About/ Comparison - Contrast/ Multiple Sources of Trauma (see the chemical dependency section), describes the physiology, neurological and hepatic changes resulting from chemical dependency that effect the delays in resolving the trauma. The delays provide time for neurological and hepatic damages to, at least in part, reverse themselves.
ETM application to chemical dependency is also systemic in its orientation. This systemic component is explained in Clinical/ Family). Because the systemic and intrapsychic elements for chemically dependent people overlap, you may find it beneficial to read that chapter in concert (before or after) with this one (also see About/ Development/ Family)
None of the comments in this chapter are intended to criticize the Twelve Steps or any aspects of the Alcoholics Anonymous self-help program; which is a competing philosophy or system of care. I believe the AA program to be a fine and very valuable treatment paradigm. Moreover, I recognize that constitutional provisions within that program preclude it from engaging in controversial processes, which could include defending its philosophy and methodology from evaluation and analysis by professionals or anyone existing outside of its organizational processes, including anything discussed here.However, because AA had developed the philosophy, theory and method for the treatment of chemical dependency in which I was trained and to which I initially subscribed, the primary method used for helping alcoholics to get and remain sober (see Level 4: "ETM Development"), and because those ideas and approaches were a part of the thought systems developed and established within the minds of chemically dependent people, who as a primary treatment provider I was also helping chemically dependent people to address psychological trauma resulting from the use, it is imperative that I explain the simultaneous application of both efforts, so that ETM philosophy, theory and methods and differences between them and the Twelve Steps are clearly understood.
This explanation is provided from the ETM/TRT perspective and is not intended to represent the views of those espousing the use of the Twelve Steps. In keeping with ETM policy on the treatment of differences between TRT and all other philosophies, theories and modalities, I recommend and encourage that any individual or professional also study or otherwise consider these comments from other vantage points, that is, from the review of the literature (The Big Book of Alcoholics Anonymous, 1939, and many other books and articles relating to the use and value of AA) describing the use of the Twelve Steps as a process for helping people to stop drinking.
This separation of the non toxic CNS from the toxic one is difficult because the psychology that adapted to the toxic biological reality has a vested interest in maintaining the toxic condition --- without the toxic condition the adapted psychology will gradually lose the physiological underpinnings of its existence. Consequently, when an individual makes a breakthrough to the realization that the use is harmful, the subsequent separation from that use also becomes an extraordinarily difficult process of separating from what had become, during the chemical use period, the only aspects of themselves about which they knew -- the psychological Self that had adapted to the toxic biological states.
During this recovery process, a value of the Twelve Steps is that they facilitate the person's realization that the adapted psychology (the one born out of changed/toxic CNS) is in control of that person, and that such controls result in a profound experience that is equivalent to being lost -- insanity. Because these adapted controls are so influential, and because they continue to exist at some psychological level despite conscious exclamations of determination to be different, and because this continuation of existence is underpinned by biological realities, that is, the brain still needs the drug(s) that has become a part of the neurophysiology, the person realizes that overcoming this apparently or prospectively inextricable system of control requires assistance from something more powerful than the newly emerging chemically-free biological and psychological state.
Thus, this additional power comes, depending on the person and his or her situation, from treatment providers, self-help groups, family members, a higher power as defined by the individual, and/or God. The more capable the combined therapies at helping the person to understand the effects of the chemical use process on CNS and accompanying psychological functioning, and withdrawal from those effects and processes, including the understanding of what can be expected to happen to, and what is expected from, the person during recovery, the more strengthened the person is thought to be in attempting to negotiate the process.
An alternative view is that an equal number of people complete the recovery process without the additional strengthening derived from participation in the helping efforts. Regardless of this view, I doubt that anyone could argue that helping assistance that provides for an interpretation of the experience and emotional processing during it is not something that is valuable to anyone suffering the trauma resulting from pathological chemical use.
