Treating Co-Occurring Trauma and Addiction: Opioid, Alcohol, and Other Public Health Challenges

Treating Co-Occurring Trauma and Addiction: Opioid, Alcohol, and Other Public Health Challenges


[Bia Carlini] Okay, well, hello hello everybody and welcome to the February webinar of the
Northwest ATTC. Let’s get it started then. So I’m Bia Carlini. I’m the Northwest
ATTC webinar coordinator and also a system changes specialist. As the slide
says, questions we’ll be taking at the end. You have a little chat box that you
can, you know, type a question any time. We are going to take them in the end. We
usually get this question a lot: we will have the presentation and the slides
available for our website right after. As we finish the presentation, they will be there. It takes about 24 hours for us to have an ADA-compliant recording, but it will also
be available the same way. We’ll like to get it started, then, but let’s
get some housekeeping. Okay okay okay. No we are gonna go directly to the presentation. So I would say we could not
find better speakers for the topic of trauma and addiction than we have today. The two speakers are from Oregon and I’m gonna briefly introduce them to
you. So Marc Girard is a psychoanalyst and a clinical social worker with a
private practice of more than 20 years in Oregon. Mr. Girard was trained in Zurich
as a, in the Jung Institute, and later in Simmons College of Social Work. He has a long trajectory both supervising other therapists, both
locally and internationally, and also serves as a therapist in his private practice.
Marc specializes in working with the underlying psycho-dynamic symbolic and
somatic process of chemical and behavioral addictions. Our second speaker, our other
speaker, is Dr. John Fitzgerald. He holds a PhD and is the
statewide addiction treatment analyst for the Oregon Criminal Justice
Commission. He’s presently leading our work on the Senate bill that
involves studying, tracking, and accounting for all public money spent in addiction
treatment in Oregon and the outcomes achieved with this money. Dr. Fitzgerald
also maintains a clinical private practices in Oregon in presently is
clinical faculty of the department psychiatry in Oregon, in Oregon Health
and Sciences University. So without further ado. Thank you so much. We have now
transitioned the slides to to these speakers. It usually takes a little time
to do this transition. Welcome, thank you. [John Fitzgerald] Yeah this is John Fitzgerald and I’m
with Mark Girard, and we are here in Lake Oswego, where it’s quite snowy today. Snow is
coming down outside us right now, I’m quite grateful that Mark was able to
make it here so we can do this together. We realize that the topic treating
co-occurring trauma and addiction as well as opioids alcohol and public
health problems is a lot to get through in about 45-50 minutes but our goal is to
try to hit two or three points that will be most useful for you as clinicians. I
want to start by saying on Monday night I was at Madison Square Garden in New
York City and I was listening to the rock band with my son, “Disturbed.” It was
the first time that they headlined Madison Square Garden and their latest
album “Evolution” has a number of songs related to addiction. David Draiman, the
lead singer, struggled with addiction. And at one point in the show he had the house
lights come on and he asked everybody you know without shame to raise their
hands if they have struggled with addiction and it was an unbelievable sight to see
how many hands went up. Now, granted, they’re a bit of a self-selected crowd
going to a Disturbed concert, but he then went ahead and sang the song, “A Reason to Fight,” and one of the things that he talked about was the idea that people
who are really fighting for their lives in some ways really don’t feel
like they have a chance. That they really struggle, they have a tremendous amount
of hopelessness, and in some ways part of what we’re talking about today as
clinicians is how to give people we’re really struggling with a lot of
stuff hope for the future. Both Mark and I have been doing this work for awhile and
really believe that trauma and addiction are treatable and that a big
part of our work is providing a patient hope. [Mark Girard] So John talked about
hopelessness, helplessness, no way out, I’m stuck in a hole, despair. So despair is
often at the core, despair about themselves, and despair about other
people, despair about the world, and how to relate to that despair in a
constructive, creative, and in the end relational, a relational way, both with
yourself as a clinician, and then you with your clients. That’s the key in an
emotional, steady, steady consistent, creative relational way. [John] I think one of the places — still getting
used to the button here — one of the places that we want to start, really, is
the idea that a lot of the work that we do is about relationships. Many
of you may be familiar with this TED Talk that Dr. Waldinger from — he’s the
director of the Harvard Study of Adult Development did on 2015, and this is
really about the the longest study ever done on happiness where they tracked
over 700 men and part of them were from poor neighborhoods in Boston and
others from Harvard, really looking over many, many decades at what were the
various contributors to a good life. And for those of you who have seen this you know
the outcome, which is that it’s relationships. There’s also another project that involved women called the “longevity
project,” where 1500 Californians were tracked over eight decades, and again
there were similar findings that a good life is about relationships. And in some
ways that’s the end point, that’s what we’re trying to do with the work,
and yet part of what gets in the way of healthy intimate relationships is trauma
and addiction. [Mark] Let’s just read this kind of out loud and let it sink in from
Bessel van der Kolk: “Trauma, whether as a result of something done to you or
something you yourself had done, almost always makes it difficult to
engage in intimate relationships. After you experience something so unspeakable, i.e. despair, that’s me, how do you learn to trust yourself or anyone else again? Or conversely how can you surrender to an intimate relationship after you have
been brutally violated?” So look, again, the sense of kind of chronic and acute
despair and how do you hold that sense of hopelessness within you? How do you
cultivate a response to the hopelessness, the helplessness, and despair, if in some
ways that your core, especially developmental trauma, your sense of
well-being in the world, and then really with yourself, is compromised. Now again
on a continuum, that’s part of the assessment process. John? [John] Yeah so I want to talk — we’re in kind of the first part of this talk, really about the nature of the
