Implications of The Adverse Childhood
Experiences Study
R. Denice Colson, PhD, LPC, MAC, CPCS
Trauma Education & Consultat...
Introductions
Objectives for Today
Adverse childhood experiences
Adult behavioral health issues
Origins of
Behavioral
health issues?
One factor that differentiates the
etiological approach…
Symptoms
Symptoms
Consider…
 Our understanding of addiction could possibly be
changed to consider substance use as an
understandable soluti...
Consider…
Childhood abuse damages a whole life,
not just a childhood.
Completely Mostly Maybe Not Much Not at All
1 2 3 4 ...
Alchemy:
…into GOLD! Turning lead…
18 months
Years later – in a
mental institution
Turning gold into lead.
www.TheAnnaInstitute.org
18 months
Anna Carolyn Je...
Challenging the traditional
views of addiction.
…Traditional views
may be missing the
point
…Traditional views
may seriously
adversely impact
treatment.
…Research challenges
their validity.
What is ?
Adverse Childhood
Experiences
Vincent Felitti, MD
(Kaiser Permanente)
Robert F. Anda, MD
(CDC)
Largest scientific
research study of it’s
kind
Analyzes the relationship
between multiple categories of
childhood trauma (ACEs), and
health and behavioral outcomes
late...
It claims to document
the…
…conversion of childhood
trauma and household
dysfunction into adult
addictions and organic
di...
It claims to demonstrate
that…
…childhood abuse is
extraordinarily common.
It claims to demonstrate
that …
…childhood abuse
damages a whole life, not
just childhood.
It claims to demonstrate
that…
…childhood abuse and
household dysfunction
are the most basic
determiners of the leading
c...
What do you think?
How it got started…
Felitti, V. (2011) Adverse Childhood Experiences and The Origins of Addiction. Neuroscience
of Addicti...
She gained 400
lbs in a shorter
time than it took
to lose 400 lbs.
Felitti, V. (2011) Adverse Childhood Experiences and Th...
Issues raised by Patient X…
 Perhaps overeating and obesity were not the core
problem; each was only the marker of the co...
may not be the essence of
the problem…
What’s looming
beneath the surface
may be what really
sinks people’s lives.
Study Design
 Initiated in 1995 and 1997- enrollees are
being tracked
 Requested participation of 26,000
consecutive pat...
Study Design
 Cohort population was 80% white including
Hispanic, 10% black, and 10% Asian.
 Their average age was 57 ye...
Finding Your ACE Score Quiz
While you were growing up, during your first 18 years of
life:
1. Did a parent or other adult ...
3. Did an adult or person at least 5 years older than you
ever…Touch or fondle you or have you touch their
body in a sexua...
5. Did you often or very often feel that …You didn’t
have enough to eat, had to wear dirty clothes, and had
no one to prot...
8. Did you live with anyone who was a problem drinker
or alcoholic or who used street drugs?
Yes No If yes enter 1 ___
9. ...
What’s Your ACE Score?
Used a simple scoring
system from 0 to 10
ACE Score Determination
Exposure during
childhood or
adolescence to any
category of ACE was
scored as one point.
ACE Score Determination
Multiple exposures within a
category were not scored:
one alcoholic within a
household counted th...
Research outcomes
tend to understate the
findings.
General Findings…
Less than half of this middle-
class population had an ACE
Score of 0.
General Findings…
One in fourteen had an ACE
Score of 4 or more.
Abuse, by Category Prevalence (%)
Psychological (by parents) 11%
Physical (by parents) 28%
Sexual (anyone) 22%
PREVALENCE ...
Neglect, by Category Prevalence (%)
Emotional 15%
Physical 10%
PREVALENCE OF ACE
Household Dysfunction, by Category (%)
Alcoholism or drug use in home 27%
Loss of biological parent < age 18 23%
Depressio...
Dose-Response Relationship
Higher ACE Score Reliably Predicts Prevalence of
Disease, Addiction, Death
Higher ACE Score
Res...
Conclusions:
ACEs are
common,
threatening, and
often denied.
ACEs have a
profound effect
even 50 years
later on
addiction, health
risks, diseases,
and death.
This combination
makes ACEs the
leading
determinant of the
health and social
well-being of the
nation and the
major factor...
The ACE Study and Addiction
ACE and Adult Alcoholism
A 500% increase in adult
alcoholism is directly related
to adverse childhood
experiences.
ACE and Adult Alcoholism
2/3rds of all alcoholism can
be attributed to adverse
childhood experiences
ACE and Adult Alcoholism
0
2
4
6
8
10
12
14
16
18%Alcoholic
ACE Score0
1
2
3
4+
ACE Leads to Early Alcohol
Initiation
•As the number of ACE increase,
the more likely a person is to begin
drinking before...
2/3rds experienced physical and/or
sexual abuse
75% of the women - sexually abused.
(SAMHSA/CSAT, 2000; SAMHSA, 1994 )
M...
6 to 12 times more likely physically
abused ,
18 to 21 times more likely sexually
abused. (Clark et al, 1997)
Teenagers ...
 86% report physical abuse histories,
69% sexual abuse histories.
 Of those with sexual abuse histories
 96.7% physica...
 86% report physical abuse histories,
69% sexual abuse histories.
 Of those with sexual abuse histories
 96.7% physica...
ACE and Obesity
66% reported one or more type
of abuse.
International Journal of Obesity (2002) 26, 1075 – 1082. doi:10.1...
ACE and Obesity
Physical abuse and verbal abuse
were most strongly associated
with body weight and obesity.
(the abuse ty...
ACE and Obesity
Obesity risk increased with
number and severity of each
type of abuse.
International Journal of Obesity (...
ACE and Current Smoking
A child with 6 or more
categories of adverse childhood
experiences is 250% more
likely to become ...
ACE and Current Smoking
0
2
4
6
8
10
12
14
16
18
20
0 1 2 3 4-5 6 or more
ACE Score
%
ACE and IV Drug Use
A male child with an ACE score
of 6 has a 4,600% increase in
the likelihood that he will
become an IV...
ACE and IV Drug Use
78% of IV drug use in women is
attributable to adverse
childhood experiences.
ACE and IV Drug Use
Relationships of this magnitude
are rare in Epidemiology.
ACE and Intravenous Drug Use
0
0.5
1
1.5
2
2.5
3
3.5
%HaveInjectedDrugs
0 1 2 3 4 or more
ACE Score
N = 8,022 p<0.001
Other examples of addiction:
More subtle examples include
Sex,
 Pornography,
 Gaming,
 Gambling,
 Shopping and more.
Serious social problems
Severe and persistent emotional problems
Health risk behaviors
Adult disease and disability
H...
Adverse Childhood Experiences
and Likelihood of > 50 Sexual
Partners
0
1
2
3
4
AdjustedOddsRatio
0 1 2 3 4 or more
ACE Sco...
ACE Score and Unintended
Pregnancy or Elective Abortion
0
10
20
30
40
50
60
70
80
%haveUnintendedPG,orAB
0 1 2 3 4 or more...
Sexual Abuse of Male Children and Their
Likelihood of Impregnating a Teenage Girl
0
5
10
15
20
25
30
35
Not 16-18yrs 11-15...
In other words…
 Boys who were sexually abused are more likely to
impregnate a teenage girl.
 The earlier the age when t...
Frequency of Being Pushed, Grabbed, Slapped, Shoved or
Had Something Thrown at Oneself or One’s Mother as a Girl
and the L...
ACE Score and Indicators of
Impaired Worker Performance
0
5
10
15
20
25
Absenteeism (>2
days/month
Serious Financial
Poble...
Severe and Persistent Emotional
Problems
Chronic Depression
 Adults with an ACE score of 4 or more were 460%
more likely to be suffering from depression .
Chronic Depression
0
10
20
30
40
50
60
70
80
%WithaLifetimeHistoryof
Depression
0 1 2 3 >=4
ACE Score
Women
Men
Suicide
The likelihood of adult suicide
attempts increased 30-fold,
or 3,000%, with an ACE score of
7 or more.
