COMPLEX TRAUMA AND SUBSTANCE USE DISORDERS

Transcription

1 COMPLEX TRAUMA AND SUBSTANCE USE DISORDERS DECEMBER 13, 2018 This training is sponsored by Florida Alcohol and Drug Abuse and State of Florida, Department of Children and Families. SUSIE KOWALSKY, LCPC Website: 1

2 OBJECTIVES Recognize the ways in which complex trauma and substance use disorders influence each other. Identify program policies and procedures for maintaining safety when treating this population. Explore clinical approaches to meet co-occurring needs and provide substance use treatment in a trauma-informed manner. COMPLEX TRAUMA AND SUBSTANCE USE DISORDERS Share a lot of common ground Interact with each other Must understand trauma history to be effective in treating substance use 2

3 WHAT IS COMPLEX TRAUMA? Exposure to traumatic events and longterm impact of the exposure Child maltreatment within the caregiving system Chronic, beginning in early childhood Emotional dysregulation, loss of a safe base, loss of direction, and inability to detect or respond to danger cues COMPLEX TRAUMA Complex trauma more common than single event traumas Child abuse and neglect is rising Annual costs: $94 billion (2001) to $103 billion (2007) Daily cost of childhood abuse and neglect: $284.3 million Complex Trauma in Children and Adolescents; Impact of Complex Trauma 3

4 IMPLICATIONS ON DEVELOPMENT Greatest threat to a human infant or young child is the absence of an adequate caregiver Body s resources are directed toward survival rather than growth and development Co-regulation as building block for self-regulation Disruption of healthy attachment DIAGNOSTIC ISSUES No diagnosis, multiple unrelated diagnoses, or inadequate diagnosis. Proposal to add Developmental Trauma Disorder to DSM-5 Emphasis on behavioral control, without recognizing the influence of interpersonal traumas and lack of safety Lack of attention to addressing and improving the developmental disruptions that underlie the symptoms Proposal for Developmental Trauma Disorder 4

5 DEVELOPMENTAL TRAUMA DISORDER (DTD) Proposal for Developmental Trauma Disorder Focus on children who have grown up with recurrent exposure to interpersonal traumas and inadequate caregiving systems. Childhood trauma usually includes ongoing, co-occurring adverse experiences and stressors. Distinguishes impact of chronic interpersonal childhood trauma from adult exposure to assaults, disasters, or accidents DEVELOPMENTAL TRAUMA DISORDER CRITERIA Exposure: The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including: Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse Proposal for Developmental Trauma Disorder 5

6 DOMAINS OF IMPAIRMENT Attachment Biology Affect Regulation Dissociation Behavioral Regulation Cognition Self-Concept Complex Trauma in Children and Adolescents Inability to trust others DOMAINS OF IMPAIRMENT: ATTACHMENT Revictimization Challenges attuning to other people s emotional states Social Isolation Problems with boundaries Victimization of others Difficulty with perspective taking 6

7 DOMAINS OF IMPAIRMENT: BIOLOGY Coordination and balance Wide span of medical problems Persistent, undiagnosable medical complaints Hyper-sensitivity to physical contact Sensorimotor developmental problems DOMAINS OF IMPAIRMENT: AFFECT REGULATION Difficulty with emotional selfregulation Challenges labeling and expressing feelings Overreactions to minor stress Inability to selfsooth Easily overwhelmed Excessive risk taking Communicating wishes and needs 7

8 DOMAINS OF IMPAIRMENT: DISSOCIATION Depersonalization Gaps in memory Appear to space out Derealization Distinct alterations in states of consciousness DOMAINS OF IMPAIRMENT: BEHAVIORAL CONTROL Poor impulse control Selfdestructive behavior Aggression Sleep disturbances Eating disorders Substance use Excessive compliance Oppositional behavior Re-enactment of trauma in behavior 8

9 DOMAINS OF IMPAIRMENT: COGNITION Learning difficulties Problems with attention, focus, and completing tasks Problems processing new information Difficulty planning and anticipating Problems with language development Lack of sustained curiosity External locus of control Problems with orienting to space and time DOMAINS OF IMPAIRMENT: SELF-CONCEPT Lack of predictable, stable sense of self Despair, hopelessness Lack of meaning and purpose Low selfesteem Body image issues Feel damaged, broken Shame, guilt, and responsibility Defensive Dark worldview Complex rauma in Children and Adolescents 9

