Transcript Section 32_Women and Trauma_UCLA 46 slides_FINAL

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
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)
2
DSM-IV Criteria for
Posttraumatic Stress Disorder
(PTSD)
A.
Exposure to a traumatic event
•
•
B.
C.
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
Event is persistently re-experienced
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
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Neurobiological Changes in
Response to Traumatic Stress
 Limbic
System -- Hippocampus and
Amygdala (Affect and Memory, e.g,
Ledoux, 2000; van der Kolk, 1996)
 Neurotransmitters
and Peptides (Numbing
and Depression, e.g., Pitman, 1991,
Southwick, 1999)
 Changes
in Hormonal System (HPA axis)
(Arousal, e.g., Yehuda, 2000)
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Pathways Between Trauma-related
Disorders and Substance Use
PTSD
TRAUMA
SUD
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Maladaptive
emotion focused
coping
Biased information
processing and
problem solving
Difficulty
managing anger
Behavioral
Impulsivity
Affective lability
Emotion Regulation
Deficits
Difficulties with
intimacy and trust
Disruptions in
attention,
memory &
consciousness
Poor tolerance
of negative
emotional states
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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)
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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
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Possible Responses to Trauma
 Intense
fear; hypervigilance
 Feelings of helplessness
 Anxiety/Worry
 Intrusive thoughts & memories
 Flashbacks
 Depression
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More Possible Responses to
Trauma
 Anger
or rage
 Nightmares & Night Terrors
 Detachment & Dissociation
 Substance Use & Misuse/Abuse
 Unusual sexual behavior
 Difficulty with relationships
 Others
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Learning Objective #1:
 Why
do you think women initiate
drug use (including alcohol &
meds)?
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Screening for Substance Abuse

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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
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Post-trauma, women with
SUDs…
 Improve
less
 Worse coping
 Greater distress
 More positive views of substance use
(understandably)
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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
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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


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PTSD does not go away with
abstinence…
…in fact, it often gets worse!
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Learning Objective #2:
What impact does unresolved
childhood trauma have on SUDs?
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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 or reckless investing/get-rich schemes
 Self-harm: cutting
 Control obsession
 Suicidal thoughts and/or attempts
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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
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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

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Learning Objective #3:
What is the main common factor in
women with SUDs?
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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
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Learning Objective #4:
What are the key components of
trauma-informed, genderresponsive services?
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Trauma-Informed TX Services
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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
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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
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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
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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!
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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?
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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
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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”
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What shouldn’t we do?

Don’t explore past trauma(s)

In general, no psychodynamic work at first

No autobiographies until stable
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Don’t ask about the trauma or the triggers

Gently guide conversation to present problems

Use complex reflections to highlight strengths
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Above all, be cautious – go slow
There is great danger in retraumatizing clients!
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Clinical Challenges in the Treatment
of Traumatic Stress and Addiction
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Abstinence may not resolve comorbid traumarelated 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
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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
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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)
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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)
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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)
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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)
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Self-Perpetuating Cycle
Substance Use
Interpersonal
difficulties, no anger
management, 
isolation
Complicated
Depression
 sleep disturbance &
irritability
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Creating Safety
“Although the world is full of
suffering, it is full also of the
overcoming of it.”
Helen Keller
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Seeking Safety
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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 selfcare
Active, structured treatment - therapist teaches,
supports and encourages
Case management
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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
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4) Four content areas: cognitive, behavioral, interpersonal, case
management

5) Attention to clinician processes (helping clinicians work on
countertransference, self-care, and other issues)
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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
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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
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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
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Questions?
Comments?
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