Trauma, Substance Abuse & Healing
We all carry wounds with us. We all have trauma that we carry within our body. Trauma is the emotional response we may have to a triggering event, but the scary thing is, trauma doesn't just go away. It lives deep within us, and can cause symptomatology to show up in masked ways. The symptoms in fact, may appear as actual physical or medical conditions. Many people are misdiagnosed with physical conditions, when in fact the symptoms are actually a representation of trauma, trapped within the body. These symptoms can range from reports of fibromyalgia type symptoms, or symptoms such as paleness, lethargy, fatigue, poor concentration, or a racing heartbeat. Additionally, the emotional signs of trauma may include night terrors, edginess, irritability, poor concentration and mood swings, as well as the tendency to cut off, or disconnect oneself from one's feelings. Lastly, an individual suffering with a trauma history may end up numbing with drugs or alcohol. There is an extremely high correlation between substance abuse and trauma, in fact. Unfortunately, there tends to also be a higher correlation among women, substance abuse, and trauma. Women are more than twice as likely as men to develop post-traumatic stress disorder (PTSD) following a traumatic experience (10% for women, 4% for men), as women are shown to blame themselves for the trauma they endure. Sexual assault causes a high rate of PTSD, and women who use substances are at a higher risk of being sexually assaulted. 1 in 5 women report to have been sexually assaulted at one point during their lifetime. Substance abuse can cause trauma in and of itself, and sexual trauma can occur while under the influence of substances. To cover up any PTSD and trauma symptoms, those who have experienced trauma will continue to use substances to numb their feelings, and to disconnect from themselves. Sexual assault leads to feelings of low self worth, and internalized toxic shame. Anger is then turned inward against oneself with substance use.
The National Institute on Drug Abuse estimates that as many as 80% of women seeking treatment for an addiction have a complex trauma history (Cohen & Hien, 2006). Furthermore, it is reported that 2/3 of women seeking treatment in dual-diagnosis addiction treatment facilities have had exposure to trauma, and 30-59% of women with substance use disorders have PTSD, typically from childhood physical or sexual abuse.
How can we learn to self-regulate and self-soothe if we have suffered from trauma in our past?
Step 1: Start with Self-Regulation
The foundation of all effective treatments involves some way for people to learn that they can change their arousal system.
Before any talking, it’s important to notice that if you get upset, taking 60 breaths, focusing on the out breaths, can calm your brain right down. Attempting some acupressure points or going for a walk can be very calming.
This is learning to modulate arousal. There’s alarmingly little in our mainstream culture to teach that. For example, this was something that kindergarten teachers used to teach, but once you enter the first grade, this whole notion that you can actually make yourself feel calm seems to disappear.
Now, there’s this kind of post-alcoholic culture where if you feel bad, you pop something into your mouth to make the feeling go away.
“The issue of self-regulation needs to become front and center in the treatment of trauma.”
It’s interesting that right now there are about six to ten million people in America who practice yoga, which is sort of a bizarre thing to do - to stand on one foot and bend yourself up into a pretzel. Why do people do that? They’ve discovered that there’s something they can do to regulate their internal systems.
So the issue of self-regulation needs to become front and center in the treatment of traumatized people. That’s step number one.
Step 2: Help Your Patients Take Steps Toward Self-Empowerment
The core idea here is that “I am not a victim of what happens”. “I can do things to change my own thoughts”, which is very contrary to the medical system where, if you can’t stand something, you can pop a pill and make it go away.
The core of trauma treatment is something is happening to you that you interpret as being frightening, and you can change the sensation by moving, breathing, tapping, and touching (or not touching). You can use any of these processes.
It’s more than tolerating feelings and sensations. Actually, it is more about knowing that you, to some degree, are in charge of your own physiological system.
There needs to be a considerable emphasis on “cultivating in myself,” – this knowing that you can actually calm yourself down by talking or through one of these other processes.
So, step number two is the cultivation of being able to take effective action.
Many traumatized people have been very helpless; they’ve been unable to move. They feel paralyzed, sit in front of the television, and they don’t do anything.
