How Trauma Work Best Occurs in Addiction Treatment (Part One)
My esteemed colleague, Dr. Christine Courtois, provides a brief definition of trauma in her new book, It’s Not You, It’s What Happened to You, writing: “Trauma is any event or experience (including witnessing) that is physically and/or psychologically overwhelming to the exposed individual.” She then notes that trauma is highly subjective; incidents that might be highly traumatizing to one person may be humdrum for another. (Some people are more resilient than others.) She also notes that there are many types of trauma:
- Impersonal Trauma – acts of God, being in the wrong place at the wrong time, etc.
- Interpersonal Trauma – intentional acts by other people, such as abuse, neglect, inappropriate enmeshment, assault, robbery, etc.
- Identity Trauma – based on the victim’s inherent characteristics, such as gender, ethnicity, sexual orientation, etc.
- Community trauma – based on the victim’s membership in a particular community, such as a family, tribe, religion, etc.
Dr. Courtois further states that the experience of trauma is often chronic in nature – repeated and layered. This is known as “complex trauma.”
Linking Early-Life Trauma and Addiction
It is well-known that childhood trauma, especially complex childhood trauma, is often a factor in the formation of addiction. In fact, research clearly reveals that the more times a young person is traumatized, the greater the likelihood of adverse reactions (including addiction) later in life. One study found that survivors of chronic childhood trauma (four or more significant trauma experiences prior to age 18) are 1.8 times as likely to smoke cigarettes, 1.9 times as likely to become obese, 2.4 times as likely to experience ongoing anxiety, 3.6 times as likely to be depressed, 3.6 times as likely to qualify as promiscuous, 7.2 times as likely to become alcoholic and 11.1 times as likely to become an intravenous drug user. In short, there is an undeniable link between early-life chronic trauma and numerous adult-life symptoms and disorders – including addiction.
Unfortunately, the relationship between early-life trauma and addiction is rarely addressed in treatment. In fact, it used to be that survivors of early-life chronic trauma who sought therapeutic intervention for addiction were treated for addiction and addiction only, with trauma put on the back burner at least until sobriety was firmly established. This occurred for two main reasons:
- Until very recently it was believed that before an addict got sober, little else could happen on the therapeutic front. After all, if we understand that addictions are a maladaptive attempt to self-soothe and self-medicate and that the basis of trauma-focused psychotherapy is recognizing, experiencing and processing past and present emotional discomfort, then logic dictates clients can’t grow past their emotional challenges (their trauma) while they are simultaneously self-medicating away the resulting anxiety, emotional instability and depression they experience.
- Most clinicians are trained to (and prefer to) work using very specific approaches. Addiction specialists, for instance, tend to use highly directive forms of therapy such as CBT (cognitive behavioral therapy). This works great when dealing with behavior modification, but not so well with trauma issues. Trauma specialists, on the other hand, tend to use various exposure and/or desensitization techniques like PE (prolonged exposure) and EMDR (eye movement desensitization and reprocessing). These work great with trauma, but they’re not overly useful when it comes to establishing and maintaining early sobriety. Thus, a clinician’s lack of comfort with certain techniques sometimes creates a “treatment box” that is not easily escaped.
Unfortunately, for many addicts this means that trauma is never addressed as a treatment concern related to addiction. At times trauma is never even acknowledged. As such, recovering addicts are sometimes turned loose without any understanding of why and how their addiction developed and became so powerful.
Is it any wonder that relapse rates are as high as they are?
Over the course of the last several years I have developed, both individually and in conjunction with Dr. Courtois, an integrated methodology designed for treating addiction and co-occurring issues, trauma in particular, beginning with assessment. This approach is briefly introduced below, with more detailed information forthcoming in my next blog.
Recognizing the all-too-common link between early-life trauma and addiction, it is imperative that therapists, when assessing for addiction, ask specific questions about traumatic events and experiences. These queries should be posed in behavioral terms like, “Did such and such ever happen to you?” This universal precaution recognizes that many (perhaps most) clients seeking help with an addiction will not spontaneously disclose past trauma histories, despite the importance thereof. Oftentimes addicted clients have not even consciously identified what happened to them as traumatic. As such, if and when you suspect a history of trauma in an addicted client (and you should always suspect this with an addicted client), it is usually best to rely on a combination of clinical interviewing and written or computerized assessment instruments that ask about specific types of traumatic experience (and also about aftereffects and psychological symptoms).
