HANDOUT 1 PTSD: Taking Back Your Power

What Is PTSD?

PTSD stands for "posttraumatic stress disorder"—a set of emotional problems that can occur after someone has
experienced a terrible, stressful life event.
PTSD means: "post traumatic stress disorder"
1'
"after" "trauma" "anxiety" "reaction"

* Do you have PTSD? Check off (✓) those below that are true for you.

1. You survived a trauma: an event outside of your control in which you experienced or witnessed a physical threat
(e.g., sexual abuse, physical abuse, war combat, seeing someone killed, surviving a hurricane, a car accident).
_2. Your response to the trauma involved intense helplessness, fear, or horror (or, if you were a child at the time,
agitated or disorganized behavior).
3. After the trauma, you suffered each of the following problems for over a month:
+ INTRUSION: The trauma comes back into mind even when you don't want it to, as in nightmares,
flashbacks, or images.
+ AVOIDANCE: Numbing, feeling detached, avoiding any reminders of the trauma.
+ AROUSAL: Feeling "hyped up" .(e.g., easily startled, sleep problems, anger).
+ LOWER FUNCTIONING: Problems with relationships, work, or other major areas of life.

Note: You have PTSD if you checked off all of the items above.

TYPES OF PTSD
There are two types of PTSD. "Simple PTSD" is from a single incident (such as a car accident or a tornado), usually as
an adult. "Complex PTSD" is from repeated incidents such as domestic violence or ongoing childhood abuse. It has a
broader range of symptoms, including problems with self-harm, suicide, dissociation ("losing time"), relationships,
memory, sexuality, health, anger, shame, guilt, numbness, loss of faith and trust, and feeling damaged.

MORE ABOUT PTSD ...

* Your PTSD symptoms are normal after what you have been through. You are not crazy, weak, or bad!
That is why PTSD has been called "a normal reaction to abnormal events."
* PTSD is considered an anxiety disorder because it is marked by an overwhelming feeling of anxiety during
or after the trauma. It is a psychiatric illness, but it is definitely possible to heal from it.
* Rates of PTSD: 61% of men experience trauma during their lives, with 5% developing PTSD; for women,
51% experience trauma, and 10% develop PTSD. Why do some people develop PTSD after trauma and others don't?
This is not fully known, but some. risk factors include more severe, repeated, and/or early trauma; poverty; parents
who had PTSD; and life stress.
* Knowledge about PTSD is relatively recent. It was first studied in soldiers who experienced combat. Later,
it came to be understood in a wide variety of terrible life events (e.g., sexual and physical abuse, natural disasters).
PTSD was added to the official list of psychiatric disorders only in 1980. More is being learned all the time because it
is so important.
* It is possible to heal from severe trauma. Some famous people who have include Oprah Winfrey (TV per-
sonality), Melanie Griffith (actress), and Maya Angelou (writer).

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).
HANDOUT 2 PTSD: Taking Back Your Power

The Link between PTSD and Substance Abuse

PTSD and substance abuse are closely connected for many people, yet this link often goes unrecognized. Below is
some information that may be helpful to you.
♦ You are not alone! For people with substance abuse, PTSD is one of the most common dual diagnoses.
A mong women in treatment for substance abuse, 30%-59% have current PTSD. Among men in substance abuse
t reatment, 11%-38% have current PTSD.
♦ There are many reasons why people with PTSD abuse substances: to access feelings or memories, or
the opposite—to escape from feelings or memories; to get through the day; to compensate for the pain of PTSD; to
commit "slow suicide"; because they grew up with substance abuse in the family; because they don't care about tak-
ing care of their bodies.
♦ People with PTSD and substance abuse tend to abuse the most dangerous substances: cocaine and
opiates.
♦ Gender differences: Women with PTSD and substance abuse typically experienced childhood physical and/
or sexual abuse; men with both disorders typically experienced crime victimization or war trauma.
♦ Two main themes of both disorders are secrecy and control. "Secrecy" means yoLi may feel ashamed
and wish to keep your problems a secret (e.g., the traumas you experienced, the amount of your substance use).
"Control" refers to the idea that with trauma and substance abuse, you feel out of control. In PTSD, a terrible event
occurred that you neither chose nor wanted; in substance abuse, you have lost control over your ability to stop using.
Learning the skills of honesty and regaining control are thus important for healing.
• Each of the disorders makes the other more likely. If you have PTSD, you are at increased risk for sub-
stance abuse. If you have substance abuse, you are at increased risk for trauma. It is thus important to try to keep
yourself safe to prevent further trauma and substance abuse.
♦ The relationship between PTSD and substance abuse is complex. Using substances can either increase
or decrease the PTSD symptoms. Yet abstinence from substances can also either increase or decrease the PTSD symp-
toms. Try to notice the patterns that occur for you. Getting to know the relationship between the two disorders in
your life can help you cope better with the recovery process.
♦ Why do PTSD and substance abuse occur together? Four patterns are common:
1. PTSD can lead to substance abuse. To overcome the terrible symptoms of PTSD, you may use sub-
stances to "self-medicate"—to try to feel better. For example, you may have begun using alcohol to get to
sleep at night.
2. Substance abuse can lead to PTSD. If you abuse substances, you may be vulnerable to dangerous
traumatic situations because your "guard is down" or your self-esteem is low—for example, getting drunk at
a bar and going home with a stranger who assaults you.
3. PTSD and substance abuse may have both occurred together. Some people grew up in a home
where family members abused substances and. also hurt each other.
4. PTSD and substance abuse can be connected in a "downward spiral." PTSD can lead you to use sub-
stances; by using substances, yOu are at increased risk for more trauma; if more trauma happens, you may
use more substances to "cope" . . . and so on.
The ."big picture" priorities in this treatment:
* Eliminate substance use * Learn to manage PTSD * Become safe
You can heal from both PTSD and substance abuse!

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

119
 PTSD: Taking Back Your Power
HANDOUT 3
er
Using Compassion to Take Back Your Pow
power." One of the
ng comp assio n for your PTSD and subs tance abuse is a way to "take back your
Havi are controlling you
abuse is that you feel powerless over them—they
most troubling aspects of PTSD and substance The oppo site of compas-
on" means accepting and respecting yourself.
rather than you controlling them. "Compassi elf at a deep level.
the goal is to understand and really listen to yours
sion is harshness. Rather than blaming yourself,
and substance abuse.
This can make it easier to heal from PTSD especially if you
easier to "beat yourself up" and hate yourself,
Compassion may feel very difficult to do. It is may view yourself as
treated. With PTSD and substance abuse, you
grew up in a family where this is how you were ways too. However,
may be people in your life who view you in those
sick, damaged, weak, crazy, bad, or lazy. There has been said that
ance abuse as attempts to survive and cope. It
it is helpful to understand your PTSD and subst age of secrets too ter-
reveal their origins; they speak in disguised langu
"these symptoms simultaneously conceal and
rible for words" (Hermarl, 1992, p. 96). major goal of this
substance abuse should continue. Indeed, the
This does not mean that the PTSD and But it helps to under-
substance abuse by learning safe ways of coping.
treatment is to help you overcome PTSD and are ill—it tells you that
of distress. It is like having a fever when you
stand your PTSD and substance abuse as signs
of yourself.
you need to get help and take good care

COMPASSION FOR YOUR PTSD

trauma. PTSD
your mind and body to survive overwhelming
PTSD can be understood as an attempt by r harm . . . feel
the terrible trauma . . . protect yourself from furthe
symptoms may have helped you to "tune out" get people to notice
. . feel safer . . . adapt to your environment . . .
more in control of an uncontrollable situation .
your pain.

with Compassion
Examples of Viewing PTSD Symptoms

Suicidal thinking
me? I should just get over it already."
Harsh view: "I'm hopeless. What's wrong with can learn other
in control, by choosing life or death. In therapy I
Compassionate view: "It's my way to feel more
sense after what I've lived through."
ways to feel control, but suicidal thoughts make

Relationship problems
ened to me. I'm a bad person."
Harsh view: "I'm unlovable. I deserved what happ on relation-
le, and that helped me survive. I can keep working
Compassionate view: "I learned not to trust peop
lf and why I have these problems."
ship issues, but I need to be respectful of mye
your PTSD. (Continue on back for more space.)''
* Write a harsh versus compassionate view of
Harsh view:

Compassionate view:

(cont.)
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ight by The Guilford Press. Permission to photocopy this form is granted to purchasers
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120
HANDOUT 3 (page 2 of 2) PTSD: Taking Back Your Power

COMPASSION FOR YOUR SUBSTANCE ABUSE

Substance abuse can be understood as a misguided attempt to cope with PTSD and other problems.
Using substances may have been a way to numb the pain . . get to sleep . . . escape negative feelings . . . forget
about the past . . . get through the day . . . access feelings or memories that you know are there . . . try to feel
normal . . . show people how bad you feel because you can't put it into words • . compensate for your suffering
. . give you some pleasure in life . . . feel in control . . . feel accepted by people . . . get rid of dissociation and
flashbacks.
Viewing your substance abuse with compassion does not mean "It's okay to use, or "If I use, I can ex-
cuse myself because I was trying to numb the pain." A major goal of this treatment is to eliminate all substance use.
If you truly view your substance abuse with compassion, you will strive to eliminate it completely because you will see
that, in the long run, it brings you only misery and dysfunction. Although it may sometimes work in the short run to
"self-medicate" problems, it never works in the long run.

Examples of Viewing Substance Abuse with Compassion

Can't stop using substances

Harsh view: "I'm such a failure. Look what I turned into—I have no self-control; what a wreck."
Compassionate view: "My substance abuse has been a way to try to deal with my overwhelming PTSD symp-
toms. I've been trying to numb the pain. I now need to learn other ways to cope. Substance abuse is a medical ill-
ness, and I need help' with it."

Lying about substance use

Harsh view: "I'm a no-good liar. I lie to my partner, my kids, my doctor. I hate my life."
Compassionate view: "I need to stop lying so I can recover. But there are real reasons why I lie about my sub-
stance abuse: shame, guilt, feeling bad about myself. I need help working on these."
* Write a harsh versus compassionate view of your substance abuse. (Continue on back for more space.)
Harsh view:

Compassionate view:

STRENGTHS FROM ADVERSITY

Another way to view PTSD and 'substance abuse with compassion is to recognize the strengths you may havedevel-
oped—the "gifts from suffering." Usually, the most profound growth occurs from overcoming difficult experiences.
PTSD and substance abuse may have given you the ability to survive under tough conditions . . imagination and cre-
ativity . . . depth . . . spirituality . . . sensitivity to others . . . awareness of the extremes in life . . . the ability to persist
despite pain and setbacks . . . appreciation for animals, children, and people outside the mainstream . . . responsive-
ness to art and nature.
* Do you notice any personal strengths from your struggles with PTSD and substance abuse? (Continue on
back for more space.)

