Links between Childhood Trauma and Adult Disease: Becoming Trauma Informed

With: R. Denice Colson, PhD, LPC, MAC, CPCS

Adult behavioral
health issues
Adverse childhood
experiences
Why it is important to consider the links between…

Origins of
Behavioral
health issues?

One factor that differentiates the
etiological approach…
Symptoms
Symptoms

Consider…
If not addressed, childhood abuse damages
a whole life, not just a childhood.
Completely Mostly Maybe Not Much Not at All
1 2 3 4 5 6 7 8 9 10

Consider…
 Our understanding of addiction could possibly be
changed to consider substance use (and subsequent
dependence) as an understandable solution to
unaddressed and usually unrecognized hurt and pain.
Completely Mostly Maybe Not Much Not at All
1 2 3 4 5 6 7 8 9 10

Alchemy:
…into GOLD! Turning lead…

18 months
Years later – in a
mental institution
Turning gold into lead.
www.TheAnnaInstitute.org
18 months
Anna Carolyn Jennings

Consider…
Challenging the traditional views
of addiction, anxiety, depression,
and other illnesses.

…Traditional views may be
missing the point

…Traditional views may
seriously adversely impact
treatment.

…Research challenges their
validity.

What is the Study?
Adverse Childhood
Experiences

Vincent Felitti, MD
(Kaiser Permanente)
Robert F. Anda, MD
(CDC)

Largest scientific
research study of it’s
kind

Analyzes the relationship
between multiple categories of
childhood trauma (ACEs), and
health and behavioral outcomes
later in life.

It claims to document
the…
…conversion of childhood
trauma and household
dysfunction into adult
addictions and organic disease.

It claims to demonstrate
that…
…childhood abuse is
extraordinarily common.

that …
…childhood abuse
damages a whole life, not
just childhood.

that…
…childhood abuse and
household dysfunction
are the most basic
determiners of the leading
causes of death, organic
disease, and addiction.

How it got started…
Felitti, V. (2011) Adverse Childhood Experiences and The Origins of Addiction. Neuroscience
of Addiction. Presentation to the Alberta Family Wellness Center. Retrieved from
http://www.albertafamilywellness.org/resources/video/origins-addiction

She gained 400
lbs in a shorter
time than it took
to lose 400 lbs.

Issues raised by Patient X…
 Perhaps overeating and obesity were not the core
problem; each was only the marker of the core
problem.
 Like smoke is the marker of a fire.

may not be the essence of
the problem…

What’s looming
beneath the surface
may be what really
sinks people’s lives.

Study Design
 Initiated in 1995 and 1997- enrollees are
being tracked
 Requested participation of 26,000
consecutive patients seeking medical
treatment at Kaiser Permanente in San
Diego; 71% agreed
 17,500+ middle-class American adults

Study Design
 Cohort population was 80% white including
Hispanic, 10% black, and 10% Asian.
 Their average age was 57 years;
 74% had been to college, 44% had
graduated college; 49.5% were men.

Finding Your ACE Score Quiz
While you were growing up, during your first 18 years of
life:
1. Did a parent or other adult in the household often or
very often…Swear at you, insult you, put you down, or
humiliate you? Or Act in a way that made you afraid
that you might be physically hurt? Yes No If yes
enter 1 ___
2. Did a parent or other adult in the household often or
very often…Push, grab, slap, or throw something at
you? Or Ever hit you so hard that you had marks or
were injured? Yes No If yes enter 1 ___

3. Did an adult or person at least 5 years older than you
ever…Touch or fondle you or have you touch their
body in a sexual way? Or Attempt or actually have oral,
anal, or vaginal intercourse with you?
Yes No If yes enter 1 ___
4. Did you often or very often feel that …No one in your
family loved you or thought you were important or
special? Or Your family didn’t look out for each other,
feel close to each other, or support each other?

5. Did you often or very often feel that …You didn’t
have enough to eat, had to wear dirty clothes, and had
no one to protect you? Or Your parents were too drunk
or high to take care of you or take you to the doctor if
you needed it? Yes No If yes enter 1 ___
6. Were your parents ever separated or divorced?
7. Was your mother or stepmother: Often or very often
pushed, grabbed, slapped, or had something thrown at
her? Or Sometimes, often, or very often kicked,
bitten, hit with a fist, or hit with something hard? Or
Ever repeatedly hit at least a few minutes or
threatened with a gun or knife?

8. Did you live with anyone who was a problem drinker
or alcoholic or who used street drugs?
9. Was a household member depressed or mentally ill, or
did a household member attempt suicide?
10. Did a household member go to prison?
Now add up your “Yes” answers: _______ This is your
ACE Score.
www.ACEStudy.org

Used a simple scoring system
from 0 to 10
ACE Score Determination

Exposure during childhood or
adolescence to any category of
ACE was scored as one point.

Multiple exposures within a
category were not scored: one
alcoholic within a household
counted the same as an
alcoholic and a drug user

Research outcomes
tend to understate the
findings.

General Findings…
Less than half of this middle-
class population had an ACE
Score of 0.

General Findings…
One in fourteen had an ACE
Score of 4 or more.

Abuse, by Category Prevalence (%)
Psychological (by parents) 11%
Physical (by parents) 28%
Sexual (anyone) 22%
PREVALENCE OF ACE

Neglect, by Category Prevalence (%)
Emotional 15%
Physical 10%
PREVALENCE OF ACE

Household Dysfunction, by Category (%)
Alcoholism or drug use in home 27%
Loss of biological parent < age 18 23%
Depression or mental illness in home 17%
Mother treated violently 13%
Imprisoned household member 5%
PREVALENCE OF ACE

Dose-Response Relationship
Higher ACE Score Reliably Predicts Prevalence of
Disease, Addiction, Death
Higher ACE Score
Responsegetsbigger
The size of the
“dose”—
the number of ACE
categories
Drives the
“response”—
the occurrence of
disease, addiction,
and death.

