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Denise U. Tordella, M.A., LPC
www.denisetordella.com
Understand the consequences of substance abuse and
sexual compulsivity on the individual’s ability to
manage and resolve trauma
Understand the relationship between exposure to
trauma and co-occurring disorders, including
depression, anxiety, PTSD, dissociation and addiction
Identify the trauma-related addiction needs of clients
Learn about assessment and integrated addiction
treatment strategies for individuals affected by trauma
Identify creative body-oriented treatment strategies
and modalities to regulate arousal level and modulate
affect to reduce the use of addictive behavior
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The conventional definition often focuses
on traumatic events or bad things that
have happened but the deeper trauma is
the absence of love, affection, care and
protection. The bigger trauma is not
feeling important or special.
(Colin Ross, 2000)
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experienced emotional abuse.
experienced physical abuse.
experienced sexual abuse.
experienced emotional neglect.
experienced physical neglect.
witnessed their mothers being treated violently.
grew up with someone in the household using alcohol
and/or drugs.
grew up with a mentally-ill person in the household.
lost a parent due to separation or divorce.
grew up with a household member in jail or prison.
(Kaiser Permanente Adverse Childhood Experiences Study, 1995-97)
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Substance Abuse:
12%-34% of men in treatment meet diagnostic
criteria for PTSD.
For women, rates are 33%-59%. 80% of women
with substance abuse disorders are survivors of
domestic violence.
Sexual Compulsivity:
25% of individuals treated for chemical dependency
also meet criteria for sexual compulsivity; 78% of
men have history of sexual abuse.
(Stavro, 2013)
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It is estimated that Hypersexual Disorder occurs in
3 – 6% of the general population and co-occurs with
substance abuse in 25% of individuals seeking
substance abuse treatment.
(Coleman, 1992; Carnes,
2006;
Stavo, Chiasson, Potvin, 2013)
PTSD usually precedes the substance abuse.
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Trauma induced alterations in biological stress
systems can adversely affect brain
development, cognitive and academic skills, and
language acquisition.
These changes may affect the way children and
adolescents respond to future stress and may
impact their long-term health
Traumatized children and adolescents display
changes in the levels of their stress hormones
similar to combat veterans.
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To forget, numb, avoid, create distance, escape physical or
emotional pain, reduce anxiey
Provide excitement, comfort, aid in sleep (actually worsens
REM)
To escape aversive bodily states, build courage, ease social
anxiety, withdrawal, dissociate (wall off memories… a part of
me uses)
To self sooth, calm, reassure a fragile sense of self
To make connections with partner, others
To access negative feelings, rather than dissociate from them
(Covington, 2010; Fisher, 2011; Najavits, 2012)
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Regulated
arousal
Hyperarousal: activation
exceeds capacity to
integrate
Window of
Tolerance
Dysregulated
arousal
(Siegel, 1999; Ogden, Minton & Pain, 2006)
Hypoarousal: insufficient
activation to integrate
Hyperarousal Symptoms:
Marijuana and Alcohol: induce relaxation, numbing,
act as a “chemical barrier” to traumatic memory,
facilitate social engagement by decreasing
hypervigilance, enhance mood
Speed and Cocaine: increase alertness, sense of
power and control to counteract feelings of
helplessness
Heroin: Most effective drug for regulating the CNS –
dampens rage, impulsivity, profoundly numbing
(Fisher, 2011)
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Hypoarousal Symptoms:
Heroin and Marijuana: induce numbing, bring both
hypoarousal and hyperarousal symptoms under
control
Speed and Cocaine: counteract feelings of
deadness, hopelessness, weakness
Alcohol: at different doses, it either induces
numbing or counteracts it. It is a stimulant in small
doses and a depressant in larger doses
(Fisher, 2011)
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Makes trauma symptoms worse
Prevents client from increasing knowledge of self
Does not facilitate client getting needs met
Stalls emotional development
Isolation
Interferes with learning tools to cope with feelings
Eliminates / reduces control
Impacts sleep
Increases negative feelings related to self-worth
Impairs physical, emotional, spiritual health
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Addiction is a chronic disease of the brain
affecting the reward/motivation/memory
systems
Addiction is defined as including process
addictions such as eating, sex and gambling
At its core, addiction is not a social or moral
problem, but a brain problem
(Miller, 2011)
American Society of Addiction Medicine
(2011)
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Substance Use Disorders
Depression
Anxiety Disorders
Sexual Dysfunction
Eating Disorders
Self-Injuring Behavior
Medical Disorders
Dissociative Disorders
Axis II
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Substance abuse often does not occur in a
vacuum. A multitude of addictions such as
drugs and alcohol, food, sex, work, gambling,
internet and gaming not only exist but
interact ,reinforce and fuse becoming part of
a package known as addiction interaction
disorder.
