5.3 Lesson: Addictions and Trauma-Informed Care

  Addictions and Trauma-Informed Care

          Trauma is similar to a rock hitting the water’s surface. The impact first creates the largest wave, which is followed by ever-expanding, but less intense, ripples. Likewise, the influence of a given trauma can be broad, but generally, its effects are less intense for individuals further removed from the trauma; eventually, its impact dissipates all around. For trauma survivors, the impact of trauma can be far-reaching and can affect life areas and relationships long after the trauma occurred. This analogy can also broadly describe the recovery process for individuals who have experienced trauma and for those who have the privilege of hearing their stories. As survivors reveal their trauma-related experiences and struggles to a counselor or another caregiver, the trauma becomes a shared experience, although it is not likely to be as intense for the caregiver as it was for the individual who experienced the trauma. The caregiver may hold onto the trauma’s known and unknown effects or may consciously decide to engage in behaviors that provide support to further dissipate the impact of this trauma and the risk of secondary trauma.

Dr. Nadine Burke Harris talks about how childhood trauma can have negative long-term mental and physical health consequences.This video is hosted by TEDEd at https://ed.ted.com/on/iOyQVfhd Links to an external site.

A Trauma-Informed Approach

According to SAMHSA’s concept of a trauma-informed approach, “A program, organization, or system that is trauma-informed:

1. Realizes the widespread impact of trauma and understands potential paths for recovery;
2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
4. Seeks to actively resist re-traumatization."

A trauma-informed approach can be implemented in any type of service setting or organization and is distinct from trauma-specific interventions or treatments that are designed specifically to address the consequences of trauma and to facilitate healing.

SAMHSA’s Six Key Principles of a Trauma-Informed Approach

A trauma-informed approach reflects adherence to six key principles rather than a prescribed set of practices or procedures. These principles may be generalizable across multiple types of settings, although terminology and application may be setting- or sector-specific:

1. Safety
2. Trustworthiness and Transparency
3. Peer support
4. Collaboration and mutuality
5. Empowerment, voice, and choice
6. Cultural, Historical, and Gender Issues

From SAMHSA’s perspective, it is critical to promote the linkage to recovery and resilience for those individuals and families impacted by trauma. Consistent with SAMHSA’s definition of recovery, services, and supports that are trauma-informed build on the best evidence available and consumer and family engagement, empowerment, and collaboration.

Source: https://www.samhsa.gov/nctic/trauma-interventions

 Reading Assignment

BASED on TIP 57 Trauma-Informed Care in Behavioral Health Services, Quick Guide for Clinicians Links to an external site.

Trauma Interventions:

          According to Herman (1992), the core experiences of psychological trauma are disempowerment and disconnection from others. As such, recovery from trauma is based on empowerment and the creation of new connections with self, the other, one’s belief system and the world. Herman offers a three-stage process of healing and recovery. Using this as a basis, a group leader or therapist dealing with trauma would consider recovery in terms of the following:

a. Establishing Safety: Restoration of physical safety by attention to physical healing, sleeping, eating and environmental needs. Normalizing Posttraumatic Stress Disorder (PTSD) symptoms, the establishment of trusted places and people, management of exposure and distance from the trauma. (In group, safety is developed by the presence of leader, empathic attunement, established frame, symptom management, pacing, containment).

b. Remembering and Mourning: Involves the retrieval, reconstruction, and transformation of traumatic memories by sharing them in a protective relationship. All trauma involves loss. The unanticipated death of a loved one involves assault and then loss. Grieving is a unique process of slowly transforming loss by connection and permission to remembering.

c. Reconnecting: Involves the movement from isolation and helplessness to connection with life, self, others by use of therapeutic relationships, support networks, coping skills, qualities of resilience such as creativity, intelligence, sense of humor, spirituality, new meanings in life- sometimes a survival mission.

