The document discusses traumatic events, PTSD, and substance abuse disorders. It notes that around two-thirds of the global population experiences a traumatic event that could meet criteria for PTSD. Around 8% of those who experience trauma receive a PTSD diagnosis. The document then discusses what can cause trauma, prevalence of PTSD and substance use disorders occurring together, and poorer treatment outcomes when PTSD and SUDs co-occur. It also discusses the proposed DSM-V criteria for PTSD and explores concepts like containment and autonomic regulation therapy, memory systems, and how trauma impacts the autonomic nervous system.

1. Michael F. Barnes, Ph.D., LPC
Clinical Program Manager
CeDAR – University of Colorado Hospital

2. INCIDENCE OF TRAUMATIC EVENTS
Worldwide, it is estimated that two-thirds of the population in
exposed to a traumatic events that meet the DSM stressor criteria
for PTSD.
According to the National Center for PTSD:
 61% of men and 51% of women report having experienced at least
one traumatic event (lifetime)
 10% of men and 6% of women report having experienced four or
more traumatic events (lifetime)
 Of these trauma victims, 8% receive diagnosis of PTSD
 1% of American Population (New England Journal of Med)

3. What Causes Trauma?
 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
 Death of a loved one
 Divorce
 Family Trauma
 Abandonment or Attachment Trauma
 Living in an alcoholic or otherwise dysfunctional family

4. PTSD & SUBSTANCE ABUSE DISORDERS
Prevalence of PTSD and SUDS
 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
SUD’s than individuals without PTSD.
 Have earlier histories with A & D, more severe use, and poor
treatment adherence.
(Khantzian & Albanese, 2008)

5. 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)

6. PTSD & SUBSTANCE ABUSE DISORDERS
 Age of onset – Childhood Trauma
 Individuals meeting diagnostic criteria for both alcohol dependence

and PTSD, who experienced childhood trauma reported greater
PTSD symptom severity, particularly intrusive symptoms, greater
alcohol symptoms severity, and greater trauma related alcohol
craving.
 Appear to be particularly vulnerable to relapse following treatment
for alcohol dependence, if PTSD symptoms are not properly
assessed and treated.
 (Schumacher, Coffey, & Stasiewicz, 2006)
 Severity of reported childhood trauma predicted cocaine relapse in
women during a 90 day follow-up.
 (Heffner, Blom, & Anthenelli, 2011)
8

7. ADVERSE CHILDHOOD EVENTS
ACE Studies – Longitudinal study carried out by the Centers for
Disease Control and Prevention (2009) and Kaiser
Permanente Department of Preventive Medicine (17,421
sample size).
ACEs are trauma exposures that constitute a frequent and
common pathway to social, emotional, and cognitive
impairments that lead to increased risk of unhealthy
behaviors, risk of violence or re-victimization, disease,
disability and premature mortality as people age and
develop. (Anda, 2008, www.aapweb.com)
 Felitti, et al. (1998) reported that individuals with ACE were found to
have:
 2.5X% greater chance of smoking over children with no aces.
 5.0X% increase in self-acknowledged alcoholism
 4.6X’s greater chance for injection drug abuse.
American Journal of Preventative Medicine (1998)

8. Trauma Informed Addiction Treatment
 It is important to recognize that trauma informed addiction
treatment started in the early 1990s.
 A 2009 survey found that 66.6% of over 13,000 addiction
treatment facilities in the US reported including trauma focused
care (33.4% did not).
 Facilities that did not provide trauma treatment were
located primarily in the South, Midwest, and West
 Primarily for-profit facilities
Capezza & Najavits (2012)
 The object is NOT to provide primary trauma therapy for past
traumatic events (no focus on the trauma story).
 Focus on resolution of trauma symptoms that are experienced
in addiction treatment.
Najavits (2006)

9. Trauma Informed Addiction Treatment
 Trauma informed care is not a model of treatment, but a
philosophy of treatment that is based on:
 An appreciation for the high prevalence of traumatic
experiences in persons who receive mental health services
 A thorough understanding of the profound neurological,
biological, psychological and social effects of trauma and
violence on the individual clients.
(Jennings, 2004)
 Acceptance of universal precautions as a trauma informed
concept (presume that every person in treatment has been
exposed to some traumatic experience).
(Caldwell, 2006)

