Running head: TRAUMA, ADDICTION, AND THE …...TRAUMA, ADDICTION, AND THE BRAIN 4 Acknowledgements Sincere thanks to my family and friends for support, understanding, and space to

Running head: TRAUMA, ADDICTION, AND THE BRAIN

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Trauma, Addiction, and the Brain: Utilizing Brain-based Interventions to Heal the Effects of

Developmental Trauma.

A Literature Review

Presented to

The Faculty of the Adler Graduate School

________________________

In Partial Fulfillment of the Requirement for

The Degree of Master of Arts in

Adlerian Counseling and Psychotherapy

_________________________

By

Danielle Landa

_________________________

Chair: Jared Bostrom

Reader: Lisa Venable

_________________________

July 2018

TRAUMA, ADDICTION, AND THE BRAIN

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Developmental Trauma.

Copyright © 2018

Danielle Landa

All rights reserved


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Abstract

This paper will examine trauma experienced in childhood that causes brain changes correlated

with addiction vulnerability later in life. Limitations with historical treatment approaches will

also be discussed along with changes in the evolving understanding of addiction. Several

recommended treatment strategies will be included that have demonstrated to be efficacious in

addressing brain changes resulting from addiction and trauma.

Keywords: trauma, addiction, mindfulness, EMDR, attachment


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Acknowledgements

Sincere thanks to my family and friends for support, understanding, and space to

complete this project. Thank you to Jared Bostrom for the encouragement and guidance along

the way. Thank you, Lisa Venable, for being my reader, and for demonstrating the power of a

reframe through an Adlerian perspective in your group therapy course. To Christine Mannella,

for starting me on this journey, and to Jana Goodermont for leading with love.


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Dedication

This project is dedicated to my family. To my parents, Dan and Val, who have provided

me with the foundation of who I am today. To Kevin, for loving me even on my worst days, and

to Cole, Kaden, Trey, and Kaia, whom I love more than I can find the words to express, who

mean everything to me, and who put up with me being an incredibly busy mom for the past two

and a half years.


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Table of Contents

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Attachment Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Attachment through an Adlerian lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Attachment and the brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Attachment and substance use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The ACE Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Trauma through an Adlerian lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Trauma and Brain Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Trauma and memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Amygdala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Hippocampus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Prefrontal Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Anterior Cingulate Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Corpus Callosum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Biopsychosocial Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Addiction through an Adlerian lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Addiction and the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Reward Circuit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Amygdala and Nucleus Accumbens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Hippocampus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Prefrontal Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Anterior Cingulate Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Trauma and Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Limitation of Behavioral Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Required Elements of Effective Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Window of Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Brain-based Therapies for Treating Trauma and Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AEDP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mindfulness Meditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mindfulness through an Adlerian lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mindfulness Meditation and Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mindfulness and the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Amygdala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Hippocampus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Prefrontal Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Anterior Cingulate Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

EMDR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

EMDR and Addiction Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

EMDR and the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Adlerian Treatment of Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Implications for Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Recommendations for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Developmental Trauma

According to JAMA Pediatrics, nearly 60% of children reported experiencing some form

of violence against them in 2011 (Finkelhor, Turner, Shattuck, & Hamby, 2013). Statistics vary

regarding the prevalence of childhood traumatic experience depending on the population

sampled and the type of trauma identified. Additionally, traumatic events are likely

underreported given the subjective nature of experience, and the fact that trauma survivors may

not speak up due to embarrassment, fear, or feelings of low self-worth. However, it is evident

that it is a problem that requires attention. Childhood trauma manifests in a variety of ways as

people go through life, and it has been documented that a significant number of traumatized

people will develop a substance use disorder (Mate, 2007). Research is plentiful regarding the

effects that childhood trauma has on the brain. The affected areas are those implicated in emotion

regulation, reward, and higher order functions such as planning and processing. It is clear that

these areas are negatively impacted by trauma--especially prolonged experiences such as neglect

or family violence. Damage to these areas can cause difficulties with impulse control, self-

esteem, and motivation. These changes are likely the cause of many diagnosed mental health and

substance use disorders.

Insecure attachment, which often results from childhood trauma, can also cause an

inability to effectively regulate emotions as well as it can impair relationship skills needed for

interpersonal connection. These deficits can leave an individual vulnerable to addiction and

other stress-related disorders. Earned secure attachment is possible to develop as an adult

through a strong therapeutic relationship. The therapist creates a right-brain to right-brain

connection with the client to help the client learn to self-regulate and to develop the areas of the


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brain related to attachment that are missing. The ability to self-soothe is a necessary foundational

skill in the process of addiction recovery.

Mindfulness meditation is one alternative therapy that has been proven to address the

underlying physiological deficits that have been caused by trauma and are associated with

addiction. Mindfulness has been scientifically proven to increase the grey matter thickness in the

areas of the brain that are damaged by trauma and improve the functional connectivity between

areas in the brain that help with concentration and emotion regulation (Ireland, 2014).

Specifically, these areas include: the hippocampus, the prefrontal cortex, and the anterior

cingulate cortex. Also, activity in the amygdala decreases and the connections that it has to other

areas of the brain weaken through the practice of mindfulness. These areas of the brain are all

involved in the addiction process.

Mindfulness-based relapse prevention is a component of some treatment protocols that

help those recovering from addiction become more aware of the way that their bodies respond to

various stimuli (Enos, 2016). Through this process, triggers are identified and brought into

greater awareness. Furthermore, meditators become proficient “urge surfers” when cravings

inevitably occur. Mindfulness is similar to the Adlerian perspective of being in the “here and

now” and also in reorienting the client to more useful behaviors.

EMDR is a front-line therapy that effectively desensitizes traumatic memories that cause

maladaptive behaviors in those who are affected. The adaptive information processing model is

the foundation upon which EMDR was developed (Shapiro & Laliotis, 2011). This model asserts

that early memories shape the way we respond to present situations and that the brain has an

innate desire to heal. EMDR has proven to be effective at reducing distress that can trigger


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substance use. Further, EMDR can be used to target and desensitize cravings and urges

associated with substance use as well as the feeling states that trigger use and relapse.

Trauma

“Trauma comes from the Greek word for wound, which vividly describes what it feels

like” (Najavits, 2017, p. 2). Traumatic experiences are those that are overwhelming and

frightening to the individual; however, it is important to understand that reactions to experiences

are not universal. The difficulty in diagnosing trauma lies in the subjective nature of experience

(what is traumatic for some is not traumatic for others), and the subjective nature of the

assessment methods (Dong Hoon Oh, 2012). Many people don’t realize that what they have

experienced is considered trauma. This is especially in family violence situations where this

lifestyle was “normal” for them, which amplifies the need for clinicians to screen for ACEs

within their practice. It is also important to remember that because traumatic interpretation is

individualized, to look for symptoms of traumatic stress rather than simply evaluate the

experience of the individual. According to the DSM-V, some of the symptoms of posttraumatic

stress disorder are: flashbacks, nightmares, persistent negative thoughts, hypervigilance, and

sleep disturbance (American Psychiatric Association, 2013). Although it is not currently a

formal diagnosis, this paper will refer to trauma as developmental trauma, which is the chronic

exposure to trauma (typically in the form of abuse) during the developmental years of a child

(DeAngelis, 2007).

During the process of normal learning, the sympathetic nervous system is activated which

signals the body to flee from a threat, followed by the activation of the parasympathetic nervous

system, which calms the body down so that learning can occur (Curran, 2017). In threatening

situations, the autonomic nervous system is activated, and the body responds by going into fight


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or flight mode (sympathetic stress response: mobilization) (Corrigan, Fisher, & Nutt, 2010).

However, if the situation is overwhelming or the individual is unable to flee, the body goes into

submission or freeze mode (parasympathetic stress response: immobilization). During this

response, the nervous system is completely activated while the body is immobilized, similar to a

car with the gas and brake pedals simultaneously pressed (Curran, 2017). It is in this state of

immobility where the body prepares to die as painlessly as possible and floods the system with

opiates. This experience that causes deep distress and overwhelm to the individual is the

experience of trauma.

National Geographic depicted the trauma response of polar bears who had been

inoculated by a tranquilizer dart (Curran, 2017). Once the polar bears began to collapse, their

bodies consistently completed the escape movements that they were making just before their

capture. The belief is that this sequence of movements is necessary in order to release the energy

from the body and reduce the traumatic effects of the event. The book, “Why Zebras Don’t Get

Ulcers” by Robert M. Sapolsky (2004) explains similar findings within zebra populations. The

author notes that when zebras escape an attack from a predator, they engage in the pattern of

movement that they were doing just before they were immobilized. Once this course of

movement was complete, they move on as if nothing had ever happened.

Similarly, if a person survives a traumatic experience, the energy generated during the

fight, flight, freeze or collapse gets stored in the body, which explains why some refer to the

language of trauma as body sensations and suggest that treating trauma is in treating the body. It

also explains the visceral reactions that some have during flashbacks of their original trauma that

are accompanied with the same body sensations that were originally experienced. Furthermore,

this energy storage can cause the individual to overreact in real time to non-threatening


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situations. Alternatively, these same individuals often dissociate and appear to not respond at all

when faced with an actual threat (Corrigan, Fisher, & Nutt, 2010). “Thus, threatening and

traumatic experiences result in a bewildering array of cognitive, emotional and physiological

symptoms: emotions of fear, shame and rage; numbing of feelings and body sensations;

overactivity of the stress response system; and painful, negative beliefs about the self that serve

to intensify the distressing feelings and body responses” (Corrigan, Fisher, & Nutt, 2010, p. 1).

This understanding of trauma energy storage in the body was the beginning of the

development of somatic experiencing that is explained by Dr. Peter Levine in his 2017 book,

Trauma and Memory: Brain and Body in a Search for the Living Past. Dr. Levine has had

tremendous success using somatic experiencing techniques to address the trauma symptoms

within the body of those who are suffering. Dr. Levine helps patients complete the movements

that were disrupted through the traumatic experience that were necessary for them to survive. For

example, one patient who he had worked with had lost function in one of his arms after trying to

start his lawnmower. The patient had visited several specialists and was preparing for a surgery

that would regain the mobility he had lost. However, the surgeon believed his symptoms were

due to an underlying trauma and referred him to Dr. Levine. Through their work together, it was

discovered that the man, who was a first responder, had come onto the scene of a fatal car crash

involving a young child. When he reached into the vehicle to grab the key, he realized the

fatality and pulled his arm back. This movement was repeated when he later tried to start his

lawnmower and it triggered a traumatic response creating the somatic symptoms. After

completing the somatic experience exercises with Dr. Levine, his mobility returned to his arm

without the need for surgery. These findings exemplify the importance of addressing the body


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sensations that accompany the traumatic memory in order to address the trauma in a holistic

manner.

The Body Keeps the Score, a book by author Bessel van der Kolk (2015), details brain

imaging results of people who are experiencing flashbacks to trauma. Functional MRIs show a

heightened level of activity in the right brains of these individuals, especially in the right

amygdala--which he refers to as the brains “smoke detector” given its function for detecting

threats. The left brains show a significant decrease in activity during a flashback. Without the

left-brain function, a person experiencing a flashback has a reduced capacity to identify what

they are experiencing since the left side of the brain is needed for organization of thoughts. It

also houses Broca’s area that is implicated in the processes of language production and

comprehension (Alamia, Solopchuk, D’Ausilio, Bever, Fadiga, Olivier, & Zenon, 2016).

Because this, too, goes offline during flashbacks, a person is often left speechless and frozen

during the experience. This can retraumatize the individual as it perpetuates feelings of

overwhelm and powerlessness. Additionally, this lack of access to speech and thought

processing experienced during flashbacks explains why talk therapy is ineffective for treating

trauma.

Other brain regions that go offline during a flashback experience are the dorsolateral

prefrontal cortex (DLPFC) and the thalamus in both the right and left hemispheres of the

brain. The thalamus receives input from the environment and sends information to the amygdala

and to the frontal lobes (van der Kolk, 2015). The thalamus is responsible for filtering

information that comes into the brain. When it goes offline such as during a traumatic

experience, the filter is gone, and the individual becomes flooded with sensations and emotions.

The DLPFC is referred by Dr. van der Kolk as the “timekeeper” of the brain as it is responsible


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for putting time on our experiences. Specifically, the relationship between present experience

and our past, and the way that this perception may affect the future (van der Kolk, 2015). The

lack of functioning in these areas during a flashback explains why trauma memories continue to

be fragmented, feel as though they are not in the past, and are accompanied by strong somatic

sensations. When the memory comes up, the individual can’t access the part of the brain that is

associated with logical reasoning or cognitive thinking and therefore, feels as though they are

reliving the memory. It is for this reason, Dr. van der Kolk explains, that it is necessary to bring

these areas of the brain back online in order to successfully integrate the traumatic memory.

