Showing Up Episode 4: Substance Abuse Self-harm and Eating Disorders

In this episode we talk about self-regulation. We discuss how substance abuse, self-harm, and eating disorders are self-regulation strategies related to trauma. Special guests include Sienna Votry, a youth mental health advocate, Kina Wolfenstein from the Complex Trauma Recovery Podcast, and Henry Hilt from Seattle Children’s Psychiatry and Behavioral Health Unit.

Learning Objective: To reflect on how substance abuse, self-harm, and eating disorders are self-regulation strategies related to trauma and ways to identify and support young people who are struggling.

Guests:

• Seattle Children's Hospital PBMU
• Complex Trauma Recovery Podcast

Transcript

Showing Up Episode : Substance Abuse Self-harm and Eating Disorders

[00:00:00.00] [MUSIC PLAYING] 

[00:00:08.48] SOPHIE: Please note that Showing Up features themes of trauma, mental health and resilience, which may be triggering for some. So please listen to your body's cues, take breaks, and use self-regulation strategies. Don't hesitate to ask for help. No issue is too big or too small. 

[00:00:26.96] REBECCA: You can always reach out to the National Suicide Prevention Lifeline at 800-273-8255 for support. They will be available to talk with you and connect you to local mental health resources. 

[00:00:49.29] SOPHIE: Hi, everyone. I'm Sophie, and I use she/her pronouns. 

[00:00:53.65] REBECCA: I'm Rebecca, and I also use she/her pronouns. So we're both part of the trauma informed care team at Cultivate Learning at the University of Washington. Welcome to Showing Up. This is a time where we talk about trauma informed care practices for Expanded Learning Opportunities or ELO programs. ELO programs, basically, include anywhere where young people spend time outside of the school day classroom setting, like after school care or summer camps and skill-based programs. 

[00:01:19.05] SOPHIE: Before we dive in today, I think it is time to start a pupdate. So this is a time where Rebecca and I just give a little update on our pups. I am excited to tell you, Rebecca, that we are putting Monty in classes to start via therapy dog. He starts on Friday. 

[00:01:35.73] REBECCA: That's so exciting. 

[00:01:37.78] SOPHIE: I am excited to take him to school. And he's very empathic little pups. I think he'll enjoy having a job to help take care of people. 

[00:01:46.41] REBECCA: That sounds great. 

[00:01:48.18] SOPHIE: How about you? How's Gus? 

[00:01:50.28] REBECCA: Gus is good. But we started doing more like socializing for him. My partner sister also has a puppy and they kind of can get really riled up together. So we've started to do some like regulation breaks when they play. So like we'll have them chase, and they get really riled up. We'll notice when they're playing, they'll start to get dysregulated or like almost fighting. So when they start to get amped up, we'll like do a little treat break. We'll pull them to different sides of the room and give them a treat, and then like let them go again. So it's just our little strategy to keep them from fighting and also like playing in a happy way. 

[00:02:28.62] SOPHIE: Yeah, I think that's really smart. And we can always use a snack break. That's not a bad answer. 

[00:02:34.59] REBECCA: Yeah. 

[00:02:35.25] SOPHIE: It's a universal strategy, snacks. 

[00:02:37.32] REBECCA: Absolutely. 

[00:02:39.00] SOPHIE: Well, today, we are talking all about self-regulation. We're going to specifically focus on some scarier or more challenging ways that self-regulation can manifest. We'll be discussing how substance abuse self-harm and eating disorders are self-regulation strategies related to trauma. We'll also talk about ways that you as an ELO provider can be therapeutic without being a therapist. This episode is pretty heavy, so please listen to your body's cues and take breaks. Again, if you or someone you know is struggling, you can always reach out to the National Suicide Prevention Lifeline at 800-273-8255 for support. They will be available to talk with you and connect you to local mental health resources. 

[00:03:23.91] REBECCA: In this episode, our youth guest is Sienna [INAUDIBLE]. We will also be talking with Kina Wolfenstein from The Complex Trauma Recovery Podcast and Henry Hilt from Seattle Children's Psychiatry and Behavioral Health Unit. Let's jump in with Sienna. 

