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Denise U. Tordella, M.A., LPC www.denisetordella.com.

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Presentation on theme: "Denise U. Tordella, M.A., LPC www.denisetordella.com."— Presentation transcript:

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2 Denise U. Tordella, M.A., LPC www.denisetordella.com

3 Understand the consequences of substance abuse and sexual compulsivity on the individual’s ability to manage and resolve trauma Understand the relationship between exposure to trauma and co-occurring disorders, including depression, anxiety, PTSD, dissociation and addiction Identify the trauma-related addiction needs of clients Learn about assessment and integrated addiction treatment strategies for individuals affected by trauma Identify creative body-oriented treatment strategies and modalities to regulate arousal level and modulate affect to reduce the use of addictive behavior 2

4 The conventional definition often focuses on traumatic events or bad things that have happened but the deeper trauma is the absence of love, affection, care and protection. The bigger trauma is not feeling important or special. (Colin Ross, 2000) 3

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8 Substance Abuse: 12%-34% of men in treatment meet diagnostic criteria for PTSD. For women, rates are 33%-59%. 80% of women with substance abuse disorders are survivors of domestic violence. Sexual Compulsivity: 25% of individuals treated for chemical dependency also meet criteria for sexual compulsivity; 78% of men have history of sexual abuse. (Stavro, 2013) 7

9 It is estimated that Hypersexual Disorder occurs in 3 – 6% of the general population and co-occurs with substance abuse in 25% of individuals seeking substance abuse treatment. (Coleman, 1992; Carnes, 2006; Stavo, Chiasson, Potvin, 2013) PTSD usually precedes the substance abuse. 8

10 Trauma induced alterations in biological stress systems can adversely affect brain development, cognitive and academic skills, and language acquisition. These changes may affect the way children and adolescents respond to future stress and may impact their long-term health Traumatized children and adolescents display changes in the levels of their stress hormones similar to combat veterans. 9

11 To forget, numb, avoid, create distance, escape physical or emotional pain, reduce anxiey Provide excitement, comfort, aid in sleep (actually worsens REM) To escape aversive bodily states, build courage, ease social anxiety, withdrawal, dissociate (wall off memories… a part of me uses) To self sooth, calm, reassure a fragile sense of self To make connections with partner, others To access negative feelings, rather than dissociate from them (Covington, 2010; Fisher, 2011; Najavits, 2012) 10

12 Hyperarousal: activation exceeds capacity to integrate Window of Tolerance Regulated arousal Dysregulated arousal Hypoarousal: insufficient activation to integrate (Siegel, 1999; Ogden, Minton & Pain, 2006)

13 Hyperarousal Symptoms: Marijuana and Alcohol: induce relaxation, numbing, act as a “chemical barrier” to traumatic memory, facilitate social engagement by decreasing hypervigilance, enhance mood Speed and Cocaine: increase alertness, sense of power and control to counteract feelings of helplessness Heroin: Most effective drug for regulating the CNS – dampens rage, impulsivity, profoundly numbing (Fisher, 2011) 12

14 Hypoarousal Symptoms: Heroin and Marijuana: induce numbing, bring both hypoarousal and hyperarousal symptoms under control Speed and Cocaine: counteract feelings of deadness, hopelessness, weakness Alcohol: at different doses, it either induces numbing or counteracts it. It is a stimulant in small doses and a depressant in larger doses (Fisher, 2011) 13

15 Makes trauma symptoms worse Prevents client from increasing knowledge of self Does not facilitate client getting needs met Stalls emotional development Isolation Interferes with learning tools to cope with feelings Eliminates / reduces control Impacts sleep Increases negative feelings related to self-worth Impairs physical, emotional, spiritual health 14

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17 Addiction is a chronic disease of the brain affecting the reward/motivation/memory systems Addiction is defined as including process addictions such as eating, sex and gambling At its core, addiction is not a social or moral problem, but a brain problem (Miller, 2011) American Society of Addiction Medicine (2011) 16

18 Substance Use Disorders Depression Anxiety Disorders Sexual Dysfunction Eating Disorders Self-Injuring Behavior Medical Disorders Dissociative Disorders Axis II 17

