”Trauma and the Challenge
of
Substance Abuse Disorders”
Tim Shannon
MA, Licensed Professional Counselor
Certified Advanced Addiction Counselor
Certified Sexual Addiction Therapist
Certified Multiple Addiction Therapist
ICADAC - International Certified Alcohol and Drug Abuse Counselor
Eye Movement Desensitisation Reprocessing #1
frostcid@ comcast.net , tshannon@cssstclair.org
1
“If all you have is a hammer then all
your problems are nails”
-Abraham Maslow
2
Core Assumption I
In the context of trauma, chemical addiction arises not as a pleasure-seeking strategy but as a
survival strategy:
•
To self-soothe and self-regulate
•
As a way to numb hyperarousal symptoms: intolerable affects, reactivity, impulsivity,
obsessive thinking
• In the service of walling off intrusive memories
•
As a way to combat helplessness by increasing hypervigilence and feelings of power and
control
•
To “treat” hypoarousal symptoms of depression, emptiness, numbness, deadening
•
In the service of facilitating dissociation
• As a way to function or to feel safer in the world
Fisher, 2007
3
Core Assumption II
How the addictive behaviors have helped trauma patients to survive: that is, which trauma
symptoms are they attempting to treat through their drinking, drugging, eating disorders, and
sexually acting out behaviors. We need to know this information for a number of reasons:
•
First, we need to know because these are precisely the symptoms that will increase once the
patient becomes sober or abstinent. EX: 12 yr old molested by grandfather, smokes
cannabis and uses alcohol to forget. In recovery has numerous flashbacks including
molestations at an earlier age she had suppressed.
•
We need to know, too, so that we can begin to anticipate other coping strategies they will
need in order to deal with those symptoms as they erupt and threaten to overwhelm
them.
Fisher, 2007
4
Core Assumption III
Furthermore, we need to be able to predict when and how the symptoms may potentially
trigger a behavior relapse so that we can help them strengthen the addictions recovery
program they have chosen.
And finally, we also need to know so that we can help the survivor appreciate their
courageous attempts to cope with the effects of the abuse and, from that recognition,
develop sufficient compassion and self-respect to counteract the shame and guilt that is
the inevitable byproduct of their addictions and trauma history.
Fisher, 2007
5
Affect refers to instinctive biology, ie the limbic
system - the fight, flight, or freeze center - that
tends to be active in addiction and other
disorders.
The individual receives overwhelming primal
messages about events that can be way out of
proportion to the actual potential for threat.
Feelings refers to psychology, how we think about
what is going on, both externally and internally ie;
the amygdala.
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• Emotion refers to the biographical story we tell
ourselves about our experience, including the ability
to remember and to project experience.
• Dominated by intrusions of the trauma, traumatized
individuals begin organizing their lives around
avoiding having them.
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Trauma
• “Because the stress response disrupts
general information processing, survivors
of trauma live in a somatic world rather
than a world of language.”
Alexander McFarlane
8
What is Trauma?
“Trauma is experiencing too much, too fast, too soon.”
Or
“The body remembers what the mind forgets”
-Jacob Moreno
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Movement from Chaos to
Connection
“The deep digging in therapy is to make conscious
these early wounds and convert them into words
so that they can be felt and understood—to use
the skills of emotional literacy.
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Movement from Chaos to Connection
Our Tasks
We help them place the trauma in proper
perspective.
Help give them a context (where, when and
how).
Help integrate them back into themselves with
understanding as to what happened and what
meaning they made out of it.
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Modulating Emotional
Responses
Intense Fear
Rage
Disassociation or Shutdown
Addiction offers relief
12
Trauma Impacts
relationships by creating
1. Enmeshment-part of trauma bonding.
2. Disengagement-avoiding skill building.
3. Chaos through impulsivity.
13
How do we help them?
4 Steps to Emotional Expertise
Our clients need to know:
• All emotions serve a function.
• Trauma and Addiction blunt our range of
emotions.
• Self Efficacy comes as consciousness of
emotions grows.
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What is Trauma
Trauma is perhaps the most avoided, ignored, belittled, denied,
misunderstood, and untreated cause of human suffering. Although
it is the source of tremendous distress and dysfunction, it is not an
ailment or a disease, but the by-product of an instinctively
instigated, altered state of consciousness.