121
 PTSD: Taking Back Your Power
HANDOUT 4

Long-Term PTSD Problems

additional information
already knowledgeable about PTSD and want
This handout is provided for people who are this if you feel too
t its long-term impa ct. It can be upse tting to read, so ask your therapist first, and do not read
abou upset, just stop.
in treatment. If you begin to read it and become
vulnerable right now—you can wait until later
that may occur with
addit ion to the stand ard defin ition of PTSD described in Handout 1, there are other problems
In have some and
repeated childhood abuse (Herman, 1992). You may
PTSD, especially for people who have suffered
not others.

1. Your sense of self

• Helplessness, difficulty taking initiative
•. Shame, guilt, self-blame
• Sense of being damaged
than human)
• Sense of being alien (e.g., not normal, less
young)
• Altered sense of age (feeling very old or very

2. Distorted views of the perpetrator

the perpetrator
• Preoccupation with one's relationship with
all of the power
• Belief that the perpetrator continues to have
, loving him or her, feeling grateful
• "Stockholm syndrome": idealizing the perpetrator
ip with the perpetrator
• Sense of a supernatural or "fated" relationsh
beliefs
• Acceptance of the perpetrator's ideas and

3. Your sense of meaning

• Loss of faith
• Despair en)
as not expecting to have a career, family, or. childr
• . Feeling that you don't have a future (such

4. Your relationships
yourself from harmful relationships)
• Tendency to be revictimized (difficulty protecting
• Isolation
icts, secrets)
• Difficulty having close relationships (distrust, confl
or perpetrators
• Tendency to view others as rescuers, victims,
rns (called "reenactment")
• Tendency to repeat problematic relationship patte

5. Your physical well-being

• Sleep problems
• More than average health problems
• Eating problems
• Risk for HIV/AIDS
• Substance abuse (cont)
sers of this
ight by The Guilford Press. Permission to photocopy this form is granted to purcha
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122
 PTSD: Taking Back Your Power
HANDOUT 4 (page 2 of 2)

aviors
6. Managing your feelings and beh
• Suicidal thinking and attempts
anxiety
• Difficulty tolerating depression and
expr essin g anger, or both
• Explosive anger, difficulty
ive invo lvement, inhibited sexuality, confusion)
• Problems with sexuality (compuls h feeling)
(no feelings) and out of control (too muc
• Alternating between feeling numb on of property)
feelings (substance abuse, self-harm, destructi
• Use of destructive methods to cope with

7. Your memory and perception

)
matic events, or overwhelming memories
• Memory problems (no memory of trau real, or that you are out-
time"); feeling as though you are not
• Dissociation (feeling "out of it," "losing
side your body
tmares, preoccupation with the event)
• Reliving experiences (flashbacks, nigh

8. Other emotional disorders

• Depression
• Eating disorders
rders
• Panic disorder and other anxiety diso
• Personality disorder

) and
American Psychiatric Association (1994
outs 1, 2, and 4 draw from. Herm an (1992), Handout 1 draws from the of these sourc es.
Acknowledgments: Hand you would like to locate any
s. Ask your therapist for guidance if
from various professional journal article

123
HANDOUT Detaching from Emotional Pain (Grounding)

Using Grounding to Detach from Emotional Pain

WHAT IS GROUNDING?

anger,
Grounding is a set of simple strategies to detach from emotional pain (e.g., drug cravings, self-harm impulses,
You can
sadness). Distraction works by focusing outward on the external world, rather than inward toward the self.
nt."
also think of it as "distraction," "centering," "a safe place," "looking outward," or "healthy detachme

WHY DO GROUNDING?
your
When you are overwhelmed with emotional pain, you need a way to detach so that you can gain control over
feelings and stay safe. As long as you are grounding, you cannot possibly use substances or hurt yourself! Grounding
"anchors" you to the present and to reality.
Many people with PTSD and substance abuse struggle with feeling either too much (overwhelming emotions
two: con-
and memories) or too little (numbing and dissociation). In grounding, you attain a balance between the
it is not who you are. When you get caught
scious of reality and able to tolerate it. Rernember that pain is a feeling;
experience —the others
up in it, it feels like you are your pain, and that is all that exists. But it is only one part of your
are just hidden and can be found again through grounding.

Guidelines
♦ Grounding can be done any time, any place, anywhere, and no one has to know.
♦ Use grounding when you are faced with a trigger, enraged, dissociating, having a substance craving,
between
or whenever your emotional pain goes above 6 (on a 0-10 scale). Grounding puts healthy distance
you and these negative feelings.
♦ Keep your eyes open, scan the room, and turn the light on to stay in touch with the present.
, rate your
♦ Rate your mood before and after grounding, to test whether it worked. Before grounding
down?
level of emotional pain (0-10, where 10 means "extreme pain"). Then rerate it afterward. Has it gone
writing—y ou want to distract away from negative feel-
• No talking about negative feelings or journal
ings, not get in touch with them.
blue; I dislike
♦ Stay neutral—avoid judgments of "good" and "bad." For example; instead of "The walls are
blue because it reminds me of depression," simply say "The walls are blue" and move on.
• Focus •on the present, not the past or future.
focuses on
• Note that grounding is not the same as relaxation training. Grounding is much more active,
than relax-
distraction strategies, and is intended to help extreme negative feelings. It is believed to be more effective
ation training for PTSD

WAYS OF GROUNDING
focusing your
Three major ways of grounding are described below—mental, physical, and soothing. "Mental" means
and "soothing" means talking to yourself in a
mind; "physical" means focusing on your senses (e.g., touch, hearing);
very kind way. You may find that one type works better for you, or all types may be helpful.

(cont.)
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133
 Detaching from Emotional Pain (Grounding)
HANDOUT (page 2 of 3)

Mental Grounding
walls are white; there are
o Describe your environment in detail, using all your senses—for example, "The
sounds, textures, colors, smells,
five pink chairs; there is a wooden bookshelf against the wall . . . " Describe objects,
on the subway: "I'm on the subway. I'll
shapes, numbers, and temperature. You can do this anywhere. For example,
The subway map has four col-
see the river soon. Those are the windows. This is the bench. The metal bar is silver.
Ors.
"jazz musicians," "states that be-
to Play a "categories" game with yourself. Try to think of "types of dogs,"
gin with 'A' ," "cars," "TV shows," "writers," "sports," "songs," or "cities."
old), you can slowly work your
a Do an age progression. If you have regressed to a younger age (e.g., 8 years
back to your current age.
way back up (e.g., "I'm now 9; I'm now 10; I'm now 11 . . . ") until you are
that you cook (e.g., "First I
o Describe an everyday activity in great detail. For example, describe a meal
an herb marinade of oregano, basil,
peel the potatoes and cut them into quarters; then I boil the water; then I make
garlic, and olive oil . . . ").
the TV channel to get to a
to Imagine. Use an image: Glide along on skates away from your pain; change
better show; think of a wall as a buffer between you and your pain.
a Say a safety statement. "My name is ; I am safe right now. I am in the present, not the past. I am
.„
located in ; the date is
so that you focus on the
to Read something, saying each word to yourself. Or read each letter backward
letters and not on the meaning of words.
to Use huMor. Think of something funny to jolt yourself out of your mood.
to Count to 10 or say the alphabet, very s . . . I . . .o. . .w. . . l . . . y.

Physical Grounding
* Run cool or warm water over your hands.
* Grab tightly onto your chair as hard as you can.
textures, colors,
* Touch various objects around you: a pen, keys, your clothing, the table, [he walls. Notice
Lighter?
materials, weight, temperature. Compare objects you touch: Is one colder?
* Dig your heels into the floor—literally "groundi ng" them! Notice the tension centered in your heels as you
do this. Remind yourself that you are connected to the ground.
a piece of cloth or yarn)
* Carry a grounding object in your pocket—a small object (a small rock, clay, a ring,
that you can touch whenever you feel triggered.
* Jump up and down.
socks; the feel of your
* Notice your body: the weight of your body in the chair; wiggling your toes in your
back against the chair. You are connected to the world.
* Stretch. Extend your fingers, arms, or legs as far as you can; roll your head around.
* Clench and release your fists.
* Walk slowly, noticing each footstep, saying "left" or "right" with each step.
* Eat something, describing the flavors in detail to yourself.
to yourself on each in-
* Focus on your breathing, noticing each inhale and exhale. Repeat a pleasant word
hale (e.g., a favorite color, or a soothing word such as "safe" or "easy").

Soothing Grounding
person going
+ Say kind statements, as if you were talking to a small child—for example, "You are a good
through a hard time. You'll get through this."
TV show.
+ Think of favorites. Think of your favorite color, animal, season, food, time of day,
(cont.)

134
HANDOUT (page 3 of 3) Detaching from Emotional Pain (Grounding)

+ Picture people you care about (e.g., your children), and look at photographs of them.
+ Remember the words to an inspiring song, quotation, or poem that makes you feel better (e.g., the
AA Serenity Prayer).
+ Remember a safe place. Describe a place that you find very soothing (perhaps the beach or mountains, or
a favorite room); focus on everything about that place—the sounds, colors, shapes, objects, textures.
+ Say a coping statement: "I can handle this," "This feeling will pass."
-4- Plan a safe treat for yourself, such as a piece of candy, a nice dinner, or a warm bath.
+ Think of things you are looking forward to in the next week—perhaps time with a friend, going to a
movie, or going on a hike.

WHAT IF GROUNDING DOES NOT WORK?

