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DO NOT REPRODUCE UNDER ANY CONDITIONS1 WOMEN, TRAUMA, & SUBSTANCE USE.

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Presentation on theme: "DO NOT REPRODUCE UNDER ANY CONDITIONS1 WOMEN, TRAUMA, & SUBSTANCE USE."— Presentation transcript:

1 DO NOT REPRODUCE UNDER ANY CONDITIONS1 WOMEN, TRAUMA, & SUBSTANCE USE

2 DO NOT REPRODUCE UNDER ANY CONDITIONS 2 5 Principles of Seeking Safety Safety is priority in this first-stage tx Integrated tx of PTSD & SUDs Focus is on ideals 4 content areas: cognitive, behavioral, interpersonal, and case management Attention to therapist processes

3 DO NOT REPRODUCE UNDER ANY CONDITIONS 3 Women in SUDs Treatment 1998, 23 men for every 10 women More likely to be tx for “hard dx;” less alcohol or MJ Entered through different avenues Less likely to misuse alcohol & dx; fewer need tx in general

4 DO NOT REPRODUCE UNDER ANY CONDITIONS 4 Women in SUDs Treatment are… More likely to have children, others who needs care; less access, & other obstacles so less likely to get tx. 1998, both men & women in tx were 35 yo, white (60%), first timers (40%). 13% had 5 or more tx episodes. Less likely to be employed (87%). (CaDADP, 1995)

5 DO NOT REPRODUCE UNDER ANY CONDITIONS 5 Women in SUDs Treatment are… More likely to blame themselves for trauma More likely to experience repeat traumas throughout their lives Information from the DASIS Report (8/01).

6 DO NOT REPRODUCE UNDER ANY CONDITIONS 6 PTSD & Substance Abuse Common COD: 12-34% in general tx; women 30-59%! Lifetime rates even more common Becoming abstinent doesn’t resolve PTSD. Tx outcomes for PTSD/SUDs worse than other COD, & SUDs only. PTSD & SUDs clts tend to misuse “hard dx” though MJ, RXs, alcohol are also common. Self-medicating

7 DO NOT REPRODUCE UNDER ANY CONDITIONS 7 PTSD & Substance Abuse Clts w/this COD are vulnerable to repeated traumas, more than AOD-only clts. Suffer a variety of life problems that may complicate treatment & life: homelessness, other D/O, HIV, DV, medical, child neglect, legal. More severe clinical profile

8 DO NOT REPRODUCE UNDER ANY CONDITIONS 8 PTSD & Substance Abuse 2-3x more common in women than men in SUDs tx. Most women w/this COD experienced childhood physical/sexual abuse; men, usually crime victim or war trauma. “Downward spiral” common: use leads to increased vulnerability leads to more use

9 DO NOT REPRODUCE UNDER ANY CONDITIONS 9 PTSD & Substance Abuse Many subgroups have this COD: homeless, veterans, teens, DV, prisoners. Connection btn this COD and SUDs is enduring, not just part of SA, w/d or overlapping criteria. Perpetrators of violent assault use substances at the time of assault in DV 50% and rape 39% (BOJ Statistics, 1992).

10 DO NOT REPRODUCE UNDER ANY CONDITIONS 10 PTSD & SUDs: Treatment Few provide combined tx for PTSD & SUDs. Most clts w/this COD don’t receive PTSD-focused tx. Many clts never get assessed, nor receive information, for this COD SUDs tx focuses on SUDs MH tx focuses on MH

11 DO NOT REPRODUCE UNDER ANY CONDITIONS 11 PTSD & SUDs: Treatment Can be effective but difficult & marked by unstable tx alliances, numerous crises, erratic attendance, relapses to SUDs. Views of clts w/this COD are negative by culture, clinicians, & themselves; countertransference is common. Effective tx for PTSD or SUDs are not often useful for this COD (benzos, AA, exposure)

12 DO NOT REPRODUCE UNDER ANY CONDITIONS 12 PTSD & SUDs: Treatment Often have intensive case management which may lead to “burnout” for clinicians. Cross-training is needed for clinicians.

