Trauma frequently is comorbid with substance abuse disorders. Despite how common trauma is in substance abuse populations, there is a lack of training and education among addiction treatment professionals. This article examines current literature in the field of trauma treatment and serves to help educate addiction treatment professionals on trauma. The article reviews the etiology and course of trauma a well as potential treatment options for working with trauma in substance abuse populations.

 Keywords: Trauma; Addiction; PTSD; EMDR; Treatment

PTSD: Post Traumatic Stress Disorder; EMDR: Eye Movement Desensitization and Reprocessing; TSY: Trauma - Sensitive Yoga

Clinicians working in the substance abuse treatment industry know how ubiquitous it is to encounter trauma when working with addiction. Trauma can take on manifold forms, and is typically understood to be the result of a major life-threatening event such as rape, molestation, child abuse, domestic abuse and combat. These types of trauma have come to be termed, “big T” traumas and are traumas many addicts their addiction itself has been a source of trauma and/or a way to relive other traumatic life experiences that would typically qualify an individual for a diagnosis of Post Traumatic Stress Disorder (PTSD). On the other hand, “little t” traumas are typically more common life events that most people wouldn’t consider disturbing. However, these “little t” traumas are causing high levels of distress similar to that of someone who had experienced a life-threatening event. Trauma is defined by an individual’s subjective emotional experience of the traumatic event, not by the severity of the event itself. Most people who experience life-threatening events never develop any long lasting symptoms and many people who experience more seemingly benign events may develop high levels of emotional distress and pathology. The dictionary defines trauma as any event that produces a lasting negative effect on that person.

With trauma being so prevalent in addiction treatment it’s surprising and concerning how little trauma is actually researched or addressed by addiction professionals. The widespread misconceptions about trauma and how it should be treated calls for greater education about trauma in the field of addiction treatment. The purpose of this article is to help provide addiction professionals with a better understanding of trauma in substance abuse populations. It is important to understand the relationship between addiction and trauma for many reasons first of all having a better understanding of trauma in addicted populations helps give professionals a better ability to identify the symptoms of trauma. Secondly, it helps give addiction professionals a sense of direction in how to best approach conceptualization and treating trauma in addicted individuals.

Trauma and substance abuse often co- occur because the use of substances offers the traumatized individual a vein (no pun intended) through with to detach and disassociate from the ongoing negative impact of the traumatic experience. In describing the relationship between trauma and addiction¹ states, “Hurt is at the center of all addictive behaviors,” (p.38). He goes on to state, “that stress and adverse experiences directly shape both the psychology and the neurobiology of addiction in the brain,” (p. 38). Therefore, it is more likely than not that an addicted individual has experienced a “big T” or “little t” trauma at some point in their personal history. Identifying trauma in addiction populations can be difficult. Many will never report their experience of trauma either because they don’t remember it, don’t want to remember it or don’t realize they have experienced trauma. In non-addicted populations the symptoms of trauma are harder to miss² describes observations from his early experiences working with VA patients and sexual abuse victims. Hesitates they reported nightmares and flashbacks and, “They also alternated between occasional bouts of explosive rage and long periods of being emotionally shut down. Most of them had great difficulty getting along with other people and had trouble maintaining meaningful relationships,”.² This description encapsulates almost every client one would encounter in addiction treatment. Usually, the rage, emotional numbness, and interpersonal struggles are attributed to symptomology of the substance abuse alone. Consequently, the underlying trauma is completely overlooked by the unenlightened addiction treatment professional.

 As prevalent as trauma is, most people that experience traumatic events do not become traumatized .postulates that what leads an individual to become traumatized is the impediment of their ability to act on the biological fight or flight instincts during or following a traumatic event³ describes trauma as human survival instincts frozen in a “nonverbal realm of human experience”. This means that during the traumatic event the body prepares for danger and the nervous system is activated to initiate a flight or flight response. However, if for whatever reason the traumatized individual is not able to act upon these instinctual drives (i.e. they are restrained), the impact of the traumatic event gets frozen in the brain and body in what⁴ terms “state-specific” form. Traumatized individuals appear to continue to experience the traumatic event(s) in the same cognitive and emotional state they where in when it occurred. They continue to relive and even seek out ways to experience trauma in a subconscious effort to see through the instinctual drives that were impeded during the initial trauma.

Many addiction treatment professionals take the “talking cure” approach to treating trauma despite research indicating this is not only ineffective but also re-traumatizing for the individual being treated. This isn’t to say that that talk - therapy isn’t useful in treating trauma. Talk therapy is a valuable tool, but the way it is commonly used with trauma suffers doesn’t maximize its efficacy.⁴ Posits that until the negative effect of the trauma is neurologically processed into a more adaptive form, the traumatized individual is unable to effectively integrate their work in traditional talk therapy. This often leaves clients feeling more stuck, intellectually “knowing” they should feel a certain way, but unable to feel it. The trauma response is a largely physiological process and information from the traumatic experience is stored in the body, brain and nervous system. The body’s response to stress (i.e the fight or flight response) is largely a process of the limbic system. During times of intense emotional arousal (i.e. fear, anger) activity in the Frontal Cortex decreases and activity in the Limbic System increases. The Limbic systems “takes over,” so to speak. The Frontal Cortex is responsible to what is referred to as higher-level thinking, attention, thought, voluntary movement, decision-making and language. The Limbic system is responsible for processing and regulating emotions, memory and sexual arousal. This part of the brain is also responsible for processing the body’s response to stress and is highly connected to the endocrine and autonomic nervous systems. Both of these systems play a large role in the fight or flight response, which is indicated in the trauma response.

