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Trauma-informed 12-Step treatment: The first six steps

March 18, 2013
by Jamie Marich, PhD, LPCC-S, LICDC
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Jamie Marich, PhD, LPCC-S, LICDC

“But if we open up all of that trauma stuff, aren’t we just giving them more excuses?”

“What if getting into the trauma destabilizes them and makes them relapse?”

“If we dwell on trauma, won’t they think they just have to work on the trauma to overcome their drinking and they’ll abandon the program?”

These are three common concerns articulated by addiction professionals and 12-Step members when the conversation turns to the subject of “trauma and addiction.” While the last two decades enhanced the field’s dialogue about the comorbidity between traumatic stress disorders and addictive disorders, the field has yet to address optimally the objections of traditionalists.

Some professionals, especially those working within a 12-Step paradigm, fear that too much emphasis on trauma and mental health elements will de-emphasize the importance of working a recovery program. Although some of this trepidation is valid, a great deal of this fear represents a misunderstanding about how trauma-informed counseling works.

This article presents 12 practical ideas on how to strike the proverbial balance between trauma-informed counseling principles and the time-honored offerings of traditional 12-Step recovery structures.

 

1. Simply honoring the history is a treatment-enhancing intervention.

In respecting the history, a professional must refrain from using lines such as, “You’re not here to deal with you’re trauma; you’re here to deal with your addiction,” or “You’re only here for a few weeks; we won’t have time to get into all of that.” Even if length of stay is limited within a treatment setting, cutting a person off is like saying, “I don’t care that these horrible things happened to you.”

A more effective approach to take, especially in an initial assessment or in the first few days of treatment, is, “I hear that these horrible things happened to you. I honor that they are a part of your story. Sure, we likely won’t have time to get into everything during your stay here, and we certainly don’t advise you to open up these things too early in your sobriety while you’re still a little shaky. Nonetheless, we honor your story; we honor your struggle.”

2. Avoid name-calling and hot seat strategies.

Many well-meaning counselors get harsh in the name of tough love, while others simply can get nasty out of their own frustration. Although certain hard-headed people may only listen to that in-your-face, militaristic form of confrontation, they are the exception rather than the rule.

For a client with unresolved trauma, the risk of destabilization from hearing a counselor’s derogations is much greater. A great rule of guidance for trauma-sensitive confrontation is to call out the behavior while always respecting the integrity of the person. Thus, “You are lying” or “You seem to be lying” is much more effective than “You’re a liar!” The latter becomes a shaming statement.

3. Closure is key.

There is a difference between allowing a client to leave a counseling session or group with something to think about and allowing a client to leave in a state of visceral, triggered activation. Activation poses a great risk in group settings.

Let’s say you have a dynamic group in which one person does a really great piece of emotionally charged work. Although it can be our tendency as counselors to focus on the ones doing the work, never underestimate how the process might have affected members of the group who are sitting there quietly taking it all in; they could have been triggered.

Thus, ending groups with a closing strategy such as a breathing exercise, an isometric muscle relaxation exercise, or simple, joking banter can be valuable. Always make yourself available individually after a group session in case a group member has an issue he/she didn’t feel comfortable vocalizing in front of the group.

4. Forced sharing is not productive.

It’s one thing, within the context of a solid therapeutic relationship, to challenge a person about his/her tendency to put off working on certain issues. Consider the difference, however, between these two statements: “It seems like you’re ready to share some of these things with the group and get some feedback,” vs. “You’ve held it in long enough. Today’s the day you’re sharing with the group. And you’re not going to be able to coin out of your program unless you share this homework assignment on your feelings with the group.”

Forced sharing can be re-traumatizing enough in individual settings, especially when counselors probe for too many details too soon. Imagine how much more damaging it could be if someone in the group is a triggering presence.

5. Actions speak louder than words with coping skills.

In trauma-sensitive treatment, the body-based coping skills are the most effective: breath work, progressive muscle relaxation, pressure point exercises, simple stretching and movement, and expressive avenues such as journaling, music, dance, or art. These skills help people use their bodies in healthier ways in order to quell the visceral, body-level disturbance that trauma reminders can generate. Such skills are much more effective for trauma survivors than cognitive-level skills such as thought stopping or talking an issue to death.

Initial treatment constitutes prime time to begin working with people on developing these skills. Having an arsenal of such skills at one’s disposal is absolutely vital before a trauma survivor can really work on tasks that may be especially triggering, such as completing a 4th and 5th Step.

6. Consider the impact of slogans.

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Comments

Speaking as someone with a background in substance abuse and mental health treatment, this is an outstanding article. Clinically astute and useful for practitioners. Thanks!

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