Transcript Slide 1

The Addiction-Trauma Connection:
Spirals of Recovery and Healing
Stephanie S. Covington, Ph.D., LCSW
Institute for Relational Development
Center for Gender & Justice
La Jolla, CA
43rd Annual Addictions Conference
May 30, 2011
Toronto, Ontario
© S. Covington, 2011
Crisis=Danger & Opportunity
© S. Covington, 2011
Levels of Violence
•
•
•
•
•
•
•
•
Childhood
Adolescence
Adult
Street (workplace and community)
Consumer Culture
Media
War
Planet
© S. Covington, 2011
Global Violence
• Violence is a leading cause of death
among people aged 15-29
Source: World Health Organization
Centers for Disease Control and Prevention
© S. Covington, 2011
International Homicide Rates
(Rate per 100,000 in 2006)
Germany
Switzerland
France
Greece
Denmark
“The death and disability caused by
violence make it one of the leading
public health issues of our time.”
Austria
Netherlands
Spain
Italy
World Health Organization
Sweden
Ireland
Norway
Australia
Poland
Canada
Finland
New Zealand
Israel
United States
0
1
2
3
SOURCE: World Health Organization, 2006; FBI 2006; Statistics Canada; Australian Bureau of Statistics
4
5
6
© S. Covington, 2011
Two Kinds of Suffering
• Natural
• Created
© S. Covington, 2011
Definition of Trauma
The diagnostic manual used by mental health providers
(DSM IV-TR) defines trauma as, “involving direct
personal experience of an event that involves actual or
threatened death or serious injury, or other threat to
one’s physical integrity; 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 associate.”
(American Psychiatric Assoc. [APA] 2000, pg. 463).
© S. Covington, 2011
Definition of Trauma (cont.)
“The person’s response to the event must
involve intense fear, helplessness or horror
(or in children, the response must involve
disorganized or agitated behavior).”
(American Psychiatric Assoc. [APA] 2000, pg. 463).
© S. Covington, 2011
Definition of Trauma
Trauma occurs when an external threat
overwhelms a person’s internal and
external positive coping resources.
(Bloom & Fallot, 2009)
© S. Covington, 2011
Violence Against Women
Violence against women is so pervasive
that the United Nations has addressed and
defined violence against women as “any
act of gender-based violence that results
in, or is likely to result in, physical, sexual
or psychological harm or suffering to
women, including threats of such acts,
coercion or arbitrary deprivations of liberty,
whether occurring in public or private life.”
(United Nations General Assembly, 1993).
© S. Covington, 2011
Moral Challenges
• 19th century - slavery
• 20th century - totalitarianism
• 21st century – brutality against women
and girls
(NY Times 9/23/09)
© S. Covington, 2011
Traumatic Events
Trauma can take many forms:
• Emotional, sexual or physical abuse
• Neglect
• Abandonment (especially for small
children)
• Extremely painful and frightening
medical procedures
© S. Covington, 2011
Traumatic Events
(cont.)
• Catastrophic injuries and illnesses
• Rape or assault
• Muggings
• Domestic violence
• Burglary
• Automobile accidents
© S. Covington, 2011
Traumatic Events
(cont.)
• Immigration
• Natural disasters (hurricanes, floods,
earthquakes, tornadoes, fires,
volcanoes)
• Terrorism such as September 11, 2001
• Witnessing violence such as a parent
harming another parent
© S. Covington, 2011
Traumatic Events (cont.)
• Loss of a loved one and severe
bereavements (even of a pet)
• Combat/war
• Torture
• Kidnapping
• Intergenerational (cultural) trauma
© S. Covington, 2011
Historical Trauma
• Across generations
• Massive group trauma
• Examples include: Aboriginal (First
Nation), Native Americans, African
Americans, Holocaust survivors,
Japanese internment survivors
© S. Covington, 2011
Traumatic Events
Of all these forms of trauma, women
are at greater risk of interpersonal
abuse than men.
© S. Covington, 2011
Trauma-Informed
Services
Trauma-informed services:
• Take the trauma into account.
• Avoid triggering trauma reactions
and/or traumatizing the individual.
(Harris & Fallot)
© S. Covington, 2011
Trauma-Informed
Services (cont)
• Adjust the behavior of counselors,
other staff and the organization to
support the individual’s coping
capacity.
• Allow survivors to manage their
trauma symptoms successfully so
that they are able to access, retain
and benefit from the services.
