Links between Childhood Trauma and Adult Disease: Becoming Trauma Informed

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Description: The Adverse Childhood Experiences Study is perhaps the largest of its kind. Evidence from this extensively published research project will be presented along with proposals for addiction evaluation, treatment and policy. View evidence which 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 Strategic Trauma and Abuse Recovery© which she developed for her dissertation.

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Links between Childhood Trauma and Adult Disease: Becoming Trauma Informed

  1. 1. With: R. Denice Colson, PhD, LPC, MAC, CPCS
  2. 2. Introductions
  3. 3. Objectives for Today
  4. 4. Adult behavioral health issues Adverse childhood experiences Why it is important to consider the links between…
  5. 5. Origins of Behavioral health issues?
  6. 6. One factor that differentiates the etiological approach… Symptoms Symptoms
  7. 7. Consider… If not addressed, 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
  8. 8. Consider…  Our understanding of addiction could possibly be changed to consider substance use (and subsequent dependence) 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
  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. Consider… Challenging the traditional views of addiction, anxiety, depression, and other illnesses.
  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 the Study? 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. Used a simple scoring system from 0 to 10 ACE Score Determination
  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. 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.
  68. 68. 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
  69. 69. 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
  70. 70. 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
  71. 71. 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
  72. 72. 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(%)
  73. 73. More than 75% of girls in juvenile justice system have been sexually abused. (Calhoun et al, 1993)
  74. 74. 80% of women in prison and jails have been sexually/physically abused. (Smith, 1998)
  75. 75. 100% of men on death row in CA have a history of family violence (Freedman, Hemenway, 2000)
  76. 76. Boys who experience or witness violence are 1,000 times more likely to commit violence than those who do not. (van der Kolk, 1998)
  77. 77. Chronic Depression  Adults with an ACE score of 4 or more were 460% more likely to be suffering from depression .
  78. 78. Chronic Depression 0 10 20 30 40 50 60 70 80 %WithaLifetimeHistoryof Depression 0 1 2 3 >=4 ACE Score Women Men
  79. 79. Suicide The likelihood of adult suicide attempts increased 30-fold, or 3,000%, with an ACE score of 7 or more.
  80. 80. Suicide Childhood and adolescent suicide attempts increased 51-fold, or 5,100% with an ACE score of 7 or more.
  81. 81. Suicide 0 5 10 15 20 25 %AttemptingSuicide ACE Score 1 2 0 3 4+
  82. 82. 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)
  83. 83. 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)
  84. 84. 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)
  85. 85. 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
  86. 86. 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
  87. 87. 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)
  88. 88. 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)
  89. 89. 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)
  90. 90. One study found childhood sexual abuse to be the single strongest predictor of suicidality. (Read et al, 2001)
  91. 91. Lasting Alterations in Self- Perception
  92. 92. • Sense of helplessness, paralysis, captivity, inadequacy, powerlessness, danger, fear…
  93. 93. Sense of Shame, Guilt, Self- Blame, Being Bad…
  94. 94. Sense of defilement, contamination, being spoiled, degraded, debased, despicable, evil…
  95. 95. Sense of complete difference from others, deviance, utter aloneness, isolation, non- human, specialness, unseen, unheard, belief no other person can ever understand…
  96. 96. Adult Disease and Disability
  97. 97. Abuse among Native American Women  One study of Native American women in a primary care setting, 77% reported childhood physical or sexual abuse or severe neglect. (2004, Duran et al)
  98. 98. History of STD 0 0.5 1 1.5 2 2.5 3 AdjustedOddsRatio 0 1 2 3 4 or more ACE Score
  99. 99. The higher the ACE score the greater the prevalence of Liver Disease
  100. 100. The Higher the ACE score the more likely a person will develop COPD
  101. 101. 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
  102. 102. 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
  103. 103. Poor Life Expectancy: ACE score of 4 or more reduces life expectancy by 20 years!
  104. 104. The Impact on View of God, Self-in relationship to God, and Attachment to God
  105. 105. Spiritual Impact  If a person’s physical and psychological health is impacted by adverse childhood experiences even 50 years after their occurrence (Felitti, 2004), then their spiritual health will also be impacted.
  106. 106. Albert Ellis (1960, 1971)  “It is the belief in sin that makes people disturbed”  “Devout religiosity tends to be emotionally harmful.”
