T hrough a Trauma Informed Lens: Rethinking Addiction Treatment - PowerPoint Presentation

Slide1

Through a Trauma Informed Lens: Rethinking Addiction Treatment

Dr

. Debbie

Ruisard

, DSW

LCSW, LCADC

druisardlcsw@gmail.comSlide2

“

One must not look hard to see that we

are losing

the

battle

against addiction”

Harvard

Psychiatrist, Ed

Khantzian

, 2013Slide3

V

arious studies have reported any where from 40% - 90% relapse rate in individuals with addictive disorders after completing treatment.Slide4

Questions that I have attempted to answer in my work

What is it about the individual that impacts their response to treatment interventions?

How can we intervene in a way that honors individual differences and avoids the “one size fits all” approach to addiction treatment?Slide5

DISEASE MODEL OF ADDICTION“Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain; they change the structure and how it works.”

(

National Institute on Drug Abuse)Slide6

NIDA and the Disease Model1994 Allen Leshner

: “That addiction is tied to changes in brain structure is what makes it, fundamentally, a brain disease”

2015 Nora

Volkow

: “It is a disease in which essential motivational and self-control symptoms of the brain are compromise”

Current discourse – is it a disease or not?Slide7

Benefits of the Disease Model

Counteracts the moral model that blames people for their bad behaviors

Reduces stigma

Leads to treatment rather than punishment

More funding for research; gets attention from Congress

Locating addiction in the brain leads to new medications that target brain functioning to help people to recover

Chronic nature of the disease puts relapse into perspective –relapse is a part of the recovery processSlide8

Drawbacks of the Disease ModelOffers false hope that there is a medical cure for addiction

Has not shown to reduce stigma

Government funding primarily supports disease model research

Based on the fact that drugs are inherently addicting (which has been disproven by research)

It does not adequately account for the reality that most people use substances to numb emotional pain or cope with difficult environmentsSlide9

Has anything changed?“The very nature of addiction challenges society’s deeply held preconceptions about willpower and self control…Addiction is not a moral failing; it is a disease in which essential motivational and self-control systems of the brain are compromised.”

Nora

Volkow

National Council Magazine, 2015Slide10

Is this really the only view of addiction that fits our clients?Slide11

Trauma and addiction

I approach the connection between these two human experiences through the lens of a trauma professional, not an addiction

professional

.Slide12

Adverse Childhood Experiences

ACEs:

Recurrent

and severe physical abuse (11%)

Recurrent and severe emotional abuse (11%)

Contact sexual abuse (22%)

Growing up with alcoholic or drug user (24%)

Growing up with a family member in prison (3%)

Growing up with a family member with mental illness (19%)

Growing up seeing your mother being treated violently (12%)

Growing up with both parents not being present (22%)Slide13

ACES and Addiction

Women were 50% more likely than men to have experienced 5 or more adverse childhood experiences

The higher the ACE score, the higher the chances of addiction to alcohol and other drugs in adulthood

4 or more ACEs = 500% increase in risk for adult alcoholism

Men with 6

or more ACE’s = 4600% increase in risk for IV drug

use

78% of IV drug use in women can be attributed to adverse childhood experiencesSlide14

Maybe its not about the drug“

…

Our findings are disturbing to some because they imply that the basic causes of addiction lie within us and the way we treat each other, not in drug dealers and dangerous chemicals. They suggest that billions of dollars have been spent everywhere except where the answer is to be found.

Vince

Felliti

, 2004Slide15

Dr. Gabor MateSlide16

Expanding definition of traumaPTSDComplex Trauma

Attachment TraumaSlide17

PTSDPTSD – first officially recognized in the mid-1980s due to the data gathered by the National Vietnam Veterans Re-adjustment Study

Classified as an anxiety disorder in the

DSM-III, DSM-IV and DSM IV-R.

Finally in the DSM 5 it was moved out of the anxiety chapter and into a new chapter “Trauma and Stressor-related Disorders”

This move is seen as controversial by researchers who see that adding symptoms, broadening the construct of PTSD and moving away from fear conditioning and extinction models will set the field back Slide18

Complex TraumaJudith Herman was the first person to acknowledge another view of psychological trauma that did not conform to the framework of PTSD – that which was seen in people who suffered considerable domestic violence, child physical and sexual abuse and neglect and who were given diagnoses of various personality disorders (Trauma and Recovery, 1992)

She called it “complex trauma”Slide19

Complex TraumaDomains of Impairment

Attachment

Affect Regulation

Behavioral

control

Biology

Dissociation

Cognition

Self-conceptSlide20

Attachment TraumaChildren have a biological instinct to attach

Attachment provides a secure base

We learn how to modulate our affective states through the attachment relationship with our primary caregiver

