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Through a Trauma Informed Lens: Rethinking Addiction Treatment
Dr. DebbieRuisard, DSWLCSW, LCADCdruisardlcsw@gmail.com
“One must not look hard to see that weare losingthebattleagainst addiction”HarvardPsychiatrist, EdKhantzian, 2013
Various studies have reported any where from 40% - 90% relapse rate in individuals with addictive disorders after completing treatment.
Questions that I have attempted to answer in my work
What is it about the individual that impacts their response to treatment interventions?How can we intervene in a way that honors individual differences and avoids the “one size fits all” approach to addiction treatment?
DISEASE MODEL OF ADDICTION
“Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain; they change the structure and how it works.”(National Institute on Drug Abuse)
NIDA and the Disease Model
1994 AllenLeshner: “That addiction is tied to changes in brain structure is what makes it, fundamentally, a brain disease”2015 NoraVolkow: “It is a disease in which essential motivational and self-control symptoms of the brain are compromise”Current discourse – is it a disease or not?
Benefits of the Disease Model
Counteracts the moral model that blames people for their bad behaviorsReduces stigmaLeads to treatment rather than punishmentMore funding for research; gets attention from CongressLocating addiction in the brain leads to new medications that target brain functioning to help people to recoverChronic nature of the disease puts relapse into perspective –relapse is a part of the recovery process
Drawbacks of the Disease Model
Offers false hope that there is a medical cure for addictionHas not shown to reduce stigmaGovernment funding primarily supports disease model researchBased on the fact that drugs are inherently addicting (which has been disproven by research)It does not adequately account for the reality that most people use substances to numb emotional pain or cope with difficult environments
Has anything changed?
“The very nature of addiction challenges society’s deeply held preconceptions about willpower and self control…Addiction is not a moral failing; it is a disease in which essential motivational and self-control systems of the brain are compromised.”NoraVolkowNational Council Magazine, 2015
Is this really the only view of addiction that fits our clients?
Trauma and addiction
I approach the connection between these two human experiences through the lens of a trauma professional, not an addictionprofessional.
Adverse Childhood Experiences
ACEs:Recurrentand severe physical abuse (11%)Recurrent and severe emotional abuse (11%)Contact sexual abuse (22%)Growing up with alcoholic or drug user (24%)Growing up with a family member in prison (3%)Growing up with a family member with mental illness (19%)Growing up seeing your mother being treated violently (12%)Growing up with both parents not being present (22%)
ACES and Addiction
Women were 50% more likely than men to have experienced 5 or more adverse childhood experiencesThe higher the ACE score, the higher the chances of addiction to alcohol and other drugs in adulthood4 or more ACEs = 500% increase in risk for adult alcoholismMen with 6or more ACE’s = 4600% increase in risk for IV druguse78% of IV drug use in women can be attributed to adverse childhood experiences
Maybe its not about the drug
“…Our findings are disturbing to some because they imply that the basic causes of addiction lie within us and the way we treat each other, not in drug dealers and dangerous chemicals. They suggest that billions of dollars have been spent everywhere except where the answer is to be found.VinceFelliti, 2004
Dr. Gabor Mate
Expanding definition of trauma
PTSDComplex TraumaAttachment Trauma
PTSD
PTSD – first officially recognized in the mid-1980s due to the data gathered by the National Vietnam Veterans Re-adjustment StudyClassified as an anxiety disorder in theDSM-III, DSM-IV and DSM IV-R.Finally in the DSM 5 it was moved out of the anxiety chapter and into a new chapter “Trauma and Stressor-related Disorders”This move is seen as controversial by researchers who see that adding symptoms, broadening the construct of PTSD and moving away from fear conditioning and extinction models will set the field back
Complex Trauma
Judith Herman was the first person to acknowledge another view of psychological trauma that did not conform to the framework of PTSD – that which was seen in people who suffered considerable domestic violence, child physical and sexual abuse and neglect and who were given diagnoses of various personality disorders (Trauma and Recovery, 1992)She called it “complex trauma”
Complex TraumaDomains of Impairment
AttachmentAffect RegulationBehavioralcontrolBiologyDissociationCognitionSelf-concept
Attachment Trauma
Children have a biological instinct to attachAttachment provides a secure baseWe learn how to modulate our affective states through the attachment relationship with our primary caregiverAn impaired or absent caregiver does not provide a secure base for secure attachment to developInsecure attachment patterns leave children with no skills to self regulateInsecurely attached children grow up to be insecurely attached adultsAttachment in Psychotherapy David
Addiction as an attachment disorder
Research demonstrates the prevalence of insecure attachments in adults with substance use disorders(Parolin &Simonelli, 2016)“Attachment theory looks at addiction as both a consequence and a failed solution to an impaired ability to form healthy emotionally regulatory relationships…the underlying driving force behind all compulsive/addictive behavior is related to an inability to manage relationships” (Flores, 2006, p. 6)The vulnerable individual’s attachment to chemicals serves both as an obstacle and as a substitute for interpersonal relationships.
