceed with the hip so that you can have a successful, healthy outcome.
00:12:39.679 --> 00:12:51.120
So in in the field of mental health, system theory becomes very, very important uh because we need to get all the information and decide what are the various problems and how to prioritize them.
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So as as as you said, Andy, if somebody is actively uh using uh substances, whether alcohol, marijuana, cocaine, or opiates, uh, and they have a significant trauma history, their brain is not going to benefit from trauma therapy until their brain recovers from the effects of those drugs.
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And that's the top priority.
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And so um being able to set up a several-step uh treatment plan makes the most sense.
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So the family and the individual patient understands that, well, this is what you need to do first.
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You need to get your brain clean.
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And then we need to address the trauma, and it may be it need to be addressed in a different kind of treatment modality than in the rehab, that we may need to have you see a trauma specialist afterwards for com continual care to try address the trauma while you continue to pursue, you know, a good treatment recovery program for your substance use.
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Because you just don't stop pursuing recovery for substance use, it has to be continued because it takes a while to really get out of the woods and to be in a relatively safe uh level of recovery.
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A lot of folks you talk to who have been in AA for years will tell you that you're never really out of the woods, that you always have to work a program.
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I'm not sure I agree with that, but for a lot of people it may be the case, and for some people it may not be necessary.
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Uh but at the same time, um you need to make sure that you continue to work that program after initially getting clean to maintain the sobriety so that you can sexually produce the uh pr pursue the trauma therapy.
00:14:18.080 --> 00:14:31.919
And the other challenge is to help the family recognize that, you know, this this trauma experience in the case of this young lady in the in the series I was watching on television, uh, this young lady's substance abuse was clearly driven by her trauma.
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The pain of of watching her mother die and the and and the missing her mother and et cetera, et cetera, was so intense that she was doing anything she could do to numb herself.
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Um and there were the scenes in the in the show where her trauma got triggered by doing something simple.
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She was an artist and she was uh actually trying to make a portrait of her mother and she could never get it right.
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And I'm sure this kept reawakening the emotional pain of the loss and the suicide uh and led her to r repeat uh substance use and and getting into trouble.
00:15:04.879 --> 00:15:11.679
And so um uh systems theory is important, putting together a list of the problems and how to approach them.
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Uh A, B, C, and D, and this is the direction we have to go in, is what uh oftentimes is necessary as part of the treatment plan.
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And you know, I think a lot of times uh we like to think that we can cure things uh but in reality in life I think it's not often that we cure emotional or behavioral problems.
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We uh in my in my thoughts, I think what I try to do with somebody who let's say has been involved with addiction and uh if there's antecedent traumas is let's see how long we can go with you b being able to not be involved with drugs and alcohol and sustain you know good functioning and not let those old traumas uh defeat you.
00:16:02.080 --> 00:16:18.879
Uh for example, if a person has had a particular trauma or loss in in in youth, um they we try to help them overcome the effects of that and not rely on drugs and alcohol and sustain good, healthy living.
00:16:19.200 --> 00:16:34.879
Uh, but there may be another loss down the road that will reignite the original trauma in that person's life and make them more vulnerable to relapsing and and relying on the same things that they relied on before.
00:16:35.120 --> 00:16:37.840
So forewarned is forearmed.
00:16:38.000 --> 00:16:43.039
And part of what I do with patients is help them realize there are gonna be some new speed bumps out there.
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There will be some new, maybe very horrible traumas, or maybe, you know, the small T types of traumas that everybody encounters in life.
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And we need to do whatever we can do to lighten the effects of the original traumas, but also give you the tools to cope better and not have a relapse into uh addiction.
00:17:05.039 --> 00:17:06.160
It's not easy.
00:17:06.319 --> 00:17:18.880
And uh I remember there's a book that was written by um one of the gurus and pioneers in uh mindfulness, and one of the books that he wrote was called Full Catastrophe Living.
00:17:19.039 --> 00:17:26.559
And I I always love the title of it because basically it acknowledges that we all have lots of catastrophes in life.
00:17:26.799 --> 00:17:28.720
Normal life has catastrophes.
00:17:28.799 --> 00:17:48.799
Some of them are small, some of them are big, but if one has had uh an accumulation of the small type traumas or even uh one or two of the big ones, it does leave you vulnerable to wanting to get out of the pain and then rely on things like alcohol and drugs and go right back to the bottom of the shoots and ladders game of life.
00:17:49.039 --> 00:18:01.200
So it's uh it it's hard for male health professionals to kind of do that balancing act, but I think more and more people are aware of that, uh need to do that balancing.
00:18:01.359 --> 00:18:09.039
And look, there are plenty of people who can't afford treatment, they don't go for treatment, and maybe the only thing they have available to them is the AAA model.
00:18:09.200 --> 00:18:22.720
And uh what I have always tried to do, and I know you have as well, is when we have the chance, is to educate people who do go to meetings or or run meetings to let them know not everybody is addicted and doesn't have other issues.
00:18:23.359 --> 00:18:27.519
I'm gonna have to remember that uh great analogy, the chutes and ladders of life.
