Michael F. Barnes, Ph.D., LPC Clinical Program ManagerCeDAR – University of Colorado Hospital
INCIDENCE OF TRAUMATIC EVENTSWorldwide, it is estimated that two-thirds of the population in exposed to a traumatic events that meet the DSM stressor criteria for PTSD.According to the National Center for PTSD: 61% of men and 51% of women report having experienced at least one traumatic event (lifetime) 10% of men and 6% of women report having experienced four or more traumatic events (lifetime) Of these trauma victims, 8% receive diagnosis of PTSD 1% of American Population (New England Journal of Med)
What Causes Trauma? Natural Disaster Events - Hurricanes, Earthquakes, Tornadoes, Floods, Fires, etc. High Speed Events - Car & Bike Accidents, Falls, etc. Assault Events - Assault, Rape, Incest, Animal Attacks Global Threat Events - Drowning, Electrocution, Caesarian, etc. Major Illness/Hospital Events - Cancer, Heart Attacks, Asthma, Full Anesthesia Surgeries Death of a loved one Divorce Family Trauma Abandonment or Attachment Trauma Living in an alcoholic or otherwise dysfunctional family
PTSD & SUBSTANCE ABUSE DISORDERSPrevalence of PTSD and SUDS Among persons who develop PTSD, 52% of men and 28% of women are estimated to develop an alcohol use disorder. 35% of men and 27% of women develop a drug use disorder. (Najavits, 2007) The numbers are even higher for veterans, prisoners, victims of domestic violence, first responders, etc. (Najavits, 2004a, 2004b, 2007) Individuals with PTSD are 3 to 4 times more likely to develop SUD’s than individuals without PTSD. Have earlier histories with A & D, more severe use, and poor treatment adherence. (Khantzian & Albanese, 2008)
PTSD & SUBSTANCE ABUSE DISORDERS Treatment outcomes - PTSD and SUDS PTSD/SUD patients more vulnerable to poorer short- and long- term outcomes. (Ouimette, Moos, & Brown, 2003) PTSD heightens the likelihood of addiction relapse, and the potential for multiple relapses. (Norman, Tate, Anderson, & Brown, 2007) A trauma history and current trauma symptoms are associated with relapse to alcohol or other substance use in alcohol dependent women. (Heffner, Blom, & Anthenelli, 2011) PTSD/SUDS has been shown to be associated with poorer treatment outcomes, and higher relapse rates. (Sonne, Back, Zuniga, Randall, & Brady, 2003)
PTSD & SUBSTANCE ABUSE DISORDERS Age of onset – Childhood Trauma Individuals meeting diagnostic criteria for both alcohol dependence and PTSD, who experienced childhood trauma reported greater PTSD symptom severity, particularly intrusive symptoms, greater alcohol symptoms severity, and greater trauma related alcohol craving. Appear to be particularly vulnerable to relapse following treatment for alcohol dependence, if PTSD symptoms are not properly assessed and treated. (Schumacher, Coffey, & Stasiewicz, 2006) Severity of reported childhood trauma predicted cocaine relapse in women during a 90 day follow-up. (Heffner, Blom, & Anthenelli, 2011) 8
ADVERSE CHILDHOOD EVENTSACE Studies – Longitudinal study carried out by the Centers for Disease Control and Prevention (2009) and Kaiser Permanente Department of Preventive Medicine (17,421 sample size).ACEs are trauma exposures that constitute a frequent and common pathway to social, emotional, and cognitive impairments that lead to increased risk of unhealthy behaviors, risk of violence or re-victimization, disease, disability and premature mortality as people age and develop. (Anda, 2008, www.aapweb.com) Felitti, et al. (1998) reported that individuals with ACE were found to have: 2.5X% greater chance of smoking over children with no aces. 5.0X% increase in self-acknowledged alcoholism 4.6X’s greater chance for injection drug abuse. American Journal of Preventative Medicine (1998)
Trauma Informed Addiction Treatment It is important to recognize that trauma informed addiction treatment started in the early 1990s. A 2009 survey found that 66.6% of over 13,000 addiction treatment facilities in the US reported including trauma focused care (33.4% did not). Facilities that did not provide trauma treatment were located primarily in the South, Midwest, and West Primarily for-profit facilities Capezza & Najavits (2012) The object is NOT to provide primary trauma therapy for past traumatic events (no focus on the trauma story). Focus on resolution of trauma symptoms that are experienced in addiction treatment. Najavits (2006)
Trauma Informed Addiction Treatment Trauma informed care is not a model of treatment, but a philosophy of treatment that is based on: An appreciation for the high prevalence of traumatic experiences in persons who receive mental health services A thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual clients. (Jennings, 2004) Acceptance of universal precautions as a trauma informed concept (presume that every person in treatment has been exposed to some traumatic experience). (Caldwell, 2006)
