Trauma and Substance Use Disorders in Youth Susan MacKenzie, MD FRCPC Staff Psychiatrist Youth Addictions and Concurrent Disorders Service Centre for Addiction.

Trauma and Substance Trauma and Substance Use Disorders in YouthUse Disorders in Youth

Susan MacKenzie, MD FRCPCSusan MacKenzie, MD FRCPC

Staff Psychiatrist Staff Psychiatrist

Youth Addictions and Concurrent Disorders ServiceYouth Addictions and Concurrent Disorders Service

Centre for Addiction and Mental Health, TorontoCentre for Addiction and Mental Health, Toronto

May 1, 2012May 1, 2012

OverviewOverview

How does early stress in a child’s life How does early stress in a child’s life render him or her vulnerable to problems render him or her vulnerable to problems regulating emotion?regulating emotion?

How does emotional dysregulation How does emotional dysregulation contribute to substance use problems?contribute to substance use problems?

What are some strategies and tools to What are some strategies and tools to best support youth with trauma histories best support youth with trauma histories and addictions problems?and addictions problems?

Impact of early traumaImpact of early trauma History of child sexual, physical and emotional History of child sexual, physical and emotional

abuse potential risk factor for range of mental abuse potential risk factor for range of mental health, interpersonal and sexual problems, health, interpersonal and sexual problems, e.g.,:e.g.,:

– DepressionDepression

– AnxietyAnxiety

– Personality Disorders Personality Disorders

– Posttraumatic Stress Disorder (PTSD)Posttraumatic Stress Disorder (PTSD)

– Substance Use Problems (Abuse and Substance Use Problems (Abuse and Dependence)Dependence)

Psychological maltreatment Psychological maltreatment an important predictoran important predictor

Until recently, most research has focused Until recently, most research has focused on youth with histories of sexual or physical on youth with histories of sexual or physical abuseabuse

Relative to other types of maltreatment, Relative to other types of maltreatment, emotional abuse and neglect may be the emotional abuse and neglect may be the most prominentmost prominent

Emotional abuse and neglect also Emotional abuse and neglect also significant predictors of substance use significant predictors of substance use problem severityproblem severity

(Rosenkranz, Muller and Henderson, in publication)(Rosenkranz, Muller and Henderson, in publication)

What is emotional regulation?What is emotional regulation? Awareness and understanding of a range of Awareness and understanding of a range of

emotionsemotions Acceptance of emotions regardless of their Acceptance of emotions regardless of their

associationassociation Ability to inhibit negative impulses when Ability to inhibit negative impulses when

experiencing negative emotionsexperiencing negative emotions Ability to apply situationally appropriate Ability to apply situationally appropriate

strategies to modulate emotional responses in strategies to modulate emotional responses in accordance with environmental demands or accordance with environmental demands or individual goalsindividual goals

(Gratz and Roemer, 2004)(Gratz and Roemer, 2004)

Role of parent-child relationshipRole of parent-child relationship Psychological maltreatment characterized by Psychological maltreatment characterized by

parents’ pattern of responding to their child parents’ pattern of responding to their child with hostility and neglect versus warmth and with hostility and neglect versus warmth and attentionattention

Reflects nature of a relationship as opposed Reflects nature of a relationship as opposed to specific action (i.e., as in physical or to specific action (i.e., as in physical or sexual abuse)sexual abuse)

Quality of parent-child relationship has Quality of parent-child relationship has significant impact on child’s functioning significant impact on child’s functioning (given that psychological and social (given that psychological and social development occur here)development occur here)

Role of parent-child relationshipRole of parent-child relationship

Authoritative style of parenting achieves Authoritative style of parenting achieves better outcomes that other parenting styles better outcomes that other parenting styles (e.g., permissive, neglectful, indifferent)(e.g., permissive, neglectful, indifferent)

Authoritative parents warm and involved; and Authoritative parents warm and involved; and firm and consistent in enforcing expectationsfirm and consistent in enforcing expectations

