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The Pain of Pleasure:
Trauma and Addiction
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D
Clinical Associate Professor
University of Georgia College of Pharmacy
Athens,Georgia
Email: mernort@uga.edu
If all you have is a hammer then all
your problems are nails
-Abraham Maslow
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Definitions of Trauma and
Addiction
Because the stress response disrupts general informatio!
processing, survivors of trauma live in a somatic world rather
than a world of language.

Alexander McFarlane
I have absolutely no pleasure in the stimulants in which I
sometimes so madly indulge. It has not been in the pursuit
of pleasure that I have periled life and reputation and
reason. It has been the desperate attempt to escape from
torturing memories, from a sense of insupportable
loneliness and a dread of some strange impending doom.
Edgar Allan Poe
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Does Trauma Cause Addiction or
Does Addiction Cause Trauma?
Both Trauma and Addiction cause changes in the brains
functionality and neurochemistry;
Both Trauma and Addiction activate the Anti-Reward Brain
System ( operates by using primarily the Glutamate and GABA
pathways);
Both Trauma and Addiction depleted and shut down the
Reward Brain System( operates by using primarily the
Dopamine, Endorphin, and Serotonin pathways);
Both Trauma and Addiction are activated by the Stress
Response;
Primarily difference is that Trauma can change the brain in
seconds; Addiction may take months or years;
Recovery from Trauma and Addiction takes a lifetime of effort.
THE WAY WE USED TO LOOK AT
SUBSTANCE ABUSE AND TRAUMA
MENTAL
ILLNESS
SUBSTANCE
ABUSE
TRAUMA
THE RELATIONSHIP BETWEEN
TRAUMA & SUBSTANCE ABUSE
TRAUMA
SUBSTANCE
ABUSE
MENTAL
ILLNESS
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THE RELATIONSHIP
BETWEEN TRAUMA &
SUBSTANCE ABUSE
There is a true cause and effect relationship between
trauma and substance abuse.
Those who have been traumatized are at risk for
substance abuse; and those who use substances are at
risk for experiencing trauma.
For those who suffer from addiction and trauma,
there is great difficulty sustaining abstinence because
of trauma-based physiological responses, emotions,
thoughts, and relationship patterns. Trauma-related
distress continuously stimulates the addiction
compulsion.

Dusty Miller (2002)
TRAUMA AND ADDICTION
CYCLE
TRAUMA
EMOTIONAL
UPHEAVEL
USE OF
SUBSTANCES
DECREASED ABILITY TO
LEARN NEW SKILLS AND
PROCESS TRAUMATIC
MATERIAL
CONTINUED
USE WHICH
CAN LEAD TO
DEPENDENCE
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Addiction is a Complex Illness
with biological,
sociological and
psychological
components
11/18/13 Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D
Biology/genes
Environment
Biology/
Environment
Interactions
11/18/13 Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D
ur. Merrlll norLon harm.u.,u.h.,lCCu-u
Iactors Contr|bunng to Vu|nerab|||ty to
Deve|op a Spec|hc Add|cnon
use of the drug of abuse essential (100%)
Genetic
(25-50%)
DNA
SNPs
other
polymorphisms
Drug-Induced Effects
(very high)

Environmental
(very high)
prenatal
postnatal
contemporary
cues
comorbidity
Kreek et al., 2000
mRNA levels
peptides
proteomics
neurochemistry
behaviors
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11/18/13 13 Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D
We know that despite
their many differences,
most abused substances
enhance the dopamine and
serotonin pathways
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The Necessary Nine
Norepinephrine/Epinephrine-
stimulant,anger,fear,anxiety,fight,flight
Serotonin-depressant,sleep,calm,pleasure
GABA-relaxant,stress reduction,seizure threshold
Endorphins-pain relief,pleasure
Acetylcholine-involutary actions,memory,motivation
Anandamide-memory,new learning,calmness
Glutamate-organization of brain signaling,memory,pain
Dopamine-perception,movement,pleasure
PIP- loving of ones self,others,GOD
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Pharm.D.,D.Ph.,ICCDP-D
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Neurotransmitters of Dependence
PIP
Dopamine
Glutamate
Acetylcholine
Anandamide
Endorphins / Enkelphins
GABA
Serotonin
Epinephrine / Norepinephrine
Addiction/Trauma
Recovery
Depletion may take
less than 12 months-
Trauma may take just
seconds to shut down
these neurochemical
systems
Replenishment may take 5
to 7 years ?????