Suicide
Childhood and adolescent
suicide attempts increased
51-fold, or 5,100% with an ACE
score of 7 or more.
Suicide
0
5
10
15
20
25
%AttemptingSuicide
ACE Score
1
2
0
3
4+
Hallucinations
Compared to persons with 0
ACEs, those with 7 or more ACEs
had a five-fold increase in the risk
of reporti...
Hallucinations
Abuse and trauma suffered in the
early years of development
resulted in a far greater likelihood
of pre-ps...
Hallucinations
In an adult inpatient sample, 77% of
those reporting CSA or CPA had one
or more of the ‘characteristic
sym...
0
2
4
6
8
10
12
0 1 2 3 4 5 6 >=7
No
Yes
ACE Score
EverHallucinated*(%)
Abused
Alcohol
or Drugs
*Adjusted for age, sex, ra...
0
5
10
15
20
25
30
35
40
45
0 1 2 3 4 5 6 7 8
Childhood Sexual Abuse and the
Number of Unexplained Symptoms
History of Chi...
0
5
10
15
20
25
30
35
40
0 1 2 3 >=4
ACE Score and Impaired Memory of
Childhood
PercentWithMemory
Impairment(%)
ACE Score
...
Adult Disease and Disability
History of STD
0
0.5
1
1.5
2
2.5
3
AdjustedOddsRatio
0 1 2 3 4 or more
ACE Score
The higher the ACE score the greater the
prevalence of Liver Disease
The Higher the ACE score the more likely a person will
develop COPD
ACEs Increase Likelihood of Heart Disease*
• Emotional abuse 1.7x
• Physical abuse 1.5x
• Sexual abuse 1.4x
• Domestic vio...
This illustrates that adverse experiences
in childhood are related to adult
disease by two ways:
1)Indirectly through atte...
High Health and Mental Health
Care Costs
The financial burden to society
of childhood abuse and trauma
is staggering.
Child abuse and neglect affects
over 1 million children a year.
Costs our nation 220 Million
every DAY.
Paid $80 Billion to address
childhood abuse and neglect in
2012
 http://www.preventchildabuse.org/images/research/pcaa_co...
Poor Life Expectancy: ACE score
of 4 or more reduces life
expectancy by 20 years!
Effect of ACEs on Mortality
0
10
20
30
40
50
60
0 2 4
PercentinAgeGroup
ACE Score
19-34
35-49
50-64
>=65
Age Group
Other Studies on
Childhood Sexual and/or
Physical Abuse
51 – 98% of public mental
health clients with severe
mental health diagnoses
have unaddressed
sexual/physical abuse
(Good...
93% of psychiatrically
hospitalized adolescents had
histories of physical and/or
sexual and emotional trauma.
32% met cri...
More than 75% of girls in
juvenile justice system
have been sexually abused.
(Calhoun et al, 1993)
80% of women in prison and
jails have been
sexually/physically abused.
(Smith, 1998)
100% of men on death row in
CA have a history of family
violence (Freedman,
Hemenway, 2000)
Boys who experience or witness
violence are 1,000 times more
likely to commit violence than
those who do not. (van der
Ko...
Unaddressed childhood sexual
abuse is significantly related to
adolescent and adult self-harm,
including suicide attempts...
One study found childhood
sexual abuse to be the single
strongest predictor of
suicidality. (Read et al, 2001)
Neurological development
Lasting Alterations in Self-
Perception
• Sense of helplessness,
paralysis, captivity,
inadequacy,
powerlessness, danger,
fear…
When not addressed…continues
over ...
Sense of Shame, Guilt, Self-Blame,
Being Bad…
When not addressed…continues
over the lifespan.
Sense of defilement,
contamination, being spoiled,
degraded, debased,
despicable, evil…
When not addressed…continues
over ...
Sense of complete
difference from others,
deviance, utter aloneness,
isolation, non-human,
specialness, unseen,
unheard, b...
Summary of ACE Impact
ACE Causes serious and
chronic health, behavioral
health and social problems
Epidemic proportions and a
major public health issue.
Impacts brain and nervous
system directly.
Impacts one’s perception of
self and others.
Often unrecognized, ignored
or denied.
Finally, ACE is A Public
Health Tragedy
Leading to long-term use of multi-
human service systems at an estimated
annual cost of $80 billion
$33 billion in direct costs and $47
billion in indirect costs, as a result of
child abuse and neglect (PCCA, May
2012)
Child Maltreatment Costs
 $124 billion over the lifetime of the traumatized
children..
 The breakdown per child is:
 $3...
Consider again the statements
from the beginning. Where
would you mark yourself now?
While, the traditional concept…
 Addiction is due to characteristics intrinsic in
the molecular structure of an addicting...
Instead, the ACE Study
shows that:
 Addiction highly correlates with characteristics
intrinsic to that individual’s life ...
Dr. Felitti’s redefinition of addiction
informed by the ACE Study:
 Addiction is the unconscious, compulsive
use of psych...
Like smoke is the evidence of a fire.
However, the evidence is buried
beneath the surface…
Addiction-use
of substances
Protected by:
Shame,
Secrecy, Guilt,
Fear...
Conventional view is…
 Certain substances are addictive based on the
evidence that its almost impossible for certain
indi...
Considering evidence from the ACE
study…
 Are we focusing on the outcome and not the cause?
 Are we overlooking a major ...
What Is The Core Problem?
 Why is treatment so difficult?
 Why are long-term results so often poor?
 Is it because trea...
Treatment Failures
 What can we learn from those who can’t give up an
addiction?
 Is the wrong thing being treated?
 Co...
Smoking Cessation: Policy and Research as it Relates to
Evidence-based Practices in the Military and Veteran
Health Care S...
The Smoking Divide
 A new analysis of federal smoking data reveals that
although the national smoking rate has been falli...
Abstract: Amphetamine Use now and
then…
 Using historical research that draws on new primary sources, I
review the causes...
Amphetamines
 Prescribed as the first anti-depressant medications in
the 1940’s.
 Crystal Meth is a potent anti-depressa...
Example: HEROIN USE IN A WAR ZONE
 In a study of 898 American soldiers in Vietnam, each of
whom acknowledged using heroin...
Rat Park Experiments
 Rats were fed morphine for 57 consecutive days.
Alexander, B.K., Coambs, R.B., and Hadaway, P.F. (1...
Rat Park Experiments
 Rats in cramped, isolated cages chose morphine over
water.
Alexander, B.K., Coambs, R.B., and Hadaw...
Rat Park Experiments
 Rats housed in a “Rat Park” chose water over morphine
most of the time.
Alexander, B.K., Coambs, R....
Could there be hidden benefits of
addiction that we aren’t considering?
 Does substance use serve to do more than get a p...
Is it possible that
Gary Allan is right
when he sings…
It Ain’t The Whiskey
 http://www.youtube.com/v/m3Xr67jp1Fo&autopla...
Implications for
Treatment
Implementing Trauma Informed Care
Break
First Step…
Admit we have a problem
18 months
Years later – in a
mental institution
Turning gold into lead.
www.TheAnnaInstitute.org
18 months
Anna Carolyn Je...
Trauma-informed treatment
(SAMHSA-National Center for Trauma Informed
Care)
 Trauma-informed care is an approach to engag...
How do implement trauma
informed treatment?
1. We can change our
perspective…
View addiction/substance-use through
the lens of trauma.
We can consider the context…
Arrested
for DUI
at 23
Raised by a
single mother
Mother was
verbally and
physically
abusive.
...
People do what almost works
and substance use is almost
working for this person.
What are they trying to
solve?
Not
blowing
away the
smoke..
But
putting
out the
fire.
Not cutting
off the
limbs…
But digging out the
roots…
2. We can change our approach to
evaluation…
Rather than only
evaluating the surface…
Make an attempt to
evaluate for the ...
