Section 32: Women and Trauma

1. Section 32: Women and Trauma Richard A. Rawson, Ph.D., Professor Semel Institute for Neuroscience and Human Behavior David Geffen School of Medicine University of California at Los Angeles

2. Scope of the Problem • 1 in 2 women in the U.S. experience some type of traumatic event(Kessler, 1995) • Approximately 33% of females under age 18 experience sexual abuse(Finkelhor, 1994; Wyatt, 1999) • Prevalence rates of PTSD in community samples have ranged from 13% to 36%(Breslau, 1991; Kilpatrick, 1987; Norris, 1992; Resnick, 1993) • Studies have documented PTSD rates among substance using populations to be between 14%-60% (Brady, 2001; Donovan, 2001; Najavits, 1997; Triffleman, 2003)

3. DSM-IV Criteria for Posttraumatic Stress Disorder (PTSD) A. Exposure to a traumatic event • Involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others • Response involved intense fear, helplessness, or horror B. Event is persistently re-experienced C. Avoidance of stimuli associated with the event, numbing of general responsiveness D. Persistent symptoms of increased arousal • Difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, exaggerated startle response

4. Neurobiological Changes in Response to Traumatic Stress • Limbic System -- Hippocampus and Amygdala (Affect and Memory, e.g, Ledoux, 2000; van derKolk, 1996) • Neurotransmitters and Peptides (Numbing and Depression, e.g., Pitman, 1991, Southwick, 1999) • Changes in Hormonal System (HPA axis) (Arousal, e.g., Yehuda, 2000)

5. Pathways Between Trauma-related Disorders and Substance Use PTSD SUD TRAUMA

6. Maladaptive emotion focused coping Biased information processing and problem solving Emotion Regulation Deficits Affective lability Disruptions in attention, memory & consciousness Difficulty managing anger Poor tolerance of negative emotional states Behavioral Impulsivity Difficulties with intimacy and trust

7. What is Trauma? • An event or series of events that threaten you, perhaps even with death – that causes physical or emotional harm and/or exploits your body and/or integrity • Trauma is pervasive and life-altering • Trauma has been reported by 55-99% of female substance abusers (Najavits et al, 1998)

8. More on Trauma • Trauma betrays our beliefs, values, and assumptions – trust – about the world around us • Trauma leads us to engage in sometimes less healthy behaviors to help us through our reactions to these events. These behaviors • Are an adaptation not a pathology • What kept us alive to get us to services

9. Possible Responses to Trauma • Intense fear; hypervigilance • Feelings of helplessness • Anxiety/Worry • Intrusive thoughts & memories • Flashbacks • Depression

10. More Possible Responses to Trauma • Anger or rage • Nightmares & Night Terrors • Detachment & Dissociation • Substance Use & Misuse/Abuse • Unusual sexual behavior • Difficulty with relationships • Others

11. Learning Objective #1: • Why do you think women initiate drug use (including alcohol & meds)?

12. Screening for Substance Abuse • Ensure privacy & confidentiality (HIPAA) • Communicate genuineness, respect, & belief in the client; build rapport • Observe behavior • Listen first; ask (OPEN) questions second • Roll with any resistance! • “Denial” is a natural human protective coating, not a pathology

13. Post-trauma, women with SUDs… • Improve less • Worse coping • Greater distress • More positive views of substance use (understandably)

14. Connections between SUDs & Trauma • Witnessing/experiencing childhood family violence • Childhood physical and emotional abuse • Women in chemical recovery • Typically have history of violent trauma • Substances used to numb or dissociate – medicinal • Violence often seen as a “natural” part of life • Coping mechanism for frustration and anger

15. Women with SUDs/Mental Illnesses • Need safety to disclose chemical use • May become disruptive when trauma hx becomes evident • Face tremendous stigma • Seen as bad mothers or people • Seen as resistant to treatment or unmotivated • Often most need these services • among those least likely to seek/receive services

16. PTSD does not go away with abstinence… …in fact, it often gets worse!

17. Learning Objective #2: What impact does unresolved childhood trauma have on SUDs?

18. Adoptive coping strategies: • Avoidance or ‘denial’ (numbness) • Substance abuse & other addictive behaviors • Compulsive eating/food disorders • Compulsive risk-taking behaviors • Risky sex, driving fast or recklessly • Gambling orreckless investing/get-rich schemes • Self-harm: cutting • Control obsession • Suicidal thoughts and/or attempts

19. Dissociation (complete numbing) • Not mentioned in DSM-IV as symptom of PTSD though sx of acute stress d/o • PTSD actually is a dissociative disorder not anxiety d/o? • Crucial to understand process – it’s the most severe consequence of PTSD

20. 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

21. Learning Objective #3: What is the main common factor in women with SUDs?

22. Traditional Tx Approach • Deficit model; focus is on problems • Single trauma event = single effect • Expected and definable course of treatment & recovery • Client is defined by their problem (ie, liars; borderline; addict; resistant, etc) • Treatment is typically crisis driven

23. Learning Objective #4: What are the key components of trauma-informed, gender-responsive services?

24. Trauma-Informed TX Services • Competence model – sees strengths • Client’s worldview is due to trauma • Distrust, danger, confusion and self-blame are normal • Sees how dealing with stresses of trauma causes clients to adopt less healthy ways to behave • Appreciates early traumas inform later complex coping skills, continue to develop over a lifetime • Understands trauma informs client’s identity even when not realized

25. Trauma-Informed TX Services • Emphasis is on whole person – how you lead your life. • “How can I come to understand this person fully?” • Focus not just on functioning • Agency message becomes “your behavior makes sense given your circumstances” • Clients & staff begin to see client behaviors as coping & brave, not pathological/unhealthy

26. Trauma-Informed TX Services • Trauma seen as complex PTSD resulting from chronic &/or repeated stressors • Strength-based approach • Clients actively involved in all aspects of tx planning & services • We are equal partners

27. Trauma-Informed TX Services • Safety guaranteed - not from other clients but from perpetrators • Priority is on choice and autonomy • Client becomes Change Agent – Empowered through increased self-efficacy!

