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Impact of Trauma on Adult Children: Mental Health and Addiction

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1 Impact of Trauma on Adult Children: Mental Health and Addiction
Mary F. Hardy, LPC, LADC LIFE Senior Services

2 Objectives: Understand how Adverse Childhood Experiences (ACE) and ACE Scores (ACEs) related to childhood trauma and living with addiction in the home prior to the age of 18 can ultimately impact health, mental health and addiction over the persons lifespan Understand how cumulative childhood trauma and addiction in the family creates imbalance or dysfunction in the family system. Understand the need to provide early identification, intervention and treatment for persons who are affected by cumulative childhood trauma.

3 Adverse Childhood Experiences (ACE) Research
The Relationship of Adverse Childhood Experiences to Adult Health: Turning Gold Into Lead, Felitti, Kaiser Permanente 2002 The Origins of Addiction: evidence from the Adverse Childhood Experiences Study Felitti, Kaiser Permanente 2003 Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use, Dube and Others, Pediatrics 2003; 111;564 Impact of Adverse Childhood Experiences on Health Problems: Evidence from Four Birth Cohorts Dating Back to 1900, Dube and Others, Preventive Medicine 37, 2003.

4 Research Continued The Health and Social Impact of Growing Up with Alcohol Abuse and Related Adverse Childhood Experiences: The Human and Economic Costs of The Status Quo, Anda, Board of Scientific Advisors, National Association for Children of Alcoholics and Co-Principal Investigator, Adverse Childhood Experiences Study, online at A Non ACE Study: Relationship Dynamics Within the Addicted/Traumatized Family System, Tian Dayton, Huffington Post, Posted 9/25/10 02:45 PM ET

5 Adverse Childhood Experiences Study
Decade-long study examine childhood origins of leading health and social problems Collaboration between Centers for Disease Control and Prevention (CDC) and Kaiser Health Plan’s Department of Preventive Medicine Key concept of Study suggests stressful or traumatic childhood experiences are a common pathway to social, emotional, and cognitive impairments that lead to increased risk of unhealthy behaviors, violence, re-victimization, disease, disability and premature mortality.

6 Adverse Childhood Experiences Or ACEs Refer to Growing Up With Any Of The Following:
Abuse: Emotional Abuse Physical Abuse Sexual Abuse Neglect: 4. Lack of Support Poverty Household Dysfunction: 6. Witnessing domestic violence 7. Alcohol/Substance Abuse 8. Mental Illness 9. Parental Discord 10.Crime We now know from breakthroughs in neurobiology that ACEs disrupt neurodevelopment and can have lasting effects on brain structure and function—the biologic pathways that likely explain the strength of the findings from the ACE.

7 Conceptual Framework Of The
ACE Study We found that ACEs are common, even in a relatively well educated population of patients enrolled in one of the Nation’s leading HMOs. More than 1 in 4 grew up with substance abuse and two-thirds had at least one ACE! More than 1 in 10 had 5 or more ACEs! And we found that ACEs are highly interrelated. In order to assess the relationship of the ACEs to health and social problems we developed the ACE Score, 3 which is a count of the number of ACEs designed to assess their cumulative impact on childhood development and therefore, their impact on a variety of health and social priorities in our country. What we found, using the ACE Score, stunned us even more. As the ACE Score increases so does the risk of numerous health and social problems throughout the lifespan . These problems are a “Who’s Who?” list of problems that encompass the priorities of many agencies, public and private, that are working to prevent and treat a vast array of problems. A summary of the problems strongly associated with the ACE Score follows

8 ACEs Are Common Prevalence of Adverse Childhood Experiences (ACE) Original Study CDC Website: ACE Category Women Men Total N=9, N=7, N=17,337 Abuse Emotional Abuse (#1) Physical Abuse (#2) Sexual Abuse (#3) Neglect Lack of Support (#4) Poverty (#5) Household Dysfunction Witnessing Domestic Violence (#6) Household Alcohol/Substance Abuse (#7) Household Mental Illness (#8) Parental Separation or Divorce (#9) Crime or Person in Household Incarcerated (#10) 13.1 7.6 10.6 27.0 29.9 28.3 24.7 16.0 20.7 16.7 12.4 14.8 9.2 10.7 9.9 13.7 11.5 12.7 29.5 23.8 26.9 23.3 19.4 24.5 21.8 5.2 4.1 4.7 4000 in study 17,337 responded Average Age 50 Results statistically significant at plus or minus 05 level

