Melinda English Kantor MA lpc ncc

1. SUBSTANCE DEPENDENCE TRAUMA EMDR (EYE MOVEMENT DESENTIZITATION REPROCESSING) Melinda English Kantor MA lpc ncc How trauma influences the use of substances and using EMDR as an effective treatment

2. introduction • Facilitator • My interest in the subject • Audience • Areas of interest and influence • Objectives • Mine and ours

3. The goal for the client ASSISTING OUR CLIENTS TO MENTAL HEALTH AND HIGH FUNCTIONING What is mental health? • The ability to emotionally regulate • Ability to effectively express themselves • Description of reasonably sense of inner contentment • What does it mean to function highly? • Social • Family • Faith – Community • Fun • Productivity • Work • Responsibility • Health • Seek fulfillment of potential

4. The goal for treatment • Explore and resolve issues relating to history of abuse/neglect victimization • Explore and resolve grief and loss issues • Provide relapse prevention and other tools for release of drug/alcohol use/dependence • Increase and practice ability to manage emotions • Develop strategies to reduce symptoms, or reduce anxiety and improve coping skills • Improve overall behavior (and attitude/mood), or maintain positive behavior (and attitude/mood) • Learn and use effective communication strategies • Improve decision making skills • Increase authenticity • Improve overall mood • Learn and use conflict resolution skills • Explore, resolve and reframe issues related to self image • Address distorted thoughts or thinking errors • Provide tools and skills to tolerate tragedy and negative life experiences

5. Statistics on substance dependence related to trauma • 34.5% of men who had PTSD at some point in their lifetime also had a problem with drug abuse or dependence • 26.9% of women who had PTSD at some point in their lifetime also had a problem with drug abuse or dependence • 51.9% of men with a history of PTSD reported alcohol dependence and classified as alcoholics • 27.9% of women with a history of PTSD reported problems with alcohol abuse or dependence • One-third to two-thirds of child maltreatment cases involve substance use to some degree. 11 • As many as two-thirds of the people in treatment for drug abuse reported being abused or neglected as children. 9 • More than a third of adolescents with a report of abuse or neglect will have a substance use disorder before their 18th birthday, three times as likely as those without a report of abuse or neglect.12 Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060. Office on Child Abuse and Neglect, Children's Bureau. Goldman, J., Salus, M. K., Wolcott, D., Kennedy, K. Y. (2003) A Coordinated Response to Child Abuse and Neglect: The Foundation for Practice, Chapter 5, retrieved from: https://www.childwelfare.gov/pubs/usermanuals/foundation/foundatione.cfm Wilson, E., Dolan, M., Smith, K., Casanueva, C., & Ringeisen, H. (2012). NSCAW Child Well-Being Spotlight: Adolescents with a History of Maltreatment Have Unique Service Needs That May Affect Their Transition to Adulthood. OPRE Report #2012-49, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. Retrieved from:http://www.acf.hhs.gov/sites/default/files/opre/youth_spotlight_v7.pdf

6. TRAUMA DEFINED • WHAT IS TRAUMA? • APA definition • Trauma is an emotional response to a terrible event like an accident, rape or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships and even physical symptoms like headaches or nausea. While these feelings are normal, some people have difficulty moving on with their lives.

7. Trauma defined • WHAT IS TRAUMA? • SAMHSA Description • Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being.

8. Trauma defined • WHAT IS TRAUMA? • DSM V Criteria The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: • Direct exposure • Witnessing, in person • Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental. • Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies or pictures.

9. Post traumatic stress disorder (PTSD) SEE SUPPLEMENTAL DOCUMENTS

10. NOT JUST DIAGNOSED TRAUMA • CHILDHOOD MALTREATMENT DEFINED • Childhood maltreatment includes all intentional and unintentional harm to, or avoidable endangerment of anyone under age 18 (Berger 2005). This definition includes emotional neglect, and physical, sexual and emotional/ verbal abuse. Neglect as a form of child maltreatment occurs when the caregivers fail to meet a child’s basic needs, including stimulation an education. Abuse includes all actions that are harmful to a child’s well being, whether deliberately inflicted or not. The victim does not have to be directly affected; witnessing abuse is just as life changing if not more so (Perry, 2002).

