Inter-Connectedness Between Trauma, Posttraumatic Stress Disorder Symptoms, Dissociative Symptoms, and Heroin Use

A study done in 2009 that explored the relationship between (number of lifetime traumatic events

, levels of PTSD symptoms, and level of dissociative symptoms) as they relate directly to lifetime heroin use among heroin abusers suggests to this author that there is the need for continued research and development in this highly specialized and complex field in order to offer the most effective treatment possible. It still appears that the addiction field as well as Mental Health field are not working together to integrate both bodies of knowledge to create more comprehensive approaches to treatment. This author believes that the complexity of trauma treatment should only be done when there is adequate supervision, staffing, and specially trained practitioners in specialty areas such as EMDR and Somatic Experiencing for the risk of re-traumatizing the individual by an untrained professional or inappropriately selected client. The literature suggests that trauma treatment should only begin when the client has adequate internal coping resources. The client generally should be stable enough emotionally to process the material that comes out in the treatment process. Starting this kind o work often is long-term in nature, rather than short-term meaning (not a 30-day fix) which is how long many clients stay at treatment centers could also be damaging in the long-run in that it's like opening "Pandora's" and box just before the client is ready to leave saying "oh, I'm sorry, I forgot to shut it." The positive thing from this study as well as the studies referenced below is that we are seeing that addictive disorders do not "stand alone" they are connected to something of the past that the client has not been able to make closure with.

Previous research done by the following researchers has noted a positive relationship between multiple traumas and both PTSD symptoms (Banyard et al., 2001; Kubiak 2005; Perkonigg, Kessler, Storz, & Wittchen, 2000) and levels of dissociation (Banyard et al., 2001). Currently the literature reflects that the levels of dissociative symptoms clients report are in fact, significantly related to lifetime heroin use, with those participating in a prior study reporting higher levels of dissociative symptoms being more likely to report having used heroin. These results are consonant with the DSM-IV-TR (APA, 2000) criteria for the avoidance/numbing symptom cluster in which clients report "efforts to avoid thoughts, feelings, or conversations associated with the trauma" (p. 218). Dissociation would provide a person a way to avoid the unpleasant thoughts and feelings associated with whatever trauma he or she has experienced.

It should be noted that 25% of the participants in a study done at a Florida addiction treatment center admitted having used heroin at some point in their lives. It's important to note that because the sample for the study consisted of the entire client census attending treatment on the day that the surveys were administered, practitioners and administrators working with a substance-abusing population should be aware that approximately 1 in 4 of their clients may have a history of lifetime heroin use. Heroin use places the individual at high risk not only for addiction but also for numerous negative legal and health-related consequences (Hser et al., 2007; Hser et al., 2001; Kalyoncu et al., 2007; Raj et al., 2007). Although clients may not be using heroin when they enter treatment, their use of this drug in the pastJournal of Addictions & Offender Counseling April 2009 Volume 29 would indicate that they are willing to engage in very risky behavior. This tendency toward risky behavior, in addition to maintaining their addiction and increasing the potential for poor health outcomes, might affect treatment outcomes and relapse potential. Therefore, determining whether a client has used heroin at some point in his or her life will help the counselor formulate treatment plans and assignments that target not just heroin use but also the possible risky lifestyle that the client may prefer.

As we move forward with enhancing treatment options, presenting the need for treatment to insurance companies, our clients, and treatment centers need to be better prepared for having to justify the need for treatment based upon more than just a "clinician's judgment" because they have been practicing 30-years. Too often, in the field of addiction especially, people rely upon "past experience" or "what has worked" in the past and when working with a trauma population it is very important to rely upon assessment tools that are designed to provide a clear picture of where the client fits diagnostically even before beginning specific trauma treatment. The need for the use of the Dissociative Experiences Scale is made very clear in light of findings of Juhnke, Vacc, Curtis, Coll, and Paredes (2003), relative to a survey of substance abuse counselors, which discovered that the frequency of use of assessment tools was very low. They showed that some of the most widely accepted assessment tools were rarely used by clinicians and hypothesized that substance abuse counselors may over rely on their abilities to diagnose without assessment tools because "they believe that they have sufficient clinical experience to make an accurate diagnosis without the use of standardized assessment instruments. However, such emphasis on clinical assessment may be unreliable and based on intuition, rather than on validated criterion data" (Juhnke et al., 2003, p. 69). These authors also indicated several other reasons for this apparent reluctance to use standardized assessment tools, including a lack of specific training on assessment, a bias against diagnosing, and a preponderance of master's-level counselors conducting assessments. Peters, Yocoubian, Baumler, Ross, and Johnson (2002) have suggested that clinicians need to be prepared to properly assess clients for specific drug usage (e.g., heroin) rather than for more generic substance use. Therefore, the present findings provide counselors with an initial indication that using the DES (a brief assessment tool that master's-level practitioners are qualified to use) can be a heroin-specific assessment tool to target treatment toward addressing either heroin use or risky behaviors, particularly with clients who are polyaddicted and treatment resistant.

