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Through a Trauma
Informed Lens:
Rethinking Addiction
Dr. Debbie Ruisard, DSW
[email protected]
“One must not look hard to see
that we are losing the battle
against addiction”
Harvard Psychiatrist, Ed Khantzian, 2013
Various studies have reported
any where from 40% - 90%
relapse rate in individuals with
addictive disorders after
completing treatment.
Questions that I have attempted
to answer in my work
What is it about the individual that impacts
their response to treatment interventions?
How can we intervene in a way that honors
individual differences and avoids the “one
size fits all” approach to addiction
“Addiction is defined as a chronic,
relapsing brain disease that is
characterized by compulsive drug seeking
and use, despite harmful consequences. It
is considered a brain disease because
drugs change the brain; they change the
structure and how it works.”
(National Institute on Drug Abuse)
NIDA and the Disease Model
1994 Allen Leshner: “That addiction is
tied to changes in brain structure is what
makes it, fundamentally, a brain disease”
2015 Nora Volkow: “It is a disease in
which essential motivational and selfcontrol symptoms of the brain are
Current discourse – is it a disease or not?
Benefits of the Disease Model
Counteracts the moral model that blames people
for their bad behaviors
Reduces stigma
Leads to treatment rather than punishment
More funding for research; gets attention from
Locating addiction in the brain leads to new
medications that target brain functioning to help
people to recover
Chronic nature of the disease puts relapse into
perspective –relapse is a part of the recovery
Drawbacks of the Disease
Offers false hope that there is a medical cure for
Has not shown to reduce stigma
Government funding primarily supports disease
model research
Based on the fact that drugs are inherently
addicting (which has been disproven by research)
It does not adequately account for the reality that
most people use substances to numb emotional
pain or cope with difficult environments
Has anything changed?
“The very nature of addiction challenges
society’s deeply held preconceptions about
willpower and self control…Addiction is not
a moral failing; it is a disease in which
essential motivational and self-control
systems of the brain are compromised.”
Nora Volkow
National Council Magazine, 2015
Is this really the only view of
addiction that fits our clients?
Trauma and addiction
I approach the connection
between these two human
experiences through the
lens of a trauma
professional, not an
addiction professional.
Adverse Childhood
Recurrent and severe physical abuse (11%)
Recurrent and severe emotional abuse (11%)
Contact sexual abuse (22%)
Growing up with alcoholic or drug user (24%)
Growing up with a family member in prison (3%)
Growing up with a family member with mental illness (19%)
Growing up seeing your mother being treated violently (12%)
Growing up with both parents not being present (22%)
ACES and Addiction
Women were 50% more likely than men to have
experienced 5 or more adverse childhood
The higher the ACE score, the higher the chances
of addiction to alcohol and other drugs in
 4 or more ACEs = 500% increase in risk for
adult alcoholism
 Men with 6 or more ACE’s = 4600% increase
in risk for IV drug use
 78% of IV drug use in women can be
attributed to adverse childhood
Maybe its not about the drug
“…Our findings are disturbing to some
because they imply that the basic causes of
addiction lie within us and the way we treat
each other, not in drug dealers and
dangerous chemicals. They suggest that
billions of dollars have been spent
everywhere except where the answer is to
be found.
Vince Felliti, 2004
Dr. Gabor Mate
Expanding definition of
Complex Trauma
Attachment Trauma
PTSD – first officially recognized in the mid-1980s due to
the data gathered by the National Vietnam Veterans Readjustment Study
Classified as an anxiety disorder in the DSM-III, DSM-IV
and DSM IV-R.