3. We can accept a redefinition of
addiction…
 Felitti wrote: “we propose giving up our old mechanistic
explanation of ad...
Definition: Addiction is understandable
as the unconscious, compulsive use of
psychoactive materials in response to
the s...
Addictions = Solutions
4. We can adjust the way
we do treatment.
Typical substance-abuse
treatment…
Focuses on reducing risky
behaviors and/or sobriety.
Role of treatment
provider…facilitate change.
Educational and motivational
and focus on reducing
substance use, decreasing
depression, anxiety, etc.
Adjusting doesn’t mean…
…We don’t do addiction
treatment
…We don’t fulfill the State or
agency requirements.
Adjusting DOES Mean…
Seek training in recognizing and
treating trauma.
Evidence Based Psychotherapy Models for
Adults with ACEs-related Disorders
 Brief Psychodynamic Therapy
 Cognitive Proce...
However, many of these are still
symptom-reduction focused and
not Source-Focused.
 That’s why I developed Structured Tra...
Source-Focused Treatment
 Focuses on etiologies.
 Etiology = the philosophical investigation of
causes and origins.
What makes trauma, trauma?
 The ACE study uses adversity and identified 10
categories. Are these the only sources of trau...
My definition
The source of trauma is unhealed,
unaddressed, unresolved wounds
to the personal identity.
(Compared to dia...
My definition
 Personal Identity is defined as the
sum of your person as you exist in
your own mind/brain and as you
are ...
Trauma happens when our
Personal Identity is wounded to the
point that we experience
unacceptable contradictions to our
ex...
Trauma Survivor Blueprint
Four Stages in Development
An event occurs…
The event contradicts expectations,
beliefs, values (personal identity). We
interpret the contradictions as
threatening i...
The threat triggers the autonomic
nervous system which secretes
chemicals we call emotions.
Psychologically, we have expe...
Our brain rallies to survive and the
survival behaviors/thoughts/
attitudes are put into action. This
includes external b...
Our own responses are evaluated and
many times contradict our own
expectations in some way (physically,
psychologically, ...
Stage 1
Event contradicts
expectations
Stage 2
Triggers autonomic
nervous system: loss and
emotion
Stage 3
Brain rallies t...
Survivors keep cycling through this
loop, developing more survival
responses (behaviors, thoughts,
attitudes) moving them...
Stage 1
Event contradicts
expectations
Stage 2
Triggers autonomic
nervous system: loss and
emotion
Stage 3
Brain rallies t...
As the cycle moves the person
further away from awareness of
this connection…
Perception of self changes.
• Personal iden...
The person moves from ACE (which are
experienced as social, emotional, and
cognitive impairment, to risky
behaviors (now ...
Level 1
Adverse
Childhood
Experiences
Level 2
Social, emotional,
cognitive impairment
Level 3
Adoption of health risk
beha...
Structured Trauma & Abuse
Recovery© is Source Focused
because:
Evaluation, testing, and treatment are
all focused on the source or etiology of
the problem with the goal of
reestablishi...
Stage 1
Event contradicts
expectations
Stage 2
Triggers autonomic
nervous system: loss and
emotion
Stage 3
Brain rallies t...
Symptoms are bypassed when at
all possible, starting by
addressing stage #1 first, then
#2, then #3 and finally #4.
It does NOT mean that
symptoms (#3-4) aren’t
considered, but it does mean
that, when possible, symptoms
are bypassed.
Structured Trauma & Abuse
Recovery is evidence informed
because…
Built on a contextual model framework.
The Contextual Model is a modern
version of the Common Factors model
and serves as...
 Includes evidence based practices included
in other models such as Motivational
Interviewing, Prolonged Exposure Therapy...
What does bypassing
symptoms mean?
We don’t engage directly in trying
to change the client’s survival
responses unless absolutely
necessary.
We follow the three phases of trauma
recovery in order. (1. Stabilizing; 2.
Reprocessing/Grieving; 3.
Reconnecting/Integr...
We keep the focus on healing
rather than fixing.
Why is bypassing symptoms
important?
Level 1
Adverse
Childhood
Experiences
Level 2
Social, emotional,
cognitive impairment
Level 3
Adoption of health risk
beha...
When the psychological management
system is overwhelmed with pain, we
chose survival responses that work for
us. These wo...
Unfortunately, they also bring
with them side-effects that are
viewed as unavoidable.
Etiology
Cause-Effect Relationship
Adapted from Collins, J., (1990) Presenters Handbook, TRT Institute, Angel Fire, New Me...
Adapted from Collins, J., (1990) Presenters Handbook, TRT Institute, Angel Fire, New Mexico
Translates to letting go of
th...
What can I do NOW?
Do a trauma evaluation as part
of intake or after first session.
Screening Instruments
 Family Health History Questionnaire
 Health Appraisal Questionnaire
(http://www.cdc.gov/ace/quest...
Others
 ACE Score
 http://acestudy.org/yahoo_site_admin/assets/docs/ACE
_Calculator-English.127143712.pdf
 Simple Traum...
Avoid Common Errors of
Trauma Informed Care
Herman writes…
“…the single most common therapeutic
error is avoidance of the traumatic
material…”
and, “…probably the sec...
Principles to Apply re: Treatment
Ask, but don’t push for too much
detail.
•Expect denial and later disclosures.
•Don’t t...
How Can I Do This?
Use screening instruments
Educate using handouts
Handouts
 Trauma Source Score Handout
 Adverse Childhood Experiences and Health
and Well-Being Over the Life-span
 Deve...
Get Trained!
3 Phases of Trauma Recovery
Incorporated in the structure of
STAR
 (Herman, 1997; Cloitre et al, 2012)
1. Establishing Safety and
Stabilizing
2. Reprocessing and Grieving
3. Reconnecting and Integrating
Establishing Safety and
Stabilizing
Reconnecting and
Integrating
Reprocessing
and Grieving
Phase 1: Establishing
Safety and Stabilizing
Substance use/addiction has to be
addressed first and some stability
and sobriety established before
moving into the Repr...
Reconnecting comes last.
Stabilization and Safety Phase is
designed to move a person to the
Reprocessing and Grieving Phase.
This is the HEART of ...
Phase 2: Reprocessing and
Grieving
 Step 1: Identify the source of trauma. If more
than one, identify most pressing. Write
about it using a structured outli...
Step 2: Identify interpretations in
personal life context along with losses.
Read out-loud in structured individual
or gr...
Step 3: Identify past and present
survival responses and losses. Read
out-loud in structured individual or
group.
Step 4...
Step 5: A forgiveness exercise. Optional
Step 6: Creative expression of Spiritual
Marker or Personal Identity Reflection.
Phase 3: Integrating and
Reconnecting
Integrate newly developed survival
responses into daily life.
Reconnect with self,...
A Source Focused Model, like Structured
Trauma and Abuse Recovery…
Adverse childhood experiences are
common but typically unrecognized.
Their link to major problems later in
life is stron...
Treating the solution may threaten
people and cause flight from
treatment.
What presents as the ‘Problem’ may in
fact be...
Change starts with us.
Contemplation is to be expected.
Trauma-Informed Care is the new best-
practices standard.
Ther...
Adverse childhood experiences
Adult behavioral health issues
Origins of
Behavioral
health issues?
One factor that differentiates the
etiological approach…
Symptoms
Symptoms
“My greatest failure was in believing
that the weight issue was just about
weight. It’s not. It’s about not handling
stres...
“I believe this is the most
important thing that you can ever
do, to begin to deal with this, with
this intergenerational ...
Denice Colson, PhD, LPC, MAC,
CPCS
 www.TraumaEducation.com
 www.ELCCC.org
 www.LifeLineBillingSolutions.com
 RDAColso...
You’re an Overcomer!