Child becomes more receptive to parental Child becomes more receptive to parental influence - protective re substance use influence - protective re substance use problemsproblems

Role of parent-child relationshipRole of parent-child relationship

Supportive family context --> youth who Supportive family context --> youth who are more responsive to parental monitoring are more responsive to parental monitoring in adolescencein adolescence

Combination of support and structure Combination of support and structure facilitate self-regulatory skills (Steinberg, facilitate self-regulatory skills (Steinberg, 2001)2001)

Lack of support and structure among youth Lack of support and structure among youth who experience psychological who experience psychological maltreatment may lead to increased risk maltreatment may lead to increased risk for problems through impaired self-for problems through impaired self-regulatory skills, and reduced provision or regulatory skills, and reduced provision or efficacy of parental monitoringefficacy of parental monitoring

Attachment theoryAttachment theory

Children develop internal working models of Children develop internal working models of the self and others based on relationships the self and others based on relationships with their parents and other adult figureswith their parents and other adult figures

Experiences of caregivers as hostile, Experiences of caregivers as hostile, rejecting or unavailable encourage rejecting or unavailable encourage development of similar expectations of development of similar expectations of othersothers

Children develop negative working models Children develop negative working models of the self as untrustworthy or badof the self as untrustworthy or bad

Insecure attachment contributes to Insecure attachment contributes to substance use problems substance use problems

Impact of trauma on Impact of trauma on developmental stage developmental stage

Developmental stage of early adulthood Developmental stage of early adulthood characterized by unique developmental characterized by unique developmental tasks: identity exploration; focus on self; tasks: identity exploration; focus on self; greater intimacy in relationshipsgreater intimacy in relationships

Youth with histories of maltreatment more Youth with histories of maltreatment more likely than peers to experience difficulty likely than peers to experience difficulty with these taskswith these tasks

Distress resulting from difficulty negotiating Distress resulting from difficulty negotiating these tasks may lead to substance use these tasks may lead to substance use problemsproblems

Maltreatment --> Impaired Maltreatment --> Impaired Self RegulationSelf Regulation

Psychological distress mediates association Psychological distress mediates association between maltreatment and substance usebetween maltreatment and substance use

Motives for substance use characterized by Motives for substance use characterized by efforts to cope with distress are salient efforts to cope with distress are salient predictors of substance use problems among predictors of substance use problems among those with maltreatment histories those with maltreatment histories

(Dixon, 2009; Goldstein 2010)(Dixon, 2009; Goldstein 2010)

A comment on Post-Traumatic A comment on Post-Traumatic Stress Disorder (PTSD)Stress Disorder (PTSD)

3 Clusters of Symptoms:3 Clusters of Symptoms:

1.1. Intrusion / ReexperiencingIntrusion / Reexperiencing - e.g., distressing - e.g., distressing memories; recurrent dreams; intense distress to memories; recurrent dreams; intense distress to internal / external cuesinternal / external cues

2.2.AvoidanceAvoidance - e.g., feelings; thoughts; activities; - e.g., feelings; thoughts; activities; places; people; detachment; inability to recall places; people; detachment; inability to recall parts of event; restricted affectparts of event; restricted affect

3.3. Increased ArousalIncreased Arousal - e.g., difficulty sleeping; - e.g., difficulty sleeping; irritability or anger; poor concentration; irritability or anger; poor concentration; hypervigilance; exaggerated startle responsehypervigilance; exaggerated startle response

Emotional dysregulation and Emotional dysregulation and trauma symptomstrauma symptoms

Trauma-exposed youth, faced with emotionally Trauma-exposed youth, faced with emotionally evocative events and memories, might evocative events and memories, might experience emotional dysregulation --> experience emotional dysregulation --> exacerbates symptomsexacerbates symptoms

Symptoms result in increased physiological Symptoms result in increased physiological arousal, perpetuating cycle of dysregulation, as arousal, perpetuating cycle of dysregulation, as increased arousal harder to regulateincreased arousal harder to regulate

