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Trauma Informed Practice
Understanding the
Effects of Trauma
The “more existential impacts include
profound emptiness, loss of connection to
spirituality or disruption in one’s ability to
hope, trust or care about oneself or
others”
(Briere & Scott, 2006, p. 17)
• A number of different symptoms and disorders
have been linked to traumatic events
• Some, listed next, are related to disorders
diagnosed through the DSM IV in many Western
countries
• The full impact of trauma cannot be completely
described by an impersonal list of symptoms and
disorders
Varying Post-traumatic Response
Diagnoses
• Depression
-Complicated Grief
-Major Depression
-Psychotic Depression
• Anxiety
-Generalized Anxiety
-Panic
-Phobic Anxiety
• Stress
-Post-Traumatic Stress
-Acute Stress
• Dissociation
• Somatoform Responses
-Physical symptoms
unexplainable through
medical phenomena
• Brief Psychotic Disorder
• Substance Use
• Borderline Personality
Disorder
• Any of the preceding diagnostic categories could be
the presenting problem for women survivors of a
trauma history
• These are legitimate coping responses to trauma that
help protect a victim of abuse
• Dually diagnosed clients (with a diagnosed mental
health issue and substance abuse) should be routinely
assessed for a trauma history by a trained mental health
clinician
PTSD & Substance Use
• Rate of PTSD among women in substance use treatment
is 30-59 %
• Substances are often used as a form of “self-medication”
to cope with the overwhelming emotional pain of PTSD
• People with this specific dual diagnosis are more
vulnerable to repeated traumatisation and are likely to
be coping with complicated life circumstances such as
homelessness, relational or medical problems, domestic
violence or child maltreatment
• Most women with this dual diagnosis have survived
childhood physical and/or sexual abuse
• Abstinence from substances may exacerbate PTSD
symptoms
• PTSD is rarely treated in conjunction with substance abuse,
as recommended by both clinicians and researchers
• There is a need for treatment integration, allowing clients
to discover the interrelationships and connections between
the conditions in their own lives
• Integrated treatment should focus attention on both
conditions at the same time in the present to facilitate
holistic healing
The following modules can be used to
work with dually diagnosed women in any
setting. They can be used to educate staff
and clients about the nature of PTSD and
substance use, as well as various safe
coping skills.
Trauma Informed Practice
PTSD and Substance Use
Do I have PTSD?
Have you ever experienced or witnessed a physical threat
outside of your control?
Was your response intense helplessness, fear, horror?
If a child when it happened was it agitated or disorganized
behaviour?
Afterward:
Have you suffered nightmares, flashbacks, images?
Numbing or feeling detached?
Feeling aroused (easily startled, problems sleeping, anger)?
Problems with relationships, work or other areas of life?
•Such symptoms of PTSD are a “normal reaction to abnormal events”;
they are your body’s way of coping with stress
•PTSD is considered a mental health disorder due to the overwhelming
anxiety present during and after trauma.
• It possible to heal from PTSD and from severe trauma.
•Some reasons why people with PTSD abuse substances are:
- to access or to avoid feelings and memories
- to compensate for the pain of PTSD
- they grew up with substance abuse
- they don’t care about themselves or their bodies
•Each of the disorders makes the other more likely
Why do substance use and PTSD co-occur?
• Substance use may “self-medicate” the
overwhelming symptoms of PTSD
• Substance use may make one vulnerable to
dangerous situations leading to trauma
• Trauma and substance use may have occurred
together in the family home when growing up
• Downward spiral: PTSD may lead to substance use
which in turn increases risk for more trauma, which
may lead to more substance use.
Reclaim Your Power
• Having compassion for your substance use and PTSD
- PTSD symptoms are natural survival mechanisms in the
face of overwhelming trauma. Understanding why you
have these
symptoms stops self-blame and allows you the space to
learn more effective coping
- Substance use is an attempt to cope with PTSD and life
problems. Understanding the role substance use plays can
allow you to reach out for help in learning more adaptive
methods.
• Notice the strengths you have developed
- How have you survived under tough conditions? How did
you do that? What kind of growth has occurred your survival of
these experiences?
Ambivalence
• Mixed feelings about giving up the familiarity of
substance use is not only normal but to be expected
• This can also be the case with getting better from PTSD,
it may feel invalidating to let go of the suffering
• While these feelings are normal, actions must focus on
safety
• Safety means not using substances, sticking with
treatment and talking openly about ambivalence.
