Beneath the Surface:

1. Beneath the Surface: Addressing Trauma & Substance Use Presented By: Sara L. Paxton LMSW/CAADC Family Outreach Center

2. Today’s Objectives Be able to: • Discuss the relationship between trauma and substance use. • Describe of the impact of historical trauma on specific populations. • Identify practical interventions (including prevention strategies) to use in therapy when working with individuals/families with a trauma history and current or potential substance use issues.

3. Trauma & SUD The Relationship • As the number of traumatic events experienced during childhood increases, the risk for the following health problems in adulthood increases: • Depression • Alcoholism • Drug abuse • Suicide attempts • Heart, liver, and pulmonary diseases • Fetal death during pregnancy • High stress • Uncontrollable anger • Family, financial, and job problems

4. Trauma & SUD The Relationship SAMHSA April 2011: Childhood Trauma's Impact on Health Risks

5. Trauma & SUD The Relationship • 90% of public mental health clients have been exposed to, and most have actually experienced, multiple exposures of trauma • 75% of women and men in substance abuse treatment report abuse and trauma histories • ACE (Adverse Childhood Experiences) Study • Almost 2/3 of the study participants reported at least one adverse childhood experience of physical or sexual abuse, neglect, or family dysfunction • More than one in five reported three or more such experiences • CTE (Childhood Traumatic Events) Study • Reviewed CTEs and adult health problems and psychosocial functioning • 1.2 to 1.5-fold increased risk for PTSD, current tobacco use, alcohol dependence, injection drug use, sex work, sexually transmitted diseases, homelessness, a myriad of physical health problems, and reduced overall quality of life

6. Trauma

7. Trauma What is Trauma? • What do you consider to be traumatic? • What makes something traumatic?

8. Trauma What is Trauma? • Dictionary.com Psychiatric Definition: • a. an experience that produces psychological injury or pain. • b. the psychological injury so caused. • Risks of an Event being Traumatic • It happened unexpectedly. • You were unprepared for it. • You felt powerless to prevent it. • It happened repeatedly. • Someone was intentionally cruel. • It happened in childhood.

9. Trauma What is Trauma? • Common Traumatic Events • An unstable or unsafe environment • Separation from a parent • Serious illness • Intrusive medical procedures • Sexual, physical, or verbal abuse • Domestic violence • Neglect • Bullying • Commonly Overlooked Traumatic Events • Falls or sports injuries • Surgery (especially in the first 3 years of life) • Sudden death of someone close • A car accident • Breakup of a significant relationship • A humiliating or deeply disappointing experience • Discovery of a life-threatening illness or disabling condition

10. Historical Trauma Historical Trauma: Definition • Multigenerational trauma experienced by a specific cultural group • It is cumulative and collective Examples • Immigrants: Prevention of cultural and spiritual practices • Intergenerational Poverty: Hunger; poor or inadequate housing; lack of access to health care; community crime • People of Color: Slavery; colonialism/imperialism • American Indians/First Nations Peoples: Americanization of Indian Boarding Schools and forced assimilation among their students SAMHSA’s GAINS Center Policy Research Associates, Inc. Historical Trauma Fact Sheet

11. Historical Trauma Activity • Identify historical events that occurred in the below time periods that may have resulted in historical trauma. • 1910-1930 • 1931-1950 • 1951-1970 • 1971-1990 • 1991-2010

12. Historical Trauma African-American Population • White racism as a trauma for African-Americans (its effects parallel how individuals are affected by chronic physical abuse). • Trauma-focused theories may mention the effects of racism and discrimination as having an emotionally injurious effect. • Afro-centric theories define white racism as a traumatic threat , particularly those that are lower-income, urban, because white racism threatens their collective survival. • Stems from Segregation from employment/educational opportunities, and relegated to living in the poorest neighborhoods. • The concentration of poverty led to rising crime rates, domestic violence, drug problems, and other social ills. • These issues in other populations might be addressed through public services.; however, in inner cities they(police, social services, etc.) were often corrupt, abusive, and discriminatory and therefore historically distrusted. • African American women are underdiagnosed with depression as symptoms manifest differently (often due to coping through hard work and determination over physical and mental well-being).

13. Historical Trauma Native American Population • Europeans brought new diseases which traditional healers were unprepared to cope with, where their methods had historically been beneficial, they no longer worked. • There was a discouragement of Traditional beliefs and practices by certain church, educational, and governmental groups. • There was the assumption that Native cultures were deficient in a way that was seen as pathological, without virtue, and without value. • Children where sent to boarding schools where their contact with family members was severely curtailed. • The same children were sent back to tribes and became the parents of the future, now devoid of a traditional understanding of what it meant to be native and what the responsibilities were for being a native parent. • It was the process of deculturalization. • In addition, Native people have been forced to define and prove themselves, often through forced treaties.

14. Substance Use

15. Substance Use Disorders Warning Signs of Use • Physical: fatigue, repeated health complaints, red and glazed eyes, and a lasting cough. • Emotional: personality change, sudden mood changes, irritability, irresponsible behavior, low self-esteem, poor judgment, depression, and lack of interest in activities. • Family: argumentative, breaking rules, or withdrawing from the family. • School: decreased interest, negative attitude, drop in grades, many absences, truancy, and discipline problems. • Social problems: new friends with lack of interest in usual home/school activities, problems with the law, and changes in dress and music (often to unconventional).

