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In this informative talk, Maren Masinosio brings a decade of treating trauma and addiction to the cutting edge of modern clinical modalities. In sharing the methods used to recover regulation to the nervous system, she will show that such recovery assists in reducing symptoms and supporting sobriety. The Khiron House treatment model uses both Sensorimotor Psychotherapy and Janina Fisher’s Dr Fisher’s model of working with parts Trauma-Informed Stabilisation Treatment. Maren will demonstrate some of the techniques which are used to: 1. Support the client in stabilisation 2. Work on processing trauma, where appropriate 3. Integrate these changes in the body into cognitive awareness. These body-centered and neurobiological techniques provide strategies to integrate trauma treatment and addictions recovery. The audience will leave with both an understanding of the premises behind this work and some simple tools to begin to integrate into their own practice in supporting trauma and addiction.

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  1. 1. Addictive Disorders and the Traumatized Brain Presented by Maren A. Masino, M.S. Clinical Lead at Khiron House Co-Written by Janina Fisher, Ph.D.
  2. 2. What is a “trauma” ? “Psychological trauma is the unique individual experience of a [single] event, a series of events, or a set of enduring conditions, in which: •The individual’s ability to integrate his or her emotional experience is overwhelmed (i.e., the ability to stay present, understand what is happening, tolerate the feelings, or comprehend the horror), or •The individual experiences (subjectively) a threat to life, bodily integrity, or sanity.” Saakvitne et al, 2000
  3. 3. Trauma is relative: it depends upon our vulnerability Because children are so dependent on their caretakers for survival and safety, many experiences are traumatic for them that might not traumatize an adult •“Frightened and frightening” caregiving (Lyons-Ruth) •Neglect, separation, abandonment (Perry) •Exposure to domestic violence, witnessing violence •Homelessness, loss of family/home •Secondary effects of parental PTSD (Yehuda) •Accidents, medical crises, surgery, invasive procedures •Death of a parent or parent figure Fisher, 2012
  4. 4. Threat and the brain Reptilian Brain: controls our instinctive responses and functions Limbic System or ‘Emotional Brain:’ perceives and reacts to threat Frontal Cortex: analyzes, problem-solves, learns from experience Sensorimotor Psychotherapy Institute Threat Amygdala Fire Alarm and Emotional Memory Center
  5. 5. Our bodies mobilize the same defensive systems as all mammals We either cry for help We freeze and try to be invisible Or we submit in humiliation Or flee We try to fight 5
  6. 6. Children need secure attachment to develop affect regulation abilities Optimal Arousal Zone Window of Tolerance* we can tolerate our emotions we can think AND feel Sympathetic Activation Parasympathetic Activation Ogden and Minton, 2000; Fisher, 2009 A R O U S A L
  7. 7. After the trauma is over, we ‘remember’ with our bodies •Brain scan research demonstrates that traumatic memories are encoded primarily as bodily and emotional states rather than in narrative form •But, when trauma is “remembered” without words, it is not experienced as memory. These non-verbal physical and emotional memory states do not “carry with them the internal sensation that something is being recalled. . . . We act, feel, and imagine without recognition of the influence of past experience on our present reality.” (Siegel, 1999) Fisher, 2009
  8. 8. These ‘Implicit’ Memories are Experienced as: •Feelings of desperation, despair, yearning to die •Fear and terror, panic attacks, social anxiety, agoraphobia •Ashamed, depressed or submissive states: numb, spacy, paralyzed, hopeless and helpless, self-loathing •States of yearning for contact, painful loneliness, needs to be ‘desirable,’ and fear of abandonment •Behavioral responses: angry outbursts, aggressive behavior, sense of urgency to “do something,” , unbearable physiological arousal, feeling ‘driven’ to run Fisher, 2011
  9. 9. Other symptoms develop as valiant attempts to cope with the triggering • Self-injury and self-starvationto discharge tension somatically • Suicidal thoughts and impulses to “control” overwhelm by combating feelings of helplessness • High-risk behaviorto activate the adrenaline response • Re-enactment behavior,a way of remembering that keeps the event memories “in their place” • Caretaking of othersto combat a sense of worthlessness • Addictive behaviorto alter consciousness and to “treat” specific traumatic symptoms Fisher, 2004
  10. 10. “When the images and sensations of experience remain in ‘implicit-only’ form [as disconnected feelings and body responses], they remain in unassembled neural disarray, not tagged as representations derived from the past . . . Such implicit-only memories continue to shape the subjective feeling we have of our here-and-now realities, the sense of who we are moment to moment. . . .” Siegel, 2010, p. 154 Past and Present Get Hopelessly Confused