Conclusions:
ACEs are
common,
threatening, and
often denied.

ACEs have a
profound effect
even 50 years
later on
addiction, health
risks, diseases,
and death.

This combination
makes ACEs the
leading
determinant of the
health and social
well-being of the
nation and the
major factor
underlying
addictions.

ACE and Adult Alcoholism
A 500% increase in adult
alcoholism is directly related
to adverse childhood
experiences.

2/3rds of all alcoholism can
be attributed to adverse
childhood experiences

0
2
4
6
8
10
12
14
16
18%Alcoholic
ACE Score0
1
2
3
4+

ACE Leads to Early Alcohol
Initiation
•As the number of ACE increase,
the more likely a person is to begin
drinking before 14, or between 15-17
and the less likely they are to begin
drinking at 18 or at 21 (the legal
age).

2/3rds experienced physical and/or
sexual abuse
75% of the women - sexually abused.
(SAMHSA/CSAT, 2000; SAMHSA, 1994 )
Men and women in SA
treatment…

6 to 12 times more likely physically
abused ,
18 to 21 times more likely sexually
abused. (Clark et al, 1997)
Teenagers with alcohol and
drug problems

 86% report physical abuse histories,
69% sexual abuse histories.
 Of those with sexual abuse histories
 96.7% physically abused .
 96% of both (sa, pa) emotionally abused.
(Saylors, 2003; 2004)
Of American Indian/American Native women
in SA treatment

 86% report physical abuse histories,
69% sexual abuse histories.
 Of those with sexual abuse histories
 96.7% physically abused .
 96% of both (sa, pa) emotionally abused.
(Saylors, 2003; 2004)
Of American Indian/American
Native women in SA treatment

ACE and Obesity
66% reported one or more type
of abuse.
International Journal of Obesity (2002) 26, 1075 – 1082. doi:10.1038=sj.ijo.0802038

ACE and Obesity
Physical abuse and verbal abuse
were most strongly associated
with body weight and obesity.
(the abuse types strongly co-
occurred)

ACE and Obesity
Obesity risk increased with
number and severity of each
type of abuse.

ACE and Current Smoking
A child with 6 or more
categories of adverse childhood
experiences is 250% more
likely to become an adult
smoker .

ACE and Current Smoking
0
2
4
6
8
10
12
14
16
18
20
0 1 2 3 4-5 6 or more
ACE Score
%

ACE and IV Drug Use
A male child with an ACE score
of 6 has a 4,600% increase in
the likelihood that he will
become an IV drug user later in
life

ACE and IV Drug Use
78% of IV drug use in women is
attributable to adverse
childhood experiences.

ACE and IV Drug Use
Relationships of this magnitude
are rare in Epidemiology.

ACE and Intravenous Drug Use
0
0.5
1
1.5
2
2.5
3
3.5
%HaveInjectedDrugs
0 1 2 3 4 or more
ACE Score
N = 8,022 p<0.001

Other examples of addiction:
More subtle examples include
Sex,
 Pornography,
 Gaming,
 Gambling,
 Shopping and more.

Adverse Childhood Experiences
and Likelihood of > 50 Sexual
Partners
0
1
2
3
4
AdjustedOddsRatio
0 1 2 3 4 or more
ACE Score
Higher # of ACEs more likelihood of the adult having had 50 or more sexual
partners and being at risk for unwanted pregnancy, socially transmitted diseases,
HIV/AIDs.

ACE Score and Unintended
Pregnancy or Elective Abortion
0
10
20
30
40
50
60
70
80
%haveUnintendedPG,orAB
0 1 2 3 4 or more
ACE Score
Unintended Pregnancy
Elective Abortion

Sexual Abuse of Male Children and Their
Likelihood of Impregnating a Teenage Girl
0
5
10
15
20
25
30
35
Not 16-18yrs 11-15 yrs <=10 yrs
abused Age when first abused
1.3x 1.4x
1.8x
1.0 ref

In other words…
 Boys who were sexually abused are more likely to
impregnate a teenage girl.
 The earlier the age when the boy was sexually abused –
the greater the likelihood that he will impregnate a
teenage girl

Frequency of Being Pushed, Grabbed, Slapped, Shoved or
Had Something Thrown at Oneself or One’s Mother as a Girl
and the Likelihood of Ever Having a Teen Pregnancy
0
5
10
15
20
25
30
35
Never Once, Sometimes Often Very
Twice often
Pink =self
Yellow =mother

ACE Score and Indicators of
Impaired Worker Performance
0
5
10
15
20
25
Absenteeism (>2
days/month
Serious Financial
Poblems
Serious Job
Problems
0 1 2 3 4 or more
ACE Score
PrevalenceofImpaired
Performance(%)

More than 75% of girls in
juvenile justice system
have been sexually abused.
(Calhoun et al, 1993)

80% of women in prison and
jails have been
sexually/physically abused.
(Smith, 1998)

100% of men on death row in
CA have a history of family
violence (Freedman,
Hemenway, 2000)

Boys who experience or witness
violence are 1,000 times more
likely to commit violence than
those who do not. (van der
Kolk, 1998)

Chronic Depression
 Adults with an ACE score of 4 or more were 460%
more likely to be suffering from depression .

Chronic Depression
0
10
20
30
40
50
60
70
80
%WithaLifetimeHistoryof
Depression
0 1 2 3 >=4
ACE Score
Women
Men

Suicide
The likelihood of adult suicide
attempts increased 30-fold,
or 3,000%, with an ACE score of
7 or more.