Attachment Theory

Attachment describes the emotional bond that forms between a baby and their adult

caregiver. Attachment can be secure or insecure based on this early relationship. A relationship

that results in an insecure attachment style is a form of trauma that can affect the individual well

into adulthood. A healthy attachment style is necessary to develop in order to maintain healthy

relationships with others as well as with the self.

Attachment theory was first developed by John Bowlby to understand the relationship

between a parent and child based on the way that the child reacted when they were separated

from their caregiver. Bowlby was working with children who were considered maladjusted

“affectionless children” and began to study the early interactions within their families as a means

for understanding their behavior (Bretherton, 1992). He later began working with children who

were hospitalized and kept away from their parents during their stay. These children, he noticed,

experienced significant and unnecessary distress as a result of this separation. (It is through his

efforts that treatment protocols have evolved within the hospital setting to allow parents and

children to remain together).


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Mary Ainsworth joined his research team in 1950 and went on to study mother child

bonds in Uganda before moving to Baltimore, where she continued to work with mother-baby

dyads. Eventually she developed her study that is referred to as the “strange situation” that was

designed to assess the correlation between a mother’s responsiveness to her baby with the baby’s

reaction to being separated and reunited with her (Bretherton, 1992). Patterns were recognized

within these babies that were consistent with the level of responsiveness of the mothers. For

example, mothers who were less responsive to the baby’s cues had babies who protested or

avoided them upon their return. This behavior was in contrast to babies with mothers who were

more responsive. When their mothers returned, they sought comfort from her and then moved

on to explorative play. The former group of babies were later determined to be insecurely

attached, while the latter, secure.

These patterns of attachment were also identified within adult test groups who were

analyzed to determine their patterns of attachment through their adult relationships. Adults were

interviewed about their recollections of their early attachment relationships. Patterns also

emerged within these interviews and three categories were identified: autonomous-secure,

preoccupied, and dismissive (Bretherton, 1992). Interestingly, the babies of these mothers were

found to be securely attached, ambivalent, or avoidant, respectively. This pattern demonstrates

the transgenerational learning of attachment and the importance of education and intervention to

interrupt maladaptive interaction patterns.

Through this research, it is understood that attachment is developed in the early years of a

child’s life through the responsiveness or attunement (ability to read and respond to the baby’s

cues) of the primary caregiver to the child. As the caregiver interacts with the baby, the baby

connects through their right brain with the right brain of the caregiver (Curran, 2017). Because


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the baby’s brain is underdeveloped, it relies on the caregiver to regulate their own emotions, and

also co-regulate the baby’s through attunement and activated mirror neurons. Affect regulation

involves the balancing of positive and negative emotions as it works to boost positive emotions

and reduce negative ones (Lipton, & Fosha, 2011). Simply put, when the baby cries, the mother

responds with a tone of voice that is higher pitched than her usual tone to match the baby’s

tone. Essentially, this validates the baby’s experience. The mother then begins to lower her tone

of voice which demonstrates an alternative response to the baby that is calm. This helps the baby

calm down as it is connecting with the mother, responding to her cues, and reducing its own

affective response. Similarly, when the baby is happy and the mother responds with enthusiasm,

the baby’s response becomes synergistic as it is amplified by the mother’s excitement. These

interaction patterns stimulate the development of the baby’s new neural pathways and are the

“scaffolding” upon which the baby’s right brain is built (Cihan, Winstead, Laulis, & Feit, 2014).

When attunement is consistent and affect regulation results, the baby develops secure

attachment. A secure attachment system helps a child develop a feeling of safety within the

world that deactivates their attachment seeking system. There are times when the parent

responds incorrectly to the baby’s cries which creates a rupture in the parent-child relationship

(Lipton, & Fosha, 2011). However, secure attachment is still able to form under these

circumstances provided the attachment figure repairs the rupture by soothing the baby. The use

of mindfulness is helpful with attunement: to pay attention to both the inner experience of the

parent as well as the experience of the child without judgement. This helps with the co-

regulation process that is imperative within the mother-baby dyad. With the attachment seeking

system calm, the child learns to explore the world through curious movement and learns to

regulate his or her own emotions.


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When a parent fails to respond to the baby’s cries, or doesn’t attune appropriately, the

baby doesn’t learn to calm down or that the attachment figure is safe. This is often the case

when a parent is experiencing depression or other mental illness. The parent has likely suffered

their own attachment injuries and is too preoccupied with their own pain to respond effectively

to their baby. Chronic misattunement leads to increased stress levels in the infant who develops

an insecure attachment style. A baby with insecure attachment has an activated attachment

seeking system that consistently tries to reach out to the caregiver but is not soothed. Over time,

the baby either becomes anxiously attached, disorganized, or avoidant (Lipton, & Fosha, 2011).

These early interaction patterns create an internal experience that is known but not

remembered by the individual because the hippocampus, which is not developed until after the

first year and a half of life, has not retained the events that connect to the feelings of the

experiences. Jack De Stefano and Shawna Atkins (2017) clearly state in their article,

Nonsuicidal Self-Injury, Interpersonal Neurobiology, and Attachment: Implications for

Counselors and Therapists, that the interpersonal environment has a direct effect on the

development of the baby’s brain. Specifically, they state that if the caregiver does not provide

appropriate attunement to the baby, the baby’s hippocampus and cortex will be underdeveloped,

while the amygdala will be hyperactive and the baby’s stress response will be chronically

activated (De Stefano & Atkins, 2017). These deficits compromise the baby’s ability to regulate

its emotions and self-soothe which lasts into adulthood and can lead to symptoms of depression

and other disorders.

It is important to identify an adult’s attachment style as it can provide insight into the

unconscious attachment patterns that are driving the relationship behavior. As explained earlier,

a baby who developed anxious attachment will most likely become an adult with an anxious


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attachment. The anxiously attached adult seeks closeness with their partner and is distressed by

separation. Additionally, this type of person has a highly activated attachment system that can

cause them to appear overly needy which can push their partner away. The avoidant attachment

style is developed in a child with a caregiver who is distant or emotionally unavailable. This

person develops a discomfort with closeness and will struggle in relationships with others who

try to become close to them. Disorganized attachment develops when the attachment figure is

abusive to the child. Babies learn early on that the attachment figure is needed for survival.

When that person is also the source of their fear, the child is forced to ignore their own feelings

and experiences in order to avoid upsetting the attachment figure in an effort to keep them

close. As an adult, this attachment system can cause attraction to a partner who is abusive, or the

person might become abusive themselves (Schwartz, 2016). Understanding the way in which we

relate to others through our attachment patterns brings conscious awareness to our behavior

which is the first step in being able to make a change.

Having an insecure attachment system creates problems in relationship with the self and

with others. Insecurely attached people have trouble regulating their emotions and managing

strong affect making it difficult to relate effectively with others. An inability to manage strong

emotions increases the risk of the individual being traumatized at some point in their lives as

they are more likely to become overwhelmed by an upsetting event. Considering that several

people can have a similar traumatic experience with only some of them becoming traumatized, it

is important to realize that those who have the most trouble managing strong emotions are more

likely to develop symptoms of PTSD (Lipton, & Fosha, 2011). Furthermore, insecurely attached

people will often end up with people who are similar to their early attachment figures as it is


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what is familiar to them. Some people believe that it is out of a need to work through unfinished

business of their childhood.

Attachment through an Adlerian lens. An Adlerian perspective of attachment would

consider the fictional final goal of an adult with an insecure attachment. The belief is that the

child who grows up with an insecure attachment system due to the inability to gain the attention

or affection of their attachment figure is attracted to a person who is also inattentive or

unaffectionate. This attraction is explained by the mistaken belief that the person will feel whole

inside if they could earn the affection, love, and attention of the new person in their life. The

reality is that even if the new person were to evolve and grow into the most loving and

responsive human, it would not erase or fill the void of the missing love from the early

attachment figure.

Attachment and the brain. Bruce Perry and Maia Szalavitz explain in their 2008 book,

The Boy Who Was Raised as a Dog, that the stress response is interconnected with the reward

circuitry of the brain. Further, when a child’s attachment seeking system is activated, the stress

response is also activated. When the baby’s caregiver responds to the baby’s cries, the baby

feels pleasure through the reward circuitry in the brain as the level of distress is reduced. This

repeated interaction between being responded to and soothed is how people learn that nurturing

is connected to pleasure which wires them for future human connection (Perry & Szalavitz,

2008). In children who have misattuned or abusive caregivers, the stress response is not calmed

through the reward pathway and pleasure is not experienced. They do not learn to value

nurturing relationships and human connections as their brains are not wired to do so. Those who

do not find comfort in human connection may be more likely to seek pleasure through artificial

means such as drugs and alcohol.


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Attachment and substance use. Insecure attachment can lead to problems with

substance use. The inability to regulate psychological distress is a primary reason believed to

cause the increase in substance use in insecurely attached individuals (Cihan, et al.,

2014). Problems specific to this population include but are not limited to: distress that

accompanies painful relationships, an inability to manage strong affect, or the need to escape the

discomfort of intimacy with others. Neuroscience has provided brain imaging scans that

demonstrate that attachment disorders have a negative impact on brain structures (Cihan, et al.,

2014). Because of the disease model of addiction, it is accepted that these brain changes are at

the root of addiction and must be addressed in order to reduce the addictive behaviors. “If

substance abuse is rooted in an inability to enter into satisfying interpersonal relationships, self-

regulate affect, and develop positive means of coping with stressors, then popularized CBT

techniques may miss the mark on long-term resolutions” (Cihan, et al., 2014, p. 535).

The caregiver-infant relationship also produces neurochemical changes during the

attachment interactions that are positive in the brains of both individuals. “As caregiver-infant

interactions progress, neural pathways are strengthened, and the resulting neurotransmitter

“high” becomes an expected and necessary part of daily life” (Cihan, et al., 2014, p.

533). Without this natural high that occurs in the brain, some individuals resort to the use of

substances as a means to experience the positive neurochemical release that they are

missing. Because of the immediate gratification that accompanies the release of drug-induced

neurotransmitters in the brain, individuals will often choose the path of substances as the fastest

or easiest way to feel better.


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The ACE Study

Nadine Burke Harris explains in her 2015 TEDTalk titled, How childhood trauma affects

health across a lifetime, that childhood adversity dramatically increases health risks throughout

life. Her information is based on a study conducted in the 90s by Dr. Vince Felitti of Kaiser

Permanente and Dr. Robert Anda of the Center for Disease Control. Together, these doctors

studied over 17,000 patients. The objective was to identify a correlation between childhood

adversity and health risks such as heart disease and cancer. The patients were screened for

ACE’s or Adverse Childhood Experiences using a 10-question survey that asked for a yes or no

answer to questions that identified adverse conditions under which they lived. Specifically, the

questions screen for physical, emotional, or sexual abuse, physical or emotional neglect, living

with a parent with a mental illness, having parents that separated, having a parent incarcerated,

living with domestic violence, or living with a parent with a substance use disorder. This

information was cross-referenced with the health outcomes that were experienced within this

same group and the results were overwhelming. They found that almost 70% of them had at least

one ACE and over 10% of them had 4 or more. The health risks were exponentially higher as the

ACE scores increased. Furthermore, functional MRIs showed anatomical differences in the

amygdalae and the prefrontal cortex in the brains of those with several ACEs compared to those

with zero or one. These differences are believed to be due to the chronic overactivation of the

autonomic nervous system that creates an environment of toxic stress within the body and also

leads to a reduction in immune and hormone function.

Children who are developing under these conditions experience a disruption in the

development of their nervous systems as they are chronically on alert for threats of danger. This

overactivation impedes their ability to be in the window of tolerance where learning and mood

regulation are integrated (Corrigan, Fisher, & Nutt, 2010). The inability to regulate emotions


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causes further distress and social isolation for children who often turn to drugs or alcohol at an

early age as a desperate attempt to self-regulate or escape. Dr. Felitti states, “Until we treat the

underlying ACE trauma, nothing will change, and a high percent of people will continue to die

early. These abuses create the top ten causes of death in the U.S.” (Felitti, 2014, p. 1).

Trauma Through an Adlerian Lens

Rudolf Dreikurs was ahead of his time when he said that “children are expert observers

but they make many mistakes in interpreting what they observe” (Dreikurs & Soltz, 1964, p.

15). The truth behind this statement is largely due to the underdevelopment of a child’s brain

and the lack of wisdom due to life experience and world view that is limited. Children often

believe that they are to blame for the maltreatment they are experiencing and develop mistaken

beliefs that they are not worthy of love or that they aren’t good enough. Other mistaken beliefs

that are commonly observed in children who are abused are that “big people overpower and hurt

little people” or “men or women are not safe”. Adler believed that gender guiding lines are

developed during childhood (Griffith & Powers, 2007). That is to say that children learn what it

means to be a man or a woman through their interactions with their parents or caregivers. When

the caregivers are not safe, children might accept this as a general truth about adults and grow up

to be attracted to an adult partner that is also unsafe. These are Adler’s “guiding fictions”

(Griffith & Powers, 2007, p. 41) that are subconscious but have tremendous influence over

decisions that are made throughout life.

