Elise Conklin
Individuals seeking treatment for alcohol and substance abuse are likely to have a history of trauma (Wiechelt, 2014). In fact, there is a relation between increased trauma exposure and substance use (Shields, Delany, & Smith, 2015; Wolf, Nochajski & Farrell, 2015). In addition, as the severity of the experienced trauma increases, there is also an increase in severity of substance abuse, as well as other negative life outcomes (Wolf et al., 2015). Despite this well-documented relation, substance abuse treatment programs tend to be separate from those addressing trauma, with a recent survey stating that only 19.7% of American outpatient substance abuse treatment programs consistently offer trauma services (Shields et al., 2015).
Traditionally, substance abuse treatment programs have held the belief that addressing trauma will trigger traumatic responses, which will overwhelm the client and cause them to relapse (Cadiz et al., 2005; Wolf et al., 2015). These programs consider substance abuse to be the primary concern and only address trauma once clients are in recovery, if at all (Shields et al., 2015). However, the self-medication pathway hypothesis posits that trauma survivors use substances to manage their posttraumatic symptoms, which in turn increases their risk of developing substance use disorders (Haller & Chassin, 2014). From this perspective, recovery is unlikely to be stable and long-term without addressing the underlying trauma (Cadiz et al., 2005; Wiechelt, 2014). In fact, research suggests that improving posttraumatic symptoms may improve substance use symptoms as well (Hien et al., 2010). Trauma can be addressed directly in alcohol and substance abuse programs by integrating trauma treatment into the substance abuse treatment process, therefore addressing both simultaneously (Amaro et al., 2007). Organizations can also adopt trauma-informed care (TIC), wherein organizations intentionally shape their policies to accommodate the needs of trauma survivors and support their recovery (Hopper, Bassuk & Olivet, 2010). This paper sought to explore the implications of the self-medication pathway for substance abuse in clinical practice and social services, asking: How is recovery from substance abuse supported by addressing trauma in treatment?
Defining Trauma
Trauma is defined as a stressful event that emotionally overwhelms an individual’s ability to cope and creates a feeling of helplessness and horror (Smyth & Greyber, 2013; Wiechelt, 2014). Many stressful life events have the potential to be traumatic, but depending on an individual’s perception of and reaction to the event, some individuals may consider an event traumatic while others may not (Smyth & Gryber, 2013; Wiechelt, 2014). Such events may include unexpected catastrophes, such as warfare and natural disasters, but traumatization more commonly occurs through abuse, assault, neglect, or witnessing violence (Potthast & Cadani, 2012; Smyth & Greyber, 2013).
Individuals who experience trauma often experience posttraumatic symptoms, which, if left unresolved, may disrupt an individual’s life and relationships (Wiechelt, 2014). Posttraumatic symptoms are categorized as avoidant, including numbing and amnesia; intrusive, such as nightmares and flashbacks; negative mood changes, including irritability and rage; or hyperarousal, such as hypervigilance or startle response (Wiechelt, 2014). If an individual’s posttraumatic symptoms reach a certain threshold for intensity and frequency, they may be clinically diagnosed with post-traumatic stress disorder (PTSD), and this diagnosis is often used in the literature as an index to measure and study trauma (Cadiz et al., 2005). However, not all individuals who have experienced trauma necessarily meet the diagnostic criteria for PTSD, despite living with the disruptive effects of trauma. Post-traumatic stress disorder represents a subcategory of individuals who have experienced trauma but does not include all individuals who live with posttraumatic symptoms (Herman, 1992). Regardless of PTSD diagnosis, posttraumatic symptoms may be significantly distressing for an individual and make it difficult for them to regain a sense of normalcy and safety for years following the trauma.
