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Psychological Trauma & Addictions Treatment Case Management and Treatment of Trauma Syndromes in Chemical Dependency Treatment Settings Bruce Carruth,

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Presentation on theme: "Psychological Trauma & Addictions Treatment Case Management and Treatment of Trauma Syndromes in Chemical Dependency Treatment Settings Bruce Carruth,"— Presentation transcript:

1 Psychological Trauma & Addictions Treatment Case Management and Treatment of Trauma Syndromes in Chemical Dependency Treatment Settings Bruce Carruth, Ph.D., LCSW San Miguel de Allende, GTO, Mexico Advanced International Winter Symposium Colorado Springs, CO January 31, 2009

2 Neurosis …. “… is the process of shrinking our world to the point where we can manage” (Rollo May, I think) Unresolved trauma causes our worlds to shrink

3 Some initial thoughts about truama 1. Almost everybody experiences a trauma event sometime in their lives. 2. It’s not what happens, it is how we handle what happens that creates trauma. Trauma isn’t an event, trauma is an experience. 3. Since trauma is a personal experience, everybody’s trauma is different. 4. Trauma is, by it’s nature, blindsiding. It happens when we aren’t looking and aren’t It happens when we aren’t looking and aren’t prepared and it strikes where we are vulnerable prepared and it strikes where we are vulnerable

4 Some initial thoughts (con’t) 5. Trauma is a wound to our personhood. We are never the same afterwards. 6. Everyone copes with trauma by withdrawing, by disconnecting. Recovery has to be about reconnecting. 7. Trauma therapy doesn’t change what happened. The therapy focus is on changing who we are today in the face of what happened The therapy focus is on changing who we are today in the face of what happened

5 SOME SPECIFIC LEARNING GOALS FOR TODAY 1. Conceptualize a variety of trauma syndromes 2. That everyone’s trauma is unique in: symptoms symptoms meaning of the trauma in their life meaning of the trauma in their life the process of recovery the process of recovery 3. There is no “best” way to treat trauma syndromes and that treatment has to evolve as the person evolves and that treatment has to evolve as the person evolves 4. Trauma treatment has to address more than symptoms: “ no symptom, no problem” isn’t an answer 5. Recovery requires a variety of healing resources self, therapy, spiritual growth, significant others, a self, therapy, spiritual growth, significant others, a healing community healing community

6 The dimensions of trauma Our reaction to our environment Our reaction to our environment Sensory awareness and perception Sensory awareness and perception amplifications, deletions, distortions amplifications, deletions, distortions Cognitions – cognitive filters Cognitions – cognitive filters Memory Memory Affect and emotion Affect and emotion terror (fear), grief (sadness), rage (anger) & shame terror (fear), grief (sadness), rage (anger) & shame How we manage relationships in our life How we manage relationships in our life trust, commitment, attachment, potency in relationships trust, commitment, attachment, potency in relationships Self and self functions – our sense of who we are as a person – our roadmaps for how to function in life Self and self functions – our sense of who we are as a person – our roadmaps for how to function in life Soul – the experience of being part of something greater than self … attachment / belonging/ commitment / connection to a world larger than self Soul – the experience of being part of something greater than self … attachment / belonging/ commitment / connection to a world larger than self

7 Some different perspectives on trauma treatment Medical perspective trauma as a neuro-psycho-biological perspective trauma as a neuro-psycho-biological perspective Cognitive-Behavioral perspective treatment of trauma by changing cognitions and behaviors treatment of trauma by changing cognitions and behaviors Affect Regulation perspective treatment of trauma by regulating powerful affects treatment of trauma by regulating powerful affects Psychodynamic perspective trauma as a wound to self trauma as a wound to self Interpersonal perspective focuses on the interpersonal wounds of trauma focuses on the interpersonal wounds of trauma

8 Since trauma touches all parts of our being, treatment and recovery have to address all parts of our being … just like addictive illness

9 trauma is ultimately a wound to self “damaged goods” “not the same person” “a part of me was lost” “forever changed” but trauma is also set of symptoms that interfere with living: hyperarousal symptoms: startle reactions, hypervigilance, irritability, misinterpreting the environment, hypersensitivity – problem of keeping the outsides out constriction symptoms: withdrawal, numbing, forgetting, deadening, isolating, holding in – problems of trying to hold the insides in Intrusion symptoms: re-enacting, intrusive memories, reliving, nightmares, preoccupied thoughts – problem of regulating the commerce between our insides and outsides

10 So, what are we treating Treatment starts with managing and treating the symptoms of trauma: (and how trauma manifests in the “now”) symptom management symptom management coping skills coping skills cognitions cognitions “reactive” affects “reactive” affects And then generally needs to proceed to doing “restorative” work that explores the meaning of the trauma experience and “works it through” primary affects primary affects telling the tale and reorganizing experience telling the tale and reorganizing experience core cognitions and schemas core cognitions and schemas building healthy life and relationships - reconnecting building healthy life and relationships - reconnecting

11 Recognizing trauma syndromes 1. When people define their life by trauma events 2. Rigid or inappropriate behaviors in the face of specific events or triggers 3. Ego defense, unconscious to the person that clearly limits functioning difficulty in giving / receiving feedback difficulty in giving / receiving feedback misrepresentations of the environment misrepresentations of the environment misperceptions of self and self-roles misperceptions of self and self-roles deadening, numbing, dissociation (disconnecting) deadening, numbing, dissociation (disconnecting) assigning painful / disowned parts of self to the assigning painful / disowned parts of self to the environment environment

