Trauma Informed Response Understanding Substance Abuse and Trauma

1. Trauma Informed ResponseUnderstanding Substance Abuse and Trauma Rita Ford Gibney LMFT LCAS Program Director Julian F. Keith Alcohol and Drug addiction Treatment Center

2. Trauma Informed Response Trauma Informed Response • Knowledge about key elements of PTSD/trauma • General awareness regarding PTSD/trauma conditions • Philosophy regarding understanding trauma • Approach to addressing PTSD/trauma • Language/terms used when addressing PTSD/trauma • Supports continuum of understanding • Offers consistent message to the client • Client centered • Accountability • Understanding of PTSD/trauma impact

3. Trauma Informed Response Research in the field of trauma and behavior has become increasingly less compartmentalized. • No longer exclusive to the world of psychotherapy • Military efforts to re-orient philosophy and leadership values • Law enforcement - CIT programs • Increased training and responsibilities for schools and teachers • Increased implementation of diversionary programs associated with court and legal problems • Increased efforts to de-stigmatize PTSD/trauma responses • Efforts to normalize trauma response • Increased open discussion about PTSD/trauma

4. Trauma Informed ResponseStatistics PTSD Prevalence: • Women – 51% experience trauma, with 10% developing PTSD Najavits, Lisa (2002) Seeking Safety Manual for PTSD • Men – 61% experience trauma, with 5% developing PTSD Najavits, Lisa (2002) Seeking Safety Manual for PTSD • Among people who suffer PTSD, approximately 31% have also abused or been dependent on drugs at some point in their lifetime(Tull, Matthew PhD, 2009) • Approximately 40% have also abused or been dependent on alcohol(Tull, Matthew , PhD, 2009)

5. Trauma Informed ResponseLegal Statistics Legal Issues: • PTSD – 33% of incarcerated men have PTSD (Ehlers et.al., 2000) • This represents four times the rate in the general population • Incarcerated women have far greater lifetime occurrences of trauma than general population (Jordan et. al., 1996) • 80% of federal and state inmates were either convicted of drug related crimes, were using at the time of offense, or committed their crime to support drug dependency (Center for Substance Abuse Treatment, 1998)

6. Trauma Informed ResponseLegal Statistics • Report to Congress by SAMHSA (2002): Lack of cross screening, dearth of programming, and funding regulations that focus on arrests/prison sentencing • Prisons have frequently become default provider for co-occurring disorders Impact on Drug Court System: • Clients entering Drug Court are often faced with limitations in treatment provisions • Limited resources to address recidivism/relapse • Attorneys, courts, probation officers often central resource for instilling motivation and harm reduction efforts

7. Seeking SafetyCurrent Treatment Needs Attention to Co-occurring Treatment Needs • Most substance abuse(SA) patients are not sufficiently assessed for PTSD issues even after multiple addiction treatments • Most SA patients are not informed of the PTSD diagnosis • Most substance abuse facilities do not endorse co-occurring treatment for SA and PTSD • Most mental health providers do not routinely screen PTSD patients for substance abuse These conditions further burden court and legal systems who face monitoring and legal oversight for individuals involved with the legal system

8. Trauma Informed ResponseConditions Shared by PTSD and Substance Abuse Common Conditions Between PTSD and SUD • Both have primary themes of secrecy and control • Each condition has high recidivism rate • Each condition is affected by the other • Each condition makes the other more likely • Both have higher rates of personality disorders • PTSD widely reported to worsen with initial abstinence • Both conditions set up a need to be in an altered state

9. Trauma Informed ResponseLink between PTSD and Substance Abuse Link is Far Ranging and Complex • Some individuals report using drugs helps them to forget or to numb the memories and other PTSD symptoms • Some report drugs and alcohol help unleash memories Najavits, L. M., (2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

10. Trauma Informed Response PTSD and Substance Abuse: A Patient’s Perspective

11. Trauma Informed ResponsePatient Perspective “As far back as I can remember someone was abusing me: my brother, my father, my distant mother. By the time I was 12, I was falling into abusive relationships with men, many who took advantage of a young desperate girl. I had begun to treat myself as I had been treated, as unimportant outside of giving people what they wanted from me. To cope with the memories and repeated traumas, I was using drugs supplied by people who professed to love me.”

12. Trauma Informed ResponsePatient Perspective “The more I use, the more I won’t feel anything. The pain is so bad you just want to die. There is no other way out. If you talk about it, it will hurt too much. So instead, keep it a secret. No one will know.” Najavits, L. M., (2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

13. Trauma Informed ResponsePatient Perspective “Night time is the absolute worst. I worry about my friends who are still there. I can’t stand noise. I can’t stand silence.”

