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Trauma Informed Care and Addiction

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What is Trauma Informed Care?

Trauma informed care, developed by Dr. Robert Anda and Dr. Vincent Felitti, is a form of holistic healthcare. Trauma informed care is based on the high likelihood that a patient has experienced a traumatic event at some point in their lives.

Definition: Trauma informed care is a patient-centric medical outlook for dealing with potential trauma history and avoidance of traumatic relapses. Trauma informed care is not used to treat a specific type of trauma but to treat patients who have undergone any traumatic event.

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BURNOUT AND ADDICTION
SLEEP DISORDERS AND ADDICTION
WITHDRAWAL TIMELINE AND SYMPTOMS

6 Main Principles of Trauma Informed Care

Trauma informed care is built on 6 principles – which includes:

Safety

Physical and psychological safety is paramount. This means both creating a physically safe environment and fostering a sense of safety among staff and patients. This can include personal items or friends and family members as requested and recommended.

Trustworthiness

Trustworthiness is centered around clear, honest communication between the healthcare provider and patient. There should also be an additional focus on nurturing trustworthiness among staff and patient families.

Collaborative

This collaboration specifically focuses on communication between all members of the diagnostic team. This means every member of the organization is treated as part of the overall diagnostic team. This practice allows for a fluid exchange of information which in turn lessens the time between correct diagnosis and treatment options. Furthermore, it lessens the power gap between the levels of the organization.

Peer

The peer principle encourages a therapeutic element wherein a patient is exposed to people who have a similar traumatic history. This can decrease feelings of isolation and create a stronger feeling of safety in the patient.

Empowerment

Empowerment is based around positive reinforcement of the achievements, positive values, remarks, and interests of the patient. To achieve empowerment as defined; healthcare providers must understand the powerful impact of listening to both patients and coworkers on any level of the organization. Additionally, medical professionals should seek to understand and validate valid patient suggestions concerning their traumatic triggers. This principle must also be applied to all staff interactions.

Culture/Gender

This principle implies medical consideration of a patient’s culture or gender in terms of both treatment and patient receptiveness to treatment. This can include historical trauma, personal trauma, and further cultivating an environment in which the patient feels safe. This principle also suggests due consideration of personal bias and perception on the part of the healthcare provider.

Each of the 6 principles of Trauma informed care share a patient-first viewpoint. However, it is suggested that to achieve and maintain these principles that the organization must also apply them to all levels of staff. I.E. The staff must be treated with consideration to their safety, empowerment, etc.

Other Principles of Trauma-informed Care

Evidence Based

Trauma informed care employs an evidence-based treatment method. This means if a patient displays signs or symptoms of known conditions then the response would be the corresponding treatment for these conditions. This method shifts medical treatment options to reflect data as opposed to hunches, or instincts.

Holistic Treatment

Trauma informed care is also focused on the overall betterment of physical and mental health, regardless of condition or treatment. It encourages the viewpoint of the patient being a unit as opposed to individualized parts. It acknowledges the effects that a condition may have on other parts of the body. For example, a person with substance use disorder may consequently experience depression which in turn can lead to high blood pressure, and so on.

Types of Trauma

Trauma can occur through a variety of factors. Here are a few of the most common traumatic events

Adverse Childhood Experiences

Adverse childhood experiences or ACE include any form of abuse, loss, or physical and/or psychological injury. 1 in 6 adults has multiple ACE experiences. These experiences can differ wildly as can the perception of these experiences. It’s important to allow room for the patient to talk about their trauma.

Combat

The effects of combat or violent experiences on the brain are well documented. This category is most often applied to combat war veterans returning from tours. However, an abusive upbringing can cause many of the same signs and triggers.

Death or Loss

Death or loss will invariably occur in everyone’s life. Depending on the longevity, emotional connection, and mental state of the patient these events can cause severe traumatic triggers and relapses. These effects can be compounded if experienced during adolescence or in violent means.

Domestic Violence

Domestic violence can severely disrupt the ability to form healthy interpersonal relationships. Survivors of domestic violence events can have issues with feelings of safety, trustworthiness, and empowerment. This includes both the person subjected to the physical effects and anyone subject to the emotional repercussions of the abuse.

