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Motivational Interviewing and Substance Abuse

Motivational interviewing (MI) is a collaborative conversation style for strengthening a person’s own motivation and commitment to change because addiction is a threat that needs to be taken seriously. As the definition would imply, this type of therapy is more guiding than directing, and it focuses on the client’s own strengths, abilities, and motivation toward positive change. It is a therapeutic intervention that was originally developed for addressing alcoholism and substance abuse and has since expanded to encompass all types of life changes, both minor and major.  Research has consistently demonstrated the efficacy of motivational interviewing in increasing one’s readiness to stop drug use, reducing the severity of substance use, and in lengthening periods of abstinence. MI utilizes a wide variety of therapy techniques, overflowing from a spirit of partnership, acceptance, compassion, and evocation.

The Development of Motivational Interviewing

The MI approach evolved from William R. Miller’s work with alcoholism. In the past, it was commonly thought that those who drank too much were unable to see how their use was harming themselves and others, that they didn’t truly want to quit, and that they were in denial. Addiction counselors, therapists, family, and friends who wanted to help would try to break through this denial by using harsh confrontation and shame, in an attempt convince individuals of their need to change. Historically, this approach has not worked well at all.

Even if they have good intentions, when someone uses a directing style and argues for change with a person who is ambivalent, it naturally brings out resistance and the person’s opposite arguments. No one appreciates when some else insists that they think they know what’s best for us, or they try to force us to change. We want to decide for ourselves and retain the right to make the choices that affect our own lives. Drawn from this insight, the strengths-based message of motivational interviewing is, “You have what you need, and together we will find it.” Evoking change from those who are seeking therapeutic interventions is far more effective than attempting to solve their problems as an outsider.

As a result of this conclusion, Miller and his colleague Stephen Rollnick authored the pioneer publication about motivational interviewing, titled Motivational Interviewing: Preparing People to Change Addictive Behavior (1991). Later, they wrote two additional editions: Motivational Interviewing: Preparing People for Change in 2002, and Motivational Interviewing: Helping People Change in 2013. The first edition explained how to talk with people about their alcohol and drug use in ways that respected their ability to decide for themselves about whether or not they wanted to change.

The authors described the core attitudes and beliefs (“The spirit of MI”), as well as the specific skills, strategies, and techniques of this approach. In the second and third editions, Miller and Rollnick further explained how motivational interviewing works, the research behind it, and how to improve and become truly proficient at practicing MI. It also described the implementation of this approach in other areas beyond addiction, such as nutrition, healthcare, mental health, criminal behaviors, and academics. The authors also expanded the intervention in the last edition to incorporate new ideas such as the four processes of MI conversations: engaging, focusing, evoking, and planning.

How Motivational Interviewing Works

Values

Motivational interviewing utilizes a wide variety of therapy techniques that have been proven effective for addressing addiction. Each aspect of the intervention is rooted in the “Spirit of MI,” or its core attitudes and beliefs. These four, interrelated elements are as follows:

  1. Partnership: Collaboration between the practitioner and the client, grounded in the point of view and experiences of the client.
  2. Acceptance: Acknowledging and prioritizing the absolute worth, dignity, and potential of each individual client.
  3. Compassion: Actively promoting the client’s welfare and giving priority to their needs. The practitioner makes a deliberate commitment to the client’s best interests, seeking to understand their experiences, values, and motivations without engaging in explicit or implicit judgment.  
  4. Evocation: The interviewer seeks to draw out the individual’s own thoughts and ideas (rather than imposing their opinion), as motivation and commitment to change is most powerful and durable when it comes from the client.

Goals

Motivational interviewing seeks to address ambivalence, or the state of having mixed feelings or contradictory ideas about something is a completely normal part of preparing for change and is a place where a person may remain stuck for a long time. Most of us can recognize when we need to make a change in our lives but lack the necessary motivation to get there. In regards to substance abuse, motivational interviewing contends that all individuals who are dealing with addiction are at least partially aware of the negative consequences of their behaviors. Each individual is also currently in varying stages of readiness when it comes to changing. Therefore, the goal of Mi is to facilitate the process of heightening the patient’s readiness to change by overcoming ambivalence or a fear of change, thereby increasing the client’s own motivation.

Process

The motivational interviewing model proposes that the process of change occurs in five stages. Firstly, in the Precontemplation stage, the client has little or no motivation to change their behavior, and may not see a need to change at all. Stage two is Contemplation, in which the individual may realize that their behavior is problematic for them, but they are ambivalent about making any changes. Next is Preparation, where the individual has made a commitment to a behavior change and accepted responsibility for doing so. The fourth stage takes place when the client moves into action and is actively involved in changing their behavior. Finally, the Maintenance stage occurs when the individual has developed some aspect of efficiency that has allowed them to change their behavior. As a general rule, individuals must have made changes that have been in place for a minimum of six months in order to qualify for this stage.

Motivational Interviewing Techniques and Strategies

To help clients move through these stages of change, practitioners of motivational interviewing utilize specific techniques, that are derivative of patient-centered counseling strategies. One acronym that is commonly used for the strategies of motivational interviewing is O.A.R.S.

O: Open-Ended Questions

  • Open questions gather broad descriptive information
  • Facilitate dialogue
  • Require more of a response than a simple yes or no
  • Often start with words like “how” or “what” or “tell me about” or “describe”
  • Usually go from general to specific
  • Convey that our agenda is about the consumer

A: Affirmations

  • Sincere acknowledgment and commentary on the client’s strengths and efforts
  • Will promotes and support self-efficacy
  • Acknowledges the difficulties the client has experienced
  • Validates the client’s experience and feelings
  • Emphasizes past experiences that demonstrate strength and success
  • Used to prevent discouragement

R: Reflections

  • Reflective listening begins with a way of thinking
  • It includes an interest in what the person has to say and a desire to truly understand how the person sees things
  • It is essentially hypothesis testing
  • What you think a person means may not be what they mean
  • Reflections can take the form of  repeating (simplest), rephrasing (substitutes synonyms), paraphrasing (major restatement), and/or reflection of feeling (deepest)

S: Summaries

  • Summaries reinforce what has been said, show that the practitioner has been listening carefully, and prepare the client to move on
  • Summaries can link together the client’s feelings of ambivalence and
  • Promote perception of discrepancy

In the midst of implementing the O.A.R.S. techniques, motivational interviewing focuses on four specific principles during the therapeutic process:

Expressing empathy

  1. Acceptance facilitates change
  2. Skillful reflective listening is fundamental to expressing empathy
  3. Ambivalence is normal
  1. Developing Discrepancy:
    1. This is accomplished by thorough goal and value exploration
    2. Interviewers help the client identify their own goals/values
    3. Identify small steps toward goals
    4. Focus on those that are feasible and healthy
    5. Explore the impact of substance abuse on reaching goals, as well as the consistency with personal values
    6. List pros and cons of using/quitting (referred to as a decisional balance worksheet or payoff matrix)
    7. Therapists should allow the client to make their own arguments for change
  2. Rolling with Resistance
    1. The interviewer avoids argumentation
    2. Acknowledges that human beings have a built-in desire to set things right (righting reflex)
    3. When the righting reflex collides with ambivalence, the client begins defending the status quo
    4. If a person argues on behalf of one position, they usually become more committed to it
    5. Resistance is a signal to change strategies
  3. Supporting Self-Efficacy
    1. Express optimism that change is possible
    2. Review examples of past successes to stop using
    3. Using reflective listening, summaries, affirmations
    4. Validating frustrations while remaining optimistic about the prospect of change

Motivational Enhancement Therapy and Substance Abuse

While Motivational Interviewing is the broad therapeutic approach, Motivational Enhancement Therapy (MET), is a specific type of motivational interviewing that involves structured feedback and future planning. MET is often combined with other forms of counseling or treatment for individuals in the midst of the recovery process. Without motivation for change, clients may be resistant to the lessons that rehab tries to teach. Motivated clients are more likely to engage in the recovery process and benefit from other therapies as well.

Individuals who are struggling with an addiction to drugs and alcohol may often find it difficult to stop using, due to the reinforcing effects of these habits. Fortunately, Motivational enhancement therapy is particularly beneficial because it can be used regardless of an individual’s commitment level, and also among individuals who have a strong ambivalence or even resistance to change.

Motivational enhancement therapy also serves to treat patients who have co-occurring mental health disorders, or a “Dual Diagnosis.” For example, the rate of a diagnosable level of PTSD among those receiving substance abuse treatment is 12%-34%, and the rates are even higher among women (30%-59%). As a result, those with PTSD and substance abuse have a more severe clinical profile than those with just one of those disorders. Not only are they seeking treatment for their substance abuse, but they are facing recovery while also dealing with the lingering effects of intense trauma. This is often true of individuals with other co-occurring mental health conditions as well. Up until recently, dually diagnosed patients were treated separately for their addiction and mental health problems, which was proving to be an incomplete form of care. Fortunately, dual diagnosis therapy now merges treatment for both mental disorders and substance abuse. Both of these can now be viewed as part of a continuum, rather than as two strictly different problems. While there is no single formula for treating dual diagnosis, motivational enhancement therapy can help treat addiction and a co-occurring disorder at the same time to prevent future relapse.

MET recognizes the unique difficulties that arise with a dual diagnosis and begins with an extensive assessment of the client’s history of substance use disorders and any possible co-occurring mental health issues. After the assessment, MET typically consists of two to four sessions. During session one, the therapist provides structured feedback based on the initial assessment of the client’s history. The practitioner will likely encourage the client to address and explore any concerns they may have about a particular issue they are experiencing, as well as identify a few short-term and long-term goals, as well as how they may be impacted by substance abuse. The goal of the second session is to enhance motivation and build commitment to change. If MET continues, the overall goal of sessions three and four is to reinforce motivations that were discussed in earlier sessions. Clients have an opportunity to review their progress and reaffirm commitment to change.

Overall, both Motivational Enhancement Therapy specifically and the Motivational Interviewing framework as a whole can help individuals make significant life changes to end substance abuse and complement other forms of treatment. It can also help turn around the negative impact of addiction on the family of the addict. While change is difficult for everyone, it is possible to gain the motivation needed to change your lifestyle and reach your goals.

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Motivational Therapy Techniques

Motivational Interviewing

Change is hard. Anytime a person is considering making a change, whether minor or major, it requires a committed decision to act. However, when the change is particularly life-altering, it is often difficult to find enough motivation to act. This is especially true when addressing a substance abuse disorder through any type of behavioral therapy. Freedom from addiction lies deeply beyond a mere desire to change, but the recognition of a need and the desire to change are the first steps in recovery. Ambivalence, or the state of having mixed feelings or contradictory ideas about something, is a completely normal part of preparing for change and is a place where a person may remain stuck for a long time. Furthermore, when a well-meaning individual (such as a family member, friend, or therapist) uses a directing style and argues for change with a person who is ambivalent, it naturally brings out resistance and the person’s opposing arguments. On the basis of these principles, Motivational Interviewing (MI) was developed. Simply put, motivational interviewing has been defined as follows (Miller & Rollnick, 2013):

What is motivational therapy interviewing? Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change.

The “conversation about change” that motivational interviewing presents can be brief or prolonged and can take place in a number of contexts, from individual therapy sessions to large groups. As the definition would imply, this type of client-centered therapy is more guiding than directing, and it focuses on the patient’s own strengths, abilities, and motivation toward positive change. Motivational interviewing utilizes a wide variety of therapy techniques within its methodology, which have been proven effective for addressing addiction. However, before exploring the specific techniques used in motivational interviewing, it is important to take a look at the underlying “spirit” of MI, it’s “mindset” and “heart-set” (Miller & Rollnick, 2013).

The Spirit of Motivational Interviewing

The creators of motivational interviewing identified four vital aspects of the spirit of MI, or the underlying perspective that anyone who wishes to practice this type of therapy should have. These four, interrelated elements are partnership, acceptance, compassion, and evocation. These aspects are truly the backbone and foundation of motivational interviewing as a whole.

Partnership

Motivational interviewing contends that the practitioner is not the expert; the client is. The interviewer acts more as a companion in the conversation, who typically does less than half of the talking. A common metaphor used to explain this principle is dancing versus wrestling. Wrestling is about a struggle for power and dominance, with a winner and a loser. It is the act of overpowering and stifling, and the individuals are on opposing teams.  On the other hand, when two individuals dance, partners move with each other and not against each other. One individual may take the lead and utilize skillful guidance, but equal collaboration is needed in order for the partners to truly flow with the music.

This is extremely important, as the goal of MI is for another person to change, and the interviewer cannot accomplish this alone. The client has an expertise of their own, that must be released in order for change to occur. In regards to substance abuse disorder, no one but the individual can force them to quit using. Only that person can truly make a commitment to take the steps necessary toward recovery. Overall, motivational interviewing is done “for” and “with” the client, and the interviewer is simply seeking to create a positive, interpersonal atmosphere that is conducive (but not coercive) to change.