  11. 11. Triggering as an added complication •Once traumatized, the human brain obeys the “negativity biased.” It is now primed to preferentially perceive negative cues and react to them as potential threats. We call this response “triggering” or “getting triggered” •The body automatically responds to all danger signals it has known before: places, day or night, days of the week or times of year, facial expressions, smells and sounds, weather, disappointment, loss, incompetence, injustice, insensitivity •Once triggered, we are suddenly overwhelmed by feelings, sensations, and impulses—usually misinterpreted as meaning “I AM in danger,” not “I was in danger then” Fisher, 2010 11
  12. 12. “When neither resistance nor escape is possible, the human system of self-defense becomes overwhelmed and disorganized. Each component of the ordinary response to danger, having lost its utility, tends to persist in an altered and exaggerated state long after the actual danger is over.” Herman, 1992 12
  13. 13. Nervous System Adapts to a Threatening World “Window of Tolerance”* Optimal Arousal Zone Hyperarousal-Related Symptoms: Fight/Flight Impulsivity, risk-taking, poor judgment Chronic hypervigilance, anxiety, ruminations and compulsions Intrusive emotions, flashbacks, nightmares, racing thoughts Compulsive behavior: addiction, self-harm, suicidality Hypo arousal-Related Symptoms: Submit Flat affect, numb, feel dead or empty, “not there” Cognitively dissociated, slowed thinking Cognitive schemas focused on hopelessness Disabled defensive responses, victim identity Sympathetic Arousal Parasympathetic Arousal *Siegel (1999) Sensorimotor Psychotherapy Institute
  14. 14. Addictive and self-destructive behavior as survival strategies •When caregivers fail to soothe or actively dysregulate, children must rely on their bodies to regulate arousal •In infancy, disconnection and dissociation are the only options available. In the preschool years, food and masturbation are the “drugs” to which they have access •In the latency years, more options open up: hurting themselves, accident-proneness, daydreaming, running away, suicidal behavior, aggression toward other children •Adolescents have increasing access to substances; eating disorders become a socially-accepted option; suicidal behavior can be more life-threatening Fisher, 2013
  15. 15. How Substances “Medicate” PTSD Hyperarousal symptoms: •Alcohol and marijuana induce relaxation and numbing, facilitate social engagement by decreasing hypervigilance, and allow sleep. Cocaine, speed, and crystal meth counteract relaxation effects or maintain hypervigilance. Heroin dampens rage and impulsivity, while ecstasy combines relaxation with increased energy Fisher, 2003 Hypo arousal symptoms: •Speed, cocaine, ecstasy and crystal meth counteract feelings of “deadness,” numbing, hopelessness and helplessness, while marijuana and other downers maintain the hypo arousal. Alcohol, at different “dosages,” can induce numbing or counteract it. Although a depressant, alcohol in small doses has a stimulating effect
  16. 16. Compulsivity and Trauma Thus, addictive and self-destructive behavior arise not as pleasure- or punishment-seeking strategies but as a survival strategy: •To self-soothe and self-regulate •To numb the hyperarousal symptoms: intolerable affects, reactivity, impulsivity, obsessive thinking •To “treat” hypo arousal symptoms of depression, emptiness, numbness, deadening •To combat helplessness by increasing feelings of control, to combat loneliness through ‘safe’connection •As a way to function or to feel safer in the world Fisher, 2011
  17. 17. An Integrated Trauma and Addictions Treatment Model •Addictive disorders begin as a survival strategy in the absence of safety, secure attachment, and healthy self- regulation. Their purpose initially is to regulate autonomic arousal and overwhelming emotion by manipulating the nervous system, creating a false Window of Tolerance. •The high risk results from the fact that compulsive behavior requires continual increases in “dosage” to maintain its effectiveness: eventually, the addiction becomes more dangerous than the symptoms it is regulating •But it doesn’t feel that way: the survivor is more afraid of the sensations and feelings than the addiction Fisher, 2014
  18. 18. Core Assumptions of an Integrated Model, continued •Sobriety or abstinence only address the addictions issues. When behavior has been a post-traumatic survival strategy, new challenges now arise . . . •The client now faces not only the risk of relapse but the risk of post-traumatic flooding, autonomic dysregulation, increased impulsivity, overwhelming emotions, and flashbacks, all of which predispose the client to relapse • Treatment must address the relationship between the trauma and the addictive behavior: the role of the addictive behavior in “medicating” traumatic activation, the origins of both in the traumatic past, and the reality that recovering from either requires recovering from both Fisher, 2007
