Chapter Fourteen – Intervening in Maladaptive Substance Use
As noted at various points in this treatment guide, substance use and abuse (SUA3) is a relatively common problem among abused adolescents.
Youth with trauma histories, perhaps especially those exposed to severe child abuse, often suffer from not only posttraumatic stress, but also diminished affect regulation capacities. This combination of sustained psychological pain and few internal methods of dealing with it frequently lead to external avoidance responses, including SUA. Although drugs or alcohol can temporarily numb distress, they are obviously not long-term solutions, and often create problems of their own. Most relevant to trauma recovery, SUA can interfere with trauma processing (Briere & Scott, 2012) and produce chronicity in both domains: unresolved posttraumatic symptoms and ongoing SUA, if not addiction.
As indicated by the Problems-to-Components Grid (see Chapter 3), ITCT-A offers several treatment components that the literature indicates are helpful in treating substance use problems. However, clinicians have noted the need for adaptation of ITCT-A components for young trauma survivors who also have SUA issues. This chapter outlines these various adaptations of ITCT-A, especially calling upon the work of Lisa Najavits, Ph.D., who has developed the Seeking Safety model (Najavits, 2002) – an intervention package specifically designed to assist trauma survivors involved in SUA.
As Najavits notes (2007), Seeking Safety was designed to be used alongside other treatments, as needed. Given the many overlaps between Seeking Safety and ITCT-A (e.g., flexibility of administration; few screening requirements; allowance for comorbidity; multiple components; psychoeducation; focus on safety, empowerment, and cultural sensitivity), there is little question that Seeking Safety is an effective add-on for adolescents undergoing ITCT-A. For this reason, we recommend that adolescent trauma survivors involved in significant SUA receive ITCT-A and concurrently attend Seeking Safety groups, if possible. In some cases, however, this cannot occur, because no Seeking Safety programs are in operation near the survivor’s home, the client does not want to attend an explicitly SUA-related program, or there is a long waiting list. Given such barriers, the remainder of this chapter describes special issues and interventions that can be used when applying ITCT-A, most of which are central aspects (or at least compatible components) of Seeking Safety.
Special Recommendations for Adolescents Involved in SUA
When working with adolescent trauma survivors with serious SUA issues, we suggest the following:
Do not screen out the majority of substance abusers, or terminate treatment because of relapse back into SUA
The usual clinical recommendation is that substance-abusing clients should be drug and alcohol abstinent before undergoing trauma therapy. This is because those abusing drugs or alcohol traditionally do not do that well in trauma treatment; both because the numbing effects of substances may interfere with the processing of trauma memories in therapy, and because heavy substance use is often associated with poor treatment compliance and attendance. Although these concerns are valid, the sobriety requirement is problematic for many clients, including traumatized adolescents, who may be quite reluctant to discontinue the use of agents that successfully numb distress. In addition, especially in underserved environments, substance abuse treatment programs are often hard to find, not always of high quality, and waiting lists are generally long. The frequent unavailability of substance abuse treatment programs for adolescents living in marginalized social contexts can mean an absence of trauma therapy when abstinence is a requirement.
For these reasons, ITCT-A encourages clients to avoid significant SUA, but in most cases (i.e., as long as the client is not severely addicted) does not require it – the youth is “taken as he or she is” and assisted within the constraints of what he or she will accept or tolerate. In our experience, youth who abuse alcohol or regularly use “hard core” drugs (e.g., cocaine or methamphetamine) have a harder time attending and using trauma-focused treatment, but may, nevertheless, benefit if treatment is customized for their specific issues and requirements. Such treatment is often slower going, and the effects of SUA become additional treatment targets. However, there is little reason to “give up” on substance using youth, or terminate treatment because the client has relapsed back into drugs or alcohol. In many cases, trauma survivors’ involvement in drugs or alcohol is, in fact, partially due to trauma exposure, and trauma therapy may eventually reduce or eliminate their reliance on psychoactive substances. The remainder of this chapter outlines some principles that may increase the likelihood of successful treatment.
Treat trauma symptoms and SUA concurrently
When ITCT-A is used with substance involved adolescents, it is important to address both trauma symptoms and drug-related issues at roughly the same time. Focusing just on SUA, alone, may delay needed trauma interventions, whereas attempting trauma treatment without attending to SUA may easily overwhelm the client and/or neutralize trauma treatment. In fact, the exposure component of ITCT-A (Chapter 10), if not tempered by SUA treatment principles, may reinforce or even encourage drug or alcohol abuse as the client attempts to avoid activated trauma memories. Fortunately, several ITCT-A treatment components (e.g., trigger identification/intervention and affect regulation training) are helpful in both SUA and trauma domains, and can be tailored to either set of problems at any given moment in therapy.
How trauma treatment and intervention in SUA are applied in the same session varies from client to client. However, it is generally recommended that the therapist and client explicitly connect the two problems: exploring ways that SUA has been used as a defense against overwhelming trauma-related distress, as well as the fact that SUA, itself, may increase the likelihood of further trauma, creating a vicious cycle. As well, when discussing ways not to act on urges that result in substance use, it may be helpful for the client to consider trauma-related triggers (e.g., through use of the Trigger Grid) in his or her environment that make drinking or drug-taking more likely. Overall, the focus and message should be that the youth’s trauma symptoms and SUA are interconnected, such that therapeutic attention to either almost inevitably includes the other.
