Exploring the Intersection of Trauma and Addiction

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Exploring the Intersection of Trauma and Addiction

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Exploring the Intersection of Trauma and Addiction

Priyanka Upadhyaya, Psy.D

Clinical Instructor, NYULMC

Psychologist- World Trade Center Health Program, Bellevue Hospital


Defining Trauma

Prevalence and Impact of Trauma

Understanding Addiction

Relationship between Trauma and AddictionTreatment ModelsTrauma Informed Care



Trauma comes from the Greek word meaning



hen is something traumatic? When our capacity to cope is overwhelmed or is inadequate.

It is more than the incident...it is the interpretation and perception of that experience as


What is Trauma?


The Substance Abuse and Mental Health Services Administration (SAMHSA) describes individual trauma as resulting from

“an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”


“The world is neither safe nor predictable.”

It disrupts this ability to accurately read others, rendering the mechanism of threat detection defective - either too sensitive or less able to detect danger

The trauma survivor may become either less able to detect danger or more likely to misperceive danger where there is none.

How Does Trauma Impact a Person?


Exposure to actual or threatened a) death, b) serious injury, or c) sexual violation: direct experiencing, witnessing



Avoidance of stimuli associated with the traumaCognitions and Mood: negative alterations Arousal and reactivity symptomsDuration of symptoms longer than 1 monthFunctional impairment due to disturbances DSM-5® Nutshell Definition of PTSDPosttraumatic Stress Disorder


Prevalence: Trauma

Lifetime prevalence : 60% for Men & 50% for Women

About 80-90% of us have had a traumatic experience ( Sledjeski et al., 2008)

Estimates: 10-20% develop PTSD ( Norris & Sloane, 2007)Long term prevalence of PTSD 7-9% ( Kirkpatrick et al., 2013)



Prevalence: Addiction



Two groups of substance-related disorders: Substance-use disorders

Substance-induced disorders

Criteria for Substance Use Disorders

Taking the substance in larger amounts or for longer than you're meant to.Wanting to cut down or stop using the substance but not managing to.Spending a lot of time getting, using, or recovering from use of the substance.Cravings and urges to use the substance.DSM-5: Addiction


Not managing to do what one should at work, home, or school because of substance use.

Continuing to use, even when it causes problems in relationships.

Giving up important social, occupational, or recreational activities because of substance use.

Using substances again and again, even when it puts a person in danger.Continuing to use, even when the person knows they have a physical or psychological problem that could have been caused or made worse by the substance.Needing more of the substance to get the effect they want (tolerance).Development of withdrawal symptoms, which can be relieved by taking more of the substance.DSM-5: Addiction



Co-morbidity: Trauma & Addiction

( Kessler et al., 1995)

National Co-morbidity Survey 199580% of those with PTSD meet criteria for at least 1 psychiatric disorder16% of them have one additional disorder17% have two other diagnosesNearly 50% have 3 or more disorders The most common disorder is Substance Use Disorders (SUDs), Anxiety & DepressionMen & Alcohol Abuse or Dependence - 52%Men & Drug Abuse or Dependence - 35%Women & Alcohol Abuse & Dependence - 28%Women & Drug Abuse or Dependence - 27%



Unclear and evolving

What do we know?

Self-medication hypothesis Addiction creates vulnerability for re-traumatizationSimilar brain regions are implicated in both Trauma and Addiction Stress and trauma create a vulnerability towards maladaptive coping The Relationship Between Trauma (PTSD) & Addiction


The Work of Trauma Treatment: Recovery & Healing

The challenge of recovery is to re-establish ownership of your body and your mind — of yourself.

This means feeling free to know what you know and to feel what you feel without becoming overwhelmed, enraged, ashamed, or collapsed.

For most people this involves finding a way to become calm and focusedlearning to maintain that calm in response to images, thoughts, sounds, or physical sensations that remind you of the pastfinding a way to be fully alive in the present and engaged with the people around younot having to keep secrets from yourself, including secrets about the ways that you have managed to survive (allowing for opportunities for validation)Reducing harm to oneself, in one’s environment and to health


The Inherent Paradoxes of Trauma Treatment

Re-visit the trauma without sensory overload which in turn can re-traumatise

Reciprocity through social contact and connectedness

Feeling safe needs a visit to an unsafe and disturbing past - in mind, body and spirit


Incorporate and understanding of relationship between SUD and PTSD/trauma

The role of the addictive behavior in managing the trauma, its triggers and various manifestations

The origins of both in the traumatic past

The reality that recovering from either requires recovering from both Abstinence & Withdrawal - ripe ground for re-activation of trauma Vulnerability to relapse Confrontational approaches Systemic/Programmatic challenges - integration of treatment The Challenge of Trauma and SUDs


Cognitive Behavioral

PE (Prolonged Exposure): In-vivo and imaginal

SIT (Stress Inoculation Training)

TREM (Trauma Recovery & Empowerment) STAIR (Skills Training in Affective & Interpersonal Regulation) EMDR (Eye Movement Desensitization Re-processing) Somatic Experiencing (Peter Levine)PTSD Treatment Approaches


PTSD & SUDs: Integrative Treatment Models

Seeking Safety (Najavits, 1998): Women with co-occurring PTSD and SUDs.

ATRIUM Addictions & Trauma Recovery Integration Model (Miller & Guidry, 2001)

TARGET Trauma Affect Regulation: Guidelines for Education & Therapy


Domains of change: Decreased symptoms of PTSD

Increased adherence in abstinence

Reduction in missed appointments

Motivational interviewing: powerful strategies for improving aftercare initiation & attending more treatment sessions Across models, PE, CBT, Psycho-education interventions, effects of treatment were maintained. TREM model: Improvement noted largely due to the development of trauma skills- Overall functioning PTSD symptoms, Reduction in use of ER services & HIV risk behaviors Decreased substance useTreatment Effectiveness


Creating Safety

Before any clinician can engage in past-oriented trauma treatments focused on resolution, a set of coping skills must be in place.

Cultivation of recovery capital- social support systems

Therapeutic relationship elements and boundary setting are also imperativeDealing with ambivalence in addiction treatment - motivational interviewing Psycho-education Building emotional expertise: The role of emotion regulation Lifestyle changes Relapse prevention Guiding Principles


Core components: Outreach & Engagement

Screening & Assessment

Treatment activities

Parenting skillsResource linkage Advocacy Trauma specific clinical services Crisis interventionPeer facilitated services Lessons Learned: For the Provider


Lessons for Systems: Trauma Informed Care

Trauma and addiction are systemic challenges and require a culture shift in treatment

Safety comes first

Cross training of staff - Trauma informed care Staff peer support, self care and supervision Mindfulness & breath work for staff and clients alikeIt’s unclear which may have have come first, but most likely trauma sets the biochemical stage for maladaptive coping, one of which is problematic substance use Trauma and addiction affect trust - building relationships and sustaining them




Websites: Resources for professionals on children, adolescents and adults



https://www.drugabuse.gov/https://www.hazeldenbettyford.org/https://www.integration.samhsa.gov/clinical-practice/traumaBooks: https://www.treatment-innovations.org/best-self---new-book.htmlTrauma services for women in Substance abuse treatment: An Integrated approach https://www.treatment-innovations.org/seeking-safety.htmls





Thank you.



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