Pennsylvania Trauma-Focused Therapies
How Trauma & Addiction Are Related
Trauma is a common underlying cause of addiction. It’s estimated that 70 percent of Americans have suffered a trauma in their lifetime, including physical or sexual abuse, experiencing violence or death, and surviving a natural disaster.
The connection between addiction and trauma is a strong one, and a large body of research has shaped the way trauma is treated. This research is the basis for modern, trauma-informed addiction treatment.
If you or someone you love has suffered a trauma, getting professional help is important for improving psychological health and quality of life and preventing a substance use disorder down the road. If you’ve already developed a substance use disorder and you have a history of trauma, a trauma-informed treatment program will offer the best outcomes of treatment.
Post-Traumatic Stress Disorder and Addiction
Post-traumatic stress disorder, or PTSD, is a mental illness that may occur after a trauma. It can set in shortly after the trauma or years later. Left untreated, PTSD can last for months or even years.
According to a study published in the journal Addictive Behaviors, up to half of the people in recovery from an addiction have a lifetime diagnosis of PTSD.
Trauma, PTSD & Substance Abuse
Many people with PTSD turn to drugs or alcohol to self-medicate their symptoms. Drugs and alcohol can help relieve sleep difficulties and prevent nightmares, and they can seem to reduce anxiety and depression. But substance abuse always makes symptoms worse in the long run, leading to even heavier substance abuse in an attempt to feel better. This creates a vicious cycle that’s hard to break without professional help.
For many people with PTSD or other trauma-related mental problems, substance abuse will transition to addiction. Addiction is characterized by compulsive substance abuse despite negative consequences. People who are addicted may want to quit or try to stop using, but most find they can’t sustain recovery for long before relapsing.
Addiction is the result of changes in the structures and functions of the brain caused by heavy substance abuse. These lead the brain’s memory, learning, motivation, and reward centers to communicate in a way that causes compulsive drug-seeking and drug-using behaviors, driven by intense cravings. These brain changes alter thought and behavior patterns, leading to self-destructive thoughts, attitudes, and behaviors—and the resulting negative consequences—that further fuel the addiction.
Symptoms of PTSD
PTSD causes a range of upsetting symptoms. Not everyone who has PTSD experiences all of the symptoms and symptoms can range from mild to severe.
The symptoms of PTSD include:
- Deep anger
- Fear and anxiety
- Intrusive thoughts
- Increased startle response
- Changes in memory
- Inability to concentrate
- Withdrawal from friends or family
- Trouble trusting others
These symptoms often lead to dysfunctional thought and behavior patterns—including substance abuse—in an attempt to cope with them.
How Trauma Affects the Brain
A study published in Dialogues in Clinical Neuroscience found that trauma reduces the volume of the hippocampus, which is the center of emotion and memory. It also increases the activity of the amygdala, which is responsible for the stress response and feelings of fear and anxiety. Additionally, many patients with PTSD have higher-than-normal blood levels of the stress hormones cortisol and norepinephrine when they’re exposed to stress.
Due to these changes in the structures and functions of the brain, trauma can cause a number of mental disorders besides PTSD.
Borderline Personality Disorder
Many people who have borderline personality disorder have a history of trauma, according to the National Institute on Mental Health.
Signs and symptoms of borderline personality disorder include:
- Viewing things in extremes, such as all good or all bad
- Rapidly shifting feelings toward friends and family members
- A pattern of intense and unstable relationships with family and friends
- Distorted and unstable self-image
- Engaging in impulsive and often self-destructive behaviors
- Suicidal thoughts
- Intense mood swings lasting from a few hours to several days
Long-term dialectical behavior therapy and cognitive behavioral therapy are effective for treating borderline personality disorder.
Dissociative disorder may result from prolonged and severe trauma, particularly when it occurs in childhood. Survivors of natural disasters and combat may also develop a dissociative disorder, according to the National Alliance on Mental Illness.
Signs and symptoms of this disorder include:
- An inability to moderate emotions
- Significant memory loss of specific times, events, and people
- Out-of-body experiences, as though you’re watching a movie of yourself
- Depression and anxiety
- Thoughts of suicide
- Emotional numbness
- Lack of a self-identity
Effective treatments for dissociative disorders include medications, cognitive behavioral therapy, dialectical behavior therapy, and eye movement desensitization and reprocessing, or EMDR.
Depression is common among people with a history of trauma. According to the U.S. Department of Veteran Affairs, depression is three to five times more prevalent in people who have PTSD than in those who don’t.
Signs and symptoms of depression include:
- Feelings of hopelessness, helplessness, and worthlessness
- Sleep disturbances
- Persistent aches, pains, or digestive troubles that have no other discernible cause
- Changes in appetite
- Loss of interest in things that once brought pleasure
- Trouble with memory and concentration
- Suicidal thoughts
Depression can be effectively treated with medication and cognitive behavioral therapy.
