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.
www.janinafisher.com
DrJJFisher@aol.com

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.
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.
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.
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.
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.
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.
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.
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.
“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.
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.
“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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
“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.
“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.
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.
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.
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.
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.
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.
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.
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.
“[The restoration of]
competence is the
single biggest issue in
trauma treatment”
Bessel van der Kolk, 2009

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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
“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.
“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.
“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.
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.
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.
For further information, please contact:
Maren Masino, M.S
Clinical Lead at Khiron House
MarenMasino@khironhouse.com
OR
Janina Fisher, Ph.D.
5665 College Avenue, Suite 220C
Oakland, California 94611
DrJJFisher@aol.com
www.janinafisher.com
Sensorimotor Psychotherapy Institute
www.sensorimotor.org