Prevalence of Trauma in Substance Abusing Population
Substance abusing individuals tend to have significantly higher rates of traumatic experiences than their non-substance abusing counterparts. Individuals with an alcohol addiction diagnosis, for instance, are six to 12 times more likely to have been physically abused and 18 to 20 times more likely to have been sexually abused than others (Potthast & Cadani, 2012). Additionally, chronicity of trauma correlates with increased number and severity of PTSD symptoms, as well as increased seriousness and frequency of substance use (Potthast & Cadani, 2012; Wiechelt, 2014). Childhood sexual abuse, in particular, is linked to significantly more negative substance abuse outcomes than other types of childhood abuse, including more frequent and intense substance abuse (Wolf et al., 2015). Individuals seeking treatment for substance abuse are highly likely to have experienced some form of trauma, and as the intensity of the experienced trauma increases, individuals are more likely to have more serious substance abuse problems.
Separating trauma and substance use treatment assumes that the two are distinct, unrelated issues and leads to an incomplete understanding of a client (Brown et al., 2013). Intentionally ignoring trauma in substance use treatment can also retraumatize clients by reinforcing the dynamic of secrecy that often surrounds trauma, thus causing substance abuse treatment to be less effective and potentially contributing to clients relapsing and dropping out of treatment (Cadiz et al., 2005; Potthast & Cadani, 2012).
In order to effectively treat substance users who have been exposed to trauma, many researchers have attempted to find a causal relation between traumatic experience and substance abuse (Haller & Chassin, 2014; Jester et al., 2015). Several hypotheses have been proposed to explain the connection, and some suggest that substance abuse is a risk factor for the development of PTSD, while others view substance abuse as a response to traumatic symptoms (Haller & Chassin, 2014). Recent longitudinal and prospective studies have provided strong evidence that trauma tends to precede substance abuse problems, which provides further support to the hypothesis that substances are frequently used to self-medicate in response to traumatic symptoms (Hien et al., 2010; Jester et al., 2015). Additionally, improvements in PTSD symptoms directly relate with reductions in substance use, a finding that was sustained one year after treatment, whereas reduction in substance use does not significantly change PTSD symptoms (Hien et al., 2010; López-Castro, Hu, Papini, Ruglass, & Hien, 2015). Given the high rates of relapse among individuals with co-occurring PTSD and substance abuse diagnoses, this strongly indicates that PTSD symptoms exacerbate substance abuse (López-Castro et al., 2015). These findings support the self-medication hypothesis, which posits that substances are often used by trauma survivors with the expectation that they will relieve stress and help with coping with their posttraumatic symptoms (Jester et al., 2015). Using the self-medication framework, the failure of substance abuse treatment programs to address trauma appears especially problematic because trauma is seen as the root cause of the problem facing the individual, while substance abuse is only a symptom. Trauma-informed care and integrated trauma services are two ways some organizations have responded to this need.
Trauma-Informed Care
Trauma-informed care involves building organization-level policies and procedures that create a supportive environment for trauma survivors and respond appropriately to their traumatic responses (Wiechelt, 2014). Although exact definitions of TIC differ by organization and researcher, it is generally agreed that TIC involves reshaping policies to make trauma survivors feel more comfortable and help them build new skills and competencies (Brown, Harris & Fallot, 2013; Hopper et al., 2010). Trauma-informed care calls for trauma awareness, meaning that clinicians should treat all clients as if they have been exposed to trauma, regardless of whether or not they disclose it, and should incorporate screening for trauma into their intake procedures (Hopper et al., 2010; Wiechelt, 2014). This also entails creating policies intended to avoid retraumatization, such as through the reenactment of the dynamics of trauma (Brown et al., 2013; Cadiz et al., 2005). For example, loss of control and agency are characteristics of traumatic events that the client has likely internalized, so if the client is not given agency in treatment, this can unintentionally reinforce their sense of powerlessness (Hopper et al., 2010). Therefore, TIC seeks to provide the client with opportunities to rebuild control and empowerment by giving the client the opportunity to make decisions and collaborate in the treatment process (Cadiz et al., 2005; Wiechelt, 2014). By taking an active role in their healing process, the client begins to recognize their abilities, allowing them to feel capable of taking control in other areas of their lives (Herman, 1992).
