Trauma and the Twelve Steps: Clinical Keys to Recovery Enhancement

Trauma and the 12 Steps: Clinical Keys For Enhancing

Recovery Services

Jamie Marich, Ph.D., LPCC-S, LICDCCounselor, PsyCare, Inc.

Founder, The Ohio Center for Mindful Living (Mindful Ohio)

Author, Trauma and the Twelve Steps

What led you to today’s workshop?

About the PresenterOhio: LPCC-S, LICDCMember of the American Academy of Experts on Traumatic StressTwelve years of experience working in social services and counseling; includes three years of experience in civilian humanitarian aid in Bosnia-HercegovinaSpecialist in addictions, trauma, abuse, dissociative disorders, performance enhancement, grief/loss, and pastoral counseling Trained in several specialty interventions for trauma, most extensively in EMDR Author, qualitative researcherCreator, Dancing Mindfulness & Founder of the Ohio Center for Mindful Living

ObjectivesO Describe how certain 12-step approaches, slogans, and

customs may be counterproductive when working with a traumatized client

O Define trauma in a biopsychosocial/spiritual manner and explain how honoring this holistic conceptualization of trauma enhances addiction treatment

O Explain how certain features of 12-step recovery are productive for working with addicted survivors of trauma stress and identify how these features can be implemented into treatment

O Develop a plan for working 12-step recovery strategies alongside appropriate treatment for the traumatic stress issue(s)

O Apply at least three clinical techniques from various psycho- therapeutic approaches to help clients attain addiction recovery in a trauma-sensitive fashion

Dr. Marich’s Working Definition

OAddiction is continuing to do something (e.g., drink alcohol, smoke cigarettes, gamble, engage in sexual activity), even when the activity causes repeated pain and consequences.

SOURCE: GWC, Inc. (1993), Human Addiction

From Dr. Kevin McCauley (2009):

O Organ Defect (Cause) Symptoms


O Organ Defect (Cause) Symptoms

O Femur Fracture (e.g., skiing) Pain

O Pancreas No Insulin Blindness, Numbness,

Wounds


O ___________ __________ _____________


O ___________ __________ _____________

O Midbrain Various * Biopsychosocial Consequences

* Addiction (McCauley): defect in the brain’s ability to perceive, process, and act upon pleasurable/painful experiences

Models of Addiction

Rigid acceptance of the disease model, or any alternative model, is not optimally trauma-sensitive.

Trauma

Once you’ve been bitten by a snake, you’re afraid even

of a piece of rope.

-Chinese Proverb

Trauma: Large T & small t

PTSD: DSM-IV-TR

O Actual or perceived threat of injury or death- response of hopelessness or horror (Criterion A)

O Re-experiencing of the traumaO Avoidance of stimuli associated with the

traumaO Heightened arousal symptomsO Duration of symptoms longer than 1 monthO Functional impairment due to disturbances

For the latest updates on DSM-5, visit the official

website at www.dsm5.org

Trauma: small-t

• Although not life-threatening, definitely life-altering

• If it’s traumatic to the person, then it’s traumatic

• Examples include grief/loss, divorce, verbal abuse/bullying, and just about everything else…

Etymological Origin

O Trauma comes from the Greek word meaning wound

O What do we know about physical wounds and how they heal?

A Client’s Perspective: Lily Burana (2009)

“PTSD means, in ‘talking over beer’ terms, that you’ve got some crossed wires in your brain due to the traumatic event. The overload of stress makes your panic button touchier than most people’s, so certain things trigger a stress reaction- or more candidly- an over-reaction. Sometimes, the panic button gets stuck altogether and you’re in a state of constant alert, buzzing and twitchy and aggressive.”