Acceptance

Related to partnership, the element of acceptance is foundational to the success of MI. Approval does not necessarily mean acceptance, as an interviewer can fully accept a client where they are at without condoning destructive behaviors. According to theorist Carl Rogers (1980), this principle of acceptance is rooted in four interlocking components. Firstly, acceptance requires the acknowledgment and prioritization of the absolute worth, dignity, and potential of each human being. Every individual, regardless of their choices, is worthy of respect. In order for a beneficial interaction to take place, this basic trust and expectation must be incorporated throughout the conversation and overall therapeutic atmosphere. The second aspect of acceptance is accurate empathy. Empathy is not sympathy, pity, or personal identification with an individual’s struggles. The dictionary definition of empathy is:

The action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner; also: the capacity for this.

Furthermore, Alfred Adler, an Austrian medical doctor, psychotherapist, and founder of the school of individual psychology, beautifully described empathy in this way:

“Empathy is seeing with the eyes of another, listening with the ears of another and feeling with the heart of another.”

Overall, empathy is an ability to understand another’s frame of reference and conviction that it is worthwhile to do so. The opposite of empathy is the imposition of one’s own perspective, usually with the assumption that the other’s views are misguided or irrelevant. Empathy is at the core of motivational interviewing, and foundational to the act of acceptance.

Thirdly, acceptance involves autonomy support. Each client has a fundamental right to self-determination, and the capacity and freedom to make the choices that affect their own lives. The opposite of this is to try to make someone do something, through coercion, manipulation, or control. As previously mentioned, MI fights against this “wrestling” tendency of dominance, and seeks to bring clients into a collaborative “dance.”

Interviewers recognize that telling someone that they can’t do something only brings about resistance and pushback. Instead, acknowledging their freedom and self-control typically diminishes defensiveness and helps to facilitate a willingness to change. Finally, acceptance involves affirmation or the intentional recognition and communication of a client’s strengths. Overall, these four aspects describe acceptance beautifully. As an interviewer, “One honors each person’s absolute worth and potential as a human being, recognizes and supports the person’s irrevocable autonomy to choose his or her own way, seeks through accurate empathy to understand the other’s perspective, and affirms the person’s strengths and efforts” (Miller & Rollnick, 2013).

Compassion

The third element of the Spirit of MI is compassion. Compassion builds upon empathy but moves an individual to action. In a nutshell, compassion is a deliberate, intentional commitment to pursue the best interests and general welfare of another. Practitioners of motivational interviewing should be driven by this guiding principle.  

Evocation

Lastly, the spirit of motivational interviewing involved evocation. This strengths-based message of MI is, “You have what you need, and together we will find it.” Evoking change from those who are seeking therapeutic interventions is far more effective than attempting to solve their problems as an outsider.

Motivational Therapy Techniques

Helping individuals find motivation for recovery is easier said than done. Using the spirit of MI as a framework, therapists use a variety of techniques to elicit responses that change the ways that clients think about their ability to change. Overall, motivational interviewing techniques are based upon patient-centered counseling strategies. Specifically, these include open-ended questions, reflections, affirmations, and eliciting self-motivating statements (referred to as “change talk”).

Open-Ended Questions

Open-ended questions foster collaborative communication because the phrasing of the question prevents clients from answering with a single word or phrase, such as “yes” and “no” statements, or “good” and “fine”. Open-ended questions encourage the client to do most of the talking, while also helping therapist avoid making judgement statements or imposing their own advice and opinions.

Reflections

When clients are speaking during a motivational interviewing session, the counselor is engaging in reflective listening. Then, the interviewer selectively issues reflective statements to clarify what the client intended to say, and to demonstrate their understanding and empathy. The reflective responses also elicit responses from the client. Reflections can range from simple to complex, attempting to verbalize and understand a client’s motivation and emotions behind their actions and words. At the end of a session, therapists also summarize earlier conversations to identify and promote their understanding of any discrepancies.

Affirmations

Because motivational interviewing relies on the client’s own strengths, abilities, and efforts, affirmations are an essential part of the process. Affirmation is both general and specific within the framework of MI. The interviewer is intentional about recognizing and commenting on the client’s strengths, good intentions, abilities, efforts, and expressed desires to change. Affirmations serve to build trust and support a client’s belief in his or her own ability to change.

Eliciting Change Talk

Throughout each session, therapists try to elicit self-motivational statements, or “change talk” that help clients recognize that life can be better if they choose to change. These statements can be elicited through reflections, affirmations, and nonverbal cues. A client’s change talk is the key to moving past ambivalence toward a true commitment to change, which occurs in stages.

5 Stages of Motivational Interviewing

The motivational interviewing model proposes that the process of change occurs according to the following stages:

  1. Precontemplation: The client has little or no motivation to make a behavior change as they do not view themselves as having a problem.
  2. Contemplation: The individual may realize that their behavior is problematic for them, but they are ambivalent about making any changes.
  3. Preparation: The individual has made a commitment to changing their behavior and accepted responsibility for doing so.
  4. Action:  The person is actively involved in changing their behavior.
  5. Maintenance: the individual has developed some aspect and finds that therapists support self-efficiency that has allowed them to change their behavior. As a general rule, individuals must have made changes that have been in place for a minimum of six months in order to qualify for this stage.

Motivational Enhancement Therapy

Overall, motivational interviewing is a broad therapeutic approach to helping clients overcome ambivalence toward change. Motivational enhancement therapy (MET), on the other hand, is a specific type of motivational interviewing that involves structured feedback and future planning. MET is particularly beneficial because it can be used regardless of an individual’s commitment level. It has also been shown to be especially effective among individuals who have a strong ambivalence to change. For example, individuals who are struggling with an addiction to drugs and alcohol may often find it difficult to stop using, due to the reinforcing effects of these habits and it may be hard to know how to avoid alcohol withdrawal. Research has consistently demonstrated the efficacy of MET in increasing one’s readiness to change and to stop drug use, reducing the severity of substance use, and in lengthening periods of abstinence. Motivational enhancement therapy begins with an extensive assessment of the client’s history of substance abuse and co-occurring mental health issues. Treatment is typically brief, consisting of approximately four sessions.

In the first of the four MET sessions, the therapist will generally provide structured feedback based on the initial assessment. This feedback helps the clients to see how their unhealthy behavior compares to that of the wider population, and it can allow an individual to view any concerns in a new light. During the session, the therapist will likely encourage the person in therapy to address and explore any concerns they may have about a particular issue they are experiencing, including any observations that others have made about the person in therapy’s behavior. The therapist may also ask an individual about short-term and long-term goals and evaluate any ways that a problem behavior may interfere with those goals. Next, the goal of the second session is to enhance motivation and build commitment to change. Finally, sessions three and four serve to reinforce motivations that were discussed in earlier sessions. Clients have an opportunity to review their progress and reaffirm commitment to change.

Overall, motivational interviewing with substance abuse and addiction cases is an important complement to traditional therapies. Without motivation for change, clients may be resistant to the lessons that rehab programs try to teach. Motivated clients are more likely to engage in the recovery process and benefit from other therapies as well.

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Dialectical Behavior Therapy for Substance Use Disorder

Dialectical Behavior therapy is a form of psychotherapy that treats patients with chronic or severe mental health illness. This form of therapy is often used on patients with substance use disorder because many patients with severe mental illness tend to have co-occurring substance abuse problems. The term dialectical is used to reference the dual integration of the often opposing concepts of situational acceptance and change. The foundation of Dialectical Behavior therapy is the goal of creating the route through which patients can find acceptance of the inevitable concept of change.

This form of evidence-based therapy has proven successful for patients who have substance abuse issues that are coping mechanisms for other problems like severe depression or, very frequently, borderline personality disorder. While DBT was initially developed for individuals with deeper rooted mental health disorders, DBT is effective with working with individuals with sole substance use issues, as it helps in creating emotional regulation and distress tolerance tools. These skills are highly effective in helping manage cravings and highly stressful events.

Dialectical Behavior Therapy can help to address addictions to everything ranging from alcohol or cigarettes to illegal drugs like heroin. The DBT methods used for mental illnesses other than addiction are the same that are used in treating substance abuse disorders. The techniques of skill building, personalized therapy, and group work can be highly effective for substance abuse problems as well.

The primary model of Dialectical Behavior therapy is the Cognitive-Behavioral model, however, with Dialectical Behavioral Therapy, Eastern philosophical principles are used to enhance the Cognitive-Behavioral model. This model is founded on principles from behavioral and cognitive psychology about how thoughts and beliefs affect all other aspects of wellbeing. These guiding principles are the leading notions for creating Dialectical Behavior therapy strategies.

Cognitive and Behavior Theories

Dialectical behavior therapy is based upon the principles of both the cognitive and behavioral theories of psychology. The foundational concept of cognitive theory is one’s schema. The schema represents one’s internal conception of the world (i.e., one’s perspective) as well as a person’s thought and problem-solving pattern. The schema concept is important for therapy practices because it can reflect how a patient tends to react to change. If a person is not adaptable to change, they will adopt a situation in their mind to fit into their existing schema. On the other hand, if a person is more accepting of change, they will alter their schema and change their perspective based on the situation.

Behavior theory is based on the idea that behavior is what is observable about what a person does, thinks, and feels. It subscribes to the notion that humans tend to seek pleasure rather than pain, and that behavior is learned. Under this assumption, behavior is changeable, however, it can be a very difficult aspect of the therapy process. Using the behavior theory in therapy usually includes reinforcements and punishments for good or bad behavior. In addition, therapists are usually encouraged not to dwell on the deeper meanings behind behaviors, but rather to proceed based on the simplest explanation and focus energy more on changing what is presently occurring in the behavior pattern.

DBT Techniques for Substance Abuse

There are a lot of components that make up dialectical behavior therapy techniques, and many of them are found useful in cases of healing substance abuse problems. The primary method of DBT is one-on-one therapy with a patient’s individual therapist. However, other methods like group therapy or telephone consultations may also be utilized. The general focus of these therapy sessions is usually to improve the patient’s ability to change and the patient’s level of acceptance of their situation. In the case of substance use disorder, methods like group therapy can be especially impactful when it comes to building up a client’s internal sense of emotional strength.

Individual Therapy

Individual in-person therapy sessions are primarily focused on skill building based off the individual patient needs. Each patient will have different areas of need and different coping mechanisms for their poor behaviors relating to change. In other words, each person with a substance use disorder will have different triggers that cause them to react by abusing a substance. The skill building aspect usually centers around improving coping abilities and trying to improve a patient’s relationship with change in order to improve their behaviors. Individual therapy tends to be the first and most crucial step in the DBT process for many clients. Therapists usually have to work hard in the early stages to keep the patient engaged in therapy without dropping their commitment. With patients who substance abuse, therapists often have to design a backup plan to have in place (such as telephone numbers and addresses where they may be found) if the client becomes “lost” and stops engaging in therapy sessions.

Coaching

Another method that can be used within the Dialectical Behavior Therapy framework is coaching over the phone. The phone coaching can allow therapists to help patients work through everyday situations or in the case of an emergency situation. This form of coaching aims at strengthening a patient’s ability to handle situations that might be points of stress for them. For some patients who struggle with relapse or fear that they may relapse, having the phone access to a coach in emergency situations can be beneficial.

Group Therapy

Group therapy is another valuable addition to the dialectical behavioral therapy process. Usually focused on skills-training, the group therapy system focuses on four modules. The four categories include mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance. These areas may be better addressed in a group setting rather than solely relying on the individual therapy sessions. The group setting tends to facilitate stronger skill building.

Interventions

Dialectical Behavior interventions involving someone with substance abuse happen in five stages. The first stage of the intervention is about assuring that the client is committed to healing and working through their substance use problem. The next stage focuses on shifting the patient from feeling out of control to having a grasp on their behavior. Next, traumatic memories and past abuses are confronted in order to heal from negative experiences. In the fourth stage, the client works on developing self respect and autonomy after being in the period of more intensive therapy. Finally, the last stage is all about the client achieving a sense of a fulfilled and happy life.

Behavioral Targets for Substance Abusers

The goals of using DBT for substance abuse problems are focused on an array of behavioral changes. Primarily, the therapy aims to decrease the abuse of all substances that are a problem with the client. In addition, it is important to alleviate discomfort associated with abstinence (i.e. withdrawal symptoms) and diminish the cravings for the substance. Another aspect of the therapy is to eliminate situations and people that may lead to relapse. For example, ending relationships with people associated with the drugs like dealers or bad influencers. It is also important to emphasize community reinforcement of good behavior and a substance-free lifestyle. This is done by fostering new positive relationships and becoming involved in healthier communal activities.

