From Trauma to Trust

Justice alerts: The Relationship Trauma Crisis
Scott Larson
9

Science Discovers the Reclaiming Approach
Darren Brown
13

The Three Pillars of Trauma-Informed Care
Howard Bath
17

The Restorative Justice Center
Julie Ashworth, Steve Van Bockern, Julie Ailts,
Jason Donnelly, Kelsey Erickson and Jenna Woltermann
22

The Power of Community
Brenda Lange
27

Reclaiming our 'Toughest' Youth
Kiaras Gharabaghi
30

Annie's Journey to Healing
Beate Kreisle
33

Voices of Youth: I Am My Own Hero
Emily D.
36

The Neuroconsequential Model of Therapeutics
Bruce D. Perry and Erin P. Hambrick
38

Clinician or Witness?
William Steele
44

The Sanctuary Model of Trauma-Informed Organizational Change
Sandra L. Bloom and Sarah Yanosy Sreedhar
48

Life Space Crisis Intervention: 'He gave me the finger!'
Mitchell Beck
54

Reclaiming Youth Library: Beasts of No Nation and A Long Way Gone
Reviewed by Godfrey M. Mnubi and John H. Hoover
58 

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Editorial:

Medicating Relational Trauma in Youth
Robert Foltz

There is a new diagnostic category emerging. Over the years, there has been a tremendous effort to understand the effects of early trauma on the developing child. What is now clearly understood is that many different forms of trauma can have a profoundly negative impact on the emotional, psychological, and physical health of the individual many years after the trauma. In order to capture the occurrence and ramifications of the trauma experience, a diagnosis of Developmental Trauma Disorder is proposed (van der Kolk, 2005).

One prominent characteristic of trauma is that the safety within interpersonal connectedness is disrupted. These breaches of trust, respect, safety, and collaboration with adults further impair children's ability to recover from traumatic experiences. They become dysregulated, impulsive, moody, aggressive, untrusting, and withdrawn. These troubled youth become wary of adults. They receive wide-ranging diagnoses. A youth who becomes too impaired (or symptomatic) is often swept up into the realms of psychiatric and psychological treatment. Moreover, it is often believed that the combination of these disciplines can result in optimal outcomes for these children.

Offering troubled youth complex, yet predictable environments is critically important to the recovery from traumatic relationships/experiences. A feeling of safety within these environments is essential-indeed, a prerequisite-for reestablishing interpersonal connectedness with adults. Cozolino (2002) highlights components of a neurologically informed psychotherapy, yet the first requirement is "the establishment of a safe and trusting relationship" (p. 27).

Neuroscience is beginning to inform the utilization of milieu strategies, as well as those traditional therapeutic methods. New understandings reveal that in conjunction with the overt measures of safety and connectedness, important changes are occurring, even at the brain cell, when children receive positive, supportive treatment from caring adults. Important chemicals involved in this process are oxytocin and vasopressin. Oxytocin is involved in a variety of functions, but has been highlighted in attention, memory, and a range of social behaviors including lactation, birth, trusting bonds, and sexual arousal (Cozolino, 2006; Melis & Argiolas, 2003). Importantly, "there is a strong link between oxytocin and vasopressin systems in the brain" (Kendrick, 2007, p. 1). Oxytocin appears to play a more prominent role in females, whereas vasopressin appears more influential in males (Young & Wang, 2004).

One prominent characteristic of trauma is that the safety within interpersonal connectedness is disrupted. If interpersonal connection and safety are critical to the recovery from trauma, and remain a goal of treatment efforts, then optimizing the presence of oxytocin and vasopressin in the body would be a positive, correlated outcome. Interestingly, these chemicals are also connected with feelings of pleasure once a social contact is made, reinforcing one's efforts to sustain those contacts (Kendrick, 2007). Yet current "standards of care" may actually be interfering with a youth's ability to establish interpersonal connectedness.

The following provides a brief overview of the different classes of medications that troubled youth are typically prescribed. The use of medications in youth is not well researched and becomes particularly complex when considering developmental aspects of children, their histories, the use of multiple, concurrent medicines (polypharmacy), and the supportive networks in their lives. Nonetheless, research does provide some insight as to how these medications may affect the ability of a child to connect when in treatment.

