A Case Report about the Interrelation of Trauma, Emotional and Behavioral Response and Severe Alcohol Use Disorder

Literature shows a high comorbidity of violent behavior and use of substances including alcohol [1-3]. A study by [4] found an association between alcohol dependence and violent offenses. Individuals with higher levels of anger expressions are at higher risk to relapse to violence and substance use [5]. Individuals are socially conditioned how to deal with emotions and behavioral response. Being male and obtaining an alcohol use disorder is associated with an increased risk of being exposed to violence [6,7]. Dominant behavior is also linked to masculine norms as males are often expected to be strong, independent, and do not show emotions [8]. Research found that individuals recovered from an anger instigation easier when they used their common way of anger expression such as communication or inhibit it [9]. For example, Native American males were found to recover from anger more quickly when they inhibited it and recovered slower when instructed to express their anger [10]. Males from marginalized ABSTRACT Objectives: To understand the complexity of the client’s problems with alcohol use disorder and the importance of treating the underlying reasons of trauma to assist the client toward full recovery. To identify the related factors including traumatic events and irrational beliefs that led to the client’s emotional response of anger. To understand that anger, when using unhealthy coping strategies, fosters violent behavior. To comprehend that alcohol is often used as a self-medication for dealing with emotional injury, irrational beliefs, and low self-esteem. Method: This case report describes the interrelation of possible etiology and emotional and behavioral responses that led to a complex mental health issue in a male client. The client’s symptomology represented violent behavior toward others specified as Intermittent Explosive Disorder 312.34 (F63.81) and severe Alcohol Use Disorder 303.90 (F10.20) in early remission (DSM-5, 2013). Alcohol use is often associated with violent behavior, but it is also important assessing and treating trauma symptoms in understanding the complexity of alcohol use and domestic violence. The case report provides a framework of clinical treatment to assist the client for recovery and gaining sustained holistic wellness. Results: The client showed good progression with re-processing traumatic events with Eye Movement Desensitization and Reprocessing (EMDR) therapy as well as applying Rational Emotive Behavioral Therapy (REBT) when working with irrational beliefs including identity, masculinity, and healthy behaviors. Conclusion: After 6 months of follow up the client has shown positive treatment outcomes as evidenced by stability in his mental health and life. Interrelation Emotional Behavioral Evi-dence-Based


Introduction
We present a case of a male client who was sent to treatment because of anger and violent behavior as well as use of alcohol.
Literature shows a high comorbidity of violent behavior and use of substances including alcohol [1][2][3]. A study by [4] found an association between alcohol dependence and violent offenses.
Individuals with higher levels of anger expressions are at higher risk to relapse to violence and substance use [5]. Individuals are socially conditioned how to deal with emotions and behavioral response. Being male and obtaining an alcohol use disorder is associated with an increased risk of being exposed to violence [6,7]. Dominant behavior is also linked to masculine norms as males are often expected to be strong, independent, and do not show emotions [8]. Research found that individuals recovered from an anger instigation easier when they used their common way of anger expression such as communication or inhibit it [9]. For example, Native American males were found to recover from anger more quickly when they inhibited it and recovered slower when instructed to express their anger [10]. Males from marginalized populations are more likely to perceive racial discrimination as threatening and experience anger but use inhibition of anger to avoid aggressive behavior [11] which can impact levels of blood pressure [12]. Hence, this shows that cultural norms impact the socially accepted mode of response to anger. Suppressed feelings of anger have been implicated to pathophysiology of health problems [13], blood pressure [14] including cardiovascular disease [15,16].
When individuals suppress their anger, they may cumulate their emotional responses within their body and respond delayed and more intense [17]. found that inhibiting emotional information is linked with prospective changes in an increased cortisol awakening response six months later and shows how it influences the Hypothalamic-Pituitary-Adrenal axis (HPA) functioning.
Anger is reflected across physical components including stress reactivity with connected autonomic arousal, hypervigilance, and hostile attributions [18]. The emotional response of anger is often expressed in violent behavior toward others and the most serious violent offenders also represent the most severe drug issues [2].
When considering clients who struggle with violent behaviors and alcohol use disorders, the clinical mental health counselor should also assess the client's trauma history. Childhood adversities are associated with early use of alcohol, which indicates high risk for alcohol use disorder in adulthood [19]. Individuals who experienced multiple adverse childhood trauma are more likely to be heavy alcohol users and males are showing a significant higher risk of violence [20]. A study by [21] investigated the correlation between drinking and trauma symptoms and found that drinking is mediating to cope with it. The results suggested the importance of assessing trauma in clients who struggle with alcohol use disorders as experienced trauma can be the etiology that leads to suppressed anger and emotional distress. The client may try to self-medicate the emotional distress with alcohol consumption which increases the risk for violent behavior. This case report provides the treatment plan based on treating re-processing trauma with EMDR including emotional catharsis, psychoeducation about emotions and coping to channel behavioral responses. The clinician considered the client's cultural background related to historical trauma that impact indigenous populations until today. In addition, the clinical mental health counselor guided the client toward implementing healthy activities toward holistic wellness.