16. Substance Use Disorders Diagnosis (DSM-IV-TR) • Substance Use/Misuse • starts to have a negative impact on a person’s functioning • the use of a substance for unintended purposes or for intended purposes but in improper amounts or doses • Substance Abuse • the deliberate, persistent, excessive use of a substance without regard to health concerns or accepted medical practices • a pattern of harmful use of any substance for mood-altering purposes • pattern of substance use that results in repeated adverse social consequences related to drug-taking—for example, interpersonal conflicts, failure to meet work, family, or school obligations, or legal problems • Substance Dependence • the desire or need to continually use a substance • the compulsive need to use a substance • stopping use would cause user to suffer mental, physical, and emotional distress • characterized by physiological and behavioral symptoms related to substance use. These symptoms include the need for increasing amounts of the substance to maintain desired effects, withdrawal if drug-taking ceases, and a great deal of time spent in activities related to substance use

17. TF-CBT • Strengthening Families Protective Factors • Somatic Experiencing • EMDR • Seeking Safety Treatment Modalities

18. Treatment Modalities TF-CBT (Trauma Focused Cognitive Behavioral Therapy) • Components-based treatment model that incorporates trauma-sensitive interventions with cognitive behavioral, family, and humanistic principles and techniques. • Children and parents learn new skills to help process thoughts and feelings related to traumatic life events; manage and resolve distressing thoughts, feelings, and behaviors; and enhance safety, growth, parenting skills, and family communication. • PRACTICE • Psychoeducation and parenting skills • Relaxation skills • Affect expression and regulation skills • Cognitive coping skills and processing • Trauma narrative • In vivo exposure (when needed) • Conjoint parent-child sessions • Enhancing safety and future development

19. Treatment Modalities Strengthening Families Protective Factors • Caregivers can buffer the impact of trauma and promote better outcomes for children even under stressful times when the following Strengthening Families Protective Factors are present: • Parental resilience • Social connections • Knowledge of parenting and child development • Concrete support in times of need • Social and emotional competence of children

20. Treatment Modalities Somatic Experiencing • Takes advantage of the body’s unique ability to heal itself. • Focus of therapy is on bodily sensations, rather than thoughts and memories about the traumatic event. • Concentrating on what’s happening in your body, causes you to gradually get in touch with trauma-related energy and tension. • Then natural survival instincts take over, safely releasing this pent-up energy through shaking, crying, and other forms of physical release.

21. Treatment Modalities EMDR (Eye Movement Desensitization &Reprocessing) • Incorporates elements of cognitive-behavioral therapy with eye movements or other forms of rhythmic, left to right stimulation. • Back-and-forth eye movements are thought to work by “unfreezing” traumatic memories, allowing you to resolve them.

22. Treatment Modalities Seeking Safety • Seeking Safety is a present-focused therapy to help people attain safety from trauma/PTSD and substance abuse. • The key principles of Seeking Safety are: • Safety as the overarching goal (helping attain safety in relationships, thinking, behavior, and emotions). • Integrated treatment (working on both PTSD and substance abuse at the same time). • A focus on ideals to counteract the loss of ideals in both PTSD and substance abuse. • Four content areas: cognitive, behavioral, interpersonal, and case management. • Specific/deliberate attention to clinician processes (helping clinicians work on countertransference, self-care, and other issues).

23. Treatment Modalities Promising Future Modalities • Child-Parent Psychotherapy (CPP) Family Violence: • Primary use with children under 7 with exposure to family violence, physical abuse, and/or physical neglect. • Stresses the importance of attachment; the connection between thoughts, feelings, and behaviors; social learning theory; and family therapy. • Utilizes the parent-child relationship to repair the inability to self-regulate emotions, increase the attachment bond, and decrease child aggressiveness and parental use of physical punishment and criticism. • Includes a trauma narration component where the parent and child create a joint narrative of the trauma. • Abuse-Focused Cognitive Behavioral Therapy (AF-CBT): • Primarily used with children ages 6-15 years and their parents. • Targets physically abusive parents’ parenting skills or practices, along with the child’s behavioral and emotional adjustment. • Parallel treatment model combing the connection between thoughts, feelings, and behaviors and learning and family therapy approaches to treat the parent and child simultaneously. • Primary goals of AF-CBT are to reduce the abusive parent’s anger and use of force, teach non-aggressive methods of discipline, reduce the risk of future abuse incidents, enhance child coping and adjustment, and improve family communication.

24. Interventions

25. Interventions • Practical Interventions • Education • Relaxation • Grounding • Cognitive Exercises • Safety/Safe Coping Skills • Emotion Identification/Expression • Healthy Relationships • Exploring the Trauma

26. Interventions Culture Specific • Interventions that have been culturally modified may ease barriers and increase the family/individual’s level of engagement. • Incorporating culturally appropriate terms in discussing the healing process and family relationships. • Integrating culturally specific stories and proverbs can increase the family’s comfort level.

27. Interventions Cultural Specific • African American: • Afro-centric values include interdependence with nature and other living things, a deep sense of spirituality, emotional expression, direct communication, and expressing one's true emotional self through dance, music, and other creative arts. • Incorporate strengths related to resisting oppression. • Allow for the expression and celebration of resilience. • Utilize strengths which in general include: strong church affiliation and sense of spirituality, flexible family roles, and strong family, extended family, and surrogate-family ties. • Remember that these strengths insulate African-Americans from the harmful effects of stress, poverty, depression, and traumatic oppression.

28. Interventions Cultural Specific • Native Americans • Requests from the Native community for a new “medicine,” one specifically developed to meet native needs, and rooted in the traditions of the past. • Traditional healing focuses on the person and the context of their community, rather than on a discreet biomedical sickness with an emphasis on health, not disease. • Traditional healing seeks to make things whole—the people, the culture, and the community. • The removal of traditional culture and support systems led to erosion of Native mental health, but is being reversed by a surge of spiritually based energy utilizing traditional techniques. • The outcomes are feelings of renewed hope and challenge. • Recognize and celebrate the fact that many Natives believe that the good of tribe/group/family supersedes that of the individual.

29. Trauma & SUD Questions/Comments/Case Studies