Stimulant Medication
Stimulant medication is most commonly used in the treatment of behaviors associated with Attention Deficit Hyperactivity Disorder. The benefits and side-effects of stimulants have been widely published. Amazingly, despite being prescribed to millions of youth, there are no short-term or long-term studies demonstrating that academic grades improve with the use of these stimulants (APA, 2006). Medications in this class (such as Ritalin, Concerta, Adderall, Vyvanse, and Dexedrine) function by increasing the availability of two chemicals in the brain: dopamine (type 2) and norepinephrine.

Ritalin (methylphenidate) is the most common treatment in ADHD treatment. Indeed, in 2006, the United States used more than 80% of the world's Ritalin supply (International Narcotics Control Board, 2007). "Ritalin presumably activates the brain stem arousal system and cortex to produce its stimulant effect ...methylphenidate is thought to block the reuptake of norepinephrine and dopamine into the presynaptic neuron and increase the release of these monoamines into the extraneuronal space" (PDR, 2006, pp. 2255-2256). In other words, Ritalin increases the release of norepinephrine and dopamine and sustains their availability within the space between brain cells.

Oxytocin seems to have a direct and positive relationship with dopamine. Dopamine is an important neurotransmitter involved in reward centers in the brain. This aspect of dopamine's functioning is also connected with the social functions of oxytocin and vasopressin. Specifically, "dopamine administration induces central oxytocin release, whereas oxytocin administration increases central dopamine levels" (Young & Wang, 2004, p.1051), so there is clearly an important interplay between these chemicals.

There are currently five known types of dopamine (Jackson, 2005). Importantly, dopamine type 2 (D2) is believed to facilitate pair-bond formation, whereas D1 interferes with it (Edwards & Self, 2006). Overall, it would appear that stimulant use could enhance the likelihood of bonding or trustbuilding in the therapeutic alliance.

Antidepressant Medication
The most common antidepressant medications used with youth are the serotonin specific reuptake inhibitors (SSRIs). Medications in this class include Prozac, Zoloft, Paxil, Luvox, and Celexa. These medications increase the availability of serotonin. Serotonin is an important chemical messenger, yet only 5% of the body's serotonin is in the brain. The vast majority of serotonin is in the digestive tract (Glenmullen, 2000).

The effectiveness of antidepressants in youth is highly questionable. Even the highly funded Treatment of Adolescent Depression Study (TADS) minimally supports any robust conclusions about the effectiveness of antidepressants in adolescents (Foltz, 2006). Moreover, an FDA review of short-term placebo controlled antidepressant trials reveals that only 3 of 15 studies demonstrated any superiority over placebo (Laughren, 2004). Finally, the increase of self-injurious ideation as well as increasing the likelihood of agitated, irritable, and impulsive behaviors (potentiating mania) has been well documented.

Little is known about the long-term administration of antidepressants in developing youth. Recently, Raeburn (2007) highlighted that "exposure to antidepressants may affect or influence the wiring of the brain, especially when it comes to certain elements having to do with stress, emotion, or the regulation of these" (p. 36).

The use of medications...becomes particularly complex when considering developmental aspects of children. In relation to oxytocin, acute administration of an SSRI seems to increase plasma oxytocin levels. However, long-term use of SSRI medications does not sustain these effects (even within two weeks of medication exposure) (Uvnas-Moberg, Bjorkstrand, Hillegaart, & Ahlenius, 1999). Related to the use of these medications in youth, Raeburn points out "drugs that affect serotonin during developmental years could alter brain function in unpredictable ways" (Raeburn, 2007, p. 37).

With over extended use, however, SSRIs appear to have a more negative effect neurochemically. "Chronically elevated serotonin levels also change certain neuroendocrine systems." Specifically, longterm use of Prozac seems to alter the sensitivity of oxytocin neurons to different drugs that increase serotonin (Cantor, Binik, & Pfaus, 1999). These authors concluded serotonin alters the normal transmission of oxytocin. It is also important to note the relationship between serotonin and dopamine. When serotonin is increased, it appears that the secondary action is that dopamine decreases (Kapur & Remington, 1996). This secondary lowering of dopamine could be related to serotonin's reduction of oxytocin.