  19. 19. Unfortunately, sobriety brings more challenges, not fewer Window of Tolerance in sobriety Hyperarousal: over-activation creates chronic de-stabilization and desperate craving for relief Hypo arousal: numbing, ‘deadness’ and passivity contribute to need for substances to either shift or maintain this state Sensorimotor Psychotherapy Institute The addiction has facilitated a “false Window of Tolerance:” the client is missing any other way to self-regulate
  20. 20. Abstinence/Relapse Cycle loss of “chemical support” Increase in PTSD symptoms intrusive memories, affective overwhelm, irritability, reactivity Relapse behavior restores equilibrium panicked attempt at self-regulation Increase in acting out impulses or behavior matches increase in PTSD symptoms Negative consequences of relapse increase over time increased negative effects of eating disorder Fisher, 2011 Abstinence
  21. 21. To address addictive tendencies, the Window of Tolerance must expand Original Window of Tolerance Hyperarousal: over-activation creates chronic de-stabilization and desperate craving for relief Hypo arousal: numbing, ‘deadness’ and passivity contribute to need for addictive behavior to either shift or maintain this state Ogden and Minton (2000) Expanded Window of Tolerance Sensorimotor Psychotherapy Institute
  22. 22. “In order for the amygdala to respond to fear reactions, the prefrontal region has to be shut down. . . . [Treatment] of pathologic fear may require that the patient learn to increase activity in the prefrontal region so that the amygdala is less free to express fear.” LeDoux, 2003 Frontal Lobe Inhibition Must Be Reversed
  23. 23. “First Things First” Increasing the ability to be mindful rather than judgmental: “wake up” the frontal lobes, increase self- awareness, observe patterns that “feed” addictive behavior Building curiosity: since curiosity regulates the nervous system, it lessens needs to act out Focusing on the relationship between trauma-related responses and compulsive behavior: learning to observe overwhelming feelings and impulses, notice relationships between triggers, symptoms, and addictive behavior Using right brain techniques to externalize or “see” heightens concentration, increasing left brain functioning Fisher, 2013
  24. 24. Experiment with Evoking Curiosity •Rather than analyze or confront inappropriate behavior, experiment with maintaining a curious, neutral stance: hearing the distorted beliefs as “just thoughts,” the intense emotions as “just feelings,” the impulsive actions as “just actions.” We cultivate awareness: we make it safe to be curious about impulsive behavior instead of triggering automatic defensive or submissive responses •Use a tone of curiosity to help the patient describe the sequence of what happened: “Wow! Something must have triggered you. . . . And then what happened next? You were so committed to staying safe, I know. Were you aware of24
  25. 25. Re-framing Addictive Symptoms •Heighten the client’s curiosity about the role of addiction in his or her survival: what was the timing of the initial attraction to drugs? How did the sex addict part help her to cope? How did later stressors impact addictive behavior? •Re-frame the history by assuming that the addiction had meaning and purpose: “How did the addiction help you to be less afraid? Able to go to work? Or go to sleep? To handle being around people? To act like everything was normal?” •Re-frame the relationship between PTSD and addictive behavior: “The cocaine helped you to feel less numb, didn’t it?” “So, you drank in order to sleep at night—that makes sense—you can’t sleep, but you can pass out,” “It makes sense that you needed the speed to be hypervigilant enough to go out”
  26. 26. Sensorimotor Psychotherapy •Sensorimotor Psychotherapy is a body-oriented talking therapy developed in the 1980s by Pat Ogden, Ph.D. and enriched by contributions from Alan Schore, Bessel van der Kolk, Daniel Siegel, Onno van der Hart, Ellert Nijenhuis, and Kathy Steele. •Sensorimotor work combines traditional talking therapy with body-centered interventions that directly address the somatic legacy of trauma. •By using the narrative only to evoke the trauma-related bodily experience, we attend first to resolving how the body has “remembered” the trauma Ogden, 2002; Fisher, 2006 Sensorimotor Psychotherapy Institute
  27. 27. Old responses are challenged using mindfulness rather than insight “Where attention goes, neural firing goes. And where neurons fire, new connections can be made.” Siegel, 2006
  28. 28. Therapy must deliberately challenge, rather than reinforce, conditioned patterns of response To challenge the patterns without further dysregulating the client, the therapist uses two interventions: •”The first is to …observe, rather than interpret, what takes place, and repeatedly call attention to it. This in itself tends to disrupt the automaticity with which procedural learning ordinarily is expressed.” •”The second therapeutic tactic is to engage in activities that directly disrupt what has been procedurally learned” and create the opportunity for new experiences (Grigsby & Stevens, p. 325) Sensorimotor Psychotherapy Institute