Mandisa
Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study
Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study
Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study
Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study
Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study
Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study
Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study
Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study
Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study
Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study
Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study
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Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study

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The Adverse Childhood Experiences Study is perhaps the largest of its kind, but generally unknown in the behavioral health and counseling field. Evidence from this extensively published research project challenges the traditional, comfortable views of the roots of many behavioral health as well as physical health issues. Dr. Vincent Felitti and Dr. Robert Anda are the lead principle investigators of the ACE study, and their extensive publications demonstrate that, 1. ACEs are common, threatening, and often denied; 2. ACEs have a profound effect even 50 years later on addiction, health risks, diseases, and death; and 3. This combination makes ACEs the leading determinant of the health and social well-being of the nation and the major factor underlying addictions. In this presentation, we will review some of the evidence and discuss implications for evaluation, treatment, and policy. The presenter will also add her own theories on treatment and present a theoretical overview of Structured Trauma Recovery© which she developed for her dissertation. S.T.R.©, is informed by the ACE research, built on the Contextual Model framework, theoretically Psychodynamic, and utilizes techniques which are evidence informed.
a. The participant will be able to identify at least 3 general outcomes of the ACE study which impact our understanding of the origins of behavioral health issues.
b. The participant will be able to identify the 3 reasons it is important to consider the links between adverse childhood experiences and adult behavioral health issues.
c. The participant will be able to identify one factor that differentiates the etiological approach to trauma and abuse recovery from other treatment models.

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Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study

  1. 1. Implications of The Adverse Childhood Experiences Study R. Denice Colson, PhD, LPC, MAC, CPCS Trauma Education & Consultation Services Eagle’s Landing Christian Counseling Center, Inc.
  2. 2. Introductions
  3. 3. Objectives for Today
  4. 4. Adverse childhood experiences Adult behavioral health issues
  5. 5. Origins of Behavioral health issues?
  6. 6. One factor that differentiates the etiological approach… Symptoms Symptoms
  7. 7. Consider…  Our understanding of addiction could possibly be changed to consider substance use as an understandable solution to unaddressed and usually unrecognized hurt and pain. Completely Mostly Maybe Not Much Not at All 1 2 3 4 5 6 7 8 9 10
  8. 8. Consider… Childhood abuse damages a whole life, not just a childhood. Completely Mostly Maybe Not Much Not at All 1 2 3 4 5 6 7 8 9 10
  9. 9. Alchemy: …into GOLD! Turning lead…
  10. 10. 18 months Years later – in a mental institution Turning gold into lead. www.TheAnnaInstitute.org 18 months Anna Carolyn Jennings
  11. 11. Challenging the traditional views of addiction.
  12. 12. …Traditional views may be missing the point
  13. 13. …Traditional views may seriously adversely impact treatment.
  14. 14. …Research challenges their validity.
  15. 15. What is ? Adverse Childhood Experiences
  16. 16. Vincent Felitti, MD (Kaiser Permanente) Robert F. Anda, MD (CDC)
  17. 17. Largest scientific research study of it’s kind
  18. 18. Analyzes the relationship between multiple categories of childhood trauma (ACEs), and health and behavioral outcomes later in life.
  19. 19. It claims to document the… …conversion of childhood trauma and household dysfunction into adult addictions and organic disease.
  20. 20. It claims to demonstrate that… …childhood abuse is extraordinarily common.
  21. 21. It claims to demonstrate that … …childhood abuse damages a whole life, not just childhood.
  22. 22. It claims to demonstrate that… …childhood abuse and household dysfunction are the most basic determiners of the leading causes of death, organic disease, and addiction.
  23. 23. What do you think?
  24. 24. How it got started… Felitti, V. (2011) Adverse Childhood Experiences and The Origins of Addiction. Neuroscience of Addiction. Presentation to the Alberta Family Wellness Center. Retrieved from http://www.albertafamilywellness.org/resources/video/origins-addiction
  25. 25. She gained 400 lbs in a shorter time than it took to lose 400 lbs. Felitti, V. (2011) Adverse Childhood Experiences and The Origins of Addiction. Neuroscience of Addiction. Presentation to the Alberta Family Wellness Center. Retrieved from http://www.albertafamilywellness.org/resources/video/origins-addiction
  26. 26. Issues raised by Patient X…  Perhaps overeating and obesity were not the core problem; each was only the marker of the core problem.  Like smoke is the marker of a fire.
  27. 27. may not be the essence of the problem…
  28. 28. What’s looming beneath the surface may be what really sinks people’s lives.
  29. 29. Study Design  Initiated in 1995 and 1997- enrollees are being tracked  Requested participation of 26,000 consecutive patients seeking medical treatment at Kaiser Permanente in San Diego; 71% agreed  17,500+ middle-class American adults
  30. 30. Study Design  Cohort population was 80% white including Hispanic, 10% black, and 10% Asian.  Their average age was 57 years;  74% had been to college, 44% had graduated college; 49.5% were men.
  31. 31. Finding Your ACE Score Quiz While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household often or very often…Swear at you, insult you, put you down, or humiliate you? Or Act in a way that made you afraid that you might be physically hurt? Yes No If yes enter 1 ___ 2. Did a parent or other adult in the household often or very often…Push, grab, slap, or throw something at you? Or Ever hit you so hard that you had marks or were injured? Yes No If yes enter 1 ___
  32. 32. 3. Did an adult or person at least 5 years older than you ever…Touch or fondle you or have you touch their body in a sexual way? Or Attempt or actually have oral, anal, or vaginal intercourse with you? Yes No If yes enter 1 ___ 4. Did you often or very often feel that …No one in your family loved you or thought you were important or special? Or Your family didn’t look out for each other, feel close to each other, or support each other? Yes No If yes enter 1 ___
  33. 33. 5. Did you often or very often feel that …You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes No If yes enter 1 ___ 6. Were your parents ever separated or divorced? Yes No If yes enter 1 ___ 7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? Or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or Ever repeatedly hit at least a few minutes or threatened with a gun or knife? Yes No If yes enter 1 ___
  34. 34. 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes No If yes enter 1 ___ 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? Yes No If yes enter 1 ___ 10. Did a household member go to prison? Yes No If yes enter 1 ___ Now add up your “Yes” answers: _______ This is your ACE Score. www.ACEStudy.org
  35. 35. What’s Your ACE Score? Used a simple scoring system from 0 to 10
  36. 36. ACE Score Determination Exposure during childhood or adolescence to any category of ACE was scored as one point.
  37. 37. ACE Score Determination Multiple exposures within a category were not scored: one alcoholic within a household counted the same as an alcoholic and a drug user
  38. 38. Research outcomes tend to understate the findings.
  39. 39. General Findings… Less than half of this middle- class population had an ACE Score of 0.
  40. 40. General Findings… One in fourteen had an ACE Score of 4 or more.
  41. 41. Abuse, by Category Prevalence (%) Psychological (by parents) 11% Physical (by parents) 28% Sexual (anyone) 22% PREVALENCE OF ACE
  42. 42. Neglect, by Category Prevalence (%) Emotional 15% Physical 10% PREVALENCE OF ACE
  43. 43. Household Dysfunction, by Category (%) Alcoholism or drug use in home 27% Loss of biological parent < age 18 23% Depression or mental illness in home 17% Mother treated violently 13% Imprisoned household member 5% PREVALENCE OF ACE
  44. 44. Dose-Response Relationship Higher ACE Score Reliably Predicts Prevalence of Disease, Addiction, Death Higher ACE Score Responsegetsbigger The size of the “dose”— the number of ACE categories Drives the “response”— the occurrence of disease, addiction, and death.
  45. 45. Conclusions: ACEs are common, threatening, and often denied.
  46. 46. ACEs have a profound effect even 50 years later on addiction, health risks, diseases, and death.
  47. 47. This combination makes ACEs the leading determinant of the health and social well-being of the nation and the major factor underlying addictions.
  48. 48. The ACE Study and Addiction
  49. 49. ACE and Adult Alcoholism A 500% increase in adult alcoholism is directly related to adverse childhood experiences.
