co-morbidity

EMDR in the Addiction Continuing Care Process

Case Study of a Cross-Addicted Female’s Treatment and Recovery

Part 1

 

There have been suggestions in the literature since 1994 that eye movement desensitization and reprocessing (EMDR) may serve as an effective adjunct to the addiction treatment process; however, follow-up research in this area has been limited.

This case study (1)  of a cross-addicted female includes a case review illustrating how EMDR was used in the continuing care process.

“Many individuals in early sobriety return to using drugs or alcohol for two primary reasons: first, they find it difficult to address their past and take appropriate responsibility for their actions, and, second, they are overwhelmed by the shame-based ideologies that they acquired as part of their trauma (Miller & Guidry, 2001; Najavits, Weiss, & Shaw, 1997; Ouimette & Brown, 2002).

The comorbidity between addiction and trauma-related psychopathology is a phenomenon that has been observed in the addiction treatment field (Cox & Howard, 2007; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Shapiro, Vogelmann-Sine, & Sine, 1994; Zweben & Yeary, 2006).

This trauma can warrant a formal diagnosis of posttraumatic stress disorder (PTSD) according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; DSM-IV-TR ), or it can be what Shapiro (2001), developer of eye movement desensitization and reprocessing (EMDR), referred to as “small-t” trauma, which are life events that, when unresolved, cause disturbance. However, these small-t events would not warrant DSM-IV-TR distinction as a criterion A trauma that is necessary for a formal PTSD diagnosis.

Relapse is common in many behavioral disorders, especially addiction ( Joseph, Breslin, & Skinner, 1999).

Although various models abound to define and explain relapse, there is consensus that low self-efficacy and a high volume of negative emotion, coupled with poor coping skills, put an individual at greatest risk for relapsing on alcohol or other drugs following a period of sobriety (Allsop, Saunders, & Phillips, 2000; Connors & Maisto, 2006; Donovan, 1996; El-Sheikh & Bashir, 2003; Marlatt & George, 1984; Moos & Moos, 2006; Tapert, Ozyurt, Myers, & Brown, 2004; Walitzer & Dearing, 2006; Walton, Blow, Bingham, & Chermack, 2003).

Connors and Maisto (2006) noted that relapse “has received considerable attention because of the high rates of relapse that follow the initiation of a period of abstinence” (p. 107). Miller and Guidry (2001) contended that traditional models of addiction recovery and relapse prevention fail to appropriately consider the signifi cant role that unresolved trauma plays in an addicted individual’s attempt at recovery, especially among women.

Of patients in substance disorder treatment, anywhere from 12% to 34% have PTSD; these numbers can be as high as 33% to 59% in women (Najavits, 2006). Miller and Guidry, whose ideas are compatible with common relapse themes in the literature, called for a more holistic approach to the treatment of co-occurring trauma and addiction.

A holistic approach means that treatment needs to extend beyond the cognitive interventions that have traditionally been used in relapse prevention counseling, or the 12-step methods associated with the Minnesota model. Using EMDR in the addiction process may provide solutions to the problems of addiction relapse and lack of adequate care for traumatized alcoholics and addicts.

emdr

EMDR Treatment of Co-Occurring Trauma and Addiction

EMDR is a psychotherapeutic approach that was developed to resolve trauma-related disorders (Shapiro, 2001). Numerous randomized clinical trials have established its effi cacy in the treatment of PTSD, and it is now recognized worldwide as a fi rst-line treatment for PTSD (for reviews, see Bisson & Andrew, 2007 ; Max- fi eld, 2007).

There have been suggestions in the literature and in clinical sources for some time that EMDR can be incorporated as an effective adjunct to the addiction treatment process (Brown, 2003; Henry, 1995; Popky, 2005; Ricci, Clayton, & Shapiro, 2006; Shapiro et al., 1994; Vogelmann-Sine, Sine, Popky, & Smyth, 1998; Zweben & Yeary, 2006). Despite the historical lack of empirical validation with addicted individuals, clinicians have been using EMDR with recovering addicts because of the well-established comorbidity between substance use disorders and PTSD (Kessler et al., 1995; Najavits et al., 1997; Ouimette & Brown, 2002).

There is one randomized controlled study evaluating EMDR treatment with the addicted population. Hase, Schallmayer, and Sack (2008) demonstrated that a group that received treatment as usual along with EMDR showed a significant reduction in addiction craving 1 month posttreatment compared to the group receiving only treatment as usual and a significant difference in relapse at 6-month follow-up.

Cox and Howard (2007) presented a case study showing the merits of using EMDR in treating a sexually addicted client, and they called for further research in using EMDR as part of the overall recovery process, not just in treating PTSD.

 

Qualitative EMDR Studies

The qualitative follow-up interview utilized in this case study represents a major step in gathering a body of knowledge on EMDR that is truly phenomenological, that is, data on experience, not just on perceptions of effectiveness or reduction of symptoms.

White and Kurtz (2006) stressed that recovery stability following addiction treatment must be measured by monitoring the “whole person” (p. 46). White and Kurtz suggested that this monitoring must not consist simply of quantitative measures such as counting attendance at Alcoholics Anonymous (AA) meetings or tallying days sober. Monitoring the whole person and his or her growth as a recovering individual can be achieved at a level of greater depth when employing qualitative, phenomenological methods of inquiry that emphasize the unique experience of the recovering person.

Research Purpose

The purpose of this study is (a) to demonstrate the impact of EMDR on a cross-addicted female’s overall treatment and initial recovery experience and (b) to explore the case’s lived experience with EMDR as part of her treatment and early recovery process as reflected on in a follow-up interview 6 months after termination of treatment.

