Reconsidering the roots of addiction: Implications of the Adverse Childhood Experiences Study

Implications of The Adverse Childhood
Experiences Study
R. Denice Colson, PhD, LPC, MAC, CPCS
Trauma Education & Consultation Services
Eagle’s Landing Christian Counseling Center, Inc.

Adverse childhood experiences
Adult behavioral health issues

Origins of
Behavioral
health issues?

One factor that differentiates the
etiological approach…
Symptoms
Symptoms

Consider…
 Our understanding of addiction could possibly be
changed to consider substance use 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

Consider…
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

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

Challenging the traditional
views of addiction.

…Traditional views
may be missing the
point

…Traditional views
may seriously
adversely impact
treatment.

…Research challenges
their validity.

What is ?
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

What’s Your ACE Score?
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.

ACE Score Determination
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.

Serious social problems
Severe and persistent emotional problems
Health risk behaviors
Adult disease and disability
High health and mental health care costs
Poor life expectancy
Other Outcomes of ACE:

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(%)

Severe and Persistent Emotional
Problems

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
2
4
6
8
10
12
0 1 2 3 4 5 6 >=7
No
Yes
ACE Score
EverHallucinated*(%)
Abused
Alcohol
or Drugs
*Adjusted for age, sex, race, and education.
ACE Score and Hallucinations

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

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

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.

Paid $80 Billion to address
childhood abuse and neglect in
2012
 http://www.preventchildabuse.org/images/research/pcaa_cost_report_2012_gelles_perlman.pdf

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

Effect of ACEs on Mortality
0
10
20
30
40
50
60
0 2 4
PercentinAgeGroup
ACE Score
19-34
35-49
50-64
>=65
Age Group

Other Studies on
Childhood Sexual and/or
Physical Abuse

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)

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)

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…
When not addressed…continues
over the lifespan.

Sense of Shame, Guilt, Self-Blame,
Being Bad…
over the lifespan.

Sense of defilement,
contamination, being spoiled,
degraded, debased,
despicable, evil…
over the lifespan.

Sense of complete
difference from others,
deviance, utter aloneness,
isolation, non-human,
specialness, unseen,
unheard, belief no other
person can ever
understand…
When not addressed…continues over the
lifespan.

ACE Causes serious and
chronic health, behavioral
health and social problems

Epidemic proportions and a
major public health issue.

Impacts brain and nervous
system directly.

Impacts one’s perception of
self and others.

Often unrecognized, ignored
or denied.

Finally, ACE is A Public
Health Tragedy

Leading to long-term use of multi-
human service systems at an estimated
annual cost of $80 billion

$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)

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

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

Conventional view is…
 Certain substances are addictive based on the
evidence that its almost impossible for certain
individuals to give them up.
Questions are…
• How did these people get to be?
• Why one person and not the other?
• How do addicts differ from non-addicts?

Considering evidence from the ACE
study…
 Are we focusing on the outcome and not the cause?
 Are we overlooking a major source?
Outcome
Source or Cause

What Is The Core Problem?
 Why is treatment so difficult?
 Why are long-term results so often poor?
 Is it because treating someone’s attempted solution may
be threatening and cause flight from treatment?
 Are we treating the smoke, but not the fire?

Treatment Failures
 What can we learn from those who can’t give up an
addiction?
 Is the wrong thing being treated?
 Consider a few examples including:
 smoking,
 amphetamine,
 heroin, and
 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?
 Does substance use serve to do more than get a person
“high”?
 Do more than provide pleasure?
 Could it provide legitimate protection sexually,
physically, and emotionally?
I am NOT promoting or encouraging
substance use!!

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

Implications for
Treatment
Implementing Trauma Informed Care

First Step…
Admit we have a problem

Trauma-informed treatment
(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/

How do implement trauma
informed treatment?

1. We can change our
perspective…

View addiction/substance-use through
the lens of trauma.

We can 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.

What are they trying to
solve?

Not
blowing
away the
smoke..
But
putting
out the
fire.

Not cutting
off the
limbs…
But 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.

3. We can accept 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).

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.

4. We can adjust the way
we do treatment.

Typical substance-abuse
treatment…

Focuses on reducing risky
behaviors and/or sobriety.

Role of treatment
provider…facilitate change.

Educational and motivational
and focus on reducing
substance use, decreasing
depression, anxiety, etc.

Adjusting doesn’t mean…
…We don’t do addiction
treatment
…We don’t fulfill the State or
agency requirements.

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.
 That’s why I developed Structured Trauma and Abuse
Recovery© (STAR©) which is a Source-Focused
Model© (SFM©).