Emotional Abuse

Emotional abuse is one of the most nuanced forms of abuse. It includes making you doubt yourself or gas-lighting, guilt-tripping, and generally any nefarious form of emotional manipulation. Survivors of emotional abuse may have difficulty trusting their instincts and possess a negative self-image.
​​Many of us will experience some kind of trauma during our lifetime. 00:10 Sometimes, we escape with no long-term effects. 00:14 But for millions of us, those experiences linger, 00:18 causing symptoms like flashbacks, 00:19 nightmares, 00:20 and negative thoughts that interfere with everyday life. 00:23 This phenomenon, called post-traumatic stress disorder, 00:27 or PTSD, 00:28 isn’t a personal failing; 00:30 rather, it’s a treatable malfunction of certain biological mechanisms 00:34 that allow us to cope with dangerous experiences. 00:39 To understand PTSD, 00:40 we first need to understand how the brain processes a wide range of ordeals, 00:45 including the death of a loved one, 00:47 domestic violence, 00:48 injury or illness, 00:50 abuse, 00:51 rape, 00:52 war, 00:53 car accidents, 00:54 and natural disasters. 00:55 These events can bring on feelings of danger and helplessness, 00:59 which activate the brain’s alarm system, 01:01 known as the “fight-flight-freeze” response. 01:04 When this alarm sounds, 01:06 the hypothalamic, pituitary, and adrenal systems, 01:09 known as the HPA axis, 01:11 work together to send signals to the parasympathetic nervous system. 01:16 That’s the network that communicates with adrenal glands and internal organs 01:19 to help regulate functions like heart rate, 01:22 digestion, 01:22 and respiration. 01:24 These signals start a chemical cascade 01:26 that floods the body with several different stress hormones, 01:30 causing physiological changes that prepare the body to defend itself. 01:34 Our heart rate speeds up, 01:36 breathing quickens, 01:37 and muscles tense. 01:39 Even after a crisis is over, 01:41 escalated levels of stress hormones may last for days, 01:44 contributing to jittery feelings, 01:46 nightmares, 01:47 and other symptoms. 01:48 For most people, these experiences disappear within a few days to two weeks 01:53 as their hormone levels stabilize. 01:55 But a small percentage of those who experience trauma 01:58 have persistent problems 02:00 —sometimes vanishing temporarily only to resurface months later. 02:04 We don’t completely understand what’s happening in the brain, 02:07 but one theory is that the stress hormone cortisol 02:10 may be continuously activating the “fight-flight-freeze” response 02:14 while reducing overall brain functioning, leading to a number of negative symptoms. 02:19 These symptoms often fall into four categories: 02:22 intrusive thoughts, like dreams and flashbacks, 02:25 avoiding reminders of the trauma, 02:27 negative thoughts and feelings, like fear, anger, and guilt, 02:31 and “reactive” symptoms like irritability and difficulty sleeping. 02:36 Not everyone has all these symptoms, 02:38 or experiences them to the same extent and intensity. 02:41 When problems last more than a month, PTSD is often diagnosed. 02:46 Genetics, 02:47 on-going overwhelming stress, 02:49 and many risk factors like preexisting mental illnesses 02:53 or lack of emotional support, 02:54 likely play a role in determining who will experience PTSD. 02:59 But the underlying cause is still a medical mystery. 03:04 A major challenge of coping with PTSD is sensitivity to triggers, 03:09 physical and emotional stimuli 03:11 that the brain associates with the original trauma. 03:14 These can be everyday sensations that aren’t inherently dangerous 03:18 but prompt powerful physical and emotional reactions. 03:21 For example, the smell of a campfire 03:24 could evoke the memory of being trapped in a burning house. 03:28 For someone with PTSD, 03:30 that memory activates the same neurochemical cascade 03:33 as the original event. 03:35 That then stirs up the same feelings of panic and helplessness 03:39 as if they’re experiencing the trauma all over again. 03:43 Trying to avoid these triggers, which are sometimes unpredictable, 03:47 can lead to isolation. 03:49 That can leave people feeling invalidated, 03:51 ignored, 03:52 or misunderstood, 03:53 like a pause button has been pushed on their lives 03:56 while the rest of the world continues around them. 03:59 But, there are options. 04:01 If you think you might be suffering from PTSD, 04:04 the first step is an evaluation with a mental health professional 04:07 who can direct you towards the many resources available. 04:11 Psychotherapy can be very effective for PTSD, 04:14 helping patients better understand their triggers. 04:17 And certain medications can make symptoms more manageable, 04:20 as can self- care practices, like mindfulness and regular exercise. 04:25 What if you notice signs of PTSD in a friend or family member? 04:29 Social support, acceptance, and empathy are key to helping and recovery. 04:33 Let them know you believe their account of what they’re experiencing, 04:37 and that you don’t blame them for their reactions. 04:39 If they’re open to it, 04:40 encourage them to seek evaluation and treatment. 04:43 PTSD has been called “the hidden wound” 04:46 because it comes without outward physical signs. 04:49 But even if it’s an invisible disorder, it doesn’t have to be a silent one.

