Week 11 - AOD and Trauma

Question 1

Association between trauma and AOD

Answer 1

▪ < 90% of individuals accessing AOD services have experienced at least one traumatic event (TE)
* The majority of these clients have experienced multiple traumatic events
* Up to two thirds would meet the criteria for PTSD
* Many clients continue to live in environments which expose them to chronic toxic stress
* AOD clients with trauma symptoms are not adequately recognised and treated
* We need to look at ways that AOD services can help to resolve trauma related problems (and not exacerbate them)

Question 2

Increased Risks and Poor Outcomes for
Comorbid Trauma Exposure and Substance Use

Answer 2

▪ The interdependent relationship between the two disorders leads to more chronic and severe symptoms

▪ Poor treatment engagement and high drop out rates

▪ Inadequate treatment of both trauma symptoms and substance use problems

▪ Difficulty receiving appropriate treatment – do they have an AOD problem or a trauma related problem?

Question 3

Trauma and
SUD

Answer 3

poorer social & occupational functioning

higher rates of inpatient treatment

chronic health conditions

poly substance use

greater risk of relapse

more co-morbid psychiatric disorders

less effective coping strategies

non-suicidal self- injury and suicide
attempts

more chronic and severe symptoms

higher rates of service utilisation

more criminal justice system contacts

child safety involvement

family violence homelessness

Question 4

Falling through the gaps

Answer 4

▪Differing views on how to treat these comorbid conditions

▪ In mental health services – the view has been that clients should first be abstinent before commencing trauma focused treatment

▪ Those clients who present for treatment of PTSD may be referred to an AOD service for detox prior to commencing treatment

▪ BUT there is an increased risk of exacerbation of PTSD symptoms during detoxification leading to treatment drop out with the consequence of neither disorders being treated

Question 5

The revolving door of treatment

Answer 5

▪ AOD services see PTSD as a mental health problem
▪ Clients may bounce back and forth between services
▪ The underlying cause may never be addressed
▪ Interdependent relationship between these conditions
means both should be treated concurrently

Question 6

Barriers to accurate identification and treatment of trauma-related difficulties in AOD services

Answer 6

▪ Majority of AOD services do not systematically screen for exposure to trauma or PTSD symptoms
▪ Reluctance amongst AOD service workers to ask about trauma
▪ Clients may not disclose trauma

▪Consequently - trauma continues to maintain their
substance use, they receive inadequate treatment, and the
likelihood of chronicity and poor outcomes is high

Question 7

Unpacking the relationship between trauma and
alcohol and other drug use (The self-medication hypothesis)

Answer 7

▪ AOD can give relief from unpleasant trauma related thoughts and feelings (e.g. hyperarousal, insomnia, intrusive thoughts, and emotional distress).

▪ The pain-relieving and numbing effects of substances (particularly central nervous system suppressants such as alcohol, cannabis, opioids, and benzodiazepines) can reduce unpleasant symptoms but perpetuate and exacerbate high levels of arousal caused by withdrawal.

▪ This relationship can maintain PTSD symptoms and reinforce ongoing substance use and dependence.

▪ Substances may also serve other functions such as providing feelings of pleasure and social connection

Question 8

The high risk hypothesis

Answer 8

▪ This suggests that the lifestyle associated with alcohol and
drug use increases the person’s risk of experiencing trauma due to factors such as intoxication and engagement with dangerous environments associated with crime.

Question 9

The susceptibility hypothesis

Answer 9

▪ This model proposes that some individuals struggle with higher levels of arousal and anxiety (in conjunction with ineffective coping strategies) which places them at greater risk for both PTSD and alcohol and drug problems.

▪ This helps to explain the connection between adverse childhood experiences/complex trauma and a higher risk for developing problematic alcohol and drug use in adulthood

Question 10

The Common Factors Hypothesis

Answer 10

This rationale suggests that there may be common causal influences driving both PTSD and alcohol and drug problems – such as:
▪ genetic risk
▪ personality traits such as impulsivity
▪ adverse environments

Question 11

Neurobiological and Endocrine System Interactions

Answer 11

▪ There are also complex neurobiological interactions between PTSD and alcohol and drug use

▪ Dopamine receptors in the prefrontal cortex are implicated in both disorders as they are involved in the processing of both fear and reward-related memories.

