Trauma Informed Addiction Treatment and Containment and Autonomic Regulation (CAR)

1. Trauma Informed Addiction Treatment and Containment and Autonomic Regulation (CAR) Michael F. Barnes, Ph.D., LPC Clinical Specialist/Educator CeDAR

2. Getting the recovery message? Inability to manage feelings, reactivity, resentments, trust, etc. Recovery Messages Recovery Messages • The goal here is to begin a recovery process for addiction. • It is critical that you are able to hear, receive, and implement the recovery messages that you receive in therapy sessions. • Within this process it is important to recognize the role that past life experiences play in your life today! • Must deal with and actively work on trauma symptoms that will prevent you from hearing the recovery messages. • Now is not the time to work on resolving the trauma itself.

3. Trauma Informed Addiction Treatment? • We believe that addiction treatment needs to be trauma integrated, in order to assist clients with trauma history to benefit from treatment. • In early recovery (Residential Treatment), the goal is to work with trauma symptoms that interfere with a client’s ability to hear and act upon the recovery messages that they are receiving. • In later recovery, clients can begin to work on healing the actual traumatic events. • The goal is for counselors to recognize trauma symptoms, particularly activation of the autonomic nervous systemand to provide a safe therapeutic environment to work through those issues. • Addressing trauma symptoms in the present moment, prevents proceduralized avoidance behaviors from interrupting recovery focused individual and group therapy.

4. 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 • Major Illness/Hospital Events- Cancer, Heart Attacks, Asthma, Full Anesthesia Surgeries • Global Threat Events - Drowning, Electrocution, Caesarian, etc. • Cyclical Trauma – Anniversary of major traumatic event • Family Trauma/Abandonment • Captivity – Life threatening events, kidnapping, dysfunctional family life as a child, etc.

5. Traumatic Stress 101:PTSD Criterion 1 – Causes of Trauma Experience • Directpersonal experienceof an event that involves threatened death, actual or threatened serious injury, or threat to one’s physical integrity; • Orwitnessing an eventthat involves death, injury, or a threat to the physical integrity of another person; • Orlearning aboutunexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associates • Resulting in great fear, helplessness, or horror DSM IV-TR

6. Continuum of Traumatic Stress Primary Trauma (Primary Trauma Victim) Secondary Trauma (Trauma Experienced by Family Members, Friends, First-Responders, Helping Professionals, etc.) Compassion Fatigue (Trauma Experienced by Care-Givers and Helping Professionals) Secondary Trauma Burnout Organizational Trauma

7. Incidence of Traumatic Events Worldwide, it is estimated that two-thirds of the population is 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) • It’s not the trauma event that will impact recovery. • Unresolved trauma symptoms interfere with treatment and can lead to relapse.

8. PTSD & Substance Abuse Disorders • Prevalence of PTSD and Substance Use Disorders • Among persons who develop PTSD, 52% of men and 28% of womenare 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)

9. PTSD & Substance Abuse Disorders • Treatment outcomes - PTSD and SUDS • PTSD/SUDS patients are more vulnerable to poorer short- and long-term outcomes. (Ouimette, Moos, & Brown, 2003) • PTSD heightens the likelihood of addiction relapseand 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)

10. PTSD & Substance Abuse Disorders • Childhood trauma – increased symptoms in TX • 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) Childhood trauma – more severe symptoms, vulnerable to relapse 8

11. Adverse Childhood Events - ACE • ACE 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) • 35% of women had sexual abuse as children (approximately 7000 children) • 30% of men experienced physical abuse (approximately 5,225 children) • Only 32% of participants (mostly middle class, well educated) had an ACE score of 0. www.acestudy.org

12. Adverse Childhood Events - ACE www.acestudy.org Overall findings indicate that there is a linear relationship between number of adverse childhood experiences (ACE) and increased risk of: • heart disease • cancer • obesity • chronic lung disease • skeletal fractures • liver disease • Felitti, et al. (1998) reported that individuals with ACE were found to have: • 250% greater chance of smoking over children with no aces. • 500% increase in self-acknowledged alcoholism • 46 X’s greater chance for injection drug abuse. American Journal of Preventative Medicine (1998)

13. Trauma Integrated Addiction Treatment • 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 Abuse Interferes with client’s ability to hear recovery message! Often labeled client resistance. Traumatic Stress Symptoms Attachment /Differentiation • Assess clients for all three aspects of this triangle. • Critical for individualized treatment, continuing care planning, etc.