Reclaim Your Life
Substance Abuse:
- increases PTSD symptoms in the long run, increasing
depression,suicidality and decreasing depression
- stalls your emotional development
- does not meet your needs (love, acceptance, nurturance)
- isolates you by facilitating secret keeping, lying and loneliness
- keeps you from coping with feelings/ prevents safe coping and
healing
- takes away your control (much like PTSD)
- is a way of neglecting yourself (impairs health, mind, relationships,
self-worth and spirituality
Climbing Mount Recovery
Handout
(Please Refer to Attached Handout For Client Work)
Self-Understanding
Blame, shame and guilt prevent understanding of why one
uses substances. Seek understanding by:
1) Notice the Choice Point:
- Make a conscious decision to use
- Listen closely and you’ll hear a need being neglected
(connection, pleasure, love, symptom relief)
2) Replay the Scene in Slow Motion
- Where were you? Who was there? What happened leading up to
using? What were you feeling/thinking? What other coping did you
try?
- Re-play in your head and identify how it could end differently
3) Explore the Meaning of Substance Use
- Sleep? Numbing? Control? Acceptance? Slow suicide? Crying
out for help? Expressing pain? Forgetting?
4) Notice the Cost:
- Interpersonally (who is it hurting?), financially (how much does
it cost?), emotionally (how does it make you feel about yourself?)
5) Notice How Much You Relate to Yourself Afterwards:
- Are you kind and caring? Harsh and judgmental? Is blame,
shame and guilt getting in the way of understanding yourself?
Trauma Informed Practice
Safety
“When a person has both substance
use and PTSD, the most urgent clinical
need is to establish safety”
(Najavits, 2004, p. 47)
Safe Coping Skills
• Ask for help
• Cry
• Take good care of your
body
• Create meaning
What are you living for?
Truth? Love ? Children?
God?
• Set a boundary
Say “no” to protect yourself
• Talk yourself through it
• Recognize substance use
as self-medication
• Avoid avoidable suffering
Prevent bad situations in
advance; notice red flags
• Seek understanding, not
blame
Listen to your behaviour;
blame prevents growth
• Imagine
(remember a safe place)
Safe Coping Cont’d
• Attend treatment
• Say what you really think
Is that assumption true?
• Listen to your needs
• Structure your day
• Notice the cost
What is the price of substance use?
• Set an action plan
Involve others
• Trust the process
• Expect growth to feel
uncomfortable
• Pretend you like yourself
See how different the day feels
•
•
•
•
•
Focus on now
Practice delay
Take responsibility
Self-nurture
Let go of destructive
relationships
Safe Coping Cont’d
• Detach from emotional
pain
Grounding
• Learn from experience
• Plan it out
Think ahead, avoid impulsivity
• Reward yourself
• Tolerate the feeling
No feeling is ever “final”, just get
through it!
• Find rules to live by
• Fight the trigger
• Recruit support
• Notice what you can
control
• Replace destructive
activities
• Pace yourself
If overwhelmed, slower; if
stagnant, faster!
• List your options
• Compassion (for yourself)
• The preceding list can be used with clients in any setting
to examine what safety skills fit for them
• Service providers can explore with clients what skills they
already possess as well as new ways of coping with stress,
life and PTSD symptoms
• For a more detailed list please refer to “Seeking Safety”
treatment manual by Lisa Najavits, 2002.
• These coping skills can be used to create personal safety
plans and in reviewing current safe and unsafe behaviours
Trauma Informed Practice
Grounding
Detach From Emotional Pain
• Distraction by focusing outward
• Detach from overwhelming emotion by anchoring
yourself in present reality
• Attain a balance between conscious reality and being
able to handle it
• Keep your eyes open, scan the room, keep lights on
• Focus on present, not past or future
• Avoid judgements of good or bad; remain neutral
Types of Grounding
1) Mental Grounding
- describe your environment in detail, play a categories game (e.g.
types of dogs), describe an activity in detail (e.g. cooking a meal),
read something slowly
2) Physical Grounding
- run cool or warm water over your hands, touch various objects and
notice their differences, jump up and down, stretch, focus on
breathing, eat something and notice flavours, clench and release
fists
3) Soothing Grounding
- say kind things, think of favourites (color, animal, season), picture
loved ones, remember a safe place, say a coping statement (I’m okay,
I can handle this), think of things you’re looking forward to.