(Carnes, 2011)
“Neurons that fire together wire together.”
(Seigel, 1999)
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Gambling Disorder is now in a class of
“behavioral” addictions.
According to APA, this change reflects the
increasing evidence that behaviors such as
gambling activate the brain reward system with
effects similar to drugs of abuse and resemble
substance use disorders to a certain extent.
Hypersexual Disorder (HD) did NOT make the
new DSM-5.
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Links between hypersexual behavior and
internalizing disorders like anxiety and depression
Theoretical similarities with compulsive disorders
like OCD
Classification as a sexual disorder
(Kafka, 2010)
Classification as a behavioral addiction and
classified within a category of non-substance
or behavioral addictions
(Winters, et. al., 2012)
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Preoccupation
Repetitive engagement
Efforts to Control Fail
Disregards risks to self and others
Present for at least 6 months
Individual is at least 18 years old
(Kafka, 2010)
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Urges, behaviors combined with personal
distress
Uncontrollable sexual fantasies
Diminished control and increased negative
consequences
Damage to self and others - divorce
Financial consequences
Health risks – STD’s and AIDS, oral HPV,
unintended pregnancies
Occupational and/or financial difficulties
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SAST – Sex Addiction Screening Test –
SARA – Sex Addiction Risk Assessment –
ISST – Internet Sex Screening Test –
www.sexhelp.com/am-i-a-sex-addict/internetsex-screening
SDI –
PTSI – www.recoveryzone.com
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1. I spend more than 5 hours a week using
my computer for sexual pursuits.
2. I have some sexual sites book marked.
3. I have participated in sexual chats.
4. I have masturbated while on the Internet.
5. I have tried to hide what is on my
computers so others don’t see it.
Limitations – honesty in reporting, denial due
to lack of consequences (especially teens)
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SAST
1. Do you feel your sexual behavior (SB) is
normal?
2. Do you ever feel bad about your SB?
3. Has your SB caused problems for you or
your family?
4. Has anyone ever been hurt emotionally
because of your SB?
5. When you engage in SB do you feel
depressed afterward?
Limitations – asks about more severe forms of acting
out and puts weight on “feelings” of test taker
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6. Have you ever cruised public areas looking
for sex with strangers?
7. Are you in crisis over your SB?
8. Have you been paid for sex?
9. Have you regularly engaged in
sadomasochistic behavior?
10. Have you engaged prostitutes/escorts to
satisfy your daily sexual needs?
Limitations – Denial: “I only scored 2 so there no is
issue”
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CAGE
Have you ever…
Tried to Cut down on drinking
Felt Annoyance with criticisms about
drinking
Felt Guilt about drinking
Used alcohol as an Eye opener
Emotional discomfort such as anger, sadness
or boredom
MAST – Minnesota Alcohol Screening Test
ASI – Addiction Severity Index
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Have you ever drank or Used drugs more than
you intended?
Have you ever Neglected some of your usual
responsibilities because of alcohol or drug use?
Have you ever felt you needed to Cut down
your drinking or drug use?
Has anyone ever Objected to your drug or
alcohol use?
Have you ever found yourself Preoccupied with
wanting to use alcohol or drugs?
Have you ever used alcohol or drugs to relieve
______?
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“The brain is the source of behavior,
but in turn it is modified by the behaviors
it produces…
…Learning sculpts brain structure.”
(Zatorre, et. al. 2012)
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Dopamine will send an addict chasing after
whatever substance or behavior spells
relief. It can change the brain by narrowing
the field of synaptic change, focusing it on
one particular reward forming a rut or
intractable path.
(Lewis, M. (2011) Memories of an Addicted Brain)
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Other life problems are common
Trauma does not go away with abstinence
Separate treatment systems
Single gender treatment not always
available but superior for female clients
(Grosenheck & Hatmaker, 2000;
Covington, 2000)
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Treatments (e.g., exposure, twelve-step
groups, benzodiazepines) helpful for either
disorder alone may be problematic if
someone has both disorders.
Also, some messages in substance abuse
treatment may be problematic:
“hitting bottom”
“confrontation”
“clean vs. dirty”
Fragile treatment alliances and multiple
crises are common.
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Denial - easy to maintain and there are often
no consequences early on (especially in teens)
so there is no motivation to seek help.