Children who are living in chaotic environments also develop various survival strategies

that are necessary to keep them as safe as they can be. For example, they are often hypervigilant

to environmental signals of danger as they must always be on alert for threatening situations. In

abusive environments, children learn to dissociate from their own bodies to escape the pain and

discomfort of abuse. Adler referred to these maladaptive strategies as “safeguarding tendencies”


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(Griffith & Powers, 2007, p. 89) that are used to avoid the underlying pain or fear that the

individual is experiencing. Safeguarding becomes part of a person’s lifestyle and is reflected in

their interactions with others and themselves. The safeguarding that they learned to keep them

alive is often the problem interaction patterns that are causing them the most distress as adults. It

is important to validate their experience and help them understand that they did the best that they

could with the wisdom of a child and that those survival skills aren’t needed or useful when they

are in a safe environment. However, it is also important to assess for safety in the person’s life

as they may currently be in an adult relationship that is abusive.

Trauma and Brain Development

Alfred Adler wrote that “The style of life and a corresponding emotional disposition exert

a continuous influence on the development of the body” (as cited in Ansbacher & Ansbacher,

1956, p. 226). He explains that the emotions are expressed through the organs of the body and

that the organs often show symptoms due to psychological stressors experienced by the

individual. Adler referred to this as “organ dialect” or “organ inferiority”. Interestingly, Adler is

also quoted as saying that, “someday it will probably be proved that every organ inferiority may

respond to psychological influences and speak the language. . . a language expressing the attitude

of the individual toward the problems confronting him” (Griffith & Powers, 2007, p. 75).

Neuroscience has proven his theory through the use of both functional MRIs and

diffusion tensor imaging to measure volumetric changes that occur within the brains of various

populations. For example, studies that are done in adult populations who endorse a history of

childhood maltreatment are compared with adults who did not have those experiences. Various

areas of the brain are identified within the test groups to be anatomically different--in many cases

smaller, and hypo functioning, compared to the control groups. These areas are also the areas of

the brain that are implicated in the addiction process. A reduction in the functioning of these


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areas creates a neurological vulnerability to addiction that is necessary to address as part of a co-

occurring disorders treatment plan.

Trauma and memory. Many theories attempt to describe the phenomenon behind

trauma memory storage. One such theory suggests that due to the overwhelming sensations that

accompany trauma, the trauma memory becomes split off from conscious processing and thus is

stored elsewhere in the brain (Dekel & Bonanno, 2013). This faulty storage results in

unpredictable recall of traumatic sensations in the present moment. It has also been believed that

trauma memories have a rigidity around them that keeps them fixed during recall whereas

normal memories change and fade with time (Dekel & Bonanno, 2013). However, a study

conducted on post 9/11 survivors suggests that trauma memories can adapt and change under

certain circumstances. Certain therapies, such as EMDR, help process the trauma memories and

allow them to be stored within the prefrontal cortex of the brain where it is understood to be in

the past. It is important to be able to put trauma memories in the past to alleviate the

disorganized, fragmented storage that causes unpredictable and emotional recall.

The hippocampus stores memories of experiences and is not developed until 18 months

to 3 years of age. Because of this, experiences prior to this development are remembered

through body sensations or “recorded experientially” and are stored in the right brain (Lipton, &

Fosha, 2011). Children who are traumatized before the hippocampus is online do not have

language associated with their experience but can have a felt sense that something bad

happened. This further demonstrates the importance of addressing the body when working with

trauma.

The amygdala. The brain has three regions that are considered the “triune brain”: the

frontal lobes, the limbic system, and the brain stem (Fisher, 2011). The amygdala is part of the


25

limbic system that is associated with emotional learning and memory (Dong Hoon Oh, 2012).

The role of the amygdala is to alert the rest of the body when danger is present. In people who

have experienced trauma, the amygdala becomes hypervigilant and perceives small threats as

large ones. For example, a person may hear a rude comment directed at them. Although this is

not life-threatening, the amygdala responds as if the person has been confronted by a hungry

tiger. Adrenaline is pumped into the brain and body, and oxygen is sent to the hands and feet to

enable the body to run; thus, leaving less oxygen in the brain to help with rational thinking, and

sending the individual into “fight, flight, or freeze” mode (PMSL Training, 2015). This is

referred to as an “amygdala hijack” and if the process is not interrupted within 10 seconds, it will

take the body approximately 18 minutes to break down the adrenaline that is released (PMSL

Training, 2015).

Studies have shown an increase in amygdala volume in children who have experienced a

traumatic event while a decrease in amygdala volume has been identified in adults who

experienced trauma as children (McCrory, De Brito, & Viding, 2010). Additionally, one study

indicated that a reduction in amygdala volume correlated to an increase in alcohol craving

(Wrase, Makris, Braus, Mann, Smolka, Kennedy, Cabiness, Hodge, Tang, Albaugh, Siegler,

Davis, Kissling, Schumann, Breiter, & Heinz, 2008). These discrepancies are not completely

understood, however, it is suggested that structural changes in the brain are dependent on the age

of the individual at the time of the trauma, as well as the duration and the severity of the

trauma. Other factors to consider are the child’s connections with other caring people, the

amount of control that they had over their environment and the predictability of the abuse (Perry

& Szalavitz. 2008). Despite the variability in experience and anatomical differences, the fact


26

remains that exposure to recurrent trauma during development increases the activity of the

amygdala that creates hypervigilance which continues into adulthood.

The hippocampus. The Hippocampus, also part of the limbic system, plays an important

role in learning and memory and is activated during novel experiences. More specifically, it

allows the brain to differentiate between past and present memories (McCrory, De Brito, &

Viding, 2010). Additionally, the hippocampus aids in the regulation of amygdala activity

(Curran, 2017). Animal studies show a reduced capacity of hippocampal functioning resulting

from exposure to chronic stress (McCrory, De Brito, & Viding, 2010). Neuroimaging in humans

has revealed shrinkage in grey matter areas of the hippocampus in patients diagnosed with PTSD

(Wlassoff, 2015). This loss of volume is associated with depression, the inability to keep

traumatic memories in the past, and the experience of flashbacks when current situations are

similar to the original trauma. Equally problematic is the way that the stimuli become

overgeneralized, creating situations where a person experiences an extreme stress response to

many triggers that faintly resemble the original.

In addition to the processing of learning and memory, the hippocampus is one of the

primary sites in the brain where neurogenesis (growth and development of nervous tissue) occurs

(LaDage, 2015). Chronic stress down regulates the process of hippocampal neurogenesis

resulting in fewer new neurons that are produced in the brain. This is explained through the

stress response system which is activated as a result of an environmental stimulus. The

hypothalamic-pituitary-adrenal (HPA) axis releases cortisol as part of the fight or flight

response. Cortisol is a glucocorticoid that directly affects hippocampal neurogenesis (LaDage,

2015). This reduction in new neurons correlates to a reduction in spatial learning, which results

in cognitive deficits and reduced memory capabilities commonly experienced by individuals who


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are exposed to chronic stress and developmental trauma. These deficits decrease the ability to

learn from mistakes and implement more adaptive behavior.

The prefrontal cortex (PFC). The prefrontal cortex is the region of the brain that “is

responsible for regulating emotional responses triggered by the amygdala” (Wlassoff, 2015, p.

1). This area is also known as the “thinking center” of the brain, and is responsible for activities

such as self-awareness, problem solving, and planning (Psych Central, 2017). Neuroimaging

reveals decreased grey matter in this area of the brains of patients with PTSD. Studies also

indicate that childhood maltreatment is associated with hypoactivity in certain brain regions

including the prefrontal cortex (McCrory, De Brito, & Viding, 2010). This reduction in volume

and functionality of the prefrontal cortex explains the emotional dysregulation that is often seen

in trauma survivors as it is also where the executive functions develop. “Executive functions

refer to a set of skills responsible for top-down regulation of behavior, that is, they are skills that

give individuals cognitive control of their actions, including their thoughts and emotions” (Dias,

Trevisan, León, Prust, & Seabra, 2017, p. 383). One model explains that the scope of executive

functions can be divided into three categories: inhibition, which includes the inability to inhibit

inappropriate behaviors and the inability to focus attention; working memory, which is needed

for reasoning and decision making; and cognitive flexibility, which allows a person to generate

alternate possibilities and viewpoints (McCrory, De Brito, & Viding, 2010). A reduced capacity

to function in these areas creates vulnerabilities related to social connection, behavior control,

school performance, substance use, and relationship skills.

The anterior cingulate cortex (ACC). The ACC is located behind the prefrontal cortex,

is situated on top of the corpus callosum, and is responsible for the regulation of emotion, mood,

and impulses. Stroop tests, which measure implicit cognitive function, also indicate that the


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ACC is implicated in the process of assessing conflict and driving avoidance behavior (Braem,

King, Korb, Krebs, Notebaert, & Egner, 2017). Damage to this area of the brain can lead to

impulsivity and a reduced ability to regulate or tolerate painful emotions as it becomes

underactive in people who have experienced trauma (Psych Central, 2017). “ACC, like the

hippocampus, might be vulnerable to prolonged glucocorticoid exposure resulting from chronic

stress, which in turn may decrease its ability to exert negative feedback control over HPA

(hypothalamic-pituitary-adrenal axis) activity” (Braem, King, Korb, Krebs, Notebaert, & Egner,

2017, p. 140).

The corpus callosum. Dr. Jill Bolte Taylor (2012) explains that the brain is distinctly

divided into two hemispheres and that each hemisphere functions uniquely from the other. The

right hemisphere works by thinking in pictures, learns through body movements, and is in the

present moment. By contrast, the left hemisphere operates in a linear manner and is concerned

about the past and the future (Taylor, 2012). This hemisphere focuses on details, categorizes

them and organizes them to imagine all future possibilities based on those details. Dr. Taylor

states that this hemisphere thinks in language and that it works to connect the internal experience

of an individual to the outer world and that it defines our separateness from others. The corpus

callosum is situated between these two hemispheres and is comprised of millions of axonal fibers

that are utilized for interhemispheric communication within the brain (Carrion, Wong, & Kletter,

2013). “Specifically, the medial and posterior areas of the CC contain interhemispheric

projections from brain structures that mediate the processing of emotional stimuli and memory –

core processes that are disturbed in PTSD” (Carrion, Wong, & Kletter, 2013, p. 57).

Diffusion tensor imaging has been used to study the brains of adolescents who were

exposed to repeated trauma during their development. A reduction in white matter in the corpus


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callosum was found in these individuals which compromises the integrity of their

interhemispheric communication abilities (Rinne-Albers, Werff, Hoof, Lang, Lamers-

Winkelman, Rombouts, Vermeiren, & Wee, 2016). Reduced functioning in the corpus callosum

correlates to a reduction in emotion and mood regulation and an increase in other

psychopathological disorders (Rinne-Albers, et al., 2016). These studies also revealed that there

are critical periods during brain development where the child is especially vulnerable to the

effects of abuse. These windows are during the early years and again during adolescence. To

demonstrate the effects of abuse during the adolescent years, a similar study was conducted on

the brains of over 800 adults who had not experienced early life trauma but were victims of

verbal abuse from their peers during their adolescent years. Brain scans revealed structural

changes in various areas of their brains as well, including a reduction of white matter within the

corpus callosum (Hurtful Words, 2011).

Addiction

According to the Surgeon General’s report, “substance misuse is the use of alcohol or

drugs in a manner, situation, amount, or frequency that could cause harm to the user or to those

around them” (HHS, 2016, p. 1-1). Additionally, over 100,000 annual deaths in the United

States are caused by the misuse of drugs and alcohol. (HHS, 2016). Substance misuse that is

maintained over time can lead to a substance use disorder which, when severe, is more

commonly referred to as addiction.

Addiction was originally believed to be a matter of will-power and was linked to a

character flaw within the individual. It is now understood that addiction is a disease that causes

changes in both the structure and function of the brain and requires a holistic understanding of

the problem. As an addiction progresses, the individual will often experience consequences due


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to their substance use such as job loss, relationship struggles or trouble with the law. Despite

these consequences, the substance use may continue due to the physiological processes that

occur within the brain as well as the individual’s genetic make-up and social environment.

Biopsychosocial Model

The biopsychosocial model incorporates biological, psychological, and social dimensions

of human functioning to provide a holistic framework that guides treatment within the field of

mental health as well as other medical disciplines (Pilgrim, Kinderman, & Tai, 2008). “At a

practical level, it is a way of understanding the patient’s subjective experience as an essential

contributor to accurate diagnosis, health outcomes, and humane care” (Borrell-Carrio, Suchman,

& Epstein, 2004, p. 576). This model asserts that in order to effectively heal an individual, one

must consider all aspects of their functioning, rather than simply managing their symptoms.