(Tull, Barrett et al., 2007)(Tull, Barrett et al., 2007)

Emotional dysregulation and Emotional dysregulation and substance use problemssubstance use problems

A number of prominent theories of substance A number of prominent theories of substance use conceptualize problems as developing in use conceptualize problems as developing in the context of impaired abilities to regulate the context of impaired abilities to regulate internal states - “self medication hypothesis”internal states - “self medication hypothesis”

Substances “treat” difficulties in regulating Substances “treat” difficulties in regulating affect, self esteem, relationships and self-careaffect, self esteem, relationships and self-care

Substances help individuals to relieve painful Substances help individuals to relieve painful affects or to experience or control emotions affects or to experience or control emotions when they are absent or confusingwhen they are absent or confusing

(Khantzian, 1997)(Khantzian, 1997)

Emotional dysregulation and Emotional dysregulation and substance use problemssubstance use problems

Distressful, repetitious aspects of drug Distressful, repetitious aspects of drug dependence linked to effects of early-life trauma dependence linked to effects of early-life trauma on emotion and personality developmenton emotion and personality development

Represent attempts to work out painful affect Represent attempts to work out painful affect states that can’t always be remembered and are states that can’t always be remembered and are often without words or symbolic representation often without words or symbolic representation in the mindin the mind

Substances provide powerful short-term Substances provide powerful short-term antidotes to painful positive (e.g., rage, anxiety, antidotes to painful positive (e.g., rage, anxiety, panic) and negative (e.g., anergia, anhedonia, panic) and negative (e.g., anergia, anhedonia, flattening) states associated with early traumaflattening) states associated with early trauma

Emotional dysregulation and Emotional dysregulation and substance use problemssubstance use problems

Self regulation and self care deficits arising Self regulation and self care deficits arising from early trauma interfere with substance from early trauma interfere with substance users’ ability to anticipate harm or dangerusers’ ability to anticipate harm or danger

Compared with nonusers, they think and feel Compared with nonusers, they think and feel differently (or ineffectually) in dangerous differently (or ineffectually) in dangerous situations --> makes experimentation with, situations --> makes experimentation with, dependence on, and relapse to substances dependence on, and relapse to substances more likely and compellingmore likely and compelling

Substance use also increases risk of Substance use also increases risk of exposure to additional traumaexposure to additional trauma

Strategies to consider when Strategies to consider when working with this populationworking with this population

Screening and assessment methods for Screening and assessment methods for trauma and substance use problemstrauma and substance use problems

Considering the various stages of traumaConsidering the various stages of trauma Applying best practice recommendations and Applying best practice recommendations and

an evidence-based model for Stage 1 trauma an evidence-based model for Stage 1 trauma and substance use treatmentand substance use treatment

Using knowledge and tools from the Seeking Using knowledge and tools from the Seeking Safety model so as to bring a trauma-informed Safety model so as to bring a trauma-informed approach to clinical practice approach to clinical practice

What is a ‘Trauma-Informed’ What is a ‘Trauma-Informed’ Clinician?Clinician?

A ‘trauma-informed clinician’ is one who is:A ‘trauma-informed clinician’ is one who is: Informed about the prevalence of trauma in their Informed about the prevalence of trauma in their

client populationclient population Informed about the effects of psychological traumaInformed about the effects of psychological trauma Able to assess for the presence of symptoms / Able to assess for the presence of symptoms /

problems related to that traumaproblems related to that trauma Able to validate the client’s experience of the Able to validate the client’s experience of the

trauma, and how it links to their addictive trauma, and how it links to their addictive behaviourbehaviour

Able to offer service to facilitate recovery; and if Able to offer service to facilitate recovery; and if not, to recognize what is outside their scope of not, to recognize what is outside their scope of practice, and make the appropriate referralpractice, and make the appropriate referral

First, a few statistics...First, a few statistics...

