Addressing Drug and Alcohol Issues in Posttraumatic Stress Disorder Patients - Essay Example

Posttraumatic Stress Disorder xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Name xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Course xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Lecturer xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Date ADDRESSING DRUG AND ALCOHOL ISSUES IN PTSD PATIENTS Introduction There is an emergent body of research investigating the link between substance abuse problems and exposure to traumatic events. A consensus around this research indicates that PTSD is not automatically associated with alcohol and drug abuse problems (Drapkins et al 2011). However, the two conditions have been proven scientifically as cormorbid as justified by a number of reasons. Development of alcohol and drug abuse has been linked to childhood physical and sexual abuse. Besides that, rates of substance abuse are reportedly high in battered women and disaster survivors as compared to others in society. Great deals of veterans diagnosed with PTSD have lifelong dependence on alcohol or other drugs further underscoring the comorbidity of PTSD and alcohol and drug problems. Evidence supporting the comorbodity of the two conditions is also evidenced in the increasing documentation of PTSD among a large number of veterans seeking alcohol and drug abuse treatments. Generally, research has proven a strong relationship between substance abuse and PTSD among both females and males. Of concern for researchers in this field, is the link between the two concepts. In order to conceptualize the link, several scientific and psychological models have been developed and have been used a framework for guiding clinicians in tackling the problem. According to the operant learning theory, substance abuse is viewed as an operant behavior which is developed and maintained by environmental, social, cognitive-emotional and pharmacological consequences contingent upon them. A common assumption by many clinicians is that PTSD patients tend to indulge in alcohol and drug abuse in order to decrease the distressing symptoms of the condition for instance avoidance of abuse-specific memories. Back (2011) terms substance abuse among patients of PTSD as an emotional avoidance whereby they are unwilling to face reality of the internal events occurring within them such as affective states, memories and thoughts associated with their traumatic or abusive histories. They therefore tend to hide under the shadow of substance abuse so as to alleviate, numb or reduce these internal self-evaluated negative experiences. The consequences of consumption in part justify acceleration of substance abuse among patients with PTSD. These consequences which include increased access to social contact, increased social confidence and temporary strength-sense of control enhance desired emotional effects. During acute alcohol and drug states, for instance, an individual is likely to express his/her hurting emotions such as rage and sadness. Sledjeski et al (2008) notes that drug and alcohol abuse increase with numbing/avoidance behavior as the patient attempts to induce sensations that are otherwise short-lived. Consistent with the self-medication hypothesis providing a rational behind substance abuse, PTSD patients will tend to use alcohol or drugs in the effort to reduce anxiety and tension. The classical conditioning theory of relapse states that the stimuli that results from alcohol and drug consumption consequently elicit certain conditioned responses such as drug craving. Stimuli triggering these automatic or involuntary responses include smell, sight, drug paraphernalia, times of the day, people and places. Exposure to these triggers and the elicited physical responses accelerate the likelihood of substance abuse. Since patients of PTSD tend to use drugs in the presence of PTSD symptoms that occur due to traumatic memories or reminders, these stimuli that is trauma-related may also elicit urges to abuse drugs. Challenges in addressing the issue of substance abuse in PTSD patients Clinical researchers have continually emphasized on a concurrent approach to treatment of the two conditions; PTSD and substance use disorders (SUD) that have now been proven cormorbid. According to research, patients of PTSD and SUD posit that the two are functionally related thus treatment should be done concurrently rather than separately to save on time and money. However, there is no substantial research that has been conducted to determine effectiveness of concurrent treatment of the two conditions although several preliminary studies have been conducted to find out the extent of use of the approach. Even with the emergence of the new approach of treatment, there are many notable barriers or challenges during the therapeutic process originating from both the care provider and the patient. These challenges greatly hinder attainment of the desired outcomes or the objectives of the process. According to Read et al (2004), PTSD patients with SUD have different coping styles relative to normal people which greatly hinder treatment