Substance use and abuse (SUA) is a common and serious problem for adolescents. Although the rate of SUA among young people appears to be declining, approximately 50 percent of youth still report having used illegal drugs by the time they leave high school, including 25 percent who have used drugs other than marijuana such as hallucinogens, cocaine or ecstasy (Johnston, O’Malley, Miech, Bachman, & Schulenberg, 2014). Similarly, over 20 percent of high school seniors report “binge drinking” within the past two weeks (Johnston et al., 2014).
As concerning as these numbers are, SUA is even more common among adolescents with a history of trauma. In the National Survey of Adolescents (Kilpatrick, Saunders, & Smith, 2003), for example, youth who had experienced physical or sexual victimization were three times more likely to report past or current substance abuse than those without a trauma history.
The relationship between trauma and SUA is complex. Many traumatized youth also experience social marginalization through poverty and various forms of discrimination—phenomena that can increase the likelihood of trauma exposure and add to or intensify the effects of victimization (Breslau, Wilcox, Storr, Lucia, & Anthony, 2004). Furthermore, early trauma appears to interfere with the development of affect regulation capacities, meaning that the trauma survivor has fewer internal mechanisms available to deal with triggered or ongoing emotional distress (Giaconia, Reinherz, Paradis, & Stashwick, 2003).
This combination of psychological pain, the effects of social stressors, and few internal methods of dealing with negative emotional states—often referred to as “complex trauma” (see Briere & Lanktree, 2011)—can lead to potentially maladaptive avoidance responses, including SUA (Briere, Hodges, & Godbout, 2010). However, although drugs or alcohol can temporarily numb and distract from distress, they are not long-term solutions and lead to problems of their own. Beyond the direct effects of addictive drugs, SUA can interfere with emotional processing of posttraumatic stress (Cohen, Mannarino, Zhitova, & Capone, 2003), potentially producing chronicity in both domains: unresolved trauma-related symptoms and ongoing SUA. As a result, there may be two related goals in the treatment of substance-using trauma survivors: a reduction of trauma-related disturbance including anxiety, depression, and posttraumatic stress; and specific interventions to address risky or problematic avoidance behaviors, including SUA.
The contributions of both high posttraumatic stress and low affect regulation capacity to the development of dysfunctional avoidance suggest two pathways in the treatment of SUA-involved trauma survivors. First, clinical interventions that promote cognitive and emotional processing of traumatic stress—such as cognitive behavioral therapy (CBT)—can be quite helpful in the treatment of young trauma survivors (Cohen, Mannarino, & Deblinger, 2006), including those who report SUA (Cohen et al., 2003). Second, recent clinical research suggests that interventions that increase affect regulation capacities can have, as theory suggests, an effect on SUA and other forms of dysfunctional emotional avoidance (see Axelrod, Perepletchikova, Holtzman, & Sinha, 2011).
Although much has been written on cognitive behavioral approaches to adolescent trauma, there is less information available to the clinician on affect regulation interventions. This is potentially problematic, since, as noted above, research highlights the value of this second pathway in treating those with significant SUA. For example, increased internal capacity to tolerate and regulate intrusive traumatic stress responses is likely to reduce the need for external methods, such as SUA or other maladaptive avoidance strategies.
In a similar vein, some traumatized clients may not be able to engage one of the most powerful aspects of CBT (therapeutic exposure) prior to their development of sufficient affect regulation capacity (Cloitre, Cohen, & Koenen, 2006). Therapeutic exposure typically involves the triggering and processing of painful, emotionally charged memories such as intense fear or disgust, a process that may not be available to some survivors until they have developed the affect regulation repertoire necessary to tolerate such emotional activation.
Integrative Treatment for Adolescents
In light of the importance of affect regulation in the treatment of traumatized youth, especially for those experiencing the additional burden of SUA, this article briefly reviews two relatively new intervention approaches that increase the survivor’s capacity to regulate trauma-related distress and manage triggered responses such as SUA. Both draw on an evidence-based therapy, Integrative Treatment of Complex Trauma for Adolescents (ITCT-A), and focuses on ITCT-A modules that emphasize mindfulness and a related component, trigger identification and intervention (Briere & Lanktree, 2013). Readers who desire further information on the use of ITCT-A with SUA-involved youth, including additional interventions, are invited to download the stand-alone guide, “Treating Substance Use Issues in Traumatized Adolescents and Young Adults: Key Principles and Components,” at attc.usc.edu.