The Link between Trauma & Substance Abuse
Most Americans will experience a trauma of some kind in their lifetime. While some people recover from trauma without help, others may be consumed by the trauma for a long time after the traumatic event. Traumas associated with physical or sexual abuse, violence, and death are particularly difficult to cope with, although any type of trauma can leave serious and lasting emotional scars. In many cases, trauma leads to substance abuse, which always compounds the negative emotional response to trauma and causes far more problems than it solves.
Exposure to childhood trauma, including physical and sexual abuse and violence in the household, can lead to cognitive problems. Childhood trauma increases the risk of mental illnesses later on, including bipolar disorder, schizophrenia, and major depression.
Research has found an important link between childhood trauma and substance abuse. The National Survey of Adolescents found that teens with a history of sexual or physical abuse are three times more likely than those without to report a history of substance abuse.
Studies show that around 60 percent of adolescents who suffer from PTSD will develop a substance use disorder. One study, published in the American Journal of Psychiatry, found that the prevalence of PTSD in adolescents who were in treatment for a substance use disorder was five times higher than in the general adolescent population.
Trauma in Women
According to a study published in the journal Psychiatric Services, up to 80 percent of women in treatment for a substance use disorder have a history of trauma, most commonly sexual abuse. Additionally, the prevalence of PTSD among women who have been sexually assaulted is 50 percent, compared to just 7.8 percent in the general population.
Women with a history of PTSD that results from sexual violence have more trouble recovering from an addiction than women who don’t have a history of sexual abuse. This is likely due to the complex relationship between substance abuse and trauma and the role drugs and alcohol play in helping them cope with symptoms of PTSD. It’s also likely that women with a history of sexual violence will experience other psychological problems stemming from the abuse, including eating disorders and critically low self-esteem.
A trauma-informed approach to treatment addresses a wide range of issues related to the trauma and the substance abuse. Women with a history of sexual violence tend to do better in a women-only trauma-informed program.
Trauma in Men
Men are likely to experience deep feelings of anger associated with sexual abuse and other traumas. They’re more likely than women to act out aggressively or violently, according to an article published in Addiction Professional Magazine. Due to the pressure men face to be “strong,” men are less likely than women to seek professional help for symptoms of PTSD. They’re also more likely than women to abuse substances in an attempt to cope with trauma.
Once in treatment for addiction or PTSD—or both—men may have a difficult time expressing emotions and communicating honestly about their experiences. They may struggle with shame and embarrassment. Men with a history of trauma—particularly sexual abuse—are more likely to benefit from a men-only trauma-informed treatment program.
Trauma in Veterans
Military veterans who have been deployed to a combat zone have high incidences of PTSD. According to the U.S. Department of Veterans Affairs, around 12 percent of Gulf War veterans, 20 percent of Operation Iraqi Freedom veterans, and 30 percent of Vietnam veterans develop PTSD in any given year. Additionally, 23 percent of female veterans report being sexually assaulted while serving in the military and are at a high risk for PTSD. Additionally, the VA reports that up to 75 percent of veterans who have been sexually assaulted while serving have problematic drinking patterns.
While the research about first responders—such as police officers, firefighters, EMTs, and emergency room personnel—is very slim, it’s expected that the prevalence of PTSD and substance abuse is also higher in these populations than in the general population.
Principles of a Trauma-Informed Approach to Treatment
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), a trauma-informed approach is one that:
- Recognizes the widespread impact of trauma and understands that there are multiple pathways to recovery
- Recognizes the signs and symptoms of trauma in clients, their families, staff, and others involved in the system
- Responds to trauma via a fully integrated program that incorporates knowledge about trauma into policies, practices, and procedures
- Seeks to actively prevent re-traumatization
Trauma-informed treatment programs recognize that:
- Survivors need to be respected, informed, connected, and hopeful about their recovery
- There’s an important relationship between trauma and symptoms of trauma, including substance abuse, eating disorders, depression, anxiety, and other mental health problems
- Recovery is a collaboration among survivors, their family and friends, and other service agencies that foster the empowerment of survivors
Six Key Principles of Care
A trauma-informed approach will follow six key principles of care, according to SAMHSA:
- Safety: Clients in a trauma-informed treatment program should feel physically and psychologically safe in the treatment program.
- Trustworthiness and transparency: The organizational decisions and operations should be transparent, with the goal of building and maintaining trust among staff, clients, and clients’ family members.
- Peer support and mutual help: Peer support is central to successful treatment and is known to be a key vehicle for establishing safety, building trust, and instilling a sense of empowerment.
- Collaboration and mutuality: Recovery from trauma and addiction comes from a partnership among staff, administrators, care providers, and the client. Healing happens through relationships and a meaningful sharing of power and decision-making. Everyone has a role to play in a trauma-informed approach.
