In my previous posting to this site I briefly discussed the undeniable link between chronic childhood trauma and adult-life psychiatric symptoms and disorders, most notably addictions, observing that this link is rarely addressed in treatment (potentially leading to addiction relapse). I then discussed the need for dual addiction/trauma assessment and treatment, with suggestions on how assessment best occurs, followed by a brief discussion on how to effectively move forward with initial treatment, noting the need for client safety, early sobriety and a trusting therapeutic alliance. This blog furthers that discussion, presenting a formalized three-stage integrated trauma/addiction treatment model.
The methodology presented below was developed by myself and my esteemed colleague, Dr. Christine Courtois, working individually at first and later jointly. This approach is based heavily on our own observations, experiences and theories, though it incorporates (often quite heavily) the well-developed work of many other clinicians.
Integrated and Concurrent Trauma-Informed Addiction Treatment
This three-stage (not including assessment) treatment methodology recognizes the interconnected nature of unresolved trauma and addictions and the fact that they often have a negative synergistic impact. In short, we believe that if both conditions are not treated concurrently and clients don’t heal from both issues simultaneously, they may not fully recover from either. This thought is well-supported by studies showing that addicts with extensive trauma histories have a much harder time maintaining sobriety than addicts without such histories.
Assessment involves a wide-ranging psychosocial evaluation, including specific but not graphic questions about trauma and other crises in the family or elsewhere, along with questions about addictive behaviors, intimate relationships and common co-occurring symptoms of trauma and addiction such as depression, anxiety and dissociation. As mentioned in my previous blog, it is best to rely on a combination of clinical interviewing and written or computerized psychological instruments, some of which can be re-administered later as a way to measure the client’s progress. Based on the client’s assessment, an individualized treatment plan is developed.
This stage is devoted to safety and early sobriety. Emphasis is on crisis management, along with extensive psychoeducation about chronic trauma, addiction, and their interaction. Group therapy, along with 12-step and other peer support groups are introduced as they relate to sobriety and overall mental and physical health. Treatment may also incorporate a variety of alternative modalities, including experiential approaches (meditation, yoga, neuro and biofeedback, acupuncture), expressive therapies (art therapy, psychodrama), massage, mindfulness stress reduction, animal assisted therapies, etc. Once the basics have been covered and the individual has achieved a reasonable degree of life-stability, functionality, sobriety and a decreased risk of relapse, a continuing treatment approach is recommended.
This stage is focused on the processing of trauma and its impact through the use of specialized, evidence-based techniques. The goal of this stage is to reintroduce and reintegrate trauma response in doses that are manageable through use of learned coping and emotional modulation skills. The therapist closely monitors the client’s responses in order to keep the individual in his or her window of tolerance, helping that person face and process trauma without becoming overwhelmed. Typically, available therapeutic techniques are discussed in advance with the client so that he or she may help to choose one (or more) that suits his or her specific needs. All of the techniques involve some degree of exposure to what has been avoided/dissociated/suppressed, often resulting in a temporary intensification of distress. Clients are encouraged to discuss their reactions in detail with the therapist, who then offers both emotional support and corrective information when problematic or erroneous interpretations and perceptions are uncovered. Shame, loss, anger and grief are usually at the forefront during this stage. Over time, this emotional and cognitive processing of past traumas and associated memories to the point of changed perceptions and resolution results in the lessening of symptoms and, in turn, an easier time maintaining sobriety.
In this stage, treatment focuses on the client’s newfound ability to make life choices based not on his or her history of trauma and addiction, but on freedom from those bonds and a newly developed sense of self-worth and personal empowerment. Clients are encouraged to apply their newfound knowledge and skills to a life of sobriety and safety from additional abuse and trauma. Many life changes may be in order during this stage – developing intimacy, improved parenting, developing new relationships and letting old ones go, discussing past abuse and trauma with perpetrators and others, determining whether to initiate a particular course of action (police report, further disclosure, confrontation, lawsuit, etc.), re-establishing a career or resetting a career path, and more.
Although the treatment stages are presented above in linear format, they are actually rather fluid in application, with clients engaging in the different treatment tasks and moving back and forth between the stages as needed. For example, if a client reports feeling unsafe and overwhelmed during the formal trauma processing that takes place in Stage Two, he or she returns to Stage One’s more cognitive safety planning and skill-building to restabilize and to practice healthy coping skills. Once stabilization and skills are reestablished, the trauma exposure work of Stage Two resumes. Furthermore, Stage Three is often implemented even though Stage Two is ongoing (and may continue to be ongoing for quite some time). Throughout the stages there is planning for backslides and relapse, with setbacks treated as problems to be solved rather than personal failures. At all stages, clients are encouraged to take risks with self-exploration in a safe and supportive environment and to engage in new behaviors based on newly acquired perspectives and skills.
Individualization of Treatment
Needless to say, every addicted trauma survivor arrives in treatment with a unique background and set of problems, so each client’s treatment arc will be different. Some addicts will respond best to individual therapy supplemented by group work. Others will do best in group settings, making little progress one-to-one. Still others will struggle utterly until they are physically and emotionally separated from the people, places and things that have perpetrated trauma on them or that remind them of their trauma, thereby triggering their addiction.
If an addicted trauma survivor is struggling with core concepts of healing or can’t seem to establish a foothold in sobriety, then either intensive outpatient or inpatient residential treatment may be recommended to jump-start the process. These concentrated programs can last as little as a few weeks or as long as several months. In such settings, addicted trauma survivors are removed from the people, places and things that initiate and/or reinforce their trauma and drive their addiction. They are instead surrounded by supportive, empathetic clinicians and other addicts who are also dealing with traumatic re-experiencing, deep shame and debilitating addictions.
It is important to remember that there is no “cure” for either chronic early-life trauma or addiction, nor is there a “one size fits all” approach to healing. What treatment and recovery do is provide addicted trauma survivors with skills and tools that can reduce their trauma’s and their addiction’s power. In all likelihood, unwanted memories of past traumas will persist to some degree even after extensive treatment, as will the desire to reengage with addictive substances and/or behaviors. But these memories and desires will not be as debilitating and all-consuming as they were before treatment.
It is also important to point out that recovery from addiction and trauma does not occur in a vacuum. A large part of recovery is dependent on relationships with other people who are also in recovery. These individuals can be found in therapy settings and various support groups, including 12-step groups. Nevertheless, many addicted trauma survivors choose to remain in individual, one-to-one therapy, as this venue tends to provide a more directed approach to dealing with the emotions that past traumas continually bring up. Whatever the setting, it helps to have empathetic others who can and will provide support in times of distress and need. The good news is that over time and with the support and guidance of knowledgeable, nonjudgmental and supportive professionals, any trauma survivor can overcome the debilitating effects of pretty much anything he or she has experienced.