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Through a Trauma Informed Lens: Rethinking Addiction Treatment Dr. Debbie Ruisard, DSW LCSW, LCADC [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 treatment? DISEASE MODEL OF 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 compromise” 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 Congress 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 process Drawbacks of the Disease Model Offers false hope that there is a medical cure for addiction 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 Experiences ACEs: 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 experiences The higher the ACE score, the higher the chances of addiction to alcohol and other drugs in adulthood 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 experiences 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 trauma PTSD Complex Trauma Attachment Trauma PTSD 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 Attachment Affect Regulation Behavioral control Biology Dissociation Cognition Self-concept 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 disorder 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 Re-Traumatizing 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 Punishment Safety Distrust Trust Confrontation Collaboration Authoritative Treatment Compliance Choice and Empowerment Transformation 12 STEP COMMUNITY 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 individual 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 experienced 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 experiences 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 treatment Cognition Emotion Body Working with Cognitions Top Down - works with cognitions Psychotherapy (talk therapy) Psychoeducation CBT 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 individuals Working with Emotions Until someone is able to establish personal emotional safety, they will be unable to process traumatic experiences 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 articulate Survivors develop “cover stories” to explain their symptoms and behaviors; these stories rarely capture the inner truth of the experience 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 list 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 Drumming Sound Healing EMDR, Brain Spotting, Theatre, Improv, Psychodrama Sensorimotor techniques SMART Sensori motor psychotherapy; Somatic Reexperiencing Neurofeedback What do you think? Can we change how we do addiction treatment?