Addiction, Trauma and Family Systems Michael F. Barnes, Ph.D., LPC Clinical Program Manager CeDAR - Center for Dependence, Addiction, & Recovery 40th Annual

Addiction, Trauma and Family Systems Michael F. Barnes, Ph.D., LPC Clinical Program Manager CeDAR - Center for Dependence, Addiction, & Recovery 40th Annual Winter Symposium "Addictive Disorders, Behavioral Health and Mental Health Colorado Springs, Colorado

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 SUDs 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/SUD patients 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

Relationship between addiction & Trauma Reference Unknown?

Like Addiction, the trauma response is a bio-psycho-social process. Most counselors see it as a linear process, where an individual is impacted by an event, and then responds to the event. What about the people who love them? Are they impacted? Are children impacted by the trauma responses and addiction of their parents? Are parents and siblings impacted by the trauma response or addiction of their child/sibling? Systemic Trauma is a Recursive Process Feedback, Dramaturgy! Impact of Trauma on Family

All Families Have Organization - Homeostasis Like a mobile adjusts to wind to maintain stability, all families adjust to lifes demands to maintain stability, and system integrity. Primary Trauma Survivor Intoxication Anxiety, Hyperarousal Intrusive Thoughts, Nightmares Anger, Conflict Dissociation, Depression FAMILY SYSTEM REVIEW

Family Systems Myth: A change by any one member of a system forces the system to change. In reality there are multiple things that can happen when one member of a family system changes: 1.The system can change to accommodate the change made by the family member. 2.The system can exert significant pressure on the member to change back. 3.Other system members can pull together and create increased distance with the changed member. Give up! For family members, as well as for primary survivors/addicts, change requires insight into reality of secondary trauma, as well as energy for dealing with the biological, emotional, and homeostatic implications!

Continuum of Traumatic Stress Primary Trauma Secondary Trauma Compassion Fatigue Organizational Trauma Secondary Trauma Burnout If you have any doubt about the recursive nature of trauma/addiction, consider the impact of compassion fatigue on counselors! Vicarious Trauma Chiasmal Trauma

Sources of Primary Traumatic Stress Response (Criterion A DSM V) Direct personal experience of an event that involves threatened, death, actual or threatened serious injury, or threat to ones 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. DSM V

Common Symptoms of Trauma Re-experiencing traumatic events (Criterion B) Recollections of the events, sudden intrusive thoughts Dreams and or nightmares Avoidance of reminders of traumatic events (Criterion C) Efforts to avoid thoughts and feelings Avoidance of people, places, situations that remind. Negative changes in thougts and mood that occurred or worsened following traumatic event (Criterion D) Inability to remember aspects of event Negative evaluation of self, others, the world Loss of interest in activities Persistent arousal (Criterion E) Irritability or outbursts of anger Difficulty concentrating Startle response All four are PTSD Criteria from DSM V

Natural Disaster Events - Hurricanes, Earthquakes, Tornadoes, Floods, Fires, etc. High Speed Events - Car & Bike Accidents, Falls, etc. Assault Events - Assault, Rape, Incest, Animal Attacks Global Threat Events - Drowning, Electrocution, Caesarian, etc. Major Illness/Hospital Events - Cancer, Heart Attacks, Asthma, Full Anesthesia Surgeries Cyclical Trauma Anniversary of major traumatic event Family Trauma Divorce, Affairs, Death of a loved one, etc. Abandonment or Attachment Trauma Living in an alcoholic or otherwise dysfunctional family What Causes Trauma?

10 Family Qualitative Study, Families of Patients with Chronic Co-Occurring Disorders (Mental Illness & Addiction ) Common Response Patterns (All issues identified by multiple informants) Common Feeling Common Defense Mechanisms Common Behavioral Responses Anxiety/worry - hypervigilance/control Traumatic Stress Response Frustration with Medical Community Anger Fear Grief Guilt Horror Terror Shock Hurt Depression Frustration Shame Denial Rationalization Intellectualization Projection Common Cognitive Responses Obsession Intrusive Thoughts Uncertainty Self Blame Fault Finding Resentments Hopelessness Helplessness Foreshortened Future (Were going to die!) Common Physical Responses Sleeplessness Exhaustion Nightmares Startle Response Hypervigilance Control self/others Care Taking Impose Structure Avoid triggers & Reminders

Reported Sources of Trauma in Families With Mentally Ill/Addicted Family Member Loved ones suicide attempts or suicidal ideation Loved ones victimization (raped, beaten, etc.) Loved ones dangerous/out of control behaviors (weapons, fire, assaultive behaviors, destruction of property, etc.) Legal involvement (Police actions, Jail, etc.) Fear for ones own and others lives Psychotic Symptoms (delusions & hallucinations) Depressive symptoms (self harm, unresponsiveness, etc.) Emergency Rooms and sudden, unexpected crisis calls Shattered dreams (will never be who we thought they would be, not who they were before) - Death Humiliation

Axiom 1: Individual Reactions Family members report having experienced emotional, cognitive and behavioral symptoms that are similar to those reported by the primary victim. Symptoms (in the literature) reported by family members: Intrusive thoughts, nightmares, flashbacks Feelings of detachment and estrangement from others Restricted affect Avoidance of activities that remind them of the traumatic event Sleep disturbances Hypervigilance Fatigue.