Finally in the DSM 5 it was moved out of the anxiety
chapter and into a new chapter “Trauma and Stressorrelated Disorders”
This move is seen as controversial by researchers who
see that adding symptoms, broadening the construct of
PTSD and moving away from fear conditioning and
extinction models will set the field back
Complex Trauma
Judith Herman was the first person to
acknowledge another view of
psychological trauma that did not
conform to the framework of PTSD – that
which was seen in people who suffered
considerable domestic violence, child
physical and sexual abuse and neglect and
who were given diagnoses of various
personality disorders (Trauma and
Recovery, 1992)
She called it “complex trauma”
Complex Trauma
Domains of Impairment
Affect Regulation
Behavioral control
Attachment Trauma
Children have a biological instinct to attach
Attachment provides a secure base
We learn how to modulate our affective states
through the attachment relationship with our
primary caregiver
An impaired or absent caregiver does not provide
a secure base for secure attachment to develop
Insecure attachment patterns leave children with
no skills to self regulate
Insecurely attached children grow up to be
insecurely attached adults
Attachment in Psychotherapy David
Addiction as an attachment
Research demonstrates the prevalence of insecure
attachments in adults with substance use disorders
(Parolin & Simonelli, 2016)
“Attachment theory looks at addiction as both a
consequence and a failed solution to an impaired ability
to form healthy emotionally regulatory
relationships…the underlying driving force behind all
compulsive/addictive behavior is related to an inability
to manage relationships” (Flores, 2006, p. 6)
The vulnerable individual’s attachment to chemicals
serves both as an obstacle and as a substitute for
interpersonal relationships.
The impact of trauma
In the moment of trauma, the body goes into fight or
flight mode. The prefrontal cortex shuts down and the
limbic brain takes over.
This loss of executive function is a protective response
because cognition is too slow.
When re-traumatized, the brain responds in the same
way: the cognitive brain deactivates and the
emotional/instinctual brain acts as if the traumatic
event is happening in the present – the person become
furious, terrified, enraged, ashamed or frozen.
Addiction Treatment Can be
Concept of powerlessness
Absolute authority of the counselor
Confrontation tactics
Shaming practices
Focus on ‘character defects’
“Addicts can’t be trusted to tell the truth”
Discharges for “non-compliance”
Punishing aggression
No choices
Withholding medication-assisted treatment
Trauma Informed Treatment
What does it look like?
It requires a paradigm shift away
from a traditional approach to
addiction treatment toward one
that seeks to reflect the principles
of trauma informed care
Choice and
12 Step program is a valuable community support and
an adjunct to evidence based treatments
This relationship-based self-help program of recovery
can be both healing and triggering to a traumatized
Unwillingness to participate may not be resistance or
denial, but a common and expected reaction of
someone who has experienced trauma in relationships
Relationships are dangerous, and yet what is damaged
in relationships can only be healed in relationships
Judith Herman
So What Does This Mean?
It is no longer adequate to treat addiction as
a primary and singular disorder
It is important to critically examine how we
do addiction treatment today and be willing
to change our practices so that we are
responsive to the trauma our clients have
Trauma informed treatment and trauma
specific interventions must become an
integral part of substance abuse treatment
Even clients who do not have a significant
trauma history will respond positively to a
trauma informed approach
Rethink addiction treatment
For many individuals, addictive behaviors
are an adaptation to traumatic
The disease model has its usefulness but
the risk is that we seek only to intervene
through the brain and ignore the body
(mind body connection)
We need to re-focus our treatment to
start from the bottom-up
The focus of trauma
 Cognition
 Emotion
 Body
Working with Cognitions
Top Down - works with cognitions
 Psychotherapy (talk therapy)
 Psychoeducation
 Mindfulness
Many addiction treatment strategies are
cognitive based
What we now know about trauma
indicates that this may not be an
effective way to treat traumatized
Working with Emotions
Until someone is able to establish
personal emotional safety, they will
be unable to process traumatic
Emotional regulation skills must be
mastered first
We are emotional regulators
Trauma is stored in the body
All trauma is preverbal; the traumatized body
re-experiences terror, rage and helplessness,
but these feelings are almost impossible to
Survivors develop “cover stories” to explain
their symptoms and behaviors; these stories
rarely capture the inner truth of the
The experience of trauma shows up in
instinctual responses such as fight, flight,
freeze, submit and attach
Vander kolk, 2014
Working with the body
May be necessary to start from the bottom up,
with the body
Breath, movement, touch, rhythm, synchronicity
Movement oriented activities should move from
the adjunctive therapy list to the primary therapy
Sensorimotor approaches
Once the body settles, then we can begin to work
through the emotional and the cognitive
modalities to heal trauma
Body based interventions
Yoga, Art, Music, Movement
Sound Healing
EMDR, Brain Spotting, Theatre, Improv,
Sensorimotor techniques
 Sensori motor psychotherapy; Somatic Reexperiencing
What do you think?
Can we change how we do
addiction treatment?