Trauma and the 12 Steps:
Clinical Keys For Enhancing
Recovery Services
Jamie Marich, Ph.D., LPCC-S, LICDC
Counselor, PsyCa...
What led you to
today’s workshop?
About the Presenter
Ohio: LPCC-S, LICDC
Member of the American Academy of Experts on
Traumatic Stress
Twelve years of ex...
Objectives
O Describe how certain 12-step approaches, slogans, and customs
may be counterproductive when working with a tr...
Dr. Marich’s Working Definition
O Addiction is continuing to do something
(e.g., drink alcohol, smoke cigarettes,
gamble, ...
From Dr. Kevin McCauley
(2009):
O Organ Defect (Cause)  Symptoms
From Dr. Kevin McCauley
(2009):
O Organ Defect (Cause)  Symptoms
O Femur Fracture (e.g., skiing)  Pain
O Pancreas  No...
From Dr. Kevin McCauley
(2009):
O ___________  __________ 
_____________
From Dr. Kevin McCauley
(2009):
O ___________  __________ 
_____________
O Midbrain  Various *  Biopsychosocial
Conseq...
Models of Addiction
Rigid acceptance of the disease
model, or any alternative model,
is not optimally trauma-sensitive.
Trauma
Once you’ve been bitten by a
snake, you’re afraid even of a
piece of rope.
-Chinese Proverb
Trauma: Large T & small t
PTSD: DSM-IV-TR
O Actual or perceived threat of injury or death- response
of hopelessness or horror (Criterion A)
O Re-exp...
For the latest updates on DSM-5,
visit the official website at
www.dsm5.org
Trauma: small-t
• Although not life-threatening, definitely life-altering
• If it’s traumatic to the person, then it’s
tra...
Etymological Origin
O Trauma comes from the Greek
word meaning wound
O What do we know about physical
wounds and how they ...
A Client’s Perspective:
Lily Burana (2009)
“PTSD means, in ‘talking over beer’ terms, that you’ve
got some crossed wires i...
A Client’s Perspective:
Lily Burana (2009)
““Your amygdala- the instinctive flight, fight, or freeze partYour amygdala- th...
A Client’s Perspective:
Lily Burana (2009)
“But your brain yells back, ‘Bullshit kid, how dumb do you
think I am? I’m not ...
A Client’s Perspective:
Lily Burana (2009)
“The long-range result is that the peace of mind you
deserve in the present is ...
A Client’s Perspective:
from Marich (2010)
Fadalia (pseudonym), a recovering heroin addict with complex
trauma reflected o...

Putting it Simply…
O Cognitive-behavioral therapies primarily target
the prefrontal regions of the brain (e.g.,
thinking, ...
Putting it Simply…
O Simply talking about the trauma can trigger this
volatile, limbic region, and if the client has no
sk...
Putting It Simply
O What does not seem to change with traditional talk
therapy is that uncomfortable experience of being
t...
Putting it Simply
O Thus, our therapeutic interventions must
address the entire brain.
O Another way to look at processing...
BREAK TIME
How Significant is Trauma When it
Comes to Treating Addictions?
-High comorbidity between PTSD and substance use
disorders...
How Significant is Trauma When it
Comes to Treating Addictions?
Comorbidity between PTSD and
addictions has been establish...
Ricci and Clayton (2008)
“Trauma may also disintegrate any sense of a
future, thus fostering a propensity for the
pursuit ...
A Brief Primer on
12-Step Recovery
O Alcoholics Anonymous founded in 1935 by Bill Wilson
and Dr. Bob Smith in Akron, OH
O ...
A Brief Primer on
12-Step Recovery
• Six steps of the Oxford Groups:
1. Admitted hopelessness
2. Got honest with self
3. G...
A Brief Primer on
12-Step Recovery
O The publication of the book Alcoholics Anonymous in
1939 gave the fellowship a name, ...
Context: A Brief Primer on
12-Step Recovery
O Bill Wilson (who was the New Yorker) and the
Akron groups wanted to keep the...
A Brief Primer on
12-Step Recovery
• The groups hoped that the initial publication of the
book in April of 1939 would prop...
A Brief Primer on
12-Step Recovery
• It was actually The Saturday Evening Post article in
March 1941 that caused the membe...
A Brief Primer on
12-Step Recovery
Fruits of Alcoholics Anonymous (A.A.):
Acknowledgment of addiction as a disease by the...
12 Steps of Alcoholics Anonymous (1939/2001)
 Step 1 - We admitted we were powerless over alcohol- that our lives had
bec...
Let’s Discuss…
O What are your thoughts/feelings on 12-step recovery?
O What limitations have you encountered with 12-step...
Common Criticisms of
12-Step Recovery
O Too much emphasis on spirituality
O Too one-size fits all
O Emphasis on powerlessn...
Common Problems in
Treatment
O Rigid application of 12-step principles
without considering role of trauma
O “They’re just ...
