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Trauma Informed Practice Understanding the Effects of Trauma The “more existential impacts include profound emptiness, loss of connection to spirituality or disruption in one’s ability to hope, trust or care about oneself or others” (Briere & Scott, 2006, p. 17) • A number of different symptoms and disorders have been linked to traumatic events • Some, listed next, are related to disorders diagnosed through the DSM IV in many Western countries • The full impact of trauma cannot be completely described by an impersonal list of symptoms and disorders Varying Post-traumatic Response Diagnoses • Depression -Complicated Grief -Major Depression -Psychotic Depression • Anxiety -Generalized Anxiety -Panic -Phobic Anxiety • Stress -Post-Traumatic Stress -Acute Stress • Dissociation • Somatoform Responses -Physical symptoms unexplainable through medical phenomena • Brief Psychotic Disorder • Substance Use • Borderline Personality Disorder • Any of the preceding diagnostic categories could be the presenting problem for women survivors of a trauma history • These are legitimate coping responses to trauma that help protect a victim of abuse • Dually diagnosed clients (with a diagnosed mental health issue and substance abuse) should be routinely assessed for a trauma history by a trained mental health clinician PTSD & Substance Use • Rate of PTSD among women in substance use treatment is 30-59 % • Substances are often used as a form of “self-medication” to cope with the overwhelming emotional pain of PTSD • People with this specific dual diagnosis are more vulnerable to repeated traumatisation and are likely to be coping with complicated life circumstances such as homelessness, relational or medical problems, domestic violence or child maltreatment • Most women with this dual diagnosis have survived childhood physical and/or sexual abuse • Abstinence from substances may exacerbate PTSD symptoms • PTSD is rarely treated in conjunction with substance abuse, as recommended by both clinicians and researchers • There is a need for treatment integration, allowing clients to discover the interrelationships and connections between the conditions in their own lives • Integrated treatment should focus attention on both conditions at the same time in the present to facilitate holistic healing The following modules can be used to work with dually diagnosed women in any setting. They can be used to educate staff and clients about the nature of PTSD and substance use, as well as various safe coping skills. Trauma Informed Practice PTSD and Substance Use Do I have PTSD? Have you ever experienced or witnessed a physical threat outside of your control? Was your response intense helplessness, fear, horror? If a child when it happened was it agitated or disorganized behaviour? Afterward: Have you suffered nightmares, flashbacks, images? Numbing or feeling detached? Feeling aroused (easily startled, problems sleeping, anger)? Problems with relationships, work or other areas of life? •Such symptoms of PTSD are a “normal reaction to abnormal events”; they are your body’s way of coping with stress •PTSD is considered a mental health disorder due to the overwhelming anxiety present during and after trauma. • It possible to heal from PTSD and from severe trauma. •Some reasons why people with PTSD abuse substances are: - to access or to avoid feelings and memories - to compensate for the pain of PTSD - they grew up with substance abuse - they don’t care about themselves or their bodies •Each of the disorders makes the other more likely Why do substance use and PTSD co-occur? • Substance use may “self-medicate” the overwhelming symptoms of PTSD • Substance use may make one vulnerable to dangerous situations leading to trauma • Trauma and substance use may have occurred together in the family home when growing up • Downward spiral: PTSD may lead to substance use which in turn increases risk for more trauma, which may lead to more substance use. Reclaim Your Power • Having compassion for your substance use and PTSD - PTSD symptoms are natural survival mechanisms in the face of overwhelming trauma. Understanding why you have these symptoms stops self-blame and allows you the space to learn more effective coping - Substance use is an attempt to cope with PTSD and life problems. Understanding the role substance use plays can allow you to reach out for help in learning more adaptive methods. • Notice the strengths you have developed - How have you survived under tough conditions? How did you do that? What kind of growth has occurred your survival of these experiences? Ambivalence • Mixed feelings about giving up the familiarity of substance use is not only normal but to be expected • This can also be the case with getting better from PTSD, it may feel invalidating to let go of the suffering • While these feelings are normal, actions must focus on safety • Safety means not using substances, sticking with treatment and talking openly about ambivalence. Reclaim Your Life Substance Abuse: - increases PTSD symptoms in the long run, increasing depression,suicidality and decreasing depression - stalls your emotional development - does not meet your needs (love, acceptance, nurturance) - isolates you