Axiom 2: Altered Family World View Family members frequently experience a change in world view associated with personal vulnerability, safety, and control. Following a traumatic event, focus shift to safety issues, related to self and others. Catherall (1998) safety issues often expressed in the form of suspicious, distrustful attributions concerning the motivations of others Think how desperate families are to get a loved one into treatment for addiction and then how quickly they listen to a patients complaints and question the motives or competency of the treatment staff/program. Key issues that result from this shift include: Hypervigilant, Enabling, overprotection, defensiveness, etc.

Michael S. Genogram 47 48 24 2212 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Uncle Denise Gary Patrick (met Denise online) MichaelAlycia ? Killed by Drunk Driver in 1996 Major focus of therapy! Miscarriage at 5 months 19?? To 1985 1998 to Present Anger Alcoholism Traumatized Major Traumas (Denise) 1.Age 14 months, leg cut off in lawn mower accident 2.Sexual Abuse from age 14 to 17 (family friend) 3.Loss of 1 child by miscarriage 4.Daughter killed by drunk driver Major issues for Michael: 1.Very little memory of childhood 2.Very upset by death of sister 3.Hyper-vigilant of mothers moods, attitudes (major enmeshment) 4.Severe anger problems that predate sisters death (most focus on father and sister) 5.Multiple concussions from football Major issues for Denise: 1.Very controlling & hypervigilant. 2.Major medical issues/ disability. 3.Issues with daughters death Alcoholism

Family Formation Values, Goals, Boundaries (Identity) Steinglass, 1987 Rules Roles Rituals Routines Relationships

Identity & Goals Rules * overt vs. covert * communication/ meta-communication * emotional closeness * express/discuss emotion Roles * decision making * parenting * care giving * patriarch/matriarch Rituals * celebrations/holidays * religious events * events that make this family separate from others. Routines * daily activities * routines * conserve energy Relationships * Boundaries * Conflicted? * Willingness to accept, ask for and accept social support Family Organization Family Stable Patterns The 5 Rs Whether the crisis is a trauma, addiction, or both, the longer the family goes without resolving a problem, the more these organizing principles tend to change, in order to allow the family to survive the crisis. Values + Goals = Identity

Anger Conflict Anxiety Enabling While family members may appear to be going in different directions and increasingly conflicted, they are operating out of the same set of rules, roles, etc. Why do people change? 1 st order change vs. 2 nd order change!

Familys Stable Patterns Pattern disrupted And family Experiences distress (Problem) Family experiences crisis Family withdraws From potential Social support Family becomes Preoccupied With crisis Family pattern Becomes organized Around crisis Crisis becomes Necessary for Family stability Family seeks Potential social support Family views Crisis in context Of its goals Family develops A new pattern For stability Crisis resolved Or managed Family resolves Distress using Preexisting strategies 1 2 3 5 Disrupting Event Family Distress Model (Cornille & Boroto) 4 5 Rs

Critical Clinical Factors - Isomorphism Isomorphism is a concept used in MFT supervision, similar to parallel process used in individual therapy. Defined as the phenomenon of identifying similar patterns that occur across various systems. (White & Russell, 1997). An example is when families replicate various system patterns in therapy. If families function within homeostasis, they will attempt to maintain customary interactional patterns within the therapy process and may struggle when therapist doesnt participate. Counselors can be easily inducted into the family system interactional patterns. Lose ability to create change.

Axiom 2: Altered Family World View May also result in disruption in ability to modulate strong affect and maintenance of inner connectedness to others. (McCann & Pearlman) See reduced ability to self sooth. See increased need for others to conform to their safety standards. Increased control, increased enabling Often Overextending, overindulging or compulsive consumption to avoid affect (overeat, overwork, drink excessively, sex, etc.) Frequent or intense self-criticism or self loathing Difficulty tolerating strong feelings or hypersensitivity to emotionally charged stimuli.

Reduced Ability to Tolerate Emotion Need for Control, Hypervigilance, Enabling Tolerable range of emotion Homeostasis Brought about by changes to Limbic System, ANS, etc. Positive Emotions Negative Emotions How might this picture be different for a patient or family member who comes to us with Significant attachment trauma (Small t)? What are the implications for growing up in a home with a traumatized parent?

Family Response to Narrowed Range of Tolerable Emotion Tolerable range of emotion/anxiety Positive Emotions Negative Emotions Secondary Trauma survivors experience increased need to reduce anxiety, fear, sadness, etc. See increase in control behaviors, enabling, hypervigilence

Effect of emotional arousal on declarative (Semantic) Memory, (van der Kolk, 1996) Auditory Olfactory Kinesthetic Thalamus Amygdala High Threat Fear-Terror Hippocampus Pre-Frontal Cortex Offline/Unavailable Visual Gustatory Traumatic Memory - Poor Integration Processing memory and Emotional Reactions Spatial Memory Shift from Short to Long Term Fit information into existing cognitive Schema Information NOT filed in memory database Experience memories as sensory triggers Bottom-Up Memory experienced as present Extreme Stress interferes with hippocampal functioning, memories based on fragments of information. Autonomic Nervous System Fight/Flight/Freeze

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 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 disconnected No Solutions Scared to death Systems perspective: enmeshment, enabling, control behaviors are homeostatic maintainers. They are also very biologically based! To face the threat of not enabling is terrifying for many!

