What is Trauma?

Every individual will experience trauma at some point in their lives. Unfortunately, most Americans have also been exposed to a form of severe trauma, either as a one-time event or a multiple, or even long-lasting repetitive traumatic events. Incidents of trauma can take the form of violence, child abuse, domestic violence, military combat, car accidents, natural disasters, life-threatening illness, fetal trauma, industrial accidents, mass shootings, terrorist attacks, prolonged neglect, or other events. The word “trauma” comes from the Greek term for penetration or wounding, an indication of how serious the effects of trauma can be. Trauma was generally not at all well-understood, or even seriously considered as a psychological injury, until Freud’s psychoanalysis in the late 1800s. Even so, conceptualizations of trauma have changed quite a bit over time, as have the methods and approaches for treating it.

The DSM-IV specifically defines trauma as:

“Direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate. The person’s response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior).”

The Impact of Trauma

Trauma, whether one-time, multiple, or long-lasting repetitive events, affects everyone differently. The impact of trauma can be subtle, hidden, or outright destructive. How an event affects an individual depends on many factors, including characteristics of the individual, the type and characteristics of the event(s), developmental processes, the meaning of the trauma, and sociocultural factors.  Usually the impact of trauma fades relatively soon, typically within one to three months. Most individuals will exhibit resilient responses or brief symptoms or consequences that fall outside of an official diagnosis. For others, trauma problems can persist for years and even decades. These lingering effects of trauma are usually diagnosed as Post-Traumatic Stress Disorder, or PTSD.

Trauma and Substance Abuse

Among those who seek treatment for substance abuse, a dual diagnosis PTSD and substance abuse disorder is surprisingly common. For most, the traumatic event or events occur first, and then the addiction develops. Substance abuse has been often viewed as “self-medication” to cope with the overwhelming pain that trauma has caused in an individual’s daily living. However, addiction can also lead to trauma, as individuals become more vulnerable while under the influence of substances. The rate of a diagnosable level of PTSD among those receiving substance abuse treatment is 12%-34%, and the rates are even higher among women (30%-59%). Most women with this dual diagnosis have experienced childhood physical or sexual abuse, and men have typically experienced war trauma or crime victimization. Various subgroups have higher rates of this dual diagnosis than others, such as combat veterans, victims of domestic violence, teenagers, prisoners, and the homeless. Overall, incidences of PTSD and substance abuse have consistently been found to co-occur, regardless of the nature of trauma or the type of substances that were abused.

As a result, those with PTSD and substance abuse have a more severe clinical profile than those with just one of those disorders. Not only are they seeking treatment for their substance abuse, but they are facing recovery while also dealing with the lingering effects of intense trauma. Furthermore, those with PTSD and substance abuse disorder are particularly vulnerable to repeated traumas, far more so than those with substance abuse or PTSD alone. Typically, there are also a wide variety of life problems that may present themselves as complicating factors in successful treatment. These may include, but are not limited to, other diagnoses and disorders, interpersonal and medical problems, child maltreatment and neglect, homelessness, HIV risk, custody battles, financial hardships, job insecurity, and domestic violence. Due to these issues, those with a dual diagnosis are at risk of falling into a “downward spiral.” Researchers describe this as one triggering event after another, burying the individual deeper and deeper into substance abuse and PTSD. For example, the increased vulnerability to new trauma can lead to increased substance abuse, and vice versa. In a nutshell, PTSD symptoms can be common triggers of substance abuse, which in turn can intensify PTSD symptoms.

However, even those who are exhibit responses to trauma that are outside of a PTSD diagnosis may choose to turn to substance abuse as a coping mechanism. Experiencing trauma early in life increases a person’s susceptibility for drug addiction in adulthood. A person is also more susceptible to drug addiction if they experience any trauma whatsoever, whether early in life or later. Furthermore, an individual may have been struggling with addiction before the traumatic event took place. Psychological trauma and substance abuse can occur in any person, regardless of their age, gender, religion, socioeconomic status, sexual orientation, or any other factor. It is important that individuals who are struggling receive treatment that is designed to address both trauma and addiction. A treatment plan that is tailored to the individual and utilized daily, or at least with regular frequency, is key to recovery.

What is Trauma Focused Cognitive Behavioral Therapy?

Trauma Focused Cognitive Behavioral Therapy (TF-CBT) is a treatment model that was designed to assist both individuals and families in overcoming the negative effects of a traumatic experience. This evidence-based method has been proven effective for treatment after multiple traumas or a single traumatic event, and therapists trained in TF-CBT are frequently able to help those experiencing the emotional effects of trauma to address and resolve these effects.

General Cognitive Behavioral Therapy (CBT) offers effective methods for treating trauma-related disorders and promoting healing, but TF-CBT offers expanded methods, incorporates techniques from family therapy, and uses an extremely trauma-sensitive approach. TF-CBT is also relatively short-term for most clients.