12 Recognizing trauma syndromes (con’t) 4. Distorted affects displaced / distorted / inappropriate affects displaced / distorted / inappropriate affects exaggerated affects (affective overload) exaggerated affects (affective overload) diminishing (repressing) affects diminishing (repressing) affects 5. Psychiatric symptoms depression (sad, angry, nihilistic, anxious) depression (sad, angry, nihilistic, anxious) anxiety (fear, phobias, obsessiveness, withdrawal) anxiety (fear, phobias, obsessiveness, withdrawal) somatization (pain, sleep disorder, appetite disorder) somatization (pain, sleep disorder, appetite disorder)

13 Recognizing trauma syndromes (con’t) 7. Distorted reactions to life events that involve helplessness, vulnerability, constraint, shame, power/control 8. Distortions in relationships: trust, commitment, potency, attachment potency, attachment 9. And by the typical trauma symptoms: intrusion intrusion hyperarousal hyperarousal constriction constriction

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15 the spectrum of psychological trauma 1. Subclinical trauma syndromes: A trauma reaction that doesn’t reach the threshold for a trauma diagnosis. 2. Cumulative childhood trauma: an adaptive response in adulthood to childhood trauma 3. Acute Stress Reaction: A psychophysiological reaction to an overwhelming stimuli. A variation of ASR is Combat Stress Reaction (CSR) 4. Grief Reaction: An inability to experience the emotions of loss 5. Post-Traumatic Stress Disorder(s): A significant wound to an individual’s sense of self / personhood 6. Complex PTSD & Dissociative States: A pervasive and disabling injury to self that produces significant psychiatric complications – often produced by ongoing traumatization or torture. Just because it isn’t in DSM 4 doesn’t mean it isn’t real

16 associated psychiatric disorders we often label trauma syndromes as something else and these disorders are likely to co-occur with trauma disorders adjustment disorders (mislabeled) adjustment disorders (mislabeled) dissociative disorders (co-occurring) dissociative disorders (co-occurring) panic disorder (co-occurring) panic disorder (co-occurring) phobic disorders (co-occurring) phobic disorders (co-occurring) major depressive disorder (both) major depressive disorder (both) dysthymia (both) dysthymia (both) substance use / abuse disorders ( both, but more likely co- occurring) substance use / abuse disorders ( both, but more likely co- occurring) the whole spectrum of personality disorders (both) the whole spectrum of personality disorders (both) The vulnerable are always more vulnerable

17 Trauma is a wound to one’s sense of self Trauma wounds our dignity and integrity Trauma alters our beliefs about ourself & the world Trauma alters our ability to rejuvenate / recuperate Trauma impacts our ability to trust: Self trust and to trust the environment Self trust and to trust the environment Trauma distorts our sense of time and timing Time gets defined by traumatic events Time gets defined by traumatic events Distorts our sense of when to act: hesitancy, impulsivity Distorts our sense of when to act: hesitancy, impulsivity Trauma impacts our sense of connection and soul Family, community, spiritual life Family, community, spiritual life

18 Emotional “symptoms” of trauma A primary effect of trauma is the inability to regulate the affects arising from or contaminated by the trauma RAGE TERROR RAGE TERROR GRIEF SHAME GRIEF SHAME Healing is being able to once again live in the face of these affects

19 trauma and vulnerability trauma strikes the vulnerable person and trauma strikes us where we are vulnerable psychological vulnerabilities psychodevelopmental vulnerabilities psychosocial vulnerabilities … the wounded are always at greater risk of more wounding … wounding …

20 4 variables in trauma vulnerability 1. previous unhealed trauma 2. psychiatric / psychological deficits / disorders 3. unique, idiosyncratic childhood wounding that makes us vulnerable to rewounding as adults 4. lack of resiliencies

21 3 primary symptoms of trauma 1. Hyperarousal, sensitivity 1. Hyperarousal, sensitivity Startle reactions Hypervigilance Startle reactions Hypervigilance Sleep disorders Nightmares Sleep disorders Nightmares Irritableness Irritableness Inability to delete annoying stimuli Inability to delete annoying stimuli Intense reaction to stimuli associated Intense reaction to stimuli associated with the trauma with the trauma

22 Primary symptoms (con’t) 2. Intrusion symptoms Reliving the traumatizing event as if Reliving the traumatizing event as if trauma was reoccurring in the present trauma was reoccurring in the present (every time I close my eyes I see it all over again”) (every time I close my eyes I see it all over again”) Reenacting the trauma event in disguised Reenacting the trauma event in disguised form (repetition compulsion) form (repetition compulsion) Intrusive traumatic memories may be out Intrusive traumatic memories may be out of context to actual trauma experience of context to actual trauma experience (“I keep having thoughts about things I don’t think happened”) (“I keep having thoughts about things I don’t think happened”) and may be encapsulated in one and may be encapsulated in one sensory experience sensory experience (“at night I hear this sound of …..”) (“at night I hear this sound of …..”)

23 Primary symptoms (con’t) 3. Constriction (Numbing and Withdrawing) People will sometimes describe their constriction symptoms as “building a wall” “Numbness” is an early response to trauma: A primary variable in recovery is getting beyond the numbness and disconnection. Feelings become the enemy & numbness is safe Forgetting is a form of constriction The ego defenses of constriction (repression, denial, dissociation, withdrawal, retroflection) are often the most difficult to work with in therapy Phobias may be an unconscious way of avoiding environmental contact

24 so, what are we treating? And when? Managing and treating the symptoms of trauma: (and how trauma manifests in the “now”) (the early recovery work) symptom management symptom management coping skills coping skills cognitions cognitions “reactive” affects “reactive” affects Doing “restorative” work that explores the trauma and “works it through” (when people are more stabilized in recovery) core cognitions and schemas core cognitions and schemas primary affects primary affects telling the tale and reorganizing the experience telling the tale and reorganizing the experience building healthy life and relationships building healthy life and relationships