Dialectical Behavior Therapy and Abstinence

Promoting abstinence from substances is a very significant component of DBT when it comes to treating substance abusers. Like many other aspects of DBT, this focuses on coping well with change. Many therapists using DBT have the patient choose small intervals to use abstinence so that the goal feels achievable. They may start the client off by trying one day or even just one hour, without using the substance. This allows the patient to slowly become acclimated to the idea of not using the substance without overstretching their comfort zone all at once. Eventually, the goal is to continue the abstinence pledge indefinitely, when the patient is strong enough to make that promise to themselves. However, if a patient does relapse, DBT therapists like to focus on helping them use the incident to learn what their behavioral triggers might be and to not see the incident as a permanent failure.  

Treating Self Harm Behaviors

Many clients with substance addiction or abuse also deal with suicidal or self-injuring tendencies as well. A crucial part of the DBT process is addressing these behaviors and tendencies in order to optimize the patient’s progress. Many times, the patient has to address these issues first or in direct conjunction with the substance abuse problem because they must first gain respect for their body. The patient needs to first be willing to stop self-harming on all levels, and they need to accept that substance use is another form of this self-harming behavior. Acceptance of the need for change is a critical element of Dialectical Behavior Therapy.

Healing with APEX Recovery

At APEX Recovery, there is a wide range of therapists and trained professionals that are equipped to design the right healing path for each individual patient with substance use disorder. Because Dialectical Behavior Therapy can be implemented in so many different ways, APEX caregivers are prepared to adapt and tailor therapy programs based on each client’s needs. With APEX Recovery therapy programs, there is hope for a brighter future and programs that make recovery a very achievable goal.

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Dialectical Behavior Therapy Techniques

DBT and the Recovering Individual

We live in a society where females are labeled as “too sensitive” for showing emotion and males are branded as “weak” and taught that “being a man” means you don’t show emotions. Popular television shows and movies further perpetuate these ideals by turning crying males into a laughing matter and emotional females into an annoyance.

So what kind of message does this send to people? The message is that emotions and emotional experiences are bad.  People are left feeling confused and uneducated on how to express and cope with difficult emotions such as anger, pain, and sadness. This can lead to people experiencing overwhelming feelings of shame, embarrassment, and debilitation by their emotions. Subsequently, people resort to self-harm behavior or tend to avoid their feelings, which only intensifies them and surfaces as passive aggression. People also turn to unhealthy coping techniques such as drugs and alcohol to numb and self-medicate. Unfortunately, with self-medication, the vicious cycle begins, as the underlying problem is still present because it is not dealt with in a healthy, effective way; the emotions become too difficult to manage, and the substance use, which was originally intended to be a numbing agent, quickly develops into a lifelong addiction. The result is that substance use ends up being a symptom of unaddressed and underlying emotional wounds.

At Apex Recovery, our trained clinical staff utilize Dialectical Behavioral Therapy (DBT), a modality developed by Marsha Linehan. DBT, a behavioral therapy supported by evidence-based programs for the treatment of substance use, works in providing insight into emotions and educating people on how to live with their emotions to allow for more manageable, functional lives.

DBT Skills

Throughout a lifetime, everyone experiences difficult emotions. A mother experiences anxiety about her son driving for the first time; a father feels sadness about his daughter going off to college; a girlfriend feels anger upon finding out her boyfriend cheated, and a young teen feels pain and grief upon the death of his grandmother. Emotions are inevitable, and while they may often feel very painful or uncomfortable, learning to express and cope with them effectively is crucial.

As outlined in the Dialectical Behavioral Therapy Skills Workbook, DBT is comprised of four important coping skills: distress tolerance, mindfulness, emotion regulation, and interpersonal effectiveness. When used effectively, these skills can prevent emotional paralysis and can promote the likelihood of individuals becoming functional members of society. It is important to note that these skills cannot just be read and forgotten; they have to be applied behaviorally. Let’s take a deeper look into each one of these skills to give you a preview of the techniques the therapists at Apex utilize to teach and support our clients.

Distress Tolerance

Emotions can affect people differently. Many emotions will be minor while others will feel more intense and overwhelming. Some emotions are easier to predict, and others might feel out of the blue. As explained earlier, a majority of people handle their emotions in unhelpful and unhealthy ways. Distress tolerance skills are the healthier alternative and prevent further pain and suffering. They are organized into categories of distraction and relaxation.

Distraction

DBT identifies distraction techniques as a means of temporarily ceasing the strong emotion and creating time and space for the individual to get to a calmer place where they can make more rational decisions. Distraction is not about avoiding the situation long-term, but instead should be thought of as pushing the distressing situation aside and leaving it for awhile until you are able to resolve the problem or fully process the emotional experience.  Perhaps Scarlett O’Hara in the classic movie Gone With The Wind said it best when she stated, “I won’t think about that today, I’ll think about that tomorrow.” DBT introduces a multitude of different distraction techniques and an abundance of skills to try.

For example, a young male who struggles with meth and heroin addiction also happens to be severely reactive to stress and struggles with the high demands of family, work, and school. Prior to entering DBT treatment at Apex Recovery, he likely turns to drugs and alcohol to avoid his intense anxiety. What this young male does not realize, is that his temporary solution isn’t much of a solution at all. Instead, it is an avoidance strategy that only prolongs and adds to the original problem. Through working with his individual therapist and being introduced to DBT, this young male can be apprised of distraction techniques. Instead of resorting to substance use when he feels anxious again, this man decides to go for a walk, watch the sunset, and call a friend, which are all healthy alternatives to drug use. After engaging in these activities, he feels less anxious and more cognitively alert. With the decrease in his anxiety, he is able to come up with the idea to create a to-do list to organize his priorities. Instead of avoiding the problem and participating in self-harm behaviors,  suicidal behaviors, and self-injurious behaviors to his body, he decreased his anxiety and cleared his mind to the point of devising an effective plan to address the original problem that led to his anxiety in the first place.

Self-soothing or Relaxation Techniques

Along with distraction techniques, DBT describes the importance of self-soothing as a form of distress tolerance. Self-soothing can be done with each of the senses and helps to relax the body and mind. When you think of self-soothing, picture an afternoon at a luxury spa. Dim lights soothe the eyes while scented candles and oils target your sense of smell on a backdrop of calming classical music.  Warm towels and a relaxing massage soothe your body while cucumber infused water is pleasant tasting. It is impossible to leave the spa upset when all of your senses are soothed. This same concept can be applied on a daily basis and can help manage overwhelming stressors to prevent substance abuse.

For example, a young female who struggles with severe alcohol abuse uses alcohol to avoid strong feelings of sadness and anger following an argument she had with a colleague. Her regret and guilt lead to her drinking a bottle of wine late into the night. She wakes up the next morning with an intense headache and body pains from the alcohol. She struggles to make it on time to work and finds herself avoiding eye contact with her colleague. She has now created more problems as she feels physically ill, and the conflict with her colleague is unresolved. However, following her discharge from Apex Recovery, she has learned new ways of handling such interactions and feelings of sadness, anger, and guilt. Instead of reaching for a bottle of wine when she has a conflict with a colleague, she now knows she can soothe herself by lighting candles, painting a picture, and playing calming music. She does this long enough to the point of devising a plan to get a good night’s rest, get to work early, and approach her colleague to apologize for her tone and offer feedback on how to make the project more effective. She feels physically rejuvenated and better about her relationship with her colleagues.

Mindfulness

Mindfulness is another crucial skill of DBT. Mindfulness is a type of meditation that brings awareness to the present moment without judgment. Mindfulness has been around for many years and is known to decrease anxiety and depression while increasing relaxation levels. Mindfulness skills are important because they help people to focus on the present moment and help people to become better oriented to their thoughts and experiences. Some people might find mindfulness challenging as it requires time and concentration. Fortunately for the beginner, there are several different mindfulness exercises introduced by DBT.

Too often, people can fixate on the past or perseverate on the future, both of which are outside of one’s control and can lead to overwhelming emotions. The focus on the past events often leads to depressive emotions, while focusing on the future contributes to fear and anxiety. With the multitude of responsibilities that work, school, families, and relationships can create, people can get lost in the fast-paced demands of life and take time, loved ones, and their surrounding environment for granted. The beauty of mindfulness is its ability to slow down a person’s thought process by orienting them to the one thing they do have control over, the present moment.  Mindfulness is done through increasing awareness and engaging the five senses in the present moment.

To put things into perspective, we’ll discuss a young female who struggled with severe alcohol and marijuana use. She has experienced high anxiety since she was 14, as she grew up in a big family with five older siblings who constantly fought and competed with one another and two parents who were rarely seen in the same room together. Being the youngest, she felt pressured to excel in all areas of her life to establish her sense of self-worth and her role in the family. To her, failure was not an option. She spent countless hours studying and applying to every after-school program that was offered with a desire to create a different life experience than the one that she knew. She quickly became overworked and overwhelmed by constant due dates and practices. Due to consistent stress and zero free-time, she failed to learn healthy ways to manage stress and unfortunately resorted to substance use to cope. With a toxic home environment and a poor support system, she felt she had no one to turn to for support and her substance use quickly spiraled out of control. Her anxiety got worse, her grades dropped, and her physical and mental health began to suffer.

After a successful stay at Apex Recovery, she left having been introduced to a DBT program and had several different mindfulness techniques to try. A week after leaving treatment, she started to feel a panic attack come on as she looked at her schedule and stressed over her responsibilities at work and school. Her thoughts were racing; her heart was pounding, and she began to sweat and feel an enormous amount of worry. She had a fleeting thought to have a drink and smoke marijuana to calm her nerves, but then she decided to implement her mindfulness skills instead, as she did not want to jeopardize her sobriety. She closed the door of her bedroom, closed her eyes, did deep breathing for several minutes, and focused on her breath as well as the sounds around her. She noticed soft music playing in the distance that she had not noticed before, and she realized she could hear the laughter of children from the yard next door, which was comforting to her. As she continued to focus on her breathing, she gently reminded herself that she was safe. She quickly noticed that her heart rate slowed down, and she felt an overwhelming sense of calm sweep over her body. When she felt more at peace, she took another look at her schedule and realized there were several opportunities to move things around and reschedule appointments to later times. With a fresh set of eyes and a much calmer demeanor, she realized she did not see her schedule as clearly as she did after she engaged in her mindfulness techniques.

Emotion Regulation

Along with distress tolerance and mindfulness, emotion regulation is another important DBT skill. Emotions are the body’s responses to different events and can vary in intensity. Emotions can provide valuable information, but if they are not handled effectively, emotions can feel overwhelming and unmanageable. As humans, we experience both primary and secondary emotions. Primary emotions are initial reactions such as sadness or happiness while secondary emotions are the responses to those initial reactions, such as anger or guilt. Since emotions can vary in intensity and have a strong impact on the mind and body, it is important to bring awareness to them, to be in control of them, and increase the likelihood of making healthy decisions. As seen too often, when people are highly emotional, they lose the ability to think clearly and make mistakes they might not have made had they been more grounded and level-headed.

DBT introduces nine emotion regulation skills to help people better manage their emotions. These skills include recognizing the emotion, increasing positive emotions, and problem-solving to name a few. DBT skills based questions and exercises to help the individual take a deeper look into the origin and effects of their emotions. This is helpful in aiding someone who has very little knowledge about their emotions and accompanying behaviors.

To understand emotion regulation skills, imagine a young male diagnosed with Borderline Personality Disorder who struggles with addiction to alcohol. He is challenged to understand his emotions and notices that he has anger outbursts and crying spells frequently and gets frustrated because he does not understand the emotions he is experiencing. He feels embarrassed and ashamed of his emotional ups and downs and resorts to heavy drinking in an attempt to suppress his feelings and avoid the frustration. However, his drinking has gotten so bad that it’s started to affect his health and exacerbate his mood fluctuations, yet he notices that he cannot stop drinking. He enters treatment at Apex Recovery and gets exposure to Dialectical Behavior Therapy,  DBT skills training, and coping skills therapy. He feels grateful and relieved when he gains insight into his emotions, their origin, and ways to manage them. With the help of a therapist, he begins to understand how his childhood and life experiences have shaped his outlook and learn to accept rather than judge his emotions, which decreases his shame and frustration. He leaves treatment with problem-solving skills so that the next time he experiences strong waves of anger or sadness (signs of the personality disorder), he employs his newly learned techniques instead of further damaging his body with toxic chemicals.