[00:03:44.16] SOPHIE: Hi, Sienna. Thanks so much for being here. 

[00:03:47.35] SIENNA: Thank you for having me. I'm so excited. My name is Sienna [INAUDIBLE]. I am 24 years old. I use she/her pronouns, and I'm passionate about mental health advocacy because I've gone through the system myself. I've dealt with a lot of different things and I've seen a lot of different programs for helping people and I've also seen how much lack of education there is on mental health awareness and just providing resources for people. So that's something that I'm really passionate about. 

[00:04:22.23] SOPHIE: Thank you so much. So I know you mentioned like you've gone through the system yourself and have struggled with that. So like during those times how did adults in your life best support you when you were struggling with your own mental health? 

[00:04:34.05] SIENNA: They were there for me in a really big way in that they would listen to me. They never diminished my problems having to do with my age and they were just very encouraging of me advocating for my own needs, whatever those might be. So when I was able to go to treatment, which I did in Chicago, they were really, really supportive. They very much encouraged me to go and not think about money or cost or anything like that. But just really willing to listen to me and support me in whatever weird facets that might have looked like at the time. 

[00:05:28.13] And then also being able to go to that program in Chicago and see how helpful it was to have a community around you when you're trying to recover from something that is as isolating and lonely as an eating disorder. Having people around you and having that community of other people who are so focused on their recovery and focused on encouraging those around them to be their best selves and to get better, that really, really changed my life and helped me so much to see the value of recovery. 

[00:06:08.60] SOPHIE: What would you like to say to someone who is listening to this and might be struggling with their mental health? 

[00:06:16.46] SIENNA: Well, as cliche is it I'm sure sounds, the whole it gets better thing is really honestly true. The more that you talk about it, the more that you let people in and let people see you and help you. Recovery is really truly possible, even if it 100% does not feel like it in that moment. I know for years and years, I genuinely just did not believe that I would ever change the way I was thinking, that I would ever be able to get past the things that were causing me to spiral in these ways, causing these issues for me. 

[00:07:03.83] And learning both through treatment and through just the experiencing of sharing my story with the people around me and seeing how willing and able they were to be there for me, proved to me that recovery was a possible thing and even more than that, showed me that I wanted recovery. That it wasn't something that secretly, under it all, I didn't want to get better because that meant giving up on all of these coping things. Being able to see truly with my own eyes that recovery was not this constraint that forced me out of all those things that were comfortable. 

[00:07:59.09] But instead, this really true freedom to stop having to think all the time about all of these things to just be able to let go and walk forward without holding on to all of these things that have tied me down for so long. That is why I so believe that recovery is possible, but it has to be your choice. No one can make you recover. What people around you can do is validate you, and show support for you, and do whatever it is that you need to help you get to the place where you can make that decision for yourself, but really truly, when you make that choice for yourself, you will see how much better it can be and how possible and beautiful recovery can be. 

[00:08:59.40] SOPHIE: That was beautiful. 

[00:09:01.33] REBECCA: Sienna, thank you. 

[00:09:02.37] SOPHIE: Yes, Sienna that was lovely. Thank you so much. 

[00:09:05.70] SIENNA: Thank you so much for having me. 

[00:09:07.26] [MUSIC PLAYING] 

[00:09:30.45] REBECCA: It's time for our word of the week, we are going to share a vocabulary word every episode to help build shared terminology for talking about trauma informed care practices. Today, we'll share our definition of the term self-regulation. Self-regulation is the ability to monitor and manage your energy states, emotions, thoughts, and behaviors in ways that allow you to stay open to learning and connection. When we are disregulated, we can feel really sleepy or lethargic or on the other end of the spectrum, feel agitated or out of control. Self-regulation strategies get us back to that comfortable baseline. 

[00:10:06.57] SOPHIE: One way for thinking about and talking about self regulation is called filling your balloon. I learned this from Brian Manzo, a Seattle Public school counselor. So filling your balloon is based on the idea that our feelings, emotions, and behaviors either create or dissipate energy in our bodies. When we think about self-regulation, we're trying to think about fighting that zone where our balloons are full enough that we're lively and engaged versus deflated or ready to burst. I especially like this concept because it invites us to think about the type of support we need in any given moment. For example, if I'm really overwhelmed and my balloon is too full, maybe I'm ready to burst, I need a self-regulation strategy that helps me calm down like reading a book or drinking some tea. 

