Day One

Becoming Trauma Informed

As an indigenous woman I appreciate the complexities and dynamics in health policy and research. Given the complexity of the impact of intergenerational trauma on the lives and wellness of Indigenous peoples, future treatment interventions must be holistic and multifaceted with the inclusion of cultural safety models in policy and legislation, with research being key to making those strides and changes and elevating the health of a nation who have suffered due to the exclusion of these concepts in the past (Czyzewski, 2011; Duran, 2006a; Gone, 2013; Marsh, Cote-Meek, et al., 2016).

Agenda - Day One

8:30 – 9:00

Registration

9:00 – 10:00

Introductions, Expectations & Experiential Exercise

Background, Literature & Rates Of PTSD

10:00 – 11:00

Introduction to Trauma

Definitions, Epidemiology, History

11:00 – 11:15

Break

11:15 – 12:15 PM

 Sequelae of Trauma / Trauma and the DSM V

Somatic Experiencing Trauma Therapy

12:15 – 1:00

Lunch

1:00 – 3:00

 Meditation/Breathing/Grounding/ focussing

A brief overview of Groups & Sharing Circles rules and guidelines

Experiential Seeking Safety Sharing Circle / Seeking Safety

3:00 – 3:15

Break

3:15 – 4:00

 Individual check-in

Feedback and a Brief Evaluation of the Day

 

What are Trauma-Informed Practices?

 “A trauma-informed approach emphasizes understanding the individual … Rather than asking ‘How do I understand this problem or this symptom?’ the service provider now asks ‘How do I understand this [person]?’ ... This approach shifts the focus to the individual and away from some particular and limited aspect of functioning.

It also gives the message that life is understandable and that behaviours make sense when they are understood as part of a whole picture (Courtois, 2012).

Trauma-informed practices provide a lens that should guide clinical responses, interventions, and other interactions with clients.

Why Is an Understanding of Trauma Important for the Addiction Workforce?

Trauma is pervasive. It can be life changing, especially for those who have faced multiple traumatic events, repeated experiences of abuse or prolonged exposure to abuse. Even the experience of one traumatic event can have devastating consequences for the individual involved.

It is very common for people accessing substance use treatment and mental health services to report overwhelming experiences of trauma and violence. Often people who have experienced trauma view their use of substances as beneficial in that it helps them to cope with trauma-related stress. Unfortunately, this seemingly adaptive coping mechanism can make people more vulnerable to substance use problems.

To meaningfully facilitate change and healing, substance use treatment providers must help people make the connections between their experience of trauma and their problematic substance use or mental health concerns.

What Are Trauma-informed Approaches?

Trauma-informed services take into account an understanding of trauma in all aspects of service delivery and place priority on trauma survivors’ safety, choice and control. They create a treatment culture of nonviolence, learning and collaboration. Working in a trauma-informed way does not necessarily require disclosure of trauma. Rather, services are provided in ways that recognize needs for physical and emotional safety, as well as choice and control in decisions affecting one’s treatment.

In trauma-informed services, there is attention in policies, practices and staff relational approaches to safety and empowerment for the service user. Safety is created in every interaction and confrontational approaches are avoided. Trauma-specific services more directly address the need for healing from traumatic life experiences and facilitate trauma recovery through counselling and other clinical interventions. Advocates for trauma-informed approaches in the substance use treatment field do not ask substance use treatment professionals to treat trauma, but rather to approach their work with the understanding of how common trauma is among those served, and how it is manifested in peoples’ lives. It could be said that trauma-informed approaches are similar to harm-reduction-oriented approaches in that they focus on safety and engagement. In trauma-informed contexts, building trust and confidence pave the way for people to consider taking further steps toward healing and recovery while not experiencing further traumatization.

 

Key Principles of Trauma-informed Approaches

 Researchers and clinicians have identified key principles of trauma-informed practice, which have parallels with principles underlying evidence-based practices in the mental health and substance use field.

  1. Trauma awareness: All services taking a trauma-informed approach begin with building awareness among staff and clients of: how common trauma is; how its impact can be central to one’s development; the wide range of adaptations people make to cope and survive; and the relationship of trauma with substance use, physical health and mental health concerns. This knowledge is the foundation of an organizational culture of trauma-informed care.
  2. Emphasis on safety and trustworthiness: Physical and emotional safety for clients is key to trauma-informed practice because trauma survivors often feel unsafe, are likely to have experienced boundary violations and abuse of power, and may be in unsafe relationships. Safety and trustworthiness are established through activities such as: welcoming intake procedures; exploring and adapting the physical space; providing clear information about the programming; ensuring informed consent; creating crisis plans; demonstrating predictable expectations; and scheduling appointments consistently.

