A survivor of trauma is at a significantly greater risk of developing some type of addiction and the reverse is also true. Having this awareness, it is imperative that we look at more effective ways of treating this unique condition.
The challenge of providing effective treatment and interventions for persons with both posttraumatic stress and addiction has caused many a seasoned clinician to shudder. “Dually diagnosed,” seems to rank with “Borderline Personality Disorder” as one of the more pejorative and emotionally laden labels that saddle clients. Addicted survivors of trauma are often the recipients of the anger, frustration, and trepidation of health care workers due to the difficulty in both conceptualizing and administering effective treatment to this population.
Sullivan & Evans (1995) describe the trajectory of treatment and recovery for an addicted survivor or trauma as one fraught with potential pitfalls and disappointment for the clinician. They discuss a process frequently experienced within this population as they begin their treatment/recovery. It seems as addicted survivors begin to gain periods of abstinence from chemicals (or behaviors) upon which they have been dependent, they find the intrusion, avoidance and arousal symptoms of their traumatic stress becoming more florid. Conversely, to compound this conundrum, as the addicted survivor becomes ready to begin the process of resolving the traumatic material, they often find themselves with elevated and irresistible cravings for their drug or addictive behavior of choice.
So, what constitutes safe and effective treatment for the addicted survivor of trauma? A few writer/clinicians have tackled this question and we recommend reading the excellent works of Sullivan and Evans (1995), Miller and Guidry (2001) and Dayton (2001). Each of these popular texts is written for clinicians but may be easily read and understood by survivors.
Sullivan and Evan (1995) discuss the impact of abuse and the absence of safety in their book Treating Addicted Survivors of Trauma. This book gives an excellent overview of the effects of abuse and trauma suggesting that the missing element is safety. Addictive behaviors are framed as “unsafe behaviors” which need to be worked through vs. punished (i.e. discharged immediately from treatment). In their book, they also provide an overview of interventions to assist the client in achieving and maintaining safety such as safe planning, contracts, and environmental concerns.
Tian Dayton’s book Trauma and Addiction (2000) is easy reading for a client and discusses the idea of “emotional literacy.” Dayton gives an overview of the traumatic response as well as the connection between trauma and addiction. She discusses the four stages of emotional literacy beginning with the ability to feel the fullness of the emotion. Very often trauma survivors are overwhelmed by emotions to the point where their method of coping is to dissociate. For addicted survivors of trauma, addiction is the primary method of dissociating.
She goes on to describe the remaining phases of emotional literacy as labeling the feeling, exploring the meaning and function within the self, and then making a choice to communicate it to another person. Through feeling the full sense of the emotion, one can use it as an inner guide for recovery. With a more fluid sense of one’s emotions, one is better equipped to determine whether they are safe.
The lynchpin that connects treatment of both traumatic stress and addiction is the development and maintenance of safety and stability. Without the ability to self-rescue, one is at great risk for being overwhelmed by memories or resuming addictive behaviors. A good analogy to use for this phenomenon is the idea of firemen being trained to control fires. The first thing they learn is what to do when the fire begins to control them. Any fireman needs to know when it is time to step back from the fire in order to maintain safety and in the end, conquer vs. be conquered. The same is true with the trauma survivor. Without the ability to self-regulate their own anxiety and arousal, the trauma survivor is at risk of being overwhelmed by memories without the ability to induce a feeling of safety. At this point, the traumatic material renders the survivor once again with the feeling of entrapment, with no way to “survive” other than resuming the addictive behavior.
Gentry (1996) attempts to define and operationalize the concept of “safety” into three levels, relative to the treatment of trauma survivors. These three levels of safety are as follows:
Removal from “war zone” (e.g., domestic violence, combat, abuse)
Resolving active addiction
Behavioral interventions to provide maximum safety;
Address and resolve self-harm.
(i.e., suicidal/homicidal ideation/behavior, eating disorders, persecutory alters/ego-states, process addictions, trauma-bonding, risk-taking behaviors, isolation)
Therapists are taught from the first days of clinical training to “above all do no harm (primum non nocere),” which makes it logical to assume that the more safety and stability that we, as clinicians, can impress in the lives of our clients, the better for their treatment – right? This may not always be the case and in many instances, the clinician’s focus on safety is more about their own apprehension and may actually escalate the crisis of the client.
So, how safe do you have to be and how do you get there? Destabilization tends to be precipitated by client behaviors and thoughts in response to the bombardment of intrusive symptoms (nightmares, flashbacks, psychological and physiological reactivity). Therefore, being able to manage these symptoms safely is imperative. There are no hard and fast criteria for safety, but we will discuss various techniques to help establish safety and stabilization and discuss reference points that can be useful to help you decide. A clinician’s best intervention to optimize safety is a non-anxious presence along with an unwavering optimism for the client’s prognosis.