Human Doing Human Being
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Pharm.D.,D.Ph.,ICCDP-D
11/18/13 Dr. Merrill Norton
Pharm.D.,D.Ph.,ICCDP-D
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Koob.G 2008
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Pharm.D.,D.Ph.,ICCDP-D
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Koob,G 2008
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Pharm.D.,D.Ph.,ICCDP-D
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Koob,G 2008
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Pharm.D.,D.Ph.,ICCDP-D
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Koob, G 2008
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Pharm.D.,D.Ph.,ICCDP-D
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Pharm.D.,D.Ph.,ICCDP-D
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LeDoux, Scientific American, 1994
The Hiker and the Rattlesnake
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AMYGDALA
Medial Prefrontal Cortex
Anterior Cingulate Cortex
Hippocampus
Thalamus
Sights
Sounds
Smells
Coordinated
Response
+
+
+
_
_
Battlemind: Dys-coordination of Threat Response &
Dissociation
dissociation
PFC bypass
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Schick Shadel Hospital, 2009
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Dr. Merrill Norton
Pharm.D.,D.Ph.,ICCDP-D
1he Ann-keward 8ra|n
1. A key e|ement of add|cnon |s the
deve|opment of a neganve emonona|
state dur|ng drug absnnence.
2. 1he neurob|o|og|ca| bas|s of the
neganve emonona| state der|ves from
two sources: decreased reward c|rcu|try
funcnon and |ncreased ann-reward
c|rcu|try funcnon.
3. 1he ann-reward c|rcu|try funcnon
recru|ted dur|ng the add|cnon process
can be |oca||zed to connecnons of the
extended amygda|a |n the basa|
forebra|n.
4. Neurochem|ca| e|ements |n the
annreward system of the extended
amygda|a have as a foca| po|nt the
extrahypotha|am|c corncotrop|n-
re|eas|ng factor system.
S. Cther neurotransm|uer systems
|mp||cated |n the ann-reward response
|nc|ude norep|nephr|ne, dynorph|n,
neuropepnde , and noc|cepnn.
6. Vu|nerab|||ty to add|cnon |nvo|ves
mu|np|e targets |n both the reward and
ann-reward system, but a common
e|ement |s sens|nzanon of bra|n stress
systems.
7. Dysregu|anon of the bra|n reward
system and recru|tment of the bra|n ann-
reward system are hypothes|zed to
produce an a||ostanc emonona| change
that can |ead to patho|ogy.
8. Nondrug add|cnons may be
hypothes|zed to acnvate s|m||ar a||ostanc
mechan|sms.
Merrlll norLon harm.u.,u.h.,lCCu-u 26
ur. Merrlll norLon harm.u.,u.h.,lCCu-u 27
AN1I-kLWAkD
1he concept of an ann-reward system was deve|oped to exp|a|n one
component of nme-dependent neuroadaptanons |n response to excess|ve
un||zanon of the bra|n reward system.
1he bra|n reward system |s dehned as acnvanon of c|rcu|ts |nvo|ved |n pos|nve
re|nforcement w|th an over|ay of pos|nve hedon|c va|ence.
1he neuroadaptanon s|mp|y cou|d |nvo|ve state-sh|hs on a s|ng|e ax|s of the
reward system (w|th|n- system change, dopam|ne funcnon decreases).
nowever, there |s compe|||ng ev|dence that bra|n stress]emonona| systems
are recru|ted as a resu|t of excess|ve acnvanon of the reward system and
prov|de an add|nona| source of neganve hedon|c va|ence that are dehned
here as the ann-reward system (between-system change, corncotrop|n-
re|eas|ng factor funcnon |ncreases). 1he comb|nanon of both a dehc|t |n the
reward system (neganve hedon|c va|ence) and recru|tment of the bra|n stress
systems (neganve hedon|c va|ence) prov|des a powerfu| monvanona| state
med|ated |n part by the ann-reward system.
(koob & Le Moa| 200S).