Grounding does work! But, like any other skill, you need to practice to make it as powerful as possible. Below are
suggestions to help make it work for you.
* Practice as often as possible, even when you don't need it, so that you'll know it by heart.
* Practice faster. Speeding up the pace gets you focused on the outside world quickly.
* Try grounding for a l0000000nnnnngggg time (20-30 minutes). And repeat, repeat, repeat.
* Try to notice which methods you like best—physical, mental, or soothing grounding methods, or some
combination.
* Create your own methods of grounding. Any method you make up may be worth much more than those
you read here, because it is yours.
* Start grounding early in a negative mood cycle. Start when a substance craving just starts or when you
have just started having a flashback. Start before anger gets out of control.
* Make up an index card on which you list your best grounding methods and how long to use them.
* Have others assist you in grounding. Teach friends or family about grounding, so that they can help
guide you with it if you become overwhelmed.
* Prepare in advance. Locate places at home, in your car, and at work where you have materials and remind-
ers for grounding.
* Create a cassette tape of a grounding message that you can play when needed. Consider asking your
therapist or someone close to you to record it if you want to hear someone else's voice.
* Think about why grounding works. Why might it be that by focusing on the external world, you become
more aware of an inner peacefulness? Notice the methods that work for you—why might those be more powerful
for you than other methods?
* Don't give up!

135
HANDOUT 1 When Substances Control You

What Is Substance Abuse?

The simplest definition of "substance abuse" is that a substance has control over your life. In the language of the
American Medical Association, it is the "compulsive use of a substance resulting in physical, psychological, or social
harm . . . and continued use despite that harm" (Rinaldi et al., 1988). The substance may become more important
than your relationships, your work, and all else.
Substance abuse is widely considered a medical illness. It is not due to being "bad," "lazy," or "just wanting to
have a good time."
No one fully understands why some people become addicted and others don't. It may be due to biology, terri-
ble life experiences, or some combination. Whatever the cause, it is essential to learn how to overcome the illness. It
can be done!
Some people are unsure.whether they truly have a problem with substances, or they may hear conflicting opinions
from others. It may be helpful to ask yourself whether either of the following formal definitions seems true for you.

DO YOU HAVE A PROBLEM WITH SUBSTANCE ABUSE?

If you have a problem with substances, you have either substance abuse (a mild version of the disorder) or substance
dependence (a severe version of the disorder). In popular language, "substance abuse" is used to refer to any prob-
lem with substances.

Substance Abuse
* Check off (✓)any that are true for you, being really honest with yourself.
Substance use that results in failure to fulfill obligations (e.g., work, parenting).
Repeated substance use in situations that are physically dangerous (e.g., driving).
Repeated legal problems resulting from substance use (e.g., disorderly conduct).
Continued substance use despite repeated, problems from it (e.g., arguments with people).
If any one above is true for you.. you would be diagnosed with substance abuse.

Substance Dependence
* Check off (V) any that are true for you, being really honest with yourself.
Q Your quantity of substance use has increased.
U You are unable to control your substance use.
I Your substance use interferes with your responsibilities (e.g., home, work, parenting).
T Your time is heavily devoted to using the substance.:
N You need more of the drug to obtain the same effect ("tolerance").
you
_O Other aspects of your life have been damaged by substance use (e.g., health, social life), but
continue to use.
W Physical withdrawal symptoms occur if you stop using the substance. Also, you may take the substance
to try to manage your withdrawal symptoms.
If any three above are true for you, you would be diagnosed with substance dependence, which you can remember
by the acronym "QUIT NOW"
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151
 When Substances Control You
HANDOUT 2

How Substance Abuse Prevents Healing from PTSD

suffering of that disorder. But are

There is no doubt that you want to heal from PTSD. No one wants to live with the
The following list may help.
you aware of how your substance abuse is preventing you from healing from PTSD?

* Check off (✓) any that feel true for you.

ABUSING SUBSTANCES ...

d, more suicidal, and less sta-
❑ Makes PTSD symptoms worse. Substances can make you feel more depresse
short while (such as getting to sleep or
ble. Even if substance abuse appears to "solve" some PTSD symptoms for a
"numbing out" for a few hours), in the long run it never solves them.
❑ Prevents you from knowing yourself. With substanc
es, you get lost. To heal from PTSD, you need to be-
come more and more aware of who you really are—without substances.
yourself, to feel less
❑ Does not get your needs met. You may be using substances.to feet 'loved, to accept
learn safe coping methods to grat-
pain, or to feel nurtured. However, substances cannot give you these. You need to
ify these very important needs.
❑ Stalls your emotional development. Although you may
be an adult in terms of your age, emotionally you
substance abuse, or both. If you
may have become "stuck" somewhere earlier in your development, due to PTSD,
give up substances, you can keep growing emotionally.
of PTSD is isolation:
❑ Isolates you. You cannot have good relationships when high. One of the main features
perpetuates that aloneness.
keeping secrets, having to lie about what happened, feeling alone., Substance abuse
❑ Keeps you from coping with feelings. It "can-feel unbearab
le to face the feelings associated with PTSD,
means learning to gain control
and it may be tempting to use substances to "self-medicate" them. But true healing
give up substance s that are getting in the way.
over your feelings through safe coping. Healing is possible if you can
you had no control over the
❑ Takes away your control. One of the most difficult aspects of PTSD is that
it runs your life. Take back your
trauma. The very nature of substance abuse is that it also takes away your control—
power by giving up substances!
controlled by a sub-
❑ Makes you hate yourself. You can't feel good about yourself when you are being
stance. With PTSD, you may already dislike yourself; substance abuse just adds to that.
your relationships, your
❑ Is a way of neglecting yourself. Using substances impairs your health, •your mind,
abuse may be a repetition of
self-worth, and your spirituality. If you suffered childhood neglect or abuse, substance
that pattern, except that now you are doing it to yourself.

keeps you stuck.

Healing from PTSD requires all of your care and attention—substance abuse

to photocopy this form is granted to purchasers of this

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission
book for personal use only (see copyright page for details).

152
HANDOUT 3 When Substances Control You

Choose a Way to Give Up Substances

Quit all at once. This is the abstinence model developed in AA; it's also called quitting "cold turkey." It
--->
works well for some people. It may feel harder to start, but may be easier to stick to.
--> Try an experiment. Try this "warm turkey" rather than "cold turkey" method—give up substances just for a
week to see what it's like. Then reevaluate it in therapy.
—÷ Cut down gradually. This is called harm reduction. Making progress, even slowly, is better than staying
where you're at. If you're using every day, you can start by using every other day. If you're using cocaine and mari-
juana, you can give up cocaine but keep using marijuana. Eventually, you can give up substances completely once
you achieve these smaller successes.

A key question: "Do Ihave to give up substance use completely?" It is clear that people with PTSD and
substance abuse need to quit substances completely—at least for a while—to successfully heal from PTSD. Later, once
their PTSD recovery is complete, they can explore whether any use is safe for them or not. Many people find that
once they recover from PTSD, they no longer even want to use. In the substance abuse field, there is a lot of contro-
versy about whether people with a history of substance abuse can ever use safely. Some people believe that "moder-
ation management" or "controlled drinking" are possible, meaning that using may be okay as long as it is kept within
certain limits. However, this is not considered safe for anyone who has a history of severe substance use. At this
point, just know that you need to give up substances to heal from your PTSD.

* What plan can you commit to starting today? Choose one below, then fill in the "Notes."
O (1) Quit all at once (the AA or "cold turkey" model).
❑ (2) Try an experiment (the "warm turkey" model). Please write down how long you'll give up sub-
stances: week(s).
❑ (3) Cut down gradually (the "harm reduction" model). Write down on the back of this page exactly
what substance(s) you'll cut down or give up. Also, write down how much and how often you'll be using at
most (you can always use less, but not more!).

Notes:
(a) I also agree to throw out my (substances) and all related paraphernalia.

(b) I also agree to ask (people in my life) not to offer me substances or use around me.

Signed: Dated:

If I cannot stick to my plan, I will leave a [phone message? note?] for my [thera-
pist? sponsor? partner? friend?] to let him or her know within hours.

(cont.)
purchasers of this
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to
book for personal use only (see copyright page for details).

153
HANDOUT 3 (page 2 of 2) When Substances Control You

SUGGESTIONS
v- Get rid of substances in your environment to help your plan work. Throw out your stash of substances
and tell people in your life not to offer you any.
You can combine "Try an experiment" and "Cut down gradually" if you need to. If you are extremely
afraid of reducing your use, you can try to give up a little just for a short time.
(Po Keep in mind that many people have strong opinions about how to give up substances. However, at
this point, no one truly knows what works best, for whom, and how. Any of the three methods above may work as
long as you keep at it. If you try one way and it doesn't work, you can reevaluate it with your therapist and then try
another plan.

No matter what happens, you can cope safely without substances!

154
 l You
When Substances Contro

HANDOUT 4
y
Climbing Mount Recover

BING A MOUNTAIN
FR OM SU BS TA NC E ABUSE IS LIKE CLIM
RECOVERY
Mount Recovery
Mount
Recovery
(No further
substance abuse
problems)

Improving
Worsening

Trail A
*. Trail B
(Some people are able to
reach Mount Recovery's
peak by a shortcut
involving no slips.
Although this is the
preferred route, it is
4 often difficult for people.
Where you Critical decision points
are now (slips). The way down is They still reach Mount
always easier, but at the Recovery, however, by
cost of having a more following Trail A.)
difficult climb the
next time.

use Problems
Sea of Substance Ab
* Danger *

t Trail A and Trail B?