Trauma Informed Addiction Treatment Committed to providing a safe physical environment Safety from substances, dangerous relationships, and extreme symptoms (suicidality and dissociation) – Najavits (2009) Safety in working with informed staff in a warm, supportive, and empowering setting. Safety in that counselors, physicians, and support staff are aware of their own trauma histories, countertransference reactions, and compassion fatigue Treatment and support environments infused with both recovery and resiliency focus Use of treatment methods that empower traumatized clients to engage in a recovery program, while also working on day-to-day trauma symptoms. Commitment to avoid re-traumatizing practices Commitment to appropriately assess trauma
Trauma Informed Addiction Treatment Recognize that addiction treatment with traumatized clients will be full of triggers that can prevent the client from receiving the recovery message and interfere with treatment compliance and treatment success. Educate clients and their family members on the interrelationship between both treatment issues. Recognize that treatment success will be associated with assisting clients to develop: Self- awareness Assertiveness Self-regulation Clear expression of need Self-soothing behaviors Clear communication Self-esteem and self-trust Accurate perception of others Clear limit setting Harris & Fallot, 2001
DSM – V: Proposed Diagnostic Criteriafor PTSD (Friedman, Resick, Bryant, & Brewin, 2010) Criterion A - The person was exposed to 1 or more of the following event(s): death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways: 1. Experiencing the event(s) him/herself. 2. Witnessing the event(s) as they occurred to others. 3. Learning that the event(s) occurred to a close relative or close friend. 4. Experiencing repeated or extreme exposure to aversive details of the event(s) (e.g., first responders collecting body parts; police officers repeatedly exposed to details of child abuse). Witnessing or exposure to aversive details does not include events that are witnessed only in electronic media, television, movies or pictures, unless this is part of your vocational role. Exposure to aversive details of death applies only to unnatural death
DSM – V: Proposed Diagnostic Criteriafor PTSD (Friedman, Resick, Bryant, & Brewin, 2010) Criterion B – Intrusion symptoms that are associated with the traumatic event(s), that began after the traumatic events (1 or more): Recurrent, involuntary, and intrusive distressing memories Distressing dreams Dissociative reactions (e.g. flashbacks.) Prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic even Physiological reactions to reminders of the traumatic events. Criterion C – Avoidance Behaviors (1 symptom needed) Intentional or Conscious Avoidance Avoidance of thoughts, feelings, or conversations associated with the stressor. Avoidance of activities, places or people associated with the stressor
DSM – V: Proposed Diagnostic Criteriafor PTSD (Friedman, Resick, Bryant, & Brewin, 2010) Criterion D - Negative alterations in cognitions and mood that are associated with the traumatic event(s) (that began or worsened after the traumatic event(s), as evidenced by 3 or more of the following: Inability to remember aspects of event – dissociative Persistent and exaggerated negative expectations about one’s self, others Persistent distorted blame of self or others about the cause or consequences of the traumatic event(s) NEW SYMPTOM IN 5!
DSM – V: Proposed Diagnostic Criteriafor PTSD Criterion E – Alterations in arousal and reactivity that are associated with the traumatic event(s) (that began or worsened after the traumatic event(s)), as evidenced by 3 or more of the following: (Note: In children, as evidenced by two or more of the following): Irritable, angry, or aggressive behavior Reckless or self-destructive behavior – NEW ITEM IN 5. Hypervigilance Exaggerated startle response Problems with concentration Sleep disturbance – for example, difficulty falling or staying asleep, or restless sleep.
Containment and Autonomic Regulation (CAR)Therapy - Background1. Peter Levine (1968 to present) • Somatic Experiencing • Applied linear modeling to describe the behavior of the Autonomic Nervous System (ANS) • Proposed that Event Memory stores ANS states and those states are accessible through sensation. • Based Theory on Ethology – the study of animal behavior • Healing takes place naturally when ANS recalibrates on its own.2. Neuroscience of Memory (Grigsby & Stevens) • Neurodynamics of Personality • View of memory as a complex relationship between different memory systems. • Memory Systems: Semantic, Episodic, Procedural, Event
Containment and Autonomic Regulation (CAR)Therapy - Background3. Eric Wolterstorff (1994 to present) – Developer of CAR Process. • Protégé of Peter Levine • Flattened Levine’s 3D model of ANS to 2D model (ANS States) • Moved from single event trauma to multi-event and complex relational trauma. • Identified the need for “solution” as prerequisite for working with dissociation. • Developed strong focus on the transference implications from working with traumatized clients, especially highly relational traumas. • Developed individual and group protocols.
