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SUBSTANCE DEPENDENCE
TRAUMA
EMDR
(EYE MOVEMENT DESENTIZITATION REPROCESSING)
MELINDA ENGLISH KANTOR MA LPC NCC
HOW TRAUMA INFLUENCES THE USE OF
SUBSTANCES AND USING EMDR AS AN
EFFECTIVE TREATMENT
INTRODUCTION
• Facilitator
• My interest in the subject
• Audience
• Areas of interest and influence
• Objectives
• Mine and ours
THE GOAL FOR THE CLIENT
ASSISTING OUR CLIENTS TO MENTAL HEALTH AND HIGH FUNCTIONING
What is mental health?
• The ability to emotionally regulate
• Ability to effectively express themselves
• Description of reasonably sense of inner contentment
• What does it mean to function highly?
• Social
• Family
• Faith – Community
• Fun
• Productivity
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Work
Responsibility
Health
Seek fulfillment of potential
THE GOAL FOR TREATMENT
• Explore and resolve issues relating to history of abuse/neglect victimization
• Explore and resolve grief and loss issues
• Provide relapse prevention and other tools for release of drug/alcohol
use/dependence
• Increase and practice ability to manage emotions
• Develop strategies to reduce symptoms, or reduce anxiety and improve coping
skills
• Improve overall behavior (and attitude/mood), or maintain positive behavior (and
attitude/mood)
• Learn and use effective communication strategies
• Improve decision making skills
• Increase authenticity
• Improve overall mood
• Learn and use conflict resolution skills
• Explore, resolve and reframe issues related to self image
• Address distorted thoughts or thinking errors
• Provide tools and skills to tolerate tragedy and negative life experiences
STATISTICS ON SUBSTANCE
DEPENDENCE RELATED TO TRAUMA
• 34.5% of men who had PTSD at some point in their lifetime also had a problem with
drug abuse or dependence
• 26.9% of women who had PTSD at some point in their lifetime also had a problem
with drug abuse or dependence
• 51.9% of men with a history of PTSD reported alcohol dependence and classified as
alcoholics
• 27.9% of women with a history of PTSD reported problems with alcohol abuse or
dependence
• One-third to two-thirds of child maltreatment cases involve substance use to some
degree. 11
• As many as two-thirds of the people in treatment for drug abuse reported being
abused or neglected as children. 9
• More than a third of adolescents with a report of abuse or neglect will have a
substance use disorder before their 18th birthday, three times as likely as those
without a report of abuse or neglect.12
Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbidity
Survey. Archives of General Psychiatry, 52, 1048-1060
Office on Child Abuse and Neglect, Children's Bureau. Goldman, J., Salus, M. K., Wolcott, D., Kennedy, K. Y. (2003) A Coordinated Response to
Child Abuse and Neglect: The Foundation for Practice, Chapter 5, retrieved
from: https://www.childwelfare.gov/pubs/usermanuals/foundation/foundatione.cfm
Wilson, E., Dolan, M., Smith, K., Casanueva, C., & Ringeisen, H. (2012). NSCAW Child Well-Being Spotlight: Adolescents with a History of
Maltreatment Have Unique Service Needs That May Affect Their Transition to Adulthood. OPRE Report #2012-49, Washington, DC: Office of
Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. Retrieved
from:http://www.acf.hhs.gov/sites/default/files/opre/youth_spotlight_v7.pdf
.
TRAUMA DEFINED
• WHAT IS TRAUMA?
• APA definition
• Trauma is an emotional response to a terrible event
like an accident, rape or natural disaster.
Immediately after the event, shock and denial are
typical. Longer term reactions include
unpredictable emotions, flashbacks, strained
relationships and even physical symptoms like
headaches or nausea. While these feelings are
normal, some people have difficulty moving on with
their lives.
TRAUMA DEFINED
• WHAT IS TRAUMA?
• SAMHSA Description
• Individual trauma results from an event, series of
events, or set of circumstances that is experienced
by an individual as physically or emotionally harmful
or threatening and that has lasting adverse effects
on the individual's functioning and physical, social,
emotional, or spiritual well-being.
