Trauma Informed Care for Substance Abuse Counseling: A Brief Summary

Trauma Informed Care, by design, helps treatment providers with the provision of services to individuals who have experienced trauma and trauma-related stressors. Considering that there is a high co-occurrence between substance use and trauma, it is recommended that individuals functioning as substance abuse counselors understand the implications of trauma informed care in order to provide the highest level of care to their patients.    

Trauma and symptoms of trauma are found frequently to be one of the co-occurring disorders with the highest prevalence rates for patients of substance use treatment (Atkins, 2014; SAMSHA, 2014b; Development Service Group, 2015). More specifically, it is estimated that individuals with a diagnosis of Post-Traumatic Stress Disorder (PTSD) engage in treatment for Substance Use Disorders (SUD) at a rate of five times higher than the general population (Atkins, 2014).  In terms of practical considerations, this suggests that treatment teams providing substance use treatment care are at greater likelihood of having patients with co-occurring trauma than many other mental health-related symptoms and diagnoses. 

In treatment settings, there is a helpful distinction between: 1) treating the trauma experience; and 2) treating the symptoms of trauma (Atkins, 2014; Friedman, Keane & Resick 2014; Dass-Brailford, 2007). This distinction is best understood as the difference between doing trauma processing therapy, which is implied when discussing treatment of the trauma experience, and helping to stabilize and treat the symptoms that occur as a response to the trauma experience.  Although there are numerous evidence-based treatment approaches for treating the experience of trauma, not all providers (whether mental health or substance abuse counselors) have been both trained and deemed qualified to treat the trauma experience due to the specialized training and supervised experience the provision of such services would require (Darmouth, 2015; SAMHSA, 2014b). As noted, this would have the potential to create a treatment gap between the number of trained providers in trauma care and the treatment need of patients with trauma histories. Even though not every provider is trained to engage in trauma processing therapies, it is recommended that institutions train their professional staff in the ability to provide care that is sensitive to the unique symptoms of trauma (SAMHSA, 2014a).  A structured approach that institutions can use for providing such care is known as Trauma Informed Care (Curran, 2013; SAMSHA, 2014b).

Trauma Informed Care Defined

Trauma Informed Care is a collection of approaches that translate the science of the neurological and cognitive understandings of how trauma is processed in the brain into informed clinical practice for providing services that address the symptoms of trauma (Curran, 2013; SAMSHA, 2014b). These approaches are not designed for the treatment of the trauma experience (e.g., processing the trauma narrative), but rather for the assistance in managing symptoms and reducing the likelihood of re-traumatization of the patient in the care experience (SAMSHA, 2014a; Najavits, 2002). As such, interventions of Trauma Informed Care are appropriate for a range of practitioners to utilize in a variety of clinical settings. 

Trauma Informed Care is guided by the neurological understanding of how the threat-appraisal system of the brain, which includes the Hypothalamic-Pituitary Adrenal Axis (HPA), responds to trauma (van der Kolk, 2014; LaDoux, 2002). In addition to the HPA axis, Trauma Informed Care also pays close attention to the autonomic nervous system, which is part of the central nervous system used to mediate arousal (Anderson, 2014; van der Kolk, 2014). The autonomic nervous system is comprised of both the sympathetic and parasympathetic nervous system.  While the sympathetic nervous system increases activation (e.g., increased heart rate, higher respiration rates, etc.), the parasympathetic nervous system relaxes the system (e.g., lowered heart rate, decreased respiration rates, etc.) (Anderson, 2014).  Many of the interventions implemented by the use of Trauma Informed Care act upon the autonomic nervous system to help reduce the otherwise often overstimulated sympathetic nervous system by increasing activation of the parasympathetic nervous system (SAMSHA, 2014b; van der Kolk, 2014; Curran, 2013; LaDoux, 2002).

Although there are many important ideas presented as part of Trauma Informed Care, three common themes can be used to summarize many, but not all, of the main ideas.  These three ideas, which are further expanded upon by SAMSHA (2014a), are: 1) Promote understanding of symptoms from a strengths-based approach; 2) minimize the risk of re-traumatizing the patient; and 3) both offer and identify supports that are trauma informed. Additionally, SAMSHA (2014a) underscores the importance of instilling hope for recovery as a thread running through all three of these approaches. 

When working with patients, it is recommended to utilize a strengths-based approach that both empowers and provides hope to the patient that recovery from symptoms is possible (SAMSHA, 2014b; van der Kolk, 2014; Najavits, 2002). Often, this is recommended to start by providing psycho-education to the patient so they can understand how most symptoms associated with trauma and trauma responses are attempts made on a biological and cognitive level (including processes happening below the conscious level-of-awareness) to protect the individual from the risk of further harm (van der Kolk, 2014; Friedman et al., 2014).  Transforming the association that patients have with symptoms from being one of further hurt to potentially one of attempting protection can evoke a shift in how individuals relate to symptoms and can thereby increase a sense of hope for recovery (van der Kolk, 2014; Friedman et al., 2014). If the individual can see how they are already trying to keep themselves safe, then it may be easier to help them transition to finding other, more effective means for coping. 

Substance abuse counselors and mental health clinicians working with patients who have trauma histories are encouraged strongly to minimize the risk of re-traumatizing the patient (Friedman et al., 2014; Najavits, 2002). As noted throughout the work by Friedman and colleagues (2014), processing the trauma narrative before patients have sufficient coping skills and stabilization (e.g., emotion/symptom regulation, living environment stability, and treatment stability) can cause further risk of harm and decompensation. As such, it is often not advised for clinicians to have patients feel forced to disclose trauma narratives (e.g., dispelling the myth that clinicians need to know all the details about a trauma before any work can be done), and it is additionally not often advised for patients to begin processing the trauma narrative while in short-term settings, as this is not necessarily treatment stability since the patient will need to transfer to another provider.  Instead, patients are often best served by first establishing a sense of stability and safety (Najavits, 2002). Once safety is established (as defined by stability, adequate supports, and coping skills), then the patient is often in a better place to begin processing the trauma in appropriate settings that have the potential for long-term care, if needed (Friedman et al., 2014; Najavits, 2002). 