Suicide
Childhood and adolescent
suicide attempts increased
51-fold, or 5,100% with an ACE
score of 7 or more.

Suicide
0
5
10
15
20
25
%AttemptingSuicide
ACE Score
1
2
0
3
4+

Hallucinations
Compared to persons with 0
ACEs, those with 7 or more ACEs
had a five-fold increase in the risk
of reporting hallucinations.
(Whitfield et al 2005)

Hallucinations
Abuse and trauma suffered in the
early years of development
resulted in a far greater likelihood
of pre-psychotic and psychotic
symptoms. (Perry, B.D., 1994)

Hallucinations
In an adult inpatient sample, 77% of
those reporting CSA or CPA had one
or more of the ‘characteristic
symptoms’ of schizophrenia listed in
the DSM-IV: hallucinations (50%);
delusions (45%) or thought disorder
(27%) (Read and Argyle, 1999)

0
5
10
15
20
25
30
35
40
45
0 1 2 3 4 5 6 7 8
Childhood Sexual Abuse and the
Number of Unexplained Symptoms
History of Childhood Sexual Abuse
PercentAbused(%)
Number of Symptoms

0
5
10
15
20
25
30
35
40
0 1 2 3 >=4
ACE Score and Impaired Memory of
Childhood
PercentWithMemory
Impairment(%)
ACE Score
ACE Score
1 2 3 4 5

51 – 98% of public mental
health clients with severe
mental health diagnoses
have unaddressed
sexual/physical abuse
(Goodman et al, 1999, Mueser et al, 1998; Cusack et al, 2003)

93% of psychiatrically
hospitalized adolescents had
histories of physical and/or
sexual and emotional trauma.
32% met criteria for PTSD
 (Goodman et al, 1999, Mueser et al, 1998; Cusack et al, 2003)

Unaddressed childhood sexual
abuse is significantly related to
adolescent and adult self-harm,
including suicide attempts,
cutting, and self-starving.
(Van der Kolk et al, 1991)

One study found childhood
sexual abuse to be the single
strongest predictor of
suicidality. (Read et al, 2001)

Lasting Alterations in Self-
Perception

• Sense of
helplessness,
paralysis,
captivity,
inadequacy,
powerlessness,
danger, fear…

Sense of
Shame,
Guilt, Self-
Blame,
Being Bad…

Sense of
defilement,
contamination,
being spoiled,
degraded,
debased,
despicable,
evil…

Sense of
complete
difference from
others, deviance,
utter aloneness,
isolation, non-
human,
specialness,
unseen, unheard,
belief no other
person can ever
understand…

Abuse among Native American
Women
 One study of Native American women in a primary
care setting, 77% reported childhood physical or
sexual abuse or severe neglect. (2004, Duran et al)

History of STD
0
0.5
1
1.5
2
2.5
3
AdjustedOddsRatio
0 1 2 3 4 or more
ACE Score

The higher the ACE score the greater the
prevalence of Liver Disease

The Higher the ACE score the more likely a person will
develop COPD

ACEs Increase Likelihood of Heart Disease*
• Emotional abuse 1.7x
• Physical abuse 1.5x
• Sexual abuse 1.4x
• Domestic violence 1.4x
• Mental illness 1.4x
• Substance abuse 1.3x
• Household criminal 1.7x
• Emotional neglect 1.3x
• Physical neglect 1.4x

This illustrates that adverse experiences
in childhood are related to adult
disease by two ways:
1)Indirectly through attempts at self-help through
use of agents like nicotine, alcohol, food, etc.
2)Directly through chronic stress

Poor Life Expectancy: ACE score
of 4 or more reduces life
expectancy by 20 years!

The Impact on View of God, Self-in relationship to God, and
Attachment to God

Spiritual Impact
 If a person’s physical and psychological health is
impacted by adverse childhood experiences even
50 years after their occurrence (Felitti, 2004), then
their spiritual health will also be impacted.

Albert Ellis (1960, 1971)
 “It is the belief in sin that makes people disturbed”
 “Devout religiosity tends to be emotionally harmful.”

Albert Ellis (2000)
 “Although I have, in the past, taken a negative attitude
toward religion, and especially toward people who
devoutly hold religious views, I now see that
absolutistic religious views can sometimes lead to
emotionally healthy behavior. As several studies have
shown (Batson et al., 1993; Donahue, 1985; Gorsuch,
1988; Hood et al., 1996; Kirkpatrick, 1997; Larson &
Larson, 1994), people who view God as a warm, caring,
and lovable friend, and who see their religion as
supportive are more likely to have positive outcomes
than those who take a negative view of God and their
religion.” (Italics added by author)

Spiritual Impact
 One study found that 77% of their targeted
population, adults who were participating in therapy
and had experienced sexual abuse as a child, reported
experiencing obstacles to spiritual development,
including:
 lack of worthiness,
 existential questions about the meaning and purpose of
life,
 unresolved religious questions about the beliefs they
grew up with,
 disillusionment about their faith or religious beliefs,
 distrust, anger, guilt, and other miscellaneous obstacles
(Ganje-Fling, Veach, Kuang, and Hoag, 2000).

