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Co-occurring Disorders _ Trauma


									Co-occurring Disorders &
      John Fullmer, LCPC
             Trauma Definition

   Extreme stress that overwhelms a person‘s
    ability to cope
   The subjective experience of a threat to
    life, bodily integrity or sanity
   A normal response to an abnormal event
    that results in a disruption of equilibrium
because they occur rarely, but rather because they
overwhelm the ordinary human adaptations to life.
Unlike commonplace misfortunes, traumatic events
generally involve threats to life or bodily integrity,
or a close personal encounter with violence or
death. They confront human beings with the
extremities of helplessness and terror, and evoke
the responses of catastrophe. The common
denominator of trauma is a feeling of intense fear,
helplessness, loss of control, and threat of
annihilation.      (Judith Herman, MD, Trauma and Recovery, 1992)
        ‗Going Out of My Mind‘
―That‘s a victim thing; you ask yourself, ‗Am
I just crazy? Did I make all this up?‘
Somehow it might be easier to accept that
you‘re crazy and you made it all up than to
admit that it happened and how awful it
was.‖         Teri Hatcher, star of TV show Desperate Housewives
                  and survivor of child sexual abuse by her uncle.
                  (Source: Janet Yassen, VOV Program, Cambridge Hospital, 2006)
            Traumatic Events
   Physical Assault       Witnessing
   Sexual Abuse            abuse/violence
    including sex work     Living in dangerous
   Emotional/              environment
    Psychological Abuse
                           Experienced as an
   Domestic Violence       adult or child
   War/Genocide
                           Occurred over time
   Accidents               or one incident or
   Natural or Man-Made     time limited
     Interpersonal Violence
Interpersonal Violence – physical/sexual
abuse is not like natural disasters, car
accidents, etc.

• Human-fostered violence against another
  human                       being
• Causes extreme disconnection from other
  human beings
              Why Trauma Matters

   A significant proportion of men and women
    entering services for substance use disorders
    have histories of trauma (Brems, 2004; Clark, 2001; Farley, 2004;
    Medrano, 1999; Moncrieff, 1996; Rice, 2001).

   Women in community samples report a lifetime
    history of physical & sexual abuse ranging from
    36 to 51%, while women with substance abuse
    problems report a lifetime history ranging from
    55 to 99%
    (Najavits et al., 1997).
             Women in Methadone
 75% report lifetime history of physical
  and/or sexual abuse
 33% report abuse in past year
 50% report abuse as children
 33% report witnessing abuse of mother
    (El-Bassel et al., 2004)

   Women who were both physically and
    sexually abused in childhood were six
    times more likely to abuse alcohol then
    non abused women.
                               (Bensley, Eenwyk, and Simmons, 2000)
  Co-occurrence of Substance
     & Domestic Violence
 Research    Institute on Addictions
 80% of women with substance use
 disorders had been the victim of
 domestic violence
 Brookhoff   et al. (1997)
 42% of victims of domestic violence
 contacting the police had used alcohol or
 other drugs on the day of the assault
   Special Issues for Victims of Violence
    Who Have Co-Occuring Disorders
The presence of both alcohol and drug use & domestic
violence increases the severity of injuries & lethality
rates (Mackey, 1992)
Perpetrators may pose risk to partners by:
       Introducing partner to drugs
       Forcing or coercing partner use
       Isolating partner from help
       Coercing partner to engage in illegal acts
       Using withholding drugs as a threat
       Using legal history as a threat
       Blaming abuse on partner use
     History of Abuse & Mental
Muesser et al., 1998
   90% of public mental health clients have
    histories of trauma
   most with multiple instances
Kessler et al, 1995
   34-53% report childhood physical or sexual
   43-81% report some type of victimization
      Domestic Violence
   & Mental Health Problems