Overculture – Normalizes excessive behavior …
any limits perceived as repression
Teens – Impulsivity, frontal lobe not fully
developed until mid 20’s
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1.
2.
3.
4.
5.
6.
7.
Thorough assessment, psychoeducation
Support – 12 step group, spiritual or secular
community to foster connection,
commitment
Trauma history/treatment – stages
Abstinence from self-destructive behaviors,
relapse prevention
Affect management skills
Expanding purpose/new pleasures
Medication/Nutritional management
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1. Increase mindfulness
2. Increase the ability to self-regulate trauma
related emotions and body sensations
3. Increase the ability to self-regulate addictive
behavior (notice the feelings rather than be
the feelings, understand how to ride through
triggers, develop somatic skills to anchor and
regulate)
4. Create a supportive protective inner self as
well as a recovery network of support.
5. Reduce shame
(Fisher, 2011)
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Hope, Compassion, Information
Access strengths (IFS) and prior successes
Set small achievable goals (treatment plan)
Promote strong relationships with (safe)
friends and family
Teach Sensorimotor Psychotherapy™
techniques to develop capacity to self-soothe
Encourage participation in scheduled activities
Draw on spiritual and religious beliefs for
comfort and perspective
Foster appreciation of new strengths, skills,
gains, insight (Victory List)
Find new passions and rewards
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Create a Safety Plan – teach clients to cope with
feelings and impulses, create action plans
Develop a Coping Skills Chart
Create a Coping Box
CARESS Model
(Ferentz, 2012)
Healing Circle using EMDR
(Schmidt, 2009)
Resource Refocusing using EMDR
(Kiessling, 2007)
Addictions Protocol in EMDR
(Popky, 2007)
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Psycho-ed
MI
DBT
EMDR
Art
Music
Imagery
EGO
State
Model
(IFS)
Yoga
Movement
Somatic
Work
SP/SE
Structural
Dissociation
Model
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Sobriety or Abstinence
Increased
acting out,
unsafe
behavior
loss of “chemical
support”
increased
negative
effects of
addiction
Increase
in PTSD
symptoms
irritability, reactivity,
emotional overwhelm,
increased traumatic
activation, or flooding
panicked attempt
at self-regulation
Substance
or behavioral
relapse or “slip”
Increase in
matches increase in
addictive impulses
PTSD symptoms
or pre-relapse behavior
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Copyright 2007, Janina Fisher, Ph.D.
How is this “slip” a golden opportunity… what
did I learn from this?
What “message” is this “slip” trying to send to
me?
What might be the legacy of that behavior?
“That 16 year old learned that drinking numbed
the pain of not belonging and feeling unlovable.”
(Fisher, 2011)
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Improve memory – working memory
impairments most damaged in addicts
AA – step work, repetition
Planning out the week day by day
Prospection – mental time travel – imagine you
are given $100... write down everything you
could buy. Imagine you are in Target – tell me
what you see, experience it – mentalizing…
Medication – Naltrexone, Vivitrol, Suboxone
Sober Link – sobriety test at random
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A body oriented therapy developed by somatic
pioneer Pat Ogden. This therapy approach
blends talk therapy techniques with body
centered interventions that directly address the
implicit memories and neurobiological effects of
trauma.
Body observations and sensations are the
primary entry point in therapy.
(Ogden, 2002)
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Regulated
arousal
Hyperarousal: activation
exceeds capacity to
integrate
Window of
Tolerance
Dysregulated
arousal
Hypoarousal: insufficient
activation to integrate
55% of emotional messages conveyed through
facial expressions and the body
38% is communicated through the rhythm of
the voice
7% is communicated through words
(Mehrabian)
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1. You have a body!
1. Develop body awareness and ability to link
thoughts feelings to body sensation
Example: “When I feel confident, I notice it in
the way I stand, my shoulders are back and my
spine feels straight. The sensation feels strong
and solid.”
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You can’t do good recovery work unless you
talk about underlying shame
Know when they are in shame – have
physicality associated with it. Feel 1st shame
at 14 months
Silence, secrecy, judgment – 3 things that
grow shame
When something happens are you more likely
to use guilt or shame self-talk?
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Reframing – I can see why you feel shame about
that, rethinking from a compassionate self
Confronting – “I wonder what you might say to
a good friend who experienced that?”
Self-disclosure – (with good boundaries) “I’ve
had days like that too. When I was your age…”
(Brown, 2012)
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“When people get close to re-experiencing their
trauma, they get so upset that they can no longer
speak… Fundamentally, words can’t integrate the
disorganized sensations and action patterns that
form the core imprint of the trauma… [In order]
to do effective therapy, we need to do things that
change the way people regulate these core
functions, which probably can’t be done by words
and language.”