  107. 107. Albert Ellis (2000)  “Although I have, in the past, taken a negative attitude toward religion, and especially toward people who devoutly hold religious views, I now see that absolutistic religious views can sometimes lead to emotionally healthy behavior. As several studies have shown (Batson et al., 1993; Donahue, 1985; Gorsuch, 1988; Hood et al., 1996; Kirkpatrick, 1997; Larson & Larson, 1994), people who view God as a warm, caring, and lovable friend, and who see their religion as supportive are more likely to have positive outcomes than those who take a negative view of God and their religion.” (Italics added by author)
  108. 108. Spiritual Impact  One study found that 77% of their targeted population, adults who were participating in therapy and had experienced sexual abuse as a child, reported experiencing obstacles to spiritual development, including:  lack of worthiness,  existential questions about the meaning and purpose of life,  unresolved religious questions about the beliefs they grew up with,  disillusionment about their faith or religious beliefs,  distrust, anger, guilt, and other miscellaneous obstacles (Ganje-Fling, Veach, Kuang, and Hoag, 2000).
  109. 109.  Same study: 68% of the comparison group, which was also participating in therapy but had not experienced sexual abuse as children, reported the same obstacles.  Whether or not this group had experienced some other type of traumatic experience was not assessed, though the fact that they were in psychotherapy would indicate the presence of some type of distress. Spiritual Impact
  110. 110.  Another study psychiatric patient population:  the more psychological distress and personality pathology was present, the more negative a person’s concept of God (Schaap-Jonker, Eurelings-Bontekoe, Verhagen, and Zock 2002).  Follow-up study drew from a non-psychiatric, church- going population:  After controlling for the influence of denomination, personality, and psychological distress, researchers found that psychological distress was the best independent predictor of negative feelings towards God (Eurelings-Bontekoe, Hekman-Van Steeg, & Verschuur, 2005). Spiritual Impact
  111. 111.  Poor attachment bonds with God are related to difficulty finding meaning and purpose in life (Beck and McDonald, 2004)  One’s image of God appears to grow out of one’s paternal and maternal care-giving images (Brokaw & Edwards, 1994; Dickie et al., 1997; Hall & Brokaw, 1995; Hall et al., 1998; Justice & Lambert, 1986; Nelson, 1971).  Parents have the strongest influence on their adolescent’s religiosity (Benson, Donahue, and Erickson, 1989). Spiritual Impact
  112. 112.  Reinert and Edwards found that verbal, physical, and sexual mistreatment were all associated with increased insecurity in attachment to God as well as with God concepts which were less loving and more controlling and distant (2009). Spiritual Impact
  113. 113. ACE and Neurological development
  114. 114. High Health and Mental Health Care Costs
  115. 115. The financial burden to society of childhood abuse and trauma is staggering.
  116. 116. Child abuse and neglect affects over 1 million children a year.
  117. 117. Costs our nation 220 Million every DAY.
  118. 118. In 2012, $80 Billion was paid to address childhood abuse and neglect  http://www.preventchildabuse.org/images/research/pcaa_cost_report_2012_gelles_perlman.pdf
  119. 119.  $33 billion in direct costs and $47 billion in indirect costs, as a result of child abuse and neglect (PCCA, May 2012)
  120. 120. 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)
  121. 121. Summary of ACE Impact
  122. 122.  ACE Causes serious and chronic health, behavioral health and social problems  Impacts one’s perception of self and others.  Often unrecognized, ignored or denied.  Finally, ACE is a public health tragedy of epidemic proportions Leading to long-term use of multi-human service systems at an estimated annual cost of $80 billion  Impacts brain and nervous system directly.
  123. 123. Consider again the statements from the beginning. Where would you mark yourself now?
  124. 124. Considering all of this information…  What can we do about it?
  125. 125. Denice Colson, PhD, LPC, MAC, CPCS
  126. 126. First Step… Admit we have a problem
  127. 127. 18 months Years later – in a mental institution Turning gold into lead. www.TheAnnaInstitute.org 18 months Anna Carolyn Jennings
  128. 128. Trauma-informed Care (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/
  129. 129. Saakvitne, a psychotherapist and researcher, points out,  A successful trauma therapy is about more than just not having symptoms. It’s really about having a life…a life that’s about pursuing dreams, pursuing happiness. But especially it’s about the right to have a present and a future that are not completely dominated and dictated by the past. (2000)
  130. 130. 4 Guidelines for Implementing Trauma-Informed Care
  131. 131. 1. We can change our perspective…
  132. 132. View symptoms through the lens of trauma.
  133. 133. …and 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.
