Addressing Psychological Trauma in the Therapeutic Community Liliane Drago, Vice President National Training Director

Goal of Workshop
To develop a clearer idea about ways we can make our treatment settings conducive to the treatment of psychological trauma

Workshop Objectives
Review the definition of trauma, PTSD, and Complex PTSD Present and discuss the stages and tasks of trauma recovery Present and discuss Seeking Safety treatment In small groups, discuss how our treatment settings can be more trauma informed

How prevalent is trauma/PTSD in our population?

Clients in Addiction Treatment

30-59% of women and 12% -34% of men have current PTSD (Najavits et al., 1997) 55-99% of women experienced trauma (Najavits et al., 1997) 66% of all individuals inpatient treatment report a history of physical or sexual abuse (Grice et al., 1995) 59% of girls and 39% of boys report a history of physical or sexual abuse (Grella & Joshi, 2003)

What do we know about outcomes for these clients?

Clients with PTSD and substance abuse have worse outcomes than those with either disorder alone. They:
Improve less Have worse coping Have more distress Have more positive view of substances Leave treatment earlier than those without Relapse at a higher rate

Integrated treatment (treatment for both at the same time) improves outcomes

Trauma
DSM IVR: Experience, threat, or witnessing of physical harm that evoked intense fear, helplessness or horror
Can include: Physical or sexual abuse Domestic violence Assault Severe car accident Life threatening illness Natural disaster/terrorism Combat Prison/torture

Who develops Post-traumatic Stress Disorder (PTSD)?

Up to 1/3 of people who experience trauma develop PTSD; 2/3 do not What about the 2/3?

PTSD
3 Core Sets of Symptoms

Intrusion Avoidance Arousal

Intrusion
Re-experiencing the trauma over and over again in ones mind
Flashbacks Nightmares Intrusive thoughts

Avoidance
Avoidance of discussion and memories of the trauma Avoidance of activities, people, places linked to the trauma Inability to recall an important aspect of the trauma Diminished interest or participation in activities Feeling of detachment from others Restricted range of affect Sense of foreshortened future

Arousal
Intensely triggered when reminded of the event Hypervigilence Exaggerated startle responses Insomnia Anger Difficulty concentrating

Identifying PTSD

PTSD can go on for years Often under-diagnosed or misdiagnosed Is often interpreted as bad behavior

Complex vs. Simple PTSD

Complex PTSD Multiple traumas beginning in childhood Often at the hands of a family member or other intimate relation Additional symptoms

Simple PTSD Single trauma, typically in adulthood DSM-IV symptoms

Complex PTSD

Broad symptoms, more damage to personality Profoundly affects self- and world view Self-harm cutting, burning Relationship problems (too close or distant) Brief psychotic symptoms (paranoia, delusions)

Complex PTSD
Somatic symptoms, the body remembers Dissociation (spacing out) Loss of sense of self (fragmented, empty, split) Traumatic re-enactments

Traumatic Reenactments
Recreating the trauma in new situations with new people Examples: A rape victim repeatedly returns to the area where the incident took place A woman with a history of incest is hypersexual An adolescent who has been physically abused provokes fights

The Function of Traumatic Re-enactments

Tests working theory about self, others and the world, e.g., I am unsafe, I am ineffective, other people are untrustworthy and will ultimately reject me Provides opportunity for mastery; victim becomes in control Vents frustration and anger May be addiction to endorphins released when in crisis Contributes to sabotage Tests caregivers and others

The symptoms of PTSD are the brains way of coping with lifethreatening danger; they are survival mechanisms.

Brain Development and Early Trauma

Brain development is affected by early trauma Constant stimulation of the limbic system via the flight or fight response results in overdevelopment of those neural pathways, underdevelopment of the pre-frontal cortex, responsible for rational decision-making, thinking

The Effect of Early Trauma on the Brain

Prefrontal cortex is less developed Emotional centers (limbic) without the checks and balances, results in
Impulsiveness Greater sensitivity to rewards Less consequential thinking Poor emotional regulation, extremes in emotion, numbness or hyperarousal

Stages of Trauma Recovery: Judith Herman

Stage 1: Safety (stabilization) Goals: abstinence from substance abuse, eliminate self-harm, acquire trustworthy relationships, gain control over overwhelming symptoms, healthy selfcare, eliminate dangerous situations (e.g., abuse, unsafe sex) Approach: teach coping skills (focus is on present) develop cognitive areas of the

Stage 2: Mourning
Goal: Processing trauma, expressing of grief and pain, transforms story of shame and humiliation to one of dignity and virtue. Approach: Exposure therapy (focus is on past) integration of emotional and cognitive

Stage 3: Reconnection
Goals: to develop a productive, fulfilling life in the present, including stable relationships and career, new identity as survivor and/or person in recovery, often includes helping others with similar problems. Approach: group work, supportive counseling

While there is no way to compensate for an atrocity, there is a way to transcend it, by making it a gift to others. The trauma is redeemed only when it becomes the source of a survivor mission. Judith Herman, Trauma and Recovery, 1992

Treatment
PTSD can be treated just by focusing on the present, e.g., cognitive behavioral treatment. Clients with SUD may not be ready for past-focused treatment. May delay or not do past-focused treatment at all. According to research, past- and presentfocused treatments both work equally well

How do we create a TC that is conducive to the simultaneous treatment of substance use disorders and the healing of trauma?

