Kimberly is a 37-year-old, Caucasian divorced female with a significant history of methamphetamine and alcohol dependence. She has a history of bipolar disorder with prior therapy and multiple psychiatrists. When she began therapy she had approximately one year of sobriety. Initially therapy began with describing her history of addiction and focusing on triggers, and with time, she began to reveal a history of trauma including abuse as a child. With more sessions, even more trauma was revealed, adding more  layers to the counseling sessions. She would avoid direct questions about the trauma and divert back to the addiction, stating that is why she is in treatment, not the trauma. 

Where do you start or how do you approach a client like Kimberly? Many mental health providers fail to recognize the impact of violence on an individual or the possibility of it contributing to substance abuse. When completing an initial assessment, practitioners should inquire about any history of violence or substance abuse. Often the clinician does not recognize the link between the substance abuse and trauma.

A client can present to a service provider and self-report multiple symptoms, yet none appear to be trauma-specific. Standard approaches to mental health and substance abuse treatment can re-
traumatize women who have experienced violence, which can set back their recovery or even cause them to refuse care (Jahn Moses, D., et al., 2003). It is important that providers understand and recognize the impact of trauma. Specifically, when a female client seeks treatment it is essential for her recovery that the counselor know how to work with an individual who has a history of trauma and substance abuse. 

What is trauma? 

According to the American Psychiatric Association - DSM IV (1994):

"trauma is the exposure to an extreme stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member of close associate."

Traumatic events can include physical, psychological and sexual abuse, domestic violence, witnessing violence against others, and accidents. According to the American Psychological Association (APA), approximately one-half (50 percent) of all individuals will be exposed to at least one traumatic event in their lifetime. Research indicates that women are twice as likely to develop Post-traumatic Stress Disorder (PTSD), and that they will have a longer duration of post-traumatic symptoms (APA, 2006). Also, they may display more sensitivity to stimuli that remind them of the trauma (APA, 2006). "Between 50 and 70 percent of women hospitalized for psychiatric reasons - 70 percent of those seen in emergency rooms, and 40 to 60 percent of psychiatric outpatients - report having experienced physical or sexual abuse (Jahn Moses, D., etal, 2003). "Fifty-five to 99 percent of women substance abusers report being victimized at some point in their lives (Jahn Moses, D. et al., 2003)." 

With approximately 10 million adults in the United States experiencing alcohol, drug abuse, or mental health disorders, the societal impact of co-occurring disorders is considerable (Regier, D.A., Farmer, M.E., & Rae, D.S., 1990). Specifically, for women, research has demonstrated that 48 percent to 90 percent of those women with mental health and substance abuse disorders also have histories of interpersonal abuse (Lipschitz, D.S., Kaplan, M.L. & Sorkenn, J.B., 1996).  In addition, sexual violence increases risk for substance abuse, alcohol dependency, problem drinking and alcohol-related difficulties (Kaukinen, C. & DeMaris, A., 2005). 

According to Jahn Moses, et al., (2003) women with abuse histories and trauma symptoms may face a range of mental health issues including:

• Anxiety
• Panic disorder
• Major depression
• Substance abuse and dependence
• Personality disorders
• Dissociative disorders
• Psychotic disorders
• Somatization
• Eating disorders
• Post-traumatic stress disorder

"At a minimum, experiences of abuse may increase the risk of substance abuse or mental health problems; substance abuse and mental health issues may put women at greater risk of victimization; and substance abuse and other self-
injurious behaviors may result from underlying trauma issues" (Jahn Moses, et al., 2003). The effects of trauma are not limited to the direct recipients. Women who are victimized as children frequently end up losing custody of their own children due to allegations of abuse or neglect; more than 50 percent of child abuse and neglect cases involve parental alcohol or drug abuse (Stevens, S. & Arbiter, N., 1995).

