From Reactivity to Regulation: A Practical Biopsychosocial Approach to Dealing with the Effects of T

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From Reactivity to Regulation A Practical
Biopsychosocial Approach to Dealing with the
Effects of Trauma in Adolescent Substance Abuse
Treatment

• Julian D. Ford, Ph.D.
• Ford_at_Psychiatry.uchc.edu
• www.ptsdfreedom.org
• Department of Psychiatry, University of
  Connecticut School of Medicine

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Why Address Trauma in Addiction Services?

• Prevalence and Impact on Treatment
• 5-6 Separate Trauma Incidents on Average
• 90 experience victimization Trauma
• 2-5x higher level of PTSD (20-59 vs. 5-10
  prevalences -- mostly undiagnosed)
• PTSD often precedes SUDs
• PTSD reduces success of SUD treatment
• Source Ouimette Brown, 2003

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PTSD Criterion A Exposure to Psychological
Trauma

• A1 Objective Life Threat/Physical Harm
• Directly Experienced, Witnessed, or Confronted
  by
• Actual or threatened death or serious injury OR
• Violation of physical integrity (e.g., sexual
  trauma)

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PTSD Criterion A Exposure to Psychological
Trauma (contd)

• A2 Subjective Traumatic Shock
• Intense Fear OR
• Helplessness OR
• Horror
• (May take the form of dissociation or
  disorganized/agitated behavior,
• particularly with children)

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PTSD Criterion B Persistent Intrusive
Re-experiencing

• Traumas Unfinished Emotional Business
• Unwanted Memories
• Disturbing Dreams
• Flashbacks
• Distress due to Reminders
• Physical Reactions due to Reminders

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PTSD Criterion C Persistent Avoidance and
Emotion Numbing

• Fallout from Unfinished Emotional Business
• Avoiding trauma reminders
• Cant remember important parts of past trauma
• Cant enjoy current life
• Cant feel (except anger, pain, numbness)
• Distant and cutoff from people
• Feel life has ended or will end soon

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PTSD Criterion D Persistent Increased
Physiologic Arousal

• Living in Survival Mode
• Cant sleep
• Easily angered, annoyed, or irritated
• Cant concentrate mentally
• Constantly on-guard (hypervigilance)
• Tense, edgy, jumpy, easily startled

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Complex PTSDDisorders of Extreme Stress

• Living in a State of Mental/Emotional Overload
• Flooded with rage or terror of abandonment
• Dangerous/Impulsive Risk Taking/Addiction
• Impulsive Self-Harm Stop the Pain/Numbing
• Dissociation Lose time, space out, automatic
  pilot, tunnel vision, out of body, feel unreal
• Body falling apart
• Self as Worthless, Life as Hopeless

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Myths (and the Truth) about Trauma and Recovery

• MYTH
• Trauma cant be dealt with until client is sober
  and stable psychosocially
• The TRUTH
• Never press a client to recall trauma, but
  learning how to deal with unfinished emotional
  business from trauma is an integral part of
  sobriety and stability

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Myths (and the Truth) about Trauma and Recovery

• MYTH
• Trauma recovery requires dredging up awful
  feelings and memories in a detailed examination
  of past trauma experiences
• The TRUTH
• Trauma recovery involves making sense of coming
  to terms with traumas unfinished emotional
  business here-and-now

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Myths (and the Truth) about Trauma and Recovery

• MYTH
• Clients feel re-victimized and fall to pieces if
  trauma is opened up
• The TRUTH
• Clients re-live and are trying to avoid trauma
  all the time, and want to learn how to stop this
  vicious cycle of unfinished business

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Why do Clients want Help with Trauma?

• Trauma Creates Unfinished Emotional Business
• Not Knowing how to feel/be safe
• Feeling misunderstood and isolated
• Feeling exploited/controlled
• Feeling unable to trust
• Feeling helpless and out of control
• Feeling permanently damaged/worthless

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Why Address Trauma in Psychosocial Treatment?

• Enhances the clients sense of safety and ability
  to achieve safety for self and family (including
  ability to identify and practically manage
  dangers)
• Enhances the clients autonomous self-control
  (including identifying, making, and following
  through on choices)

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Why Address Trauma in Psychosocial Treatment?

• Enhances the clients understanding of how
  post-traumatic symptoms are an attempt to regain
  a sense of safety, self-respect, connectedness,
  and empowerment
• Enhances the clients understanding in
  non-stigmatizing terms of how s/he learned to
  cope with trauma and why these types of coping
  made sense for dealing with trauma

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Why Address Trauma in Psychosocial Treatment?