14. Trauma Informed ResponsePTSD and Substance Abuse Cultural Issues • In the US rates of PTSD do not differ by race (Kessler et al., 1995) • In the US Hispanics and African–Americans have lower substance abuse rates than Caucasians • Native Americans have higher substance abuse rates than Caucasians. Najavits, L. M., (2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

15. Trauma Informed ResponseTreatment Issues In a study of 77 women with current PTSD and substance dependence most of the treatment focused on substance abuse. • 80% would choose to treat PTSD (either combined with substance abuse or alone) • Fewer than 20% would choose substance abuse treatment alone Najavits, L. M., (2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

16. Trauma Informed ResponseDefining PTSD • Post Traumatic Stress Disorder is the result of an event or series of events that were acutely damaging to the emotional, physical, and psychological well being of an individual. - The traumatic experience would be defined as occurring out of the control of the traumatized individual - The traumatized individual could have witnessed or been directly involved in the event - The event outside of the individual’s control would be experienced as a physical threat (e.g., physical/sexual abuse, war combat, seeing someone killed or abused, surviving catastrophic events such as a hurricane or car accident) Najavits, L. M., (2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

17. Trauma Informed ResponseHistory of Treating PTSD Knowledge About PTSD Relatively New • First emerged in the study of soldiers returning from combat • Later broader application to other types of abuse emerged • 1980 PTSD added to the official list of psychiatric disorders Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

18. Trauma Informed ResponsePTSD Symptoms PTSD Symptoms: (Symptoms persist for more than a month) • Intrusion: The trauma comes back into memory even with attempts to avoid thinking about the event(s) • Flashbacks, nightmares, images • Avoidance: Numbing, feeling detached, avoiding reminders of the trauma • Arousal: Feeling “hyped-up” • Startle response, hyper-vigilant, sleep disturbance, anger, crying, impulsivity • Reduced functioning: Problems with relationships, work, or other major life areas

19. Trauma Informed ResponseTypes of PTSD • Simple PTSD From a single incident (such as a car accident, or weather related catastrophe), usually as an adult • Complex PTSD Results from repeated incidents such as domestic violence, childhood abuse, combat tour of duty • Secondary PTSD – lingering effects with reduced disturbance of life function ( Chronic disturbance of environment with reduced acuity, such as non-abusive alcoholic family history) Najavits, L. M., (2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

20. Trauma Informed Response PTSD Symptoms • Self harm • Suicide • Dissociation • Memory • Sexuality • Shame • Anger • Guilt • Numbness • Loss of Faith • Loss of Trust • Health • Security Concerns • Anxiety • Feeling Damaged • Flashbacks • Disturbances in relationships • Sleep disturbance • Depression

21. Trauma Informed ResponsePTSD Response Why do Some Individuals Exposed to Trauma Develop PTSD and Others Do Not • Much is unknown • Personality may influence PTSD response • Life situation during and after trauma event may contribute • Quality of lifetime relationships Najavits, L. M., (2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

22. Trauma Informed ResponseDifferential Trauma/PTSD Differential PTSD/trauma • Sexual Abuse • Combat • Natural Disaster • Chronic Illness • Domestic • Social Violence • Secondary Trauma

23. Trauma Informed ResponseBehavioral Indicators of Potential Trauma/PTSD What to Notice: • Impulsivity • Sudden deterioration of functioning- self defeating • Memory disturbances • Chronic relationship disturbances • Paranoia – hyper-vigilance, unusual distrust • Cuts marks on body • Reports excessive fears/anxiety/sleep disturbance • Difficulty responding to helping efforts • Lacks appropriate assertive skills & dealing with anger • Distrusts authority - oppositional

24. Trauma Informed ResponseApproaches with Clients Approach Strategies with Distressed Clients • Monitor Tone – non-judgmental • Elicit answers from the client • Asked questions related to behavior you are seeing • Note discrepancies in non-judgmental manner • Respectful distance from client’s problems • Keep trauma details to a minimum- present focus • Focus on solutions • Offer a emotion regulation exercise Note: These approaches can help increase client accountability

25. Trauma Informed ResponseApproach Strategies Approach Strategies • Eliciting client answers • Looking Forward, Looking Back, Addressing Barriers • Addressing Resistance by noticing contradictions • Note discrepancies with the client between intentions and behaviors in non-judgmental manner • Let client know that you understand there are mixed feelings about change and address that as a dilemma • Solution Focus • Miracle Question – this moves the focus from problems to solutions Tip: Asking permission to offer feedback, advice, or direction can reduce client’s resistance

26. Addressing Emotional Distress Goal is to return to present focus and reduce distress • Ask scaling question to assess level of distress – 1-10 Three Types of Emotional Regulation/Grounding Exercises: • Cognitive – Goal is to shift focus and thought processes • Examples: 4321 exercise, chain of events, categories (sports, music), counting • Physical – Goal is to shift the body focus to reduce distress response • Examples: Arm wrap, facial taps, breathing exercises, ear soothing, thumb trick • Self Soothing – Goal is to create emotional soothing/comfort • Examples: Internalized parent exercise, music, cheerleader exercise, self soothing, 3X5’s Goal is to create : Intentionality, Empowerment, Strengths Focus Accountability and “Undoing” old patterns