An addition in our program to the intrapsychic elements of the recovery process (as it is discussed in this heading) is the systemic effects of the application of TRT to those surrounding the chemically dependent person. As described in Clinical Family and About/ Development, the resolution of the family member trauma resulting from the CDP's chemical use behaviors prevents, in theory, the CDP from projecting his or her own internal experience of trauma resulting from the pathological chemical use on to the family members who are participating in TRT.
Thus, when such projection is no longer available (to the CDP) as a vehicle for avoiding the experience of the internally retained trauma resulting from the use and use behaviors, the emotional pain and loss comprising the trauma begins to be consciously experienced. This conscious experience of the internal dynamics of the trauma, formerly repressed or obfuscated by survival and other defensive processes (denial), is identified as the initiation of a process through which the CDP is constantly confronted with the reality of his or her situation. Chemical dependency recovery and counseling language refers to this process as "bottoming out" or "hitting bottom." Therefore, systemic application of TRT to family members results in the facilitation of the process of "hitting bottom," where such a process is only thought to be an intrapsychic experience in other programs. In other words, some approaches claim that the chemically dependent person must choose sobriety after "hitting bottom," and that until this decision is made, nothing can be done to persuade this choice.
Through facilitation of the ETM family model, the concept of "choice" for sobriety is bypassed through facilitation of the experience that otherwise underpins such notions (the idea that chemically dependent people are choosing things).
To summarize this description of chemical dependency counseling as it is generally understood and provided within the parameters of ETM clinical applications, pathological chemical use is seen to foster an adaptive psychology that when confronted with sobriety, loses its hold on the person, but not without a struggle. This struggle is called recovery as it becomes a process of reclaiming a non toxically affected psychological identity out of one that has emanated from toxic influences.
Although some people argue that help is not needed to make this transition, chemical dependency counselers can at least claim that such help does provide for understanding of the process and the experience of a return to control of life processes. In the ETM program, resolution of the trauma for family members will, as a rule, bring about an increased probability of attaining sobriety when compared to the alternatives that or solely intrapsychically-based.
Treatment consists of a combination of cognitive-behavioral and psychodynamic therapies integrated with a parallel participation in the Twelve Step programs (Twelve Step program attendance is not required, but recommended). The goal is sustained sobriety. Objectives include identification of the drug use's adverse influences on life management processes and the establishment of a commitment to maintain a program of recovery, to eventually include addressing the psychological trauma resulting from the drug use. Myriad other goals, objectives and concepts surround chemical dependency treatment and the attainment of sobriety, but we leave them to other books on the subject, as the focus in this work is primarily resolving psychological trauma resulting from the use.
The CDP is assisted in applying into the Phase One format all trauma-causing drinking/drug use related incidents that may have contradicted the existential aspects of identity. Instead of using the second person language "you," the CDP writes the descriptions using first person language "I." This list of contradicting drug-influenced behaviors are shared with peers, other chemically dependent people. This sharing takes less than one group session. The CDP is facilitated in recalling as many of the episodes as possible before the family confrontation (of chemical use/ trauma-causing behaviors) session (see the Clinical/ Family Treatment). Because the CDP is able to observe other CDP's progressing through the same process prior to his or her experience of it, the client is aided in understanding what is required to complete the clinical procedure. Thus, this list is fairly accurately written by most chemically dependent participants.
The CDP then participates, with an additional agenda, in the family confrontation session; not only is the confrontation process (described in Clinical/ Family Treatment) intended to provide the system with certain benefits, that is, the confrontation provides for the beginnings of reestablishment of communication by the system and the system's identification of the trauma-causing incidents, but the information presented during the confrontation clarifies the CDP's recollections of those incidents that were left out, for example, incidents caused by chemically-induced blackout. Following the family confrontation, the CDP can make any necessary adjustments to his or her descriptions and then share what is written within the CDP peer group.