(Harris & Fallot)
© S. Covington, 2011
Core Principles
of Trauma-Informed Care
• Safety (physical and emotional)
• Trustworthiness
• Choice
• Collaboration
• Empowerment
(Fallot & Harris, 2006)
© S. Covington, 2011
Process of Trauma
TRAUMATIC EVENT
Overwhelms the Physical & Psychological Systems
Intense Fear, Helplessness or Horror
RESPONSE TO TRAUMA
Fight or Flight, Freeze, Altered State of Consciousness, Body Sensations, Numbing,
Hyper-vigilance, Hyper-arousal
SENSITIZED NERVOUS SYSTEM
CHANGES IN BRAIN
CURRENT STRESS
Reminders of Trauma, Life Events, Lifestyle
PAINFUL EMOTIONAL STATE
RETREAT
SELF-DESTRUCTIVE ACTION
DESTRUCTIVE ACTION
ISOLATION
DISSOCIATION
DEPRESSION
ANXIETY
SUBSTANCE ABUSE
EATING DISORDER
DELIBERATE SELF-HARM
SUICIDAL ACTIONS
AGGRESSION
VIOLENCE
RAGES
© S. Covington, 2011
ACE Study
(Adverse Childhood Experiences)
Before age 18:
•
•
•
•
•
Recurrent and severe emotional abuse
Recurrent and severe physical abuse
Contact sexual abuse
Physical neglect
Emotional neglect
© S. Covington, 2011
ACE Study
(Adverse Childhood Experiences)
Growing up in a household with:
• An alcoholic or drug-user
• A member being imprisoned
• A mentally ill, chronically depressed, or
institutionalized member
• The mother being treated violently
• Both biological parents not being present
(N=17,00)
© S. Covington, 2011
ACE Study
(Adverse Childhood Experiences)
Results
ACEs still have a profound effect 50 years
later, although now transformed from
psychosocial experience into organic disease,
social malfunction, and mental illness.
•
•
•
•
Smoking
Alcoholism
Injection of illegal drugs
Obesity
(Felitti, V.J.: Origins of Addictive Behavior: Evidence from the ACE Study. 2003
Oct:52(8): 547-59. German. PMID: 14619682 (PubMed-indexed for MEDLINE).
© S. Covington, 2011
ACE Study
(continued)
Men 16% Sexual Abuse
Men 30% Physical Abuse
Women 27% Sexual Abuse
(Felitti and Anda, 2010)
© S. Covington, 2011
ACE Study
(continued)
Women 50% more likely than men to have a
score of 5 or more.
(Felitti & Anda, 2010)
© S. Covington, 2011
ACE Study
(continued)
If a male child has six or more “yes”
answers, his risk of becoming an IV drug
user increases by 4,600% compared to a
boy with a score of zero.
(Felitti & Anda, 2010)
© S. Covington, 2011
ACE Study
(continued)
Population Studied:
• 75% white
• 39% college (36% some)
• 18% high school grads
(Felitti & Anda, 2010)
© S. Covington, 2011
ACE Study
(continued)
6 or more “yes” answers
=
2 decades shorter life expectancy than
person with 0 “yes” answers
(Felitti & Anda, 2010)
© S. Covington, 2011
ACE Study
(continued)
“I see that you have…
Tell me how that has affected you later in your life.”
(Felitti & Anda, 2010)
© S. Covington, 2011
Childhood Traumatic Events
Largest Effect-Mental Health
• Psychotropic medication
• Mental health treatment
• Attempted suicide
• Traumatic stress
(Messina & Grella, 2005)
© S. Covington, 2011
Childhood Traumatic Events
Largest Effect-Mental Health
• 980% increase in odds if exposed
to 7 CTE’s
(Messina & Grella, 2005)
© S. Covington, 2011
Critical and Interrelated
Issues
• Substance Abuse
• Mental Health
• Trauma
• Physical Health
© S. Covington, 2011
Areas of Separation
• Training
• Treatment
• Categorical Funding
© S. Covington, 2011
Key Elements
(Staff and Clients)
• Learn what trauma/abuse is
• Understand typical responses
• Develop coping skills
© S. Covington, 2011
Definition of Recovery
The definition of recovery has shifted from
a focus on what is deleted from one’s life
(alcohol and other drugs, arrests for
criminal acts, hospitalizations) to what is
added to one’s life (the achievement of
health and happiness).