The diagnosis of depression and the use of antidepressants have increased dramatically in recent years (Foltz, 2006). Troubled youth often feel as if their resources are depleted and that others can offer little help in resolving their difficulties. Connecting with these young people is essential in creating strategies to assist them in regaining a successful trajectory. However, given the literature presented, it would appear that the use of SSRI antidepressants actually creates a disadvantage in establishing a bond within the therapeutic alliance.

Anticonvulsant Medication
Anticonvulsant medications have also been labeled "mood stabilizers" because they are used in the treatment of Bipolar Disorder. However, drugs in this class (such as Depakote, Tegretol, Topamax, and Trileptal) primarily function by increasing a chemical in the body called GABA (gamma-aminobutyric acid). "GABA is the main inhibitory neurotransmitter present in the brain" (Melis & Argiolas, 2003, p. 63), meaning, the more GABA that is present, the more inhibited the brain functioning is.

While anticonvulsant medications may subdue impulsive and disruptive behaviors, it should be noted that anticonvulsants can have neurotoxic effects on cognitive functioning including reduced processing speed, reduced cognitive flexibility, and diminished complex attention. The worst of these neurotoxic effects are seen with Tegretol (carbamazepine), Depakote (valproic acid), and Topamax (topiramate) (Gualtieri & Johnson, 2006).

Because of GABA's inhibitory actions in the brain, simply put, the release of this neurochemical disrupts the release of oxytocin. There appears to be an inverse relationship between GABA and oxytocin (Engelmann et al., 2004; Engelmann & Ludwig, 2004). When GABA is increased with anticonvulsant medication, oxytocin levels decrease. This also seems to be true for vasopressin, although the relationship between GABA and vasopressin is less clear.

The diagnosis of Bipolar Disorder has skyrocketed in recent years-up 4000% since 1996 by some estimates (Gaviria, 2008). The dysregulated behaviors characteristic of this diagnosis also are quite representative of the emerging diagnostic category of Developmental Trauma Disorder, so it is reasonable to assume that with the release of the DSM-V, many of the youth currently diagnosed with Bipolar Disorder will be placed in this new diagnostic category. Regardless, it would appear that the use of anticonvulsant medications (or mood stabilizers) may actually interfere with the youth's ability to establish a productive bonding experience in a therapeutic alliance.

Antipsychotic Medication
While antipsychotic (neuroleptic) medications are studied and designed to treat conditions such as schizophrenia, their use is increasing for non-psychotic conditions in an effort to decrease aggressive, agitated, and even mood conditions. Antipsychotic medications influence a range of brain chemicals, but their "therapeutic effect" is thought to be based on their reduction of dopamine and serotonin transmission. For the popular Rispderdal, "the drug's therapeutic activity in schizophrenia is mediated through a combination of dopamine type 2 (D2) and serotonin type a (5HT2) receptor antagonism" (PDR, 2006, p. 1659). As with other atypical antipsychotics, generally speaking, the receptor's ability to absorb dopamine type 2 and serotonin type 2 is blocked, decreasing the transmission of these important chemicals.

Abilify is a third-generation antipsychotic medication becoming popular in the treatment of a variety of conditions. The way Abilify works is complicated. It has been identified that this medication "stabilizes dopamine output by activation at low dopaminergic tone and inhibition at high dopaminergic tone, i.e., blocks D2 receptors sufficiently ...in the mesolimbic pathway, but does not simultaneously reduce dopamine activity in the nigrostriatal pathway; may boost dopamine activity in the mesocortical pathway" (Bezchlibnyk-Butler & Jeffries, 2006, p. 94).

The mesolimbic pathway includes the amygdala, which is critically important in "determining the emotional `value' of simple sensory input, complex multisensory perceptions and complex cognitive abstractions, even responding specifically to complex, socially relevant stimuli" (Perry, 2001, p. 6). Oxytocin is largely involved in the amygdala and hypothalamus, particularly as it relates to the modulation of stress and social relatedness (Uvnas-Moberg, Arn, & Magnusson, 2005). Because aripiprazole potently blocks D2 in the mesolimbic pathway, it likely has the secondary function of decreasing oxytocin levels, thereby creating a disadvantage in establishing a therapeutic alliance.

