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Beneath the
Addressing Trauma
& Substance Use
Presented By:
Sara L. Paxton LMSW/CAADC
Family Outreach Center
Today’s Objectives
Be able to:
 Discuss the relationship between trauma and
substance use.
 Describe of the impact of historical trauma on
specific populations.
 Identify practical interventions (including
prevention strategies) to use in therapy when
working with individuals/families with a trauma
history and current or potential substance use
Trauma & SUD
The Relationship
As the number of traumatic events
experienced during childhood increases, the
risk for the following health problems in
adulthood increases:
Drug abuse
Suicide attempts
Heart, liver, and pulmonary diseases
Fetal death during pregnancy
High stress
Uncontrollable anger
Family, financial, and job problems
Trauma & SUD
The Relationship
SAMHSA April 2011: Childhood
Trauma's Impact on Health
Trauma & SUD
The Relationship
90% of public mental health clients have been exposed
to, and most have actually experienced, multiple
exposures of trauma
75% of women and men in substance abuse treatment
report abuse and trauma histories
ACE (Adverse Childhood Experiences) Study
Almost 2/3 of the study participants reported at least one
adverse childhood experience of physical or sexual abuse,
neglect, or family dysfunction
More than one in five reported three or more such
CTE (Childhood Traumatic Events) Study
Reviewed CTEs and adult health problems and psychosocial
1.2 to 1.5-fold increased risk for PTSD, current tobacco use,
alcohol dependence, injection drug use, sex work, sexually
transmitted diseases, homelessness, a myriad of physical
health problems, and reduced overall quality of life
What is Trauma?
 What
do you consider
to be traumatic?
 What
something traumatic?
What is Trauma?
a. an experience that produces
psychological injury or pain.
b. the psychological injury so caused.
 Risks
Psychiatric Definition:
of an Event being Traumatic
It happened unexpectedly.
You were unprepared for it.
You felt powerless to prevent it.
It happened repeatedly.
Someone was intentionally cruel.
It happened in childhood.
What is Trauma?
Common Traumatic Events
 An unstable or unsafe
 Separation from a
 Serious illness
 Intrusive medical
 Sexual, physical, or
verbal abuse
 Domestic violence
 Neglect
 Bullying
Commonly Overlooked Traumatic
 Falls or sports injuries
 Surgery (especially in the first 3
years of life)
 Sudden death of someone
 A car accident
 Breakup of a significant
 A humiliating or deeply
disappointing experience
 Discovery of a life-threatening
illness or disabling condition
Historical Trauma
Historical Trauma: Definition
Multigenerational trauma experienced by a
specific cultural group
It is cumulative and collective
Immigrants: Prevention of cultural and spiritual practices
Intergenerational Poverty: Hunger; poor or inadequate
housing; lack of access to health care; community crime
People of Color: Slavery; colonialism/imperialism
American Indians/First Nations Peoples: Americanization
of Indian Boarding Schools and forced assimilation
among their students
SAMHSA’s GAINS Center Policy
Research Associates, Inc. Historical
Trauma Fact Sheet
Historical Trauma
 Identify
historical events that occurred in
the below time periods that may have
resulted in historical trauma.
Historical Trauma
White racism as a trauma for African-Americans (its effects parallel how
individuals are affected by chronic physical abuse).
Trauma-focused theories may mention the effects of racism and
discrimination as having an emotionally injurious effect.
Afro-centric theories define white racism as a traumatic threat ,
particularly those that are lower-income, urban, because white racism
threatens their collective survival.
Stems from Segregation from employment/educational opportunities,
and relegated to living in the poorest neighborhoods.
The concentration of poverty led to rising crime rates, domestic
violence, drug problems, and other social ills.
These issues in other populations might be addressed through public
services.; however, in inner cities they(police, social services, etc.) were
often corrupt, abusive, and discriminatory and therefore historically
African American women are underdiagnosed with depression as
symptoms manifest differently (often due to coping through hard work
and determination over physical and mental well-being).
Historical Trauma
Native American Population
Europeans brought new diseases which traditional
healers were unprepared to cope with, where their
methods had historically been beneficial, they no longer
There was a discouragement of Traditional beliefs and
practices by certain church, educational, and
governmental groups.
There was the assumption that Native cultures were
deficient in a way that was seen as pathological, without
virtue, and without value.
Children where sent to boarding schools where their
contact with family members was severely curtailed.
The same children were sent back to tribes and became
the parents of the future, now devoid of a traditional
understanding of what it meant to be native and what
the responsibilities were for being a native parent.
It was the process of deculturalization.
In addition, Native people have been forced to define
and prove themselves, often through forced treaties.
Substance Use Disorders
Warning Signs of Use
Physical: fatigue, repeated health complaints, red and
glazed eyes, and a lasting cough.
Emotional: personality change, sudden mood changes,
irritability, irresponsible behavior, low self-esteem, poor
judgment, depression, and lack of interest in activities.
Family: argumentative, breaking rules, or withdrawing
from the family.
School: decreased interest, negative attitude, drop in
grades, many absences, truancy, and discipline
Social problems: new friends with lack of interest in usual
home/school activities, problems with the law, and
changes in dress and music (often to unconventional).