Interpersonal Effectiveness

The fourth skill of DBT is interpersonal effectiveness. Interpersonal effectiveness skills are a combination of social skills, communication skills, and negotiation skills. As a species, we are social beings, and we get involved in several different types of relationships, whether they are familial, amicable, working, or romantic. Relationships play a major role in our lives and can have a significant impact on our mood. As such, effective communication can help promote healthy, positive emotions, so it’s important to be aware of what those interpersonal effectiveness skills are.

Similar to the other DBT skills, interpersonal effectiveness is learned through engagement with helpful questions, exercises, and logs to orient the individual to their unhelpful patterns and teach more effective ways of communicating. These skill sets are aimed at bringing awareness to important relational topics such as mindful attention, passive and aggressive behavior, and obstacles to interpersonal effectiveness. These skills help develop assertiveness, boundaries in relationships, and self-advocacy.

For example, a male in his mid-forties comes to treatment with a bad temper and a dependence on cocaine and alcohol. Prior to treatment, he fought with his wife frequently following long hours at the office. His kids stopped talking to him, and he noticed that his relationship with his friends began to suffer as well. Feeling the pressure to “be a man,” he stuffed his frustrations instead of naming them and turned to alcohol and cocaine to avoid his feelings of confusion, sadness, and anger. While in treatment and individual therapy, this man was highly motivated to address the underlying problem and learned ways to better communicate. He gained insight that his anger was a secondary response to fears and stress from work. He learned to identify his emotions and communicate them in a way that did not involve explosive anger, which ultimately improved the relationship with his wife. He learned how to actively listen and ask questions that would prompt a genuine response. He also learned how to advocate for himself by setting boundaries, which he planned to do at work to cut down on the amount of stress he was experiencing. He left treatment feeling confident in his abilities and enrolled in couples therapy with his wife. Their communication improved significantly, as has their level of happiness and intimacy.

As described, emotions are the body’s natural response to outside experiences and events. While some emotions can be pleasurable, others will feel painful and difficult. DBT therapy is an evidence-based therapeutic approach that helps educate people on their emotions and provide helpful and safe coping techniques so that people are not resorting to self-destructive behaviors and harmful coping strategies such as self-mutilation, eating disorders, and substance abuse. At Apex Recovery, with the help of our trained clinical staff, you will learn how to implement Dialectical Behavioral Therapy techniques as you embark on the journey with a DBT therapist. We believe that successful treatment is aimed towards not only stopping the use of drugs and alcohol but also through addressing the underlying emotional wounds our clients may have been too afraid or unaware of to address. Call Apex Recovery today.

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PTSD and Substance Abuse

What is PTSD?

The American Psychiatric Association defines Posttraumatic Stress Disorder (PTSD) as “a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, rape, or other violent personal assault.” Other traumatic events can include mental illness, childhood trauma, child abuse, sexual assault, sexual abuse. Trauma experienced may be acute (a single occurrence), chronic (repeated and prolonged trauma such as domestic violence or abuse), or complex (repetitive, prolonged trauma involving ongoing abuse or abandonment within an interpersonal relationship with an uneven power dynamic). It is important that individuals who have experienced or been exposed to some type of traumatic event and/or substance abuse receive treatment for seeking safety therapy in order to increase the safety for themselves and for the people around them.

Someone diagnosed with PTSD continues to experience intense and disturbing thoughts and feelings related to the experience after it has ended. Someone may experience vivid flashbacks or nightmares related to the event and may experience a bodily response more closely linked to extreme stress or fear despite presently being out of danger. An individual may also experience feelings of anxiety, sadness, fear, depression, or disconnection from others.  Many times, when a person experiences something traumatic, the experience is locked away in the brain with strong emotional responses tied to the memories. Despite being safe in the current moment, the emotional response to a trigger or memory is so strong that the body responds as if they are still in immediate danger.

The PTSD symptoms someone may experience are pervasive and may make it difficult for a person to live fully and participate fully in their activities of daily life. Work, relationships, hobbies, and the daily tasks of life feel overwhelming and impossible to navigate. Typically, when someone experiences symptoms of PTSD, they also find a way to tolerate those symptoms, to make it through their day or night.

Each of us finds ways to cope with unpleasant feelings of emotions. Many people use safe coping skills like talking with a friend or therapist, taking a walk, engaging in a relaxing experience or using soothing self-talk. Many people also use unsafe coping skills when experiencing emotional discomfort. They may distance themselves from others, use alcohol or substances to numb their pain, engage in cutting behaviors, or use degrading and harsh self-talk. Our brain is always trying to find a way to cope or make sense of life. We are hardwired for survival, so when our emotion center takes the reigns and sends us into panic, fear, stress, or survival mode as a result of one or more traumatic events from the past, our brains will work overtime to keep us afloat. It is important to remember that regardless of whether our coping is safe or unsafe, we are engaged in a behavior in which we believe will make the pain or discomfort stop.

Typically, when we find a behavior that “fixes” the problem, we will continue to use it until it no longer works. We are creatures of habit. For some people, the behavior that brings the most reprieve from the discomfort is alcohol or substance use. Some research shows that at least 50% of individuals in inpatient treatment for substance abuse also suffer from PTSD (see Souza & Spades). While substance use may have origins elsewhere for some, for many, a history of trauma is involved in the desire to feel different. By their very nature, use of alcohol and other substances typically induces an alternate feeling or experience in the body.

SAMSA estimates that in 2016, 20.1 million people aged 12 or older had a substance use disorder related to use of alcohol or illicit drug abuse. While their findings do not specify how many of those individuals were also suffering from PTSD, it is important to recognize the high rates of substance abuse we’re seeing in the United States at this time and to know that this is not an issue limited to a select group of individuals. Research shows that in the veteran population, veterans stand as a high percentage of the individuals with a substance use disorder who also suffer from PTSD. The VA sites that more than 2 of 10 veterans with PTSD also have a substance use disorder and almost 1 of every 3 veterans seeking treatment for a substance abuse disorder also has PTSD.

Substance abuse does not discriminate on the basis of race, socioeconomic status, gender, or religious beliefs. The problem with substance dependence or alcohol abuse is that it becomes a common coping skill used to deal with anxiety, fear, loneliness, depression, sadness, and for many, is a behavioral reaction to just about any emotion one might experience.

Given the high rates of alcohol misuse and substance abuse, and the overwhelming symptoms experienced emotionally and physiologically, it is understandable that someone diagnosed with PTSD who is experiencing the symptoms or reliving the trauma might use a substance or alcohol to cope.

Treatment Modalities Commonly Used With Substance Abuse

Generally speaking, substance abuse treatment typically involves increasing internal motivation for change and then helping individuals increase coping skills to deal with triggers that previously led them to the substance abuse. It also involves a look at underlying issues that might be causing problematic symptoms someone might try to numb with the use of alcohol or a substance.

Motivational Interviewing (MI) is a therapeutic model that helps individuals resolve ambivalent feelings and insecurities to find the internal motivation they need to make changes in their behavior. It is a highly empathetic, short-term model that respects the challenges involved in making changes and helps individuals move through the emotional process of change required to increase motivation.

Cognitive-behavioral therapy (CBT) is a short-term, goal-focused modality with the goal of changing thought patterns and behaviors that are behind an individual’s challenges, thus changing the way an individual feels as a result.

Acceptance and Commitment Therapy (ACT) uses mindfulness and behavioral activation to increase psychological flexibility and the ability to engage in values-based, positive behaviors while experiencing difficult thoughts, emotions, or sensations.

Dialectical behavioral therapy (DBT) is a treatment modality that emphasizes balancing behavioral change, problem-solving, and emotional regulation with validation, mindfulness, and acceptance.

Treatment Modalities Commonly Used for People With PTSD

Treatment for post-traumatic stress disorder and trauma typically involves some form of processing a trauma while also increasing coping skills to tolerate the strong emotion that comes along with the memory of it. It may involve desensitizing a memory or restructuring thoughts related to the trauma to be adaptive and supportive. This can be accomplished by various types of trauma focused therapy.

Exposure therapy involves the client coming into some form of contact with the traumatic memory. Exposure to the memory may be done in imaginal (remembering the event), interoceptive (remembering the emotion or physiological reactions during the event), or in vivo (returning back to a place or having direct contact with an object or place related to trauma). Each exposure is intended to decrease the intense emotional and physiological arousal state associated with the memory and increase the individual’s ability to desensitize their brain and body to triggering stimuli.

Cognitive therapy works by modifying negative assessments and memories of trauma with the intent to alter the behavior and/or thought patterns that have been problematic in the individual’s activities of daily living. Cognitive therapy uses some exposure to the trauma with the intent of identifying strong emotional responses and the restructuring of thoughts in the moment.

Relaxation training is used to manage physiological reactions which manifest as a result of ongoing exposure to the traumatic memory. Using techniques like mindfulness, grounding, yoga, and deep breathing, and relaxation training increases an individual’s ability to tolerate and be successful in more traditional therapies.

Eye Movement Desensitization and Reprocessing (EMDR) targets the unprocessed memories that connect negative emotions, sensations, and beliefs. By activating the brain’s information processing system, old memories can be digested with the idea that what is useful can be learned and what is no longer useful can be discarded. A clinician uses bilateral stimulation via eye movements, tapping, or sounds to activate both sides of the brain while processing the trauma.

Treatment for PTSD and Substance Abuse

There is good news. It is possible to heal from PTSD and to maintain a recovery free from substances if you are ready. Many people have braved the road to recovery for both PTSD and substance abuse and used different treatment options for addressing both.

Many practitioners recommend that an individual begins managing the substance use prior to beginning processing trauma, or to handle them both simultaneously. This may involve attending 12-Step meetings, admitting to a treatment facility, or attending an outpatient treatment program. The primary goal of obtaining sobriety initially or while also working to process trauma, is to increase coping skills. Therefore, when an individual begins to work through the trauma, they will have some coping skills other than the substance use to manage the overwhelming thoughts or emotions associated with the trauma that will likely emerge during the process. Without the addition of new, safe coping strategies, an individual is likely to return to problematic substance use to manage symptoms of trauma in the same way they had managed them initially.

Some modalities like Seeking Safety, target individuals who have a history of both trauma and substance abuse and help them when building and seeking safety coping skills that will help the healing process of both PTSD and substance abuse, simultaneously. In general, it is recommended that an individual has support as they begin to work towards sobriety and processes trauma. Support can entail a formal inpatient or outpatient treatment program, a therapeutic relationship, support groups, or sponsors/mentors. Though the processing and recovery are independent, increased support is encouraged through multiple channels when possible. Individuals might couple a treatment program with individual therapy or twelve-step programs with an individual therapist. Someone might join a PTSD support group for group treatment and admit to a treatment program. As with any major change one might make, individuals are encouraged to increase their safe support system in as many ways as are possible.

You Are Not Alone

Many times, individuals who are experiencing symptoms of PTSD and addiction to substance use feel very alone and isolated from others. The weight of it may feel unbearable, and the thought of working through it all may feel impossible. Know that you are not alone and you are not meant to bear this alone. You are not the first ,and you are not the last. There is hope and help for you. It is a brave thing to take the first step towards healing when you are unsure where the path will lead you. The path each person takes is different, and no two journeys are ever the same – there is room for everyone on this road to wellness. When we are ready and able to take that first step, we will learn that there are others walking this journey with us. When we look closer, we will notice that not only are they on their own journey towards wellness, but they are ALL cheering us on, every step of the way.

You had no control of the trauma that occurred in your life, but you have the ability to take control of the trauma you experienced, now. The first step might be telling a friend or loved one that you think you need help. It may be calling the VA for referrals. Your first step might be checking yourself into rehab, and at APEX Recovery, our trained clinical staff are able to help you not just achieve sobriety, but also overcome underlying traumatic experiences and issues. Whatever that first step is, take it. People all over the world will tell you that hope and healing is possible if you’re ready to engage and do the work. You are worth any amount of work it will take to achieve wellness. At APEX Recovery, we are ready to hear your story and help you write the rest of it in its best form. By contacting us today, you can invite our team to be a part of your healing journey.

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Borderline Personality Disorder Dialectical Behavior Therapy

If you or someone you love one has recently been diagnosed with borderline personality disorder and/or a substance use disorder, it is common to feel uneasy, isolated, or overwhelmed. One of the best things that anyone can do after a recent diagnosis is to learn the facts about the mental health condition, as well as the available treatment options. Both borderline personality disorder and substance abuse can be treated through dialectical behavior therapy. Before beginning treatment, here are some things you need to know:

Borderline Personality Disorder

Prevalence

It is estimated that 1.6% of the adult U.S. population has Borderline Personality Disorder, a statistic that is representative of over four million people. However, that number may be as high as 5.9%. This may be due to the fact that over 40% of people with Borderline Personality Disorder have been previously misdiagnosed with more well-known or easily treated disorders, such as bipolar disorder or major depressive disorder. It’s also common for individuals to have other diagnoses in conjunction with BPD (such as substance abuse disorder). For example, a striking 20% of those diagnosed with Borderline Personality Disorder have been found to have a type of bipolar disorder, making treatment more complicated than treating one disease alone.