 Same study: 68% of the comparison group, which
was also participating in therapy but had not
experienced sexual abuse as children, reported the
same obstacles.
 Whether or not this group had experienced some
other type of traumatic experience was not
assessed, though the fact that they were in
psychotherapy would indicate the presence of
some type of distress.
Spiritual Impact

 Another study psychiatric patient population:
 the more psychological distress and personality
pathology was present, the more negative a person’s
concept of God (Schaap-Jonker, Eurelings-Bontekoe,
Verhagen, and Zock 2002).
 Follow-up study drew from a non-psychiatric, church-
going population:
 After controlling for the influence of denomination,
personality, and psychological distress, researchers
found that psychological distress was the best
independent predictor of negative feelings towards God
(Eurelings-Bontekoe, Hekman-Van Steeg, & Verschuur,
2005).
Spiritual Impact

 Poor attachment bonds with God are related to
difficulty finding meaning and purpose in life
(Beck and McDonald, 2004)
 One’s image of God appears to grow out of one’s
paternal and maternal care-giving images (Brokaw
& Edwards, 1994; Dickie et al., 1997; Hall &
Brokaw, 1995; Hall et al., 1998; Justice & Lambert,
1986; Nelson, 1971).
 Parents have the strongest influence on their
adolescent’s religiosity (Benson, Donahue, and
Erickson, 1989).
Spiritual Impact

 Reinert and Edwards found that verbal, physical,
and sexual mistreatment were all associated with
increased insecurity in attachment to God as well
as with God concepts which were less loving and
more controlling and distant (2009).
Spiritual Impact

ACE and Neurological
development

High Health and Mental Health
Care Costs

The financial burden to society
of childhood abuse and trauma
is staggering.

Child abuse and neglect affects
over 1 million children a year.

Costs our
nation 220
Million
every DAY.

In 2012,
$80 Billion
was paid to
address
childhood
abuse and
neglect
 http://www.preventchildabuse.org/images/research/pcaa_cost_report_2012_gelles_perlman.pdf

 $33 billion in direct costs and $47 billion in
indirect costs, as a result of child abuse and
neglect (PCCA, May 2012)

Child Maltreatment Costs
 $124 billion over the lifetime of the traumatized
children..
 The breakdown per child is:
 $32,648 in childhood health care costs
 $10,530 in adult medical costs
 $144,360 in productivity losses
 $7,728 in child welfare costs
 $6,747 in criminal justice costs
 $7,999 in special education costs (Stevens, 2012)

 ACE Causes serious and chronic health, behavioral
health and social problems
 Impacts one’s perception of self and others.
 Often unrecognized, ignored or denied.
 Finally, ACE is a public health tragedy of epidemic
proportions Leading to long-term use of multi-human
service systems at an estimated annual cost of $80
billion
 Impacts brain and nervous system directly.

Consider again the statements
from the beginning. Where
would you mark yourself now?

Considering all of this information…
 What can we do about it?

Denice Colson, PhD, LPC, MAC, CPCS

First Step…
Admit we have a problem

Trauma-informed Care
(SAMHSA-National Center for Trauma Informed
Care)
 Trauma-informed care is an approach to engaging
people with histories of trauma that recognizes the
presence of trauma symptoms and acknowledges the
role that trauma has played in their lives. …seeks to
change the paradigm from one that asks, "What's
wrong with you?" to one that asks, "What has
happened to you?“
 http://www.samhsa.gov/nctic/

Saakvitne, a psychotherapist and researcher,
points out,
 A successful trauma therapy is about more than
just not having symptoms. It’s really about having
a life…a life that’s about pursuing dreams, pursuing
happiness. But especially it’s about the right to
have a present and a future that are not completely
dominated and dictated by the past. (2000)

4 Guidelines for Implementing
Trauma-Informed Care

1. We can change our
perspective…

View symptoms through the lens of
trauma.

…and consider the context…
Arrested
for DUI
at 23
Raised by a
single mother
Mother was
verbally and
physically
abusive.
Bullied in
School
Started
drinking
at 13,
smoking
pot at 14
Abandoned
by father at 8.

People do what almost works
and substance use is almost
working for this person.

We can ask ourselves, what is the person
trying to solve?
How might this “symptom” logically
connect to what was done to them?
Then we can focus on the source rather
than the symptoms.

Not
blowing
away the
smoke..
Like
putting
out the
fire…

Not cutting off
the limbs…
Like digging
out the roots…

2. We can change our approach to
evaluation…
Rather than only
evaluating the surface…
Make an attempt to
evaluate for the root of
the problem.

Typical Evaluation…
What brought you here today?
What are you hoping to accomplish?
What changes do you want to make?
What diagnosis will I give?
Focus is on symptoms and changing
the symptoms.

Take the S-BIRT approach: Screen, brief
intervention, referral to treatment.
Quite a bit of evidence that SBIRT is effective in
reducing hazardous drinking in patients presenting
in primary care and other health care settings.

While not the same, follow the 5 As
1. Ask about childhood adversity.
2. Advise them of link between adversity and the
top ten diseases that adults die from, including
substance abuse.
3. Assess willingness to address childhood
adversity.
4. Assist to identify sources of adversity.
5. Arrange for follow-up and support.

EFFECT OF Trauma-Oriented
Evaluations on Doctor Office Visits
Benefits of Incorporating a Trauma-oriented Approach
 Biomedical evaluation: 11% reduction in DOVs
(Control group) (Doctor Office Visits)
in subsequent year.
(700 patient sample)
 Biopsychosocial evaluation: 35% reduction in DOVs
(Trauma-oriented approach) in subsequent year.
(>120,000 patient sample)

Simple Trauma-Source
Assessment©
 2 sections: child/adult.
 Simple questions.
 Check-list.
 A few scaling questions.
 Provides for discussion, not “diagnosis”.

3. We can consider a redefinition
of addiction…
 Felitti wrote: “we propose giving up our old mechanistic
explanation of addiction in favor of one that explains it in
terms of its psychodynamics: unconscious although
understandable decisions being made to seek chemical
relief from the ongoing effects of old trauma, often at the
cost of accepting future health risk. Expressions like ‘self-
destructive behavior’ are misleading and should be
dropped because, while describing the acceptance of
long-term risk, they overlook the importance of the
obvious short-term benefits that drive the use of these
substances” (2004).