PROBLEM #1
Rigid application of 12-step
principles without
considering role of trauma
Potentially Problematic
12-Step Slogans
O Just For Today/One Day at a Time
O Take the Cotton Out of Your Ears and Put it
i...
And The Gauntlet…
4th
and 5th
Step Work
4. Made a searching and fearless moral
inventory of ourselves
5. Were entirely rea...
Case Study: Nancy (Marich, 2009)
You can’t put anything in the proper perspective. And you can’t
really get a heads up on ...
PROBLEM #2
“They’re just addicts…”
-and/or-
“You’re here to work on your
addiction, not your trauma.”
Evans & Sullivan (1995):
Living in the Solution
1.) A large portion of clients presenting for treatment in
any setting hav...
Evans & Sullivan (1995):
Living in the Solution
3.) Substance use disorders are a significant part of the
clinical picture...
Evans & Sullivan (1995):
Living in the Solution
4.) The disease model of addiction and conventional 12-
step approaches to...
Practical Tips for
12-Step Facilitation
O Get to know the local meetings in your area that
are known for tolerance
O Encou...
Practical Tips for
12-Step Facilitation
O Encourage clients to bring their concerns about
what they see/hear at 12-step me...
Practical Tips for
12-Step Facilitation
O Consider using individual counseling to help clients
identify their roadblocks t...
Practical Tips for
12-Step Facilitation
O Be prepared to process pejorative slogans or
insults to self that clients may he...
PROBLEM #3
Tricky scenarios in group
work…
Case Study Exercise
Wrap-Up: Best Practices for
Interacting with Clients
O Do not re-traumatize!
O Do be genuine
O Do ask open-ended questions...
What is Shame?
Guilt is feeling bad about what
you’ve done,
Shame is feeling bad about who
you are.
“Shame is the lie that...
“When we honestly ask ourselves which
person in our lives means the most to us,
we often find that it is those who, instea...
Please Return by 1:00pm
From Dr. Bessel Van Der Kolk
“The purpose of trauma treatment
is to help a person feel safe in his
or her own body.”
-from...
General Consensus Model of
Trauma Treatment
OPHASE I: Stabilization
OPHASE II: Processing of Trauma
OPHASE III: Reintegrat...
Incorporating into Addiction Treatment
O Research is continuing to demonstrate that any of
these past-oriented treatments ...
Tying it All Together…
O Before any clinician can engage in past-
oriented trauma treatments focused on
resolution, a set ...
Phase I Treatment Planning
-A set of coping skills must be in place
before heavier trauma resolution
therapies can take pl...
What Types of Coping
Skills Work Best???
O Breath work
O Muscle relaxation/pressure points
O Yoga
O Imagery/multisensory s...
Breathing Basics
“The mind controls the body, but the
breath controls the mind.”
B.K.S. Iyengar
Breathing Basics
"Practicing regular, mindful breathing can be
calming and energizing and can even help with
stress-relate...
Breathing Basics
“Teaching breathing exercises to your client is like
teaching a teenager when to accelerate and when
to b...
Strategy #1: Breathing Basics
ODiaphragmatic breathing
OComplete breathing
OUjjayi breathing
Breathing Basics
O Clients who are easily activated may not feel
comfortable closing their eyes during breath work..
O Sta...
Strategy #2:
Progressive Muscle Relaxation
Strategy #3: Pressure Points
Sea of Tranquility
Letting Go/Butterfly Hug
Gates of Consciousness
Third Eye (and variati...
Yoga: Hype or Hope?
O Dr. Bessel Van Der Kolk is a leading research
proponent of using yoga as a primary and
adjunctive tr...
Yoga (Union)
O Recommendation:
Yoga (Union)
O Recommendation:
Yoga and the 12-Step Path
By Kyczy Hawk
Strategy 4:
Body Cuing & Soothing
OImagery
OSound
OSmell
OTouch/Tactile
OTaste
Strategy #5: Mindfulness
Mindfulness means paying attention in a
particular way: on purpose, in the presence
of the moment...
Strategy #6: Acceptance
- acceptance as Buddhist principle
- 12-step recovery (Alcoholics Anonymous, 2001;
p. 417)
-”radic...
Strategy #7: Empowerment
O Encourage that change is possible, no matter how
chronic the relapser… be sincere about it (Mar...
BREAK TIME
Factors to Consider Before
Going Farther …
O Does the client have a reasonable amount of
coping skills to access?
O Is the...
Reprocessing Made Simple
OI am not good enough 
OI am good enough

The Common Factors
O Client and extratherapeutic factors
O Models and techniques that work to engage
and inspire the parti...
Some Reprocessing
Approaches You May
Already Incorporate…
O Narrative Therapy
O Trauma-Focused CBT
O Gestalt Elements
O Mi...
