Developing Trauma Informed Addiction Treatment Using

Trauma Informed Addiction
and Containment and Autonomic
Regulation (CAR)
Michael F. Barnes, Ph.D., LPC
Clinical Specialist/Educator
Getting the recovery message?
Inability to
trust, etc.
• The goal here is to begin a recovery process for addiction.
• It is critical that you are able to hear, receive, and implement
the recovery messages that you receive in therapy sessions.
• Within this process it is important to recognize the role that past
life experiences play in your life today!
• Must deal with and actively work on trauma symptoms that will
prevent you from hearing the recovery messages.
• Now is not the time to work on resolving the trauma itself.
Trauma Informed Addiction Treatment?
We believe that addiction treatment needs to be trauma
integrated, in order to assist clients with trauma history to benefit
from treatment.
In early recovery (Residential Treatment), the goal is to work with
trauma symptoms that interfere with a client’s ability to hear and
act upon the recovery messages that they are receiving.
In later recovery, clients can begin to work on healing the actual
traumatic events.
The goal is for counselors to recognize trauma symptoms,
particularly activation of the autonomic nervous system and to
provide a safe therapeutic environment to work through those
Addressing trauma symptoms in the present moment, prevents
proceduralized avoidance behaviors from interrupting recovery
focused individual and group therapy.
What Causes Trauma?
• Natural Disaster Events - Hurricanes, Earthquakes, Tornadoes,
Floods, Fires, etc.
• High Speed Events - Car & Bike Accidents, Falls, etc.
• Assault Events - Assault, Rape, Incest, Animal Attacks
• Major Illness/Hospital Events - Cancer, Heart Attacks, Asthma,
Full Anesthesia Surgeries
• Global Threat Events - Drowning, Electrocution, Caesarian, etc.
• Cyclical Trauma – Anniversary of major traumatic event
• Family Trauma/Abandonment
• Captivity – Life threatening events, kidnapping, dysfunctional
family life as a child, etc.
Traumatic Stress 101:
PTSD Criterion 1 – Causes of Trauma Experience
• Direct personal experience of an event that involves
threatened death, actual or threatened serious injury, or
threat to one’s physical integrity;
• Or witnessing an event that involves death, injury, or a
threat to the physical integrity of another person;
• Or learning about unexpected or violent death, serious
harm, or threat of death or injury experienced by a family
member or other close associates
• Resulting in great fear, helplessness, or horror
Continuum of Traumatic Stress
Primary Trauma
(Primary Trauma Victim)
Secondary Trauma
(Trauma Experienced by Family
Members, Friends, First-Responders,
Helping Professionals, etc.)
Compassion Fatigue
(Trauma Experienced by Care-Givers
and Helping Professionals)
Organizational Trauma
Incidence of Traumatic Events
Worldwide, it is estimated that two-thirds of the population is
exposed to a traumatic events that meet the DSM stressor
criteria for PTSD.
According to the National Center for PTSD:
• 61% of men and 51% of women report having experienced at
least one traumatic event (lifetime)
• 10% of men and 6% of women report having experienced four
or more traumatic events (lifetime)
• Of these trauma victims, 8% receive diagnosis of PTSD
• 1% of American population (New England Journal of Med)
• It’s not the trauma event that will impact recovery.
• Unresolved trauma symptoms interfere with treatment and
can lead to relapse.
PTSD & Substance Abuse Disorders
• Prevalence of PTSD and Substance Use Disorders
• Among persons who develop PTSD, 52% of men and 28% of
women are estimated to develop an alcohol use disorder.
• 35% of men and 27% of women develop a drug use disorder.
(Najavits, 2007)
• The numbers are even higher for veterans, prisoners, victims of
domestic violence, first responders, etc.
(Najavits, 2004a, 2004b, 2007)
• Individuals with PTSD are 3 to 4 times more likely to develop
SUD’s than individuals without PTSD have earlier histories with
A & D, more severe use, and poor treatment adherence.
