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Experiential column: When talking isn’t enough

Action methods in addiction and trauma recovery.

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Giacomucci, S. (2021, November 8). Experiential column: When talking isn’t enough. https://www.apadivisions.org/division-49/news-events/action-methods-addiction

Woman in a therapy session

Addiction, substance use and overdose rates have significantly increased in recent years, particularly during the COVID-19 pandemic. Relapse rates are high and many clients struggling with substance use disorder have been to treatment multiple times. Most of these clients have accrued significant knowledge about addiction and recovery—they could probably present a lecture on addiction just as well most addiction counselors. The problem is, however, that knowledge alone does not lead to change—it must be put into action. This very concept is reiterated by the popular Alcoholics Anonymous saying that “self-knowledge availed us nothing.” Families understand this just as well as others as they have heard their addicted loved one apologize and verbally commit to recovery many times, only to experience them continue to drink, use drugs and engage in the same behaviors. When it comes to addiction, words so quickly become meaningless unless followed with action. Psychodrama and other experiential therapies have a unique capacity to engage clients in addiction treatment, addressing underlying fueling factors of addiction, and role training clients for the life skills needed for sustained recovery (Dayton, 2005; Giacomucci et al., 2018).

Many addiction experts have asserted trauma to be one of the primary causes of addiction—some research studies indicate self-reported histories of trauma in over 80% of inpatient addiction populations (Cohen & Hien, 2006). Post-Traumatic Stress Disorder (PTSD) is one of the most common co-occurring disorders for folks with a substance use disorder (Creamer et al., 2001; Roberts et al., 2015). Trauma and addiction exist in a cyclical relationship. Trauma survivors often turn to alcohol or drugs (or other addictive behaviors) to self-medicate the stress, feelings or physical sensations related to prior trauma, loss, neglect or abandonment (Morgan, 2019). Furthermore, the lifestyles often associated with addiction makes someone much more vulnerable to experience more trauma, which in turn creates more adverse feelings to fuel substance use. All addiction treatment is trauma treatment; addiction recovery is incomplete without trauma recovery. Maintaining long-term recovery from addiction requires that we address underlying causes which often include trauma, loss, neglect and abandonment. Otherwise, we are simply engaging in symptom control and avoiding the causes of the addiction.

When it comes to addiction and trauma, words and talking is limited. Many people in recovery and trauma survivors have no words for their trauma, avoid talking about it, or talk about their trauma but are clearly dissociated from the associated feelings. Research even shows that the Broca’s Area, the language and speech center of the brain, (and the entire left-brain hemisphere) is largely inactive when one remembers a traumatic memory (Rauch et al., 1996; van der Kolk, 2014). Similarly, addiction involves the hijacking of survival systems and choices which often appear absent of rational thought (Morgan, 2019). Neurobiologically, both trauma responses and addictive behaviors operate below levels of consciousness, rational thought or cognition. Trauma impacts the body and the nervous system in implicit and unconscious ways. Even when one doesn’t consciously remember a traumatic event, the nervous system may still be impacted and imprinted by it. Both trauma and addiction impact an individual biologically, psychologically, socially and spiritually (or existentially) (Giacomucci, 2021). Breaking these cycles requires new experiences that can create new neural pathways in the brain. Experience changes both the brain and the mind—this is the most important neuroscience finding of the century (Siegel, 2012). The brain maintains neuroplasticity, or the ability to change, throughout the entire lifespan. This means that new experiences have the power to renegotiate and change the impact past experiences have had upon an individual. Experiences in treatment, therapy and recovery can be corrective and effectively repair the damage done from past experiences of trauma or addiction (Giacomucci and Stone, 2019). 

Psychodrama and other action methods actively engage the whole person in the therapeutic process. Instead of relying only on talking or cognition, experiential therapies involve the body. Psychodrama, the first body-oriented therapy, integrates role-playing techniques into group therapy allowing clients to move beyond talking and into action (Giacomucci, 2021). Experiential sociometry methods from the field of psychodrama quickly cultivate mutual aid, cohesion and connection (Giacomucci, 2017, 2020b). Rather than verbally discuss a future relapse prevention plan, we can role-play scenes related to relapse prevention in the safety of the group to practice for the real world. Instead of just talking about a deceased loved-one, psychodrama allows us to talk directly to that person and find closure (Giacomucci, 2020a). Rather than talk about addiction, with psychodrama we could talk directly to addiction. In psychodrama, a client could have a dialogue with their self in the past or with a vision of themselves in recovery in the future. The lynchpin of psychodrama is the role reversal, which is when the client assumes the other role(s) in the scene and responds to them self from that role. This allows for avenues of resolving grief/loss, instilling hope, cultivating understanding, accepting forgiveness or simply putting oneself in the shoes of another. The psychodramatic experience can be both fun and powerful at the same time—it offers new corrective emotional experiences to clients that may be impossible otherwise (Giacomucci and Marquit, 2020). 

