What is Trauma-Informed Care?

Alcohol and substance use disorders have many contributing factors to on-set. While the path to these disorders are different for everyone, over the past two decades mental health professionals have determined adult alcohol and drug addiction are often closely associated with past trauma, particularly that which occurs during childhood.

Most people understand trauma to mean any stressful event that has a significant and lasting impact on an individual. That’s a solid working definition, but where treatment and recovery are concerned, it needs to be expanded to include the role trauma plays in the lives of people struggling with alcohol or substance use disorders.

This article will offer that expanded definition of trauma, explain the relationship between trauma and addiction, and then discuss the best clinical practices established by the Substance Abuse and Health Services Administration (SAMHSA) for the treatment of people with co-occurring trauma disorders – such as PTSD – and alcohol/substance use disorders.

Trauma and Addiction

A traumatic event is any incident – from childhood, adolescence, or otherwise – that overwhelms the ability to process that incident in a healthy and productive manner. Traumatic events can be one-time incidents, such as an accident, surgery, or a death in the family, or they can be long-term stressors, such as neglect, sexual abuse, domestic partner abuse, incarceration, or experiencing war. In either case, a traumatic event leads an individual to fear for their physical safety and question their emotional or psychological stability. This type of trauma can cause a chronic psychological condition known as Post-Traumatic Stress Disorder (PTSD), which can lead to depression, anxiety, confusion, and memory loss. Intense feelings of despair, hopelessness, and low self-esteem also often accompany PTSD.

Further symptoms may include:

• Intrusive and disruptive memories of the traumatic event, a.k.a. flashbacks
• Avoidance of events that feel similar to the traumatic event
• Emotional numbness and/or detachment
• Difficulty falling or staying asleep
• Nightmares
• Problems concentrating
• Irritability
• Anger

To handle these uncomfortable and overwhelming emotions, thoughts, and physical symptoms, many people who experience trauma turn to alcohol or drugs to self-medicate. Self-medication is an attempt to make it all go away, or at very least, help forget about the traumatic event and associated emotions for a short period of time. It’s a self-defense mechanism common not only to trauma survivors, but also to those struggling with mental health disorders unrelated to trauma. That’s why trauma-informed care is an essential component of alcohol and substance abuse treatment: when therapists and counselors meet their patients, talk to them, and dig beneath the surface to find the contributing factors of the onset and progression of their addiction, they often find both co-occurring disorders and a history of trauma. Identifying these conditions and how they relate to addiction becomes part of their work as addiction professionals, and part of the patient’s task as they work to achieve long-term, sustainable sobriety and/or recovery.

Addiction and Adverse Childhood Experiences (ACEs)

In 1998, the Centers for Disease Control, in collaboration with Kaiser Health, launched a study on the effect of adverse childhood experiences on an individual’s long-term health. Known as the ACE Study, this effort is often cited as the origin of trauma-informed care in the U.S. Research verifies children exposed to traumatic experiences have an increased risk of developing alcohol and substance use disorders as adults. Here’s a list of experiences identified as traumatic by the ACE Study:

• Physical, emotional, or sexual abuse
• Physical or emotional neglect
• Domestic violence
• Divorce of parents
• Living with an individual struggling with substance abuse, an individual diagnosed as mentally ill or an individual who was incarcerated or sentenced to be incarcerated
• Experiencing racism and/or bullying
• Living in foster homes
• Living in an unsafe neighborhood
• Witnessing violence

Anyone who has experienced four (4) or more of these ACEs is at increased risk of developing PTSD, depression, anxiety, and/or an alcohol or substance use disorder.

An Evidence-Based Approach to Trauma

Fortunately, there are a number of addiction treatment programs in the U.S. that understand past trauma and know how to help patients with co-occurring PTSD and addiction. The most highly regarded programs follow a clear set of guidelines established by SAMHSA for best practices in trauma-informed care.

SAMHSA recommends that clinicians and staff:

1. Realize the widespread impact of trauma and understand potential paths for recovery.
2. Recognize the signs and symptoms of trauma.
3. Seek to actively resist re-traumatization.