- Empowerment, voice, and choice: All staff members in a trauma-informed treatment program aim to recognize and validate the clients’ strengths and build on them. They recognize that every client’s experience is unique, and an individualized approach is key to successful recovery. Staff members have a belief in resilience and the ability of individuals to heal. Recovery isn’t about responding to a client’s perceived deficits but rather a process of building upon the strengths of the client, empowering trauma survivors, and giving them a voice in the treatment process.
- Cultural, historical and gender issues: A treatment program and its staff must actively move past cultural stereotypes and biases based on race, ethnicity, sexual orientation, age, and geography. The program should offer gender-responsive services, acknowledge the healing power of traditional cultural connections, and address historical traumas.
Trauma-Focused Therapies Used in Treatment
Trauma and a co-occurring substance use disorder are often devastating to every aspect of an individual’s life. They impact relationships, physical and mental health, finances, quality of life, and perceptions of well-being.
Trauma-informed treatment isn’t a pre-ordained set of practices and procedures. Rather, it’s an all-encompassing approach to treatment that promotes whole-person healing and addresses multiple issues through creating safety and trust and building on the client’s strengths and values.
A variety of research-based, trauma-focused therapies are used in a trauma-informed program. Not every therapy will be appropriate or useful for every individual. Individualized treatment plans include the therapies that will be most beneficial to the client.
Acceptance and Commitment Therapy
Acceptance and commitment therapy, or ACT, is a mindfulness intervention that helps individuals develop psychological flexibility. It teaches the principles of thinking and acting in ways that support each person’s values. During ACT, clients examine the challenges present in their attempts to control and suppress negative emotions and experiences.
ACT involves six core processes that help clients become adept at making healthy decisions that promote their psychological health and well-being:
- Acceptance rather than avoidance
- Cognitive diffusion techniques that help individuals improve the way they interact with their thoughts
- Being present and mindful without judgment
- Being aware of one’s own experiences without being attached to them
- Defining one’s values of what is important in life
- Developing healthy patterns of thought and behavior that align with each individuals chosen values
Dialectical Behavior Therapy
Another mindfulness-based intervention, dialectical behavior therapy, or DBT, helps clients reduce conflicts in their relationships and develop the emotional coping skills they need. It helps clients understand that problematic behaviors emerge as a coping mechanism and, while these may offer short-term relief, they cause more problems down the road.
DBT helps with the development of new, healthier behaviors and coping skills, including:
- Maintaining mindfulness
- Regulating emotions
- Improving interpersonal relationships
- Developing tolerance for distress
DBT involves four stages of treatment:
- Stage 1 helps clients move from feeling a lack of control to developing control over their thoughts and behaviors.
- Stage 2 helps the client move from quiet desperation to experiencing a full range of emotions. This stage effectively treats PTSD.
- Stage 3 helps the client define life goals, build self-respect, and find authentic happiness in life.
- Stage 4 helps clients find deeper life meaning through spirituality. It helps them achieve a feeling of completeness, freedom and joy.
DBT has been shown to reduce suicidal thoughts, self-harm behaviors, substance abuse, and anger that result from trauma.
Eye Movement Desensitization & Reprocessing
Developed in the 1980s to treat PTSD, eye movement desensitization and reprocessing, or EMDR, helps individuals overcome the devastating psychological effects of trauma.
EMDR is an eight-phase, evidence-based method of psychotherapy. It identifies and addresses the experiences that have overridden the brain’s natural coping capacity and led to dysfunctional coping strategies and trauma-related symptoms. EMDR helps clients reprocess traumatic experiences so that they no longer disrupt brain function. It can help generate insight into disturbing events and long-held negative thoughts about the self.
EMDR integrates successful elements of a variety of psychotherapies. What’s unique to EMDR is the utilization of left-to-right eye movements to produce bi-lateral stimulation of the brain.
During EMDR, a specially trained therapist leads the client through a series of back-and-forth eye movements while the client focuses on various aspects of a traumatic memory. Bi-lateral stimulation of the brain facilitates the safe processing of memories to effectively alleviate negative thoughts and emotions. It helps individuals regard difficult memories in a larger context of life experience.
In addition to eye movements, bilateral stimulation during EMDR can be produced by alternating sound from the left ear to the right through headphones or using tactile stimulation with the help of hand-held devices that vibrate on alternating sides.
Mindfulness-based meditation helps individuals manage distracting and distressing thoughts and feelings by remaining aware of them in the present moment without judgment.
According to a Harvard and MIT study, eight weeks of mindfulness meditation changes the brain’s physical structures and chemical functions. It increases the amount of gray matter in the areas of the brain that govern executive decision making, working memory, self-relevance, emotional regulation, compassion, and perspective. It also reduces the volume of the amygdala, the brain region involved in the fight-or-flight stress response and the center for feelings of anxiety, stress, and fear.
