Trauma and the Challenge of Substance Abuse Disorders

”Trauma and the Challenge of Substance Abuse Disorders” Tim Shannon MA, Licensed Professional Counselor Certified Advanced Addiction Counselor Certified Sexual Addiction Therapist Certified Multiple Addiction Therapist ICADAC - International Certified Alcohol and Drug Abuse Counselor Eye Movement Desensitisation Reprocessing #1 frostcid@ comcast. net , tshannon@cssstclair. org 1

“If all you have is a hammer then all your problems are nails” -Abraham Maslow 2

Core Assumption I In the context of trauma, chemical addiction arises not as a pleasure-seeking strategy but as a survival strategy: • To self-soothe and self-regulate • As a way to numb hyperarousal symptoms: intolerable affects, reactivity, impulsivity, obsessive thinking • In the service of walling off intrusive memories • As a way to combat helplessness by increasing hypervigilence and feelings of power and control • To “treat” hypoarousal symptoms of depression, emptiness, numbness, deadening • In the service of facilitating dissociation • As a way to function or to feel safer in the world 3 Fisher, 2007

Core Assumption II How the addictive behaviors have helped trauma patients to survive: that is, which trauma symptoms are they attempting to treat through their drinking, drugging, eating disorders, and sexually acting out behaviors. We need to know this information for a number of reasons: • First, we need to know because these are precisely the symptoms that will increase once the patient becomes sober or abstinent. EX: 12 yr old molested by grandfather, smokes cannabis and uses alcohol to forget. In recovery has numerous flashbacks including molestations at an earlier age she had suppressed. • We need to know, too, so that we can begin to anticipate other coping strategies they will need in order to deal with those symptoms as they erupt and threaten to overwhelm them. 4 Fisher, 2007

Core Assumption III Furthermore, we need to be able to predict when and how the symptoms may potentially trigger a behavior relapse so that we can help them strengthen the addictions recovery program they have chosen. And finally, we also need to know so that we can help the survivor appreciate their courageous attempts to cope with the effects of the abuse and, from that recognition, develop sufficient compassion and self-respect to counteract the shame and guilt that is the inevitable byproduct of their addictions and trauma history. 5 Fisher, 2007

Affect refers to instinctive biology, ie the limbic system - the fight, flight, or freeze center - that tends to be active in addiction and other disorders. The individual receives overwhelming primal messages about events that can be way out of proportion to the actual potential for threat. Feelings refers to psychology, how we think about what is going on, both externally and internally ie; the amygdala. 6

• Emotion refers to the biographical story we tell ourselves about our experience, including the ability to remember and to project experience. • Dominated by intrusions of the trauma, traumatized individuals begin organizing their lives around avoiding having them. 7

Trauma • “Because the stress response disrupts general information processing, survivors of trauma live in a somatic world rather than a world of language. ” Alexander Mc. Farlane 8

What is Trauma? “Trauma is experiencing too much, too fast, too soon. ” Or “The body remembers what the mind forgets” -Jacob Moreno 9

Movement from Chaos to Connection “The deep digging in therapy is to make conscious these early wounds and convert them into words so that they can be felt and understood—to use the skills of emotional literacy. 10

Movement from Chaos to Connection Our Tasks We help them place the trauma in proper perspective. Help give them a context (where, when and how). Help integrate them back into themselves with understanding as to what happened and what meaning they made out of it. 11

Modulating Emotional Responses Intense Fear Rage Disassociation or Shutdown Addiction offers relief 12

Trauma Impacts relationships by creating 1. Enmeshment-part of trauma bonding. 2. Disengagement-avoiding skill building. 3. Chaos through impulsivity. 13

How do we help them? 4 Steps to Emotional Expertise Our clients need to know: • All emotions serve a function. • Trauma and Addiction blunt our range of emotions. • Self Efficacy comes as consciousness of emotions grows. 14