outcomes. PTSD is characterized with coping strategies that are emotional-focused rather than problem-focused similar to SUD patients. These coping styles which include avoidance coping are ineffective in the sense they precipitate substance abuse and reinforce ongoing trauma-related symptoms. As a result, patients focus on eliminating the symptoms rather than treating the core issue. In addition to emotion-focused coping, PTSD patients with SUD comorbidity demonstrate reduced expectation of benefits from anything they do including quitting from drugs and alcohol and thus find it futile to embark on any interventions. Patients’ belief about trauma and PTSD is another major barrier impeding effective treatment outcomes. Some of the beliefs that PTSD patients report during treatment procedures are self-blame, shame and emotional pain that are associated with the condition. They demonstrate mistrust towards the treatment provider and they fear that others will get to know about their traumatic history which will make the situation worse. The result is that most of the PTSD-SUD patients’ end up unscreened and the condition might reach levels that are difficult to control or manage. Even so, some patients comply with referrals but are still unwilling to provide all the relevant information necessary to complete the treatment (Bonin ate al 2003). Development of PTSD and SUD brings along a series of changes in the life of the patient usually associated with behavior change and the task of coping. The problems include constant conflicts with others, health problems, diminished social support, short-term memory, impaired concentration and low job performance. The problems present a whole new challenge in addition to the ongoing trauma symptoms. The process of treating the condition becomes complicated as the patient becomes confused on the issue to handle first and loses focus in course of the therapeutic process. This problem is associated with difficulties in self-monitoring; the patient cannot assess progress due to emergence of other minor conditions in the course of treatment (Santiago et al 2010). The common challenge faced by care providers during rehabilitation of patients with PTSD is misdiagnosis of the disorder. Symptoms of PTSD are quite similar to those of substance abuse disorders and the two are routinely confused. Even with evidence about comorbidity of the two conditions, clinicians are often quick to judge symptoms of PTSD as those of substance abuse. The masked symptoms worsen the situation as traumatic conditions go unattended. Ways of overcoming the challenges Underdiagnosis is clearly a key challenge in effective rehabilitation of PTSD patients with alcohol and drug abuse disorders. As such, clinicians have the role to conduct systematic screening by routinely assessing substance abusers with traumatic histories and on the hand screening substance abuse in patients with PTSD. Wilson and Keane (2004) maintain that constant inquiry about a substance abuser past experiences gradually increase the probability to identify or diagnose PTSD thus facilitating early intervention. It should be noted that symptoms of SUD often suppress or mask those of PTSD which necessitates systematic and careful screening. In addition to systematic screening, functional assessment is also recommendable. The primary goals of functional assessment are to determine changes in behavior and to understand context, functions and utility of behavior problem. Essentially, the therapist embarks on the task with the aim of establishing the controllable variables in the behavior change whose manipulation can assist in achieving the desired outcomes. As such, the therapist identifies instances when the client is likely to indulge in drinking or drugging, the frequency and quantity of consumption. This can be achieved through interviews with the client and use of comprehensive instruments such as Comprehensive Drinker Profile, Alcohol use Inventory and Addiction Severity Index. The therapist can also give the patient homework assignment to record problematic situations such as work stress and marital disputes, PTSD symptoms and urges to drink or use drugs. This creates a form of self-monitoring strategy and fosters a sense of abstinence. As part of assessment and valuation, therapists should ensure follow-up systems preferably through telephone in order to gather information concerning therapy progress. Results obtained are valuable in redesigning interventions (Bennett 2006). Developing a therapeutic relationship is a proven fact in eliminating interpersonal problems possessed by patients of PTSD such as interpersonal fear, conflict with authority, anger and mistrust. This is because therapies are conducted in social contexts including support groups where the individual interacts with other poeple. This can be achieved by use of nonconfrontational approach rather than the traditional confrontational approaches that tend to stir up conflicts. Client’s perceived safety with the clinicians may be determined by a number of factors including the general set up the clinic, gender of the care provider and the