14. Attachment, Differentiation, Trauma & Substance Abuse • There has been a lot more information about the impact of attachment on substance abuse. • Early bonding with significant caregiver is essential for development of healthy communication skills and regulation of emotion and behavior. • Thorberg & Lyvers (2009) found that clients in an inpatient addiction unit scored the following: • Higher anxious attachment style • Higher fear of intimacy • Lower confidence in ability to alter negative mood.

15. Attachment, Differentiation, Trauma & Substance Abuse • PTSD is an attachment disorder? • 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: • We either never developed healthy attachment due to early childhood trauma or neglect, or • We developed it, but it was destroyed through other childhood trauma (ACEs), or • We developed it, but it was destroyed through adult trauma

16. Containment and Autonomic Regulation (CAR) Therapy - Background • 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. • Neuroscience of Memory (Grigsby & Stevens) • Neurodynamics of Personality • View of memory as a complex relationship between different memory systems. • Memory Systems: Semantic, Episodic, Procedural

17. Containment and Autonomic Regulation (CAR) Therapy - Background • 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.

18. Containment and Autonomic Regulation (CAR) • Exposure therapy focused on the autonomic nervous system • Reproducible, testable, and phase-based protocol • 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 • Attachment focused – one person’s nervous system learning to attach to another person’s nervous system • Attachment work is procedural auto-regulation • Stressed “yes” and Stressed “No” • Focus on boundary development, affect management, and ownership of the recovery process. • 3. Trauma Assessment • Assess sources of trauma and the degree of activation that the individual experiences when briefly talking about each.

19. 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 • 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?

20. MEMORY SYSTEMS (Grigsby & Stevens, 2000) • Semantic Memory System (Knowledge, tell the story, cognitive processing, often short lived and flexible) • Event Memory System(Timeless, being there, Autonomic Nervous System activation, triggers trauma symptoms and initiation of procedural response, often in the form of pictures, strong emotions) • Procedural Memory System (Adaptive and automatic memory, immediate and often unconscious, habit, hyper-vigilance, control activities, emotional reactivity) SEMANTIC EVENT PROCEDURAL Threat! Event Memory + Semantic Memory + Procedural Memory Time

21. 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 State 4: pure dissociation marked by a distinct lack of physical sensation and flat affect, numbed out, blank, feeling ‘floaty’, depersonalized, and disconnected No Solutions “Scared to death”

22. Trauma and the Autonomic Nervous System Threat, Response Options, and Procedural Memory 1 0 2 4 3 • The greater the threat, the fewer choices the individual perceives to be available to him/her. • As client experiences increased sympathetic response and dual activation, memory system response shifts from semantic to procedural. • Appears more impulsive and less strategic. • Reduced effectiveness of talk therapy. Need to resource and work on reactivity. Severe Traumatic Threats Traumatic Threats Absence of Threat Stressful Threats

23. Trauma Integrated Addiction Treatment • Staff Education • Introductory lecture on Trauma Integrated Care • Training on CAR Process • Weekly Chapter/Article Club focused on Trauma Education • Patient Education • Regular Trauma lecture • Family Education • Regular Trauma Lecture in Family Program • Focus on the impact of primary and secondary trauma • Trauma Assessment & Treatment Planning • TSI 2 • Focus on trauma symptoms awareness and implementation of trauma focused treatment to addressing active symptoms of PTSD and Attachment • DBT individual and group therapy