[00:10:50.87] REBECCA: I love that visual. I think it's a really helpful way to talk to kids of all ages about self-regulation. It makes me think of ways to inflate my balloon when it's feeling low, like doing something that makes me happy and gives me energy, like playing with Gus or dancing alone in my living room. 

[00:11:05.57] SOPHIE: What's your favorite dance move for self-regulation, Rebecca? 

[00:11:08.93] REBECCA: Wouldn't you like to know. 

[00:11:10.19] [LAUGHING] 

[00:11:11.02] [MUSIC PLAYING] 

[00:11:31.64] SOPHIE: Hi, Kina. Thank you so much for being here today. 

[00:11:34.74] KINA WOLFENSTEIN: Hi, thank you for having me. I'm excited. My name is Kina Wolfenstein. My pronouns are she/her. I'm a therapist and social worker from Portland, Oregon, but living in San Antonio, Texas right now. My education and my work in therapy has been really focused on trauma so I do a lot of trauma research. I'm really passionate about trauma informed therapy and trauma informed mental health protocols. And I have a podcast that is about specifically CPTSD, which is complex post-traumatic stress disorder, and I use that podcast to kind of share research about trauma and bring on other trauma informed therapists as guests to interview them and just kind of share what a trauma informed approach to different mental health issues might look like and talk about that. 

[00:12:23.77] REBECCA: Also a fan of your podcast. So it's great having you on here. 

[00:12:27.51] KINA WOLFENSTEIN: Thank you. 

[00:12:28.17] REBECCA: And just from your experience in the clinical world, from like a high level perspective, can you tell us why behaviors like substance use or eating disorders or other forms of self-harm happen? 

[00:12:41.97] KINA WOLFENSTEIN: Yeah, absolutely. So I think one of the tenants of a lot of trauma informed approaches to those issues is to understand that people don't do things unless they serve a purpose and meet a need. So there's kind of a phrase that I like, which is that people don't come to therapy with their problems, they come to therapy with their solutions, meaning that the things that people struggle with are solutions that they found to other problems. Like people find ways to cope with different issues in their lives and a lot of it has to do with meeting unmet needs and self regulation. 

[00:13:15.04] So things like eating disorders, substance abuse, self-harm, they all have a few main things in common. And those things would be being used as a way to regulate emotions and regulate the nervous system in the body for people that experience a lot of disregulation, whether that's anxiety or depression or emotional numbness or racing thoughts or loneliness or whatever these different kind of emotional experiences are. I think those behaviors are used as a way to manage those problems and those emotions when people don't know how else to do it. 

[00:13:46.92] REBECCA: Yeah, I think that that's a really great perspective. And something that we've been hearing as we've been doing research for this episode. 

[00:13:52.75] SOPHIE: We know you focused a lot of your research on looking at common treatment modalities for substance abuse with a trauma informed care lens. Could you tell us a little bit about that research? And I'm curious to hear if you feel like our current treatment practices are trauma informed or not. 

[00:14:07.23] KINA WOLFENSTEIN: Yeah. Well I have a lot of critiques of kind of popular current addiction treatment modalities for a few reasons. I find that a lot of them don't actually include much of an emphasis on trauma or on appreciating why people are doing the things that they're doing. There seems to be a lot of focus on kind of stigmatizing and pathologizing those behaviors. Most of the work is really focused around just relapse prevention and what I would kind of view as treating the symptom, like treating the issue of the drug use or the alcohol use without really looking at what purpose it's serving and why people have developed these behavioral patterns. 

[00:14:48.27] REBECCA: What are some key shifts that you'd like to see in our collective thinking and discussions about trauma or substance abuse going forward? 

[00:14:54.78] KINA WOLFENSTEIN: I would really like for people to open their minds to some of the other models. One of those models would be the social bonding model or the attachment theory model of addiction. This is something that I think makes a lot of sense for a lot of people and isn't really talked about much, which is that people will bond to substances and actually will bond to things like eating disorders and self-harm too when they don't have supportive healthy, safe environments to create secure attachments and to bond with. So people will kind of create relationships with drugs or an eating disorder to fill the void of unsafe or insecure attachments. 

