Trauma Informed Care for Substance Abuse Counseling

By Michael J. Tkach, PsyD, LP

Trauma Informed Care, by design, helps treatment providers with the provision of services to individuals who have experienced trauma and trauma-related stressors. Considering that there is a high co-occurrence between substance use and trauma, it is recommended that substance abuse counselors understand the implications of Trauma Informed Care in order to provide the highest level of care to their patients.

The Prevalence of Trauma Experiences in Substance Use Populations

Trauma and symptoms of trauma are found frequently to be one of the co-occurring disorders with the highest prevalence rates for patients of substance use treatment.^{1, 2, 3} More specifically, it is estimated that individuals with a diagnosis of Post-Traumatic Stress Disorder (PTSD) engage in treatment for Substance Use Disorders (SUD) at a rate five times higher than the general population.¹ In terms of practical considerations, this suggests that treatment teams providing SUD treatment are at greater likelihood of having patients with co-occurring trauma than many other mental health-related symptoms and diagnoses.

In treatment settings, there is a helpful distinction between: 1) treating the trauma experience and 2) treating the symptoms of trauma.^{1, 4, 5} This distinction is best understood as the difference between doing trauma processing therapy, which is implied when discussing treatment of the trauma experience, and helping to stabilize and treat the symptoms that occur as a response to the trauma experience. Although there are numerous evidence-based treatment approaches for treating the experience of trauma, not all providers (whether mental health or substance abuse counselors) have been both trained and deemed qualified to treat the trauma experience due to the specialized training and supervised experience the provision of such services would require.^{2, 6} As noted, this would have the potential to create a treatment gap between the number of trained providers in trauma care and the treatment needs of patients with trauma histories. Even though not every provider is trained to engage in trauma processing therapies, it is recommended that institutions train their professional staff in the ability to provide care that is sensitive to the unique symptoms of trauma.⁷ A structured approach that institutions can use for providing such care is known as Trauma Informed Care.^{2, 8}

Trauma Informed Care Defined

Trauma Informed Care is a collection of approaches that translate the science of the neurological and cognitive understanding of how trauma is processed in the brain into informed clinical practice for providing services that address the symptoms of trauma.^{2, 8} These approaches are not designed for the treatment of the trauma experience (e.g., processing the trauma narrative), but rather for assistance in managing symptoms and reducing the likelihood of re-traumatization of the patient in the care experience.^{7, 9} As such, interventions of Trauma Informed Care are appropriate for a range of practitioners to utilize in a variety of clinical settings.

Trauma Informed Care is guided by the neurological understanding of how the threat-appraisal system of the brain, which includes the Hypothalamic-Pituitary Adrenal (HPA) axis, responds to trauma.^{10, 11} In addition to the HPA axis, Trauma Informed Care also pays close attention to the autonomic nervous system, which is the part of the central nervous system used to mediate arousal.^{10, 12} The autonomic nervous system is comprised of both the sympathetic and parasympathetic nervous system. While the sympathetic nervous system increases activation (e.g., increased heart rate, higher respiration rate, etc.), the parasympathetic nervous system relaxes the system (e.g., lowered heart rate, decreased respiration rate, etc.).¹²

Many of the interventions implemented by the use of Trauma Informed Care act upon the autonomic nervous system to help reduce the otherwise often overstimulated sympathetic nervous system by increasing activation of the parasympathetic nervous system.^{2, 8, 10, 11}

Three Main Ideas Highlighted with Trauma Informed Care

Although there are many important ideas presented as part of Trauma Informed Care, three common themes can be used to summarize many, but not all, of the main ideas. These three ideas, which are further expanded upon by SAMSHA,7 are: 1) Promote understanding of symptoms from a strengths-based approach, 2) minimize the risk of re-traumatizing the patient and 3) both offer and identify supports that are trauma informed. Additionally, SAMSHA7 underscores the importance of instilling hope for recovery as a thread running through all three of these approaches.

When working with patients, it is recommended to utilize a strengths-based approach that both empowers and provides hope to the patient that recovery from symptoms is possible.^{2, 9, 10} Often, this is recommended to start by providing psycho-education to the patient so they can understand how most symptoms associated with trauma and trauma responses are attempts made on a biological and cognitive level (including processes happening below the conscious level-of-awareness) to protect the individual from the risk of further harm.^{4, 10} For example, the increased activation and startle response experienced by individuals who have experienced trauma can be interpreted as an adaptation by the brain after trauma whereby the likelihood of being caught off guard is theoretically reduced, even at the cost of having a great number of 'false alarms'.^{4, 5, 10, 11} Transforming the association that patients have with symptoms from being one of further hurt to potentially one of attempting protection can evoke a shift in how individuals relate to symptoms and can thereby increase a sense of hope for recovery.^{4, 10} If the individual can see how they are already trying to keep themselves safe, then it may be easier to help them transition to finding other, more effective means for coping.

Substance abuse counselors and mental health clinicians working with patients who have trauma histories are encouraged strongly to minimize the risk of re-traumatizing the patient.^{4, 9} As noted throughout the work by Friedman and colleagues, processing the trauma narrative before patients have sufficient coping skills and stabilization can cause further risk of harm and decompensation.⁴ As such, it is often not advised for clinicians to have patients feel forced to disclose trauma narratives (e.g., dispelling the myth that clinicians need to know all the details about a trauma before any work can be done), and it is additionally not often advised for patients to begin processing the trauma narrative while in short-term settings, as this is not necessarily treatment stability since the patient will need to transfer to another provider. Instead, patients are often best served by first establishing a sense of stability and safety.⁹ Once safety is established (as defined by stability, adequate supports and coping skills), then the patient is often in a better place to begin processing the trauma in appropriate settings that have the potential for long-term care, if needed.^{4, 9}

Interventions aimed at connecting patients with supports and resources that are designed to be sensitive to the presence of symptoms of trauma is another major focus area in Trauma Informed Care.² From an institutional point of view, this might include the regular use of a screener at intake to help identify the presence of symptoms associated with trauma, as well as providing referrals to providers who are best able to help patients at every stage of their treatment for symptoms of trauma.^{7, 9} This might also include providing patients with referrals to additional services beyond therapy, such as medication management, social support services or other supportive activities that the provider believes would be appropriate for the patient's specific symptoms and experiences.⁸

Implementing Trauma Informed Care with Seeking Safety

Practitioners in settings that provide substance use treatment that want to implement Trauma Informed Care principles may want to consider providing Seeking Safety groups.⁹ Developed by Najavits, Seeking Safety is an evidence-based practice approach to treating symptoms of trauma in a group setting.^{6, 9} Najavits designed Seeking Safety with the emphasis on fostering resilience and teaching coping skills for managing symptoms of trauma rather than processing trauma.⁹ In fact, Najavits understood that processing trauma with a patient before the patient has the skills to manage the symptoms of trauma successfully could be harmful. As such, the guidelines for implementing Seeking Safety groups includes establishing an understanding with participants that the purpose of the group is to learn skills and bolster resilience, not to process trauma narratives.