problem, and one of the things that helps us to kind of frame it is what we’ve
learned from a variety of different studies particularly around the
neuroscience piece of this. And in 2003, we mapped out the human genome,
so we learned a lot about the building blocks of life, and now what we have is
the Human Connectome Project, which is really about constructing a map of the
complete structural and functional neural connections in vivo within and
across individuals. This is the first large-scale attempt to
collect and share data of a scope and detail sufficient to begin the process
of addressing deeply fundamental questions about human connection or
anatomy and variation. So we’re really now in this project getting at a point
where we’re starting to look at the connections in the brain in these
different systems that start opening us up for having a better understanding of
the disorders and treating the disorders. There’s a book called “Connectome” that by
Sebastian Seung, I think that’s how you pronounce his last name, that is sort of
really a nice read about opening up sort of what the future holds for us. But I
think in some ways we know a lot right now about trauma and addiction — sorry, Bia, the slides are… where is my button to go back? Hey Bia?[Woman] Can you try like the left arrow key on your keyboard? [John] Okay let me see if I can
do that. There we go there we go. All right I’ll
use the keyboard. So going back: you know one of the things about the
neuroscience today is we know a lot about trauma and addiction already that
I think is helpful for us when we’re turning to talk about treatment. We know that for trauma that both parts of the amygdala for emotion and
different parts of the brain related to memory systems, the hippocampus, are
involved in trauma. We also know that similar processes and parts of the brain
are also involved in addiction. One of my colleagues Dr. Erik Metzler, he is the
director of the FrIedman Brain Institute at Mount Sinai, and during last year
we’ve had a couple occasions where I’ve been able to interview and talk with him
about trauma and addiction. The last time that we met, I had some papers mapping
out kind of what we knew about trauma and the brain as well as addiction, but
part of our conversation was really around why there haven’t been more
papers integrating what we’ve learned from both of these. And the answer is
that funding streams really are separate. That when you look at the way that work
is being done right now in laboratories and by different scientists, it really is
quite fragmented. And yet in his work and at Mount Sinai,
one of the biggest take-homes that he left me with was that these disorders
are very, very much integrated in the brain and that we need to, when we think
about treatments, really start moving in a direction of more integrated
treatments. Kind of the two — there’s a couple of big take-homes that we’ve learned from some of this work in neuroscience: on the trauma side of the equation, which
is on the left here in this slide, this is an image that comes out of Bessek van der Kolk’s book on “The Body Keeps the Score,” but the limbic area, the visual
cortex, it’s red, these are the areas that light up in the brain related to emotion
and being able to see images in the past related to flashbacks. One of the big
findings out of their imaging studies was the fact that Broca’s Area
shuts down — that’s the yellow area — and so in the book he calls trauma a “speechless
horror” — that people have a very challenging time putting into words the
nature of the problem. On the right hand side what we also know is that when
people go down the path of addiction, and 80-90% of people go
down that path prior to the age of 15, so in some ways this is a disorder of
adolescence, that gets played out in teenage years, and as people are going
down that path, I think it’s important to realize, you know, nobody sets out to
struggle with addiction. Alan Leshner, the past director of NIDA, used to say
“nobody sets out to get heart disease, they just like fried chicken,” and I think
it’s the same. People experiment when they’re young with drugs, with
alcohol, with gambling, with a variety of different things. They don’t set down the
path to hijack their brain but there’s a there’s a variety of things that happen
over time, a variety of risk factors and protective factors that help us to
understand that at some point the brain does get hijacked and when it does and
we neural image it, we do know that those who struggle, you know their brains are
different, they’ve changed. Erik Metzler has really been key in helping to
understand how that happens through mapping out the protein of delta-FosB which
is really kind of the switch that gets flipped in the brain around being
hijacked, but again part of what he really wanted me to take home was the
idea that now their work has shown that there’s multiple switches in the brain,
and then, again, trauma and addiction are integrated as two problems. [Mark] John, can you
go back to the brain brain image? And so with this, one way to take the
fragmentation — John talked about the fragmentation the delivery of services — I
remember back in the 80s when I was starting out that it was pretty distinct. You know if you had a mental health problem, you went to a mental health therapist of
some kind, and if you had an addiction problem, you went to an addiction person
and they were really separate. They’re coming together now but it reflects the,
in some ways, the lack of integration policy-wise in terms of how to harness
our resources to address this. That stated, the reason I’m looking at the trauma and
addiction models here is because, in a simple sense, from a feeling point of
view, all these pieces of somebody’s brain who’s just in their trauma slash
addiction, in their addiction, their parts are going wacko, you know, they’re not
hooked up. It’s in a fight flight freeze response and so there’s not an organized
flow necessarily — you know it’s much more complex and subtle than this, than
I’m saying, but the piece, the sense to take away, is that there’s a disconnect,
there’s a disassociation to the parts literally in the neuro-physiology of
somebody’s brain, so it’s layered — both policy brain then the psychological
sense of being disconnected, disconnected. This despair, despair, there’s no
kind of hope. [John] But yeah so I think again we’re trying to move through the nature
of the problem fairly quickly and just highlight some pieces so that we can
really talk about treatment but it’s important to understand that you know
it’s not just biology and genetics, that the environment plays a huge role in how these problems evolve over time. In Oregon a lot of my work right
now on Senate Bill 1041 is looking at a lot of big picture factors in the