25 Co-occurring trauma and addiction: approaches to addressing both disorders Sequential treatment treating (stabilizing) one disorder first then treating the other treating (stabilizing) one disorder first then treating the other Parallel treatment treating both disorders at the same time, but with different treatment protocols (and sometimes different agencies and different counselors / therapists treating both disorders at the same time, but with different treatment protocols (and sometimes different agencies and different counselors / therapists Integrated Treatment treating the individual with one master treatment plan, in one setting, addressing the individual’s unique needs treating the individual with one master treatment plan, in one setting, addressing the individual’s unique needs requires that the therapist/counselor and treatment team understand and have the skills to treat both disorders requires that the therapist/counselor and treatment team understand and have the skills to treat both disorders

26 Relative occurrence of trauma disorders SUBCLINICAL TRAUMA SYNDROMES SUBCLINICAL TRAUMA SYNDROMES many people some time(s) in life many people some time(s) in life ACUTE STRESS REACTIONS ACUTE STRESS REACTIONS Almost everyone, some time(s) in life CUMULATIVE CHILDHOOD TRAUMA A significant number of people GRIEF REACTIONS GRIEF REACTIONS A significant percentage (10- 15%) of people A significant percentage (10- 15%) of people POST TRAUMATIC STRESS DISORDER POST TRAUMATIC STRESS DISORDER small percentage of people (4-7%) small percentage of people (4-7%) COMPLEX PTSD AND DISSOCIATIVE DISORDERS COMPLEX PTSD AND DISSOCIATIVE DISORDERS Very few people Very few people

27 Subclinical Trauma trauma that doesn’t incapacitate but lurks around in our life Blindsided by event(s). It strikes where we are vulnerable Blindsided by event(s). It strikes where we are vulnerable We have trouble finding meaning, We have trouble finding meaning, “Why me?”, finding cause doesn’t resolve the issue “Why me?”, finding cause doesn’t resolve the issue We may reject or not accept (recognize) support of others We may reject or not accept (recognize) support of others We feel disoriented (things aren’t the same) We feel disoriented (things aren’t the same) Our feelings are out of proportion (and we know it) to the circumstance, uncomfortable and may be displaced Our feelings are out of proportion (and we know it) to the circumstance, uncomfortable and may be displaced We revert to old coping strategies (smoking, drug use, withdrawing, blaming others, trying to fix “it”) We revert to old coping strategies (smoking, drug use, withdrawing, blaming others, trying to fix “it”) It connects to some vulnerability in our history It connects to some vulnerability in our history The hurt seems to go on and on, we obsess, we keep it in front of us even when it doesn’t need to be The hurt seems to go on and on, we obsess, we keep it in front of us even when it doesn’t need to be Often are a series of events that overwhelm coping skills Often are a series of events that overwhelm coping skills May manifest as transient or “on & off” or ongoing May manifest as transient or “on & off” or ongoing And in the face of all this we keep going and maintain life on a day-to- day basis And in the face of all this we keep going and maintain life on a day-to- day basis

28 Treating subclinical trauma Support …. That the trauma experience is valid …. That the trauma experience is valid …. That the trauma experience will pass …. That the trauma experience will pass …. To keep the experience in perspective …. To keep the experience in perspective Psychoeducation about trauma reactions and process of recovery Acknowledgement of connections of current traumatic event to past traumas / history Provide opportunities to step out of the trauma reaction to rest and replenish

29 Cumulative childhood trauma Repeated childhood experience that leaves the individual feeling unworthy, defective, different… Repeated childhood experience that leaves the individual feeling unworthy, defective, different… abandonment, physical disfigurement, learning disabilities, family abandonment, physical disfigurement, learning disabilities, family violence, parental addiction or psychiatric illness, physical illness and violence, parental addiction or psychiatric illness, physical illness and disability, poverty and social shunning, abusive siblings, narcissistic, disability, poverty and social shunning, abusive siblings, narcissistic, antisocial or borderline personality disordered parents antisocial or borderline personality disordered parents The child develops coping skills to address the personal and interpersonal experience and these skills become engrained in the repertoire of the individual The child develops coping skills to address the personal and interpersonal experience and these skills become engrained in the repertoire of the individual The individual develops “deep schemas” about self and the world that are congruent with and support the understanding of the childhood experience & coping skills The individual develops “deep schemas” about self and the world that are congruent with and support the understanding of the childhood experience & coping skills The child has to adapt an effective response that is congruent with their environment and this response becomes engrained The child has to adapt an effective response that is congruent with their environment and this response becomes engrained

30 Cumulative childhood trauma (con’t) As a young adult, the child seeks out an environment that supports core schema, affective adaptations and coping behaviors of childhood. This is the “entrenched adaptive stance” As a young adult, the child seeks out an environment that supports core schema, affective adaptations and coping behaviors of childhood. This is the “entrenched adaptive stance” All of this is largely unconscious All of this is largely unconscious When the “breakdown” begins to occur (often between 25 – 40), the person is truly befuddled and doesn’t know how else to be. When the “breakdown” begins to occur (often between 25 – 40), the person is truly befuddled and doesn’t know how else to be. Efforts at therapy/counseling may unwittingly become “part of the problem” Efforts at therapy/counseling may unwittingly become “part of the problem” for instance, seeking out counseling that supports the engrained for instance, seeking out counseling that supports the engrained view of the world … “I’m a bad person”, “It’s my fault”, finding a view of the world … “I’m a bad person”, “It’s my fault”, finding a rescuing counselor, getting retraumatized in counseling rescuing counselor, getting retraumatized in counseling All of the above has been well described in the ACOA literature. All of the above has been well described in the ACOA literature.

