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Healing emotional wounds: substance abuse and feelings.

Michael sat across from me fidgeting in his chair. He was eight days clean and sober off marijuana and alcohol when he first came to see me. He'd been trying to do 90 in 90, but the fear and shame he felt at announcing himself as a newcomer after having two years sober followed by a nasty and public nine-month relapse were about to take him out again.

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In his late 20s, recently married to a woman with children of her own, Michael had become a father for the first time 18 months earlier, and his relapse began shortly thereafter. Over several months, his use of alcohol and marijuana quickly escalated, and his new wife demanded that he move out of their home. At the time of our first visit, having just begun to reestablish a relationship with his spouse, he feared losing everything should he fail again.

Michael needed immediate help managing the powerful emotions threatening his attempts at sobriety. Fortunately for Michael, this help was available in the Affect Management Skills Training (AMST) protocol.

Immediate relief from intrusive memories

I initiated Michael's emotional triage with a skill called Containment that facilitates quarantining disturbing memories and images of adversity and trauma, some of them recent and others accumulated over his lifetime. Michael's disturbing memories were stored in his emotional memory where they were assembled with unresolved emotions. Because these emotions were unresolved, they were held in an excitatory state in which they were more likely to be elicited under stress, even the stress of a 12-Step meeting.

Both of Michael's parents were alcoholics, and his father often raged and shamed his young son in front of playmates. More than 20 years later, Michael was more likely to experience fear and shame in the stressful situation of announcing himself as a newcomer.

I explained to Michael that the first skill I'd be teaching him would provide him immediate relief and also would prevent the intrusion of old disturbing memories into our work. Then I said to him, "Michael, give me an image of a container sufficient to hold every disturbing thing." He looked slightly puzzled, and I told him that he could trust his unconscious to know what every disturbing thing was. I explained that the brain stores memories as images and that this skill would make therapeutic use of imagery to wall off the memories with their associated emotions that had contributed to his drinking.

Looking satisfied with my explanation, Michael said, "What first came to my mind when you asked me was one of those huge tanks like you see in a refinery."

I asked my client to form the intention that every disturbing thing would now move into the container. I suggested that he might see a collective image like smoke or oil, and I emphasized that he was not to look at any individual disturbing thing. "Trust your unconscious," I told Michael. "All you need to do is hold the intention and just watch as the smoke or oil moves into the container."

I had already introduced my client to the little battery-powered device that delivers a gentle vibrating tactile stimulus through probes he holds in his hands, and I'd explained that the alternating bilateral stimulation appears to improve the effectiveness and efficiency of learning the skills. I turned on the device and coached him as he filled the container, asking him to raise an index finger when as much had gone in as would go in at this time. Soon, Michael's left index finger shot up, and I then instructed him to weld the container's lid closed and then to add a special valve that would allow him to remove an item to work on it or to add material should it surface later. I also asked him to add a sign saying: to be opened only when it serves my healing.

Michael completed Skill I by repeating after me the positive cognition, "I am learning to use my container to store away every disturbing thing." Turning off the device, I asked Michael, "What comes up now?" He replied, "Whew! That's a relief." When I asked him how much of every disturbing thing had gone into the container, he said he'd put it all in.

Creating a resource of safety

From reading Michael's history, I knew that his childhood was somewhat chaotic. While there was no sexual or severe physical abuse, he experienced a lot of emotional abuse. His parents drank and fought and eventually divorced when he was a juvenile. His home was not a safe place, and neither parent provided an emotional safe haven for him to return to when life was stressful.

I explained to Michael that our next skill, called Safe Place, would provide him with an internal image of safety and security that he could use currently to manage stressful situations.

Like the other AMST skills, Skill II anchors itself with an image. Skill II begins with a visual image of a remembered safe place from adulthood and then expands the visual image to include auditory, olfactory and tactile perceptual stimuli. Michael produced an image of a California ocean beach, and facilitated by tactile alternating bilateral stimulation (TABS), he elaborated the visual image to include seagulls and fishing boats, then added the sound of waves, the smell of seaweed, and the feeling of a light breeze and the sun on his skin.

Continuing Skill II, I helped Michael to assemble this rich image with the knowledge-based statement "I am safe" and then the emotion-based statement "I feel safe." The protocol provides for evaluation of the validity of each of these positive cognitions, and it also provides for installation of missing resources if the client is unable to endorse certainty. In Michael's case, he was unable to endorse certainty for the statement "I feel safe." We identified the quality "trust" as the resource he would need to be more certain of feeling safe.

Apparently in Michael's stressful childhood, his parents did not create an environment their child could trust. When asked for an image that embodied the quality of trust, Michael suggested a lion, and we developed and installed this image and then used it to help him achieve certainty that he felt safe in his safe place environment.

AMST also provides a means in Skill II to help the client identify the sensations by which his body communicates that he feels safe. Michael identified a "relaxation in my shoulders and hands" as the sensation and body location that told him he felt safe. Using TABS, this knowledge was installed in the form of a positive cognition: "The relaxation in my shoulders and hands tells me I'm feeling safe."

Skill II finishes by developing a cue word--Michael's was "Bolinas"--that designates the image, knowledge, emotion and sensations assembled in the safe place construct. I then taught Michael how to use this construct to create emotional safety for himself in upcoming situations. I suggested he visualize himself attending his 12-Step meeting that evening and announcing himself as a newcomer. "Before you put your hand up, see yourself saying your cue word and allowing the image, the certain knowledge that you are safe and you feel safe, and the sensations of safety to come up for you," I said.