* What do you notice alm to the top.
alo ng the wa y, bu t pe ople eventually make it
mistakes way!
Trail A is trial and error— ry few people do it this
no pro ble ms , jus t a dir ect path to the top. Ve
Trail B is perfect—
il will get you there.
The message: Either tra
n coun-
oth er im ag e tha t wo rks for you: A trip to a foreig
select an
ine mountain climbing,
If you do not like to imag ve vi ca r? Or none at all?
nn ing a ma rat ho n? Le arning to dri
try? Ru

TRIP
PREPARING FOR YOUR ,
need to take hiking boots
pre pa red . Jus t as for climbing a mountain you
y, you need to be following:
As with any other journe ur rec ov ery trip you will need to do the
lig ht, for yo
food, a tent, and a flash the m to help you with it (e.g.,
not using sub-
e he ad ing an d ask
you where you'r
Tell everyone close to ces). (cont)
ver offering you substan
stances around you, ne sers of this
form is granted to purcha
rd Press. Per mission to photocopy this
Copyright by The Guilfo
Lisa M. Najavits (2002).
From Seeking Safety by pag e for det ails ).
y (see copyright
book for personal use onl
155
 When Substances Control You
HANDOUT 4 (page 2 of 2)

find that as they stop using substances, their PTSD gets

--> Be prepared for "bad weather." Some people s that
forever. It simply means that you need to face feeling
worse for a while. Just like a storm, this does not last best as you can
those feelings. Strive to cope with them as
have been hidden by substance abuse. Accept and honor
without using.
as vital as food to survive on this mountain! It's also best
--> Take your list of Safe Coping Skills—they're just Keep all
a list of rewards for yourself for each day you don't use.
to pack a list of reasons not to use substances, and
of these in your wallet for easy access.
there are times that are not fun. When you give up sub-
—> Be prepared for down times. On all adventures, ahead.
keep climbing up the mountain—better times await you
stances, you may feel miserable and deprived. Just
The view from the top is incredible!
, you'll need to learn everything you can about your
--> Take "maps." Just like having maps and a tourist guide
videos, and talking to people who have recovered.
journey—from self-help groups, books, educational
help if you get stranded.
--> Carry a phone so that you can reach out for
—> Set a starting date. How about today?
you down.
---> Don't take guilt, self-hatred, blame—these weigh
use. Even if you're homeless, had a fight, and lost all of
--> Remember that there is never a good reason to
to use." Using a substance will not get you a home, get
your money in a single day—none of this means "It's okay
it will make you less able to cope with your problems.
you out of a fight, or get your money back . . . but this, seek
-4 Remember that as you reduce subst
ance use, your PTSD may get worse; be prepared for
help, and remember that it won't last forever.
--> Surround yourself with safety—saf
e people, safe places, safe things.
should never
-4 Never "test" yourself by seeing
whether you can turn down a substance. Just as you
sub-
you should never test your recovery by walking into a
test your safety by walking down a dark alley at night,
stance abuse situation.
don't actually use, you're okay.
—> Know that cravings are normal, As long as you
is a common pattern in recovery: If you use once,
--> Fight "AVE" (the "abstinence violation effect"). This
already failed. No—don't keep using! Just stop and pick your-
you think you might as well keep using because you've
.
self up. Having 1 drink is better than having 10 drinks
--> Remember the bottom line: To heal from PTSD , strive to be substance-free!
They are
-4 Memorize the "Three Main Thoughts
That Lead to Substance Use" (see the box,below).
when you're not looking.
like snakes in the grass—they will jump out and hurt you

THREE MAIN THOUGHTS THAT LEAD TO SUBSTANCE USE:

T "NI just have one" T
I "I can handle this alone" f
"1 don't care" 0

* Is there anything else you need for your journey?

156
HANDOUT 5 When Substances Control You

Mixed Feelings

* What do you think? Circle "true" or "false," then see the answers at the bottom of the page.

1. It's best to wait until you feel motivated to give up substances. True False
2. Most people have mixed feelings about giving up substances. True False
3. There's something wrong with you if you still want to use substances. True False
4. People who recover are totally sure they want to give up substances. True False

* You may have mixed feelings about giving up substances. You may alternate between wanting to re-
cover from substance abuse and then not wanting to. Such mixed feelings are called "ambivalence:" This is a very
common stage in early recovery. Despite all the suffering you go through with substance abuse, it is familiar. Giving
up substances can feel like the loss of a close friend. Most people who give up substances frequently have mixed
feelings about it. If you talk to people Who have succeeded in achieving long-term abstinence, they too felt mixed
about it when they were in early recovery.
" With PTSD, there may also be mixed feelings about getting better. PTSD can feel very familiar, and
can even become your identity. It can be scary to move forward and let go of it: "If I keep feeling pain, this shows
how bad the trauma was," "If I get better, it's like my abuser has won," "I don't have a right to get better when my
buddies died on the battlefield," To let go of such suffering may feel as though it invalidates what happened to you.
+ How can you cope with mixed feelings? You can have lots of mixed feelings; it is normal to have them.
But always remember that no matter what you feel, you need to focus your actions on safety. This means not using
substances, sticking with treatment, and talking about'your mixed feelings openly. You don't have to feel like giving
up substances or PTSD symptoms. Isn't that a relief?

[Answers to questions: F, T, F, F]

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

157
HANDOUT 6 When Substances Control You

Self-Understanding of Substance Use

If you use a substance, the key is to understand why. No shame, no blame, no guilt, no "beating yourself up"—these
all prevent you from understanding yourself.
Note, however, that understanding substance use does not mean excusing it. It does not mean that it was right
or okay to use. Substance use is never a safe way of coping for someone who is in recovery from PTSD and sub-
stance abuse. Thus, "seek explanations but not excuses."
Here are some ways to seek understanding about your substance use.

NOTICE THE CHOICE POINT

Every time you use, you make a decision to do so. "Own" the decision—notice what you said to yourself to
justify it. If you listen closely, every time you use a substance, you'll hear a need that's being neglected: a need for
pleasure, connection, relaxation, love, celebration, symptom relief. Some examples: "When my friend passed the
joint, I felt like I wanted to be part of things," or "I saw the liquor store and said, 'I'm stressed and just want one
drink.' " These are all legitimate needs that deserve attention, but not with substances. Also, it may be helpful not to
talk about your substance use as "slips" or "backsliding"—these make it sound as though they were accidents. Using
a substance is never an accident; it is always a choice. Owning the choice can help you understand yourself and your
needs.
Explore your unconscious. There may be times when you use and you truly do not know how it hap-
pened. Particularly for people who dissociate (which is common in PTSD), you may find yourself sitting at a bar
with a drink in hand, not knowing how you got there.. The best strategy for this is to explore what unconscious
part of yourself led you to use. This is sometimes called the "Jekyll—Hyde personality" or the "split self"—there are,
feelings that you are having trouble letting yourself feel, and they sneak up and surprise you. For example, you
may be having urges to use but denying them ("I shouldn't feel thiS way, so I won't let myself think about it"); or
you may be angry but not fully aware of it ("I don't have a right to be angry"). Just know that every time you
use and are not conscious of it, you can become more conscious with effort. Here too, listen for unmet needs
that require attention.

REPLAY THE SCENE IN SLOW MOTION

As if you are watching a movie in slow motion, describe everything that led up to using, trying to un-
derstand what motivated you to use and being really honest with yourself:
Who were you with?
Where were you?
What happened that day?
What were you feeling .and thinking?
What time was it?
What coping did you attempt?
What was the dialogue you went through, either with yourself or others?
Now try to figure out abetter way to cope next time—replay the movie in slow motion, but this time with
a better ending. Again, no shame or blame—just identify how you can treat yourself better next time. Look at the
Safe Coping Skills list to identify better solutions.
(cont.)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

158
 When Substances Control You
HANDOUT 6 (page 2 of 2)

For example, if you used because . . .

You felt upset . . . then talk to someone.
izes in sleep problems.
You can't sleep at night . . . then talk to a doctor who special
lf cry and mourn the loss.
Your sister just died and you miss her . . . then let yourse

USE
EXPLORE THE MEANING OF YOUR SUBSTANCE
ngs. Substance use can be a way of getting to
For people with PTSD, substance use can have many meani
you feel accepted by people, committing slow suicide, getting
sleep, numbing the pain, giving you control, helping
how much pain you feel, blotting out memories, accessing
back at an abuser, crying out for help, showing others
use, try to understand the meaning.
memories . . . or many other meanings. Each time you

NOTICE THE COST

nce use; Both emotionally and financially, substance
Just as there's "no free lunch," there is no free substa
s or hours, but you'll pay the cost later. Think about the inter-
use has a cost. Using may feel good for a few minute
a good use of your money?); and the emotional costs
personal costs (who is it hurting?); the financial costs (is this
(how will it make, you feel about yourself?).

USING
NOTICE HOW YOU RELATE TO YOURSELF AFTER
using. They attack, reject, shame, and yell at them-
Many people with PTSD "beat themselves up" after
hear, with an open,heart and open mind, your needs and
selves. This prevents growth because you're not able to
tionism: If you use once, you harshly view it as failure and
motivations for using. Another destructive pattern is perfec
your head after you use: Is it the voice of someone who
so keep on using, turning 1 drink into 10. Notice the voice in
voice remind you of anyone who treated you harshly
is kind and caring,? Or harsh and judgmental? (And does the
when you were growing up?)

159
 Integrating the Split Self
HANDOUT

The Split Self

* Do you . . .

(e.g., find yourself at a bar, not aware of how you got

1. Do things and not remember how they happened
there)? Yes / No / Not sure
shift very quickly and intensely)? Yes / No / Not sure
2. "Flip" into different emotional states (e.g., your moods "the
te people (such as "the young one," the "big one,"
3. Have different sides of yourself that feel like separa
weak one," "the angry one")? Yes / No / Not sure
positive toward someone at one time and then to-
4. Feel opposite extremes in relationships (e.g., feel totally
tally negative at another time)? Yes / No / Not sure
decisions in your life (such as whether to stay in treatment,
5. Frequently have mixed feelings about important
whether to get a job, etc.)? Yes / No / Not sure

What Is "the Split Self"?

occur in both PTSD and substance abuse. Becoming aware
"The split self" refers to different sides of the self that can
of these different sides can help you recover.
to use substances while another part doesn't. This is
Substance abuse examples. One part of you wants
sometimes called "Jekyll and Hyde."
who needs protection; a "fighter" who bullies; a
PTSD examples. Parts of you might feel like "a little child"
tomorrow; and a "healthy one" who wants to work hard
"teenager" who wants to have fun without worrying about
on recovery.

Splitting Happens for a Very Good Reason

world has different states of consciousness that emerge at
Splitting is a psychological defense in which your internal
e, so too the mind needs defenses when it is being at-
different times. Just as a country needs an army for defens they
are normal and typical in PTSD and substance abuse;
tacked by devastating life experiences. Remember, these al" people have splits to
you are crazy. Also, many "norm
were necessary for your survival. They do not mean that
and how dangerous they are.
some degree; the issue is how much they have them,
need earlier in your life to reject some part of yourself.
If you have splits, it means that you had a psychological
accident, you may have felt extremely guilty but could not
For example, if you drove drunk and caused a terrible car
"popping up" in various ways in your life (as in bad dreams or
face those feelings at the time. The guilt may keep
rejected important parts of you. If it was not safe for you
flashbacks). Splits can also arise in childhood if your family
e split off. But the split-off side doesn't go away—it stays
to express anger, for example, the anger may have becam
may notice that you feel ashamed about whatever side of
hidden and emerges at times that may surprise you. You
yourself has been split off.
are typically those that want to use substances (you
With PTSD and substance abuse, the sides that get rejected
feel you should always be "nice"), or that feel vulnerable
may feel "bad" for having cravings), that get angry (you
(you feel you should always be "strong").
without awareness. (If you were aware of it, it wouldn't
None of this is your fault—it all happens unconsciously,
be split!) (cant)
ers of this
by The Guilford Press. Permission to photocopy this form is granted to purchas
From Seeking Safety by Lisa M. Najavits (2002). Copyright
book for personal use only (see copyrig ht page for details).

