An interview with Psychologist Robyn Walser
Dr. Robyn Walser is a Psychologist in the Bay Area, specializing in the utilization of ACT therapy to treat issues such as trauma and addiction.
(note: this interview is also available as a podcast)
Jennifer Ghahari: Thanks for joining us today. I’m Dr. Jennifer Ghahari, Administrative Director at Seattle Anxiety Specialists. I’d like to welcome with us licensed psychologist Dr. Robyn Walser who is Director of TL Consultation Services, Co-Director of the Bay Area of Bay Area Trauma Recovery Center and Staff at the National Center for PTSD Dissemination and Training Division. A master ACT trainer, much of her work is focused on trauma and addiction, and that’s what we’ll be discussing today. Before we get started, Robyn, can you please let us know a little bit about yourself, some of the work you’ve done and the books that you’ve written?
Robyn Walser: Ah, sure. Thank you and thank you for inviting me to be here today to chat about these important topics. Let’s see, I got interested in ACT in 1991, long time ago. I did my first training in 1997 or ‘98 in Ireland, which was such an amazing experience, and then I think wrote my first book on PTSD and trauma in 2007 for ACT, for PTSD and trauma. And then I’ve written several books since then and just released ACT for Moral Injury, The Heart of ACT (one of my favorites), and then a colleague and I are working on ACT for Anger so we’ll be getting that out pretty soon, too. Pretty exciting stuff in terms of the publishing world.
Jennifer Ghahari: That’s fantastic, it’s a good base. So today we’re going to be discussing PTSD and addiction. Just to kind of get us started and provide a basis for the discussion, can you explain what is trauma?
Robyn Walser: So, that’s a very interesting question in a number of senses because when you are working with clients or you’re just talking with people in sort of the lay world, and sometimes even in the clinical world, “trauma” gets used a lot for things that are not actually criteria made traumas which is the DSM diagnosis or criteria for getting PTSD. So, those criteria are life-threatening typically, hearing about the sudden loss of another person, an ongoing trauma of past lifetime such as sexual abuse and sexual assault or something like that. Often people will come and say they were traumatized by this experience and what it was, was somebody perhaps said something really threatening or something really awful or maybe they got fired from a job or something like that. Those wouldn’t actually meet the criteria for trauma. Although the client or the person may experience it as a very horrible and challenging event, trauma – as defined by the diagnostic system – is actually a life-threatening experience where intense fear and horror or response of helplessness are part of what the individual experience is. Just making a little clarity around those things can be helpful.
Jennifer Ghahari: Right. Perfect. So then, in terms of PTSD, how does a trauma contribute to it and what types of events or traumatizing events are most commonly leading to the development of PTSD in a person?
Robyn Walser: Well, so, it’s normal for almost anyone to respond to a traumatic event like a natural disaster, a man-made disaster, like a shooting or maybe a crash or work accident or anything like that, with some degree of fear and panic and feeling unsettled. Most of us would have that response. But what you would expect is that it would linger for a bit of time, that we might be edgy and jumpy and worried and not feel safe for a period of time. But, typically what happens is people begin to go down in that kind of reactive emotional quality within a week or a few weeks after the traumatic event. What happens is that some folks have all of these reactions and they actually don’t experience a decrease and, after about a month of these kinds of reactions continuing, they would get the diagnosis of Post-Traumatic Stress Disorder. They’d have to meet certain criteria. So, hyper-arousal where you’re feeling keyed up and on edge and you’re searching the environment for danger. Mood struggles and thought struggles like your mood is low or blue or anxious and your thoughts are about the trauma or about safety or worrying about things. There’s also avoidance, this is another criteria, so you stop going to see people that you know, you stop visiting places, you stop going anywhere where you might be reminded of the trauma, you try not to think about what happened, you try to get away from the memories and so all kind avoidance inside of that as well. There’s a forth criteria of that hyper-arousal…avoidance, mood & thought struggles…slipped out of my mind at this moment; here, the expert on PTSD not getting the last criteria… (laughs) it’s intrusiveness. Keep experiencing the event over and over again, like you have memories of it intruding on your normal time and you’re struggling with those intrusions.
Jennifer Ghahari: So, in terms of avoidance, it sounds like becoming addicted to something or some type of addictive behavior might develop to try to break away from those intrusive thoughts and the fears and the ongoing stresses. How prevalent, in your experience, is addiction in those with PTSD and are there certain types of addiction that are more common than others?
Robyn Walser: Well, PTSD and substance use are highly co-morbid. It’s not unusual to have somebody come into the clinical setting who is using a substance in some way, it may not be a full addiction but often it would qualify for abuse or regular use that’s not of the social nature. Where they’re using to actually suppress the anxiety and fear that they are experiencing to try and block the worry that’s happening. So, it’s quite co-occur relatively at a great rate. There are lots of co-occurrences though with PTSD – like depression – is also quite highly co-occurring. You know, it’s got something an 80% rate. The co-occurrence of PTSD isn’t quite that high but it is something to be assessed if you’re seeing individuals who have Post-Traumatic Stress Disorder or just some clinical trauma. People can be seeking ways to escape their experiences by using substances and probably, the one I see the most, is alcohol. People, it’s easy access, it’s you know, legal and so people are drinking as a way to suppress I mean not that they couldn’t have other experiences on board like other substances; I’ve certainly seen plenty of those as well. Poly-substance use can also be part of the profile where they’re using multiple substances to try to escape their experience.
