The majority of clients with substance use disorder (SUD) have a concurrent traumatic stress disorder (Mate, 2010). The traumatic stress disorder often precedes the SUD (Wright, 2022).  Both disorders have unique triggers. The two disorders in combination can play off each other and lead persons with co-occurring disorders to slip through the cracks (Sanders, 2011). Slipping through the cracks involves going back and forth between SUD treatment, trauma treatment, prisons, jails, and mental health facilities without recovery. This can be exhausting and debilitating.

The interplay between PTSD and SUDs (two examples)

Ron

Ron's post-traumatic stress disorder (PTSD) developed when he returned from war. His symptoms included nightmares, difficulty falling and staying asleep, difficulty concentrating, intrusive thoughts, and flashbacks. Ron quickly discovered that opioids and alcohol temporarily reduced the impact of his PTSD symptoms, and he developed a SUD. Ron continued to use drugs for four years. His co-occurring disorder impacted his ability to sustain relationships and work. Ron completed a residential co-occurring disorders treatment program and remained in dual recovery (SUD and PTSD) for a year. One day he witnessed a bad car accident, and one of the cars in the crash went up in flames. Witnessing this, Ron experienced flashbacks from his days on the battlefield and returned to drug use to cope. Six months later he was readmitted to treatment.

Dana

Dana's SUD began when she was 14 years old after experiencing childhood sexual abuse. Through her teen years she primarily utilized marijuana, alcohol, and Xanax to medicate PTSD. By age 21 she started using crack cocaine and supported her SUD with money earned through prostitution and theft. After several arrests, Dana was referred to a drug court program that she successfully completed and was soon linked with 12-Step groups to maintain her recovery. Two years into recovery, Dana started a romantic relationship. In recovery, sex with her partner triggered traumatic memories of childhood sexual abuse, and shame returned. Dana returned to cocaine use, theft, and prostitution and was re-arrested.  

What if Ron and Dana had received help soon after their early traumatic experiences? Would they have developed PTSD and SUD? It is said that an ounce of prevention is more important than a pound of cure. This post focuses on strategies to prevent acute stress disorders from becoming PTSD and increasing the risk of developing a SUD.

Similarities and Differences Between Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder (PTSD)

ASD refers to the initial traumatic stress symptoms that arise immediately after a traumatic event. PTSD refers to the long -term aftermath of trauma. With ASD, the traumatic stress symptoms last less than a month. PTSD is diagnosed when the traumatic stress symptoms last a month or longer. Both conditions can affect social and occupational functioning, with PTSD having an impact for months or years and increasing the risk of an SUD (SAMHSA TIP 57, 2014). As it pertains to treatment, ASD often focuses on managing and alleviating symptoms during the acute phase. PTSD often involves more long-term therapeutic interventions.

Strategies to Decrease the Risk of ASD Becoming PTSD

Here are several recommendations for helping clients with ASD. Emphasizing client voice and choice throughout counseling is crucial (SAMHSATIP 57, 2014). These suggestions can be shared with clients to support their needs.

1. Early counseling soon after the traumatic event.
2. In counseling, it’s often helpful to brainstorm with the client about what will help them feel safe at home, in the community, and in counseling (Herman, 2015).
3. Utilize evidence-based practices, which have been found to be helpful in addressing acute stress disorder including, CBT and EMDR (Van Der Kolk, 2015).
4. You can introduce art and/or music therapy if the clients want alternatives to talk therapy and these approaches are aligned with your expertise as a counselor/therapist. They have been found to be effective recovery tools (Quinn, 2020). 
5. If the client has a strong support network, encourage them to seek support from their natural network.
6. Encourage sleep, rest, exercise, good nutrition, being in nature, and other self-care strategies.
7. Teach meditation and mindfulness practices. These approaches can help regulate traumatic stress symptoms when they emerge (Marich, 2023).
8. Encourage movement (e.g., walking, exercising, dancing, yoga etc.). Trauma lodges itself in the body, and movement has proven to be helpful in reducing its impact (Van der Kolk, 2015).
9. Help the client develop a survivor mission. Purpose contributes to healing (Frankl, 2014).
10. If the client has begun to use substances to deal with the trauma, it can be helpful to reframe the substance use as a coping mechanism and brainstorm with the client ways of coping with trauma, which are less likely to have negative consequences.

For years SUDs and traumatic stress disorders were addressed in separate silos. June is PTSD awareness month. Let’s make a commitment to address the conditions in an integrated manner. 

References

American Psychiatric Association (2022).Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC, pp 313-319

Frankl, V. (2014). Man's Search for Meaning. Beacon Press. Boston, MA.

Herman, J. (2015). Trauma and Recovery. Basic Books. New York, NY.

Marich, J. (2023). Trauma and the 12 Steps-The Workbook: Exercises and Meditations For Addictions and Trauma Recovery. North Atlantic Books. Berkeley, CA.

Mate, G. (2010). In The Realm of Hungry Ghosts: Close Encounters with Addiction. North Atlantic Books. Berkeley, CA.

Quinn, P. Art Therapy in The Treatment of Addiction and Trauma. Jessica Kingsley Publishers. London England, UK

SAMHSA TIP 57. (2014). Trauma-Informed Care in Behavioral Health Services.store.samhsa.gov

Sanders, M. (2011). Slipping Through the Cracks: Intervention Strategies for Clients with Multiple Addictions and Disorders. Health Communications Inc. Deerfield Beach, FL. 

Wright, E. (2022). The Connection Between Childhood Trauma and Substance Abuse: Heal from The Emotions to Overcome Addiction. Self-published, Evie Wright.

About the Authors

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Isa Vélez Echevarria, PsyD, is a Puerto Rican clinical psychologist. She is the Ohio State Project Manager for the Great Lakes Addiction, Mental Health, and Prevention Technology Transfer Centers managed by the Center for Health Enhancement Systems Studies at the University of Wisconsin-Madison.  During her pre-doctoral internship at Children’s Institute in Los Angeles, CA, she obtained a certification as Interpersonal Psychotherapy Clinician. She was trained in Trauma-Focused Cognitive Behavioral Therapy and Family Therapy. In addition, she provides telehealth services to communities of color in Massachusetts and Puerto Rico. Her clinical work has focused on culturally tailored and trauma-informed services to Latinx communities.

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Mark Sanders, LCSW, CADC, is the Illinois state project manager for the Great Lakes ATTC, MHTTC, and PTTC. He's an international speaker and behavioral health consultant whose presentations and publications have reached thousands throughout the United States, Europe, Canada, West Indies, Lithuania, and Guam. Hes the recipient of four lifetime achievement awards, including NAADAC’s prestigious Enlightenment Award, the National Association for Addiction Professionals’ 50^th Anniversary Legends Award, the Illinois Certification Board's Professional of the Year Award and Jessica Hayes Lifetime Achievement Award, and the Barbara Bacon Award for outstanding contributions to the social work profession as an alumnus of Loyola University.