Ron Shore ronshore4@gmail.com Shoreconsulting.ca November, 2013, Kingston On.

Trauma Addiction Effects of trauma coping self medication selfregulation Understanding drug use Validation and recognition trauma informed services Moving forward with a resiliency lens

A deeply distressing or disturbing experience A very difficult or unpleasant experience An emotional wound or shock Causing a disturbance from normal functioning Type of damage to the psyche From Greek: a wound

 Used to refer to both the negative events that result in the distress and to the distress itself Defined by its intensity An event may be traumatic if it is extremely upsetting and at least temporary overwhelms an individuals internal resources (Briere, 2006) The individual may not able to integrate the emotions and ideas involved in the event

 Greek, Sanskrit and Persion origin of tere, refers to an open hole Also related to root, and to rub, to pierce, to turn, to twist

 Not nature vs. nurture, but nature and nurture combined The genome dynamically responds to the environment. Stress, diet, behaviour, toxins and other factors activate chemical switches that regulate gene expression
www.genetics.utah.edu

 In response to perceived threat, the hypothalamus (tiny, at base of brain) sets off an alarm signal in your brain, a combination of nerve and hormonal signals resulting in a surge of hormones Cortisol, the primary stress hormone, increases sugar in your bloodstream; also modifies non essential systems such as digestion, growth and reproduction Norepinephrine (adrenaline), elevates blood pressure and boosts energy

 Usually self limiting but if not.overexposure creates conditions for

Anxiety Depression GI problems Sleep problems Memory problems Cognitive problems

The cognitive conditions for risk

 17,000 middle class Americans enrolled with Kaiser Permanente HMO in California perhaps the largest scientific research study of its kind, analyzing the relationship between multiple categories of childhood trauma (ACEs), and health and behavioral outcomes later in life.

 Growing up experiencing any of the following conditions in the household prior to the age of 18:

Recurrent physical abuse Recurrent emotional abuse Contact sexual abuse An alcohol and/or drug abuser in the household An incarcerated household member Someone who is chronically depressed, mentally ill, institutionalized, or suicidal Mother is treated violently One or no parents Emotional or physical neglect

 When we studied the relation of injecting illicit drugs to adverse childhood experiences, we again found a similar dose-response pattern; the likelihood of injection of street drugs increases strongly and in a graded fashion as the ACE Score increases. At the extremes of ACE Score, the figures for injected drug use are even more powerful. For instance, a male child with an ACE Score of 6, when compared to a male child with an ACE Score of 0, has a 46-fold (4,600%) increase in the likelihood of becoming an injection drug user sometime later in life.
The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study Vincent J. Felitti, MD. 2004

 In our detailed study of over 17,000 middleclass American adults of diverse ethnicity, we found that the compulsive use of nicotine, alcohol, and injected street drugs increases proportionally in a strong, graded, dose-response manner that closely parallels the intensity of adverse life experiences during childhood Our findings are disturbing to some because they imply that the basic causes of addiction lie within us and the way we treat each other, not in drug dealers or dangerous chemicals
The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study Vincent J. Felitti, MD. 2004

 Expressions like self-destructive behavior are misleading and should be dropped because, while describing the acceptance of long-term risk, they overlook the importance of the obvious short-term benefits that drive the use of these substances.
The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study. Vincent J. Felitti, MD. 2004

putting drugs in their place

 I contended, first, that in order to understand what impels someone to use an illicit drug and how that drug affects the user, three determinants must be considered: drug (the pharmacologic action of the substance itself), set (the attitude of the person at the time of use, including his personality structure), and setting (the influence of the physical and social setting within which the use occurs.

 Of these three determinants, setting had received the least attention and recognitionthe second hypothesis, a derivative of the first, was that it is the social setting, through the development of sanctions and rituals, that brings the use of illicit drugs under control.
Norman Zinberg. Drug, Set and Setting. 1984

 35% of EM tried heroin; 85% offered 54% of these became addicted Recidivism?: after 3 years back home only 12% remained addicted Over of returning users did try heroin once back in the states

Drug use as selfmedication/ coping

 The drug, the person and the pain The vulnerability involved in addiction says that there is something in the use of the substance that has to do with our penchant to seek comfort, connection and wholeness in the core of ourselves Substance abuse as an attempt to cope what do drugs do for you, not to you Addressing self-esteem, isolation; The challenge for the clinician is to target the suffering in the person and not only the brain synapses or symptoms alone

 If drug use is an effort to self-medicate, to quiet or palliate depression, anxiety, loss or pain, than the addict displays a propensity for self-care Addiction not as pleasure seeking but remedial action in the hope of relieving pain and suffering The more a drug resembles what a person is missing the more powerful and reinforcing Getting better a human process, learning other strategies, building self-esteem, positive social supports

