The importance of providing trauma-informed care in alcohol and other drug services.

Abstract

A history of trauma exposure is almost universal among clients of alcohol and other drug (AOD) treatment settings. In Australia, more than 80% of entrants to treatment report having experienced a traumatic event in their lifetime, most commonly having been physically or sexually assaulted, witnessing serious injury or death, being threatened with a weapon, held captive or kidnapped 1, 2. The vast majority have experienced multiple traumas. It is therefore not surprising that up to two-thirds of AOD clients have also been found to suffer from post-traumatic stress disorder (PTSD), a chronic and debilitating psychiatric disorder 1. The significance of these figures for AOD treatment providers cannot be understated. Traumatic events are often defining, life-changing moments, regardless of whether a person goes on to develop PTSD or any other trauma-related disorder. Whether it be a one-off event or more prolonged, trauma can shape or redefine a person's views about themselves (e.g. I am weak, bad, worthless), the world around them (e.g. the world is not safe) and how they relate to it (e.g. people cannot be trusted). For those who are unfortunate enough to have experienced trauma during childhood 3, 4, these beliefs may be particularly well entrenched. Knowledge and awareness of a client's trauma history is, therefore, a crucial piece of the puzzle needed to understand the cause and nature of their presenting problems and inform the development of the most suitable treatment approach. Self-medication of PTSD symptoms plays a significant role in the development and maintenance of AOD use disorders 5. The onset of trauma exposure and the development of PTSD symptoms predates the onset of an AOD use disorders in at least half of cases 6, 7. Improvements in PTSD symptoms are associated with subsequent improvements in AOD use, a relationship demonstrated by Lopez-Castro et al. 8 in this issue. The authors conduct a secondary analysis of data from the ‘Women and Trauma Study’ 9, the largest randomised clinical trial of co-occurring AOD and PTSD to date. Improvements in PTSD symptom severity were associated with a reduced likelihood of substance use 1-year post treatment. Although treating PTSD symptoms may lead to improved AOD outcomes, the reciprocal relationship is not observed 10-12: PTSD symptoms do not remit following improvements in substance use. On the contrary, PTSD symptoms may worsen in the absence of substance use 13, making it difficult for patients to sustain abstinence and increasing their risk of relapse to AOD use 12, 14, 15. This situation has led experts to advocate for a ‘trauma-informed’ approach to providing care 16. As outlined by Killeen et al. 17 in their article on the implementation of integrated therapies for PTSD and substance use disorders (SUD), trauma-informed care is ‘a service delivery approach whereby programs: (i) recognise the high rates of exposure to trauma in the patient populations they serve; and (ii) provide a safe environment and services that accommodate the needs of patients presenting with a history of significant trauma’ 17. It is about understanding the potential impact of trauma on AOD treatment so as to ‘create treatment environments that are more healing and less retraumatising’ 17. Despite its intuitive appeal, this recommended approach has not been adopted in the vast majority of AOD services. There are several reasons for this as outlined below. First, despite the pervasiveness of trauma exposure and PTSD among AOD clients and their potential to impact on treatment, both go largely unrecognised at the service level. Very few services systematically assess for a history of trauma exposure among their clients, with most preferring to put the onus on the client to raise the issue. However, for a multitude of reasons (e.g. shame, issues relating to trust), most clients are unlikely to volunteer information about their past trauma experiences unless specifically asked 18. Hence, the scale of the problem is often underestimated, and providers are missing a crucial piece of information that may fundamentally alter a person's treatment plan. This reluctance to assess for trauma is in large part related to concerns regarding client safety; specifically, fears regarding AOD clients' ability to cope with the emotions that may be elicited. Rather than risk client safety, services prefer to err on side of doing nothing at all. Although well intentioned, this practice is likely to be doing more harm than good. Whether or not clients' trauma is openly acknowledged, services are dealing with its consequences. Furthermore, research has demonstrated that while some people may become upset when talking about these events, talking about the trauma does not overwhelm or retraumatise the majority of people. On the contrary, most people describe the process as a positive experience 19. Second, service providers are understandably concerned about their capacity to respond. Trauma training is not a core feature of most certification courses. In their survey of Australian AOD workers, Ewer et al. 20 found that close to two-thirds of respondents had undergone trauma training; however, the type and content of that training was unclear. At a minimum, all members of the AOD workforce should: (i) have an awareness of the extent of trauma exposure among their clientele; (ii) understand the consequences of trauma exposure and its potential to impact on a recovery; (iii) be able to recognise the signs and symptoms of PTSD and other trauma-related disorders; and (iv) integrate that knowledge into their practice. However, trauma-informed practices can only be effective if organisational policies and procedures operate within a trauma-informed framework, such as that proposed by the US Substance Abuse and Mental Health Services Administration 21. Third, until recently, there was very little empirical evidence to guide treatment responses. There is, however, a growing body of evidence that supports the use of integrated treatments for PTSD and SUD; that is, treatment of both disorders at the same time by the same clinician 22, 23. Killeen et al. provide an overview of these treatments and discuss factors that may need to be considered when deciding which to implement. It should be noted, however, that although the ability of services to provide integrated trauma-focused treatment is desirable, it is not necessary for the provision of trauma-informed care. Until such time as training in the treatment of trauma responses becomes more widespread, the provision of trauma-focused treatment is likely to remain in the realm of specialist providers. A final reason that trauma has largely been ignored relates specifically to the focus of Ewer et al.'s article in this issue: concerns regarding the well-being of AOD workers themselves 20. How trauma is managed within a service not only impacts upon the clients but also the staff of that service. In this issue, Ewer et al. 20 report findings from a survey of Australian AOD workers that examined the impact of working with traumatised clients on their well-being. Close to 20% met criteria for secondary traumatic stress as a result of working with clients with a history of trauma. The findings highlight the crucial importance of adequate and appropriate training and support for AOD workers. In sum, there is a clear need trauma-informed care within AOD services. A history of trauma exposure is more common than not among clients of these services, and for many clients, this exposure is integrally linked to their substance use. The reluctance of services to address trauma among their clients stems from valid concerns regarding client and worker safety and a lack of evidence-based treatments to guide best practice. However, research in this area has grown substantially in recent years, highlighting the importance of addressing trauma among AOD clients and demonstrating the efficacy of trauma-focused treatments. By providing a supportive trauma-informed model of care, the outcomes for clients, and health of the AOD workforce, may be improved. A/Prof Mills currently receives funding for research from the Australian National Health and Medical Research Council (NHMRC), the Australian Government Department of Health and NSW Health.