00:18:27.599 --> 00:18:29.440
If you don't mind, I'll quote you from time to time.
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It's really true.
00:18:30.559 --> 00:18:31.279
But you're absolutely right.
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There's no absolute answer.
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I mean, uh both you and I, as we've gotten older, have learned that we have to cope with the aches and pains and limitations of getting older.
00:18:39.839 --> 00:18:45.039
So there's nothing nobody has a hundred percent um recovery of anything.
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Um it's a matter of quality of life and functional capability.
00:18:49.839 --> 00:19:09.440
Um and so, for example, uh an individual who has been traumatized will not forget the nature of the nature of the trauma, but the goal would be so that the the the trauma nightmares and the flashbacks and the emotional reactivity and the intrusive thinking is no longer there.
00:19:09.839 --> 00:19:15.920
They they still will from time to time uh be traumatized, so to speak, by the memory of what they went through.
00:19:16.000 --> 00:19:23.599
Um but um if if their functional capabilities and their quality of life has improved, uh that's a good goal to reach for.
00:19:23.759 --> 00:19:32.480
You know, one of the classic models of of trauma and substance abuse is the uh the war veteran, you know, the soldier who's been in combat.
00:19:32.799 --> 00:19:38.640
Uh most most uh veterans will tell you that you you go into combat and you come back a different person.
00:19:38.880 --> 00:19:41.519
Um and for many of them it's been traumatic.
00:19:41.680 --> 00:19:48.640
Uh and they def m a certain number develop PTSD, a certain number develop uh subclinical trauma syndromes.
00:19:48.799 --> 00:19:56.240
But the the reason why it becomes a model that's a classic model is the incidence of substance use in veterans is pretty high.
00:19:56.400 --> 00:20:02.720
Um and clearly it's it's part of the the desire to to self-medicate and deal with the pain.
00:20:02.880 --> 00:20:16.319
Um and um I think it's only relatively recently that the Veterans Administration has has demon recognized that they have to really spend a fair amount of money on trauma therapy to help their uh their veterans.
00:20:16.480 --> 00:20:19.519
Um trauma therapies have evolved over the years.
00:20:19.599 --> 00:20:37.119
In in the early days, um the idea was if somebody goes through a horrendous traumatic episode like a a car crash or a bombing is you you do a rehash of the event right after w it happens, right there and then, until people studied it carefully and realized it made people worse, not better.
00:20:37.279 --> 00:20:40.319
Um so uh trauma therapy has come a long way.
00:20:40.480 --> 00:20:46.319
But like I said, coming up with a list of priorities and a treatment plan is absolutely critical.
00:20:46.559 --> 00:20:54.000
The other aspect of the of the veteran who's been in combat, we're now learning, unfortunately, is uh closed head injury.
00:20:54.160 --> 00:21:07.920
Um being exposed to the blast effects um um uh can can lead to, over time, something similar to CTE, chronic traumatic encephalopathy, which is what we're seeing in football players.
00:21:08.000 --> 00:21:24.880
And they're raising concerns about uh the effects of concussive effects from uh bomb blasts and from even firing off a howitzer when you're um the the uh soldier who's press pressing the button that fires the howitzer, there's a blast of uh pressure that hits you.
00:21:24.960 --> 00:21:26.400
It's not just the noise.
00:21:26.640 --> 00:21:40.720
Um they're beginning to recognize that fighter pilots who uh uh are are blasted off of the deck of an aircraft carrier, the G-force is so uh impressive and so powerful, you do that repetitively enough, and it has an impact upon the brain.
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So um we're learning a lot more uh in many respects, unfortunately, as to how we've uh had an impact on the brain.
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And uh trauma needs to be needs to be identified and treated, as well as uh the the aspects of of head injury and recognizing that that's uh a component.
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And that's where the systems approach becomes.
00:22:00.160 --> 00:22:15.279
So important because you can almost make a list of what are the factors that are interfering with this individual's ability to pursue a higher quality of life, and let's prioritize them and work on each one one at a time to maximize the chance to have as good a life as they can.
00:22:15.680 --> 00:22:33.599
Now let's also remember that um I I I remember when I was in my original training and uh particularly in the in psychoanalysis and in those days we'd put somebody on the couch who was drinking a lot and or alcoholic and and uh or drug addicted.
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And um you know, the kind of the focus of the treatment was let's figure out what happened earlier in your life, you know, what your disappointments were, whatever, whatever.
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And and if we can if we can get insight into that, then it's likely that you won't drink anymore or w you won't drink excessively.
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And so, you know, treatment would go on for a long time until we maybe found out what some of those little traumas were, you know, whether it'd be parenting, etc.
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And then we realized, well, wait a minute, you know, uh maybe maybe that's kind of like even enabling the problem.
00:23:08.720 --> 00:23:12.160
Uh you can drink for the next few years while we work on the problem.
00:23:12.559 --> 00:23:21.759
So uh the enabling aspect of that kind of flipped over into no we don't care what your reasons for drinking are.
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You drink because you drink.