13 DO NOT REPRODUCE UNDER ANY CONDITIONS 13 PTSD: DSM-IV DEFINITION Person is exposed to a traumatic event in which both of the following were present: Person experienced, witnessed, or was confronted with an event(s) that involved actual or threatened death or serious injury, or threat to physical integrity of self or others. Person’s response involved intense fear, helplessness, or horror.

14 DO NOT REPRODUCE UNDER ANY CONDITIONS 14 B. The traumatic event is persistently reexperienced in 1 or more of the following ways: Recurrent & intrusive distressing recollections of the event w/images, thoughts, perceptions. Recurrent distressing dreams of the event. Acting or feeling as if the traumatic event were recurring such as illusions hallucinations, dissociative flashbacks inc. when intoxicated. Intense psychological distress at exposure to internal/external cues of the traumatic event. Physiological reactivity on exposure to internal or external cues to an aspect of the traumatic event.

15 DO NOT REPRODUCE UNDER ANY CONDITIONS 15 C. Persistent avoidance of stimuli associated with the trauma & numbing of general responsiveness as indicated by 3 + of the following: Efforts to avoid thoughts, feelings, or conversations assoc. w/the trauma. Efforts to avoid activities, places, or people that arouse recollections of the trauma. Inability to recall an important aspect of the trauma. Markedly diminished interest or participation in significant activities. Feeling of detachment or estrangement from others. Restricted range of affect (i.e. no loving feelings) Sense of a foreshortened future

16 DO NOT REPRODUCE UNDER ANY CONDITIONS 16 D. Persistent symptoms of increased arousal as indicated by 2+ of the following: Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilence Exaggerated startle response

17 DO NOT REPRODUCE UNDER ANY CONDITIONS 17 PTSD: DSM-IV definition E. Duration of the disturbance is more than 1 month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

18 DO NOT REPRODUCE UNDER ANY CONDITIONS 18 PTSD: DSM-IV Acute: if duration of symptoms is less than 3 months. Chronic: if duration of symptoms is 3 months or more With Delayed Onset: onset of symptoms is at least 6 months after the stressor.

19 DO NOT REPRODUCE UNDER ANY CONDITIONS 19 PTSD: DSM-IV After a trauma, a person has each of the following key sx for more than 1 month which results in a decreased ability to function.

20 DO NOT REPRODUCE UNDER ANY CONDITIONS 20 PTSD INTRUSION flashbacks; nightmares AVOIDANCE Refuse to discuss or remember AROUSAL Insomnia; anger

21 DO NOT REPRODUCE UNDER ANY CONDITIONS 21 PTSD: TYPES SIMPLE single event as adult complex (NOT IN DSM) multiple events esp. in childhood

22 DO NOT REPRODUCE UNDER ANY CONDITIONS 22 PTSD LIFETIME RATES 10% women 5% men Can be chronic DIFFICULT LIVES More events Earlier trauma Lower socio- econ status Women more vulnerable to developing PTSD Men experience more traumas

23 DO NOT REPRODUCE UNDER ANY CONDITIONS 23 ‘GETTING’ PTSD WOMEN: 30-59% (of female clts in SUDS tx) Childhood/sexual abuse Self-harm (self-blame, etc) 55-90% trauma (includes witnessing)

24 DO NOT REPRODUCE UNDER ANY CONDITIONS 24 WOMEN WITH PTSD Alcohol use: 28% Other drug use: 27% (Kessler, et al, 1995)

25 DO NOT REPRODUCE UNDER ANY CONDITIONS 25 WOMEN HAVE… Higher rates of PTSD/SUDS 2/3 develop PTSD first, then SUDs Have worse outcomes for COD Have a need for control and secrecy Have no real drug of choice and…

26 DO NOT REPRODUCE UNDER ANY CONDITIONS 26 AFTER TRAUMA, WOMEN ALSO… Improve less Worse coping Greater distress More positive views of SU

27 DO NOT REPRODUCE UNDER ANY CONDITIONS27 PTSD does not go away with abstinence; In fact, it often gets WORSE!

28 DO NOT REPRODUCE UNDER ANY CONDITIONS 28 PTSD… May take years to treat Substantial reduction of sx w/I 90 days w/ focused proper treatment Most don’t get treatment