    The needs of service providers are also considered within a trauma-informed service approach. Education and support related to vicarious trauma experienced by service providers themselves is a key component.

  3. Opportunity for choice, collaboration and connection: Trauma-informed services create safe environments that foster a client’s sense of efficacy, self-determination, dignity and personal control. Service providers try to communicate openly, equalize power imbalances in relationships, allow the expression of feelings without fear of judgment, provide choices as to treatment preferences, and work collaboratively. In addition, having the opportunity to establish safe connections— with treatment providers, peers and the wider community—is reparative for those with early/ongoing experiences of trauma. This experience of choice, collaboration and connection is often extended to client involvement in evaluating the treatment services, and forming consumer representation councils that provide advice on service design, consumer rights and grievances.
  4. Strengths-based and skill building: Clients in trauma-informed services are assisted to identify their strengths and to further develop their resiliency and coping skills. Emphasis is placed on teaching and modelling skills for recognizing triggers, calming, centering and staying present. In her Sanctuary Model of trauma-informed organizational change, Sandra Bloom described this as having an organizational culture characterized by ‘emotional intelligence’ and ‘social learning.’ Again, parallel attention to staff competencies and learning these skills and values characterizes trauma-informed services.

Canadian Centre on Substance Abuse

Somatic Experiencing Trauma Therapy

Trauma Healing offers a framework to assess where a person is “stuck” in the fight, flight, freeze, or collapse responses and provides clinical tools to resolve these fixated physiological states. It provides effective skills appropriate to a variety of healing professions including: mental health, medicine, physical and occupational therapies, bodywork, addiction treatment, first response, education, and others.

Healing Trauma: hint: It’s not about reliving the trauma

Trauma Healing offers a framework to assess where a person is “stuck” in the fight, flight, freeze, or collapse responses and provides clinical tools to resolve these fixated physiological states. It provides effective skills appropriate to a variety of healing professions including: mental health, medicine, physical and occupational therapies, bodywork, addiction treatment, first response, education, and others.

Why Heal Old Trauma? Shouldn’t I leave well enough alone?

When the nervous system is freed from accumulated stress and trauma, the benefits are pronounced.

  • Improve relationships
  • Eliminate chronic pain
  • Enjoy more physical energy
  • Become less accident prone and forgetful (become more present)
  • Increase ability to focus
  • Reconnect to your ability to trust
  • Calm the nervous system
  • Live more of your potential

What is Somatic Experiencing (SE)?

Somatic Experiencing is a body-awareness approach to trauma being taught throughout the world. It is the result of over forty years of observation, research, and hands-on development by Dr. Peter Levine. Based upon the realization that human beings have an innate ability to overcome the effects of trauma, Somatic Experiencing has touched the lives of many thousands. SE restores self-regulation, and returns a sense of aliveness, relaxation and wholeness to traumatized individuals who have had these precious gifts taken away. This work has been applied to combat veterans, rape survivors, Holocaust survivors, auto accident and post surgical trauma, chronic pain sufferers, and even to infants after suffering traumatic births.

Symptoms of Overwhelm or Traumatic Stress

Traumatic symptoms are not caused by the “triggering” event itself. Symptoms stem from the leftover survival energy that has not been resolved and discharged due to a disturbance in the self-regulatory capacity of our autonomic nervous system and physiology.

Each time we are not able to return to a relaxed ‘normal’ state our nervous system becomes more hypersensitive or unresponsive and we are more likely to be affected by events, actions or experiences that previously may not have had an impact. Over time, after months or years, symptoms of the following types may arise:

  • Heart palpitations, breathing problems, dizziness
  • Hyper vigilance, being on guard or over alert
  • Extreme startle response
  • Hyperactivity
  • Extreme sensitivity to light, sound or touch
  • Involuntary behavior: tics, jerking limbs
  • Anxiety, including chronic low level anxiety
  • Panic attacks and phobias
  • Fears and terrors
  • Flashbacks and intrusive memories or images
  • Overwhelming emotional responses such as shame, anger, depression
  • Insomnia, poor sleep, nightmares, night terrors
  • Psychosomatic illnesses, particularly some headaches, migraines, neck and back problems
  • Muscle weakness, muscle pain e.g. fibromyalgia, myofacial pain
  • Digestive problems, e.g. irritable bowel syndrome, spastic colon
  • Immune system disorders
  • Skin reactions
  • Environmental sensitivities
  • Physical, mental or emotional exhaustion
  • Mood swings, shame, depression, rage, aggression, lack of self worth, easily irritated
  • Feelings of helplessness and powerlessness
  • Mental ‘blankness’ or feeling spaced-out
  • Amnesia, forgetfulness
  • Indecisiveness and feelings of overwhelm
  • Attraction to dangerous situations or people
  • Addictive behavior: smoking, alcohol dependency, drug abuse
  • Avoidance behavior: avoiding places, activities, memories, situations or people
  • Attachment difficulties in nurturing, bonding or committing to others or receiving from others