“My greatest failure was in believing
that the weight issue was just about
weight. It’s not. It’s about not handling
stress properly. It’s about sexual abuse.
It’s about all the things that cause other
people to become alcoholics and drug
addicts.”
Oprah Winfrey

Is it possible that
Gary Allan is right
when he sings…
It Ain’t The Whiskey
 http://www.youtube.com/v/m3Xr67jp1Fo&autoplay=1

While, the traditional concept…
 Addiction is due to characteristics intrinsic in
the molecular structure of an addicting
substance.
If you take heroin enough times you won’t be able to
stop.

Instead, the ACE Study
shows that:
 Addiction highly correlates with characteristics
intrinsic to that individual’s life experiences,
particularly in childhood.

Dr. Felitti’s redefinition of addiction
informed by the ACE Study:
 Addiction is the unconscious, compulsive
use of psychoactive materials or agents in an
attempt to deal with a problem.
 “It’s hard to get enough of something that almost works.”
Addiction is evidence of another
problem.

Like smoke is the evidence of a fire.

However, the evidence is buried
beneath the surface…
Addiction-use
of substances
Protected by:
Shame,
Secrecy, Guilt,
Fear
4 Unspoken
Rules in an
Alcoholic Family

If we could lift the shame,
secrecy, guilt, and fear we see…
ACEs recorded
in memory
Time does not heal – it conceals.

Consider a few studies that challenge
traditional “chemical-based” views
including:
 smoking
 amphetamine
 heroin
 morphine

Smoking Cessation: Policy and Research as it Relates to
Evidence-based Practices in the Military and Veteran
Health Care SettingsFeb. 27, 2014, 1-2:30 p.m. (EST)
Overview
 On January 11, 1964, Surgeon General Dr. Luther Terry released the first
Surgeon General’s Report on Smoking and Health. This scientifically rigorous
federal government report not only linked smoking with ill health and diseases
such as lung cancer and heart disease; it also laid the foundation for tobacco
control efforts in the United States.
 Fifty years later, despite the release of 31 subsequent Surgeon General’s Reports
on Smoking and Health detailing the devastating health and financial burdens
caused by tobacco use, smoking remains the leading cause of preventable
deaths in the United States and kills 443,000 people each year. (U.S.
Department of Health and Human Services, 2014)
 The Smoking Divide
 A new analysis of federal smoking data reveals that although the national
smoking rate has been falling, there is a clear geographic divide. Poorer
counties, like some in Kentucky, have experienced smaller declines than
wealthier counties.

The Smoking Divide
 A new analysis of federal smoking data reveals that
although the national smoking rate has been falling,
there is a clear geographic divide. Poorer counties, like
some in Kentucky, have experienced smaller declines
than wealthier counties.
 2012 in Georgia (down 2% since 1996):
 All adults: 21%
 Women: 18%
 Men: 24%

Abstract: Amphetamine Use now and
then…
 Using historical research that draws on new primary sources, I
review the causes and course of the first, mainly iatrogenic
[doctor caused] amphetamine epidemic in the United States
from the 1940s through the 1960s. Retrospective epidemiology
indicates that the absolute prevalence of both nonmedical
stimulant use and stimulant dependence or abuse have reached
nearly the same levels today as at the epidemic’s peak around
1969. Further parallels between epidemics past and present,
including evidence that consumption of prescribed
amphetamines has also reached the same absolute levels today as
at the original epidemic’s peak, suggest that stricter limits on
pharmaceutical stimulants must be considered in any efforts to
reduce amphetamine abuse today.
 Rasmussen, N. (2008). America’s first Amphetamine epidemic 1929–1971: A quantitative and qualitative
retrospective with implications for the present. American Journal of Public Health. Vol 98, No. 6.

Amphetamines
 Prescribed as the first anti-depressant medications in
the 1940’s.
 Crystal Meth is a potent anti-depressant!
 Is more regulation treating the problem or the
outcome?

Example: HEROIN USE IN A WAR ZONE
 In a study of 898 American soldiers in Vietnam, each of
whom acknowledged using heroin daily for at least the
prior 30 consecutive days, upon return to the US, 95%
were no longer using heroin at 10 month follow-up. No
treatment was received.
Robins LN, Helzer JE, Davis DH. Arch Gen Psychiatry 1975 Aug;32(8):955-61
Narcotic use in southeast Asia and afterward. An interview study of 898
Vietnam returnees.
Robins LN. Vietnam Veterans’ rapid recovery from heroin addiction: a fluke or
normal expectation? Addiction 1993; 88:1041-1054.

Rat Park Experiments
 Rats were fed morphine for 57 consecutive days.
Alexander, B.K., Coambs, R.B., and Hadaway, P.F. (1978). "The effect of housing and gender on morphine
self-administration in rats," Psychopharmacology, Vol 58, 175–179.

 Rats in cramped, isolated cages chose morphine over
water.

 Rats housed in a “Rat Park” chose water over morphine
most of the time.

Could there be hidden benefits of
addiction that we aren’t considering?
 Is getting “high” more than recreation, as many people
say and think?
 Could it provide legitimate protection sexually,
physically, and emotionally?
I am NOT promoting or encouraging
substance use!!

Reconsider the definition:
Addiction is understandable as the unconscious,
compulsive use of psychoactive materials in
response to the stress of life experiences, typically
dating back to childhood. These life experiences are
very likely to be lost in time, and protected by
shame, by secrecy, and by social taboos against
exploring certain aspects of human experience.