Interventions aimed at connecting patients with supports and resources that are designed to be sensitive to the presence of symptoms of trauma is another major focus area in Trauma Informed Care (SAMSHA, 2014b). From an institutional point of view, this might include the regular use of a screener at intake to help identify the presence of symptoms associated with trauma, as well as providing referrals to providers who are best able to help patients at every stage of their treatment for symptoms of trauma (SAMSHA, 2014a; Najavits, 2002). This might also include providing patients with referrals to additional services beyond therapy, such as medication management, social support services, or other supportive activities that the provider believes would be appropriate for the patient’s specific symptoms and experiences (Curran, 2013).

Discussion Of How This Can Be Implemented

SAMSHA (2014a) identified several key concepts that are highlighted in the implementation of Trauma Informed Care. These key areas of focus include concepts that structure approaches for both individual practitioners to consider, as well as ways to make entire treatment organizations sensitive to the experience of symptoms of trauma by their patients. Recommendations range from the use of universal screening processes for trauma (to inform practitioners of the potential for the presence of symptoms of trauma) to taking a strengths-based approach to the treatment and understanding of symptoms of trauma. 

The idea of re-conceptualizing symptoms of trauma from a strengths-based approach and providing the patients with this psycho-education is an important part of Trauma Informed Care (SAMSHA, 2014b). For example, a means of providing psycho-education to patients may include explaining how an increased startle response may be related to adaptations made after trauma in order to help reduce the likelihood of being caught off-guard by subsequent situations that may be interpreted as traumatic. The following paragraph outlines an approach that can be used to help explain this approach. Clinicians are encouraged to consider how to simplify the information as appropriate depending on their audience. 

Many of the interventions utilized by Trauma Informed Care are designed to act on the autonomic nervous system directly (Curran, 2013). From a strengths-based view, many of the symptoms associated with trauma can be interpreted as further attempts at ensuring survival. For example, the increased activation and startle response experienced by individuals who have experienced trauma can be interpreted as an adaptation by the brain after trauma whereby the likelihood of being caught off guard is theoretically reduced (Friedman, Keane, & Resick, 2014; van der Kolk, 2014; LaDoux, 2002). Although individuals with these symptoms may not experience the startle response as an adaptation, it becomes easier to understand it as such when conceptualizing the symptom from a statistical perspective.  In this instance, a part of the individual’s consciousness conceives not responding to a threat to be a greater risk and therefore more valuable than responding unnecessarily when there was not an actual threat (in statistics, this is known as making a Type 2 Error). From this perspective, many of the symptoms of trauma can be understood as adaptations towards protecting and sustaining survival, even at the cost of having a great number of ‘false alarms’ (Friedman et al., 2014; van der Kolk, 2014; Dass-Brailford, 2007; LaDoux, 2002). 

Practitioners in settings that provide substance use treatment that want to implement Trauma Informed Care principles may want to consider providing Seeking Safety groups (Najavitis, 2002). Developed by Najavits (2002), Seeking Safety is an evidence-based practice approach to treating symptoms of trauma in a group setting (Dartmouth, 2015). Najavits (2007) designed Seeking Safety with the emphasis on fostering resilience and teaching coping skills for managing symptoms of trauma rather than processing trauma. In fact, Najavits understood that processing trauma with a patient before the patient has the skills to manage the symptoms of trauma successfully could be harmful. As such, the guidelines for implementing Seeking Safety groups includes establishing an understanding with participants that the purpose of the group is to learn skills and bolster resilience, not to process trauma narratives. 

Learning More About Trauma Informed Care

Trauma Informed Care is designed to be implemented both by individual practitioners and by treatment organizations as a whole (SAMSHA, 2014b).  Individuals who are interested in becoming a substance use counselor or substance use practitioner that uses Trauma Informed Care interventions can often obtain this training by attending trainings, obtaining supervision and consultation by practitioners trained in this approach, and by also reading about it. There are numerous articles and books published on this topic. Additionally, the SAMSHA organization has an excellent Treatment Improvement Protocol (TIP) that does a wonderful job explaining this approach further (SAMSHA, 2014b). 

Conclusion

Due to the prevalence of co-occurring symptoms of trauma and substance use disorders, substance use counselors and mental health practitioners are encouraged to be familiar with the practices of Trauma Informed Care (SAMSHA, 2014a; Najavits, 2002). Trauma Informed Care promotes the use of strength-based approaches in a purposeful way to minimize the risk of re-traumatization of the patient (SAMSHA, 2014b; Dass-Brailford, 2007). By utilizing an understanding of trauma that is informed scientifically, Trauma Informed Care interventions are designed to be sensitive to the physiological, psychological, and social modes through which the symptoms of trauma present (SAMSHA, 2014b; Curran, 2013; van der Kolk, 2014). Substance use counselors and mental health practitioners who are interested in learning more about the use of Trauma Informed Care are encouraged to explore further training opportunities on the topic, as well as exploring the SAMSHA (2014b) resources made available that provide further detail on the topic.  

Michael Tkach, PsyD, MA, BA
Dr. Michael Tkach served as a core faculty member for the Hazelden Betty Ford Graduate School of Addiction Studies. Dr. Tkach previously served as an adjunct faculty member for the Minnesota School of Professional Psychology.