1. The Addiction-Trauma Connection: Spirals of Recovery and Healing
Stephanie S. Covington, Ph.D., LCSW
Institute for Relational Development
Center for Gender & Justice
La Jolla, CA
43rd Annual Addictions Conference
May 30, 2011
Toronto, Ontario
A-T Connection, Santa Fe
Plenary Addiction Trauma Connection May 30, 2011 Toronto 1

2. A-T Connection, Santa Fe 040710
© S. Covington, 2011
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3. Crisis=Danger & Opportunity
© S. Covington, 2011
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4. Levels of Violence Childhood Adolescence Adult
Street (workplace and community)
Consumer Culture
Media
War
Planet
© S. Covington, 2011

5. Global Violence
Violence is a leading cause of death among people aged 15-29
Source: World Health Organization
Centers for Disease Control and Prevention
© S. Covington, 2011

6. International Homicide Rates (Rate per 100,000 in 2006)
“The death and disability caused by violence make it one of the leading public health issues of our time.”
World Health Organization
© S. Covington, 2011
SOURCE: World Health Organization, 2006; FBI 2006; Statistics Canada; Australian Bureau of Statistics
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7. Two Kinds of Suffering
Natural
Created
© S. Covington, 2011

8. Definition of Trauma
The diagnostic manual used by mental health providers (DSM IV-TR) defines trauma as, “involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.”
(American Psychiatric Assoc. [APA] 2000, pg. 463).
© S. Covington, 2011

9. Definition of Trauma (cont.)
“The person’s response to the event must involve intense fear, helplessness or horror (or in children, the response must involve disorganized or agitated behavior).”
(American Psychiatric Assoc. [APA] 2000, pg. 463).
© S. Covington, 2011

10. Definition of Trauma
Trauma occurs when an external threat overwhelms a person’s internal and external positive coping resources.
(Bloom & Fallot, 2009)
© S. Covington, 2011
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11. Violence Against Women
Violence against women is so pervasive that the United Nations has addressed and defined violence against women as “any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or private life.”
(United Nations General Assembly, 1993).
© S. Covington, 2011

12. Moral Challenges 19th century - slavery 20th century - totalitarianism
21st century – brutality against women
and girls
(NY Times 9/23/09)
© S. Covington, 2011

13. Traumatic Events Trauma can take many forms:
Emotional, sexual or physical abuse
Neglect
Abandonment (especially for small children)
Extremely painful and frightening medical procedures
© S. Covington, 2011

14. Traumatic Events (cont.)
Catastrophic injuries and illnesses
Rape or assault
Muggings
Domestic violence
Burglary
Automobile accidents
© S. Covington, 2011

15. Traumatic Events (cont.)
Immigration
Natural disasters (hurricanes, floods, earthquakes, tornadoes, fires, volcanoes)
Terrorism such as September 11, 2001
Witnessing violence such as a parent harming another parent
© S. Covington, 2011

16. Traumatic Events (cont.)
Loss of a loved one and severe bereavements (even of a pet)
Combat/war
Torture
Kidnapping
Intergenerational (cultural) trauma
© S. Covington, 2011

17. Historical Trauma Across generations Massive group trauma
Examples include: Aboriginal (First Nation), Native Americans, African Americans, Holocaust survivors, Japanese internment survivors
© S. Covington, 2011

18. Traumatic Events
Of all these forms of trauma, women are at greater risk of interpersonal abuse than men.
© S. Covington, 2011

19. Trauma-Informed Services
Take the trauma into account.
Avoid triggering trauma reactions and/or traumatizing the individual.
(Harris & Fallot)
© S. Covington, 2011

20. Trauma-Informed Services (cont)
Adjust the behavior of counselors, other staff and the organization to support the individual’s coping capacity.
Allow survivors to manage their trauma symptoms successfully so that they are able to access, retain and benefit from the services.
(Harris & Fallot)
© S. Covington, 2011