““Your amygdala- the instinctive flight, fight, or Your amygdala- the instinctive flight, fight, or freeze part of your brain- reacts to a trigger freeze part of your brain- reacts to a trigger before your rational mind can deter it. You before your rational mind can deter it. You can tell yourself, ‘it’s okay,’ but your wily can tell yourself, ‘it’s okay,’ but your wily brain is already ten steps ahead of the game, brain is already ten steps ahead of the game, registering danger and sounding the alarm. So registering danger and sounding the alarm. So you might say once again, in a calm, reasoned you might say once again, in a calm, reasoned cognitive-behavioral-therapy kind of way, cognitive-behavioral-therapy kind of way, ‘Brain, it’s okay…’ ‘Brain, it’s okay…’


“But your brain yells back, ‘Bullshit kid, how dumb do you think I am? I’m not falling for that one again.’ By then, you’re hiding in the closet, hiding in a bottle, and/or hiding from life, crying, raging, or ignoring the phone and watching the counter on the answering machine go up, up, up, and up. You can’t relax, and you can’t concentrate because the demons are still pulling at your strings.”


“The long-range result is that the peace of mind you deserve in the present is held hostage by the terror of your past.”

A Client’s Perspective: from Marich (2010)

Fadalia (pseudonym), a recovering heroin addict with complex trauma reflected on where she was at before receiving the integrated treatment that led to her longest sobriety to date (3 years):

“Before [treatment], my feelings, thoughts and experiences were all tangled like a ball of yarn. I needed something to untangle them.”

Putting it Simply…OCognitive-behavioral therapies primarily

target the prefrontal regions of the brain (e.g., thinking, judgment, and willpower). However, when a person gets activated or triggered by traumatic memories or other visceral experiences, the prefrontal cortex is likely to shut down and the limbic brain (e.g., emotional brain) takes over.

Putting it Simply…OSimply talking about the trauma can

trigger this volatile, limbic region, and if the client has no skills to regulate these intense emotions, a client can be re-traumatized.

Putting It Simply

O What does not seem to change with traditional talk therapy is that uncomfortable experience of being triggered at a visceral level, (bottom of the brain) when the person is faced with reminiscent features of the original trauma in the present (Brown, 2003)

Putting it Simply

OThus, our therapeutic interventions must address the entire brain.

OAnother way to look at processing is to think of these three brains “linking up”

BREAK TIME

How Significant is Trauma When it Comes to Treating Addictions?

-High comorbidity between PTSD and substance use disorders: 27.9% of those with PTSD meet criteria for substance abuse, 34.5% meet criteria for dependence (Kessler et al., 1995; (Peirce, Kindbom, Waesche, Yuscavage, & Brooner, 2008)

-Of patients in substance disorder treatment, 12-34% have PTSD; these numbers can be as high as 33-59% in women (Najavits,2001; 2005).

How Significant is Trauma When it Comes to Treating Addictions?

Comorbidity between PTSD and addictions has been established, and untreated PTSD has been identified as a factor in relapse

(Miller & Guidry, 2001; Zweben & Yeary, 2006)

Ricci and Clayton (2008)

“Trauma may also disintegrate any sense of a future, thus fostering a propensity for the pursuit of instant gratification” (p. 42).

A Brief Primer on 12-Step Recovery

O Alcoholics Anonymous founded in 1935 by Bill Wilson and Dr. Bob Smith in Akron, OH

O Both had been members of the Oxford Groups

O Decided to focus on reaching out just to the alcoholic (a difference from the Oxford Groups), but kept many of the same principles


• Six steps of the Oxford Groups:

1.Admitted hopelessness2.Got honest with self3.Got honest with another4.Made amends5.Help others6.Prayed to God as you understand him


O The publication of the book Alcoholics Anonymous in 1939 gave the fellowship a name, saw the publication of the first draft of the 12-steps, and gave the A.A. fellowship some uniformity

O Although A.A. co-founder Bill Wilson is the primary author of the first part of the “Big Book,” various edits of the book were passed back and forth between the New York and Akron groups.

Context: A Brief Primer on 12-Step Recovery

O Bill Wilson (who was the New Yorker) and the Akron groups wanted to keep the focus on spirituality.

O The New York groups wanted to keep the focus on the physical aspects of alcoholism.

O What emerged was a combination of the two approaches


• The groups hoped that the initial publication of the book in April of 1939 would propel the message of Alcoholics Anonymous into the mainstream

• To the dismay of the groups, orders for the book only “trickled” in

• The Rockerfeller foundation assisted with getting the 4,000 non-purchased copies of the book out of storage

• There was not a need for a second printing of the so-called “Big Book” until 1941


• It was actually The Saturday Evening Post article in March 1941 that caused the membership of Alcoholics Anonymous to expand exponentially throughout the United States.