  134. 134. People do what almost works and substance use is almost working for this person.
  135. 135. We can ask ourselves, what is the person trying to solve? How might this “symptom” logically connect to what was done to them? Then we can focus on the source rather than the symptoms.
  136. 136. Not blowing away the smoke.. Like putting out the fire…
  137. 137. Not cutting off the limbs… Like digging out the roots…
  138. 138. 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.
  139. 139. Typical Evaluation… What brought you here today? What are you hoping to accomplish? What changes do you want to make? What diagnosis will I give? Focus is on symptoms and changing the symptoms.
  140. 140. Take the S-BIRT approach: Screen, brief intervention, referral to treatment. Quite a bit of evidence that SBIRT is effective in reducing hazardous drinking in patients presenting in primary care and other health care settings.
  141. 141. While not the same, follow the 5 As 1. Ask about childhood adversity. 2. Advise them of link between adversity and the top ten diseases that adults die from, including substance abuse. 3. Assess willingness to address childhood adversity. 4. Assist to identify sources of adversity. 5. Arrange for follow-up and support.
  142. 142. EFFECT OF Trauma-Oriented Evaluations on Doctor Office Visits Benefits of Incorporating a Trauma-oriented Approach  Biomedical evaluation: 11% reduction in DOVs (Control group) (Doctor Office Visits) in subsequent year. (700 patient sample)  Biopsychosocial evaluation: 35% reduction in DOVs (Trauma-oriented approach) in subsequent year. (>120,000 patient sample)
  143. 143. Simple Trauma-Source Assessment©  2 sections: child/adult.  Simple questions.  Check-list.  A few scaling questions.  Provides for discussion, not “diagnosis”.
  144. 144. 3. We can consider 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).
  145. 145. “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
  146. 146. Is it possible that Gary Allan is right when he sings… It Ain’t The Whiskey  http://www.youtube.com/v/m3Xr67jp1Fo&autoplay=1
  147. 147. 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.
  148. 148. Instead, the ACE Study shows that:  Addiction highly correlates with characteristics intrinsic to that individual’s life experiences, particularly in childhood.
  149. 149. 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
  150. 150. Like smoke is the evidence of a fire.
  151. 151. 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
  152. 152. If we could lift the shame, secrecy, guilt, and fear we see… ACEs recorded in memory Time does not heal – it conceals.
  153. 153. Consider a few studies that challenge traditional “chemical-based” views including:  smoking  amphetamine  heroin  morphine
  154. 154. 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.
  155. 155. 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%
  156. 156. 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.
  157. 157. 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?
  158. 158. 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.
  159. 159. 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.
  160. 160. 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.
  161. 161. 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.
  162. 162. Could there be hidden benefits of addiction that we aren’t considering?  Is getting “high” more than recreation, as many people say and think?  Could it provide legitimate protection sexually, physically, and emotionally? I am NOT promoting or encouraging substance use!!
  163. 163. Reconsider the 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.
  164. 164. Addictions = Solutions
  165. 165. Addictions = Survival Responses
  166. 166. My working definition in terms of its function:  Substance use is a survival response;  When the survival response (substance use) takes over and becomes a source of trauma in itself = addiction.  Many other “symptoms” are also survival responses.  Anger/rage  Depression  Defensiveness  Anxiety  Etc…
  167. 167. 4. We can adjust the way we do treatment.
  168. 168. Adjusting doesn’t mean… …We don’t do addiction treatment …We don’t fulfill the State or agency requirements. …We don’t address symptoms like suicidal thoughts, self-harm, etc…
  169. 169. Adjusting DOES Mean… • Seek training in recognizing and treating trauma.
  170. 170. 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.
  171. 171. However, many of these are still symptom-reduction focused and not Source-Focused.  S.T.A.R.: Strategic Trauma and Abuse Recovery; a Source-Focused Model.
  172. 172. Source-Focused Treatment  Focuses on etiologies.  Etiology = the philosophical investigation of causes and origins.
  173. 173. Considering Source-Focused treatment…  Where do we start?
  174. 174. 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
  175. 175. 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
  176. 176. • What makes trauma, trauma? • Why is something trauma for one person, but not another? • Why do some people develop serious symptoms and other people don’t? • Can the impact of trauma be reversed? • If so, how?
  177. 177. “Trauma”  Derived from the Greek word that means an injury or wound.  Traumatic stress is the demand for action derived from a trauma because it is a physical or psychological injury (Encyclopedia of Violence, 2008).