Additionally, 75% of people that are diagnosed with Borderline Personality Disorder are women. However, it has been hypothesized that men may be more equally affected by BPD, but are commonly misdiagnosed with depression or post-traumatic stress disorder (PTSD). These numbers may also be a reflection of the fact that women are typically more likely than men to seek treatment for personality disorders.

Definition

According to the National Institution of Mental Health, Borderline Personality Disorder (BPD) can be defined as, “A mental illness marked by an ongoing pattern of varying moods, self-image, and behavior. These symptoms often result in impulsive actions and problems in relationships. People with BPD may experience intense episodes of anger, depression, and anxiety that can last from a few hours to days.” Overall, Borderline Personality Disorder is a condition that is characterized by difficulties in regulating emotion. Individuals may feel emotions (such as happiness, sadness, anger, regret) intensely and for extended periods of time. Additionally, it is very difficult for them to return to a stable baseline after an emotionally triggering event.

Symptoms

According to the Diagnostic and Statistical Manual (DSM-IV) diagnostic framework, the following are common signs and symptoms of Borderline Personality Disorder:

  • Separation anxiety
  • An intense and chronic fear of rejection. This may be evidenced by efforts to avoid real or imagined abandonment, such as rapidly initiating intimate relationships (either physically or emotionally). On the other hand, an individual may cut off communication or interactions with someone due to the anticipation or fear of being abandoned.
  • Interpersonal/relationship difficulties. People with Borderline Personality Disorder may long for intimacy with others, but struggle with navigating the emotions necessary to maintain healthy relationships. Individuals may frequently experience hostile, angry, or resentful feelings toward those they love, often without explanation. They may also become disproportionately angry in response to minor issues, or even alternate between idolizing and rejecting the people they love the most.
  • Identity struggles. Persons with BPD may frequently appear to modify or alter aspects of their identity, or have no sense of self at all. The frequent modifications often are a result of a desire to please others, in order to find love and acceptance. They may also have a low self-worth or a distorted self-image.
  • Impulsive behavior
  • Risky behavior
  • Self-Harm
  • Suicidal ideation or suicidal behaviors
  • Emotional instability, characterized by intense mood swings or extreme highs and lows. Many people with Borderline Personality Disorder have a “black and white” worldview, with viewpoints that frequently reflect people, places, things, and ideas as either “all good” or “all bad.”
  • Chronic and persistent feelings of boredom or emptiness. These feelings may relate to a person’s fear of abandonment or the lack of a clearly defined sense of self.
  • Inappropriate, intense or uncontrollable anger. This is typically followed by shame and guilt.
  • Dissociative feelings. This involves disconnecting from your thoughts or sense of identity, similar to an “out of body” experience, as well as stress-related paranoia. This may also lead to brief psychotic episodes.

Causes

As with any mental health disorder, it is often impossible to uncover the direct cause of a diagnosis. However, Borderline Personality Disorder is characterized by a few, specific risk factors.

Firstly, environmental, cultural, and social factors play a role. Many people with BPD have reported report traumatic life events, particularly during childhood. Some estimates suggest as many as 75% of those with Borderline Personality Disorder have a history of sexual abuse. Other examples of childhood trauma include: physical abuse, emotional abuse, neglect, witnessing violence in the home, abandonment, or poverty. Others have reported traumatic events throughout their lifespan and into adulthood, such as chronic disease, exposure to unstable relationships, hostile conflicts, violence, and other adverse experiences.

Secondly, family history is a viable risk factor in the development of Borderline Personality Disorder. Individuals who have a close family member (such as a parent or sibling) with the disorder may be at higher risk of developing it themselves. There is also some evidence that BPD is an intergenerational disease, and parents can pass down the condition to their children through environmental exposure, rather than genetics. For example, a caregiver’s instability may model harmful coping mechanisms to their children.

Thirdly, some symptoms of Borderline Personality Disorder may be rooted in neurology. Structural and functional changes in the brain, particularly the areas that control impulses and emotional regulation, may contribute to the development and severity of BPD. However, it is difficult to determine whether these neurological changes are risk factors for the disorder, or rather are caused by the disorder themselves.

Consequences

Because individuals with Borderline Personality Disorder have difficulties regulating their emotions, this can lead to a variety of harmful consequences. These may include but are not limited to, impulsivity, poor self-image, tenuous or tumultuous relationships, intense responses to everyday stressors, and even dangerous behaviors such as self-harm or suicidal ideations. In fact, approximately 70% of people with Borderline Personality Disorder attempt suicide at least once. Furthermore, between 8 and 10 percent of those individuals will complete suicide. Overall, the suicide rate among individuals with BPD is over 50 times higher than the general population as a whole.

The consequences of Borderline Personality Disorder have to the potential to become much more severe when individuals do not seek adequate treatment after receiving a diagnosis. However, among those receiving seek appropriate treatment, the prognosis for BPD is very good. In fact, almost half of those who are diagnosed with Borderline Personality Disorder will not meet the criteria for a diagnosis just two years later. Additionally, after ten years, a striking 88 percent of individuals who were once diagnosed with BPD no longer meet criteria for a diagnosis.

Dialectical Behavior Therapy and Borderline Personality Disorder

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that is widely used to treat Borderline Personality Disorder. DBT is a modification of Cognitive Behavioral Therapy, combined from the basic principles of both behavioral and cognitive psychology. These theories contend that our thoughts and beliefs influence our all of our behaviors, emotions, and physiology. Dialectical Behavior Therapy is based on the perspective that some individuals develop pervasive problems in social functioning due to a lack of interpersonal and self-regulation skills. As a result, their potential to develop appropriate, adaptive behaviors is inhibited by both personal and environmental factors.

Using a variety of tools and assessments, Dialectical behavior therapy first targets a client’s immediate, life-threatening behaviors. The intervention then moves on to address problem behaviors that may intervene with the client’s ability to participate in therapy, as well as their overall quality of life. The end goal of DBT is to help people learn and use new skills and strategies to develop a “life worth living.”

Dialectical Behavior Therapy utilizes Individual Therapy, a Skills-Training Group, Coaching, and Consultation, in order to achieve the treatment targets through the various stages of intervention. After the client has expressed a commitment to therapy, they are able to begin with the first stage. The goal of Stage 1 is to achieve behavioral control. The goal of Stage 2 is for the client to learn skills that enable them to experience and process a full range of emotions, as well as reduce post-traumatic stress symptoms. Both the third and fourth stages of Dialectical behavior therapy focus on the development of self-respect and autonomy, as well as issues surrounding an individual’s own meaning and purpose. During Stage 3, the client is challenged to set life goals, and work toward living a life of healthy emotional regulation, being able to experience appropriate levels of happiness and unhappiness. Finally, in Stage 4, the overall goal of treatment is for the client to move from a sense of incompleteness or emptiness towards a spiritually fulfilling life.

Over 30 years of research have demonstrated the effectiveness of Dialectical Behavior Therapy (DBT) for people diagnosed with borderline personality disorder (BPD). DBT has been evaluated and found to be effective among individuals from diverse backgrounds in terms of age, gender, sexual orientation, and race/ethnicity, while being implemented within a wide variety of practice settings around the world. For example, Dr. Marsha Linehan (the founder of DBT) and her colleagues found that DBT resulted in significant improvements for chronically suicidal and self-injuring women who had been diagnosed with Borderline Personality Disorder (Linehan et al., 1991).

Borderline Personality Disorder and Substance Use Disorder

According to a 2014 National Survey on Drug Use and Health, 7.9 million people in the U.S. experience both a mental disorder and substance use disorder simultaneously. Individuals who are experiencing a mental health condition such as Borderline Personality Disorder may turn to alcohol or other drugs as a form of self-medication, in order to mask the mental health symptoms they are experiencing. In actuality, alcohol and drug use worsens the symptoms of mental illnesses.

As a result, those with a mental disorder as well as a substance use disorder have a more severe clinical profile than those with just one diagnosis. Therefore, it is important to seek a treatment method that will be effective in addressing both conditions simultaneously.

Dialectical Behavior Therapy and Substance Abuse

Fortunately, Dialectical Behavior Therapy for Substance Use Disorders (DBT-SUD) was developed for individuals with both substance use disorder and Borderline Personality Disorder. DBT-SUD is effective in treating substance use problems while simultaneously addressing other complex problems related to emotion dysregulation. The following addictions and mental health concerns associated with Borderline Personality Disorder and Substance Abuse can be addressed using DBT-SUD:

  • Alcohol
  • Tobacco or nicotine
  • Prescription pain medication
  • Opiates
  • Stimulants (e.g., methamphetamine, ecstasy)
  • Depressants
  • Antidepressants
  • Hallucinogens (e.g., LSD)
  • Illegal drug addiction (e.g., cocaine, heroin)
  • Recreational drug addiction (e.g., marijuana)
  • Eating disorders
  • Depression
  • Impulsivity
  • Anxiety
  • Post-traumatic stress disorder (PTSD)

Dialectical Behavior Therapy for Substance Use Disorders utilizes the same treatment strategies and protocols as standard DBT, while incorporating specific skills and targets relating to substance use behaviors. The four components of standard Dialectical behavior therapy (skills training, individual therapy, phone coaching and therapist consultations) are conducted with a particular emphasis on decreasing the abuse of different types of substances. This is accomplished through reducing painful withdrawal symptoms, regulating emotions, diminishing cravings and urges to use, avoiding tempting situations, increasing community support by developing relational skills, and encouraging recreational or vocational activities that support abstinence.

Overall, Dialectical behavior therapy has been proven to dramatically improve outcomes for clients who were suffering from co-occurring disorders, such as Borderline Personality Disorder and substance abuse. The implementation of behavioral skills such as effective mindfulness, interpersonal effectiveness, distress tolerance, and emotional regulation through DBT has helped countless individuals truly develop a “life worth living.”

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What is Dialectical Behavior Therapy?

What is Dialectical Behavior Therapy? In short, Dialectical behavior therapy (DBT) is an evidence-based psychotherapy used to treat chronic or severe mental health issues. DBT utilizes the components of capability enhancement, generalization, motivational enhancement, and the structuring of the environment to help individuals achieve specific goals. The treatment targets of Dialectical Behavior Therapy are life-threatening behaviors, therapy interfering behaviors, quality of life behavior, and skills acquisition. The intervention is “dialectical” in the sense that it involves the integration of opposites. The primary dialectic synthesis within Dialectical behavior therapy is between the seemingly “opposite” strategies of acceptance and change. For example, DBT therapists focus their interventions as practitioners who accept clients as they are, while also acknowledging that they need to change in order to reach their goals. In addition, all of the skills, components, strategies, and ideas that are taught in Dialectical behavior therapy are equally balanced in terms of acceptance and change.

The Development of Dialectical Behavior Therapy

In the late 1970s, Cognitive Behavior Therapy (CBT) had gained popularity as one of the most effective psychotherapies for a range of severe mental health issues. During that time, a researcher by the name Dr. Marsha Linehan took a particular interest in investigating whether or not CBT would prove helpful for women whose suicidal tendencies were activated in response to trauma and pain. Due to her training, Dr. Lineham was initially interested in treating discrete behaviors. However, through consultation with colleagues, she concluded that she was actually treating women who met the diagnostic criteria for Borderline Personality Disorder (BPD).

Dr. Lineman and her colleges quickly discovered major gaps in the effectiveness of Cognitive Behavioral Therapy among their target population of women with Borderline Personality Disorder. As a result, Dialectical Behavior Therapy was developed. The sets of strategies and the theories found in Cognitive Behavioral Therapy became the very foundation upon with Dialectical Behavior Therapy was built.

Who Can Benefit From Dialectical Behavior Therapy?

Today, Dialectical Behavior Therapy has since expanded to treat a wide variety of mental health concerns, including, but not limited to:

  • Borderline personality disorder, including those with co-occurring:
    • Suicidal and self-harming behavior
    • Substance use disorder
    • Posttraumatic stress disorder
    • High irritability
  • Cluster B personality disorders
  • Self-harming individuals with personality disorder
  • Attention deficit hyperactivity disorder (ADHD)
  • Posttraumatic stress disorder related to childhood sexual abuse
  • Major depression, including:
    • Treatment resistant major depression
    • Older adults with chronic depression and one or more personality disorders
  • Bipolar disorder
  • Transdiagnostic emotion dysregulation
  • Suicidal and self-harming adolescents
  • Pre-adolescent children with severe emotional and behavioral dysregulation
  • Binge eating disorder
  • Bulimia nervosa

The Cognitive-Behavioral Model

In order to truly understand Dialectical behavior therapy, it must be explored within the context of its theoretical framework. DBT is a form of cognitive behavioral treatment, which is based upon the combination of the basic principles from behavioral and cognitive psychology. The cognitive-behavioral model is based upon the assumption that our thoughts and beliefs influence our behavior, emotions, and physiology. In function, Dialectical behavior therapy is combined with cognitive and behavioral interventions. Both cognitive and behavior theories are founded on specific core concepts that serve as guiding principles.