I guided Michael through an exposure exercise in which he used his cue word and then said aloud, "My name is Michael and today I've got nine days." He endorsed significantly less stress saying it in session, and most importantly, at our next session he reported feeling comfortable and safe actually saying the words at a meeting.

Emotion management tools

Having laid the groundwork, I next taught Michael AMST Skills III through VI. Collectively, these skills help the client to recognize emotions, to tolerate experiencing them, to notice the self having emotional experience, and to decrease distressing emotions and increase comfortable emotions. Taken together, these abilities constitute emotion management.

I asked Michael to tell me a recent time that he felt a low level of fear, a level three or four on an intensity scale from zero to 10. He described being stopped for an expired tag a few weeks earlier. With TABS facilitation, Michael was able to identify "tension in my back and shallowness in my breathing" as the sensations by which he recognized his fear experience. This is Skill III, recognizing an emotion by its sensations.

Skills IV and V employ an image of a grounding resource. Michael visualized a large boulder that allows the client to stay grounded and present while feeling the index emotion. This resource helps the client avoid acting out through drinking or using. When clients can tolerate an emotion, they can mobilize alternative, positive emotional management techniques that take the place of substance abuse, which is the means they've used to manage emotions previously.

Once Michael could stay grounded and present while feeling fear, I could help him develop the self-reflective ability to see or witness himself having a fear experience. This is the Skill VI and is called Noticing; it helps the client disidentify from his emotion experience. When substance abusers are identified with an emotion experience, they will drink or use. Disidentification promotes recovery.

Skill VII, the final skill in the AMST protocol, is called Regulation. Again using images, the client learns how to down-regulate distressing emotions such as fear. Michael chose a sink disposal unit to use for his down-regulation resource. With TABS facilitation, he was able to endorse decreasing his fear by 95 percent, and he was able to affirm certainty for the positive cognition "I am learning to decrease my fear."

Regulating a range of emotions

Having developed the basic AMST skills targeting the emotion fear, I took Michael through Skills III to VI of the protocol several more times, each time focusing on a different emotion.

We humans are genetically programmed to experience 10 affects. Affect is the word psychologists use when referring to the hard-wired. DNA-encoded affective response patterns. Most of these affects occur in a range from less intensive to more so. The 10 are: interest-excitement, enjoyment-joy, yearning, fear-terror, anger-rage, surprise-startle, distress-anguish, embarrassment-shame, disapproval-disgust, and dismell, which is the affective response to a noxious odor. Yearning is a basic emotion involved in early attachment to parents and later in love relationships and in spirituality. Yearning, which many will recognize by the names longing or aching, is the desire for merger with the desired object.

Any one of these hard-wired affects can be trauma-coded. Trauma coding means that an affect is elicited at a level that overwhelms the child's ability to process the affect to an adaptive resolution. Michael needed to learn how to recognize each of the affects so that he could then uncover which of them were being re-experienced in his alcoholism and addiction. These traumacoded affects provide the emotional motivation for substance abuse.

My research suggests that there are patterns of affect regulation in which a particular drug is often used to regulate a specific affect. The fact that each drug often seems to help the substance abuser chemically dissociate a particular emotion out of awareness explains the "drug of choice" phenomenon. Michael was able to identify yearning and excitement as the basic emotions motivating his alcoholic drinking. He also uncovered a deep sense of loss that he had re-experienced in a dissociated state when he smoked marijuana.

In our continuing counseling, Michael traced his yearning back to childhood experiences with his parents in which he longed for their love and attention, but which they were not capable of providing due to their own alcoholism and self-absorption. As a child, Michael had felt excited at the prospect of receiving parental love and affection, and he was able to identify the profound loss he felt, especially in his relationship to his father, when the bonding was not forthcoming.

In our first meeting, Michael had told me he drank and smoked pot to numb out. As a result of our work, he had now identified the emotions he was numbing out with drugs and alcohol, and he had developed new skills to manage these emotions.

An essential foundation

The AMST skills remediate deficits and prepare clients for subsequent psychotherapy. Every substance abuser is a potential candidate for AMST, because the protocol makes up for deficits in the abuser's childhood experience that left him or her unable to recognize, tolerate, notice, or regulate a range of emotions. Abusers use their drug of choice as a means to regulate emotions that would otherwise overwhelm them.

The AMST also prepares clients for subsequent psychotherapy to resolve the adversities and traumas that are often a part of their pathology. Childhood adversity and trauma have loaded the substance abuser with trauma-coded emotions that his childhood deficits experiences have left him ill-prepared to tolerate. When addicts and alcoholics abused in childhood learn the AMST, their personality system is better prepared to work through the childhood abuse. AMST is an essential first stage in treatment of many forms of substance abuse.

By John Omaha, Ph.D.

John Omaha, Ph.D., specializes in the field of emotion regulation, having developed an Affect Management Skills Training protocol to teach emotion regulation skills to clinical and non-clinical populations. The therapeutic orientation he founded is called Affect Centered Therapy. His book, Psychotherapeutic Interventions for Emotion Regulation, was published this year by W.W. Norton & Co. Omaha can be reached at jomaha@sunset.net.
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Author:Omaha, John
Publication:Addiction Professional
Geographic Code:1USA
Date:Nov 1, 2004
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