Cascades of Chaos

In my last post, I looked at cognitive scripts and the concept of stuckness. In this post, I’ll look more closely at how this concept is particularly relevant to youth with a history of trauma, abuse or neglect.

More than eight million American children suffer from serious, diagnosable trauma-related mental health problems (Perry & Szalavitz, p. 3); adolescents with impaired stress response systems resulting from long-term traumatic exposure are most likely to develop ongoing, significant drug problems (Perry & Szalavitz, p. 189) and other mental health problems (Perry & Szalavitz, p. 246). Additionally, surveys of adolescents receiving treatment for substance abuse found that more that 70% reported a history of trauma exposure, while other studies have found that 57% of adolescents in treatment come from homes where violence occurred frequently, and 40% reported being physically abused (Lawson & Lawson, p.176).

These statistics clearly show that there is a strong connection between substance abuse and a history of traumatic stress. In addition to substance abuse, adolescents with such histories often turn to a number of potentially destructive behaviors in an effort to avoid or defuse the intense negative emotions that accompany this traumatic stress. These behaviors often include engaging in risky sexual behaviors, self-mutilation, bingeing and purging, and suicidal behaviors. This serve to further traumatize these youth, reinforcing their already maladaptive cognitive scripts. Understanding the connection between substance abuse, trauma, and this cascade of chaos is important if we wish to assist our clients in moving forward.

Trauma in Early Childhood
As I’ve written before, nearly all my clients have predictable cognitive scripts. This is especially true with trauma survivors. When faced with even small life challenges, these youth predictably act up, shut down, or use. Hebb wrote, “…any two cells or systems of cells that are repeatedly active at the same time will tend to become ‘associated,’ so that activity in one facilitates activity in the other” (qtd. in Siegel, p. 26). In other words, “Experience, gene expression, mental activity, behavior, and continued interactions with the environment are tightly linked in a transactional set of processes” (Siegel, p. 19).

These processes begin at birth. Repeated similar experiences lead the mind to make generalized representations that form the basis of mental models used to “interpret present experiences as well as anticipate future ones” (Siegel, p. 29-30), suggesting that an individual is most likely to respond to life events in standard, predictable and learned ways.

Perry and Szalavitz stated that repeated activation of the stress response system cleads to “a cascade of altered receptors, sensitivity, and dysfunction” (p. 24). In other words, over-activation of a system can result in becoming over-reactive, or they as described it “sensitized” (Perry & Szalavitz, p. 36). A common causation of this sensitized state is childhood neglect, abuse and other early childhood trauma. In these cases, that trauma becomes part of the individual's mental models. In other words, traumatic stress leads to the expectation of more traumatic stress, which becomes a self-fulfilling prophecy. After all, expecting stress is stressful all by itself.

When individuals exposed to childhood trauma move into adolescence, they face a new cascade of problems. These can include a higher incidence of mental health disorders, school-related concerns, placement in separate classes, and increased association with peers who exhibit similar maladaptive issues. This cascade of problems frequently results in youth with limited academic success, a continued escalation of behavioral problems, social marginalization, interactions with deviant peers, and a significantly increased likelihood of substance abuse. In addition, the neurobiological changes cataloged above increase the likelihood of developing anxiety disorders (Romer & Walker, p. 350) and substance-related problems (Romer & Walker, p. 446).

Simply put, not only are these youth stuck with maladaptive cognitive scripts, they are these stuck in a seemingly endless cascade of chaos. For these adolescents, school failure, negative peer relations, environmental stressors, mental health disorders, and substance abuse are all likely to co-evolve. An additional factor in this co-evolution is brain development. For an adolescent already suffering the negative impacts from early childhood trauma, the additional impact caused by these environmental problems would likely contribute to his cascade of problems.

A former client, “Andrew,” illustrates this. By the age of three, Andrew’s parents were both heroin dependent and the family lived in a car. It is reasonable to make two assumptions here. First, the environmental stressors caused by addicted parents and homelessness had already negatively impacted Andrew's brain development. Second, with both parents heroin dependent, Andrew likely had a genetic predisposition for addiction.

At age four, Andrew witnessed the death-by-overdose of both parents. With no relatives to provide care, he entered the foster care system. Between four and 15 he had over a dozen different placements. Andrew reported, “I moved around so much that I didn’t even unpack my suitcase.” Not surprisingly, his behavior became increasing problematic. He reported first use of alcohol at age 10 and first use of marijuana shortly thereafter. At 13 he went to detention for the first time. At 15, he ran away from the group home where he was living.