10. Trauma Informed Addiction Treatment
 Committed to providing a safe physical environment
 Safety from substances, dangerous relationships, and extreme
symptoms (suicidality and dissociation) – Najavits (2009)
 Safety in working with informed staff in a warm, supportive,
and empowering setting.
 Safety in that counselors, physicians, and support staff are
aware of their own trauma histories, countertransference
reactions, and compassion fatigue
 Treatment and support environments infused with both recovery
and resiliency focus
 Use of treatment methods that empower traumatized clients
to engage in a recovery program, while also working on
day-to-day trauma symptoms.
 Commitment to avoid re-traumatizing practices
 Commitment to appropriately assess trauma

11. Trauma Informed Addiction Treatment
 Recognize that addiction treatment with traumatized clients will
be full of triggers that can prevent the client from receiving the
recovery message and interfere with treatment compliance and
treatment success.
 Educate clients and their family members on the interrelationship
between both treatment issues.
 Recognize that treatment success will be associated with assisting
clients to develop:
 Self- awareness  Assertiveness
 Self-regulation  Clear expression of need
 Self-soothing behaviors  Clear communication
 Self-esteem and self-trust  Accurate perception of others
 Clear limit setting Harris & Fallot, 2001

12. DSM – V: Proposed Diagnostic Criteria
for PTSD (Friedman, Resick, Bryant, & Brewin, 2010)
 Criterion A - The person was exposed to 1 or more of the
following event(s): death or threatened death, actual or threatened
serious injury, or actual or threatened sexual violation, in one or
more of the following ways:
1. Experiencing the event(s) him/herself.
2. Witnessing the event(s) as they occurred to others.
3. Learning that the event(s) occurred to a close relative or close
friend.
4. Experiencing repeated or extreme exposure to aversive details of
the event(s) (e.g., first responders collecting body parts; police
officers repeatedly exposed to details of child abuse).
 Witnessing or exposure to aversive details does not include events
that are witnessed only in electronic media, television, movies or
pictures, unless this is part of your vocational role. Exposure to
aversive details of death applies only to unnatural death

13. DSM – V: Proposed Diagnostic Criteria
for PTSD (Friedman, Resick, Bryant, & Brewin, 2010)
 Criterion B – Intrusion symptoms that are associated with the
traumatic event(s), that began after the traumatic events (1 or
more):
 Recurrent, involuntary, and intrusive distressing memories
 Distressing dreams
 Dissociative reactions (e.g. flashbacks.)
 Prolonged psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the
traumatic even
 Physiological reactions to reminders of the traumatic events.
 Criterion C – Avoidance Behaviors (1 symptom needed)
 Intentional or Conscious Avoidance
 Avoidance of thoughts, feelings, or conversations associated
with the stressor.
 Avoidance of activities, places or people associated with the
stressor

14. DSM – V: Proposed Diagnostic Criteria
for PTSD (Friedman, Resick, Bryant, & Brewin, 2010)
 Criterion D - Negative alterations in cognitions and mood that are
associated with the traumatic event(s) (that began or worsened
after the traumatic event(s), as evidenced by 3 or more of the
following:
 Inability to remember aspects of event – dissociative
 Persistent and exaggerated negative expectations about one’s
self, others
 Persistent distorted blame of self or others about the cause or
consequences of the traumatic event(s) NEW SYMPTOM IN 5!

15. DSM – V: Proposed Diagnostic Criteria
for PTSD
 Criterion E – Alterations in arousal and reactivity that are
associated with the traumatic event(s) (that began or worsened
after the traumatic event(s)), as evidenced by 3 or more of the
following: (Note: In children, as evidenced by two or more of the
following):
 Irritable, angry, or aggressive behavior
 Reckless or self-destructive behavior – NEW ITEM IN 5.
 Hypervigilance
 Exaggerated startle response
 Problems with concentration
 Sleep disturbance – for example, difficulty falling or staying
asleep, or restless sleep.

16. Containment and Autonomic Regulation (CAR)
Therapy - Background
1. Peter Levine (1968 to present)
• Somatic Experiencing

• Applied linear modeling to describe the behavior of the
Autonomic Nervous System (ANS)
• Proposed that Event Memory stores ANS states and those states
are accessible through sensation.
• Based Theory on Ethology – the study of animal behavior
• Healing takes place naturally when ANS recalibrates on its
own.
2. Neuroscience of Memory (Grigsby & Stevens)
• Neurodynamics of Personality
• View of memory as a complex relationship between different
memory systems.
• Memory Systems: Semantic, Episodic, Procedural, Event

17. Containment and Autonomic Regulation (CAR)
Therapy - Background
3. Eric Wolterstorff (1994 to present) – Developer of CAR Process.
• Protégé of Peter Levine
• 
Flattened Levine’s 3D model of ANS to 2D model (ANS States)
• Moved from single event trauma to multi-event and complex
relational trauma.
• Identified the need for “solution” as prerequisite for working
with dissociation.
• Developed strong focus on the transference implications from
working with traumatized clients, especially highly relational
traumas.
• Developed individual and group protocols.