Innovative & Specialty
Training Approaches
O Art/music/performance therapies
O EMDR
O Hypnotherapy
O EFT/NET/TFT
Intense Affect & Abreaction
O “The therapeutic process of bringing forgotten or
inhibited material (i.e., experiences, mem...
For Continued Development
O What are my personal barriers with addiction and
trauma?
O How do I handle intense affect and ...
Why it Matters…
O The literature in general traumatic stress
studies suggests that the therapeutic alliance
between client...
Tips for Collaborative Referral
O Know your limits. If a client is triggering you too
much, don’t be afraid to refer.
O Ne...
Tips for Collaborative Referral
O In making psychiatric referral, get to know the doctors
(or nurse practitioners) in your...
RESOURCE
Medications and the Recovering Person (pdf)
Available at: www.glenbeigh.com
(Under “Resources”)
References
O Alcoholics Anonymous World Services. (2001). Alcoholics anonymous. (4th
ed.) New York: Author.
O American Psy...
References
O Marich, J. (2009). EMDR in addiction continuing care: Case study of a cross-addicted female’s
treatment and r...
To contact today’s presenter:
Jamie Marich, Ph.D., LPCC-S, LICDC
The Ohio Center for Mindful Living
jamie@jamiemarich.com
...
Trauma and the Twelve Steps: Clinical Keys to Recovery Enhancement
Trauma and the Twelve Steps: Clinical Keys to Recovery Enhancement
Trauma and the Twelve Steps: Clinical Keys to Recovery Enhancement
Trauma and the Twelve Steps: Clinical Keys to Recovery Enhancement
Trauma and the Twelve Steps: Clinical Keys to Recovery Enhancement
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Trauma and the Twelve Steps: Clinical Keys to Recovery Enhancement

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Course Description:

Some of the toughest clients presenting for therapy are plagued by issues of co-occurring trauma and addiction. Although the popular 12-step approaches to addiction treatment are still appropriate for clients with posttraumatic stress disorder (PTSD) and other trauma-related diagnoses, rigid application of the disease model and 12-step principles may prove more harmful than helpful for clients in need. In this workshop, participants will learn how to blend traditional knowledge about the disease of addiction and 12-step approaches to recovery with the latest research and practice knowledge on trauma. As a result, participants will find that they will be able to better connect with addicted clients who struggle with trauma, and deliver the help that they so desperately need in a way that honors their experience. In this workshop, participants will learn how to blend traditional knowledge about the disease of addiction and 12-step approaches to recovery with the latest research and practice knowledge on trauma. As a result, participants will find that they will be able to better connect with addicted clients who struggle with trauma, and deliver the help that they so desperately need in a way that honors their experience.

Objectives:
Describe how certain 12-step approaches, slogans, and customs may be counterproductive when working with a traumatized client

Explain how certain features of 12-step recovery are productive for working with addicted survivors of trauma stress and identify how these features can be implemented into treatment

Develop a plan for working 12-step recovery strategies alongside appropriate treatment for the traumatic stress issue(s)

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  • Apply at least three clinical techniques from various psychotherapeutic approaches to help a client through addiction and trauma interaction
    (in longer version)
  • NOTE TO SELF….Address this in terms of the shame piece 
  • Trauma and the Twelve Steps: Clinical Keys to Recovery Enhancement

    1. 1. Trauma and the 12 Steps: Clinical Keys For Enhancing Recovery Services Jamie Marich, Ph.D., LPCC-S, LICDC Counselor, PsyCare, Inc. Founder, The Ohio Center for Mindful Living (Mindful Ohio) Author, Trauma and the Twelve Steps
    2. 2. What led you to today’s workshop?
    3. 3. About the Presenter Ohio: LPCC-S, LICDC Member of the American Academy of Experts on Traumatic Stress Twelve years of experience working in social services and counseling; includes three years of experience in civilian humanitarian aid in Bosnia-Hercegovina Specialist in addictions, trauma, abuse, dissociative disorders, performance enhancement, grief/loss, and pastoral counseling Trained in several specialty interventions for trauma, most extensively in EMDR Author, qualitative researcher Creator, Dancing Mindfulness & Founder of the Ohio Center for Mindful Living
    4. 4. Objectives O Describe how certain 12-step approaches, slogans, and customs may be counterproductive when working with a traumatized client O Define trauma in a biopsychosocial/spiritual manner and explain how honoring this holistic conceptualization of trauma enhances addiction treatment O Explain how certain features of 12-step recovery are productive for working with addicted survivors of trauma stress and identify how these features can be implemented into treatment O Develop a plan for working 12-step recovery strategies alongside appropriate treatment for the traumatic stress issue(s) O Apply at least three clinical techniques from various psycho- therapeutic approaches to help clients attain addiction recovery in a trauma-sensitive fashion
    5. 5. Dr. Marich’s Working Definition O Addiction is continuing to do something (e.g., drink alcohol, smoke cigarettes, gamble, engage in sexual activity), even when the activity causes repeated pain and consequences. SOURCE: GWC, Inc. (1993), Human Addiction
    6. 6. From Dr. Kevin McCauley (2009): O Organ Defect (Cause)  Symptoms
    7. 7. From Dr. Kevin McCauley (2009): O Organ Defect (Cause)  Symptoms O Femur Fracture (e.g., skiing)  Pain O Pancreas  No Insulin  Blindness, Numbness, Wounds
    8. 8. From Dr. Kevin McCauley (2009): O ___________  __________  _____________
    9. 9. From Dr. Kevin McCauley (2009): O ___________  __________  _____________ O Midbrain  Various *  Biopsychosocial Consequences * Addiction (McCauley): defect in the brain’s ability to perceive, process, and act upon pleasurable/painful experiences
    10. 10. Models of Addiction Rigid acceptance of the disease model, or any alternative model, is not optimally trauma-sensitive.