When I met Andrew, he was 16 years old and had just moved into a shelter after being homeless for almost a year. He reported two recent physical assaults and had mental health diagnoses that included PTSD, Conduct Disorder, ADHD and Major Depressive Disorder. He also had diagnoses for Alcohol Dependence, Cannabis Dependence, Opiate Abuse, and Amphetamine Abuse. In addition, Andrew exhibited difficulty remembering details, time frames, and other factual information. Andrew reported using because “it makes me feel normal,” even though he acknowledged amphetamines made him “jittery and paranoid.” With a blank look he continued, “I guess jittery and paranoid is my normal.”

Being Stuck
Working with teens that have co-occurring disorders, I see a lot of clients with a history of trauma. Like Andrew, these adolescents frequently appear to be stuck in an endless cascade of chaos. Here are two additional examples:

• “Carl” is 16 and a convicted felon for multiple car thefts. He suffered physical and emotional abuse from his father starting around age four. At age six his mother died. All three older brothers have drug problems; two of them are currently in jail. Carl has diagnoses of Cocaine Dependence, Cannabis Abuse, Alcohol Abuse and PTSD.

• “Melissa” is 15. She grew up subjected to significant neglect at the hands of her mentally ill mother and was sexually abused by several of her mother’s boyfriends. In addition to diagnoses of Amphetamine Dependence, Alcohol Abuse and Cannabis Abuse, Melissa has a history of disordered eating, suicidal ideation and self-harming behaviors.

Most of my clients don’t have histories as intense as Andrew, Carl or Melissa. however, the majority of them have experienced neglect, parental substance abuse, or other traumatic stress. In my experience, the more severe the history of trauma, the more likely the client will be using stimulants. Stimulants replicate trauma by releasing dopamine and noradrenaline, which are released during the hyper-arousal response. “Brain changes related to hyper-arousal may make some trauma victims more prone to stimulant addiction” (Perry & Szalavitz, p. 190). If this is so, then are these adolescents attempting to recreate the feeling of trauma from their pasts? This likely isn’t their overt intention. However, as Melissa said, “I only feel normal when I’m on meth.” Her brain has changed to make this hyper-arousal her normal state of being.

Melissa’s entire life has contributed to a trauma-focused development of her brain. By using meth, she artificially stimulates the production of those neurotransmitters that she has physically become accustomed to being present. For Melissa and others, perhaps the absence of stress-induced neurotransmitters should be considered a type of withdrawal. Perhaps, these youth are using stimulants to avoid withdrawal caused by a decrease in their accustomed levels of dopamine and noradrenaline caused by the past trauma.

Likewise, perhaps the extreme behavior many of these youth engage in—auto theft, prostitution, drug dealing, risky sex, graffiti, running away, assault, and more—is also a way to increase levels of dopamine and noradrenaline, thereby avoiding withdrawal from stress-related neurotransmitters.

For years I have referred to these clients as “chaos junkies”—a term these youth readily understand and frequently acknowledge as true—but always thought of this as a psychologically based behavioral pattern, a repeating of life strategies that had been modeled in chaotic family environments. Could there be something more happening here? Could these youth actually be physically addicted chaos? More accurately, could these youth be physically dependent upon the chemicals released as a result of the stress caused by their chaotic lifestyles and environments?

This isn’t true for all my clients, but I definitely believe some of them—such as Carl, Melissa and Andrew—are addicted to the cascades of chaos in their lives. If our goal as a substance abuse counselors is to help these adolescents create more adaptive cognitive scripts, then part of my work must to help them resolve their addictions to chaos.

In my experience, teens without a history of significant trauma do not typically identify stimulants as a drug of choice. They may have tried meth, crack or Ecstasy, but only in limited amounts. In fact, it seems to me that stimulant dependence or abuse in adolescents could be considered indicative of trauma. Unfortunately, for these youth, this sign—as well as others—is often missed. Andrew, Melissa, and Carl all came into treatment with long lists of diagnoses such as Conduct Disorder, Major Depressive Disorder, Bipolar Disorder, and Attention Deficient-Hyperactivity Disorder, among others.

While it is possible that those other issues might be present in some cases, without addressing their obvious trauma-laden histories that positive growth seems unlikely. Acknowledging, understanding and addressing the traumatic histories of these youth allows for the possibility of getting unstuck. First, though, it is important to further explore why these youth stay stuck.