9 Prevalence of the ACE Score by Gender:
Number of Adverse Childhood Experiences (ACE Score) Women 34.5 Men 38.0 Total 36.1 1 24.5 27.9 26.0 2 15.5 16.4 15.9 3 10.3 8.6 9.5 4 or More 15.2 9.2 12.5

10 ACE Score - General Findings
Cumulative impact of multiple exposures can be captured in an “ACE Score” ACE score has strong, graded relationship to numerous health, social, and behavioral problems throughout a person’s lifespan Adverse childhood experiences (ACEs) are common 1 in 4 grew up with substance abuse More than 10% had 5 or more ACEs ACE- related problems tend to be co-morbid or co-occurring

11 ACES Have A Strong Influence On:
Adolescent Health Teen Pregnancy Smoking Alcohol Abuse Illicit Drug Abuse Sexual Behavior Mental Health Risk of Re-Victimization Stability of Relationships Performance in the Work Place This vast array of problems that arise from ACEs calls for an integrated, rather than a separate or categorical perspective of the origins of health and social problems throughout the lifespan. This approach to growing up with alcohol abuse and related ACEs, and to the consequences of exposure to them, may unify and improve our understanding of many seemingly unrelated health and social problems that tend to be identified and treated as categorically separate issues in Western society. Development of more integrated approaches will likely contribute to more meaningful diagnoses, improved treatment of affected persons, and better integration of research priorities, preventive and social services, and legal venues.

12 ACEs Increase The Risk Of:
Heart Disease Chronic Lung Disease Liver Disease Suicide Injuries HIV and STDs And Other Risks For The Leading Causes Of Death

13 Same ACE data from original study
The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study, Felitti, Kaiser Permanente 2003 Same ACE data from original study Added look at ACE Score vs. Adult Alcoholism Looked at Vietnam Veteran Data Many Veterans used heroin regularly in Vietnam Only 5% of those considered addicted were still using 10 months after their return – Why? ACEs Suggests Smoking, Alcoholism And Injected Drug Use As Coping Mechanisms To Get Relief

14 ACE Score vs. Smoking Cigarette smoking is the leading cause of preventable morbidity and mortality in the United States. Unfortunately, as with initiation of alcohol use, ACEs increase the likelihood of early smoking initiation.

15 Ace Score vs. COPD Moreover, ACEs lead to continued smoking and the risk of Chronic Obstructive Pulmonary Disease (COPD; one of the 10 leading causes of death in the US).

16 Prevalence of ACE Continued
ACEs of 4 or Higher Result in Increase Prevalence of Intravenous Drug Abuse and Depression ACEs of 4 or Higher Result in Increased Suicide Attempts; 2/3rd of Attempts May Be Attributable to ACEs ACEs of 6 or More Has a 4,600% Increase in Likelihood of Later Becoming an IV Drug User When Compared to an ACE Score of 0

17 ACE Score vs. Intravenous Drug Use

18 ACE Score vs. Attempted Suicide
Depression is now recognized to be a leading cause of disability worldwide, and ACEs bear a strong relationship to this common mental health problem; the relationship is equally strong for both men and women.15 Suicide is a leading cause of death in the US with a “bimodal” age pattern of attempts—one peak in adolescence and one in middle age. Here also, ACEs have a powerful graded relationship to the risk of suicide attempts; this holds for attempts by men and women and attempts during adolescence or adulthood. By now it should be obvious that the long term human costs of ACEs are enormous and that the problems associated with these problems also translate into costs of health care, disability, and social services. Now, let’s turn to two examples where the costs—in economic terms—are most obvious.