Firemen who only stay in the firehouse practicing what to do in the event of a fire never gain mastery over fighting fires. Clients should develop the minimum (“good enough”) level of safety and stabilization and then address and resolve the intrusive symptoms by enabling a narrative of the traumatic experience. This is often counter-intuitive and usually anxiety producing for the clinician. However, the client will be much better equipped to change his/her self-destructive patterns (e.g., addictions, eating disorders, abusive relationships) with the intrusive symptoms resolved because s/he will have much more of their faculties available for intervention on their own behalf.
Level One of Safety includes the resolution of environmental danger. When treating an addicted survivor, environmental danger may manifest itself in unsafe situations such as those of domestic violence, living with an active addict or self-destructive behaviors. Traumatic memories will not resolve if the client is in active danger.
Active addiction IS active danger. The addicted survivor must arrest active addiction before treatment for recovery to be effective. This needs be clearly communicated to the addicted survivor and may be articulated as: “Safety is the requirement for resolving both your addiction and your traumatic stress. This safety will require that you bring your using behavior under control (i.e., abstinence) and that you develop ways of effectively regulating your own anxiety, without the use of chemicals or self-destructive behaviors.”
Many trauma survivors feel as if danger is always lurking around every corner. In fact, the symptom cluster of “Arousal” is mostly about this phenomenon. It is important for the clinician to confront this distortion and help the client to distinguish, objectively, between “outside danger” and “inside danger.” Outside danger, or a “real” environmental threat, must be met with behavioral interventions designed to help the survivor remove or protect her/himself from this danger. Inside danger, or the fear resultant from intrusive symptoms of past traumatic experiences, must be met with interventions designed to lower arousal and develop awareness and insight into the source (memory) of the fear.
Addicted survivors of trauma are used to resolving internal danger with mood altering substances. Not feeling safe is often a precursor to impulsive behavior. As noted above, Dayton (2001) discusses the phenomenon of emotional literacy. It is not necessary that a trauma survivor be fluid in their emotional literacy in order to resolve traumatic material yet they do need to be able to distinguish when they are not feeling safe. With addicts, it may be useful to develop a few words for the feelings of discontent that predispose the individual to turning to mood altering substances and behaviors. For instance, a client may not be able to articulate feelings of powerlessness or vulnerability but they may be able to distinguish an internal cue that tells them that things are “not right.” An example of this may be a commitment to tell someone when feeling “irritable” or “uncomfortable.”
Addicted survivors of trauma are accustomed to using mood altering substances and behaviors to self-soothe. The ability to use alternative methods of self-soothing is often a turning point for the survivor as they move from engulfment by the traumatic material to feeling a sense of empowerment over it.
When dealing with the traumatic material, the client must be able to identify to what extent they may explore the material before needing to retreat and return to the safety of the present. Just as with a fireman, before s/he can learn how to self-rescue, they need to be able to identify when it is warranted. One method of teaching the client how to determine this is by utilizing the Subjective Units of Distress Scale (SUDS). This is a scale from zero to ten that indicates what level of discomfort a client is experiencing. Traumatic material will inevitably produce discomfort, but the trauma survivor must practice leaning into the resistance without being overwhelmed. With a SUDS scale, the client can identify their own limits and when self-rescue is necessary. A SUDS rating of 10 would indicate the most discomfort a survivor could imagine feeling. This may be indicated during a flashback. A SUDS rating of 0 or 1 would indicate no discomfort. By using this scale, the client is then able to gain a sense of awareness as to what extent they may safely explore the traumatic material, without becoming overwhelmed.
It is useful to ask the client to begin to narrate the traumatic experience(s) and as their emotions intensify, the clinician may challenge the client to rescue themselves from these overwhelming feelings by implementing the skills above. This successful experience can then be utilized later in treatment to empower the client to extricate him/herself from overwhelming traumatic memories. It is also a testament to the client now being empowered with choice to continue treatment and confront trauma memories.
The final important ingredient of the Safety Phase of treatment is negotiating the contract with the client to move forward to Phase II (Trauma Resolution). Remember the importance of mutual goals in the creation and maintenance of the therapeutic alliance. It is important for the clinician to harness the power of the client’s willful intention to resolve the trauma memories before moving forward. An acknowledgment of the client’s successful completion of the Safety Phase of treatment coupled with an empowering statement of positive prognosis will most likely be helpful here (i.e., “I have watched you develop some very good skills to keep yourself safe and stable in the face of these horrible memories. Judging from how well you have done this, I expect the same kind of success as we begin to work toward resolving these traumatic memories. What do you need before we begin to resolve these memories?”).
Arizona Trauma Institute promotes the Empowerment and Resiliency Treatment Structure.