  178. 178. Traumatology  The study of the causes and treatment of PTSD (McNally, 2005).  Interdisciplinary, far-reaching, and vast.  Brings together many different related sciences, including: psychology, theology, sociology, medicine, and others (Encyclopedia of Violence, 2008).
  179. 179. What makes trauma, trauma?  The ACE study uses adversity and identified 10 categories. Are these the only sources of trauma? • What other events or experiences might we consider traumatic? • What other experiences trigger the autonomic nervous system to fight, flight, or freeze? • Why do these experiences cause pain? NO.
  180. 180. Psychological Pain=Contradictions to…  Expectations  Values  Beliefs  Needs Personal Identity
  181. 181. Psychological Trauma happens when our Personal Identity is wounded to the point that we experience unacceptable contradictions to our identity (Expectations, values, beliefs, needs).
  182. 182. The Still-Face Experiment
  183. 183. Blueprint for building a Trauma Survivor Four Stages in Development
  184. 184. Stage 1 Event contradicts expectations Stage 2 Triggers Limbic 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. (Adapted from Collins & Carson. (1989). The Integrated Trauma Management System)
  185. 185. Stage 1: An event occurs… Sexual abuse Physical abuse Death of a loved one or pet Bullying Yelled at Parents yelling at each other Dad doesn’t say, “I love you”. Parent gets drunk and acts a fool. Parent cusses at a waitress Etc….
  186. 186. The event contradicts expectations, beliefs, values, needs (personal identity). In other words, we interpret the contradictions as threatening in some way (physically, psychologically, emotionally, and spiritually). Stage 1 (continued) (Adapted from Collins & Carson. (1989). The Integrated Trauma Management System)
  187. 187.  The contradictions (threat) trigger the Limbic system which secretes chemicals we call emotions.  Psychologically, we have experienced loss. This begins the grief response.  If this loss can’t be resolved, the loss is stored in the brain along with the accompanying emotions and the grief (healing) process is stuck. Stage 2 (Adapted from Collins & Carson. (1989). The Integrated Trauma Management System)
  188. 188.  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.  Survival responses “almost work” to distract from the pain. Also, distract from the source. Stage 3 (Adapted from Collins & Carson. (1989). The Integrated Trauma Management System)
  189. 189.  As we evaluate our own responses, many times they contradict our own expectations in some way (physically, psychologically, emotionally, or spiritually).  We experience additional loss and additional grief emotion which is also stored in the brain when it can’t be resolved. Stage 4 (Adapted from Collins & Carson. (1989). The Integrated Trauma Management System)
  190. 190. 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
  191. 191. 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.
  192. 192. As the cycle moves the person further away from awareness of this connection… Perception of self changes. • Personal identity changes.
  193. 193. 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.
  194. 194. 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
  195. 195. Self-Perception= limited Perception of others= He’s an angry violent person!
  196. 196. yellinghitting addictionphysical abuse threatening VIOLENCE blaming Violence is a symptom.Violence is a symptom.
  197. 197. yellinghitting addictionphysical abuse threatening VIOLENCE blaming Roots are adverse experiences. (Colson, 2007)
  198. 198. Strategic Trauma & Abuse Recovery© is Source Focused meaning:
  199. 199. 1. Evaluation, testing, and treatment are all focused on the source or etiology of the problem, cutting off the base of the pyramid so that it stops feeding the top.
  200. 200. 2. Each stage of development is addressed in the order in which they developed.
  201. 201. 3. Symptoms are bypassed when at all possible and allowed to resolve on their own as the “wound” is healing.
  202. 202. 1. We keep the focus on healing rather than fixing or changing the person. 2. We follow the three phases of trauma recovery in order. 1. Safety &,Stabilization 2. Reprocessing & Grieving 3. Reconnecting & Integrating 3. We identify sources of trauma and show their logical connection to symptoms. 4. We use “survival responses” to label symptoms. To bypass symptoms…
  203. 203. Why is bypassing symptoms important? • As the ACE study shows, there is a direct connection between adverse childhood experiences and risky behaviors. These behaviors are not attempts to self- destruct, but attempts to survive.
  204. 204. 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
  205. 205. Why is bypassing symptoms important? • 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. • Unfortunately, they also bring with them side-effects that are viewed as unavoidable.
  206. 206. 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 healing the trauma source)…
  207. 207. Being trauma-informed means…  Focus is on what was done to you, not what you’ve done. (SAMHSA)
  208. 208. Focus on survival responses…  Unintentionally places blame on client.  Increases shame and guilt, further repressing the source or wound.