19 ACE Score vs. Adult Alcoholism
One of the strongest relationships seen was between the ACE score and alcohol use and abuse. Given recent research indicating the negative impact of alcohol use on neurodevelopment of adolescents, the relationship of ACEs to early initiation of alcohol use is particularly worrisome. The negative health and social consequences of alcohol abuse and alcoholism constitute a major public health problem—and ACEs have a particularly strong association with alcohol abuse. In addition, it is notable that the perpetuation of the cycle of alcohol abuse appears to be tightly interwoven with the number of ACEs, including marriage to an alcoholic.

20 Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use
2003 Retrospective Study – N=8,613 found ACEs Correlates With Early Adolescent Drug Initiation Initiation by Age 14 increases the Adulthood Risk of Illicit Drug Use 2-4 Fold Risk Appears Stratified by Birth Cohort For Lifetime Use – 5 or More ACEs – 4.3% – 20.8% – 56.8% – 57.7%

21 Research Included Exposure Over Age 18, Versus the ACEs (Under 18).
A Descriptive Epidemiology of Lifetime Trauma and the Physical Health Status of Older Adults (Not An ACE Study) Research Evaluated Exposure to 22 Trauma Events Over the Life Course by Age Cohort Research Included Exposure Over Age 18, Versus the ACEs (Under 18). Findings Indicated Older Adults Experience Cumulative Exposure to Trauma Over Their Lifetime Valuable Research – Although they were looking at the affects of cumulative exposure to trauma on health, research gives us important information that has implications for trauma, substance abuse across the lifespan. This research revealed that trauma is associated with worse health in older adults. How traumatic events may influence physical health: Affect a persons ability to develop and maintain personal relationships Lowers a sense of control and mastery Traumatic events, such as family violence, are associated with health risk behaviors in later life, including the use of alcohol and drugs (Davis, Combs-Lane & smith, 2004) – Exposure to stressors compromise the immune functioning (McEwen and Lasley, 2002) Study, examines 6 questions regarding trauma and health

22 Lifetime Exposure To Trauma Examples - Ages 65-85+ (N=1,518)
TRAUMATIC EVENT Spouse died Child died At or near birth Major fire, flood, earthquake, natural disaster Fired a weapon in combat Sexual abuse or assault Physical abuse or assault Addiction in the family Parent dies or divorces before you are age 18 % of Sample % % % Some examples above . interviewed how often older people experienced each of 22 traumatic events at any point in their life. Examine cohort variation Cumulative measure of exposure to trauma across the lifespan with indicators of physical health status Global self-rated health Acute and chronic conditions Functional disability Lifetime trauma and health, focusing on developmental age Review impact by age cohort Three Age groups: Depression Cohort Born prior to 1919 World War II Cohort Post War Cohort

23 SAMHSA, Treatment Episode Data Set (TEDS) (From 1992-2008 – Age 50+),
SA Treatment Admissions more than doubled from 6.6% in 1992 to 12.2% in 2008 Age 50+ Alcohol Admissions Decreased from 84.6% to 59.9%, while primary heroin abuse more than doubled (from 7.2% to 16.0%) Age 50 + Admissions of multiple substance abuse tippled from 13.7% to 39.7% Age 50 + Those who initiated use of their primary substance of abuse within the past 5 years were more likely that those in 1992 to have reported prescription pain relievers as their primary substance (25.8% vs. 5.4%)

24 ACE As Indicator of Effects of Cumulative Stress on (Neuro) Development
Link of childhood maltreatment to long-term changes in brain structure and function involving several interconnected brain regions Prefrontal Cortex Hippocampus Amygdala Corpus Callosum Cerebellum Neuroscientists have linked childhood maltreatment--using experimental animal models as well as case-control studies in humans--to long-term changes in brain structure and function, involving several inter-connected brain regions including the prefrontal cortex, hippocampus, amygdala, corpus callosum, and cerebellum. Numerous publications have documented Prefrontal Cortex Hippocampus Amygdala Corpus Callosum Cerebellum