We enter this state - let us call it survival mode - when we perceive
that our lives are being threatened. If we are overwhelmed by the
threat and are unable to successfully defend ourselves, we can
become stuck in survival mode. This highly aroused state is
designed solely to enable short-term defensive actions; but left
untreated over time, it begins to form the symptoms of trauma.
Peter Levine
15
Effects of Trauma
(Dayton,2000)
•Long term fear of intimacy.
•Relational Commitment-Simultaneous fears of
abandonment and being overwhelmed.
•Poor Communications-as the internal dictionary, listening,
and seeking feedback are distorted.
•Boundaries are enmeshed.
•Deregulated emotions-high frequency, intensity and
• duration to complete shutdown.
•Distrust, unable to receive and lack of faith in others.
•Blunted play –inability to move freely in a space.
•Unconscious patterns of disconnecting, reenacting,
transference, splitting, hyper-vigilance and perfectionism.
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Somatic Experiencing
“Somatic Experiencing® is a body-awareness
approach to trauma being taught throughout the
world. Based upon the realization that human beings
have an innate ability to overcome the effects of
trauma.”
-Dr. Peter Levine
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Bessel van der Kolk
“The imprint of the trauma is in the limbic system and in the
brainstem: in our animal brains, not our thinking brains”
Survival responses based on the following criteria:
1.Severity of trauma.
2.Genetic Predisposition.
3.Developmental Phase when trauma occurs.
4.A Social Support System.
5.Prior traumas.
6. Preexisting phobias and maladaptive behavior
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Pierre Janet
1859-1947
• “[Traumatized] patients ... are
[repeatedly] continuing the
action, or rather the attempt at
action, which began when the
event happened, and they
exhaust themselves in these
everlasting
recommencements.”
•
1919/25, p. 663
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Trauma and the Brain
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The Triune Brain
x
21
“Bottom-up, The Hi-Jacked Brain”
Everyday experiences connected to the trauma will trigger
instinctive survival responses: fight, flight, freeze, collapse
and numbing, dissociation, re-enactment behavior. The
client’s animal brain takes over, the ability to think goes “off
line,” &
acting out behavior takes place without
consciousintention or judgment, even without awareness!
Janina Fisher, 2007
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Trauma vs. Intimacy
Visual
Cortex
Normal Response
Trauma Response
Amygdala
Fight, Flight or Freeze Response
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Peter Levine
“Trauma originates as a response in the nervous
system, and does not originate in an event. Trauma is
in the nervous system, not in the event.”
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Brief Overview of the
Autonomic Nervous System
The Polyvagal Theory
by
Stephen Porges, PhD
www.stephenporges.com
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The Parasympathetic Nervous System
The Sympathetic Nervous System
Originates in the brain stem and
lower part of the spinal cord;
opposes physiological effects of the
sympathetic nervous system:
stimulates digestive secretions;
slows the heart; constricts pupils;
dilates blood vessels.
The SNS gets our whole body ready
for action. It regulates arousal. It
increases activity during times of
stress and arousal – whether positive
or negative. It is active when we’re
alert, excited, or engaged in physical
activity. It prepares us to meet
emergencies and threat.
Trauma may result in the PNS
staying “on”, which causes it to
superimpose shutdown over the
hyperarousal of the SNS, rather than
discharging its energy.
The Parasympathetic branch acts
like the brake pedal for our nervous
system. It helps us to relax, unwind
and ultimately discharge the arousal
of sympathetic activation.
The Sympathetic branch is like the
gas pedal of our nervous system. It
gives us energy for any action we
plan, and it helps us prepare for
threat.