Avoiding retraumatization is also a part of TIC’s emphasis on safety, including the physical and emotional safety of the client and clinician (Amaro et al., 2007). Unsafe environments may recall the feelings of vulnerability clients experienced in their trauma, triggering feelings of victimization and fear (Herman, 1992). Trauma-informed care uses a strengths-based approach to create a safe emotional space, focusing on identifying clients’ strengths, building further skills, and reframing problems as potential strengths (Hopper et al., 2010). For example, conceptualizing substance abuse as a way to cope with otherwise unbearable experiences shifts the perception from a personal weakness to an attempt to survive (Herman, 1992; Jester et al., 2015). This reframing also draws attention to the need to build new coping skills rather than correct individual failings.
It is also important to note that trauma is expressed and perceived differently across cultures, and therefore clients may respond differently to treatments (Herman, 1992; Hopper et al., 2010). Trauma-informed care addresses these differences by striving for cultural sensitivity across ethnic and religious populations, socioeconomic classes, and genders. For example, women tend to consider experiences not traditionally viewed as traumatic, such as being separated from their children, to be very painful (McHugo et al., 2005). Another example of culturally sensitive practice would be incorporating relevant spiritual beliefs, practices, or methods of healing into treatment, as in some Native American communities, where traditional spiritual practices such as healing lodges are used in conjunction with counseling to address trauma (Gone, 2009). Acknowledging and responding to cultural differences and clients’ lived experience may help clients to feel understood and “seen” within treatment, which prevents early termination and avoids the trauma dynamic of feeling insignificant or invisible (Cadiz et al., 2005).
The most basic goal of TIC is to avoid causing harm and facilitate more positive and stable outcomes (Brown, Harris & Fallot, 2013). Because it is not a direct form of treatment, TIC can be implemented in the many systems with which substance users interact, which may not otherwise have the capacity to implement trauma treatment. For instance, drug courts, where individuals facing nonviolent drug charges are tried, could make use of TIC. Substance abusing populations have higher prevalence rates of trauma than non-substance abusing peers, with rates of sexual abuse as high as 54.5% for men and 83% for women (Potthast & Cadani, 2012). Trauma survivors in drug court are also much more likely to have had prior arrests than drug court participants with no trauma background, suggesting that they are likely to return to drug use after completing drug court and to reenter the drug court system (Wolf et al., 2015). Given the consistent contact of clients with trauma histories with the drug court system, trauma-informed court policies could make courts more conducive to treating both trauma and substance abuse, which would therefore reduce recidivism (Wolf et al., 2015).
Homeless individuals are also at high risk for both trauma exposure and substance use disorders (Hopper et al., 2010). In one study, over 70% of the inpatient substance abuse participants had been homeless at some point in their lives, and another found that 40-50% were homeless at the time they began receiving substance abuse treatment services (Amaro et al., 2007; Cadiz et al., 2005). The experience of homelessness itself is traumatizing, and homelessness puts individuals at an increased risk for further trauma exposure (Hopper et al., 2010). A trauma-informed perspective would be beneficial in services for the homeless that do not have the capacity to provide direct trauma treatment due to lack of resources or time constraints, such as housing assistance and food providers (Hopper et al., 2010).
Integrated Trauma Treatment
Trauma-informed care provides a strong foundation for working with traumatized individuals on which trauma treatment builds. By integrating trauma treatment into substance abuse programs, these programs can provide a space to process traumatic experiences and build coping skills (Amaro et al., 2007). This, in turn, reduces clients’ need to self-medicate with substances (Jester et al., 2015). Integrated trauma treatment emphasizes the interrelatedness of substance use and trauma and implements evidence-based therapies, such as cognitive behavioral therapy (CBT), to address the specific experience of substance users with trauma exposure (Amaro et al., 2007; Cadiz et al., 2005; Hien et al., 2010; Hopper et al., 2010). Trauma-specific group therapy has been found to be significantly more effective than psychoeducation-focused therapy in improving PTSD and substance use symptoms in women who were heavy drug users, indicating that the focus on trauma has additional benefits beyond those of therapy in general (Hien et al., 2010).
