A Case Study Exploration by Kelly Smyth-Dent, MA and Nancy Brittain, MSW
Substance abuse is often like the tip of an iceberg: the visible manifestation of underlying pain that runs much deeper. In treating substance abuse, it is important to understand and address not just what is immediately visible, but also what lies below the surface. In order to safely explore underlying issues, teens and young adults must get out of “crisis mode” and achieve a level of safety and stability. This case example illustrates how outpatient substance abuse treatment can lay the groundwork for successful resolution of both substance misuse and underlying trauma.
Rachel entered Sandstone Care’s intensive outpatient substance abuse treatment program at age 16. She had been smoking marijuana heavily, and had been fighting nearly constantly with her parents. The whole family was exhausted and at their wits’ end. Rachel had begun running away from home for longer and longer periods of time. Her parents frantically read parenting books, searching for the formula that would help them understand and manage Rachel’s behavior, but seemed to get caught up in the same fights despite their best efforts.
When Rachel began the program, she was shut down and distrustful of the adults leading the groups, and somewhat aloof from her peers in the program. She showed little emotion and would sleep all day if allowed. She was deeply unhappy. As she settled into her IOP program, Rachel gradually began to share more in groups with her peers and to joke around with the staff. She slowly engaged more and more with her family as well, going from stonewalling them during the first multi-family group to actively engaging and participating in family activities.
Rachel’s marijuana use also declined steadily during her time in the program. When she worked with Sandstone’s psychiatrist Dr. Mary Braud to find a medication and dosage that was right for her, started to open up to her peers, got caught up on her schoolwork, and was experiencing less family conflict, she found she had less of an urge to use marijuana to numb herself. However, as Rachel began feeling less numb and experienced more safety in her relationships, she revealed that she had been sexually abused by a family friend as a child. She was reluctant to share this, not wanting to have to relive every detail of the experience or to share it with people that she did not want to. However, by revealing her secret, Rachel opened up a door into even greater healing – her behaviors which previously had seemed inexplicable now could be made sense of in the context of a trauma response. By addressing this root cause of her pain, Rachel could find an even greater degree of freedom and integration.
One of the beautiful aspects of psychotherapy is that one does not necessarily need to relive or explain in detail the traumatic experiences they had in past in order to obtain a sense of healing in the present. Often times, people are scared to see therapists to discuss their trauma or disturbing experiences due to shame or just a desire to move on with their life and not rehash the painful memories. Fortunately, there is hope for all those who want to experience emotional and relational healing.
It was through establishing a foundation of sobriety, decreasing family conflict enough that the house did not feel like a war zone, and experiencing the safety of caring peers and therapists that Rachel reached a point where she was ready to begin addressing the trauma that lay at the root of her challenging behaviors.
Every person responds to traumatic events or situations in different ways. A traumatic event could be a very obvious and overt situation of victimization, such as abuse, rape or experiencing/witnessing domestic violence. It could be a car accident, the sudden death of a loved one, or an unexpected illness or surgery. Or, you could have experienced (or are still experiencing) a different type of disturbing situation, one that is less obvious, a more implicit type of trauma perhaps, that has become your new normal. These disturbing experiences were such normal and regular occurrence in your life that eventually, you didn’t see much of a problem with it anymore, even though it still bothered you. Or, maybe you have thought to yourself that you “shouldn’t” have a problem with this situation because this is normal in your family. You wonder, isn’t it normal for everyone? But deep down, you may be feeling shame, sadness, anger, frustration, or a lack of connection with yourself and others, as a result of these disturbing occurrences.
Examples of these less subtle messages or occurrences in your life could be:
Situations such as the ones above are tricky to recognize as “trauma” because they are not as overt as sexual abuse, a severe car accident or coming home from war. But the messages received during these situations stick with us. They become so integrated into our brains and bodies that they continue to affect our daily lives and relationships. They become our new normal. We accept messages, such as “I’m worthless,” “I’m not good enough,” “I should have known better,” or “I am powerless.” However, when we accept these situations and messages as normal, as our fault, as “the way it is” then the negative feelings associated with them creep into us and throughout our bodies. We begin to feel depressed, anxious, confused, frustrated or “crazy.”