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The Polyvagal Theory
By Stephen Porges
The Vagus Nerve in three parts, all working
simultaneously:
Ventral Vagal System:
Is part of the Parasympathetic Nervous
System
(Social Engagement/frontal cortex)
Sympathetic Nervous System:
(Fight/Flight, Freeze - Limbic Brain)
Dorsal Vagal System:
Is part of the Parasympathetic Nervous
System
(Freeze/Immobility/Brainstem)
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28
Social Engagement
Safe
Ventral
Vagal
Fight, Flight,
Freeze
Immobility
Sympathetic
Nervous
System
Dorsal
Vagal
System
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Danger
Life Threatening
Autonomic Arousal is Designed to Adapt to Environmental Demands
Sympathetic Hyperarousal
A
R
O
U
S
A
L
easy charge
sympathetic
easy discharge
Window of Tolerance
feelings can be tolerated, able to think and feel
parasympathetic
Parasympathetic Hypoarousal
Foundation of Human Enrichment
Ogden and Minton (2000)
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Autonomic Adaptation to a Threatening World
Stuck on “ON”
Sympathetic Hyperarousal
A
R
O
U
S
A
L
• Hyperactivity
• Panic
• Rage
• Hypervigilance
• Elation/Mania
Window of Tolerance
Optimal Arousal Zone
Stuck on “OFF”
Parasympathetic Hypoarousal
Foundation of Human Enrichment
Fisher, 2006
31
•
•
•
•
Depression
Disconnection
Deadness
Exhaustion
How Chemical Addiction Modulates and “Medicate”
Complex PTSD to attempt Self-Regulation
Sympathetic Hyperarousal
Acting out
A
R
O
U
S
A
L
Window of Tolerance
Optimal Arousal Zone
Acting in
Parasympathetic Hypoarousal
Foundation of Human Enrichment
Fisher, 2006
32
The Challenge of Trauma and Chemical Addiction
Treatment must address the relationship between:
A. the trauma and the addictive behavior
B. the role of the addictive behavior in “medicating” traumatic activation
C. the origins of both in the traumatic past
D. the reality that recovering from either requires recovering from both.
Fisher, 2007
33
Modes of Inventions
Cognitive Behavioral Therapy
EMDR
Somatic Experiencing
Hypnotherapy
Transactional Analysis
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Provider Tasks
• Screening & Assessing
• See trauma as a defining and organizing experience that
can shape a survivor’s sense of self and others.
(understanding ability to cope).
• Psycho-educational information on how intertwined
SUDS and Trauma are during and after an event.
• Establish and maintain consumer support and developing
coping skills. (Ex: Learning communication and problem
solving strategies such as healthy fighting.
(cont.)
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Addiction Labeling
• The goals associated with any problem are at least
partially determined by the way the problem is assessed.
• What you do about something is influenced by what you
call it.
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Our Lens
• We tend to call ourselves objective but we interpret
situations from their own particular theoretical,
philosophical or ideological perspective.
• Do we need to transcend it?
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Our Lens (cont.)
We know clients don’t see themselves as addicts but often
seek to negotiate an alternative explanation to negate
acting out behaviors or minimize having to change.
38
Provider Tasks
• Helping consumer understand the range of parallel
connections between SUDS and trauma.
• Minimizing re-occurance of trauma
• Ensuring consumers’ physical and emotional safety
where possible and avoiding shame inducing
confrontations triggering trauma related responses.
• Helping with referrals for ancillary services such as legal,
financial, vocational, housing and health care.
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Resiliency
• Recognizing and Reinforcing Resiliency
• Definition-The process of “bouncing back.”
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The Post Traumatic Stress
Inventory
The Inventory consists of 144 questions designed by David
Delmonico, M.Ed. and Patrick Carnes, PhD. Questions fall
into 1 of 8 categories providing when tallied a strategic map
on how the client can once again gain internal locus of
control.
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The Post Traumatic Stress Inventory
8 Specific Therapy Strategies
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1.Trauma Reacting
Trauma Reacting- Experiencing current reactions to
trauma events in the past.
Study ways client is still reacting. EX: projected anger out
on others.
Write letters to perpetrator telling them of the long-term
impact you are experiencing.
Write amend letters to those you know you have harmed.
• Decide with therapist what information is appropriate to
disclose and send.
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2. Trauma Repetition
• Trauma Repetition – Repeating behaviors or situations
which parallel early trauma experiences.
• Understand how history repeats itself in your life
experiences.
• Develop habits which center yourself- Ex. Breathing or
journaling so you are doing what you intend –not the
cycles once used.
• Work on setting boundaries-using effective
communication.
• Boundary failure is key to repetition compulsion.
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3. Trauma Bonding
• Trauma Bonding- Being connected (loyal, helpful,
supportive, enmeshed) to people who are dangerous
shaming, or exploitive.
• Learn to recognize trauma bond by identifying those in
your life.
• Look for patterns.
• Use “detachment” strategies for difficult people.
• Use a First-Step if necessary.
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4. Trauma Shame
• Trauma Shame - Feeling unworthy and having self-hate
because of the trauma experience.