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Or you drug because you drug.
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There's no reasons.
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There's no there's no need to go look at that stuff because all that does is give you an excuse to drink or drug.
00:23:34.000 --> 00:23:48.079
And it's the answer is probably somewhere in between, is why we're talking about the role, for example, of trauma, because we can't say it's uh the reason why you drink and drug as if it's an excuse and permission.
00:23:48.240 --> 00:24:01.039
But we do have to acknowledge that if you've had trauma, there's an increase in likelihood that you will turn to substances to deal with that psychic pain that the trauma gave you.
00:24:01.519 --> 00:24:09.519
So uh it's just it's really important to see it as for those who are thinking, well, if you're looking for causes, then you're g you're enabling.
00:24:09.680 --> 00:24:09.920
No.
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We're trying to do all we can do to reduce the opportunities for uh continuation of of drinking and drugging and or relapse.
00:24:18.720 --> 00:24:26.000
And if you ignore certain things, you're just leaving that person very, very vulnerable to uh to a relapse.
00:24:26.160 --> 00:24:34.720
Just like in general medicine, if you ignore certain things, uh maybe that you're leaving that pre uh person very vulnerable to some bad event.
00:24:34.880 --> 00:24:37.920
So it's it's important to know the whole picture.
00:24:38.000 --> 00:24:49.839
And you and I have always talked about that uh human behavior and the human mind and brain is the most complicated thing there is on the planet, and to know a little bit of it just is not right.
00:24:50.000 --> 00:24:57.599
We have to know a lot of it and know it well, and and uh maybe that gives us a chance to help people a little bit better.
00:24:58.079 --> 00:25:00.480
And that's why critical thinking is so important.
00:25:00.720 --> 00:25:08.880
And you as you described, the the individuals who say you d drink because you drink and drug because you drug, et cetera, that's that's not critical thinking.
00:25:09.039 --> 00:25:14.400
That's the that's really uh believing in a model without uh trying to better understand it.
00:25:14.480 --> 00:25:27.839
And that raises the other issue that's always been a problem, and I think it's an inherent in a lot of mental health uh thinking and treatment, which is that if somebody is not improving in treatment, it's because they're resistant or because they're not improving.
00:25:27.920 --> 00:25:39.680
And so if the drug addict is not getting better, it's it's i the responsibility is put on their shoulders rather than saying, well, let's take step back a treatment team and put get back into a huddle and try to rethink what's going on here.
00:25:39.839 --> 00:25:43.680
Maybe they're not getting better because we didn't pay attention to the underlying trauma.
00:25:43.839 --> 00:25:47.440
Um, maybe they're not getting better because the brain hasn't hasn't recovered yet.
00:25:47.599 --> 00:25:48.799
We haven't given them enough time.
00:25:49.039 --> 00:25:53.599
Many of these 28-day programs uh don't give the brain enough chance to recover.
00:25:53.759 --> 00:26:18.000
And so the this whole concept of resistance, which was part of your training and my training in the early days of learning psychotherapy and learning how to treat mental health problems, was uh a big part of it, which was unfortunate, because um i there is a resistance there, but our job is to help the individual understand why they're scared of making progress, why they're scared of opening up, while their defenses are so strong and where they come from.
00:26:18.079 --> 00:26:33.839
And maybe their defenses are there for a good reason, that if they came from a painful, abusive childhood, uh they they keep things close to the chest and for for a good reason, and therefore it's going to take time and trust for them to be able to believe that uh things can change and they can open up.
00:26:34.000 --> 00:26:43.519
And so um it's it's like the end of that wonderful movie Goodwill Hunting, when uh uh they tell uh Damon that it's it's not your fault.
00:26:43.680 --> 00:26:55.039
He spent his entire life w unconsciously and consciously believing that it was his fault for the terrors that occurred within his life until finally says to uh somebody, I think it was Robin Williams, who says to him, it's not your fault.
00:26:55.200 --> 00:26:59.279
And the reality is that that uh we need to have critical thinking.
00:26:59.359 --> 00:27:08.319
We need to be able to prioritize, put together the list of the variables and the problems that have to be addressed, and then tackle them oftentimes one at a time.
00:27:08.559 --> 00:27:11.359
And so I hope I hope this discussion has been helpful.
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Um we're happy to hear from you all if you have comments or interests in this.
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Uh, we're open to uh emails, etc.
00:27:18.240 --> 00:27:19.119
But I'm Dr.
00:27:19.200 --> 00:27:20.559
David Gross, a psychiatrist.
00:27:20.880 --> 00:27:21.200
And Dr.
00:27:21.279 --> 00:27:24.480
Andrew Rosen, psychologist, and this has been Two Shrinks in a Mic.
00:27:24.720 --> 00:27:27.039
And Shrink and Hooks and Ladders of Life.
00:27:27.599 --> 00:27:32.480
The Two Shrinks in a Mic podcast is for informational and entertainment purposes only.
00:27:32.640 --> 00:27:38.799
The views expressed are those of the host and guests and do not constitute medical, legal, or professional advice.