What is Trauma is perhaps the most avoided, ignored, belittled, denied, misunderstood, and untreated cause of human suffering. Although it is the source of tremendous distress and dysfunction, it is not an ailment or a disease, but the by-product of an instinctively instigated, altered state of consciousness. We enter this state - let us call it survival mode - when we perceive that our lives are being threatened. If we are overwhelmed by the threat and are unable to successfully defend ourselves, we can become stuck in survival mode. This highly aroused state is designed solely to enable short-term defensive actions; but left untreated over time, it begins to form the symptoms of trauma. 15 Peter Levine

Effects of Trauma (Dayton, 2000) • Long term fear of intimacy. • Relational Commitment-Simultaneous fears of abandonment and being overwhelmed. • Poor Communications-as the internal dictionary, listening, and seeking feedback are distorted. • Boundaries are enmeshed. • Deregulated emotions-high frequency, intensity and • duration to complete shutdown. • Distrust, unable to receive and lack of faith in others. • Blunted play –inability to move freely in a space. • Unconscious patterns of disconnecting, reenacting, transference, splitting, hyper-vigilance and perfectionism. 16

Somatic Experiencing “Somatic Experiencing® is a body-awareness approach to trauma being taught throughout the world. Based upon the realization that human beings have an innate ability to overcome the effects of trauma. ” -Dr. Peter Levine 17

Bessel van der Kolk “The imprint of the trauma is in the limbic system and in the brainstem: in our animal brains, not our thinking brains” Survival responses based on the following criteria: 1. Severity of trauma. 2. Genetic Predisposition. 3. Developmental Phase when trauma occurs. 4. A Social Support System. 5. Prior traumas. 6. Preexisting phobias and maladaptive behavior 18

Pierre Janet 1859 -1947 • “[Traumatized] patients. . . are [repeatedly] continuing the action, or rather the attempt at action, which began when the event happened, and they exhaust themselves in these everlasting recommencements. ” • 1919/25, p. 663 19

Trauma and the Brain 20

The Triune Brain x 21

“Bottom-up, The Hi-Jacked Brain” Everyday experiences connected to the trauma will trigger instinctive survival responses: fight, flight, freeze, collapse and numbing, dissociation, re-enactment behavior. The client’s animal brain takes over, the ability to think goes “off line, ” & acting out behavior takes place without consciousintention or judgment, even without awareness! Janina Fisher, 2007 22

Trauma vs. Intimacy Visual Cortex Normal Response Trauma Response Amygdala Fight, Flight or Freeze Response 23

Peter Levine “Trauma originates as a response in the nervous system, and does not originate in an event. Trauma is in the nervous system, not in the event. ” 24

Brief Overview of the Autonomic Nervous System The Polyvagal Theory by Stephen Porges, Ph. D www. stephenporges. com 25

The Parasympathetic Nervous System The Sympathetic Nervous System Originates in the brain stem and The SNS gets our whole body ready lower part of the spinal cord; for action. It regulates arousal. It opposes physiological effects of the increases activity during times of sympathetic nervous system: stress and arousal – whether positive stimulates digestive secretions; or negative. It is active when we’re slows the heart; constricts pupils; alert, excited, or engaged in physical dilates blood vessels. Trauma may result in the PNS staying “on”, which causes it to superimpose shutdown over the hyperarousal of the SNS, rather than discharging its energy. The Parasympathetic branch acts like the brake pedal for our nervous system. It helps us to relax, unwind and ultimately discharge the arousal of sympathetic activation. activity. It prepares us to meet emergencies and threat. The Sympathetic branch is like the gas pedal of our nervous system. It gives us energy for any action we plan, and it helps us prepare for threat. 26

The Polyvagal Theory By Stephen Porges The Vagus Nerve in three parts, all working simultaneously: Ventral Vagal System: Is part of the Parasympathetic Nervous System (Social Engagement/frontal cortex) Sympathetic Nervous System: (Fight/Flight, Freeze - Limbic Brain) Dorsal Vagal System: Is part of the Parasympathetic Nervous System (Freeze/Immobility/Brainstem) 27

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Social Engagement Safe Ventral Vagal Fight, Flight, Freeze Immobility Sympathet ic Nervous System Dorsal Vagal System 29 Danger Life Threatening