19 Substance abuse often does not occur in a vacuum. A multitude of addictions such as drugs and alcohol, food, sex, work, gambling, internet and gaming not only exist but interact,reinforce and fuse becoming part of a package known as addiction interaction disorder. (Carnes, 2011) “Neurons that fire together wire together.” (Seigel, 1999) 18

20 Gambling Disorder is now in a class of “behavioral” addictions. According to APA, this change reflects the increasing evidence that behaviors such as gambling activate the brain reward system with effects similar to drugs of abuse and resemble substance use disorders to a certain extent. Hypersexual Disorder (HD) did NOT make the new DSM-5. 19

21 Links between hypersexual behavior and internalizing disorders like anxiety and depression Theoretical similarities with compulsive disorders like OCD Classification as a sexual disorder (Kafka, 2010) Classification as a behavioral addiction and classified within a category of non-substance or behavioral addictions (Winters, et. al., 2012) 20

22 Preoccupation Repetitive engagement Efforts to Control Fail Disregards risks to self and others Present for at least 6 months Individual is at least 18 years old (Kafka, 2010) 21

23 Urges, behaviors combined with personal distress Uncontrollable sexual fantasies Diminished control and increased negative consequences Damage to self and others - divorce Financial consequences Health risks – STD’s and AIDS, oral HPV, unintended pregnancies Occupational and/or financial difficulties 22

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25 1.I spend more than 5 hours a week using my computer for sexual pursuits. 2.I have some sexual sites book marked. 3.I have participated in sexual chats. 4.I have masturbated while on the Internet. 5.I have tried to hide what is on my computers so others don’t see it. Limitations – honesty in reporting, denial due to lack of consequences (especially teens) 24

26 1.Do you feel your sexual behavior (SB) is normal? 2.Do you ever feel bad about your SB? 3.Has your SB caused problems for you or your family? 4.Has anyone ever been hurt emotionally because of your SB? 5.When you engage in SB do you feel depressed afterward? Limitations – asks about more severe forms of acting out and puts weight on “feelings” of test taker SAST 25

27 6.Have you ever cruised public areas looking for sex with strangers? 7.Are you in crisis over your SB? 8.Have you been paid for sex? 9.Have you regularly engaged in sadomasochistic behavior? 10.Have you engaged prostitutes/escorts to satisfy your daily sexual needs? Limitations – Denial: “I only scored 2 so there no is issue” 26

28 CAGE Have you ever… Tried to Cut down on drinking Felt Annoyance with criticisms about drinking Felt Guilt about drinking Used alcohol as an Eye opener Emotional discomfort such as anger, sadness or boredom MAST – Minnesota Alcohol Screening Test ASI – Addiction Severity Index 27

29 Have you ever drank or Used drugs more than you intended? Have you ever Neglected some of your usual responsibilities because of alcohol or drug use? Have you ever felt you needed to Cut down your drinking or drug use? Has anyone ever Objected to your drug or alcohol use? Have you ever found yourself Preoccupied with wanting to use alcohol or drugs? Have you ever used alcohol or drugs to relieve ______? 28

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31 “The brain is the source of behavior, but in turn it is modified by the behaviors it produces… …Learning sculpts brain structure.” (Zatorre, et. al. 2012) 30

32 Dopamine will send an addict chasing after whatever substance or behavior spells relief. It can change the brain by narrowing the field of synaptic change, focusing it on one particular reward forming a rut or intractable path. (Lewis, M. (2011) Memories of an Addicted Brain) 31

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35 Other life problems are common Trauma does not go away with abstinence Separate treatment systems Single gender treatment not always available but superior for female clients (Grosenheck & Hatmaker, 2000; Covington, 2000) 34

36 Treatments (e.g., exposure, twelve-step groups, benzodiazepines) helpful for either disorder alone may be problematic if someone has both disorders. Also, some messages in substance abuse treatment may be problematic: “hitting bottom” “confrontation” “clean vs. dirty” Fragile treatment alliances and multiple crises are common. 35

37 Denial - easy to maintain and there are often no consequences early on (especially in teens) so there is no motivation to seek help. Overculture – Normalizes excessive behavior … any limits perceived as repression Teens – Impulsivity, frontal lobe not fully developed until mid 20’s 36