Staying Stuck
Thus far, I’ve looked at traumatic experiences as causal pathway for substance abuse in adolescents. While this appears to be the primary causal pathway among adolescents and adult, it is possible for substance abuse to lead to trauma. For Melissa, prostitution helped pay for her expensive drug habit of meth and cocaine. It also led to multiple sexual assaults. For Carl, a severe lack of impulse control and untreated Attention Deficient-Hyperactivity Disorder was at the root of repeated auto thefts, high-speed car chases with the police, and stimulant dependence. It also led to repeated jail sentences. For Andrew, drug dealing supported his substance abuse. It also led to several physical assaults.

These high-risk behaviors clearly re-traumatize the youth. In other cases, such high-risk behavior could be the causation of the initial trauma. Either way, it is easy to see that these youth are stuck. As stated already, Andrew currently lives in a group home. This group home has a drug testing policy and continued use will result in him losing his placement. Yet, he continues to use. Some chemical dependency counselors would say Andrew is in denial, or maybe he’s resistant to treatment, but either way until he “hits his bottom” nobody will be able to help him.

I believe this assessment of Andrew is both simplistic and pessimistic, and so I offer a different analysis: Andrew is not resistant and he is not in denial. In fact, he readily acknowledges the problems in his life. But, he is stuck. His lifelong cascade of problems has impacted his brain’s architecture in ways that have shaped his behavior and determined his cognitive scripts. Andrew knows no responses to his world but acting up, shutting down or using. Furthermore, I believe his brain is not physically capable of making other choices. Helping Andrew become unstuck requires discovering ways to assist him create, practice and then apply more adaptive cognitive scripts.

Writing New Scripts
Evans and Sullivan wrote, “Survivors frequently have excellent artistic abilities, a reflection of their extensive use of right-hemisphere survival strategies” (p. 143). If this is true, then experiential learning—including initiatives, games, art therapy, music therapy, games, and other activities—could be a vital clinical approach for working with trauma survivors. Ross and Bernstein support this conclusion. They wrote, “[G]ames and activities offer youth a workshop for discovering and developing new ways to manage obstacles” (qtd in Rose, p. 24).

Active, experiential learning achieves this goal by not only providing participants the opportunity to try new behaviors, but to also practice them in a safe, supportive environment. In addition, these interactive approaches provide opportunities to increase problem-solving skills, self-efficacy and openness to taking good risks, so that the participants are willing to implement these newly developed, more adaptive scripts.

For adolescents struggling with both substance abuse and traumatic stress, remaining stuck in chaos is a safe, tempting possibility. Melissa stated once, “When I smoke weed, all the bad feelings go away. I don’t want to cut. I don’t want to purge. As long as I’m high, everything seems okay.” As we’ve seen, substance-related disorders and traumatic stress are frequently an intricate, co-evolving, cascading series of obstacles. Helping youth get unstuck from this loop requires challenging these adolescents to risk developing new cognitive scripts.

Works Cited
Lawson, G. & Lawson, A. (1992). Adolescent Substance Abuse. Gaithersburg, ME: Aspen Publishing.
Perry, B. & Szalavitz, M. (2006). Boy Who Was Raised as a Dog, The. New York: Basic Books.
Romer, D. & Walker, E. (2007). Adolescent Psychopathology and the Developing Brain. New York: Oxford University Press.
Rose, S. (1998). Group Therapy with Troubled Youth. Thousand Oaks, CA: Sage Publications.
Siegel, D. (1999). Developing Mind, The. New York: Guilford Press.

Here I Go!

I've recently finished The Art of Changing the Brain, by James Zull. This book is packed full of interesting information on the biology of learning. The author did an excellent job of providing the information needed to understand this potentially challenging topic, so even if you have little understanding, you should be able to jump right in.

Zull wrote, “The main message [of this book] is that learning is change. It is change in ourselves, because it is change in the brain. Thus the art of teaching must be the art of changing the brain” (p. xivv). Zull builds on this statement throughout the book, exploring ways to use what is known about neuroscience in the process of teaching, and more important to my focus here, in facilitating for change.

Although the book is focused on teaching, the material presented is equally relevant to counseling and group facilitation. Over the last couple years I’ve started viewing myself more as a facilitator than a counselor. To me a counselor is someone who gives advice, and I try to avoid that most of the time!

In my experience, teens just aren’t much for advice taking. More importantly, though, I have come to believe that treatment is inherently an experiential learning process and hope to help clients reach their own decisions, building whatever necessary skills as we go. If I’m doing good work, what I’m really doing is facilitating the process of change, not providing advice. Like any facilitator, what I'm doing is providing opportunities.

