The provision of trauma-informed care in AOD treatment settings is essential and described in more detail in Chapter B2. Given that substances are often used to self-medicate trauma-related symptoms [30], it is not surprising that many people report experiencing an increase in trauma-related symptoms when they reduce or stop using substances [380]. Evidence to date however, indicates that, as with symptoms of depression and anxiety, on average, PTSD symptoms also decline in the context of well managed withdrawal [381–383].
As described in Chapter B2, it is important to note that avoidance symptoms, rather than reexperiencing symptoms, have been associated with the perpetuation of trauma-related symptoms [398, 1287–1291]. It is therefore crucial that if a person does experience an exacerbation of trauma-related symptoms, that they are not encouraged to avoid or suppress these thoughts or feelings. Telling a person not to think or talk about what happened may also intensify feelings of guilt and shame. For those who have experienced abuse, it may closely re-enact their experience of being told to keep quiet about it [136]. This does not mean that clients should be pushed to revisit events or disclose information if they are not ready to do so. Rather, it means that it is understandable that the person may be upset by these thoughts and feelings that may arise, and they should be allowed to engage with these feelings in order to help process the trauma emotionally.
Chapter B3 provides guidance on how to discuss trauma with clients. As mentioned previously, it is crucial that clients are not forced to discuss any details about past events if they do not wish to. It is preferable that clients develop good self-care and have skills to regulate their emotions before they delve deeply into their traumatic experiences or are exposed to the stories of others; however, choice and control should be left to the client [136]. In-depth discussion of a person’s trauma experiences should only be conducted by someone who is trained in dealing with trauma responses [135].
Even without knowing the details of a client’s trauma, AOD workers can use the techniques outlined in Table 52 to help clients manage their symptoms. Encouraging clients for their resilience in the face of adversity is important even if past adaptations and ways of coping are now causing problems (e.g., AOD use). Understanding AOD use as an adaptive response reduces the client’s guilt and shame and provides a framework for developing new skills to better cope with symptoms [384].
Table 52: Dos and don’ts of managing a client with trauma-related symptoms
| Do: |
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Give the client your undivided attention, empathy and unconditional positive regard.
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Use relaxation and grounding techniques where necessary.
|
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Display a comfortable attitude if the client chooses to describe their trauma experience.
|
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Normalise the client’s response to the trauma and validate their feelings.
|
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Recognise the client’s resilience in the face of adversity.
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Recognise the client’s courage in talking about what happened.
|
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Let the client know what to expect if they undergo detoxification (e.g., possible changes in trauma-related symptoms).
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Maximise opportunities for client choice and control over treatment processes.
|
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Monitor depressive and suicidal symptoms.
|
| Don't: |
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Rush or force the client to reveal information about the trauma.
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Engage in an in-depth discussion of the client’s trauma unless you are trained in trauma responses.
|
|
Judge the client in relation to the trauma or how they reacted to the trauma.
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Abruptly end the session.
|
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Encourage the client to suppress their thoughts or feelings.
|
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Engage in aggressive or confrontational therapeutic techniques.
|
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Be afraid to seek assistance.
|
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Use overly clinical language without clear explanations.
|
Adapted from Ouimette and Brown [1292], Elliot et al. [384], SAMHSA [102], Marsh et al. [135], and Mills and Teesson [136].
Brief psychoeducation about common reactions to trauma and symptom management has also been found to be of benefit to AOD clients who have experienced trauma [1293]. It is important to normalise clients’ feelings and convey that such symptoms are a typical and natural reaction to an adverse traumatic event; they are not ‘going crazy’. Letting them know that their reactions are quite normal may also help to alleviate some of the shame and guilt they have been feeling about not recovering from the trauma sooner. It is also important that people who have experienced trauma hear that what happened was not their fault, especially for those who have experienced sexual assault. An information sheet for clients on common reactions to trauma is provided in the Worksheets section of these Guidelines. Clients may also find the relaxation techniques described in Appendix CC useful for managing trauma-related symptoms. Many common procedures and practices may re-trigger trauma reactions. For example, aggressive or confrontational group techniques can trigger memories of past abuse. Such techniques are counterproductive; those who have been exposed to abuse in particular may revert to techniques used to cope during the trauma such as dissociating or shutting down emotionally. Engaging in these strategies may then lead to the client being labelled as ‘treatment resistant’ and, consequently, feelings of self-blame. Chapter B2 also provides guidance on other aspects of service provision to consider in providing a trauma-informed approach to care.
As discussed in Chapter B8, it is also essential that workers attend to their own responses to working with traumatised clients through self-care. Hearing the details of others’ trauma can be distressing, and in some cases may lead to vicarious traumatisation or secondary traumatic stress [404, 1294]. By attending to one’s own self-care and engaging in clinical supervision, the likelihood of developing secondary traumatic stress may be reduced. Chapter B8 provides more detail on strategies for promoting and enhancing AOD worker self-care and reducing burnout.