by facilitating secret keeping, lying and loneliness - keeps you from coping with feelings/ prevents safe coping and healing - takes away your control (much like PTSD) - is a way of neglecting yourself (impairs health, mind, relationships, self-worth and spirituality Climbing Mount Recovery Handout (Please Refer to Attached Handout For Client Work) Self-Understanding Blame, shame and guilt prevent understanding of why one uses substances. Seek understanding by: 1) Notice the Choice Point: - Make a conscious decision to use - Listen closely and you’ll hear a need being neglected (connection, pleasure, love, symptom relief) 2) Replay the Scene in Slow Motion - Where were you? Who was there? What happened leading up to using? What were you feeling/thinking? What other coping did you try? - Re-play in your head and identify how it could end differently 3) Explore the Meaning of Substance Use - Sleep? Numbing? Control? Acceptance? Slow suicide? Crying out for help? Expressing pain? Forgetting? 4) Notice the Cost: - Interpersonally (who is it hurting?), financially (how much does it cost?), emotionally (how does it make you feel about yourself?) 5) Notice How Much You Relate to Yourself Afterwards: - Are you kind and caring? Harsh and judgmental? Is blame, shame and guilt getting in the way of understanding yourself? Trauma Informed Practice Safety “When a person has both substance use and PTSD, the most urgent clinical need is to establish safety” (Najavits, 2004, p. 47) Safe Coping Skills • Ask for help • Cry • Take good care of your body • Create meaning What are you living for? Truth? Love ? Children? God? • Set a boundary Say “no” to protect yourself • Talk yourself through it • Recognize substance use as self-medication • Avoid avoidable suffering Prevent bad situations in advance; notice red flags • Seek understanding, not blame Listen to your behaviour; blame prevents growth • Imagine (remember a safe place) Safe Coping Cont’d • Attend treatment • Say what you really think Is that assumption true? • Listen to your needs • Structure your day • Notice the cost What is the price of substance use? • Set an action plan Involve others • Trust the process • Expect growth to feel uncomfortable • Pretend you like yourself See how different the day feels • • • • • Focus on now Practice delay Take responsibility Self-nurture Let go of destructive relationships Safe Coping Cont’d • Detach from emotional pain Grounding • Learn from experience • Plan it out Think ahead, avoid impulsivity • Reward yourself • Tolerate the feeling No feeling is ever “final”, just get through it! • Find rules to live by • Fight the trigger • Recruit support • Notice what you can control • Replace destructive activities • Pace yourself If overwhelmed, slower; if stagnant, faster! • List your options • Compassion (for yourself) • The preceding list can be used with clients in any setting to examine what safety skills fit for them • Service providers can explore with clients what skills they already possess as well as new ways of coping with stress, life and PTSD symptoms • For a more detailed list please refer to “Seeking Safety” treatment manual by Lisa Najavits, 2002. • These coping skills can be used to create personal safety plans and in reviewing current safe and unsafe behaviours Trauma Informed Practice Grounding Detach From Emotional Pain • Distraction by focusing outward • Detach from overwhelming emotion by anchoring yourself in present reality • Attain a balance between conscious reality and being able to handle it • Keep your eyes open, scan the room, keep lights on • Focus on present, not past or future • Avoid judgements of good or bad; remain neutral Types of Grounding 1) Mental Grounding - describe your environment in detail, play a categories game (e.g. types of dogs), describe an activity in detail (e.g. cooking a meal), read something slowly 2) Physical Grounding - run cool or warm water over your hands, touch various objects and notice their differences, jump up and down, stretch, focus on breathing, eat something and notice flavours, clench and release fists 3) Soothing Grounding - say kind things, think of favourites (color, animal, season), picture loved ones, remember a safe place, say a coping statement (I’m okay, I can handle this), think of things you’re looking forward to. Trauma Informed Practice Coping With Triggers Triggers • Actively identify what they are • Never test yourself with triggers • Stay far away from triggers; avoid avoidable suffering • Triggers will occur in life, prepare to cope with them Safety Zone Create safety by: • Changing Who - detach from unsafe people, move toward safe people (family, friends, sponsor), talk about feelings or light, distracting topics, carry photos of loved ones • Changing What - keep busy with safe activities such as reading, exercise, tv, calming music • Changing Where - find a safe place; leave area, take a drive or walk, throw out drug accessories Trauma Informed Practice Response Based Approach Everyday Resistance • Assumes that every individual innately possesses the ability to resist violence and oppression • Resistance is expanded beyond physical fighting back to include “any mental or behavioural act through which a person attempts to