[00:15:35.97] And I think just looking at addiction in general as more of a response to outside environmental conditions instead of just as a personal failure would be really great because there tends to be this perspective that's like, well you know addiction, the problem is located inside the psychology of the person that's addicted. Right? Like there's something wrong with their pathology. When in reality, I think a lot of the times addiction is a response to huge environmental problems. 

[00:16:05.37] We know, for example, that addiction rates are a lot higher in abusive homes and in communities with high trauma rates and high adverse childhood experience scores, the addiction rates go up. So addiction is often a response to these environmental conditions and I really think that we need to stop blaming the individuals and start looking more at how to meet their needs and create an environment for success. 

[00:16:30.39] There's been a lot of research that kind of backs that up. There were the Rat Park Studies by Bruce Alexander in the 1970s, I believe. He had these rats in a cage with no stimulation, with no friends, if they were alone in a cage and they were given a bottle with normal water and a bottle with water that had morphine in it. They would always get addicted to the morphine or sometimes it would be cocaine in the water, they would always get addicted to it. 

[00:16:56.13] And this was originally used as proof of this idea that, well addiction is just the outcome of being exposed to these addictive chemicals. Like any animal that's exposed to these addictive chemicals enough times will become addicted to it. But Bruce Alexander set up another cage that was rat paradise, where the rats had friends and they had toys and they had slides and all of this environmental stimulation, and the rats in that cage were given the same. One bottle with drugged water and one bottle with normal water and most of those rats would try the drugged water and then not go back to it because they weren't interested in it. They had so much other than so many other sources for connection and stimulation and dopamine, right? 

[00:17:38.87] And so he was one of the people that put forth this idea that's like, addiction is a response to the cage or the environment. It's not just about being exposed to a drug a certain number of times and there have been a number of other studies that kind of correlate that with humans. So I think that's probably one of the biggest things I would like to see embraced is like, let's stop looking at just the person and let's start looking at the environment to solve these problems. 

[00:18:06.62] SOPHIE: Yeah. I really love that lens zooming out a little bit and understanding the full context around an individual and also being able to use that perspective to then address these issues on a social level, like a community level. But I think that also then informs the way that we may relate to people that are struggling with eating disorders, self-harm or substance abuse is that we're understanding that this is a reaction to an unmet need or it is meeting a need. Kina, thank you so much for sharing all of this insight and research. 

[00:18:41.31] KINA WOLFENSTEIN: Thank you so much for having me. I'm always happy to talk about this stuff. 

[00:18:44.15] [MUSIC PLAYING] 

[00:18:57.64] KINA WOLFENSTEIN: My name is Colonel Wolfenstein, I'm a therapist and social worker, I do a lot of trauma research. I'm really passionate about trauma informed therapy. I have a podcast that is about specifically CPTSD, complex post-traumatic stress disorder. My podcast is called The Complex Trauma Recovery Podcast. You can find it on YouTube, Spotify, Apple Podcasts. Any of the podcast places. I also have an Instagram account, complex trauma recovery pod, to share what a trauma informed approach to different mental health issues might look like and talk about that. 

[00:19:31.33] [MUSIC PLAYING] 

[00:19:37.22] REBECCA: Welcome, Henry. It's great to have you here. 

[00:19:40.22] HENRY HILT: Thanks, Rebecca. Great to be here. 

[00:19:42.24] REBECCA: So Henry is from Seattle Children's Psychiatry and Behavioral Medicine Unit or the PBMU, and I actually had a client who had gone there before and would refer to it as the peanut butter marshmallow unit so that's kind of how I remember the letters, because it wasn't always called the PBMU, so during that transition, I was like, Oh OK. It's just the peanut butter marshmallow unit. 

[00:20:07.34] SOPHIE: What a delicious place to work, honestly. 

[00:20:09.86] REBECCA: Yeah. 