▪ Reactions to both trauma and drug cues are intensified and reinforced in people with both PTSD and substance use disorders

▪ There are similar and complementary alterations in reward circuits produced by both PTSD and substance use disorders causing anhedonic states (i.e., reduced pleasure and motivation).

▪ In the case of alcohol use disorders, heavy drinking makes PTSD symptoms worse, extends the course of illness and raises the risk of suicidality and suicide attempts

Question 12

Cycle of trauma and addiction

Answer 12

1. Trauma/adverse life event
2. Emotional dysregulation, PTSD, negative self-belief, social disconnection
3. Self-medication - drug and alcohol use
4. life complications - increased shame and pain
5. More self-medication leading to greater severity of drug and alcohol problems

Question 13

What is trauma?

Answer 13

• Trauma can be defined as the experience and effects of overwhelming stress
• Trauma poses a threat that evokes a survival response
• Trauma is subjective (it involves the individual’s perception of threat) and can differ in its severity and impact based on factors such as the context and meaning of the trauma, the person’s age and prior experiences, the extent and duration of the stress, and the support available to the person

Question 14

Different types of trauma - Type 1: Single incident trauma

Answer 14

• Experiences in which we feel our lives are threatened (e.g., physical and sexual assaults, serious accidents or illnesses)
• Witnessing or being exposed to the effects or details of someone else being harmed

Question 15

Different types of trauma - Type 2: Complex trauma

Answer 15

▪ Complex trauma refers to multiple or combined traumatic events that mainly occur in childhood (but also applies to persistent interpersonal or relational trauma in adults such as in family and domestic violence).

Question 16

Other types of trauma

Answer 16

▪ Stressful life events or “little t” traumas can be experiences that are extremely stressful for an individual and are perceived as threatening.

▪ Being bullied, fired from a job, or rejected by a loved one are examples of experiences that can have a significant negative impact on a person.

▪ The effect of these experiences can be cumulative – if you face a series of stressful life events, you may find it more and more difficult to cope

Question 17

Response to Trauma

Answer 17

▪ When we are frightened, threatened or harmed, the brain’s
‘alarm’ system is activated. This triggers our Sympathetic Nervous System to turn on the “fight, flight or freeze” response.

Question 18

Differences in ways that people respond to trauma

Answer 18

▪ The majority of people in the general population will experience at least one traumatic event in their lifetime (<70%) and will be able to recover without too much difficulty.

▪ A small percentage of people are not able to return to their previous normal functioning and will suffer persistent stress symptoms after the event.

▪ If severe enough, these difficulties are called posttraumatic stress disorder (PTSD).

Question 19

Posttraumatic Stress Disorder

Answer 19

▪ PTSD may develop following exposure to a Type 1 (single incident) traumatic event. Symptoms must have persisted for more than one month and include:

intrusion symptoms
persistent avoidance of stimuli associated with the trauma
negative alterations in thinking and mood
alterations in arousal and reactivity

Question 20

What is persistent avoidance of stimuli associated with the trauma (symptom of PTSD)

Answer 20

▪ these could be external (avoiding reminders of people, places or things that are associated with the traumatic event) or internal (trying not to think about or feel anything associated with the event).

Question 21

What is intrusion symptoms (symptom of PTSD)

Answer 21

▪ recurring, unwanted and uncontrolled memories of the traumatic event that can feel as if they are reliving the experience (e.g., nightmares, flashbacks or distressing feelings

Question 22

What is negative alterations in thinking and mood (symptom of PTSD)

Answer 22

▪ such as problems with memory, negative thoughts about self and others, strong emotions (e.g., anger, guilt, fear) and feeling disconnected from others and engagement with the world

Question 23

What is alterations in arousal and reactivity (symptom of PTSD)

Answer 23

hyperarousal (i.e., being on edge or easily startled), hypervigilance (i.e., looking out for threat or something bad that could happen), irritability, poor concentration, disturbed sleep

Question 24

Complex Post traumatic Stress Disorder (CPTSD)