11. GETTING TO KNOW DE • VIDEO

12. TRAUMA IMPACT • EMOTIONAL DISREGULATION • ILLUSION BROKEN • SENSE OF SAFETY DAMAGED OR DESTROYED • SENSE OF CONTROL DAMAGED OR DESTROYED • FLASHBACKS • MEMORY LOSS • CONTINUOUS RACING THOUGHTS • SELF BLAME AND SHAME • DISSOCIATION • BRAIN RE-WIRING • DISTORTED VIEW

13. The brain is the key • PREDISPOSITION • GENETIC • ENVIRONMENTAL INFLUENCE ON THE BRAIN • FAMILY OF ORIGIN – CULTURAL • EVENTS AND IMPACT • NEUROPLASTICITY – CHEMICALS AND CONNECTIONS • RESOLVING IN THE BRAIN • NEUROPLASTICITY – RESTORING EQUILIBRIUM

14. TRAUMA IMPACT The brain A BASIC BRAIN EDUCATON IS AN ADVANTAGE • HUMAN THREE BRAIN SYSTEM • BEGINS WITH THE REPTILIAN BRAIN • PERFORMS THE BASIC FUNCTIONS OF LIFE • HUNGER, BREATHING, SEXUAL DRIVES ETC • INCLUDES MID BRAIN, PONS AND MEDULA (BRAIN STEM) • PART OF THE FLIGHT, FIGHT AND FREEZE SYSTEM

15. TRAUMA IMPACT The brain • LIMBIC SYSTEM or MID BRAIN • AMYGDALA or ALARM CENTER

16. TRAUMA IMPACT The brain • PREFRONTAL CORTEX • THINKING BRAIN or CORTEX

17. TRAUMA IMPACTTHE BRAIN • STRESS RESPONSES – 4-WAY IMPACT • NEUROCHEMICALS • HYPOTHALMIC-PITUITARY-ADRENAL AXIS (PATHWAY) • AMYGDALA (SCANNER) • HIPPOCAMPUS (CONSOLIDATES AND CATEGORIZES MEMORY)

18. TRAUMA IMPACT The brain • STRESS RESPONSES - NEUROCHEMICALS • EPINEPHRINE • FAST, EFFICIENT, SHORT LASTING • NOREPINEPHRINE • NARROWS ATTENTION FOR FOCUS • CORTISOL • SLOWER AND REMAINS IN THE BLOOD STREAM LONGER [IN TRAUMA GOES AWRY] LONG TERM EXISTENCE BURNS SYNAPTIC CONNECTIONS BETWEEN BRAINS CONNECTIONS AND HEMISPHERES

19. TRAUMA IMPACT The brain • HYPOTHALMIC-PITUITARY-ADRENAL AXIS • FEEDBACK LOOP IN THE BRAIN • INFORMS THE BODY WHEN THE DANGER IS OVER • CORTISOL REACHES A CERTAIN LEVEL AND OPERATES AS A MESSAGE INDICATOR (PITUITARY-ADRENAL) • WHEN THIS MESSAGE CENTER DOES NOT OPERATE WELL AS IN TRAUMA A REDUCTION IN THREE BRAIN COMMUNCATION AND HEMISPHERE RESULTS. • SIGNIFICANT HEALTH ISSUES RESULT AS WELL

20. TRAUMA IMPACT The brain • LIMBIC SYSTEM/AMYGDALA GATEWAY (EMOTIONAL) • REPEATED STRESS INCREASES SENSITIVITY • CREATING CONDITIONING FOR KINDLING • KINDLING EVENTUALLY CREATES A FIRE • LATER A SMALL SPARK SETS NEURONS FIRING AT THE RATE SIMILAR TO THE ORIGINAL EVENT • FROM CHILD MALTREATMENT THERE IS A %100 INCREASE IN NEURONS FIRING THAN IN THE AVERAGE PERSON Whitsett, D., & Kent, S. (2003). Cults and families. Families in Society, 84(4), 1-11.