31 Treating cumulative childhood trauma Treatment needs to be seen as an ongoing (2-5 year) process Treatment needs to be seen as an ongoing (2-5 year) process Therapy needs to be relationally focused and the corrective experience needs to, in part, arise from the therapeutic relationship. The relationship is critical to treatment Therapy needs to be relationally focused and the corrective experience needs to, in part, arise from the therapeutic relationship. The relationship is critical to treatment Intellectualization, idealization, projection, introjection and withdrawing are primary defenses that have to be confronted and utilized in the treatment Intellectualization, idealization, projection, introjection and withdrawing are primary defenses that have to be confronted and utilized in the treatment Treatment needs to utilize the adaptive stance, maximizing the assets and strengthening the limiting parts Treatment needs to utilize the adaptive stance, maximizing the assets and strengthening the limiting parts

32 Treating cumulative childhood trauma (con’t) When treating any trauma, but especially cumulative childhood trauma, therapy has to consider the world the adult has created for themselves. Good treatment is going to mess it up! When treating any trauma, but especially cumulative childhood trauma, therapy has to consider the world the adult has created for themselves. Good treatment is going to mess it up! The treatment needs to focus on missed developmental phases and missed skills The treatment needs to focus on missed developmental phases and missed skills A big piece of the treatment has to be coming to accept what happened and living in the face of what happened A big piece of the treatment has to be coming to accept what happened and living in the face of what happened The result of treatment doesn’t have to be the perfect person, just good enough The result of treatment doesn’t have to be the perfect person, just good enough

33 Acute Stress Reactions (ASR) A trauma response to being overwhelmed with a recent trauma experience. A trauma response to being overwhelmed with a recent trauma experience. Occurs within a short period following the trauma event Occurs within a short period following the trauma event In “uncomplicated ASRs” improvement often occurs without treatment In “uncomplicated ASRs” improvement often occurs without treatment ASRs often occur when a trauma event in the now activates a prior trauma experience (although the person make not make the connection) ASRs often occur when a trauma event in the now activates a prior trauma experience (although the person make not make the connection)

34 Treating Acute Stress Reactions 1. Diagnosing: a) helping people understand what is happening a) helping people understand what is happening “I’m falling apart”, “I think I’m going crazy” “I’m falling apart”, “I think I’m going crazy” b) differential diagnosis b) differential diagnosis addictive illness and addictive illness relapse addictive illness and addictive illness relapse “hidden” PTSD with active trigger event “hidden” PTSD with active trigger event other anxiety disorder w/ environmental stressor other anxiety disorder w/ environmental stressor “complicated” acute stress reactions with “complicated” acute stress reactions with people who don’t have very good coping people who don’t have very good coping skills and lack resilience skills and lack resilience

35 Treating ASD’s (Con’t ) 2. Creating safety slowing the physiological response slowing the physiological response exploring & reorganizing the cognitions exploring & reorganizing the cognitions building boundaries / structure building boundaries / structure education about ASD education about ASD “normalizing” the emotional responses “normalizing” the emotional responses building supports in the environment building supports in the environment building safety within self building safety within self 3. Relapse prevention with recovering CD clients

36 Treating ASD’s (con’t) 4. Giving room to tell the tale Be creative in letting people tell the story in the way Be creative in letting people tell the story in the way. they need … “words can’t describe …”. they need … “words can’t describe …” 5. Use of medication Benzodiazepines ??? Benzodiazepines ??? Sleep meds Sleep meds SSRIs are generally counterindicated SSRIs are generally counterindicated Blunt the affect and take too long to work Blunt the affect and take too long to work

37 “BICEPS” model for crisis intervention 1. Brief 1. Brief 2. Immediate 2. Immediate 3. Centralized resources 3. Centralized resources 4. Expectations of outcome 4. Expectations of outcome 5. Proximity to the trauma site 5. Proximity to the trauma site 6. Simplicity 6. Simplicity

38 Acute Stress Disorder and Mass Traumas In catastrophic disasters and in warfare, acute stress reactions are fairly common and may go undetected In catastrophic disasters and in warfare, acute stress reactions are fairly common and may go undetected A variation of ASR is a Combat Stress Reaction (CSR) A variation of ASR is a Combat Stress Reaction (CSR) We may be more likely to see the coping symptoms: drug and alcohol use, numbness & withdrawal, inappropriate affects, impulsive decisions We may be more likely to see the coping symptoms: drug and alcohol use, numbness & withdrawal, inappropriate affects, impulsive decisions Critical Incident Stress Debriefing (CISD) has not been shown to be effective in preventing or diminishing symptoms in mass trauma events, but may be efficacious when treatment is individualized

39 Grief reactions Grief is the emotional expression of loss Complicated grief is getting “stuck” in feelings of loss Grief reaction is the blocking or distorting of the normal emotional expression of loss

40 Grief, complicated grief and grief reactions require different responses Grief: support in expressing the emotions of loss Grief: support in expressing the emotions of loss Complicated grief: moving beyond being stuck in the loss Complicated grief: moving beyond being stuck in the loss Grief reaction: being able to experience and express the emotions of loss Grief reaction: being able to experience and express the emotions of loss

41 3 categories of losses Tangible losses – marriages, money, careers, driver’s licenses, social status, friendships Tangible losses – marriages, money, careers, driver’s licenses, social status, friendships Intangible losses: self esteem, hope, belonging and connectedness, joy, love, trust in self and others, Intangible losses: self esteem, hope, belonging and connectedness, joy, love, trust in self and others, What could have been had this experience not happened to me … the loss of a future What could have been had this experience not happened to me … the loss of a future