228
 Integrating the Split Self
HANDOUT (page 2 of 2)

e Behavior
Splitting Leads to Unsaf
e control over them, they
side s, bec aus e they are hidden. When you don't hav
You are not in control of you
r reje cted lthier sides. This can be
s whe n you don 't exp ect them, or by "blotting out" hea
at time
can control you by emerging
unsafe.

Sides of Yourself
Exploring the Different need more space.
the que stio ns below Use the back of this page if you
* If you want, answer
yourself?
1 Do you notice any sides to

Substance abuse:
PTSD:
Other:
Which sides do you dislike?
2. Which sides do you like?
ous behaviors from your splits?
3. Do you notice any danger

N
THE GOAL OF INTEGRATIO
Overcome the Split Self
Integration Is the Way to
at would it be
acc ept the side s of you rsel f that have been rejected. Wh
integrate and ld
The way out of splitting is to Rather than stifling it, you wou
wou ld resp ect tha t the ang er is there for a good reason. f whe nev er you
like? If you felt angry, you e access to all parts of yoursel
exp ress it in a safe way. The goal is to hav they remind you of
seek to "he ar" it and to
be diff icu lt afte r a lifet ime of rejecting those sides, or if
t this ma y
choose to. However, know tha
(e.g ., an abu ser).
someone you hated
the Different Sides?
How Can You Work with n't like them. It may feel as
n" the se diff erent sides, even if you do
'90 Acknowledge, res
pec t, and "ow reason. A deeply car-
e par t of you . This doe sn't work, as it is there for a good
rid of som
though you just want to get recovery.
eve ry par t of you is what helps your
ing attitude toward that wants to drink,
oth er side s if one sid e takes over. If a side emerges
9- Try to remind yourself of
the tment, remind
sn't wan t to. If a side of you doesn't want to come to trea
side of you doe
remind yourself that another
s.
yourself of the side that doe and "beating yourself up" in-
som eth ing wrong. Blame, guilt, shame,
AP-Do not punish you rse lf if you do . if you do something
spli ts. Wh y? Bec aus e they represent a lack of acceptance
inin g
crease the likelihood of mainta
to und ers tan d it calmly and respectfully.
you don't like, try "calling a conference"
the diff ere nt side s. Some people find success in
Create healthy dialogue am
ong ther side. Al-
all side s can be hea rd. Or one side can try to soothe ano
the self, so tha t
among the different sides of healing. Try rehearsing, out loud
to one ano the r ma y sou nd bizarre, but in fact can be very
lowing the sides to "talk" ht sound like.
er, wha t a hea lthy dial ogu e among sides of yourself mig
or on pap

229
 .00/./ Agr

HANDOUT Creating Meaning

Creating Meaning

Below are some meanings typical of people with trauma and substance abuse. Read each meaning and, if you want, rate how much you believe
each one from 0% (never) through 100% (all the time). If you can think of examples from your own life, write them in the margins.

Rate
Meanings, (0%-
That Harm Definition 100%) Examples Meanings That Heal

Deprivation Because you have Suffered a lot, 'I've had -a hard time, so Live Well. A happy, fUnctional life will make up for yoUr
Reasoning you need substances (or other self- I'm entitled to get high." suffering far more .than will hurting yourself. Focus on
destructive behavior). "If you went through what positive steps to make your life better.
I did, you'd. huit yourself
too."'
I'm Crazy You believe that you shouldn't feel "I must be crazy to feel Honor Your Feelings. You are not crazy. Your feelings
the way you do. this upset." make sense in light of what you have been through.
"I shouldn't be having this You can get over them by talking about them and
craving." ' learning to cope with them.

Time Warp Your sense of time is distorted; "This,craving won't stop." Observe Real Time. Take a clock and time how long it
you believe that a negative feeling "If I were to cry, I would really, lasts. Negative feelings will usually subside after a
will go on forever. never stop." while; often they will go away sooner if you distract
with activities.
Beating In your mind, you yell at yourself "I'm a bad person." Love—Not Hate—Creates Change. Beating yourself up
Yourself Up , and put yourself down. "My family was right: I'm may echo what people in the past have said to you. But
worthless." yelling at yourself does not change your behavior; in
fact, it makes you less likely to change. Care and
understanding promote real change.
The Past Is the Because you were a victim in the "I can't trust anyone." Notice Your Power. Stay in the present: "I am an adult
Present past, you,are a victim in the "I'm trapped." (not a child); I have choices (I am not trapped); I am
pres6nt. getting help (I am not alone)."

(cont.)

From Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).
2`2?(:::f '"*::/*/

Creating Meaning
HANDOUT (page 2 of 4)

Rate
Meanings (0%—
That Harm Definition 100%) Examples Meanings That Heal

The Escape An escape is necessary (e.g., food, "I'm upset; I have to binge Keep GroWing. Emotional growth and learning are the
substances, gambling) because on food." only real escape from pain. You can learn to tolerate
feelings are just too painful. "I can't stand cravings; I feelings and solve problems.
have to smoke a joint."

The Good Old You remember the wonderful "Cocaine made me feel See Both Sides. The drug may have felt good but the
Days highs from something (a drug, an happy." cost was losing your job; the relationship may have had
abusive relationship), but ignore "I still love my partner, even some positives, but it had some serious negatives too.
the tragedy of it. though he abused me."

Feelings Are Because something feels true, you "I feel like I'll never recover, Listen to What You Know. Use your mind rather than
Reality believe it must be a fact. so I might as well drink." your feelings as a guide. What do you know to be best
"I feel depressed, so I for you? Feelings are valid, but they are not reality
might as well kill myself."

Ignoring Cues If you don't notice a problem, it "If I ignore this toothache Attend to Your Needs. Listen to what you're hearing;
will go away. it will go away." notice what you're seeing; believe your gut feeling.
"I don't have a problem.
with substances."

Dangerous You give yourself permission for "Just one won't hurt." Seek Safety. Acknowledge your urges and feelings, and
Permission self-destructive behavior. "I'll buy a bottle of wine then find a safe way to cope with them.
for the recipe I want to try."

The Squeaky If you get better you will not get "If I do well, my therapist Get Attention from Success. People love to pay
Wheel Gets as much attention from people. will focus on sicker patients." attention to success. If you don't believe this, try doing
the Grease "No one will listen to me better and notice how people respond to you.
unless I'm in distress."

Mind Reading You believe you can tell what "I know he didn't say hello. Check It Out. Ask the person! You may be amazed by
other people are thinking without because he hates me." what you find out.
having to ask. "My sponsor would feel
burdened if I called her
late at night."
(cont.)
 Creating Meaning
HANDOUT (page 3 of 4)

Rate ,
Meanings (0%-
That Harm Definition 100%) Examples Meanings That Hea/

It's All My Everything that goes wrong is due ."The trauma was my fault." dive Yourself a Break. You do not have to carry the
Fault to you. "If I have a disagreement world on your shoulders. When you have conflicts with
with someone, it means others, try taking a 50-50 approach (50% is their
I'm doing something wrong." responsibility, 50% is yours).

If This ... You put off something important If I get -a job, then I'll Stay in the Present. Whatever you need to do, start
Then That while waiting for something else. stop smoking pot." now. Every step forward counts. Putting off an
"lf I lose weight, then I'll important goal will not help.
go to AA."

Actions Speak You show your distress by actions; "The scratches on my arm Break through the Silence. Put feelings into words.
Louder Than otherwise, people won't see your will ,show what I feel." Language is the most powerful way for people to know
Words pain.. "I'd like my partner to find you.
my body after. I've killed
myself."

I Am My Your trauma is your identity; it is "My life is pain." Create a Broad Identity. You are more than what you
Trauma more important than anything else "I am what I have have suffered. Think of your different roles in life, your
about you. suffered." varied interests, your goals and hopes.

The You alone have a particular "Unless you've lived Reach Out. Give people a chance to help you. Find a
Uniqueness problem; no one else could through what I have, you safe person to talk to (therapist, AA sponsor) and try
Fallacy possibly understand. can't help me." opening up.
"Why bother talking? No
one will get it."

No Future The future is bleak; there is no "My life is wasted already." You Have Choices. No matter what has happened so
hope. "I might as well give up." far, you control the present and future. Notice your
choices and choose wisely.

Life-or-Death Things take on life-or-death "I'll never' get over the fact Keep Perspective. What is the worst that can happen?
meaning in your mind. that she (or he) left me." If you suffer a loss, you can learn to mourn and move
Thinking
"I'll die if I don't get that job." on. The possibilities in life are endless.

(cont.)
 HANDOUT (page 4 of 4) Creating Meaning

Rate
Meanings (0%—
That Harm Definition 100%) Examples Meanings That Heal
Confusing You want something very badly, "I need to relax with Recovery Is the Need. You may want many things, but
Needs and so that means you have to have it. heroin." needs are- few. You may want heroin, but you do not
Wants "I need to find a romantic need heroin. Needs are essentials: food, shelter,
partner." clothes—and your recovery!
Short-Term You focus_ only on your feelings "I'm more sociable when I Think of the Consequences. Imagine how good you'll
Thinking today rather than tomorrow. drink." feel about yourself tomorrow if you do what you know
"I'm buying that new outfit is right. Imagine how low you'll feel if you give in to the
even if I can't afford it." moment.
Shoulds You have rules about how the "My friend should invite Soften Your Language. Try to ease the tension (e.g.,
world should work. If the rules are me over." "I want my, friend to invite me over."). You may still
violated, you feel angry. "I should not have to deal want what you want, but you may feel more tolerant.
with the PTSD."
N
co
Instant You seek immediate satisfaction. "I need it now." Work Hard. The most enduring satisfactions come from
Satisfaction Life should be easy. "I should always feel working hard and having patience: at your job, at
good." relationships, at recovery.
Focusing on You notice the negatives in a "That person is a total Notice the Good. What went right? What is good
the Negative situation and ignore the positives. jerk." about you? What was a positive aspect of the situation?
"I can't do anything right."
All-or-None Things are either all good or all "Life is only misery." Seek a Balanced View►. Life is more complex and
Thinking bad. There is no middle ground. "I have no power." interesting than "all or none." Look at things with a
balanced view; find the middle ground. Look at what
went well, what went badly, and what was neutral.