21. TRAUMA IMPACTTHE BRAIN • HIPPOCAMPUS • CONSOLIDATES AND CATEGORIZES MEMORY • USES EXPLICIT SYMBOLS – LANGUAGE AND SYMBOLS • IN TRAUMA THE HIPPOCAMPUS IS INHIBITED FROM FUNCTIONING • TRAUMA ACTIVATES THE LIMBIC STRESS CHEMICAL RESPONSES WHICH CIRCUMVENTS THE HIGHER END PROCESS • THEREFORE THE TRAUMA REMAINS STORED IN THE IMPLICIT SYSTEM • PERCEPTUAL, BEHAVIORIAL, AND EMOTIONAL VERSUS RATIONAL

22. TRAUMA IMPACT The brain • IMPLICIT VERSUS EXPLICIT BRAIN FUNCTION • LIMBIC AND RIGHT SIDED BRAIN • PRE-LANGUAGE AND SYMBOLS • DOMINATES UP TO AGE FOUR • LEFT SIDED BRAIN • EXPLICIT, DECLARARITIVE, AND CONSCIOUS BRAIN • DOMINATES FROM AROUND AGE FOUR

23. Trauma impactThe brain • THE CONNECTION • INFORMATION PROCESSING • NORMAL OPERATION • PRIMITIVE “LOW ROAD” BRAIN (FIGHT, FLIGHT OR FREEZE) • EARLY YEARS • FASTER – ONE SYNAPSE • EVOLVED “HIGH ROAD” BRAIN (RATIONAL) • LATER YEARS • SLOWER – SEVEN SYNAPSES • MORE DETAILED PRE-FRONTAL CORTEX • WHAT HAPPENS IN TRAUMA • THE AMYGDALA SCANS DATA FOR DANGER BASED ON HISTORY • THIS HAPPENS BEFORE THE PRE-FRONTAL CORTEX CAN ENGAGE AND REALITY TEST

24. TRAUMA IMPACTTHE BRAIN • SO, IN SUMMARY IN TRAUMA • THE SYNAPTIC CONNECTIONS THAT ALLOWS A GREATER PATHWAY BETWEEN THE TWO BRAINS AND THE TWO HEMISPHERES ARE BURNED AWAY BY NEUROCHEMICALS • THE PATHWAY VIA THE NORMAL FEEDBACK LOOP HYPOTHALMIC-PITUITARY-ADRENAL AXIS IS INTERUPTED AND THE INFORMATION TAKES THE FASTER “LOW ROAD” PRIMITIVE ROAD (FIGHT, FLIGHT OR FREEZE), BYPASSING THE LEFT BRAIN ANALYSIS. • THE AMYGDALA IS SENSITIZED TO DATA THAT SETS OFF THE BRAINS DANGER SIGNALS. • THEREFORE, THE HIPPOCAMPUS IS CIRCUMVENTED ANDDOES NOT HAVE THE OPPORTUNITY TO CONSOLIDATE AND CATEGORIZE THE INFORMATION. WHEN STORED PROPERLY THE EMOTIONAL PART OF THE MEMORY IS STORED IN THE CORTEX AND NOT THE LIMBIC SYSTEM TO BE REACTIVATED TO THE LEVEL OF CURRENT DANGER.

25. DE PART 2 • VIDEO

26. SUBSTANCE DEPENDENCE DEFINED • Dependence versus Abuse • Abuse • Some neglect of responsibility • Risk taking with substances (e.g. Driving under the influence) • Possible legal problems • Continued use in spite of social or interpersonal negative effects • Dependence (Dependence Severity is related to how many of the following the person exhibits) • Some or all of the above MILD 2 -3 of following symptoms MODERATE 4 – 5 of the following symptoms SEVERE 6 or more of the following symptoms • Continued need increase amount (tolerance) to achieve same effect • Need to take substance to feel normal • Give up normal activities (work, social, recreational) • Continued use despite serious physical or psychological problems • Spend a significant amount of time obtaining the substance • Withdrawal symptoms when unable to obtain substance • Individual is unable to “cut down” despite of desire or effort

27. Neurochemicals that influence substance dependence • Dopamine: The pleasure principle • Addictive substance affects dopamine release in what's known as the brain's 'reward pathway', the equivalent of a neurological circuit connecting experience with feeling good. • Alongside pleasure, these receptors ensure the involvement of dopamine in a range of activities, from movement to memory. Drugs, such as cocaine and amphetamines, lead to a sharp, temporary, rise in dopamine within the brain.

28. Neurochemicals that influence substance dependence • Serotonin: Feeling groovy • Within the brainthis chemical is associated with mood - a person's overall state of mind, how they feel about themselves and the external world at a point in time. • A lack of serotonin in the brain is associated with depression, which is why drugs called SSRIs (selective serotonin reuptake inhibitors) such as fluoxetine (Prozac), are commonly prescribed to help treat depression. Such drugs cause an increase in the overall levels of serotonin in the brain leading, in many cases, to diminished symptoms. Certain illegal drugs, such as MDMA ('ecstasy') and LSD ('acid') can also stimulate different serotonin receptors, leading to altered or extreme moods.