21. Core Principles of Trauma-Informed Care
Safety (physical and emotional)
Trustworthiness
Choice
Collaboration
Empowerment
(Fallot & Harris, 2006)
© S. Covington, 2011
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22. SENSITIZED NERVOUS SYSTEM PAINFUL EMOTIONAL STATE
Process of Trauma
TRAUMATIC EVENT
Overwhelms the Physical & Psychological Systems
Intense Fear, Helplessness or Horror
RESPONSE TO TRAUMA
Fight or Flight, Freeze, Altered State of Consciousness, Body Sensations, Numbing, Hyper-vigilance, Hyper-arousal
SENSITIZED NERVOUS SYSTEM
CHANGES IN BRAIN
CURRENT STRESS
Reminders of Trauma, Life Events, Lifestyle
PAINFUL EMOTIONAL STATE
RETREAT
SELF-DESTRUCTIVE ACTION
DESTRUCTIVE ACTION
ISOLATION
DISSOCIATION
DEPRESSION
ANXIETY
SUBSTANCE ABUSE
EATING DISORDER
DELIBERATE SELF-HARM
SUICIDAL ACTIONS
AGGRESSION
VIOLENCE
RAGES
© S. Covington, 2011

23. ACE Study (Adverse Childhood Experiences)
Before age 18:
Recurrent and severe emotional abuse
Recurrent and severe physical abuse
Contact sexual abuse
Physical neglect
Emotional neglect
© S. Covington, 2011
A Woman's Way, Hazelden April 23, 2010
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24. ACE Study (Adverse Childhood Experiences)
Growing up in a household with:
An alcoholic or drug-user
A member being imprisoned
A mentally ill, chronically depressed, or institutionalized member
The mother being treated violently
Both biological parents not being present
(N=17,00)
© S. Covington, 2011
A Woman's Way, Hazelden April 23, 2010
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25. ACE Study (Adverse Childhood Experiences)
Results
ACEs still have a profound effect 50 years later, although now transformed from psychosocial experience into organic disease, social malfunction, and mental illness.
Smoking
Alcoholism
Injection of illegal drugs
Obesity
(Felitti, V.J.: Origins of Addictive Behavior: Evidence from the ACE Study. 2003
Oct:52(8): German. PMID: (PubMed-indexed for MEDLINE).
© S. Covington, 2011

26. ACE Study (continued) Men 16% Sexual Abuse Men 30% Physical Abuse
Women 27% Sexual Abuse
(Felitti and Anda, 2010)
© S. Covington, 2011

27. Women 50% more likely than men to have a score of 5 or more.
ACE Study (continued)
Women 50% more likely than men to have a score of 5 or more.
(Felitti & Anda, 2010)
© S. Covington, 2011

28. ACE Study (continued)
If a male child has six or more “yes” answers, his risk of becoming an IV drug user increases by 4,600% compared to a boy with a score of zero.
(Felitti & Anda, 2010)
© S. Covington, 2011

29. ACE Study (continued) Population Studied: 75% white
39% college (36% some)
18% high school grads
(Felitti & Anda, 2010)
© S. Covington, 2011
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30. ACE Study (continued) 6 or more “yes” answers =
2 decades shorter life expectancy than
person with 0 “yes” answers
(Felitti & Anda, 2010)
© S. Covington, 2011
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31. Tell me how that has affected you later in your life.”
ACE Study (continued)
“I see that you have…
Tell me how that has affected you later in your life.”
(Felitti & Anda, 2010)
© S. Covington, 2011
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32. Childhood Traumatic Events Largest Effect-Mental Health
Psychotropic medication
Mental health treatment
Attempted suicide
Traumatic stress
(Messina & Grella, 2005)
© S. Covington, 2011

33. Childhood Traumatic Events Largest Effect-Mental Health
980% increase in odds if exposed
to 7 CTE’s
(Messina & Grella, 2005)
© S. Covington, 2011

34. Critical and Interrelated Issues
Substance Abuse
Mental Health
Trauma
Physical Health
© S. Covington, 2011

35. Areas of Separation Training Treatment Categorical Funding
© S. Covington, 2011

36. Key Elements (Staff and Clients)
Learn what trauma/abuse is
Understand typical responses
Develop coping skills
© S. Covington, 2011

37. Definition of Recovery
The definition of recovery has shifted from a focus on what is deleted from one’s life (alcohol and other drugs, arrests for criminal acts, hospitalizations) to what is added to one’s life (the achievement of health and happiness).
(Miller & Kurtz, 2005)
© S. Covington, 2011

38. Prevalence of Trauma and PTSD in Substance Use/Abuse
60% to 90% of a treatment-seeking sample of substance abusers also have a history of victimization
More than 80% of women seeking treatment for a substance use disorder reported experiencing physical/sexual abuse during their lifetime
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39. Prevalence of Trauma and PTSD in Substance Use/Abuse
Between 44% and 56% of women seeking treatment for a substance use disorder had a lifetime history of PTSD
10.3% of the men and 26.2% of the women with a lifetime diagnosis of alcohol dependence also had a history of PTSD
© S. Covington, 2011