Rates of Comorbid PTSD and Substance Rates of Comorbid PTSD and Substance Disorders in ‘Community Samples’Disorders in ‘Community Samples’

National Comorbidity Survey (Kessler et al, National Comorbidity Survey (Kessler et al, 1995, sample 5877):1995, sample 5877):– Range 65.1%-84.3% in womenRange 65.1%-84.3% in women– Range 52.7%-62.5% in menRange 52.7%-62.5% in men– Note: PTSD preceded substance use in Note: PTSD preceded substance use in

majority of casesmajority of cases

Statistics continued...Statistics continued...

Rates of Comorbid PTSD and Rates of Comorbid PTSD and Substance Disorders in ‘Substance Substance Disorders in ‘Substance Abusing’ SamplesAbusing’ Samples::

20-33% of patients with substance 20-33% of patients with substance use disorders seeking treatment use disorders seeking treatment meet criteria for current PTSD meet criteria for current PTSD

Assessment of trauma: General Assessment of trauma: General PrinciplesPrinciples

Keep assessment of trauma details to a Keep assessment of trauma details to a minimum (to avoid overwhelming distress minimum (to avoid overwhelming distress without adequate coping skills)without adequate coping skills)

If you know generally of a trauma history, may If you know generally of a trauma history, may not be a need to inquire further at point of not be a need to inquire further at point of assessmentassessment

If you have no knowledge of client, consider If you have no knowledge of client, consider using a self-report questionnaire (using simple using a self-report questionnaire (using simple questions) - e.g., Trauma Antecedents questions) - e.g., Trauma Antecedents Questionnaire; GAIN short screenerQuestionnaire; GAIN short screener

Myths that can interfere with Myths that can interfere with assessment and treatmentassessment and treatment

““Labels aren’t good for clients”Labels aren’t good for clients” ““Assessing for trauma is enough”Assessing for trauma is enough” ““I need to wait until the client is through I need to wait until the client is through

the substance use and withdrawal before the substance use and withdrawal before assessing for trauma”assessing for trauma”

The importance of diagnosisThe importance of diagnosis Diagnosis is a precursor to effective Diagnosis is a precursor to effective

treatmenttreatment Trauma and substance use problems are Trauma and substance use problems are

both prone to minimizationboth prone to minimization Growing recognition that a ‘No Wrong Door’ Growing recognition that a ‘No Wrong Door’

approach is most helpful:approach is most helpful:– Wherever clients enter the system, they Wherever clients enter the system, they

should be screened / assessed for BOTH should be screened / assessed for BOTH disordersdisorders

Split systems believed to be less effective Split systems believed to be less effective than concurrent / integrated treatmentthan concurrent / integrated treatment

A brief review of trauma txA brief review of trauma tx

Stage 1 trauma treatmentStage 1 trauma treatment– stabilizationstabilization– reflectionreflection– groundinggrounding

It does NOT involve exposure therapyIt does NOT involve exposure therapy Most clients must complete first stage Most clients must complete first stage

before moving on to second stagebefore moving on to second stage

A brief review of trauma txA brief review of trauma tx

Stage 2 trauma treatmentStage 2 trauma treatment– Exposure work - focuses on the Exposure work - focuses on the

event / narratives connected to eventevent / narratives connected to event– Risk of re-traumatization if begin Risk of re-traumatization if begin

second stage before firstsecond stage before first

A brief review of trauma txA brief review of trauma tx

Stage 3 trauma treatmentStage 3 trauma treatment– Increased personal growth via:Increased personal growth via:

reconciling with oneselfreconciling with oneself reconnecting with othersreconnecting with others finding a survivor missionfinding a survivor mission resolving the traumaresolving the trauma

Treatment of trauma and Treatment of trauma and substance use symptomssubstance use symptoms

Historically, treatment was Historically, treatment was sequential: First treat the substance sequential: First treat the substance problem, then address the trauma problem, then address the trauma

Was thought that exploration of past Was thought that exploration of past trauma would be overwhelming and trauma would be overwhelming and lead to increased substance uselead to increased substance use

Treatment of trauma and Treatment of trauma and substance use symptomssubstance use symptoms