Addiction Through an Adlerian Lens

According to Adler, addiction is a form of neurosis and is a symptom of a discouraged

individual who is lacking social interest (Ansbacher & Ansbacher, 1956). Further, he believed

that over indulgence in substances is a means to avoid pain and discomfort often rooted in

inferiority feelings. In line with the biopsychosocial model, Adler endorsed a perspective that is

“an integrated, holistic model of human nature, psychopathology and treatment” (Pienkowski,

nd, p. 1) when treating addiction that is built upon a supportive relationship between the therapist

and the client.

Addiction and the Brain

The brain registers pleasure the same whether it is stimulated by a natural cue or a

synthetic substance (HHS, 2016). Dopamine is flooded into the synapses of the brain, and the

feeling of happiness is experienced. A person can experience this release of dopamine through

natural means such as eating or accomplishing a goal. However, drugs and alcohol create a short


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cut to this dopamine surge that is with little effort and in greater amounts. Functional MRIs

allow researchers to look closely at brain activity and adaptations. Over time, neural adaptations

occur that further the addictive process as the circuitry becomes linked in a manner that

perpetuates drug-seeking behavior. The areas of the brain implicated in the addiction process

are: the reward circuit, the amygdala, the nucleus accumbens, the hippocampus, the prefrontal

cortex, and the anterior cingulate cortex.

The reward circuit. The brain’s reward circuit is responsible for identifying rewarding

stimuli and signaling the individual to continue to engage in rewarding activities and is

implicated in the process of drug-seeking behavior (Eisch, 2005). The reward circuit is also

referred to as the mesolimbic dopamine pathway as dopamine is the primary neurotransmitter

that is released in these areas in response to pleasurable stimuli (Advokat, Comaty & Julien,

2014). Dopamine is primarily produced in the VTA when it is activated by a stimulus and is

then sent to the nucleus accumbens, the amygdala, the prefrontal cortex, and the hippocampus

(Advokat, et al., 2014).

The reward circuit can be activated to varying degrees depending on the stimulus. Food,

sex, affection, and praise are examples of stimuli that activate the reward circuitry in the brain

and release dopamine that in turn produces a rewarding feeling such as happiness. Drugs and

alcohol also activate the reward circuit. When a person uses drugs or alcohol, the natural stimuli

often lose their appeal as they don’t activate the reward system to the heightened degree that the

synthetic stimuli do. This helps to understand the addictive process and the disregard that the

addicted person often has for other people who are affected by their use.

The amygdala and nucleus accumbens. The amygdala is one of the most common

areas of the brain discussed with regard to trauma. Trauma causes the amygdala to be


32

hypervigilant to environmental stimulus, causing the individual to overreact. Also, the amygdala

releases dopamine into the nucleus accumbens when it is activated by either positive or negative

stimulus. The nucleus accumbens is a key component in the addiction process as it is the brain’s

pleasure center. Drugs activate the nucleus accumbens by flooding it with dopamine. This

dopamine surge is higher than is achieved through natural events such as eating. The higher the

dopamine surge, the greater the likelihood that it will become addictive.

If childhood trauma causes the amygdala to flood the nucleus accumbens with dopamine

over prolonged periods of life, it is possible that this predisposes a person to substance misuse

given the need to continue this flood of dopamine to achieve homeostasis in the brain. It is

difficult to find research that directly answers this question. What is known, however, is that an

overactive amygdala contributes to emotion dysregulation that often underlies substance use

problems. Further, the neural networks activated through trauma are related to those activated

during substance use.

The hippocampus. The hippocampus is involved in the addiction process as it is

activated to remember novel experiences (Kantak, 2007). As drugs are introduced into the

reward pathway, the hippocampus records the environmental cues and feelings associated with

the drug. This memory storage of environmental cues contributes to cravings and compulsion

associated with substance use. Additionally, this memory storage is implicated in the relapse

potential of an individual in recovery. Specifically, a relapse can be initiated through exposure

to visual cues such as a hypodermic needle or a glass of wine.

The prefrontal cortex (PFC). Dysfunction within the prefrontal cortex contributes to

the lack of impulse control and the denial of the addiction that is common among substance

misusers. Further, the PFC modulates the planning and anticipation of reward and also inhibits


33

inappropriate actions (van der Kolk, 2015). Once the brain has been introduced to illicit

substances, the prefrontal cortex is hijacked to focus on obtaining more of the drug. The PFC

receives messages from the nucleus accumbens that stimulate craving for the drugs that

previously activated the reward pathway (van der Kolk, 2015). This repeated pattern strengthens

neural connections between these two regions that further influence addictive behaviors.

The anterior cingulate cortex (ACC). The anterior cingulate cortex helps to regulate

mood and emotion as it integrates interhemispheric cerebral information. A decrease in ACC

functioning is associated with mood dysregulation which often leads individuals to use

substances as a means to ease discomfort. Reduced function in the ACC can also affect impulse

control that can lead to difficulty in abstaining from drugs and alcohol (Congleton, Holzel, &

Lazar, 2015).

Trauma and Addiction

According to Recovery.org (2015), between “25 and 75 percent of people who survive

abuse or violent trauma develop issues related to alcohol misuse”. (The range in this percentage

exemplifies the difficulty of quantifying the prevalence of trauma). The most common reason in

the literature that explains the high incidence of use in trauma survivors is the need to self-

medicate. Trauma survivors self-medicate for a variety of reasons: to avoid feeling unsafe or

threatened, to soothe pain, to suppress traumatic memories, or reduce anxiety, to list a few. Put

another way: “to feel something, to feel nothing, or to feel different” (Curran, 2017). Prolonged

substance use results in dysregulation of the brain’s reward pathway and a down regulation of

dopamine receptors (Eisch, 2005). The reduction in the dopamine receptors occurs as a result of

too much dopamine in the brain and is the brain’s attempt to regain homeostasis. However,

fewer dopamine receptors means that it takes more of a stimulus in order for the individual to


34

experience feelings of happiness. This contributes to the anhedonia often expressed by prolonged

substance users. Additionally, disruption of the brain reward circuitry is also caused by chronic

stress placed on a developing child. “Many clinical characteristics of addictive illness can be

linked to the acute activation and chronic disruption of brain reward circuits” (Dackis & Miller,

2003). Children who are subjected to chronic stress during their development are

physiologically vulnerable to addictive behaviors as adults.

Another possible reason for the high prevalence of addiction in trauma survivors resides

in the body’s response to stress. Laboratory studies reveal important relationships between stress

and addiction that may provide insight into this correlation that is seen in human populations

(Eisch, 2005). Stressful environments that were created in the laboratory varied from

maltreatment to deprivation to isolation and ranged from acute to chronic stress (Eisch,

2005). Each stressful situation correlated to an increase in drug taking behavior.

One relationship that was discovered from this research is that stress and abusive

substances cause similar changes within the reward pathway of the brain. The areas highlighted

were the ventral tegmental area, the nucleus accumbens, the prefrontal cortex, and the

connections within these areas that transmit information bidirectionally (Eisch, 2005). As

Hebb’s axiom states, “neurons that fire together, wire together” (Brown & Milner, 2003). If both

the use of substances and exposure to stress activate the body’s stress response as well as the

reward pathway, it is possible that these neural pathways become deeply connected through

either experience. “This suggests that exposure to either drugs or stress may ‘prime’ the brain

for the next exposure to either stimulus” (Eisch, 2005, p. 31).

Another relationship that was discovered between stress and substance misuse is that

early exposure to stressful situations correlated to the increased incidence of drug self-


35

administration and also the increased effect of the reward (Eisch, 2005). Exposure to stress on a

developing brain has proven to be detrimental. The brain develops in a use dependent manner

which means that it forms in response to both the positive and negative experiences of the

individual (van Duiven, 2009). Particular vulnerabilities are within the sensitive periods that

occur in the early years and again during adolescents. (Sensitive periods are times when the brain

is especially vulnerable to change and has a heightened ability to learn). Because these sensitive

periods occur during childhood, it is particularly damaging for children in abusive environments

as it alters their brain development, creating an increased risk for substance use. Additionally,

these brain changes create a heightened sensitivity to the effects of illicit substances. “A current

working hypothesis in the field is that stressful experiences produce long lasting increases in

stress hormones as well as dopamine, which thereby make the subject more vulnerable to the

rewarding aspects of drugs of abuse” (Eisch, 2005, p. 34). This increase in the rewarding effects

of drugs can increase the likelihood of addiction as great pleasure is experienced by the

individual in association with the drug.

The final relationship discovered between stress and substance misuse from this study

indicated that a future stressful experience increased the likelihood that a relapse would occur

after a period of abstinence. It was noted that more predictable stressors were less threatening to

a relapse while, conversely, more intense stressors were more likely to impose a relapse situation

(Eisch, 2005). Neuroadaptations identified after cessation of drug exposure included a reduction

in dopamine activity and in increase in activity within the HPA axis (Eisch, 2005). This

reduction in dopamine and increase in the stress response can trigger cravings that occur on a

physiological level. These findings highlight the neurological vulnerability developed through


36

exposure to stress and illicit substances and the need to address these brain areas in humans who

are seeking treatment for co-occurring disorders.

An interesting difference that was discovered between a stress-induced relapse and a

drug-induced relapse was that the stress induced relapse (in this case, a shock to the animal’s

foot) was activated through a dopamine surge reliant on the amygdala while a drug induced

relapse activated a dopamine release through the nucleus accumbens (Eisch, 2005). While both

elicited a relapse in the animal, the activation of the reward circuitry began in different locations.

Further, the stress-induced relapse was reliant on the amygdala which has been shown to be

hypervigilant in those who have experienced chronic stress. It is possible that humans who have

been exposed to chronic stress are more susceptible to a stress-induced relapse than a drug-

induced relapse. Further study is needed to identify this correlation in human subjects.

One human study did identify an increase in mesolimbic dopamine activation in response

to evocative cues related to drug use in populations of adults with cocaine use history who report

child abuse experiences (Regier, Monge, Franklin, Wetherill, Teitelman, Jagannathan, Suh,

Wang, Young, Gawrysiak, Langleben, Kampman, O’Brien, & Childress, 2017). Participants

were treatment-seeking adults for cocaine dependence. They were screened for experiences of

abuse in childhood that were either physical, emotional, or sexual in nature. The study utilized

fMRI to monitor reactions in the brains as the subjects were exposed to video cues relating to

cocaine use as well as neutral cues. The results indicated a heightened dopaminergic response

within the brains of those who reported a history of abuse. Further, the degree of activation in

their brains was correlated to the severity of the early life abuse (Regier, et al., 2017). This study

exemplifies the connection between the human stress response system and the reward system as

predicted in the laboratory studies.


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Limitation of Behavioral Treatments

Many of the addiction treatment facilities available today are based on the principles set

forth in the original treatment facilities of the 1960s that viewed addictions as character disorders

(U.S. Department of Health and Human Services, 2016). These treatment programs utilize

cognitive behavioral therapy and skill building to address thoughts and cravings associated with

substance use. While these are useful tools, they do not address the biopsychosocial conditions

that create vulnerabilities to addiction in those who have experienced developmental trauma. If

the activity of the amygdala is not reduced and the brain’s neural networks are not rewired for

more adaptive thinking patterns, the adaptive information processing model asserts that the

individual will continue to react in the present based on their past maladaptive experiences. This

continued pattern of reactivity, emotion dysregulation, and maladaptive coping strategies

perpetuates pathological conditions and addictive habits. Thus, if the underlying neurobiology is

not addressed and treated, the addicted person might continue to be physiologically drawn

toward the use of substances. A life tied to fighting internally against cravings and urges is a life

of survival and is not a life of purpose and meaning.

Required Elements of Effective Treatment

Through the biopsychosocial model, it is evident that substance use treatment requires a

holistic approach. Neuroscience has proven that anatomical changes occur in the brains of those

who are exposed to recurrent trauma. The disease model asserts that addiction is a medical

condition that incorporates biological, neurological, genetic, and environmental factors. A

holistic approach to chemical health treatment must address the underlying causes that are

driving the addictive behavior. In order to do so, it is important to first be thorough in the

diagnostic portion of clinical work. Tools such as the ACE inventory can help identify early life

trauma. Other screening tools such as the Vulnerable Attachment Style Questionnaire can help


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identify insecure attachment patterns. Once trauma is identified, it is important to utilize brain-

based therapies that heal the effects of the trauma on a physiological level. Some brain-based

therapies include: Accelerated Experiential Dynamic Psychotherapy, Mindfulness Meditation,

and EMDR. These brain-based therapies create space for the individual to learn to function

within their window of tolerance, where they can think and feel at the same time, and where they

can thrive.