    11. 11. Trauma
    12. 12. Once you’ve been bitten by a snake, you’re afraid even of a piece of rope. -Chinese Proverb
    13. 13. Trauma: Large T & small t
    14. 14. PTSD: DSM-IV-TR O Actual or perceived threat of injury or death- response of hopelessness or horror (Criterion A) O Re-experiencing of the trauma O Avoidance of stimuli associated with the trauma O Heightened arousal symptoms O Duration of symptoms longer than 1 month O Functional impairment due to disturbances
    15. 15. For the latest updates on DSM-5, visit the official website at www.dsm5.org
    16. 16. Trauma: small-t • Although not life-threatening, definitely life-altering • If it’s traumatic to the person, then it’s traumatic • Examples include grief/loss, divorce, verbal abuse/bullying, and just about everything else…
    17. 17. Etymological Origin O Trauma comes from the Greek word meaning wound O What do we know about physical wounds and how they heal?
    18. 18. A Client’s Perspective: Lily Burana (2009) “PTSD means, in ‘talking over beer’ terms, that you’ve got some crossed wires in your brain due to the traumatic event. The overload of stress makes your panic button touchier than most people’s, so certain things trigger a stress reaction- or more candidly- an over-reaction. Sometimes, the panic button gets stuck altogether and you’re in a state of constant alert, buzzing and twitchy and aggressive.”
    19. 19. A Client’s Perspective: Lily Burana (2009) ““Your amygdala- the instinctive flight, fight, or freeze partYour amygdala- the instinctive flight, fight, or freeze part of your brain- reacts to a trigger before your rationalof your brain- reacts to a trigger before your rational mind can deter it. You can tell yourself, ‘it’s okay,’ butmind can deter it. You can tell yourself, ‘it’s okay,’ but your wily brain is already ten steps ahead of the game,your wily brain is already ten steps ahead of the game, registering danger and sounding the alarm. So youregistering danger and sounding the alarm. So you might say once again, in a calm, reasoned cognitive-might say once again, in a calm, reasoned cognitive- behavioral-therapy kind of way, ‘Brain, it’s okay…’behavioral-therapy kind of way, ‘Brain, it’s okay…’
    20. 20. A Client’s Perspective: Lily Burana (2009) “But your brain yells back, ‘Bullshit kid, how dumb do you think I am? I’m not falling for that one again.’ By then, you’re hiding in the closet, hiding in a bottle, and/or hiding from life, crying, raging, or ignoring the phone and watching the counter on the answering machine go up, up, up, and up. You can’t relax, and you can’t concentrate because the demons are still pulling at your strings.”
    21. 21. A Client’s Perspective: Lily Burana (2009) “The long-range result is that the peace of mind you deserve in the present is held hostage by the terror of your past.”
    22. 22. A Client’s Perspective: from Marich (2010) Fadalia (pseudonym), a recovering heroin addict with complex trauma reflected on where she was at before receiving the integrated treatment that led to her longest sobriety to date (3 years): “Before [treatment], my feelings, thoughts and experiences were all tangled like a ball of yarn. I needed something to untangle them.”
    23. 23.
    24. 24. Putting it Simply… O Cognitive-behavioral therapies primarily target the prefrontal regions of the brain (e.g., thinking, judgment, and willpower). However, when a person gets activated or triggered by traumatic memories or other visceral experiences, the prefrontal cortex is likely to shut down and the limbic brain (e.g., emotional brain) takes over.
    25. 25. Putting it Simply… O Simply talking about the trauma can trigger this volatile, limbic region, and if the client has no skills to regulate these intense emotions, a client can be re-traumatized.
