It is so important to understand that PTSD can occur following any type of trauma; and subclinical PTSD – PTSD symptoms that do not meet the diagnostic threshold – is related to similar levels of impairment as diagnostic PTSD. However, while the majority of people in the general population (up to 80% or more) experience a traumatic life event, only 7-9% of those individuals develop PTSD.
In other words, the experience of trauma is not necessarily equivalent to PTSD – or to negative outcomes, more generally. For populations exposed to chronic trauma and stress, such as military service members or first responders, PTSD prevalence rates are typically at least double that of the general populace.
In fact, our recent work has focused upon better understanding the psychological health of firefighters, a vulnerable and understudied population chronically exposed to trauma and stress. We have found that rates of both PTSD and alcohol use disorder among firefighters are significantly higher than those of the general population and comparable to rates documented among military veterans.
Furthermore, most people are surprised to hear that PTSD rarely manifests as a single disorder; and up to 80% of individuals with PTSD also meet diagnostic criteria for another psychiatric disorder. Co-occurring psychological disturbances become intertwined over time.
For example, people who use substances and suffer from PTSD may find it difficult to stop using because the substance use may help them – in the short term – to cope with or “numb out” from disturbing memories, thoughts, or emotions. For many years – until relatively recently – substance use disorders were treated separately from PTSD and other psychiatric disorders.
The sequential model was commonly employed wherein an individual’s SUD would be treated first, and once sobriety was attained, that individual was thought to be ‘ready’ to engage in treatment for mood, anxiety, or trauma-related disorders. We have realized over the past 10-15 years that this model of treatment does not tend to work well. If the psychiatric disorder co-occurring with SUD is not treated, people often relapse to substance use following treatment.
Most new approaches to treating SUD with co-occurring PTSD, for example, subscribe to an integrated model of care wherein the SUD is treated alongside other psychiatric disorders.
Can you explain your research on mindfulness as a treatment for PTSD?
Mindfulness is generally defined as bringing one’s full attention to the present moment and taking a stance of nonjudgmental acceptance to the ongoing flow of sensations, thoughts, and/or emotional states that may arise.
Theoretical postulations have discussed mindfulness as an important protective factor in the development and maintenance of Post Traumatic Stress Disorder, Substance Use Disorder and PTSD/SUD. In addition, mindfulness-based interventions may offer a potentially promising avenue for the treatment of PTSD and SUD, including alcohol use disorder.
However, relevant research is in its initial stages of development. Mindfulness may foster adaptive coping with negative emotions or stressful situations. Such coping might include a present-oriented focus and acceptance of the transient nature of challenging emotional or physical states.
When individuals are emotionally triggered by reminders of a traumatic event or struggling through withdrawal symptoms or cravings, mindfulness practices can help them to ‘ride the wave’ of difficult experience without resorting to experiential avoidance, suppression of thoughts and emotions, and/or other unhealthy behaviors, such as substance use.
Theoretically, with greater nonjudgmental acceptance of one’s present experience, an individual may be less likely to be weighed down by the effects of stigma or judgment. Furthermore, individuals who are more aware of present experience – through a cultivation of mindfulness – may be better able to effectively engage in various forms of treatment. Clinical trials of mindfulness-based interventions have shown preliminary promise in reducing PTSD symptoms and substance use, respectively, in a variety of populations.
However, much more work needs to be done in order for us to better understand the potential clinical utility of mindfulness for PTSD/SUD.
Can cannabis effectively treat PTSD?
The legalization of cannabis and the utilization of medical cannabinoids are certainly controversial and important issues. The self-medication model of addiction has been used to explain the comorbidity of PTSD and various types of SUDs, including cannabis use disorder.
Historically, the scientific study of the association between cannabis use and PTSD was perhaps limited by the varied potencies and strains of cannabis available for use across geographical locations and historical time periods. We still do not know definitively whether cannabis is helpful for PTSD.
Emerging research suggests that cannabis is comprised of over 100 ingredients; and cannabidiol (CBD), specifically, may have anxiolytic properties, meaning that it may help to decrease anxiety symptoms. Unlike THC, CBD does not possess intoxicating effects.
Research is currently being conducted on whether CBD can be effectively used in the treatment of PTSD and other psychiatric and medical conditions. However, at this point in time, the scientific evidence relevant to the potential therapeutic benefits of cannabis or CBD is in its infancy. In essence, it is too early to take a definitive, research-informed stance on the question at the present time.
How did you develop an interest in the psychology of trauma?
My maternal grandparents were both World War II veterans, and my extended family was affected by the civil war across the former Yugoslavia through the 1990’s. Throughout my childhood and adolescence, I was exposed to stories of trauma, loss, and grief. From a young age, I was struck by the varied trajectories of risk and resilience in the aftermath of trauma. I was drawn to understanding human behavior and to learning more about how to foster growth following trauma. I entered my undergraduate career knowing that I wanted to pursue a career in clinical psychology.
Early in my graduate career, my research interests were focused upon better understanding risk and maintenance processes relevant to PTSD. My interest in the comorbidity of PTSD and substance use disorders emerged through clinical practice. As I worked with trauma survivors, I realized that most suffered from comorbid psychiatric diagnoses, and substance use disorders (SUD) were among the most prominent. Yet, few evidence-based treatment programs were available for those with PTSD/SUD comorbidity. This confluence of experiences led to my investigation of the interplay of PTSD/SUD as a core aspect of my research program.
In your career, what has been your biggest obstacle and how did you overcome it?
For me, finding the optimal balance among research, teaching, and clinical practice has been an ongoing challenge. My research program is directly informed by clinically-relevant questions, and my work is intended to improve our understanding of issues pertinent to clinical practice.
I believe that the best research questions and grant ideas emerge from clinical interactions and from the input of the young and creative minds of students and trainees, who are approaching the field of traumatic stress with a fresh lens. I have found that working with my graduate students provides me with the gratification of investing in and cultivating a new generation of clinical scientists and practitioners, and that reserving a half-day per week for clinical practice, including clinical supervision, keeps me connected to the populations for whom my research program is dedicated.
All of the work we do together serves the ultimate goal of improving the health and well-being of adults deleteriously impacted by trauma.
What advice would you give to a student thinking of specializing in your field?
A commitment to methodologically rigorous research and scientifically informed treatment practice is the essence and future of the field of clinical psychology. I would advise students interested in pursing a career as a clinical psychologist to get involved in research — early and often!
Volunteer and/or paid research assistant positions can be invaluable in helping a student to steer their career goals. Admission to most clinical psychology doctoral programs is competitive. The ‘match’ between the prospective graduate student’s experience and interests and the faculty mentor’s research is heavily weighted in the admissions decision process.
Reading the literature, attending conferences, and talking to graduate students and faculty are all important elements to informing not only a student’s broad-based decision to pursue a doctoral degree but also to informing the particular area of work that in which she/he wishes to specialize.