Cognitive Theory

A major concept of cognitive theory is the development and function of one’s schema. A schema is our internalized representation of the world, or patterns of thought, action, and problem solving. It dictates the way that we organize thoughts, store information, process new information, and integrate the products of those operations (knowledge). It reflects necessary biases with which we view the world, based on both our direct and indirect learning. When we encounter a new situation, we either assimilate it to “fit” our existing schema, or we accommodate it, changing the schema. Although a flexible schema is desirable, all schemas tend to be somewhat rigid by nature.

Behavior Theory

The principles and assumptions of behavior theory include:

  • Behavior is what a person does, thinks, or feels that can be observed.
  • People are motivated to seek pleasure & avoid pain.
  • People behave based on their learning.
  • Behavior is amenable to change. Behavior concern must be defined in terms of measurable indicators.  
  • Intervention should focus on influencing reinforcements or punishments for client  behaviors.
  • Thoughts & feelings are behaviors subject to reinforcement principles.
  • The simplest explanations for behavior are preferred. Practitioners should avoid searching for ultimate causes of behavior.

Dialectical Behavior Therapy

Dialectical behavior therapy combines concepts from both cognitive and behavior theories. It may be appropriate for use as an intervention when an individual’s core difficulty is affective instability. From the perspective of DBT, some individuals develop pervasive problems in social functioning due to a lack of interpersonal and self-regulation skills. As a result, their potential to develop appropriate, adaptive behaviors is inhibited by both personal and environmental factors.

Behavior Chain Analysis

Overall, dialectical behavior therapy recognizes that certain internal and external stimuli have the potential to trigger problem behaviors through learned associations. In order to identify an individual’s cognitive, behavioral, affective, interpersonal, and environmental triggers, DBT utilizes an assessment strategy known as a behavior chain analysis. First, the client’s problem behavior is specified as clearly and concisely as possible. Then, the environmental conditions or cues that enhance or maintain the behavior are identified. Finally, the consequences of the behavior are considered. Another way to look at a behavior chain analysis is through the relationship sequence of A, B, and C.

A ——> B ——-> C

  • A stands for Antecedent. This refers to the various triggers or cues that precede a specific behavior. Antecedents can be social, physical, environmental, emotional, or cognitive.
  • B stands for Behavior. This refers to the actual problem behaviors that the individual is exhibiting.
  • C stands for Consequences. During this portion of the analysis, the potential consequences of each problem behavior are explored. These can be either positive or negative, and are drawn from past experiences or inferred as future possibilities.

Using the behavior chain analysis as an assessment tool, Dialectical behavior therapy first targets a client’s immediate, life-threatening behaviors, and then moves on to address problem behaviors that may intervene with the intervention itself and the client’s overall quality of life. The end goal of DBT is to help people learn and use new skills and strategies to develop a life that they experience as worth living.

The Components of DBT

Dialectical Behavior Therapy works to achieve these goals through a variety of components.

Individual Therapy

Individual sessions address the client’s specific maladaptive behaviors while strengthening and generalizing their coping skills. Each of the individual sessions are related to the themes of the skills-training group.

Skills-Training Group

In addition to individual therapy sessions, clients participate in group-oriented therapy sessions. The skills-training group explores four different modules. The first is mindfulness, which is based upon the awareness of self and context through mindful observation, as well as the ability to control one’s focus of attention on the present moment. The other three modules implement skills training in the areas of interpersonal effectiveness, emotional regulation, and distress tolerance.

Coaching

An important component in Dialectical behavior therapy is coaching via telephone. Some client-practitioner contact is permitted between sessions for support and crisis intervention. The goal is to coach clients on how to use their DBT skills to effectively cope with difficult situations that arise in their everyday lives.

Therapist Consultation

This is a platform for the therapists who are offering Dialectical behavior therapy. The consultation team helps DBT therapists remain competent and stay motivated to work with disorders that are especially difficult to treat, such as substance abuse. The support helps ensure that the practitioners will be able to provide the best possible treatment to their clients.

Stages of Intervention

Dialectical behavior therapy incorporates five intervention stages. The first of these is referred to as a pre-commitment stage in which the model is explained and the client is oriented to its expectations. During this stage, it is required that the client commits to three things:

  1. Reducing self-harm behaviors
  2. Working on interpersonal difficulties
  3. Developing new skills

Once the client has made a commitment to DBT, the next four stages of intervention can begin.

Stage One

The goal of Stage 1 is for the client to move from feeling as if they are “out-of-control” to achieving behavioral control. The practitioner helps the client develop new behavior skills in order to reduce life-threatening behaviors, as well as any behaviors that may interfere with the client’s ability to consistently attend therapy. Quality-of-life issues and basic safety are addressed in this stage.

Stage Two

Stage 2 includes exposure to traumatic memories and the processing of past abuse. The goal of this stage is for the client to learn skills that enable them to experience and process a full range of emotions, as well as reduce post-traumatic stress symptoms. The client will progress towards moving from a state of quiet desperation to one of full emotional experiencing. This stage is particularly beneficial for those who have been diagnosed with PTSD.

Stage Three

Both the third and fourth stages of Dialectical behavior therapy focus on the development of self-respect and autonomy, as well as issues surrounding an individual’s own meaning and purpose. The client is challenged to set life goals, and work toward living a life of ordinary happiness and unhappiness.

Stage Four

In this stage, the overall goal of treatment is for the client to move from a sense of incompleteness or emptiness towards a spiritually fulfilling life. Clients are challenged to develop an ongoing capacity for experiences of joy, happiness, and freedom; as well as a sense of connectedness to something greater than themselves.

The Effectiveness of DBT

Like other interventions that are derivative of cognitive theory, Dialectical behavior therapy lends itself to empirical research methods. DBT has been extensively researched for individuals with a wide range of mental health conditions, who are receiving treatment in different practice settings across the globe. DBT has been evaluated and found to be effective among individuals from diverse backgrounds in terms of age, gender, sexual orientation, and race/ethnicity. Over and over again, Dialectical behavior therapy is an intervention which has been shown to be both well-established and efficacious.

  • In 1991, the very first randomized controlled trial (RCT) of DBT was published. Dr. Marsha Linehan (who is the founder of Dialectical behavior therapy) along with her colleagues, found that DBT resulted in significant improvements for chronically suicidal and self-injuring women with borderline personality disorder. These findings were significant, as this specific clinical population had previously been considered “untreatable” (Linehan et al., 1991).
  • In 2004, a controlled trial conducted in an inpatient setting found that those who received three months of DBT improved at a greater rate than those who received treatment as usual (Bohus et al. 2004).
  • In 2006, findings from another research study showed that Dialectical behavior therapy may be effective in reducing suicide attempts. This data showed that those who received DBT were half as likely to attempt suicide than those who did not. They had less psychiatric hospitalizations and were far less likely to drop out of treatment, compared to those who received other psychotherapy interventions (Linehan et al. 2006).
  • Overall, multiple controlled trials and independent studies found that one year of Dialectical behavior therapy decreased the instances of self-harming behaviors at a greater rate than alternative treatments. One such study reported that participants who received DBT had only .55 incidents of self-injurious behavior over one month, compared to 9.33 incidents among those who received other common treatments (SAMHSA National Registry of Evidence-based Programs and Practices).
  • Another review of the modality consisting of sixteen different randomized studies found that Dialectical behavior therapy had a moderate effect on reducing the participants’ suicidal behaviors (Kliem, Kroger, & Kosfelder, 2010).
  • A more recent meta-analysis of thirteen studies conducted among persons with eating disorders found that Dialectical behavior therapy was successful in addressing eating disorder behaviors (Bankoff, Karpel, Forbes, & Pantalone, 2012).

The APEX Difference

While Dialectical Behavior Therapy has proven to be useful among a wide variety of diverse individuals, there is truly no single intervention for treating any form of mental health condition. Because of this, the broad range of therapies available at Apex Recovery and the diversity of highly-qualified professionals make us able to provide highly flexible and personalized treatments to our patients.

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What is Trauma Focused Therapy?

What is Trauma?

Every individual will experience trauma at some point in their lives. Unfortunately, most Americans have also been exposed to a form of severe trauma, either as a one-time event or a multiple, or even long-lasting repetitive traumatic events. Incidents of trauma can take the form of violence, child abuse, domestic violence, military combat, car accidents, natural disasters, life-threatening illness, fetal trauma, industrial accidents, mass shootings, terrorist attacks, prolonged neglect, or other events. The word “trauma” comes from the Greek term for penetration or wounding, an indication of how serious the effects of trauma can be. Trauma was generally not at all well-understood, or even seriously considered as a psychological injury, until Freud’s psychoanalysis in the late 1800s. Even so, conceptualizations of trauma have changed quite a bit over time, as have the methods and approaches for treating it.

The DSM-IV specifically defines trauma as:

“Direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate. The person’s response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior).”

The Impact of Trauma

Trauma, whether one-time, multiple, or long-lasting repetitive events, affects everyone differently. The impact of trauma can be subtle, hidden, or outright destructive. How an event affects an individual depends on many factors, including characteristics of the individual, the type and characteristics of the event(s), developmental processes, the meaning of the trauma, and sociocultural factors.  Usually the impact of trauma fades relatively soon, typically within one to three months. Most individuals will exhibit resilient responses or brief symptoms or consequences that fall outside of an official diagnosis. For others, trauma problems can persist for years and even decades. These lingering effects of trauma are usually diagnosed as Post-Traumatic Stress Disorder, or PTSD.

Trauma and Substance Abuse

Among those who seek treatment for substance abuse, a dual diagnosis PTSD and substance abuse disorder is surprisingly common. For most, the traumatic event or events occur first, and then the addiction develops. Substance abuse has been often viewed as “self-medication” to cope with the overwhelming pain that trauma has caused in an individual’s daily living. However, addiction can also lead to trauma, as individuals become more vulnerable while under the influence of substances. The rate of a diagnosable level of PTSD among those receiving substance abuse treatment is 12%-34%, and the rates are even higher among women (30%-59%). Most women with this dual diagnosis have experienced childhood physical or sexual abuse, and men have typically experienced war trauma or crime victimization. Various subgroups have higher rates of this dual diagnosis than others, such as combat veterans, victims of domestic violence, teenagers, prisoners, and the homeless. Overall, incidences of PTSD and substance abuse have consistently been found to co-occur, regardless of the nature of trauma or the type of substances that were abused.

As a result, those with PTSD and substance abuse have a more severe clinical profile than those with just one of those disorders. Not only are they seeking treatment for their substance abuse, but they are facing recovery while also dealing with the lingering effects of intense trauma. Furthermore, those with PTSD and substance abuse disorder are particularly vulnerable to repeated traumas, far more so than those with substance abuse or PTSD alone. Typically, there are also a wide variety of life problems that may present themselves as complicating factors in successful treatment. These may include, but are not limited to, other diagnoses and disorders, interpersonal and medical problems, child maltreatment and neglect, homelessness, HIV risk, custody battles, financial hardships, job insecurity, and domestic violence. Due to these issues, those with a dual diagnosis are at risk of falling into a “downward spiral.” Researchers describe this as one triggering event after another, burying the individual deeper and deeper into substance abuse and PTSD. For example, the increased vulnerability to new trauma can lead to increased substance abuse, and vice versa. In a nutshell, PTSD symptoms can be common triggers of substance abuse, which in turn can intensify PTSD symptoms.

However, even those who are exhibit responses to trauma that are outside of a PTSD diagnosis may choose to turn to substance abuse as a coping mechanism. Experiencing trauma early in life increases a person’s susceptibility for drug addiction in adulthood. A person is also more susceptible to drug addiction if they experience any trauma whatsoever, whether early in life or later. Furthermore, an individual may have been struggling with addiction before the traumatic event took place. Psychological trauma and substance abuse can occur in any person, regardless of their age, gender, religion, socioeconomic status, sexual orientation, or any other factor. It is important that individuals who are struggling receive treatment that is designed to address both trauma and addiction. A treatment plan that is tailored to the individual and utilized daily, or at least with regular frequency, is key to recovery.

What is Trauma Focused Cognitive Behavioral Therapy?

