WOMEN, TRAUMA, & SUBSTANCE USE

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WOMEN, TRAUMA, SUBSTANCE USE

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5 Principles of Seeking Safety

• Safety is priority in this first-stage tx
• Integrated tx of PTSD SUDs
• Focus is on ideals
• 4 content areas cognitive, behavioral,
  interpersonal, and case management
• Attention to therapist processes

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Women in SUDs Treatment

• 1998, 23 men for every 10 women
• More likely to be tx for hard dx less alcohol
  or MJ
• Entered through different avenues
• Less likely to misuse alcohol dx fewer need tx
  in general

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Women in SUDs Treatment are

• More likely to have children, others who needs
  care less access, other obstacles so less
  likely to get tx.
• 1998, both men women in tx were 35 yo, white
  (60), first timers (40). 13 had 5 or more tx
  episodes.
• Less likely to be employed (87).
• (CaDADP, 1995)

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Women in SUDs Treatment are

• More likely to blame themselves for trauma
• More likely to experience repeat traumas
  throughout their lives
• Information from the DASIS Report (8/01).
  www.samhsa.gov.

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PTSD Substance Abuse

• Common COD
• 12-34 in general tx women 30-59!
• Lifetime rates even more common
• Becoming abstinent doesnt resolve PTSD.
• Tx outcomes for PTSD/SUDs worse than other COD,
  SUDs only.
• PTSD SUDs clts tend to misuse hard dx though
  MJ, RXs, alcohol are also common.
• Self-medicating

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PTSD Substance Abuse

• Clts w/this COD are vulnerable to repeated
  traumas, more than AOD-only clts.
• Suffer a variety of life problems that may
  complicate treatment life homelessness, other
  D/O, HIV, DV, medical, child neglect, legal.
• More severe clinical profile

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PTSD Substance Abuse

• 2-3x more common in women than men in SUDs tx.
• Most women w/this COD experienced childhood
  physical/sexual abuse men, usually crime victim
  or war trauma.
• Downward spiral common use leads to increased
  vulnerability leads to more use

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PTSD Substance Abuse

• Many subgroups have this COD homeless,
  veterans, teens, DV, prisoners.
• Connection btn this COD and SUDs is enduring, not
  just part of SA, w/d or overlapping criteria.
• Perpetrators of violent assault use substances at
  the time of assault in DV 50 and rape 39 (BOJ
  Statistics, 1992).

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PTSD SUDs Treatment

• Few provide combined tx for PTSD SUDs.
• Most clts w/this COD dont receive PTSD-focused
  tx.
• Many clts never get assessed, nor receive
  information, for this COD
• SUDs tx focuses on SUDs
• MH tx focuses on MH

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PTSD SUDs Treatment

• Can be effective but difficult marked by
  unstable tx alliances, numerous crises, erratic
  attendance, relapses to SUDs.
• Views of clts w/this COD are negative by culture,
  clinicians, themselves countertransference is
  common.
• Effective tx for PTSD or SUDs are not often
  useful for this COD (benzos, AA, exposure)

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PTSD SUDs Treatment

• Often have intensive case management which may
  lead to burnout for clinicians.
• Cross-training is needed for clinicians.

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PTSD DSM-IV DEFINITION

• Person is exposed to a traumatic event in which
  both of the following were present
• Person experienced, witnessed, or was confronted
  with an event(s) that involved actual or
  threatened death or serious injury, or threat to
  physical integrity of self or others.
• Persons response involved intense fear,
  helplessness, or horror.

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B. The traumatic event is persistently
reexperienced in 1 or more of the following ways

• Recurrent intrusive distressing recollections
  of the event w/images, thoughts, perceptions.
• Recurrent distressing dreams of the event.
• Acting or feeling as if the traumatic event were
  recurring such as illusions hallucinations,
  dissociative flashbacks inc. when intoxicated.

• Intense psychological distress at exposure to
  internal/external cues of the traumatic event.
• Physiological reactivity on exposure to internal
  or external cues to an aspect of the traumatic
  event.

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C. Persistent avoidance of stimuli associated
with the trauma numbing of general
responsiveness as indicated by 3 of the
following

• Efforts to avoid thoughts, feelings, or
  conversations assoc. w/the trauma.
• Efforts to avoid activities, places, or people
  that arouse recollections of the trauma.
• Inability to recall an important aspect of the
  trauma.