“Programs with physical impact would be very, very effective treatments.”
Programs with physical impact, like model mugging (a form of self-defense training), martial arts or kickboxing, or an activity that requires a range of physical effort where you actually learn to defend yourself, stand up for yourself, and feel power in your body, would be very, very effective treatments. Basically, they reinstate a sense that your organism is not a helpless (tool) of fate.
Step 3: Learn to Express Their Inner Experience
The third thing I would talk about is learning to know what you know and feel what you feel. And that’s where psychotherapy comes in: finding the language for internal experience.
The function of language is to tie us together; the function of language is communication.
“Without being able to communicate, you’re locked up inside of yourself.”
So, learning to communicate and finding words for your internal states would be very helpful in terms of normalizing ourselves - accepting and making (the communication of internal states) a part of ourselves and part of the community. That’s the third part.
Step 4: Integrate the Senses Through Rhythm
We’re physical animals, and to some level, we’re always dancing with each other. Our communication is as much through head nodding and smiles and frowns and moving as anything else. Kids, in particular, and adults, who as kids were victims of physical abuse and neglect, lose those interpersonal rhythms.
“Rhythmical interaction to establish internal sensory integration is an important piece.”
So, some sort of rhythmical interaction to establish internal sensory integration is an important piece that we are working on. With kids, we work with sensory integration techniques like having them jump on trampolines and covering them with heavy blankets to have them feel how their bodies relate to the environment because that’s an area that gets very disturbed by trauma, neglect, and abuse, especially in kids.
For adults, I think we’ve resolved rhythmical issues with experiences like tango dancing, Qi Gong, drumming – any of these put one organism in rhythm with other organisms and is a way of overcoming this frozen sense of separation that traumatized people have with others.
These are four keystones that can make healing from trauma faster and more effective.
And LAST BUT NOT LEAST........
How do we treat trauma as clinicians? It is important to treat trauma and underlying disorders at the same time, according to experts.
Also, clients prefer this:
1) Decide how to treat PTSD in context of active substance abuse.
2) Focus on present only (coping skills, psychoeducation, educate about symptoms) -safest approach, widely recommended!
3) Focus on past only (tell the trauma story) - high risk; works for some clients
4) Focus on both present and past
Helpful Additional Resources:
EMDR Institute: www.emdr.com
Kristina Wandilak, The Lost Years http://thelostyearsbook.com
Seeking Safety: www.seekingsafety.org
Resources on Substance Abuse and PTSD
a) Substance abuse
National Clearinghouse for Alcohol and Drug Information
800-729-6686; www.health.org
National Drug Information, Treatment and Referral Hotline
800-662-HELP; http://csat.samsha.gov
Alcoholics Anonymous
800-637-6237; www.aa.org
SMART Recovery (alternative to AA)
www.smartrecovery.org
Addiction Technology Transfer Centers
www.nattc.org
Harm Reduction Coalition
212-213-6376; www.harmreduction.org
b) Trauma / PTSD
International Society for Traumatic Stress Studies
708-480-9028; www.istss.org
International Society for the Study of Dissociation
847-480-9282; www.issd.org
National Centers for PTSD (extensive literature on PTSD)
802-296-5132; www.ptsd.va.gov
National Child Traumatic Stress Network
310-235-2633; www.nctsn.org
National Center for Trauma-Informed Care
866-254-4819; mentalhealth.samhsa.gov/nctic
National Resource Center on Domestic Violence
800-537-2238; www.nrcdv.org
Department of Veterans Affairs
800-827-1000; www.va.gov
EMDR International Association
866-451-5200; www.emdria.org
Community screening for PTSD and other disorders
www.mentalhealthscreening.org
Sidran Foundation (trauma information, support)
410-825-8888; www.sidran.org
Educational Materials
Books on PTSD
- Herman J. L. (1992). Trauma and Recovery. New York, Basic Books.
- Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the Therapist: Countertransference and Vicarious
Traumatization in Psychotherapy with Incest Survivors. New York: WW Norton.
- Briere, J.N. & Scott, C. (2006). Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment.