Trauma Informed Care in Addiction Treatment

Often, trauma and substance use disorder occur concurrently. Psychologically, these two elements compound and create havoc within the body and mind.

Correlation Between Trauma and Substance Use Disorder

On average, people with PTSD are 5 times more likely to need treatment for substance use disorder. The connection between the two is enough evidence to include trauma therapy and treatment to most patients in substance use recovery programs.

A PTSD diagnosis also means there is an increased risk of consuming alcohol at a much higher rate and frequency than other groups of drinkers. Often this can create a cycle of drinking to subdue PTSD-affected thoughts and feelings, which in turn builds both dependence and tolerance. Often, concurrent treatment for the two will involve therapy to teach healthy coping mechanisms.

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PTSD and SUD Rates

The following are statistics for PTSD and Substance use disorder as it affects combat veterans and domestic abuse survivors:

  • 46% of people with PTSD also have SUD
  • 59% of all woman in SUD treatment programs also have PTSD
  • The combination of PTSD and SUD affects 40% of the population
  • People who have been physically abused are 12 times more likely to develop an alcohol use disorder

A majority of patients with PTSD and SUDS develop SUDS due to alcohol dependency. This is due to the wide range of people with traumatic experiences, the general social acceptance of drinking totaled with the cheapness and availability of alcohol.

Treating SUD and Trauma at the Same Time

One of the key elements of treating concurrent Trauma and SUD is psychotherapy. Here are a few of the goals for this element of treatment:

  • Healthy coping mechanisms
  • Improving self-image
  • Change in mindset
  • Letting go of certain emotional triggers when applicable
  • Self-care

The second element is medical treatment to help with the symptoms of withdrawal and to help stabilize overall mood after dealing with long term substance use and/or depression. Any treatment options for concurrent trauma and SUD will integrate these two elements for effective care.

Exposure Treatment

Trauma informed care uses evidence proven treatment. In that regard, prolonged exposure treatment or PE is an effective and time-proven option for recovery. Studies have shown that PE is safe, effective, and acceptable. Exposure therapy is considered a form of CBT or cognitive behavioral therapy. Its documented use has been as a treatment for PTSD and many other traumatic events.

PE involves visualizing past trauma in a controlled, therapeutic environment and gradually escalating to replicating certain triggers. This allows you to examine and review the event in a new light and, hopefully, better cope with it.

Non-Exposure Treatment

Non-exposure therapy involves any treatment except those that would be categorized as exposure treatment. This can include therapy to treat emotional processing, develop a better understanding of the effects of trauma, and managing of self-image. Non-exposure therapy is used by medical professionals either unwilling to risk patient progress with exposure or if patients don’t exhibit a reduction in symptoms from exposure therapy. Non-exposure therapy is considered equally acceptable in most cases and is considered a form of CBT as well.

Pharmacological Treatment

Currently, no one medication treats both the effects of trauma and SUD. This is due partially to the nature of pharmacological test groups and their low chance of admitting a person with SUD into the test group.

Focus on Empowerment

Empowerment is critical to recovery success. In terms of both trauma and SUD, this can easily lead to developing a negative sense of self-worth. Reversing, and preventing this self-view is key to preventing relapse. Empowerment requires a nurturing recovery environment in which everyone feels both heard and validated.

Studies on the Effectiveness of Treating Trauma While Treating SUD

Replicating effective treatment for concurrent trauma and substance use is a complex endeavor. The literature on the effectiveness of varied social groups and environments is still being written.

