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Beneath the Surface:. 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.

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Beneath the surface

Beneath the Surface:

Addressing Trauma & Substance Use

Presented By:

Sara L. Paxton LMSW/CAADC

Family Outreach Center

Today s objectives
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 issues.

The relationship

Trauma & SUD

The Relationship

  • As the number of traumatic events experienced during childhood increases, the risk for the following health problems in adulthood increases:

    • Depression

    • Alcoholism

    • Drug abuse

    • Suicide attempts

    • Heart, liver, and pulmonary diseases

    • Fetal death during pregnancy

    • High stress

    • Uncontrollable anger

    • Family, financial, and job problems

The relationship1

Trauma & SUD

The Relationship

SAMHSA April 2011: Childhood Trauma's Impact on Health Risks

The relationship2

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 experiences

  • CTE (Childhood Traumatic Events) Study

    • Reviewed CTEs and adult health problems and psychosocial functioning

    • 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 is Trauma?

  • What do you consider to be traumatic?

  • What makes something traumatic?

What is trauma1


What is Trauma?

  • Psychiatric Definition:

    • a. an experience that produces psychological injury or pain.

    • b. the psychological injury so caused.

  • Risks 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 trauma2


What is Trauma?

  • Common Traumatic Events

    • An unstable or unsafe environment

    • Separation from a parent

    • Serious illness

    • Intrusive medical procedures

    • Sexual, physical, or verbal abuse

    • Domestic violence

    • Neglect

    • Bullying

  • Commonly Overlooked Traumatic Events

    • Falls or sports injuries

    • Surgery (especially in the first 3 years of life)

    • Sudden death of someone close

    • A car accident

    • Breakup of a significant relationship

    • A humiliating or deeply disappointing experience

    • Discovery of a life-threatening illness or disabling condition

Historical trauma definition

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.

    • 1910-1930

    • 1931-1950

    • 1951-1970

    • 1971-1990

    • 1991-2010

African american population

Historical Trauma

African-American Population

  • 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 distrusted.

  • 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).

Native american population

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 worked.

  • 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.

Warning signs of use

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 problems.

  • 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).

Diagnosis dsm iv tr

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 distress

    • 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

Treatment modalities

  • TF-CBT

  • Strengthening Families Protective Factors

  • Somatic Experiencing

  • EMDR

  • Seeking Safety

Treatment Modalities

Tf cbt trauma focused cognitive behavioral therapy

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

Strengthening families protective factors

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 present:

    • Parental resilience

    • Social connections

    • Knowledge of parenting and child development

    • Concrete support in times of need

    • Social and emotional competence of children

Somatic experiencing

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.

Emdr eye movement desensitization reprocessing

Treatment Modalities

EMDR (Eye Movement Desensitization &Reprocessing)

  • Incorporates elements of cognitive-behavioral therapy with eye movements or other forms of rhythmic, left to right stimulation.

  • Back-and-forth eye movements are thought to work by “unfreezing” traumatic memories, allowing you to resolve them.

Seeking safety

Treatment Modalities

Seeking Safety

  • Seeking Safety is a present-focused therapy to help people attain safety from trauma/PTSD and substance abuse.

  • 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, self-care, and other issues).

Promising future modalities

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 communication.


  • Practical Interventions

    • Education

    • Relaxation

    • Grounding

    • Cognitive Exercises

    • Safety/Safe Coping Skills

    • Emotion Identification/Expression

    • Healthy Relationships

    • Exploring the Trauma

Culture specific


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 relationships.

    • Integrating culturally specific stories and proverbs can increase the family’s comfort level.

Cultural specific


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 African-Americans from the harmful effects of stress, poverty, depression, and traumatic oppression.

Cultural specific1


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 techniques.

    • The outcomes are feelings of renewed hope and challenge.

    • Recognize and celebrate the fact that many Natives believe that the good of tribe/group/family supersedes that of the individual.

Questions comments case studies

Trauma & SUD

Questions/Comments/Case Studies