Week 11 - Trauma informed care in AOD Flashcards
Association between trauma and AOD
▪ < 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)
Risks and poor outcomes for trauma and substance use
▪ 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?
Why do some clients fall through the gaps
view is that client should be abstinent but this increases risk of exacerbation of PTSD symptoms during detoxification leading to treatment drop out
Revolving door of treatment
- PTSD seen as mental health problem
- clients bounce between services
- underlying cause may never be addressed
- both MH and SU should be treated concurrently
barriers to accurate identification and treat of trauma in AOD services
- services don’t systematically screen for exposure to trauma or PTSD symptoms
- reluctance from workers to ask about trauma
- clients may not disclose
Self-medication hypothesis
- AOD gives relief from unpleasant stimuli
- pain-relieving and numbing effect reduce unpleasant symptons but exacerbate arousal from withdrawal (particularly alc, cannabis, opiods, bzd’s)
- can maintain PTSD symptoms reinforcing AOD use and dependence
- provides feelings of pleasure and social connection
high risk hypothesis
lifestyle associated with AOD use increased risk of experiencing trauma due to intoxication and dangerous environments
susceptibility hypothesis
- some individuals struggle with higher levels of arousal and anxiety increasing rish of PTSD and AOD problems
- helps explain connection between childhood experiences and developing problematic drug use
common factors hypothesis
theres common causal influences driving both AOD use and PTSD such as:
- genetic risk
- personality traits such as impulsivity
- adverse environments
neuobiological and endocrine system interactions
- dopamine receptors in prefrontal cortex involved in processing fear and reward memories
- reactions to trauma and drug cues are intensified in people with PTSD and SUD
- similar and ocmplementary alterations in reward circuits produced by PTSD and SUD causing anhedonic states
- in alcohol use disorders, heavy drinking makes PTSD symptoms worse, extending course of illness and raising suicidality and attempts
Cycle of trauma and addiction
Trauma/adverse life experiences –> emotion dysregulation, PTSD, negative self beliefs, social disconnection –> self-medication - drug use and alcohol use <–> life complications; increased pain, shame –> more self medication leading to greater severity of drug and alcohol problems
Trauma
- experience and effects of overwhelming stress
- evokes survival response
- is subjective and can differ in severity based on context and meaning of the trauma, age, prior experiences, extent and duration, an support available
Single incident trauma
- 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
Complex trauma
multiple or combined traumatic events mainly occur in childhood (also applies to persistent trauma in adults such as DV)
Other types of trauma
- Stressful life events (little t traumas)
- being bullied, fired from a job, rejection from loved one
- effects of these can be cumulative
Response to trauma
Sympathetic nervous system is activated to turn on fight, flight or freeze
differences in ways people respond to trauma
- <70% of population with experiences a traumatic life event and will recover without much difficulty
- some people are unable to return to normal functioning and suffer persistent stress symptoms after event
- if severe enough called PTSD
Posttraumatic Stress Disorder (PTSD)
- develops after exposure to type 1 (single incident) event with symptoms persisting for more than one month
intrusion symptoms: - recurring, unwanted and uncontrolled memories that feel like the experience is being relieved
persistent avoidance of stimuli associated with trauma - can be external (avoiding people places or things) or internal (trying not to think or feel thing about event)
PTSD cont.
negative alteration in thinking and mood
- problems with memory, negative thoughts about self and others, strong emotions, feeling disconnected
alteration in arousal and reactivity
- hyperarousal, hypervigilance, irritability, poor concentration, disturbed sleep
Comples post traumatic stress disorder (CPTSD)
- occurs in people who experience complex trauma
- requirements for PTSD are met plus additional difficulties:
1. problems in emotional 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
Vulnerable populations
- CALD
- women
- Indigenous people
- LGBTQI
- young people
The Adverse Childhood Experiences Study
ACE study
- a study over 10 years involving 17,000 people
- 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.
Types of ACES
Abuse:
- emotional
- physical (highest 28%)
- sexual
Household challenges:
- mother reated violently
- substance abuse (highest 27%)
- mental illness
- seperation/divorce
- incarcerated household member
Neglect
- emotional (highest 15%)
- physical
ACES can have lasting effects on?