[00:20:11.45] SOPHIE: So Henry, could you tell us about you? So introduce yourself, share your pronouns and tell us a bit about the Seattle Children's Psychiatry and Behavioral Medicine Unit and your role there. 

[00:20:21.81] HENRY HILT: My name is Henry and I've worked on the PBMU for about two years. I have he/him pronouns. The PBMU is an inpatient and short term crisis management unit for kids who are just really struggling with some acute behavioral crises and sort of providing a therapeutic environment for them to be safe and supported while those crises are happening. And so typically after kids go here, they go either home or to other treatment levels through community outpatient or residential programs. Most of our patients first come through to the emergency department, some do come through from residential programs or other hospitals though. 

[00:20:58.19] REBECCA: Thank you so much. So our episode today is about self-regulation strategies, specifically like substance use or self-harm and eating disorders, and it sounds like because of the kids who are coming into the PBMU, you're probably pretty familiar with those behaviors. How are those framed at the PBMU? 

[00:21:17.21] HENRY HILT: Really, self-harm, substance abuse and eating disorders all sound pretty different but at the PBMU, those behaviors and many others, we would all view is that they serve a function for a patient or for anybody who's dealing with those behaviors. So really we sort of start by looking at like what function that behavior is serving. Maybe it's giving a patient relief from some emotion, maybe it's communicating that they're in distress, maybe it's sort of communicating something to other people, maybe it's trying to prove something to themselves. 

[00:21:48.71] But by starting there, we can try to figure out what alternative might be more helpful. With the example of self harm, like sometimes self-harm is distracting from like a deeper emotional pain, and it's important to remind ourselves that pain in those cases might be like even worse than the physical harm those patients might be seeing. And so then finding another way to get that patient past that emotional pain, whether it's playing a game, doing some coloring or something like that, can really help that patient deal with those emotions in a way that's not as harmful is self-harm 

[00:22:23.06] REBECCA: Yeah, I really like the framing that you have around how we're looking for what need is being met with some of these behaviors and you gave some examples already but I'm curious to hear more about how you respond when these different behaviors come up in the unit. Like I know that they're probably pretty scary to witness, so I'm curious how you and your team respond as they arise. 

[00:22:44.85] HENRY HILT: Yeah, absolutely. I think it's good to realize they're scary for us and they're also very scary for patients too because if they're scary for us, then the patients have been dealing with this for a lot longer than we've been seeing them. We talked about self harm. I can talk about substance use too since we touched on that. So substance use on the PBMU, it's an enclosed unit and we don't allow patients to bring substances with them. 

[00:23:11.19] And so many patients who've been maybe using substances like outside of the unit to connect with other peers or distract from some pain that's going on in their lives, they might be going through some physical withdrawal too as well as whatever psychological reasons I just touched on. And so recognizing that just even being on the unit, away from like those coping skills that they've really been used to, is really, really hard. Recognizing that is really step one. And then like meeting them with empathy, just even saying out loud that like, wow, this is probably really hard for you to have to make this change and be forced to make this change and then that can be the first step to guiding them to alternatives or brainstorming things that really work for them. 

[00:23:53.40] REBECCA: So I know we've touched on self-harm and substance use, would you also speak to like eating disorders too? 

[00:24:01.79] HENRY HILT: Yeah, absolutely. So eating disorders, we've talked a little bit about meeting things with empathy first. A lot of the kids who've struggled with eating disorders, by the time they get to our unit are really in danger of like serious physical harm from their eating disorder. And so we really want to make sure that we're supporting that first and giving them clear expectations and being transparent about the harm these behaviors have, then being transparent about that allows us to recognize that wow, what we're asking you to do is really hard and now that we've laid out why we're asking you to do it, let's really meet you with empathy and help you as much as we can to get you through these times. 

[00:24:41.56] And recognizing that we don't have to share in the same discomfort to really want to support those patients as best they can and recognize that there might be a lot of things contributing to the eating disorder that we don't see too. It might be things from society, friends or family. And so giving them the space to have those limits and boundaries that can help protect from feeling like they have to be perfect all the time and like really know what's expected of them can allow patients to actually know what they can control and assert control in their lives healthily. 