• Noted writer Jack Alexander had set out to expose A.A. as a fraud…what emerged was 6 pages of praise about the A.A. fellowship, necessitating a second printing of the Big Book.


Fruits of Alcoholics Anonymous (A.A.):

Acknowledgment of addiction as a disease by the American Medical Association in 1952

Influenced the development and rise to popularity of the Minnesota model of treatment in the 1950’s

Prompted the founding of hundreds of related fellowships that also use the 12-steps

12 Steps of Alcoholics Anonymous (1939/2001) Step 1 - We admitted we were powerless over alcohol- that our

lives had become unmanageable Step 2 - Came to believe that a Power greater than ourselves could

restore us to sanity Step 3 - Made a decision to turn our will and our lives over to the

care of God as we understood God Step 4 - Made a searching and fearless moral inventory of

ourselves Step 5 - Admitted to God, to ourselves and to another human being

the exact nature of our wrongs Step 6 - Were entirely ready to have God remove all these defects

of character Step 7 - Humbly asked God to remove our shortcomings Step 8 - Made a list of all persons we had harmed, and became

willing to make amends to them all Step 9 - Made direct amends to such people wherever possible,

except when to do so would injure them or others Step 10 - Continued to take personal inventory and when we were

wrong promptly admitted it Step 11 - Sought through prayer and meditation to improve our

conscious contact with God as we understood God, praying only for knowledge of God's will for us and the power to carry that out

Step 12 - Having had a spiritual awakening as the result of these steps, we tried to carry this message to other addicts, and to practice these principles in all our affairs

Let’s Discuss…

O What are your thoughts/feelings on 12-step recovery?

O What limitations have you encountered with 12-step recovery in certain populations?

O What does it mean for an intervention, such as 12-step recovery, to be trauma-sensitive?

Common Criticisms of 12-Step Recovery

O Too much emphasis on spiritualityO Too one-size fits allO Emphasis on powerlessness and character

defects is counter-therapeutic O Certain 12-step groups and treatment centers

can get too fanaticO Disease model of addiction is not acceptable

Common Problems in Treatment

ORigid application of 12-step principles without considering role of trauma

O“They’re just addicts”O“You’re here to work on your

addiction, not the trauma”OTricky scenarios in group work

PROBLEM #1

Rigid application of 12-step principles without

considering role of trauma

Potentially Problematic 12-Step Slogans

O Just For Today/One Day at a TimeOTake the Cotton Out of Your Ears and

Put it in Your MouthOYour Best Thinking Got You HereOThink, Think, ThinkOWe Are Only as Sick as Our Secrets OAny misplaced spirituality slogan…

And The Gauntlet…

4th and 5th Step Work

4. Made a searching and fearless moral inventory of ourselves

5. Were entirely ready to have God remove all these defects of character

What makes these steps nearly impossible for someone with unresolved trauma issues?

Case Study: Nancy (Marich, 2009)

You can’t put anything in the proper perspective. And

you can’t really get a heads up on what really happened

because you were so traumatized and you had such bad

experiences and like in my case, I had the trauma then I

had the- I call it the after-effect of my ex-husband-

pounding over and over and over and over it for like 14

years after that. I took so much responsibility for it. It

was almost like I victimized myself all over again in my

mind.

PROBLEM #2

“They’re just addicts…” -and/or-

“You’re here to work on your addiction, not your trauma.”

Evans & Sullivan (1995): Living in the Solution

1.) A large portion of clients presenting for treatment in any setting have a history of childhood trauma. Respecting this history enhances treatment.

2.) Successful treatment of the trauma must include working through memories of the trauma in an experiential way, after the clinician and client have established a foundation of safety and coping skills


3.) Substance use disorders are a significant part of the clinical picture for a substantial number of survivors of childhood abuse, thus:

-Treatment of the abuse issues that doesnot address the substance use issues willbe ineffective- Treating only the addiction in those with survivor issues will likely be ineffective


4.) The disease model of addiction and conventional 12-step approaches to treatment are productive in treating the addicted survivor of trauma

5.) Treatment models for addicted survivors of trauma must be integrated, and must address the synergism of trauma and addiction. A two-track approach is generally ineffective.