On average, over half of women seen in a
range of mental health settings are either
currently experiencing or have experienced
abuse by an intimate partner.
           Prostitution &Trauma
   99% report at least one traumatic event
   93% report multiple traumas
   53% report 6 or more traumatic events
   75% report child sexual abuse
   26% report child sexual abuse before age 6
   81 % raped as adults
   81% physically assaulted as adults
(Roxburgh, Degenhardt, & Copeland [2006])
             Adverse Childhood
                 ACE Study
   Kaiser Permanente (Felitti) & CDC (Anda)
   Large-scale epidemiological study of
    influence of stressful/traumatic childhood
   Interviewed over 17, 000 people
   Compares adverse childhood experiences
    against adult health status
                ACE Study
 Scoring system used – one point for each
  category of Adverse Childhood Experiences
  (ACE) before 18
 ACEs not only common, but effects were
 Compared to persons with ACE score of 0,
  those with ACE score of 4 or more were 2x
  more likely to be smokers, 12x more likely to
  have attempted suicide, 2x more likely to be
  alcoholic and 10x more likely to have injected
  street drugs
Adverse Childhood Experiences
 Recurrent and severe physical abuse
 Recurrent and severe emotional abuse
 Sexual abuse
 Growing up in household with:
    – Alcohol or drug user
    – Member being imprisoned
    – Mentally ill, chronically depressed, or
      institutionalized member
    – Mother being treated violently
    – Both biological parents absent
    – Emotional or physical abuse
      (Fellitti, 1998)
                   ACE Study
Controlling for other adverse childhood
   Women with a history of childhood sexual abuse
    were 60% more likely to have alcohol problems
    and 70% more likely to have used illegal drugs.

   Men with a history of childhood sexual abuse
    were 30% more likely to have alcohol problems
    and 60% more likely to have used illegal drugs.
                                          (Dube et al. (2005)
      Messina and Grella (2006)
Number of childhood traumatic events associated
     Prostitution
     Eating Disorders
     Mental Health disorders
     STIs
     Alcohol problems
     Early onset of criminal behavior
            Impacts of Trauma
   Physiological – Changes in neurobiology and
    physical health
   Cognitive – Flashbacks, dissociation
   Feelings – Feeling numb or overhwhelmed
   Beliefs – About self, other people, the world
   Skill Deficits – Self-protection, self-soothing
   Mental Health – PTSD, Substance Abuse
   Relational Disconnection
Pathways of Co-Occurrence
          Sequelae              Self-
       Mental Health

                     (Begin Anywhere)

  Victimization                     Addiction

                      Lack of
    What Makes Impact More
           Trauma Characteristics
 Interpersonal violence
 Perpetrator is known/trusted
 Recurrent
 Degree of exposure
 Response of social environment
    What Makes Impact More
           Person Characteristics
 Age
 Prior coping skills
 Prior trauma history
 Chronic stressors
 Current stressors
The impact of violence/trauma on both men and
women is inadequately understood and
addressed by service providers.

Less than half of the women with interpersonal
trauma and co-morbidity will receive treatment
that addresses their trauma history and co-
occurring conditions.
(Timko & Moos, 2002)
―I am an incest survivor and never dealt with it.
Left treatment, did drugs. The most important
thing is to integrate [services]. I‘m a slicer and
before no place would take me and if [I] say I‘ve
been sexually abused they boot you…I thought,
here we go again. Substance abuse identified
and you‘re welcome… need to work all 3
areas…others throw you out because they are
                                       (WELL Project, 2005)
         Treatment Programs Often Fail to
          Adequately Deal with Trauma.
   Lack of research/knowledge dissemination;
   Trauma not seen as central/critical to recovery
   ―Uncovering‖ trauma would ―destabilize‖
    symptoms – need to stabilize mental health/
    substance abuse – Opening a ―Pandora‘s Box‖
   A belief that trauma work requires more
    sophisticated clinical skills
         Failure to understand
      and address trauma can lead
1.   Failure to engage in treatment services                        (Farley,

2.   Increase in symptoms (eating disorders,
3.   Increase in management problems
4.   Retraumatization   (Harris and Fallot, 2001)