29 DO NOT REPRODUCE UNDER ANY CONDITIONS 29 REMEMBER: PTSD is a normal reaction to abnormal events Behind every symptom is a story People can and do recover

30 DO NOT REPRODUCE UNDER ANY CONDITIONS 30 Limbic system

31 DO NOT REPRODUCE UNDER ANY CONDITIONS 31 PTSD, Trauma & Limbic System A complex psychophysical experience even with no direct bodily harm PTSD disrupts daily functioning “Somatic memory” (van der Kolk) Somatic disturbance at core of PTSD Direct somatic interventions Not all develop PTSD or trauma symptoms Prepared for stress? developmental hx; beliefs; prior experience; internal resources; support.

32 DO NOT REPRODUCE UNDER ANY CONDITIONS 32 PTSD, Trauma & Limbic System Hans Seyle (1984) & stress: “the nonspecific response of the body to any demand.” Positive or negative experiences lead to stress responses Posttraumatic stress is “traumatic stress that persists following a traumatic experience.” (Rothschild, 1995a)

33 DO NOT REPRODUCE UNDER ANY CONDITIONS 33 PTSD, Trauma & Limbic System Fight, flight, freeze (includes dissociation) Hormones (neurotransmitters) released ANS= parasympathetic & sympathetic NS SNS – aroused in states of effort & stress; eustress & distress PNS – aroused in states of rest & relaxation

34 DO NOT REPRODUCE UNDER ANY CONDITIONS 34 PTSD, Trauma & Limbic System: the Tiger (& the HPA axis) Threat leads to: Amydala signals hypothalamus to turn on 1) SNS and 2)CRH (corticotropin-releasing hormone) SNS activates adrenals to release epinephrine/norepi nephrine CRH activates pituitary to release adrenocortio-tropic (ACTH) which activates pituitary to release cortisol Incident is over & cortisol stops ‘alarm’ & adrenaline; homeostasis

35 DO NOT REPRODUCE UNDER ANY CONDITIONS 35 Why is this important? In PTSD, something goes wrong w/this HPA axis PTSD clts don’t release enough cortisol to turn off ‘alarm’ when trauma is over Is PTSD purely biological then? Unclear.

36 DO NOT REPRODUCE UNDER ANY CONDITIONS 36 Instinctive responses! Limbic system/ANS responses are instant & instinctive responses to perceived threat Not chosen or thought-out

37 DO NOT REPRODUCE UNDER ANY CONDITIONS 37 PTSD, Trauma, and Memory Hippocampus & amygdala Record, file, remember Hippocampus Time & space context; perspective & time line Gives start, middle, end Amygdala Processes highly charged emotional memories i.e., terror & horror

38 DO NOT REPRODUCE UNDER ANY CONDITIONS 38 PTSD, Trauma, and Memory Hippocampus Activity becomes suppressed Storing not available Traumatic event prevented from becoming historical & remains current incorrectly “flashbacks”

39 DO NOT REPRODUCE UNDER ANY CONDITIONS 39 Dissociation Not mentioned in DSM-IV as symptom of PTSD though sx of acute stress d/o PTSD actually a dissociative disorder not anxiety d/o? Crucial to understand process – it’s the most severe consequence of PTSD

40 DO NOT REPRODUCE UNDER ANY CONDITIONS 40 PTSD, Trauma & Consequences Varies due to: Age of survivor Nature of trauma Response to trauma Support to survivor afterwards Survivors suffer reduced quality of life Body signals can cause relapse Ability to orient to safety & danger decreases

41 DO NOT REPRODUCE UNDER ANY CONDITIONS 41 PTSD & SUDs healing requires ID transformation Isolation v Powerless v Silence v Victim v Connection Sense of control Finding one’s voice Survivor

42 DO NOT REPRODUCE UNDER ANY CONDITIONS 42 WHAT WORKS? Exposure EMDR (not w/schizophrenia) Narrative Mourning (not for all) CBT MI Seeking Safety Somatic Experiencing

43 DO NOT REPRODUCE UNDER ANY CONDITIONS 43 WHAT’S NEEDED? SAFETY* MOURNING RECONNECTION *Seeking Safety works only on Safety. JUDITH HERMAN, MD;TRAUMA & RECOVERY, 1992.