The window of tolerance. The fluctuation between hyper and hypo arousal states results

in mood dysregulation that is difficult for individuals to tolerate. The “window of tolerance”

model was developed to help explain the space between these two responses where emotions can

be felt and experienced at the same time and information can be integrated (Corrigan, Fisher, &

Nutt, 2010). For trauma survivors, this window can be small, and the object of therapy is to

function at the outer edges of each end in order to foster growth. The outer edges mark the range

that is uncomfortable for the client, yet still tolerable. In this growth area, patients are able to

think and feel simultaneously which allows them to process thoughts, feelings, and emotions,

while facilitating their ability to develop self-regulation skills. People strive to be within the

window of tolerance on their own, and trauma survivors often use maladaptive coping strategies

such as drugs, alcohol, or compulsive activities in an effort to do so (Corrigan, Fisher, & Nutt,

2010). Specifically, alcohol use is often associated with chronic hyperarousal states in an effort

to reduce the emotional state down towards the window of tolerance, while drugs such as cocaine

or amphetamines are often used to counteract hypo arousal and bring the emotional state up. It is

important to note, that depressed individuals who use stimulants have an increased risk of

suicide, as it is believed that the stimulant can provide the individual with a burst of energy that

is sometimes used to complete a suicide (Corrigan, Fisher, & Nutt, 2010).


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Brain-based Therapies for Treating Trauma and Addiction

Trauma and addiction are often co-occurring, and it isn’t always clear which is the cause

of the other. What is clear is that both trauma and addiction cause physiological changes in the

brain that create vulnerability to further addictive behavior and further trauma. Brain-based

therapies are necessary to address the physiological effects of trauma at the root. Brain-based

interventions discussed in this paper are: accelerated experiential dynamic psychotherapy,

mindfulness meditation, and EMDR.

Accelerated Experiential Dynamic Psychotherapy (AEDP)

AEDP is a form of psychotherapy that asserts that earned secure attachment can be

achieved in adulthood through the therapeutic relationship under the right circumstances (Lipton

& Fosha, 2011). It is based on the belief that, neurobiologically, human brains strive toward

healing, the right brain is shaped through the early attachment relationship and can be further

shaped through right brain connection with an attuned therapist (Lipton & Fosha, 2011). The

therapist uses right brain to right brain communication to maintain attunement with the client to

foster the development of affect regulation. The therapist establishes a sense of togetherness

with the client by demonstrating that he or she is in the experience with the client. Insecure

attachment can cause significant feelings of aloneness that can be combated by this

approach. The goal is to create emotional safety for the client to experience the body sensations

together with their emotional experience. The therapist co-regulates the emotions of the

therapeutic dyad as the client learns to develop their own self-regulation skills, much in the way

that they would have in their early interactions with their caregiver.

The therapeutic stance is one of acceptance of all feelings to create a space for the client

to examine their experience throughout the therapeutic process as explained through the use of

“metaprocessing” (Lipton & Fosha, 2011). The belief is that learning takes place through the


40

reflection of the therapeutic experience which is occurring in the present and experienced in the

right brain and integrates the felt experience of being understood and attuned to into the left

hemisphere (Lipton & Fosha, 2011). This process mimics the early interactions between the

mother-baby dyad that are crucial for the development of emotion and mood regulation.

Neuroplasticity allows this interaction to develop new neural pathways in the brain and

strengthens areas that were underdeveloped as a child.

The corpus callosum, the prefrontal cortex, the insula, and the anterior cingulate cortex

play a primary role in attachment (Lipton & Fosha, 2011). These same brain areas are engaged

during the use of meta-processing in therapy. Metaprocessing incorporates both left brain and

right brain experiences that are needed to heal. Through this psychologically safe environment,

it is believed that the areas of the brain that were underdeveloped can thrive. It is written that

trauma weakens the bridge between the felt experiences in the right brain and the ability to

reflect on them coherently in the left brain (Lipton & Fosha, 2011). This reduction in

interhemispheric communication is possibly due to the reduced size and functioning of the

corpus callosum. The AEDP model has two parts: to heal the hurt and pain of the self, and to

develop the latent resilient parts of the self.

Mindfulness Meditation

The formal practice of mindfulness meditation is an ancient tradition thought to originate

from the Buddhist culture (Wolfe & Serpa, 2015). It has been used for centuries to calm the

brain and body and is becoming increasingly popular in mainstream culture. It is a way of being

in the present moment, fully aware of the senses, including thoughts and feelings, and without

judgement. It is often practiced with a focus on breathing and an acceptance of circumstances as

they are. As thoughts enter the mind, they are non-judgmentally dismissed and the attention is

returned to the breath. Mindfulness must be accompanied by kindness or compassion in order to


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avoid detachment or sentimentality (Wolfe & Serpa, 2015). Having compassion for the self and

others or a kindness towards one’s experiences combined with the act of being mindful is the

process that leads to the reduction of suffering.

Mindfulness can be used informally as a means of managing emotions and stress. It is

the act of noticing one’s experience internally as well as externally without judgement that

allows one to remain in the window of tolerance for longer periods of time. Further, noticing

one’s experience without judgment activates the neocortex which sends messages to the

amygdala to calm down and reduces the possibility of the amygdala hijack mentioned

previously.

Research has demonstrated the positive effects of mindfulness in the areas of symptom

reduction, biological markers and neuroplasticity (Wolfe & Serpa, 2015). Specifically,

mindfulness has proven to reduce symptoms of depression, anxiety, and pain as well as increase

quality of sleep and overall quality of life--which is one of the main goals for treatment of

individuals with post-traumatic stress disorder according to Dr. Bessel van der Kolk

(2015). Biological markers such as a reduction in cortisol levels have also been observed in

meditators, as well as improvements to immune function and anti-aging functions.

Mindfulness through an Adlerian lens. Adler is quoted in an article by Powers and

Griffith (1996, p. 3) as saying, “the cure or reorientation is brought about by a correction of the

faulty picture of the world and the unequivocal acceptance of a mature picture of the

world”. This idea of reorienting is also found in the practice of mindfulness as it distances a

person from their feelings and allows them to view them objectively. This provides them with

the opportunity to reorient themselves and respond more appropriately to situations. The

Adlerian approach to treating PTSD focuses on the “here and now” which is also a strategy of


42

mindfulness and mindfulness meditation. During mediation, the person focuses on the present

moment without judgement, notices thoughts and feelings, and simply accepts them.

Additionally, the mindfulness practice of integrating kindness and compassion is supportive of

the Adlerian practice of social interest. As we choose compassion towards ourselves and others,

we let go of judgment and anger and embrace loving kindness. This practice fortifies peace and

understanding which are the underpinnings of social interest and Gemeinschaftsgefūhl.

Mindfulness meditation and addiction. The science behind mindfulness reveals

improved function in areas of the brain that are implicated in the addiction process and it is

beginning to be used as part of addiction treatment programs such as mindfulness-based relapse

prevention programs (MBRP). These programs aim to teach clients to use mindfulness to help

identify triggers, body sensations, thoughts, and feelings that may stimulate their substance use.

This process of identification sets clients in motion towards creating space to respond to these

sensations rather than impulsively reacting with substance use (Enos, 2016). Urge surfing is

another way that mindfulness is applied to the substance use population. When cravings occur,

clients are instructed to imagine that they are riding the craving as if they were riding on a wave.

They become kindly aware of the cravings and feelings that come up, without judging them, and

ride them out to sea.

It is also possible to use mindfulness in clients who are actively using. For many,

substance use has been their only source of relief from painful feelings of rejection and shame.

Teaching the practice of loving compassion and acceptance of all of life’s circumstances could

be the first step in freeing them from negative feelings that are perpetuating their substance

use. “People with addictions tend to be rather diffuse in their ability to stay present and often

ruminate about negative things, which fosters more negative feelings and compulsive


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behaviours. Mindfulness training insulates one's thoughts to be more present, positive, and life-

affirming” (Prousky, 2012, p. 53).

Mindfulness and the brain. The practice of paying attention to the present moment with

the stance of loving kindness wires new neural pathways through the process of neuroplasticity

(Wolfe & Serpa, 2015). This repetition and creation of new neural pathways makes it easier for

a person to respond with kindness and compassion to their circumstances as the circuitry

becomes stronger with practice. Mindfulness meditation is similar to the practice of executing

fire drills to prepare for an actual fire. Over time, the process becomes automatic when the fire

drill sounds and everyone knows what to do and where to go. Similarly, as the brain becomes

more accustomed to responding to circumstances with kindness, a new situation that would have

triggered strong negative emotions in the past is less likely to do so in the present.

The amygdala. The amygdala is part of the limbic system that gathers information from

the environment and prepares the body to react to it. An overactive amygdala sends the body

into fight, flight, or freeze mode unnecessarily and can keep the body in a constant state of

stress. Daily meditation has resulted in a decrease in brain cell volume of the amygdala and also

in its activity (Wolkin, 2015). Reducing the activity of the amygdala has an overall calming

effect on the individual as it provides space to think about their feelings and distance from them

enough to feel less affected by them. Mindfulness meditation has also demonstrated reductions

in the connections between the amygdala and the rest of the brain. This reduction is a result of

the decreased activation of neural networks. These networks weaken as the new ones related to

compassion strengthen. Reducing the reactivity and connections of the amygdala also allows

more time for the thalamus’ signals to reach the prefrontal cortex which increases the chance for

a calm and rational response to occur.


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The hippocampus. The hippocampus is also part of the limbic system and is associated

with emotion, memory, and the development of resilience (Congleton et. al., 2015). Studies have

indicated that those with a history of stress-related disorders such as PTSD or depression tend to

have smaller hippocampal regions. Functional MRIs following mindfulness practice revealed an

increased grey matter density in this area. This increase in grey matter can improve the overall

function of the hippocampus, which is needed to regulate the reactivity of the amygdala.

The prefrontal cortex. The prefrontal cortex is located behind the frontal lobe and is

associated with the executive functions (Wolkin, 2015). This area of the brain gives humans the

ability to think critically and respond peacefully when it is well-developed. After an eight-week

mindfulness study, the prefrontal cortex showed an increase in the thickness of the grey matter

(Ireland, 2014). Connections between the prefrontal cortex to the amygdala are weakened

through the regular practice of mindfulness meditation allowing connections to strengthen with

other areas involved in higher order functions such as attention and concentration (Wolkin,

2015). As the connections between the prefrontal cortex and the amygdala weaken, there is less

emotional reactivity experienced by the individual. As this neural connectivity weakens, the

communication from the amygdala to the prefrontal cortex in drug and alcohol seeking behavior

is subsequently reduced.

Studies that scanned the brains of meditators with 40,000 hours of mindfulness practice

found that the prefrontal cortex had gone back to its original size, indicating that after prolonged

practice, the improvements become automatic and require less effort (Ireland, 2014). These

studies also found that the brains of meditators in a resting state looked similar to those in a

meditative state, and that the positive effects on the brain are permanent.


45

The anterior cingulate cortex. The anterior cingulate cortex is associated with the

unpleasantness of pain and learning from past experience (Congleton et. al., 2015). Damage to

this area can reduce mental flexibility and can cause a person to hold on to old ways of doing

things even when they are no longer useful. The reason for this could be the reduction of

interhemispheric communication that occurs through this brain region. Studies of meditators

show improved function in the ACC and also show high performance on tests of self-regulation

and focus. Eight-week mindfulness studies showed a significant increase in the grey matter

density in this area and an improvement in the functional connectedness it has to other areas of

the brain.

EMDR

Eye movement desensitization was developed by Francine Shapiro who realized the

desensitizing effects that eye movements had on troubling thoughts as she was walking in the

park (Rosen, McNally, & Lilienfeld, 1999). Her eyes began involuntarily shifting right and left

and she realized that her level of distress decreased through this process. Following her

discovery, she began testing this process on her friends and colleagues. Inspired by the results,

she conducted a study on patients with post-traumatic stress disorder (PTSD) as part of her

doctoral dissertation (Rosen, McNally, & Lilienfeld, 1999). The results of her 22-patient study

were astounding. Dr. Shapiro renamed this therapy to add reprocessing to include the part of the

therapy that changes the negative thinking patterns, and EMDR has since been deemed a front-

line approach for treating trauma-related illnesses.

EMDR is based on the adaptive information processing (AIP) which asserts that new

experiences and information are understood within the context of old memories and beliefs

(Shapiro & Laliotis, 2011). Further, this information processing system is adaptive and strives

towards the reduction of distress and more adaptive thinking patterns. Specifically, “what is


46

useful is incorporated, what is useless is discarded, and the event serves to guide the person

appropriately in the future” (Shapiro & Laliotis, 2011, p. 193).