5.   Increase in relapse
6.   Withdrawal from service relationship
7.   Poor treatment outcomes             (Easton et al 2000; Ouimette et al
     ―It was not until I became a part of the Women,
Co-Occurring Disorders & Violence Study that I became
trauma informed. I remember realizing one day, what
perfect sense this all makes. I was able to finally fit the
pieces of the puzzle together. Being a survivor was the
reason I drank & used drugs. Post Traumatic Stress
Disorder had set in, & the drinking and using
suppressed my true feelings. I am among one of the
lucky few. So many of us have not solved the puzzle –
survivors, & providers.
     One of the most important things I have learned is
how to keep myself safe. The word Safety never came
up in treatment. I now realize how much jeopardy I put
myself in when I was using substances, not caring what
time of the night it was, not caring that the guy just
came into the room waving a gun, just give me another
hit. We continue to put ourselves in situations that can
retraumatize us on a daily basis. Learning how
important safety is to my recovery process has changed
my outlook.‖
      What are Trauma-Informed
 Trauma-informed vs. trauma-specific
 Characteristics of trauma-informed
    – Incorporate knowledge about trauma—
      prevalence, impact, and recovery—in all
      aspects of service delivery
    – Hospitable and engaging for survivors
    – Minimize revictimization
    – Facilitate recovery and empowerment
      Why Trauma-Informed
   Trauma is pervasive
   Trauma‘s impact is broad and diverse
   Trauma‘s impact is deep and life-shaping
   Trauma, especially interpersonal violence, is
    often self-perpetuating
   Trauma is insidious and differentially affects
    the more vulnerable
   Trauma affects how people approach
   The service system has often been
A Repetitive Cycle of Risk

    Incarceration                  Homelessness

                    Violence and

      Substance                    Mental Health
        Abuse                       Problems
 Comparing Traditional and
Trauma-Informed Paradigms

 Understanding of Trauma
 Understanding of the
 Understanding of Services
 Understanding of the Service
      A Culture Shift: The Core
       Principles of a Trauma-
      Informed System of Care
   Safety: Ensuring physical and emotional
   Trustworthiness: Maximizing trustworthiness,
    making tasks clear, and maintaining
    appropriate boundaries
   Choice: Prioritizing consumer choice and
   Collaboration: Maximizing collaboration and
    sharing of power with consumers
   Empowerment: Prioritizing consumer
  A Culture Shift: Scope of
Change in a Distressed System
 Involves all aspects of program activities,
  setting, and atmosphere (more than
  implementing new services)
 Involves all groups: administrators, supervisors,
  line staff, consumers, families (more than direct
  service providers)
 Involves making change into a new routine, a
  new way of thinking and acting (more than new
    Protocol for Developing a
    Trauma-Informed Service
 Services-level changes
   – Service procedures and settings
   – Formal service policies
   – Trauma screening, assessment, and service
 Systems-level/administrative changes
   – Administrative support for program-wide
     trauma-informed services
   – Trauma training and education
   – Human resources practices
    Trauma-Informed Services:
    Qualitative Pilot Outcomes
 Consumers report greater safety, trust, and
  engagement in services; more collaboration with
  providers; emphasis on empowerment, recovery,
  and healing
 Providers report greater collaboration with
  consumers; enhanced skills and sense of
  efficacy; more support from agency
 Administrators report more collaboration within
  and outside agency; enhanced staff morale;
  fewer negative events and more effective
 What we know about trauma, its impact, and
  the process of recovery calls for trauma-
  informed service approaches
 A trauma-informed approach involves
  fundamental shifts in thinking and practice at all
  programmatic levels
 Trauma-informed services offer the possibility of
  enhanced collaboration for all participants in the
  human service system
                     Multi-Axial System

Axis I All mental (clinical) disorders are coded on Axis I; all
  substance-related disorders are also coded on Axis I.

Axis II Personality Disorders and Borderline Intellectual
  Functioning / Mental Retardation are coded on Axis II.