Integrated trauma treatment can also be incorporated with individual counseling sessions to avoid the possibility of triggering group members through the sharing of traumatic experiences (Cadiz et al., 2005). Several studies have found higher retention rates for women in particular in residential treatment programs that integrate trauma services than residential programs that do not address trauma, and length of retention predicts more positive outcomes six months after the conclusion of treatment (Amaro et al., 2007). Although there is a paucity of research including male participants, it is possible that similarly high retention rates occurs for men. Regardless of how trauma is treated in substance use treatment, organization-level policies and procedures should continually be reviewed to ensure that they are as supportive as possible of trauma survivors (Brown et al., 2013). Because the body of literature around integrated treatment is in its infancy, clinicians and social workers need to be responsive to the needs of their clients and prepared to modify treatment to best suit the communities they serve.
Conclusion
Addressing the needs of substance abusing and traumatized populations together can better support treatment outcomes given the considerable overlap between the two (Lopez-Castro et al., 2015; Potthast & Catani, 2012). Trauma-informed care and integrated trauma services are two ways to accommodate their needs. Taking a trauma-informed perspective allows participants to feel safe and avoids retriggering their traumatic experiences by giving them agency and voice within their treatment process (Hopper et al., 2010). Trauma-informed care also reduces rates of dropping out, optimizing the effectiveness of treatment (Brown et al., 2013). Because TIC consists primarily of changing policies and practices, organizations whose clients are likely to have experienced trauma can implement this type of care without the additional strain that incorporating trauma treatment can add in terms of resources like funding and space (Amaro et al., 2007; Brown et al., 2013; Cadiz et al, 2005). However, when implementation is feasible, integrating trauma treatment into substance abuse treatment programs is likely to make sobriety more stable and long term by addressing underlying trauma symptoms that are often self-medicated by abusing substances (Jester et al., 2015; Shields et al., 2015). Integrated trauma treatment may mean making evidence-based individual or group therapy available in a substance abuse treatment program to provide space for clients to process traumatic experiences and develop more adaptive coping strategies (Brown et al., 2013; Cadiz et al, 2005).
Research indicates the benefits of taking a trauma-informed approach in substance abuse treatment and of integrating trauma treatment into substance abuse treatment programs. However, there are also several major limitations in the current body of literature. Studies tend to lack random assignment, making it difficult to draw causal conclusions about the effectiveness of TIC as compared to more traditional treatment paradigms (Cadiz et al., 2005; Hopper et al., 2010). Additionally, it is difficult to separate out the effects of specific elements of TIC from those of an intervention as a whole (Cadiz et al., 2005). Many of these interventions focus only on a specific population, such as women in inpatient centers (e.g., Amaro et al., 2007; Cadiz et al., 2005). While this may serve the purpose of addressing the specific needs of that subset of the substance abusing-population with traumatic history, some groups are largely ignored by the literature, including men and the elderly. The findings in the literature cannot be generalized to other genders, races, and geographical areas that are not represented in the research. In addition, the current assessment tools for measuring the implementation of TIC fail to acknowledge fidelity, or the degree to which the principles are implemented. This means there may be a great deal of variability between the practices of two different organizations who both consider themselves to be “trauma-informed.”
Future research needs to address these gaps in the literature and continue developing innovative interventions for the overlap between substance abuse and trauma treatment. Additionally, more research should be conducted in outpatient and community settings, since much of the current research is based on inpatient or residential treatment models. Although it is likely that many individuals who seek inpatient treatment have been exposed to trauma, failing to include those who do not seek inpatient treatment excludes a large segment of the population and could cause a self-selection bias in research — there may be significant differences between those who seek residential treatment and those who do not. The intersections between trauma-informed care and harm reduction in treating substance abuse should also be explored, as this perspective has the potential to align well with TIC’s principle of client choice and empowerment. Social service, public health, and healthcare settings could benefit universally from implementing TIC principles, surrounding clients in a trauma-informed network of services that would give them the greatest opportunity for healing and wellness.
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