  209. 209. 3 Phases of Trauma Recovery Incorporated in the structure of S.T.A.R.  (Herman, 1997; Cloitre et al, 2012)
  210. 210. 1. Establishing Safety and Stabilization 3. Reconnecting and Integrating 2. Reprocessing and Grieving ©Denice Colson, 2014
  211. 211. 1. Establishing Safety and Stabilization A. Foundation of a therapeutic relationship (Wampold, et al. 2009). • Characteristics that make therapy work: Empathy Alliance Cohesion (alliance in a group setting) Goal consensus Collaboration • Probably help: positive regard, congruence/genuineness, feedback, repair of alliance ruptures, self-disclosure, management of countertransference, and quality of relational interpretations
  212. 212. 1. Establishing Safety and Stabilization A. Foundation of a therapeutic relationship (Wampold, et al. 2009). • Things that interfere with the therapeutic relationship include: • confrontations, negative processes, assumptions, therapist centricity, rigidity, Ostrich behavior, and “Procrustean Bed” treatment models (Wampold et al, 2009).
  213. 213. 1. Establishing Safety and Stabilization (con’t) B. Tasks include 1. Assessment, 2. Education, 3. Commitment to sobriety from alcohol and drugs, as well as other emotion numbing substances which interfere with grief, and 4. Commitment to the Grieving and Reprocessing Phase.
  214. 214. 1. Establishing Safety and Stabilization (con’t) 1. Herman describes safety as putting control and empowerment in the hands of the survivor (1997). 2. She also believes that anything that takes control away of the survivor will sabotage her sense of safety and security. 3. For trauma survivors, this is the paradoxical state in which they find themselves: what they are doing to take control of their lives, their survival beliefs and behaviors, gives them a sense of safety, but not real safety. 4. Instead it is a false safety keeping them stuck where they are and preventing their identification of their losses from past or present trauma and subsequent movement through the grief process.
  215. 215. 1. Establishing Safety and Stabilization (con’t) 5. While Najavits (2002) focuses on safety theoretically, practically she attempts to help survivors reach stabilization; stopping self-injurious behaviors long- enough to address and grieve the trauma. 6. Conversely, Collins and Carson (1989a and 1989b) suggest circumventing this paradox by avoiding a focus on behavioral change altogether and going straight to resolving the trauma. 7. They believe that any focus on behavioral change keeps the client focused on themselves, increasing shame and further repressing the trauma, thereby not focusing on the source of the trauma: contradicted values and beliefs.
  216. 216. 1. Establishing Safety and Stabilization (con’t) 8. However, they also require the participant to have six months of sobriety from alcohol and mood altering drugs before they can begin the process (Collins and Carson, 1989a and 1989b). This means that their methodology, ETM/TRT©, can not be used with anyone who is self-medicating, which research shows is a high percentage of survivors (Felitti, 2004). 9. In addition, they discourage ETM/TRT© use with any one taking psychotropic medication, currently considered the gold-standard in trauma and addiction treatment, saying that many medications may also interfere with the success of treatment (Collins and Carson, 1989a and 1989b).
  217. 217. 1. Establishing Safety and Stabilization (con’t) 10. In addition, they absolutely prohibit the use of their model with any type of “higher-power” or faith-based integration. 11. While the structure this model uses does provide security for the non-substance using client, convincing a self-medicating client to start the resolution process while giving up any substance use can be difficult.
  218. 218. 2. Reprocessing and Grieving • Phase 2 is a six step procedure which brings together multiple approaches to trauma recovery, most of which are evidence-based. • One “source” of trauma is addressed through the 6 steps at a time. • A “source” is usually a person, but may be an event. • Each step of the grieving process is composed of three parts: preparation, writing, and emotional reprocessing.
  219. 219. 3. Reconnecting and Integrating  Survival responses that have not changed can be addressed directly.  Couple’s counseling and family counseling will be more effective.
  220. 220. GOALS: S.T.A.R.© provides a structured way to: 1. Meet the client where they are. 2. Increase the client’s active participation and investment in the treatment through empowerment. 3. Provide regular feedback to the therapist on the client’s experience of the therapy. 4. Allows for flexibility in the therapists approach to the client and the treatment.