Answer 24

▪ People who have experienced complex trauma are at risk of developing Complex PTSD. In this condition, all diagnostic requirements for PTSD are met but are also accompanied by additional difficulties. These are characterized by severe and persistent:
1. problems in emotion regulation
2. beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic events
3. difficulties in sustaining relationships and in feeling close to others

Question 25

What are Vulnerable populations, cultural differences and minority groups

Answer 25

People who belong to a cultural group that has faced
disempowerment, poverty and discrimination and more
likely to experience traumatic events. Growing up in conditions of chronic stress and adversity can make it more difficult for people to cope with traumatic events when they
happen in adulthood making them more vulnerable to developing PSTD and other significant problems

Question 26

What are examples of Vulnerable populations, cultural differences and minority groups

Answer 26

Culturally and Linguistically Diverse People (CALD)
Women
LGBTQI
Aboriginal and Torres Strait Islander
Young people

Question 27

The Adverse Childhood Experiences Study

Answer 27

• The Center for Disease Control and Kaiser Permanente in United States conducted a study over 10 years involving 17,000 people recruited between 1995-1997.
• They looked at the effects of adverse childhood experiences (ACEs) and their association with a range of negative health outcomes and behaviours in adulthood.
• Scores between 0 and 10 were allocated based on how many of these 10 types of experiences were reported to which they had been exposed.

Question 28

What are the three types of ACE’s (Adverse Childhood Experience)

Answer 28

Abuse
Household Challenges
Neglect

Question 29

Adverse Childhood Experiences can have lasting effects on..

Answer 29

Health (obesity, diabetes suicide, STD etc)
Behaviour (drugs, alcohol, smoking etc)
Life potential (graduation rates, academic achievement, lost time from work)

Question 30

ACES and AOD Problems

Answer 30

• The more ACEs that you’ve had, the more susceptible you are to early initiation of alcohol and other drug use and continued and problematic use into adulthood.
• ACEs were found to account for one half to two thirds of serious drug use.
• For each additional event experienced, the odds of developing a drug problem increased by 30-40%

Question 31

The neurology of ACE’s and AOD use

Answer 31

ACEs can cause structural and functional abnormalities in
neurobiological areas relating to attachment, stress response and reward pathways.

▪ Early experience and patterns of maternal caregiving modify and shape these inter-related systems - the dopamine system, the oxytocin system, and the glucocorticoid system

▪ This makes people more susceptible to developing AOD problems and more likely to have worse PTSD symptoms during withdrawal

Question 32

Exploring exposure to stress and its effects

Answer 32

• Too much stress and trauma during childhood can make it hard for the person’s nervous system to regulate itself later in life causing greater sensitivity to stress and a chronically activated fight-flight-freeze response.
• Childhood trauma affects the development of the prefrontal cortical regions and functioning. This can have implications for the child’s learning and ability to self regulate

(hyperactivity of the amygdala and hypoactivity of the prefrontal cortex)

• Dysregulation of hypothalamic-pituitary-adrenal (HPA) axis is caused by exposure to chronic stress developmentally
• Endocrine features of PTSD include abnormal regulation of cortisol and thyroid hormones (both hyper and hypocortisol levels) - may promote abnormal stress reactivity

Question 33

What is Homeostasis

Answer 33

Homeostasis is a dynamic balance between the automatic branches (parasympathetic and sympathetic)

Question 34

What is parasympathetic

Answer 34

Rest and Digest
parasympathetic activity dominates

Question 35

What is sympathetic

Answer 35

Fight or flight
sympathetic activity dominates

Question 36

Adaptations to manage the effects of trauma

Answer 36

▪ When someone is affected by trauma, their nervous system may not be operating effectively and they may be unable to regulate themselves.

▪ They may seek other ways to try to regulate.

▪ Alcohol and other drugs can be an attempt to cope. Some people may seek stimulation and others might seek soothing.

▪ Different kinds of substances may be used to achieve different effects.

Question 37

Mal)adaptive coping and emotions

Answer 37

Both PTSD and alcohol and other drug problems also
share a common basis in maladaptive avoidant emotional coping styles that seek to block out and disconnect from unpleasant internal experiences

These deficits in adaptive emotion regulation are shared
by both disorders and play a key role in maintaining both
problems - and when they co- occur, the two are maintained
and exacerbated by their interdependent relationship.