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+
Desire Corresponds with Drug Use
Liking
Non-problematic Use
Wanting
Abuse
Craving
Addiction
+
Desire Corresponds with Drug Use
Liking
Non-problematic Use
Wanting
Use
Craving
Addiction
50%
89%
11%
50% 0f US population DOES NOT USE any alcohol/drugs
+
Cravings
! Craving: memory of rewarding aspects of drug use
superimposed on a negative emotional state
! Compels drug-seeking in dependent individuals
! 3 Types of Cravings
! Withdrawal induced
! Cue-induced
! Drug-induced
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Stages of the Addiction Cycle
Neurobiology of Addiction
Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction,
Neuropsychopharmacology reviews 35 (2010) 217-238
Binge/Intoxication Stage
Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction,
Neuropsychopharmacology reviews 35 (2010) 217-238
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Withdrawal/Negative Affect Stage
Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction,
Neuropsychopharmacology reviews 35 (2010) 217-238
Preoccupation/Anticipation Craving Stage
Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction,
Neuropsychopharmacology reviews 35 (2010) 217-238
Positive
Reinforcement
Negative
Reinforcement
Non-dependent
Negative
Reinforcement
Positive
Reinforcement
Dependent
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Brain Arousal-Stress System Modulation
in the Extended Amygdala
From: Koob, G.F. 2008 Neuron 59:11-34
Merrill Norton D.Ph.,NCAC II,CCS 38
Merrill Norton D.Ph.,NCAC II,CCS 39
Allostasis - Definition
The ability to achieve stability through change
To obtain stability, an organism must vary all of
the parameters of its internal milieu and match
them appropriately to environmental demands.
From: Sterling P and Eyer J, Allostasis: a new paradigm to explain arousal pathology. In Fisher S and Reason J (eds),
Handbook of Life Stress, Cognition and Health, John Wiley, New York, 1988, pp. 629-647.
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Brain Reward Pathways
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Activation of Reward
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Drug-induced Craving
High
Craving
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D
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Basolateral
Amygdala
Prefrontal
Cortex
Mediodorsal
Thalamus
Motor
Nuclei
Ventral
Pallidum
Nucleus
Accumbens
Ventral Tegmental
Area
GABA and Glutamate Role in Motivation
Adapted from Kalivas and Nakamura, Curr. Opin. Neurobiol., 1999.
Dopamine
Glutamate
GABA
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What is Trauma?
Trauma is experiencing too much, too fast, too soon.
Or
The body remembers what the mind forgets
-Jacob Moreno
Movement from Chaos to
Connection
The deep digging in therapy is to make conscious
these early wounds and convert them into words so
that they can be felt and understoodto use the
skills of emotional literacy.
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We help them place the trauma in proper
perspective.
Help give them a context (where, when
and
how).
Help integrate them back into themselves
with understanding as to what happened
and what meaning they made out of it.
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Movement from Chaos to Connection
Our Tasks
Modulating Emotional
Responses
Intense Fear
Rage
Disassociation or Shutdown
Addiction offers relief
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Trauma Impacts
relationships by creating
1. Enmeshment-part of trauma bonding.
2. Disengagement-avoiding skill building.
3. Chaos through impulsivity.
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How do we help them?
4 Steps to Emotional Expertise
Our clients need to know:
All emotions serve a function.
Trauma and Addiction blunt our range of emotions.
Self Efficacy comes as consciousness of emotions
grows.
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What is Trauma
Trauma is perhaps the most avoided, ignored, belittled, denied,
misunderstood, and untreated cause of human suffering. Although it
is the source of tremendous distress and dysfunction, it is not an
ailment or a disease, but the by-product of an instinctively instigated,
altered state of consciousness.
We enter this state - let us call it survival mode - when we perceive
that our lives are being threatened. If we are overwhelmed by the
threat and are unable to successfully defend ourselves, we can
become stuck in survival mode. This highly aroused state is designed
solely to enable short-term defensive actions; but left untreated over
time, it begins to form the symptoms of trauma.
Peter Levine
Effects of Trauma
(Dayton,2000)
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Long term fear of intimacy.
Relational Commitment"Simultaneous fears of
abandonment and being overwhelmed.
Poor Communications"as the internal dictionary, listening,
and seeking feedback are distorted.
Boundaries are enmeshed.
Deregulated emotions"high frequency, intensity and
duration to complete shutdown.
Distrust, unable to receive and lack of faith in others.
Blunted play #inability to move freely in a space.
Unconscious patterns of disconnecting, reenacting,
transference, splitting, hyper"vigilance and perfectionism.
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The imprint of the trauma is in the limbic system and in the brainstem:
in our animal brains, not our thinking brains
Survival responses based on the following criteria:
1.Severity of trauma.
2.Genetic Predisposition.
3.Developmental Phase when trauma occurs.
4.A Social Support System.
5.Prior traumas.
6.Preexisting phobias and maladaptive behavior
Bessel van der Kolk
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Trauma and the Brain
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The Triune Brain
x
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Bottom-up, The Hi-Jacked Brain
Janina Fisher, 2007
Everyday experiences connected to the trauma will trigger instinctive
survival responses: fight, flight, freeze, collapse and numbing,
dissociation, re-enactment behavior. The clients animal brain takes over,
the ability to think goes off line, & acting out behavior takes place
without conscious intention or judgment, even without awareness!
