Addiction, Trauma and
Family Systems
Michael F. Barnes, Ph.D., LPC
Clinical Program Manager
CeDAR - Center for Dependence, Addiction, & Recovery
40th Annual Winter Symposium
"Addictive Disorders, Behavioral Health and Mental Health“
Colorado Springs, Colorado
PTSD & Substance Abuse Disorders
Prevalence of PTSD and Substance Use Disorders
 Among persons who develop PTSD, 52% of men and 28% of
women are estimated to develop an alcohol use disorder.
 35% of men and 27% of women develop a drug use disorder.
(Najavits, 2007)
 The numbers are even higher for veterans, prisoners, victims of
domestic violence, first responders, etc.
(Najavits, 2004a, 2004b, 2007)
 Individuals with PTSD are 3 to 4 times more likely to develop
SUD’s than individuals without PTSD.
 Have earlier histories with A & D, more severe use, and poor
treatment adherence.
(Khantzian & Albanese, 2008)
PTSD & Substance Abuse Disorders
Treatment outcomes - PTSD and SUDS
 PTSD/SUD patients more vulnerable to poorer short- and longterm outcomes.
(Ouimette, Moos, & Brown, 2003)
 PTSD heightens the likelihood of addiction relapse, and the
potential for multiple relapses.
(Norman, Tate, Anderson, & Brown, 2007)
 A trauma history and current trauma symptoms are associated
with relapse to alcohol or other substance use in alcohol
dependent women.
(Heffner, Blom, & Anthenelli, 2011)
 PTSD/SUDS has been shown to be associated with poorer
treatment outcomes, and higher relapse rates.
(Sonne, Back, Zuniga, Randall, & Brady, 2003)
Relationship between addiction & Trauma
Reference Unknown?
Impact of Trauma on Family
Like Addiction, the trauma response is a bio-psycho-social
process.
Most counselors see it as a linear process, where an individual
is impacted by an event, and then responds to the event.
What about the people who love them? Are they
impacted?
 Are children impacted by the trauma responses and
addiction of their parents?
 Are parents and siblings impacted by the trauma response
or addiction of their child/sibling?
Systemic Trauma is a Recursive Process – Feedback,
Dramaturgy!
FAMILY SYSTEM REVIEW
All Families Have Organization - Homeostasis
Like a mobile adjusts to
wind to maintain
stability, all families
adjust to life’s demands
to maintain stability, and
system integrity.
Intoxication
Anxiety, Hyperarousal
Intrusive Thoughts,
Nightmares
Dissociation, Depression
Anger, Conflict
“Primary Trauma Survivor”
Family Systems Myth:
•
A change by any one member of a system forces the system to
change.
•
In reality there are multiple things that can happen when one
member of a family system changes:
1.
The system can change to accommodate the change made
by the family member.
2.
The system can exert significant pressure on the member to
change back.
3.
Other system members can pull together and create
increased distance with the changed member. Give up!
For family members, as well as for primary survivors/addicts,
change requires insight into reality of secondary trauma, as well as
energy for dealing with the biological, emotional, and
homeostatic implications!
Continuum of Traumatic Stress
If you have any
doubt about the
recursive nature of
trauma/addiction,
consider the
impact of
compassion
fatigue on
counselors!
Secondary
Trauma
Vicarious Trauma
Chiasmal Trauma
Primary Trauma
Secondary Trauma
Compassion Fatigue
Organizational Trauma
Burnout
Sources of Primary Traumatic Stress Response
(Criterion A – DSM V)
• Direct personal experience of an event that involves threatened,
death, actual or threatened serious injury, or threat to one’s
physical integrity
• Or witnessing an event that involves death, injury, or a threat to
the physical integrity of another person;
• Or learning about unexpected or violent death, serious harm, or
threat of death or injury experienced by a family member or
other close associates.
DSM V
Common Symptoms of Trauma
•
Re-experiencing traumatic events (Criterion B)
–
–
•
Avoidance of reminders of traumatic events (Criterion C)
–
–
•
Efforts to avoid thoughts and feelings
Avoidance of people, places, situations that remind.
Negative changes in thougts and mood that
occurred or worsened following traumatic
event (Criterion D)
–
–
–
•
Recollections of the events, sudden intrusive thoughts
Dreams and or nightmares
Inability to remember aspects of event
Negative evaluation of self, others, the world
Loss of interest in activities
Persistent arousal (Criterion E)
–
–
–
Irritability or outbursts of anger
Difficulty concentrating
Startle response
What Causes Trauma?
• Natural Disaster Events - Hurricanes, Earthquakes, Tornadoes,
Floods, Fires, etc.
• High Speed Events - Car & Bike Accidents, Falls, etc.