40. Histories of Trauma / Violence among Clients Treated for Methamphetamine
Persons in treatment for methamphetamine report high rates of trauma
85% women
69% men
© S. Covington, 2011

41. Histories of Trauma / Violence among Clients Treated for Methamphetamine
Most common source of trauma/violence:
For women, was a partner (80%)
For men, was a stranger (43%)
History of sexual abuse
57% women
16% men
© S. Covington, 2011

42. Disorders Related to Trauma and Substance Abuse in Women’s Lives
Depressive Disorders NOS %
Major Depressive Disorders %
Post traumatic Stress Disorders %
Neurotic Anxiety Disorders %
Bipolar Disorders %
Mood or Dysthymic Disorders %
Psychotic Disorders %
Personality and Misc. Disorders %
Source: Patterns of Comorbidity among Women with Childhood Interpersonal Trauma, Mental Health Disorders, and Substance Related Disorders. Journal of Behavioral Health Services & Research (in press)
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43. Post-Traumatic Stress Disorder
Re-experiencing the event through flashbacks and nightmares.
Avoidance of stimuli associated with the event (for example, if a woman was raped in a park, she may avoid parks, or if she was assaulted by a blonde man, she may avoid men with blonde hair).
© S. Covington, 2011

44. Post-Traumatic Stress Disorder (cont.)
Estrangement (the inability to be emotionally close to anyone)
Numbing of general responsiveness (feeling nothing most of the time)
© S. Covington, 2011

45. Post-Traumatic Stress Disorder (cont.)
Hyper-vigilance (constantly scanning one’s environment for danger, whether physical or emotional)
Exaggerated startle response (a tendency to jump at loud noises or unexpected touch) (DSM – IV)
© S. Covington, 2011

46. Trauma and Abuse Sexual abuse Physical abuse Emotional abuse
Domestic violence
Witnessing abuse/violence
Self-inflicted violence
Military sexual assault (MST)
© S. Covington, 2011

47. Trauma and Abuse (cont.)
Trauma of Stigmatization
Poverty
Race/Culture
Sexual Orientation
Mental Illness
Physical Disability
Incarceration
© S. Covington, 2011

48. Trauma
Gender Differences
© S. Covington, 2011

49. Gender-Responsive Treatment
Creating an environment through:
site selection
staff selection
program development
content and material
that reflects an understanding of the realities of the lives of women and girls, and
addresses and responds to their strengths and challenges.
Source: Covington, S.S., & Bloom, B.E. (2006). Gender-responsive treatment and services in correctional settings. In E. Leeder (Ed.), Inside and out: Women, prison, and therapy. Binghamton, NY: Haworth.
© S. Covington, 2011

50. Gender-Responsive Materials (Trauma-informed)
Women and Addiction: A Gender-Responsive Approach
Helping Women Recover
Helping Men Recover
Voices: A Program for Girls
Beyond Trauma: A Healing Journey for Women
Women in Recovery
A Woman’s Way through The Twelve Steps
Beyond Violence: A Prevention Program for Women

51. Trauma Materials for Women
ATRIUM (Dusty Miller)
Beyond Trauma (Stephanie Covington)
Healing Trauma (Stephanie Covington)
Seeking Safety (Lisa Najavits)
TREM (Maxine Harris)
Trauma Materials for Men
M-TREM (Roger Fallot)
© S. Covington, 2011
Plenary Addiction Trauma Connection May 30, 2011 Toronto

52. Helping Women Recover: A Program for Treating Addiction
Theory of Addiction
Holistic health model
Chronic neglect of self in favor of something or
someone else
Theory of Women’s Psychological Development
Relational–Cultural Model (Stone Center)
Theory of Trauma
Three Stage Model (Herman)
Upward Spiral – A Transformational Model
(Covington)
© S. Covington, 2011

53. Helping Men Recover: A Program for Treating AddictionBy
Covington, Griffin & Dauer
© S. Covington, 2011
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54. Helping Men Recover
Impact of male socialization on the recovery process
Relational needs of men
Issues of abuse and trauma
Self, relationships, sexuality and spirituality
© S. Covington, 2011