(Khantzian & Albanese, 2008)
PTSD & Substance Abuse Disorders
• Treatment outcomes - PTSD and SUDS
• PTSD/SUDS patients are more vulnerable to poorer short- and
long-term outcomes.
(Ouimette, Moos, & Brown, 2003)
• PTSD heightens the likelihood of addiction relapse and the
potential for multiple relapses.
(Norman, Tate, Anderson, & Brown, 2007)
• A trauma history and current trauma symptoms are associated
with relapse to alcohol or other substance use in alcohol
dependent women.
(Heffner, Blom, & Anthenelli, 2011)
• PTSD/SUDS has been shown to be associated with poorer
treatment outcomes and higher relapse rates.
(Sonne, Back, Zuniga, Randall, & Brady, 2003)
PTSD & Substance Abuse Disorders
Childhood trauma – increased symptoms in TX
Individuals meeting diagnostic criteria for both alcohol
dependence and PTSD, who experienced childhood trauma
reported greater PTSD symptom severity, particularly intrusive
symptoms, greater alcohol symptoms severity, and greater
trauma related alcohol craving;
Appear to be particularly vulnerable to relapse following
treatment for alcohol dependence, if PTSD symptoms are not
properly assessed and treated.
(Schumacher, Coffey, & Stasiewicz, 2006)
Severity of reported childhood trauma predicted cocaine relapse
in women during a 90-day follow-up.
(Heffner, Blom, & Anthenelli, 2011)
Childhood trauma – more severe
symptoms, vulnerable to relapse
Adverse Childhood Events - ACE
• ACE Studies – Longitudinal study carried out by the Centers for
Disease Control and Prevention (2009) and Kaiser Permanente
Department of Preventive Medicine (17,421 sample size)
• 35% of women had sexual abuse as children
(approximately 7000 children)
• 30% of men experienced physical abuse
(approximately 5,225 children)
• Only 32% of participants (mostly middle class, well educated)
had an ACE score of 0.
Adverse Childhood Events - ACE
Overall findings indicate that there is a linear relationship between
number of adverse childhood experiences (ACE) and increased
risk of:
heart disease
chronic lung disease
skeletal fractures
liver disease
Felitti, et al. (1998) reported that individuals with ACE were found
to have:
• 250% greater chance of smoking over children with no aces.
• 500% increase in self-acknowledged alcoholism
• 46 X’s greater chance for injection drug abuse.
American Journal of Preventative Medicine (1998)
Trauma Integrated Addiction Treatment
• A lens that we look through to understand client behaviors
and to better understand the roadblocks that trauma
symptoms provide for clients in addiction treatment.
Often labeled
client resistance.
Interferes with
client’s ability to hear
recovery message!
• Assess clients for all three aspects of this triangle.
• Critical for individualized treatment, continuing care
planning, etc.
Attachment, Differentiation, Trauma &
Substance Abuse
• There has been a lot more information about the impact of
attachment on substance abuse.
• Early bonding with significant caregiver is essential for
development of healthy communication skills and regulation of
emotion and behavior.
• Thorberg & Lyvers (2009) found that clients in an inpatient
addiction unit scored the following:
• Higher anxious attachment style
• Higher fear of intimacy
• Lower confidence in ability to alter negative mood.
Attachment, Differentiation, Trauma &
Substance Abuse
• PTSD is an attachment disorder?
• Two new books have come out in the past year that have
supported this issue.
Trauma and the Avoidant Client: Attachment-Based
Strategies for Healing by R.T. Muller (2011)W.W. Norton & CO
Healing Developmental Trauma: How Early Trauma Affects
Self-Regulation, Self-Image and the Capacity for
Relationships. L.Heller & A LaPierre(2012) North Atlantic Books
• From a trauma perspective:
1. We either never developed healthy attachment due to
early childhood trauma or neglect, or
2. We developed it, but it was destroyed through other
childhood trauma (ACEs), or
3. We developed it, but it was destroyed through adult
Containment and Autonomic Regulation (CAR)
Therapy - Background
1. Peter Levine (1968 to present)
• Somatic Experiencing
• Applied linear modeling to describe the behavior of the
Autonomic Nervous System (ANS)
• Proposed that Event Memory stores ANS states and those
states are accessible through sensation.