The way the human mind and body responds to traumatic experiences is why traditional talk therapy has not had much efficacy in treating trauma. Talk therapy is more about higher-level cognitive processes that occur in the frontal parts of the brain. Trauma is rooted in instinctual survival responses processed in the Limbic System. Trying to talk someone through trauma is kind of like trying to reason with someone in a blackout rage. Their limbic system has “taken over” and the frontal cortex has left the building. The ability to reason isn’t available to someone in a black outrage or a panic. Likewise, this ability to reason isn’t available to traumatized individuals. Individuals suffering from trauma can often reason what they “should” be feeling or thinking about their traumatic experience, after the fact. However, they struggle to integrate that into what they are actually feeling. This is why many rape victims report knowing that they aren’t to blame for their rape but still feeling guilty. The part of their brain that “knows” isn’t able to communicate with the part that “feels” the trauma. For this reason many trauma researchers are saying that trauma treatment should involve processes that engage the Limbic System and enable traumatized individuals to integrate information about the trauma in a more adaptive way. This isn’t to say there is zero utility in talk therapy, but that talk therapy should be paired with other treatment modalities and not to be used when at the detriment of the client.

Trauma has strong roots in biological as well as psychological processes. Consequently, leading experts in the field of trauma have been working to develop mind- body approaches to trauma treatment. At present, one of the most widely researched modalities for trauma treatment is Eye Movement Desensitization and Reprocessing (EMDR). “EMDR therapy targets the unprocessed memories that contain the negative emotions, sensations and beliefs. By activating the brain’s information processing system (…) the old memories can then be ‘digested’ [4]. In other words, as the traumatic memories are processed through EMDR, new adaptive thoughts and feelings are integrated and dysfunctional thoughts and feelings associated with the trauma are discarded. EMDR was first developed in 1987 and has been widely investigated since its inception. Trauma - Sensitive Yoga (TSY) is another modality for trauma treatment that has recently received growing attention.⁵ Describes TSY as using breath and body forms to, “experiment with the purposeful direction of attention, to the body (p.7). TSY helps clients suffering from trauma reconnect with their body in a positive way. Describes several studies that have given support for the utility of yoga in treating trauma. Furthermore⁶ states that medication, biofeedback, EMDR, Yoga, Tai Chi, Qigong, acupuncture, and massage therapy can all be utilized in effectively treating trauma. Other treatment modalities called, Somatic Interventions, have been growing in popularity for use in trauma treatment. Somatic interventions are clinical interventions that specifically address or acknowledge the body in treating trauma. These models include TSY, the Hakomi method, sensorimotor psychotherapy, and Somatic Experiencing.

In summary, trauma is a complex phenomenon that incorporates physiological processes and mental processes to produce a subjective experience that varies greatly per individual. Trauma has a large physiological component so trauma experts have focused their efforts on understanding the physiological processes and developing treatment modalities that address those processes. The treatment modalities reviewed in this article are just a few of many such models found to be effective in treating individuals suffering from trauma. In addicted individuals trauma can be easily over looked, because many of the symptoms are misattributed to the client’s substance use history alone. Therefore, it is important for addiction professionals to be educated on how to identify and treat trauma. There appears to be a large deficit in the field of addiction treatment when it comes to understanding trauma in substance abuse populations. There is a great need for education on understanding how to identify and treat trauma in addicted individuals. This article provides a brief overview of current research, theory and treatment modalities used in trauma treatment. However, more comprehensive trainings and resources need to be made readily available to professionals in the field of addiction treatment. For more information about working with trauma sufferers see the reference section of this article.

 In summary, trauma is a complex phenomenon that incorporates physiological processes and mental processes to produce a subjective experience that varies greatly per individual. Trauma has a large physiological component so trauma experts have focused their efforts on understanding the physiological processes and developing treatment modalities that address those processes. The treatment modalities reviewed in this article are just a few of many such models found to be effective in treating individuals suffering from trauma. In addicted individuals trauma can be easily over looked, because many of the symptoms are misattributed to the client’s substance use history alone. Therefore, it is important for addiction professionals to be educated on how to identify and treat trauma. There appears to be a large deficit in the field of addiction treatment when it comes to understanding trauma in substance abuse populations. There is a great need for education on understanding how to identify and treat trauma in addicted individuals. This article provides a brief overview of current research, theory and treatment modalities used in trauma treatment. However, more comprehensive trainings and resources need to be made readily available to professionals in the field of addiction treatment.

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The author declares no conflict of interest.

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2. Levine P. In An Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley CA. North Atlantic Books, US; 2011.
3. Shapiro F. Eye movement desensitization and reprocessing: Basic Principles, Protocols, and Procedures. Perm J. 2001;18(1):71–77.
4. Shapiro F. Getting Past Your Past: Take Control of Your Life with Self-Help Techniques from EMDR Therapy. New York, USA: Rodale Inc.; 2012.
5. Emerson D. Trauma sensitive Yoga in therapy: bringing the body into treatment. New York, USA: W.W. Norton & Company Inc.; 2015.
6. Bessel VK. The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma. New York, USA: NY. Viking Adult; 2014.