    26. 26. Putting It Simply O What does not seem to change with traditional talk therapy is that uncomfortable experience of being triggered at a visceral level, (bottom of the brain) when the person is faced with reminiscent features of the original trauma in the present (Brown, 2003)
    27. 27. Putting it Simply O Thus, our therapeutic interventions must address the entire brain. O Another way to look at processing is to think of these three brains “linking up”
    28. 28. BREAK TIME
    29. 29. How Significant is Trauma When it Comes to Treating Addictions? -High comorbidity between PTSD and substance use disorders: 27.9% of those with PTSD meet criteria for substance abuse, 34.5% meet criteria for dependence (Kessler et al., 1995; (Peirce, Kindbom, Waesche, Yuscavage, & Brooner, 2008) -Of patients in substance disorder treatment, 12-34% have PTSD; these numbers can be as high as 33-59% in women (Najavits,2001; 2005).
    30. 30. How Significant is Trauma When it Comes to Treating Addictions? Comorbidity between PTSD and addictions has been established, and untreated PTSD has been identified as a factor in relapse (Miller & Guidry, 2001; Zweben & Yeary, 2006)
    31. 31. Ricci and Clayton (2008) “Trauma may also disintegrate any sense of a future, thus fostering a propensity for the pursuit of instant gratification” (p. 42).
    32. 32. A Brief Primer on 12-Step Recovery O Alcoholics Anonymous founded in 1935 by Bill Wilson and Dr. Bob Smith in Akron, OH O Both had been members of the Oxford Groups O Decided to focus on reaching out just to the alcoholic (a difference from the Oxford Groups), but kept many of the same principles
    33. 33. A Brief Primer on 12-Step Recovery • Six steps of the Oxford Groups: 1. Admitted hopelessness 2. Got honest with self 3. Got honest with another 4. Made amends 5. Help others 6. Prayed to God as you understand him
    34. 34. A Brief Primer on 12-Step Recovery O The publication of the book Alcoholics Anonymous in 1939 gave the fellowship a name, saw the publication of the first draft of the 12-steps, and gave the A.A. fellowship some uniformity O Although A.A. co-founder Bill Wilson is the primary author of the first part of the “Big Book,” various edits of the book were passed back and forth between the New York and Akron groups.
    35. 35. Context: A Brief Primer on 12-Step Recovery O Bill Wilson (who was the New Yorker) and the Akron groups wanted to keep the focus on spirituality. O The New York groups wanted to keep the focus on the physical aspects of alcoholism. O What emerged was a combination of the two approaches
    36. 36. A Brief Primer on 12-Step Recovery • The groups hoped that the initial publication of the book in April of 1939 would propel the message of Alcoholics Anonymous into the mainstream • To the dismay of the groups, orders for the book only “trickled” in • The Rockerfeller foundation assisted with getting the 4,000 non-purchased copies of the book out of storage • There was not a need for a second printing of the so- called “Big Book” until 1941
    37. 37. A Brief Primer on 12-Step Recovery • It was actually The Saturday Evening Post article in March 1941 that caused the membership of Alcoholics Anonymous to expand exponentially throughout the United States. • Noted writer Jack Alexander had set out to expose A.A. as a fraud…what emerged was 6 pages of praise about the A.A. fellowship, necessitating a second printing of the Big Book.
    38. 38. A Brief Primer on 12-Step Recovery Fruits of Alcoholics Anonymous (A.A.): Acknowledgment of addiction as a disease by the American Medical Association in 1952 Influenced the development and rise to popularity of the Minnesota model of treatment in the 1950’s Prompted the founding of hundreds of related fellowships that also use the 12-steps
    39. 39. 12 Steps of Alcoholics Anonymous (1939/2001)  Step 1 - We admitted we were powerless over alcohol- that our lives had become unmanageable  Step 2 - Came to believe that a Power greater than ourselves could restore us to sanity  Step 3 - Made a decision to turn our will and our lives over to the care of God as we understood God  Step 4 - Made a searching and fearless moral inventory of ourselves  Step 5 - Admitted to God, to ourselves and to another human being the exact nature of our wrongs  Step 6 - Were entirely ready to have God remove all these defects of character  Step 7 - Humbly asked God to remove our shortcomings  Step 8 - Made a list of all persons we had harmed, and became willing to make amends to them all  Step 9 - Made direct amends to such people wherever possible, except when to do so would injure them or others  Step 10 - Continued to take personal inventory and when we were wrong promptly admitted it  Step 11 - Sought through prayer and meditation to improve our conscious contact with God as we understood God, praying only for knowledge of God's will for us and the power to carry that out  Step 12 - Having had a spiritual awakening as the result of these steps, we tried to carry this message to other addicts, and to practice these principles in all our affairs
    40. 40. Let’s Discuss… O What are your thoughts/feelings on 12-step recovery? O What limitations have you encountered with 12-step recovery in certain populations? O What does it mean for an intervention, such as 12-step recovery, to be trauma-sensitive?