Many addiction counselors intuitively try to make their groups and programs more engaging through creative exercises. Psychodrama training offers a time-tested and systematic approach to using action methods in addiction treatment and beyond. Experiential therapies and psychodrama have had a long relationship with the addiction treatment world tracing their connections back to psychodrama’s use in the original addiction therapeutic communities or prominent trainers such as Virginia Satir, Sharon Wegscheider-Cruse, or Tian Dayton who were very active in teaching psychodrama to addiction counselors (Dayton, 2005). As the addiction treatment community continues to evolve it has been further adopting trauma-informed principles, philosophies of empowerment, and holistic approache—all of which are congruent with psychodrama (Giacomucci, 2021). In my own experience integrating psychodrama at Mirmont Treatment Center, an addiction treatment center, we found that the patients respond very well to it. It was one of the most requested therapies on their patient satisfaction surveys propelling us a few years before COVID-19 to significantly expand our use of experiential therapies and psychodrama throughout the entire inpatient clinical program. The trauma-focused psychodrama group that I run is in such high demand that it almost always has a waitlist of patients wanting to join.

Trauma and addiction result in repetitive patterns, reenactments, helplessness, frozenness and stuckness. Talking about it is often simply not enough to promote change or healing. Clients often state that their addiction treatment groups (inpatient, PHP, IOP and OP) feel no different than a free 12-step meetings or other support groups. Many clients are sick of talking about it again and again throughout their treatment experiences and have lost hope in the “talking cure.‟ Breaking free of the cycles of addiction and trauma requires action and more action. The experiential nature of psychodrama and experiential therapies helps to get clients into action—exploring new roles, rehearsing new behavior, role training new skills, renegotiating somatic imprints of trauma, releasing frozen emotion and developing action insights throughout the process.

References

Cohen, L. R. and Hien, D. A. (2006). Treatment outcomes for women with substance abuse and PTSD who have experienced complex trauma. Psychiatr. Serv. 57, 100–106. doi: 10.1176/appi.ps.57.1.100

Creamer, M., Burgess, P. and McFarlane, A. C. (2001). Post-traumatic stress disorder: findings from the Australian National Survey of Mental Health and Well-Being. Psychol. Med. 31, 1237–1247. doi: 10.1017/s0033291701004287

Dayton, T. (2005). The Living Stage: A Step-by-Step Guide to Psychodrama, Sociometry, and Experiential Group Therapy. Deerfield, Florida: Health Communications Inc.

Giacomucci, S. (2017). The sociodrama of life and death: young adults and addiction treatment. Journal of Psychodrama Sociometry, & Group Psychotherapy, 65(1): 137–143

Giacomucci, S. (2020a). Addiction, traumatic loss, and guilt: a case study resolving grief through psychodrama and sociometric connections. Arts Psychotherapy, 67:101627.

Giacomucci, S. (2020b). Experiential sociometry in group work: mutual aid for the group-as-a-whole. Social Work with Groups 33, 53–68. doi: 10.1080/01609513.2020.1747726

Giacomucci, S. (2021). Social Work, Sociometry, and Psychodrama: Experiential Approaches for Group Therapists, Community Leaders, and Social Workers. Springer Nature. https://doi.org/10.1007/978-981-33-6342-7

Giacomucci, S., Gera, S., Briggs, D. and Bass, K. (2018). Experiential addiction treatment: creating positive connection through sociometry and therapeutic spiral model safety structures. Journal of Addiction & Addictive Disorders, 5, 17.

Giacomucci, S. and Marquit, J. (2020). The Effectiveness of Trauma-Focused Psychodrama in the Treatment of PTSD in Inpatient Substance Abuse Treatment. Frontiers in Psychology, 11, 896. https://dx.doi.org/10.3389%2Ffpsyg.2020.00896

Giacomucci, S. and Stone, A. M. (2019). Being in two places at once: Renegotiating traumatic experience through the surplus reality of psychodrama. Social Work with Groups. 42(3), 184-196. https://doi.org/10.1080/01609513.2018.1533913

Morgan, O. J. (2019). Addiction, Attachment, Trauma and Recovery: The Power of Connection. New York: W. W. Norton & Company Publishing.

Rauch, S.L., van der Kolk, B.A., Fisler, R.E., et al. (1996). A Symptom Provocation Study of Posttraumatic Stress Disorder Using Positron Emission Tomography and Script-Driven Imagery. Arch Gen Psychiatry. 53(5): 380–387.

Roberts, N. P., Roberts, P. A., Jones, N. and Bisson, J. I. (2015). Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder: a systematic review and meta-analysis. Clin. Psychol. Rev. 38, 25–38. doi: 10.1016/j.cpr.2015.02.007

Siegel, D.J. (2012). Developing mind: How relationships and the brain interact to shape who we are. New York: Guilford Press. 

van der Kolk, B. A. (2014). The body keeps the score: brain, mind, and body in the healing of trauma. New York: Viking Press.

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