November/December 2010 Issue

The Legacy of Addictions: A Form of Complex PTSD?
By Claudia J. Dewane, DEd, LCSW
Social Work Today
Vol. 10 No. 6 P. 16

“The alcoholic family is one of chaos, inconsistency, unclear roles, and illogical thinking. Arguments are pervasive, and violence or even incest may play a role. Children in alcoholic families suffer trauma as acute as soldiers in combat; they also carry the trauma like an albatross throughout their lives.”

— Pamela Weintraub

Does this albatross make adult children of addiction prone to a type of posttraumatic stress disorder?

Much of my clinical work has involved clients with posttraumatic stress disorder (PTSD), from Vietnam War veterans to victims of military sexual trauma and those with adult trauma. Many women who were sexually assaulted while serving in the military had experienced childhood trauma, and research continues to explore that connection. Is it an overrepresentation of already-traumatized women who join the military as a means to escape toxic childhoods or family situations? Or because they experienced childhood trauma, are they more susceptible to another trauma as adults? Do they in essence become “trauma magnets”?

The question is similar for those living with the legacy of addiction. This article explores that possibility and presents a treatment protocol building on the work of Pete Walker, MA, MFT, a marriage and family therapist who has worked extensively with adults traumatized in childhood. His work focuses on the complex PTSD secondary to childhood abuse. I found his framework applicable to those who also endured the confusing childhood environment of addiction.

PTSD, as we know it in the DSM-IV, is a reaction to a prescribed event, usually a one-time specific and defined trauma such as war, rape, or a natural disaster. Recurrent, intrusive images or recollections of the event, sometimes dissociative episodes, are symptomatic of PTSD.

For example, I had worked with, by all appearances, a very functional former Marine who was a veteran of the Vietnam War. He ostensibly “had it all”—a college education, a lucrative business, a beautiful wife, and two young boys he adored. While he was on a business trip, I received a call from security officials at an airport. (The client had my card in his pocket.) My client had been waiting to board a plane. As he slung his suitcase bag over his shoulder to board, he experienced a true flashback: He was back in the jungle slinging his rucksack over his shoulder. He began acting as if he were on patrol, which led to security being called. He came out of the flashback as I talked to him on the phone, but we both decided he should not board the plane that day.

That example is a true flashback, an intrusive and dissociative recollection. The National Center for PTSD distinguishes between this type of PTSD and complex PTSD. Complex PTSD is not listed in the DSM-IV, and many researchers assert it should be considered for inclusion in the DSM-V, corroborated by the argument that neuroscience should now be incorporated into the DSM.

Many clinicians and researchers believe cumulative, prolonged, or repeated trauma, such as being a prisoner of war or a Holocaust survivor, deserves its own category (Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997). This history of subjection to totalitarian control can also be exemplified by living in extremely dysfunctional families. The symptoms of complex PTSD include alterations in emotional regulation and consciousness, changes in self-perception, alterations in perception of the perpetrator, alterations in relations with others, and changes in a person’s system of meanings, including a tendency to blame oneself for the abuse (Herman, 1997). Comparing these symptoms of complex PTSD to those features of adult children of addiction reveals striking similarities (see Table 1).

The tendency has historically been to view victims of dysfunctional childhoods as irreparably damaged, with a characterological disorder suggesting that the severe psychological consequence that occurs with prolonged exposure to trauma is some form of character weakness. Reconsideration is being given to diagnoses such as borderline, antisocial, and schizoid personality disorders and dissociative identity disorders as potentially having complex PTSD.

The symptomatology of complex PTSD includes a conception of emotional flashbacks—emotional and intrusive recollections of overwhelming feeling states of childhood: fear, shame, alienation, rage, grief, and/or depression. Walker (2009) calls these sudden and often prolonged emotional regressions to the frightening and abandoned feelings of childhood “amygdala hijackings.” The amygdala performs a primary role in the formation and storage of memories associated with emotional events, suggesting that prolonged fear may result in permanent changes in the brain, with lingering synapse hyperreactivity.