Focus initially on stabilization and coping
One of the ways in which trauma therapy is especially modified for those involved in SUA is in the area of stabilization; most traumatized adolescents who drink excessively or frequently use psychoactive drugs have problems with affect regulation, as noted in Chapter 7. Further, significant SUA may be associated with a chaotic lifestyle, tumultuous relationships, involvement in other risky behaviors, and exposure to dangerous people or circumstances during the process of getting money for, acquiring, or using drugs. The combination of a reduced ability to “handle” emotions without becoming overwhelmed and the typical sequelae of SUA means that the substance using trauma survivor is often in crisis, psychologically and/or physically unsafe, and prone to “acting out” or self-harm behaviors when stressed – which may be much of the time. For this reason, ITCT-A for such clients especially involves the relationship-building, safety focus, affect regulation training, and titrated exposure described in Chapters 4 through 10. Also important will be psychoeducation, as presented in Chapter 6, so that the client has the opportunity to see the connections between trauma and SUA, recognize common triggers for both trauma memories and the urge to use drugs or alcohol, be aware of community resources (including self-help and 12-step-like groups), and, in general, have access to information that normalizes his or her experience and reduces feelings of guilt and shame about what are, ultimately, coping responses. See Najavits (2002) for the many ways in which cognitive interventions, coping skills development, and psychoeducation can be used to help trauma clients involved in SUA.
Importantly, although treatment should include attention to both trauma and SUA issues, therapeutic exposure to trauma memories, as described in Chapter 10, should not occur before the client is stable and has adequate coping capacities. Indeed, in most cases, treatment should initially emphasize the stabilization components described above, with therapeutic exposure to trauma memories occurring later, once the client is sufficiently safe and able to tolerate activated trauma memories. Some exposure will almost always occur, however, whenever the client refers to his or her trauma history. When this happens early in treatment, when the client is still involved in major SUA and is not yet stable enough for sustained emotional processing, we recommend, like Najavits (2007), that the client’s trauma disclosures be acknowledged and received as important parts of treatment, but with some sort of communication that such processing should happen to a greater extent later in therapy when the client is more able to accommodate it. Again, this does not mean that the client is discouraged from discussing traumatic things from the past, only that such disclosures do not result in extended discussions or processing until it is appropriate to do so. This balance of honoring and validating the youth’s desire to talk about trauma, which, in fact, is an important component of connecting his or her past to her current SUA (and other) problems – and yet not processing this material in depth too early in treatment – is part of the art of good therapy, ITCT-A or otherwise.
Avoid confrontation
Although less prevalent now than in the past, it is still not uncommon to hear of the use of confrontation in the treatment of substance abusers. This typically involves confronting the individual with their denial or misrepresentation of their SUA and/or its impacts on the person or those around him or her. In contrast, there is no real place for this modality in ITCT-A. From our perspective, confrontation presents several problems, as it (1) may easily increase, not decrease the youth’s defenses and avoidance, since it can be seen as shaming, aggressive, or disconfirming; (2) implies that the client is voluntarily engaging in a bad behavior that, upon being revealed for what it is, can be simply terminated; (3) is seemingly the antithesis of the support, caring, and compassion that is considered a core relational aspect of ITCT-A, and (4) may adversely affect the therapeutic relationship. Rather than using confrontation, the clinician should help the client to understand the etiology of SUA, especially as it involves posttraumatic coping, and communicate appreciation of what the client is “up against” in terms of trying to self-medicate overwhelmingly negative internal states. From this perspective, the role of the therapist is to work with, not against, the adolescent, and to help the youth to do what he or she often wants to do – to decrease or terminate SUA while, at the same time, being able to survive trauma-related distress. The result, ideally, is to problem-solve, not to create an adversarial relationship.
Focus on empowerment
SUA can sometimes deplete the adolescent’s sense of autonomy, because what he or she is facing (trauma) does not seem to get better, and his or her solutions (SUA) create problems of their own that seem unresolvable, such as addiction, exposure to violence or exploitation by others, declining interpersonal and social functioning, medical issues, possible arrest and incarceration, and increasingly lower self-esteem. The various components of ITCT-A, for example trigger identification, affect regulation training, and mindfulness, on the other hand, focus on skills the youth can develop to increase self-control and his or her capacity to affect life outcomes. Often this perspective helps the client to feel like an active participant in therapy, as opposed to a passive receiver of treatment.
Overall, an overbridging philosophy of treatment in ITCT-A, regardless of whether or not it is focused on SUA, is that the client is an equal partner in treatment, and that one of the goals of therapy is greater self-efficacy. This perspective is often appreciated by youth who do not trust authority and expect that letting one’s guard down means revictimization. Although the relational aspects of ITCT-A can help to reduce these concerns, the fact that this approach increases self-control and teaches psychological skills may make it easier to initially accept by adolescents who feel alienated and distrustful of psychotherapy, per se.