Containment and Autonomic Regulation(CAR) Therapy Based on the belief that there is a fundamental relationship between trauma memory systems and the Autonomic Nervous System. Counselors must possess ability to recognize Nervous System activation and understand what memory states will be accessable for intervention. What type of therapy will work with different memory systems.
Integrating Trauma Memories(van der Kolk, 1996, Trauma and Memory from Traumatic Stress: The Effects of OverwhelmingExperience on the Mind, Body, and Society) In dissociation, there is interference with proper information processing and storage of information in narrative (Semantic) Memory Van der Kolk calls this “speechless terror.” Words fail to describe situation. Trauma organized in memory on a perceptual level. During periods of extreme ANS activation (stress or dissociation), see decrease in activation of Broca’s area (part of brain most critical for transformation of subjective experience into speech). Also see significant increase in activation of areas in right hemisphere that are thought to process intense emotions and visual images. Development of Event Memory of traumatic event. Narrative memory (i.e., memory of what happened or the trauma story) is therefore semantic and symbolic. Semantic memory is social and adapted to the needs of both the narrator and the listener It can be expanded or contracted, according to social demands.
Memory Systems Declarative Memory – explicit memory referring to intentional or conscious awareness of facts or events that have happened to the individual. Episodic Memory – recall of subjective events in one’s life Semantic Memory – (knowledge) – recall of objective facts and other nonpersonal information. Nondeclarative Memory – implicit memory referring to unconscious memories of skills and habits, emotional responses, reflexive actions and classically conditioned responses. Procedural Memory – learned from prior experience. Lack ability to utilize new existing knowledge, given unconscious nature of the memory. Event Memory –subcortical mechanism of emotional learning that bypasses the cerbral cortex. Generally experienced as intense emotion or fragments of sensory information.
THE AUTONOMIC NERVOUS SYSTEM The ANS governs many automatic body processes such as: Heart rate Breathing Metabolism Temperature Sympathetic (fight/flight) Parasympathetic (calming, digestion, autoregulation) Dissociation, numbing freeze responses
Trauma and the Autonomic Nervous System State 0: (zero): calm, responsive, awake State 1: slightly anxious, annoyed, nervous, physical tension State 2: highly anxious, angry, panic symptoms, intense physical tension (stomach, chest, breathing), powerful fight or flight responses State 3: Dual activated (a mixture of activation with dissociative symptoms): tension with somatic collapse, anxiety, sleepy, panic, hopelessness, heaviness, blurred vision No Solutions “Scared to death” State 4: pure dissociation marked by a distinct lack of physical sensation and flat affect, numbed out, blank, feeling ‘floaty’, depersonalized, and disconnected Somatic Experiencing (Peter Levine, Ph.D.) Containment and Autonomic Regulation (CAR) Eric Wolterstorff, Ph.D.)
TOP DOWN VS. BOTTOM UP THERAPY Most therapy is top-down approachbottom-upfunctioning From Trauma Integrated Addiction perspective, must calm ANS activation in order to promote Semantic Memory system access. Increase effectiveness of talk therapy increase access to “recovery message.”
Containment and Autonomic Regulation (CAR)Exposure therapy focused on the autonomic nervous systemReproducible, testable, and phase-based protocol1. Building Resources • Teach clients tools needed to manage activation of the autonomic nervous system • Grounding techniques needed as prep for working with trauma.2. Building Relational Skills 1. Attachment focused – one person’s nervous system learning to attach to another person’s nervous system 2. Attachment work is procedural auto-regulation 3. Stressed “yes” and Stressed “No” 4. Focus on boundary development, affect management, and ownership of the recovery process.3. Trauma Assessment • Trauma Symptoms Inventory-2 (Assessment Procedural Memory) • Assess sources of trauma (Event Memory) and the degree of activation that the individual experiences when briefly talking about each.