Recent best practice Recent best practice recommendations suggest that recommendations suggest that treatment techniques should combine treatment techniques should combine standard substance disorder standard substance disorder treatment with trauma-related treatment with trauma-related treatment = concurrent approachtreatment = concurrent approach

Treatment of trauma and Treatment of trauma and substance use symptomssubstance use symptoms

Overall task of therapist: motivate clients Overall task of therapist: motivate clients toward healthy choices rather than short-toward healthy choices rather than short-sighted, self-destructive, pleasure-seeking sighted, self-destructive, pleasure-seeking behaviorsbehaviors

Educate clients about origins of their lack of Educate clients about origins of their lack of self-care and self-destructive behaviorsself-care and self-destructive behaviors

Assist clients to reduce / cease substance Assist clients to reduce / cease substance use while recognizing / addressing use while recognizing / addressing emotional vulnerabilities and teach new emotional vulnerabilities and teach new practical ways to copepractical ways to cope

Parallels in treatment Parallels in treatment approachesapproaches

Similarities in treatment techniques of both Similarities in treatment techniques of both trauma and substance use symptoms:trauma and substance use symptoms:StagingStagingLong term perspectiveLong term perspectiveStabilization before attempting insightStabilization before attempting insightBuilding basic relational skills before addressing Building basic relational skills before addressing symptomssymptomsTreatment for both: empathy, support, Treatment for both: empathy, support, psychoeducationpsychoeducationTherapist supportive and directiveTherapist supportive and directive

A treatment model for concurrent A treatment model for concurrent trauma and substance use trauma and substance use Seeking Safety (Najavits, 2002)Seeking Safety (Najavits, 2002) Offers manualized evidence based practice Offers manualized evidence based practice

approach to first stage treatment for trauma and approach to first stage treatment for trauma and substance use (stabilization, reflection, grounding)substance use (stabilization, reflection, grounding)

Non-exposure modelNon-exposure model ‘‘Present-focused’ therapy to help clients attain Present-focused’ therapy to help clients attain

safety from trauma and substance use historiessafety from trauma and substance use histories Consists of 25 topics: cognitive, behavioural, Consists of 25 topics: cognitive, behavioural,

interpersonalinterpersonal Each addresses a “safe coping skill” to help patient Each addresses a “safe coping skill” to help patient

attain safety from both trauma symptoms and attain safety from both trauma symptoms and substance usesubstance use

Seeking Safety Outcome Seeking Safety Outcome EvidenceEvidence

High acceptability among diverse clients High acceptability among diverse clients and cliniciansand clinicians

Positive randomized contolled trial of Positive randomized contolled trial of adolescent outpatient girlsadolescent outpatient girls

Superiority to treatment as usualSuperiority to treatment as usual Comparability to a gold standard of Comparability to a gold standard of

treatment (relapse prevention)treatment (relapse prevention)

Seeking SafetySeeking Safety

““Although the world is full of suffering, it is Although the world is full of suffering, it is full also of the overcoming of it.”full also of the overcoming of it.”

--Helen KellerHelen Keller

About Seeking SafetyAbout Seeking Safety

Topics are:Topics are:– in simple languagein simple language– emotionally compellingemotionally compelling– provide a respectful toneprovide a respectful tone– honour client’s courage in fighting the honour client’s courage in fighting the

disordersdisorders– teach new ways of copingteach new ways of coping– convey idea that no matter what convey idea that no matter what

happens, they can learn to cope in happens, they can learn to cope in safe ways without substances and safe ways without substances and other destructive behaviourother destructive behaviour

About Seeking SafetyAbout Seeking Safety

Key principles:Key principles:– Safety as priority for first stage Safety as priority for first stage

treatmenttreatment SubstancesSubstances Dangerous relationshipsDangerous relationships Extreme symptoms - dissociation Extreme symptoms - dissociation

and self-harmand self-harm Integrated treatment for both disorders Integrated treatment for both disorders

at same timeat same time

Key Principles continuedKey Principles continued

Focus on ideals to counteract the loss of Focus on ideals to counteract the loss of ideals in both trauma and substance ideals in both trauma and substance abuse and the search for meaningabuse and the search for meaning