As SE works directly with the neurophysiology of the body to help regulate the nervous system and its effects on the endocrine and immune systems, these symptoms can gradually be reduced.

Trauma Healing

Traumatic symptoms are not caused by the “triggering” event itself. They stem from the frozen residue of energy that has not been resolved and discharged; this residue remains trapped in the nervous system where it can wreak havoc on our bodies and spirits. The long-term, alarming, debilitating, and often bizarre symptoms of post traumatic stress disorder (PTSD) develop when we cannot complete the process of moving in, through and out of the “immobility” or “freezing” state.

Somatic Experiencing is a gentle and profound way of working with trauma stored in the body.

Trauma can be of two types: shock trauma and developmental trauma. Shock trauma results from distressing incidents such as a fall, surgery, a car accident, or being the victim of a crime or a natural disaster. Developmental trauma refers to having had a childhood history fraught with family dysfunction, neglect and/or abuse.

Somatic Experiencing (SE) facilitates the completion of self-protective motor responses and the release of thwarted survival energy bound in the body, thus addressing the root cause of trauma symptoms. This is approached by gently guiding clients to develop increasing tolerance for difficult bodily sensations and suppressed emotions.

SE does not require the traumatized person to re-tell or re-live the traumatic event. Instead, it offers the opportunity to engage, complete and resolve, in a slow and supported way, the body’s instinctual fight, flight, freeze, and collapse responses. Individuals locked in anxiety or rage then relax into a growing sense of peace and safety. Those stuck in depression gradually find their feelings of hopelessness and numbness transformed into empowerment, triumph, and mastery. SE catalyzes corrective bodily experiences that contradict those of fear and helplessness. This resets the nervous system, restores inner balance, enhances resilience to stress, and increases people’s vitality, equanimity, and capacity to actively engage in life.

Traumatic symptoms are not caused by the “triggering” event itself. They stem from the frozen residue of energy that has not been resolved and discharged; this residue remains trapped in the nervous system where it can wreak havoc on our bodies and spirits. The long-term, alarming, debilitating, and often bizarre symptoms of post traumatic stress disorder (PTSD) develop when we cannot complete the process of moving in, through and out of the “immobility” or “freezing” state.

How Does SE Differ From Other Therapeutic Modalities?

Traditional cognitive and emotional based ‘talk’ therapies can be considered as being “top-down” approaches. They focus on insight and emotions first and secondarily may focus on the bodily responses to trauma. Talking about the trauma can have an adverse effect as the person can be re-traumatised with the flooding of reactions and overwhelm that rises during the process if their nervous system is not able to regulate itself. Sometimes, this is when people leave good therapy feeling that they are feeling worse.

In contrast Somatic Experiencing is a “bottom-up” approach. SE focuses on the brain stem – the reptilian brain and its survival-based functions that are not under conscious or emotional control. Access to these instinctual action and arousal systems is through the mode of physical bodily sensations, imagery and motor patterns. In the process of working with the ‘felt sense’ of the body other elements of the trauma experience may arise such as meaning and emotions. Thus cognitions and emotions are included in SE practice but they are secondary or derivative from physical sensations through the bottom-up processing.

SE uses techniques and interventions that work directly and gently with the neurophysiology of the body. SE avoids some of the issues that catharsis, re-enactment or talking about the story may create such a re-traumatisation or re-arousal of intense emotional states that can be frightening or too confronting to clients and may discourage them from continuing on their healing journey.