If a service provider is working with a female client and is unaware of previous trauma suffered by the client, it is possible for the client to suffer retraumatization. For example, according to Jahn Moses, et al. (2003), an unaddressed trauma history can result in a woman resorting back to drug use to manage her anxiety and flashbacks. If this is understood only as a relapse and/or a lack of commitment to sobriety, neither staff nor the woman will make the connections necessary to assist her in developing other means of coping with or reducing the symptoms of trauma (Jahn Moses, et al., 2003). 

The relationship among mental illness, substance abuse, and violence is complex. Most substance abuse counselors are aware of victims using alcohol or drugs to self medicate or escape. The counselor should focus on the client recognizing the purpose of the need to escape. Frequent self-medication may eventually lead to physical or psychological dependence on alcohol or drugs. The order of the events can vary, which can make it difficult for the counselor to know which came first or where to start. Ideally, both mental health problems and substance abuse should be treated simultaneously. For any substance abuser, however, the first step in treatment MUST be detoxification - a period of time during which the body is allowed to cleanse itself of alcohol or drugs. 

Another difficulty with this population is the ability to gain their trust. A counselor is faced with an even greater challenge when working with clients who have a history of trauma, or who have had bad experiences with multiple service providers who were not trustworthy. The client may have attempted therapy several times and/or have had a bad treatment experience. Many trauma survivors have been silenced due to service providers and systems misdiagnosing and mistreating them. 

Screening and assessment

Trauma survivors often live their lives and may not fully recognize trauma as a source of their struggles. For many women, their first abuse occurred when they were children or adolescents. As a result, it can take numerous sessions for a client to fully reveal the extent of the trauma that she has experienced. Trauma survivors often do not trust service providers and feel that they will not understand what they have experienced. 

It is the counselors' responsibility to accurately screen and assess clients, and provide the best quality of care. Basic therapeutic tools such as establishing rapport and conducting a thorough assessment, are the foundations of working with this challenging population. "Healing is a process of growth in which, by increasing understanding of the impact and repercussions of trauma, the survivor begins to expand her perspective and options for making choices" (Mazelis, R., 2003). It is crucial that a woman direct her own healing process and not be stigmatized, punished or retraumatized for her choices (Mazelis, R., 2003). 

It may be helpful for a survivor to share experiences with a service provider who can assist in developing a plan to address these struggles comprehensively. When faced with a complex client, the first goal should always be safety and security. When a client feels safe and secure with the counselor, she is more likely to be honest about any substance use. It is not until the client feels the clinician is trustworthy and "safe" that she will begin to reveal details or disclose the extent to which she was victimized. This initial focus of safety and security is just the beginning not the ONLY focus of treatment.

Each individual client is unique and there is no one way to treat a client. According to the Substance Abuse and Mental Health Services Administration (SAMSHA), there are useful skills that the counselor can implement with a client to aid help in developing healthy coping mechanisms (2005):

Listen. Encourage the survivor to talk about the experience, when he or she is ready. This will help acknowledge and validate what has happened, and can reduce stress and feelings of isolation. Let the client take the lead, and try not to jump in with too many questions/comments right away.

Research. If the victim wants more information, would like to report a crime, or has other questions, the counselor can help find answers and resources.

Reassure. As strange as it may sound, survivors often question whether an incident was their fault or what they could have done to prevent the crime against them. They need to hear that it was not their fault and be assured that they are not alone.

Empower. Following trauma, victims can feel as though much of their lives are beyond their control. 

Be patient. Every journey through the healing process is unique. Try to understand that it will take time. The healing process has no pre-determined timeline.

Mental health, substance abuse and trauma are often addressed by separate providers even when the best treatment could be accomplished if they were addressed simultaneously. The primary goal of treatment should be to place the woman in control of her treatment goals and evaluation of progress. The focus of treatment should be on giving the victim or survivor her power back, so that she can learn to develop healthy coping mechanisms. If there is a history of chemical dependency, a primary goal must be to maintain sobriety. It may be necessary to refer the client to local self-help groups such as Alcoholics Anonymous (AA) to help maintain sobriety, while addressing the trauma-related symptoms.

