The Centrality of Trauma

1. The Centrality of Trauma October 7, 2009 Trauma Informed Care Interagency Workgroup Meeting Colleen Clark, Ph.D. Florida Mental Health Institute University of South Florida Colleen Clark, Ph.D. University of South Florida

2. Centrality of trauma • Impact of trauma • Mental health, substance use, and Trauma • Special issues for adolescents • Intervention principles • Intervention examples • The importance of self-care Colleen Clark, Ph.D. University of South Florida

3. The Centrality of Trauma Colleen Clark, Ph.D. University of South Florida

4. Definitions • Trauma – Shock or severe distress from experiencing a disastrous event Colleen Clark, Ph.D. University of South Florida

5. For this discussion: • Interpersonal abuse and violence • Including primarily physical and sexual but may include emotional • Experienced as an adult or a child • May have occurred over time or been one incident and/ or time limited Colleen Clark, Ph.D. University of South Florida

6. Prevalence of Childhood Sexual Abuse Colleen Clark, Ph.D. University of South Florida

7. Adverse Childhood Events (ACE) Study • Kaiser Permanente and the CDC • Large-scale epidemiological study of the influence of stressful and traumatic childhood experiences • Interviewed over 17,000 people • Motivated by an obesity study Colleen Clark, Ph.D. University of South Florida

8. Colleen Clark, Ph.D. University of South Florida

9. ACE Study Colleen Clark, Ph.D. University of South Florida

10. ACE Score vs. Adult Alcoholism Colleen Clark, Ph.D. University of South Florida

11. ACE Study • Higher rates of self-injurious behaviors (addiction, overeating, smoking) associated with higher ACE’s • Such behaviors in long term lead to disease and disability • In short term, may be effective in ameliorating the effects of childhood trauma • Conclusion: childhood trauma must be addressed for both short term and long term reasons Colleen Clark, Ph.D. University of South Florida

12. “The counterintuitive aspect was that, for many people, obesity was not their problem; it was their protective solution to problems that previously had never been acknowledged to anyone. An early insight was the remark of a woman who was raped at age twenty-three and gained 105 pounds in the year subsequent: ‘Overweight is overlooked and that’s the way I need to be.’ The contrast was striking between this statement and her desire to lose weight.” - Felitti Colleen Clark, Ph.D. University of South Florida

13. Colleen Clark, Ph.D. University of South Florida

14. The Impact of Trauma Colleen Clark, Ph.D. University of South Florida

15. Bonanno, George. American Psychologist, Jan. 2004 Colleen Clark, Ph.D. University of South Florida

16. ↑Clinically significant symptoms : • the abuse occurred at a younger age • persisted over a longer period of time • involved several individuals • more marked by violence Colleen Clark, Ph.D. University of South Florida

17. violation of trust attachment no safety no intimacy lies holding in feelings powerlessness pain Origins of symptomatology Colleen Clark, Ph.D. University of South Florida

18. Sequelae of chronic abuse: • Disorders of Thought • Guilt, negativity, memory difficulties, intrusive / obsessive thoughts, impaired attention / concentration • Disorders of Emotion • Wide range of affective / anxiety symptoms Colleen Clark, Ph.D. University of South Florida

19. Disorders of Personality • Compare with borderline personality disorder: unstable relationships, abandonment issues, suicidal gestures, identity disturbance, paranoia, emptiness, intense anger, dissociative • Disorders of Behavior • Truancy / promiscuity; self-injury, rage episodes/substance disorders Colleen Clark, Ph.D. University of South Florida

20. Posttraumatic Stress Disorder • DSM-IV criteria – considered an anxiety disorder • Person is exposed to a traumatic event involving threat of death or serious injury • they respond with intense horror, fear, or helplessness Colleen Clark, Ph.D. University of South Florida

21. They persistently re-experience the event • Intrusive thoughts, perceptions, images, dreams • Reliving of event – including hallucinations, illusions, dissociative flashbacks Colleen Clark, Ph.D. University of South Florida

22. Persistent avoidance or numbing of reactions (not present before) • avoids thoughts, feelings, conversations • avoids people, places, activities • unable to recall elements of trauma • detachment or estrangement • diminished interest • sense of foreshortened future Colleen Clark, Ph.D. University of South Florida

23. Persistent symptoms of increased arousal • difficulty falling or staying asleep • irritability / outbursts • impaired concentration • hypervigilance • exaggerated startle response Colleen Clark, Ph.D. University of South Florida

24. PTSD • Rates in substance abuse treatment populations • 12-34% • Rates for Women in SA treatment • 33 – 59% (Najavits, 2002) Colleen Clark, Ph.D. University of South Florida

25. Lifetime Abuse Among Patients With SUD Diagnoses Colleen Clark, Ph.D. University of South Florida

26. How mental health, substance abuse, violence work together Colleen Clark, Ph.D. University of South Florida

27. Trauma ♀ Substance Abuse Colleen Clark, Ph.D. University of South Florida

28. Trauma and Substance Abuse • Following traumatic event – substance abuse as “self-medication” “self-soothing” • Substance abuse leading to high risk situations or poor judgment increasing chances of victimization Colleen Clark, Ph.D. University of South Florida

29. Trauma ♀ Mental illness, Emotional disorders Colleen Clark, Ph.D. University of South Florida

30. Trauma and Mental Illness • Violence and abuse, especially over a long term, abuse by multiple perpetrators and/or extremely violence abuse is associated with the development of many disorders. • Some responses to abuse – SIV, flashbacks, result in involuntary hospitalization, seclusion , restraints and possible retraumatization • People with mental illnesses are more likely to be victims of violence Colleen Clark, Ph.D. University of South Florida