(van der Kolk, 2006)
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Body sensations (tight, warm, tingly, open)
Emotions (positive and negative feeling tones –
angry, overwhelmed)
Five-sense perception (sight, taste, smell, touch,
hearing)
Movement (voluntary, involuntary, gross motor
and micro movements)
Thoughts (cognitions)
(Ogden & Minton, Pain, 2006)
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Safety as the priority:
Discontinuing substance abuse /
compulsive, self-harming behaviors
Decreasing suicidality
Minimizing exposure to HIV
Letting go of dangerous relationships,
Gaining control over extreme symptoms
Every session addresses both substance
abuse and PTSD
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U
The Body Keeps Score: Bessel van der Kolk
The Body Remembers: Babette Rothschild
Focus on client’s body sensations.
Increase awareness of client’s physical
processes.
Assess whether client is being triggered
or hyper-aroused.
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Muscle tension or tightening
Clenching
Changes in rate or depth of breathing
Changes in heart rate
Achy feeling
Sharp or dull pain
Nausea / stomach pain
Change in body temperature
Tingling / Numbing
Heaviness / Immobility
Lump in throat / difficulty swallowing
Falling / going limp
Shaking / trembling
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Develop present focused awareness
Sight
Sound
Taste
Smell
Touch
Use Grounding Kits
Learn to identify and scale feelings
Enhance ability to choose how to respond
(rather than react) based on goals and values,
rather than transient feelings
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Cognitive Distortions
Denial
Rationalizing
Blaming
Mind reading
Emotional Reasoning
Labeling
Over-generalizing
Magnifying
Minimizing
Dichotomous thinking
(Beck, 1976)
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Mental Grounding
Play categories game
Describe an everyday activity in great
detail
Say a safety statement
Read something aloud
Count to 10
Recite the alphabet
(Najavits, 2002)
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Physical Grounding
Run cool or warm water over hands
Grab tightly onto chair
Touch surrounding objects
Dig heels into the floor
Carry a grounding object
Jump up and down
Stretch
Clench and release muscles
Walk slowly, noticing each footstep
Eat something, describing the flavors out loud
Focus on breathing
(Najavits, 2012)
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Soothing Grounding
Say kind statements
Think of favorites
Picture people you care about
Recite the words to an inspiring song,
quotation or poem
Describe your safe place
Say a coping statement
Plan a safe treat
Think of safe things that you are
looking forward to doing
(Najavits, 2002)
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Art Therapy
Drawing, painting, creating collages,
sculpting with clay/model magic
Journaling
“Taking notes during session”, writing
poetry, prose, journaling
Mapping
Creating a visual roadmap of
therapeutic issues
Two handed dialogues
Guided Imagery
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Protocol of 8 weeks including yoga postures,
mantras, breath work, creative activities and
mindfulness.
(Lilly & Hedlund, 2010)
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Trauma Sensitive Yoga – Hanson & Hopper (2011)
Life Force Yoga – Weintaub (2004)
Yoga Warriors – Cimini (2011)
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Seated Mountain Pose – Core Posture
Seated Sun Breathes – lift hands up in
arc…palms down
Seated Sun Breath Variations:
A. Palms at center – extend arms to
side…as you exhale palms back to
center
B. Hand on heart… other on abdomen
C. With a twist…
D. Forward fold
(Emerson & Hopper, 2011)
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Failing to validate the relief offered by
addictive behavior
Failing to understand the fear of relying on
people and the safety in relying on a substance
or behavior under your own control
Failing to see that care of the body is not a
priority for the trauma survivor: when your
body only matters as a vehicle for discharging
tension, its care becomes meaningless
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Failing to convey that trauma-related shame
and secrecy will make it feel “normal” to
lie/evade and “unsafe” to disclose
Becoming engaged in a struggle in which the
therapist becomes the spokesperson in favor of
sobriety and the client the spokesperson for
addictive behavior, neglecting the task of
helping the client to struggle with the strong
internal opposing forces
Copyright 2006, Janina Fisher, Ph.D.
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Informed consent
Awareness of counselor’s
issues related to substance
abuse and trauma
Developing and maintaining
boundaries
Counselor self-care
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“The expectation that we can be immersed in
suffering and loss daily and not be touched by it
is as unrealistic as expecting to be able to walk
through water without getting wet.”
Rachel Remen
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