Axis III General Medical Condition, particularly those that
  may impact the clinical picture are coded on Axis III.

Axis IV Problems related to all areas of psychosocial difficulty,
  as well as environmental factors are coded on Axis IV.

Axis V Global Assessment of Functioning or GAF refers to the
  clinical judgment of a person’s overall level of functioning
  and is coded on
  Axis V.
               Assessment Guidelines
 Structure. Structure. Structure.
 Assessment and observation over time are essential.
 Detoxification and crisis stabilization must occur first.
 Psychiatric symptoms related to substance abuse remit
  with abstinence.
 Atypical presentations of symptoms of both mental
  illness and substance abuse are indicators of co-
  occurring disorders.
 Comprehensive bio-psycho-social formats are essential.
 Resist the impulse to provide therapy.
 Thorough mental status evaluations are essential.
 See TIP 42, P.67
Steps in the Assessment Process
   Start where the client is
   Review preliminary data, collect data from
    significant others
   Screen for substance and mental disorders
    symptoms = diagnostic impressions
   Identify strengths, preferences, needs and
   Plan treatment by linking goals/objectives with
    problem definition, client and agency strengths,
    needs, preferences and expectations
   See TIP 42, P.72
                         Differential Diagnosis

             Psychosis vs. Substance Induced Symptoms

   ongoing psychotic symptoms during abstinence vs. symptoms that
    remit relatively quickly with cessation of use
   intact delusional system vs. absence of bizarre delusions
   auditory hallucinations and “running commentary vs. typically visual
    and tactile hallucinations
   disorganized, tangential speech vs. incoherent, slurred speech
   disorganized behavior vs. impaired motor functioning
   ongoing difficulty with life skills (negative symptoms) vs. return of life
    skills with abstinence
   persistently flat or restricted affect vs. normal range of affective
    response or erratic moods associated with episodes of use
   chronic admissions to CSU’s vs. chronic admissions to detox units
                       Differential Diagnosis

           Depression vs. Substance Induced Symptoms

   ongoing depression vs. depression that remits with cessation of use
    (a few days to 4-6 weeks)
   consistent and enduring personality features vs. erratic personality
   enduring depressed mood vs. erratic moods correlating to periods of
    intoxication and withdrawal
   mood-related and well planned suicide attempts vs. impulsive
    suicidal gestures associated with intoxication and withdrawal
                        Differential Diagnosis

               Mania vs. Substance Induced Symptoms

   discrete episodes of elevated, expansive moods cycling with
    depressed moods vs. erratic mood changes that correlate to
    episodes of intoxication and withdrawal (i.e. mood changes vs.
    “mood swings”)
   grandiosity vs. low self-esteem, shame and guilt
   a decreased need for sleep vs. insomnia
   an increase in goal-directed activity vs. hyperactivity and agitation
                        Differential Diagnosis

              Anxiety vs. Substance Induced Symptoms

   ongoing anxiety vs. anxiety that remits with cessation of use (a few
    days to 4-6 weeks)
   anxiety marked by panic and fear vs. anxiety marked by
    tremulousness, restlessness and agitation
   anxious themes of worry and helplessness vs. anxious themes of
    paranoia associated with drug use and drug seeking behaviors
   anxiety which provokes agoraphobia and isolation vs. a willingness
    to leave home and socialize to achieve ongoing drug use
                        Differential Diagnosis

      Personality Disorders vs. Substance Induced Symptoms

   enduring personality features vs. erratic personality changes
    consistent and enduring personality features vs. erratic personality
   features which appear in adolescence vs. first onset in adulthood
   “deviant” behaviors vs. addictive behaviors
    Adult Assessments for Co-occurring Disorders and Trauma

Abuse / Trauma-Related Questions

   What type of discipline did you receive as a child?

   Did you ever have an injury, or have to go to the hospital because of the
    way in which you were disciplined?