The tendency to overreact may be rooted in permanent fear conditioning, both emotionally and physiologically, with a number of resultant sympathetic nervous system responses (e.g., rapid heartbeat, respiration, cortisol production, immobility). The psychic imprinting of PTSD results in changed brain chemistry; the amygdala triggers the nervous system and panic, and prolonged panic may result in permanent panic.

For example, a highly educated, 45-year-old professional woman described an incident in which her father, whose parenting was characterized by emotional unavailability, railed at her for some of her parenting techniques. She became immobilized and described being reduced to an emotional pile of rubble, feeling that she was again a 10-year-old girl and totally incapable of responding appropriately. Is this perhaps an example of an amygdala hijacking?

Walker says, “I believe one of the key processes of recovering from complex PTSD is deconstructing the toxic superego/critic and reconstructing and replacing it with a healthy ego/executive function that is user friendly to the individual. As this is achieved, one’s narrative about one’s life becomes more complete, accurate, congruent, and capable of generating healthy self-compassion and self-protection.”

That interpretation is reminiscent of ego reconstructive goals of psychodynamic approaches, providing the secure object relation, but it also goes further. The approach combines the best of the theoretical frameworks of psychodynamic and postmodern. Some may see these theoretical approaches as being contradictory, with one soundly rooted in the past and the other fluidly rooted in the future. I prefer to view them as using the past and the present to create the future.

Conceptualizations of Trauma
In his reconceptualization of trauma, Walker suggests that complex PTSD is an attachment disorder and that clients who go untreated rely on a number of self-injurious defenses. His trauma typology includes the four Fs: the tendency to use the fight, flight, freeze, or fawn responses. These reactions are defense mechanisms designed to escape danger and ways to get some sense of attachment. In object-relations explanations, this process is called “trauma bonding” (Cooper, & Lesser, 2002), which comes from an earlier psychoanalytic term of “identification with the aggressor.”

Some children react to abuse or neglect by overidentifying with their inadequate caretaker, sometimes even merging their identity with this person and adopting perfectionism as the only way to survive in an unpredictable and unsafe world—the trauma bond. The child learns to act in a certain way to avoid or prevent the trauma of abuse or abandonment. Paradoxically, the child develops a strong affective bond to the abusive person. The child needs the relationship, so separation from that person can intensify the bond, increase idealization of the relationship, contribute to the victim’s sense of psychological powerlessness, and result in an inability to form another primary relationship. What may appear as a strong connection in a child-parent relationship may actually be a strong trauma bond and not a healthy, secure attachment.

This arrested development morphs into damaged self-esteem. In adulthood we see the unrealistic and self-blaming “if only” behaviors: “If only I were perfect,” “If only I didn’t do stuff to make him mad.”

Emotional Neglect
When we think of trauma, we think in terms of physical abuse and fear, but emotional neglect is suggested as the primary cause of complex PTSD. Emotional neglect occurs when a supportive caretaker is unavailable to provide comfort or protection. Adults who were neglected as children never felt special, loved, wanted, or important. We’ve all seen kids get off the school bus and run into someone’s waiting arms. What if they had no one who was happy to see them get off the school bus or, worse, were expecting to be met at the bus and learned not to rely on such expectations? These children grew up thinking they were a burden and as adults think of the world as a terrifying place with no refuge. No one answered their cries for help, literally or figuratively, giving way to emotional flashbacks in which defensive reactions are used throughout life. “How can you stand to listen to people’s problems all day? You must be so sick of hearing the same ones from me” may be a disguised repetition of this world view.

Emotional flashbacks usually do not have a visual or memory component to them like a recurrent intrusive recollection of PTSD. Therefore, the individual rarely realizes that he or she is reexperiencing a traumatic time from childhood. It may be seen as a descendent of dissociation, what Walker calls “a gross overfiring of right-brain emotional processing with a decrease in cognitive processing in the left brain.”