Like the family sessions, but unlike other TRT Phase One processes (for other trauma victims) where only one or a few incidents are shared at a time, the CDP client reads all of the incidents to the other CDP's (in the individual CDP group) in one session. This reading by the chemically dependent person of the trauma-causing behaviors usually takes 45 minutes, depending on the number of incidents recalled, and is profoundly moving for the group members as well as cathartic for the reader.
Thus, within the first 6 weeks of care, the CDP has a foundation in cognitive-behavioral, client centered, Twelve Step and the beginning of the TRT treatment methods. The sharing of the list of contradicting chemical use behaviors marks the end of the acute phase and the beginning of continuing care.
Moreover, everyone with over 6-10 months of sobriety is also participating in a CDP TRT group. Consequently, the patient's experience in the continuing care program is influenced by people who participate in both the Twelve Steps and the TRT trauma and loss resolution processes.
When the CDP begins to demonstrate abilities to modulate between emotional experiences and abstract thought, to maintain from session to session recollections of these experiences and other important emotional/intellectual interchanges, the person is referred into a TRT group. The CDP continues at least one continuing care (individual CDP) group and usually drops all others. The purpose of the TRT group is to provide for the resolution of the trauma resulting from the chemical use experience.
The first phase of TRT is usually rewritten to include considerably more detail than was provided in the writing and reading processes of acute care (occurring 6 - 10 months earlier). Then, the incidents described in the rewriting of Phase One are shared with the group. The pace and progression of this rewriting and reading process is the same as the pace and progressions of other TRT participants who have been affected by different sources of trauma.
When relapse does occur, standard relapse procedures are administered; they include the application of increased structure (more groups and Twelve Step meetings). Twelve Step program attendance is required following relapse.
Relapse usually results in attendance in at least one professional group and one AA group per day for the standard 90-meetings-in-90-days protective coverage. If the person stops quickly and is able to abstain, TRT is continued after a short period of discontinued reading or writing. The person does stay in TRT during this period. If the relapse is lengthy, say 2 to 4 weeks, then TRT is discontinued and the person becomes a candidate to begin the initial treatment cycle again. No CDP who is using is allowed to participate in any TRT or other kind of professional group. Frequently during sustained relapses, interventions are facilitated which assist the person into residential care. After a period of sustained sobriety, and depending on the judgment of the treatment team, the CDP enters the TRT group again.
With the disclaimer that I have not academically followed up on any of these cases for many years, but only periodically met chemically dependent people, their family members, and friends within the community, I have never heard of an individual (CDP) who has relapsed following completion of TRT. Neither has such a relapse been reported to me via the professionals now using TRT for the treatment of psychological trauma resulting from pathological drug use.
My guess is that if empirical studies on this subject were conducted (sustained sobriety is not the goal of TRT, but only a prospective additional benefit; the goal is resolution of the trauma resulting from the pathological use), the outcomes would show that no chemically dependent person would return to drug use following the application of TRT.
There is a purpose to this usage, especially when chemical dependency is involved. Many clinicians who are not ETM trained see chemical dependency either as a cause of everything or an effect of the same. When in reality, the science of the biology of chemical dependency shows cogently that the chemical dependency may be a variable that presents simultaneously, even coincidentally, with others. When that view is held, then the scope of the problems confronting the clinician are wider, and I believe reflective of the true clinical challenge. Without "comorbity," one or the other of the issues is usually minimized, which minimization can preclude achievement of any clinical goals. The clinician may then use personal philosophy to blame the patient for the failure.
Comorbity -- in this section, referring to ETM's address of multiple sources of trauma that include chemical dependency -- is referenced to and in About/ Theory/ Multiple Sources of Trauma. It provides formulas for applying TRT to the multiple sources of trauma, which include chemical dependency as a cause of trauma. The science of chemical dependency (as a cause of trauma) is considered in About/ Comparison - Contrast/ Multiple Sources/ Chemical Dependency.
To summarize these two reference chapters and their recommendations, when chemical dependency is one of the multiple sources, it usually is considered the most pressing trauma (it makes the greatest demand for clinical attention). TRT is applied to the chemical dependency-caused trauma, first, and then applied to the others. There are guidelines in the first reference that show how to make those applications.