25 Hypothalamic-pituitary-adrenal axis Monoamine neurotransmitter systems
Early Stress Associated With Lasting Alterations in Stress-Responsive Neurobiological Systems Hypothalamic-pituitary-adrenal axis Monoamine neurotransmitter systems Lasting effects on the developing brain would be expected to affect numerous human functions into adulthood, i.e. emotional regulation, somatic signal processing, substance abuse, sexuality, memory, arousal and aggression Early stress is also associated with lasting alterations in stress-responsive neurobiological systems, including the hypothalamic-pituitary-adrenal axis and monoamine neurotransmitter systems; these lasting effects on the developing brain would be expected to affect numerous human functions into adulthood including (but not limited to) emotional regulation, somatic signal processing (body sensations), substance abuse, sexuality, memory, arousal, and aggression. Hypothalamic-pituitary-adrenal axis Monoamine neurotransmitter systems

26 ACE Captures A Graded “Dose-Response”
ACE appears to capture cumulative exposure to the developing brain to activate stress response This appears to be the pathway by which ACEs exert their neurobiological impact As “dose-response” goes up, risk of problems from adolescence to adulthood also go up Numerous publications have documented a graded or “dose-response” relationship between the number of categories of ACEs (ACE Score) and a wide variety of health and social problems of national importance. I consider the “dose-response” findings quite literally; the ACE Score appears to capture cumulative exposure of the developing brain to the activated stress response, which is the pathway by which ACEs exert their neurobiological impact. This “dose response” relationship is evident in the figures that follow in the next section; as the ACE Score goes up, so does the risk of problems from adolescence to adulthood.

27 A Closer Look at Relationship Dynamics Within the Addicted - Traumatized Family System

28 Source: Tian Dayton, Huffington Post, Posted 9/25/10 02:45 PM ET

29 Family Dynamics

30 Dynamics In The Family System
“No Talk” Rule Trauma Extremes: High Intensity vs. Shutting Down Impulsivity versus Rigidity Despair vs. Denial Enmeshment vs. Disengagement Over Functioning vs. Under Functioning Caretaking vs. Neglect Abuse vs Victimization

31 The Cost of “No Talk” Rules
Defenses such as denial and minimization Resist talking about resulting fear and anxiety Emotions explode into the container of the family (get acted out rather than talked out) Acting out results in temporary relief – nothing gets fixed Walls go up – may blame others Avoid discussion – may not be able to take action Because alcoholic family systems are often steeped in defenses such as denial and minimization, they may actively resist talking about the fear and anxiety they are experiencing. Instead intense emotions explode into the container of the family and get acted out rather than talked out. Though acting out brings temporary relief, it does not lead to any real resolution or understanding, so nothing really gets fixed, mended or amended. Walls go up and battle lines get drawn as family members silently collude to keep their ever widening well of pain from surfacing, blaming it on anything but what's really going on. They avoid talking about their worries, thinking that if they don't get discussed, they aren't really all that bad or might just disappear on their own. Perhaps they worry that talking is a tacit "call to action" that they don't feel ready to take. Because these families are not finding healthy ways of staying on emotional middle ground, they tend to achieve balance by swinging from one end of the pendulum to the other. Their emotions and behaviors seesaw back and forth from 0-10 and 10-0 with no speed bumps in between. They have trouble staying balanced and living within a range of 4,5 and 6.

32 Trauma Extremes: High Intensity vs. Shutting Down
Emotions of fear and high states of stress Often accompanied by living with addiction Ignite fight or flight trauma response Feeling trapped (can not fight or flee to safety) May shut down or freeze to avoid negative emotions Recurrence of fleeing flooded with feelings to shutting down reoccur affect how you p0rocess emotions Emotional see sawing affects thinking, feeling, and behavior of the family How does the dynamic of seesawing between emotional and behavioral extremes get set up? Here is one explanation that grows out of trauma theory. The intense emotions of fear and high states of stress, that so often accompany living with addiction, ignite our natural fight, flight trauma response. They flood the body with adrenaline so that we can prepare to flee for safety or stand and fight. When we can do neither, when fighting seems exhausting and pointless or when children or spouses feel that they are trapped and cannot really get away, which is often the case in pain filled families, we may simply shut down or freeze so that we don't have to feel our intense, negative emotions. Shutting down is our body/mind system trying to preserve itself from overheating, in this case, with too much emotion. Watch any frightened cat, dog or salamander freeze (read: shut down) because it senses danger and you are seeing a natural trauma response. When these swings from feeling flooded with feeling to shutting down, happen over and over again, they can become central to the way we process emotion. Following are some ways in which this see sawing from one emotional extreme to the other, may manifest or creep into in the thinking, feeling and behavior of the family:

33 Impulsivity vs. Rigidity
Impulsive behavior – may be manifested by blame, anger, rage, emotional, physical or sexual abuse, over or under spending and sexually acting out Rigidity - may be manifested by rigid rules or routines or becoming both controlled and controlling Recovery Option – Self regulation of thoughts, feelings and behavior so they fall within appropriate range for the situation Impulsive behavior can lead to chaos, wherein a pain filled inner world is surfacing in action. Painful feelings that are too hard to sit with, explode into the container of the family and get acted out. Blame, anger, rage, emotional, physical or sexual abuse, over or under spending and sexual acting out, are some ways of acting out emotional and psychological pain in dysfunctional ways that engender chaos. Rigidity is an attempt to control or shut down that chaos both inwardly and outwardly. Adults in an addictive/traumatizing family system may tighten up on rules and routines in an attempt to ward off the feeling of falling apart. Or family members may contract in their personal styles becoming both controlled and controlling. Recovery Option: Self regulation is a basic developmental accomplishment that allows the growing child and eventually the adult to regulate their thinking, feeling and behavior so that it is within an appropriate range for the situation they are engaged in.

34 Despair vs. Denial Denial – is a dysfunctional attempt to ward off every growing feelings of Despair. Reality is “rewritten” in an attempt to make it less threatening Cover up anxiety, guilt, resentment and fear Denial replaces honest self-disclosure Despair deepens Denial is a dysfunctional attempt to ward off ever growing feelings of despair. Reality gets rewritten as family members attempt to bend it to make it less threatening; to cover up their increasing anxiety, guilt, resentment and fear. Denial takes the place of honest self disclosure, worries and anxieties are hidden rather than talked about and as a result, despair deepens. Recovery Option: Reality orientation or an ability to live with life on life's terms is an important part of recovering one's balanced sense of self and a balanced orientation toward the world.

35 Enmeshment vs. Disengagement
Enmeshment is a relational style that lacks boundaries and often discourages differences or disagreement or a way of coping with the fear the family is “falling apart” Disengagement is when family members see the solution to keep pain from their inner worlds from erupting and avoid subjects, people, places and situations that might trigger it – isolation. Recovery Option: Balanced relationships (allowing yourself to move in and out of close connection with others in a natural fashion) Enmeshment is a relational style that lacks boundaries and often discourages differences or disagreement, seeing them not as healthy and natural but disloyal or even threatening. Enmeshment can also be a way of coping with the fear that the family is falling apart in which certain family members huddle together for a sense of safety and may develop traumatic bonds. Enmeshed styles of relating formed in childhood tend to repeat themselves in adult relationships. With disengagement family members are seeing the solution to keeping pain from their inner worlds from erupting as avoiding subjects, people, places and things that might trigger it. They retreat into their own emotional and psychological orbits and they don't share their inner worlds with each other. They isolate. Many addicted families cycle back and forth between enmeshment and disengagement, they yearn for closeness but lack the kinds of healthy boundaries that would let them take space, hold different points of view or hang onto a sense of self while in each other's presence and allow others to do the same. Recovery Option: Balanced relatedness is neither a withdrawal from another person nor a fusion with them. It allows each person their own identity and to move in and out of close connection in a natural, modulated fashion.