The impact of trauma
In the moment of trauma, the body goes into fight or flight mode. The prefrontal cortex shuts down and the limbic brain takes over.This loss of executive function is a protectiveresponse because cognition is too slow.When re-traumatized, the brain responds in the same way: thecognitive brain deactivates and theemotional/instinctualbrain acts as if the traumatic event is happening in the present –the person becomefurious, terrified, enraged, ashamed or frozen.
Addiction Treatment Can beRe-Traumatizing
Concept of powerlessnessAbsolute authority of the counselorConfrontation tacticsShaming practicesFocus on ‘character defects’“Addicts can’t be trusted to tell the truth”Discharges for “non-compliance”Punishing aggressionNo choicesWithholding medication-assisted treatment
Trauma Informed Treatment
What does it look like?It requires a paradigm shift away from a traditional approach to addiction treatment toward one that seeks to reflect the principles of trauma informed care
PunishmentSafetyDistrustTrustConfrontationCollaborationAuthoritativeChoiceandTreatmentEmpowermentComplianceTransformation
12 STEP COMMUNITY
12 Step program is a valuable community support and an adjunct to evidence based treatmentsThis relationship-based self-help program of recovery can be both healing and triggering to a traumatized individualUnwillingness to participatemay not be resistanceor denial, butacommon and expected reaction of someone who has experienced trauma in relationshipsRelationships are dangerous, and yet what is damaged in relationships can only be healed in relationshipsJudith Herman
So What Does This Mean?
It is no longer adequate to treat addictionas a primary and singular disorderIt is important to critically examine how we do addiction treatment today and be willing to change our practices so that we are responsive to the trauma our clients have experiencedTrauma informed treatment and trauma specific interventions must becomean integral partofsubstanceabuse treatmentEven clients who do not have a significant trauma history will respond positively to a trauma informed approach
Rethink addiction treatment
For many individuals, addictive behaviors are an adaptation to traumatic experiencesThe disease model has its usefulness but the risk is that we seek only to intervene through the brain and ignore the body (mind body connection)We need to re-focus our treatment to start from the bottom-up
The focus of trauma treatment
CognitionEmotionBody
Working with Cognitions
Top Down -works with cognitionsPsychotherapy (talk therapy)PsychoeducationCBTMindfulnessManyaddiction treatmentstrategies arecognitivebasedWhat we now know about trauma indicates that this may not be an effective way to treat traumatizedindividuals
Working with Emotions
Until someone is able to establish personal emotional safety, they will be unable to process traumatic experiencesEmotional regulation skills must be mastered firstWe are emotional regulators
Trauma is stored in the body
All trauma is preverbal; the traumatized body re-experiences terror, rage and helplessness, but these feelings are almost impossible to articulateSurvivors develop “cover stories” to explain their symptoms and behaviors; these stories rarely capture the inner truth of the experienceThe experience of trauma shows up in instinctual responses such as fight, flight, freeze, submit and attachVanderkolk, 2014
Working with the body
May be necessary to startfrom the bottom up, withthe bodyBreath, movement,touch, rhythm, synchronicityMovement oriented activities should move from the adjunctive therapy list to the primary therapy listSensorimotor approachesOnce the body settles, then we can begin to work through the emotional and the cognitive modalities to heal trauma
Body based interventions
Yoga, Art, Music,MovementDrummingSound HealingEMDR, Brain Spotting, Theatre,Improv, PsychodramaSensorimotor techniquesSMARTSensorimotor psychotherapy; Somatic Re-experiencingNeurofeedback
What do you think?
Can wechangehow we do addictiontreatment?