• Based Theory on Ethology – the study of animal behavior
• Healing takes place naturally when ANS recalibrates on its
2. Neuroscience of Memory (Grigsby & Stevens)
• Neurodynamics of Personality
• View of memory as a complex relationship between
different memory systems.
• Memory Systems: Semantic, Episodic, Procedural
Containment and Autonomic Regulation (CAR)
Therapy - Background
3. Eric Wolterstorff (1994 to present) – Developer of CAR Process.
• Protégé of Peter Levine
• Flattened Levine’s 3D model of ANS to 2D model (ANS
• Moved from single event trauma to multi-event and
complex relational trauma.
• Identified the need for “solution” as prerequisite for
working with dissociation.
• Developed strong focus on the transference implications
from working with traumatized clients, especially highly
relational traumas.
• Developed individual and group protocols.
Containment and Autonomic Regulation (CAR)
Exposure therapy focused on the autonomic nervous system
Reproducible, testable, and phase-based protocol
1. Building Resources
Teach clients tools needed to manage activation of the
autonomic nervous system
Grounding techniques needed as prep for working with
2. Building Relational Skills
Attachment focused – one person’s nervous system learning to
attach to another person’s nervous system
Attachment work is procedural auto-regulation
Stressed “yes” and Stressed “No”
Focus on boundary development, affect management, and
ownership of the recovery process.
3. Trauma Assessment
Assess sources of trauma and the degree of activation that the
individual experiences when briefly talking about each.
Containment and Autonomic Regulation (CAR)
4. ANS Recalibration / Re-exposure –
A method of discharging the ANS of stress and trauma (event
memory response), utilizing a process of containment.
Focus on physiological response, while not acting on physical
impulses to avoid or distract. Goal is to complete defensive
responses and reintegrate the ANS.
Complex process that works with both hot (anxiety) and cold
symptoms (dissociation).
Requires significant awareness to pace and staying within client’s
working window (tolerance threshold).
5. Integration –
Allowing clients to tell their story in a new way.
Similar to Herman’s reintegration into society
Use Figley’s Five Healing Questions
• 1.What happened? 2.Why did it happen? 3.Why did it happen
to me? 4.Why did I react the way I did? 5.What will I do if
something similar happens in the future?
MEMORY SYSTEMS (Grigsby & Stevens, 2000)
Semantic Memory System
(Knowledge, tell the story, cognitive
processing, often short lived and
• Event Memory System
(Timeless, being there, Autonomic
Nervous System activation, triggers
trauma symptoms and initiation of
procedural response, often in the form
of pictures, strong emotions)
• Procedural Memory System
(Adaptive and automatic memory,
immediate and often unconscious,
habit, hyper-vigilance, control
activities, emotional reactivity)
Event Memory + Semantic Memory + Procedural Memory
Trauma and the Autonomic Nervous System
State 0: (zero): calm, responsive, awake
State 1: slightly anxious, annoyed, nervous,
physical tension
State 2: highly anxious, angry, panic symptoms,
intense physical tension (stomach, chest,
breathing), powerful fight or flight responses
No Solutions
“Scared to death”
State 3: Dual activated (a mixture of activation with
dissociative symptoms): tension with somatic
collapse, anxiety, sleepy, panic, hopelessness,
heaviness, blurred vision
State 4: pure dissociation marked by a distinct lack
of physical sensation and flat affect, numbed out,
blank, feeling ‘floaty’, depersonalized, and
Trauma and the Autonomic Nervous System
Threat, Response Options, and Procedural Memory
Absence of Threat
The greater the threat, the fewer choices the individual perceives
to be available to him/her.