How it Works

Trauma Therapy is administered in three distinct phases, which includes eight components that are recognized as the acronym P.R.A.C.T.I.C.E.

Phase One: Stabilization

In phase one, the therapist will walk the clients through the TF-CBT approach, educate patients about trauma, and help them develop the skills they will need to promote meaningful healing and development. This phase includes the PRACTICE components of P through C.

P – Psycho-education: This phase starts off therapy by learning about trauma. The patients receive information on trauma and the most common reactions to traumatic experiences, as well at PTSD. The goal is to ensure patients that their reactions are understandable, and to validate their feelings.

R – Relaxation Skills: The second component is relaxation and self-care skills. These are intended to help reverse the physiological arousal effects of the trauma they have suffered.

A – Affective Regulation Skills: Similar to the relaxation skills component, the affective regulation skills component is intended to help the patients learn helpful strategies for identifying, modulating, and regulating any upsetting affective states that may arise, especially those that are a result of the trauma experience.

C – Cognitive Processing Skills: The intent of this component is to help the client build the necessary coping skills to manage their stress and achieve meaningful healing from their trauma. Cognitive processing skills help recognize the connections between thoughts, feelings, and behaviors and replace harmful or unhelpful thoughts with more accurate or more helpful ones.

Phase Two: Trauma Narrative

In this phase, the therapist will walk the client through creating a trauma narrative.

T – Trauma Narration and Processing: The trauma narrative is the telling of the story of their traumatic experience or experiences. They are often quite difficult to begin, as the emotions engendered by the original trauma can come flooding back as the sufferer recalls the details of the event(s), but it will get easier as the process goes on. Most clients find it helpful to begin by focusing on the concrete facts (the who, what, when, and where of the experience). Next, they can add the thoughts and feelings that arose during the experience. Once they are comfortable listing or describing their thoughts and feelings during the experience, they can move on to the most difficult or disturbing moments of their trauma. This will be difficult, but it is necessary to put together a comprehensive narrative of the trauma.

Phase Three: Integration / Consolidation

The aim of phase three is to consolidate the lessons learned, continue to build skills and improve connections, and prepare for future success. This phase includes the final PRACTICE components of I, C, and E.

I – In Vivo Mastery of Trauma Reminders: Trauma reminders are stimuli that individuals may experience in their daily lives that can trigger intense, painful, and often debilitating memories of the trauma suffered. It is also possible for these reminders to skip the memories entirely and send the client straight into the physiological arousal that thinking about the trauma could provoke (i.e. unexplained hyperventilation, heart palpitations, etc). The in vivo mastery component involves helping individuals overcome their avoidance of generalized reminders and work towards mastering more specific reminders. The therapist will develop a hierarchy of reminders and work with the client to gradually master feared stimuli and triggers, working from least feared to most feared. This component may actually start in the stabilization phase, and then reach completion toward the end of the PRACTICE components.

C – Conjoint Sessions: This component was originally designed for children who are receiving Trauma Focused Cognitive Behavioral Therapy. Its intention is to provide key opportunities for the therapist to help families reconnect and plan for continued healing and growth. It is in these sessions that the child can share their trauma narrative with their parents, and work together on improving their communication both about the trauma and in general. These sessions may also help families address healthy boundaries and behaviors, as well as develop a family safety plan for potential future crises.

E – Enhancing Safety: This component involves recollecting all of the positive skills and insights gained through therapy and applying it to the future. It is imperative that both individuals and families create plans to deal with the stressors and trauma reminders that will arise in the future.

How APEX Difference

While Trauma-Focused Cognitive Behavioral Therapy has proven to be useful among a wide variety of diverse individuals and families, there is truly no single formula for treating a dual diagnosis of substance abuse and trauma-related disorders. Because of this, the broad range of therapies available at Apex and the diversity of highly-qualified professionals make us able to provide highly flexible and personalized treatments to our dually diagnosed patients.

Using a trauma focused treatment approach, the clinically trained staff at Apex Recovery Rehab understand the impact of trauma and the resulting behaviors.  With judgment-free empathy and responses, the Apex staff understands the ramifications of trauma and can help you implement the necessary tools to increase your wellbeing and deliver truly effective holistic care.  We will help you rebuild a sense of control and develop personal empowerment in a setting that promotes and emphasizes psychological, physical and emotional safety.

More often than not, people struggling with an addiction have some type of co-occurring mental health diagnosis or other trauma related disorder. Not only does APEX Recovery addiction treatment team specialize in all aspects of drug and alcohol dependency, we also treat co-occurring disorders and help patients learn how to manage the often debilitating effects of traumatic experiences.

Here at APEX, we believe that thorough assessment and treatment of co-occurring disorders is a critical piece in maximizing the chance of success in treatment. Fortunately, trauma focused, dual diagnosis therapy now brings these patients the best of both worlds – treatment for both trauma and substance abuse.