TRAUMA DEFINED
• WHAT IS TRAUMA?
• DSM V Criteria
The person was exposed to: death, threatened death, actual or
threatened serious injury, or actual or threatened sexual
violence, as follows:
• Direct exposure
• Witnessing, in person
• Indirectly, by learning that a close relative or close friend was
exposed to trauma. If the event involved actual or threatened
death, it must have been violent or accidental.
• Repeated or extreme indirect exposure to aversive details of
the event(s), usually in the course of professional duties (e.g.,
first responders, collecting body parts; professionals repeatedly
exposed to details of child abuse). This does not include
indirect non-professional exposure through electronic media,
television, movies or pictures.
POST TRAUMATIC STRESS DISORDER
(PTSD)
SEE SUPPLEMENTAL DOCUMENTS
NOT JUST DIAGNOSED TRAUMA
• CHILDHOOD MALTREATMENT DEFINED
• Childhood maltreatment includes all intentional and
unintentional harm to, or avoidable endangerment of
anyone under age 18 (Berger 2005). This definition includes
emotional neglect, and physical, sexual and emotional/
verbal abuse. Neglect as a form of child maltreatment
occurs when the caregivers fail to meet a child’s basic
needs, including stimulation an education. Abuse includes
all actions that are harmful to a child’s well being, whether
deliberately inflicted or not. The victim does not have to be
directly affected; witnessing abuse is just as life changing if
not more so (Perry, 2002).
GETTING TO KNOW DE
• VIDEO
TRAUMA IMPACT
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EMOTIONAL DISREGULATION
ILLUSION BROKEN
SENSE OF SAFETY DAMAGED OR DESTROYED
SENSE OF CONTROL DAMAGED OR DESTROYED
FLASHBACKS
MEMORY LOSS
CONTINUOUS RACING THOUGHTS
SELF BLAME AND SHAME
DISSOCIATION
BRAIN RE-WIRING
DISTORTED VIEW
THE BRAIN IS THE KEY
• PREDISPOSITION
• GENETIC
• ENVIRONMENTAL INFLUENCE ON THE BRAIN
• FAMILY OF ORIGIN – CULTURAL
• EVENTS AND IMPACT
• NEUROPLASTICITY – CHEMICALS AND CONNECTIONS
• RESOLVING IN THE BRAIN
• NEUROPLASTICITY – RESTORING EQUILIBRIUM
TRAUMA IMPACT
THE BRAIN
A BASIC BRAIN EDUCATON IS AN ADVANTAGE
• HUMAN THREE BRAIN SYSTEM
BEGINS WITH THE REPTILIAN BRAIN
• PERFORMS THE BASIC FUNCTIONS OF LIFE
• HUNGER, BREATHING, SEXUAL DRIVES ETC
• INCLUDES MID BRAIN, PONS AND MEDULA (BRAIN STEM)
• PART OF THE FLIGHT, FIGHT AND FREEZE SYSTEM
TRAUMA IMPACT
THE BRAIN
• LIMBIC SYSTEM or MID BRAIN
• AMYGDALA or ALARM CENTER
TRAUMA IMPACT
THE BRAIN
• PREFRONTAL CORTEX
• THINKING BRAIN or CORTEX
TRAUMA IMPACT
THE BRAIN
• STRESS RESPONSES – 4-WAY IMPACT
• NEUROCHEMICALS
• HYPOTHALMIC-PITUITARY-ADRENAL AXIS
(PATHWAY)
• AMYGDALA (SCANNER)
• HIPPOCAMPUS (CONSOLIDATES AND
CATEGORIZES MEMORY)
TRAUMA IMPACT
THE BRAIN
• STRESS RESPONSES - NEUROCHEMICALS
• EPINEPHRINE
• FAST, EFFICIENT, SHORT LASTING
• NOREPINEPHRINE
• NARROWS ATTENTION FOR FOCUS
• CORTISOL
• SLOWER AND REMAINS IN THE BLOOD STREAM LONGER
[IN TRAUMA GOES AWRY]
LONG TERM EXISTENCE BURNS SYNAPTIC CONNECTIONS BETWEEN
BRAINS CONNECTIONS AND HEMISPHERES
TRAUMA IMPACT
THE BRAIN
• HYPOTHALMIC-PITUITARY-ADRENAL AXIS
• FEEDBACK LOOP IN THE BRAIN
• INFORMS THE BODY WHEN THE DANGER IS OVER
• CORTISOL REACHES A CERTAIN LEVEL AND OPERATES AS A
MESSAGE INDICATOR (PITUITARY-ADRENAL)
• WHEN THIS MESSAGE CENTER DOES NOT OPERATE WELL AS IN
TRAUMA A REDUCTION IN THREE BRAIN COMMUNCATION AND
HEMISPHERE RESULTS.