 

Case History

Nancy (not her real name) estimated that she had received 12 courses (both inpatient and outpatient) of treatment for alcoholism and addiction over a 12-year period. Nancy identifi ed as an alcoholic/addict at time of assessment and also admitted to a problem with compulsive sex. She reported intermittent involvement with Alcoholics Anonymous (AA) since her fi rst treatment in 1995, although she was never able to obtain more than 4 months of sobriety at any given time. Nancy’s father was an alcoholic, and she disclosed that she took her fi rst drink at age 12; her drinking escalated to what she identifi ed as alcoholic consumption by the age of 16. Nancy revealed that she had been sexually assaulted by a sister’s husband at the age of 12, which was ignored by her family. Nancy dropped out of high school at the age of 16 to marry her husband, who was also an alcoholic/addict. Nancy described a tumultuous marriage in which she was sexually assaulted by her husband on numerous occasions and in which their mutual drug and alcohol use yielded more than 20 years of unhappiness.

Nancy divorced her husband 7 years prior to this treatment episode, at which time her alcohol and drug addiction seemed to further fuel her sexually compulsive behavior with other addicted men. Nancy revealed that she and her husband had three children who were now young adults. Nancy openly identifi ed that her addictions had strained her relationship with her children and her elderly mother. Course of Treatment Intake Assessment At the time of intake assessment, Nancy was diagnosed with alcohol dependence, cannabis dependence, sedative dependence, and PTSD according to DSM-IV-TR criteria. Nancy’s sexual assault at the age of 12 was identifi ed as the primary criterion A trauma. Nancy’s sexually compulsive behavior was coded on axis IV.

Nancy successfully completed a 12-step facilitation treatment program  also reestablished contact with several AA groups during this treatment program, and she established a successful working relationship with an AA sponsor. As her 12-step facilitation program neared its end, Nancy requested to receive individual counseling…and started EMDR.

Nancy established two core treatment goals: (a) to remain abstinent from all alcohol and euphoria-producing drugs as evidenced by negative urine and saliva screens and (b) to address issues connected to self-image, especially those affected by her alcoholism, as evidenced by confronting issues connected to her self-image and her past, which would positively impact her ability to abstain from addictive behaviors. Nancy completed 15 EMDR sessions over a 9-month period, including fi ve sessions of future template work. Nancy chose to use tactile stimulation for her EMDR treatment after being presented with available options (eye movements, audio tones, tactile) during the preparation phase. Sessions 2 and 3 were the only 90- minute sessions; all others lasted 50 minutes. Nancy began EMDR with the original negative cognition of “I am shameful.” The cognition was fully resolved, and it generalized nicely since shame proved to be at the root of many of Nancy’s self-image problems and perceptions of her sexuality.

Sessions 2 to 6 focused on processing what Nancy assessed to be the negative cognition most inhibiting her progress in sobriety (i.e., “I am shameful”). Although she identified the sexual assault at age 12 as being her earliest memory of sexual trauma, a floatback was used to determine Nancy’s earliest experience of “I am shameful.”

At the end of session 2, Nancy engaged in a prolonged set of cathartic tears, noting relief that she was “finally able to tell somebody” the secret of what happened at age 10. The experience at age 10 seemed to affect the shame-based cognition even more than the blatant sexual assault at age 12 because of the secrecy factor. Nancy had managed to talk to certain individuals, albeit in a  superficial manner, about the sexual assault (age 12) over the years, but she maintained that the EMDR session was the first time that she ever voiced what happened to her at age 10.

In sessions 9 to 11, Nancy worked on another negative cognition that emerged as she attempted to do her fourth AA step: “I’m a failure.”

 

Throughout these three sessions on the new target, less affective disturbance was observed when compared to the processing of “I am shameful.” Session 12 addressed future template work that related to dealing with her mother’s belittling style of communication. Following session 12, Nancy took a hiatus from EMDR for two and a half months and worked on delivering her fi fth AA step to her EMDR therapist; Nancy felt it was important that someone with a trauma-sensitive perspective who already “knew her secrets” hear this step. Step 5 of the AA program is “Admitted to God, to ourselves, and to another human being the exact nature of our wrongs” (Alcoholics Anonymous World Services, 2001, p. 59), and it is permissible for a therapist to hear this step.

Other behavioral memories connected to her promiscuous sexual behavior while in active addiction also surfaced during the verbal delivery of her fifth step, and she reported relief after “getting the secrets out,” which is how she also felt at the end of session 2. Sessions 13 to 15 focused on EMDR closure, evaluating how she can apply her newly obtained beliefs “I am honorable” and “I am capable” to future scenarios in relationships, sexuality, work, and family relations.

 

Post-EMDR Assessment

Toward the end of her EMDR experience, Nancy was able to leave a job where she felt devalued, and she sought more meaningful employment. She attributed this exit to believing that she no longer had to tolerate being put down by others. Nancy was able to do the AA “inventory” steps (4 and 5) and “amends” steps (8 and 9) for the fi rst time in 12 years of recovery attempts. Nancy recognized that the shame blocks had kept her from doing these steps during past attempts at recovery. When treatment terminated in February 2008, Nancy had been free of alcohol and drug use for more than a year, she no longer met criteria for PTSD, and she had also refrained from sexually acting out since the beginning of her treatment. At the time of termination, she reported that she finally felt “worthy of a healthy relationship in which a man respects my total self as God does.”

TBC

 

References

1. Marich, J. (2009). EMDR in the Addiction Continuing Care Process Case Study of a Cross-Addicted Female’s Treatment and Recovery. Journal of EMDR Practice and Research, 3(2), 98-106.

 

 

 

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