   Have there ever been times when discipline consisted of being isolated for
    long periods of times, or locked in a place where you could not get out?

   Have there ever been times when discipline consisted of withholding food
    or water from you, or forcing you to eat or drink things you didn’t like or
    didn’t want?

   Have there been times when someone abandoned you? What were the

   Have there been times when people have hit, slapped, punched, kicked or
    physically harmed you in other ways?

   Have there been times when people did things with you or to you that
    made you uncomfortable, guilty or ashamed?
                Abuse / Trauma-Related Questions (continued)

   Were there ever times when people did things to you or with you that you
    couldn’t talk about with others, or were told not to talk about?

   Have there been prolonged periods of time when someone caring for you,
    or living with you teased you, insulted you, called you names or verbally
    abused you in other way?

   Were there ever times when you were made to watch other people being
    hurt or mistreated? Were you ever made to watch movies or read books
    that made you feel embarrassed or ashamed?

Other Psychosocial Concerns

   In what ways did (any of the above) affect or change your life from that
    point on?

   Did you ever tell anyone about (any of the above)? What happened after
    you told? Were you treated differently by anyone after you told?

   In what ways are you still affected today?
      Child Assessments for Co-occurring Disorders and Trauma

Abuse / Trauma-Related Questions

   What happens to you when you get into trouble?

   Did you ever get hurt or have to go to the hospital after somebody punished

   Did anyone ever close you in a room or a closet and not let you out?

   Did anyone ever tell you that you couldn’t eat or drink because you were
    being punished? Did anyone ever force you to eat or drink something to try
    and punish you?

   Can you think of a time when you were left alone with no adults around?
    How long were you alone?

   Have people ever hit you, slapped you, punched you, or kicked you because
    you did something wrong? What other ways have people hurt you?

   Did anyone ever do something to you that made you feel bad? Did anyone
    ever do something to you that made you feel ashamed?

   Did anyone ever do something to you and then tell you not to tell anyone?

Why Bio-Psycho-Social Assessments?

    Causative Factors and influences in the development of
    mental and substance-related disorders:

   Biological: Genetics, Neurochemistry

   Psychological: Psychodynamics, Emotional Factors,
    Cognitive Factors, Behavioral Factors

   Social: Family, Peer Groups, Interpersonal Factors, Life
    Stressors, Cultural and Environmental Factors
                Abuse / Trauma-Related Questions (continued)

   Has anyone ever touched you and then told you not to tell anyone?

   Did anyone ever play a game with you and then tell you not to tell anyone?

   Do people tease you, or call you names? Does anyone ever say things to
    you that make you feel bad?

   Do you ever have to look at movies that you don’t want to see? Do you
    ever have to look at pictures that you don’t want to see? Has anyone ever
    showed you a movie or a picture that made you feel bad (or embarrassed,

Other Psychosocial Concerns

   How did you feel about (any of the above)? How does it make you feel to
    talk about it now?

   Did you ever tell anyone about (any of the above)? What did they do when
    you told?