About Seeking Safety

Seeking Safety is a manualized psycho-educational counseling program that targets the unique problems resulting from struggling with SUD or trauma. The program aims to increase the coping skills of participants with the goal of reducing the chance of relapse by emphasizing values such as respect, care, integration, and healing of self (Najavits, 2007). In this program, participants work to reduce suicidal and self-harming thoughts and behaviours, including the urge to use substances and engage in other unsafe behaviours. They also work to remove themselves from unhealthful relationships to gain a sense of control and healing (Najavits, 2002a). Participants develop skills such as grounding, joining the present, and changing what can be changed to reduce the severity of their urge to self-harm (Najavits, 2009). Seeking Safety is considered a first-stage therapy: the primary goals of treatment are abstinence from substances and acquiring coping skills to obtain personal safety (Najavits, 2002a).

Seeking Safety has been used successfully among many minority populations, including African-Americans, Hispanics, and Asian Americans, as well as challenging populations (e.g., the homeless, prisoners, adolescents, public-sector clients, and veterans). The model has also been translated into numerous languages with international implementation (Najavits 2002a, 2007, 2009; Najavits & Hein, 2013).

The Seeking Safety model includes spiritual discussions through the offering of a philosophical quote at the beginning of the group sessions (Najavits, 2007; Najavits & Hein, 2013), as well as discussions about safety, cultural continuity, gentle language, and teachings about the genesis of intergenerational trauma and SUD (Najavits, 2002a; Najavits & Hein, 2013). Seeking Safety incorporates the inclusion of the mind, body, spirit, and self-awareness during treatment, as well as connection to community through emphasis on the utilization of community resources. Specifically, this model was chosen because it offered an individually empowering approach to the treatment of trauma and SUD (Najavits, 2002).

The Five Central Ideas the Treatment is Based On

(1) Safety as the priority of treatment.  The title “Seeking Safety” expresses its basic philosophy: when a person has both substance abuse and PTSD, the most urgent clinical need is to establish safety.  Safety is a broad term that includes discontinuing substance use, reducing suicidality and self-harm behavior, ending dangerous relationships (such as domestic abuse and drug using friends), and gaining control over symptoms of both disorders.  In Seeking Safety, safety is taught through Safe Coping Skills, a Safe Coping Sheet, a Safety Plan, and a report of safe and unsafe behaviors at each session, for example.

(2) Integrated treatment.  Seeking Safety is designed to treat PTSD and substance abuse at the same time.  An integrated model is recommended as more likely to succeed, more sensitive to client needs, and more cost-effective than sequential treatment of one disorder then the other (Abueg & Fairbank, 1991; Evans & Sullivan, 1995).  In Seeking Safety, integrated treatment includes helping clients understand the two disorders and why they so frequently co-occur; teaching safe coping skills that apply to both; exploring the relationship between the two disorders in the present (e.g., using drugs to cope with trauma flashbacks); and teaching that healing from each disorder requires attention to both disorders.

(3) A focus on ideals. Both PTSD and substance abuse individually, and especially in combination, lead to demoralization and loss of ideals. Thus, Seeking Safety evokes humanistic themes to restore clients' feeling of potential for a better future.  The title of each session is framed as a positive ideal, one that is the opposite of some pathological characteristic of PTSD and substance abuse.  For example, the topic Honesty combats denial, lying, and the “false self”.  Commitment is the opposite of irresponsibility and impulsivity.  The language throughout emphasizes values such as “respect”, “care”, “integration”, and “healing”.  By aiming for what can be, the hope is to instill motivation for the hard work of recovery from both disorders.

(4) Four content areas: cognitive, behavioral, interpersonal, and case management.  While originally designed as a cognitive-behavioral intervention (a theoretical orientation that appears well-suited for early recovery stabilization), the treatment was expanded to include interpersonal and case management domains. The interpersonal domain is an area of special need because PTSD most commonly arises from traumas inflicted by others, both for women and men (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).  Interpersonal issues include how to trust others, confusion over what can be expected in relationships, and the need to avoid reenactments of abusive power.  Similarly, addiction is often perpetuated in relationships.  The case management component offers help obtaining referrals for problems such as housing, job counseling, HIV testing, domestic violence, and childcare.

(5) Attention to clinician processes.  It can be a challenge to provide effective therapy to clients with this dual diagnosis, who are often considered “difficult.”  Clinician processes emphasized in Seeking Safety include compassion for clients’ experience; using coping skills in one’s own life; giving the client control whenever possible (to counteract the loss of control inherent in both trauma and addiction); meeting the client more than halfway (e.g., doing anything possible within professional bounds to help the client get better); and obtaining feedback about how clients view the treatment.  A balance of praise and accountability are also suggested.   The opposite of such positive therapist processes are negative processes such as harsh confrontation, sadism, difficulty holding clients accountable due to misguided sympathy, becoming “victim” to the client’s abusiveness, and power struggles.