[00:25:15.49] REBECCA: Thank you so much some things that I heard was that anytime a kiddo comes in with whatever they're dealing with at the time is to just approach it with empathy and know that their behavior serves a function. There's a reason why they're doing what they're doing, and then once you understand that, then you can offer different strategies and solutions that might be beneficial for them. Well, thank you Henry for being here and think you for all the work that you do. 

[00:25:41.72] HENRY HILT: Thanks, Rebecca. 

[00:25:43.15] SOPHIE: Thanks so much, Henry. 

[00:25:44.77] HENRY HILT: Yeah. Thank you too, Sophie. 

[00:25:46.06] [MUSIC PLAYING] 

[00:26:01.31] SOPHIE: Strategy spotlight is the time for us to share one thing that you could implement in your ELO program or classroom. Our strategy spotlight today is about making a calm down area. So I know from my own experience and ELO programs and from working with ELO programs that this type of strategy can feel a little frustrating if you don't have a permanent space or if you share your space. But today, we're going to talk about some ways that you can implement a Calm Down Corner or area that can easily move or disassemble between program sessions. 

[00:26:32.33] REBECCA: Designing a calming space can be an option to use when dysregulated, but hopefully, as you start to support the development of self-awareness, it can also be a place where young people can use proactively as they notice big emotions building up inside them. 

[00:26:45.42] SOPHIE: Exactly. So if you are in a shared space, you can consider bringing in just a single large fluffy pillow, or even just a soft blanket that people can sit on and just place this in a low traffic area of your program space that you can still see though to ensure everyone's safety. If you are in a permanent space, you can decorate with maybe multiple pillows, beanbag chair, soft rug, things like that. And you can also choose to hang transparent fabrics to create a sense of privacy. But again, if you're hanging fabric, just make sure that you can always see within the space. 

[00:27:19.52] REBECCA: It's also helpful to provide a suggestion or a menu of options to use in the coming corner, so having movement options like 1 minute plank challenges or teaching them your favorite dance move. You can also have visuals with step by step breathing exercises or a CD player with some calming music and headphones or even just art supplies, you can also offer resources like play-doh, stress balls, sensory bottles or fidget activities, something that they can do with their hands. 

[00:27:46.91] SOPHIE: Yeah, so these are just a handful of different ways and activities that you can offer to young people to help them regulate. So having young people know what to expect and offering them different choices to meet their needs helps create a safe environment that supports everyone, including and especially young people who have experienced trauma. 

[00:28:05.29] [MUSIC PLAYING] 

[00:28:11.57] As we wrap up this episode, we'll leave you with a few reflection questions. Part of building a trauma informed care practice is building your own self awareness so we can better show up for the young people in our lives. 

[00:28:22.29] REBECCA: Our first question is, how do know when you're self regulated or when you're dysregulated? Next, what strategies do you use to get yourself back to baseline? Next, how do you support self-regulation in youth? And lastly, what is one thing you want to incorporate into your work after listening to this episode? 

[00:28:41.31] SOPHIE: For those of you listening that are working directly with young people either professionally or in your personal life, we know that these topics are heavy and having someone in your life experiencing this much pain is really difficult. Our hope is that this episode helps you understand these behaviors a little better. Bluntly, you are likely not a therapist or mental health provider, and it is not your job nor is it appropriate to provide therapy to young people to try and fix these underlying issues. What you can do and what is incredibly helpful and important is to be a safe and supportive person in their life. You can do this by offering clear and loving expectations, space to make choices and listening without judgment. 

[00:29:22.98] REBECCA: Keep showing up for them as a safe and supportive adult in their lives. In the show notes, we've included some resources for finding help along with books and additional professional development materials and links to our guest today from The Complex Trauma Recovery Podcast and Seattle Children's PBMU. 

[00:29:39.12] SOPHIE: Thank you so much for joining us today. 

[00:29:41.53] REBECCA: This podcast was produced by Cultivate Learning at the University of Washington, with funding from the Ballmer Group. We'd like to thank our media producers, TFR Tom and Ryan m and our graphic designer Tammy Topa. You can find more of Cultivate Learning's work by going to cultivatelearning.uw.edu 

[00:29:55.60] [MUSIC PLAYING]