  29. 29. The Language of Mindfulness • “Notice what just happened right now . . .” • “Let us be curious about that. . . “ • “What happens inside you when you remember that?” • “Notice the sequence: you were home alone, then you started to get agitated and feel trapped, and then you just had to get out of the house. How could you tell you needed to leave?” • “As you say those words, notice what part of you is speaking . . . The addict or the wise mind?” Fisher, 2014
  30. 30. Intervening with Mindful Curiosity •When faced with the client’s imminent or long-term threats to health and safety, the therapist often feels pressure to DO something. However, that urgency can dysregulate the client. We can accomplish the same purpose by increasing curiosity: •“Notice what happens if we assume that the urge to use belongs to just one part of you . . . is that better or worse?” •“Let’s be curious about what triggered these intense impulses to kill yourself? Think back to yesterday . . .” •“Notice on the arousal chart where you were when you had the overwhelming urge to drink. . . And then how did having those beers change your activation?” Fisher, 2013
  31. 31. “[The restoration of] competence is the single biggest issue in trauma treatment” Bessel van der Kolk, 2009
  32. 32. Sensorimotor Psychotherapy Institute Teaching the Skills to Regulate Arousal Within the Window of Tolerance Hyperarousal Hypo arousal Ogden 2006; Fisher, 2009 •Psychoeducation •Curiosity •Reframing •Mindfulness •Differentiating body, thoughts, feelings •Identifying triggers •Tracking patterns •Breathing or sighing •DBT skills •Somatic skills Notice the triggering Interventions Then regulate the arousal
  33. 33. Experimenting with Somatic Resources for Traumatic Reactions Resources: Slowing the pace Sighing, deep breath Lengthening the spine Hand over the heart (pressure for 3 second intervals) Grounding with the feet Clenching/relaxing Movement Traumatic Reactions: Shaking, trembling Numbing Muscular hypervigilance Accelerated heart rate Collapse Impulses to hurt the body Numbing, disconnection Ogden, 2000Sensorimotor Psychotherapy Institute
  34. 34. Right and Left Brains Hold Different Aspects of Experience “[Traumatic] memories are recorded in the right hemisphere outside of conscious awareness, and this realm represents the traumatic memories in imagistic form along with the survival behavior employed as a result of the abuse. The [two] cortical hemispheres contain two different types of representational processes and separable, dissociable memory systems, and this allows for the fact that [the] emotional learning of the right [hemisphere], especially of stressful, threatening experiences, can be unknown to the left [hemisphere].” Schore, 2001
  35. 35. Primary Dissociation: a single incident trauma Pre-traumatic Personality Apparently Normal Part of the Personality Emotional Part of the Personality A split now occurs between the Left Brain part of the Self that “carries on” with normal life and adaptation during and after the trauma And the part of the Self that holds the body and emotional memories of what happened and the survival responses needed to survive it Van der Hart, Nijenhuis & Steele, 2006 At whatever age we are traumatized, we have a pre-traumatic personality that begins undividedTrauma
  36. 36. Client-Friendly Language Pre-traumatic Personality “Going On with Normal Life” Part of the Personality Traumatized Part of the Personality This Left Brain part of the self “carries on” with normal life and adaptation during and after the trauma This Right Brain part of self holds both the traumatic memories and the survival responses employed Van der Hart, Nijenhuis & Steele, 1999
  37. 37. Secondary Dissociation: Complex PTSD, BPD, Bipolar, DDNOS Emotional Part of the Personality Apparently Normal Part of the Personality Fight EP Flight EP Freeze EP Submit EP Attachment Cry EP Van der Hart, Nijenhuis & Steele, 2006 The Emotional Part of the Personality becomes more split and compartmentalized: separate subparts evolve reflecting the different survival strategies needed in a dangerous world
  38. 38. Each part of the personality contributes a defensive strategy Emotional Part of the Personality “Going on with Normal Life” Part Fight: Protector Flight: Distancer Freeze: Terrified Submit: Ashamed Attach: Needy Fight is the hypervigilant bodyguard, holding ‘the suicide card’ if drugs don’t work Flight comes to the rescue by using addictive behavior to get quick relief, to ‘turn off’ the body The terrified Freeze EP triggers other parts to respond with alarm Shame, self- loathing, and passivity of Submit feeds helplessness, hopelessness The Attach part uses vulnerability and desperate help- seeking to get protection Van der Hart, Nijenhuis & Steele, 2006; Fisher, 2009 “I can’t afford to feel overwhelmed. I have to function!”