Acknowledgments: In this handout, several of the harmful meanings ("Mind Reading," "Shoulds," "Focusing on the Negative," "All-or-None Thinking," and "Feelings Are Reality") are from Burns
(1980), with the latter termed "emotional reasoning" in his book. "Life-or-Death Thinking" and "Instant Satisfaction" are from Beck and colleagues (1993) and "The Good Old Days" is from Earley
(1991). Ask your therapist for guidance if you would like to locate any of these sources.

0,004k6i.iMWM.. "."
HANDOUT 2 Community Resources

Consumer Guidelines for Treatment

When you seek out any services, remember that you are a consumer. This means that you have choices and rights,
and that if you are not satisfied with the treatment you are receiving you can "shop around" to find treatments that
fit better for you.1 Some guidelines are as follows:
* The quality of treatment differs widely. There are many health care professionals who can be enormously
helpful to you. Unfortunately, there are also professionals who are not helpful, and some who are actually harmful.
Research on psychotherapy, for example, shows that therapists differ widely in their effectiveness, and that such dif-
ferences are not associated with number of years' experience, type of training (e.g., social worker vs. psychiatrist
vs. psychologist), recovery status (whether the person has overcome an addiction problem), or how much is charged.
This means that when selecting a therapist, you will need to evaluate the person based on factors other than these.
* Find specialists. Because you are struggling with two particular disorders—PTSD and substance abuse—you
should seek out the best available help you can from people who are up to date on specialized treatments for these
types of problems (and similarly for any other problem for which you need help).
* Shop around. Before deciding on a treatment, especially in mental health, try to "shop around" by visiting
several treaters. For example, you may want to have at least one session with three different therapists to find out
who feels most helpful. Keep trying additional ones until you find one you truly like. Treaters differ in their styles,
and, just as in other relationships, there are some combinations of people who work better with each other. Try to
notice whom you feel most "heard" by, and what style you like (e.g., highly supportive? very direct? confrontational?
warm? intelligent? informative?). Notice whether you feel you can truly open up to this person.
* Ask questions. When you are talking with a potential treater, you have a right to ask questions such as
"What is your model of treatment (and are there any other types of treatment for my problems)?", "How would you
help me?", "How long would treatment last?", "Have you worked with patients like me before?", "Where did you
complete your training?", "Do you accept my health insurance?", "How much will treatment cost?", "Are there any
less expensive treatments available?"
* Stay only in treatments that work for you. If you try a treatment and don't like it, remember that you can
leave. Never stay in a treatment out of guilt that you'll hurt the treater's feelings or because you feel pressured. See
"How to Evaluate Your Psychotherapy," below.
* Report unethical treaters. If a treater is unethical (e.g., propositions you sexually), you can report the
treater by contacting the head of the clinic or hospital, calling a state board that licenses the treater (e.g., the state
medical board), contacting the office of consumer affairs in your state, or contacting the ethics board of the treater's
professional association (e.g., the American Psychological Association, the National Association of Social Workers, or
the American Psychiatric Association).
* Locate consumer information. Some states are beginning to provide phone information designed for con-
sumers of health care. For example, in Massachusetts, the Massachusetts Medical Society (800-377-0550) provides a
listing of all physicians in the state (including psychiatrists), their credentials, and any disciplinary actions against
them for ethical violations. Also, the Internet has a multitude of information, which you can access at many public li-
braries.

'If you are mandated by a court to attend treatment, many of these guidelines may not apply until you have completed the man-
dated treatment. However, even if mandated, you may have choices of which treatment to attend.
(cont.)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

260
 Community Resources
HANDOUT 2 (page 2 of 4)

* Know your insurance benefits.

nce plans differ widely. Contact your insurance com-
a. Find out about your insurance coverage. Insura
your identification number (even within insurance plans,
pany before selecting a treater; give the company for
everything you can about the amount that can be covered,
the amount covered may vary); and find out whet her there is a list of treate rs
n" to have services covered,
how long, whether you need "preauthorizatio you have to pay),
n (using such a list may reduce the cost
for that particular insurance plan that you can obtai be de-
on the treater, and whether coverage will at any point
whether the amount paid will differ depending apy cov-
some patients with depression cannot get psychother
termined by a clinical review of your case (e.g., as well). Keep a list of the peo-
take antidepressant medication
ered for more than.a few sessions unless they
ple you talked to and on what dates. s the in-
a concern. You will need to sign a waiver that allow
b. Confidentiality of your records may be is infor-
information about you and your treatment. if there
surance company to have access to confidential antid epres sant medic a-
have access to (e.g., that you are on
mation that you do not want anyone ever to
than having this covered by your insurance.
tion), you may, choose to pay directly rather rs
protect your financial interests. Indeed, many treate
c Know that it is up to you—not your treater—to it be
age. As with buying any other service or product, may
will not even ask you about your insurance cover treatm ent. Whe n '11
pay very different amounts for the same
wise to do some comparison shopping. You can
they charge before booking an appointment.
contacting treaters, it is fine to ask how much a treater
Blue Cross/Blue Shield, Medicare, or Medicaid,
Also, many people do not know that under that in-
agrees to treat you is legally obligated to accept
who is listed as a provider for,any of these and who these types of in-
. Some treaters do not accept patients with
surance first before any private practice billing a patie nt,
treater is listed as a provider and accepts you as
surance, and it is entirely legal to do so. But if a "bal-
s that there are limits on the amount that can be
then the treater must accept that insurance. This mean the provid er is obliga ted to
um rates that are allowed, and
ance-billed" (i.e., each of these plans sets maxim treate r is not obli-
calendar year). Note, however, that the
accept theSe until the 'insurance runs out for that would be
s you ask, you may end up paying for services that
gated to ask you if you have insurance, so unles billing will
dear at the beginning of treatment abOut how
covered. In short, knovv your insurance and be
occur:

APY
HOW TO EVALUATE YOUR PSYCHOTHER
ents to evalu-
people, but it can be one of the most difficult treatm
Psychotherapy can be enormously helpful to many nalitie s of both
greatly, and its effectiveness depends on the perso
ate. It consists of treatment techniques that vary apy is based in sci-
ip you develop together. Although psychother
you and the therapist, as well as on the relationsh uniformly applied
cal care, it is not typically a "procedure" that gets
ence, it is also an art. Unlike other areas of medi
the same way for each person.
you "know it
is available, and as with most good things in life,
♦ Remember that good psychotherapy feels beneficial
you see it." Many peop le with PTSI5 and subst ance abuse have been able to find treatment that
when , try not to give up
around. If you have had a bad treatment experience
to them after some making the effort to shop find someone you feel
validate your feelings, and search until you
on treatment or blame yourself. Respect and
better'about. psychotherapy
session. Research indicates that how helpful a
♦ Evaluate your treatment after the third had three ses-
throughout treatment even years later. If you have
feels by the third session stays largely consistent one new than sticking
with a thera pist and the treatm ent feels unhelpful, you may be better off finding some
sions
with it. (cont.)

261
HANDOUT 2 (page 3 of 4) Community Resources

4. Expect some ups and downs as long as the treatment feels helpful overall. Be aware that there are
likely to be times when you feel angry or disappointed by the therapist. This is a normal part of psychotherapy. But if
it feels like an ongoing problem or frequently feels too intense, you may need to evaluate it more. If you have gener-
ally felt helped by the treater, it is usually advisable to stay in the treatment and try to work it through (which may
provide you with a real opportunity for important growth). If you have generally not felt helped by the treater, then it
may be advisable to leave.
• Remember that your life decisions are your own, as long as you choose safely. If a therapist gives you
advice to stay or leave a particular job or relationship, to confront your abuser, to go to AA, or any other major ad-
vice, view it as input that you can accept or reject (as long as you are safe).
• One of the most common complaints about psychotherapy is that the therapist is kind and sup-
portive, but does not promote growth (e.g., give direct feedback, help identify important issues to work on, help
you develop new skills). A good psychotherapy is both supportive and growth-producing. If you feel you are just talk-
ing a lot but not moving on in visible ways in your life, or that the therapist is "nice" but not really helpful, 'you may
want to find someone who has more to offer you.
• Stay in treatment as long as it feels helpful. How long does psychotherapy last? Most psychothera-
pies end because the patient decides to leave rather than because the therapist suggests it. As long as you are safe
and functional (e.g., not suicidal, not actively abusing substances, able to take care of your responsibilities), the gen-
eral guideline is to stay in treatment as long as it feels beneficial to you and you want to attend. Talking with the ther-
apist about your wish to leave, getting feedback, and going through a termination process can all be helpful. But as
long as you are safe, it is up to you when to be in treatment and when to leave. If you decide to end a treatment, do
not feel guilty, ashamed, or bad about it. If you are not currently safe, as described above, you may need to stay in
treatment until you feel more stable or at least until you find a new treatment.
• If a treatment feels as if it is not working . . .
• Try telling the treater, stating the problem directly but respectfully.
• If you have specific requests, state them. For example, you might say, "I would like to request that you
stop asking me to go on, medication; I do not want it at this time."
• You can request consultation with a senior person in the field. Many people do not know that this is an
option. A consultant is hired by you to meet with you and the therapist (usually in separate meetings)
and then to make recommendations. This is typically used in long-term therapy if the therapy reaches an
impasse that you and the therapist cannot overcome, or if the therapist insists on treatment recommen-
dations with which you do not agree.
• Be aware that it is legal and acceptable to tape your psychotherapy sessions (using your own tape re-
corder and tapes) as long as you let the therapist know. Some people do this as a way to get more out
of the sessions, listening to them later. It may also be useful if you want someone else to hear the ses-
sions (e.g., if you hire a consultant to evaluate the treatment).
• Know that many clinics will allow you to switch therapists if you ask. If you feel that you cannot work
with the person to whom you've been assigned and you have given it a reasonable chance, find out
whether you can switch (e.g., ask the therapist and clinic director).
• Be wary of treaters who ..
• Convey that impasses in treatment are all your fault (e.g., they're all due to your "resistance," "lack Of
motivation," or "defensiveness"). While there are issues that may be due to you, if a treatment feels
stuck for a long time (e.g., more than a month), it is generally due to both the therapist and the patient.
A high-quality therapist is able to help you move beyond an impasse and does not just blame it on you.
• Give you the sense that their needs are being met rather than yours, such as repeatedly directing you to
topics that you feel are not important to you

(cont.)