Thousand Oaks, CA: Sage.
5. Fallot, R.D. & Harris, M. (2001). Using Trauma Theory to Design Service Systems. San Francisco: Jossey-Bass. 5. Hoge, C. C. (2010). Once a Warrior--Always a Warrior: Navigating the Transition from Combat to Home--Including
Combat Stress, PTSD, and mTBI. GPP Life Press.
Books on Substance Abuse
- Beck A. T., Wright J., et al. (1993). Cognitive Therapy of Substance Abuse. New York: Guilford.
- Marlatt G., Gordon J. (1985). Relapse Prevention. New York: Guilford.
- Fletcher, A. (2001). Sober for Good. Boston: Houghton Mifflin.
- Najavits L. M. (2002). A Woman’s Addiction Workbook. Oakland, CA: New Harbinger.
- Miller, W. R., Zweben, A., et al. (1995). Motivational Enhancement Therapy Manual (Vol. 2). Rockville, MD: U.S. Department of Health and Human Services. Obtain from www.health.org (free).
Books on PTSD and Substance Abuse
1. Najavits L. M. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York: Guilford. Spanish and other translations also available (www.seekingsafety.org) 2. Ouimette, P. & Brown, P. (2002) Trauma and Substance Abuse: Causes, Consequences, and Treatment of
Comorbid Disorders. Washington, DC: American Psychological Association Press.
Videos
a) Najavits, L.M. (2006). Video training series on Seeking Safety; www.seekingsafety.org (section Order). b) Najavits, L.M., Abueg F, Brown PJ, et al. (1998). Nevada City, CA: Cavalcade [800-345-5530]. Trauma and substance abuse. Part I: Therapeutic approaches [For professionals]; Part II: Special treatment issues [For professionals]; Numbing the Pain: Substance abuse and psychological trauma [For clients]
Clinically-Relevant Articles
1. Seal, KH, Bertenthal, D, Miner, CR, Sen, S, Marmar, C (2007). Bringing the war back home: mental health disorders among 103 788 us veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007;167(5):476-482. 2. Golier, J.A., Yehuda, R. et al. (2003). The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events. American J Psychiatry,160, 2018-24.
3. Najavits, LM, Schmitz, M, Johnson, KM, Smith, C, North, T et al. (2009). Seeking Safety therapy for men: Clinical and research experiences. In Men and Addictions. Nova Science Publishers, Hauppauge, NY. 4. Brady, K.T., Dansky, B.S. et al. (2001). Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: Preliminary findings. J Substance Abuse Treatment, 21, 47-54.
5. Bradley, R., Greene J., et al. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214-227. 6. Kessler, R.C., Sonnega, A., et al. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52, 1048-1060. [Provides rates]
7. Najavits, L.M. (2004). Assessment of trauma, PTSD, and substance use disorder: A practical guide. In J. P. Wilson & T. M. Keane (Eds.), Assessment of Psychological Trauma and PTSD (pp. 466-491). New York: Guilford. 8. Ougrin D. (2011). Efficacy of exposure versus cognitive therapy in anxiety disorders: systematic review and meta- analysis. BMC Psychiatry. 11(1):200.
9. Vogelmann-Sine, S., Sine, L., et al. (1998). EMDR: Chemical Dependency Treatment Manual. Unpublished manuscript, Honolulu, Hawaii. 10. Najavits, L., Highley, J., Dolan, S., & Fee, F. (2012). Substance use disorder, PTSD, and traumatic brain injury. In J. Vasterling, R. Bryant & T. Keane (Eds.), PTSD and Mild Traumatic Brain Injury. New York: Guilford Press
11. Najavits LM (2007). Psychosocial treatments for posttraumatic stress disorder. In P. E. Nathan & J. Gorman, A Guide to Treatments that Work (3rd ed.). Oxford Press: New York. 12. Brown et al. (2007). Implementing an evidence-based practice: Seeking Safety group. Journal of Psychoactive Drugs, 39, 231-240.
Pubmed (medical literature): http://www.ncbi.nlm.nih.gov/entrez/