• Markedly diminished interest or participation in
  significant activities.
• Feeling of detachment or estrangement from
  others.
• Restricted range of affect (i.e. no loving
  feelings)
• Sense of a foreshortened future

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D. Persistent symptoms of increased arousal as
indicated by 2 of the following

• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating

• Hypervigilence
• Exaggerated startle response

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PTSD DSM-IV definition

• E. Duration of the disturbance is more than 1
  month.
• F. The disturbance causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.

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PTSD DSM-IV

• Acute if duration of symptoms is less than 3
  months.
• Chronic if duration of symptoms is 3 months or
  more
• With Delayed Onset onset of symptoms is at
  least 6 months after the stressor.

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PTSD DSM-IV

• After a trauma, a person has each of the
  following key sx for more than 1 month which
  results in a decreased ability to function.

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PTSD

• INTRUSION
• flashbacks nightmares
• AVOIDANCE
• Refuse to discuss or remember
• AROUSAL
• Insomnia anger

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PTSD TYPES

• SIMPLE
• single event as adult
• complex (NOT IN DSM)
• multiple events esp. in childhood

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PTSD

• LIFETIME RATES
• 10 women
• 5 men
• Can be chronic
• DIFFICULT LIVES
• More events
• Earlier trauma
• Lower socio-econ status

• Women more vulnerable to developing PTSD
• Men experience more traumas

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GETTING PTSD

• WOMEN 30-59 (of female clts in SUDS tx)
• Childhood/sexual abuse
• Self-harm (self-blame, etc)
• 55-90 trauma (includes witnessing)

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WOMEN WITH PTSD

• Alcohol use 28
• Other drug use 27 (Kessler, et al, 1995)

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WOMEN HAVE

• Higher rates of PTSD/SUDS
• 2/3 develop PTSD first, then SUDs
• Have worse outcomes for COD
• Have a need for control and secrecy
• Have no real drug of choice and

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AFTER TRAUMA, WOMEN ALSO

• Improve less
• Worse coping
• Greater distress
• More positive views of SU

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PTSD does not go away with abstinence

• In fact, it often gets WORSE!

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PTSD

• May take years to treat
• Substantial reduction of sx w/I 90 days w/
  focused proper treatment
• Most dont get treatment

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REMEMBER

• PTSD is a normal reaction to abnormal events
• Behind every symptom is a story
• People can and do recover

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Limbic system

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PTSD, Trauma Limbic System

• A complex psychophysical experience even with no
  direct bodily harm
• PTSD disrupts daily functioning
• Somatic memory (van der Kolk)
• Somatic disturbance at core of PTSD
• Direct somatic interventions
• Not all develop PTSD or trauma symptoms
• Prepared for stress? developmental hx beliefs
  prior experience internal resources support.

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PTSD, Trauma Limbic System

• Hans Seyle (1984) stress the nonspecific
  response of the body to any demand.
• Positive or negative experiences lead to stress
  responses
• Posttraumatic stress is traumatic stress that
  persists following a traumatic experience.
  (Rothschild, 1995a)

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PTSD, Trauma Limbic System

• Fight, flight, freeze (includes dissociation)
• Hormones (neurotransmitters) released
• ANS parasympathetic sympathetic NS
• SNS aroused in states of effort stress
  eustress distress
• PNS aroused in states of rest relaxation

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PTSD, Trauma Limbic System the Tiger ( the
HPA axis)

• Threat leads to
• Amydala signals hypothalamus to turn on 1) SNS
  and 2)CRH (corticotropin-releasing hormone)
• SNS activates adrenals to release
  epinephrine/norepinephrine

• CRH activates pituitary to release
  adrenocortio-tropic (ACTH) which activates
  pituitary to release cortisol
• Incident is over cortisol stops alarm
  adrenaline homeostasis

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Why is this important?

• In PTSD, something goes wrong w/this HPA axis
• PTSD clts dont release enough cortisol to turn
  off alarm when trauma is over
• Is PTSD purely biological then? Unclear.

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Instinctive responses!