(Miller & Kurtz, 2005)
© S. Covington, 2011
Prevalence of Trauma and PTSD
in Substance Use/Abuse
• 60% to 90% of a treatment-seeking
sample of substance abusers also have
a history of victimization
• More than 80% of women seeking
treatment for a substance use disorder
reported experiencing physical/sexual
abuse during their lifetime
© S. Covington, 2011
Prevalence of Trauma and PTSD
in Substance Use/Abuse
• Between 44% and 56% of women
seeking treatment for a substance use
disorder had a lifetime history of PTSD
• 10.3% of the men and 26.2% of the
women with a lifetime diagnosis of
alcohol dependence also had a history
of PTSD
© S. Covington, 2011
Histories of Trauma / Violence among
Clients Treated for Methamphetamine
Persons in treatment for methamphetamine
report high rates of trauma
• 85% women
• 69% men
© S. Covington, 2011
Histories of Trauma / Violence among
Clients Treated for Methamphetamine
Most common source of trauma/violence:
• For women, was a partner (80%)
• For men, was a stranger (43%)
History of sexual abuse
• 57% women
• 16% men
© S. Covington, 2011
Disorders Related to Trauma and
Substance Abuse in Women’s Lives
•
•
•
•
•
•
•
•
Depressive Disorders NOS
Major Depressive Disorders
Post traumatic Stress Disorders
Neurotic Anxiety Disorders
Bipolar Disorders
Mood or Dysthymic Disorders
Psychotic Disorders
Personality and Misc. Disorders
22.9%
17.5%
16.3%
13.8%
13.7%
5.3%
4.8%
5.8%
Source: Patterns of Comorbidity among Women with Childhood Interpersonal Trauma, Mental
Health Disorders, and Substance Related Disorders. Journal of Behavioral Health Services &
Research (in press)
© S. Covington, 2011
Post-Traumatic
Stress Disorder
• Re-experiencing the event through flashbacks
and nightmares.
• Avoidance of stimuli associated with the event
(for example, if a woman was raped in a park,
she may avoid parks, or if she was assaulted
by a blonde man, she may avoid men with
blonde hair).
© S. Covington, 2011
Post-Traumatic
Stress Disorder (cont.)
• Estrangement (the inability to be emotionally
close to anyone)
• Numbing of general responsiveness (feeling
nothing most of the time)
© S. Covington, 2011
Post-Traumatic
Stress Disorder (cont.)
• Hyper-vigilance (constantly scanning one’s
environment for danger, whether physical or
emotional)
• Exaggerated startle response (a tendency to
jump at loud noises or unexpected touch)
(DSM – IV)
© S. Covington, 2011
Trauma and Abuse
• Sexual abuse
• Physical abuse
• Emotional abuse
• Domestic violence
• Witnessing abuse/violence
• Self-inflicted violence
• Military sexual assault (MST)
© S. Covington, 2011
Trauma and Abuse (cont.)
Trauma of Stigmatization
• Poverty
• Race/Culture
• Sexual Orientation
• Mental Illness
• Physical Disability
• Incarceration
© S. Covington, 2011
Trauma
Gender Differences
© S. Covington, 2011
Gender-Responsive Treatment
• Creating an environment through:
• site selection
• staff selection
• program development
• content and material
• that reflects an understanding of the realities of
the lives of women and girls, and
• addresses and responds to their strengths and
challenges.
Source: Covington, S.S., & Bloom, B.E. (2006). Gender-responsive treatment and
services in correctional settings. In E. Leeder (Ed.), Inside and out: Women, prison,
and therapy. Binghamton, NY: Haworth.
© S. Covington, 2011
Gender-Responsive Materials
(Trauma-informed)
• Women and Addiction: A Gender-Responsive Approach
• Helping Women Recover
• Helping Men Recover
• Voices: A Program for Girls
• Beyond Trauma: A Healing Journey for Women
• Women in Recovery
• A Woman’s Way through The Twelve Steps
• Beyond Violence: A Prevention Program for Women
Trauma Materials for Women
• ATRIUM (Dusty Miller)
• Beyond Trauma (Stephanie Covington)
• Healing Trauma (Stephanie Covington)
• Seeking Safety (Lisa Najavits)
• TREM (Maxine Harris)
Trauma Materials for Men
• M-TREM (Roger Fallot)
© S. Covington, 2011
Helping Women Recover:
A Program for Treating Addiction
Theory of Addiction
• Holistic health model
• Chronic neglect of self in favor of something or
someone else
Theory of Women’s Psychological Development
• Relational–Cultural Model (Stone Center)
Theory of Trauma
• Three Stage Model (Herman)
• Upward Spiral – A Transformational Model
(Covington)
© S. Covington, 2011
Helping Men Recover:
A Program for Treating Addiction
By
Covington, Griffin & Dauer
© S. Covington, 2011
Helping Men Recover
• Impact of male socialization on the
recovery process
• Relational needs of men
• Issues of abuse and trauma
• Self, relationships, sexuality and spirituality
© S. Covington, 2011
Power and Control Wheel
From the manual In Our Best Interest: A Process for Personal and Social Change.