  50. 50. ACE and Adult Alcoholism 2/3rds of all alcoholism can be attributed to adverse childhood experiences
  51. 51. ACE and Adult Alcoholism 0 2 4 6 8 10 12 14 16 18%Alcoholic ACE Score0 1 2 3 4+
  52. 52. ACE Leads to Early Alcohol Initiation •As the number of ACE increase, the more likely a person is to begin drinking before 14, or between 15-17 and the less likely they are to begin drinking at 18 or at 21 (the legal age).
  53. 53. 2/3rds experienced physical and/or sexual abuse 75% of the women - sexually abused. (SAMHSA/CSAT, 2000; SAMHSA, 1994 ) Men and women in SA treatment…
  54. 54. 6 to 12 times more likely physically abused , 18 to 21 times more likely sexually abused. (Clark et al, 1997) Teenagers with alcohol and drug problems
  55. 55.  86% report physical abuse histories, 69% sexual abuse histories.  Of those with sexual abuse histories  96.7% physically abused .  96% of both (sa, pa) emotionally abused. (Saylors, 2003; 2004) Of American Indian/American Native women in SA treatment
  56. 56.  86% report physical abuse histories, 69% sexual abuse histories.  Of those with sexual abuse histories  96.7% physically abused .  96% of both (sa, pa) emotionally abused. (Saylors, 2003; 2004) Of American Indian/American Native women in SA treatment
  57. 57. ACE and Obesity 66% reported one or more type of abuse. International Journal of Obesity (2002) 26, 1075 – 1082. doi:10.1038=sj.ijo.0802038
  58. 58. ACE and Obesity Physical abuse and verbal abuse were most strongly associated with body weight and obesity. (the abuse types strongly co- occurred) International Journal of Obesity (2002) 26, 1075 – 1082. doi:10.1038=sj.ijo.0802038
  59. 59. ACE and Obesity Obesity risk increased with number and severity of each type of abuse. International Journal of Obesity (2002) 26, 1075 – 1082. doi:10.1038=sj.ijo.0802038
  60. 60. ACE and Current Smoking A child with 6 or more categories of adverse childhood experiences is 250% more likely to become an adult smoker .
  61. 61. ACE and Current Smoking 0 2 4 6 8 10 12 14 16 18 20 0 1 2 3 4-5 6 or more ACE Score %
  62. 62. ACE and IV Drug Use A male child with an ACE score of 6 has a 4,600% increase in the likelihood that he will become an IV drug user later in life
  63. 63. ACE and IV Drug Use 78% of IV drug use in women is attributable to adverse childhood experiences.
  64. 64. ACE and IV Drug Use Relationships of this magnitude are rare in Epidemiology.
  65. 65. ACE and Intravenous Drug Use 0 0.5 1 1.5 2 2.5 3 3.5 %HaveInjectedDrugs 0 1 2 3 4 or more ACE Score N = 8,022 p<0.001
  66. 66. Other examples of addiction: More subtle examples include Sex,  Pornography,  Gaming,  Gambling,  Shopping and more.
  67. 67. Serious social problems Severe and persistent emotional problems Health risk behaviors Adult disease and disability High health and mental health care costs Poor life expectancy Other Outcomes of ACE:
  68. 68. Adverse Childhood Experiences and Likelihood of > 50 Sexual Partners 0 1 2 3 4 AdjustedOddsRatio 0 1 2 3 4 or more ACE Score Higher # of ACEs more likelihood of the adult having had 50 or more sexual partners and being at risk for unwanted pregnancy, socially transmitted diseases, HIV/AIDs.
  69. 69. ACE Score and Unintended Pregnancy or Elective Abortion 0 10 20 30 40 50 60 70 80 %haveUnintendedPG,orAB 0 1 2 3 4 or more ACE Score Unintended Pregnancy Elective Abortion
  70. 70. Sexual Abuse of Male Children and Their Likelihood of Impregnating a Teenage Girl 0 5 10 15 20 25 30 35 Not 16-18yrs 11-15 yrs <=10 yrs abused Age when first abused 1.3x 1.4x 1.8x 1.0 ref
  71. 71. In other words…  Boys who were sexually abused are more likely to impregnate a teenage girl.  The earlier the age when the boy was sexually abused – the greater the likelihood that he will impregnate a teenage girl
  72. 72. Frequency of Being Pushed, Grabbed, Slapped, Shoved or Had Something Thrown at Oneself or One’s Mother as a Girl and the Likelihood of Ever Having a Teen Pregnancy 0 5 10 15 20 25 30 35 Never Once, Sometimes Often Very Twice often Pink =self Yellow =mother
  73. 73. ACE Score and Indicators of Impaired Worker Performance 0 5 10 15 20 25 Absenteeism (>2 days/month Serious Financial Poblems Serious Job Problems 0 1 2 3 4 or more ACE Score PrevalenceofImpaired Performance(%)
  74. 74. Severe and Persistent Emotional Problems
  75. 75. Chronic Depression  Adults with an ACE score of 4 or more were 460% more likely to be suffering from depression .
  76. 76. Chronic Depression 0 10 20 30 40 50 60 70 80 %WithaLifetimeHistoryof Depression 0 1 2 3 >=4 ACE Score Women Men
  77. 77. Suicide The likelihood of adult suicide attempts increased 30-fold, or 3,000%, with an ACE score of 7 or more.
  78. 78. Suicide Childhood and adolescent suicide attempts increased 51-fold, or 5,100% with an ACE score of 7 or more.
  79. 79. Suicide 0 5 10 15 20 25 %AttemptingSuicide ACE Score 1 2 0 3 4+
  80. 80. Hallucinations Compared to persons with 0 ACEs, those with 7 or more ACEs had a five-fold increase in the risk of reporting hallucinations. (Whitfield et al 2005)
  81. 81. Hallucinations Abuse and trauma suffered in the early years of development resulted in a far greater likelihood of pre-psychotic and psychotic symptoms. (Perry, B.D., 1994)
  82. 82. Hallucinations In an adult inpatient sample, 77% of those reporting CSA or CPA had one or more of the ‘characteristic symptoms’ of schizophrenia listed in the DSM-IV: hallucinations (50%); delusions (45%) or thought disorder (27%) (Read and Argyle, 1999)
  83. 83. 0 2 4 6 8 10 12 0 1 2 3 4 5 6 >=7 No Yes ACE Score EverHallucinated*(%) Abused Alcohol or Drugs *Adjusted for age, sex, race, and education. ACE Score and Hallucinations
  84. 84. 0 5 10 15 20 25 30 35 40 45 0 1 2 3 4 5 6 7 8 Childhood Sexual Abuse and the Number of Unexplained Symptoms History of Childhood Sexual Abuse PercentAbused(%) Number of Symptoms
  85. 85. 0 5 10 15 20 25 30 35 40 0 1 2 3 >=4 ACE Score and Impaired Memory of Childhood PercentWithMemory Impairment(%) ACE Score ACE Score 1 2 3 4 5
  86. 86. Adult Disease and Disability
  87. 87. History of STD 0 0.5 1 1.5 2 2.5 3 AdjustedOddsRatio 0 1 2 3 4 or more ACE Score
  88. 88. The higher the ACE score the greater the prevalence of Liver Disease
  89. 89. The Higher the ACE score the more likely a person will develop COPD
  90. 90. ACEs Increase Likelihood of Heart Disease* • Emotional abuse 1.7x • Physical abuse 1.5x • Sexual abuse 1.4x • Domestic violence 1.4x • Mental illness 1.4x • Substance abuse 1.3x • Household criminal 1.7x • Emotional neglect 1.3x • Physical neglect 1.4x
  91. 91. This illustrates that adverse experiences in childhood are related to adult disease by two ways: 1)Indirectly through attempts at self-help through use of agents like nicotine, alcohol, food, etc. 2)Directly through chronic stress
  92. 92. High Health and Mental Health Care Costs
  93. 93. The financial burden to society of childhood abuse and trauma is staggering.