29. Neurochemicals that influence substance dependence • Acetylcholine: Remember me? • Plays an important role in learning and memory. The neurons that produce this neurotransmitter - cholinergic neurons - are found in several regions of the brain where, when stimulated, they release their stores of neurotransmitter onto waiting neurons. But to have any effect, those neurons need to have the right receptors; in this instance, the nicotinic and muscarinic receptors. • Glutamate: • Glutamate is the brain's 'on switch'. Known as an 'excitatory neurotransmitter', this tiny molecule does pretty much what it says on the tin - wherever it finds a receptor to dock with, it causes the hosting neuron to become excited. An excited nerve is one that's more likely to 'fire', resulting in the release of its own unique mix of neurotransmitters. • GABA: ...must come down • Not a reference to hardcore techno, GABA is the neurotransmitter acting as glutamate's lazy twin, its sole purpose being to slow things down, dampen and inhibit nervous activity. Drugs that stimulate these receptors tend to slow the brain down, so it's no surprise to discover alcohol affects these receptors. • Drugs activating GABA receptors are found everywhere - liquid ecstasy, or GHB, has become well known as a 'date rape drug' while other activators, such as the benzodiazepines, are used in clinical contexts to help people get more sleep or lessen anxiety, for example

30. DE Part 3 • VIDEO

31. Relationship theories • High-Risk TheoryThe high-risk theory states that drug and alcohol problems occur before PTSD develops. Proponents of this model believe that the use of alcohol and drugs puts people at greater risk for experiencing traumatic events, and therefore, at greater risk for developing PTSD. • Self-Medication TheoryThe self-medication theory states that people with PTSD use substances as a way of reducing distress tied to particular PTSD symptoms. For example, alcohol (a depressant) may be used to reduce extreme hyperarousal symptoms. • Susceptibility TheoryThe susceptibility theory suggests that there is something about alcohol and drug use that may increase a person's risk for developing PTSD symptoms after experiencing a traumatic event. • Shared Vulnerability TheoryThis theory states that some people may have a genetic vulnerability that increases the likelihood that they will develop both PTSD and substance abuse problems following a traumatic event. Brady, K.T., Back, S.E., & Coffey, S.F. (2004). Substance abuse and posttraumatic stress disorder. Current Directions in Psychological Science, 13, 206-209. Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060. Tull, M.T., Baruch, D., Duplinsky, M., & Lejuez, C.W. (in press). Illicit drug use across the anxiety disorders: Prevalence, underlying mechanisms, and treatment. In M.J. Zvolensky & J.A.J. Smits (Eds.), Health behaviors and physical illness in anxiety and its disorders: Contemporary theory and research. New York, NY: Springer.

32. Trauma impact and substance dependence neurochemical relationships • SENSITIZATION TO NEUROCHEMICALS • Normal responses are blunted • EXAGGERATED RESPONSES INCREASE ADDICTIVE POTENTIAL • Hypervigilance and paranoia is mediated by the dopamine system • Greater than normal reaction to the introduction of substance like cocaine • Endogenous opioid releases in reaction to triggers as an “internal pain killer” • Greater than normal reaction to the introduction of substances like heroin http://www.cnsforum.com/lundbeckinstitute/about

33. RELATIONSHIP BETWEEN TRAUMA AND SUBSTANCE DEPENDENCE • EMOTIONAL NUMBING; EMOTIONAL INDUCEMENT • TO ELIMINATE EMOTIONS THAT ARE PAINFUL • Substances such as benzodiazepines or opiatesintended to provide physical pain relief also have the ability to eliminate negative emotional experiences • TO CREATE POSITIVE FEELINGS WHEN EMOTIONS ARE ABSENT • Individuals who have shut down their emotions or disassociated can achieve positive feelings • STRESS RESPONSES • Substances such as methamphetamine provide a temporary sense of well being by increasing dopamine and reducing adrenalin and cortisol surges from triggers associated with trauma.

34. RELATIONSHIP BETWEEN TRAUMA AND SUBSTANCE DEPENDENCE • FAMILY OF ORIGIN • Impact on ability to emotionally regulate • Learning tolerance and management of emotions • Modeling • Toxic or chaotic home environment creates ongoing internal disturbances that at minimum can be considered maltreatment and at worst abuse. • Susceptibility • Individuals who grow up with susceptibility to both substance dependence and trauma demonstrate a correlation between both increase the possibility of the existence of the other.