   Did someone treat you different after you told?
Trauma-Specific Group
Traumatic-Specific Interventions
   Services designed specifically to address
    violence, trauma, and related symptoms
    and reactions.
   Increase skills and strategies that allow
    survivors to manage their trauma
    symptoms and reactions and eventually to
    reduce or eliminate debilitating symptoms
    and prevent further traumatization and
     Trauma-Specific Curricula Used in
    Substance Abuse Treatment Settings
   Maxine Harris—Trauma Recovery &
         Empowerment (TREM)
   Lisa Najavits—Seeking Safety
   Dusty Miller—Addiction & Trauma Recovery
         Integration Model (ATRIUM)
   Clark & Fearday—TRIAD
   Stephanie Covington—Helping Women Recover &
    Beyond Trauma
   Julian Ford—Trauma Adaptive Recovery Group Education
    & Therapy for Persons in Recovery from Addiction
        Features in Common
 Stages of trauma recovery
 Cognitive behavioral
 Coping skills
 Group orientation, adaptable for individual
 Can be co-facilitated by a professional and
  a peer
       Stages of Trauma Recovery:
             Treatment Aims
    – Securing safety
    – Stabilizing symptoms
    – Fostering self-care
    – Reconstructing the trauma
    – Transforming traumatic memory
   Stage Three: RECONNECTION
    – Reconciliation with self
    – Reconnection with others
    – Resolving the trauma            (Herman, Trauma and Recovery)
 Stage One: Establishing Safety
 Focusupon establishing both physical
 & psychological safety
           understanding of links
 Increasing
 between trauma & substance abuse
 Teaching   coping skills
               (Herman, Trauma and Recovery)
                  Seeking Safety
Najavits, L.M. (2002). Seeking Safety: A treatment manual for
  PTSD and substance abuse. New York: Guilford Press.
   • Integrates safety and recovery
   • Stresses accessing other community supports
   • 25 topics, including Safety, When substances control you,
   • Session format:
      ◦ Check in
      ◦ Quotation
      ◦ Relating topic to women‘s lives
      ◦ Closing
   • 80 safe coping skills
Addiction and Trauma Recovery Integrated Model
Miller, D. & Guidry, L. (2001). Addictions and Trauma
  Recovery: Healing the body, mind, and spirit. New
  York: WW. Norton & Co.

   • Addresses mental, physical & spiritual health
   • Creating sacred connections to the world beyond the
   • 12 sessions, including self-harm, relationship
     changes, spiritual disconnections
Clark, C. & Fearday, F. (Eds.) (2003). Triad women‘s
  project: Group facilitator‘s manual. Tampa, FL: Louis
  de la Parte Florida Mental Health Institute,
  University of South Florida.
   • Promotes survival, recovery & empowerment
   • 16 sessions, divided into 4 phases
      ◦ Mindfulness
      ◦ Interpersonal effectiveness skills
      ◦ Emotional regulation
      ◦ Distress tolerance
   • Has been modified for use in jails
  Trauma Recovery and Empowerment
Harris, M. & The Community Connections Trauma Work
  Group (1998). Trauma Recovery and Empowerment: A
  clinician‘s guide for working with women in groups. NY:
  Free Press.
   • Current problematic behaviors and symptoms may
      have originated as legitimate and courageous
      attempts to cope with or defend against trauma
   • 33 topics, divided into four categories:
      ◦   Empowerment (11 sessions)
      ◦   Trauma Recovery (10 sessions)
      ◦   Advanced Trauma Recovery Issues (9 sessions)
      ◦   Closing Rituals (3 sessions)
      Helping Women Recover
Covington, S.S. (1999). Helping Women Recover: A
  program for treating addiction. San Francisco:

  • Integrates expressive arts
  • Accompanying journal
  • 17 sessions, divided into four modules:
        ◦   Self
        ◦   Relationships
        ◦   Sexuality
        ◦   Spirituality
 Trauma Adaptive Recovery Group Education and
    Therapy for Persons in Addiction Recovery

Ford, J.D., Mahoney, K., Russo, E., Kasimer, N., & MacDonald, M.
   (2003). Trauma Adaptive Recovery Group Education and
  Therapy (TARGET): Revised composite 9 session leader and
  participant guide. Farmington, CT: University of Connecticut
  Health Center.

   •   Cognitive-behavioral
   •   Present-focused
   •   Systematic skills training
   •   Designed to be brief treatment
      Considerations for Choosing a
   Evidence of effectiveness
   Fit with client characteristics
   Program values and treatment philosophy
   Curriculum length and format
   Group facilitator‘s expertise
   Adaptations for specific populations
   Cost, training, setting
    Integrating the Curriculum into
     Substance Abuse Treatment
 Pilot-testing the curriculum
 Adapting, if necessary, based on pilot results
  (Trying evidence-based adaptations first.)
 Training for staff and supervisors
 Ongoing supervision and support for the new
 Monitoring of fidelity

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