  94. 94. Child abuse and neglect affects over 1 million children a year.
  95. 95. Costs our nation 220 Million every DAY.
  96. 96. Paid $80 Billion to address childhood abuse and neglect in 2012  http://www.preventchildabuse.org/images/research/pcaa_cost_report_2012_gelles_perlman.pdf
  97. 97. Poor Life Expectancy: ACE score of 4 or more reduces life expectancy by 20 years!
  98. 98. Effect of ACEs on Mortality 0 10 20 30 40 50 60 0 2 4 PercentinAgeGroup ACE Score 19-34 35-49 50-64 >=65 Age Group
  99. 99. Other Studies on Childhood Sexual and/or Physical Abuse
  100. 100. 51 – 98% of public mental health clients with severe mental health diagnoses have unaddressed sexual/physical abuse (Goodman et al, 1999, Mueser et al, 1998; Cusack et al, 2003)
  101. 101. 93% of psychiatrically hospitalized adolescents had histories of physical and/or sexual and emotional trauma. 32% met criteria for PTSD  (Goodman et al, 1999, Mueser et al, 1998; Cusack et al, 2003)
  102. 102. More than 75% of girls in juvenile justice system have been sexually abused. (Calhoun et al, 1993)
  103. 103. 80% of women in prison and jails have been sexually/physically abused. (Smith, 1998)
  104. 104. 100% of men on death row in CA have a history of family violence (Freedman, Hemenway, 2000)
  105. 105. Boys who experience or witness violence are 1,000 times more likely to commit violence than those who do not. (van der Kolk, 1998)
  106. 106. Unaddressed childhood sexual abuse is significantly related to adolescent and adult self-harm, including suicide attempts, cutting, and self-starving. (Van der Kolk et al, 1991)
  107. 107. One study found childhood sexual abuse to be the single strongest predictor of suicidality. (Read et al, 2001)
  108. 108. Neurological development
  109. 109. Lasting Alterations in Self- Perception
  110. 110. • Sense of helplessness, paralysis, captivity, inadequacy, powerlessness, danger, fear… When not addressed…continues over the lifespan.
  111. 111. Sense of Shame, Guilt, Self-Blame, Being Bad… When not addressed…continues over the lifespan.
  112. 112. Sense of defilement, contamination, being spoiled, degraded, debased, despicable, evil… When not addressed…continues over the lifespan.
  113. 113. Sense of complete difference from others, deviance, utter aloneness, isolation, non-human, specialness, unseen, unheard, belief no other person can ever understand… When not addressed…continues over the lifespan.
  114. 114. Summary of ACE Impact
  115. 115. ACE Causes serious and chronic health, behavioral health and social problems
  116. 116. Epidemic proportions and a major public health issue.
  117. 117. Impacts brain and nervous system directly.
  118. 118. Impacts one’s perception of self and others.
  119. 119. Often unrecognized, ignored or denied.
  120. 120. Finally, ACE is A Public Health Tragedy
  121. 121. Leading to long-term use of multi- human service systems at an estimated annual cost of $80 billion
  122. 122. $33 billion in direct costs and $47 billion in indirect costs, as a result of child abuse and neglect (PCCA, May 2012)
  123. 123. Child Maltreatment Costs  $124 billion over the lifetime of the traumatized children..  The breakdown per child is:  $32,648 in childhood health care costs  $10,530 in adult medical costs  $144,360 in productivity losses  $7,728 in child welfare costs  $6,747 in criminal justice costs  $7,999 in special education costs (Stevens, 2012)
  124. 124. Consider again the statements from the beginning. Where would you mark yourself now?
  125. 125. While, the traditional concept…  Addiction is due to characteristics intrinsic in the molecular structure of an addicting substance. If you take heroin enough times you won’t be able to stop.
  126. 126. Instead, the ACE Study shows that:  Addiction highly correlates with characteristics intrinsic to that individual’s life experiences, particularly in childhood.
  127. 127. Dr. Felitti’s redefinition of addiction informed by the ACE Study:  Addiction is the unconscious, compulsive use of psychoactive materials or agents in an attempt to deal with a problem.  “It’s hard to get enough of something that almost works.” Addiction is evidence of another problem. Felitti, V. (2011) Adverse Childhood Experiences and The Origins of Addiction. Neuroscience of Addiction. Presentation to the Alberta Family Wellness Center. Retrieved from http://www.albertafamilywellness.org/resources/video/origins-addiction
  128. 128. Like smoke is the evidence of a fire.
  129. 129. However, the evidence is buried beneath the surface… Addiction-use of substances Protected by: Shame, Secrecy, Guilt, Fear 4 Unspoken Rules in an Alcoholic Family
  130. 130. Conventional view is…  Certain substances are addictive based on the evidence that its almost impossible for certain individuals to give them up. Questions are… • How did these people get to be? • Why one person and not the other? • How do addicts differ from non-addicts?
  131. 131. Considering evidence from the ACE study…  Are we focusing on the outcome and not the cause?  Are we overlooking a major source? Outcome Source or Cause
  132. 132. What Is The Core Problem?  Why is treatment so difficult?  Why are long-term results so often poor?  Is it because treating someone’s attempted solution may be threatening and cause flight from treatment?  Are we treating the smoke, but not the fire?
  133. 133. Treatment Failures  What can we learn from those who can’t give up an addiction?  Is the wrong thing being treated?  Consider a few examples including:  smoking,  amphetamine,  heroin, and  morphine
  134. 134. Smoking Cessation: Policy and Research as it Relates to Evidence-based Practices in the Military and Veteran Health Care SettingsFeb. 27, 2014, 1-2:30 p.m. (EST) Overview  On January 11, 1964, Surgeon General Dr. Luther Terry released the first Surgeon General’s Report on Smoking and Health. This scientifically rigorous federal government report not only linked smoking with ill health and diseases such as lung cancer and heart disease; it also laid the foundation for tobacco control efforts in the United States.  Fifty years later, despite the release of 31 subsequent Surgeon General’s Reports on Smoking and Health detailing the devastating health and financial burdens caused by tobacco use, smoking remains the leading cause of preventable deaths in the United States and kills 443,000 people each year. (U.S. Department of Health and Human Services, 2014)  The Smoking Divide  A new analysis of federal smoking data reveals that although the national smoking rate has been falling, there is a clear geographic divide. Poorer counties, like some in Kentucky, have experienced smaller declines than wealthier counties.
  135. 135. The Smoking Divide  A new analysis of federal smoking data reveals that although the national smoking rate has been falling, there is a clear geographic divide. Poorer counties, like some in Kentucky, have experienced smaller declines than wealthier counties.  2012 in Georgia (down 2% since 1996):  All adults: 21%  Women: 18%  Men: 24%
  136. 136. Abstract: Amphetamine Use now and then…  Using historical research that draws on new primary sources, I review the causes and course of the first, mainly iatrogenic [doctor caused] amphetamine epidemic in the United States from the 1940s through the 1960s. Retrospective epidemiology indicates that the absolute prevalence of both nonmedical stimulant use and stimulant dependence or abuse have reached nearly the same levels today as at the epidemic’s peak around 1969. Further parallels between epidemics past and present, including evidence that consumption of prescribed amphetamines has also reached the same absolute levels today as at the original epidemic’s peak, suggest that stricter limits on pharmaceutical stimulants must be considered in any efforts to reduce amphetamine abuse today.  Rasmussen, N. (2008). America’s first Amphetamine epidemic 1929–1971: A quantitative and qualitative retrospective with implications for the present. American Journal of Public Health. Vol 98, No. 6.
  137. 137. Amphetamines  Prescribed as the first anti-depressant medications in the 1940’s.  Crystal Meth is a potent anti-depressant!  Is more regulation treating the problem or the outcome?