 Attempt to cope Substance use as self-medication Substance Abuse is a Self-Regulation Disorder

Reference: Edward Khantzian, Addiction as a Human Process

 Older term, commonly replaced now by dependence Rooted in Greek term addicto bound or devoted to a practice Implies loss of control, compulsivity, sacrifice of other life pursuits, inability to resist or desist

copyright ron shore, shoreconsulting.ca

 DSM IV criteria Implies both physical and psychological dependency maladaptive pattern of substance use leading to clinically significant impairment or distress

copyright ron shore, shoreconsulting.ca

Tolerance Withdrawal Consuming larger amounts over longer period of time than was intended Persistent desire to cut down or control use Great deal of time spent obtaining, using, recovering from drug effects Important social, occupational, recreational activities given up or reduced due to drug use Continued use despite knowledge of persistent or recurring physical of psychological problem caused or made worse by drug use
copyright ron shore, shoreconsulting.ca

Self efficacy (Bandura, 1977) Sense of coherence (Antonovsky, 1987) Self esteem (Brown & Lohr, 1987) Prosociality (Dovidio, Piliavin, Schroeder & Penner, 2006)

Decision making Hardiness Will, commitment, strength, determination Flexibility Creativity Emotional regulation Goal-setting

 Resilience is defined as a set of behaviours over time that reflect the interactions between individuals and their environments, in particular the opportunities for personal growth that are available and accessible (Ungar, 2010, 2011) resilience results from a cluster of ecological factors that predict positive human development

 Resilience does not occur in isolation. It is an interactive process that requires someone or something to interact with. It is dependent upon context or environment, including our most important relationships. How are individuals and their brains resilient in their social environment? The short answer is that our neurophysiological constitutions find viable ways of being in our worlds. (Martha Kent, Ch. 11)

 Taking a resiliency lens, this presentation argues for the creation of opportunities for communities to actively engage in navigating, networking and negotiating for their own health. This involves improving the way in which we provide options and opportunities for people to participate in altering and improving their social environment rather than looking at individuals as clients to whom we provide service.

 client (n.) late 14c., from Anglo-French clyent (c.1300), from Latin clientem (nominative cliens) "follower, retainer," perhaps a variant of present participle of cluere "listen, follow, obey" (see listen); or, more likely, from clinare "to incline, bend," from suffixed form of PIE root *klei- "to lean" (see lean (v.)).
www.etymonline.com

 Viewing the student, participant or client as a passive object to be filled, fixed or shaped (tabula rasa) Roots in critical educational philosophy
"it transforms students into receiving objects. It attempts to control thinking and action, leads men and women to adjust to the world, and inhibits their creative power" (Freire, Pedagogy of the Oppressed, 1970)

 The process of developing a critical awareness of ones social reality through reflection and action. Action is fundamental because it is the process of changing the reality. Paulo Freire says that we all acquire social myths which have a dominant tendency, and so learning is a critical process which depends upon uncovering real problems and actual needs. - See more at: http://www.freire.org/conscientization/#sthash.RtLPNeaI. dpuf

Trauma/Risk Recognition but Asset Based

Harm Reduction Practice

Resiliency Oriented
Developmental Measures (of
Individuals & Communities)

Addictions Informed

Social Ecology Lens

Drug Aware

Addictions Competency

Anti-Stigma

 Understand, informed about addition related matters Framework for understanding mental health within resiliency orientation The notion of resiliency is key

 Power basis of service provision

Power and abuse of power as often the foundation of trauma Residual scar tissue people carry (completely normal!)

Experience of the client Vulnerability, honesty

 Avoid seeing people as their problem!

reification

Resiliency lens means you see strengths and assets not just deficits and problems
For folks trying to process their suffering they are trying to find meaning but also exercise their agency so that their problems dont define them Put set backs within context of achievement

 Drug use as a sign of resiliency, adaptation, coping; a volition and intentionality An intention to ameliorate suffering and create a sense of meaning, and create a sense of connection to the world Seeking help is an additional sign of resilience!

 Trauma informed services are largely about understanding trauma, understanding addiction, working within a resiliency lens and creating an environment in which people are not triggered or retraumatized but valued for their strengths Examples how do you handle late appointments, difficult clients, when you are mindful of power imbalances

Environment needs to be based on acceptance Less rule based Let client drive the care Look at not what client needs to do differently but what service provider needs to do differently High no show and poor retention rates are most likely not a reflection on the client but the service

 What can we do?

Are we providing an environment that is open That is supportive That meets people where they are at That meets client need That engages the capacities of the client to participate and to lead

 What if we connect with people more dynamically? At the end of the day, therapeutic relationships are a substitute for social relationships and poor social attachments Attachment and relationships are key What people are trying to do is reattach to the world, develop a sense of trust and attachment
Its not really about the problem they are seeking help for!