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43 Grief reactions from the “outside” Emotional constriction or inappropriateness Apparent feelings on the surface that are denied or displaced (denying sad or anger) Avoidance behaviors, lonely in a crowd Judgmentalness, perfectionism, blaming Difficulty experiencing self, including positive and negative feedback Obsessive thought and compulsive ritual Loss of spontaneity

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45 The process of grief work Diagnosis and differential diagnosis cd relapse, “dry drunk” depression, PTSD, personality disorder cd relapse, “dry drunk” depression, PTSD, personality disorder Education about grief and grief reactions Exploration about client’s experience with their grief Creating safety with feelings … especially the disavowed feelings especially the disavowed feelings Catharsis – telling the story as well as expressing affect Getting closure on events that precipitated the grief – saying goodbye, letting go, finishing unfinished business, forgiving self and others Reintegration of past self with present self

46 The goal of grief work is not to “get rid” of painful feelings, but to accept the pain as a meaningful part of life, to honor the pain rather than repressing or disavowing it. The pain connects us to something(s) that we lost that were very important to us. The goal of grief work is not to “get rid” of painful feelings, but to accept the pain as a meaningful part of life, to honor the pain rather than repressing or disavowing it. The pain connects us to something(s) that we lost that were very important to us.

47 Diagnostic Criteria for PTSD Exposure to traumatic event(s) in which: A) the event involves actual or potential death, injury or threat to physical integrity of self or others A) the event involves actual or potential death, injury or threat to physical integrity of self or others B) intense fear, helplessness or horror B) intense fear, helplessness or horror Intrusion symptoms Intrusive dreams, memories, flashbacks and distress at environmental cues of the event Withdrawal symptoms Avoidance of stimuli related to event and numbing of general responsiveness Thoughts and feelings People, places & things Thoughts and feelings People, places & things Difficulty recalling aspects of trauma Difficulty recalling aspects of trauma Feeling detached Loss of interest in activities Feeling detached Loss of interest in activities Restricted affect Loss of hope Restricted affect Loss of hope

48 PTSD Diagnostic criteria (con’t) Hypervigilance symptoms: Increased emotional arousal Problems falling asleep Problems falling asleep Irritability / outbursts of anger Irritability / outbursts of anger Difficulty concentrating Difficulty concentrating Hypervigilance Hypervigilance Exaggerated startle response Exaggerated startle response These symptoms last over time (though they may be transient)

49 Trauma, and PTSD in particular, is a wound to one’s sense of self 1. Our self perception / self esteem 2. Our trust in ourselves and in others 3. Our perception of self in relation to others 4. Our perception of the needs and desires of self and others 5. Our beliefs about the nature of the world (faith) 6. Our memories and how we remember 7. The affects we allow ourselves to feel (and the affects we have to disavow) 8. How we experience our future 9. Our values and ethical stances 10. Our spiritual beliefs and positions

50 Some issues about trauma in chemical dependency recovery especially cumulative childhood trauma, grief reactions and PTSD Trauma symptoms can look similar to addiction issues in early recovery The expectation is that the trauma symptoms will go away with CD recovery The trauma is obscured by being an experience rather than a specific event Early addiction treatment efforts tend to repress the trauma Deal with the present, not the past Deal with the present, not the past Suppress strong feelings Suppress strong feelings Flooding of trauma may provoke relapse Flooding of trauma may provoke relapse Trauma often stays buried until later in recovery

51 What can you really expect to do In the first 90 days In the first 90 days build safety, recognize trauma symptoms (in a non-shaming way), symptom containment & reduction, stabilize, educate, build trauma issues into relapse plan, build commitment to future work. Primary treatment resource is manualized treatment programs (for instance: “Seeking Safety”) build safety, recognize trauma symptoms (in a non-shaming way), symptom containment & reduction, stabilize, educate, build trauma issues into relapse plan, build commitment to future work. Primary treatment resource is manualized treatment programs (for instance: “Seeking Safety”) Once stabilized in recovery Once stabilized in recovery make trauma work part of the ongoing recovery plan, make trauma work part of the ongoing recovery plan, increase awareness of triggers and how they manifest, increase awareness of triggers and how they manifest, manage trauma symptoms when exposed to triggers manage trauma symptoms when exposed to triggers begin to explore beliefs that arose from trauma, begin to explore beliefs that arose from trauma, begin to explore how disavowed affects relate to trauma, begin to explore how disavowed affects relate to trauma, watch for how the “trauma drama” manifests & gets played out watch for how the “trauma drama” manifests & gets played out help client begin to tell the story and get the story straight help client begin to tell the story and get the story straight

52 Addictive illness, psychological trauma and suicide People with co-occurring addictive illness and psychological trauma are at high risk for suicidal thoughts and behavior People with co-occurring addictive illness and psychological trauma are at high risk for suicidal thoughts and behavior And people who have a previous suicide attempt are at even greater risk And people who have a previous suicide attempt are at even greater risk The other high risk factors are treatment transitions, drug relapse, relationship break-ups, sudden debilitating depression. The other high risk factors are treatment transitions, drug relapse, relationship break-ups, sudden debilitating depression. Suicide risk doesn’t necessarily decrease with sobriety Suicide risk doesn’t necessarily decrease with sobriety

53 Ask these questions of every client with suicide risk 1. Are you thinking about killing yourself 2. Have you ever tried to end your life before 3. Do you think you might try to kill yourself today (or in the immediate future) 4. Have you thought about ways you might kill yourself 5. Do you have a way of killing yourself available now

54 The GATE protocol for clients with suicide risk G ather information G ather information A ccess consultation / supervision A ccess consultation / supervision T ake responsible action T ake responsible action E xtend the action – follow-up E xtend the action – follow-up