Addictions = Survival
Responses

My working definition in terms of
its function:
 Substance use is a survival response;
 When the survival response (substance use) takes over
and becomes a source of trauma in itself = addiction.
 Many other “symptoms” are also survival responses.
 Anger/rage
 Depression
 Defensiveness
 Anxiety
 Etc…

4. We can adjust the way
we do treatment.

Adjusting doesn’t mean…
…We don’t do addiction treatment
…We don’t fulfill the State or agency
requirements.
…We don’t address symptoms like suicidal
thoughts, self-harm, etc…

Adjusting DOES Mean…
• Seek training in recognizing
and treating trauma.

Evidence Based Psychotherapy Models for
Adults with ACEs-related Disorders
 Brief Psychodynamic Therapy
 Cognitive Processing Therapy
 Emotion Focused Therapy for Trauma
 Eye Movement Desensitization and Reprocessing
 Imagery Rehearsal/Rescripting Therapy
 Narrative Exposure Therapy
 Phased Model for Treatment of Dissociation
 Prolonged Exposure Therapy
 Present Centered Therapy
 Present Focused Group Therapy
 Seeking Safety
 Skills Training in Affect and Interpersonal Regulation
 Trauma Affect Regulation: Guide for Education and Therapy.

However, many of these are still
symptom-reduction focused and
not Source-Focused.
 S.T.A.R.: Strategic Trauma and Abuse Recovery; a
Source-Focused Model.

Source-Focused Treatment
 Focuses on etiologies.
 Etiology = the philosophical investigation of
causes and origins.

Considering Source-Focused
treatment…
 Where do we start?

Level 1
Adverse
Childhood
Experiences
Level 2
Social, emotional,
cognitive impairment
Level 3
Adoption of health risk
behaviors
Level 4
Disability, disease, and
social problems
ACE Conversion
Level 5
Death

• What makes trauma, trauma?
• Why is something trauma for one
person, but not another?
• Why do some people develop
serious symptoms and other
people don’t?
• Can the impact of trauma be
reversed?
• If so, how?

“Trauma”
 Derived from the Greek word
that means an injury or
wound.
 Traumatic stress is the
demand for action derived
from a trauma because it is a
physical or psychological
injury (Encyclopedia of
Violence, 2008).

Traumatology
 The study of the causes and treatment
of PTSD (McNally, 2005).
 Interdisciplinary, far-reaching, and
vast.
 Brings together many different related
sciences, including: psychology,
theology, sociology, medicine, and
others (Encyclopedia of Violence,
2008).

What makes trauma, trauma?
 The ACE study uses adversity and identified 10
categories. Are these the only sources of trauma?
• What other events or experiences might we consider
traumatic?
• What other experiences trigger the autonomic nervous
system to fight, flight, or freeze?
• Why do these experiences cause pain?
NO.

Psychological Pain=Contradictions
to…
 Expectations
 Values
 Beliefs
 Needs
Personal
Identity

Psychological Trauma happens
when our Personal Identity is
wounded to the point that we
experience unacceptable
contradictions to our identity
(Expectations, values, beliefs,
needs).

Blueprint for building a
Trauma Survivor
Four Stages in Development

Stage 1
Event contradicts
expectations
Stage 2
Triggers Limbic system:
loss and emotion
Stage 3
Brain rallies to survive:
develops survival
responses
Stage 4
Own responses
contradict expectations
Event occurs
outside of
conscious
control.
(Adapted from Collins & Carson.
(1989). The Integrated Trauma
Management System)

Stage 1: An event occurs…
Sexual abuse
Physical abuse
Death of a loved one or pet
Bullying
Yelled at
Parents yelling at each other
Dad doesn’t say, “I love you”.
Parent gets drunk and acts a fool.
Parent cusses at a waitress
Etc….

The event contradicts expectations,
beliefs, values, needs (personal
identity).
In other words, we interpret the
contradictions as threatening in some
way (physically, psychologically,
emotionally, and spiritually).
Stage 1 (continued)
(Adapted from Collins & Carson. (1989). The Integrated Trauma Management System)

 The contradictions (threat) trigger the Limbic
system which secretes chemicals we call emotions.
 Psychologically, we have experienced loss. This
begins the grief response.
 If this loss can’t be resolved, the loss is stored in
the brain along with the accompanying emotions
and the grief (healing) process is stuck.
Stage 2

 Our brain rallies to survive and the survival
behaviors/thoughts/ attitudes are put into action.
 This includes external behaviors and internal
repression of loss/emotion.
 Survival responses “almost work” to distract from
the pain. Also, distract from the source.
Stage 3

 As we evaluate our own responses, many times
they contradict our own expectations in some way
(physically, psychologically, emotionally, or
spiritually).
 We experience additional loss and additional grief
emotion which is also stored in the brain when it
can’t be resolved.
Stage 4

Survivors keep cycling through this
loop, developing more survival
responses (behaviors, thoughts,
attitudes) moving them further and
further away from the awareness of the
starting point--#1 The event which
contradicted expectations, values, and
beliefs (personal identity).
Ongoing, unresolved trauma

Stage 1
Event contradicts
expectations
Stage 2
Triggers autonomic
nervous system: loss and
emotion
Stage 3
Brain rallies to survive:
develops survival
responses
Stage 4
Own responses
contradict expectations
Event occurs
outside of
conscious
control.

As the cycle moves the person
further away from awareness of
this connection…
Perception of self changes.
• Personal identity changes.

The person moves from ACE (which are
experienced as social, emotional, and
cognitive impairment,
…to risky behaviors (now perceived as
choices), to disease, disability and
social problems (now perceived as
choices), and
…finally to death all while losing
awareness of the base of the pyramid.

Self-Perception=
limited
Perception of
others= He’s an
angry violent
person!

yellinghitting
addictionphysical abuse
threatening
VIOLENCE
blaming
Violence is a symptom.Violence is a symptom.

yellinghitting
addictionphysical abuse
threatening
VIOLENCE
blaming
Roots are adverse experiences. (Colson, 2007)

1. Evaluation, testing, and treatment
are all focused on the source or
etiology of the problem, cutting off
the base of the pyramid so that it
stops feeding the top.