  138. 138. Example: HEROIN USE IN A WAR ZONE  In a study of 898 American soldiers in Vietnam, each of whom acknowledged using heroin daily for at least the prior 30 consecutive days, upon return to the US, 95% were no longer using heroin at 10 month follow-up. No treatment was received. Robins LN, Helzer JE, Davis DH. Arch Gen Psychiatry 1975 Aug;32(8):955-61 Narcotic use in southeast Asia and afterward. An interview study of 898 Vietnam returnees. Robins LN. Vietnam Veterans’ rapid recovery from heroin addiction: a fluke or normal expectation? Addiction 1993; 88:1041-1054.
  139. 139. Rat Park Experiments  Rats were fed morphine for 57 consecutive days. Alexander, B.K., Coambs, R.B., and Hadaway, P.F. (1978). "The effect of housing and gender on morphine self-administration in rats," Psychopharmacology, Vol 58, 175–179.
  140. 140. Rat Park Experiments  Rats in cramped, isolated cages chose morphine over water. Alexander, B.K., Coambs, R.B., and Hadaway, P.F. (1978). "The effect of housing and gender on morphine self-administration in rats," Psychopharmacology, Vol 58, 175–179.
  141. 141. Rat Park Experiments  Rats housed in a “Rat Park” chose water over morphine most of the time. Alexander, B.K., Coambs, R.B., and Hadaway, P.F. (1978). "The effect of housing and gender on morphine self-administration in rats," Psychopharmacology, Vol 58, 175–179.
  142. 142. Could there be hidden benefits of addiction that we aren’t considering?  Does substance use serve to do more than get a person “high”?  Do more than provide pleasure?  Could it provide legitimate protection sexually, physically, and emotionally? I am NOT promoting or encouraging substance use!!
  143. 143. Is it possible that Gary Allan is right when he sings… It Ain’t The Whiskey  http://www.youtube.com/v/m3Xr67jp1Fo&autoplay=1
  144. 144. Implications for Treatment Implementing Trauma Informed Care
  145. 145. Break
  146. 146. First Step… Admit we have a problem
  147. 147. 18 months Years later – in a mental institution Turning gold into lead. www.TheAnnaInstitute.org 18 months Anna Carolyn Jennings
  148. 148. Trauma-informed treatment (SAMHSA-National Center for Trauma Informed Care)  Trauma-informed care is an approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. …seeks to change the paradigm from one that asks, "What's wrong with you?" to one that asks, "What has happened to you?“  http://www.samhsa.gov/nctic/
  149. 149. How do implement trauma informed treatment?
  150. 150. 1. We can change our perspective…
  151. 151. View addiction/substance-use through the lens of trauma.
  152. 152. We can consider the context… Arrested for DUI at 23 Raised by a single mother Mother was verbally and physically abusive. Bullied in School Started drinking at 13, smoking pot at 14 Abandoned by father at 8.
  153. 153. People do what almost works and substance use is almost working for this person.
  154. 154. What are they trying to solve?
  155. 155. Not blowing away the smoke.. But putting out the fire.
  156. 156. Not cutting off the limbs… But digging out the roots…
  157. 157. 2. We can change our approach to evaluation… Rather than only evaluating the surface… Make an attempt to evaluate for the root of the problem.
  158. 158. 3. We can accept a redefinition of addiction…  Felitti wrote: “we propose giving up our old mechanistic explanation of addiction in favor of one that explains it in terms of its psychodynamics: unconscious although understandable decisions being made to seek chemical relief from the ongoing effects of old trauma, often at the cost of accepting future health risk. Expressions like ‘self- destructive behavior’ are misleading and should be dropped because, while describing the acceptance of long-term risk, they overlook the importance of the obvious short-term benefits that drive the use of these substances” (2004).
  159. 159. Definition: Addiction is understandable as the unconscious, compulsive use of psychoactive materials in response to the stress of life experiences, typically dating back to childhood. These life experiences are very likely to be lost in time, and protected by shame, by secrecy, and by social taboos against exploring certain aspects of human experience.
  160. 160. Addictions = Solutions
  161. 161. 4. We can adjust the way we do treatment.
  162. 162. Typical substance-abuse treatment…
  163. 163. Focuses on reducing risky behaviors and/or sobriety.
  164. 164. Role of treatment provider…facilitate change.
  165. 165. Educational and motivational and focus on reducing substance use, decreasing depression, anxiety, etc.
  166. 166. Adjusting doesn’t mean… …We don’t do addiction treatment …We don’t fulfill the State or agency requirements.
  167. 167. Adjusting DOES Mean… Seek training in recognizing and treating trauma.
  168. 168. Evidence Based Psychotherapy Models for Adults with ACEs-related Disorders  Brief Psychodynamic Therapy  Cognitive Processing Therapy  Emotion Focused Therapy for Trauma  Eye Movement Desensitization and Reprocessing  Imagery Rehearsal/Rescripting Therapy  Narrative Exposure Therapy  Phased Model for Treatment of Dissociation  Prolonged Exposure Therapy  Present Centered Therapy  Present Focused Group Therapy  Seeking Safety  Skills Training in Affect and Interpersonal Regulation  Trauma Affect Regulation: Guide for Education and Therapy.
  169. 169. However, many of these are still symptom-reduction focused and not Source-Focused.  That’s why I developed Structured Trauma and Abuse Recovery© (STAR©) which is a Source-Focused Model© (SFM©).
  170. 170. Source-Focused Treatment  Focuses on etiologies.  Etiology = the philosophical investigation of causes and origins.
  171. 171. What makes trauma, trauma?  The ACE study uses adversity and identified 10 categories. Are these the only sources of trauma? NO.  What other events or experiences might we consider traumatic? What other experiences trigger the autonomic nervous system to fight, flight, or freeze?  What do these experiences have in common? Kidney stone example.
  172. 172. My definition The source of trauma is unhealed, unaddressed, unresolved wounds to the personal identity. (Compared to diagnoses which are groups of symptoms)
  173. 173. My definition  Personal Identity is defined as the sum of your person as you exist in your own mind/brain and as you are expressed through your thoughts, beliefs, values, expectations, and emotions.
  174. 174. Trauma happens when our Personal Identity is wounded to the point that we experience unacceptable contradictions to our expectations. In addition, these contradictions cause unacceptable personal losses.
  175. 175. Trauma Survivor Blueprint Four Stages in Development
  176. 176. An event occurs…
  177. 177. The event contradicts expectations, beliefs, values (personal identity). We interpret the contradictions as threatening in some way (physically, psychologically, emotionally, and spiritually). Stage 1
  178. 178. The threat triggers the autonomic nervous system which secretes chemicals we call emotions. Psychologically, we have experienced loss. Begins the grief response. Stage 2
  179. 179. Our brain rallies to survive and the survival behaviors/thoughts/ attitudes are put into action. This includes external behaviors and internal repression of loss/emotion. Stage 3
  180. 180. Our own responses are evaluated and many times contradict our own expectations in some way (physically, psychologically, emotionally, or spiritually). We experience additional loss and additional grief emotion. Stage 4
  181. 181. Stage 1 Event contradicts expectations Stage 2 Triggers autonomic nervous system: loss and emotion Stage 3 Brain rallies to survive: develops survival responses Stage 4 Own responses contradict expectations Event occurs outside of conscious control.
  182. 182. Survivors keep cycling through this loop, developing more survival responses (behaviors, thoughts, attitudes) moving them further and further away from the awareness of the starting point--#1 The event which contradicted expectations, values, and beliefs (personal identity). Ongoing, unresolved trauma
  183. 183. Stage 1 Event contradicts expectations Stage 2 Triggers autonomic nervous system: loss and emotion Stage 3 Brain rallies to survive: develops survival responses Stage 4 Own responses contradict expectations Event occurs outside of conscious control.
  184. 184. As the cycle moves the person further away from awareness of this connection… Perception of self changes. • Personal identity changes.