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Normal Response
Trauma Response
Amygdala
Fight, Flight or Freeze Response
Visual
Cortex
Trauma vs. Intimacy
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Trauma originates as a response in the nervous
system, and does not originate in an event.
Trauma is in the nervous system, not in the
event.
Peter Levine
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The Polyvagal Theory
by
Stephen Porges, PhD
www.stephenporges.com
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The Parasympathetic Nervous System The Sympathetic Nervous System
Originates in the brain stem and
lower part of the spinal cord;
opposes physiological e!ects of the
sympathetic nervous system:
stimulates digestive secretions; slows
the heart; constricts pupils; dilates
blood vessels.
Trauma may result in the PNS
staying on, which causes it to
superimpose shutdown over the
hyperarousal of the SNS, rather than
discharging its energy.
The SNS gets our whole body ready
for action. It regulates arousal. It
increases activity during times of
stress and arousal whether positive
or negative. It is active when were
alert, excited, or engaged in physical
activity. It prepares us to meet
emergencies and threat.
The Parasympathetic branch acts
like the brake pedal for our nervous
system. It helps us to relax, unwind
and ultimately discharge the arousal
of sympathetic activation.
The Sympathetic branch is like the
gas pedal of our nervous system. It
gives us energy for any action we
plan, and it helps us prepare for
threat.
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The Polyvagal Theory
By Stephen Porges
The Vagus Nerve in three parts, all
working simultaneously:
Ventral Vagal System:
Is part of the Parasympathetic Nervous
System
(Social Engagement/frontal cortex)
Sympathetic Nervous System:
(Fight/Flight, Freeze - Limbic Brain)
Dorsal Vagal System:
Is part of the Parasympathetic Nervous
System
(Freeze/Immobility/Brainstem)
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Social Engagement
Fight, Flight,
Freeze
Immobility
Safe
Danger
Life Threatening
Ventral
Vagal
Sympathetic
Nervous
System
Dorsal
Vagal
System
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Sympathetic Hyperarousal
Parasympathetic Hypoarousal
Autonomic Arousal is Designed to Adapt to Environmental Demands
Window of Tolerance
feelings can be tolerated, able to think and feel
easy charge
easy discharge
sympathetic
parasympathetic
Foundation of Human Enrichment
Ogden and Minton #2000$
A
R
O
U
S
A
L
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Parasympathetic Hypoarousal
Stuck on ON
Stuck on OFF
Hyperactivity
Panic
Rage
Hypervigilance
Elation/Mania
Depression
Disconnection
Deadness
Exhaustion
Foundation of Human Enrichment
Fisher, 2006
Window of Tolerance
Optimal Arousal Zone
Autonomic Adaptation to a Threatening World
A
R
O
U
S
A
L
Sympathetic Hyperarousal
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Parasympathetic Hypoarousal
Foundation of Human Enrichment
Fisher, 2006
Window of Tolerance
Optimal Arousal Zone
How Chemical Addiction Modulates and Medicate Complex PTSD to
attempt Self-Regulation
Acting out
Acting in
A
R
O
U
S
A
L
Sympathetic Hyperarousal
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Treatment must address the relationship between:
A. the trauma and the addictive behavior
B. the role of the addictive behavior in medicating traumatic activation
C. the origins of both in the traumatic past
D. the reality that recovering from either requires recovering from both.
The Challenge of Trauma and Chemical Addiction
Fisher, 2007
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Modes of Inventions
Cognitive Behavioral Therapy
EMDR
Somatic Experiencing
Hypnotherapy
Transactional Analysis
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Provider Tasks
Screening & Assessing
See trauma as a dening and organizing experience that can
shape a survivors sense of self and others. $understanding
ability to cope%.
Psycho"educational information on how intertwined SUDS
and Trauma are during and after an event.
Establish and maintain consumer support and developing
coping skills. $Ex: Learning communication and problem
solving strategies such as healthy ghting. $cont.$
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Addiction Labeling
The goals associated with any problem
are at least partially determined by the
way the problem is assessed.
What you do about something is
inuenced by what you call it.
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Our Lens
We tend to call ourselves objective but
we interpret situations from their own
particular theoretical, philosophical or
ideological perspective.
Do we need to transcend it?
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Our Lens (cont.)
We know clients dont see themselves as
addicts but often seek to negotiate an
alternative explanation to negate acting
out behaviors or minimize having to
change.