Reinforce idealism and hope
As Najavits (2002) notes, treatment for the joint effects of trauma and SUA may be more effective to the extent that it is “idealistic,” encouraging the trauma survivor to aspire to a more positive future and regain a sense of hope. Many trauma exposed youth, including those involved in SUA, have been demoralized and view themselves as unworthy and their future as essentially hopeless. To the extent that therapy reinforces the notion that the client is essentially good, not bad, and helps the youth to identify and further develop self-attributes like courage, concern for others, and morality, it can confer self-esteem and self-compassion that otherwise might be illusive. Sometimes this is hard; the client involved in drug-related prostitution or gang-related activity, or the adversarial dynamics sometimes found among the homeless, may have a difficult time noticing things he or she nevertheless did that were idealistic, such as helping a friend, worrying about someone’s well-being, protecting or standing up for someone, or sharing food, shelter, or advice4. As the notion of being a “good person” and caring for others – regardless of one’s victimization history and whether one has done “bad things” – more deeply permeate the adolescent’s perspective and becomes an explicit goal for the future, self-esteem and hopefulness may accrue.
Also relevant to traumatized youth, whether involved in SUA or not, is the notion of posttraumatic growth – the phenomenon whereby trauma not only confers negative states and problems, but also can make a person stronger, wiser, and more aware of what is important in life (Tedeshi & Calhoun, 2004). Many traumatized youth believe that their experiences of childhood sexual abuse or peer assaults have permanently corrupted or diminished them, leading to feelings of shame, implicit badness, and unacceptability – responses that can be exacerbated by chronic substance abuse. To the extent that the therapist helps the client identify ways in which he or she triumphed over victimization by, for example, gaining survival skills or being more able to empathize with others who have been hurt, there may be an opportunity for shame or self-invalidation to be contradicted.
When appropriate, titrate exposure to trauma memories
When the client with SUA issues is sufficiently stable, the emotional processing component of ITCT-A may be initiated, albeit carefully. As noted in Chapter 10, the sometimes limited affect regulation capacities and ongoing challenging circumstances experienced by young trauma survivors means that therapeutic exposure, usually involving discussion of traumatic events, must be carefully titrated. If the youth exceeds the “therapeutic window” by experiencing more trauma-related distress than he or she can accommodate, the result may be further traumatization and avoidance. These concerns are especially heightened for traumatized youth involved in SUA, who, by definition, are likely to especially suffer problems with emotional regulation.
For this reason, the dictum “start low, go slow” is particularly applicable. In general, we advise that, even after stabilization has occurred, clients with both trauma and SUA issues be encouraged to discuss their victimization histories in small “chunks,” and that the clinician use the principles outlines in Chapters 3 and 10 to make sure that the client’s therapeutic window is not exceeded. As indicated in these chapters, the clinician should be emotionally attuned to the client so that any evidence of overwhelming internal states can be addressed by reduced exposure, grounding activities, or a switch to more cognitive material. This is not to say that emotional processing should not occur. When the client is ready, it is a very important component of trauma therapy. The issue is, instead, the timing, pace, and intensity of that work. When these issues are not attended to sufficiently, the outcome may be an emotionally overwhelmed client who, in fact, may become more involved in SUA as a way to downregulate therapy-related distress.
Expect and control countertransference
A final issue associated with working with youth who have trauma histories and SUA has to do with the clinician, not the client. For any therapist, exposure to the stories and pain presented by trauma survivors can be challenging. Repeatedly being faced with the cruelty people can do to each other, let alone to children, understandably can produce strong reactions. This is especially the case if the clinician, himself or herself, has an unresolved trauma history.
Unfortunately, traumatized adolescents with SUA are sometimes even more likely to activate strong emotional states in the therapist. Among the issues that may arise are impatience and, in some cases, a sense of helplessness. SUA is not an easily treated problem, and the client’s struggle with drugs or alcohol may continue into the longer-term. SUA may wax and wane over time, and may frustrate both client and therapist as it interferes with trauma therapy and leads to unwanted outcomes. Or, the client may develop several months of sobriety, only to “fall off the wagon” for reasons that may or may not be apparent. The guilt, shame, and low self-esteem often associated with SUA, let alone trauma, may be, to some extent, contagious, as the therapist’s attunement and hopes for the client can inadvertently lead him or her to blame the client for SUA or SUA relapses. Feelings of helplessness may lead to frustration with, or anger at, the youth. The clinician may retreat to an overly authoritarian or pathologizing stance in an effort to maintain control or deal with his or her own emotional responses.
These various issues must be consistently monitored by the therapist. Although strong countertransference in this area should be addressed by regular, formal consultation and/or one’s own therapy, it is nevertheless true that some feelings of helplessness, hopelessness, sadness, and frustration are almost inevitable when treating traumatized, SUA-involved youth. For this reason, it is very important that the therapist have others to turn to when working with this population. In general, we suggest a regular consultation group, or even just regular access to informed, supportive colleagues with whom the clinician can share the load of this challenging but important, work.