Mindfulness can be defined as the learned capacity to engage in moment-by-moment awareness of ongoing experience, and to do so without judgment and with acceptance. Mindfulness training is increasingly used as an empirically-based intervention for children and adolescents to reduce symptoms and increase emotional stability (Semple & Lee, 2011). Often involving meditative practices, it teaches youth to watch their thoughts, feelings, and bodily sensations come and go in an objective, noninvolved way. Over time, youth typically come to realize that these products of the mind are not always reflective of immediate reality, a process that is sometimes referred to as “metacognitive awareness” (Teasdale et al., 2002).
This ability to be, in a sense, less personally involved in one’s internal experiences, especially preoccupations about the past and worries about the future, has been shown to decrease anxiety, depression, and low self-esteem, as well as reducing overall emotional reactivity—see Baer, 2003, for a review—all of which may lessen the individual’s need to engage in SUA or other avoidance activities (Bowen, Chawla, & Marlatt, 2010).
More generally, because a mindful state is characterized by attention to the present, as opposed to the past or the future, it tends to result in decreased stress, potentially including the autonomic hyperarousal often associated with trauma exposure. The development of such settling skills, to the extent that they decrease sympathetic nervous system activation and fight-or-flight responses, potentially reduces the need for the trauma survivor to use drugs or alcohol to downregulate chronic anxiety and tension (Chilcoat & Breslau, 1998).
Beyond reducing anxious arousal, ITCT-A employs a mindfulness skill often helpful for SUA-involved adolescents, referred to as “urge surfing” (Bowen et al., 2010). In this approach, adapted for trauma clients, youth learn to apply mindfulness skills to trauma-related urges to use or abuse substances, or to engage in other avoidance behaviors such as self-injury or compulsive sexual behavior. Clients are encouraged to view the need to engage in SUA or other behaviors as similar to riding a wave: the urge—typically triggered by a trauma-related thought, feeling or memory—starts small, builds in size, peaks (often within minutes), and then, if not reinforced, slowly falls away. If clients are able to experience triggered feelings as temporary intrusions of history that can be ridden as if on a surfboard, neither fighting against them nor acting upon them, they may be able to avoid SUA or other problematic behavior.
Interestingly, to the extent that clients can engage mindfulness while discussing past traumatic events in treatment, they may accomplish an especially helpful form of therapeutic exposure (Briere, 2013; Pollak, 2005). Mindfulness allows clients to both remember without as much avoidance, and to do so while grounded in a state that involves decreased emotional reactivity and greater metacognitive awareness. This process supports acceptance, wherein the survivor does not reject or resist painful internal states, but rather engages them and “allows” them to occur. When thoughts and emotions are allowed to arise, and are neither suppressed—which otherwise can result in hyperaccessibility and continued intrusions (see Gold & Wegner, 1995)—nor “hung onto” or obsessed and ruminated about, they may become habituated, if not extinguished, and eventually lose their power to produce distress. Although there are as yet no studies examining the efficacy of this form of exposure relative to what is found in more classic CBT, clinical experience suggests that mindful processing of traumatic material may be, in some cases, less challenging for the client than traditional methods.
In ITCT-A, mindfulness is used as an optional module, because not all clinicians have training in this area and they do not necessarily have an ongoing personal mindfulness practice. As a result, although some mindfulness techniques, such as mindfulness-based breath training (see Briere & Lanktree, 2013), can be used by a clinician with only basic mindfulness experience, more extensive mindfulness interventions typically require the clinician to have additional training and practice.
Furthermore, there are some contraindications for mindfulness training; for example, if youth are experiencing especially severe anxiety, depression or posttraumatic stress, or are experiencing psychotic or manic episodes. Nevertheless, there is little evidence that adolescents are unable to learn mindfulness, and much to suggest that, if used judiciously, it may be helpful for many young trauma survivors (Semple & Madni, 2015).
Many of the difficulties that traumatized adolescents experience in the world arise when stimuli in their immediate environment trigger upsetting memories. Once these memories are evoked, youth may experience thoughts involving, for example, helplessness, imminent danger, betrayal or abandonment. Also triggered may be emotions that youth experienced at the time of the trauma, such as extreme fear, anger, shame or sadness. In response to these potentially overwhelming states, adolescents may engage in SUA or other avoidant behaviors. For example, a young person may undergo a relational break-up, which triggers memories of parental unavailability and emotional neglect, which in turn activates catastrophic cognitions of unlovability and loss, and intense feelings of sadness and anger. These cognitions and emotions may engender an urge to take alcohol or drugs, or to engage in an “acting out” behavior that distracts or soothes, such as aggression or dysfunctional sexual behavior.
In such instances, the therapeutic goal may be for clients to recognize that their thoughts and feelings are triggered remnants of the past, as opposed to accurate responses to the current environment; and learn how to de-escalate and problem-solve these cognitive and emotional experiences before they lead to problematic behaviors. These outcomes are supported by increased metacognitive awareness: youth ideally come to realize that their thoughts and feelings do not necessarily represent accurate perceptions of current reality: they are “just” triggered phenomena.
