Dr Debbie Ruisard DSW LCSW LCADC druisardlcswgmailcom One must not look hard to see that we are losing the battle against addiction Harvard Psychiatrist Ed ID: 689728
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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?