• An acutely self-conscious state in which the self is “split”
imagining the self in the eyes of the, other; by contrast, in
guilt the self is unified. (Gilliland, et al. 2011).
• Judgment of self by another whether real or imagined.
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4. Trauma Shame (cont)
Goal: Shame Reduction and resolution.
Understand shame dynamics of family and family of
origin.
Who was important to that you should feel shameful?
Do a list of problems, excuses and secrets.
Complete an inventory of affirmations.
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5. Trauma Pleasure
• Trauma Pleasure – Finding pleasure in the presence of
danger, violence, risk or shame.
• Do a history of how excitement/ shame are hooked to the
past traumatic event (s).
• Note the costs and dangers to you over time.
• Do a First Step and relapse prevention plan about how
powerful this is in your life.
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6. Trauma Blocking
• Trauma Blocking- A pattern exists to numb, block out, or
overwhelm feelings that stem from trauma in your life.
• Work to identify experience which caused pain or
diminished you.
• Re-experience feelings and make sense of them with
help.
• This will reduce the power they have had.
• Do a First Step if appropriate.
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7. Trauma Splitting
• Trauma Splitting- Ignoring traumatic realities by
disassociating or “splitting off” experience of parts of self.
• Learn that disassociating is a “normal” response to
trauma.
• Identify ways you split reality and the triggers that cause
that to happen.
• Cultivate a “caring” adult who stays present so you can
stay whole.
• Notice any powerlessness you feel.
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8.Trauma Abstinence
• Trauma Abstinence- Depriving yourself of things you
need or deserve because of traumatic acts.
• Understand how deprivation is a way to continue serving
perpetrators.
• Write a letter to the victim(s) that was you learning to
tolerate pain and deprivation.
• Work on strategies to self –nurture including inner child
visualizations.
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WHAT NEXT30 Performables
1. Break through Denial
2. Understand Addiction
3. Surrender
4. Limit change
5. Establish Sobriety
6. Physical Integrity
7. Culture of support
16. Lifestyle Balance
17.Building Support
18.Exercise and nutrition
19.Spiritual Life
20. Resolve Conflicts
21. Restore Healthy Sexuality
22. Family Therapy
8. Multiple addictions
9. Cycle of Abuse
10. Reduce Shame
11. Grieve losses
12. Closure to shame
13. Relationship with self.
14. Financial Viability
15. Meaningful work
23. Family Relationships
24. Recovery commitment
25.Issues with children
26. Extended Family
27. Differentiation
28. Primary Relationship
29. Coupleship
30. Primary Intimacy
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Bibliography
Carnes, Patrick, & Delmonico, David. The Post
Traumatic Stress Inventory. Carefree, Az, 2008.
Carnes, Patrick & Stephanie, Bailey, John. Facing
Addiction. Carefree, Az 2011. Gentle Path Press.
Dayton, Tian, (2000), Trauma and Addiction; Ending the
Cycle of Pain through Emotional Literacy, Deerfield
Beach, Fl., Health Communication.
Gilliland, et al. “The role of guilt and shame in
Hypersexual Behavior.” Sexual Addiction and
Compulsivity; The Journal of Treatment and Prevention. p
14-15.
53
BIBLIOGRAPHY (cont.)
• Fisher, Janina, (2008), Addictions and Trauma Recovery
• Levine, Peter, (1997), Waking the Tiger. Berkley, CA,
North Atlantic Books.
• Ogden, Pat, (2006), Trauma and the Body. New York:
W.W. Norton & Company, Inc.
• Porges, Stephen, 2006), How your nervous system
sabotages your ability to relate. www.nexuspub.com
• Van der Kolk, Bessel, & McFarlane, Alexander(1996)
Traumatic Stress. New York: The Guilford Press.
54
Anchor Consulting Services
1110 West Cross St. Ypsilanti,
Mi.48197
Phone : 734-649-9989
http://anchortherapy.com/
frostcid@ comcast.net , tshannon@cssstclair.org
Tim Shannon
MA, Licensed Professional Counselor
Certified Advanced Addiction Counselor
Certified Sexual Addiction Therapist
Certified Multiple Addiction Therapist
ICADAC - International Certified Alcohol and Drug Abuse Counselor
Eye Movement Desensitization Reprocessing #1
55