55 Trauma and CD recovery Emerging trauma may be a sign of getting healthier. But it doesn’t feel that way Trauma symptoms can look like “dry drunk” Hyperarousal, intrusion and constriction symptoms Hyperarousal, intrusion and constriction symptoms Ego defenses of trauma and addiction are similar Experiencing the trauma provokes the trauma in others in the treatment environment

56 When trauma brings people into treatment …. People often come into addictions treatment as a result of some traumatic experience. People often come into addictions treatment as a result of some traumatic experience. Don’t let the trauma get overlooked in the hustle to treat the addiction Don’t let the trauma get overlooked in the hustle to treat the addiction Often, “resistance to treatment” is a function of the trauma response, not resistance to recovery Often, “resistance to treatment” is a function of the trauma response, not resistance to recovery Resistance to experiencing the trauma wound Resistance to experiencing the trauma wound

57 And when the treatment is traumatizing Some people have the potential to be traumatized by addictions treatment settings shame based people who get humiliated / scapegoated when traumatic history is “exposed” and the person is overwhelmed and “runs away” when the treatment process activates buried trauma & the person acts out & is blamed confrontation, touching, being confined, even showing interest and concern inappropriate behavior on the part of other clients or inappropriate behavior on the part of other clients or staff staff

58 4 core elements in treating trauma states Creating safety Building hope Building resilience and strengths to transcend the “dark times” Consciously using the therapeutic relationship as a healing factor in treatment

59 Creating Safety I can’t make someone feel safe with themselves: Safety has to come from within I can’t make someone feel safe with themselves: Safety has to come from within Therapy itself is an inherently unsafe environment for trauma survivors Therapy itself is an inherently unsafe environment for trauma survivors Trauma survivors will test to see if the therapy is safe. Trauma survivors will test to see if the therapy is safe. I can provide an environment that doesn’t reinforce “unsafety” I can provide an environment that doesn’t reinforce “unsafety”

60 symptom containment as safety building safety is helping the client be safe from their symptoms. Intrusion – intrusive memories, reliving the event, re-enactments Intrusion – intrusive memories, reliving the event, re-enactments hyperarousal – startle reactions, nightmares, hypervigilance hyperarousal – startle reactions, nightmares, hypervigilance constriction – going numb – forgetting – phobias and avoiding constriction – going numb – forgetting – phobias and avoiding

61 Hope and despair as a special issue for traumatized recovering people Hope (the belief that life can be better) is essential to recovery Hope (the belief that life can be better) is essential to recovery Without hope we have despair Without hope we have despair People with a history of despair come into recovery and get a message of hope. Hope activates despair and the individual becomes cynical, indifferent, distant, disparaging. “You can’t trust happiness” People with a history of despair come into recovery and get a message of hope. Hope activates despair and the individual becomes cynical, indifferent, distant, disparaging. “You can’t trust happiness”

62 chronic hopelessness chronic hopelessness therapeutic therapeutic intervention intervention negates hope to manage the anxiety creates hope creates hope creates anxiety creates anxiety

63 Some issues in addressing hope and despair 1. you can’t argue someone into hope 1. you can’t argue someone into hope 2. hope often best comes in small doses 2. hope often best comes in small doses 3. encourage people to embrace hope when they have it 3. encourage people to embrace hope when they have it 4. and prepare for the times they don’t have it - building islands in the swamp 4. and prepare for the times they don’t have it - building islands in the swamp 5. redefine despair as ego-dystonic 5. redefine despair as ego-dystonic 6. hope is both an affect and a self experience – have the affect, hold the experience 6. hope is both an affect and a self experience – have the affect, hold the experience

64 The “hope box” Building strengths for when people crash into shame, hopelessness, despair, emptiness Building strengths for when people crash into shame, hopelessness, despair, emptiness Create a scrapbook, memories box or other depository to store ego enhancing memories. Create a scrapbook, memories box or other depository to store ego enhancing memories. The memories are composed of photos, documents, newspaper clippings, writings ….. The memories are composed of photos, documents, newspaper clippings, writings ….. Each memory contains a story that validates and supports the person Each memory contains a story that validates and supports the person Add to the box as therapy progresses Add to the box as therapy progresses Have clients take out the box occasionally and look at the “scenes” and remember the feelings Have clients take out the box occasionally and look at the “scenes” and remember the feelings Be able to access the box when needed Be able to access the box when needed

65 Resilience in trauma treatment “you just don’t know who you are dealing with” Resilience is more than “getting by” Resilience is the ability to “bounce back” in the face of adversity: Resilience is l ife’s desire to move forward in Resilience is l ife’s desire to move forward in the face of adversity the face of adversity Resilience is the ability to tap an inner strength to persevere strength to persevere The question for therapists is “how do I help The question for therapists is “how do I help an individual tap their resilience” an individual tap their resilience”

66 Using the therapeutic relationship to treat trauma states 1. Modeling integrity, boundedness & safety 2. Monitoring transference managing expectations of abandonment, managing expectations of abandonment, disregard & other negative experience disregard & other negative experience 3. Monitoring counter-transference in the face of revulsion, ego defense and client in the face of revulsion, ego defense and client provocation provocation in the face of over-identification or rescue fantasies, in the face of over-identification or rescue fantasies, get supervision and work it through get supervision and work it through 4. Supporting the work without doing the work

67 the therapeutic relationship (con’t) 5. modeling interest / concern w/o activating shame “why are you so interested in me?” “why are you so interested in me?” 6. working with projections onto therapist / interpreting the projections w/o activating defense The therapeutic relationship becomes a model for building integrity based relationships