38 1.Thorough assessment, psychoeducation 2.Support – 12 step group, spiritual or secular community to foster connection, commitment 3.Trauma history/treatment – stages 4.Abstinence from self-destructive behaviors, relapse prevention 5.Affect management skills 6.Expanding purpose/new pleasures 7.Medication/Nutritional management 37

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40 1.Increase mindfulness 2.Increase the ability to self-regulate trauma related emotions and body sensations 3.Increase the ability to self-regulate addictive behavior (notice the feelings rather than be the feelings, understand how to ride through triggers, develop somatic skills to anchor and regulate) 4.Create a supportive protective inner self as well as a recovery network of support. 5.Reduce shame (Fisher, 2011) 39

41 Hope, Compassion, Information Access strengths (IFS) and prior successes Set small achievable goals (treatment plan) Promote strong relationships with (safe) friends and family Teach Sensorimotor Psychotherapy™ techniques to develop capacity to self-soothe Encourage participation in scheduled activities Draw on spiritual and religious beliefs for comfort and perspective Foster appreciation of new strengths, skills, gains, insight (Victory List) Find new passions and rewards 40

42 Create a Safety Plan – teach clients to cope with feelings and impulses, create action plans Develop a Coping Skills Chart Create a Coping Box CARESS Model (Ferentz, 2012) Healing Circle using EMDR (Schmidt, 2009) Resource Refocusing using EMDR (Kiessling, 2007) Addictions Protocol in EMDR (Popky, 2007) 41

43 EGO State Model (IFS) Psycho-ed MI DBT EMDR Somatic Work SP/SE Art Music Imagery Yoga Movement Structural Dissociation Model 42

44 Sobriety or Abstinence panicked attempt at self-regulation loss of “chemical support” increased negative effects of addiction matches increase in PTSD symptoms irritability, reactivity, emotional overwhelm, increased traumatic activation, or flooding Copyright 2007, Janina Fisher, Ph.D. Increase in PTSD symptoms Increased acting out, unsafe behavior Substance or behavioral relapse or “slip” Increase in addictive impulses or pre-relapse behavior 43

45 How is this “slip” a golden opportunity… what did I learn from this? What “message” is this “slip” trying to send to me? What might be the legacy of that behavior? “That 16 year old learned that drinking numbed the pain of not belonging and feeling unlovable.” (Fisher, 2011) 44

46 Improve memory – working memory impairments most damaged in addicts AA – step work, repetition Planning out the week day by day Prospection – mental time travel – imagine you are given $100... write down everything you could buy. Imagine you are in Target – tell me what you see, experience it – mentalizing… Medication – Naltrexone, Vivitrol, Suboxone Sober Link – sobriety test at random 45

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48 A body oriented therapy developed by somatic pioneer Pat Ogden. This therapy approach blends talk therapy techniques with body centered interventions that directly address the implicit memories and neurobiological effects of trauma. Body observations and sensations are the primary entry point in therapy. (Ogden, 2002) 47

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50 Hyperarousal: activation exceeds capacity to integrate Window of Tolerance Regulated arousal Dysregulated arousal Hypoarousal: insufficient activation to integrate

51 55% of emotional messages conveyed through facial expressions and the body 38% is communicated through the rhythm of the voice 7% is communicated through words (Mehrabian) 50

52 1.You have a body! 1.Develop body awareness and ability to link thoughts  feelings  to body sensation Example: “When I feel confident, I notice it in the way I stand, my shoulders are back and my spine feels straight. The sensation feels strong and solid.” 51

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57 You can’t do good recovery work unless you talk about underlying shame Know when they are in shame – have physicality associated with it. Feel 1 st shame at 14 months Silence, secrecy, judgment – 3 things that grow shame When something happens are you more likely to use guilt or shame self-talk? 56

58 Reframing – I can see why you feel shame about that, rethinking from a compassionate self Confronting – “I wonder what you might say to a good friend who experienced that?” Self-disclosure – (with good boundaries) “I’ve had days like that too. When I was your age…” (Brown, 2012) 57