• SIGNIFICANT HEALTH ISSUES RESULT AS WELL
TRAUMA IMPACT
THE BRAIN
• LIMBIC SYSTEM/AMYGDALA GATEWAY (EMOTIONAL)
• REPEATED STRESS INCREASES SENSITIVITY
• CREATING CONDITIONING FOR KINDLING
• KINDLING EVENTUALLY CREATES A FIRE
• LATER A SMALL SPARK SETS NEURONS FIRING AT THE RATE SIMILAR
TO THE ORIGINAL EVENT
• FROM CHILD MALTREATMENT THERE IS A %100 INCREASE IN NEURONS
FIRING THAN IN THE AVERAGE PERSON
Whitsett, D., & Kent, S. (2003). Cults and families. Families in Society, 84(4), 1-11.
TRAUMA IMPACT
THE BRAIN
• HIPPOCAMPUS
• CONSOLIDATES AND CATEGORIZES MEMORY
• USES EXPLICIT SYMBOLS – LANGUAGE AND SYMBOLS
• IN TRAUMA THE HIPPOCAMPUS IS INHIBITED FROM
FUNCTIONING
• TRAUMA ACTIVATES THE LIMBIC STRESS CHEMICAL
RESPONSES WHICH CIRCUMVENTS THE HIGHER END PROCESS
• THEREFORE THE TRAUMA REMAINS STORED IN THE IMPLICIT
SYSTEM
• PERCEPTUAL, BEHAVIORIAL, AND EMOTIONAL VERSUS RATIONAL
TRAUMA IMPACT
THE BRAIN
• IMPLICIT VERSUS EXPLICIT BRAIN FUNCTION
• LIMBIC AND RIGHT SIDED BRAIN
• PRE-LANGUAGE AND SYMBOLS
• DOMINATES UP TO AGE FOUR
• LEFT SIDED BRAIN
• EXPLICIT, DECLARARITIVE, AND CONSCIOUS BRAIN
• DOMINATES FROM AROUND AGE FOUR
TRAUMA IMPACT
THE BRAIN
• THE CONNECTION
• INFORMATION PROCESSING
• NORMAL OPERATION
• PRIMITIVE “LOW ROAD” BRAIN (FIGHT, FLIGHT OR FREEZE)
• EARLY YEARS
• FASTER – ONE SYNAPSE
• EVOLVED “HIGH ROAD” BRAIN (RATIONAL)
• LATER YEARS
• SLOWER – SEVEN SYNAPSES
• MORE DETAILED PRE-FRONTAL CORTEX
• WHAT HAPPENS IN TRAUMA
• THE AMYGDALA SCANS DATA FOR DANGER BASED ON HISTORY
• THIS HAPPENS BEFORE THE PRE-FRONTAL CORTEX CAN ENGAGE AND
REALITY TEST
TRAUMA IMPACT
THE BRAIN
• SO, IN SUMMARY IN TRAUMA
• THE SYNAPTIC CONNECTIONS THAT ALLOWS A GREATER
PATHWAY BETWEEN THE TWO BRAINS AND THE TWO
HEMISPHERES ARE BURNED AWAY BY NEUROCHEMICALS
• THE PATHWAY VIA THE NORMAL FEEDBACK LOOP
HYPOTHALMIC-PITUITARY-ADRENAL AXIS IS INTERUPTED AND THE
INFORMATION TAKES THE FASTER “LOW ROAD” PRIMITIVE ROAD
(FIGHT, FLIGHT OR FREEZE), BYPASSING THE LEFT BRAIN ANALYSIS.