• Assault Events - Assault, Rape, Incest, Animal Attacks
• Global Threat Events - Drowning, Electrocution, Caesarian, etc.
• Major Illness/Hospital Events - Cancer, Heart Attacks, Asthma,
Full Anesthesia Surgeries
• Cyclical Trauma – Anniversary of major traumatic event
• Family Trauma
– Divorce, Affairs, Death of a loved one, etc.
– Abandonment or Attachment Trauma
– Living in an alcoholic or otherwise dysfunctional family
10 Family Qualitative Study, Families of Patients with Chronic
Co-Occurring Disorders (Mental Illness & Addiction)
Common Response Patterns (All issues identified by multiple informants)
Common
Feeling
Anger
Fear
Grief
Guilt
Horror
Terror
Shock
Hurt
Depression
Frustration
Shame
Common
Defense
Mechanisms
Common
Cognitive
Responses
Common
Physical
Responses
Denial
Rationalization
Intellectualization
Projection
Obsession
Intrusive Thoughts
Uncertainty
Self Blame
Fault Finding
Resentments
Hopelessness
Helplessness
Sleeplessness
Exhaustion
Nightmares
Startle Response
Foreshortened Future
(We’re going to die!)
Anxiety/worry - hypervigilance/control
Traumatic Stress Response
Frustration with Medical Community
Common
Behavioral
Responses
Hypervigilance
Control – self/others
Care Taking
Impose Structure
Avoid triggers &
Reminders
Reported Sources of Trauma in Families With
Mentally Ill/Addicted Family Member
• Loved one’s suicide attempts or suicidal ideation
• Loved one’s victimization (raped, beaten, etc.)
• Loved one’s dangerous/out of control behaviors (weapons, fire, assaultive
behaviors, destruction of property, etc.)
• Legal involvement (Police actions, Jail, etc.)
• Fear for one’s own and other’s lives
• Psychotic Symptoms (delusions & hallucinations)
• Depressive symptoms (self harm, unresponsiveness, etc.)
• Emergency Rooms and sudden, unexpected crisis calls
• Shattered dreams (will never be who we thought they would be, not who they
were before) - “Death”
• Humiliation
Axiom 1: Individual Reactions
• Family members report having experienced emotional,
cognitive and behavioral symptoms that are similar to
those reported by the primary victim.
• Symptoms (in the literature) reported by family
members:
• Intrusive thoughts, nightmares, flashbacks
• Feelings of detachment and estrangement from
others
• Restricted affect
• Avoidance of activities that remind them of the
traumatic event
• Sleep disturbances
• Hypervigilance
• Fatigue.
Axiom 2: Altered Family World View
 Family members frequently experience a change in
world view associated with personal vulnerability,
safety, and control.
 Following a traumatic event, focus shift to safety issues,
related to self and others.
 Catherall (1998) – safety issues often expressed in the
form of suspicious, distrustful attributions concerning
the motivations of others
 Think how desperate families are to get a loved one into
treatment for addiction and then how quickly they listen to a
patient’s complaints and question the motives or
competency of the treatment staff/program.
 Key issues that result from this shift include:
Hypervigilant, Enabling, overprotection, defensiveness,
etc.
Michael S. Genogram
Maternal
Maternal
Paternal
Paternal
Grandmother
Grandfather
Grandmother
Grandfather
Major issues for Denise:
1.
Very controlling &
hyper- vigilant.
2.
Major medical
issues/ disability.
3.
Issues with
daughter’s death
Uncle
19?? To 1985
Denise
Patrick (met Denise online)
Gary
47
1998 to Present
24
48
Major issues for Michael:
Major Traumas (Denise)
1.
Age 14 months, leg
cut off in lawn mower
accident
2.
Sexual Abuse from
age 14 to 17 (family
friend)
3.
Loss of 1 child by
miscarriage
4.
Daughter killed by
drunk driver
22
12
Michael
Alycia
Killed by Drunk
Driver in 1996
Major focus of
therapy!
?
Miscarriage at
5 months
1.
Very little memory of
childhood
2.
Very upset by death of sister
3.
Hyper-vigilant of mother’s
moods, attitudes (major
enmeshment)
4.
Severe anger problems that
predate sister’s death (most
focus on father and sister)
5.
Multiple concussions from
football
Family Formation – Values, Goals,
Boundaries (Identity) – Steinglass, 1987
Rules
Roles
Rituals
Routines
Relationships
Family Organization – Family Stable Patterns
“The 5 R’s”
Rules
* overt vs. covert
* communication/
meta-communication
* emotional closeness
* express/discuss emotion
Rituals
* celebrations/holidays
* religious events
* events that make this
family separate from
others.
Identity &
Goals
Relationships
* Boundaries
* Conflicted?