Containment and Autonomic Regulation (CAR)4. ANS Recalibration / Re-exposure – A method of discharging the ANS of stress and trauma (event memory response), utilizing a process of containment. Focus on physiological response, while not acting on physical impulses to avoid or distract. Goal is to complete defensive responses and reintegrate the ANS. Complex process that works with both hot (anxiety) and cold symptoms (dissociation). Requires significant awareness to pace and staying within client’s working window (tolerance threshold). 5. Integration – Allowing clients to tell their story in a new way. Similar to Herman’s reintegration into society Use Figley’s Five Healing Questions (My preference!) 1.What happened? 2.Why did it happen? 3.Why did it happen to me? 4.Why did I react the way I did? 5.What will I do if something similar happens in the future?
Containment & Autonomic Resolution (CAR) Pilot Study (2011) t Scores at or above 65 are considered Clinically Significant • Identified in Red Above
TRAUMA INTEGRATED ADDICTIONTREATMENT A lens that we look through to understand client behaviors and to better understand the roadblocks that trauma symptoms provide for clients in addiction treatment. Substance Often labeled Abuse Interferes with client’s client resistance. ability to hear recovery message! Attachment Traumatic Stress /Differentiation Symptoms• Assess clients for all three aspects of this triangle.• Critical for individualized treatment, continuing care planning, etc.
Trauma Integrated Addiction Counseling – Assessment Briere, J. (2011) – Trauma Symptoms Inventory -2 Professional Manual TSI 2 Clinical Scales/Subscales• Anxious Arousal • Sexual Disturbance • Anxiety • Sexual Concerns • Hyperarousal • Dysfunctional Sexual• Depression Behavior• Anger • Insecure Attachment • Relational Avoidance• Intrusive Experiences Rejection Sensitivity• Defensive Avoidance • Impaired Self-Reference• Dissociation • Reduced Self-Awareness • Other-Directedness• Suicidality • Ideation • Tension Reducing Behaviors • Behavior• Somatic Preoccupations Tool used to identify procedural memory/ • Pain habitual trauma response patterns and event • General memory data that needs to be addressed later in therapy.
Trauma Integrated Addition TreatmentTSI-2 Codes/Questions (Briere, J. 2011)Identifying Proceduralized Trauma ResponsesAnxious Arousal (Anxiety) 1 Nervousness 0 29 Feeling afraid of certain things, even though there probably wasnt any real danger 0 57 Worrying about things more than you needed to 0 85 Your mind going over and over things that might go wrong 0 113 Feeling afraid you might die or be injured 0 Anger 3 Feeling mad or angry inside 0 31 Getting angry about something that wasnt very important 0 59 Yelling or telling people off 0 87 Thoughts or fantasies about hurting someone 0 115 Wanting to hit someone or something 0 Intrusive Experiences 4 Nightmares or bad dreams 0 32 Flashbacks (sudden memories or images of upsetting things) 0 60 Suddenly feeling like you were back in the past when something bad happened 0 88 Suddenly disturbing memories when you were not expecting them. 0 116 Memories of the past that wont go away 0 Defensive Avoidance 5 Trying to forget about a bad time in your life 0 33 Stopping yourself from thinking about the past 0 61 Trying not to have any feelings about something that once hurt you 0 89 Trying not to think or talk about things in your life that were painful 0 117 Staying away from certain people or places because they reminded you of something 0
TRAUMA INTEGRATED ADDICTION TREATMENT Working with Procedural Memory System Resourcing and other mindfulness exercises allows clients to learn that they have the ability to become reacquainted with their body and that they have some control over the ANS by learning to reduce level of stress and to remain present rather than dissociating. Over 30+ days will provide significant changes to procedural memory system. May want to begin every session with a check-in and resourcing exercise to insure that the client is able to fully engage in semantic level discussion. As we work with clients at semantic level, may want to check-in periodically to reinforce the importance of client awareness of ANS activation. Resource as needed to maximize therapy effectiveness. Stressed yes and no exercises (see Relational Abilities above) allow clients to work on relational triggers that allow the client to maintain control of ANS and reduce potential for relapse. 8
TRAUMA INTEGRATED ADDICTION TREATMENT Working with Event Memory - Containment in Primary Residential Treatment? Containment of stress related situations would be very appropriate and effective in residential treatment. Once a client can demonstrate increased skills in relational abilities, and improvement in affect regulation, it is OK to contain stressors. It is not recommended to use containment of trauma in primary residential treatment. It should be very appropriate to utilize containment in REC or other extended care programs. Client experience with resourcing, stressed yes/no, and containment of stressors in residential, should enhance opportunities for containment of trauma early in the REC process. Might want to develop a trauma specific group, to enhance utilization of CAR components.