  185. 185. The person moves from ACE (which are experienced as social, emotional, and cognitive impairment, to risky behaviors (now perceived as choices), to disease, disability and social problems (now perceived as choices), and finally to death all while losing awareness of the base of the pyramid.
  186. 186. Level 1 Adverse Childhood Experiences Level 2 Social, emotional, cognitive impairment Level 3 Adoption of health risk behaviors Level 4 Disability, disease, and social problems ACE Conversion Level 5 Death
  187. 187. Structured Trauma & Abuse Recovery© is Source Focused because:
  188. 188. Evaluation, testing, and treatment are all focused on the source or etiology of the problem with the goal of reestablishing the connection between #1 and #2-4.
  189. 189. Stage 1 Event contradicts expectations Stage 2 Triggers autonomic nervous system: loss and emotion Stage 3 Brain rallies to survive: develops survival responses Stage 4 Own responses contradict expectations Event occurs outside of conscious control.
  190. 190. Symptoms are bypassed when at all possible, starting by addressing stage #1 first, then #2, then #3 and finally #4.
  191. 191. It does NOT mean that symptoms (#3-4) aren’t considered, but it does mean that, when possible, symptoms are bypassed.
  192. 192. Structured Trauma & Abuse Recovery is evidence informed because…
  193. 193. Built on a contextual model framework. The Contextual Model is a modern version of the Common Factors model and serves as a meta-framework to which techniques are attached in order to form a more cohesive approach within a particular cultural context (Wampold, et al, 2009).
  194. 194.  Includes evidence based practices included in other models such as Motivational Interviewing, Prolonged Exposure Therapy, Cognitive Processing Therapy, Emotion Focused Therapy for Trauma, Eye Movement Desensitization and Reprocessing, Narrative Exposure Therapy, and Seeking Safety.
  195. 195. What does bypassing symptoms mean?
  196. 196. We don’t engage directly in trying to change the client’s survival responses unless absolutely necessary.
  197. 197. We follow the three phases of trauma recovery in order. (1. Stabilizing; 2. Reprocessing/Grieving; 3. Reconnecting/Integrating)
  198. 198. We keep the focus on healing rather than fixing.
  199. 199. Why is bypassing symptoms important?
  200. 200. Level 1 Adverse Childhood Experiences Level 2 Social, emotional, cognitive impairment Level 3 Adoption of health risk behaviors Level 4 Disability, disease, and social problems ACE Conversion Level 5 Death Direct connection between adverse childhood experiences and risky behaviors
  201. 201. When the psychological management system is overwhelmed with pain, we chose survival responses that work for us. These work to reduce the pain and/or internal conflict and produce survival responses.
  202. 202. Unfortunately, they also bring with them side-effects that are viewed as unavoidable.
  203. 203. Etiology Cause-Effect Relationship Adapted from Collins, J., (1990) Presenters Handbook, TRT Institute, Angel Fire, New Mexico Survival Responses Cause Effect (Unresolved past trauma) Symptoms or unavoidable side-effects
  204. 204. Adapted from Collins, J., (1990) Presenters Handbook, TRT Institute, Angel Fire, New Mexico Translates to letting go of their solution. 1 2 3 The Paradox of Symptom Focused Treatment Unintentionally results in overall increased symptoms. Solution Solution Focus on reducing symptoms (without addressing the trauma source)…
  205. 205. What can I do NOW? Do a trauma evaluation as part of intake or after first session.
  206. 206. Screening Instruments  Family Health History Questionnaire  Health Appraisal Questionnaire (http://www.cdc.gov/ace/questionnaires.htm)  Also:  Trauma Symptom Inventory (Briere, 1995)  PTSD-8 (Hansen, et al., 2010)  Primary Care PTSD Screen (PC-PTSD) (Prins, et al., 2003).
  207. 207. Others  ACE Score  http://acestudy.org/yahoo_site_admin/assets/docs/ACE _Calculator-English.127143712.pdf  Simple Trauma Source Assessment (by Denice Colson)
  208. 208. Avoid Common Errors of Trauma Informed Care
  209. 209. Herman writes… “…the single most common therapeutic error is avoidance of the traumatic material…” and, “…probably the second most common error is premature or precipitate engagement in exploratory work, without sufficient attention to the tasks of establishing safety and securing a therapeutic alliance” (1997, p. 172)
  210. 210. Principles to Apply re: Treatment Ask, but don’t push for too much detail. •Expect denial and later disclosures. •Don’t try to go too far, too fast.
  211. 211. How Can I Do This? Use screening instruments Educate using handouts
  212. 212. Handouts  Trauma Source Score Handout  Adverse Childhood Experiences and Health and Well-Being Over the Life-span  Develop your own.  Visit ACESConnection.com for more help.
  213. 213. Get Trained!
  214. 214. 3 Phases of Trauma Recovery Incorporated in the structure of STAR  (Herman, 1997; Cloitre et al, 2012)
  215. 215. 1. Establishing Safety and Stabilizing
  216. 216. 2. Reprocessing and Grieving
  217. 217. 3. Reconnecting and Integrating
  218. 218. Establishing Safety and Stabilizing Reconnecting and Integrating Reprocessing and Grieving
  219. 219. Phase 1: Establishing Safety and Stabilizing
  220. 220. Substance use/addiction has to be addressed first and some stability and sobriety established before moving into the Reprocessing and Grieving Phase
  221. 221. Reconnecting comes last.
  222. 222. Stabilization and Safety Phase is designed to move a person to the Reprocessing and Grieving Phase. This is the HEART of trauma recovery.
  223. 223. Phase 2: Reprocessing and Grieving
  224. 224.  Step 1: Identify the source of trauma. If more than one, identify most pressing. Write about it using a structured outline. Identify contradicted expectations, values, beliefs, needs. Identify losses. Read out-loud in structured individual or group. 6 step, structured process.
  225. 225. Step 2: Identify interpretations in personal life context along with losses. Read out-loud in structured individual or group.
  226. 226. Step 3: Identify past and present survival responses and losses. Read out-loud in structured individual or group. Step 4: Summarize losses from the event and your interpretation of the event. Summarize losses from your own survival responses, past and present. Read out-loud in structured individual or group.
  227. 227. Step 5: A forgiveness exercise. Optional Step 6: Creative expression of Spiritual Marker or Personal Identity Reflection.
  228. 228. Phase 3: Integrating and Reconnecting Integrate newly developed survival responses into daily life. Reconnect with self, others, and God.
  229. 229. A Source Focused Model, like Structured Trauma and Abuse Recovery…
  230. 230. Adverse childhood experiences are common but typically unrecognized. Their link to major problems later in life is strong, proportionate, and logical. They are the nation’s most basic public health problem, and therefore our problem.
  231. 231. Treating the solution may threaten people and cause flight from treatment. What presents as the ‘Problem’ may in fact be an attempted solution. It is understandable to mistake intermediary mechanism for basic cause.
  232. 232. Change starts with us. Contemplation is to be expected. Trauma-Informed Care is the new best- practices standard. There is a learning curve.
  233. 233. Adverse childhood experiences Adult behavioral health issues
  234. 234. Origins of Behavioral health issues?
  235. 235. One factor that differentiates the etiological approach… Symptoms Symptoms
  236. 236. “My greatest failure was in believing that the weight issue was just about weight. It’s not. It’s about not handling stress properly. It’s about sexual abuse. It’s about all the things that cause other people to become alcoholics and drug addicts.” Oprah Winfrey
  237. 237. “I believe this is the most important thing that you can ever do, to begin to deal with this, with this intergenerational transmission of adversity that causes so many problems in our society.” Robert F. Anda, MD
  238. 238. Denice Colson, PhD, LPC, MAC, CPCS  www.TraumaEducation.com  www.ELCCC.org  www.LifeLineBillingSolutions.com  RDAColson@gmail.com  Supervision, training, coaching , and trauma recovery.
  239. 239. You’re an Overcomer! Mandisa

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