68 4 basic therapy processes for working through trauma: Ongoing trauma treatment with recovering c.d. clients 1. Bringing the past to the present & building new options for managing life today Cognitive Behavioral approaches Cognitive Behavioral approaches CBT, Desensitization, Exposure Therapy, ACT, DBT CBT, Desensitization, Exposure Therapy, ACT, DBT Psychodynamic psychotherapies Psychodynamic psychotherapies Supportive psychotherapy, Psychodynamic Supportive psychotherapy, Psychodynamic Psychotherapy, Narrative Therapy, Emotionally Focused Therapy Psychotherapy, Narrative Therapy, Emotionally Focused Therapy Motivational Interviewing (MI) is a bit of both Motivational Interviewing (MI) is a bit of both 2. Hypnosis a) Traditional medical hypnotherapy (NOT recommended) a) Traditional medical hypnotherapy (NOT recommended) b) Ericksonian hypnosis b) Ericksonian hypnosis 3. EMDR (Eye Movement Desensitization & Reprocessing) and similar therapies 4. Experiences in living today that reorganize the trauma experience – corrective life experiences

69 Psychopharmacology treatment with PTSD 1. Anti-anxiety drugs Benzodiazepines and SSRI’s Benzodiazepines and SSRI’s 2. Mood stabilizers Tegretol, Depakote, Lithium Tegretol, Depakote, Lithium 3. Anti-depressants SSRI’s, Tricycliates SSRI’s, Tricycliates 4. Anti-psychotics Haldol Haldol 5. Drugs that block the stress (flight or fight) responses Klonopin (Catapres), Inderal Klonopin (Catapres), Inderal

70 All of these drugs only control symptoms. There is NO “Anti-Trauma” pill All of these drugs only control symptoms. There is NO “Anti-Trauma” pill Drugs that control trauma symptoms may be counterindicated for management of other disorders: Drugs that control trauma symptoms may be counterindicated for management of other disorders: Anxiety Anxiety Depression Depression (and especially) Addictive Illness (and especially) Addictive Illness

71 Three variables in adopting a specific approach to therapy with trauma survivors Approach is understandable & Approach is understandable & acceptable to the client acceptable to the client Therapist feels confident, Approach is congruent Therapist feels confident, Approach is congruent capable & congruent with with the nature of the capable & congruent with with the nature of the the approach trauma & condition of the approach trauma & condition of the client the client

72 Cognitive-Behavioral Treatments for PTSD 1. Exposure therapies Prolonged exposure (PE) (Foa) Prolonged exposure (PE) (Foa) Systematic desensitization Systematic desensitization CPT (Cognitive Processing Therapy) (Resick) (expos. + cog. restructuring) CPT (Cognitive Processing Therapy) (Resick) (expos. + cog. restructuring) 2. Anxiety management SIT (Stress Inoculation Training) (Meichenbaum) SIT (Stress Inoculation Training) (Meichenbaum) Relaxation / meditation training Relaxation / meditation training Anxiety management training (Kilpatrick) Anxiety management training (Kilpatrick) 3. Cognitive Restructuring Challenging limiting / inaccurate beliefs Challenging limiting / inaccurate beliefs Constructive Narrative Perspective (Meichenbaum) Constructive Narrative Perspective (Meichenbaum) Stopping / changing limiting cognitions Stopping / changing limiting cognitions Challenging perceptions of the trauma event(s), their Challenging perceptions of the trauma event(s), their meanings and impacts meanings and impacts 4. Skill Building Building new / more diverse coping skills and behaviors Building new / more diverse coping skills and behaviors

73 Cognitive –behavioral treatments (con’t) 5. Newer CBTs emphasize acceptance, non- judgmentalness, present-centered, mindfulness ACT (Acceptance & Commitment Therapy) (Hayes) ACT (Acceptance & Commitment Therapy) (Hayes) DBT (Dialectical Behavior Therapy) (Lineha DBT (Dialectical Behavior Therapy) (Lineha 6. Schema therapy (Young) 7. Other CBT approaches Manualized treatments Manualized treatments Internet based treatment Internet based treatment

74 A psychodynamic approach to treating PTSD / related trauma 1. Developing safety – stabilizing being safe enough “inside” and with the environment being safe enough “inside” and with the environment 2. Telling the tale, getting the story straight experiencing / embracing the wounded self experiencing / embracing the wounded self 3. Corrective emotional experience the repair work – methods include CBT, redecisioning, finishing the repair work – methods include CBT, redecisioning, finishing unfinished business, forgiving, letting go, affect regulation, challenging schemas unfinished business, forgiving, letting go, affect regulation, challenging schemas 4. Integrating a new (repaired) sense of self & reconnecting with the world reconnecting, getting closure on history, coming to belong again, building reconnecting, getting closure on history, coming to belong again, building healthy relationships and perception of self in relation to others healthy relationships and perception of self in relation to others

75 4 stages in recovery from trauma 1. Developing safety The very nature of the trauma experience is that it is unsafe. The “true fear” is of exposing the damaged self & the pain attached to the damage The fear is most often externalized to the environment. In therapy, the fear may be disowned to the therapist or the therapy … as unsafe. Therapy, in structure, may recreate the trauma scene, where the “victim” submits to an unequal relation- ship with the therapist who has inordinate power and status ship with the therapist who has inordinate power and status

76 4 stages of therapy (con’t) 2. Getting the story straight We speak of trauma as being “unspeakable” Trauma may be expressed through physical experience and symbols as well as words “Symptoms” of trauma may become a way of telling the tale “Victim psychology” will focus excessively on blame Victims will take responsibility for the trauma as a way of having control “What happened” isn’t as important as what it means Trying to “remember everything” is futile

77 Telling our tale (con’t) Our tales are told in metaphor. Our metaphor may or may not have much resemblance to the reality of others. The therapist is the witness to the unfolding of the tale. The therapist’s job is to provide a container for the tale as it evolves and to facilitate the person telling the story in the most healing way possible. Getting the story straight is like constructing a jigsaw puzzle. Seemingly unconnected pieces get put together to form a coherent image and the missing parts become more obvious. The missing parts often contain the core of the trauma experience.