It is important for therapists to understand that even though assessing for trauma is not intended to be stressful, it typically is. Certainly some individuals are relieved to be asked about their trauma histories, but most are not. Questions about traumatic experience, even when asked with sensitivity, often cause pain and discomfort. As such, the pacing and intensity of questions should be adjusted based on the client’s “window of tolerance.” If necessary, assessment for trauma can be paused and/or postponed.
Clinicians should also be aware that clients who live with shame as a normative experience will typically disown, deny or even outright lie about the nature and extent of their trauma history. Some of the more common reasons that trauma survivors withhold or mislead include:
- They are not comfortable discussing their trauma.
- They don’t understand what happened as traumatic or problematic.
- They are ashamed of what happened to them.
- They are under threat of retribution if they say anything.
- Disclosure feels disloyal, especially within the family or some other system where loyalty is expected.
- They don’t trust authority figures or anyone in a helping role.
- They don’t think what happened to them is relevant or connected to their current difficulties.
- They can’t/don’t/won’t remember the trauma.
Treatment professionals should never make assumptions or judgments about motives for nondisclosure by trauma survivors. For some, silence is in the interest of self-protection. For others, a degree of trust is needed before they are able to divulge such sensitive information. In such cases, disclosure will typically occur over time as the therapeutic alliance develops. Usually, when clients understand that their therapist is respectful, non-voyeuristic, non-judgmental, attentive, and simply trying to uncover and understand the issues with them, they are more likely to accurately report their experiences and symptoms.
Moving Forward with Treatment: The Basics
When dealing with trauma survivors (addicted or not), safety must always come first, as clients simply cannot heal from past traumas if/when they are still being traumatized. This means therapists must work with clients to assess current risks and to develop and implement specific actions and skills (i.e., emotional regulation and healthy means of self-soothing) that can ensure personal safety in the present. When clients are actively at risk (i.e., still in an abusive relationship, engaged in self-harm, highly suicidal, etc.), establishing safety may take a great deal of attention and effort.
Similarly, addicts cannot effectively heal when they are still actively self-medicating via their addiction. As such, a plan for establishing sobriety must be developed and implemented (in conjunction with safety) before other therapeutic work can effectively occur. Usually this involves a highly directive and accountability-based therapeutic approach (most often some form of CBT). Clients may also be asked to sign a written contract in which they agree to become and remain sober. For substance abusers, this likely means complete abstinence. For behavioral addicts, the definition of sobriety may differ. For instance, sex addicts seek to eliminate their problematic sexual behaviors but not to eliminate sexual activity completely. (This is much like treatment for an eating disorder, where completely abstaining is not an option.)
In addition to safety and initial sobriety, therapists should work to develop a trusting and meaningful therapeutic alliance. The simple truth is trauma is an injury that occurs between people and heals between people. (Dr. Sandra Bloom, in her book Creating Sanctuary, has aptly described the building of a therapeutic alliance as “relational healing for relational injury.”) Typically this alliance develops over time and is based on the trustworthiness and attunement of the therapist, along with the client understanding that he or she and the therapist are working together in the client’s best interests. With addicts, this alliance extends to not just the therapist, but to others in the therapeutic milieu, including the client’s peer support group (other recovering addicts in group therapy, 12-step groups, etc.) Through peer support, trauma survivors learn that they are not alone in what happened to them and in the feelings and self-perceptions they developed, nor are they alone in the maladaptive coping methods they’ve relied upon. Establishing the therapeutic alliance in these ways can help to undo a lifetime of mistrust – a major therapeutic advance in and of itself.
Generally speaking, establishing safety, initial sobriety and the therapeutic alliance prepares addicted survivors of chronic early-life trauma for the more intensive psychotherapeutic work to come. With addiction, this means learning to recognize triggers and to implement healthier coping mechanisms whenever triggers arise. With trauma, this means re-experiencing, processing and resolving past traumatic events. That said, integrating addiction and trauma work in ways that keep a client within his or her window of tolerance (i.e., in ways that don’t cause addiction relapse) is no easy task. As mentioned above, in my next posting to this site I will discuss in detail a formalized integrated trauma/addiction treatment approach developed by myself and Dr. Courtois, which we are now using with addicted trauma survivors.
Weiss LCSW, R. (2015). How Trauma Work Best Occurs in Addiction Treatment (Part One). Psych Central. Retrieved on March 19, 2018, from https://blogs.psychcentral.com/sex/2014/12/how-trauma-work-best-occurs-in-addiction-treatment-part-one/