The AIP model is also guided by the belief that instability and pathology are a result of

unprocessed distressing memories that, once integrated, result in a reduction of symptoms

(Shapiro & Laliotis, 2011). Memories that are integrated whether they are positive or negative

get stored appropriately in the brain and are usually forgotten. However, events that overwhelm

the system with negative emotions do not get processed effectively and get trapped in the right

hemisphere of the brain in fragmented pictures along with the original body sensations (Shapiro

& Laliotis, 2011). These body sensations become activated in the present when an experience is

similar to the original and the old feelings flood the system creating a visceral response that is

seen as an overreaction to the situation.

EMDR is an eight-phase approach to treating trauma. The first two phases revolve

around installing the resources a client needs in order to maintain stability once the trauma

network is accessed. These phases are called client history and preparation. During these

phases, the therapist establishes rapport with the client and develops an understanding of the life

experiences that are the underpinnings of the current distress as indicated by the adaptive

information processing model.

An important skill to develop in this phase is to use breathing to access the

parasympathetic nervous system. Deep, diaphragmatic breathing has been demonstrated to bring

the PNS online which in turn calms the body down (Klotter, 2009). An easy way to help clients

engage in this breathing technique is to suggest that they exhale for twice the amount of time as

they inhale. For example, if they inhale to the count of 4, they would exhale to the count of 8.

An important side note is that when working with clients who have OCD, it is best to vary the


47

numbers as they count in and out to avoid activating an OCD response to the breathing as this

would be counter-productive.

Resourcing is also an essential goal of the preparation phase of EMDR therapy (Shapiro

& Laliotis, 2011). Through resourcing, the therapist works to install the necessary supports,

cognitions, and calming strategies that the client will need in order to remain stable while

processing the traumatic memory. Specifically, the client will develop their container and their

comfortable place. The container exercise asks that the client visualize a container that can hold

anything that they do not yet have the resources to manage. The therapist guides the client

through an imagery exercise aimed to build the container and fill it with whatever they need to

put in there. Comfortable place is used to help the client connect to an inner calm that can be

accessed whenever it is needed. This, too, is accomplished through guided imagery. The

therapist helps the client make this place as real and vivid as possible by incorporating sights,

sounds, smells, and positive feelings. In both of these instances, the theratappers are turned on to

install the positive feelings and experiences that are noticed through the process. For example,

the therapist will ask the client how it feels to put everything in the container. Often, the

response is that they feel relieved. The therapist helps the client identify where they feel that

relief in their body and, if possible, to identify the color that they see with it (engaging as many

of the senses as possible). The client is instructed to focus on that feeling of relief that is

associated with putting everything away and imagine it getting as big as possible while the

tappers are turned on for the equivalent of about two full breaths.

Other important resourcing techniques to be done before any processing are the

installation of nurturing, protective, and wise figures (Curran, 2017). Installing nurturing figures

requires that the client list people that represent nurturing to them. These people could be real or


48

imagined; they could be television characters or animals. The important part of this exercise is

that they identify the nurturing qualities that are associated with these beings. These qualities are

“tapped in” with the theratappers for the length of two or three deep, diaphragmatic breaths. It is

important to keep the repetitions short in this phase as the client’s brain could jump to a negative

thought and that is not part of the resourcing phase (Curran, 2017). This exercise is also done

with the protective and wise figures to install the protective feelings and wise counsel that were

missing during the traumatic experience. During the processing phase, these resources are drawn

upon to help support the client when they feel distressed. It is important to understand that some

clients remain in the resourcing phase for a year or more and that it is better to “over-resource”

then “under-resource” (Curran, 2017).

The third phase of EMDR therapy is when the trauma network is accessed. It is

suggested that the clinician help the client begin with the earliest or worst trauma. In this phase,

the client is asked for the subjective unit of distress or SUDs that they feel as they think of the

worst part of the memory on a scale of 1 to 10 (Curran, 2017). Additionally, the client is asked

to identify the negative cognition that is associated with this memory such as, “I am not good

enough”, or “I am to blame for my abuse”. They are then asked to list the preferred cognition

such as, “I am enough”, “I did the best I could”, or “I am not responsible for other people’s bad

behavior” and the validity of this cognition on a scale from 1 to 7. To add some clarity, the

practice of identifying the SUDs and the VOC was implemented during the clinical study that

Francine Shapiro did in order to prove the efficacy of EMDR as it was necessary to establish

criteria to demonstrate a reduction in distress and a reprocessing of the memory (Curran, 2017).

However, asking the client for the validity of the cognition often confuses them and gets them

back into their left brain which shuts down the trauma network. The desensitizing that occurs in


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phase four requires that the trauma network be activated. Therefore, it is ok to forego the

preferred cognition at this point (it will often emerge through the processing) and begin

processing as soon as the trauma network is activated (Curran, 2017). The network is activated

when the client tears up or looks visibly flooded while describing the original memory. At this

point, initiate the alternating bilateral stimulation and allow the client to process the memory.

While the client is processing, the therapist is instructed to slightly vary the rate of the

ABS. This keeps the hippocampus online which is necessary to keep the amygdala from firing

(Curran, 2017). The therapist reminds the client of their body being in the room to create the

dual awareness that helps the client stay grounded in the present as they revisit the trauma

memory. The therapist also reminds the client that this is only a memory, that it is over, and that

they are safe now. The therapist checks in with the client periodically by stopping the ABS and

asking what they notice, what has come up, or what they are saying to themselves now as they

think of the original memory. Whatever comes up, the client is encouraged to “go with that” and

continue to process.

Interestingly, other memories will often emerge as the client processes the original

memory. Typically, the memories that come up share the same negative cognition that was

associated with the original memory. This subconscious process reveals the reality of the

adaptive information processing model as it demonstrates that experiences are connected through

the context of memory networks that are similar. More compelling is the similarity between the

negative cognitions that link our memories and Adler’s concept of private logic. Adler

recognized that people don’t remember everything that ever happens to them. However, he

noted that they tend to remember that which fit their private logic. That is to say that people

collect memories that “prove” their original beliefs about themselves. EMDR brings this


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collection of memories together through the processing phase and insight is developed as people

begin to recognize their faulty thinking patterns and where they originated.

If the client gets stuck in the memory, the therapist can ask, “what does the child need to

get through this” which helps the client connect to their nurturing, protective, or wise figures to

help them continue to process. Clients are always allowed to stop if they need to and go to their

comfortable place if the experience feels too overwhelming.

Sometimes body sensations are experienced during the processing of a

memory. Interestingly, these body sensations are often a result of something that is needed

during the processing. For example, if a client states that they are feeling tightness in their

throat, it could be that there is something that they need to say to someone in their memory. The

therapist will instruct them to “go with that” and often times, the sensation will diminish once

they “said” what they needed to.

Eventually, the new more adaptive cognition emerges, and the SUDs is reduced to a 0 or

1. Ideally, the SUDs needs to be a 0; however, for some clients, a 1 is the lowest it will ever be

and if they express that this is an acceptable SUD, it is acceptable to move on. At this point the

EMDR moves into phase five: installation. In this phase, the client holds the positive belief with

the original memory and utilizes the ABS to “tap it in” to their neural network. This is believed

to create the new neural pathways that are associated with the adaptive thinking. The therapy

then moves into phase six which is the body scan. The therapist asks the client to scan their body

to check for any sensations that are unpleasant such as tightness or pain. If anything is still there,

they focus on that area and continue to process. Once the body is showing no sign of distress, the

client is directed back to their comfortable place through guided imagery and then the attention is

brought back to the room. This is phase seven of the EMDR therapy: closure. Closure focuses


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on discussing what occurred during the session. Phase eight happens in the following session

when the client is asked to revisit the memory that was processed and list the SUDs and VOC of

the preferred belief. If the SUDs have elevated, the client goes back to phase four and processes

the memory again.

EMDR brings forward subconscious thinking patterns based on memories that are linked

together that drive maladaptive behavior. This process of making connections demonstrates the

brain’s desire and ability to move towards wholeness as it is done automatically and without

direction. The connections that are made provide insight into beliefs and behaviors that might

not have been discovered through talk therapy. Equally important, EMDR activates the thalamus

that is deactivated during trauma and is needed to effectively integrate the trauma memory

(Bergmann, 2008). Further, the desensitization to the original trauma memory calms the brain

down as the memory is moved out of the limbic system and into the prefrontal cortex where it is

now understood to be in the past (Curran, 2017). It is then that a client can begin to develop new

adaptive coping strategies to deal with the challenges of life.

EMDR and addiction treatment. Bessel van der Kolk reports several cases in which

spontaneous termination of addiction occurred following the completion of EMDR therapy in his

book, The Body Keeps the Score (2015). The belief is that through the desensitization and

reprocessing of trauma memories, the need to self-soothe no longer exists, the person is able to

be present and connect to their embodied experience, and they are able to develop adaptive

coping skills and thinking patterns once the trauma memory has successfully moved to the

prefrontal cortex. That said, specific therapies have been developed that utilize alternating

bilateral stimulation to target specific situations related to addiction: triggers and urges, and

feelings associated with substance use.


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DeTUR is a therapy that uses ABS to process the urges and cravings that are associated

with the substance use. This process accesses internal resources that the client already has and

processes them to strengthen neural connections associated with positive states. Additionally,

the DeTUR protocol targets the client’s triggers and processes them until their “level of urge”

(LOU) is a 0 or 1. The positive feeling state is then linked with the trigger and anchored in the

body through the use of ABS.

The Feeling State Addiction Protocol asserts that positive feelings and body sensations

can become linked in our brains to positive events just as traumatic events can be linked to

negative feelings (Miller, 2012). Thus, it is the desired feeling state associated with the

substance use that drives impulsive behavior. Further, once the feeling state has been developed,

it is activated by the anticipation of the substance through environmental cues. This treatment

targets the positive feelings that are desired through the use of substances, assesses the feeling

state on a 0-10 scale, and processes using ABS until the level is down to 0 or 1 (Miller, 2012).

EMDR and the brain. EMDR began with the use of alternating bilateral eye

movements but has adapted to incorporate other forms of alternating bilateral stimulation (ABS)

using theratappers or music tones after experiencing success using these methods with blind

patients (Rosen, McNally, & Lilienfeld, 1999). In order to resolve traumatic memories, the right

side of the brain must be activated while the left side of the brain is also online to add logical,

adaptive reasoning to the original memory. It has been speculated that the alternating bilateral

stimulation works because it distracts the client enough to be able to work through the memory

without becoming flooded by it. Another possibility is that the bilateral stimulation functions to

increase the interhemispheric communication that might have decreased due to a weakened

anterior cingulate cortex. Additionally, the ABS causes new neural networks to fire that are


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associated with positive, more adaptive thinking patterns (Curran, 2017). Finally, EMDR

activates the thalamus, or the brain’s filter, that was deactivated during the trauma (Bergmann,

2008). This activation is necessary in order to integrate the original memory with logical

reasoning.

Alternating bilateral stimulation activates interhemispheric communication that facilitates

the desensitization and the processing of trauma memories (Propper & Christman, 2008). “This

allows you to get to the root of the problem and reshape your brain, not just mask your

symptoms” (NeuroDevelopment Center, 2013).

Adlerian Treatment of Trauma

Blackburn, O'Connell, and Richman (1984) discuss PTSD from an Adlerian perspective

in their article, Post-Traumatic Stress Disorder, The Vietnam Veteran, and Adlerian Natural

High Therapy. The focus is on the fact that the combat veterans have survived the trauma and

that they are experiencing a sense of deep discouragement. The treatment lies in uncovering

mistaken beliefs and reorienting the client to more useful goals. Adler believed that people’s

maladaptive behaviors were symptoms of deeper problems. Identifying the mistaken beliefs and

the source of discouragement that has set in following a trauma is the beginning to healing the

individual in a holistic manner.

The Adlerian Style of Life Tree (Stein & Lalonde, 2003) depicts the foundational

influences that collaborate to create the individual’s lifestyle. Thus, through the use of creative

power, each child does his or her best to make sense of the world with what he or she has; often

with the use of inefficient tools. If we accept this, it would only make sense to address all

problems at their roots.


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Discussion

Brain-based interventions for the treatment of trauma and addiction provide a promising

future for those afflicted with substance use disorders, or who have been impacted by trauma.

Utilizing these therapies stimulates the growth of new neural pathways in areas of deficit caused

by trauma. Functional MRI studies demonstrate that the areas of the brain that are implicated in

the addiction process exhibit reduced functioning and volumetric properties in those who have

been exposed to developmental trauma. Studies also show a correlation between increased grey

matter density in the areas involved in emotion regulation and a reduction in symptoms

(Boukezzi, El Khoury-Malhame, Auzias, Reynaud, Rousseau, Richard, Zendjidjian, Roques,

Castelli, Correard, Guyon, Gellato, Samuelian, Cancel, Comte, Latinus, Guedj & Khalfa, 2017).