• THE AMYGDALA IS SENSITIZED TO DATA THAT SETS OFF THE
BRAINS DANGER SIGNALS.
• THEREFORE, THE HIPPOCAMPUS IS CIRCUMVENTED AND DOES
NOT HAVE THE OPPORTUNITY TO CONSOLIDATE AND
CATEGORIZE THE INFORMATION. WHEN STORED PROPERLY THE
EMOTIONAL PART OF THE MEMORY IS STORED IN THE CORTEX
AND NOT THE LIMBIC SYSTEM TO BE REACTIVATED TO THE LEVEL
OF CURRENT DANGER.
DE
PART 2
• VIDEO
SUBSTANCE DEPENDENCE DEFINED
• Dependence versus Abuse
• Abuse
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Some neglect of responsibility
Risk taking with substances (e.g. Driving under the influence)
Possible legal problems
Continued use in spite of social or interpersonal negative effects
• Dependence
(Dependence Severity is related to how many of the following the person exhibits)
• Some or all of the above
MILD 2 -3 of following symptoms MODERATE 4 – 5 of the following symptoms
SEVERE 6 or more of the following symptoms
• Continued need increase amount (tolerance) to achieve same effect
• Need to take substance to feel normal
• Give up normal activities (work, social, recreational)
• Continued use despite serious physical or psychological problems
• Spend a significant amount of time obtaining the substance
• Withdrawal symptoms when unable to obtain substance
• Individual is unable to “cut down” despite of desire or effort
NEUROCHEMICALS THAT INFLUENCE
SUBSTANCE DEPENDENCE
• Dopamine: The pleasure principle
• Addictive substance affects dopamine release in what's
known as the brain's 'reward pathway', the equivalent of a
neurological circuit connecting experience with feeling
good.
• Alongside pleasure, these receptors ensure the involvement
of dopamine in a range of activities, from movement to
memory. Drugs, such as cocaine and amphetamines, lead
to a sharp, temporary, rise in dopamine within the brain.
NEUROCHEMICALS THAT INFLUENCE
SUBSTANCE DEPENDENCE
• Serotonin: Feeling groovy
• Within the brain this chemical is associated with mood - a
person's overall state of mind, how they feel about
themselves and the external world at a point in time.
• A lack of serotonin in the brain is associated with
depression, which is why drugs called SSRIs (selective
serotonin reuptake inhibitors) such as fluoxetine (Prozac),
are commonly prescribed to help treat depression. Such
drugs cause an increase in the overall levels of serotonin in
the brain leading, in many cases, to diminished symptoms.
Certain illegal drugs, such as MDMA ('ecstasy') and LSD
('acid') can also stimulate different serotonin receptors,
leading to altered or extreme moods.
NEUROCHEMICALS THAT INFLUENCE
SUBSTANCE DEPENDENCE
• Acetylcholine: Remember me?
• Plays an important role in learning and memory. The neurons that produce this
neurotransmitter - cholinergic neurons - are found in several regions of the brain
where, when stimulated, they release their stores of neurotransmitter onto waiting
neurons. But to have any effect, those neurons need to have the right receptors; in
this instance, the nicotinic and muscarinic receptors.
• Glutamate:
• Glutamate is the brain's 'on switch'. Known as an 'excitatory neurotransmitter', this tiny
molecule does pretty much what it says on the tin - wherever it finds a receptor to
dock with, it causes the hosting neuron to become excited. An excited nerve is one
that's more likely to 'fire', resulting in the release of its own unique mix of
neurotransmitters.
• GABA: ...must come down
• Not a reference to hardcore techno, GABA is the neurotransmitter acting as
glutamate's lazy twin, its sole purpose being to slow things down, dampen and inhibit
nervous activity. Drugs that stimulate these receptors tend to slow the brain down, so
it's no surprise to discover alcohol affects these receptors.