Above excerpt from American Group Psychotherapy Association. (2004). Group interventions for treatment of psychological trauma,  Module 7: Countertransference: Effects on the group therapist working with trauma. Links to an external site.Retrieved from  http://www.agpa.org/docs/default-source/practice-resources/countertransference--effects-on-the-group-therapist-working-with-trauma.pdf?sfvrsn=2

Links to an external site.Advice to Counselors: Decreasing the Risk of Secondary Trauma and Promoting Self-Care

• Peer support. Maintaining adequate social support will help prevent isolation and depression.
• Supervision and consultation. Seeking professional support will enable you to understand your own responses to clients and to work with them more effectively.
• Training. Ongoing professional training can improve your belief in your abilities to assist clients in their recoveries.
• Personal therapy. Obtaining treatment can help you manage specific problems and become better able to provide good treatment to your clients.
• Maintaining balance. A healthy, balanced lifestyle can make you more resilient in managing any difficult circumstances you may face. Setting clear limits and boundaries with clients. Clearly separating your personal and work life allows time to rejuvenate from stresses inherent in being a professional caregiver.

Advice to Counselors: Strategies To Help Clients Draw Connections    

Strategy #1: Writing about trauma can help clients gain awareness of their thoughts, feelings, and current experiences and can even improve physical health outcomes (Pennebaker, Kiecolt-Glaser, & Glaser, 1988; Smyth, Hockemeyer, & Tulloch, 2008). Although this tool may help some people draw connections between current experiences and past traumas, it should be used with caution; others may find that it brings up too much intense trauma material (especially among vulnerable trauma survivors with co-occuring substance abuse, psychosis, and current domestic violence). Journal writing is safest when you ask clients to write about present-day specific targets, such as logging their use of coping strategies or identifying strengths with examples. Writing about trauma can also be done via key questions or a workbook that provides questions centered upon trauma experiences and recovery.      

Strategy #2: Encourage clients to explore the links among traumatic experiences and mental and substance use disorders. Recognition that a mental disorder or symptom developed after the trauma occurred can provide relief and hope that the symptoms may abate if the trauma is addressed. Ways to help clients connect substance use with trauma histories include (Najavits, 2002b; Najavits, Weiss, & Shaw, 1997): 

• Identifying how substances have helped “solve” trauma or PTSD symptoms in the short term (e.g., drinking to get to sleep). 

• Teaching clients how trauma, mental, and substance use disorders commonly co-occur so that they will not feel so alone and ashamed about these issues.

• Discussing how substance abuse has impeded healing from trauma (e.g., by blocking feelings and memories).

• Helping clients recognize trauma symptoms as triggers for relapse to substance use and mental distress.

• Working on new coping skills to recover from trauma and substance abuse at the same time.

• Recognizing how both trauma and substance abuse often occur in families through multiple generations.

Advice to Counselors: Strategies To Identify and Manage Trauma-Related Triggers       

Strategy #1: Use the Sorting the Past From the Present technique for cognitive realignment (Blackburn, 1995) to help separate the current situation from the past trauma. Identify one trigger at a time, and then discuss the following questions with the client: • When and where did you begin to notice a reaction? 

• How does this situation remind you of your past history or past trauma?

• How are your reactions to the current situation similar to your past reactions to the trauma(s)?

• How was this current situation different from the past trauma?

• How did you react differently to the current situation than to the previous trauma?

• How are you different today (e.g., factors such as age, abilities, strength, level of support)?

• What choices can you make that are different from the past and that can help you address the current situation (trigger)?

After reviewing this exercise several times in counseling, put the questions on a card for the client to carry and use outside of treatment. Clients with substance use disorders can benefit from using the same questions (slightly reworded) to address relapse triggers.     

Strategy #2: After the individual identifies the trigger and draws connections between the trigger and past trauma, work with him or her to establish responses and coping strategies to deal with triggers as they occur. Initially, the planned responses will not immediately occur after a trigger, but with practice, the planned responses will move closer to the time of the trigger. Some strategies include an acronym that reflects coping strategies (Exhibit 1.5-1), positive self-talk generated by cognitive–behavioral covert modeling exercises (rehearsal of coping statements), breathing retraining, and use of support systems (e.g., calling someone).     