36 Over Functioning vs. Under Functioning
Over Functioning – may wear many hats to maintain order (while the addict goes in and out of “normal” functioning) Under Functioning – may be associated with learned helplessness is part of the trauma response. Recovery Option: Balanced functioning is the obvious in between over and under-functioning. Over functioning can wear many hats; spouses may over function to maintain order and "keep the show on the road" while the addict falls in and out of normal functioning. Children may over function, taking care of siblings when parents drop the ball. Or they may work over time striving to restore order and dignity to a family who is becoming increasingly neglectful, irresponsible or strange. In a maladaptive attempt to maintain family balance, some family members may over function in order to compensate for the under functioning of others. . Under-functioning may be associated with the learned helplessness that is part of the trauma response, in which one comes to feel that nothing they can do will make a difference or make things better, so they give up. Family members may freeze like deer in the headlights, unable to mobilize, think clearly or make useful choices. It is also not uncommon, that the addict themselves, along with others in the system, may do both, over functioning to make up for periods of under functioning. Recovery Option: Balanced functioning is the obvious in between of over and under-functioning. When we do what is appropriate to the circumstance and when we have conscious choice around the degree to which we function.

37 Caretaking vs. Neglect Caretaking – can be an attempt to attend to, in another person, what needs to be attended to within the self. We cant see the real need within another person because we can’t identify the real need within ourselves. Neglect – Thinking they have too many needs to meet and mistrustful of deep connection – may push away others that might help – mainly relationships Recovery Option: Balanced care of self and others is a part of healthy life Caretaking can be an attempt to attend to, in another person, what needs to be attended to within the self. We project our own unconscious anxiety or pain onto someone else, seeing it as about them rather than understanding it as our own. Then we set about fixing in them what actually may need fixing in us. It is a form of care that is all too often motivated by our own unidentified pain rather than a genuine awareness of another's. Because this is the case, neglect can be its dark side. We neglect or don't see what is real need within another person because we can't identify real need within ourselves. Neglect can take the form of ignoring or not seeing another's humanness, withholding care, nurturing and attention or a shutting down of the relational behaviors that reflect attunement and connection. Neglect can be particularly difficult to address in recovery because there is no obvious parental abuse to point to. Clients are left feeling that they have too many needs for anyone to meet and are often mistrustful of deep connection. Consequently, they may push away the very vehicle that might help them to heal, mainly relationships. Recovery Option: Balanced care of self and others is part of living a healthy life.

38 Abuse vs. Victimization
When individuals can’t process personal pain, they are at risk of acting it out instead. Sometimes roles become stratified and obvious abuser and obvious victim Abuse and Victimization are roles that often get passed down inter-generationally. Recovery Option: Learn or relearn the skill of emotional regulation When individuals are unable to process personal pain, anger and hurt and talk it out, they are at risk for acting it out instead. Generally these roles are traded back and forth many times within the same interaction as family members bully and hurt each other over and over and over again. Sometimes the roles become stratified and certain family members become the obvious abuser while others become the obvious victim, certainly small children are sitting ducks for being abused and victimized by out of control parents and older siblings. Both roles can become personality styles or relationship dynamics that get carried along through life. Abuse and Victimization are roles that often get passed down inter-generationally, the abused child or the victim, is at risk, without recovery, of becoming an abusing parent. Rather than identifying and feeling their own helplessness and rage at being a victim of abuse, for example, they act out their childhood pain by passing it on in the form in which they received it,(e.g. the abused child becomes the abusive parent) or in an opposing form (e.g. the abused child becomes either the over distanced or over controlling parent). At the center of abuse is the inability to sit with and process painful emotions, abuse is acting out pain at another person's expense. Recovery Option: Emotional modulation is a skill that we learn literally in our parents arms and within our family systems. When children have extreme emotional responses they are "wooed" back into emotional balance through the nurturing and sustaining actions of parents and caring adults. Over time they absorb the skills of self regulation through these family interactions. As we see in this article the opposite is also true, we can equally learn the skills of emotional disregulation if we live with disregulated patterns for long enough. The good news is that the skills of regulation can be relearned in recovery through regulating activities like twelve step programs, therapy, meditation, yoga, massage, deep breathing and exercise; activities that quiet and soothe the emotional system and teach skills of mind/body regulation.