44 DO NOT REPRODUCE UNDER ANY CONDITIONS 44 WHAT ELSE CAN WE DO? Listen more than talk Help clts link SUDs & PTSD Discuss current – not past - problems ‘Listen’ to clt behaviors Get training! Appreciate that substances do manage/solve PTSD symptoms

45 DO NOT REPRODUCE UNDER ANY CONDITIONS 45 Seeking Safety includes… Use of educational research strategies Focus on potential not pathology Attention to language Relating the material to clts’ lives Clinical realism An urgent approach to time Making the tx interesting SUDs as a priority

46 DO NOT REPRODUCE UNDER ANY CONDITIONS 46 WHAT SHOULDN’T WE DO? Don’t explore past trauma(s) No interpretive psychodynamic work No autobiographies until emotionally stable Homework may not be helpful for SUDs Don’t ask about the trauma or the triggers

47 DO NOT REPRODUCE UNDER ANY CONDITIONS 47 WE ALSO SHOULD AVOID… Asking our client to confront their abuser Minimize their pain

48 DO NOT REPRODUCE UNDER ANY CONDITIONS48 ABOVE ALL, BE CAUTIOUS: There is great danger in retraumatizing clients!

49 DO NOT REPRODUCE UNDER ANY CONDITIONS 49 When is a client ready for trauma processing? Can remain abstinent or moderate for some time Able to control some destructive behaviors Able to use some coping skills Can ask for help Is in a system of care (treatment, etc) Is willing to begin trauma work Has no other major current crises such as DV, homelessness

50 DO NOT REPRODUCE UNDER ANY CONDITIONS 50 TRAUMA-INFORMED TREATMENT… Includes all staff from ED to kitchen More effective than traditional treatment Cost effective

51 DO NOT REPRODUCE UNDER ANY CONDITIONS51 SUCCESSFUL TRAUMA PROCESSING EQUALS … “1 foot in the past and 1 foot in the future.” --LISA NAJAVITS

52 DO NOT REPRODUCE UNDER ANY CONDITIONS52 “THEY CONSTANTLY TELL THEIR STORIES, SOMETIMES EVEN WITH WORDS.” LISA NAJAVITS, PH.D., AUTHOR, SEEKING SAFETY

53 DO NOT REPRODUCE UNDER ANY CONDITIONS53 FIRST, DO NO HARM Loving and appreciating our clients “for they are the heroes of their lives.” --- SCOTT D. MILLER

54 DO NOT REPRODUCE UNDER ANY CONDITIONS54 ETHICS: WHEN TRAUMA HAPPENS IN TREATMENT Practicing ethical treatment

55 DO NOT REPRODUCE UNDER ANY CONDITIONS 55 ETHICS: TRAUMA IN TREATMENT Client-Centered Outcome-Informed Session rating scales Outcome rating scales For more on CDOI, go to

56 DO NOT REPRODUCE UNDER ANY CONDITIONS56 “ You yourself, as much as anybody in the entire universe, deserve your loves and affection.” --Buddha ( 5 th c BCA Indian philosopher)

57 DO NOT REPRODUCE UNDER ANY CONDITIONS 57 ACKNOWLEDGEMENTS “SEEKING SAFETY: A Treatment Manual for PTSD and Substance Abuse.” Lisa Najavits, PhD Guilford Press. New Directions for Mental Health Services, Using Trauma Theory to Design Service Systems, No. 89, Spring Maxine Harris and Roger D. Fallot, Jossey-Bass.

58 DO NOT REPRODUCE UNDER ANY CONDITIONS 58 ACKNOWLEDGEMENTS The Body Remembers: the Psychophysiology of Trauma & Trauma Treatment. Babette Rothschild, WW Norton. Trauma & Recovery. Judith Herman, MD Basic Books. Many Roads, One Journey: Moving Beyond the 12-Steps. Charlotte Kasl, Ph.D HarperCollins.


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