• Assists the client in creating her own
  alternatives to post-traumatic symptoms, so she
  can safely begin to develop personally satisfying
  ways of achieving the goals that she had been
  trying unsuccessfully to accomplish with
  post-traumatic avoidance, numbing, worry,
  dissociation, self-sacrifice, risk taking, anger,
  or substance abuse

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Trauma and Working Memory

• Interpersonal trauma in childhood (key age 0-3
  8-18) may disrupt brain development related to
  working memory (DeBellis, 20011 Schmahl et al.,
  20032 Bremner et al., 20033 Benes et al.,
  19944 Kanemura et al., 20035)
• Bilateral neural integration (corpus callosum1)
• Emotion memory (dorsolateral2 medial/orbital2,3
  prefrontal cortices, anterior cingulate2)
• Implicit memory (hippocampal formation4)
• Integrative memory/decisions (dorsolateral PFC5)

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Trauma and Self-Development

• Interpersonal trauma in childhood interferes with
  affect regulation and self-definition development
  (Ford, Fisher Larson, 1997)
• Distinguishing self vs. others
• Trust and optimism in relationships
• Forming emotional connections
• Understanding how other people think

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Trauma and Working Memory

• Interpersonal trauma in childhood (key age 0-3
  8-18) may disrupt brain development related to
  working memory (DeBellis, 20011 Schmahl et al.,
  20032 Bremner et al., 20033 Benes et al.,
  19944 Kanemura et al., 20035)
• Bilateral neural integration (corpus callosum1)
• Emotion memory (dorsolateral2 medial/orbital2,3
  prefrontal cortices, anterior cingulate2)
• Implicit memory (hippocampal formation4)
• Integrative memory/decisions (dorsolateral PFC5)

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Trauma and Moral Development

• Psychological trauma in childhood simultaneously
  accelerate and interfere with moral development
  by confronting the child with ethical and
  spiritual violations yet also with heroic
  altruism (Goenjian et al., 1999children
  surviving an earthquake)
• Violence teaches survival-based fanatic ethics
  unless processed with supportive adults
  (Garbarino, 1999)
• Abuse teaches an ethics of aggression,
  intimidation, coercion, and betrayal (Farley,
  2004 Freyd, 1996)

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Trauma and Peer Acceptance

• Interpersonal trauma in childhood puts teens at
  risk for peer rejection and affiliation with
  deviant peers-and thus for juvenile delinquency
  and antisocial problems (Ford, 2002)
• Stage 1 Problems with anxiety/depression
• Stage 2 Oppositionality and Risk Taking
• Stage 3 Isolation or Deviant Peer Relations
• Stage 4 Substance Abuse and/or Violence and/or
  Victimization and/or Legal Problems

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d Dorsal Ventral v
?Anterior MEDIAL Posterior?
cingulate
thalamus
hippocampus
amygdala
hypothalamus
The Limbic System
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?Anterior MEDIAL Posterior?
d Dorsal Ventral v
Sensory Association Cortices
Dorsolateral PFC
Sensorimotor Cortices
Prefrontal Cortex PFC
Orbital PFC
Midbrain
Brainstem (Locus Coeruleus Raphe Nuclei, Ventral
Tegmentum)
Cerebellum
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Brain Development and Attachment

• Seeking social contact
• Social Cooperation/Play/Mating
• Empathy (interest in others frame of reference)
• Explicit and Implicit (non-conscious) reaction to
  and distrust of unfamiliar/untrustworthy faces
• Recognizing positive affect in others face
• Modulating pain/distress of social separation

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Brain Development and Affect Regulation

• Bioaffective Self-Monitoring
• Detecting Threats
• Seeking Reward
• Avoiding Aversive Outcomes
• Regulation of Affect-Driven States
• Regulation of Affect-Driven Behavior

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Brain Development and Information Processing

• Selective/Sustained Attention
• Cognitive Control
• Memory Acquisition, Consolidation, Extinction,
  and Reconsolidation
• Inhibition of Action while Processing Cognitions
• Working Memory (shaping new gestalts)
• Autobiographical Memory

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Implications of Brain Development Attachment,
Affect Regulation, Information Processing for
Therapy

• Brains Alarm Keeps You Alert and Alive but You
  Have to Be Able to Turn it Off
• How? Teach Body Mind to communicate
• Three Steps to Helping your Mind Listen to your
  Body and Get It SOS
• Teach the Brain Its Safe to Turn off the Alarm
  7 Steps that spell FREEDOM

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Normal Stress Body Brain Working Effectively
Together
Brains Thinking Center My life makes sense and
I feel in control.
Brains Computer Filing System I can figure out
this situation and decide what I need to do about
it.
Brains Alarm System Somethings wrong I need
to protect myself.
Bodys Nervous System Get the right balance of
arousal calmness Bodys Accelerator, Brakes,
Gear Shift
Stress
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Posttraumatic Stress Disorder (PTSD) The Never
Ending Life-and-Death Alarm
Brains Thinking Center I feel confused,
overwhelmed, and defeated.
Brains Alarm System Red Alert Constant State of
Alarm I cant stop feeling scared.
Brains Computer Filing System Overload Shut
Down Nothing makes sense.
XXX
Bodys Nervous System Extreme Adrenaline Rush or
Total Exhaustion Body Cant Stop Speeding Up or
Shutting Down
TRAUMA
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Trauma Adaptive Recovery Group Education and
Therapy Key Concepts

• Brains Alarm Keeps You Alert and Alive but You
  Have to Be Able to Turn it Off
• How? Teach Body Mind to communicate
• Three Steps to Helping your Mind Listen to your
  Body and Get It SOS
• Teach the Brain Its Safe to Turn off the Alarm
  7 Steps that spell FREEDOM

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Trauma Adaptive Recovery Group Education and
Therapy 7 Steps to FREEDOM

• Focus (Slow Down, Observe, Self-Check)
• Recognize Triggers
• Emotion Self-Check
• Evaluate Thoughts
• Define Personal Needs/Goals
• Open New Options for Achieving Goals
• Make a Contribution (Helping Others)