39 What Adult Children Have in Common With The Identified Addict
Self-Delusion or Denial Compulsive Behavior Frozen Feelings Low Self-Esteem Medical Complications Adapted from Sharon W. Cruz – Another Chance Self-Delusion or Denial - Identified client and family members both in denial. Compulsive behavior - Identified client tries to control chemical use; family member tries to control dependent. Both attempt to control what they can not control. Frozen Feelings – Not in touch with their feelings – “Don’t think, don’t feel, don’t talk.” Low Self Esteem – A result of guilt (using drugs, breaking values, not being able to control dependent) Medical Complications – A result of drug use OR for family stress related illnesses, eating disorders.

40 Common Stratified Family Roles
Dependent Enabler Hero Scapegoat Lost Child Mascot Can play multiple roles Can play different roles over their lifespan We will take a look at each of these roles.

41 Dependent Shame Motivating Feeling Chemical Use Identifying Symptoms
Relief of Pain None Addiction Motivating Feeling Identifying Symptoms Payoff for Individual Payoff for Family Possible Price INSIDE: Pain & Shame OUTSIDE: Blaming, withdrawal & perfectionism Role of Dependent: Repressed feelings Medication of Feelings Feelings of inadequacy Anger Fear Guilt Hurt Perfectionist (critical, demanding, rigid) Uses chemicals to get relief Blames others Blackouts distort memory Unkept promises Feels threatened, frightened Withdraw/isolation Problems in marriage Inside: Pain and Shame Outside: Blaming, Withdrawing, Perfectionism

42 Enabler Anger Motivating Feeling Powerlessness Identifying Symptoms
Importance; self-righteousness Responsibility Illness; “martyrdom” Motivating Feeling Identifying Symptoms Payoff for Individual Payoff for Family Possible Price INSIDE: Pain, Anger OUTSIDE: over responsible, low self-esteem, powerlessness Enabler – the person closest to the dependent is the first to be effected by the illness. They say things like “Can’t you see what you are doing to yourself?” They begin to protect, enable and keep secrets. Enabling - is standing between the dependent person and their crisis. Enabler has fear that if they say what they believe or confront, the dependent will leave. Prime Enabler - Anger is the prime feeling kept inside – usually the spouse. If dependent is a child, usually one or both parents. If single, a good friend or co-worker. They keep feelings inside and find some way to compulsively get relief. They feel a lot of anger and shame, a super worker, and often develop physical illness (ulcers, headaches, backaches, stomach problems or stress related illnesses). They tend to be over responsible, not wanting people to know, hide the pain. They are in physical and emotional pain most of the time, especially if they get most of the blame. Inside: Pain, Anger Outside: Over responsible, Low Self-Worth, Powerlessness 4 specific behavior patterns of children Oldest child – Hero Scapegoat Mascot Lost Child

43 Hero Motivating Feeling Identifying Symptoms Payoff for Individual
Payoff for Family Possible Price INSIDE: inadequacy, guilt OUTSIDE: overachiever, performance driven, works for approval Inadequacy; guilt Overachievement Attention (positive) Self-worth Compulsive drive Usually the oldest child is the Hero Relates most often with Prime Enabler (also called the Grand Enabler) Has no other automatic peer group – not another child to model after Role is after adult; like a little adult (walk early, take early) Children bond with their parents through their emotions and feelings This child is not able to bond, can not relate on a feelings level as their parents either medicate (CD) or repress feelings (Enabler) Child learns to hold feelings inside and finds other behavior to give relief to feelings Child tries harder to do well (overachiever, performance driven, works for approval, involved in sports, has good grades, sports, etc) Child’s performance can’t change the Chemically dependent Child feels inadequate and guilty Child can’t sort out what’s going on no matter how hard they try, they can’t change Child feels guilty when they are experiencing feeling happy Smaller children in this role, try to be good, listen, become performance driven in sports and try to have great accomplishments to make up for the lack of emotional closeness This child compulsively works to feel worthwhile – and their success is a sign to the family that they are OK. Everyone thinks this child is doing well because of their performance, but they are emotionally hurting inside – rarely are this child’s needs met. The more successful they are, the more they turn off their own feelings. They tend to go into the helping profession (1 in 4), marry alcoholics or CD or have children that are alcoholic or CD. They bring self worth to the family; but INSIDE they feel guilty and inadequate, while OUTSIDE they work for approval, are successful and perceived as a “good kid.”