addiction treatment system in Oregon and some of you probably are aware the
social determinants of health and a lot of these different factors that play out
in terms of trying to understand, again, you know, as a clinician what shows up in
the office and the picture on the right really in some ways tells
the complete story. People that are homeless that are on the streets
compared to somebody who can sleep at home in their bed have very
very different experiences in their body. As
Mark was talking about even just starting with a sense of safety, so
environment matters. [Mark] So now me just looking if we take in the homeless
person, you know being in Portland, you know, a lot of homeless people, especially
in the downtown area, and I often think about how to make tolerate the anxiety
that’s in their skin — you can see it in their faces — laying exposed in the night, both the weather and both the threat of violence
in some shape or form, and the randomness of it — who wouldn’t do some kind of drug,
drink alcohol, just some meth, methamphetamine to stimulate, but just
it’s always fight flight freeze — kind of chronically stuck in our fight flight
freeze response, and we’re not built to operate forever at that level, but it
gets stuck there. You know, people get stuck and the physiology, the adrenaline, the
cortisol, as well in terms of brain scans, pictures and such, that it’s on fire,
chronically on fire, and then people you know they wanna cope. The short-term, they do things to chill, chill out baby, let’s chill out. [John] Yes,
the other thing that, you know, speaking about what Mark just said is that, you know,
the language we use with patients I think really matters and one of the
things that I have become practiced in talking with clients around this idea of
addiction is really using more the word “adaptive” in that a lot of
what people have been through in their life is a tremendous amount of suffering,
and when people have suffered with adverse childhood experiences, with
traumas, with things that really are overwhelming, the body with the defenses
that people can handle, there’s a natural sort of process that occurs where people
understand that various addictions, whether they’re substances or behaviors,
really are adaptive. They’re ways of helping people to be in their body, to
kind of continue to go forward in life even though the body has had to survive
something that was really unbearable and so I, you know, people beat themselves up
there’s a tremendous amount of shame and stigma around these disorders and the
idea that they are adaptive is something that I try to get people to really
understand in a real sense. I want to make just a brief comment about, again
… Yeah, go ahead. [Mark] If we go back to the, and so environment matters, just to highlight
this again. So if you grew up in a safe enough
community, where there’s good education the schools are safe, teachers are good,
you have a stable family, and you’re not chronically in the family caught
in an adrenalized or cortisol state, you know, routinely. You know the
difference when you’re in a crisis. You have safe creative substantive friends,
the neighborhood itself, it’s you know equal enough, it’s mutual enough, people
are respectful, it’s not a huge class conflict. I’m not pushing Marxism here,
it’s not that point, but there’s an equitable distribution, so everybody’s
kind of safe enough, safe enough, then developmentally you can grow into your
body, you can grow into your feelings, into your cognitive structures, into your
imagined structures, into your sense of body sensation, and being intimate,
connected to yourself, then you can be connected to somebody else at all these
levels. If that doesn’t happen — you know years ago I worked in the state prisons
of Massachusetts and so, really, 97% of the people are in a state prison
system were essentially poor, and into the system early. [John] I want to just make a brief comment about the fact that, again, we we fragment disorders — you know the DSM is
really the classic example of this — and even right now as I’m mapping out the
Oregon addiction treatment system, we really have a system that’s built around
mental health and then substance abuse. That’s been historic;
that’s not just in Oregon. But the point in this slide is again the idea
that as clinicians, we really need to see addiction and all
of the various different objects of addiction as a package of behavior. And
again with trauma, there’s a variety of different kinds of traumas that we need
to be assessing. But in some ways, we feel a sense of control, I think, when we’re
able to diagnose and label, and yet the brain doesn’t necessarily do the same
thing. All this stuff is kind of integrated. So really part of this is
setting the stage for moving into kind of this next part of this
presentation, around the fact that what we need are tools and ways of
intervening with our clients that appreciate all of the addictions and not
fragmenting them, and just working with substances or just working with
behaviors, we need we need approaches that address all addictions as a package. In a similar way also with trauma which is which is kind of where we’re going. [Mark] The Body Keeps the Score, big book from Bessel van der Kolk. The body keeps score — so again look at the young boy in the
corner, you know, he’s not fighting he’s trying to withdraw but he can’t, so you
gets a sense — we could call that he’s “freezing up” — he’s freezing up — and again
it’s the fight flight freeze response. If I freeze up, no it’s not conscious, they
won’t see me, I’ll be camouflaged, and I start to dissociate, I’m not really there. Sometimes people faint. The reason is “I get out of my body, so it won’t hurt so
much.” Then you get stuck in that place “I’m stuck, I’m stuck in my skin. I can
move, I can’t work on that issue” etc, people say that all the time. So the stance is less cognitive, we’re building a cognitive structure here, but
at the same time when you work with individuals or you’re in a group with
people working these issues, you’ve got to speak to beyond their frontal lobes, you’ve
got to speak to their midbrain and speak directly in an intentional way so that
they start to hear the tone of your voice, the position of your body, how you
look at them, how you move your body, are you a threat, and you start to elicit
these micro-states or more-than-micro-states, where people get
cued in the interaction between you and your client, and I’m a psychoanalyst, a Jungian psychoanalyst, so I’m always paying attention to the transference,
countertransference issue, but in a simple way — how do people relate to me in
the interpersonal way? How do I interpersonally, , in my own skin, relate to them? [John] Last slide, and then we’re gonna move into talking about treatment. But in my experience we in the field really focus very heavily