Trauma Focused Cognitive Behavioral Therapy (TF-CBT) is a treatment model that was designed to assist both individuals and families in overcoming the negative effects of a traumatic experience. This evidence-based method has been proven effective for treatment after multiple traumas or a single traumatic event, and therapists trained in TF-CBT are frequently able to help those experiencing the emotional effects of trauma to address and resolve these effects.

General Cognitive Behavioral Therapy (CBT) offers effective methods for treating trauma-related disorders and promoting healing, but TF-CBT offers expanded methods, incorporates techniques from family therapy, and uses an extremely trauma-sensitive approach. TF-CBT is also relatively short-term for most clients.

How it Works

Trauma Therapy is administered in three distinct phases, which includes eight components that are recognized as the acronym P.R.A.C.T.I.C.E.

Phase One: Stabilization

In phase one, the therapist will walk the clients through the TF-CBT approach, educate patients about trauma, and help them develop the skills they will need to promote meaningful healing and development. This phase includes the PRACTICE components of P through C.

P – Psycho-education: This phase starts off therapy by learning about trauma. The patients receive information on trauma and the most common reactions to traumatic experiences, as well at PTSD. The goal is to ensure patients that their reactions are understandable, and to validate their feelings.

R – Relaxation Skills: The second component is relaxation and self-care skills. These are intended to help reverse the physiological arousal effects of the trauma they have suffered.

A – Affective Regulation Skills: Similar to the relaxation skills component, the affective regulation skills component is intended to help the patients learn helpful strategies for identifying, modulating, and regulating any upsetting affective states that may arise, especially those that are a result of the trauma experience.

C – Cognitive Processing Skills: The intent of this component is to help the client build the necessary coping skills to manage their stress and achieve meaningful healing from their trauma. Cognitive processing skills help recognize the connections between thoughts, feelings, and behaviors and replace harmful or unhelpful thoughts with more accurate or more helpful ones.

Phase Two: Trauma Narrative

In this phase, the therapist will walk the client through creating a trauma narrative.

T – Trauma Narration and Processing: The trauma narrative is the telling of the story of their traumatic experience or experiences. They are often quite difficult to begin, as the emotions engendered by the original trauma can come flooding back as the sufferer recalls the details of the event(s), but it will get easier as the process goes on. Most clients find it helpful to begin by focusing on the concrete facts (the who, what, when, and where of the experience). Next, they can add the thoughts and feelings that arose during the experience. Once they are comfortable listing or describing their thoughts and feelings during the experience, they can move on to the most difficult or disturbing moments of their trauma. This will be difficult, but it is necessary to put together a comprehensive narrative of the trauma.

Phase Three: Integration / Consolidation

The aim of phase three is to consolidate the lessons learned, continue to build skills and improve connections, and prepare for future success. This phase includes the final PRACTICE components of I, C, and E.

I – In Vivo Mastery of Trauma Reminders: Trauma reminders are stimuli that individuals may experience in their daily lives that can trigger intense, painful, and often debilitating memories of the trauma suffered. It is also possible for these reminders to skip the memories entirely and send the client straight into the physiological arousal that thinking about the trauma could provoke (i.e. unexplained hyperventilation, heart palpitations, etc). The in vivo mastery component involves helping individuals overcome their avoidance of generalized reminders and work towards mastering more specific reminders. The therapist will develop a hierarchy of reminders and work with the client to gradually master feared stimuli and triggers, working from least feared to most feared. This component may actually start in the stabilization phase, and then reach completion toward the end of the PRACTICE components.

C – Conjoint Sessions: This component was originally designed for children who are receiving Trauma Focused Cognitive Behavioral Therapy. Its intention is to provide key opportunities for the therapist to help families reconnect and plan for continued healing and growth. It is in these sessions that the child can share their trauma narrative with their parents, and work together on improving their communication both about the trauma and in general. These sessions may also help families address healthy boundaries and behaviors, as well as develop a family safety plan for potential future crises.

E – Enhancing Safety: This component involves recollecting all of the positive skills and insights gained through therapy and applying it to the future. It is imperative that both individuals and families create plans to deal with the stressors and trauma reminders that will arise in the future.

How APEX Difference

While Trauma-Focused Cognitive Behavioral Therapy has proven to be useful among a wide variety of diverse individuals and families, there is truly no single formula for treating a dual diagnosis of substance abuse and trauma-related disorders. Because of this, the broad range of therapies available at Apex and the diversity of highly-qualified professionals make us able to provide highly flexible and personalized treatments to our dually diagnosed patients.

Using a trauma focused treatment approach, the clinically trained staff at Apex Recovery Rehab understand the impact of trauma and the resulting behaviors.  With judgment-free empathy and responses, the Apex staff understands the ramifications of trauma and can help you implement the necessary tools to increase your wellbeing and deliver truly effective holistic care.  We will help you rebuild a sense of control and develop personal empowerment in a setting that promotes and emphasizes psychological, physical and emotional safety.

More often than not, people struggling with an addiction have some type of co-occurring mental health diagnosis or other trauma related disorder. Not only does APEX Recovery addiction treatment team specialize in all aspects of drug and alcohol dependency, we also treat co-occurring disorders and help patients learn how to manage the often debilitating effects of traumatic experiences.

Here at APEX, we believe that thorough assessment and treatment of co-occurring disorders is a critical piece in maximizing the chance of success in treatment. Fortunately, trauma focused, dual diagnosis therapy now brings these patients the best of both worlds – treatment for both trauma and substance abuse.

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Seeking Safety Coping Skills

Seeking Safety Coping Skills 

The primary goal of Seeking Safety therapy is to increase safe coping skills an individual may use to reduce the dangerous behavior related to symptoms of Post Traumatic Stress Disorder (PTSD) and Substance Abuse. All skills provided in the Seeking Safety model are applicable to someone who has experienced trauma and/or Substance Abuse. In general, the coping skills presented as part of the Seeking Safety Model can be used across a wide variety of concerns including depression, anxiety, mania, psychosis, panic attacks, grief, etc. The skills presented are categorized as cognitive, behavioral, interpersonal, or case management.

When considering building coping skills it is important to think of these skills as tools one might keep in a tool belt. As a good craftsman would have all the tools he might need in close proximity as he works on a particular project, so it is important to have many coping skills available and ready for use. Even without having experienced a traumatic event or substance abuse problem, everyone should have some coping skills in their back pocket to help manage the sadness, stress, and pressures that arise as a part of everyday life. You probably already use some coping skills without actually calling them “coping skills. “ These might be things like calling a trusted friend after a stressful day, taking several deep breaths as you wait for the doctor to come back with your test results, or meeting with a therapist during a crisis.  Many people also use coping skills that are unsafe. Unsafe coping skills might include having more drinks than you should after a stressful day, using a substance to feel more comfortable in a social setting, cutting yourself to numb emotional pain, or acting on impulse.

Seeking Safety is a trauma focused therapy modality and as such, focuses on the premise that many of the ways an individual responds to something is based on a pattern of behavior that has at some point been helpful for us. It is important to recognize that we all have developed a pattern of using particular safe or unsafe coping skills as a result of trying to manage overwhelming feelings or emotional pain. Some of us have been lucky enough to have stumbled onto coping tools that help us manage overwhelming emotion safely and effectively while others of were not as fortunate.

We may have observed unsafe behavior in our environment and assumed that it was just the way to deal with life. Regardless of what coping you were using, remember that your brain was trying to keep you safe from the overwhelming pain being experienced. At some point, each person must decide what is working and what is no longer working to manage our emotional pain, stress, sadness, fear, etc.

Some warning signs that your current coping skills are no longer working for you:

  • You feel unable to engage in meaningful relationships.
  • It becomes challenging to get out of bed in the morning and show up for life.
  • You have difficulty with completing your work or schoolwork with the integrity and quality that you once had.
  • Trusted friends or family members regularly provide feedback that you don’t seem well or okay.
  • You find it difficult to sleep at night.
  • You are struggling with your finances because you are spending more money than you have on alcohol or other substances.

When you determine that your current methods of coping are no longer working, it becomes time to try something new. Seeking safety offers new and safe coping skills.

Grounding Techniques

Seeking safety presents three categories of grounding skills that an individual can learn and utilize to ground oneself. These include mental grounding, physical grounding, and soothing grounding. Individuals are encouraged to learn and practice each type of grounding but will likely gravitate towards one type of grounding which they find most effective.  It is important to note that while grounding, we do not assign positive or negative values – things aren’t pretty, ugly, good, or bad, they simply are.

Mental Grounding

Mental grounding uses one’s ability to focus on something external. It may be focusing on the external environment or engaging our brain in an activity in which our full attention is required (eg. the color of the walls, the textures in a painting, the variety of flowers outside, reading letters backwards, or naming all the sports teams you can think of).

To practice mental grounding, try the following exercise:

Take a moment and look at the space that you are in. Name all the colors you can see from where you are seated. Now, start at the number 100, and count down by 5’s. Finally, name all the cities you can think of.  

Physical Grounding

Physical grounding uses one’s ability to focus on the sensation of something external using our sense of smell, touch, taste, sight, or hearing.

To practice physical grounding, try the following exercise:

Touch an object around you and describe it – is it cold, warm, smooth, rough, small, or large? Next, press your palms together firmly and hold for 5 seconds. Now, release your palms and notice the difference in sensation of your hands.

Soothing Grounding

Soothing grounding uses the positive associations one already experiences internally and brings our focus to them. It may be identifying favorite things, calm places, and soothing experiences.

To practice soothing grounding, try the following exercise:

Think of your favorite color. Now think about your favorite animal. Finally, think about your favorite season. Now, think of your favorite upbeat song and try to sing a few bars of the song.

Self-Help Groups and Importance of a Safe Community

One of the key elements of Seeking Safety is the connection of community resources. These may be connecting to a specialty physician, finding a support group, locating a 12-Step or other substance treatment-focused group, locating supportive housing or identifying an individual therapist.

Self-Help Groups

Self-help groups are what many individuals think of when they consider the road to substance abuse recovery.  The biggest benefit of a self-help group is the community available as you work through your recovery. Self-help groups offer a safe space to be vulnerable and connect with others who can provide empathy as well as new insight as you share and listen to the stories and ways others have learned how to cope. Many people in self-help groups report being able to connect with “someone who gets it” for the first time in their lives. Shame is heavy when one is considering recovery and finding a safe place with others you trust is invaluable in this journey. Most self-help groups are not facilitated by a professional and may compliment individual therapy.

Twelve Step meetings like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) are available almost everywhere and offer a safe environment to work through recovery from an addiction. They offer a set of principles that members work through with the support of a community and/or sponsor to support long-term sobriety. These meetings are free of charge and offer a connection to others struggling with an addiction with the intention of moving towards sobriety. Meetings are typically facilitated by a non-professional and may be closed or open to the public. For more information about AA, visit their website.

SMART Recovery is another community-based self-help group with the intention of achieving sobriety and abstinence from substances. SMART is based on a cognitive-behavioral psychotherapy called Rational Emotive Behavioral Therapy with the underlying belief that managing the beliefs and emotions that lead one to drink or use a substance will empower you to quit and then abstain from use.  Meetings are facilitated by individuals that have been trained in SMART Recovery and may be professionals or community members. For more information about SMART Recovery, visit their website

Many community organizations host Twelve Step or SMART Recovery meetings or may facilitate other recovery-based meetings. Some Buddhist Temples may host a Recovery Sangha while Protestant Churches may host Celebrate Recovery.  A quick search online for “substance abuse self-help groups” will likely reveal numerous resources.

In addition to substance-based recovery self-help groups, some people may also consider self-help groups to address other specific concerns. Many people find it helpful to connect with others dealing with depression, anxiety, PTSD, ADD/ADHD or other mental-health related diagnoses. Others may find it helpful to attend a grief support group to increase support after a loss or a cancer/cancer survivor support group to connect with others experiencing a similar health problem. Survivors of domestic violence or sexual assault may find a support group beneficial as they recover from traumatic events. Many local hospitals or clinics offer FREE support groups that may increase insight and coping skills also supportive of long-term sobriety.

Safe Communities

A safe community is a haven as you work through your recovery. It provides new insight, feedback, and hope along the way of this journey towards healing. Each of us belongs to a family of some kind. Each of also has the ability to create or join a community of our choice that can become a second family to us. It is a safe space of like-minded people who meet with the intention of providing support to one another in recovery. A safe community offers space to ask questions and get a variety of responses. It supports the joyful and challenging days of life and celebrates and mourns with us. A safe community also provides us with numerous people we can count on when we need it most. When that one person isn’t available, there will be others who are equally committed to supporting you and the direction you intend to travel.  