• Drugs activating GABA receptors are found everywhere - liquid ecstasy, or GHB, has
become well known as a 'date rape drug' while other activators, such as the
benzodiazepines, are used in clinical contexts to help people get more sleep or lessen
anxiety, for example
DE
PART 3
• VIDEO
RELATIONSHIP THEORIES
• High-Risk Theory
The high-risk theory states that drug and alcohol problems occur before PTSD
develops. Proponents of this model believe that the use of alcohol and drugs puts
people at greater risk for experiencing traumatic events, and therefore, at greater
risk for developing PTSD.
• Self-Medication Theory
The self-medication theory states that people with PTSD use substances as a way of
reducing distress tied to particular PTSD symptoms. For example, alcohol (a
depressant) may be used to reduce extreme hyperarousal symptoms.
• Susceptibility Theory
The susceptibility theory suggests that there is something about alcohol and drug
use that may increase a person's risk for developing PTSD symptoms after
experiencing a traumatic event.
• Shared Vulnerability Theory
This theory states that some people may have a genetic vulnerability that increases
the likelihood that they will develop both PTSD and substance abuse problems
following a traumatic event.
Brady, K.T., Back, S.E., & Coffey, S.F. (2004). Substance abuse and posttraumatic stress disorder. Current Directions in Psychological Science, 13,
206-209.
Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbidity
Survey. Archives of General Psychiatry, 52, 1048-1060.
Tull, M.T., Baruch, D., Duplinsky, M., & Lejuez, C.W. (in press). Illicit drug use across the anxiety disorders: Prevalence, underlying mechanisms,
and treatment. In M.J. Zvolensky & J.A.J. Smits (Eds.), Health behaviors and physical illness in anxiety and its disorders: Contemporary theory and
research. New York, NY: Springer.
TRAUMA IMPACT AND SUBSTANCE
DEPENDENCE NEUROCHEMICAL
RELATIONSHIPS
• SENSITIZATION TO NEUROCHEMICALS
• Normal responses are blunted
• EXAGGERATED RESPONSES INCREASE ADDICTIVE
POTENTIAL
• Hypervigilance and paranoia is mediated by the dopamine
system
• Greater than normal reaction to the introduction of substance
like cocaine
• Endogenous opioid releases in reaction to triggers as an
“internal pain killer”
• Greater than normal reaction to the introduction of substances
like heroin
http://www.cnsforum.com/lundbeckinstitute/about
RELATIONSHIP BETWEEN TRAUMA
AND SUBSTANCE DEPENDENCE
• EMOTIONAL NUMBING; EMOTIONAL INDUCEMENT
• TO ELIMINATE EMOTIONS THAT ARE PAINFUL
• Substances such as benzodiazepines or opiates intended to
provide physical pain relief also have the ability to eliminate
negative emotional experiences
• TO CREATE POSITIVE FEELINGS WHEN EMOTIONS ARE ABSENT
• Individuals who have shut down their emotions or disassociated
can achieve positive feelings
• STRESS RESPONSES
• Substances such as methamphetamine provide a temporary
sense of well being by increasing dopamine and reducing
adrenalin and cortisol surges from triggers associated with trauma.
RELATIONSHIP BETWEEN TRAUMA
AND SUBSTANCE DEPENDENCE
• FAMILY OF ORIGIN
• Impact on ability to emotionally regulate
• Learning tolerance and management of emotions
• Modeling
• Toxic or chaotic home environment creates ongoing internal
disturbances that at minimum can be considered maltreatment
and at worst abuse.
• Susceptibility
• Individuals who grow up with susceptibility to both substance
dependence and trauma demonstrate a correlation between
both increase the possibility of the existence of the other.