Trigger Identification and Intervention is a specific module in ITCT-A, in which the youth learns to mindfully recognize when he or she has been triggered by a relational stimulus, and then practices interpreting and managing the attendant thoughts and feelings so that they do not overwhelm and thereupon motivate SUA or other problematic behaviors. Related approaches to trigger management can be found in other interventions as well, for example, Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS) and Attachment, Self-Regulation, and Competency (ARC) (DeRosa & Pelcovitz, 2008; Blaustein & Kinniburgh, 2010).
The Trigger Grid
The ITCT-A treatment guide provides a Trigger Grid worksheet, wherein clients, with assistance from the therapist, respond to a series of questions at various points in therapy, including instances when they have been triggered since the last session. The goal of the Trigger Grid exercise is for clients to:
- Learn about triggers, including their “unreal” (i.e., non-here-and-now, historical) nature
- Identify specific occasions during which they have been triggered
- Determine their major triggers and how to identify when they are being triggered
- Problem-solve strategies that might be effective once triggering has occurred
In response to the Trigger Grid, clients typically identify a number of trauma-related triggers, including interpersonal conflicts, sexual situations or stimuli, seemingly arbitrary criticism, and rejection or perceived abandonment. Once the clients’ triggers have been identified, they then respond to the question, “How do I know I’ve been triggered?”
The qualities of triggered responses described by many adolescent trauma survivors are:
- A thought, feeling, or sensation that doesn’t fully “make sense,” or so intense that it is out of proportion to the current environment
- An unexpected alteration in awareness (e.g., depersonalization or derealization)
- Physical reactions such as feeling one’s heart pounding, shortness of breath, sudden stomach distress or facial flushing
Another Trigger Grid question, “What happens after I get triggered?” encourages adolescents to explore thoughts, feelings, and behaviors that follow each major trigger, so that triggering as a construct becomes more obvious to him or her, and his or her responses to the trigger are better understood as reactions to the past, not the present.
The final question on the grid is, “What I could do or say to myself so that I wouldn’t get triggered, or for the trigger to be less bad?” which is answered for each of the major triggers that the client has previously identified. Among possible answers to this section are:
- Changing the scenario or using “time-outs” during especially stressful moments (e.g., leaving a party when others become intoxicated; intentionally minimizing arguments with authority figures; or learning how to discourage unwanted flirtatious behavior from others)
- Analyzing the triggering stimulus or situation until a greater understanding changes one’s perception and thus terminates the trigger (e.g., carefully considering the behavior of someone who is triggering posttraumatic fear and eventually becoming aware of the fact that this individual is not actually behaving in a threatening manner)
- Increasing support systems (e.g., bringing a friend to a party where one might feel threatened or be triggered, or arranging for cell phone contact with a friend or AA sponsor in the event of an upsetting situation)
- Positive self-talk following a triggered state, such as “I am safe,” “I don’t have to do anything I don’t want to do,” or “This is just my past talking, this isn’t real.”
As youth develop more mindfulness of, and metacognitive awareness about, triggers and their associated feelings and behaviors, triggered states can be more recognizable as such, or as replayed “movies” or ancient computer programs rather than perceptions of the contemporary world. This increased psychological distance from the triggered experience—referred to as “reduced identification” or “decentering” in Buddhist psychology—often attenuates the power of the feeling and lessens the likelihood that problematic behaviors such as SUA will ensue.
A less structured version of this technique, not necessarily involving use of the Trigger Grid, can be approximated in repeated, explicitly nonjudgmental conversations between youth and the therapist about what their triggers are, how they can be detected, and how associated impulses to escape (e.g., through SUA) or inappropriately engage (e.g., through SUA or aggression) can be forestalled in the future.
Both mindfulness training and trigger management interventions allow traumatized adolescents to become more aware of the causes and effects of prior adverse events, including ways in which they may confuse the past with the present and respond in maladaptive ways. Such interventions provide an additional pathway to trauma resolution and reduced SUA, above and beyond the emotional and cognitive interventions associated with CBT and psychodynamic or relational therapies. At the same time, both interventions overlap with other components of trauma therapy; mindfulness is likely to promote therapeutic exposure while promoting a sense of groundedness and increased distress tolerance, while trigger management increases metacognitive awareness of activated posttraumatic states, in some ways similar to cognitive therapy. As demonstrated with ITCT-A (Lanktree et al., 2012), all of these components—cognitive interventions, therapeutic exposure, mindfulness training, and trigger management—are likely to be helpful in the treatment of SUA-involved, traumatized youth.
Acknowledgements: This article was supported by grant #1U79SM06126-01 from the Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services.
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