    41. 41. Common Criticisms of 12-Step Recovery O Too much emphasis on spirituality O Too one-size fits all O Emphasis on powerlessness and character defects is counter-therapeutic O Certain 12-step groups and treatment centers can get too fanatic O Disease model of addiction is not acceptable
    42. 42. Common Problems in Treatment O Rigid application of 12-step principles without considering role of trauma O “They’re just addicts” O “You’re here to work on your addiction, not the trauma” O Tricky scenarios in group work
    43. 43. PROBLEM #1 Rigid application of 12-step principles without considering role of trauma
    44. 44. Potentially Problematic 12-Step Slogans O Just For Today/One Day at a Time O Take the Cotton Out of Your Ears and Put it in Your Mouth O Your Best Thinking Got You Here O Think, Think, Think O We Are Only as Sick as Our Secrets O Any misplaced spirituality slogan…
    45. 45. And The Gauntlet… 4th and 5th Step Work 4. Made a searching and fearless moral inventory of ourselves 5. Were entirely ready to have God remove all these defects of character What makes these steps nearly impossible for someone with unresolved trauma issues?
    46. 46. Case Study: Nancy (Marich, 2009) You can’t put anything in the proper perspective. And you can’t really get a heads up on what really happened because you were so traumatized and you had such bad experiences and like in my case, I had the trauma then I had the- I call it the after-effect of my ex-husband- pounding over and over and over and over it for like 14 years after that. I took so much responsibility for it. It was almost like I victimized myself all over again in my mind.
    47. 47. PROBLEM #2 “They’re just addicts…” -and/or- “You’re here to work on your addiction, not your trauma.”
    48. 48. Evans & Sullivan (1995): Living in the Solution 1.) A large portion of clients presenting for treatment in any setting have a history of childhood trauma. Respecting this history enhances treatment. 2.) Successful treatment of the trauma must include working through memories of the trauma in an experiential way, after the clinician and client have established a foundation of safety and coping skills
    49. 49. Evans & Sullivan (1995): Living in the Solution 3.) Substance use disorders are a significant part of the clinical picture for a substantial number of survivors of childhood abuse, thus: -Treatment of the abuse issues that does not address the substance use issues will be ineffective - Treating only the addiction in those with survivor issues will likely be ineffective
    50. 50. Evans & Sullivan (1995): Living in the Solution 4.) The disease model of addiction and conventional 12- step approaches to treatment are productive in treating the addicted survivor of trauma 5.) Treatment models for addicted survivors of trauma must be integrated, and must address the synergism of trauma and addiction. A two-track approach is generally ineffective.
    51. 51. Practical Tips for 12-Step Facilitation O Get to know the local meetings in your area that are known for tolerance O Encourage gender-specific meetings O Advise looking for a sponsor who has at least a basic understanding of trauma and/or someone who is not strictly “letter of the law”
    52. 52. Practical Tips for 12-Step Facilitation O Encourage clients to bring their concerns about what they see/hear at 12-step meetings to counseling O Work with clients to build a set of practical, body- based coping skills (e.g., breath work, muscle relaxation, exercise, music, journaling) especially before 4th and 5th step work
    53. 53. Practical Tips for 12-Step Facilitation O Consider using individual counseling to help clients identify their roadblocks to successfully completing 4th and 5th steps (may also apply to 8th and 9th steps) O Evaluate with a client whether or not the 5th step will be best completed with a trained professional… remember, the step just says another human being
    54. 54. Practical Tips for 12-Step Facilitation O Be prepared to process pejorative slogans or insults to self that clients may hear in meetings or from traditional counselors O Name calling and hot seat strategies, even if done in a spirit of “tough love” can be incredibly damaging for the traumatized client
    55. 55. PROBLEM #3 Tricky scenarios in group work…
    56. 56. Case Study Exercise
    57. 57. Wrap-Up: Best Practices for Interacting with Clients O Do not re-traumatize! O Do be genuine O Do ask open-ended questions O Do be non-judgmental O Do make use of the stop sign when appropriate O Do assure the client that they may not be alone in their experiences (if appropriate) O Have closure strategies ready O Do consider the role of shame in addiction, trauma, and grief
    58. 58. What is Shame? Guilt is feeling bad about what you’ve done, Shame is feeling bad about who you are. “Shame is the lie that someone told you about yourself.” -Anais Nin
    59. 59. “When we honestly ask ourselves which person in our lives means the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm and tender hand.” -Henri Nouwen
    60. 60. Please Return by 1:00pm
    61. 61. From Dr. Bessel Van Der Kolk “The purpose of trauma treatment is to help a person feel safe in his or her own body.” -from a the new documentary Trauma Treatment for the 21st Century (Premier, 2012)
    62. 62. General Consensus Model of Trauma Treatment OPHASE I: Stabilization OPHASE II: Processing of Trauma OPHASE III: Reintegration
    63. 63. Incorporating into Addiction Treatment O Research is continuing to demonstrate that any of these past-oriented treatments can be appropriately applied to an integrated addiction treatment program when proper precautions are taken (Marich, 2010)
    64. 64. Tying it All Together… O Before any clinician can engage in past- oriented trauma treatments focused on resolution, a set of coping skills must be in place.