44 Scapegoat Motivating Feeling Identifying Symptoms
Payoff for Individual Payoff for Family Possible Price INSIDE: Hurt OUTSIDE: Delinquency, peer acceptance, low achiever, defiant Hurt Delinquency Attention (negative) Focus away from Dependent Think about the dysfunctional family and how you would see yourself fitting in, your worth to the family – how would you feel? Child feels hurt and angry, can never measure up to the first born or Hero – parents usually bragging about the Hero Child acts out to get attention – if you can’t get positive attention you will get negative attention – attempting to hang on to any self worth they can get – perceived as “bad kid” Child follows his/her role models and doesn’t talk about their feelings Peer group serves as pseudo-family - offering some acceptance and short-term relief for emotional pain At highest risk for CD (becomes excellent counselor when in recovery) If female, may become pregnant (gets parental attention, gives them something to love) Low achiever, defiance builds (almost always a cover up for hurt) High suicide risk Frozen tears – stay in their eyes INSIDE: Hurt OUTSIDE: CD, peer group, low achiever, defiance

45 Lost Child Motivating Feeling Identifying Symptoms
Payoff for Individual Payoff for Family Possible Price INSIDE: Loneliness OUTSIDE: Shy, loner, physical illness, treasures pets & things Loneliness Solitariness; shyness Escape Relief Social isolation This child can’t connect Stay busy Shy, loner, withdrawn Has problems in school Not able to relate well to others Low self-worth Problems in school; but often very bright Treasures things (pets, possessions) Escapes - Avoids stress; i.e., argument at dinner table – goes and reads a book Relief for family - the child is not a problem and they don’t worry about them. INSIDE: Loneliness, inability to share, bed wetting, asthma, stress related illnesses (may become sexually active to make up for lack of emotional intimacy) OUTSIDE: Treasure pets and things, shy (avoids people), loner, physical illness

46 Mascot Fear Motivating Feeling Clowning; hyperactivity
Attention (amused) Fun Immaturity; emotional illness Motivating Feeling Identifying Symptoms Payoff for Individual Payoff for Family Possible Price INSIDE: Fear, confused OUTSIDE: Humor, attention seeking, slow learner Most often the mascot is the youngest or younger child. Family members try to protect this child Child feels confused and doesn’t know what is going on Child likely to have phobias, trust issues adnfear of being abandon Behavior: humor, teasing, acting out to get attention, clowning – often misdiagnosed as ADD or hyperactive Is a poor learner, has problems concentrating and at high risk for using sedative drugs. INSIDE: Fear OUTSIDE: Humor, attracts attention (silly, clown, act out), slow learner

47 There is HOPE for the family
Families and Recovery Family members may continue their dysfunctional behavior in order to try to cope and/or feel safe OR They may get into treatment and recovery themselves Family members can and do recover. They need to be involved in primary treatment and get counseling for their own health, mental health and substance abuse issues, including past trauma. Important aspects of recovery that help especially where there is a history of trauma include 12 step programs, therapy, meditation, yoga, massage, deep breathing and exercise: activities that quiet and soothe the emotional system and teach skills of mind/body regulation. Family members in recovery can begin to reconnect and move toward balance and harmony in their lives. There is HOPE for the family 47

48 ACEs Calls For Integrated Perspective of Health and Social Problems Throughout The Lifespan
The results of the ACE study call for an integrated approach to intervene early on children growing up with alcohol abuse in the home and the abuse, violence, neglect that frequently co-occur in these homes. Prevention and treatment of one ACE frequently can mean that similar efforts are needed to prevent and treat multiple persons in affected families.

49 Our Job as Professionals
Identify the impact of family dysfunction and trauma across the life span Recognize the far reaching effects of childhood stress and trauma in the family system Provide primary prevention, intervention and treatment to impacted family members across the life span Don’t allow family members to become a “lost child” in the recovery process

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51 Questions & Discussion
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