By Michael J. Tkach, PsyD, LP
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 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.1, 2, 3 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 five times higher than the general population.1 In terms of practical considerations, this suggests that treatment teams providing SUD treatment 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.1, 4, 5 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.2, 6 As noted, this would have the potential to create a treatment gap between the number of trained providers in trauma care and the treatment needs 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.7 A structured approach that institutions can use for providing such care is known as Trauma Informed Care.2, 8
Trauma Informed Care is a collection of approaches that translate the science of the neurological and cognitive understanding of how trauma is processed in the brain into informed clinical practice for providing services that address the symptoms of trauma.2, 8 These approaches are not designed for the treatment of the trauma experience (e.g., processing the trauma narrative), but rather for assistance in managing symptoms and reducing the likelihood of re-traumatization of the patient in the care experience.7, 9 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 (HPA) axis, responds to trauma.10, 11 In addition to the HPA axis, Trauma Informed Care also pays close attention to the autonomic nervous system, which is the part of the central nervous system used to mediate arousal.10, 12 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 rate, etc.), the parasympathetic nervous system relaxes the system (e.g., lowered heart rate, decreased respiration rate, etc.).12
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.2, 8, 10, 11
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,7 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, SAMSHA7 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.2, 9, 10 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.4, 10 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, even at the cost of having a great number of 'false alarms'.4, 5, 10, 11 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.4, 10 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.4, 9 As noted throughout the work by Friedman and colleagues, processing the trauma narrative before patients have sufficient coping skills and stabilization can cause further risk of harm and decompensation.4 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.9 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.4, 9
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.2 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.7, 9 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.8
Practitioners in settings that provide substance use treatment that want to implement Trauma Informed Care principles may want to consider providing Seeking Safety groups.9 Developed by Najavits, Seeking Safety is an evidence-based practice approach to treating symptoms of trauma in a group setting.6, 9 Najavits designed Seeking Safety with the emphasis on fostering resilience and teaching coping skills for managing symptoms of trauma rather than processing trauma.9 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.
There is a strong correlation between trauma and addiction; research has shown that there is significant comorbidity of post-traumatic stress disorder (PTSD) and substance use disorders prevalent in adults13 and adolescents,14 and studies have suggested that up to 95 percent of substance use disorder patients also report a history of trauma.15 As a result, Hazelden Betty Ford Foundation places a high value on the use of Trauma Informed Care for patient interventions. Our clinics use the Seeking Safety group model,9 as well as intensive, gender-specific, Trauma Informed Care groups based on Stephanie Covington's work with gender and trauma.16 The popularity of these groups among patients has encouraged Hazelden Betty Ford Foundation leaders to continue to develop and implement core programming that incorporates Trauma Informed Care into all of our clinical practices. Hazelden Betty Ford Foundation also emphasizes the use of Trauma Informed Care through education and training events, including staff in-service trainings and patient education sessions.
Question: Instead of focusing on the symptoms of trauma, shouldn't patients just process the traumatic experience directly?
Response: In most instances, it is the preference of the provider to treat the source of a patient's concern, rather than treating the symptoms. However, there are few mental health providers who have completed the training and have required qualifications for processing traumatic events with patients, and the risks of attempting to process trauma too quickly or improperly can be lasting and severe. Since there is an imbalance in the number of clinicians with this training and the need for such services, and also since symptoms of trauma can be very pervasive and debilitating, Trauma Informed Care presents an alternative wherein a larger number of providers can work with patients to reduce trauma symptoms without needing to face the risks of incorrectly processing traumatic experiences.
Clinicians: 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 resources made available that provide further detail on the topic, including an excellent Treatment Improvement Protocol (TIP) that does a wonderful job explaining this approach further.2
Patients: Trauma Informed Care is an opportunity to find healthy ways to reduce the severity of symptoms related to a trauma you may have experienced, but does not require you to process the details of your traumatic experience until you are ready. Talking to your counselor or therapist about exploring Trauma Informed Care can be a wonderful tool to reduce your symptoms in a safe, structured environment without having to commit to the direct processing of your traumatic event. You should never attempt to process a traumatizing event if you are not comfortable doing so, and any clinical professional who is working with you to process a traumatic experience should have specific training and experience in doing so; otherwise you could be put at risk of re-traumatization.
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.7, 9 Trauma Informed Care promotes the use of strength-based approaches in a purposeful way to minimize the risk of re-traumatization of the patient.2, 5 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.2, 8, 10
1. Atkins, C. (2014). Co-occurring disorders: Integrated assessment and treatment of substance use and mental disorders. Eau Claire, WI: PESI Publishing and Media.
2. Substance Abuse and Mental Health Service Administration (2014). Trauma-informed care in behavioral health services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services
3. Development Service Group, Inc. (2015). Learning center literature review: Posttraumatic stress disorder. SAMHSA's National Registry of Evidence-based Programs and Practices.
4. Friedman, M. J., Keane, T. M., & Resick, P. A. (2014). Handbook of PTSD: Science and practice (2nd ed.). The Guilford Press.
5. Dass-Brailsford, P. (2007). A practical approach to trauma: Empowering interventions. Thousand Oaks, CA: Sage Publications.
6. Dartmouth (2015). IDDT Integrated dual disorders treatment revised: Best practices, skills, and resources for successful client care. Center City, MN: Hazelden
7. Substance Abuse and Mental Health Service Administration (2014). SAMHSA's concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration.
8. Curran, L. A. (2013). 101 trauma-informed interventions: Activities, exercises and assignments to move the client and therapy forward. Eau Claire, WI: PESI Publishing and Media.
9. Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY: The Guilford Press.
10. van der Kolk, B. (2015). The body keeps the score: Brain, mind, and body in the healing of trauma. New York, NY: Penguin Group.
11. LeDoux, J. (2003). Synaptic self: How our brains become who we are. New York, NY: Penguin Books.
12. Anderson, J. R. (2014). Cognitive psychology and its implications (8th ed.). New York, NY: Worth Publishing.
13. Tull, M. T., Berghoff, C. R., Wheeless, L., Cohen, R. T., & Gratz, K. L. (2017). PTSD symptom severity and emotion regulation strategy use during trauma cue exposure among patients with substance use disorders: Associations with negative affect, craving, and cortisol reactivity.
Behavior Therapy. Advance online publication. doi: 10.1016/j.beth.2017.05.005
14. Simmons, S., & Suárez, L. (2016). Substance abuse and trauma. Child and Adolescent Psychiatric Clinics of North America, 25, 723-734.
15. Brown, P. J., Stout, R. L., & Mueller, T. (1999). Substance use disorder and posttraumatic stress disorder comorbidity: Addiction and psychiatric treatment rates. Psychology of Addictive Behaviors, 13, 115-122.
16. Covington, S. S. (2007). Women and addiction: A gender responsive approach. Center City, MN: Hazelden.