The indications overall regarding this populationprovide clinicians with some guidance about how the link between subclinical dissociation and heroin use may affect treatment. Dissociation is often thought of as falling on a continuum that goes from common daydreaming and absorption, to less common meditative and hypnotic experiences, to even less common shamanic possession and religious healing experiences, to the extremes of the dissociative disorders (Holmes et al., 2005; Martinez-Taboas & Bernal, 2000). The results generally indicated that mean dissociation scores for both the heroin use and nonuse groups were below clinical levels; however, the mean was significantly higher for the heroin use group than for the nonuse group. It is possible, therefore, that clients with a history of heroin use may be more likely to engage in dissociation during treatment as a means of escape from the discomfort experienced during the treatment process than are their peers who do not use heroin. Thus, practitioners should become aware of Journal of Addictions & Offender Counseling April 2009 Volume 29 91 the need for screening for dissociative disorders among their clients who abuse substances, particularly individuals who use heroin, because that kind of disorder could affect clients' ability to complete treatment successfully. Furthermore, they should keep their eyes open for signs of excessive daydreaming and absorption in their clients with a history of heroin use. These lower levels of dissociation indicate a tendency to psychologically wander away from therapeutic activities, thus placing these clients at higher risk of leaving treatment against clinical advice or of relapse.

The higher mean score on the DES reported by participants who admitted lifetime heroin use may also be particularly important in light of Peters et al.'s (2002) finding that heroin is a "drug of maintenance rather than a drug of experimentation" (p. 58). Any use of heroin is, of course, potentially dangerous because it is so highly addictive (Epstein & Gfroerer, 1997; Giannini, 1997; Inciardi & McElrath, 1998). Nevertheless, if clients have used heroin intermittently at subclinical levels, it may be possible that they have done so as a method for coping with underlying trauma (that has not produced the elevated symptoms associated with PTSD) when the memories associated with the trauma become overwhelming for some reason. The size of the sample in the current study precluded asking participants about their levels of heroin use over time. That is, we do not know what proportion of the participants acknowledging lifetime heroin use had used at subclinical abuse or dependency levels. Further research is needed to explore this issue in greater detail. In light of the results presented in the current study, however, counselors working with clients reporting any heroin use should assess their level of use over time to determine whether that use is related to discomfort associated with trauma in some way. Otherwise, clients who have not made an association between an experienced (or repressed) trauma may remain at elevated risk of relapse with inadequate therapeutic support. Information gathered from that assessment could then be used in treatment planning for a more targeted intervention.

In closing,a very significant and another important clinical practice implication is that overall counselors need a more useful way to integrate research and practice in a way that can be easily used by substance abuse counselors to provide the highest level of care for individuals who abuse heroin. The trend toward evidence-based practice and other elements of practice (e.g., assessment) that are informed by research findings is becoming increasingly important in the mental health field (Rosen, 2003; Walker & Briggs, 2007). Campbell, Daood, Catlin, and Abelson (2005) discussed several factors that impede the integration of research and practice in substance abuse, as well as several remedies to overcome these impediments. One remedy in particular that was suggested was to increase communication between researchers and practitioners. One way to do this is to partner academic researchers with substance abuse clinicians in the field at a treatment center in a collaborative effort. Further practice-based research with individuals who use heroin is clearly needed to address the 92 Journal of Addictions & Offender Counseling April 2009 Volume 29 gaps in the knowledge base concerning trauma, PTSD symptomatology, dissociation, and heroin use.

Inter-Connectedness Between Trauma, Posttraumatic Stress Disorder Symptoms, Dissociative Symptoms, and Heroin Use

By: Christopher Tang

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