35. RELATIONSHIP BETWEEN TRAUMA AND SUBSTANCE DEPENDENCE • BRAIN REACTIONS • Dopamine rush • Intensity • Blunting • Every day stimuli • Disruption of memory • Pleasure triggers override history of negative consequences • Provides escape from disturbing thoughts • Disruption of inhibition control over behavior • Frontal brain regions are affected and cannot function to control desire • Trauma and substances both reduce healthy frontal lobe functioning National Institute on Health (NIH) – National Institute on Drug Abuse (NIDI)

36. RELATIONSHIP BETWEEN TRAUMA AND SUBSTANCE DEPENDENCE • BRAIN REACTIONS • Chemical Resolutions • The right self medication • Lack of energy – Depression • Too much energy – Anxiety/Lack of focus (ADHD) • Reward circuitry • Desensitization • Normal pleasures cannot compete • Loss of relative value in pleasure • With trauma life pleasures are minimized and substances provide a sense of wellbeing that had not been previously experienced as normal individuals experience National Institute on Health (NIH) – National Institute on Drug Abuse (NIDI)

37. treatment • Psychotherapy • Emotional Regulation Techniques • Various • Cognitive Behavioral Therapy (e.g. Prolonged Exposure Therapy TF-CBT) • Changing how you think changes how you feel • Present Focused Therapy (e.g. Seeking Safety) • Feeling safe and in a trusting environment allows open dialogue • Analytical Therapy • Dealing with the shadows • Narrative Therapy • Identifying and Reframing early acquired negative self images • Trauma Sensitization Therapies (e.g.TARGET) • Sensory incorporation; TARGET uses the acronym FREEDOM • EMDR (Eye Movement Desensitization Reprocessing) • Incorporating multi-dimensional approaches along with hemisphere connection techniques

38. TREATMENT METAPHOR Pre-Frontal Cortex Processing with treatment delivers the memories to where they belong eliminating chemical reactions Limbic System Memories that create chemical reactions when triggers • Remnants • Emotional Flooding

39. How treatment works • Linking implicit “low road "circuits with explicit circuits “high road”. • Eliciting the emotional (low road operation) brain experience while verbalizing (high road operation) and integrating into a coherent connection between the two brain hemispheres. • Rerouting the alarm response through the pre-frontal cortex disconnecting the immediate primitive reaction. • Eliminates future similar events from taking the “low road” faster route and allows the hippocampus to properly filter and categorize the memory.

40. EMDR institute • VIDEO

41. EMDR as one treatment modality • WHY EMDR? • Separation to integration • Dual attention processing (memory + here and now) • Emotional and body memories coupled with imagery • Activates the normal processing in REM (Rapid Eye Movement) sleep. • Memory categorizing and integration (short term to long term) • Engaging both hemispheres • Assists the process and enhances the natural REM sleep process • Components of other therapies combined with the enhanced processing • Emotional Regulation • Verbalization • Desensitization • Therapeutic alliance

42. EMDR Eye movement desensitization reprocessing • Eight Phases for one event trauma • Phase I – History • Current stressors are evaluated to determine appropriateness • Dysfunctional behaviors and symptoms • Identify targets (Past, Present and Future) • Phase 2 – Preparation • Educating client and assessing ability to emotionally regulate • Using EMDR as one tool for emotional regulation – DEMONSTRATION • Phase 3 – Assessment • Image selection • Negative cognition • Example: “I am powerless” • Combined current level of disturbance (SUD scale-10 point) • Positive cognition and validity (VOC scale- 7 point) • Physical sensation

43. EMDR Eye movement desensitization reprocessing • Phase 4 – Desensitization • Negative affect • Actual reprocessing (Eye, Taps, Sound etc.) • Phase 5 – Installation • Positive cognitions with target event(VOC to level 7) • Example: “I am in control now” • Phase 6 – Body Scan • Target remaining physical sensations • Phase 7 – Closure • Between session education • Journal • Identify further targets • Phase 8 – Re-evaluation • Review continued processing between sessions and assess for further treatment

44. Emdr demonstration CALM SAFE PLACE

45. Back to the flip chart HAVE TO INITIAL OBJECTIVES BEEN MET? QUESTIONS?

46. THANKYOU! MELINDA ENGLISH KANTOR MA LPC NCC melindak@turningpointga.com 770-683-9375 office 404-918-5992 cell