After a payment-driven hiatus of more than two decades, “trauma” is making a comeback in addiction treatment. Experts are saying now, as they did more than a generation ago, that treating addiction without treating underlying trauma in patients who are trauma victims is likely to lead to relapse.
Addiction treatment providers need to understand the dynamics of trauma, so that they can provide trauma-informed care, says Stephanie Covington, PhD, co-director of the Institute for Relational Development and a nationally regarded authority on gender-specific treatment. “If people have nothing else that is self-soothing, they'll go back to drinking alcohol or using drugs,” Covington says. “We're taking away their primary coping skills-alcohol or drugs.”
So it is no wonder that so many patients for whom trauma is the basis of their substance abuse end up relapsing, says Claudia Black, PhD, senior clinical and family services advisor for Central Recovery Treatment and Las Vegas Recovery Center. “Our relapse patients, otherwise known as treatment failures, are coming in because their trauma history has never been addressed,” Black says.
Covington and Black are two gurus in the trauma world, both coming from the early days of the 1980s when funded addiction treatment services were more comprehensive and were able to address more issues, including trauma.
People knew in the 1970s and 1980s that trauma was a core issue in addiction, and especially relapse, says Judy Crane, founder and executive director of The Refuge, A Healing Place, in Ocklawaha, Fla., who is a modern-day embodiment of the trauma movement. “Insurance is what happened” to trauma care, says Crane.
“The pieces about trauma and trauma history weren't allowed; you didn't get paid for that,” she says. “This is very unfortunate, because now we have a generation or two of folks who are really good with addiction, but not adequately trained in trauma.”
Eating disorders, sex addiction and self-harming behaviors all are “self-soothing behaviors” like drinking and using drugs are, says Crane. Trauma victims who stop drinking or using drugs might turn to these types of behaviors, she says. “That's the core of relapse prevention-teaching them how to live with very uncomfortable feelings.”
Crane started doing trauma work when she saw so many friends with long-term sobriety still be “in the morass of sex addiction or anger problems or eating disorders or psychiatric medications,” she says. “Something wasn't working. Even if they weren't relapsing on substances, their life wasn't manageable. Several of my friends committed suicide after being sober seven or eight years. They all had terrible trauma and it just wasn't addressed.”
Retraumatized by systems
Addiction treatment that is not trauma-informed risks harming patients who are trauma victims, experts say. Larke Huang, director of the Office of Behavioral Healthcare Equity at the Substance Abuse and Mental Health Services Administration (SAMHSA), explains that trauma victims need to be empowered to direct their own care, or their histories actually could prevent treatment from working-and even could make treatment more harmful than helpful.
“Treatment providers need to recognize that this is a person who may have come out of a coercive relationship sometime in their past or present, and that they are coping with the trauma through alcohol or drugs,” says Huang, who is also lead for SAMHSA's strategic initiative on trauma and justice.
Not being trauma-informed, in fact, risks “retraumatization,” especially for people who enter addiction treatment through child welfare or criminal justice settings where coercion is prevalent, says Huang. SAMHSA is working to encourage these settings to be trauma-informed, says Huang, noting that some of the trauma-specific treatments that were developed with SAMHSA support, such as Seeking Safety, came directly from the addiction treatment field.
In fact, SAMHSA is encouraging all service providers to screen everyone for trauma, and has been providing training in the public sector on trauma-informed care and specific trauma interventions. Its targets here have been community-based organizations that serve a safety-net population.
What is trauma?
SAMHSA's definition of trauma is “very broad,” says Huang, adding that she recently convened trauma centers to look at different definitions. A consensus meeting scheduled by SAMHSA for November 2011 was expected to work on getting “standardization,” she says.
In addition to the personal traumas people experience in their own lives (child abuse, domestic abuse, etc.), there are the effects of historical and continuing trauma, such as the experience of Indians forced onto reservations and blacks forced into slavery.
Huang defines trauma as a stress that “causes physical or emotional harm from which you cannot remove yourself.” Complex trauma is more narrowly defined as trauma “done by someone who is familiar to you on a repeated basis that you can't remove yourself from.”
Post-traumatic stress disorder (PTSD) is not the same as trauma, Huang emphasizes. “Many people do not have PTSD symptoms but may still have a trauma history,” she says. Because most traditional trauma screens are focused on PTSD, these screens tend to miss some trauma victims, she says.
There also are traumas associated with disasters such as hurricanes, mass shootings and, of course, the experience of combat. But trauma experts agree that people who can't cope with these situations usually have some other trauma history that events such as these trigger.