Trauma and Substance Abuse
There is a wealth of literature positing the comorbidity of trauma and substance use disorders (Brown, 2021; Knight, 2014; Miller, 2002; Shier & Turpin, 2017). The prevalence of posttraumatic stress disorder (PTSD) among the substance use disorder (SUD) population is exceptionally high, with recent data showing that over 30% of clients seeking treatment meet the criteria for a diagnosis of PTSD (Brown, 2021). Among individuals with Opioid Use Disorder, the prevalence of a PTSD diagnosis was over 40% of the population (Brown, 2021).
Although complex-posttraumatic stress disorder (C-PTSD) is not included in any iteration of the Diagnostic and Statistical Manual and therefore, no diagnosis can be made, the prevalence of prolonged childhood trauma within the substance use population has been well documented (Brown, 2021; Knight, 2014; Miller, 2002; Shier & Turpin, 2017). The Adverse Childhood Experiences (ACE) study conducted in 1998 illustrated the strong relationship between early adversity and long-term health complications such as alcohol and drug abuse (Felitti et al., 1998).
While the ACE study participants were not seeking treatment services for addictions, the study demonstrates a causal relationship between childhood trauma and later substance use and misuse among the population (Felitti et al., 1998). Recent studies have noted that those who have experienced childhood trauma are nearly four times more likely to begin abusing substances than their counterparts (Shier & Turpin, 2017). Research suggests that the prevalence of substance abuse among those who have experienced a traumatic event or endured adversity in childhood will often turn to substances as a way of coping with unwanted feelings or pain associated with trauma (Ford & Russo, 2006; Shier & Turpin, 2017). Intrusive memories of traumatic experiences or events and the craving for substances to cope with the trauma exacerbate the automatic behavior patterns and impulsivity that sustain the addiction cycle (Ford & Russo, 2006; Shier & Turpin, 2017). Unfortunately, this may also pose a risk factor for the substance abuse population as they may experience additional trauma while in active addiction, which may perpetuate symptoms of PTSD and other mental health disorders (Brown, 2021).
Impact of Problem
Traditionally, there appears to be a separation of mental health treatment and addiction treatment in which clients are treated for the presenting problem of either substance use disorders or mental health disorders rather than both disorders concurrently (Miller, 2002). This treatment approach appears to be maladaptive as both Substance Use Disorders, Posttraumatic Stress Disorders, and other Mental Health Disorders are highly comorbid with one another (Brown, 2021). As previously noted, the mental health symptoms caused by trauma-related distress continuously stimulate the compulsions associated with addiction, forming what has been called a toxic feedback loop for this population (Miller, 2002).
While it may appear that the primary focus of addiction treatment should be on attaining and maintaining sobriety, the negative feedback loop poses additional challenges to achieving sobriety if trauma-related distress is not concurrently managed. Recent research has also noted that the separation of addiction and mental health treatment has contributed to the high recidivism rates among the population who present with co-occurring trauma and Substance Use Disorders (Miller, 2002; Shier & Turpin, 2017).
Agency Provision of Trauma-Informed Care
Najavits (2002a) contends that posttraumatic stress disorder (PTSD) and substance use disorders (SUD) frequently co-occur with a higher prevalence rate among women than their male counterparts in studies conducted within substance abuse treatment facilities. Inadequate treatment, such as treating only SUD or PTSD often leads to poor treatment outcomes for this client population (Najavits 2002a). Despite nearly 30 years of research, most substance use disorder treatment facilities have yet to adopt an integrated model that concurrently addresses SUD and trauma (Najavits, 2002a; Substance Abuse and Mental Health Services Administration [SAMHSA], 2014).
Trauma-Informed Treatment Approaches
The Substance Abuse and Mental Health Services Administration (SAMHSA) conceptualizes a trauma-informed approach as, "A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in client, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and seeks to actively resist re-traumatization." (Substance Abuse and Mental Health Administration [SAMHSA], 2014b, p.10). There are five core values of a trauma-informed approach: safety, trust, collaboration, empowerment, and choice (Brown, 2021; Shier & Turpin, 2017). Each value addresses different aspects of trauma and incorporating the five core values allows a program to be trauma-informed (Brown, 2021; Shier & Turpin, 2017).
Trauma-informed practice is not an additional program. Rather, it is a specialized approach to service delivery, in which trauma is the expectation rather than the exception for the client population (Brown, 2021; Shier & Turpin, 2017). Trauma-informed practices are approaches that incorporate an understanding of both the prevalence and psychological impact of trauma and are designed in a way that avoids potential re-traumatization in the helping process (Brown, 2021; Brown, Harris, & Fallot, 2013; Knight, 2014).
The Substance Abuse and Mental Health Services Administration (SAMHSA) asserts that trauma-informed care (TIC) is a strengths-based approach to service delivery (SAMHSA, 2014). TIC involves viewing trauma as the expectation rather than the exception for this client population, and the primary element of a trauma-informed approach begins with a comprehensive understanding and awareness of the prevalence of trauma endured among this client population (SAMHSA, 2014). Trauma-informed care emphasizes the physical, psychological, and emotional safety of survivors as well as treatment providers, with careful consideration of institutional processes and practices that could potentially retraumatize survivors of trauma and create opportunities for survivors to rebuild a sense of control and empowerment through collaborative treatment approaches and objectives (SAMHSA, 2014).
SAMHSA (2014b) contends that despite the high prevalence rates, many individuals seeking treatment for substance use often do not recognize the ways in which the trauma histories correlate to their immediate presenting problems and often avoid addressing trauma altogether. Therefore, it is imperative for clinicians to utilize a trauma-informed approach in which trauma is the expectation rather than the exception, in which each client receives adequate screening and assessment for trauma history and receives treatment for trauma and substance use concurrently.
References
Brown, V.B. (2021). A Trauma-Informed Approach to Enhancing Addiction Treatment. In: El-Guebaly, N., Carra, G., Galanter, M., & Baldacchino, A.M. (eds). Textbook of Addiction Treatment (401-415). Springer, Cham.
Capezza, N.M., & Najavits, L.M. (2012). Rates of trauma-informed counseling at substance abuse treatment facilities: Reports from over 10,000 programs. Journal of Psychiatric Services, 63(4), 390-394.
Felitti, V.J., Anda, R.F., Nordenber, D., Williamson, D., Spitz, A.M., et al., (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245-259.
Shier, M.L., & Turpin, A. (2017). A multi-dimensional conceptual framework for trauma-informed practice in addictions programming. Journal of Social Service Research, 43(5), 609-623.
Substance Abuse and Mental Health Services Administration, (2014a). Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. Rockville, MD: Substance Abuse and Mental Health Services Administration.
Substance Abuse and Mental Health Services Administration. (2014b). SAMHSA's concept of trauma and guidance for a trauma-informed approach (2-18). Rockville, MD.: Substance Abuse and Mental Health Services Administration.