However, empirical data involving women in domestic violence situations has been published. These studies show that 3 months after a PTSD and SUD program, the group had reduced signs of both conditions. Furthermore, those that completed the program were further along in their dependency than those that didn’t. This suggests that the treatment is effective for the recovery of long-term dependency.

Treatment Models for SUD and Trauma

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ATRIUM

ATRIUM, short for, addiction and trauma recovery integration model. It is a 12-week model designed for women who have suffered childhood or interpersonal trauma. ATRIUM is centered around the betterment of mind, body, and spirit as a method for recovery. ATRIUM also teaches the scientific physical and psychological impacts that trauma causes. It also encourages artistic expression as a form of CBT.

Helping Women Recover

Helping Women Recover is a 17-session model with a focus on self. Throughout the course, women learn the psychological and spiritual understanding of self. Sessions will focus on understanding how external factors affect the self and how these changes are viewed and internalized. It also opens discussion into sexuality, body image, motherhood, and interpersonal or familial relationships.

Seeking Safety

Seeking Safety is an evidenced-based 24 session model for trauma recovery. It’s specialized for women and adolescents but can be used to help any trauma survivor. It is centered around safety, ideals, content, and integrated treatment options.

TREM

TREM, short for, Trauma Recovery and Empowerment Model is a 29-session model for women-centered around self-care. It has a pronounced focus on recovery skills and coping mechanisms. TREM also teaches the understanding of the long-lasting effects of traumatic events.

Triad

Triad is a 16-week course to teach essential emotional skills and lessons vital for long-term recovery. It’s centered around bettering the effects of trauma, mental health, and substance abuse. Triad is considered a holistic approach due to the view that trauma can cause other conditions in separate parts of the mind and body.

What is Re-Traumatization?

The avoidance of re-traumatization is the primary goal of any trauma informed care environment. Re-traumatization, outside of exposure therapy, can result in a severe psychological regression and relapsing of substance use disorder. Every possible measure should be taken to avoid re-traumatization.

Definition

Re-traumatization includes any event or external stimuli that causes thoughts and feelings of trauma to re-emerge within an individual. The body and mind of individuals in a re-traumatized state may respond as though it is still in the original traumatic environment. This includes heavy breathing, sweating, outburst, etc.

Common Triggers

Traumatic triggers are nuanced and individualized. An inter-personal relationship is often required to know a patient’s specific trigger. However, are a few of the most common triggers:

  • Loud Noises
  • Touch without consent
  • Specific songs
  • Phrases
  • Smells
  • The place of the traumatic event
  • The day of the traumatic event
  • The presence or semblance of the abuser
  • Colors
  • Unbridled negative thought

Practices to Avoid Re-Traumatization

Here are some best practices to avoid re-traumatization from a patient perspective.

  • Identify and recognize triggers
  • Build a routine
  • Strengthen coping mechanisms
  • Study how trauma changes the brain

Here are some best practices to avoid re-traumatization from a healthcare provider perspective.

  • Build a rapport with a patient
  • Explain the impact of trauma
  • Maintain an open communication
  • Consider and respond to patient remarks
  • Positive reinforcement

How Should Addiction Treatment Address Trauma in Treatment?

Because of the high comorbidity of trauma and SUD, overlapping treatment is recommended. Difficulties arise in treating multiple conditions in a group setting. This is due to the high likelihood of multiple traumatic re-traumatization given the nature of a recovery group setting. Difficulties also arise in replicating prior tactics as there is no one size fits all approach to individualized treatment options. Healthcare must progress carefully and take note of a patient’s specific trauma.

Policies and Procedures

An organization must have policies and procedures in place that are conducive to trauma informed care. This allows for a seamless and integrated recovery environment in which all members of the diagnostic team share a direct and common focus and understanding of trauma informed care. These procedures should be refreshed periodically for renewed understanding.

Focuses and Aspirations

Trauma informed care is focused on shifting the overall view and day to day practice of healthcare as it’s historically known. This holistic method allows for deeper, more effective treatment options. To be successful in this practice, an organization or recovery environment must maintain its focus and aspiration on the patient and the betterment of their health while also fostering a staff that upholds the essence of trauma informed care.

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