on the pathology side of the equation and we need to recognize that those who
come into our office are a lot more than their diagnoses, their problems, their
pathologies. That people have incredible creativity, talents, virtue, strengths, and
in some ways what I found as a clinician is that working on that side of the
equation actually at times gets me more mileage towards good outcomes, that we’ll
talk about in a minute, then then focusing actually on the pathology side
of the equation. Picasso said “All children are artists The problem is how
to remain an artist once once he grows up.” And I think that’s true, that, you know
little kids you know they draw, they have, they have absolutely no pretenses
in terms of joking with each other, and drawing each other’s pictures, and yet I
think as we get older we sort of educate ourselves out of creativity in many ways. The field of positive psychology is offering a whole lot of tools and ways
for us to not only assess people’s positive strengths and virtues but also
to work with those clinically, and so I think this slide is just, again, to kind
of wrap up the nature of the problem, the idea that we need a balanced approach
when patients come in trauma and addiction or all of these issues,
particularly people who, you know, are struggling with opioids and, you know,
injecting heroin. You know, yes in some ways they are in a fight for their lives
and it becomes very easy to, in some ways as a clinician I have felt kind of
overwhelmed with patients and kind of entering into their world in a
way to try to save their lives, and I often forget that they’re more than
their addictions, they’re more than their traumas. And yet it’s important for me to
continue to remind myself that, you know, people are more than their problems. [Mark] So with that piece about how to elicit the artist within oneself, both as a
clinician that’s why I’m a Jungian analyst or a depth psychology approach,
in the sense that the wound is the cure, in the right dose, the wound is the cure,
in the right dose. Paradoxically if I engage my despair as I talked, if I
engaged my inability to really grieve, to be sad, to be afraid, to be angry,to be
despairing, to be shamed, if I have limited ability to connect with that
because my ego structure is just so broken up from my years of addiction and
trauma, if I can start to connect, help a client facilitate some entry, into their
suffering, that they feel me connecting to their despair in an affect, in an
emotional way, just like a good mom would do with her child, or a good father would
do, or a good friend, or good lover, or we empathetically, empathetically connect
and we help them bear the unbearable, that’s the healing piece. It’s really
terrible — how can one, anybody, deal with such acute despair, hopelessness, no way
out, no way out, if there’s not some sound sense that there’s an alternative. So
fundamental to the treatment process is a relationship where both by what
you say as a clinician but really who you are in yourself, how do you handle
your own affective stage, your emotional states, including despair, which your
ability to tolerate your own despair, your own sadness, your own grief, your own
shame, parallels or both connected both connected. [John] So to wrap up this part: the nature of the problem — the key takeaways really are I think: we are in the same
boat. That you know when our patients enter into kind of the clinical room
and we’re working with them, in some ways you know, we also have to pay attention
to our own bodies, to our own histories. Mark talked earlier about you know again
as a Jungian analyst, paying attention to sort of the psychodynamic transference
and countertransference, and the relational pieces of this, but we’re in
the same boat. We I think as a field we fragment these problems and we fragment
our treatments and so as we start talking about treatment, we’re going to
talk more about integrated solutions, integrated unified protocols for
treatment. The body is incredibly important in this work, both for
addiction as well as for trauma, paying attention to the body, being able to
really sense when patients are sitting in front of us, even well or whether we might think that they’re on substances, and then being able again in
a safe, nurturing way, relational way, to ask them about, you know, have they been
using substances, not in a way to get them to run out and not come back and see us but
again to create a framework for how to move forward productively. And again
last point, as I said is we need to see our patients as more than their problems
and their pathologies. We need to really understand how to help them see a bigger
frame of life. [Mark] So with that, so again the piece about body, you know, what’s, what’s
my body, what does that mean? So it’s my ability as clinician to engage in,
tolerate, work with, listen to, my body sensations, my body sensations. And the
other piece primary is my building to connect with my emotions, again, my
capacity to tolerate affect, and sadness, fear, happiness, shame, despair,
anger and so then you’re paying attention to that in yourself, so then
you develop that capacity to work with other people inter-personally, inter-personally. [John] Good so we’re going to talk now about treatment and give again,
realizing that we have limited time, try to put up a few ideas that you can take
away and maybe follow up in your own work. This is an old, it’s an old quote from
Stephen Covey, you might remember the “Seven Habits of Highly Effective People.” “To begin with the end in mind means to start with a clear understanding of your
destination. It means to know where you’re going so that you better
understand where you are now and so that the steps you take are always in the right
direction.” So taking that forward, thinking about our clinical work, I want
to walk through just quite quickly here actually how we think about treatment
outcomes and the work that we do, and the model that frames the work is the
contextual model by Bruce Wampold, and his colleague Imel, and there’s some
other folks. The book is “The Great Psychotherapy Debate.” I think it came,
there’s a second edition that came out in 2015. But the model says that good
outcomes from clinical work, there are really two that we focus on: one is a
better quality of life for our patients, and the second is that we help them
reduce the symptoms that they’re struggling with in their life, addiction,
trauma, other co-occurring challenges. And these two sets of outcomes really come
about through three change pathways. So if you look in the bottom, read back up,
let’s three pathways for change or the clinical relationship, the
expectations that we as therapists set for their patients by talking about the