Practical Tips for 12-Step Facilitation

O Get to know the local meetings in your area that are known for tolerance

O Encourage gender-specific meetings

O Advise looking for a sponsor who has at least a basic understanding of trauma and/or someone who is not strictly “letter of the law”


O Encourage clients to bring their concerns about what they see/hear at 12-step meetings to counseling

O Work with clients to build a set of practical, body-based coping skills (e.g., breath work, muscle relaxation, exercise, music, journaling) especially before 4th and 5th step work


O Consider using individual counseling to help clients identify their roadblocks to successfully completing 4th and 5th steps (may also apply to 8th and 9th steps)

O Evaluate with a client whether or not the 5th step will be best completed with a trained professional…remember, the step just says another human being


O Be prepared to process pejorative slogans or insults to self that clients may hear in meetings or from traditional counselors

O Name calling and hot seat strategies, even if done in a spirit of “tough love” can be incredibly damaging for the traumatized client

PROBLEM #3

Tricky scenarios in group work…

Case Study Exercise

Wrap-Up: Best Practices for Interacting with Clients

ODo not re-traumatize! ODo be genuineODo ask open-ended questions ODo be non-judgmentalODo make use of the stop sign when

appropriate ODo assure the client that they may not be

alone in their experiences (if appropriate) OHave closure strategies readyODo consider the role of shame in addiction,

trauma, and grief

What is Shame?Guilt is feeling bad about what you’ve done,

Shame is feeling bad about who you are.

“Shame is the lie that someone told you about yourself.”-Anais Nin

“When we honestly ask ourselves which person in our lives means the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm and tender hand.”

-Henri Nouwen

Please Return by 1:00pm

From Dr. Bessel Van Der Kolk

“The purpose of trauma treatment is to help a person feel safe in his or her own body.”

-from a the new documentaryTrauma Treatment for the 21st Century (Premier, 2012)

General Consensus Model of Trauma Treatment

OPHASE I: Stabilization

OPHASE II: Processing of Trauma

OPHASE III: Reintegration

Incorporating into Addiction Treatment

OResearch is continuing to demonstrate that any of these past-oriented treatments can be appropriately applied to an integrated addiction treatment program when proper precautions are taken (Marich, 2010)

Tying it All Together…

OBefore any clinician can engage in past-oriented trauma treatments focused on resolution, a set of coping skills must be in place.

Phase I Treatment Planning

-A set of coping skills must be in place before heavier trauma resolution therapies can take place.

-Initial treatment is a valuable time to help with coping skills training and installation.

What Types of Coping Skills Work Best???

O Breath work O Muscle relaxation/pressure points O YogaO Imagery/multisensory soothing O Resources & Recovery CapitalO Spiritual principles O Anything that incorporates the body

in a positive, adaptive way!!!

Breathing Basics

“The mind controls the body, but the breath controls the mind.”

B.K.S. Iyengar

Breathing Basics

"Practicing regular, mindful breathing can be calming and energizing and can even help with stress-related health problems ranging from panic attacks to digestive disorders.“

Andrew Weil, M.D.

Breathing Basics

“Teaching breathing exercises to your client is like teaching a teenager when to accelerate and when to brake the car.”

Amy Weintraub

Strategy #1: Breathing Basics

ODiaphragmatic breathing

OComplete breathing

OUjjayi breathing

Breathing BasicsO Clients who are easily activated may not

feel comfortable closing their eyes during breath work..

O Start slowly…if a client is not used to breathing deliberately, don’t overwhelm him. Starting with a few simple breaths, and encouraging repetition as a homework assignment, is fine.

O If a client has a history of medical difficulties, make sure to obtain a release to speak with her medical provider before proceeding.