Autonomic Arousal is Designed to Adapt to Environmental Demands Sympathetic Hyperarousal A R O U S A L easy charge sympathetic easy discharge Window of Tolerance feelings can be tolerated, able to think and feel parasympathetic Parasympathetic Hypoarousal Foundation of Human Enrichment Ogden and Minton (2000) 30

Autonomic Adaptation to a Threatening World Stuck on “ON” Sympathetic Hyperarousal A R O U S A L • • • Hyperactivity Panic Rage Hypervigilance Elation/Mania Window of Tolerance Optimal Arousal Zone Stuck on “OFF” Parasympathetic Hypoarousal Foundation of Human Enrichment Fisher, 2006 31 • • Depression Disconnection Deadness Exhaustion

How Chemical Addiction Modulates and “Medicate” Complex PTSD to attempt Self-Regulation Sympathetic Hyperarousal Acting out A R O U S A L Window of Tolerance Optimal Arousal Zone Acting in Parasympathetic Hypoarousal Foundation of Human Enrichment Fisher, 2006 32

The Challenge of Trauma and Chemical Addiction Treatment must address the relationship between: A. the trauma and the addictive behavior B. the role of the addictive behavior in “medicating” traumatic activation C. the origins of both in the traumatic past D. the reality that recovering from either requires recovering from both. Fisher, 2007 33

Modes of Inventions Cognitive Behavioral Therapy EMDR Somatic Experiencing Hypnotherapy Transactional Analysis 34

Provider Tasks • Screening & Assessing • See trauma as a defining and organizing experience that can shape a survivor’s sense of self and others. (understanding ability to cope). • Psycho-educational information on how intertwined SUDS and Trauma are during and after an event. • Establish and maintain consumer support and developing coping skills. (Ex: Learning communication and problem solving strategies such as healthy fighting. (cont. ) 35

Addiction Labeling • The goals associated with any problem are at least partially determined by the way the problem is assessed. • What you do about something is influenced by what you call it. 36

Our Lens • We tend to call ourselves objective but we interpret situations from their own particular theoretical, philosophical or ideological perspective. • Do we need to transcend it? 37

Our Lens (cont. ) We know clients don’t see themselves as addicts but often seek to negotiate an alternative explanation to negate acting out behaviors or minimize having to change. 38

Provider Tasks • Helping consumer understand the range of parallel connections between SUDS and trauma. • Minimizing re-occurance of trauma • Ensuring consumers’ physical and emotional safety where possible and avoiding shame inducing confrontations triggering trauma related responses. • Helping with referrals for ancillary services such as legal, financial, vocational, housing and health care. 39

Resiliency • Recognizing and Reinforcing Resiliency • Definition-The process of “bouncing back. ” 40

The Post Traumatic Stress Inventory The Inventory consists of 144 questions designed by David Delmonico, M. Ed. and Patrick Carnes, Ph. D. Questions fall into 1 of 8 categories providing when tallied a strategic map on how the client can once again internal locus of control. 41

The Post Traumatic Stress Inventory 8 Specific Therapy Strategies 42

1. Trauma Reacting- Experiencing current reactions to trauma events in the past. Study ways client is still reacting. EX: projected anger out on others. Write letters to perpetrator telling them of the long-term impact you are experiencing. Write amend letters to those you know you have harmed. • Decide with therapist what information is appropriate to disclose and send. 43

2. Trauma Repetition • Trauma Repetition – Repeating behaviors or situations which parallel early trauma experiences. • Understand how history repeats itself in your life experiences. • Develop habits which center yourself- Ex. Breathing or journaling so you are doing what you intend –not the cycles once used. • Work on setting boundaries-using effective communication. • Boundary failure is key to repetition compulsion. 44

3. Trauma Bonding • Trauma Bonding- Being connected (loyal, helpful, supportive, enmeshed) to people who are dangerous shaming, or exploitive. • Learn to recognize trauma bond by identifying those in your life. • Look for patterns. • Use “detachment” strategies for difficult people. • Use a First-Step if necessary. 45

4. Trauma Shame • Trauma Shame - Feeling unworthy and having self-hate because of the trauma experience. • An acutely self-conscious state in which the self is “split” imagining the self in the eyes of the, other; by contrast, in guilt the self is unified. (Gilliland, et al. 2011). • Judgment of self by another whether real or imagined. 46