As I started reading Zull and realized how teacher-focused it was, I had a bit of a challenge accepting that the material could apply to me. I don’t even like being called a counselor; I certainly don’t want to consider myself a teacher! Teachers provide new information and I operate on the assumption that my clients already know what they need. Sure, they're likely missing certain skills and frequently don’t have some factual information, but if treatment is an experiential process, than doesn't being effective in my work means not giving advice (at least not too often) and not teaching new information (at least not too much)? Isn't that what a facilitator does?

Having finished the book, I’ve altered my take on this a bit. It seems to me there’s really not much difference between teaching, counseling and facilitating—at least when they are done well. I still see myself as a facilitator, because that fits best with my approaches to counseling and fostering change, and I like how that role name fits. However, the distinctions between the three seem less relevant to me.

Prior Knowledge
One idea from Zull that has especially impacted me is the importance of prior knowledge. Zull wrote, “[P]rior knowledge is the beginning of new knowledge” (p. 93). He expanded on that with this statement: “When we speak of prior knowledge, we are speaking of something physical. It builds as brains physically change, and it is held in place by physical connections” (p. 94).

According to Zull, that physical something consists of all the neuronal networks that exist in our brains. “Whatever the neuronal networks are in the student brain, a teacher cannot remove them” (p. 101). So, rather than try to eliminate these neuronal networks, which won’t be effective anyway, it is more effective to build upon them. Taking this idea a small step further, it seems to me that prior knowledge actually provides a foundation that allows the teacher/facilitator/counselor to start in progress with the process of change. Prior knowledge, even if not entirely accurate, gives you a head start in facilitating change.

With that in mind, it seems only reasonable to have this first blog entry address what I already believe about that work I do. Core to my counseling approach is that everyone has cognitive scripts. Simply put, cognitive scripts are learned responses to situations. They are habits of both though and behavior. Like any habit, if I do something enough times it becomes automatic. This idea has roots in basic brain development. What wires together fires together. If someone is wired for adaptive cognitive scripts, that person is unlikely to have major problems in life. However, if someone is wired for maladaptive scripts, that person is stuck.

My clients are stuck. They have brains wired to make bad choices. In some cases, that wiring results from their environment. In other cases, it is due to genetic predisposition. In most cases, it seems to me that the maladaptive scripts result from a combination of these factors. Regardless of the causation, though, the cognitive scripts of my clients are usually limited to three options: acting up, shutting down, and using.

For my clients, acting up, shutting down, and using are solutions that have been effective in the past. Of course, effective doesn't necessarily mean adaptive. Rather, it means the behavior helped the individual meet her/his needs at that time. Since her/his needs were met by the behavior, it was repeated and became hardwired. This is basic behaviorist stuff. Do something, like the outcome, do it again.

Helping my clients move forward requires helping them get unstuck from this behaviorist loop, and that means helping them develop new, more adaptive cognitive scripts.

Zull's concept of prior learning would imply that my goal as a facilitator/counselor/teacher should not be to eliminate these maladaptive scripts, and that seems somewhat revolutionary to me. Instead, Zull suggested that it would be more effective to start with them. This bit of neuroscience would seem to support motivational interviewing, an "evidence-based approach to overcoming the ambivalence that keeps many people from making desired changes in their lives" (Miller & Rollnick, dust jacket), takes this approach also. More to come on that in the future!

Growth Zones
Getting unstuck means making changes and that’s hard. There are many reasons that change is hard, but I believe there are two factors that are especially relevant. The first is that brains are lazy. More accurately, brains are efficient and will automatically default to what is already known—those neurons that have fired together over and over in the past, those well rehearsed cognitive scripts whether they’re adaptive or not. The second factor that makes getting unstuck hard is that change is risky because it requires stepping outside your Comfort Zone.

A popular model in the experiential learning field is Growth Zones. I use this model with my clients regularly, and have found it to be useful for them in conceptualizing the process of change. Imagine an archery target with three rings. The innermost ring is an individual’s Comfort Zone. Here there are no challenges and no risks, but also no learning or change.

Most people spend most of their time in their Comfort Zone, and that's reasonable and appropriate. However, it is only when you move outside your Comfort Zone and enter your Change Zone, the middle ring, that you have the opportunity for growth or new learning. With this opportunity comes risk, though, because the outcome is uncertain. Should you go too far from your Comfort Zone, straying past your Change Zone and into the outermost ring, you'll end up in your Crisis Zone. At this point, you’re no longer learning or growing.

Comfort, Change, and Crisis are my names for these three zones. I like the alliteration and I like that it reinforces the idea of change. Most versions of this model call the three zones Comfort, Learning, and Panic.