Substance Use Disorders
Diagnosis (DSM-IV-TR)
Substance Use/Misuse
 starts to have a negative impact on a person’s functioning
 the use of a substance for unintended purposes or for intended purposes
but in improper amounts or doses
Substance Abuse
 the deliberate, persistent, excessive use of a substance without regard to
health concerns or accepted medical practices
 a pattern of harmful use of any substance for mood-altering purposes
 pattern of substance use that results in repeated adverse social
consequences related to drug-taking—for example, interpersonal conflicts,
failure to meet work, family, or school obligations, or legal problems
Substance Dependence
 the desire or need to continually use a substance
 the compulsive need to use a substance
 stopping use would cause user to suffer mental, physical, and emotional
 characterized by physiological and behavioral symptoms related to
substance use. These symptoms include the need for increasing amounts of
the substance to maintain desired effects, withdrawal if drug-taking ceases,
and a great deal of time spent in activities related to substance use
 Strengthening
 Somatic
 Seeking Safety
Treatment Modalities
TF-CBT (Trauma Focused Cognitive
Behavioral Therapy)
Components-based treatment model that incorporates
trauma-sensitive interventions with cognitive behavioral,
family, and humanistic principles and techniques.
Children and parents learn new skills to help process
thoughts and feelings related to traumatic life events;
manage and resolve distressing thoughts, feelings, and
behaviors; and enhance safety, growth, parenting skills,
and family communication.
Psychoeducation and parenting skills
Relaxation skills
Affect expression and regulation skills
Cognitive coping skills and processing
Trauma narrative
In vivo exposure (when needed)
Conjoint parent-child sessions
Enhancing safety and future development
Treatment Modalities
Strengthening Families
Protective Factors
Caregivers can buffer the impact of trauma
and promote better outcomes for children
even under stressful times when the following
Strengthening Families Protective Factors are
Parental resilience
Social connections
Knowledge of parenting and child
Concrete support in times of need
Social and emotional competence of children
Treatment Modalities
Somatic Experiencing
Takes advantage of the body’s unique ability
to heal itself.
Focus of therapy is on bodily sensations, rather
than thoughts and memories about the
traumatic event.
Concentrating on what’s happening in your
body, causes you to gradually get in touch
with trauma-related energy and tension.
Then natural survival instincts take over, safely
releasing this pent-up energy through shaking,
crying, and other forms of physical release.
Treatment Modalities
(Eye Movement Desensitization &
 Incorporates
elements of cognitivebehavioral therapy with eye movements
or other forms of rhythmic, left to right
 Back-and-forth eye movements are
thought to work by “unfreezing” traumatic
memories, allowing you to resolve them.
Treatment Modalities
Seeking Safety
Seeking Safety is a present-focused therapy to help
people attain safety from trauma/PTSD and substance
The key principles of Seeking Safety are:
 Safety as the overarching goal (helping attain safety
in relationships, thinking, behavior, and emotions).
 Integrated treatment (working on both PTSD and
substance abuse at the same time).
 A focus on ideals to counteract the loss of ideals in
both PTSD and substance abuse.
 Four content areas: cognitive, behavioral,
interpersonal, and case management.
 Specific/deliberate attention to clinician processes
(helping clinicians work on countertransference, selfcare, and other issues).
Treatment Modalities
Promising Future Modalities
Child-Parent Psychotherapy (CPP) Family Violence:
 Primary use with children under 7 with exposure to family violence, physical abuse,
and/or physical neglect.
 Stresses the importance of attachment; the connection between thoughts, feelings,
and behaviors; social learning theory; and family therapy.
 Utilizes the parent-child relationship to repair the inability to self-regulate emotions,
increase the attachment bond, and decrease child aggressiveness and parental
use of physical punishment and criticism.
 Includes a trauma narration component where the parent and child create a joint
narrative of the trauma.
Abuse-Focused Cognitive Behavioral Therapy (AF-CBT):
 Primarily used with children ages 6-15 years and their parents.
 Targets physically abusive parents’ parenting skills or practices, along with the child’s
behavioral and emotional adjustment.
 Parallel treatment model combing the connection between thoughts, feelings, and
behaviors and learning and family therapy approaches to treat the parent and
child simultaneously.
 Primary goals of AF-CBT are to reduce the abusive parent’s anger and use of force,
teach non-aggressive methods of discipline, reduce the risk of future abuse
incidents, enhance child coping and adjustment, and improve family
 Practical
Cognitive Exercises
Safety/Safe Coping Skills
Emotion Identification/Expression
Healthy Relationships
Exploring the Trauma
Culture Specific
 Interventions
that have been culturally
modified may ease barriers and increase
the family/individual’s level of engagement.
Incorporating culturally appropriate terms in
discussing the healing process and family
Integrating culturally specific stories and
proverbs can increase the family’s comfort
Cultural Specific
African American:
Afro-centric values include interdependence with
nature and other living things, a deep sense of
spirituality, emotional expression, direct
communication, and expressing one's true emotional
self through dance, music, and other creative arts.
Incorporate strengths related to resisting oppression.
Allow for the expression and celebration of resilience.
Utilize strengths which in general include: strong
church affiliation and sense of spirituality, flexible
family roles, and strong family, extended family, and
surrogate-family ties.
Remember that these strengths insulate AfricanAmericans from the harmful effects of stress, poverty,
depression, and traumatic oppression.
Cultural Specific
Native Americans
Requests from the Native community for a new
“medicine,” one specifically developed to meet native
needs, and rooted in the traditions of the past.
Traditional healing focuses on the person and the context
of their community, rather than on a discreet biomedical
sickness with an emphasis on health, not disease.
Traditional healing seeks to make things whole—the
people, the culture, and the community.
The removal of traditional culture and support systems led
to erosion of Native mental health, but is being reversed
by a surge of spiritually based energy utilizing traditional
The outcomes are feelings of renewed hope and
Recognize and celebrate the fact that many Natives
believe that the good of tribe/group/family supersedes
that of the individual.
Trauma & SUD