Michael DeFalco, Psy.D. Program Director The Military Wellness Program at Holliswood Hospital

1. Integrated Treatment of Substance Misuse andCo-occurring Disorders for Service members and Veterans Michael DeFalco, Psy.D. Program Director The Military Wellness Program at Holliswood Hospital Aynisa Leonardo, LCAT AT-R BC Program Coordinator The Military Wellness and Family Reintegration Programs at Holliswood Hospital and Hope for the Warriors

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5. Learning Objectives • Discuss evidence based and complimentary modalities to utilize in working with service members that have substance misuse issues. • Interpret the relationship between complex/adult onset trauma, and the development of substance misuse issues. Michael Defalco, Psy.D. mdefalco1@libertymgt.com

6. Trends • Posttraumatic Stress Disorder (and co- morbid disorders- depression, anxiety, “behavioral acting out”) • Substance Abuse/Misuse • Suicide Attempts (completions) • Military Sexual Trauma • TBI • Chronic Pain The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

7. The Army Substance Abuse Program- ASAP c. The Army maintains the following principles: (1) Abuse of alcohol or the use of illicit drugs by both military and civilian personnel is inconsistent with Army Values, the Warrior Ethos, and the standards of performance, discipline, and readiness necessary to accomplish the Army’s mission. (2) Unit commanders must intervene early and refer all Soldiers suspected of being alcohol and/or drug abusers to the ASAP. The unit commander should recommend enrollment based on the Soldier’s potential for continued military service in terms of professional skills, behavior, and potential for advancement. (3) The ASAP participation is mandatory for all Soldiers who are command referred and subsequently enrolled. Failure to attend a mandatory counseling session may constitute a violation of Article 86 of the Uniform Code of Military Justice (UCMJ). (4) Soldiers who abuse alcohol and/or other drugs will be enrolled in the ASAP when such enrollment is clinically recommended. civilian corps members who abuse alcohol and/or other drugs may be enrolled in the ASAP when such enrollment is clinically recommended, space is available, and the employee agrees. (5) Soldiers who fail to participate adequately in or to respond successfully to rehabilitation will be processed for administrative separation and not be provided another opportunity for rehabilitation except under the most extraordinary circumstances, as determined by the Clinical Director (CD) in consultation with the unit commander.

8. 1–8. Army Values and the Warrior Ethos Alcohol and drug abuse by Soldiers and civilian corps members can seriously damage their physical and behavioral health, jeopardize their safety and the safety of those around them, and can lead to criminal and administrative disciplinary actions. Alcohol and drug abuse is detrimental to a unit’s operational readiness and command climate and is inconsistent with Army Values and the Warrior Ethos. The Army strives to be free of all effects of alcohol and drug abuse.

9. Profile of Servicemembers Admitted to The Military Wellness Program • Represent a complex combination of the above-listed problems • 90% male • Average age 24 (ranges 20-30+) • Most deployed- OEF/OIF • 75% are dually-diagnoses with a significant behavioral health disorder (depression, anxiety, PTSD) and substance/alcohol abuse/dependence • Most are active-duty from Army, Marines, Navy, and Coast Guard The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

10. Profile of Servicemembers Admitted to The Military Wellness Program • Cases are complicated by a myriad of psychosocial problems • Family • Financial • Service-related • Legal The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

11. What is PTSD? A construct based on clinical and historical observations. Initially codified in DSM-III (1980)- Vietnam Veterans Current conceptualizations are changing as research explores various aspects of individuals reactions to traumatic stress throughout the lifespan. Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

12. PTSD- Important, but Limited • Represents an important, but myopic conceptualization of the impact of traumatic stress on individuals • Does not capture the multitude of negative consequences associated with Trauma • Needs to be expanded to encompass the unique effects of Trauma experienced during childhood, especially Traumas of an interpersonal nature. Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

13. PTSD- Critical Considerations • Drop the “Disorder”- a natural reaction to extreme stress • Resiliency • Dimensional, with different subtypes • PTS (COS) and its effects are treatable, not “life sentences” Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

14. PTSD- Broad Strokes • Exposure to a potentially traumatic event • Persistent re-experiencing of the PTE • Persistent avoidance of reminders and a numbing of responsiveness • Persistent states of increased arousal PTSD is a bio-psych-social-spiritual condition

15. Integration of Developmental Trauma Theory with Adult/Situational Trauma

16. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study Vincent J Felitti, MD, FACP Robert F Anda, MD, MS Dale Nordenburg, MD David S Williamson, MS Allison M Spitz, MS Valerie Edwards, BA Mary P Koss, PhD James S Marks, Ms, MPH American Journal of Preventative Medicine, Vol 14, Issue 4, pages 245 – 258 (May 1998) Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

17. ACE Study N = over 17,000 Adult members of a large HMO in California Average age = 57 Looked at relationship between 10 Adverse Childhood Events and current emotional, physical, and behavioral health.