Strategy #2: Progressive Muscle Relaxation

Strategy #3: Pressure Points

Sea of Tranquility

Letting Go/Butterfly Hug

Gates of Consciousness

Third Eye (and variations)

Karate Chop/Inner Gate

Yoga: Hype or Hope? O Dr. Bessel Van Der Kolk is a leading

research proponent of using yoga as a primary and adjunctive treatment for PTSD

O Yoga, if integrated safely and appropriately, is at very least, an ideal coping skill technique in traumatized individuals

O Many addiction treatment centers throughout the world offer yoga

Yoga (Union)

O Recommendation:

Yoga (Union) O Recommendation:

Yoga and the 12-Step PathBy Kyczy Hawk

Strategy 4: Body Cuing & SoothingOImageryOSoundOSmellOTouch/TactileOTaste

Strategy #5: Mindfulness

Mindfulness means paying attention in a particular way: on purpose, in the presence of the moment, and non-judgmentally.

-Jon Kabat-Zinn (1994)

Strategy #6: Acceptance

- acceptance as Buddhist principle- 12-step recovery (Alcoholics Anonymous, 2001; p. 417)-”radical acceptance” (from dialectical behavioral therapy)-acceptance and commitment therapy

Strategy #7: Empowerment

O Encourage that change is possible, no matter how chronic the relapser… be sincere about it (Marich, 2010).

O Foster identification as a survivor, not a victim (Hantman & Solomon, 2007)

BREAK TIME

Factors to Consider Before Going Farther …

O Does the client have a reasonable amount of coping skills to access?

O Is there a sufficient amount of positive material (e.g., recovery capital) in the client’s life?

O Is the client willing (and ready) to look at past issues? In 12-step terms, this is best done between steps 1-3 and 4-5.

O Have you assessed for secondary gains and other related issues?

O Have you considered number of sessions available?

Reprocessing Made Simple

OI am not good enough

OI am good enough

The Common FactorsO Client and extratherapeutic factorsO Models and techniques that work to

engage and inspire the participantsO The therapeutic relationship/alliance O Therapist factors

Source: Duncan, B.L., Miller, S.D., Wampold, B.E., Hubble, M.E. (2009). The heart and soul of change: Delivering what works in psychotherapy. (2nd ed.) Washington, D.C.: American Psychological Association.

Some Reprocessing Approaches You May Already Incorporate…

O Narrative TherapyO Trauma-Focused CBTO Gestalt ElementsO Mindfulness-Based Cognitive

Therapy O Somatic experiencing

Innovative & Specialty Training Approaches

O Art/music/performance therapiesO EMDRO Hypnotherapy O EFT/NET/TFT

Intense Affect & Abreaction

O “The therapeutic process of bringing forgotten or inhibited material (i.e., experiences, memories) from the unconscious into consciousness, with concurrent emotional release and discharge of tension and anxiety.”

APA Dictionary of Psychology; VandenBos (2007)

For Continued DevelopmentO What are my personal barriers with

addiction and trauma?O How do I handle intense affect and

abreaction? O What factors may inhibit me from being

effective with a traumatized addict? O When is the best time to use collaborative

referrals?

Why it Matters…OThe literature in general traumatic

stress studies suggests that the therapeutic alliance between client and clinician is an important mechanism in facilitating meaningful change for clients with complex PTSD (Fosha, 2000; Fosha & Slowiaczek, 1997; Courtois & Pearlman, 2005)

Tips for Collaborative Referral

O Know your limits. If a client is triggering you too much, don’t be afraid to refer.

O Network in your local community—get to know who offers what and who seems to be most knowledgeable in trauma and addiction.

O The Internet is a treasure trove of resources. Many of the major websites in trauma therapies have data bases listing clinicians around the country who have gone through extra training.

Tips for Collaborative Referral

O In making psychiatric referral, get to know the doctors (or nurse practitioners) in your area who have a prudent, balanced approach to medication.

O It is not wise to send a client who struggles with addiction and trauma issues to a psychiatrist who relies heavily on benzodiazepine prescribing (or use of other controlled substances)

RESOURCE

Medications and the Recovering Person (pdf)

Available at: www.glenbeigh.com (Under “Resources”)

ReferencesO Alcoholics Anonymous World Services. (2001). Alcoholics anonymous. (4th ed.) New York:

Author. O American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorders. (4th ed.-text revision) Washington, D.C.: Author. O Brown, S. (2003). The missing piece: The case for EMDR-based treatment for

posttraumatic stress disorder and co-occurring substance use disorder. LifeForce Trauma Solutions. Retrieved June 4, 2008, from http://www.lifeforceservices.com/ article_detail.php?recordid=5

O Burana, L. I love a man in uniform: A memoir of love, war, and other battles. New York: Weinstein Books.