An impaired or absent caregiver does not provide a secure base for secure attachment to develop

Insecure attachment patterns leave children with no skills to self regulate

Insecurely attached children grow up to be insecurely attached adults

Attachment in Psychotherapy DavidSlide21

Addiction as an attachment disorderResearch demonstrates the prevalence of insecure attachments in adults with substance use disorders

(Parolin &

Simonelli

, 2016)

“Attachment theory looks at addiction as both a consequence and a failed solution to an impaired ability to form healthy emotionally regulatory relationships…the underlying driving force behind all compulsive/addictive behavior is related to an inability to manage relationships” (Flores, 2006, p. 6)

The vulnerable individual’s attachment to chemicals serves both as an obstacle and as a substitute for interpersonal relationships.Slide22

The impact of traumaIn the moment of trauma, the body goes into fight or flight mode. The prefrontal cortex shuts down and the limbic brain takes over.

This loss of executive function is a protective

response because cognition is too slow.

When re-traumatized, the brain responds in the same way: the

cognitive brain deactivates and the

emotional/instinctual

brain acts as if the traumatic event is happening in the present –

the person become

furious, terrified, enraged, ashamed or frozen.Slide23

Addiction Treatment Can be Re-Traumatizing

Concept of powerlessness

Absolute authority of the counselor

Confrontation tactics

Shaming practices

Focus on ‘character defects’

“Addicts can’t be trusted to tell the truth”

Discharges for “non-compliance”

Punishing aggression

No choices

Withholding medication-assisted treatmentSlide24

Trauma Informed TreatmentWhat does it look like?

It requires a paradigm shift away from a traditional approach to addiction treatment toward one that seeks to reflect the principles of trauma informed careSlide25

Punishment Safety

Distrust

Trust

Confrontation

Collaboration

Authoritative

Choice

and

Treatment

Empowerment

Compliance

TransformationSlide26

12 STEP COMMUNITY12 Step program is a valuable community support and an adjunct to evidence based treatments

This relationship-based self-help program of recovery can be both healing and triggering to a traumatized individual

Unwillingness to participate

may not be resistance

or denial, but

a

common and expected reaction of someone who has experienced trauma in relationships

Relationships are dangerous, and yet what is damaged in relationships can only be healed in relationships

Judith HermanSlide27

So What Does This Mean?

It is no longer adequate to treat addiction

as a primary and singular disorder

It is important to critically examine how we do addiction treatment today and be willing to change our practices so that we are responsive to the trauma our clients have experienced

Trauma informed treatment and trauma specific interventions must become

an integral part

of

substance

abuse treatment

Even clients who do not have a significant trauma history will respond positively to a trauma informed approachSlide28

Rethink addiction treatmentFor many individuals, addictive behaviors are an adaptation to traumatic experiencesThe disease model has its usefulness but the risk is that we seek only to intervene through the brain and ignore the body (mind body connection

)

We need to re-focus our treatment to start from the bottom-upSlide29

The focus of trauma treatmentCognitionEmotion

BodySlide30

Working with CognitionsTop Down -

works with cognitions

Psychotherapy (talk therapy

)

Psychoeducation

CBT

Mindfulness

Many

addiction treatment

strategies are

cognitive

based

What we now know about trauma indicates that this may not be an effective way to treat traumatized

individualsSlide31

Working with EmotionsUntil someone is able to establish personal emotional safety, they will be unable to process traumatic experiences

Emotional regulation skills must be mastered first

We are emotional regulatorsSlide32

Trauma is stored in the bodyAll trauma is preverbal; the traumatized body re-experiences terror, rage and helplessness, but these feelings are almost impossible to articulate

Survivors develop “cover stories” to explain their symptoms and behaviors; these stories rarely capture the inner truth of the experience

The experience of trauma shows up in instinctual responses such as fight, flight, freeze, submit and attach

Vander

kolk

, 2014Slide33

Working with the bodyMay be necessary to start from the bottom up, with

the body

Breath, movement,

touch, rhythm, synchronicity

Movement oriented activities should move from the adjunctive therapy list to the primary therapy list

Sensorimotor approaches

Once the body settles, then we can begin to work through the emotional and the cognitive modalities to heal traumaSlide34

Body based interventionsYoga, Art, Music,

Movement

Drumming

Sound Healing

EMDR, Brain Spotting, Theatre,

Improv

, Psychodrama

Sensorimotor techniques

SMART

Sensori

motor psychotherapy; Somatic Re-experiencing

NeurofeedbackSlide35

What do you think?

C

an we

change

how we do addiction

treatment?