Mindfulness-Based Relapse Prevention
Relapse prevention is a major focus in addiction recovery. Mindfulness-based relapse prevention, or MBRP, helps clients develop a high level of mindfulness to help prevent relapse.
The goals of MBRP include helping clients:
- Develop awareness of their habitual reactions to external events and identify their personal triggers
- Learn how to pause automatic reactions in order to examine them more closely
- Develop skills for responding to challenging physical and emotional experiences
- Develop self-compassion and approach their thoughts, experiences, and emotions without judgment
- Develop a healthy lifestyle through mindfulness that supports recovery from trauma and addiction
An evidence-based counseling model, Seeking Safety focuses on the present rather than on the past. It’s designed to help trauma survivors regain a sense of safety. While Seeking Safety addresses the trauma and substance abuse, it doesn’t require delving into the details of the trauma.
Rather, it covers 25 topics that operate on several key principles:
- Safety as the treatment priority
- Integrated treatment
- Focusing on ideals
- Addressing four content areas: Cognitive, behavioral, interpersonal, and case management
Seeking Safety is a very flexible program, and the topics can be addressed in any order. It works in both group and individual settings and is effective for men and women, adolescents and adults, and people in all levels of care.
Yoga is known to reduce stress, improve body awareness, increase mindfulness, and alleviate feelings of depression and anxiety.
Trauma-focused yoga is taught by a certified trauma-informed yoga instructor. It’s based on the understanding that trauma affects the whole mind-body system, leaving an imprint on body, mind and spirit. Trauma-informed yoga emphasizes awareness of one’s physical and psychological state in the present moment. It helps traumatized individuals feel safer inside their bodies, increasing feelings of ease.
Trauma-informed yoga is highly sensitive to the needs of people with a history of trauma. It’s designed to help individuals stabilize their nervous system to achieve states of deep concentration, clarity and unity.
Trauma-informed yoga instructors create a safe environment in a number of ways, including:
- Reviewing protocol for safe practice before each session, including honoring the need to step away from class if necessary
- Avoiding hands-on adjustments of participants
- Avoiding applying creams or essential oils to participants without their permission
- Understanding that some participants may not want to close their eyes
- Using carefully selected guided imagery to avoid triggering negative emotions
- Offering modifications for poses that may be uncomfortable for some participants
- Avoiding telling a class how a pose “should” feel
- Inviting dialogue after class to address issues during class
Treatments for Nightmares
Recurring nightmares are common among people who have suffered a trauma. In many cases, people with PTSD will use drugs or alcohol to help them achieve a dreamless sleep. Nightmares can also lead back to relapse once someone is in recovery. A variety of therapies are used in trauma-informed treatment programs to help reduce nightmares.
Imagery Rehearsal Therapy
Imagery Rehearsal Therapy involves writing down a nightmare in fine detail and then reimagining it with a positive ending. Before sleeping, you rehearse the new version of the dream and use a relaxation technique to ease you into sleep.
Systematic Desensitization involves teaching clients relaxation techniques and then having the client create a hierarchy of nightmares, starting with the one that’s the least disturbing. Clients imagine the first nightmare and, when anxiety increases, they use the relaxation technique. This is repeated up the nightmare hierarchy. This therapy effectively reduces the intensity of nightmares and the negative emotions that occur once you awaken from a nightmare.
Prazosin is a blood pressure medication that blocks some of the effects of adrenaline, which is associated with PTSD-related nightmares. However, prazosin has side effects, including headaches, drowsiness, dizziness, and decreased energy.
Risking Connection for Caregivers
Risking Connection is a trauma-informed model designed to educate all levels of mental health practitioners and substance abuse treatment staff about trauma-informed best practices. It helps caregivers in a treatment setting understand that relationships are essential to the healing process and that their own self-care is crucial for maintaining the ability to effectively help treat trauma survivors.
Risking Connection is modeled on RICH relationships, using the acronym RICH which stands for respect, information sharing, connection, and hope. It focuses on empowerment, collaboration, and an understanding of how trauma causes pain. It stresses the importance of creating and maintaining a trauma framework when responding to people in crisis.
Trauma-Informed Treatment Transforms Lives
Trauma and addiction both reduce the quality of life and causes multiple problems with relationships, employment or school, and physical and mental health. A trauma-informed addiction rehab program fully integrates treatment for addiction and trauma so that each is addressed in the context of the other.
Treating only the trauma or only the addiction is generally ineffective for people with a history of trauma. Trauma-informed treatment through a high-quality program leads to whole-person healing from both trauma and addiction and promotes a higher quality of life and sense of happiness and well-being for the long-term.