O Courtois, C.A., & Pearlman, L.A. (2005). Clinical applications of the attachment framework: Relational treatment of complex trauma. Journal of Traumatic Stress, 18(5), 449-459.

O Cunningham, A. (2010). Healing addiction with yoga: A yoga program for people in 12-step recovery. Forres, Scotland, UK: Findhorn Press.

O Duncan, B.L., Miller, S.D., Wampold, B.E., Hubble, M.E. (2009). The heart and soul of change: Delivering what works in psychotherapy. (2nd ed.) Washington, D.C.: American Psychological Association.

O Evans, K., & Sullivan, J.M. (1995). Treating addicted survivors of trauma. New York: The Guilford Press.

O Fosha, D. (2000). The transforming power of affect: A model for accelerated change. New York: Basic Books.

O Fosha, D., & Slowiaczek, M.I. (1997). Techniques to accelerate dynamic psychotherapy. American Journal of Psychotherapy, 51(2), 229-251.

O GWC, Inc. (1993). Human addiction [VHS Tape]. Cahokia, IL: Author. O Hantman, S., & Solomon, Z. (2007). Recurrent trauma: Holocaust survivors cope with

aging and cancer. Social Psychiatry & Psychiatric Epidemiology, 42, 396-402.O Kabat-Zinn, J. (1994). Full catastrophe living: Using the wisdom of your body and mind to

face stress, pain, and illness. New York: Dell Publishing. O Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic

stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52, 1048-1060.

ReferencesO Marich, J. (2009). EMDR in addiction continuing care: Case study of a cross-addicted

female’s treatment and recovery. Journal of EMDR Practice and Research, 3(2), 98-106.

O Marich, J. (2010). EMDR in addiction continuing care: A phenomenological study of women in early recovery. Psychology of Addictive Behaviors, 24(3), 498-507. McCauley, K. (2009). Pleasure unwoven. [DVD]. Salt Lake City, UT: Institute for Addiction Study.

O Miller, D. & Guidry, L. (2001). Addictions and trauma recovery: Healing the body, mind, and spirit. New York: W.W. Norton.

O Najavits, L. (2001). Seeking safety: A treatment manual for PTSD and substance abuse. New York: The Guilford Press.

O O Najavits, L. (2005). Handouts for training on PTSD and Seeking Safety. ODADAS

Women’s Symposium, May 16-19, 2006.O Peirce, J.M., Kindbom, K.A., Waesche, M.C., Yuscavage, A.S., & Brooner, R.K. (2008).

Post-traumatic stress disorder, gender and problem profiles in substance dependent patients. Substance Use and Misuse, 43, 596-611.

O Premiere Education & Media. (2012). Trauma treatment: Psychotherapy for the 21st century [DVD]. Eau Claire, WI: Author.

O Ricci, R.J., & Clayton, C.A. (2008). Trauma resolution treatment as an adjunct to standard treatment for child molesters. Journal of EMDR Practice and Research, 2(1), 41-50.

O VandenBos, G.R. (Ed.) (2007). APA dictionary of psychology. Washington, DC: The American Psychological Association.

O Weintraub, A. (2012). Yoga skills for therapists. New York: W.W. Norton. O Zweben, J., & Yeary, J. (2006). EMDR in the treatment of addiction. Journal of

Chemical Dependency Treatment, 8(2), 115-127.

To contact today’s presenter:

Jamie Marich, Ph.D., LPCC-S, LICDCThe Ohio Center for Mindful Living

jamie@jamiemarich.comwww.jamiemarich.comwww.drjamiemarich.comwww.TraumaTwelve.com www.DancingMindfulness.com

Phone: 330-881-2944

Trauma and the Twelve Steps: Clinical Keys to Recovery Enhancement

Healthcare

Transcript of Trauma and the Twelve Steps: Clinical Keys to Recovery Enhancement