18. Containment and Autonomic Regulation
(CAR) Therapy
 Based on the belief that there is a fundamental relationship
between trauma memory systems and the Autonomic Nervous
System.
 Counselors must possess ability to recognize Nervous System
activation and understand what memory states will be accessable
for intervention.
 What type of therapy will work with different memory
systems.

19. Integrating Trauma Memories
(van der Kolk, 1996, Trauma and Memory from Traumatic Stress: The Effects of Overwhelming
Experience on the Mind, Body, and Society)
 In dissociation, there is interference with proper information processing
and storage of information in narrative (Semantic) Memory
 Van der Kolk calls this “speechless terror.” Words fail to describe
situation.
 Trauma organized in memory on a perceptual level.
 During periods of extreme ANS activation (stress or dissociation), see
decrease in activation of Broca’s area (part of brain most critical for
transformation of subjective experience into speech).
 Also see significant increase in activation of areas in right hemisphere
that are thought to process intense emotions and visual images.
 Development of Event Memory of traumatic event.
 Narrative memory (i.e., memory of what happened or the trauma story)
is therefore semantic and symbolic.
 Semantic memory is social and adapted to the needs of both the
narrator and the listener
 It can be expanded or contracted, according to social demands.

20. Memory Systems
 Declarative Memory – explicit memory referring to intentional or
conscious awareness of facts or events that have happened to the
individual.
 Episodic Memory – recall of subjective events in one’s life
 Semantic Memory – (knowledge) – recall of objective facts and
other nonpersonal information.
 Nondeclarative Memory – implicit memory referring to unconscious
memories of skills and habits, emotional responses, reflexive actions
and classically conditioned responses.
 Procedural Memory – learned from prior experience. Lack ability
to utilize new existing knowledge, given unconscious nature of the
memory.
 Event Memory –subcortical mechanism of emotional learning that
bypasses the cerbral cortex.
 Generally experienced as intense emotion or fragments of
sensory information.

21. THE AUTONOMIC NERVOUS SYSTEM
The ANS governs
many automatic
body processes such as:
 Heart rate
 Breathing
 Metabolism
 Temperature
 Sympathetic (fight/flight)
 Parasympathetic (calming,
 digestion, autoregulation)
 Dissociation, numbing
 freeze responses

22. 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
No Solutions
“Scared to death”
State 4: pure dissociation marked by a distinct lack of
physical sensation and flat affect, numbed out, blank,
feeling ‘floaty’, depersonalized, and disconnected
 Somatic Experiencing (Peter Levine, Ph.D.)
 Containment and Autonomic Regulation (CAR) Eric Wolterstorff, Ph.D.)

23. TOP DOWN VS. BOTTOM UP THERAPY
Most therapy
is top-down
approach
bottom-up
functioning
 From Trauma Integrated Addiction perspective, must calm ANS activation in
order to promote Semantic Memory system access.
 Increase effectiveness of talk therapy increase access to “recovery message.”

24. Containment and Autonomic Regulation (CAR)
Exposure therapy focused on the autonomic nervous system
Reproducible, testable, and phase-based protocol
1. Building Resources
• Teach clients tools needed to manage activation of the autonomic
nervous system
• Grounding techniques needed as prep for working with trauma.
2. Building Relational Skills
1. Attachment focused – one person’s nervous system learning to
attach to another person’s nervous system
2. Attachment work is procedural auto-regulation
3. Stressed “yes” and Stressed “No”
4. Focus on boundary development, affect management, and
ownership of the recovery process.
3. Trauma Assessment
• Trauma Symptoms Inventory-2 (Assessment Procedural Memory)
• Assess sources of trauma (Event Memory) and the degree of
activation that the individual experiences when briefly talking
about each.

25. Containment and Autonomic Regulation (CAR)
4. ANS Recalibration / Re-exposure –
 A method of discharging the ANS of stress and trauma (event memory
response), utilizing a process of containment.

 Focus on physiological response, while not acting on physical impulses
to avoid or distract. Goal is to complete defensive responses and
reintegrate the ANS.
 Complex process that works with both hot (anxiety) and cold
symptoms (dissociation).
 Requires significant awareness to pace and staying within client’s
working window (tolerance threshold).
 5. Integration –
 Allowing clients to tell their story in a new way.
 Similar to Herman’s reintegration into society
 Use Figley’s Five Healing Questions (My preference!)
 1.What happened? 2.Why did it happen? 3.Why did it happen to me?
4.Why did I react the way I did? 5.What will I do if something similar
happens in the future?