Client History
A 33-year-old male was seeking mental health counseling services after having completed detoxification and crisis management in the clinic. The client was tall, raw boned, and represented some hesitance in our first session but answered questions and appeared feeling more comfortable after the first intake counseling session. On a mental examination, the client reported symptoms of anger since he started school at age 8 years old when his peers started bullying him because of his Native American background. He shared that he was never feeling a happy child as his family members were struggling with alcoholism, poverty, and conflicts that mostly resulted in domestic violence.
The client described that he has not only witnessed violence from his father against his mother and siblings but was also exposed to physical and emotional abuse himself since he can remember.
He reported that he started being physically abusive towards his peers and younger siblings at age 13 years as it made him feel being strong like his father. The client shared that he was also physically abusive toward his first girlfriend when he was 18 years old, and his romantic relationships did not last for long throughout his life.
The client shared not being in a romantic relationship and having no family support. He reported that he often felt unable to concentrate or cope and dropped out of high school and started construction work when he was 21 years that he continued at different workplaces over eight years. The client reported that he did not feel comfortable with his co-workers in general. He reported having been let go at his job because he was angry and threatening towards one of his team members. This was the time when the client increased his consumption of alcohol and got into legal issues due to driving under the influence of alcohol.

Treatment Process
The treatment process was based on theory and research as  (Shapiro, 1991). Because the client was found to be benefitting from EMDR therapy, the content for the next 6 sessions was the application of Reprocessing (EMDR) therapy for re-processing some of his recalled physical and emotional abuses by his father. The clinician prepared the client with resources including gained appropriate self-regulation skills and selfmanagement skills such as breathing techniques and progressive muscle relaxation before focusing on trauma re-processing. The identified irrational core beliefs related to the earliest and the most intense traumatic events at age 5 were the core of the EMDR treatment.
The process was based on a three-pronged protocol that utilized past, present, and future for organizing the targets of the application.

Discussion
Addiction is a worldwide concern and governments are recognizing that more care is needed to help individuals to recover . Substance use problems are one of the primary issues that are linked to social and health problems in indigenous people [23]. Nevertheless, there is also a high prevalence of relapse when clients seek treatment for addiction. According to the American Addiction Centers [24] the percentage of people who will relapse after a period recovery ranges from 50% to 90%. Researchers understand alcohol-related behavior change as a process over time by identifying relapse patterns and remission factors for longterm clinical outcomes [25]. Although medication helps to detoxify individuals from drugs it cannot replace treatment [26] provided by a clinical mental health counseling is necessary to assist the client for a long-term recovery. A comprehensive examination of published articles about relapse characteristics related to alcohol use disorders identified that comorbidity, severity, craving, using other substances, and social factors are crucial for risk of relapse after remission [27]. To treat addiction effectively, the underlying issues as well as the whole person must be considered. Trauma is manifested on emotional, behavioral, and physical levels and traumatized clients are acting out past events and experiencing loss of self-worth as the individual's relationship with existence itself is shattered.
Childhood trauma was associated to significant increased health risk for alcoholism [28] and trauma that is not integrated increases sensitization and stress in the individual [29]. EMDR is a method developed to treat trauma and can be well integrated into various theoretical approaches to mental health counseling and psychotherapy. Clinicians who work with clients in the addiction field need to be trained well to deal with trauma and addiction treatment, as most clients presenting addiction have a trauma history [30]. In addition, the client's cultural background is related to historical trauma as his ancestors experienced genocide and historical oppression over generations. Providing psychoeducation about the impact of historical trauma and how the collective experience of his community has resulted in higher risk for dysfunctional families, violence, and the use of alcohol helps the individuals to understand his internalized negative beliefs about himself. Acknowledging historical trauma in an honest and direct way enhances any relationship and is essential in the healing circle for Native Americans [31]. The memory of this collective injury and emotional and behavioral responses might be conserved at the molecular level inbuilt in epigenetic inheritance [32]. The clinical mental health counselor's overall treatment framework was based on the self-medication model that believes that individuals develop addiction to mask other underlying issues. Therefore, one of the effective ways to heal addiction is to treat the underlying problem [33]. In this case report, the client has experienced multiple traumas throughout his childhood and his emotional response of anger manifested in his violence against others. Alcohol has been part of the problem to numb the pain that was the driving force behind his anger. The treatment of these underlying issues helped to build a steady foundation for the client to recover and prevent relapse. Working with the client on emotional and behavioral responses as well as his cultural background [34] was an effective approach. The clinical mental health counselor worked with the client on his irrational beliefs about himself to enhance his selfworth with REBT therapy. In addition, the integration of physical, mental, spiritual, and relational care including walking in nature, wood gathering, sweats, and other traditional healing practices improved the client's holistic wellness and sustained sobriety.

Conclusion
The provision of trauma treatment for a client who was meeting the DSM-5 criteria for Intermittent Explosive Disorder 312.34 (F63.81) and severe Alcohol Use Disorder 303.90 (F10.20) in early remission (DSM-5, 2013) but not for PTSD was effective in this case report and led to achieve long-term recovery. This case report highlights the importance of involving clinical mental health counselors in treating clients with both addiction and underlying issues such as traumatic events. Clinicians must consider how trauma contributes to the progress of symptoms including anger and addiction as they are often connected.

Conflict of Interest
We have no conflicts of interest to disclose. Highlights a.
EMDR was considered as an effective therapy to reprocess early traumatic events that have led to anger.