nature of the problem, and then the solution, that you know we are
essentially doing in our clinical work. And then the third is the actual
interventions or what some people say are the evidence-based practices. These
are the three pathways, and in some ways to even get into those pathways, it’s
that very first session — you have to have an initial therapeutic bond, just like
when you meet somebody new for the first time, we do read a lot of book by its
cover, and there’s a lot of research to show that those first interactions are
very, very important in that therapeutic bond you know and and again not every
therapist is right for every patient so in those first few moments if the bond
occurs and it’s strong and that relationship moves into a clinical
relationship, we have three pathways that really help us to
understand outcomes. [Mark] So with that, so talk about the real relationship, so I’m
really, in the last 10 years, I’m of the school, you know, I do a bunch of training
part of the Jung Institute in in Portland here, and we’re typically, when you assess
people who come in for, to be a therapist, whatever tradition, that you look for, you
know, how smart are they more from a [unintelligible], you know, their IQ, and can
they do the book work, really, you know then secondarily, almost, is their empathy. But I’m increasingly of the school that what makes good therapists is their
social emotional intelligence out of the gate and then how well they develop that,
because then they’re more in an embodied sense compassionate, including first
with themselves then with another person, so we can’t overestimate the quality and
importance of the real relationship, that you relate to your client, you know, you
have a persona in the context, but you’re a real person, because they need real
experiences, positive connectors literally in their neural physiology, so
that the dopamine, the serotonin is released just like a good mother with a
child, a good father with a good mother, where they set a frame for the kid,
dopamine, serotonin and are banging banging banging the good-feel drugs. That we create these unit of experiences so then people can deal with the core
negative feelings, you know, their fear, their shame, their despair. [John] The research in the contextual model has shown that 65% of the variability in outcomes
really comes from that real relationship this is — another way that people think
about the contextual model is the common factors model, that there are common
factors, relational factors, that contribute to good outcomes. The
relationship is 13 times more important than the model technique or
evidence-based practice used in treatment. So instead of spending our time talking
about a lot of very specific treatments and specific therapies and models, in
some ways the very best that we can do is really understand, you know, how to
evolve our relationship with our clients. One way we do that is by providing them
hope through enhancing their expectations for the future. And one way
we do that is by getting good at being able to frame the nature of the problem —
addiction and trauma — you know understanding, again, the nature of these
issues, how they occur in the overtime in the brain, as well as how they they play
out together, so that as I talked about earlier, the idea that addiction is
adaptive is really important in helping clients to reduce their stigma and their shame around what they’ve been through. Evidence-based
practices as you can see in the slide you know it’s a small sliver and it’s
not that they’re not important, they’re absolutely critical, it’s just that the
search for a practice that works better than another practice has really failed. What we have is a collection of practices that all work moderately well. So it’s important to pick one because you can have a real relationship and
have good expectations for the future but you still have to do something as a
clinician. [Mark] Let me just say so with that, so again I’m not pushing everybody
become a psychodynamic psychotherapist, I can do a bunch of kinds of therapy
because I worked with a lots of kinds of people over a long period of time, but
that empathically congruently kind of with who you are as a person,
what’s your model, what’s the model that you move from, that it’s congruent with
who you are as a person and it’s obvious in relationship to your clients — that
they get, you know, the way you’re working is well you know “That’s Mark” or “That’s
John” — you know that’s kind of his style and may be different or some similarity
but the genuineness, the authenticity, the real deal, I mean real deal begets real
deal. Real deal begets real deal. That’s, that’s deep. [laughter] [John] All right, moving right along, who are expert
therapists — I wanna, you know, age gender profession theoretical orientation
returns to treatment protocol — none of these predict expert therapists. The
people who really get the best outcomes again really learn how to fine-tune
those three pathways. So pathway 1 is the relationship. Tim
Anderson talks about facilitated interpersonal skills, the ability for us
to instill hope in our clients, verbal fluency, persuasiveness, emotional
expression, these are all the things that Mark has been talking about relationally. Pathway 2 again is this idea that you know we have to get good at being able
to really talk with our clients about the nature of the problem, of the
solutions that we are offering in a way that they buy into and that they
appreciate and that we can then actually deliver the intervention. If they’re not
buying into the way that we frame the problem and the solutions that we offer,
you know, we can have the very best evidence-based practices but they don’t
get very far. The last piece on the right here is this idea that as therapists,
just doing therapy, there’s not research that suggests that we become better
therapists. What makes us become better therapists is really evaluating our work
both formally and informally. We can use tools with patients. Scott Miller
called this “feedback informed treatment.” I use the outcome questionnaire-45; I
give it to patients once a month, look at their scores. But the other is that we
also videotape sessions, we show our videotapes, you know, to our colleagues we
get feedback on our blind spots, and then we practice those blind spots, again,
going back to you know what is it in those three pathways where we need to
practice. But it’s really about deliberate practice. We get better at
getting good outcomes by really honing in on what we do well, what we don’t do
so well, and then practicing those, those blind spots. [Mark] So again so with that you
know, the weight is path 1 and again how I would experience that would
be social emotional intelligence, and you, the clinician, deliberately developing