Helping Clients with Trauma

Trauma-Specific Treatment Services that are specifically geared to the treatment of trauma, such as Seeking Safety Trauma-Informed Treatment : Having a Trauma Lens
Treatment settings take into account knowledge about trauma, including its impact, effects on individuals, relationships, and paths to recovery, and incorporate this understanding into all aspects of service delivery

Key Themes for Traumatized Clients: Control and Shame

Control Helplessness is a central issue for those with trauma Struggles around control under- or over- controlling In treatment, empowerment is key Shame
Most feel somehow responsible for trauma Reducing shame is a central issue in recovery

Seeking Safety Therapy for PTSD and Substance Use Disorders

Seeking Safety is a present-focused, evidence-based, cognitive-behavioral treatment for PTSD and substance abuse. It is geared to first stage recovery. Clients with either disorder appropriate; do not need both disorders to benefit

Lisa Najavits, PhD, developer

Seeking Safety
Focuses on first stage of recovery safety vs. danger Teaches coping skills useful to recovery from PTSD and substance use disorders Details of trauma are not processed Trauma may be named, but details are discouraged

Positive Coping Skills Replace Unsafe Behavior such as:

Substance use, other addictions Unsafe sex Violence Dangerous people, places, things Self-harm Binging/purging Impulsive behavior Not taking prescribed medication

Research Support
Found to be effective with: Women Men Adolescents Co-occurring disorders In prison, inpatient and outpatient settings

Uses Cognitive Behavioral Techniques

Psychoeducation Cognitive Re-structuring Skills Development

Psychoeducation
Enhances the clients understanding of how post-traumatic symptoms and substance abuse are an attempt to regain a sense of safety, selfrespect, connectedness, and empowerment Enhances the clients understanding in nonstigmatizing terms of how s/he learned to cope with trauma and why these types of coping made sense for dealing with trauma

Is strength-based

Cognitive Re-structuring
Challenges self-defeating beliefs in a nonconfrontational, non-judgmental way Current beliefs and feelings are validated first Thought-provoking questions, peer feedback, information, and encouragement can replace cognitive distortions with more recovery-oriented thinking

Skills Development
1. Discuss the skill 2. Rehearse the skill in group
Interpersonal topics e.g., role play (talk through) Cognitive topics e.g., think aloud (think through) Behavioral topics 3.

e.g., what would you do? (walk through) Commitments at the end of group practice in real world and report back

Creating A TraumaInformed Treatment Environment

Basic education for all staff about trauma Routine assessment of trauma and PTSD symptoms Elimination of potentially re-traumatizing practices Services should maximize client safety, choice and empowerment

Core Principles of a Trauma Informed Approach Safety: How can we ensure physical and emotional safety for clients? Staff? Trustworthiness: How can we maximize trustworthiness? Make tasks clear? Maintain appropriate boundaries? Choice: How can we enhance client

Principles of Trauma Informed Treatment

Collaboration: How can we maximize collaboration and sharing of power with clients? Empowerment: How can we prioritize client empowerment and skill-building at every opportunity? How can we emphasize and respect clients strengths?

Practices That Can Retraumatize

Shaming techniques
name calling scarlet letter techniques public humiliation relapse as failure

Intrusive monitoring
strip searches body cavity searches urine screens using inappropriate staff or practices

Demanding premature self-disclosure

 Excessive confrontation Moral inventories that encourage clients to assume more than their share of responsibility for past abuses

Modifications in the Phoenix House TC

Screening for trauma Seeking Safety therapy, training and supervision Training for all staff with client contact Modification of Encounter Groups, confrontational practices Less sanction, more rewards Consequences for negative behavior are learning- oriented

References
Bloom, S., Creating Sanctuary: Toward the Evolution of Sane Societies, New York: Rutledge, 1997. Herman, Judith, Trauma and Recovery, New York: Basic Books, 1997 Jaycox, L, Ebener, P., Damesek, L., Becker, K., Trauma Exposure and Retention in Adolescent Substance Abuse Treatment, Journal of Traumatic Stress, Vol. 17, No. 2, April 2004, pp. 113121 Grella, C. E. and Joshi, V. (2003). Treatment processes and outcomes among adolescents with a history of abuse who are in drug treatment. Child Maltreatment: Journal of the American Professional Society on the Abuse of Children, 8(1), 7-18. Griece, D.E., Brady, K., Rustan,L., Malcolm, R., Kilpatrick, D., Sexual and Physical Assault History and PTSD in SubstanceDependent Individuals, American Journal on the Addictions, Vol. 4, Issue 4, pgs. 297-305

References, continued
Harris, M., Fallot, R., Using Trauma Theory to Design Service Systems, San Francisco, CA: Jossey-Bass, 2001. Najavits, L., Seeking Safety: A Treatment Manual for PTSD and Substance Abuse, New York: Guilford Press, 2002. Najavits, L., Implementing Seeking Safety Therapy for PTSD and Substance Abuse: Clinical Guidelines. http://www.bhrm.org/guidelines/PTSD.pdf Najavits, L.M.; Weiss, R.D.; and Shaw, S.R. The link between substance abuse and posttraumatic stress disorder in women: A research review. American Journal on Addictions 6(4):273-283, 1997. www.seekingsafety.org www.sidran.org (resource to find a trained trauma