26. Containment & Autonomic Resolution (CAR) Pilot Study (2011)

t Scores at or above 65 are considered Clinically Significant
• Identified in Red Above

27. TRAUMA INTEGRATED ADDICTION
TREATMENT
 A lens that we look through to understand client behaviors and to
better understand the roadblocks that trauma symptoms provide
for clients in addiction treatment.
Substance
Often labeled Abuse Interferes with client’s
client resistance. ability to hear recovery
message!
Attachment Traumatic Stress
/Differentiation Symptoms
• Assess clients for all three aspects of this triangle.
• Critical for individualized treatment, continuing care planning, etc.

28. Trauma Integrated Addiction Counseling – Assessment
Briere, J. (2011) – Trauma Symptoms Inventory -2 Professional Manual
TSI 2 Clinical Scales/Subscales
• Anxious Arousal
• Sexual Disturbance
• Anxiety
• Sexual Concerns
• Hyperarousal
• Dysfunctional Sexual
• Depression Behavior
• Anger • Insecure Attachment
• Relational Avoidance
• Intrusive Experiences
Rejection Sensitivity
• Defensive Avoidance
• Impaired Self-Reference
• Dissociation • Reduced Self-Awareness
• Other-Directedness
• Suicidality
• Ideation • Tension Reducing Behaviors
• Behavior
• Somatic Preoccupations Tool used to identify procedural memory/
• Pain habitual trauma response patterns and event
• General memory data that needs to be addressed
later in therapy.

29. Trauma Integrated Addition Treatment
TSI-2 Codes/Questions (Briere, J. 2011)
Identifying Proceduralized Trauma Responses
Anxious Arousal (Anxiety)
1 Nervousness 0
29 Feeling afraid of certain things, even though there probably wasn't any real danger 0
57 Worrying about things more than you needed to 0
85 Your mind going over and over things that might go wrong 0
113 Feeling afraid you might die or be injured 0
Anger
3 Feeling mad or angry inside 0
31 Getting angry about something that wasn't very important 0
59 Yelling or telling people off 0
87 Thoughts or fantasies about hurting someone 0
115 Wanting to hit someone or something 0
Intrusive Experiences
4 Nightmares or bad dreams 0
32 Flashbacks (sudden memories or images of upsetting things) 0
60 Suddenly feeling like you were back in the past when something bad happened 0
88 Suddenly disturbing memories when you were not expecting them. 0
116 Memories of the past that won't go away 0
Defensive Avoidance
5 Trying to forget about a bad time in your life 0
33 Stopping yourself from thinking about the past 0
61 Trying not to have any feelings about something that once hurt you 0
89 Trying not to think or talk about things in your life that were painful 0
117 Staying away from certain people or places because they reminded you of something 0

30. TRAUMA INTEGRATED ADDICTION TREATMENT
 Working with Procedural Memory System
 Resourcing and other mindfulness exercises allows clients to learn that
they have the ability to become reacquainted with their body and that

they have some control over the ANS by learning to reduce level of
stress and to remain present rather than dissociating.
 Over 30+ days will provide significant changes to procedural memory
system.
 May want to begin every session with a check-in and resourcing
exercise to insure that the client is able to fully engage in semantic level
discussion.
 As we work with clients at semantic level, may want to check-in
periodically to reinforce the importance of client awareness of ANS
activation. Resource as needed to maximize therapy effectiveness.
 Stressed yes and no exercises (see Relational Abilities above) allow
clients to work on relational triggers that allow the client to maintain
control of ANS and reduce potential for relapse.
8

31. TRAUMA INTEGRATED ADDICTION TREATMENT
 Working with Event Memory - Containment in Primary
Residential Treatment?

 Containment of stress related situations would be very appropriate
and effective in residential treatment.
 Once a client can demonstrate increased skills in relational abilities,
and improvement in affect regulation, it is OK to contain stressors.
 It is not recommended to use containment of trauma in primary
residential treatment.
 It should be very appropriate to utilize containment in REC or
other extended care programs.
 Client experience with resourcing, stressed yes/no, and
containment of stressors in residential, should enhance
opportunities for containment of trauma early in the REC process.
 Might want to develop a trauma specific group, to enhance
utilization of CAR components.