  221. 221. Goals: S.T.A.R.© provides a structured way to: 5. Work with clients who have substance use disorders and clients who don’t. 6. It draws from evidence based practices including:  Motivational interviewing  Seeking Safety©  Cognitive-behavioral techniques  Emotional reprocessing  Narrative Therapy 7. The structure is influenced by Alcoholics Anonymous©, Seeking Safety©, and ETM/TRT©.
  222. 222. The Backbone of S.T.A.R. is…
  223. 223. It holds the 3-phases together, provides for transitions, and breaks down the process in a simpler fashion.
  224. 224. Provides a strategy for moving through the healing process, much like a map.
  225. 225. The 12-Strategic Steps to Trauma and Abuse Recovery  Phase One: 1. I admit that I have been wounded by a relationship with a person or a substance, or by an event, and I am accepting that I am powerless over the wounding. 2. I have decided to give up trying to fix myself and will humbly ask God (as I understand Him now) to heal me; fully understanding that healing will require my participation. 3. I am accepting that I have to grieve in order to heal and I’m determined to give up my bargaining behavior including self- medicating and any substance use that results in numbing my grief and I will allow myself to move through the healing process even though it will be painful. 4. I am forming a partnership with at least one other person (counselor or recovery coach) to boldly identify in a focused and structured manner the people or events that wounded me.
  226. 226. The 12-Strategic Steps to Trauma and Abuse Recovery (con’t)  Phase Two: 5. I am courageously identifying and writing my painful experiences (my story), along with my contradicted expectations, and my losses. I am boldly sharing these with my partner (counselor or recovery coach), fellow- grievers (group), and God (Higher Power), expressing my grief in my own way. 6. I am freely identifying my interpretations of the hurtful event(s) and what they meant about me, the perpetrator, life, and God (church, religion, spirituality). 7. I am identifying and admitting to myself, my partner or partners, and to God (Higher Power) my own survival thoughts, behaviors, and attitudes, developed in response to my wounding.
  227. 227. The 12-Strategic Steps to Trauma and Abuse Recovery (Phase Two con’t) 8. I am identifying and admitting the contradictions my own survival responses had to my expectations of myself and the losses these contradictions have caused me. 9. After completing this thorough inventory of my experiences, contradicted expectations, losses, survival behaviors (new thoughts, behaviors, identity) and the losses these caused me, I humbly and courageously choose forgiveness; forgiving my perpetrator for robbing me and forgiving myself for my responses. 10. I understand that healing is an ongoing process from the inside-out, and I humbly acknowledge God’s (as I understand Him now) hand in healing me and will make a spiritual marker to represent where He met me on my path of healing.
  228. 228. The 12-Strategic Steps to Trauma and Abuse Recovery (con’t)  Phase Three: 11. I am beginning to intentionally move toward reconnecting with myself, with God (as I understand Him now), and with others. 12. I am remaining open to identifying other wounds in my life that need to be healed, without attempting to heal them myself, while maintaining a willing attitude to work through these steps again if necessary, or to assist someone else who needs to work through these steps to healing.
  229. 229. What can I do NOW?
  230. 230. Avoid Common Errors of Trauma Informed Care
  231. 231. 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)
  232. 232. Principles to Apply re: Evaluation and Treatment ….Ask, but don’t push for too much detail. Expect denial and later disclosures. Don’t try to go too far, too fast. Do a trauma evaluation as part of intake or after first session.
  233. 233. How Can I Do This? Use screening instruments Educate using handouts
  234. 234. 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).
  235. 235. Others  ACE Score  http://acestudy.org/yahoo_site_admin/assets/docs/ACE _Calculator-English.127143712.pdf  Simple Trauma Source Assessment (by Denice Colson)
  236. 236. 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.
  237. 237. Get Trained! Strategic Trauma and Abuse Recovery Oct. 2-3, McDonough! Sign-up for email newsletter.
  238. 238. 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.
  239. 239. Treating the solution only 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 (addiction, depression, etc.) for basic cause.
  240. 240. Change starts with us. Contemplation is to be expected. Trauma-Informed Care is the new best- practices standard. There is a learning curve.
  241. 241. Adverse childhood experiences Adult behavioral health issues
  242. 242. Origins of Behavioral health issues?
  243. 243. One factor that differentiates the etiological approach… Symptoms Symptoms
  244. 244. “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
  245. 245. Denice Colson, PhD, LPC, MAC, CPCS  www.TraumaEducation.com  www.ELCCC.org  RDAColson@gmail.com  Supervision, training, coaching , and trauma recovery.
  246. 246. You’re an Overcomer! Mandisa

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