that, deliberately developing that. Hopefully you got enough of that so
that you’re in the game to begin with, you’re in the game to begin with, and
then practicing your own emotional intelligence, your ability to identify, to
tolerate, to work, to bear and use your own feelings, your body sensations, in
connection with other parts with you like your imagination,
your cognitive processes, your memory. So that you can connect to these pieces in
yourself, if you could do that then you’re in relationship with somebody who
you’re practicing the same thing with them — that’s the nature of trauma, where these
things go sideways. The path to the problems-solutions focus is aspects of
the framework you know how do you frame your ability to emotionally connect with
somebody? You need some cognitive structure, ie, you know, I’ll see you once a week,
I’ll see you twice a week, we’re gonna work on your sobriety, because you can’t
relax enough if you’re always getting high. And so then we work on cognitive
structures with other things they can hang their hat on, to get a relapse
prevention model that gives them a base, but then my estimation, then you got to
go after the feeling, emotions, what’s fueling the fire of the behavioral
addiction, the chemical addiction. [John] So I want to talk a little bit completely
about assessment and then some specific — so this is again sort of pathway 2, and
then we’ll talk a little bit about some of the actual practices and then we’ll
take some questions. You know I’ve experimented in a variety
of ways how to assess clients particularly that have a whole host of
issues coming into session, again, trauma, all of the different addictions, and I’ve
landed on kind of creating a comprehensive behavioral health
self-evaluation that works for a majority of clients, who again you
know are less functioning, and I will work through this evaluation with them
in session, but for the majority of clients that can read and write, this
packet has a variety of validated assessment tools. I’m going to make this
packet also available to all of you, you know, you guys can download it. But I’ll
make sure that you get a copy of it and it’s a, it’s a Word document, so you can
go in and cut and paste and do whatever you want with it. But a lot of the
validated tools in there are, they’re all in the public domain. For trauma I use
the PCL-5 which is the VA tool, 0 to 80, there’s kind of a cut-off score around
33, and it’s a tool that can be used more than once to assess trauma. I also have
in here assessing ACE score, 0 to 10, so ACE score. The other thing is that also looking at the fact that many of
the patients that struggle with trauma and addiction also struggle with a version
of insecure attachment — we didn’t talk a lot about, or at all really, in the
beginning about attachment but in the general population, about 40% of people
have a version of insecure attachment, but in terms of clinical populations,
people showing up with trauma and addiction, it’s much much higher. And in
some ways, John Bowlby, the father of attachment theory, is that you know in
some ways attachment is cradle-to-grave and it influences the ability for people
to initiate form and really have healthy relationships. Attachment is in place
somewhere around 18 months of age, so again, you know, people don’t have a
lot of say in the attachment style that they end up coming out of the gates
with. Nobody is destined to maintain their attachment style, though, people can
earn secure attachment through some interventions. We’ll talk about it in a
minute but the idea with this evaluation is that patients fill out the packet,
they come into session, and then and then it’s very relational, that part of
building, that hope for the future, and increasing and enhancing the positive
expectation, is going over the results of these different tools and putting a
complete, as best as possible, picture together of what a person’s been
struggling with. My experience has been that very often, you know, patients
struggle with with disintegration, you know we’ve been talking about how all of this
creates fragmentation within people, not only their psyches and their bodies are
fragmented, but we did you know we fragment all these disorders, so having a
comprehensive evaluation where you can sit with a patient and then relationally
go over the results in a session, sometimes two sessions, and really use
the session as putting the puzzle together. And at the same time
that that’s being done, checking in with the body — I ask patients you know what’s
your experience right now just sitting here as we go through this evaluation,
what are you noticing in your body, and then processing the emotion that comes
up as we go through the evaluation. But very often,
at the end of this session or a couple sessions, the whole goal is to enhance
the motivation and the hope for the future that you know we do have tools
and strategies and practices that can help people overcome you know the
picture that we frame in the evaluation. [Mark] So with that — that was well-stated, John, so the piece about motivation, you know, motivational interviewing,
motivation, how do you build motivation? Again I’m of the school: affect is king, emotion
is king, emotions put this in motion and then typically when people have trauma
again sort of you know complex from a simple trauma, complex trauma
developmental trauma, we’re talking mostly here about developmental trauma,
long-standing, and also complex trauma in substance, but it’s a problem of affected
body sensations that they get separated from thoughts, kind of, structures,
memories, images, and then when they do connect, they come back in a grand relief
with lots of pain, and then people dissociate because it’s overwhelming. They do weird stuff compulsively to try to, as John says, protect themselves. So
the ability, again, to, so two big takeaways I want to communicate: one is
the wound is the cure in the right dose, so you have to work people’s wound. Trauma,
in the end, in the Greek, it means wound. Big wound, little wound, we’ve all got trauma, we all have wounds, how do we handle our traumas. And, the right dose, so when we work with people
in their body, with their body sensations for emotions, or eliciting that state to
come up into session, just like a good mama would, just like a good daddy would
for the child or an adolescent, the other piece is: what’s the seed, what’s the
creative seed that’s trying to come out of the wound? It’s not just reductive, you
know it’s all bad, and acting bad and I just got to get behind, there’s some kind
of push that’s trying to come out, some creative piece. You know that, we had the quote from Picasso etc, what’s the seed that’s trying to manifest? [John] One of the things too, that has happened with this evaluation tool is with clients that