2. Each stage of development is
addressed in the order in which they
developed.

3. Symptoms are bypassed when
at all possible and allowed to
resolve on their own as the
“wound” is healing.

1. We keep the focus on healing rather than fixing
or changing the person.
2. We follow the three phases of trauma recovery in
order.
1. Safety &,Stabilization
2. Reprocessing & Grieving
3. Reconnecting & Integrating
3. We identify sources of trauma and show their
logical connection to symptoms.
4. We use “survival responses” to label symptoms.
To bypass symptoms…

Why is bypassing symptoms important?
• As the ACE study shows, there is a direct connection
between adverse childhood experiences and risky
behaviors. These behaviors are not attempts to self-
destruct, but attempts to survive.

Level 1
Adverse
Childhood
Experiences
Level 2
Social, emotional,
cognitive impairment
Level 3
Adoption of health risk
behaviors
Level 4
Disability, disease, and
social problems
ACE Conversion
Level 5
Death
Direct connection between
adverse childhood
experiences and risky
behaviors

Why is bypassing symptoms important?
• When the psychological management system is
overwhelmed with pain, we chose survival responses
that work for us. These work to reduce the pain and/or
internal conflict and produce survival.
• Unfortunately, they also bring with them side-effects
that are viewed as unavoidable.

Adapted from Collins, J., (1990) Presenters Handbook, TRT Institute, Angel Fire, New Mexico
Translates to letting go of
their solution.
1
2
3
The Paradox of
Symptom Focused
Treatment
Unintentionally
results in
overall
increased
symptoms.
Solution
Solution
Focus on reducing
symptoms (without
healing the trauma
source)…

Being trauma-informed means…
 Focus is on what was done to you, not what you’ve
done. (SAMHSA)

Focus on survival responses…
 Unintentionally places blame on client.
 Increases shame and guilt, further repressing the
source or wound.

3 Phases of Trauma Recovery
Incorporated in the structure of
S.T.A.R.
 (Herman, 1997; Cloitre et al, 2012)

1. Establishing Safety
and Stabilization
3. Reconnecting
and Integrating
2.
Reprocessing
and Grieving
©Denice Colson, 2014

1. Establishing Safety and Stabilization
A. Foundation of a therapeutic relationship (Wampold, et
al. 2009).
• Characteristics that make therapy work:
Empathy
Alliance
Cohesion (alliance in a group setting)
Goal consensus
Collaboration
• Probably help: positive regard,
congruence/genuineness, feedback, repair of alliance
ruptures, self-disclosure, management of
countertransference, and quality of relational
interpretations

1. Establishing Safety and Stabilization
A. Foundation of a therapeutic relationship (Wampold, et
al. 2009).
• Things that interfere with the therapeutic relationship
include:
• confrontations, negative processes, assumptions,
therapist centricity, rigidity, Ostrich behavior, and
“Procrustean Bed” treatment models (Wampold et
al, 2009).

1. Establishing Safety and Stabilization (con’t)
B. Tasks include
1. Assessment,
2. Education,
3. Commitment to sobriety from alcohol and drugs, as
well as other emotion numbing substances which
interfere with grief, and
4. Commitment to the Grieving and Reprocessing
Phase.

1. Herman describes safety as putting control and
empowerment in the hands of the survivor (1997).
2. She also believes that anything that takes control away of
the survivor will sabotage her sense of safety and
security.
3. For trauma survivors, this is the paradoxical state in
which they find themselves: what they are doing to take
control of their lives, their survival beliefs and behaviors,
gives them a sense of safety, but not real safety.
4. Instead it is a false safety keeping them stuck where they
are and preventing their identification of their losses
from past or present trauma and subsequent movement
through the grief process.

5. While Najavits (2002) focuses on safety theoretically,
practically she attempts to help survivors reach
stabilization; stopping self-injurious behaviors long-
enough to address and grieve the trauma.
6. Conversely, Collins and Carson (1989a and 1989b)
suggest circumventing this paradox by avoiding a focus
on behavioral change altogether and going straight to
resolving the trauma.
7. They believe that any focus on behavioral change keeps
the client focused on themselves, increasing shame and
further repressing the trauma, thereby not focusing on
the source of the trauma: contradicted values and
beliefs.

8. However, they also require the participant to have six
months of sobriety from alcohol and mood altering
drugs before they can begin the process (Collins and
Carson, 1989a and 1989b). This means that their
methodology, ETM/TRT©, can not be used with anyone
who is self-medicating, which research shows is a high
percentage of survivors (Felitti, 2004).
9. In addition, they discourage ETM/TRT© use with any
one taking psychotropic medication, currently
considered the gold-standard in trauma and addiction
treatment, saying that many medications may also
interfere with the success of treatment (Collins and
Carson, 1989a and 1989b).

10. In addition, they absolutely prohibit the use of their
model with any type of “higher-power” or faith-based
integration.
11. While the structure this model uses does provide
security for the non-substance using client, convincing a
self-medicating client to start the resolution process
while giving up any substance use can be difficult.

2. Reprocessing and Grieving
• Phase 2 is a six step procedure which brings together
multiple approaches to trauma recovery, most of
which are evidence-based.
• One “source” of trauma is addressed through the 6
steps at a time.
• A “source” is usually a person, but may be an event.
• Each step of the grieving process is composed of three
parts: preparation, writing, and emotional
reprocessing.

3. Reconnecting and Integrating
 Survival responses that have not changed can be
addressed directly.
 Couple’s counseling and family counseling will be
more effective.