- health
- behaviours
- life potential
ACES and AOD problems
- more ACES = more susceptible to early initiation of AOD use and continued use into adulthood
- account for 1/2 to 2/3 of serious drug use
- each additional event increased odds of developing drug problem by 30-40%
neurobiology of ACEs and AOD use
- structual and functional abnormalities in areas relating to attachment, stress response and reward pathways
- maternal caregiving modify and shape inter-related systems (dopamine, oxytocin, and glucocorticoid system)
- makes people more susceptible to developing AOD problems and worse PTSD symptoms during withdrawal
Stress and its effects
- stress and trauma in childhood make it hard for a persons nervous system to regulate later in life causing greater sensitivity to stress and chronically activated fight-flight-freeze
- affects development of prefrontal cortical regions and functioning (effects learning and self-regulation)
- dysregulation of HPA axis cause by exposure to chronic stress developmentally
- endocrine features of PTSD include abnormal regulation or cortisol and thyroid hormones
Homeostasis
dynamic batance between parasympathetic and sympathetic activation
(Mal)adaptive coping and emotions
- PTSD and AOD problems share maladaptive avoidant emotional coping styles (blocking out and disconnection)
- when they co-occur they are maintained and exacerbated by their interdependent relationship
emotional dysregulation and AOD use
- emotion dysregulation encourages intiation and maintenance of AOD use
- emotional distress elicits substance use
- can create positive emotional states creating motivation for substance use
- emotion is a component of impaired decision making and impulsivity
anxiety and substance use
- anxiety sensitivity is the tendency to fear anxiety related symptoms and increased fear response
- ## related to emotional dysregylation and development of PTSD
clients with high ACES are likely to have?
- insecure attachment
- modelling of emotional dysregulation and maladaptive coping strategies
- fera of negative emotions
- unhelpful beliefs about emotion
Avoidance of difficult emotions
- situational avoidance
- reassurance seeking and checking
- distraction and suppression
- numbing and withdrawing
- harmful releases
- stimulation seeking
why avoidance doesn’t work?
- reinforces fear/intolerance of difficult emotion
- when AOD are main coping strategy leads to unpleasent side effects, tolerance and life problems
How can services provide better care for clients?
Trauma informed care
Trauma Informed Care
- reflect an understanding of the
impact of trauma on survivors and to meet the needs of treatment-seekers with trauma histories - adopts a framework of “what happened to you? “how did you cope? not “what is wrong with you?”
five principles or TIC
- trustworthiness - clarity, consistency, interpersonal boundaries
- choice - maximising choice and control
- empowerment - prioritising emopowerment and skills
- collaboration - maximising collaboration, sharing power
- safety - physical, emotional, environmental, cultural, systemic
building on the TIC principles
- having a strengths focus
- displaying acceptance
- being non-judgmental or non-blaming
- showing compassion
Clients strategies to adapt
- 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
Phase 1 of Trauma focused treatment
Safety and stabilisation
- Development of strategies of self
managment and emotion regulation. - Psychoeducation regarding the effects of trauma and interaction with alcohol & drug use
Phase 2 of Trauma focused treatment
Trauma Processing
Review and re-appraisal of trauma memories usually involving exposure based psychological treatment
Phase 3 of Trauma focused treatment
Integration and reconnection
Consolidating gains, building independence and community supports
Vicarious trauma
- the negative changes in clinician working with clients affected by trauma over time
- overlaps with burnout, secondary traumatic stress and compassion fatigue
- involves eduring stress response mirroring the effects of trauma
- experienced through:
1. stories of trauma
2. working with trauma affected clients
AOD workers and secondary traumatic stress
- 19.9% of workers met the criteria for secondary traumatic stress
- defined as a syndrome of symptoms that parallels PTSD symptoms
How to have better outsomes in AOD services
▪ 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
What helps people to recover from trauma
- Building adaptive ways to cope
- Learning interpersonal skills and effective communication
- Understand their needs and having a healthy sense of responsibility for
themselves and self care - Forming healthy relationships and connections with others
- Developing self acceptance and self compassion
- Engaging with relevant community supports and organisations
- Realising valued goals and participating in valued roles