As client experiences increased sympathetic response and dual
activation, memory system response shifts from semantic to
Appears more impulsive and less strategic.
Reduced effectiveness of talk therapy. Need to resource and
work on reactivity.
Trauma Integrated Addiction Treatment
1. Staff Education
o Introductory lecture on Trauma Integrated Care
o Training on CAR Process
o Weekly Chapter/Article Club focused on Trauma
2. Patient Education
o Regular Trauma lecture
3. Family Education
o Regular Trauma Lecture in Family Program
o Focus on the impact of primary and secondary trauma
4. Trauma Assessment & Treatment Planning
o TSI 2
5. Focus on trauma symptoms awareness and implementation
of trauma focused treatment to addressing active symptoms
of PTSD and Attachment
o DBT individual and group therapy
Trauma Integrated Addiction Counseling Assessment
Trauma Symptoms Inventory – John Briere, Ph.D.
• Widely-used measure of trauma related symptoms and
• High reliability and validity
• Evaluates acute and chronic symptomatology.
• Evaluates symptoms across the lifespan, with no links to
single stressors/traumas or specific points in time.
• We have used the TSI I and are in the process of transitioning
to the TSI 2.
• TSI 1 has 100 questions and 10 clinical scales
• TSI 2 has 136 questions and 12 clinical scales and 4
Trauma Integrated Addiction Counseling Assessment
TSI 2 Clinical Scales/Subscales
• Anxious Arousal
• Depression
• Anger
• Intrusive Experiences
• Defensive Avoidance
• Dissociation
• Suicidality
• Somatic Preoccupations
• Sexual Disturbance
Sexual Concerns
Dysfunctional Sexual
• Insecure Attachment
Relational Avoidance
Rejection Sensitivity
• Impaired Self-Reference
Reduced Self-Awareness
• Tension Reducing
Trauma Integrated Addiction Counseling
Use of TSI Data in Treatment Planning
Anxious Arrousal (AA)
22 Periods of trembling or shaking
Feeling tense or "on edge"
Worrying about things
Feeling jumpy
High anxiety
Being startled or frightened
Feeling afraid you might die or be injured
Intrusive Experience (IE)
1 Nightmares or bad dreams
8 Flashbacks (sudden memories or images of upsetting things)
12 Sudden disturbing memories when you were not expecting them
Suddenly remembering something upsetting from your past
Suddenly being reminded of something bad
Violent dreams
Just for a moment, seeing or hearing something upsetting that
happened earlier in your life.
Frightening or upsetting thoughts popping into your mind
Trauma Integrated Addiction Counseling
Use of TSI Data in Treatment Planning
Impaired Self Reference (ISR)
Feeling empty inside
Feeling like you don't know who you really are
Not understanding why you did something
Not being sure of what you want in life
Needing other people to tell you what to do
Getting confused about what you thought or believed
Getting your own feelings mixed up with someone else's
Your feelings or thoughts changing when you were with other people
Being easily influenced by others
Dissociation (DIS)
Feeling like you were outside of your body
Your mind going blank
Feeling like you were watching yourself from far away
Not feeling like your real self
Not being able to feel your emotions
Feeling like things weren't real
Feeling like you were in a dream
Trauma Integrated Addiction Treatment
• Safety – Treatment Environment
o To create a safe treatment environment, critical that we are
able to identify hyperarousal, intrusive thoughts and
memories, affect disregulation, dissociation as times when
traumatized clients become vulnerable and overwhelmed,
recognize triggers in the treatment environment, and deal
with them effectively.
o Important to assist clients in making the distinction between
feeling safe and being safe (Gentry).
o Must create a therapeutic environment where clients can shift
from “unpredictable danger to reliable safety both in their
environment and within themselves” (Baranowsky, Gentry &
Schultz, 2011)
Trauma Integrated Addiction Treatment
• Safety – Counselor Characteristics
o Staff must possess a non-anxious presence and be fully aware of
our own:
• ANS activation
• Procedural responses to stress
• Countertransference
• Compassion Fatigue
o Must be aware that we are asking clients to break the rules of
“don’t talk, don’t feel, and don’t trust.” (Black, 1981)
o Pace is important. Must be aware of developmental needs of
• Development of positive therapeutic relationship before
work on attachment
• Resourcing to establish reconnection to body and new
procedural responses.