28. Trauma-Informed Services… • Ask: Are our policies and procedures, program, hiring practices, etc. all in line with preventing the re-traumatization of the client? OR • Are we letting our rules – defined as the need for safety - actually mimicking any dynamics of an abusive relationship?

29. What else can we do? • Listen more than talk • Gently help clients link SUDs & trauma • Discuss current - not past - problems • Listen to client behaviors • Get training • Appreciate that substances do solve PTSD/trauma sx

30. Language is crucial: • Abstinent, sober, or drug-free • Powerful; empowered • Women united for women • Supportive relationships • Not “clean” • Not “Powerless” • No “Gossiping” • Not “enabling” or “co-dependency”

31. What shouldn’t we do? • Don’t explore past trauma(s) • In general, no psychodynamic work at first • No autobiographies until stable • Don’t ask about the trauma or the triggers • Gently guide conversation to present problems • Use complex reflections to highlight strengths

32. Above all, be cautious – go slow There is great danger in re-traumatizing clients!

33. Clinical Challenges in the Treatment of Traumatic Stress and Addiction • Abstinence may not resolve comorbid trauma-related disorders – for some PTSD may worsen • Women with PTSD abuse the most severe substances and are vulnerable to relapse, as well as re-traumatization • Confrontational approaches typical in addictions settings frequently exacerbate mood and anxiety disorders • 12-Step Models often do not acknowledge the need for pharmacologic interventions

34. Clinical Challenges in the Treatment of Traumatic Stress and Addiction • Treatment programs do not often offer integrated treatments for Substance Use and PTSD • Treatments for only one disorder—such as Exposure-Based Approaches are often marked by complications • treatments developed for PTSD alone may not be advisable to treat women with addictions

35. PTSD Treatment Approaches • Cognitive Behavioral • Prolonged Exposure: in vivo & imaginal; conditioning theory (Foa & Kozak, 1986; Cooper & Klum, 1989; Keane, 1991; Foa, 1991) • SIT – Stress Inoculation Training (Foa, 1991) • TREM – Trauma Recovery and Empowerment (Harris, 1998) • STAIR – Skills Training in Affective and Interpersonal Regulation (Cloitre, 2002) • EMDR – Eye Movement Desensitization and Reprocessing (Shapiro, 1995)

36. PTSD/SUD Integrative Treatments • Seeking Safety (Najavits, 1998) • ATRIUM: Addictions and Trauma Recovery Integrated Model (Miller & Guidry, 2001) • Not specifically designed for PTSD • TARGET - Trauma Affect Regulation: Guidelines for Education and Therapy (Ford; www.ptsdfreedom.org)

37. Other Challenges • Social isolation/alienation/lack of trust in others • Feelings of guilt or unworthiness • Shrinkage of world • Profound fear of own emotions and thoughts • Sleep disturbance/nightmares • Frightening re-experiencing symptoms • Foreshortened sense of the future (why bother)

38. Other Challenges • Cognitive rigidity/poor attention capacities when stressed • Numb and unable to tap into reinforcers • Anger dyscontrol/irritability • Trauma anniversaries during first month of treatment • Disability/service connection issues (possibly)

39. Self-Perpetuating Cycle Substance Use Interpersonal difficulties, no anger management,  isolation Complicated Depression  sleep disturbance & irritability

40. Creating Safety “Although the world is full of suffering, it is full also of the overcoming of it.” Helen Keller

41. Seeking Safety • Developed as a group treatment for PTSD/SUD women • Based on CBT models of SUDs, PTSD treatment, women’s treatment and educational research • Educates patients about PTSD and SUD’s and their interaction • Goals include abstinence and decreased PTSD symptoms • Focuses on enhancing coping skills, safety and self-care • Active, structured treatment - therapist teaches, supports and encourages • Case management

42. Key Principles • 1) Safety as the overarching goal (helping clients attain safety in their relationships, thinking, behavior, and emotions). • 2) Integrated treatment (working on both PTSD and substance abuse at the same time) • 3) A focus on ideals to counteract the loss of ideals in both PTSD and substance abuse • 4) Four content areas: cognitive, behavioral, interpersonal, case management • 5) Attention to clinician processes (helping clinicians work on countertransference, self-care, and other issues)

43. Seeking Safety Topics • Safety • PTSD: Taking Back Your Power • Detaching from Emotional Pain (Grounding) • When Substances Control You • Asking for Help • Taking Good Care of Yourself • Healing from Anger

44. More Seeking Safety Topics • Coping with Triggers • Setting Boundaries in Relationships • Community Resources • Healthy Relationships • Integrating the Split Self • Self-Nurturing • Life Choices • Recovering Thinking

45. Contributors • Dee-Dee Stout, MA, CADC II, MINT • Lisa R. Cohen, PhD: Columbia University School of Social Work • Denise Hien, PhD, LI Node, Columbia University • Tracy Simpson, PhD, VAPSHCS, University of Washington

46. Questions? Comments?