Axiom 3: Structural/Organizational Changes Conflict, Anger, Resentment, Emotional Distance, Emotional Intensity, shifts in intimacy, shifts in parenting, shifts in decision making, etc. Child Mother Father Triangulation Persuer/Distancer Relationship Brothers Sisters Rigid External Boundaries Diffuse Internal Boundaries Sibling Role Changes Shifts in all 5 Rs & organization around the problems of addiction and trauma!

Axiom 4 - Centrality of Parental/Familial Perceptions Family member perceptions/experience of stress/anxiety associated with the traumatizing event will influence interactional patterns, coping mechanisms, and degree of emotional consequence experienced by family system. Perceived stress is more influential on symptoms development than actual, observable stressors (Miles, 1985) The crisis is not the problem, but it is the familys constraining beliefs that restrict alternative views about the crisis that becomes the problem (Shaw & Halliday, 1992) Denver Trauma Institute, 2013

Factors Influencing Coping and Familial Response Age of Onset Diagnosis Severity of Symptoms Proximity of Family Patient Problems Adaptive Coping Strategies Not Adaptive Individual/ Family Response Use of Available Resources Perception Based on memory theory, each member of the family will remember the traumatic event(s) differently. This impacts family perception, adaptation, and healing process! What are the implications for traditional homework assignments like cost letters, etc.?

What Sets Adaptive/Resilient Families Apart? Figley (1989) identified characteristics of families that tend to cope more efficiently with stress and trauma: Accept responsibility for dealing with the situation and to mobilize energy and resources for action. Shift focus from any one family member and recognize that it is a problem that the entire family must face together. Move quickly from a blaming stance to a solution- oriented problem solving focus. Family members exhibit increased tolerance and patience for one another. 30

What Sets Adaptive/Resilient Families Apart? Clearly identify and express emotions associated with the traumatic event and verbalize their commitment to one another throughout the posttraumatic process. Allow members to access their own individual and interpersonal resources, both internal and external to the family system Reach out for social support with little difficulty or embarrassment. Finally, they are able to do this without resorting to impulsive violence or dependence on alcohol or other drugs. (Figley,1989) 31

Resilience Dennis Charney, M.D., ISTSS Keynote Presentation, 2013 Professor Psychiatry and Neuroscience at Mount Sinai Hospital Resilience Active Coping Social Support Facing Fears Exercise Role Model Spirituality / Religion Cognitive Appraisal Moral Compass Optimism prisoners of war special forces, victims of abuse natural disaster individuals living in poverty first responders -9/11 Core beliefs that few things can shatter! To some degree genetic, but can be learned Much of current resilience based on neurobiology developed in childhood, adult caring, social competence, capacity for self reflection and self-regulation. As we begin to shift to a treatment model that is focused on a more chronic model of addiction treatment, it struck me that building resilience is one of the critical components of the treatment process! How do we already do this? What can we add to really maximize a patients ability to carry resilience into the next phases of treatment?

Transference/Countertransference Bowen identified roles that family members may assume during times of high stress/anxiety that serve to organize the family. Savior Perpetrator Bystander Victim Usually all family members assume each of the roles at different times in their day to day life, which, depending on the role and the meaning that the role has for the individual can make therapy more difficult.

Transference/Countertransference While working in therapy, clients will often demonstrate or play out one or more of these roles, while also projecting other roles out onto the therapist in the form of transference. Especially important to understand when working with highly relational traumas such as complex trauma from incest, abuse, etc. Also important when doing couple or family therapy around trauma issues. All roles played out in the room at the same time. It is critical for trauma therapists to understand how these roles played out in their own life/family and recognize countertransference issues that could cause conflict or slow down the therapeutic process.

Clinical considerations: 1.Counselor must present non-anxious presence & clinical competence Clear awareness of counter transference issues, personal trauma, etc. 2.All family members will have their own recollection of what happened and level of comfort in discussing it. It is important that family members are able to express their thoughts and recollections without interruption (in session safety!) 3.Family system behaviors are old homeostatic mechanisms for keeping family together and functioning. It is easier for families to induct us into their way of functioning than to engage in new behavior Be aware of how patterns repeat throughout different relationships Be conscious of First order change vs second order change 4.Must develop healing theory by collaboratively answer 5 Healing Questions (Figley, 1989) 1. What Happened? 2. Why did it happen? 3. Why did it happen to us? 4. Why did we react the way we did when it happened? 5. What will we do differently if it were to happen again?

Documents

Addiction, Trauma and Family Systems Michael F. Barnes, Ph.D., LPC Clinical Program Manager CeDAR - Center for Dependence, Addiction, & Recovery 40th Annual