59 “When people get close to re-experiencing their trauma, they get so upset that they can no longer speak… Fundamentally, words can’t integrate the disorganized sensations and action patterns that form the core imprint of the trauma… [In order] to do effective therapy, we need to do things that change the way people regulate these core functions, which probably can’t be done by words and language.” (van der Kolk, 2006) 58

60 Body sensations (tight, warm, tingly, open) Emotions (positive and negative feeling tones – angry, overwhelmed) Five-sense perception (sight, taste, smell, touch, hearing) Movement (voluntary, involuntary, gross motor and micro movements) Thoughts (cognitions) (Ogden & Minton, Pain, 2006) 59

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62 Safety as the priority: Discontinuing substance abuse / compulsive, self-harming behaviors Decreasing suicidality Minimizing exposure to HIV Letting go of dangerous relationships, Gaining control over extreme symptoms Every session addresses both substance abuse and PTSD 61

63 The Body Keeps Score: Bessel van der Kolk The Body Remembers: Babette Rothschild Focus on client’s body sensations. Increase awareness of client’s physical processes. Assess whether client is being triggered or hyper-aroused. 62

64 Muscle tension or tightening Clenching Changes in rate or depth of breathing Changes in heart rate Achy feeling Sharp or dull pain Nausea / stomach pain Change in body temperature Tingling / Numbing Heaviness / Immobility Lump in throat / difficulty swallowing Falling / going limp Shaking / trembling 63

65 Develop present focused awareness Sight Sound Taste Smell Touch Use Grounding Kits Learn to identify and scale feelings Enhance ability to choose how to respond (rather than react) based on goals and values, rather than transient feelings 64

66 Cognitive Distortions Denial Rationalizing Blaming Mind reading Emotional Reasoning Labeling Over-generalizing Magnifying Minimizing Dichotomous thinking (Beck, 1976) 65

67 Mental Grounding Play categories game Describe an everyday activity in great detail Say a safety statement Read something aloud Count to 10 Recite the alphabet (Najavits, 2002) 66

68 Physical Grounding Run cool or warm water over hands Grab tightly onto chair Touch surrounding objects Dig heels into the floor Carry a grounding object Jump up and down Stretch Clench and release muscles Walk slowly, noticing each footstep Eat something, describing the flavors out loud Focus on breathing (Najavits, 2012) 67

69 Soothing Grounding Say kind statements Think of favorites Picture people you care about Recite the words to an inspiring song, quotation or poem Describe your safe place Say a coping statement Plan a safe treat Think of safe things that you are looking forward to doing (Najavits, 2002) 68

70 Art Therapy Drawing, painting, creating collages, sculpting with clay/model magic Journaling “Taking notes during session”, writing poetry, prose, journaling Mapping Creating a visual roadmap of therapeutic issues Two handed dialogues Guided Imagery 69

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72 (Lilly & Hedlund, 2010) Protocol of 8 weeks including yoga postures, mantras, breath work, creative activities and mindfulness. 71

73 Trauma Sensitive Yoga – Hanson & Hopper (2011) Life Force Yoga – Weintaub (2004) Yoga Warriors – Cimini (2011) 72

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75 Seated Mountain Pose – Core Posture Seated Sun Breathes – lift hands up in arc…palms down Seated Sun Breath Variations: A.Palms at center – extend arms to side…as you exhale palms back to center B.Hand on heart… other on abdomen C.With a twist… D.Forward fold (Emerson & Hopper, 2011) 74

76 Failing to validate the relief offered by addictive behavior Failing to understand the fear of relying on people and the safety in relying on a substance or behavior under your own control Failing to see that care of the body is not a priority for the trauma survivor: when your body only matters as a vehicle for discharging tension, its care becomes meaningless 75

77 Failing to convey that trauma-related shame and secrecy will make it feel “normal” to lie/evade and “unsafe” to disclose Becoming engaged in a struggle in which the therapist becomes the spokesperson in favor of sobriety and the client the spokesperson for addictive behavior, neglecting the task of helping the client to struggle with the strong internal opposing forces Copyright 2006, Janina Fisher, Ph.D. 76

78 Informed consent Awareness of counselor’s issues related to substance abuse and trauma Developing and maintaining boundaries Counselor self-care 77

79 “The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet.” Rachel Remen 78


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