32. 1. ACCESSING
1. Begin by identifying at least one internal or external resource.
2. DEEPENING
1. Choose one resource (either a memory or fantasy) to explore imaginally through
adding details and the five senses. Stay with this until person feels relatively calm
and relaxed.
2. Ask client to provide details of what they notice in their body. If client has a hard
time locating body sensations, model for client: “I am noticing my hands are
warm, my breathing is easy, my shoulders are a little tense.”)
3. Often need to start with basic mindfulness exercises.
3. ANCHORING
1. Make a plan with client participation to find a way to remember to use the
memory during the week.
2. Practice to proceduralize the resourcing process.
4. WIDENING
1. Once client achieves a resourced state, ask client to remember more memories or
fantasies that are positive.
5. STRENGTHENING & TESTING
1. Once client has done the previous steps, you can check client’s ability to bring self
from a stressed state to a resourced state. Ask client to provide details of what
client notices in client’s body before and after. Feel free to practice with client a
few times.
2. This can be done during a session by remembering something mildly stressful,
and then having client return self to the positive memory state. (“We want to
make sure that, if you are upset, you can bring yourself back into a good
emotional state.”)

33. Working with Procedural Memory System
 Dialectical Behavior Therapy (Marsha Linehan, Ph.D.)
 Has the ability to assist clients in the semantic memory system,
but most effective in procedural.
 At CeDAR we utilize addiction focused DBT Groups and
Individual Therapy.
 Four Modules
 Mindfulness (core concept, helps individual accept and
tolerate powerful emotions.
 Distress Tolerance (stresses learning to bear pain skillfully,
acceptance of self and the current situation without
judgment)
 Emotion Regulation (identify and label emotions, obstacles
for changing emotions, reduce vulnerability to emotion,
etc.)
 Interpersonal effectiveness (asking for what we need,
saying no, coping with interpersonal conflict)

34. Trauma Integrated Addiction Treatment
• Working with Attachment
• Two new books have come out in the past year that have
supported this issue.
• 
Trauma and the Avoidant Client: Attachment-Based Strategies for
Healing by R.T. Muller (2011)W.W. Norton & CO
• Healing Developmental Trauma: How Early Trauma Affects Self-
Regulation, Self-Image and the Capacity for Relationships. L.Heller
& A LaPierre(2012) North Atlantic Books
• From a trauma perspective:
1. We either never developed healthy attachment due to early
childhood trauma or neglect, or
2. We developed it, but it was destroyed through other childhood
trauma (ACEs), or
3. We developed it, but it was destroyed through adult trauma

35. Trauma Integrated Addiction Treatment
 Muller (2011)- Trauma and the Avoidant Client: Attachment-Based
Strategies for Healing

 As adults, experience overwhelming attachment-related distress –
profound hurt, rejection, feelings of vulnerability, etc.
 Resort to cutting off relationships (i.e., short term, minimal problem
solving efforts) to avoid feeling
 Compulsive or Insistent Self-Reliance (“I don’t need anyone else!”)
 Devalue social relationships
 Focus more on personal achievements or lack of achievement
 Avoidance of social support – find it exceedingly hard to turn to others
for assistance.
 May seek counseling for symptoms based reasons, but appear
resistant to looking more deeply at root causes of personal problems.

36. TRAUMA INTEGRATED ADDICTION TREATMENT
 Working with Attachment in Substance Abuse Treatment
(Attachment-Oriented Therapy, Flores, 2006)
 Flores uses model in group therapy as well as individual.
 Must:
 Build Therapeutic Relationship

 Challenge the Therapeutic Relationship
 Heal the Therapeutic Relationship.
 Facilitate groups that allow clients to deal with conflict and
disagreement and then work through differences with counselor
and/or peers.
 Not to say that the groups should be confrontational, but clients must
be uncomfortable enough to provide them with:
 the opportunity to learn/practice healthy communication skills
 learn affect regulation
 find that it is possible to remain close to someone that they have
had conflict with.
 Process and experiential groups are most helpful in this area, while
psychoeducational groups are critical for semantic learning.

37. TRAUMA INTEGRATED ADDICTION TREATMENT
 Self-Help Program Participation and Memory Systems
 Participation in AA, NA, CA, SA, etc. is very helpful for clients in

working on semantic and procedural memory systems.
 Self-Help program participation provides clients with significant
positive cognitive information learning from the various sayings,
working steps, etc. (Semantic Memory System improvement)
 Very helpful in recognizing a more clear recovery story. Will become
more clear as they remain active in the program.
 Also very helpful in assisting clients to change patterned or habit based
behaviors. 90 meetings in 90 days can provide significant procedural
change.
 Getting a sponsor, making coffee, etc. can assist in development of
more mature attachment and mature interdependence.
 Traumatized clients may resist Self-help due to lack of trust, attachment
issues, etc.