262
 Community Resources
HANDOUT 2 (page 4 of 4)
ly, get into intense power
rs to therapists who get mad at you repeated
• Convey harsh negativity. This refe r to constructive feedback
down" as a person. However, it does not refe
struggles, or make you feel "put
is supportive.
that feels painful to hear but for you, particularly if you've already
st tha t you stay in a trea tme nt that feels as if it's not working
• Insi
treater.
tried to work it out with that al
a therapist attempts to initiate sexu
has ina ppr opr iate bou ndaries, you can just leave. If inap prop riate com -
♦ If a therap ist an office, mak es
you to soci al eve nts or to sessions in places that are not ice is neve r to
activity with you, invites adv
unprofessional behavior, the best
abo ut you r attra ctiv ene ss, or engages in any other serious
ments that treater again.
explain your decision or talk to
return. You do not need to

S
HEALTH CARE TREATMENT
RESOURCES TO EVALUATE to evaluate your treat-
s boo ks that can give you more information about how
V Books. There are numerou
library. "psychotherapy," outcomes,"
ment. See a local bookstore or s suc h as "PTSD," "substance abuse,"
can .sea rch und er term
✓ The Internet. You -art knowledge and treatments.
atment. " The re is a wea lth of information on state-of-the
and "tre
does
research on patient satisfaction
d is adv ertis ing "pa tien t satisfaction" data. Much of the
Note: A growing tren promotional than informative.
und ergo rigo rous scie ntifi c evaluation and may be more
not

263
HANDOUT 1 Setting Boundaries in Relationships

Healthy Boundaries

Healthy boundaries are:

• Flexible. You are able to be both close and distant, adapting to the situation. You are able to let go of
relationships that are destructive. You are able to connect with relationships that are nurturing.
• Safe. You are able to protect yourself against exploitation by others. You are able to read cues that someone
is abusive or selfish.
• Connected. You are able to engage in balanced relationships with others and maintain them over time. As
conflicts arise, you are able to work them out.
Both PTSD and substance abuse can result in unhealthy boundaries. In PTSD, your boundaries (your body
and your emotions) were violated by trauma. It may be difficult for you now to keep good boundaries in relation-
ships. In substance abuse, you have lost boundaries with substances (you use too much, and may act in ways you
normally would not, such as getting high and saying things you don't mean). Learning to establish healthy bound-
aries is an essential part of recovery from both disorders.
Boundaries are a problem when they are too close or too distant.

Boundaries can be too close (letting people in too much; enmeshed). * Do you:
❑ Have difficulty saying "no" in relationships?
❑ Give too much?
❑ Get involved too. quickly?
❑ Trust too easily?
❑ Intrude on others (e.g., violate other people's boundaries)?
❑ Stay in relationships too long?
Boundaries can be too distant. (not letting people in enough; detached). * Do you:
❑ Have difficulty saying "yes" in relationships?
❑ Isolate?
❑ Distrust too easily?
❑ Feel lonely?
❑ Stay in relationships too briefly?

Note that many people have difficulties in both areas.

Boundary problems are a misdirected attempt to be loved. By "giving all" to people, you are trying to win
them over; instead, you teach them to exploit you. By isolating from others, you may be trying to protect yourself,
but then don't obtain the support you need.
Healthy boundaries can keep you safe.
Learning to say "no" can . . . keep you from getting AIDS (saying "no" to unsafe sex); keep you from using sub-
stances (saying "no" to substances); prevent exploitation (saying "no" to unfair demands); protect you from
abusive relationships and domestic violence.
Learning to say "yes" can . . allow you to rely on others; let yourself be known to others; help you feel sup-
ported; get you through tough times.

(cont.)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

272
 Setting Boundaries in Relationships
HANDOUT 1 (page 2 of 2)
ries, you can avoid painful
nda ries pre ven ts ext rem es in relationships. By setting bounda
Setting good bou aluing others. Neither
us too dist ant , givi ng too muc h versus too little, idealizing versus dev
extremes: too close vers
crucial.
extreme is healthy; balance is
with others.
bou nda ries with yourself as well as
it is imp orta nt to set ise yourself you won't smoke pot, but
ing "no " to yourself. For example, you prom
You may hav e diff icul ty say say you won't go back to an
You may ove rind ulge in food , sex, or other addictions. You may
then you do.
do.
abusive partner, but then you For exa mple, you may deprive yourself too
much by not eating
ing "yes " to you rsel f.
You may have difficulty say wing yourself pleasure.
h, wor king too har d, not taki ng time for yourself, or not allo
enoug well. This may ap-
bou nda ries ma y vio late other people's boundaries as
People with difficulty setting g
s, trying to control others, or bein
"tes ts" for othe r peo ple, intr uding into other people's busines
pear as setting up
verbally or physically abusive. ndaries. Hurting yourself or
lf or oth ers , you need immediate help with bou
If you physically hu rt you rse al pain through physical
nda ry viol atio n. It mea ns that you act out your emotion
others is an extreme form of bou for more on this.)
set a Safe ty Con trac t. (See the topic Healing from Anger
t to
abuse. Work with your therapis

273
HANDOUT 2 Setting Boundaries in Relationships

Too Much Closeness: Learning to Say "No" in Relationships

Why is it important to say "no"? It means setting a limit to protect yourself in relationships. For example, "If you
show up with coke, I'm leaving," or "Unless you stop yelling at me, I'm walking out." Saying "no" is an important
skill for setting boundaries. At a deeper level, setting boundaries is a way of conveying that both people in a relation-
ship deserve care and attention. It is a healthy way of respecting your separate identity.

SITUATIONS WHERE YOU CAN LEARN TO SAY "NO"

♦ Refusing drugs and alcohol.
♦ Pressure to say more than you want to.
♦ Going along with things that you do not want to do.
♦ When you're taking care of everyone but you.
• When you do all the giving in a relationship.
• When you make promises to yourself that you do not keep.
♦ When you're doing things that take your focus away from recovery.
* Any others that you notice? Write them on the back of the page.

EXAMPLES: SAYING "NO" IN SUBSTANCE ABUSE AND PTSD

With Others With Yourself

Substance "No thanks; I don't want any now." "Self-respect means no substances today."
Abuse "If anybody offers me drugs at the party, I
"Drinking is not allowed on my diet."
need to leave."
PTSD "I need you to stop talking to me like that." "Working as a prostitute is making my PTSD
worse; I need to stop."
"Please don't call me again." "Seeing war movies is triggering my PTSD; I
need to stop."

HOW TO SAY "NO"

* Try different ways to set a boundary:
• Polite refusal: "No thanks, I'd rather not."
• Insistence: "No, I really mean it, and I'd like to drop the subject."
• Partial honesty: "I cannot drink because I have to drive."
• Full honesty: "I cannot drink because I'm an alcoholic."
• Stating consequences: "If you keep bringing drugs home, I will have to move out."
* Remember that it is a sign of respect to say "no." Protecting yourself is part of developing self-respect.
Rather than driving people away, it helps them value you more. You can be vulnerable without being exploited. You
can enjoy relationships without fearing them. In healthy relationships, saying "no" appropriately promotes closeness.
(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

274
 Setting Boundaries in Relationships
HANDOUT 2 (page 2 of 2)
you say is up to you. However, if you
can comfortably provide an explanation,
* How much or how little
the other person.
this can make it easier on
ecting your needs,
motivated to say "no." Once you commit to prot
You will find the words if you are
the how will present itself.
live your life, not theirs.
care of you rsel f; let othe rs take care of themselves. You can only
* Take
take repeated work, both with the
other person, remember that it may
* If you are afraid of hurting the ate hearing what you think
and with in your self. Ove r time , you will realize that healthy people can toler
other person
and feel.
e. Try discussing a difficult
set a bou nda ry befo re, dur ing, or after an interaction with someon
* You can ng an interaction (e.g., try saying "no" to al-
sex before a sexual encounter), duri
topic beforehand (e.g., discuss safe not like being talked to abusively).
l whe n it is offe red) , or afte rwa rd (e.g., go back and tell someone you did
coho
sensitive topics, and discrimination
reveal. PTSD and substance abuse are
* Be careful about how much you t once it has been said. You do
rder s is very real and harm ful. You can never take back a statemen
against thes e diso le who are abusive to you.
ope n with peop le you do not kno w well, people in work settings, or peop
not need to be
essional guidance.
eme ly care ful if ther e is a pos sibility of physical harm. Seek prof
* Be extr

ROLE PLAYS FOR SAYING "NO"

tions but loud. What could you say?
* Try rehearsing the following situa

With Others
drink!"
boss says, "Let's celebrate! Have a
--> You are at a holiday party and your
t get over your trauma already."
—> Your partner says you should "jus tance abuse too."
A d tells you not to take psyc hiatric medications because "that's subs
—> frien y to tell her.
ut your trauma, but you don't feel read
--> Your sister wants to know all abo deal with it."
nd you, saying "You need to learn to
—> Your partner keeps drinking arou
place," and you don't want to.
—> Your date says, Let s go to my h.
-4 Your boss gives you mor
e and more work, and it's too muc
ing your daughter.
—> You suspect that your uncle is abus

With Yourself
k."
--> You want to have "just one drin
rs but not yourself.
—> You keep taking care of othe
on food but keep doing it.
—> You promised to stop bingeing
with no time left for recovery activities.
—> You are working too many hours,

275
HANDOUT 3 Setting Boundaries in Relationships

Too Much Distance: Learning to Say "Yes" in Relationships

Why is it important to say "yes"? It means connecting with others. It is a way of recognizing that we are all
human and all need social contact. It is a healthy way of respecting your role as part of a larger community. It means
becoming known to others.

SITUATIONS WHERE YOU CAN LEARN TO SAY "YES"

♦ Asking someone out for coffee.
♦ Telling your therapist how you really feel.
♦ Asking someone for a favor.
♦ Joining a club or organization.
♦ Calling a hotline.
♦ Being vulnerable about your "weak" feelings.
♦ Letting people get to know you.
♦ Soothing "young" parts of yourself.
* Any others that you notice? Write them on the back of the page.

EXAMPLES: SAYING "YES" IN SUBSTANCE ABUSE AND PTSD

With Others With Yourself

Substance "I am having a drug craving—please help talk "I can give myself treats that are healthy
Abuse me through it." rather than destructive."
"Please come with me to an AA meeting." "I will try speaking at an AA meeting."
PTSD "I need your help—I am scared." "I need to reach out to people when I'm
upset."
"I would like you to call and check in on me "I can start creating healthy friendships step
to see if I'm okay." by step."