Neuroleptics, including typical, atypical, and third-generation, all demonstrate very potent antagonism at the D2, the two exceptions to the strong potency being clozapine (Clozaril) and quetiapine (Seroquel), which still block D2 receptors, but less dramatically (Bezchlibnyk-Butler & Jeffries, 2006). Because dopamine demonstrates a positive relationship with oxytocin, potent blockade of dopamine functioning reduces oxytocin function as well. With the importance of oxytocin in social connection, the D2 antagonism (reduction) proves to create a significant disadvantage when attempting to establish social bonds or a trust-building experience.

Neuroleptics have wide-ranging side-effects that would also impair the likelihood of enhancing the therapeutic alliance. Drowsiness, agitation, cardiovascular effects, weight gain, metabolic disorders, etc. (Bezchlibnyk-Butler & Jeffries, 2006) can create barriers in establishing and enhancing the trustbuilding alliance. Moreover, long-term exposure of neuroleptics in youth has been poorly studied, leaving an uncertainty of their effects on the developing central nervous system.

Discussion
Children and adolescents are increasingly becoming involved in the mental health system to address a wide variety of diagnoses. Because most "evidence-based" treatment strategies recommend combined treatment (including psychosocial approaches with psychopharmacology), the purpose here is to examine how psychotropic medications may enhance - or interfere with - the therapeutic alliance.

As stated above, the focus of this work is to investigate how psychotropics impact two important neuropeptides involved in social bonding, attachment, and trust-building. These are all important components of a therapeutic alliance. Oxytocin and vasopressin were chosen because of their obvious relevance to the bonding process. In looking at the typical medications prescribed for different diagnostic categories, the mechanisms of action for those medications were then identified.

Except for the use of stimulants (increasing dopamine type 2), all other common psychotropic medications examined in this work appear to interfere with normal oxytocinergic levels in the brain. Many of the functions thought to be the primary mechanism of action for the psychotropics (increasing GABA, blocking dopamine, increasing serotonin) seem to have negative effects on the oxytocin and vasopressin levels. As a result, they appear to interfere with establishing a therapeutic alliance or trusting attachment in the context of therapeutic setting.

Admittedly, the influence of "bonding chemicals" in the brain is not the sole mediator of establishing a productive therapeutic alliance in treatment. However, as the knowledge of neurochemistry, neurophysiology, and neuroplasticity grows, it is important to devote attention to the various influences and how current treatment interventions may impact them.

It is also important to recognize that even with the known functions of psychotropic medications, there is a great deal that is still not understood. Moreover, there are increasing tendencies toward "polypharmacy," that is, the use of multiple medications in the treatment of psychological disorders. With the complications and interactions of multiple medications, it is virtually impossible to reliably identify the true neurochemical events occurring within this sort of treatment regimen, as individual metabolic differences, competing binding affinities of the medications, and other unknown factors influence the effects of medications.

There is an urgent need for more research about how these medications affect a youth across childhood and adolescence. Developmental aspects of these issues are critically important. More children are being prescribed these powerful medications. However, there is an urgent need for more research about how these medications affect a youth across childhood and adolescence. For example, in contrast to an average 8-year-old, the average teen boy sees a dramatic increase in testosterone, yet if these two youth are diagnosed with Bipolar Disorder, they will likely receive similar medications. It is unknown as to how these medications may react with this common developmental event. There are, obviously, countless other developmental influences that require close scrutiny when considering the use of psychotropic medications, or when assuming that a youth will require a particular regimen of medications for the foreseeable future, given a diagnosis.

As a clinician, the next appropriate question would be: what are the implications for psychotherapy? More investigation is required to better understand how medicated youth can more effectively be engaged in the psychotherapy process. Knowing that under certain medication conditions, some youth may be at a disadvantage for establishing a trusting connection, clinicians should be mindful of their efforts to engage with and pursue these troubled youth. Rather than seeing a detached style from the adolescent as "resistance," clinicians should be mindful that it may also be a reflection of other intervention strategies.

References
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