The medical model identifies various disorders through their diagnostic criteria and

therapy is then focused on symptom reduction. While it is necessary to teach clients new skills,

it is also necessary to treat the underlying physiology that is causing the symptoms as understood

through the disease model. In order to identify the underlying causes, it is necessary to carefully

screen for developmental trauma and attachment injuries. Those who have experienced

developmental trauma will likely have reduced functioning in the areas of the brain that are

needed for emotion regulation as well as other higher order thinking. This reduction in

functionality is correlated to an increase in the risk for further trauma as well as substance

misuse. To teach emotion regulation skills is useful and necessary; however, that alone is similar

to subscribing a statin drug for high cholesterol without suggesting that the patient also change

their diet.

Brain-based therapies are those that improve the structure and function of the brain.

These therapies develop new neural connections that are associated with increased emotion

regulation, reduced reactivity, and improved impulse control. Specific areas of the brain that


55

show improvement are: the amygdala, the hippocampus, the anterior cingulate cortex, and the

prefrontal cortex. Not only is the functionality within these regions improved, but the

connections between them are altered in a way that further improves emotion regulation and

executive functions.

Mindfulness is an on-going practice that will further develop positive neural connections

within the brain, resulting in the ability to remain in the window of tolerance for longer periods

of time. The more a person can function within this window, the more they can learn, grow, and

thrive as an individual. EMDR brings the areas of the brain back online that were not available

during the traumatic events, which is needed in order to fully integrate the trauma memory into

the brain.

Developmental trauma will more than likely result in an insecure attachment style of the

adult. This style of attachment hurts the person’s ability to connect with safe people and form

secure, lasting, relationships. Without this ability, the individual is often in painful relationships

that might be abusive in nature. Because of this, it is necessary to identify the attachment style

and provide corrective emotional experiences that allow new growth to develop earned secure

attachment as an adult. Accelerated experiential dynamic psychotherapy is one that supports the

development of secure attachment through the client/therapist relationship. This dynamic offers

a supportive, right brain-to-right brain connection, between the two, that is similar to the early

connection between a baby and the primary caregiver. This connection helps the client learn to

regulate their emotions as well as develop safety within the context of a relationship.

One of the primary reasons that people who have experienced developmental trauma

misuse substances is to avoid feeling pain. This pain can be from flashbacks of trauma, shame

they are experiencing as a result of the trauma, frustration resulting from emotion dysregulation,


56

or feelings of low self-worth, for example. Therapies that reduce flashbacks, by effectively

integrating them into the brain as past memories, reduce emotional reactivity, and alter brain

pathways to improve impulse control and higher-order thinking are needed in order to heal the

problems at their source. This can calm the inner world of those who are suffering. This internal

change could reduce the need for substances and improve the desire for connection in the world

which supports a meaningful life of purpose.

Implications for Practice

The subjective nature of trauma requires that clinicians proactively assess for experiences

that have traumatized their clients. Further, it is necessary to screen for various types of addictions

as clients are often unable to identify that they have a substance use problem or an underlying

mental health disorder. It is necessary to conduct a thorough diagnostic assessment including the

use of tools that effectively screen for trauma, attachment patterns, and substance use. Screening

tools such as the ACE inventory help identify any developmental trauma that has been

experienced. Further, the AUDIT or CAGE-AID can screen for substance misuse. It is also

important to identify the style of attachment. The Vulnerable Attachment Style Questionnaire

(VASQ) is a screening tool used for this purpose. The focus of the therapist is to gain the clearest

picture possible of what it was like to grow up in the environment of the client and what sense they

made out of it. Early Recollections can also help with this as well as the Mistaken Beliefs

Questionnaire.

If a client reports a history of trauma, it is necessary to screen for dissociation, as EMDR

is not suitable for those who are dissociated. If the client is a candidate for EMDR, the therapist

begins with extensive resourcing to develop the client’s ego strength in order to process their

targets later in therapy. The installation of comfortable place, container, protective, wise and

nurturing figures, is an important part of the resourcing phase. Additionally, positive feelings that


57

accompany growth throughout the therapy process can be “tapped in” to help develop neural

connections in the brain that are associated with positive feelings.

Mindfulness can be used in this stage as a means to help the client begin to activate their

“noticing brain” that practices paying attention on purpose to their circumstances without

judgment. AEDP can also be used to begin to establish a connection within the context of a safe

relationship. The therapist helps the client notice the relationship through metaprocessing, which

is the practice of paying attention to thoughts and feelings associated with feeling heard, safe, and

understood. This helps the client begin to develop trust within a safe relationship, which is the

beginning of repairing their early attachment injuries. EMDR can be used early in therapy to target

cravings, and urges, if the client is using substances.

Once the client has developed ego strength and is connected with resources outside of

therapy such as support groups or friends and family who are available, it is time to process their

trauma targets if they want to do so. In this phase, it is important to help the client continue to

monitor their inner experience and to keep them grounded. The sessions always include container

and comfortable place and a check in to notice any body sensations that may be problematic.

As therapy progresses, it is also important to monitor substance use. Initially, it is possible

that their use could increase as old feelings are coming to the surface. However, the practice of

mindfulness, and the use of the container, can help the client learn to navigate difficult emotions

without the use of substances. Further, re-administering the substance use screening tools at

various intervals can provide encouragement to the client if they begin to notice that their use is

decreasing over time.

Recommendations for Future Research

Research is limited within the co-occurring disorders population as most studies screen

out people who have chemical health problems. In order to understand the lasting effects of


58

brain-based therapies in this population, it would be beneficial to include these participants. For

example, mindfulness is being utilized in substance use treatment programs to help identify

triggers, and ride out cravings; however, research does not appear to be available to identify

whether the changes in the brain, due to meditation, reduce or eliminate the need for the

substance altogether. If studies show permanent changes in the brain due to meditation, further

studies would be helpful to identify the lasting effects these changes have with relation to

substance use. Additionally, sample sizes tend to be small. Larger studies with varied

populations would help to further the understanding of brain alterations resulting from alternative

therapies as well as establish a larger control group to exemplify the differences between various

treatment methods. Finally, EMDR studies are often limited to fMRI studies that identify brain

areas activated during aversive visual stimulation. Larger studies are needed within the co-

occurring disorders population as well as those with PTSD to identify brain changes after EMDR

is complete.

Conclusion

Trauma experienced in childhood causes brain changes that correlate to addiction

vulnerability later in life. Neuroimaging has demonstrated a reduction in functioning and

volume in the areas of the brain that are implicated in the addiction process. Utilizing brain-

based therapies such as accelerated experiential dynamic psychotherapy, mindfulness meditation,

and EMDR correlates to improved function in these brain areas. The biopsychosocial model

asserts that a holistic approach is necessary to meet the unique needs of the individual which is

further supported by Adler’s belief in holism. Treating the effects of trauma at their root

provides the best possibility for helping those with addiction develop a life of meaning and

purpose.


59

References

Advokat, C., Comaty, J., & Julien, R. (2014). Julien's primer of drug action: A comprehensive

guide to the actions, uses, and side effects of psychoactive drugs. New York, NY: Worth

Publishers.

Alamia, A., Solopchuk, O., D'Ausilio, A., Bever, V., Fadiga, L., Olivier, E., & Zénon, A. (2016).

Disruption of Broca's Area Alters Higher-order Chunking Processing during Perceptual

Sequence Learning. Journal Of Cognitive Neuroscience, 28(3), 402-417.

doi:10.1162/jocn_a_00911

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Arlington, VA: Author.

Ansbacher, H. L. & Ansbacher, R. R. (Eds.). (1956). The Individual Psychology of Alfred Adler.

New York, NY: Basic Books.

Bergmann, U. (2008). The neurobiology of EMDR: Exploring the thalamus and neural

integration. Journal of EMDR Practice and Research, 2(4), 300-314.

doi: 10.1891/1933-3196.2.4.300

Blackburn, A., O'Connell, W., & Richman, B. (1984). Post-Traumatic Stress Disorder, the

Vietnam veteran, and Adlerian natural high therapy. Individual Psychology: The Journal

of Adlerian Theory, Research & Practice, 40 (3), 317.

Bolte Taylor, J. (2008). My stroke of insight. [Video file]. Retrieved from

www.youtube.com/watch?v=UyyjU8fzEYU.

Boukezzi, S., El Khoury-Malhame, M., Auzias, G., Reynaud, E., Rousseau, P., Richard, E.,

Zendjidjian, X., Roques, J., Castelli, N., Correard, N., Guyon, V., Gellato C., Samuelian,

JC., Cancel A., Comte, M., Latinus, M., Guedj, E., & Khalfa, S. (2017). Grey matter


60

density changes of structures involved in Posttraumatic Stress Disorder (PTSD) after

recovery following Eye Movement Desensitization and Reprocessing (EMDR) therapy.

Psychiatry Research. Neuroimaging, 266, 146-152.

doi:10.1016/j.pscychresns.2017.06.009

Borrell-Carrió, F., Suchman, A., & Epstein, R. (2004). The biopsychosocial model 25 years later:

Principles, practice, and scientific inquiry. Annals of Family Medicine, 2(6), 576–582.

http://doi.org/10.1370/afm.245

Braem, S., King, J., Korb, F., Krebs, R., Notebaert, W., & Egner, T. (2017). The role of anterior

cingulate cortex in the affective evaluation of conflict. Journal of Cognitive

Neuroscience, 29(1), 137-149.

Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth.

Developmental Psychology, 28(5), 759-775. Doi:10.1037/0012-1649.28.5.759

Brown, R. E., & Milner, P. M. (2003). The legacy of Donald O. Hebb: More than the Hebb

synapse. Nature Reviews Neuroscience, 4(12), 1013-1019. doi:10.1038/nrm1257

Carrion, V., Wong, S., & Kletter, H. (2013). Update on neuroimaging and cognitive functioning

in maltreatment-related pediatric PTSD: Treatment implications. Journal of Family

Violence, 28(1), 53-61. doi:10.1007/s10896-012-9489-2

ChrisCompany. (2013). Calm down and release the amygdala [Video file]. Retrieved from:

https://www.youtube.com/watch?v=Zs559guIGDo

Cihan, A., Winstead, D. A., Laulis, J., & Feit, M. D. (2014). Attachment theory and substance

abuse: Etiological links. Journal of Human Behavior in the Social Environment, 24(5),

531-537. doi:10.1080/10911359.2014.908592


61

Corrigan, F., Fisher, J., & Nutt, D. (2010). Autonomic dysregulation and the Window of

Tolerance model of the effects of complex emotional trauma. Journal of

Psychopharmacology, 25(1), 17-25. doi:10.1177/0269881109354930

Congleton, C., Holzel, B., & Lazar, S. (2015). Mindfulness can literally change your brain.

Harvard Business Review Digital Articles, 2-5. Retrieved from

https://hbr.org/2015/01/mindfulness-can-literally-change-your-brain

Curran, L. (2017). EMDR 3 day intensive training: Eye Movement Desensitization and

Reprocessing. Eau Claire, WI: PESI, Inc.

Dackis, C. A., & Miller, N. S. (2003). Neurobiological effects determine treatment options for

alcohol, cocaine, and heroin addiction. Psychiatric Annals, 33(9), 585-592.

DeAngelis, T. (2007). A new diagnosis for childhood trauma? Monitor on Psychology, 38(3). 32.

Retrieved from http://www.apa.org/monitor/mar07/diagnosis.aspx

Dekel, S., & Bonanno, G. A. (2013). Changes in trauma memory and patterns of posttraumatic

stress. Psychological Trauma: Theory, Research, Practice, and Policy, 5(1), 26-34.

doi:10.1037/a0022750

Demers, L., Olson, E., Crowley, D., Rauch, S., & Rosso, I. (2015). Dorsal anterior cingulate

thickness is related to alexithymia in childhood trauma-related PTSD. Plos ONE, 10(10),

1-11. doi:10.1371/journal.pone.0139807

De Stefano, J., & Atkins, S. (2017). Nonsuicidal self-injury, interpersonal neurobiology, and

attachment: Implications for counselors and therapists. Journal of Mental Health

Counseling, 39(4), 289-304. doi:10.17744/mehc.39.4.02


62

Dias, N., Trevisan, B., León, C., Prust, A., & Seabra, A. (2017). Can executive functions predict

behavior in preschool children? Psychology & Neuroscience, 10(4), 383-393.

doi:10.1037/pne0000104

Dong Hoon Oh (2012). Traumatic experiences disrupt amygdala – Prefrontal connectivity, the

amygdala - A discrete multitasking manager, Dr. B. Ferry (Ed.), InTech, doi:

10.5772/48691. Available from: https://www.intechopen.com/books/the-amygdala-a-

discrete-multitasking-manager/traum atic-experiences-disrupt-amygdala-prefrontal-

connectivity

Dreikurs, R., & Soltz, V. (1964). Children: The challenge. New York, NY: Penguin Books.