HOW TO SAY "YES"

* Try different ways:
• Share an activity: "Would you like to go to a movie with me?"
• Say how you feel: "I feel so alone; it is hard for me to talk about this."
• Focus on the other person: "Tell me about your struggles with cocaine."
• Watch how others do it: Go to a gathering and listen to others relate.
* Plan for rejection. Everyone gets rejected at times. It is a normal part of life. Let go of that person and move
on to someone else who might be available.
* Practice in advance, if possible. Therapy may be a safe place to rehearse.
(cont.)

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

276
 Setting Boundaries in Relationships
HANDOUT 3 (page 2 of 2)

ive.
* Choose safe people. Select people who are friendly and support
feel uncomfortable to reach out to others
* Know that it's normal to make mistakes along the way. It will
at first. Allow yourself room to grow—it will get easier over time.
just as you would in other areas of your life.
* Set goals. Keep yourself moving forward by making a clear plan,
a week.
Decide to make one social call a week, or try one new meeting
* Recognize that you may feel very "young." Parts of you
may feel vulnerable, like a child who is just learn-
may not have had a chance to develop due to PTSD or
ing how to relate to people. That is expected, as parts of you
substance abuse.
rather than a huge one (e.g., asking
* Start small. Start with a simple event (e.g., saying hello or smiling)
someone out on a date).
different. Work hard to see your similarities
* Notice what you have in common rather than how you are
with others; this can make it easier to connect.

ROLE PLAYS FOR SAYING "YES"

* Try rehearsing the following situations out loud.

With Others
- You talk about your impulse to hurt yourself before doing it
—> You ask someone at work to go to lunch.
vacation.
You tell your therapist you missed her when she was away on
---> You call your sponsor when you feel like drinking.
—> You tell someone, "I love you."
—> You tell someone how alone you feel.
—> You admit a weakness to someone.
—> You talk to your friend honestly about your anger at him.
can you call?
- It is 4:00 A.M. and you are so depressed you can't sleep. Whom
. What can you do?
4 The Weekend is coming and you have no'plans with anyone

With Yourself
You feel scared; how can you soothe yourself?
—> You have worked hard; how can you give yourself a safe treat?
to that part?
- Part of you ("the child within") feels hurt. How can you talk
yourself?
—> You are angry at yourself for failing a test. How can you forgive

277
HANDOUT 4 Setting Boundaries in Relationships

Getting Out of Abusive Relationships

* Are you in any relationship right now in which someone:

1. Offers you substances or uses in your presence after you've asked the person Yes No
not to?
2. Repeatedly criticizes you, invalidates your feelings, or humiliates you? Yes No
3. Manipulates you (e.g., threatens to harm your children)? Yes No
4. Is physically hurting you or threatening to? Yes No
5. Discourages you from getting help (e.g., medication, therapy, AA)? Yes No
6. Lies to you repeatedly? Yes No
7. Betrays your trust (e.g., tells your secrets to others)? Yes No
8. Makes unreasonable requests (e.g., demands that you pay for everything)? Yes No
9. Exploits you (e.g., sells pornographic pictures of you)? Yes No
10. Ignores your physical needs (e.g., refuses safe sex)? Yes No.
11. Is controlling and overinvolved (e.g., tells you what to do)? Yes No

If you said "Yes" to any of the questions above, read the rest of this handout. You deserve better than destructive
people!

HOW TO DETACH FROM DAMAGING RELATIONSHIPS

If you have difficulty with boundaries, you may not notice dangerous cues in others. This makes sense if you lived in a
past in which a veil of silence was imposed, you were not allowed to express your feelings, or you could not tell oth-
ers about your trauma. You may need to make special efforts now to notice your reactions to people and to learn
when to end relationships that are hurtful.

# If someone doesn't "get it," give up for now. In early recovery, don't waste your energy on changing
other people; just focus on helping yourself. If someone doesn't understand you after you've tried to communicate
directly, kindly, and repeatedly, find other people.

f Even if you cannot leave a damaging relationship, you can still detach from it. If it is someone you
must see (such as a family member), protect yourself by not talking to that person about vulnerable topics, such as
your trauma or your recovery.

# If enough reasonable people tell you a relationship is bad, listen to them. You may feel so confused
or controlled that you have lost touch with your own needs. Listen to others.

(cont.)
From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

278
 Setting Boundaries in Relationships
HANDOUT 4 (page 2 of 2)

# it's better to be alone than in a destructive relationship. It may be that for now, your only safe relation-
ships are with treaters. That's okay.
# Destructive relationships can be as addictive as drugs. If you cannot stay away from someone you know
feel familiar, and you may be
is bad for you, you may be addicted to that person. Destructive relationships may
is the same as for
drawn to them over and over if your main relationships in life were exploitative. The best strategy
to do so.
all addictions: Actively force yourself to stay away, no matter how hard it feels
# Remember that you are no longer a child, forced to endure bad relationships. You have choices.
your recovery from
# Recognize the critical urgency of detaching from bad relationships. They impair
others (e.g., children).
PTSD and substance abuse. They prevent you from taking care of yourself and
ip, the "how" will present itself. If you do
f Once you make a decision to leave a damaging relationsh
leave.
not know how to leave, it usually means that you have not yet made the decision to
live it.
If you feel guilty, remember that it is your life to live. You can decide how to
. Find ways to
# Expect fallout. When you leave a bad relationship, others may become angry or dangerous
and a shelter if necessary.
protect yourself, including the support of people "on your side," your treatment team,
leave.
I You do not have to explain yourself to the other person; you can just
you don't have to let the
11 Create an image to protect yourself. For example, you are a knight in armor and
person in; you are a TV and you can change the channel.
people who become dependent on dam-
t Try Co-Dependents Anonymous. This is a twelve-step group for
aging relationships (W 602-277-7991).
are in a situation of domes-
$ You should never have to tolerate being physically hurt by anyone. If you
tic violence, this is very serious and requires expert help. You can call:
800-799-7233
lir National Domestic Violence Hotline
800-537-2238
U` National Resource Center on Domestic Violence
If there is a pattern
# If someone is physically hurting you, don't buy into "Ill be different next time."
get out.. Listen to the person's ac-
of abuse after you have given someone repeated chances to treat you decently,
tions, not the words.

* Take care of yourself! *

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HANDOUT 5 Setting Boundaries in Relationships

Boundary Problems Associated with PTSD

and Substance Abuse

Note: Some people become upset when reading the list below. Only read it if you feel safe to do so, and stop if it is
too upsetting.

People with PTSD and substance abuse may be prone to boundary problems, such as the following:

• Extremes: trusting too much or too little; isolation or enmeshment.

• Relationships that are brittle (easily damaged, fragile).
• Tolerating others' flaws too much; doing anything to preserve the relationship.
• Use of substances as an attempt to connect with others.
• Avoiding relationships because they are too painful.
• Overcompliance at times; too much resistance at other times.
• Always being the one to give.
• Spending time with unsafe people.
• Not seeing the hostility in others' words or actions.
• Being overly angry, with a hair-trigger temper; often ready to "blow up."
• Difficulty expressing feelings; expressing them in actions rather than words (acting out).
• May respect men for being "strong" and disrespect women for being "weak."
• Feeling that one can never get over a loss; not knowing how to mourn; fear of abandonment.
• Difficulty getting out of bad relationships.
• Confusion between fear and attraction (i.e., feeling excited when it is really fear).
• Relationships with people who use substances.
• Living for someone else rather than yourself.
• Manipulation: guilt, threats, or lying.
• Reenactments: getting involved in repeated destructive relationship patterns (e.g., recreating the trauma
roles of abuser, bystander, victim, rescuer, or accomplice).
• "Stockholm Syndrome": feeling attachment and love fOr the abuser.
• Wanting to be rescued; wanting others to take responsibility for the relationship.
• Confusion about what is appropriate in relationships: What can one rightly expect of others? When should a
relationship end? How much should one give in a relationship? Is it okay to say "no" to others?
• "Identification with the aggressor": believing the abuser is right.

Acknowledgment This handout is drawn largely from Herman (1992). Ask your therapist for guidance if you would like to locate the source.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

280
HANDOUT 1 Discovery

Discovery versus Staying Stuck

Discovery is one of the most powerful tools in recovery.

"Discovery" means finding out . . . learning from experience . . . adapting . . . curiosity . . . openness . . . moving
forward . . . growth.
Discovery is what children do naturally—they try to explore, find out, and have fun in trying new things. Other
people who discover are explorers, artists, scientists, detectives, and hopefully you!
Staying stuck is the opposite of discovery.
"Staying stuck" means assuming . . . avoiding . . rigid thinking . . . hiding . . . living in the past . . . being closed
to the world.
One of the difficulties of PTSD and substance abuse is staying stuck. For example, if you've had PTSD for years
without getting better, you may not feel like trying any more. Or, if you've been using heroin to feel relaxed,
you may not search for other ways to relax.

A STORY
Situation: Amy has been lying to her therapist, Dr. Burke, about her cocaine use because she feels ashamed.
She believes he'll stop working with her if he finds out.
Compare two different endings to the story:
Amy tries discovery. She tells Dr. Burke the truth because she thinks, "It'll be better to find out than to keep liv-
ing with this shame." Dr. Burke asks her to start getting weekly urine tests, because the treatment cannot
work if Amy hides her substance use. Amy resents this, but also sees that Dr. Burke is trying to help and will
keep working with her.
Amy stays stuck. She keeps hiding the truth from Dr. Burke. Eventually she feels so bad that she stops attending
treatment altogether because she can't take the self-hatred. She uses more and more cocaine.

THE PROCESS OF DISCOVERY

1. Notice your belief. For example:
"I believe that if I tell my friend I'm angry with him, he'll leave."
"I believe calling a hotline will make me feel more depressed."
"I believe I'll never get a job."
"I believe AA will be boring."
2. Find an image (optional). If you want, think of an image that helps you discover:
An explorer . . embarking on a search
A detective . . . trying to find out
A child . . . interested and curious
An artist . . . playing with possibilities
A scientist . . . searching for the truth
Or, write your own image here:
3. Try discovery. Create a plan to actually find out if your belief is true. Some ways are listed in Handout 2.

From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).

287