Exhibit 1.5-1: The OBSERVATIONS Coping Strategy
• Take a moment to just Observe what is happening. Pay attention to your body, your senses, and your environment.
• Focus on your Breathing. Allow your feelings and sensations to wash over you. Breathe.
• Name the Situation that initiated your response. In what way is this situation familiar to your past? How is it different?
• Remember that Emotions come and go. They may be intense now, but later they will be less so. Name your feelings.
• Recognize that this situation does not define you or your future. It does not dictate how things will be, nor is it a sign of things
to come. Even if it is familiar, it is only one event.
• Validate your experience. State, at least internally, what you are feeling, thinking, and experiencing.
• Ask for help. You don’t have to do this alone. Seek support. Other people care for you. Let them!
• This too shall pass. Remember: There are times that are good and times that are not so good. This hard time will pass.
• I can handle this. Name your strengths. Your strengths have helped you survive. 
• Keep an Open mind. Look for and try out new solutions.

• Name strategies that have worked before. Choose one and apply it to this situation.

• Remember you have survived. You are a Survivor! Name strategies that have worked before. Choose one and apply it to this situation.

Strategy #3: Self-monitoring is any strategy that asks a client to observe and record the number of times something happens, to note the intensity of specific experiences, or to describe a specific behavioral, emotional, or cognitive phenomenon each time it occurs. For individuals with histories of trauma, triggers and flashbacks can be quite frightening, intense, and powerful. Even if the client has had just one or two triggers or flashbacks, he or she may perceive flashbacks as happening constantly. Often, it takes time to recover from these experiences. Using self-monitoring and asking the client to record each time a trigger occurs, along with describing the trigger and its intensity level (using a scale from 1–10), clients and counselors will gain an understanding of the type of triggers present and the level of distress that each one produces. Moreover, the client may begin to see that the triggers don’t actually happen all the time, even though they may seem to occur frequently.

•   The Subjective Units of Distress Scale (SUDS) uses a 0 –10 rating scale, with 0 representing content that causes no or minimal distress and 10 representing content that is exceptionally distressing and overwhelming. (Wolpe & Abrams, 1991) 

 Advice to Counselors: Strategies To Build Trust 

Strategy #1: Clients can benefit from a support or counseling group composed of other trauma survivors. By comparing themselves with others in the group, they can be inspired by those who are further along in the recovery process and helpful to those who are not faring as well as they are. These groups also motivate clients to trust others by experiencing acceptance and empathy.

Strategy #2: Use conflicts that arise in the program as opportunities. Successful negotiation of a conflict between the client and the counselor is a major milestone (van der Kolk, McFarlane, & Van der Hart, 1996). Helping clients understand that conflicts are healthy and inevitable in relationships (and that they can be resolved while retaining the dignity and respect of all involved) is a key lesson for those whose relationship conflicts have been beset by violence, bitterness, and humiliation.      

Strategy #3: Prepare clients for staff changes, vacations, or other separations. Some clients may feel rejected or abandoned if a counselor goes on vacation or is absent due to illness, especially during a period of vulnerability or intense work. A phone call to the client during an unexpected absence can reinforce the importance of the relationship and the client’s trust. You can use these opportunities in treatment to help the client understand that separation is part of relationships; work with the client to view separation in a new light. 

Strategy #4: Honor the client–counselor relationship, and treat it as significant and mutual. You can support the development of trust by establishing clear boundaries, being dependable, working with the client to define explicit treatment goals and methods, and demonstrating respect for the client’s difficulty in trusting you and the therapeutic setting. 

Advice to Counselors: Strategies To Build Resilience 

Strategy #1: Help clients reestablish personal and social connections. Access community and cultural resources; reconnect the person to healing resources such as mutual-help groups and spiritual supports in the community.

Strategy #2: Encourage the client to take action. Recovery requires activity. Actively taking care of one’s own needs early in treatment can evolve into assisting others later on, such as by volunteering at a community organization or helping military families.   