Trauma Informed Practice
Coping With Triggers
Triggers
• Actively identify what they are
• Never test yourself with triggers
• Stay far away from triggers; avoid avoidable suffering
• Triggers will occur in life, prepare to cope with them
Safety Zone
Create safety by:
• Changing Who
- detach from unsafe people, move toward safe people (family,
friends, sponsor), talk about feelings or light, distracting topics, carry
photos of loved ones
• Changing What
- keep busy with safe activities such as reading, exercise, tv, calming
music
• Changing Where
- find a safe place; leave area, take a drive or walk, throw out drug
accessories
Trauma Informed Practice
Response Based
Approach
Everyday Resistance
• Assumes that every individual innately possesses the
ability to resist violence and oppression
• Resistance is expanded beyond physical fighting back to
include “any mental or behavioural act through which a
person attempts to expose, withstand, repel, stop,
prevent, abstain from, strive against, impede, refuse to
comply with or oppose any form of violence or
oppression”
(Wade, 1998, p. 25)
Victim’s Dilemma
• Perpetrators of violence will suppress any challenge to
their authority, making open defiance one of the least
likely forms of resistance
• “Small acts of living” become the most common way of
resisting violence or oppression
(Goffman as cited in Wade, 1997, p. 32)
• Such small acts may include lying, withdrawal, feigned
ignorance, tone of voice, facial expressions, muttering,
acts of the imagination (including comforting thoughts,
detachment and dissociation)
Responses to Violence
Staff working with trauma survivors can focus conversations
on the client’s response to, versus the effects of,
experienced violence
Shifts away from the potential re-telling of traumatizing
stories to uncovering acts of resistance
Shifts our perceptions from passive victimization to active
resistance and cultivates conversations about client
capability
Trauma Informed Practice
Cultural Considerations
• As seen earlier, the potential effects of trauma are
widely variable and depend not only on the trauma itself
but also numerous individual and environmental factors
• Differing cultures may therefore experience responses
to extreme stress in very different ways
• The PTSD diagnosis is itself culture-bound in that it
describes symptoms of individuals born and raised in
Anglo-European/American cultures.
Culture as a Construct Beyond
Simply Race
Culture pertains to individual worldview as affected by race, language,
social interaction and socioeconomic status
Culture is continuously evolving and never static
Racial categories therefore reveal little about cultural context, however
cultural difference translates into widely varying trauma
presentations and expectations of clinical contact
Cultural awareness and sensitivity does not maintain helpers should
have expert knowledge of every cultural background, this is
impossible
It does call for a stance of curiosity and willingness to learn alternate
worldviews. It also seeks to actively learn the rules of engagement
and cultural trauma presentations for clients from nonAnglo/European cultural groups
Best Practice Guidelines
Service
Recommendations
Service Integration
Separate services for mental health and addictions operating
under differing treatment philosophies not only creates access
barriers but fails to meet a client’s holistic needs
A housing first approach addresses basic needs initially, later
incorporating clinical treatment, addiction support, medical
care, support for accessing financial resources, social work and
occupational therapy in one treatment environment
Please refer to http://www.thealex.ca/ for more information on
the housing first model
Trauma Assessment
Statistics estimate that 30-59% of women with a substance
use disorder meet the criteria for PTSD, while 55-99% of
them will report suffering physical or sexual abuse
(Najavits, Weiss, Shaw & Muenz, 1998; Savage, Quiros, Dodd& Bonvota, 2007)
Standard trauma assessment practices are recommended in
mental health and substance abuse treatment settings
Integrated Intervention
Prolonged re-exposure to traumatic material is not
recommended for dually diagnosed clients as resulting
distress can become a significant risk factor for
substance use
Cognitive-behavioural interventions have been developed
for combined treatment of trauma symptoms and
substance abuse
(Harris, 1998; Najavits, 2002)
These interventions can be adapted to work with
individuals or groups
Empowerment Model
An empowerment model is the single most important
feature of any trauma intervention
Maximizing choice in treatment planning is essential to
respecting client self-determination and working to
restore autonomy often stolen by experiences of abuse
Clinicians must be accountable for facilitating this process
and promoting client safety throughout
References
Briere, J. & Scott, C. (2006). Principles of trauma therapy: A guide to symptoms, evaluation, and
treatment. Thousand Oaks, CA: Sage Publications.
Harris, M. (1998). Trauma recovery and empowerment: A clinician’s guide for working with women in
groups. New York, NY: Free Press.
Najavits, L. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY:
Guilford Press.
Najavits, L. (2004). Treatment of posttraumatic stress disorder and substance abuse: Clinical
guidelines for implementing seeking safety therapy. Alcoholism Treatment Quarterly, 22(1), 4361.
Newmann, J. & Sallmann, J. (2004). Women, trauma histories and co-occurring disorders: Assessing
the scope of the problem. Social Service Review, 78 (3), 466-499.
Pathways to Housing Calgary (n.d.). Retrieve from http://www.thealex.ca/pathways/.
Savage, A., Quiros, L., Dodd, S.J., & Bonvota, D. (2007). Building trauma-informed practice:
Appreciating the impact of trauma in the lives of women with substance abuse and mental
health problems. Journal of Social Work Practice in the Addictions, 7 (1/2), 91-116.
Stromwall, L. & Larson, N. (2004). Women’s experience of co-occurring substance use and mental
health conditions. Journal of Social Work Practice in the Addictions, 4(1), 81- 96.
Wade, A. (1997). Small acts of living: Everyday resistance to violence and other forms of oppression.
Contemporary Family Therapy, 19(1), 23-40.