stay do the PCL 5 on trauma, it’s happened many times that patient will score a
zero or they’ll put a two or three out of eighty, like like they had absolutely
no trauma, and then in a recent session I had a client telling me about when he
was ten years old and his mother put him in the car and in this particular part
of town there was a cliff and so she said as they’re driving towards the
cliff that they’re gonna be better off after the car drives off, over this cliff,
and he’s saying it in a matter-of-fact way. This is a guy who put
zero on his PCL 5, and I said, well, you know, what were you thinking? And as
they’re driving in this car, racing towards this cliff, he said, you know, I
was really pleading with my mom not to drive over, and I was thinking in my mind
I’m gonna jump out of the car before the car goes over, and he said, you know,
fortunately at the last minute she decided not to do it. But again when I,
you know, in the assessment and asking him, you know, was this traumatic for him
it was absolutely not traumatic, but again if you think about “the body keeps
the score” and what happens with the body in order for him to survive this moment,
you know, in some ways he had to shut down, he had a freeze response, and I
think in some ways part of the challenge we have right now with the opioid
epidemic, if you think about it, is that when people have trauma and they go into
the freeze response. Part of that freeze response is natural opioids flooding the
body and I think, you know, there is a connection to the fact that a lot of
people right now that gravitate toward pain pills and heroin. Opiates are able
to reconnect with an experience of freezing. I don’t hear a lot about that
but there’s absolutely a link between the freeze response and the opioid
epidemic in my opinion. [Mark] And I would say from a phenomenological point of
view, being around somebody who’s high on, you know, street heroin, that’s what they
look like, you know, they start to nod off and they’re soothed, at
least initially, and they’re kind of frozen, they’re stuck in place, they can
move etc, so it’s not a true freeze in the classic sense, but it’s it’s a
response to too much stimulant. In the end, that blunted, flat affect is not the absence of emotion or body sensation, it’s not the absence, it’s
too much, and so the brain, the central nervous system compensates by
flattening, blunting affective response. You see that all the time.
Street people, hardcore addicts, you see that in prison population, high-end
military operatives, etc, so affect — follow the affect, follow the emotion. [John] We talked
earlier about the problems really being, being kind of a combination of the
biology, the genes in the environment, and so our treatments really have to
appreciate both of those as well. And as clinicians, when working with trauma and
particularly working with addictions, and and right now with opiates, you know,
being familiar with the arsenal of addiction medications is very, very
important. We don’t have time to go through all of these, I assume many of
you are aware of these different medicines, but if you’re working
clinically with patients and other addictions, understanding these different
medicines, the benefits, the risks, and the costs, and learning how to talk with
these medicines, with patients, is absolutely critical. Many that are
struggling with, you know, opioid use disorders are gonna make little progress
and until their brains get stabilized enough through medicines to be able to
do the deeper work of trauma that, you know, Mark and I have been talking about. I want to talk briefly about two protocols
that you may or may not be aware of, again, we have a limited time and we want
to have, give you some time for questions, but the two protocols: one is
Dan Brown and David Elliott’s work on treating attachment disturbances. This
book came out in 2016. You can go to a website, theattachmentproject.com where you
can learn more about this, but in our experience the majority of clients that
we work with have attachment disturbances, and in some ways part of
what I’ve learned from working with — Dan is one of my mentors — is that clinically
we treat the earliest disturbance first. Now clearly if people are coming in and
and you know they’re high on drugs or using alcohol, you know, people
need to be detoxed, we need to work with that piece first, but when people are
stable enough to work with clinically, usually I start with attachment, and the
very best protocol that I have come upon to really help people remap their
attachment systems is the three pillars model of comprehensive attachment. The
idea has been in the past that our relationship in therapy can kind of
repair these attachment problems, but you know one hour, two hours a week is not
enough, and so this model is really one that uses the imagination, and that we
create these idealized parent figures that can remap attachment within three
to six months — it’s very very powerful. If you’re not familiar with Dan Brown’s
work or you know with with this particular protocol — part of it is just
making you available and saying you know I encourage you to go and look at this
work. On top of that, once attachment has been addressed then we’re really talking
about, you know, and again, we’ve been talking about these three pathways —
assuming that you have a good relationship with the patient, and you’ve
been able to kind of express the problem and the solution, then it comes down to
that third pathway is, you know, what do we do,
and I have been working more and more with the “unified protocol for transdiagnostic treatment of emotional disorders” developed by David Barlow and
his group in Boston. This is one protocol that treats all of those different
disorders up there: PTSD, OCD, panic, VAD, social anxiety, treats all of them with
one approach, which, to me, again, is leveraging my time, my resources. In
addition to these protocols, there’s also workbooks for clients that they can use,
so there’s actually homework, and things that clients can do on their own. And the
feedback that I’ve gotten from clients has been really phenomenal with this
approach. If again, if you’re not familiar with the unified protocol, there’s a
website, you can check it out. But in some ways these two resources really have
kind of been the backbone of that third path. You know when somebody says okay you form a relationship, you have the
expectations lined up, what do you do now, these two researchers would
be what I do. [Mark] So what that, so, you know you can see the tension, and at best you
know it’s a creative tension between kind of the prescriptive approach, you
know, based on, at best based on data, and you know, thoughtful reflections on the