27. Trauma Informed ResponseInteraction with Clients Client Interaction • The effectiveness of interactions with clients, with substance abuse in particular, is determined as much or more by the helper’s style as by orientation or patient characteristics • Emphasize building on positive engagement processes – compassion, developing an alliance, modeling by using skills,“trying hard”, giving clients control • Solicit genuine feedback from clients about their experiences

28. Trauma Informed ResponseInteraction with Client Suggestions for Interaction with Clients • Attend to counter productive responses • Harsh confrontation • Voyeurism • Inability to hold patients accountable – misguided sympathy • Allowing patients to be scape-goated • Becoming a victim • Identification with patient’s PTSD which can result in excessive support and overindulgence with patient’s vulnerability • Being afraid of patients

29. Trauma Informed ResponseEvidenced Based Treatment Treatment for PTSD/Trauma • Seeking Safety – Lisa Najavits • Treatment addresses substance abuse and PTSD/Trauma concurrently • Each condition is seen as adversely affecting the other • Model creates a balance between exposure to dual treatment issues while avoiding exposure to significant trauma memories • Elements of the model can be used without advanced clinical practice or background • Central theme in early recovery is on coping with PTSD/Trauma symptoms and safety • First treatment for PTSD with published outcomes(Najavits et al., 1997,1998)

30. Trauma Informed ResponseTreatment Issues Seeking Safety Model: • Study with incarcerated women • After three months 53% no longer met PTSD criteria • Six weeks post-release 70% did not meet substance abuse disorder(SUD) criteria (Najavits, 2002) • Treatment studies have also shown success with: • Male and female veterans • Young African American males • Adolescents

31. Trauma Informed ResponseTreatment Issues Prevalence of the dual diagnosis of PTSD and Substance Abuse • Co-occurring diagnosis of PTSD and Substance Abuse in addiction treatment facilities - 12% - 34% • Women in substance treatment – 30% - 59% • Men in substance treatment – 11% - 38% Typically PTSD symptoms preceded the onset of substance abuse. Najavits, L. M., (2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

32. Trauma Informed ResponseSeeking Safety Najavits’ Three Stage Model of Recovery • Safety • Mourning • Reconnections • Safety Stage is the initial process of Najavits’ treatment model and is the treatment stage presented in this training • Mourning and Reconnections are later stages of recovery that are initiated in therapy work separate from the Seeking Safety Skills Group

33. Trauma Informed ResponseSeeking Safety Lisa Najavits Seeking Safety Model • Encourages understanding of relationship between client’s PTSD/trauma and substance abuse • Emphasizes importance of treating PTSD and substance abuse concurrently • Establishes clear clinical guidelines for combining PTSD and substance abuse treatment • Utilizes homework and the practice of new behaviors • Incorporates Cognitive Behavioral Therapy Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

34. STrauma Informed ResponseSeeking Safety Treatment manual comprised of : • Comprised of 25 topic areas addressing recovery and coping skill development • Each 25 topic areas are evenly divided among cognitive, behavioral, and interpersonal domains • Each topic area includes a safety oriented skill relevant to both PTSD and substance abuse • Focus is on self care, accountability, relapse prevention and self monitoring outcome of commitment • Attention to management of emotions, cravings, urges, and PTSD symptoms Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

35. Trauma Informed ResponseSeeking Safety Recovery Tasks which are common to both PTSD and Substance Abuse treatment • Safety elements within the management of PTSD symptoms reflect traditional safety elements in substance abuse recovery: • Education • Present time orientation • Assessing the impact of condition • Dealing with urges and cravings • Focus on self care • Attention to relapse prevention Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

36. Trauma Informed ResponseSeeking Safety Safety Stage Goals: • Develop commitment to practicing safety • Master coping skills (responses to symptoms) • Utilize safety planning (prevention) • Report unsafe behaviors (asking for help) • Utilize Safety contract (response to urges) Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

37. Trauma Informed ResponseSeeking Safety Frequently asked questions: What is the strongest theme of Seeking Safety? • Empowering patients to have faith, and believe that their lives can get better by initiating safety as the central theme in their first stage of recovery : Instillation of Hope Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford

38. Trauma Informed ResponseSeeking Safety Seeking Safety is an effort to facilitate the healing process, to contribute to that patient’s opportunity for change and believing in life again. It is an act of participation in helping the individual see beyond what they are experiencing at the moment. “When you do a thing, do it with all your might. Put your whole soul into it. Stamp it with your personality. Be active, be energetic, be enthusiastic and faithful, and you will accomplish your object.” – Ralph Waldo Emerson Najavits, L. M.,(2002) Seeking Safety A Treatment Manual for PTSD and Substance Abuse. New York: Guilford