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

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

My definition
The source of trauma is unhealed,
unaddressed, unresolved wounds
to the personal identity.
(Compared to diagnoses which are
groups of symptoms)

My definition
 Personal Identity is defined as the
sum of your person as you exist in
your own mind/brain and as you
are expressed through your
thoughts, beliefs, values,
expectations, and emotions.

Trauma happens when our
Personal Identity is wounded to the
point that we experience
unacceptable contradictions to our
expectations.
In addition, these contradictions
cause unacceptable personal
losses.

Trauma Survivor Blueprint
Four Stages in Development

The event contradicts expectations,
beliefs, values (personal identity). We
interpret the contradictions as
threatening in some way (physically,
psychologically, emotionally, and
spiritually).
Stage 1

The threat triggers the autonomic
nervous system which secretes
chemicals we call emotions.
Psychologically, we have experienced
loss. Begins the grief response.
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.
Stage 3

Our own responses are evaluated and
many times contradict our own
expectations in some way (physically,
psychologically, emotionally, or
spiritually). We experience additional
loss and additional grief emotion.
Stage 4

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.

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

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.

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

Evaluation, testing, and treatment are
all focused on the source or etiology of
the problem with the goal of
reestablishing the connection between
#1 and #2-4.

Symptoms are bypassed when at
all possible, starting by
addressing stage #1 first, then
#2, then #3 and finally #4.

It does NOT mean that
symptoms (#3-4) aren’t
considered, but it does mean
that, when possible, symptoms
are bypassed.

Structured Trauma & Abuse
Recovery is evidence informed
because…

Built on a contextual model framework.
The Contextual Model is a modern
version of the Common Factors model
and serves as a meta-framework to
which techniques are attached in order
to form a more cohesive approach
within a particular cultural context
(Wampold, et al, 2009).

 Includes evidence based practices included
in other models such as Motivational
Interviewing, Prolonged Exposure Therapy,
Cognitive Processing Therapy, Emotion
Focused Therapy for Trauma, Eye Movement
Desensitization and Reprocessing, Narrative
Exposure Therapy, and Seeking Safety.

What does bypassing
symptoms mean?

We don’t engage directly in trying
to change the client’s survival
responses unless absolutely
necessary.

We follow the three phases of trauma
recovery in order. (1. Stabilizing; 2.
Reprocessing/Grieving; 3.
Reconnecting/Integrating)

We keep the focus on healing
rather than fixing.

Why is bypassing symptoms
important?

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

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 responses.

Unfortunately, they also bring
with them side-effects that are
viewed as unavoidable.

Etiology
Cause-Effect Relationship
Adapted from Collins, J., (1990) Presenters Handbook, TRT Institute, Angel Fire, New Mexico
Survival
Responses
Cause
Effect
(Unresolved
past trauma)
Symptoms or
unavoidable
side-effects

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
addressing the trauma
source)…

What can I do NOW?
Do a trauma evaluation as part
of intake or after first session.

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)

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: Treatment
Ask, but don’t push for too much
detail.
•Expect denial and later disclosures.
•Don’t try to go too far, too fast.

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

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.

3 Phases of Trauma Recovery
Incorporated in the structure of
STAR
 (Herman, 1997; Cloitre et al, 2012)

1. Establishing Safety and
Stabilizing

3. Reconnecting and Integrating

Establishing Safety and
Stabilizing
Reconnecting and
Integrating
Reprocessing
and Grieving

Phase 1: Establishing
Safety and Stabilizing

Substance use/addiction has to be
addressed first and some stability
and sobriety established before
moving into the Reprocessing and
Grieving Phase

Stabilization and Safety Phase is
designed to move a person to the
Reprocessing and Grieving Phase.
This is the HEART of trauma
recovery.

Phase 2: Reprocessing and
Grieving

 Step 1: Identify the source of trauma. If more
than one, identify most pressing. Write
about it using a structured outline. Identify
contradicted expectations, values, beliefs,
needs. Identify losses. Read out-loud in
structured individual or group.
6 step, structured process.

Step 2: Identify interpretations in
personal life context along with losses.
Read out-loud in structured individual
or group.

Step 3: Identify past and present
survival responses and losses. Read
out-loud in structured individual or
group.
Step 4: Summarize losses from the
event and your interpretation of the
event. Summarize losses from your own
survival responses, past and present.
Read out-loud in structured individual
or group.

Step 5: A forgiveness exercise. Optional
Step 6: Creative expression of Spiritual
Marker or Personal Identity Reflection.

Phase 3: Integrating and
Reconnecting
Integrate newly developed survival
responses into daily life.
Reconnect with self, others, and
God.

A Source Focused Model, like Structured
Trauma and Abuse Recovery…

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 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 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.

“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

“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
 www.LifeLineBillingSolutions.com
 RDAColson@gmail.com
 Supervision, training, coaching , and trauma recovery.

You’re an Overcomer!
Mandisa

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