Based on Cognitive - Behaviour Therapy Based on Cognitive - Behaviour Therapy model: four content areas model: four content areas (interpersonal, cognitive, behavioural, (interpersonal, cognitive, behavioural, case management)case management)

Attention to therapist processes: Attention to therapist processes: balance praise with accountability, balance praise with accountability, notice counter-transference, self-carenotice counter-transference, self-care

SS Interpersonal TopicsSS Interpersonal Topics

1.1. HonestyHonesty

2.2. Asking for helpAsking for help

3.3. Setting Boundaries in RelationshipsSetting Boundaries in Relationships

4.4. Getting Others to Support your Getting Others to Support your RecoveryRecovery

5.5. Healthy RelationshipsHealthy Relationships

6.6. Community ResourcesCommunity Resources

SS Cognitive TopicsSS Cognitive Topics

1.1. PTSD: Taking Back Your PowerPTSD: Taking Back Your Power

2.2. When Substances Control YouWhen Substances Control You

3.3. DiscoveryDiscovery

4.4. Recovery ThinkingRecovery Thinking

5.5. Creating MeaningCreating Meaning

6.6. Integrating the Split SelfIntegrating the Split Self

7.7. CompassionCompassion

SS Behavioural TopicsSS Behavioural Topics

1.1. Taking Good Care of YourselfTaking Good Care of Yourself

2.2. CommitmentCommitment

3.3. Respecting your TimeRespecting your Time

4.4. Coping with TriggersCoping with Triggers

5.5. Self-NurturingSelf-Nurturing

6.6. Red and Green FlagsRed and Green Flags

7.7. Detaching from Emotional Pain Detaching from Emotional Pain (Grounding)(Grounding)

Other aspects of the modelOther aspects of the model

Other topicsOther topics

1.1. Introduction / Case managementIntroduction / Case management

2.2. Safety Safety

3.3. Life Choices Life Choices

4.4. TerminationTermination Designed for flexible useDesigned for flexible use

• Group / IndividualGroup / Individual

• Women / Men / MixedWomen / Men / Mixed

• Can use all / fewer topicsCan use all / fewer topics

• Applicable to variety of settings / Applicable to variety of settings / providersproviders

Other aspects of the modelOther aspects of the model

Trauma details not part of group Trauma details not part of group therapytherapy

Aims to identify meanings of substance Aims to identify meanings of substance use in context of traumause in context of trauma

Optimistic - has ‘future’ and ‘strengths’ Optimistic - has ‘future’ and ‘strengths’ focusfocus

Helps clients to obtain more treatment, Helps clients to obtain more treatment, and attend to daily life problemsand attend to daily life problems

Other aspects of the modelOther aspects of the model

Harm reduction modelHarm reduction model 12-step groups encouraged (but not 12-step groups encouraged (but not

required)required) Give clients control wherever possibleGive clients control wherever possible Make the treatment engaging - Make the treatment engaging -

quotations and every day languagequotations and every day language Emphasize core concepts (e.g., “You can Emphasize core concepts (e.g., “You can

get better”)get better”)

What professional issues What professional issues might arise in treating this might arise in treating this population?population?

Professional IssuesProfessional Issues

TRAUMATRAUMA– Tends to evoke identification with Tends to evoke identification with

client’s vulnerability; excessive support client’s vulnerability; excessive support at expense of growthat expense of growth

SUBSTANCE USESUBSTANCE USE– Anxiety about client’s substance use; if Anxiety about client’s substance use; if

extreme, can become harsh, judgmental extreme, can become harsh, judgmental and controllingand controlling

INTEGRATIVE CAREINTEGRATIVE CARE– Support and accountability are the 2 Support and accountability are the 2

central central processes in the treatmentprocesses in the treatment

Countertransference in the Countertransference in the treatment of trauma and treatment of trauma and substance use disorderssubstance use disorders