Importantly for this chapter, because chemical dependency is (eventually) usually documented to early life years, there is a good chance that additional and non chemical dependency related trauma has occurred simultaneously with chemical dependency's. Making matters more complicated, although the pathological drug use may be biologically-based and occurring coincidental with the other trauma causes, like loss of a loved one to disease, accident, or violent crime unrelated to the chemical dependency, the pathological drug use will not only cause trauma but also act as a medicator of it, both that trauma caused by the chemical dependency and the other source(s).
Compounding the multiple sources issue even more, some chemical dependency behaviors resulting from toxic conditions can lead to circumstances where other trauma occurs. For example, when a person gets drunk, through impaired judgement the CDP can enter into circumstances where an accident caused by someone or something else can create the additional trauma. Another and frequent example involves rape of chemically dependent people. Because of judgement that is impaired by the toxic condition, the individual can become easy prey for violent predators. In these circumstances, the chemical dependency (instead of the perpetrators or other causes) is often blamed for the events. This blaming also leads to self deprecation. That supports continuance of the etiology, making its reversal more difficult.
In addition and regardless of the complications encountered because of the other source, it will begin to present during sobriety. Address it interimly (while focusing on sobriety and / or during etiology reversal of the chemical dependency-caused trauma) with TRT Phase One or client centered methods, but do not mistake that partial address for etiology reversal via TRT's full (all 5 phases) application to the additional source. That reversal should occur at a later time per the guidelines provided in the theory section pertaining to multiple sources.
The consequence of chemical dependency's myriad influences on trauma's address is that applications of TRT to the different sources are required over an extended period, and always in concert with maintenance of sobriety. This sounds tough, but CDP's are a much more resilient group of people that they may appear during the chemical use or early recovery stages. And even though the amount of work sounds substantial, and it is, CDP's always conclude that it is better to do it, and to do it completely, rather than to continue to living life within the nightmare of not knowing what happened to themselves.
First, not all CD experiences include this many different kinds of trauma-causing experiences for both the CDP and the family members. For example, only a small percentage of CDP's are batterers and sexual offenders (although large percentages of batterers and sexual offenders are CDP's).
Second, the list readings (Phase One) for CDP's assume that legal matters for perpetrators are properly, legally, and ethically addressed. This book does not cover this subject, as these are subjects for CD counseling (not restricted to psychological trauma counseling).
Third, the Phase One episodes are not written in the detail that a standard Phase One list would be written. The emphasis for this example is on the trauma's effects, all 4 patterns, and not the descriptions of the episodes. These examples, do, however, represent the standard for writing the first description of drinking/drug use behaviors that are provided by the CDP during the acute phase of care (these episodes are then rewritten, redescribed, when TRT Phase One is begun between the 6th to 14th month following the initiation of sobriety).
Fourth, readers who are interested in the idea of responsibilty and drug use are referred to About/ Comparison - Contrast/ Multiple Sources/ Chemical Dependency. There is, however, no reference in this book to the debate in the literature that considers the cause of violence: that is, does the alcoholism cause or disinhibit the violence? We have read that material, completed a review, but have saved it for another work that focuses solely on chemical dependency, perpetrators and psychological trauma.
Fifth, this example was initially written to correspond to a family treatment exercise that included the previous codependency trauma examples as the spouse of this (CDP) character. Thus, these examples are similar to the previous (spouse) episodes, but are provided from the perspective of the alcoholic.
Sixth, the reader is reminded that this example is fiction. It was created to meet professional training needs.
When chemically dependent people complete TRT, however, they do not believe that it is necessary to continue in a recovery program for life. They might (usually do) elect continued participation in the AA groups because they enjoy that program. The chemically dependent person who completes TRT enjoys integration and fellowship with people similarly affected by chemical use as he or she was affected, but not because the CDP considers that such participation is mandatory for the maintenance of continued sobriety.
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