Available through Domestic Abuse Intervention Project, 206 W. 4th St., Duluth, MN 55806
© S. Covington, 2011
Voices:
A Program of Self-Discovery and Empowerment
for Girls
Theory of Girls’ Psychological Development
• Relational–Cultural Model (Stone Center, Gilligan, Brown)
Theory of Attachment
• Ainsworth, Bowlby, Harlow, Stern
Theory of Trauma
• Three Stage Model (Herman)
• Transformational Spiral (Covington)
Theory of Resilience
• Biscoe, Wolin & Wolin
Theory of Addiction
• Holistic Health Model
© S. Covington, 2011
Beyond Trauma:
A Healing Journey for Women
Trauma Theory
Sandra Bloom, M.D.
Mary Harvey, Ph.D.
Judith Herman, M.D.
Peter Levine, Ph.D.
Integrates cognitive-behavioral, expressive
arts, guided imagery, and relational therapy.
© S. Covington, 2011
Client Assessment Scores Improve
after Completion of HWR and BT
Mean Score Change
30
25
26.3
20
19.3
17.5
15
10
Beck
TSC-40
10.2
7.4
5
4.5
0
45 Days
HWR
BT
TOTAL=40-44 (p <.05 or less)
Source: KIVA Program records – BDI & TSC
Assessment, August 31, 2004 – October 13, 2006
Keaton, Curtis, and Burke (2006) SANDAG
© S. Covington, 2011
Prison Study
(NIDA Funded)
• Randomized control group
• Gender-responsive vs. Therapeutic Community
• Significant differences
• Greater reduction of drug use
• More likely to complete treatment
• Remained longer in aftercare
• Less recidivism (re-incarcerated) at
12 months
(p ≤ .05)
© S. Covington, 2011
Drug Court Study
(NIDA Funded)
• Four sites in San Diego County
• Randomized control group
• Preliminary results
•
•
•
•
Less substance use
Fewer sanctions
Longer in treatment
Judge notices differences
© S. Covington, 2011
Trauma: Stages of Recovery
Syndrome
Stage One
Stage Two
Stage Three
Hysteria
(Janet 1889)
Stabilization,
Symptomoriented
treatment
Exploration of
traumatic
memories
Personality
reintegration,
rehabilitation
Re-experiencing
trauma
Integration of
trauma
Combat trauma Trust, stressmanagement
Scurfield
education
(1985)
Source: Herman, 1992, 1997
© S. Covington, 2011
Trauma: Stages of Recovery
Syndrome
Stage One
Stage Two
Stage Three
Complicated
post-traumatic
stress
disorders
Stabilization
Integration of
memories
Development of
self, drive
integration
Source: Herman, 1992, 1997
© S. Covington, 2011
Trauma: Stages of Recovery
Syndrome
Stage One
Stage Two
Stage Three
Multiple
personality
disorder
(Putnam 1989)
Diagnosis,
stabilization,
communication
cooperation
Metabolism of
trauma
Resolution,
integration,
development of
post-resolution
coping skills
Remembrance
and mourning
Reconnection
Traumatic
Safety
disorders
(Herman 1992)
Source: Herman, 1992, 1997
© S. Covington, 2011
Trauma
Three Group Models
Recovery
Stage One
Recovery
Stage Two
Recovery
Stage Three
Therapeutic
task
Safety
Remembrance
and mourning
Reconnection
Time
orientation
Present
Past
Present, future
Focus
Self-care
Trauma
Interpersonal
relationships
Group
Source: Herman, 1992, 1997
© S. Covington, 2011
Trauma
Three Group Models
Group
Recovery
Stage One
Recovery
Stage Two
Recovery
Stage Three
Membership
Homogeneous
Homogeneous
Heterogeneous
Boundaries
Flexible,
inclusive
Closed
Stable, slow
turnover
Cohesion
Moderate
Very high
High
Source: Herman, 1992, 1997
© S. Covington, 2011
Trauma
Three Group Models
Recovery
Stage One
Recovery
Stage Two
Recovery
Stage Three
Conflict
tolerance
Low
Low
High
Time limit
Open-ended or
repeating
Fixed Limit
Open-ended
Structure
Didactic
Goal-directed
Unstructured
Example
Twelve-step
programs
Survivor group
Interpersonal
psychotherapy
group
Group
Source: Herman, 1992, 1997
© S. Covington, 2011
Emerging Paradigm
Values-Based Services
• Gender-responsive
• Trauma-informed
• Culturally competent
• Recovery-oriented
© S. Covington, 2011
Sanctuary
© S. Covington, 2011
What is Sanctuary?
• Sacred place
• Place of refuge/protection
• Shelter
• Oasis
© S. Covington, 2011
What Makes a Difference?
• Creating a safe environment
• Listening to her/his story
• Empathy
© S. Covington, 2011
Upward Spiral
Transformation
Addiction
&
Trauma
(constriction)
Recovery
&
Healing
(expansion)
© S. Covington, 2011