Jennifer Ghahari: You had mentioned that PTSD is diagnosed after someone is experiencing these symptoms for about a solid month or so and have you found that prompt psychotherapeutic treatment following a trauma lessens the chance of developing an addictive coping behavior or does the timing not really make too much of a difference? And, just as a quick follow-up to that in terms of timing, is there ever a time where it’s essentially too late to seek treatment for a trauma or is psychotherapeutic treatment helpful at any point for somebody following PTSD and a trauma?
Robyn Walser: No; let me answer the latter half of your question then I’ll answer the first part of it. It is, you can get treatment at any point in time for trauma especially if you’re having ongoing and lasting symptoms. I mean there’s a couple of models about how trauma can work…like one says that right after the trauma you’d have long-lasting and sustained symptoms across time; the other is sort of more waxing and waning…it comes and it goes and it comes and it goes and it depends a little bit on the situational factors like maybe life isn’t too stressful for you at one point and you’re doing ok and your symptoms are lower but then a life stressor happens and the symptoms get triggered and are up again. And then there’s also this idea that you can go for a long time without really struggling too much with symptoms, sort of a delay onset and you get symptoms much later in life. So, a good example of this might be let’s say a WWII veteran who was maybe was a POW and saw lots of, had lots of terrible experiences in battle and actually had symptoms but came back from the war and went work and had a family and did all the things that thought, to help sort of manage and avoid or distract, maybe even using substances along the way. It’s not that unusual for me to see somebody who, for years & years, like 30 years of using alcohol to kind of keep the symptoms down, they retire or they have a significant event that sort of lowers their coping ability – like the death of a spouse – and suddenly their symptoms are really high and they’re struggling with the PTSD late in life. So, there’s different courses and it just depends a little bit on who’s sitting in front of you and what their circumstances have been
With respect to intervening right after the trauma, the data is a little more mixed. There’s some data that says if you can come in and help people with their cognitions post-trauma, the cognitions that are the intrusive thoughts that are coming in, that you can perhaps lower the possibility of getting PTSD later. There feels like there’s something important about that. And there is certainly work of, like psychological first aid, where mental health providers can come in and provide psychological first aid immediately following the trauma, like within a few days or so, and that can be helpful. But some of the key factors are social support like, right after the trauma, are there people there to help you, re-establishment of safety, do you feel you are safe again, are people hearing you and helping you, getting connected to resources if you need resources. So, you sort of feel like that if you can get that kind of social and resource foundation underneath somebody right away that it can be helpful. But some people are just going to struggle because of earlier vulnerabilities, like maybe they’ve had other traumas prior to a significant trauma and that that puts them at risk for developing trauma in this one circumstance and so there’s an ideo-graphic quality to it in some way as to who will and who will not get PTSD.
I think I answered both of those, did I catch them both?
Jennifer Ghahari: Absolutely, thank you. In terms of overcoming addiction when you have PTSD and when you’re suffering from that, is it possible to overcome and conquer some addiction without treating the PTSD or is it really fundamental to first conquer the PTSD and get some type of treatment for that and then be able to battle and conquer whatever addiction that a person might have? Or are they completely separate?
Robyn Walser: They are heavily intertwined. So, the lore for a long time, and we now know this is not the case but it stills happens, is that you go and get your substance use handled first and then you come and do the trauma treatment. That’s sort of been the way that people think about…take care of this, and then we’ll take care of that. But actually, what the data shows is, it’s better to treat simultaneously to be addressing both the PTSD and the substance use at the same time – that’s where you get the greatest outcomes and recovery. It’s hard to do though, I mean there aren’t a lot of programs that are designed to treat both of them simultaneously and not everyone knows exactly what to do in terms of how you address those. There are a few treatments that are out there that have proven effective but they tend to be IOP type, in-patient type and then one other treatment, that addresses both simultaneously, is seeking safety. If you think of Judith Herman’s model of treatment, it’s sort of like safety then trauma then reintegration kind of processes. This sort of follows in that initial stage where you’re teaching coping skills to deal both with drinking or whatever substance it is and the trauma at the same time. There are 24, 25 different skills in there…there sort of DBT-like in terms of the type of skills that you would teach and the data essentially shows that it’s about as effective as relapse prevention. So it’s one of the few and we really need to do a lot more work in this area. One of the reasons why I like acceptance and commitment therapy, and you might think about PTSD, is because of that overarching quality that it has where it’s addressing multiple things at the same time. I still think you’ve got to do exposure work, like if you’re going to address the trauma, but ACT kind of has this nice quality of addressing avoidance and looking at how substance use is part of that avoidance process, while you’re simultaneously working with the trauma and reducing the avoidance.