A safe community can be found in self-help groups but can be anywhere you feel accepted and that your sobriety is supported. It may be a group of hunting buddies. Maybe your safe community is the mom-friends you meet at the park. Your safe community could be the depression support group you attend or the coffee enthusiast group you met at a Meet Up. They may be the entrepreneur mentoring group you joined or your weekly church Bible study. Whatever that safe community is, invest and engage in it. It is as important to find this safe community, as it is to be an active part in it. Show up again, and again, and again. Get to know the individuals in it, and allow them to know you.

Utilizing Safe Supportive Individuals

Why Do I Need Support?

We ALL need support. As humans, we are not meant to exist alone and isolated from one another. Vulnerability and accountability are imperative to recovery. We can’t heal and grow without being honest about what has already happened, what has kept us from moving forward and being honest about our hopes for the future. We also can’t begin to trust that the world is safe and good, without experiencing safe and good relationships with others. Vulnerability is the enemy of shame. When we are willing to show up as ourselves, we invite others to do the same and are likely to find that we are not alone. We find that someone else understands and that someone else is also imperfect. We find that people like us and choose us despite all of our imperfections. We begin to believe that we are enough. This belief that we are worthy of love… that we are enough, is the fuel we need to move forward towards change.

Who is a Safe Supportive Individual?

A safe supportive person can look like many things to different people. To some, this may be a trusted friend who will ask how you’re doing, and ask again when you answer “I’m fine.” It may look like a parent who sets boundaries in the relationship while reminding you that they love you and that your wellbeing is at the forefront of their intention. To others, this may be a therapist. An AA Sponsor. A priest or Rabbi, or Minister. These individuals are people you trust to have your best intention in mind and do not want you to continue making unsafe choices for yourself. They will be available to talk you through a craving or a flashback. They will remind you about how good you felt when you were sober and will encourage you to make it through another day, hour, or minute. A safe supportive individual will not judge you if you slip. They will ask what happened and continue to encourage you to pick up where you left off on your journey to sobriety. They will remind you that they are here and that you and your choices are important.

It can be scary to invite someone in. Most people experience some anxiety when they are identifying support people. It is normal to wonder if those people or groups will be there when we need them and if they will judge us when we slip. Support people are human, just like we are human. They will slip, like we will slip. The difference is that they will continue to show up for us and will ask us to continue showing up for ourselves.  This is how we know that they are safe and that the relationship is important to invest in and hold on to.

Our trained clinicians at APEX Recovery want to be a safe supportive person for you.  Our staff will provide you the support necessary to implement Seeking Safety safe coping skills, and began to live a life congruent with your goals.  Contact us today.

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What is Seeking Safety?

The Dual Diagnosis

Trauma is an epidemic, with most Americans at some point in their lives surviving one or more incidents – violence, child abuse, domestic violence, military combat, rape, car accidents, natural disasters, life-threatening illness, and industrial accidents. For most people, the impact of trauma fades relatively soon, typically within one to three months. But for others, trauma problems can persist for years and even decades. This type of lingering trauma is typically diagnosed as Post-Traumatic Stress Disorder, or PTSD. Among those who seek treatment for substance abuse, a dual diagnosis PTSD and substance abuse disorder is surprisingly common. For most, the traumatic event or events occur first, and then the addiction develops. Substance abuse has been often viewed as “self-medication” to cope with the overwhelming pain that trauma has caused in an individual’s daily living.

However, addiction can also lead to trauma, as individuals become more vulnerable while under the influence of substances. The rate of a diagnosable level of PTSD among those receiving substance abuse treatment is 12%-34%, and the rates are even higher among women (30%-59%). Most women with this dual diagnosis have experienced childhood physical or sexual abuse, and men have typically experienced war trauma or crime victimization. Various subgroups have higher rates of this dual diagnosis than others, such as combat veterans, victims of domestic violence, teenagers, prisoners, and the homeless. Overall, incidences of PTSD and substance abuse have consistently been found to co-occur, regardless of the nature of trauma or the type of substances that were abused.

As a result, those with PTSD and substance abuse have a more severe clinical profile than those with just one of those disorders. Not only are they seeking treatment for their substance abuse, but they are facing recovery while also dealing with the lingering effects of intense trauma. Furthermore, those with PTSD and substance abuse disorder are particularly vulnerable to repeated traumas, far more so than those with substance abuse or PTSD alone. Typically, there are also a wide variety of life problems that may present themselves as complicating factors in successful treatment. These may include, but are not limited to, other diagnoses and disorders, interpersonal and medical problems, child maltreatment and neglect, homelessness, HIV risk, custody battles, financial hardships, job insecurity, and domestic violence. Due to these issues, those with a dual diagnosis are at risk of falling into a “downward spiral.” Researchers describe this as one triggering event after another, burying the individual deeper and deeper into substance abuse and PTSD. For example, the increased vulnerability to new trauma can lead to increased substance abuse, and vice versa. In a nutshell, PTSD symptoms can be common triggers of substance abuse, which in turn can intensify PTSD symptoms.

The Presenting Problem

Because of the possibility of this “downward spiral,” many clinicians have chosen to avoid trauma therapy in their modalities for substance abuse treatment, arguing that it may be too distressing a topic to discuss in the midst of recovery. While there is some validity among these concerns, becoming abstinent does not resolve PTSD and, in some cases, may even cause the symptoms to worsen if they are not addressed. On the other hand, traditional trauma based interventions involve delving into a detailed narrative of the traumatic events, which can leave a client who is struggling with substance abuse more vulnerable as well.

However, it is important for clinicians to recognize that trauma and substance abuse are intrinsically intertwined. Research has shown that an integrated model of treating both PTSD and substance abuse disorder at the same time is recommended as more likely to produce successful results. Unfortunately, clinical programs have historically been known to treat PTSD or substance abuse, but rarely both. As a result, the majority of patients with PTSD and substance abuse never receive trauma-focused therapy, and many patients who are in addiction recovery are never even assessed for PTSD. Treatments that are usually effective for treating each diagnosis individually may not be advisable when the two disorders occur together, hence the need for an integrated modality.

The Treatment

Currently, there is only one evidence-based model that is endorsed by professionals for treating the dual diagnosis of substance abuse and PTSD. This model used to address both addiction and trauma together is known as Seeking Safety. Seeking Safety is an evidence-based therapy model that can be used in group or individual counseling, and can be conducted with the broadest range of clients – including the highly complex, chronic, and multiply burdened clients who often cycle in and out of treatment. It was specifically developed to help survivors with trauma and substance abuse disorder in a way that does not ask them to delve into emotionally distressing trauma narratives. This significantly minimizes the risk of instigating the “downward spiral” that other forms of trauma-based therapies often present. Thus, “safety” is a deep concept with varied layers of meaning throughout the modality: the safety of the client as they do the work, helping clients envision what safety would look and feel like in their lives, and helping them learn specific new ways of coping.

How it Works

Seeking Safety stays in the present, teaching a broad array of safe coping skills that patients may never have learned if they grew up in dysfunctional families or may have lost along the way as their addiction and trauma spiraled downward. All of the Seeking Safety coping skills apply to both trauma and addiction at the same time – providing integrated treatment that can help boost motivation and guide clients to see the connections between their trauma and addiction issues. Seeking Safety provides various options for recovery, in keeping with current research and understanding about substance abuse. It can be done as part of an abstinence-based approach (with clients giving up all substances of abuse), harm reduction (decreasing use, perhaps with an ultimate goal of abstinence), or controlled use (decreasing use to a safe level).

Helping to meet the both patient’s trauma and substance abuse needs at the same time and in safe fashion can build hope in new ways.

The 25 Seeking Safety Topics

There are 25 topics that clients are exposed to during therapy, each a safe coping skill. Each topic is independent of the others so they can be used in any order and for as long or short as the client’s time in treatment. The topics address cognitive, behavioral, and interpersonal skills, plus there is a focus on engaging clients in community resources.

  1. Introduction/Case Management: Introduction to the treatment, getting to know the patient, and assessment of case management needs.
  2. Safety: Patients explore what safety means to them, and are provided with a list of over 80 “Safe Coping Skills”
  3. PTSD – Taking Back Your Power: Clients are provided information regarding “What is PTSD?”; “The Link between PTSD and Substance Abuse”; “Using Compassion to Take Back Your Power”; and “Long-Term PTSD Problems.”
  4. Detaching From Emotional Pain (Grounding): Three types of grounding are presented, along with an experiential exercise to help clients detach from emotional pain.
  5. When Substances Control You: Eight handouts are provided regarding various substance abuse topics.
  6. Asking for Help: Encourages patients to become aware of their needs and learn how to seek assistance.
  7. Taking Good Care of Yourself: Tips for Self-Care and a commitment to improvement and immediate action.
  8. Compassion: Patients are taught that a loving perspective towards oneself can produce lasting change.
  9. Red and Green Flags: A safety plan is developed to identify signs of both danger and safety.
  10. Honesty: Exploring the role of honesty and dishonesty in the journey to recovery.
  11. Recovery Thinking: The power of rethinking is demonstrated through various exercises.
  12. Integrating the Split Self: Patients are trained to notice splits as a defense mechanism and strive for self integration.
  13. Commitment: Creative strategies for keep commitments are described.
  14. Creating Meaning: Meanings that are harmful versus those that bring healing are discussed.
  15. Community Resources: A lengthy list of national non-profit resources is offered to aid patients’ recovery. Also, guidelines are offered to help patients take a consumer approach in evaluating treatments.
  16. Setting Boundaries in Relationships: Ways to set healthy boundaries are explored, and domestic violence information is provided.
  17. Discovery: Discovery is offered as a tool to reduce the cognitive rigidity common to PTSD and substance abuse.
  18. Getting Others to Support Your Recovery: Patients are encouraged to identify which people in their lives are supportive, neutral, or destructive toward their recovery.
  19. Coping with Triggers: A simple three-step model is offered to actively fight triggers of PTSD and substance abuse.
  20. Respecting Your Time: Balancing structure versus spontaneity, work versus play, and time alone versus in relationships are addressed.
  21. Healthy Relationships: Healthy and unhealthy relationship beliefs are contrasted. Patients are guided to notice how PTSD and substance abuse can lead to unhealthy relationships.
  22. Self-Nurturing: Safe self-nurturing is distinguished from unsafe self-nurturing.
  23. Healing from Anger: Guidelines for working with both constructive and destructive types of anger are offered.
  24. Life Choices: As part of termination, patients are invited to play a game as a way to review the material covered in the treatment.  Patients pull from a box slips of paper that list challenging life events (e.g., “You find out your partner is having an affair”).  They respond with how they would cope, using game rules that focus on constructive coping.
  25. Termination: Patients express their feelings about the ending of treatment, discuss what they liked and disliked about it, and finalize aftercare plans.

Benefits of this Approach

The concept of safety is designed to protect the clinician as well as the client. By helping clients move toward safety, clinicians are protecting themselves from treatment that could move too fast without a solid foundation. Increased substance use and harm to self or others are of particular concern with this vulnerable population. Thus, seeking safety is both the clients’ and clinicians’ goal. Over many years, feedback on the model indicates that its structured approach and compassionate tone make it practical and user-friendly for both the clinician and client.

The approach has been successfully implemented with a wide range of populations including both males and females; adolescents; military and veterans; homeless people; survivors of domestic violence; criminal justice and racially/ethnically diverse populations; clients with cognitive or reading impairments (including mild traumatic brain injury); those who are seriously and persistently mentally ill; individuals with behavioral addictions such as pathological gambling; active substance users; and clients in all levels of care (outpatient, residential, inpatient, community care, and private practice).

Seeking Safety is one of the lowest-cost trauma models available as only the book is needed to conduct it. No degree or licensure is required to conduct Seeking Safety. It has been used successfully in peer-led format, by case managers, and by domestic violence advocates.

Seeking Safety was developed over a ten-year period beginning in the early 1990’s under a grant from the National Institute on Drug Abuse. Clinical experience and research studies informed revisions of the manual, resulting in the final published version in 2002. Altogether, more than 20 studies have been conducted including pilots, controlled trials, multisite trials, and dissemination studies. While most studies on PTSD exclude people with complex problems, Seeking Safety research has been conducted with such populations.
It is currently classified as the only model for co-occurring PTSD and substance abuse disorder “strongly supported by research” and the only one that has evidenced significant improvements on both disorders by the end of treatment.

Our Mission at APEX Recovery

Overall, our mission at Apex Recovery Rehab is to use this research and other treatments to provide the best possible evidence – based individual recovery in the world. We are committed to treating every person and family in recovery with dignity, respect, love, personal care and attention. We choose to follow the best scientific, medical, holistic and smart ways to deal with one’s addiction and offer a comfortable setting and memorable experience to last a lifetime for every client and their family. We achieve our mission by having very strong convictions, a set of beliefs and solid core values, family-centered, comprehensive, individualized, treatment that takes place in a safe, substance-free environment.

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