Eisch, A. J. (2005). Common neural adaptations and bidirectional influences of stress and

addictions: Recent insights from basic research. Journal of Dual Diagnosis, 1(3), 25-46.

doi:10.1300/J374v01n03-04

Enos, G. (2016). Research explores mindfulness approach for difficult-to-treat population.

Alcoholism & Drug Abuse Weekly, 28(33), 1-8. doi:10.1002/adaw.30682

Felitti, V. (2014). The origins of addiction: Evidence from the adverse childhood experiences

study. Retrieved from: https://attachmentdisorderhealing.com/origins-addiction/

Finkelhor, D., Turner, H., Shattuck, A., & Hamby, S. (2013). Violence, crime, and abuse

exposure in a national sample of children and youth. JAMA Pediatrics, 167(7), 614-621.

doi: 10.1001/jamapediatrics.2013.42 Retrieved from: http://www.unh.edu/ccrc/pdf/05-

13%20PED%20childhood%20exposure%20to%20violence.pdf

Fisher, J. (2011). Psychoeducational aids for working with psychological trauma. (10th ed.).

Boston, MA: Author.


63

Fuhrmann, D., Knoll, L. J., & Blakemore, S. (2015). Adolescence as a sensitive period of brain

development. Trends in Cognitive Sciences, 19(10), 558-566.

doi:10.1016/j.tics.2015.07.008

Giordano, A. Prosek, E. A., Stamman, J., Callahan, M., Loseu, S., Bevly, C., Cross, K., Woehler,

E., Calzada, R., & Chadwell, K. (2016). Addressing trauma in substance abuse treatment.

Journal of Alcohol & Drug Education, 60(2), 55-71.

Griffith, J. (1984). Adler's organ jargon. Individual Psychology: The Journal of Adlerian Theory,

Research & Practice, 40(4), 437.

Griffith, J., & Powers, R. (2007). The lexicon of Adlerian psychology: 106 terms associated with

the Individual Psychology of Alfred Adler. (2nd ed.). Port Townsend, WA: Adlerian

Psychology Associates, Ltd.

Harris, N. (2015). How childhood trauma affects health across a lifetime [Video file]. Retrieved

from www.youtube.com/watch?v=95ovIJ3dsNk

Hanson, R. (2014). Emotion in the brain. Wildmind: Buddhist meditation. Retrieved from:

http://www.wildmind.org/blogs/on-practice/emotion-in-the-brain

Huang, H., Gundapuneedi, T., & Rao, U. (2012). White matter disruptions in adolescents

exposed to childhood maltreatment and vulnerability to psychopathology.

Neuropsychopharmacology, 37(12), 2693-2701. doi:10.1038/npp.2012.13

'Hurtful words: Association of exposure to peer verbal abuse with elevated psychiatric symptom

scores and corpus callosum abnormalities': Correction. (2011). The American Journal of

Psychiatry, 16(2), 213. doi:10.1176/appi.ajp.2010.168.2.213


64

Ireland, T. (2014). What does mindfulness meditation do to your brain? Scientific American.

Retrieved from: https://blogs.scientificamerican.com/guest-blog/what-does-mindfulness-

meditation-do-to-your-brian/

JAMA Pediatrics, (2013). Retrieved from: http://www.unh.edu/ccrc/pdf/05-

13%20childhood%20exposure%20to%20violence.pdf

Kantak, K. (2007). Navigating extinction of drug addiction: Role of the hippocampus. Paper

presented at the 115th Annual Convention of the American Psychological Association,

San Francisco, CA. doi:10.1037/e682082007-001

Klotter, J. (2009). Breathing technique may help nervous system in chronic fatigue. Townsend

Letter, (316), 20-21.

Know your brain: Nucleus accumbens. (2014). Neuroscientifically challenged. Retrieved from:

http://www.neuroscientificallychallenged.com/blog/2014/6/11/know-your-brain-nucleus-

accumbens

Kok, R., Lucassen, N., Bakermans-Kranenburg, M., van IJzendoorn, M., Ghassabian, A., Roza,

S., Govaert, P., Jaddoe, V., Hofman, A., Verhulst, F., & Tiemeier, H. (2014). Parenting,

corpus callosum, and executive function in preschool children. Child Neuropsychology,

20(5/6), 583-606. doi:10.1080/09297049.2013.832741

Koob, G, & Volkow, N. (2010). Neurocircuitry of addiction. Neuropsychopharmacology , 35 (1),

217–238. http://doi.org/10.1038/npp.2009.110

LaDage, L. (2015). Environmental change, the stress response, and neurogenesis, Integrative and

Comparative Biology, 55(3), 372-383. doi.org/10.1093/icb/icv040

Levine, P. (2010). In an unspoken voice: How the body releases trauma and restores goodness.

Berkeley, CA: North Atlantic Books.

Commented [EH1]: This link does not work and in not

correct for an article from JAMA Pediatrics.

http://www.unh.edu/ccrc/pdf/05-13%20childhood%20exposure%20to%20violence.pdf

http://www.unh.edu/ccrc/pdf/05-13%20childhood%20exposure%20to%20violence.pdf


65

Lipton, B., & Fosha, D. (2011). Attachment as a transformative process in AEDP:

Operationalizing the intersection of attachment theory and affective neuroscience.

Journal of Psychotherapy Integration, 21(3), 253-279. doi:10.1037/a0025421

Lutton, S. & Swank, J. (2018). The importance of intentionality in untangling trauma from

severe mental illness. Journal of Mental Health Counseling, 40(2), 133-128.

Mate, G. (2017). The direct link between trauma and addiction. Roots Through Recovery.

Retrieved from: http://roots-recovery.com/the-direct-link-between-trauma-and-addiction/

Markin, R. D., McCarthy, K. S., Fuhrmann, A., Yeung, D., & Gleiser, K. A. (2017). The process

of change in accelerated experiential dynamic psychotherapy (AEDP): A case study

analysis. Journal of Psychotherapy Integration, 28(2), 213-232. doi:10.1037/int0000084

McCrory, E., De Brito, S., & Viding, E. (2010). Research review: The neurobiology and genetics

of maltreatment and adversity. Journal of Child Psychology and Psychiatry, and Allied

Disciplines. 51(10), 1079-1095. doi:10.1111/j.1469-7610.2010.02271.x

Miller, R. (2012). Treatment of behavioral addictions utilizing the feeling-state addiction

protocol: A multiple baseline study. Journal of EMDR Practice and Research, 6(4), 159-

169. doi:10.1891/1933-3196.6.4.159

Nadel, L., & Jacobs, W. J. (1998). Traumatic memory is special. Current Directions in

Psychological Science, 7(5), 154-157. doi:10.1111/1467-8721.ep10836842

Najavits, L. (2017). Recovery from trauma, addiction, or both: Strategies for finding your best

self. New York, NY: The Guilford Press.

Najavits, L., & Johnson, K. (2014). Pilot study of creating change: A new past-focused model for

PTSD and substance abuse. American Journal on Addictions, 23(5), 415-422.

doi:10.1111/j.1521-0391.2014.12127.x


66

Perry, B., & Szalavitz, M. (2008). The boy who was raised as a dog: And other stories from a

child psychiatrist’s notebook: What traumatize children can teach us about loss, love and

healing. New York, NY: Basic Books.

Pienkowski, D. (n.d.). Substance abuse from a Classical Adlerian perspective. Alfred Adler

Institute of Northwestern Washington. Retrieved from: http://adlerian.us/aa-1.htm

Pilgrim, D., Kinderman, P., & Tai, S. (2008). Taking stock of the biopsychosocial model in the

field of 'mental care'. Journal of Social & Psychological Sciences, 1(2), 1-38.

PMSL Training. (2015). Amygdala hijack [Video file]. Retrieved from:

https://www.youtube.com/watch?v=9u3UvXqArqs

Popky, A. J. (2010). The desensitization of triggers and urge reprocessing (DeTUR) protocol. In

M. Luber (Ed.) Eye movement desensitization and reprocessing (EMDR) scripted

protocols: Special populations (pp. 489-511). New York, NY: Springer Publishing Co.

Powers, R., & Griffith, J. (1996). Enhancing the quality of Adlerian life: An assessment and

reorientation. Individual Psychology: Journal of Adlerian Theory, Research & Practice,

52(1), 3-21.

Propper, R., & Christman, S. (2008). Interhemispheric interaction and Saccadic horizontal eye

movements: Implications for episodic memory, EMDR, and PTSD. Journal of EMDR

Practice and Research. 2(4):269-281. doi:10.1891/1933-3196.2.4.269

Prousky, J. E. (2012). 6 STEPS TO overcoming addictions. Alive: Canada's Natural Health &

Wellness Magazine, (353), 51-55.

Psych Central. (2017). The 3 parts of your brain affected by trauma. Psych Central. Retrieved

from: https://psychcentral.com/blog/archives/2017/07/03/the-3-parts-of-your-brain-

affecte d-by-trauma/


67

Regier, P. S., Monge, Z. A., Franklin, T. R., Wetherill, R. R., Teitelman, A., Jagannathan, K.,

Suh, J., Wang, Z., Young, K., Gawrysiak, M., Langleben, D., Kampman, K., O’Brien, C.,

& Childress, A. (2017). Emotional, physical and sexual abuse are associated with a

heightened limbic response to cocaine cues. Addiction Biology, 22(6), 1768-1777.

doi:10.111/adb.12445

Rinne-Albers, M., Werff, S., Hoof, M., Lang, N., Lamers-Winkelman, F., Rombouts, S.,

Vermeiren, R., & Wee, N. (2016). Abnormalities of white matter integrity in the corpus

callosum of adolescents with PTSD after childhood sexual abuse: a DTI study. European

Child & Adolescent Psychiatry, 25(8), 869-878. doi:10.1007/s00787-015-0805-2

Rosen, G. M., McNally, R. J., & Lilienfeld, S. O. (1999). Eye movement magic. Skeptic, 7(4),

66.

Schwartz, A. (2016). The complex PTSD workbook: A mind-body approach to regaining

emotional control & becoming whole. Berkeley, CA: Althea Press.

Shapiro, F., & Laliotis, D. (2011). EMDR and the adaptive information processing model:

Integrative treatment and case conceptualization. Clinical Social Work Journal, 39(2),

191-200. doi:10.1007/s10615-010-0300-7

Shapiro, F., & Solomon, R. (2017). Eye movement desensitization and reprocessing therapy. In

S. N. Gold, S. N. Gold (Eds.), APA handbook of trauma psychology: Trauma practice

(pp. 193-212). Washington, DC: American Psychological Association.

doi:10.1037/00000020-009

Stein, H. T., & Lalonde, A. (2003). The style of life tree. Retrieved from

http://www.adlerian.us/tree.htm


68

Thomaes, K., Engelhard, I., Sijbrandij, M., Cath, D., & van den Heuvel, O. (2016). Degrading

traumatic memories with eye movements: a pilot functional MRI study in PTSD.

European Journal of Psychotraumatology, 7, 31371. doi:10.3402/ejpt.v7.31371

Understanding Addiction: How Addiction Hijacks the Brain. Helpguide.org. Retrieved from:

https://www.helpguide.org/harvard/how-addiction-hijacks-the-brain.htm

U.S. Department of Health and Human Services (HHS). (2016). Facing addiction in America:

The Surgeon General’s report on alcohol, drugs, and health. Washington, DC: Author.

van der Kolk, B. (2015). The body keeps the score: Brain, mind, and body in the healing of

trauma. New York, NY: Penguin Books.

van der Kolk, B. (2017). Trauma. Psychotherapy Networker Magazine, 41(1), 34-35.

van Duiven, K. (2009, October 15). Smart starts. The Press, p. GL8.

Wlassoff, V. (2015). How does Post-Traumatic Stress Disorder change the brain? Brain Blogger.

Retrieved from: http://brainblogger.com/2015/01/24/how-does-post-traumatic-stress-

disorder-change-the- brain/

Wolkin, J. (2015). How the brain changes when you meditate. Mindful: Taking Time for What

Matters. Retrieved from: https://www.mindful.org/how-the-brain-changes-when-you-

meditate/

Wrase, J., Makris, N., Braus, D., Mann, K., Smolka, M., Kennedy, D., Caviness, V., Hodge, S.,

Lena, T., Albaugh, M., Ziegler, D., Davis, O., Kissling, C., Schumann, G., Breiter, H., &

Heinz, A. (2008). Amygdala volume associated with alcohol abuse relapse and craving.

American Journal of Psychiatry, 165(9), 1179-1184.

doi:10.1176/appi.ajp.2008.07121877

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