1. WOMEN, TRAUMA, & SUBSTANCE USE
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
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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
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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)
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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).
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6. DO NOT REPRODUCE UNDER ANY CONDITIONS
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
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7. DO NOT REPRODUCE UNDER ANY CONDITIONS
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
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8. DO NOT REPRODUCE UNDER ANY CONDITIONS
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
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9. DO NOT REPRODUCE UNDER ANY CONDITIONS
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).
DO NOT REPRODUCE UNDER ANY CONDITIONS

10. DO NOT REPRODUCE UNDER ANY CONDITIONS
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
DO NOT REPRODUCE UNDER ANY CONDITIONS

11. DO NOT REPRODUCE UNDER ANY CONDITIONS
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)
DO NOT REPRODUCE UNDER ANY CONDITIONS

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

14. DO NOT REPRODUCE UNDER ANY CONDITIONS
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.
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15. DO NOT REPRODUCE UNDER ANY CONDITIONS
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
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16. DO NOT REPRODUCE UNDER ANY CONDITIONS
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
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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.
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18. DO NOT REPRODUCE UNDER ANY CONDITIONS
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.
DO NOT REPRODUCE UNDER ANY CONDITIONS

19. DO NOT REPRODUCE UNDER ANY CONDITIONS
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.
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20. DO NOT REPRODUCE UNDER ANY CONDITIONS
PTSD
INTRUSION
flashbacks; nightmares
AVOIDANCE
Refuse to discuss or remember
AROUSAL
Insomnia; anger
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21. DO NOT REPRODUCE UNDER ANY CONDITIONS
PTSD: TYPES
SIMPLE
single event as adult
complex (NOT IN DSM)
multiple events esp. in childhood
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22. DO NOT REPRODUCE UNDER ANY CONDITIONS
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
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23. DO NOT REPRODUCE UNDER ANY CONDITIONS
‘GETTING’ PTSD
WOMEN: % (of female clts in SUDS tx)
Childhood/sexual abuse
Self-harm (self-blame, etc)
55-90% trauma (includes witnessing)
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24. DO NOT REPRODUCE UNDER ANY CONDITIONS
WOMEN WITH PTSD
Alcohol use: 28%
Other drug use: 27% (Kessler, et al, 1995)
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25. DO NOT REPRODUCE UNDER ANY CONDITIONS
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…
DO NOT REPRODUCE UNDER ANY CONDITIONS

26. AFTER TRAUMA, WOMEN ALSO…
Improve less
Worse coping
Greater distress
More positive views of SU
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27. PTSD does not go away with abstinence;
In fact, it often gets WORSE!
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28. DO NOT REPRODUCE UNDER ANY CONDITIONS
PTSD…
May take years to treat
Substantial reduction of sx w/I 90 days w/ focused proper treatment
Most don’t get treatment
DO NOT REPRODUCE UNDER ANY CONDITIONS

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

30. DO NOT REPRODUCE UNDER ANY CONDITIONS
Limbic system
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.
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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)
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
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/norepinephrine
CRH activates pituitary to release adrenocortio-tropic (ACTH) which activates pituitary to release cortisol
Incident is over & cortisol stops ‘alarm’ & adrenaline; homeostasis
DO NOT REPRODUCE UNDER ANY CONDITIONS

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

39. DO NOT REPRODUCE UNDER ANY CONDITIONS
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
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
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
DO NOT REPRODUCE UNDER ANY CONDITIONS

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

44. DO NOT REPRODUCE UNDER ANY CONDITIONS
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
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
DO NOT REPRODUCE UNDER ANY CONDITIONS

46. DO NOT REPRODUCE UNDER ANY CONDITIONS
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
DO NOT REPRODUCE UNDER ANY CONDITIONS

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

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

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

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

52. “THEY CONSTANTLY TELL THEIR STORIES, SOMETIMES EVEN WITH WORDS.”
LISA NAJAVITS, PH.D.,
AUTHOR, SEEKING SAFETY
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53. DO NOT REPRODUCE UNDER ANY CONDITIONS
FIRST, DO NO HARM
Loving and appreciating our clients “for they are the heroes of their lives.”
--- SCOTT D. MILLER
DO NOT REPRODUCE UNDER ANY CONDITIONS

54. ETHICS: WHEN TRAUMA HAPPENS IN TREATMENT
Practicing
ethical treatment
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55. ETHICS: TRAUMA IN TREATMENT
Client-Centered
Outcome-Informed
Session rating scales
Outcome rating scales
For more on CDOI, go to
DO NOT REPRODUCE UNDER ANY CONDITIONS

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

57. DO NOT REPRODUCE UNDER ANY CONDITIONS
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.
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58. DO NOT REPRODUCE UNDER ANY CONDITIONS
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.
DO NOT REPRODUCE UNDER ANY CONDITIONS