31. Substance abuse ♀ Mental illness, Emotional disorders Colleen Clark, Ph.D. University of South Florida

32. Substance Abuse and Mental Illness • Substance abuse may be used to self-medicate symptoms of mental illness. • For some disorders, substance use can increase the symptoms and problems • Substance abuse is associated with many other mental illnesses – everything from depression (e.g. with ETOH) to paranoia (e.g. with meth) Colleen Clark, Ph.D. University of South Florida

33. Trauma and Physical Health Particularly chronic sexual and physical abuse in childhood affect adult rates • Heart disease • Cancer • Gastrointestinal disorders • Chronic pain Colleen Clark, Ph.D. University of South Florida

34. Trauma and Physical Health • Those with more severe trauma experienced worse physical health • More likely to engage in poor health behaviors Colleen Clark, Ph.D. University of South Florida

35. Trauma’s impact on HIV issues • ↑Sexual risk behaviors • ↑Risk of adult sexual revictimization • Poor treatment adherence • Linked to sex work • Multiple sex partners Colleen Clark, Ph.D. University of South Florida

36. Increase Risk of Trauma with HIV • Trauma of diagnosis • Complicated medical treatments • Stigma tied to HIV • Loss of support networks due to AIDS bereavement • Loss of income due to disability/ discrimination Colleen Clark, Ph.D. University of South Florida

37. Integrating Mental Health, Substance Abuse & Trauma Issues for Adolescent Girls • The Need • Considerations & Goals • Model Interventions • Practice in a research environment Colleen Clark, Ph.D. University of South Florida

38. Rate* of Hospitalization for Depression Among Persons Aged 5--19 Years, by Sex Colleen Clark, Ph.D. University of South Florida

39. The Need: Girls and Substance Abuse – National Prevalence Data • Earlier initiation • Increase marijuana use • Narrowing of the gap with boys’ drug use Colleen Clark, Ph.D. University of South Florida

40. The Need: Girls and Substance Abuse –Florida Prevalence Data • Ages 11 - 18 • 35.7% of males and 34.2% of females reported using any illicit drug in the past 30 days • More girls than boys reported using alcohol only (15% vs. 13.2%) Colleen Clark, Ph.D. University of South Florida

41. The Need: Substance Abuse, Violence and Emotional Problems • Abused high school girls & those with symptoms of depression are twice as likely to drink or smoke frequently than non-abused or non-depressed girls • Girls experience stronger physiological effects from drugs and alcohol than men or boys; often place themselves at increased risk for sexual assault (i.e., unwanted or forced sex). Colleen Clark, Ph.D. University of South Florida

42. The Need: Substance Abuse, Violence and Emotional Problems • Boys consume more alcohol than girls • African American adolescent girls have the highest average number of problems per ounce of alcohol consumed • Girls appear more vulnerable to their parents’ role modeling of drug abuse Colleen Clark, Ph.D. University of South Florida

43. The Need: Substance Abuse, Violence and Emotional Problems • Rates of PTSD among adolescent with Substance Use Disorder – 11% - 47% • Adolescent girls have higher rates of PTSD than boys Colleen Clark, Ph.D. University of South Florida

44. The Need: Substance Abuse, Violence and Emotional Problems • Among those surveyed, 13 percent of teenage girls, admit to being physically injured or hit and one in four report being pressured to perform oral sex or engage in intercourse, according to the survey by the private research group Teenage Research Unlimited. Liz Claiborne Study – n = 300,000 Colleen Clark, Ph.D. University of South Florida

45. The Need: Juvenile Justice System • In one study, more than half of the 2,300 adolescent substance abusers reported an arrest. • Typically women in criminal justice system: • non-violent and gender-congruent criminal activity earlier in life such as prostitution and shoplifting. • Following an increased severity in drug abuse, their crimes tended to be more violent Colleen Clark, Ph.D. University of South Florida

46. The Need: Juvenile Justice System • Female juvenile offenders not becoming more violent. • Rather, preliminary studies suggest, the response of the justice system has changed such that • girls’ family conflicts are re-labeled as violent offenses, • police practices regarding arrests for domestic violence and aggressive behavior have changed Colleen Clark, Ph.D. University of South Florida

47. The Need: Risky Behaviors • Substance abuse is a risky behavior that intersects with many other risky behaviors such as unprotected sex • Except for HIV/AIDS, adolescent girls have the highest rates of sexually transmitted diseases of any group of men or women Colleen Clark, Ph.D. University of South Florida

48. The Need: Risky Behaviors • AIDS is a significant problem. It was found to be the sixth leading cause of death among 15- to 24-year-olds, the third leading cause for black women in this age range, and three out of five cases of AIDS are among black girls • Among the adult and adolescent females in the United States who do have AIDS, nearly 71% of the cases can be attributed to IV drug use and sexual contact with IV drug users Colleen Clark, Ph.D. University of South Florida

49. The Need: Risky Behaviors • Girls who become mothers before the age of 18 are more likely to drop out of school, remain at lower income levels, and get divorced. Colleen Clark, Ph.D. University of South Florida

50. Research base • No controlled studies of effective substance abuse treatment for adolescent girls • In large scale SAMHSA study of prevention of substance had surprising findings Colleen Clark, Ph.D. University of South Florida