    65. 65. Phase I Treatment Planning -A set of coping skills must be in place before heavier trauma resolution therapies can take place. -Initial treatment is a valuable time to help with coping skills training and installation.
    66. 66. What Types of Coping Skills Work Best??? O Breath work O Muscle relaxation/pressure points O Yoga O Imagery/multisensory soothing O Resources & Recovery Capital O Spiritual principles O Anything that incorporates the body in a positive, adaptive way!!!
    67. 67. Breathing Basics “The mind controls the body, but the breath controls the mind.” B.K.S. Iyengar
    68. 68. Breathing Basics "Practicing regular, mindful breathing can be calming and energizing and can even help with stress-related health problems ranging from panic attacks to digestive disorders.“ Andrew Weil, M.D.
    69. 69. Breathing Basics “Teaching breathing exercises to your client is like teaching a teenager when to accelerate and when to brake the car.” Amy Weintraub
    70. 70. Strategy #1: Breathing Basics ODiaphragmatic breathing OComplete breathing OUjjayi breathing
    71. 71. Breathing Basics O Clients who are easily activated may not feel comfortable closing their eyes during breath work.. O Start slowly…if a client is not used to breathing deliberately, don’t overwhelm him. Starting with a few simple breaths, and encouraging repetition as a homework assignment, is fine. O If a client has a history of medical difficulties, make sure to obtain a release to speak with her medical provider before proceeding.
    72. 72. Strategy #2: Progressive Muscle Relaxation
    73. 73. Strategy #3: Pressure Points Sea of Tranquility Letting Go/Butterfly Hug Gates of Consciousness Third Eye (and variations) Karate Chop/Inner Gate
    74. 74. Yoga: Hype or Hope? O Dr. Bessel Van Der Kolk is a leading research proponent of using yoga as a primary and adjunctive treatment for PTSD O Yoga, if integrated safely and appropriately, is at very least, an ideal coping skill technique in traumatized individuals O Many addiction treatment centers throughout the world offer yoga
    75. 75. Yoga (Union) O Recommendation:
    76. 76. Yoga (Union) O Recommendation: Yoga and the 12-Step Path By Kyczy Hawk
    77. 77. Strategy 4: Body Cuing & Soothing OImagery OSound OSmell OTouch/Tactile OTaste
    78. 78. Strategy #5: Mindfulness Mindfulness means paying attention in a particular way: on purpose, in the presence of the moment, and non-judgmentally. -Jon Kabat-Zinn (1994)
    79. 79. Strategy #6: Acceptance - acceptance as Buddhist principle - 12-step recovery (Alcoholics Anonymous, 2001; p. 417) -”radical acceptance” (from dialectical behavioral therapy) -acceptance and commitment therapy
    80. 80. Strategy #7: Empowerment O Encourage that change is possible, no matter how chronic the relapser… be sincere about it (Marich, 2010). O Foster identification as a survivor, not a victim (Hantman & Solomon, 2007)
    81. 81. BREAK TIME
    82. 82. Factors to Consider Before Going Farther … O Does the client have a reasonable amount of coping skills to access? O Is there a sufficient amount of positive material (e.g., recovery capital) in the client’s life? O Is the client willing (and ready) to look at past issues? In 12-step terms, this is best done between steps 1-3 and 4-5. O Have you assessed for secondary gains and other related issues? O Have you considered number of sessions available?
    83. 83. Reprocessing Made Simple OI am not good enough  OI am good enough
    84. 84.
    85. 85. The Common Factors O Client and extratherapeutic factors O Models and techniques that work to engage and inspire the participants O The therapeutic relationship/alliance O Therapist factors Source: Duncan, B.L., Miller, S.D., Wampold, B.E., Hubble, M.E. (2009). The heart and soul of change: Delivering what works in psychotherapy. (2nd ed.) Washington, D.C.: American Psychological Association.
    86. 86. Some Reprocessing Approaches You May Already Incorporate… O Narrative Therapy O Trauma-Focused CBT O Gestalt Elements O Mindfulness-Based Cognitive Therapy O Somatic experiencing
    87. 87. Innovative & Specialty Training Approaches O Art/music/performance therapies O EMDR O Hypnotherapy O EFT/NET/TFT
    88. 88. Intense Affect & Abreaction O “The therapeutic process of bringing forgotten or inhibited material (i.e., experiences, memories) from the unconscious into consciousness, with concurrent emotional release and discharge of tension and anxiety.” APA Dictionary of Psychology; VandenBos (2007)
    89. 89. For Continued Development O What are my personal barriers with addiction and trauma? O How do I handle intense affect and abreaction? O What factors may inhibit me from being effective with a traumatized addict? O When is the best time to use collaborative referrals?