Everyone responds to these events differently. Some people feel angry, confused, and agitated. Others feel they aren’t safe, can’t trust people and become isolated. Others feel that they are unlovable or will never succeed. These are all common responses to trauma or disturbing experiences, but they don’t have to dictate or control your life. Psychotherapy can help you take the control back, learn new coping skills and liberate yourself from those experiences. Many people do not even realize that their disturbing experiences may qualify as trauma. You know something “isn’t right,” but you don’t know what to do with feeling.
Many people are afraid to confront their trauma, thinking that they need to share every detail of their experience with their therapist. It is possible to work through your traumatic experiences without rehashing every detail or explaining all of your experience to your therapist. Research suggests that having a consistent and safe attachment figure experience can heal trauma wounds (i.e., my relationship with Paul). Another evidence-based practice is an approach that I use with clients called EMDR – Eye Movement Desensitization Reprocessing. It is a process that allows your brain to work through the trauma in order to become a fully integrated experience, which ultimately relieves you of the negative beliefs and symptoms associated with it.
Eye movement desensitization reprocessing (EMDR) is a type of psychotherapy that enables people to heal from the symptoms and emotional distress that are the result of disturbing life experiences. It is widely assumed that severe emotional pain requires a long time to heal. EMDR therapy shows that the mind can heal from psychological trauma much in the same way that the body can recover from physical trauma if given the proper environment in which to heal.
For example: when you cut your hand, your body works to heal the wound. If your wound is not given the proper cleaning, medication, and protection, it will likely get infected and could cause further damage elsewhere throughout your body as it spreads. But, in a consistently clean and protected environment with bandages and medication, your wound will normally have the ability to heal itself. Even if it leaves a scar, you will likely be able to move forward with your life. EMDR creates the environment for your mind and emotions to heal themselves.
The brain’s information processing system naturally moves toward mental health. If the system is blocked or imbalanced by the impact of a disturbing event, the emotional wound festers and can cause intense suffering. Once the block is removed, healing resumes. Using EMDR therapy, clinicians can help clients activate their natural healing processes. To learn more details about EMDR, visit http://www.emdr.com.
Although EMDR is an effective method for healing trauma and disturbing experiences, it is important to understand that EDMR is not an alternative to substance abuse treatment, family therapy, play therapy and other types of psychotherapy treatments. Rather, EMDR is a supportive tool to use in conjunction with the treatment one is already receiving. It is not a quick fix or the sole therapy with which one is recommended to receive for healing. However, EMDR in conjunction with other types of therapy can be used to help people get to the root of the issue faster and potentially speed up certain areas of treatment as a result.
Not every person is eligible for EMDR at all phases of their treatment. There is a screening process to make sure that clients are ready for EMDR before it begins, so as to not be harmful to clients. The process of EMDR can bring a lot of painful emotions and experiences to the surface of their mind, which can be difficult to tolerate. Therefore, clients must be motivated and have a positive support system and coping skills, to be in a stable enough emotional state for EMDR to be safe and effective. Often times, weeks or months of prep work is needed before EMDR therapy begins.
To learn more about Kelly Smyth-Dent’s practice, go to www.kellysmythdent.com. Kelly Smyth-Dent is trained to conduct EMDR with clients and is available to receive new clients. She offers therapy services in both English and Spanish and is located in Northwest Denver. In addition to individual EMDR therapy, she also provides play therapy, and family and couples therapy.
Nancy Brittain does community outreach and helped build the family program for Sandstone Care. She also has a private practice in Greenwood Village where she works with families with teenagers as well as couples and individuals. Learn more about her practice at https://thrivefamilyservices.com/.