• Limbic system/ANS responses are instant
  instinctive responses to perceived threat
• Not chosen or thought-out

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PTSD, Trauma, and Memory

• Hippocampus amygdala
• Record, file, remember
• Hippocampus
• Time space context perspective time line
• Gives start, middle, end
• Amygdala
• Processes highly charged emotional memories i.e.,
  terror horror

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PTSD, Trauma, and Memory

• Hippocampus
• Activity becomes suppressed
• Storing not available
• Traumatic event prevented from becoming
  historical remains current incorrectly
• flashbacks

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Dissociation

• Not mentioned in DSM-IV as symptom of PTSD though
  sx of acute stress d/o
• PTSD actually a dissociative disorder not anxiety
  d/o?
• Crucial to understand process its the most
  severe consequence of PTSD

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PTSD, Trauma Consequences

• Varies due to
• Age of survivor
• Nature of trauma
• Response to trauma
• Support to survivor afterwards
• Survivors suffer reduced quality of life
• Body signals can cause relapse
• Ability to orient to safety danger decreases

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PTSD SUDs healing requires ID transformation

• Isolation v
• Powerless v
• Silence v
• Victim v

• Connection
• Sense of control
• Finding ones voice
• Survivor

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WHAT WORKS?

• Exposure
• EMDR (not w/schizophrenia)
• Narrative
• Mourning (not for all)
• CBT
• MI
• Seeking Safety
• Somatic Experiencing

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WHATS NEEDED?

• SAFETY
• MOURNING
• RECONNECTION
• Seeking Safety works only on Safety.
• JUDITH HERMAN, MDTRAUMA RECOVERY, 1992.

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WHAT ELSE CAN WE DO?

• Listen more than talk
• Help clts link SUDs PTSD
• Discuss current not past - problems

• Listen to clt behaviors
• Get training!
• Appreciate that substances do manage/solve PTSD
  symptoms

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Seeking Safety includes

• Use of educational research strategies
• Focus on potential not pathology
• Attention to language
• Relating the material to clts lives

• Clinical realism
• An urgent approach to time
• Making the tx interesting
• SUDs as a priority

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WHAT SHOULDNT WE DO?

• Dont explore past trauma(s)
• No interpretive psychodynamic work
• No autobiographies until emotionally stable
• Homework may not be helpful for SUDs
• Dont ask about the trauma or the triggers

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WE ALSO SHOULD AVOID

• Asking our client to confront their abuser
• Minimize their pain

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ABOVE ALL, BE CAUTIOUS

• There is great danger in retraumatizing clients!

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When is a client ready for trauma processing?

• Can remain abstinent or moderate for some time
• Able to control some destructive behaviors
• Able to use some coping skills

• Can ask for help
• Is in a system of care (treatment, etc)
• Is willing to begin trauma work
• Has no other major current crises such as DV,
  homelessness

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TRAUMA-INFORMED TREATMENT

• Includes all staff from ED to kitchen
• More effective than traditional treatment
• Cost effective

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SUCCESSFUL TRAUMA PROCESSING EQUALS

• 1 foot in the past
• and 1 foot in the future.
• --LISA NAJAVITS

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THEY CONSTANTLY TELL THEIR STORIES, SOMETIMES
EVEN WITH WORDS.

• LISA NAJAVITS, PH.D.,
• AUTHOR, SEEKING SAFETY

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FIRST, DO NO HARM

• Loving and appreciating our clients for they are
  the heroes of their lives.
• --- SCOTT D. MILLER

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ETHICS WHEN TRAUMA HAPPENS IN TREATMENT

• Practicing
• ethical treatment

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ETHICS TRAUMA IN TREATMENT

• Client-Centered
• Outcome-Informed
• Session rating scales
• Outcome rating scales
• For more on CDOI, go to www.talkingcure.com

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You yourself, as much as anybody in the entire
universe, deserve your loves and affection.

• --Buddha (5thc BCA Indian philosopher)

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ACKNOWLEDGEMENTS

• SEEKING SAFETY A Treatment Manual for PTSD and
  Substance Abuse. Lisa Najavits, PhD. 2002.
  Guilford Press. www.seekingsafety.org
• New Directions for Mental Health Services, Using
  Trauma Theory to Design Service Systems, No. 89,
  Spring 2001. Maxine Harris and Roger D. Fallot,
  Jossey-Bass.

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ACKNOWLEDGEMENTS

• The Body Remembers the Psychophysiology of
  Trauma Trauma Treatment. Babette Rothschild,
  2000. WW Norton.
• Trauma Recovery. Judith Herman, MD. 1992.
  Basic Books.
• Many Roads, One Journey Moving Beyond the
  12-Steps. Charlotte Kasl, Ph.D. 1992.
  HarperCollins.