Question 38

Are problems with alcohol and drug use better
understood as problems with managing emotions?

Answer 38

Emotion dysregulation can play a role in the initiation and maintenance of alcohol and drug use:
* Emotional distress can elicit substance use

• Substances can create positive emotional states and anticipation of positive emotions is a motivation for substance use
• Emotion is a component of impaired decision-making and impulsivity

Question 39

Emotions, anxiety, PTSD and substance use

Answer 39

 We know that many people who have experienced trauma (especially in childhood) will have “anxiety sensitivity”

 Anxiety sensitivity is described as the tendency to fear anxiety related symptoms and an increased fear response to perceived threat
 Anxiety sensitivity is strongly related to emotion dysregulation and can also play a role in the development of PTSD

 Individuals with high negative emotions and low emotion
regulation capability are at greater risk of using substances to cope, and then after dependence has developed, they continue to use substances to avoid negative or unpleasant feelings associated with withdrawal

Question 40

Clients with high ACES are likely to also have:

Answer 40

• Insecure attachment (they would not have learned to understand and manage their emotions through a responsive and attuned caregiver)
• Modelling of emotion dysregulation and maladaptive coping strategies in their family (they may have observed parents exploding in anger or using substances and avoidance to cope)
• Fear of negative emotions (lack of adaptive coping strategies can make unpleasant feelings less tolerable)
• Unhelpful beliefs about emotion (e.g., “I can’t stand
  this”)

Question 41

Avoidance as the solution to difficult emotions can take the forms of..

Answer 41

• Situational avoidance (e.g., avoiding places or situations that evoke anxiety or discomfort)
• Reassurance seeking and checking (e.g., looking to others for confirmation)
• Distraction and suppression (e.g., excessive use of phone/internet, binge watching shows, socialising, trying to ignore or block out thoughts and feelings)
• Numbing and withdrawing (e.g., alcohol and drugs, gambling, sleeping, self isolating)
• Harmful releases (e.g., explosive anger, emotional outbursts)
• Stimulation seeking (e.g. risky behaviour)

Question 42

Does avoidance work?

Answer 42

NO
Avoidance gives short term relief but the person feels worse in the long run –
▪ it reinforces the fear/intolerance of the difficult emotion
▪ and when alcohol and other drugs are the main coping strategy, it leads to more unpleasant side effects, tolerance and associated life problems.

Question 43

What is Trauma Informed Care?

Answer 43

▪ In TIC, all aspects of the organisation are reoriented to reflect an understanding of the impact of trauma on survivors and to meet the needs of treatment-seekers with trauma histories.

▪ Rather than a set of prescriptive practices, TIC is a framework that reflects an adherence to five TIC principles of trustworthiness, choice, empowerment, collaboration and safety. Services may apply these principles differently depending on their circumstances.

Question 44

What are the five Trauma Informed Care principles

Answer 44

empowerment
Trustworthiness
choice
collaboration
safety

Question 45

What does a trauma-informed care perspective emphasise?

Answer 45

A trauma informed care perspective adopts a framework that emphasises “what happened to you?” and “how did you cope?” instead of “what is wrong with you?

Question 46

What are the four pillars of safety (physical, emotional, environmental, cultural, systematic)

Answer 46

Trustworthiness- clarity, consistency, interpersonal boundaries

Choice - maximising choice and control

Empowerment - prioritising empowerment and skills

Collaboration - maximising sharing power

Question 47

We can continue to build on the application of these principles in the therapeutic relationship by including the following elements:

Answer 47

• Having a strengths focus (emphasising their strengths, ways they have survived and coped)
• Displaying acceptance (shame is almost ubiquitous in our clients and our acceptance of them can be enormously validating)
• Being non-judgemental or non-blaming (clients can be quick to perceive judgement and often are highly self critical)
• Showing compassion (showing interest, kindness and care for clients’ suffering and what they have been through, but also monitoring how the client responds as this can be triggering for some people)

It is also helpful to recognise that some clients who did not have healthy experiences of having their needs met in childhood may have developed other strategies to adapt. Behaviours that might appear to be maladaptive may have been helpful at an earlier time. They may have learned:

• no one will respond to them unless they escalate their distress or anger
• deception or breaking rules can help them to achieve goals
• giving up and withdrawing is the only option when faced with challenges or set backs
• not to share their experiences or needs as others won’t care or respond
• only rely on yourself as others won’t be there for you
  If we can make sense of these behaviours when they appear in clients, it can help us to maintain a sensitive and empathic relationship.