• Support for struggle with trauma symptoms, etc.
• Be aware of the potential for re-traumatize.
Trauma Integrated Addiction Treatment
• Working with Attachment in Substance Abuse Treatment
(Attachment-Oriented Therapy, Flores, 2006)
o Need to develop a solid therapeutic relationship and then be aware of
rupture of that relationship (and/or others in the treatment environment).
o “. . . Normal development is not the movement from
dependence to independence, rather it is the movement from
immature dependence to mature inter-dependence or
mutuality. (p. 15)”
o Clients need to learn that they can rupture and then repair
meaningful relationships through the development of new
communication and affect regulation skills.
o Flores uses model in group therapy as well as individual.
o Not to say that the groups should be confrontational, but clients
must be uncomfortable enough to provide them with:
• learn affect regulation
• the opportunity to learn/practice healthy communication skills
• find that it is possible to remain close to someone that they
have had conflict with.
Trauma Integrated Addiction Treatment
• Working with Procedural Memory System
o Resourcing and other mindfulness exercises allows clients to learn
that they have the ability to become reacquainted with their
body and that they have some control over the ANS by learning
to reduce level of stress and to remain present rather than
o Over 30+ days will provide significant changes to procedural
memory system.
o May want to begin every session with a check-in and resourcing
exercise to insure that the client is able to fully engage in
semantic level discussion.
o As we work with clients at semantic level, may want to check-in
periodically to reinforce the importance of client awareness of
ANS activation. Resource as needed to maximize therapy
o Stressed yes and no exercises allow clients to work on relational
triggers that allow the client to maintain control of ANS and
reduce potential for relapse.
Trauma Integrated Addiction Treatment
• Working with Procedural Memory System
We are very fortunate to have staff with significant experience in
Dialectical Behavior Therapy.
o Provides effective, evidence based therapy for co-occurring
o DBT has the capacity to assist clients in the semantic memory
systems, but seems most effective in procedural.
o Very effective in balancing behavior change, problemsolving, and emotional regulation with validation, mindfulness,
and acceptance.
o Need to insure that clients with attachment and trauma issues
are referred to work specifically in DBT group and individual
Trauma Integrated Addiction Treatment
• ANS Recalibration and Containment in Primary
Residential Treatment
o Containment of stress related situations would be very
appropriate and effective in residential treatment.
o Once a client can demonstrate increased skills in relational
abilities, and resource to reduce ANS activation, it is OK to
contain stressors.
o It is not recommended to use containment of trauma in primary
residential treatment.
o It should be very appropriate to utilize containment in REC or
other extended care programs.
o Client experience with resourcing, stressed yes/no, and
containment of stressors in residential, should enhance
opportunities for containment of trauma early in the REC
o Might want to develop a trauma specific group, to enhance
utilization of CAR components.
Trauma Integrated Addiction Treatment
• Self-Help Program Participation and Memory Systems
o Participation in AA, NA, CA, SA, etc. is very helpful for clients in
working on semantic and procedural memory systems.
o Self-Help program participation provides clients with significant
positive cognitive information learning from the various sayings,
working steps, etc. (Semantic Memory System improvement)
o Very helpful in recognizing a more clear recovery story. Will
become more clear as they remain active in the program.
o Also very helpful in assisting clients to change patterned or habit
based behaviors. 90 meetings in 90 days can provide significant
procedural change.
o Getting a sponsor, making coffee, etc. can assist in development
of more mature attachment and mature interdependence.
o Traumatized clients may resist Self-help due to lack of trust,

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