78 Telling our tale (con’t) Words may not be a very good vehicle for communicating the trauma experience. Visual symbols, movies, music, drawings and physical movement may more accurately and effectively communicate the experience. A variety of unfolding techniques can be applied to help reveal the tale including hypnosis, psychodramatic technique, group support and psychomotor therapies. But unfolding techniques are a means to the end, not the end in itself! One story or event in the tale can be a metaphor for a series of events. It isn’t necessary or practical to tell the whole tale, particularly with prolonged and pervasive trauma.

79 Step 3: Corrective Emotional Experience Corrective emotional experience is about: Corrective emotional experience is about: 1. Creating and living new options that refute the trauma experience 1. Creating and living new options that refute the trauma experience 2. Being able to have and “work through” the emotions that were attached to the trauma 2. Being able to have and “work through” the emotions that were attached to the trauma

80 Corrective Emotional Experience Creating and living new options Trauma traps us into a set of truths and beliefs that are self limiting and often repeat the trauma experience. A goal of therapy is to challenge these truths & beliefs and create new options for living a more rewarding and versatile life. Trying out new ways of living / coping create the “corrective emotional experience”

81 Corrective Emotional Experience Creating and living new options Therapy needs to strategically address new coping options. Clients resist because the new options are incongruent with the existing truths and beliefs. The primary defense against challenging beliefs and truths is to change them in the therapy office but not in “life”.

82 Corrective Emotional Experience: Reworking the emotions of trauma 4 primary emotional responses to trauma are: rage, terror, grief and shame. rage, terror, grief and shame. No one “does” each of these responses equally well. Some trauma experiences lead themselves more to expression through one of these emotions than through others When one avenue of expression is unavailable, we will use other avenues to express that emotion Blocking rage limits experiences of empowerment Blocking terror limits experiences of feeling safe Blocking grief limits experiences of love and belonging Blocking shame limits experiences of self love and self acceptance

83 Corrective emotional experience (con’t) The fear of experiencing rage is uncontrolled violence toward self and others The fear of experiencing rage is uncontrolled violence toward self and others The fear of experiencing terror is uncontrolled panic The fear of experiencing grief is depression and emptiness The fear of experiencing shame is deep humiliation and worthlessness Terror, grief, rage and shame will emerge in a sequence that is unique to the individual. As one emotional response is worked through, another will appear. The most difficult emotional experience for the individual will be the last to appear.

84 Corrective emotional experience (con’t) THE EMOTIONAL BLOCK WITH THE TRAUMA EXPERIENCE IS NOT WITH THE AFFECT THAT IS EXPRESSED, BUT WITH THE AFFECT THAT IS UNEXPRESSED.

85 Corrective emotional experience (con’t) Other emotional themes of trauma survivors include: Guilt Rejection/Abandonment Loneliness Hurt Overwhelmed Empty The catharsis of these emotions is not the end in itself But the expression of these emotions of the trauma give emotional life to the experience. The trauma experience cannot be resolved w/o the expression of the emotional experience of the emotional experience

86 These emotional themes are worked out in the therapy experience transferentially as well. A primary defense of the emotional themes is to project the disowned feeling. The types of therapies that work best in providing corrective emotional experience are the therapies that acknowledge and support the awareness and expression of affect: Emotionally Focused Therapy (S. Johnson) Emotionally Focused Therapy (S. Johnson) Contemporary Gestalt Therapy Contemporary Gestalt Therapy Grief work Grief work Affect regulation therapies Affect regulation therapies

87 Stage 4: Integrating a new sense of self As the corrective emotional experience unfolds, the damaged sense of self that underlies the pain is exposed Some agendas for selfhood work include redefining the trauma experience in terms of: Self trust Self trust Self in relation to others Self in relation to others Self perception and self esteem Self perception and self esteem Beliefs about self and relation of self to the world Beliefs about self and relation of self to the world Self in relation to the future Self in relation to the future Value and ethical positions Value and ethical positions Spiritual beliefs Spiritual beliefs

88 The process of healing the self 1. Creating a safe place: emotionally, physically, interpersonally emotionally, physically, interpersonally 2. Struggling to find a way to tell the tale 3. Experiencing the pain (and joy) 4. Experiencing the damaged self and 5. Embracing (& allowing others to embrace) the damaged self 6. Building a stronger sense of self: Self esteem, potency, interpersonally, Self esteem, potency, interpersonally, physically, spiritually physically, spiritually 7. Connecting with the world in a more potent way

89 Healing is sufficient when: Healing is sufficient when: 1. We can address problems as they arise 2. We can have at least one person in our life with whom we can intimately reveal ourselves 3. We can have firm and flexible boundaries “I” boundaries, value boundaries, body “I” boundaries, value boundaries, body boundaries, expressive and exposure boundaries, expressive and exposure boundaries, comfort boundaries boundaries, comfort boundaries 4. We have (and take) opportunities to rejuvenate: Physically, emotionally, intellectually, Physically, emotionally, intellectually, interpersonally, spiritually interpersonally, spiritually

90 Resolution The experience of trauma is never fully resolved and recovery is never complete. The natural unfolding of events reactivates the trauma experience which, again, needs to be recognized, confronted and expressed. Healing is sufficient when the trauma does not dominate experience, but, rather, sits alongside the mundane and the ordinary, when the person can live in relative harmony with their environment

91 For more information Bruce Carruth, Ph.D., LCSW Bruce Carruth, Ph.D., LCSW (713) (713) Overheads from this (and other) presentations are available at:


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