1. ACCESSING 1. Begin by identifying at least one internal or external resource.2. DEEPENING 1. Choose one resource (either a memory or fantasy) to explore imaginally through adding details and the five senses. Stay with this until person feels relatively calm and relaxed. 2. Ask client to provide details of what they notice in their body. If client has a hard time locating body sensations, model for client: “I am noticing my hands are warm, my breathing is easy, my shoulders are a little tense.”) 3. Often need to start with basic mindfulness exercises.3. ANCHORING 1. Make a plan with client participation to find a way to remember to use the memory during the week. 2. Practice to proceduralize the resourcing process.4. WIDENING 1. Once client achieves a resourced state, ask client to remember more memories or fantasies that are positive.5. STRENGTHENING & TESTING 1. Once client has done the previous steps, you can check client’s ability to bring self from a stressed state to a resourced state. Ask client to provide details of what client notices in client’s body before and after. Feel free to practice with client a few times. 2. This can be done during a session by remembering something mildly stressful, and then having client return self to the positive memory state. (“We want to make sure that, if you are upset, you can bring yourself back into a good emotional state.”)
Working with Procedural Memory System Dialectical Behavior Therapy (Marsha Linehan, Ph.D.) Has the ability to assist clients in the semantic memory system, but most effective in procedural. At CeDAR we utilize addiction focused DBT Groups and Individual Therapy. Four Modules Mindfulness (core concept, helps individual accept and tolerate powerful emotions. Distress Tolerance (stresses learning to bear pain skillfully, acceptance of self and the current situation without judgment) Emotion Regulation (identify and label emotions, obstacles for changing emotions, reduce vulnerability to emotion, etc.) Interpersonal effectiveness (asking for what we need, saying no, coping with interpersonal conflict)
Trauma Integrated Addiction Treatment• Working with Attachment • Two new books have come out in the past year that have supported this issue. • Trauma and the Avoidant Client: Attachment-Based Strategies for Healing by R.T. Muller (2011)W.W. Norton & CO • Healing Developmental Trauma: How Early Trauma Affects Self- Regulation, Self-Image and the Capacity for Relationships. L.Heller & A LaPierre(2012) North Atlantic Books• From a trauma perspective: 1. We either never developed healthy attachment due to early childhood trauma or neglect, or 2. We developed it, but it was destroyed through other childhood trauma (ACEs), or 3. We developed it, but it was destroyed through adult trauma
Trauma Integrated Addiction Treatment Muller (2011)- Trauma and the Avoidant Client: Attachment-Based Strategies for Healing As adults, experience overwhelming attachment-related distress – profound hurt, rejection, feelings of vulnerability, etc. Resort to cutting off relationships (i.e., short term, minimal problem solving efforts) to avoid feeling Compulsive or Insistent Self-Reliance (“I don’t need anyone else!”) Devalue social relationships Focus more on personal achievements or lack of achievement Avoidance of social support – find it exceedingly hard to turn to others for assistance. May seek counseling for symptoms based reasons, but appear resistant to looking more deeply at root causes of personal problems.
TRAUMA INTEGRATED ADDICTION TREATMENT Working with Attachment in Substance Abuse Treatment (Attachment-Oriented Therapy, Flores, 2006) Flores uses model in group therapy as well as individual. Must: Build Therapeutic Relationship Challenge the Therapeutic Relationship Heal the Therapeutic Relationship. Facilitate groups that allow clients to deal with conflict and disagreement and then work through differences with counselor and/or peers. Not to say that the groups should be confrontational, but clients must be uncomfortable enough to provide them with: the opportunity to learn/practice healthy communication skills learn affect regulation find that it is possible to remain close to someone that they have had conflict with. Process and experiential groups are most helpful in this area, while psychoeducational groups are critical for semantic learning.
TRAUMA INTEGRATED ADDICTION TREATMENT Self-Help Program Participation and Memory Systems Participation in AA, NA, CA, SA, etc. is very helpful for clients in working on semantic and procedural memory systems. Self-Help program participation provides clients with significant positive cognitive information learning from the various sayings, working steps, etc. (Semantic Memory System improvement) Very helpful in recognizing a more clear recovery story. Will become more clear as they remain active in the program. Also very helpful in assisting clients to change patterned or habit based behaviors. 90 meetings in 90 days can provide significant procedural change. Getting a sponsor, making coffee, etc. can assist in development of more mature attachment and mature interdependence. Traumatized clients may resist Self-help due to lack of trust, attachment issues, etc.