RELATIONSHIP BETWEEN TRAUMA
AND SUBSTANCE DEPENDENCE
• BRAIN REACTIONS
• Dopamine rush
• Intensity
• Blunting
• Every day stimuli
• Disruption of memory
• Pleasure triggers override history of negative consequences
• Provides escape from disturbing thoughts
• Disruption of inhibition control over behavior
• Frontal brain regions are affected and cannot function to
control desire
• Trauma and substances both reduce healthy frontal lobe
functioning
National Institute on Health (NIH) – National Institute on Drug Abuse (NIDI)
RELATIONSHIP BETWEEN TRAUMA
AND SUBSTANCE DEPENDENCE
• BRAIN REACTIONS
• Chemical Resolutions
• The right self medication
• Lack of energy – Depression
• Too much energy – Anxiety/Lack of focus (ADHD)
• Reward circuitry
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Desensitization
Normal pleasures cannot compete
Loss of relative value in pleasure
With trauma life pleasures are minimized and substances
provide a sense of wellbeing that had not been previously
experienced as normal individuals experience
National Institute on Health (NIH) – National Institute on Drug Abuse (NIDI)
TREATMENT
• Psychotherapy
• Emotional Regulation Techniques
• Various
• Cognitive Behavioral Therapy (e.g. Prolonged Exposure Therapy TFCBT)
• Changing how you think changes how you feel
• Present Focused Therapy (e.g. Seeking Safety)
• Feeling safe and in a trusting environment allows open dialogue
• Analytical Therapy
• Dealing with the shadows
• Narrative Therapy
• Identifying and Reframing early acquired negative self images
• Trauma Sensitization Therapies (e.g.TARGET)
• Sensory incorporation; TARGET uses the acronym FREEDOM
• EMDR (Eye Movement Desensitization Reprocessing)
• Incorporating multi-dimensional approaches along with hemisphere
connection techniques
TREATMENT METAPHOR
Processing with treatment delivers
the memories to where they belong
eliminating chemical reactions
Limbic System
Memories that
create chemical
reactions when
triggers
• Remnants
• Emotional Flooding
Pre-Frontal Cortex
HOW TREATMENT WORKS
• Linking implicit “low road "circuits with explicit
circuits “high road”.
• Eliciting the emotional (low road operation) brain
experience while verbalizing (high road operation)
and integrating into a coherent connection
between the two brain hemispheres.
• Rerouting the alarm response through the prefrontal cortex disconnecting the immediate
primitive reaction.
• Eliminates future similar events from taking the “low
road” faster route and allows the hippocampus to
properly filter and categorize the memory.
EMDR INSTITUTE
• VIDEO
EMDR AS ONE TREATMENT MODALITY
• WHY EMDR?
• Separation to integration
• Dual attention processing (memory + here and now)
• Emotional and body memories coupled with imagery
• Activates the normal processing in REM (Rapid Eye Movement)
sleep.
• Memory categorizing and integration (short term to long term)
• Engaging both hemispheres
• Assists the process and enhances the natural REM sleep process
• Components of other therapies combined with the enhanced
processing
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Emotional Regulation
Verbalization
Desensitization
Therapeutic alliance
EMDR
EYE MOVEMENT DESENSITIZATION
REPROCESSING
• Eight Phases for one event trauma
• Phase I – History
• Current stressors are evaluated to determine appropriateness
• Dysfunctional behaviors and symptoms
• Identify targets (Past, Present and Future)
• Phase 2 – Preparation
• Educating client and assessing ability to emotionally regulate
• Using EMDR as one tool for emotional regulation – DEMONSTRATION
• Phase 3 – Assessment
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Image selection
Negative cognition
Example: “I am powerless”
Combined current level of disturbance (SUD scale-10 point)
Positive cognition and validity (VOC scale- 7 point)
Physical sensation
EMDR
EYE MOVEMENT DESENSITIZATION
REPROCESSING
• Phase 4 – Desensitization
• Negative affect
• Actual reprocessing (Eye, Taps, Sound etc.)
• Phase 5 – Installation
• Positive cognitions with target event(VOC to level 7)
• Example: “I am in control now”
• Phase 6 – Body Scan
• Target remaining physical sensations
• Phase 7 – Closure
• Between session education
• Journal
• Identify further targets
• Phase 8 – Re-evaluation
• Review continued processing between sessions and assess for
further treatment
EMDR DEMONSTRATION
CALM SAFE PLACE
BACK TO THE FLIP CHART
HAVE TO INITIAL OBJECTIVES BEEN MET?
QUESTIONS?
THANKYOU!
MELINDA ENGLISH KANTOR MA LPC NCC
[email protected]
770-683-9375 office
404-918-5992 cell