55. Power and Control Wheel
From the manual In Our Best Interest: A Process for Personal and Social Change.
Available through Domestic Abuse Intervention Project, 206 W. 4th St., Duluth, MN
© S. Covington, 2011
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56. Voices: A Program of Self-Discovery and Empowerment for Girls
Theory of Girls’ Psychological Development
Relational–Cultural Model (Stone Center, Gilligan, Brown)
Theory of Attachment
Ainsworth, Bowlby, Harlow, Stern
Theory of Trauma
Three Stage Model (Herman)
Transformational Spiral (Covington)
Theory of Resilience
Biscoe, Wolin & Wolin
Theory of Addiction
Holistic Health Model
© S. Covington, 2011

57. Beyond Trauma: A Healing Journey for Women
Trauma Theory
Sandra Bloom, M.D.
Mary Harvey, Ph.D.
Judith Herman, M.D.
Peter Levine, Ph.D.
Integrates cognitive-behavioral, expressive arts, guided imagery, and relational therapy.
© S. Covington, 2011

58. Client Assessment Scores Improve after Completion of HWR and BT
Mean Score Change
(p <.05 or less)
Source: KIVA Program records – BDI & TSC Assessment, August 31, 2004 – October 13, 2006
Keaton, Curtis, and Burke (2006) SANDAG
© S. Covington, 2011

59. Prison Study (NIDA Funded)
Randomized control group
Gender-responsive vs. Therapeutic Community
Significant differences
Greater reduction of drug use
More likely to complete treatment
Remained longer in aftercare
Less recidivism (re-incarcerated) at
12 months
(p ≤ .05)‏
© S. Covington, 2011
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60. Drug Court Study (NIDA Funded)
Four sites in San Diego County
Randomized control group
Preliminary results
Less substance use
Fewer sanctions
Longer in treatment
Judge notices differences
© S. Covington, 2011

61. Trauma: Stages of Recovery
Syndrome
Stage One
Stage Two
Stage Three
Hysteria
(Janet 1889)
Stabilization, Symptom-oriented treatment
Exploration of traumatic memories
Personality reintegration, rehabilitation
Combat trauma
Scurfield (1985)
Trust, stress- management education
Re-experiencing trauma
Integration of
trauma
Source: Herman, 1992, 1997
© S. Covington, 2011

62. Trauma: Stages of Recovery
Syndrome
Stage One
Stage Two
Stage Three
Complicated post-traumatic stress disorders
Stabilization
Integration of memories
Development of self, drive integration
Source: Herman, 1992, 1997
© S. Covington, 2011

63. Trauma: Stages of Recovery
Syndrome
Stage One
Stage Two
Stage Three
Multiple personality disorder
(Putnam 1989)
Diagnosis, stabilization, communication cooperation
Metabolism of trauma
Resolution, integration, development of post-resolution coping skills
Traumatic disorders
(Herman 1992)
Safety
Remembrance and mourning
Reconnection
Source: Herman, 1992, 1997
© S. Covington, 2011

64. Trauma Three Group Models
Recovery Stage One
Recovery Stage Two
Recovery Stage Three
Therapeutic task
Safety
Remembrance and mourning
Reconnection
Time orientation
Present
Past
Present, future
Focus
Self-care
Trauma
Interpersonal relationships
Source: Herman, 1992, 1997
© S. Covington, 2011

65. Trauma Three Group Models
Recovery Stage One
Recovery Stage Two
Recovery Stage Three
Membership
Homogeneous
Heterogeneous
Boundaries
Flexible, inclusive
Closed
Stable, slow turnover
Cohesion
Moderate
Very high
High
Source: Herman, 1992, 1997
© S. Covington, 2011

66. Trauma Three Group Models
Recovery Stage One
Recovery Stage Two
Recovery Stage Three
Conflict tolerance
Low
High
Time limit
Open-ended or repeating
Fixed Limit
Open-ended
Structure
Didactic
Goal-directed
Unstructured
Example
Twelve-step programs
Survivor group
Interpersonal psychotherapy group
Source: Herman, 1992, 1997
© S. Covington, 2011

67. Emerging Paradigm Values-Based Services
Gender-responsive
Trauma-informed
Culturally competent
Recovery-oriented
© S. Covington, 2011

68. Sanctuary A-T Connection, Santa Fe 040710
© S. Covington, 2011
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69. What is Sanctuary? Sacred place Place of refuge/protection Shelter
Oasis
© S. Covington, 2011
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70. What Makes a Difference?
Creating a safe environment
Listening to her/his story
Empathy
© S. Covington, 2011
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71. Upward Spiral Transformation Addiction & Trauma (constriction)
Recovery
&
Healing
(expansion)
© S. Covington, 2011