Beneath the Surface:

Addressing Trauma & Substance Use

Presented By: Sara L. Paxton LMSW/CAADCFamily Outreach Center

Today’s ObjectivesBe able to:Discuss the relationship between trauma and substance use.Describe of the impact of historical trauma on specific populations.Identify practical interventions (including prevention strategies) to use in therapy when working with individuals/families with a trauma history and current or potential substance use issues.

The Relationship As the number of traumatic events

experienced during childhood increases, the risk for the following health problems in adulthood increases: Depression Alcoholism Drug abuse Suicide attempts Heart, liver, and pulmonary diseases Fetal death during pregnancy High stress Uncontrollable anger Family, financial, and job problems

Trauma & SUD

The Relationship

Trauma & SUD

SAMHSA April 2011: Childhood Trauma's Impact on Health Risks

The Relationship 90% of public mental health clients have been exposed

to, and most have actually experienced, multiple exposures of trauma

75% of women and men in substance abuse treatment report abuse and trauma histories

ACE (Adverse Childhood Experiences) Study Almost 2/3 of the study participants reported at least one

adverse childhood experience of physical or sexual abuse, neglect, or family dysfunction

More than one in five reported three or more such experiences

CTE (Childhood Traumatic Events) Study Reviewed CTEs and adult health problems and

psychosocial functioning 1.2 to 1.5-fold increased risk for PTSD, current tobacco

use, alcohol dependence, injection drug use, sex work, sexually transmitted diseases, homelessness, a myriad of physical health problems, and reduced overall quality of life

Trauma & SUD

Trauma

What is Trauma?

What do you consider to be traumatic?

What makes something traumatic?

Trauma

What is Trauma? Dictionary.com Psychiatric Definition:

a. an experience that produces psychological injury or pain.

b. the psychological injury so caused. Risks of an Event being Traumatic

It happened unexpectedly. You were unprepared for it. You felt powerless to prevent it. It happened repeatedly. Someone was intentionally cruel. It happened in childhood.

Trauma

What is Trauma? Common Traumatic Events

An unstable or unsafe environment

Separation from a parent

Serious illness Intrusive medical

procedures Sexual, physical, or

verbal abuse Domestic violence Neglect Bullying

Commonly Overlooked Traumatic Events Falls or sports injuries Surgery (especially in the first

3 years of life) Sudden death of someone

close A car accident Breakup of a significant

relationship A humiliating or deeply

disappointing experience Discovery of a life-threatening

illness or disabling condition

Trauma

Historical Trauma: Definition Multigenerational trauma experienced by a

specific cultural group It is cumulative and collective

Historical Trauma

Examples Immigrants: Prevention of cultural and spiritual

practices Intergenerational Poverty: Hunger; poor or inadequate

housing; lack of access to health care; community crime

People of Color: Slavery; colonialism/imperialism American Indians/First Nations Peoples:

Americanization of Indian Boarding Schools and forced assimilation among their students SAMHSA’s GAINS Center Policy

Research Associates, Inc. Historical Trauma Fact Sheet

Activity Identify historical events that occurred

in the below time periods that may have resulted in historical trauma. 1910-1930 1931-1950 1951-1970 1971-1990 1991-2010

Historical Trauma

African-American Population

White racism as a trauma for African-Americans (its effects parallel how individuals are affected by chronic physical abuse).

Trauma-focused theories may mention the effects of racism and discrimination as having an emotionally injurious effect.

Afro-centric theories define white racism as a traumatic threat , particularly those that are lower-income, urban, because white racism threatens their collective survival.

Stems from Segregation from employment/educational opportunities, and relegated to living in the poorest neighborhoods.

The concentration of poverty led to rising crime rates, domestic violence, drug problems, and other social ills.

These issues in other populations might be addressed through public services.; however, in inner cities they(police, social services, etc.) were often corrupt, abusive, and discriminatory and therefore historically distrusted.

African American women are underdiagnosed with depression as symptoms manifest differently (often due to coping through hard work and determination over physical and mental well-being).

Historical Trauma

Native American Population Europeans brought new diseases which traditional

healers were unprepared to cope with, where their methods had historically been beneficial, they no longer worked.

There was a discouragement of Traditional beliefs and practices by certain church, educational, and governmental groups.

There was the assumption that Native cultures were deficient in a way that was seen as pathological, without virtue, and without value.

Children where sent to boarding schools where their contact with family members was severely curtailed.

The same children were sent back to tribes and became the parents of the future, now devoid of a traditional understanding of what it meant to be native and what the responsibilities were for being a native parent.

It was the process of deculturalization. In addition, Native people have been forced to define

and prove themselves, often through forced treaties.

Historical Trauma

Substance Use

Warning Signs of Use Physical: fatigue, repeated health complaints, red and

glazed eyes, and a lasting cough. Emotional: personality change, sudden mood changes,

irritability, irresponsible behavior, low self-esteem, poor judgment, depression, and lack of interest in activities.

Family: argumentative, breaking rules, or withdrawing from the family.

School: decreased interest, negative attitude, drop in grades, many absences, truancy, and discipline problems.

Social problems: new friends with lack of interest in usual home/school activities, problems with the law, and changes in dress and music (often to unconventional).