24. Trauma Integrated Addiction Counseling - Assessment • Trauma Symptoms Inventory – John Briere, Ph.D. • Widely-used measure of trauma related symptoms and behaviors. • High reliability and validity • Evaluates acute and chronic symptomatology. • Evaluates symptoms across the lifespan, with no links to single stressors/traumas or specific points in time. • We have used the TSI I and are in the process of transitioning to the TSI 2. • TSI 1 has 100 questions and 10 clinical scales • TSI 2 has 136 questions and 12 clinical scales and 4 factors

25. Trauma Integrated Addiction Counseling - Assessment TSI 2 Clinical Scales/Subscales • Anxious Arousal • Anxiety • Hyperarousal • Depression • Anger • Intrusive Experiences • Defensive Avoidance • Dissociation • Suicidality • Ideation • Behavior • Somatic Preoccupations • Pain • General • Sexual Disturbance • Sexual Concerns • Dysfunctional Sexual Behavior • Insecure Attachment • Relational Avoidance Rejection Sensitivity • Impaired Self-Reference • Reduced Self-Awareness • Other-Directedness • Tension Reducing Behaviors

26. Trauma Integrated Addiction CounselingUse of TSI Data in Treatment Planning

27. Trauma Integrated Addiction CounselingUse of TSI Data in Treatment Planning

28. Trauma Integrated Addiction Treatment • Safety – Treatment Environment • To create a safe treatment environment, critical that we are able to identify hyperarousal, intrusive thoughts and memories, affect disregulation, dissociation as times when traumatized clients become vulnerable and overwhelmed, recognize triggers in the treatment environment, and deal with them effectively. • Important to assist clients in making the distinction betweenfeeling safe and being safe(Gentry). • Must create a therapeutic environment where clients can shift from “unpredictable danger to reliable safety both in their environment and within themselves” (Baranowsky, Gentry & Schultz, 2011) 8

29. Trauma Integrated Addiction Treatment • Safety – Counselor Characteristics • Staff must possess a non-anxious presence and be fully aware of our own: • ANS activation • Procedural responses to stress • Countertransference • Compassion Fatigue • Must be aware that we are asking clients to break the rules of “don’t talk, don’t feel, and don’t trust.” (Black, 1981) • Pace is important. Must be aware of developmental needs of clients. • Development of positive therapeutic relationship before work on attachment • Resourcing to establish reconnection to body and new procedural responses. • Support for struggle with trauma symptoms, etc. • Be aware of the potential for re-traumatize.

30. Trauma Integrated Addiction Treatment • Working with Attachment in Substance Abuse Treatment (Attachment-Oriented Therapy, Flores, 2006) • Need to develop a solid therapeutic relationship and then be aware of rupture of that relationship (and/or others in the treatment environment). • “. . . Normal development is not the movement from dependence to independence, rather it is the movement from immature dependence to mature inter-dependenceor mutuality. (p. 15)” • Clients need to learn that they can rupture and then repair meaningful relationships through the development of new communication and affect regulation skills. • Flores uses model in group therapy as well as individual. • Not to say that the groups should be confrontational, but clients must be uncomfortable enough to provide them with: • learn affect regulation • the opportunity to learn/practice healthy communication skills • find that it is possible to remain close to someone that they have had conflict with. 8

31. 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 allow clients to work on relational triggers that allow the client to maintain control of ANS and reduce potential for relapse. 8

32. Trauma Integrated Addiction Treatment • Working with Procedural Memory System • We are very fortunate to have staff with significant experience in Dialectical Behavior Therapy. • Provides effective, evidence based therapy for co-occurring disorders • DBT has the capacity to assist clients in the semantic memory systems, but seems most effective in procedural. • Very effective in balancing behavior change, problem-solving, and emotional regulation with validation, mindfulness, and acceptance. • Need to insure that clients with attachment and trauma issues are referred to work specifically in DBT group and individual therapy. 8

33. Trauma Integrated Addiction Treatment • ANS Recalibration and 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 resource to reduce ANS activation, 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. 8

34. 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, etc. 8