Strategy #3: Encourage stability and predictability in the daily routine. Traumatic stress reactions can be debilitating. Keeping a daily routine of sleep, eating, work, errands, household chores, and hobbies can help the client see that life continues. Like exercise, daily living skills take time to take hold as the client learns to live through symptoms.  

Strategy #4: Nurture a positive view of personal, social, and cultural resources. Help clients recall ways in which they successfully handled hardships in the past, such as the loss of a loved one, a divorce, or a major illness. Revisit how those crises were addressed. 

Strategy #5: Help clients gain perspective. All things pass, even when facing very painful events. Foster a long-term outlook; help clients consider stress and suffering in a spiritual context. Strategy #6: Help maintain a hopeful outlook. An optimistic outlook enables visions of good things in life and can keep people going even in the hardest times. There are positive aspects

Strategy #6: Help maintain a hopeful outlook. An optimistic outlook enables visions of good things in life and can keep people going even in the hardest times. There are positive aspects to everyone’s life. Taking time to identify and appreciate these enhances the client’s outlook and helps him or her persevere.

Strategy #7: Encourage participation in peer support, 12-Step, and other mutual-help programs.

Source: American Psychological Association, 2003.

Advice to Counselors: Strategies To Acknowledge and Address Grief

Strategy #1: Help the client grieve by being present, by normalizing the grief, and by assessing social supports and resources.

Strategy #2: When the client begins to discuss or express grief, focus on having him or her voice the losses he or she experienced due to trauma. Remember to clarify that losses include internal experiences, not just physical losses.

Strategy #3: For a client who has difficulty connecting feelings to experiences, assign a feelings journal in which he or she can log and name each feeling he or she experiences, rate the feeling’s intensity numerically and describe the situation during which the feeling occurred. The client may choose to share the journal in an individual or group session.

Strategy #4: Note that some clients benefit from developing a ritual or ceremony to honor their losses, whereas others prefer offering time or resources to an association that represents the loss.

 Advice to Counselors: Strategies To Manage Traumatic Memories

Strategy #1: Most people who were sexually abused as children remember all or part of what happened to them, although they do not necessarily fully understand or disclose it. Do not assume that the role of the clinician is to investigate, corroborate, or substantiate allegations or memories of abuse (American Psychiatric Association [APA], 2000b).

Strategy #2: Be aware that forgotten memories of childhood abuse can be remembered years later. Clinicians should maintain an empathic, nonjudgmental, neutral stance toward reported memories of sexual abuse or other trauma. Avoid prejudging the cause of the client’s difficulties or the veracity of the client’s reports. A counselor’s prior belief that physical or sexual abuse, or other factors, are or are not the cause of the client’s problems can interfere with appropriate assessment and treatment
(APA, 2000b).

Strategy #3: Focus on assisting clients in coming to their own conclusions about the accuracy of their memories or in adapting to uncertainty regarding what actually occurred. The therapeutic goal is to help clients understand the impact of the memories or abuse experiences on their lives and to reduce their detrimental consequences in the present and future (APA, 2000b).

Strategy #4: Some clients have concerns about whether or not a certain traumatic event did or did not happen. In such circumstances, educate clients about traumatic memories, including the fact that memories aren’t always exact representations of past events; subsequent events and emotions can have the effect of altering the original memory. Inform clients that it is not always possible to determine whether an event occurred but that treatment can still be effective in alleviating distress.

Strategy #5: There is evidence that suggestibility can be enhanced and pseudomemories can develop in some individuals when hypnosis is used as a memory enhancement or retrieval strategy. Hypnosis and guided imagery techniques can enhance relaxation and teach self-soothing strategies with some clients; however, use of these techniques is not recommended in the active exploration of memories of abuse (Academy of Traumatology, 2007).

Strategy #6: When clients are highly distressed by intrusive flashbacks of delayed memories, help them move through the distress. Teach coping strategies and techniques on how to tolerate strong affect and distress (e.g., mindfulness practices). 

Source: TIP 57: Trauma-Informed Care in Behavioral Health Services