* Willingness to
accept, ask for
and accept
social support
Values + Goals = Identity
Roles
* decision making
* parenting
* care giving
* patriarch/matriarch
Routines
* daily activities
* routines
* conserve energy
Whether the crisis is a trauma, addiction, or both, the longer the family
goes without resolving a problem, the more these organizing principles
tend to change, in order to allow the family to survive the crisis.
• While family members may appear to be going in different directions and
increasingly conflicted, they are operating out of the same set of rules,
roles, etc.
• Why do people change? 1st order change vs. 2nd order change!
Family Distress Model
(Cornille & Boroto)
5 R’s
1
Family’s
Stable Patterns
Disrupting Event
2
4
Pattern disrupted
And family
Experiences distress
(Problem)
Family seeks
Potential social
support
Family resolves
Distress using
Preexisting
strategies
Family views
Crisis in context
Of it’s goals
5
Family withdraws
From potential
Social support
Family becomes
Preoccupied
With crisis
Family pattern
Becomes organized
Around crisis
3
Family experiences
crisis
Crisis resolved
Or managed
Family develops
A new pattern
For stability
Crisis becomes
Necessary for
Family stability
Critical Clinical Factors - Isomorphism
• Isomorphism is a concept used in MFT supervision, similar to
parallel process used in individual therapy.
• Defined as the “phenomenon of identifying similar patterns
that occur across various systems.” (White & Russell, 1997).
• An example is when families replicate various system patterns
in therapy.
• If families function within homeostasis, they will attempt to
maintain customary interactional patterns within the therapy
process and may struggle when therapist doesn’t participate.
• Counselors can be easily inducted into the family system
interactional patterns. Lose ability to create change.
Axiom 2: Altered Family World View
• May also result in disruption in ability to modulate strong
affect and maintenance of inner connectedness to others.
(McCann & Pearlman)
•
•
•
See reduced ability to self sooth.
See increased need for others to conform to their
safety standards.
Increased control, increased enabling
•
Often Overextending, overindulging or compulsive
consumption to avoid affect (overeat, overwork,
drink excessively, sex, etc.)
•
Frequent or intense self-criticism or self loathing
•
Difficulty tolerating strong feelings or hypersensitivity
to emotionally charged stimuli.
Reduced Ability to Tolerate Emotion
Need for Control, Hypervigilance, Enabling
Positive Emotions
Negative Emotions
Tolerable range of emotion
Homeostasis
Brought about by changes to
Limbic System, ANS, etc.
• How might this picture be different for a patient or family member who
comes to us with Significant attachment trauma (Small t)?
• What are the implications for growing up in a home with a traumatized
parent?
Family Response to Narrowed Range of
Tolerable Emotion
• Secondary Trauma survivors experience increased “need” to
reduce anxiety, fear, sadness, etc.
• See increase in control behaviors, enabling, hypervigilence
Positive Emotions
Negative Emotions
Tolerable range of emotion/anxiety
Effect of emotional arousal on declarative
(Semantic) Memory, (van der Kolk, 1996)
Information NOT filed in memory database
Experience memories as sensory triggers
Auditory
Bottom-Up Memory – experienced as present
Olfactory
Thalamus
Kinesthetic
Pre-Frontal Cortex
Offline/Unavailable
Gustatory
Visual
Extreme Stress interferes with
hippocampal functioning, memories
based on fragments of information.
Hippocampus
Spatial Memory
Shift from Short to Long Term
Fit information into existing
cognitive Schema
Autonomic Nervous System
Fight/Flight/Freeze
Amygdala
High Threat
Fear-Terror
Traumatic Memory - Poor Integration
Processing memory
and Emotional
Reactions
Trauma and the Autonomic Nervous System
State 0: (zero): calm, responsive, awake
State 1: slightly anxious, annoyed, nervous,
physical tension
State 2: highly anxious, angry, panic symptoms,
intense physical tension (stomach, chest,
breathing), powerful fight or flight responses
State 3: Dual activated (a mixture of activation with
dissociative symptoms): tension with somatic
collapse, anxiety, sleepy, panic, hopelessness,
heaviness, blurred vision
No Solutions
“Scared to death”
State 4: pure dissociation marked by a distinct lack
of physical sensation and flat affect, numbed out,
blank, feeling ‘floaty’, depersonalized, and
disconnected
Systems perspective: enmeshment, enabling, control behaviors are homeostatic maintainers.
• They are also very biologically based!
• To face the threat of not enabling is terrifying for many!
Axiom 3: Structural/Organizational Changes
Conflict, Anger, Resentment, Emotional Distance, Emotional Intensity,
shifts in intimacy, shifts in parenting, shifts in decision making, etc.