The four Fs are conceptualized in Table 3, describing appropriate and inappropriate examples of defensive reactions.

Fight, rooted in a protective narcissistic survival response, happens when people demand perfection of themselves and others and get stuck in “injustice collecting.” Flight defenses, such as obsessive-compulsive behaviors, can manifest in a variety of physical and emotional escapes. I’ve seen PTSD clients counting the ceiling tiles in my office or obsessively focusing on bodily sensations while simultaneously recounting trauma-laden material. It can also be seen in a tendency to personalize and catastrophize: “My husband looked at me funny; I know he is having an affair.”

Freeze reactions, usually a type of dissociative defense, don’t need to be as dramatic as a dissociative identity disorder; it can be manifest in a chronic inability to make a decision. Fawn, a defense rooted in the loss of ego differentiation, is evident in codependent behaviors or being inappropriately passive.

Some clinicians who specialize in traumatology define complex PTSD as an attachment disorder. Thus the therapeutic relationship in working with adult children of addiction is so important because it represents the only safe relationship in which to try different ways of relating and attachment. In the context of the therapeutic relationship, the client can begin to replace unhealthy responses and construct a new life narrative, one in which traumatic events don’t define them.

Treatment with those traumatized by a legacy of addiction and experiencing emotional flashbacks would include the following, as laid out by Walker in the article “13 Steps for Managing Flashbacks:”

• Providing psychoeducation about emotional flashbacks, realizing that knowing gives some relief, but insight is not always followed by change.

• Helping clients identify flashbacks, the unique defenses used, and how they are hampering healthy relationships.

• “Tears of relief and tears of grief”—grieving the lost childhood and nurturing.

• Deconstructing the “inner critic,” a hypervigilant superego makes a person develop perfectionism; the person is always on trial or always on guard.

• Giving specific tools to handle emotional flashbacks.

Walker says our role may lie in rescuing the wounded child. Emotional flashbacks can be seen as messages from the wounded child, as if the child is seeking validation of past abuse and neglect: “See how bad it was? See how scared I was most of the time? I try not to be that scared, so I _____ (fight, flee, freeze, or fawn).” The needs for nurturing are still being sought. Clients can be taught that these emotional flashbacks are messages from a child still searching for attachment and seeking safety.

If a therapist consistently responds in a compassionate manner to a client’s manifestation of suffering, the client can begin to internalize self-empathy and strive toward self-soothing. The client may not take total ownership of reactions to childhood abuse and neglect. As flashbacks decrease, the defenses, in the form of narcissism, obsessive-compulsive disorder, codependence, and the like, also start to crumble.

It seems reasonable to hypothesize that clients who present with the legacy of addiction may indeed have a form of complex PTSD, an attachment disorder. Using this framework may open the way to a liberating approach for both clients and therapists.

— Claudia J. Dewane, DEd, LCSW, a clinical social worker for 30 years with a specialty in trauma work, is an associate professor of social work at Temple University.

References
Cooper, M., & Lesser, J. (2002). Clinical social work practice: An integrated approach. Boston: Allyn and Bacon.

Herman, J. (1997). Trauma and recovery: The aftermath of violence — from domestic abuse to political terror. New York: Basic Books.

Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F. S. (1997). Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV Field Trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress, 10(4), 539-555.

Walker, P. (2009). Emotional flashback management in the treatment of complex PTSD. Retrieved from http://www.psychotherapy.net/article/Emotional_Flashback_Management

Table 1

— Table created with information from Adult Children of Alcoholics by Janet Geringer Woititz, EdD, and Trauma and Recovery: The Aftermath of Violence — From Domestic Abuse to Political Terror by Judith Herman, MD

Table 2

— Conceptualized by Claudia J. Dewane, DEd, LCSW

Table 3
Trauma Typology

— Conceptualized by Claudia J. Dewane, DEd, LCSW, based on the work of Pete Walker, MA, MFT