Substance Use Disorders

Diagnosis (DSM-IV-TR) Substance Use/Misuse

starts to have a negative impact on a person’s functioning the use of a substance for unintended purposes or for intended purposes

but in improper amounts or doses Substance Abuse

the deliberate, persistent, excessive use of a substance without regard to health concerns or accepted medical practices

a pattern of harmful use of any substance for mood-altering purposes pattern of substance use that results in repeated adverse social

consequences related to drug-taking—for example, interpersonal conflicts, failure to meet work, family, or school obligations, or legal problems

Substance Dependence the desire or need to continually use a substance the compulsive need to use a substance stopping use would cause user to suffer mental, physical, and emotional

distress characterized by physiological and behavioral symptoms related to

substance use. These symptoms include the need for increasing amounts of the substance to maintain desired effects, withdrawal if drug-taking ceases, and a great deal of time spent in activities related to substance use

Substance Use Disorders

Treatment Modalities

TF-CBT Strengthening

Families Protective Factors

Somatic Experiencing

EMDR Seeking Safety

TF-CBT (Trauma Focused Cognitive Behavioral Therapy) Components-based treatment model that

incorporates trauma-sensitive interventions with cognitive behavioral, family, and humanistic principles and techniques.

Children and parents learn new skills to help process thoughts and feelings related to traumatic life events; manage and resolve distressing thoughts, feelings, and behaviors; and enhance safety, growth, parenting skills, and family communication.

PRACTICE Psychoeducation and parenting skills Relaxation skills Affect expression and regulation skills Cognitive coping skills and processing Trauma narrative In vivo exposure (when needed) Conjoint parent-child sessions Enhancing safety and future development

Treatment Modalities

Strengthening Families Protective Factors Caregivers can buffer the impact of trauma

and promote better outcomes for children even under stressful times when the following Strengthening Families Protective Factors are present: Parental resilience Social connections Knowledge of parenting and child

development Concrete support in times of need Social and emotional competence of children

Treatment Modalities

Somatic Experiencing

Takes advantage of the body’s unique ability to heal itself.

Focus of therapy is on bodily sensations, rather than thoughts and memories about the traumatic event.

Concentrating on what’s happening in your body, causes you to gradually get in touch with trauma-related energy and tension.

Then natural survival instincts take over, safely releasing this pent-up energy through shaking, crying, and other forms of physical release.

Treatment Modalities

EMDR (Eye Movement Desensitization & Reprocessing) Incorporates elements of cognitive-

behavioral therapy with eye movements or other forms of rhythmic, left to right stimulation.

Back-and-forth eye movements are thought to work by “unfreezing” traumatic memories, allowing you to resolve them.

Treatment Modalities

Seeking Safety Seeking Safety is a present-focused therapy to help

people attain safety from trauma/PTSD and substance abuse.

The key principles of Seeking Safety are: Safety as the overarching goal (helping attain

safety in relationships, thinking, behavior, and emotions).

Integrated treatment (working on both PTSD and substance abuse at the same time).

A focus on ideals to counteract the loss of ideals in both PTSD and substance abuse.

Four content areas: cognitive, behavioral, interpersonal, and case management.

Specific/deliberate attention to clinician processes (helping clinicians work on countertransference, self-care, and other issues).

Treatment Modalities

Promising Future Modalities Child-Parent Psychotherapy (CPP) Family Violence:

Primary use with children under 7 with exposure to family violence, physical abuse, and/or physical neglect.

Stresses the importance of attachment; the connection between thoughts, feelings, and behaviors; social learning theory; and family therapy.

Utilizes the parent-child relationship to repair the inability to self-regulate emotions, increase the attachment bond, and decrease child aggressiveness and parental use of physical punishment and criticism.

Includes a trauma narration component where the parent and child create a joint narrative of the trauma.

Abuse-Focused Cognitive Behavioral Therapy (AF-CBT): Primarily used with children ages 6-15 years and their parents. Targets physically abusive parents’ parenting skills or practices, along with the

child’s behavioral and emotional adjustment. Parallel treatment model combing the connection between thoughts, feelings,

and behaviors and learning and family therapy approaches to treat the parent and child simultaneously.

Primary goals of AF-CBT are to reduce the abusive parent’s anger and use of force, teach non-aggressive methods of discipline, reduce the risk of future abuse incidents, enhance child coping and adjustment, and improve family communication.

Treatment Modalities

Interventions

Practical Interventions Education Relaxation Grounding Cognitive Exercises Safety/Safe Coping Skills Emotion Identification/Expression Healthy Relationships Exploring the Trauma

Interventions

Culture Specific Interventions that have been culturally

modified may ease barriers and increase the family/individual’s level of engagement. Incorporating culturally appropriate terms in

discussing the healing process and family relationships.

Integrating culturally specific stories and proverbs can increase the family’s comfort level.

Interventions

Cultural Specific African American:

Afro-centric values include interdependence with nature and other living things, a deep sense of spirituality, emotional expression, direct communication, and expressing one's true emotional self through dance, music, and other creative arts.

Incorporate strengths related to resisting oppression. Allow for the expression and celebration of resilience. Utilize strengths which in general include: strong

church affiliation and sense of spirituality, flexible family roles, and strong family, extended family, and surrogate-family ties.

Remember that these strengths insulate African-Americans from the harmful effects of stress, poverty, depression, and traumatic oppression.

Interventions

Cultural Specific Native Americans

Requests from the Native community for a new “medicine,” one specifically developed to meet native needs, and rooted in the traditions of the past.

Traditional healing focuses on the person and the context of their community, rather than on a discreet biomedical sickness with an emphasis on health, not disease.

Traditional healing seeks to make things whole—the people, the culture, and the community.

The removal of traditional culture and support systems led to erosion of Native mental health, but is being reversed by a surge of spiritually based energy utilizing traditional techniques.

The outcomes are feelings of renewed hope and challenge.

Recognize and celebrate the fact that many Natives believe that the good of tribe/group/family supersedes that of the individual.

Interventions

Questions/Comments/Case Studies

Trauma & SUD