Shifts in all 5 R’s & organization around the problems of addiction and trauma!
Child
Mother
Brothers
Father
Sisters
Sibling Role Changes
Rigid External
Boundaries
Diffuse Internal
Boundaries
Axiom 4 - Centrality of Parental/Familial
Perceptions
• Family member perceptions/experience of stress/anxiety
associated with the traumatizing event will influence
interactional patterns, coping mechanisms, and degree of
emotional consequence experienced by family system.
•
• “Perceived stress is more influential on symptoms development
than actual, observable stressors” (Miles, 1985)
• “The crisis is not the problem, but it is the family’s constraining
beliefs that restrict alternative views about the crisis that
becomes the problem” (Shaw & Halliday, 1992)
Denver Trauma Institute, 2013
Factors Influencing Coping and Familial
Response
Perception
Age of
Onset
Based on memory theory,
each member of the
family will remember the
traumatic event(s)
differently. This impacts
family perception,
adaptation, and healing
process!
Adaptive
Diagnosis
Individual/
Family
Response
Patient
Problems
Severity of
Symptoms
Proximity of
Family
Use of
Available
Resources
What are the
implications for
traditional
homework
assignments like
“cost letters,” etc.?
Coping
Strategies
Not
Adaptive
What Sets Adaptive/Resilient Families Apart?
Figley (1989) identified characteristics of families
that tend to cope more efficiently with stress and
trauma:
• Accept responsibility for dealing with the situation and
to mobilize energy and resources for action.
• Shift focus from any one family member and recognize
that it is a problem that the entire family must face
together.
• Move quickly from a blaming stance to a solutionoriented problem solving focus.
• Family members exhibit increased tolerance and
patience for one another.
30
What Sets Adaptive/Resilient Families Apart?
•
Clearly identify and express emotions associated with
the traumatic event and verbalize their commitment to
one another throughout the posttraumatic process.
•
Allow members to access their own individual and
interpersonal resources, both internal and external to
the family system
•
Reach out for social support with little difficulty or
embarrassment.
•
Finally, they are able to do this without resorting to
impulsive violence or dependence on alcohol or other
drugs.
(Figley,1989)
31
Resilience
Dennis Charney, M.D., ISTSS Keynote Presentation, 2013
Professor Psychiatry and Neuroscience at Mount Sinai Hospital
Core beliefs
that few
things can
shatter!
Moral
Compass
Role
Model
Cognitive
Appraisal
Spirituality
/ Religion
prisoners of war
special forces,
victims of abuse
natural disaster
individuals living in poverty
first responders -9/11
Optimism
To some
degree
genetic, but
can be
learned
Social
Support
Facing
Fears
Much of current resilience
based on neurobiology
developed in childhood, adult
caring, social competence,
capacity for self reflection
and self-regulation.
Active
Coping
Resilience
Exercise
As we begin to shift to a treatment model that is focused on a more chronic model of
addiction treatment, it struck me that building resilience is one of the critical components
of the treatment process!
How do we already do this? What can we add to really maximize a patients ability to carry
resilience into the next phases of treatment?
Transference/Countertransference
• Bowen identified roles that family members may assume
during times of high stress/anxiety that serve to organize the
family.
– Savior
– Perpetrator
– Bystander
– Victim
• Usually all family members assume each of the roles at
different times in their day to day life, which, depending on
the role and the meaning that the role has for the individual
can make therapy more difficult.
Transference/Countertransference
• While working in therapy, clients will often demonstrate or play
out one or more of these roles, while also projecting other roles
out onto the therapist in the form of transference.
• Especially important to understand when working with highly
relational traumas such as complex trauma from incest,
abuse, etc.
• Also important when doing couple or family therapy around
trauma issues. All roles played out in the room at the same
time.
• It is critical for trauma therapists to understand how these roles
played out in their own life/family and recognize
countertransference issues that could cause conflict or slow
down the therapeutic process.
Clinical considerations:
1.
Counselor must present non-anxious presence & clinical competence
–
2.
All family members will have their own recollection of what happened
and level of comfort in discussing it.
–
3.
It is important that family members are able to express their thoughts and
recollections without interruption (in session safety!)
Family system behaviors are old homeostatic mechanisms for keeping
family together and functioning.
–
–
–
4.
Clear awareness of counter transference issues, personal trauma, etc.
It is easier for families to induct us into their way of functioning than to
engage in new behavior
Be aware of how patterns repeat throughout different relationships
Be conscious of First order change vs second order change
Must develop healing theory by collaboratively answer 5 Healing
Questions (Figley, 1989)
1. What Happened?
2. Why did it happen?
3. Why did it happen to us?
4. Why did we react the way we did when it happened? 5. What will we do differently if it
were to happen again?