10 Adverse childhood experiences (ACEs) Survey of over 17,000 adults from , completed through Center for Disease Control (CDC) and Kaiser Permanente Inquired about childhood experiences and current health and behavior Adverse childhood experiences are the single greatest unaddressed public health threat facing our nation today. - Dr. Robert Block, former President of the American Academy of Pediatrics WHAT IS THE IMPACT? ACEs Study ADVERSE CHILDHOOD EXPERIENCES ABUSE Emotional abuse Physical abuse Sexual abuse NEGLECT Emotional neglect Physical neglect HOUSEHOLD CHALLENGES Mother treated violently Household substance abuse Mental illness in household Parental separation or divorce Criminal household member ACEs Study 10

11 Prevalence of ACEs ACES cluster: having 1 ACE increases the likelihood of having others ACES STUDY ACEs are often passed down across generations ACES accumulate: higher ACE scores are linked to more severe and multiple physical and behavioral health issues SAMHSA ACEs On average, having 6+ ACES shortens life expectancy by 20 years 11

12 ACES STUDY Physical Health 4 ACES = 2x risk of heart disease and cancer Mental Health 4+ ACES = 13x rate of suicide attempts Substance Use 4+ ACES = 7x rate of alcohol use disorder, 10x rate of intravenous drug use 6+ ACES (men) = 46x rate of intravenous drug use SAMHSA ACEs COMPLEX TRAUMA AND SUBSTANCE USE Teens with history of physical or sexual abuse = 3x rate of current or past substance use 70% of adolescents in substance use treatment had history of trauma exposure 59% of adolescents with PTSD develop substance use problems. Substance use as a coping strategy for complex trauma Making the Connection: Trauma and Substance Abuse 12

13 SUBSTANCE USE AS A RISK FACTOR FOR TRAUMATIZATION Increase Substance use can increase engagement in risky behaviors Alter Substance use can alter ability to discern safety from danger Inhibit Severe substance use disorder can inhibit ability to cope with traumatic events JOHANN HARI: EVERYTHING WE THINK WE KNOW ABOUT SUBSTANCE USE IS WRONG 13

14 DOMAINS OF IMPAIRMENT: SUBSTANCE USE DISORDERS Attachment Biology Affect Regulation Dissociation Behavioral Regulation Cognition Self-Concept SUBSTANCE USE DISORDER CRITERIA IN CONTEXT Question: What domain(s) of impairment from complex trauma are associated with the diagnostic criteria for substance use disorders? Answer: Please type in your responses for each criterion. DSM-5 Defintion for Substance Use Disorder: Problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period 14

15 SUBSTANCE USE DISORDERS CRITERIA Domains: Attachment, Biology, Affect Regulation, Dissociation, Behavioral Regulation, Cognition, Self-concept 1. Substance is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control substance use 3. A great deal of time is spent in activities necessary to obtain substance, use substance, or recover from its effects. 4. Craving, or a strong desire or urge to use substance. SUBSTANCE USE DISORDERS CRITERIA Domains: Attachment, Biology, Affect Regulation, Dissociation, Behavioral Regulation, Cognition, Self-concept 5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of substance use 15

16 SUBSTANCE USE DISORDERS CRITERIA Domains: Attachment, Biology, Affect Regulation, Dissociation, Behavioral Regulation, Cognition, Self-concept 7. Important social, occupational, or recreational activities are given up or reduced because of substance use. 8. Recurrent substance use in situations in which it is physically hazardous. 9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance. SUBSTANCE USE DISORDERS CRITERIA Domains: Attachment, Biology, Affect Regulation, Dissociation, Behavioral Regulation, Cognition, Self-concept 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of substance to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of substance. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for substance. b. Substance is taken to relieve or avoid withdrawal symptoms. 16

17 CHALLENGES IN TREATING COMPLEX TRAUMA AND SUBSTANCE USE DISORDER Abstinence may not resolve comorbid traumarelated symptoms or disorders; for some, trauma symptoms may worsen Confrontational approaches can exacerbate mood and anxiety disorders and disempower individuals 12-Step Models may not acknowledge the value of pharmacologic interventions, the impact of trauma, and carry shame-based messages Treatments for PTSD only, such as Exposure-Based Approaches, may not be effective in addressing substance use INTEGRATED TREATMENT APPROACHES 17