Jennifer Ghahari: Lastly, I recently saw you had an interview regarding the social and psychological impacts of Covid-19 and wanted to know have you seen effects of PTSD due to the pandemic yet, particularly those who have gotten the virus or have lost loved ones from it? And what’s the importance of self care during this uncertain environment?
Robyn Walser: Yeah, we do know this - that there’s often a second pandemic that occurs behind the first, like Covid, which is a mental health pandemic and all of the data isn’t in on Covid-19 because we’re still right in the middle of it. So, while I don’t have any exact facts and figures about what’s happening, I can speak a little bit anecdotally about it. I can also speak in terms of the, larger impact and maybe even some about what’s happening in our clinic. We do know that numbers of things can happen and that the kind of stressors that people are experiencing right now can increase their symptoms of PTSD. So, if you’re tracking symptoms, let’s say if you working on treating them and they’re not going down, I’m kind of curious… is it because of the treatment or something’s not happening with the treatment or because everything is so stressful right now that’s it’s just kind of hard so maybe keeping them steady is helping, they’re not going up in the time of Covid, not going up in their increase in symptoms. People are struggling and I think it has impacts that we still haven’t quite figured out yet fully and how it influences PTSD, I think, is a little bit unknown. In our clinic one of the things we are noticing in our Bay Area Trauma & Recovery Clinic is that the clinicians are also really stressed. They’re trying to work with people who have trauma and who are really stressed and so you can kind of feel that there’s this environment of just trying to get the work done without sort of burning out and helping people manage their own stress of job losses while having PTSD or losing individuals to Covid and not being able to say goodbye. So a lot of emotional turmoil and we may see increases in experiences of traumas due to the loss/losses that people are experiencing as a result of Covid. I’m hearing whisperings of those kinds of things. And, that people feel more vulnerable right now and I think there’s a little bit of a kind of something that’s not really spoken to in terms of the kind of ongoing, iconic isolation that people might be experiencing and the sort of repetitiveness that is now happening in people’s days due to, you know, restaurants being closed, can’t go to the movies, can’t go see your friends and so it’s like each day starts to look like the last day… maybe you’ve even experienced that yourself? I know I have… I’m like is today Thursday or Friday? What is the impact of that kind of repetitiveness, like we’re sort of curious animals in a way, right? We’ve got a lot going on up here and we’re into discovery and technology and all of these explorers in a way and, on an individual level, being able to get out and connect is, I think, pretty important and so for those who are isolated, lost jobs, lost family members, I think it’s hard for me to imagine that their PTSD symptoms aren’t worsening as result of that. There are papers being written, people are doing the research in real time and I can’t keep up with it, myself. I’ve done some reading and I’ve just published, with some colleagues, on things to be looking for in terms of pandemics but the full outcome of this pandemic I don’t think is going to be known but I would not be surprised if its intense in terms of mental health outlooks.
Jennifer Ghahari: Ok. So, it seems that, especially if people are suffering or find themselves under the stressors of what’s going on, they should seek help just to make sure it doesn’t develop into something that would be more chronic?
Robyn Walser: They should seek help and if they can’t find help clinically because – maybe you’re experiencing this you’ll have to let you know – but every clinician I’ve talked to is like I’m full I’m full, I’m full. I’m getting emails that say things like I’ve contacted 10 therapists and nobody is available and, you know, I would invite people to persist and maybe to consider other options as temporary kind of space holders like, I hope this doesn’t sound too trite because I know some people are really suffering, but looking online for social groups that you can join if you’re having a substance use issue and you know that you’re struggling, you know, take a peek at some of these online recovery groups like Smart Recovery or AA – like if you can’t get a hold of somebody, if you can’t make something happen, don’t suffer alone JUST KEEP TRYING. I would download apps that are you know helpful, doing like mindfulness apps or listening to meditations on the internet… just almost anything that sort of helps you through the process especially if you’re unable to get services at the moment. Hopefully you can but, I don’t know if you find this happening in your area, where clinicians are saying they’re full?
Jennifer Ghahari: Unfortunately, yes, and I think you brought up an important point is that people are not alone in this. The amount of suffering is so widespread and it’s just an active part of the pandemic, unfortunately – so, like you said, pursuing and being persistent and trying to get some type of help is really necessary at this time.
Robyn Walser: And even if you have to do something like join a social group online, like a book club – these are not enough, I know that – but just somehow feeling like you’re connecting I think can be useful and helpful, cause you know social support in the middle of such a huge, you know, worldwide-like forced isolation process can be just invaluable.
Jennifer Ghahari: Perfect. Well thank you so much for your time we really appreciate it. Be safe and well during this time and we look forward to speaking with you again in the future.
Robyn Walser: Thank you again for having me.
Jennifer Ghahari: Thank you.
For more information, click here to access an interview with Psychologist Michele Bedard-Gilligan on trauma & recovery.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.