With the co-occurrence of sexual assault, problem drinking, and substance abuse among women, it is imperative that clinical approaches address these interrelated issues and tailor interventions to the victims who are at the most risk for long-term health consequences (Kaukinen, C. & Demaris, A., 2005). According to a recent study conducted by SAMHSA (2005), the most effective way to combat trauma, substance abuse, and mental problems is through an integrated, holistic approach, taking into account how each individual problem affects the others.

"Current service delivery systems are woefully inadequate in identifying and meeting the needs of women affected by trauma, mental health and substance abuse" (Jahn Moses, et al., 2003). Regarding the Surgeon General's Workshop on Women's Mental Health, it was recently cited that "more communication about trauma, making professionals aware of the signs of trauma and how it comes about" is vital for the recovery of women (Pace, 2006). Women suffer severely as a result of a service provider or agency that does not provide appropriate, integrated services. Trauma survivors often cycle in and out of treatment for years, using numerous resources without experiencing any improvement (Jahn Moses, et al., 2003). The client's problem should be prioritized, with the most severe, threatening and disruptive symptoms addressed first (Foa, E. & Rothbaum, B., 1998). 

Substance abuse needs to be addressed before the PTSD, because "the substance abuse will inhibit the necessary emotional processing" to aid in recovery (Foa, E. & Rothbaum, B., 1998). After sobriety is maintained, the trauma-related symptoms should be addressed. Cognitive Behavioral Techniques (CBT) have been found to be effective in addressing flashbacks and related triggers (Foa, E. & Rothbaum, B., 1998). As a counselor working with a substance abuse population it is essential to understand, research, and learn how to effectively treat women with a trauma history.  It is necessary, as a counselor, to keep skills up to date and to work with populations where you are competent.  It is essential to her recovery to learn that she is not a victim but, empower her to be a SURVIVOR!

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychological Association. (n.d.) Facts About Women and Trauma. Retrieved April 30, 2006 from  http://www.apa.org/ppo/issues/womentraumafacts.html

Foa, E. & Rothbaum, B. (1998). Treating the Trauma of Rape: Cognitive Behavioral Therapy for PTSD. New York, NY:Guilford Publications.

Jahn Moses, D., Reed, B.G., Mazelis, R., & D'Ambrosio, B. (2003). Creating trauma services for women with co-occurring disorders: Experiences from the SAMHSA women with alcohol, drug abuse and mental health disorders who have histories of violence study. Delmar, NY: Policy Research Associates (Women and Violence Coordinating Center).

Kaukinen, C. & DeMaris, A. (2005). Age at First Sexual Assault and Current Substance Use and Depression. Journal of Interpersonal Violence, 20 (10), 1244 -1270.

Lipschitz, D.S., Kaplan, M.L. & Sorkenn, J.B. (1996). Prevalence and characteristics of physical and sexual abuse among psychiatric outpatients. Psychiatric Services. 47(2), 189-191

Mazelis, R. (2003). Understanding and responding to women living with self-inflicted violence. Women, Co-Occurring Disorders & Violence Study Fact Sheet. Retrieved February 21, 2006. from http://www.prainc.com/wcdvs/publications/default.asp

Pace, P. (2006).Women's Mental Health - Surgeon General Gathers Input from meeting. NASW News, 51, 2.

Regier, D.A., Farmer, M.E., & Rae, D.S. (1990). Co morbidity of mental disorders with alcohol and other drug use: Results from the epidemiological catchment area (ECA) study. Journal of the American Medical Association. 264: 2511-2518.

Stevens, S. & Arbiter, N. (1995). A therapeutic community for substance-abusing pregnant women and women with children: Process and outcome. Journal of Psychoactive Drugs, 27, 49-56.

U.S. Department of Health and Human Services - Substance Abuse and Mental Health Services Administration (SAMHSA). (April 2005). Supporting the Survivor. Retrieved February 21, 2006, from http://mentalhealth.samhsa.gov/publications/allpubs/SMA05-4028/victimforprint.asp

This article is published in Counselor,The Magazine for Addiction Professionals, December 2006, v.7, n.6, pp.12-17.

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