Risking Change
Since making changes means taking risks, I believe success in the work I do requires the intentional creation of an environment where taking risks feels less risky. Doing that requires acknowledging that change is risky, exploring good risks versus bad risks, and providing opportunities to practice safe risk-taking. I believe that one of the best ways to provide opportunities to practice safe risk-taking is through experiential activities.

Experiential learning provides opportunities for participants to:
1. Test their pre-existing assumptions and reject what they no longer find effective;
2. Practice alternate behaviors; and,
3. Engage in healthy risk taking.

For many of my clients, risk-taking is something of a paradox. They’ve regularly engaged in behaviors that most people would considered extremely high risk—illicit drug use, illegal activities and so on. However, when it comes to making changes they are often extremely risk-adverse. They would often rather continue engaging in maladaptive, no longer effective behaviors than even consider doing anything different. At least that’s what they say and that’s what they do.

In fact, I believe most of my clients actually have more complex feelings about changing their behaviors, initially presenting with a certain amount of cognitive dissonance apparent in their words and actions. However, this risk-taking paradox is definitely a barrier to becoming unstuck for my clients.

It seems to me that this paradox is rooted in one simple fact: the Known, which is always inside someone's Comfort Zone, is safer than the Unknown, which is outside someone's Comfort Zone. For many of my clients, high-risk behavior is Very Much Known. Or at least the chaos created by the high-risk behavior is Very Much Known.

Nearly all of my clients have histories of trauma, abuse, neglect, or (at the very least) dysfunctional family systems. The cognitive scripts of these clients include chaos. It is hard-wired in their brains. In addition, stress releases neurochemicals that act on the brain’s reward center in the same way that meth, cocaine and other stimulants do. What a double whammy!

For these youth, high-risk behavior has become normalized. It exists inside their Comfort Zones and so no longer seems risky. In addition, when they engage in high-risk behavior, the behavior is reinforced because they get high. Perhaps there is no paradox here. Perhaps this behavior is completely understandable.

Another way to conceptualize this paradox occurred to me as I wrote this blog post: For these chaos junkie youth, maybe high-risk behavior isn't really in their Comfort Zone. After all, they generally do exhibit cognitive dissonance and generally are able to identify problems related to their behavior (not always the problems I've identified, but problems nonetheless).

I wonder if this cognitive dissonance means that the high-risk behaviors of these youth are, in fact, not in their Comfort Zone. I wonder if maybe these youth are stuck in their Crisis Zone.

Most treatment strategies for these youth are about trying new behaviors. In other words, most treatment strategies for these youth involve getting them to leave their Comfort Zones. However, they can't leave if they aren't even there. Maybe this treatment approach is backward. Maybe what should be happening is these youth should be nudged back into their Comfort Zone. Hummm...

Stages of Change
Another model of change I utilize frequently is the Stages of Change. This model states that any change requires progression through a series of stages. These stages include Pre-contemplation, Contemplation, Preparation, Action and Maintenance. Without progressing through all stages, lasting change won't happen.

In the past, most chemical dependency treatment was focused entirely on Action. Upon entering treatment, the client was expected to immediately stop all using. If that didn’t happen, the client was consider in denial or resistant to treatment and was often discharged. Not very effective. Would an M.D. discharge a cancer patient because the cancer didn't go away immediately? I hope not.

Alternatively, the client was perhaps compliant, attending all group sessions and having nothing but clean UAs. In this case, the client would be rewarded for her/his success. However, compliance has nothing to do with change, at least to in my opinion. Compliant clients are relapses waiting to happen.

The Stages of Change model suggests that you meet the client where she/he is and work on facilitating movement to the next stage. Discovering the motivation to move is the key to progressing through the Stages of Change.

There’s also the Recycle or Relapse stage, which is an important part of this theoretical model. In the Recycle stage, the individual cycles back through some of the earlier stages. When working with clients attempting to create any kind of change, I believe it is important to remember that relapse is not a sign of failure. Instead, relapse is a vital part of the change process and an important learning opportunity.

Relapse is experiential learning. It allows the client to test her/his pre-existing assumptions and reject what they no longer find effective, practice alternate behaviors, and engage in some healthy risk taking by learning something new. What didn’t work? What do you need to do differently? How can you move forward now, better prepared and with greater understanding of your personal challenges for staying clean?

Recently, I’ve been thinking about how an individual’s Stage of Change is their Comfort Zone. It seems to me there must be some interesting dynamic between these two models, but I don’t yet know what. It also seems to me that there is likely much more to discover in the crevasse between facilitating change and traumatic stress. I’m ready to go explore!

Works Cited
Zull, James. (2002). Art of Changing the Brain, The. Sterling, VA: Stylus Publishing.