Question 48

Trauma Focused Treatment for Concurrent PTSD and AOD Disorder

Answer 48

Phase 1: Safety and stablisation
Development of strategies of self managment and emotion regulation. Psychoeducation regarding the effects of trauma and interaction with alcohol & drug use

Phase 2: Trauma Processing
Review and re-appraisal of trauma memories
usually involving exposure based psychological treatment

Phase 3: integration and reconnection
Consolidating gains, building independence and community supports

Question 49

What is Vicarious trauma?

Answer 49

It describes the negative changes in clinicians working with clients affected by trauma over time.

▪ It overlaps with concepts of burnout, secondary traumatic stress and compassion fatigue

▪ It involves a more enduring stress response mirroring the effects of trauma

▪ More likely to be indirectly experienced through:
o exposure to the stories of trauma experienced by clients
o cumulative stress associated with working with trauma
affected clients over the course of a career

*“The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet” (Remen, 2006, p.52)

Question 50

Who is effected by Vicarious trauma?

Answer 50

Being affected by VT is not a result of personal
weakness but is a risk faced by anyone who is exposed to severe or cumulative trauma associated with their work

A study of AOD workers in Australia found 19.9% met the criteria for secondary traumatic stress (Secondary traumatic stress being defined as a syndrome of symptoms that parallels post traumatic stress symptoms caused by exposure to clients with trauma related difficulties)

▪ There are a range of variables that can increase a person’s risk of experiencing VT

▪ AOD services working from a trauma informed approach can engage in strategies to prevent and manage the risk of VT in workers

Question 51

Recap: What do we know about trauma
related difficulties?

Answer 51

▪ Most people will experience natural recovery from traumatic events BUT some people will have persistent problems.

▪ Those who have experienced trauma or adverse events in childhood can be more prone to problems with managing arousal and emotions in adulthood – AND they are more at risk of developing PTSD if they experience further
traumatic events.

▪ There are a range of physical and mental health problems that are associated with trauma. Although PTSD and complex PTSD are specifically identified as a consequence of trauma, other broader mental health problems such as
anxiety, depression, phobias, eating disorders and psychotic disorders are also connected.

Question 52

And when it comes to trauma and alcohol and
drug problems:

Answer 52

• If you already have an alcohol and drug problem – it may be more difficult to recover from traumatic experiences
• Substance use can arise as a solution to the problem of trauma related difficulties, and then places the person at risk of experiencing further traumatic events
• Substance use and withdrawal pose additional stress on a person’s already compromised stress response system and create an exaggerated stress response
• Early trauma (particularly relating to disrupted attachment with caregivers) can adversely affect the development of a child’s opioid and dopamine circuitry. These children can have fewer opioid and dopamine receptors and can be more prone to developing substance use problems in adulthood
• Repeated drug and alcohol use triggers neuroplastic changes in glutamatergic and dopamine neurons enhancing the brain’s reactivity to drug cues, reducing the sensitivity to non-drug rewards, weakening self-regulation, and increasing the sensitivity to stressful stimuli and dysphoria
• Both PTSD and AOD problems also share a common basis in maladaptive avoidant emotional coping styles that seek to block out and disconnect from unpleasant internal experiences. These deficits in adaptive emotion regulation are shared by both disorders and play a key role in maintaining both problems - and when they co-occur, the two are maintained and exacerbated by their interdependent relationship

Question 53

How to have better outcomes in AOD
services?

Answer 53

▪ Trauma informed care
▪ Improved training for staff in understanding and responding to trauma affected clients
▪ Concurrent treatment of trauma and AOD difficulties
▪ Management and prevention of vicarious trauma