18 TRAUMA- INFORMED INTEGRATED CARE Traumainformed care Traumaspecific treatment Enhancing Substance Abuse Recovery Through Integrated Trauma Treatment SAMHSA S 4RS OF TRAUMA-INFORMED CARE A program, organization, or system that: Realizes the widespread impact of trauma and understands potential paths for recovery Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system Responds by fully integrating knowledge about trauma into policies, procedures, and practices Seeks to actively resist re-traumatization Trauma-Informed Care in Behavioral Health Services 18

19 MULTI- DIMENSIONAL SAFETY Internal Safety Relational Safety Physiological Safety Environmental Safety Therapeutic Safety Agency/System Level Safety Core Components in Complex Trauma Intervention; Trauma Informed Systems SAFETY AND SUBSTANCE USE Offering and providing balanced, transparent information about: Treatment services, requirements, eligibility, policies, expectations, privacy Safer consumption strategies and resources Withdrawal, tolerance, and overdose risk factors Medication assisted treatment 19

20 TRAUMA-INFORMED INTEGRATED TREATMENT Recognize trauma as a defining and organizing experience Proactively create collaborative relationship that prioritizes individuals safety, choice, and control Understand the multiple, layered interactions between substance use and complex violence Enhancing Substance Abuse Recovery Through Integrated Trauma Treatment TRAUMA-INFORMED INTEGRATED TREATMENT Simultaneously address substance use and complex trauma Empower individuals to engage in collaborative decision making during all phases of treatment Implement ancillary services for comprehensive, whole-person interventions. Enhancing Substance Abuse Recovery Through Integrated Trauma Treatment 20

21 What is the MOST important thing you learned today? What is ONE change you are going to make when you return to work? How will you CONTINUE your growth and learning? QUESTIONS? COMMENTS? THANK YOU! 21

22 REFERENCES AND RESOURCES Adverse Childhood Experiences Study: and Felitti, V. et al., (1998) Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experience (ACE) Study. American Journal of Preventive Medicine, 14: Guarino, K., Soares, P., Konnath, K., Clervil, R., and Bassuk, E. (2009). Trauma-Informed Organizational Toolkit. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, and the Daniels Fund, the National Child Traumatic Stress Network, and the W.K. Kellogg Foundation. Available at and REFERENCES AND RESOURCES Hodas, G.R. (2006). Responding to childhood trauma: The promise and practice of trauma informed care. Statewide Child Psychiatric Consultant, Pennsylvania Office of Mental Health and Substance Abuse Services: Hopper, E. K., Bassuk, E. L., & Olivet, J. (2010). Shelter from the storm: Trauma-informed care in homelessness services settings. The Open Health Services and Policy Journal, 3, Kinniburg, K., Stolbach, B., & Arvidson, J. (2014). Trauma-Informed Systems. National Child Traumatic Stress Network Regional Learning Community Conference: ress-trauma_informed_systems_change_(english).pdf 22

23 REFERENCES AND RESOURCES National Center for Trauma-Informed Care (2008). Models for developing trauma-informed behavioral health systems and traumaspecific services. National Child Traumatic Stress Network (NCTSN): National Child Traumatic Stress Network. Impact of Complex Trauma: _trauma.pdf National Child Traumatic Stress Network (2008). Making the Connection: Trauma and Substance Abuse. ction_trauma_substance_abuse.pdf REFERENCES AND RESOURCES National Child Traumatic Stress Network Complex Trauma Task Force (2003). Complex Trauma in Children and Adolescents. per-ctwg_nctsn.pdf National Trauma Consortium (2004). Enhancing Substance Abuse Recovery Through Integrated Trauma Treatment: Perry, B. et al (1995) Childhood Trauma, the Neurobiology of Adaptation, and "Use-dependent" Development of the Brain: How "States" Become "Traits. Infant Mental Health Journal, Vol. 16 (4). 23

24 REFERENCES AND RESOURCES Spinazzola, J. (2010). Core Components in Complex Trauma Intervention. Complex Trauma Treatment Network, Northeast Region Systems of Care Conference, Springfield, MA. Substance Abuse and Mental Health Services Administration. Trauma- Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, REFERENCES AND RESOURCES van Dernoot Lipsky, L and Burk, C. (2009) Trauma Stewardship: An everyday Guide to Caring for Self While Caring for Others. San Francisco: Berrett- Koehler Publishers, Inc. Van der Kolk, B. (2014) The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York : Penguin Books. van der Kolk, et al. (2009). Proposal to include a Developmental Trauma Disorder Diagnosis for Children and Adolescents in DSM-V. 24