expose, withstand, repel, stop, prevent, abstain from, strive against, impede, refuse to comply with or oppose any form of violence or oppression” (Wade, 1998, p. 25) Victim’s Dilemma • Perpetrators of violence will suppress any challenge to their authority, making open defiance one of the least likely forms of resistance • “Small acts of living” become the most common way of resisting violence or oppression (Goffman as cited in Wade, 1997, p. 32) • Such small acts may include lying, withdrawal, feigned ignorance, tone of voice, facial expressions, muttering, acts of the imagination (including comforting thoughts, detachment and dissociation) Responses to Violence Staff working with trauma survivors can focus conversations on the client’s response to, versus the effects of, experienced violence Shifts away from the potential re-telling of traumatizing stories to uncovering acts of resistance Shifts our perceptions from passive victimization to active resistance and cultivates conversations about client capability Trauma Informed Practice Cultural Considerations • As seen earlier, the potential effects of trauma are widely variable and depend not only on the trauma itself but also numerous individual and environmental factors • Differing cultures may therefore experience responses to extreme stress in very different ways • The PTSD diagnosis is itself culture-bound in that it describes symptoms of individuals born and raised in Anglo-European/American cultures. Culture as a Construct Beyond Simply Race Culture pertains to individual worldview as affected by race, language, social interaction and socioeconomic status Culture is continuously evolving and never static Racial categories therefore reveal little about cultural context, however cultural difference translates into widely varying trauma presentations and expectations of clinical contact Cultural awareness and sensitivity does not maintain helpers should have expert knowledge of every cultural background, this is impossible It does call for a stance of curiosity and willingness to learn alternate worldviews. It also seeks to actively learn the rules of engagement and cultural trauma presentations for clients from nonAnglo/European cultural groups Best Practice Guidelines Service Recommendations Service Integration Separate services for mental health and addictions operating under differing treatment philosophies not only creates access barriers but fails to meet a client’s holistic needs A housing first approach addresses basic needs initially, later incorporating clinical treatment, addiction support, medical care, support for accessing financial resources, social work and occupational therapy in one treatment environment Please refer to http://www.thealex.ca/ for more information on the housing first model Trauma Assessment Statistics estimate that 30-59% of women with a substance use disorder meet the criteria for PTSD, while 55-99% of them will report suffering physical or sexual abuse (Najavits, Weiss, Shaw & Muenz, 1998; Savage, Quiros, Dodd& Bonvota, 2007) Standard trauma assessment practices are recommended in mental health and substance abuse treatment settings Integrated Intervention Prolonged re-exposure to traumatic material is not recommended for dually diagnosed clients as resulting distress can become a significant risk factor for substance use Cognitive-behavioural interventions have been developed for combined treatment of trauma symptoms and substance abuse (Harris, 1998; Najavits, 2002) These interventions can be adapted to work with individuals or groups Empowerment Model An empowerment model is the single most important feature of any trauma intervention Maximizing choice in treatment planning is essential to respecting client self-determination and working to restore autonomy often stolen by experiences of abuse Clinicians must be accountable for facilitating this process and promoting client safety throughout References Briere, J. & Scott, C. (2006). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage Publications. Harris, M. (1998). Trauma recovery and empowerment: A clinician’s guide for working with women in groups. New York, NY: Free Press. Najavits, L. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY: Guilford Press. Najavits, L. (2004). Treatment of posttraumatic stress disorder and substance abuse: Clinical guidelines for implementing seeking safety therapy. Alcoholism Treatment Quarterly, 22(1), 4361. Newmann, J. & Sallmann, J. (2004). Women, trauma histories and co-occurring disorders: Assessing the scope of the problem. Social Service Review, 78 (3), 466-499. Pathways to Housing Calgary (n.d.). Retrieve from http://www.thealex.ca/pathways/. Savage, A., Quiros, L., Dodd, S.J., & Bonvota, D. (2007). Building trauma-informed practice: Appreciating the impact of trauma in the lives of women with substance abuse and mental health problems. Journal of Social Work Practice in the Addictions, 7 (1/2), 91-116. Stromwall, L. & Larson, N. (2004). Women’s experience of co-occurring substance use and mental health conditions. Journal of Social Work Practice in the Addictions, 4(1), 81- 96. Wade, A. (1997). Small acts of living: Everyday resistance to violence and other forms of oppression. Contemporary Family Therapy, 19(1), 23-40.