Client attempts to avoid unbearable affectClient attempts to avoid unbearable affect Working with fluctuating youth motivationWorking with fluctuating youth motivation Therapist may become torn between Therapist may become torn between

abandonment and collusive indulgence, with abandonment and collusive indulgence, with desires to both desert and rescue clientsdesires to both desert and rescue clients

Therapeutic alliance cornerstone of successful Therapeutic alliance cornerstone of successful treatment with concurrent disorders clientstreatment with concurrent disorders clients

With trauma and substance use problems in With trauma and substance use problems in particular, successful treatment depends on particular, successful treatment depends on management of countertransference and management of countertransference and phenomenon of parallel processphenomenon of parallel process

ConclusionsConclusions

Early trauma interferes with youth ability Early trauma interferes with youth ability to regulate emotions in adaptive and to regulate emotions in adaptive and healthy wayhealthy way

Impaired emotional regulation predisposes Impaired emotional regulation predisposes youth to problems with substance use youth to problems with substance use

Active trauma symptoms mediate the Active trauma symptoms mediate the relationship between a trauma history and relationship between a trauma history and substance use outcomessubstance use outcomes

Concurrent treatment of both trauma and Concurrent treatment of both trauma and substance use problems is current best substance use problems is current best practicepractice

ReferencesReferences

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Goldstein AL, Flett GL and Wekerle C (2010). Child maltreatment, alcohol use Goldstein AL, Flett GL and Wekerle C (2010). Child maltreatment, alcohol use and drinking consequences among male and female college students: An and drinking consequences among male and female college students: An examination of drinking motives as mediators. examination of drinking motives as mediators. Addictive BehaviorsAddictive Behaviors, 35, 636-, 35, 636-639.639.

Gratz KL, Roemer, L (2004). Multidimensional assessment of emotion Gratz KL, Roemer, L (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. validation of the difficulties in emotion regulation scale. Journal of Journal of Psychopathology and Behavioral AssessmentPsychopathology and Behavioral Assessment, 26, 41-54., 26, 41-54.

Kessler RC, Sonnega A, Bromet E, Hughes M and Nelson CB (1995). Kessler RC, Sonnega A, Bromet E, Hughes M and Nelson CB (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Posttraumatic stress disorder in the National Comorbidity Survey. Archives of Archives of General PsychiatryGeneral Psychiatry, 52, 1048-1060., 52, 1048-1060.

Khantzian EJ (1997). The self-medication hypothesis of substance use Khantzian EJ (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. disorders: A reconsideration and recent applications. Harvard Review of Harvard Review of PsychiatryPsychiatry, 4, 231-244., 4, 231-244.

Navajits LM. Navajits LM. Seeking Safety: A treatment manual for PTSD and Substance Seeking Safety: A treatment manual for PTSD and Substance AbuseAbuse. The Guildford Press, New York, 2002.. The Guildford Press, New York, 2002.

ReferencesReferences

Rosenkranz SE, Muller RT, Henderson JL (2012). Psychological Rosenkranz SE, Muller RT, Henderson JL (2012). Psychological maltreatment and Substance Use, submitted for publication.maltreatment and Substance Use, submitted for publication.

Steinberg L (2001). We know some things: Parent-adolescent Steinberg L (2001). We know some things: Parent-adolescent relationships in retrospect and prospect. relationships in retrospect and prospect. Journal of Research on Journal of Research on AdolescenceAdolescence, 11, 1-19., 11, 1-19.

Tull MT, Barrett HM, McMillan ES and Roemer L (2007). A Tull MT, Barrett HM, McMillan ES and Roemer L (2007). A preliminary investigation of the relationship between emotion preliminary investigation of the relationship between emotion regulation difficulties and posttraumatic symptoms. regulation difficulties and posttraumatic symptoms. Behavior Behavior TherapyTherapy, 38(3), 303-313., 38(3), 303-313.