4. Trauma Shame (cont) Goal: Shame Reduction and resolution. Understand shame dynamics of family and family of origin. Who was important to that you should feel shameful? Do a list of problems, excuses and secrets. Complete an inventory of affirmations. 47

5. Trauma Pleasure • Trauma Pleasure – Finding pleasure in the presence of danger, violence, risk or shame. • Do a history of how excitement/ shame are hooked to the past traumatic event (s). • Note the costs and dangers to you over time. • Do a First Step and relapse prevention plan about how powerful this is in your life. 48

6. Trauma Blocking • Trauma Blocking- A pattern exists to numb, block out, or overwhelm feelings that stem from trauma in your life. • Work to identify experience which caused pain or diminished you. • Re-experience feelings and make sense of them with help. • This will reduce the power they have had. • Do a First Step if appropriate. 49

7. Trauma Splitting • Trauma Splitting- Ignoring traumatic realities by disassociating or “splitting off” experience of parts of self. • Learn that disassociating is a “normal” response to trauma. • Identify ways you split reality and the triggers that cause that to happen. • Cultivate a “caring” adult who stays present so you can stay whole. • Notice any powerlessness you feel. 50

8. Trauma Abstinence • Trauma Abstinence- Depriving yourself of things you need or deserve because of traumatic acts. • Understand how deprivation is a way to continue serving perpetrators. • Write a letter to the victim(s) that was you learning to tolerate pain and deprivation. • Work on strategies to self –nurture including inner child visualizations. 51

WHAT NEXT 30 Performables 1. Break through Denial 2. Understand Addiction 3. Surrender 4. Limit change 5. Establish Sobriety 6. Physical Integrity 7. Culture of support 16. Lifestyle Balance 17. Building Support 18. Exercise and nutrition 19. Spiritual Life 20. Resolve Conflicts 21. Restore Healthy Sexuality 22. Family Therapy 8. Multiple addictions 9. Cycle of Abuse 10. Reduce Shame 11. Grieve losses 12. Closure to shame 13. Relationship with self. 14. Financial Viability 15. Meaningful work 23. Family Relationships 24. Recovery commitment 25. Issues with children 26. Extended Family 27. Differentiation 28. Primary Relationship 29. Coupleship 30. Primary Intimacy Carnes, 2 52

Bibliography Carnes, Patrick, & Delmonico, David. The Post Traumatic Stress Inventory. Carefree, Az, 2008. Carnes, Patrick & Stephanie, Bailey, John. Facing Addiction. Carefree, Az 2011. Gentle Path Press. Dayton, Tian, (2000), Trauma and Addiction; Ending the Cycle of Pain through Emotional Literacy, Deerfield Beach, Fl. , Health Communication. Gilliland, et al. “The role of guilt and shame in Hypersexual Behavior. ” Sexual Addiction and Compulsivity; The Journal of Treatment and Prevention. p 53 14 -15.

BIBLIOGRAPHY (cont. ) • Fisher, Janina, (2008), Addictions and Trauma Recovery • Levine, Peter, (1997), Waking the Tiger. Berkley, CA, North Atlantic Books. • Ogden, Pat, (2006), Trauma and the Body. New York: W. W. Norton & Company, Inc. • Porges, Stephen, 2006), How your nervous system sabotages your ability to relate. www. nexuspub. com • Van der Kolk, Bessel, & Mc. Farlane, Alexander(1996) Traumatic Stress. New York: The Guilford Press. 54

Anchor Consulting Services 1110 West Cross St. Ypsilanti, Mi. 48197 Phone : 734 -649 -9989 http: //anchortherapy. com/ frostcid@ comcast. net , tshannon@cssstclair. org Tim Shannon MA, Licensed Professional Counselor Certified Advanced Addiction Counselor Certified Sexual Addiction Therapist Certified Multiple Addiction Therapist ICADAC - International Certified Alcohol and Drug Abuse Counselor Eye Movement Desensitization Reprocessing #1 55