nature of the interview by the clinical and clerical staff. Back (2011) maintains that trauma-related discussion should be done completely separate from other therapeutic group activities which therefore, implies that a patient attempting to discuss their traumatic experiences in substance abuse group discussions should be disrupted immediately. Since PTSD is often characterized by mistrust, shame and guilt, treatment should begin at an individual level instead of the group-centered treatment approach which advocates for commencement of the treatment at the group level. Setting goals during the early stages of the treatment bestows a sense of responsibility upon the client and builds motivation to achieve positive results. Motivation levels at the initial stages are relatively low as the patient focuses more on healing from the trauma-related problem and overlooks the substance related problems. In actual fact, the problem of substance abuse in PTSD patients is likely to accelerate during this stage as they consider it part of the remediation strategy to their distress. In order to avoid this, the therapist should discuss the drawbacks and benefits of substance abuse with the patient right at the commencement of the treatment. Better still; the client can be given homework assignments to record the pros and cons that he/she identifies during drug/alcohol use and during abstinence. More importantly is to set goals concerning drug and alcohol use. This together with review of drawbacks and benefits will establish a concrete commitment for the patient to make change (Bennett 2006). Motivation can also be enhanced by supporting self-efficacy, avoiding arguments, developing discrepancy and expressing empathy. The aim of these strategies is to minimize therapist-client conflict as well the probability of resisting therapy. Motivation should be maintained throughout the treatment as withdrawal symptoms are unavoidable during early abstinence. There is often an increased risk of suicide resulting from worsening PTSD symptoms and resurgence of traumatic memories. As such, patients require maximum support during this period more so by helping them to develop strategies of controlling the symptoms and urges to substance use (Back 2011). Bonin ate al (2003) asserts that repeated exposure to drugs and alcohol poses a great threat to the treatment process and undermines attainment of sustained abstinence. Thus, a fundamental goal is to change the patient’s lifestyle and environment in order to minimize exposure. Neighborhoods, recreational activities, occupation, peers and family are factors that increase accessibility to drugs and alcohol. In addition, a crucial step in sobriety is to alter the social environment of the patient. This means improving the interaction of the patient with other people, reducing their contact with substance user and increasing their participation is support groups comprising of other abstainers. Conclusion PTSD and SUD are characterized by a range of commonalities which has actually led to a form of combined treatment for the two conditions. The two are associated with overuse of avoidance strategies, difficulties in controlling physiological arousals and intrusive thoughts. Comorbidity of the two conditions presents a variety of challenges during treatment procedures. The challenges are related with mistrust, fear, lack of motivation and relapse of symptoms. Strategies to overcome the challenges include modification of the social environment, minimizing exposure to alcohol and drugs, building motivation, developing a therapeutic relationship and use of functional assessment. References Back, S 2011, Towards an improved model of treating co-occurring PTSD and substance use disorders. American journal of psychiatry, Volume 167, no. 1, p.11-13. Bennett, L 2006, New topics in substance abuse treatment. New York: Nova Science Publications. Bonin, M, Norton, G, Asmundson, G, Dicurzio, S, and Pidlubney, S 2003, Drinking away the hurt: The nature and prevalence of PTSD in substance abuse patients attending a community-based treatment program. Journal of Behavior Therapy and Experimental Psychiatry, Volume 31, p. 55−66. Drapkins, M, Yusko, D, Yasinski, C, Oslin, D, Hembree, E, Foa, E 2011, Baseline functioning among individuals with posttraumatic stress disorder and alcohol dependence. Journal of substance abuse treatment. Volume 41, p. 186-192. Read, J, Brown, P, and Kahler, C 2004, Substance abuse and posttraumatic stress disorders: symptom interplay and effects on outcome. Addictive Behaviors, Volume 29, p. 2665−2672. Santiago, P, Wilk, J, Milliken, C, Castr, C, Engel, C, Hoge 2010, Screening for alcohol misuse and alcohol-related behaviors among combat veterans. Psychiatric services, Volume 61, no. 6. Sledjeski, E, Speisman, B, and Dierker, L 2008, Does number of lifetime traumas explain the relationship between PTSD and chronic medical conditions? Answers from the National Comorbidity Survey-Replication (NCS-R). Journal of Behavioral Medicine, Volume 31, p. 341−349. Wilson, J, and Keane, T 2004, Assessing psychological trauma and PTSD. New York: Guilford press. Read More