18. ACE Study The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

19. ACE Study

20. ACE Study

21. ACE Study • midrange ACE score of 4 is associated with a 390% greater change of COPD as compared with an ACE of 0. The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

22. ACE Study and Depression Persons with an ACE Score of 4 or more were 460% more likely to be depressed when compared to ACE of 0. Historical risk of suicide was 1,220% greater for ACE 4: much higher for 5-6. 2/3 of suicide attempts were correlated with ACE. The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

23. ACE Study and Alcoholism The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

24. ACE Study • male with an ACE of 6 has 4,900% greater chance of IV drug use than ACE of 0. The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

25. Population attributable riskassociated with early adversity: •50% for drug abuse •54% for current depression •65% for alcoholism •67% for suicide attempts •78% for iv drug use. ACES scores strongly related to many other health/functioning issues: hepatitis, heart disease, fractures, diabetes, obesity, alcoholism, occupational health and job performance The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

26. Why do ACEs have such a deleterious impact on health and functioning? The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

27. ACE Triangle The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

28. The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

29. Anda, Felitti, Bremmer, Walker, Whitfield, Perry, Dube and Giles. 2006. The enduring effects of abuse and related adverse experiences in childhood.European Archives of Psychiatry and Clinical neuroscience 256: 174-186 The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

30. Effect of Abuse and Neglect on the Corpus Callosum Myelinated regions, such as the corpus callosum (CC) are potentially vulnerable to the impacts of early exposure to excessive levels of stress hormones, which suppress glial cell division critical for myelination. CONTROL NEGLECT The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

31. Attachment • Sets the template or “internal working models” for self and others • Example: infant and mother • Beatrice Beebe split screen studies • Ed Tronick: Still Face Studies • Others… • Neglect or abuse by caretakers disrupts this natural process and can have devastating consequences The Military Wellness Program at The Holliswood Hospital www.militarywellnessprogram.com

32. CDC Risk Factors For Suicide andOverlap With Symptoms of PTSD- continued • History of alcohol/substance use- continued: - According to the CDC, the National Violent Death Reporting System examined toxicology reports of those who committed suicide in 13 states in 2004: - 33.3% were positive for alcohol - 16.4% were positive for opiates - 9.4% were positive for cocaine - 7.7% were positive for marijuana - 3.9% were positive for amphetamines

33. Integration of Trauma and Addictions Theory Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

34. The Window of Tolerance High Arousal Window of Tolerance Optimal Arousal Zone Low Arousal Ogden and Minton (2000) Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

35. Bi-Phasic Trauma Response Emotional reactivity Hypervigilance Intrusive imagery Obsessive/cyclical cognitive processing Tension, shaking, ungrounded. Hyperarousal: too much arousal to integrate Window of Tolerance Optimal Arousal Zone Flat affect Inability to think clearly Numbing Collapse Hypoarousal: too little arousal to integrate Ogden and Minton (2000) Siegel (1999)

36. Trauma and Addiction: A Paradoxical Way of Trying to Stay Safe In the context of trauma, addictive behavior is NOT a pleasure-seeking strategy, it is a survival strategy • To self-soothe and self-regulate • To reduce intrusive symptoms • To facilitate re-enactment symptoms • To combat helplessness • To treat hyper and hypo-arousal symptoms • To function and feel safer in the world Fisher 2000 & 2005 Fisher, 2005 Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

37. How Substances “Medicate” Complex Trauma Symptoms Hyperarousal Symptoms: • Induce relaxation and/or numbing effects, initiate sleep, enhance mood, decrease anxiety and paranoia, dampen rage and aggression (Alcohol, Marijuana, Opiates, Benzodiazepines) Intrusive Symptoms: • Act as a “chemical barrier” to traumatic memory, block intrusive thoughts/images, decreasing traumatic memories and nightmares (Heroin and opiates are the most effective for keeping intrusive symptoms at bay) Fisher, 2000 & 2003 Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

38. How Substances “Medicate” Complex Trauma Symptoms Hypoarousal Symptoms: • Increase alertness, confidence, sense of well-being • Counteract feelings of “deadness,” hopelessness, or weakness (Cocaine, Speed, Stimulants, Alcohol) Alcohol is the most versatile substance for addressing hypoarousal because at different dosages, it either induces numbing or counteracts it.) Fisher, 2003 M ichael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