GOALS: S.T.A.R.© provides a structured way to:
1. Meet the client where they are.
2. Increase the client’s active participation and
investment in the treatment through empowerment.
3. Provide regular feedback to the therapist on the
client’s experience of the therapy.
4. Allows for flexibility in the therapists approach to
the client and the treatment.

Goals: S.T.A.R.© provides a structured way to:
5. Work with clients who have substance use disorders
and clients who don’t.
6. It draws from evidence based practices including:
 Motivational interviewing
 Seeking Safety©
 Cognitive-behavioral techniques
 Emotional reprocessing
 Narrative Therapy
7. The structure is influenced by Alcoholics
Anonymous©, Seeking Safety©, and ETM/TRT©.

The Backbone of S.T.A.R. is…

It holds the 3-phases together, provides for
transitions, and breaks down the process in
a simpler fashion.

Provides a strategy for moving through
the healing process, much like a map.

The 12-Strategic Steps to Trauma and Abuse
Recovery
 Phase One:
1. I admit that I have been wounded by a relationship with a
person or a substance, or by an event, and I am accepting that I
am powerless over the wounding.
2. I have decided to give up trying to fix myself and will humbly
ask God (as I understand Him now) to heal me; fully
understanding that healing will require my participation.
3. I am accepting that I have to grieve in order to heal and I’m
determined to give up my bargaining behavior including self-
medicating and any substance use that results in numbing my
grief and I will allow myself to move through the healing
process even though it will be painful.
4. I am forming a partnership with at least one other person
(counselor or recovery coach) to boldly identify in a focused
and structured manner the people or events that wounded me.

Recovery (con’t)
 Phase Two:
5. I am courageously identifying and writing my painful
experiences (my story), along with my contradicted
expectations, and my losses. I am boldly sharing these
with my partner (counselor or recovery coach), fellow-
grievers (group), and God (Higher Power), expressing my
grief in my own way.
6. I am freely identifying my interpretations of the hurtful
event(s) and what they meant about me, the perpetrator,
life, and God (church, religion, spirituality).
7. I am identifying and admitting to myself, my partner or
partners, and to God (Higher Power) my own survival
thoughts, behaviors, and attitudes, developed in
response to my wounding.

Recovery (Phase Two con’t)
8. I am identifying and admitting the contradictions my
own survival responses had to my expectations of myself
and the losses these contradictions have caused me.
9. After completing this thorough inventory of my
experiences, contradicted expectations, losses, survival
behaviors (new thoughts, behaviors, identity) and the
losses these caused me, I humbly and courageously
choose forgiveness; forgiving my perpetrator for robbing
me and forgiving myself for my responses.
10. I understand that healing is an ongoing process from the
inside-out, and I humbly acknowledge God’s (as I
understand Him now) hand in healing me and will make
a spiritual marker to represent where He met me on my
path of healing.

Recovery (con’t)
 Phase Three:
11. I am beginning to intentionally move toward
reconnecting with myself, with God (as I understand
Him now), and with others.
12. I am remaining open to identifying other wounds in
my life that need to be healed, without attempting to
heal them myself, while maintaining a willing
attitude to work through these steps again if
necessary, or to assist someone else who needs to
work through these steps to healing.

Avoid Common Errors of
Trauma Informed Care

Herman writes…
“…the single most common therapeutic
error is avoidance of the traumatic
material…”
and, “…probably the second most common
error is premature or precipitate engagement
in exploratory work, without sufficient
attention to the tasks of establishing safety
and securing a therapeutic alliance” (1997, p.
172)

Principles to Apply re: Evaluation
and Treatment
….Ask, but don’t push for too much
detail.
Expect denial and later disclosures.
Don’t try to go too far, too fast.
Do a trauma evaluation as part of intake
or after first session.

How Can I Do This?
Use screening instruments
Educate using handouts

Screening Instruments
 Family Health History Questionnaire
 Health Appraisal Questionnaire
(http://www.cdc.gov/ace/questionnaires.htm)
 Also:
 Trauma Symptom Inventory (Briere, 1995)
 PTSD-8 (Hansen, et al., 2010)
 Primary Care PTSD Screen (PC-PTSD) (Prins, et al.,
2003).

Others
 ACE Score
 http://acestudy.org/yahoo_site_admin/assets/docs/ACE
_Calculator-English.127143712.pdf
 Simple Trauma Source Assessment (by Denice Colson)

Handouts
 Trauma Source Score Handout
 Adverse Childhood Experiences and Health
and Well-Being Over the Life-span
 Develop your own.
 Visit ACESConnection.com for more help.

Get Trained!
Strategic Trauma and Abuse Recovery Oct. 2-3, McDonough!
Sign-up for email newsletter.

Adverse childhood experiences are
common but typically unrecognized.
Their link to major problems later in
life is strong, proportionate, and
logical.
They are the nation’s most basic public
health problem, and therefore our
problem.

Treating the solution only may
threaten people and cause flight from
treatment.
What presents as the ‘Problem’ may in
fact be an attempted solution.
It is understandable to mistake
intermediary mechanism (addiction,
depression, etc.) for basic cause.

Change starts with us.
Contemplation is to be expected.
Trauma-Informed Care is the new best-
practices standard.
There is a learning curve.

Adverse childhood experiences
Adult behavioral health issues

“I believe this is the most
important thing that you can ever
do, to begin to deal with this, with
this intergenerational transmission
of adversity that causes so many
problems in our society.”
Robert F. Anda, MD

Denice Colson, PhD, LPC, MAC,
CPCS
 www.TraumaEducation.com
 www.ELCCC.org
 RDAColson@gmail.com
 Supervision, training, coaching , and trauma recovery.

You’re an Overcomer!
Mandisa

Links between Childhood Trauma and Adult Disease: Becoming Trauma Informed

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