In addition, best practices dictate that integrated, trauma-informed treatment programs include SAMHSA’s six key guiding principles for trauma-informed care:

1. Safety. This element is essential. People who have been traumatized can be easily triggered, and instantly relive the traumatic event, which floods their bodies with stress hormones that can cause long-term physical and emotional damage. Therefore, both the treatment environment and the people in it should always make the patient feel 100 percent safe and secure.
2. Trustworthiness and Transparency. Before they open up to counselors, therapists, or psychiatrists, people with a history of trauma need to trust both the people providing treatment and the center/location/hospital from which they receive treatment. Treatment programs with open, communicative, and helpful staff – at all levels – create an optimal environment for healing.
3. Peer Support. Evidence shows that sharing stories, challenges, and experiences with other trauma survivors is an effective way to create hope, build trust, and collaborate on developing techniques and skills that help manage the most difficult symptoms of PTSD. The role of peer support in addiction treatment is well-known: we now know it’s equally important for trauma survivors.
4. Collaboration and Mutuality. This principle should be modeled by the treatment provider on many levels. SAMSHA advises treatment centers to embrace the idea that healing happens in relationships, including the relationships between patients and one another, patient and therapist, therapists and support staff, support staff and administration, and administration and the general public.
5. Empowerment, Voice, and Choice. Treatment centers should recognize and value the strength, resiliency, and ability of trauma survivors to heal from their trauma as well as recover from alcohol and substance use disorders. Patients should be given a voice in their treatment plan and a choice in how to move forward in their recovery. SAMSHA advises that clinicians view themselves as facilitators of healing and recovery rather than controllers, and that the patients themselves should be supported in learning practical self-advocacy skills that enable them to direct their own recovery process.
6. Cultural, Historic, and Gender Issues. It’s incumbent upon providers to move past stereotypes based on race, ethnicity, gender, gender identity, sexual orientation, age, religion, or geography, while recognizing that historical and institutional trauma plays a role in PTSD and alcohol and substance use disorders. Traditional and non-traditional cultural needs should be honored and valued at all times in an inclusive and respectful manner.

The overall concept behind these guidelines that treatment centers can best serve patients by creating an atmosphere where they can explore, understand, and process their past trauma while feeling safe and supportive. Clinicians and treatment center staff – when they understand trauma – can help survivors learn the coping skills they need to move forward and break the painful cycles of substance abuse and mental health disorders.

Evidence-Based, Compassionate Treatment Works

One thing trauma survivors need is to be seen and heard without judgment. Trauma survivors who develop an alcohol or substance use disorder need this on two levels: with regards to their trauma, and with regards to their addiction. However, taking the step to share their stories with people who will listen – and can help – is incredibly hard. For those who haven’t experienced early trauma or experienced traumatic events as an adult, it’s difficult to explain why trauma victims don’t always want to share their stories or seek treatment – but we’ll try.

The feeling that’s common to most people living with co-occurring trauma and addiction – and the feeling that keeps them from seeking support – is shame. While this is not true for all people living with co-occurring trauma and addiction, it’s the one most people in treatment spend a great deal of time and energy overcoming.

Our cultural norm of stigmatizing addiction and blaming trauma victims – which is finally fading from our society – does not help. People living with past trauma and current addiction often fear ridicule and judgment from peers, family members, and co-workers. This is compounded by the phenomenon that trauma victims often blame themselves for what happened to them long ago, and over time, develop the idea that they’re unworthy, unlovable, and somehow less than those who do not share their lived experience of trauma. That’s one reason they often turn to alcohol and drugs: to temporarily mitigate the sense of isolation and loneliness that accompanies these difficult emotions.

Trauma-informed treatment for alcohol and substance use disorders means that those offering treatment for people living with co-occurring trauma and addiction understand all of the above – not just a piece here and there. Trauma-informed providers recognize the special obstacles survivors face and honor their bravery in coming forward and sharing themselves at their most vulnerable moments.

Trauma-informed counselors and therapists live by the following motto:

I hear you, I see you, and I know how to help. 

When someone with a history of trauma seeks treatment for an addiction problem, hearing these words can make all the difference in the world. It means they know they’re in the right place, with the right people, doing what they need to be doing for themselves. It means they can begin to rebuild their lives and learn practical and effective coping mechanisms to move past their addiction and manage their PTSD symptoms. In short, it means a full and vibrant life in recovery is within their reach – and they can start working toward that life right away.