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Provider Tasks
Helping consumer understand the range of parallel
connections between SUDS and trauma.
Minimizing re"occurance of trauma
Ensuring consumers physical and emotional safety where
possible and avoiding shame inducing confrontations
triggering trauma related responses.
Helping with referrals for ancillary services such as legal,
nancial, vocational, housing and health care.
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Resiliency
Recognizing and Reinforcing
Resiliency
Denition"The process of bouncing
back.
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The Post Traumatic Stress
Inventory
The Inventory consists of 144 questions
designed by David Delmonico, M.Ed.
and Patrick Carnes, PhD. Questions fall
into 1 of 8 categories providing when
tallied a strategic map on how the client
can once again gain internal locus of
control.
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The Post Traumatic Stress
Inventory
8 Specic Therapy Strategies
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1.Trauma Reacting
Write amend letters to those you know you have harmed.
Decide with therapist what information is appropriate to disclose
and send.
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Trauma Reacting" Experiencing current reactions to trauma events i"
the past.
Study ways client is still reacting. EX: projected anger out on others.
Write letters to perpetrator telling them of the long"term impact
you are experiencing.
2. Trauma Repetition
Trauma Repetition # Repeating behaviors or situations which
para#el early trauma experiences.
Understand how history repeats itself in your life
experiences.
Develop habits which center yourself" Ex. Breathing or
journaling so you are doing what you intend #not the cycles
once used.
Work on setting boundaries"using e&ective communication.
Boundary failure is key to repetition compulsion. 77
3. Trauma Bonding
Trauma Bonding" Being connected $loyal, helpful, supportive,
enmeshed% to people who are dangerous shaming, or exploitive.
Learn to recognize trauma bond by identifying those in your
life.
Look for patterns.
Use detachment strategies for di'cult people.
Use a First"Step if necessary.
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4. Trauma Shame
Trauma Shame & Feeling unworthy and having self&hate becaus'
of the trauma experience.
An acutely self"conscious state in which the self is split
imagining the self in the eyes of the, other; by contrast, in guilt
the self is unied. $Gilliland, et al. 2011%.
Judgment of self by another whether real or imagined.
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4. Trauma Shame (cont)
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Goal: Shame Reduction and resolution.
Understand shame dynamics of family and family of origin.
Who was important to that you should feel shameful?
Do a list of problems, excuses and secrets.
Complete an inventory of a'rmations.
5. Trauma Pleasure
Trauma Pleasure # Finding pleasure in the presence of danger,
(iolence, risk or shame.
Do a history of how excitement/ shame are hooked to the past
traumatic event $s%.
Note the costs and dangers to you over time.
Do a First Step and relapse prevention plan about how
powerful this is in your life.
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6. Trauma Blocking
Trauma Blocking& A pattern exists to numb, block out, or
overwhelm feelings that stem )om trauma in your life.
Work to identify experience which caused pain or diminished
you.
Re"experience feelings and make sense of them with help.
This will reduce the power they have had.
Do a First Step if appropriate.
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7. Trauma Splitting
Trauma Splitting" Ignoring traumatic realities by disassociating
or splitting o* experience of parts of self.
Learn that disassociating is a normal response to trauma.
Identify ways you split reality and the triggers that cause that
to happen.
Cultivate a caring adult who stays present so you can stay
whole.
Notice any powerlessness you feel.
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8.Trauma Abstinence
Trauma Abstinence" Depriving yourself of things you need or
deserve because of traumatic acts.
Understand how deprivation is a way to continue serving
perpetrators.
Write a letter to the victim$s% that was you learning to tolerate
pain and deprivation.
Work on strategies to self #nurture including inner child
visualizations.
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WHAT NEXT-
30 Performables
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1. Break through Denial
2. Understand Addiction
3. Surrender
4. Limit change
5. Establish Sobriety
6. Physical Integrity
7. Culture of support
16. Lifestyle Balance
17.Building Support
18.Exercise and nutrition
19.Spiritual Life
20. Resolve Conicts
21. Restore Healthy Sexuality
22. Family Therapy
8. Multiple addictions
9. Cycle of Abuse
10. Reduce Shame
11. Grieve losses
12. Closure to shame
13. Relationship with self.
14. Financial Viability
15. Meaningful work
23. Family Relationships
24. Recovery commitment
25.#Issues with children
26. Extended Family
27. Di&erentiation
28. Primary Relationship
29. Coupleship
30. Primary Intimacy
Carnes,2011
Questions??????????
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Merrill Norton Pharm.D.,D.Ph.,ICCDP-D
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