39. How Substances “Medicate” Complex Trauma Symptoms Facilitate Re-enactment Symptoms: • Attract dangerous situations, risk-taking • Ensure that the individual is on and endorphin or adrenaline “high” that decreases trauma symptoms • (Alcohol and Cocaine) • Combat Helplessness • Increase feelings of power and control that battle • powerlessness • Facilitate social engagement • Allow individual to do activities in the community, be • with family, have intimate relationships • Fisher, 2000 & 2003

40. How Substances “Medicate” Complex Trauma Symptoms Hyperarousal can be decreased by: alcohol, marijuana, heroin, overeating or restricting, binging, cutting, planning suicide, or self-harm Hyperarousal Window of Tolerance Optimal Arousal Zone Hypoarousal is decreased by: cocaine, crystal meth, high-risk behavior, purging, cutting, suicide planning, and sexual acting out Hypoarousal Ogden and Minton (2000) Fisher (2004)

41. Mind-Body Focused Practices: Re-Gaining Natural Control of One’s Physiology • Yoga- Trains somatic awareness, pain reduction, • thought clarity- Holistic pain reduction • Acupuncture- Targets symptoms directly, and non- • chemically (anxiety, chronic or acute pain, depression) • Meditation and Mindfulness- Teaches quieting response, • natural down regulation of Amygdala (stress center of • brain) • EMDR and Brainspotting- Uses somatic and visual cues • to promote neurological movement and non-verbal • trauma processing and release The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

42. Trauma and Addictions- Processing Techniques • Prolonged Exposure- Strong evidence base. Effective in • treating symptoms of anxiety and hyper-arousal • In Vivo Desensitization- Opportunities to practice coping • strategies in real life scenarios- Exposure to stimuli and • triggers to dependency • Cognitive Processing Therapy-Re-framing cycles of misuse • EMDR (Eye Movement Desensitization and Reprocessing) • Brainspotting • Narrative Therapy- Provides contextual framework • Art Therapy and Expressive Techniques- Symbolic • representations- Increase insight and regain control

43. Expressive Treatments- Art Therapy “Oftentimes, in trauma, healing cannot be fully completed because traumatic experiences become locked in various areas of the brain. We can’t work trauma through just by talking about it. Talking is primarily a left hemisphere activity. In order to complete the healing process, a person must access the limbic system and the right hemisphere, where images, body sensations and feelings are stored. By accessing them, a person is then able to attach meaning to them and move this traumatic material to a more adaptive resolution.” ~Belleruth Naparstek, Invisible Heroes: Survivors of Trauma and How They Heal, 2005

44. Integrative Methods: Venn Diagram- Past, Present, Futures Selves

45. Exprssing the Conflict- Mixed Emotions in Recovery Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

46. Case Example “Heroin Kept Me Alive” Ben’s Story

47. Integrated Trauma/Substance Abuse Treatment Model • For individuals with histories of trauma, any addictive behavior begins as a posttraumatic survival strategy aimed at regulating autonomic arousal and decreasing the traumatic memory. • The dependency results from the fact that the substances and behaviors require continued increases in dosage to maintain their effectiveness: eventually, use becomes misuse, and misuse becomes dependency. • Treatment MUST address the relationship between the trauma and the addictive behavior: the role of the addictive behavior in “medicating” traumatic activation, the origins of both in the traumatic past, and the reality that recovering from either requires recovering from both Fisher, 2007 Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

48. “There is no problem that drugs and alcohol can’t make WORSE” • The substance use is intended to increase functioning, but eventually it becomes even more disruptive to the individual’s functioning than the initial symptoms that individual was self-medicating • May contribute to: • Relational Problems • Legal Issues • Financial Struggles • Health Problems (including increased mental health issues, suicide) Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

49. Co-occurring Disorders, Co-occurring Treatment • Best to treat trauma and substance misuse at the same time, rather than previous schools of thought that suggested one should complete substance abuse treatment entirely before addressing trauma symptoms • Not separate problems but enmeshed, contribute to • one another in a complex, meaningful way • Trauma symptoms will exacerbate in sobriety • Need to predict and anticipate triggers and new • coping strategies • In certain cases, it may be too dangerous to attempt • complete sobriety right away and could potentially • jeopardize recovery • Schiraldi, 2009 Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com

50. How do we do this? • Create a trauma-informed (safe, respectful, mindful, compassionate) space for the therapeutic work • Meet the client where he/she is Michael Defalco, Psy.D. mdefalco1@libertymgt.com Aynisa Leonardo, LCAT, AT-R BC aleonardo@libertymgt.com