  39. 39. The parts are experienced as: •Loss of ability to communicate: client becomes mute, shut down, unwilling to speak, can’t find words •Voices: usually shaming, punitive, controlling •Constriction: withdrawal, social isolation, agoraphobia •Regressive behavior: loss of ability for well-learned skills, personal hygiene, ADLs, social engagement •Increasing preoccupation with helpers: the only safe/unsafe place becomes the office/hospital/house •Alternating dependence and counter dependence •Unchecked self-harm, suicidality and addictive behavior Fisher, 2014
  40. 40. Evolutionary-Determined Internal Tensions What threatens stability is not the compartmentalization or the disorder: it is the conflict between competing survival responses:  Trusting the therapist competes with impulses to flee or resist the treatment  “Submission” (for example, willingness to work with the therapist) is in conflict with fighting for control  Going on with normal life and putting the past behind competes with hypervigilance and mistrust  Wanting to be sober and stable competes with impulses to get immediate “fast and dirty” relief Fisher, 2018
  41. 41. Establishing Mindfulness of Parts •Helping the client to notice the addictive behavior as that of a part, not the whole of the client •Cultivating curiosity: “Which part smokes marijuana? Which part takes opiates?” “How is that part trying to help?” “What is the addict part trying to prevent or trying to accomplish? •Noticing addictive behavior as a part trying to help other parts: “I see . . . So when the little part of you is crying and crying, the addict part sedates her so she stops crying. . .” •Noticing inner chaos and overwhelm as parts: “Notice the struggle that’s going on inside you. . .” “I’m noticing that a part of you wants to go forward, and another part just wants to keep using to get that instant relief.” Fisher, 2011
  42. 42. “Speaking the Language” of Parts • Use of the “language of parts” facilitates mindfulness and increases awareness of their internal struggles • “The language of parts” decreases over-identification with symptomatic parts: when the client says, “I want to die,” the therapist responds, “So there is a part of you that wants to die—hmmm. . . I wonder what triggered that part?” When the client says, “It’s just hopeless,” we re-frame, “Is that the same part or a different part?” • “Relentless reframing” of traumatic responses as “parts” helps to inhibit self-destructive impulses and cultivates the ability to notice overwhelming affects or impulses, rather than being overwhelmed by them Fisher, 2015
  43. 43. “Which one of the many people who I am, the many inner voices inside of me, will dominate [today]? Who, or how, will I be? Which part of me will decide?” Hofstadter, 1986 We use parts language to bring the clients attention to the following question:
  44. 44. “Integration requires both differentiation and linkage”[Siegel, 2010] •We cannot integrate aspects of ourselves that we have not acknowledged and “owned” as part of “me” •Approaches in which the fragmented client is treated “as if” s/he were one integrated person always fail. •The parts must first be noticed and identified, then linked so they become essential aspects of one system that is adaptive and “flows.” As Siegel (2010) says, “Failure of integration leads to chaos, rigidity or both.” Fisher, 2010
  45. 45. Most common mistakes made by therapists in working with addictive behavior •Failing to validate the relief offered by addictive behavior •Failing to understand the fear of relying on people rather than relying on a substance or behavior under your own control •Failing to see that one’s life and body are not a priority: when your life doesn’t matter or your body only matters as a vehicle for others to discharge tension, its care becomes meaningless •Failing to understand trauma-related shame and secrecy: lies feel “safe and normal” and disclosure “unsafe” •Becoming engaged in a struggle in which the therapist becomes the spokesperson in favor of sobriety and the client the spokesperson in favor of using, neglecting the task of helping clients resolve their own internal wars and struggles Copyright 2006 Janina Fisher, PhD
  46. 46. The Guest House This being human is a guest house. Every morning a new arrival. A joy, a depression, a meanness, some momentary awareness comes as an unexpected visitor. Welcome and entertain them all! Even if they are a crowd of sorrows, who violently sweep your house empty of its furniture, still, treat each guest honourably. He may be clearing you out for some new delight. The dark thought, the shame, the malice, meet them at the door laughing and invite them in. Be grateful for whatever comes. because each has been sent as a guide from beyond. — Jellaludin Rumi, translation by Coleman Barks
  47. 47. For further information, please contact: Maren Masino, M.S Clinical Lead at Khiron House OR Janina Fisher, Ph.D. 5665 College Avenue, Suite 220C Oakland, California 94611 Sensorimotor Psychotherapy Institute