    90. 90. Why it Matters… O The literature in general traumatic stress studies suggests that the therapeutic alliance between client and clinician is an important mechanism in facilitating meaningful change for clients with complex PTSD (Fosha, 2000; Fosha & Slowiaczek, 1997; Courtois & Pearlman, 2005)
    91. 91. Tips for Collaborative Referral O Know your limits. If a client is triggering you too much, don’t be afraid to refer. O Network in your local community—get to know who offers what and who seems to be most knowledgeable in trauma and addiction. O The Internet is a treasure trove of resources. Many of the major websites in trauma therapies have data bases listing clinicians around the country who have gone through extra training.
    92. 92. Tips for Collaborative Referral O In making psychiatric referral, get to know the doctors (or nurse practitioners) in your area who have a prudent, balanced approach to medication. O It is not wise to send a client who struggles with addiction and trauma issues to a psychiatrist who relies heavily on benzodiazepine prescribing (or use of other controlled substances)
    93. 93. RESOURCE Medications and the Recovering Person (pdf) Available at: www.glenbeigh.com (Under “Resources”)
    94. 94. References O Alcoholics Anonymous World Services. (2001). Alcoholics anonymous. (4th ed.) New York: Author. O American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th ed.-text revision) Washington, D.C.: Author. O Brown, S. (2003). The missing piece: The case for EMDR-based treatment for posttraumatic stress disorder and co-occurring substance use disorder. LifeForce Trauma Solutions. Retrieved June 4, 2008, from http://www.lifeforceservices.com/ article_detail.php?recordid=5 O Burana, L. I love a man in uniform: A memoir of love, war, and other battles. New York: Weinstein Books. O Courtois, C.A., & Pearlman, L.A. (2005). Clinical applications of the attachment framework: Relational treatment of complex trauma. Journal of Traumatic Stress, 18(5), 449-459. O Cunningham, A. (2010). Healing addiction with yoga: A yoga program for people in 12-step recovery. Forres, Scotland, UK: Findhorn Press. O Duncan, B.L., Miller, S.D., Wampold, B.E., Hubble, M.E. (2009). The heart and soul of change: Delivering what works in psychotherapy. (2nd ed.) Washington, D.C.: American Psychological Association. O Evans, K., & Sullivan, J.M. (1995). Treating addicted survivors of trauma. New York: The Guilford Press. O Fosha, D. (2000). The transforming power of affect: A model for accelerated change. New York: Basic Books. O Fosha, D., & Slowiaczek, M.I. (1997). Techniques to accelerate dynamic psychotherapy. American Journal of Psychotherapy, 51(2), 229-251. O GWC, Inc. (1993). Human addiction [VHS Tape]. Cahokia, IL: Author. O Hantman, S., & Solomon, Z. (2007). Recurrent trauma: Holocaust survivors cope with aging and cancer. Social Psychiatry & Psychiatric Epidemiology, 42, 396-402. O Kabat-Zinn, J. (1994). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Dell Publishing. O Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52, 1048-1060.
    95. 95. References O Marich, J. (2009). EMDR in addiction continuing care: Case study of a cross-addicted female’s treatment and recovery. Journal of EMDR Practice and Research, 3(2), 98-106. O Marich, J. (2010). EMDR in addiction continuing care: A phenomenological study of women in early recovery. Psychology of Addictive Behaviors, 24(3), 498-507. McCauley, K. (2009). Pleasure unwoven. [DVD]. Salt Lake City, UT: Institute for Addiction Study. O Miller, D. & Guidry, L. (2001). Addictions and trauma recovery: Healing the body, mind, and spirit. New York: W.W. Norton. O Najavits, L. (2001). Seeking safety: A treatment manual for PTSD and substance abuse. New York: The Guilford Press. O   O Najavits, L. (2005). Handouts for training on PTSD and Seeking Safety. ODADAS Women’s Symposium, May 16-19, 2006. O Peirce, J.M., Kindbom, K.A., Waesche, M.C., Yuscavage, A.S., & Brooner, R.K. (2008). Post-traumatic stress disorder, gender and problem profiles in substance dependent patients. Substance Use and Misuse, 43, 596-611. O Premiere Education & Media. (2012). Trauma treatment: Psychotherapy for the 21st century [DVD]. Eau Claire, WI: Author. O Ricci, R.J., & Clayton, C.A. (2008). Trauma resolution treatment as an adjunct to standard treatment for child molesters. Journal of EMDR Practice and Research, 2(1), 41-50. O VandenBos, G.R. (Ed.) (2007). APA dictionary of psychology. Washington, DC: The American Psychological Association. O Weintraub, A. (2012). Yoga skills for therapists. New York: W.W. Norton. O Zweben, J., & Yeary, J. (2006). EMDR in the treatment of addiction. Journal of Chemical Dependency Treatment, 8(2), 115-127.
    96. 96. To contact today’s presenter: Jamie Marich, Ph.D., LPCC-S, LICDC The Ohio Center for Mindful Living jamie@jamiemarich.com www.jamiemarich.com www.drjamiemarich.com www.TraumaTwelve.com www.DancingMindfulness.com Phone: 330-881-2944

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