1. Listening to Traumatized Individuals Joseph A. Troncale, MD FASAM Medical Director Retreat at Lancaster County Retreat at Palm Beach County

2. Background Much of what we see in addiction has ties to some form of trauma which in turn has ties to other mental illness diagnoses and symptoms Neurobiology confirms that the neural pathways regarding addiction tie in closely with the same pathways we see in traumatized individuals Understanding the limbic system and treating trauma as a co- occurring disorder allows us to maximize progress for the addicted individual.

3. The Limbic Cortex Trauma has been shown to be closely related to the amygdala, a structure in the limbic cortex. In animal models, a traumatized animal will show enlargement of the amygdala when compared to pre-trauma. The amygdala is strongly paired with the olfactory apparatus of the brain and so not only visual cues but also “smell” cues play into traumatic imprinting.

4. Trauma and Addiction When the amygdala is not regulated, the rest of the limbic system is also teetering and is a set-up for relapse. Re-traumatizing cues can be the triggers for relapse even with no substances present. Conversely, calming the limbic system has beneficial effects on long-term sobriety and relapse prevention.

5. More Background Trauma and Recovery by Judith Herman, MD, outlined the history of how trauma was treated by the psychiatric community. She divided the history of the diagnosis of psychiatric trauma into three main eras: The recognition and treatment of hysteria by Charcot and later by Freud. The problem at that time was that although Freud and others discovered that listening to the patient’s story was therapeutic, the therapists didn’t believe the stories! The recognition of war trauma by numerous military psychiatrists. Once again, the prejudice of many psychiatrists prevented proper treatment. Feminist and post-Vietnam veteran self-help and self-directed groups.

6. Stages of Trauma Work Safety Remembrance and mourning Reintegration with normal life Herman, J. Trauma and Recovery p.155

7. Treatment Needs to be Ongoing. Symptoms Persist The American Journal of Psychiatry, Vol 162, (3) Specialized Inpatient Trauma Treatment for Adults Abused as Children: A Follow-Up Study. Stalker et al showed that while treatment was valuable at decreasing symptoms, at one year, the cohort that was treated became increasingly symptomatic almost back to pre-treatment baseline. Therefore, treatment cannot be “once-and-done.” We know this from addiction treatment with the need for 12- step recovery, outpatient groups, ongoing therapy, etc. Limbic trauma “hard-wires” the individual. “People, places and things” has to do with trauma as much as familiarity…

8. The Therapeutic Bottom Line: Being heard and understood. Good boundaries No rescuing by the therapist, but therapist needs to work through the trauma as well as the client in a separate venue. Truth telling and accurate diagnosis Calming of the limbic cortex without addictive substances. Having knowledgeable therapists who do not cause inadvertent re-trauma. Being able to work through grief without being coerced. Having an ongoing plan and ongoing support after initial treatment.

9. Being Heard and Understood The story is the treatment. Freud and others discovered this a hundred years ago. Wise practitioners have known this for centuries before that. Being able to disclose in a confidential and safe environment is the basis for trauma therapy. The “facts” are not as important as the perception. It may be years before the actual “facts” of a traumatic situation surface. Many traumatized individuals see their trauma in the third person as an observing bystander rather than as victim.

10. Good boundaries No relationship with therapist outside of treatment setting to minimize transference and counter-transference. Stick to the schedule of therapeutic sessions Clear rules on contact outside of regular sessions

11. No Rescuing by Therapist The therapist is to be the listener and processor. Rescuing behaviors and attempts to save the client distort the boundaries and lead to transference issues. As long as the client is safe, the work should be empathetic but not co-dependent Therapy is not meant to shelter the client from pain, but rather allow the client to tell their story in a safe environment. Balint Groups and actually AA and NA are meant to do the same thing in that no judgment is offered regarding the story being shared.

12. Truth telling and accurate diagnosis Trauma is a complicated diagnosis to make unless there is clear evidence or history that makes the diagnosis obvious. Many individuals, however, present with symptoms other than overt traumatic recollections and instead present with unexplained somatic symptoms (formally known as hysteria) or anxiety, sleep-disturbances or dissociative symptoms. It is important that once the therapist is relatively certain of the trauma diagnosis that the patient/client be notified that this is the diagnostic consideration.

13. Calming the Limbic System without Addictive Substances. Important to allow the traumatized person to restore control. While the use of addictive substances is the antithesis of control, it gives immediate relief and is used to self-medicate trauma The goal is, in addition to listening, to teach the traumatized person ways of self-soothing that works for them. Warmth Pleasant aromas Hydration and good nutrition Rest Humor Music

14. Avoiding Re-trauma Therapy sometimes needs to be reframed. That is, some people do not want to “do therapy” but are willing to share their story if they believe that it is not therapy. The importance of safety as the initial goal of treatment cannot be over-emphasized. The “contract for safety” that we use with suicidal individuals can be extended to the traumatized individual so that the agreement that we extend to them regarding our relationship is one of building trust first and foremost. In many ways, that alone is the therapy. It takes an experienced therapist to recognize triggers and re- traumatizing experiences. Also important once again to emphasize the importance of the therapist as not doing the work for the person to “get them to feel safe.”

15. Working Through Grief Without Coercion The onion has to peel itself to a certain degree. Trauma surfaces much like fossils in a plowed field. Ever go arrowhead hunting? (One never knows when they will pop up out of the ground, nor do you know exactly what you are looking for.) Once found, it may be wise to examine from afar rather than digging it out of the ground. The therapist should not be the one to pick it up. At the same time, grief work in groups is felt to be more successful with goal directed work rather than unstructured group sessions.

16. Ongoing treatment As mentioned earlier in this presentation, it has been shown that trauma work really does not have a finite end. The military had a model where the soldier would be reintroduced to their unit after 72 hours. This only takes care of the “safety” part of the therapy. It does not deal with the grief or the actual reintegration of the individual back into normal living. Intensive therapy has a finite “staying power. “ It is important that memory retrieval be done at the pace of the victim, but at the same time, there is a big difference from getting in touch with the trauma and subsequently dealing with it. Teaching people who have been victimized and traumatized to “use their voice” is an ongoing challenge.

17. Trauma Unit at Retreat 8-16 bed gender specific unit Individuals are screened for previous trauma and previous treatment. Severity is assessed. Groups are run by experienced trauma therapists. Individual sessions held as needed. Decompression room with weighted blankets, music therapy, aroma therapy available to maximize the perception of safety.

18. Thank you. “Anything that’s human is mentionable, and anything that is mentionable can be more manageable. When we can talk about our feelings, they become less overwhelming, less upsetting, and less scary. The people we trust with that important talk can help us know that we are not alone.” ― Fred RogersFred Rogers “The conflict between the will to deny horrible events and the will to proclaim them aloud is the central dialectic of psychological trauma.” ― Judith Lewis Herman, Trauma and RecoveryJudith Lewis HermanTrauma and Recovery

19. Questions? josepht@retreatmail.com