nature of the problem: how do we intervene with these problems? But again
I push, you know, I’m a thinker so I like all this conceptual framework, but it’s
you as a clinician and so then how attached are you and your relationships,
how attached are you to yourself, and so then, you know, there’s a classic depth
psychology point of view, you really can’t go farther with your clients
beyond where you are, and you can stretch that but push comes to shove in a
long-term psychotherapeutic relationship, I think that’s substantively true,
because I’m the lesson I teach, you know, in my my self-expression to my
clients. Again in that framework. My ability to tolerate affect, work with it
creatively, hooks up to my imagination. We’re built to be creative
and then how do we get creative, and you know these are huge puzzles, and they’re
way beyond in some ways our cognitive strict-cognitive, frontal lobes’ ability to
organize and put a plan together so we have to really connect the brain, central
nervous system’s capacity to hyper develop in one of those circumstances
where development happens. [John] So, I’m aware of the time: last two slides. Just want to
comment that both Mark and I in working with patients you know in some ways
share patients — we do individual, we have other colleagues that we work with that
do couples counseling, we put clients in men’s groups and
women’s groups, we work with medical professionals on medicines, on doing you
know psychiatric evaluations, if there’s anything cognitive traumatic brain
injury, we work with physicians, we’re very supportive of self-help groups, the 12-step community as well as others, you know, smart recovery
and using the community as a support. I frequently refer clients to yoga studios,
to dietitians, you know in some ways encourage clients to explore theater and
cooking in a creative way. It takes a village. So that kind of wraps us up. We’re in the same boat, our overall goal is to try to help clients integrate, we
also want to focus on not only helping clients with what they struggle with in
life, but also, you know, their strengths and their virtues and assessing those,
and again this is tough work so practicing self-care. [Mark] Practice practice practice [John] All right we have a few minutes for
questions, Bia, is that are you taking that on? [Bia] Yes, so let’s move here so this is the
contact information of our speakers, thank you so very much for this very
interesting perspective. We are now open for questions. Please type your questions
in the box. Meanwhile we depend on your evaluation and we really appreciate if
you take a moment to respond. There are two short surveys — one is going to be
sent right now right after this, and the other one is sent in a month. We want to
get better at what we do and we need your feedback for that and you even get a $5
gift card when you complete each of our of the surveys, so it’s your cup of
coffee right there. We also like to remind you that we have a webinar on the 4th Wednesday of every month so our next webinar is going to be about SBIRT
model for teens please join us. Okay so we have one
question here for: how long the detox would you recommend starting the process of trauma work? [John] This is John, I would say, you know, detox isn’t treatment
and very often you know people will go through detox and then sometimes fall
through the cracks and not get treatment. So in some ways following detox, really
the very next thing is to focus on the stabilization specific around the
addiction, so somebody doesn’t relapse and so, you know, normally I think an
appreciation of the role of trauma building in that expectation and helping
people to understand that at some point, the reason why addiction has been a
problem in their life is that adaptive nature to what happened earlier on,
whether it’s attachment trauma-related and so I start the conversation very
very early, right there in the assessment. But when it comes to the actual, you know,
treatment for me, at least it starts around the education piece, but
actually working with trauma and bringing up memories and working with
the body comes much later, probably you know, could be, could be months later, but
but not right after detox. [Mark] Yeah, and again you’re doing an assessment, you know,
what’s the degree of detox, how pervasive the behavior, or the chemical use, you know, what
was the effect function [unintelligible]. So again bottom line for me is you use
your empathy. I’m going to inform by practical experience but in detox as
John says it’s you know detox is not treatment except to start to build a
frame, so what’s the quality of the frame in their day-to-day life, you know, do
they need then, you know, further treatment in a residential setting, they
need to go to an intensive outpatient program, so you’re making these judgments
like you would with a child or adolescent or somebody who’s recovering
from surgery, you don’t do PT for the first two weeks after you know, knee
replacement, you know, but you base it on the specificity of the person’s state
who you’re treating. [Bia] Okay well thank you very much, we are two minutes to the
end so I’m gonna try to get one more question here, and a question is: what
what would you say would be the best therapy on the air of being “creative” for
a person struggling with addiction? [Mark] So for me once they’re focused, actually, what I
do typically, I learned this in my Jungian analyst training, but a staple of
play therapy for kids is to draw pictures, spontaneous pictures, it’s a way to
bypass the frontal lobes, including with artists. So you can say even, where you ask them to use another, their opposite hand. It’s not about craft it’s about symbolic process. You’re bypassing frontal lobes
in substance, and you’re getting into the amygdala, to that imaginative reason. The
first time I did that back in my early 20s, when I was seeing a Jungian analyst
for the first time, he asked me to draw a picture, I was like, huh, and I drew the
picture, and the picture that I drew was a dumpster, and I was in the dumpster, and
so the tale begins, you know, that’s been a guiding principle how I work with
people’s dumpsters. [Bia] That’s very interesting, so we have way more
questions that we can answer but I want to remind you that this webinar is going
to be up as soon as we finish this and then their emails and contact
information is in this slides and you can, you know, email them and they may have the opportunity to respond
to you — we can’t assure that. And so again thank you so much for for today, we really
appreciate the opportunity to hear from you, and thanks for attending, all
attendees. We had a record number of people joining us today. And talk to you
next fourth Wednesday of the month! Thanks, thank you, thank you everybody.


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