There is a significant relationship between the experience of trauma and subsequent substance abuse (Kilpatrick et al., 2003; Rosenberg, 2011). For many individuals, drugs and alcohol are used to self-medicate the emotional and psychological reactions that result from experiencing a traumatic event. The use of drugs and alcohol to self-medicate is supported by studies which show that trauma often precedes problems with substance use (Douglas et al., 2010); cumulative exposure to multiple traumatic events increases the likelihood of posttraumatic stress disorder (PTSD) as well as alcohol dependence and substance use and abuse (Dube et al., 2003); and a history of traumatic events is most likely to be associated with substance abuse when individuals continue to experience anxiety or depression subsequent to their trauma (Wu, Schairer, Dellor, & Grella, 2010).
Substance abuse disorders can also lead individuals to behave in ways that create ‘risky’ personal environments, resulting in additional trauma and potentially further substance abuse (Stewart & Conrod, 2008).
In order to address both substance abuse and the underlying psychological concerns related to trauma, it has been recommended that behavioral health agencies apply a trauma-informed approach to substance abuse treatment (Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005). Trauma-informed services require that staff members have knowledge about the impact of violence and other forms of trauma on individuals. Elliott et al. (2005) list ten principles that can be used to direct the implementation of trauma-informed interventions:
- Recognition by staff of the impact of violence and victimization on the development of coping strategies among clients
- Identifying recovery from trauma as one of the primary goals of treatment
- Using an empowerment model to guide treatment
- Maximizing clients’ choices and their control over recovery
- Focusing on relational collaboration between clients and staff
- Respecting clients’ needs to feel acceptance and safety
- Utilizing clients’ strengths
- Minimizing possibilities of retraumatization
- Understanding clients within their cultural contexts
- Soliciting clients’ input as part of program evaluation
It is recommended that these principles be understood and be used to guide the actions of all staff members, from people at the front desk to substance abuse counselors.
Substance abuse treatment programs which address trauma as well as substance abuse as part of their protocols have yielded positive results for many clients, resulting in higher treatment retention, reductions in trauma symptoms and substance abuse, and improvements in recidivism. A majority of outcome studies on integrated treatment for trauma and substance abuse have focused on women participants (Clark & Young, 2009; Messina, Calhoun, & Braithwaite, 2014). The few substance abuse treatment outcome studies that have included both men and women (e.g., Marsh, Cao, & D’Aunno, 2004; McGovern, Lambert-Harris, Alterman, Xie, & Meier, 2011) have found that both men and women who receive integrated services show significant reductions in substance use as well as improvements in other areas of functioning.
Despite the common co-occurrence of trauma and substance abuse, the trauma histories of participants in substance abuse treatment programs vary, as does the expression of trauma symptoms, and need for and responsiveness to integrated programs. Gender appears to play a significant role in all three areas; that is, while men and women in substance abuse treatment program tend to report significant histories of trauma, the nature of those experiences also tend to differ, as does their expression of trauma symptoms and responsiveness to treatment. Thus, there is a need to understand gender differences in trauma exposure, trauma symptoms, and responsiveness to integrated treatment for substance abuse and trauma in order to develop programs that are effective for diverse participants.
Differences by Gender
The co-occurrence of substance abuse and trauma is apparent in both men and women who are in substance abuse treatment (Danielson et al., 2009). There are differences, however, in the types of traumatic experiences reported by men and women and the impact of those experiences on reported trauma symptoms. Women are more likely than men to report sexual and physical abuse (Keyser-Marcus et al., 2014), while men are more likely than women to report other types of potentially traumatic events, including accidents, witnessing violence, and combat (Tolin & Foa, 2006). Further, compared to men, women tended to report higher levels of psychological distress related to traumatic events.
Differences in the clients’ history of trauma are likely to affect their experience of trauma symptoms; in turn, the severity of their trauma symptoms is likely to affect the type of intervention from which they would gain greatest benefit. We conducted a study to identify differences in trauma symptoms among, and between, men and women in substance abuse treatment. The data were analyzed using Latent Transition Analysis (LTA). LTA is a statistical method used to identify participant groupings based on a set of specific shared characteristics. This analysis allows investigators to identify natural groupings when those groupings are unknown, and to look at changes in the nature and prevalence of groupings over time. In the current study, groupings were based on trauma symptoms as reflected on the trauma symptom inventory (TSI; Briere, 1995). These groupings were analyzed separately for men and women, allowing us to identify differences in the way trauma symptoms clustered for men and women at intake and six months into treatment, the number of men and women who fell into each group at each time, and the trajectories of group membership over the six-month intervention.
The participants in the study were 381 adults enrolled in one of two justice-involved, substance abuse treatment programs: a drug treatment court and a program for pregnant and parenting women with substance abuse problems. Both treatment programs were funded by grants through the Substance Abuse and Mental Health Services Administration (SAMHSA). The grants included funding to train staff members on the principles of trauma-informed care. In addition, counselors at each participating agency were trained to implement Seeking Safety (Najavits, 2001). Seeking Safety is a cognitive-behavioral intervention designed to help clients understand the relationship of substance abuse and trauma and the impact of both on their daily functioning. The curriculum has a present-orientation focus on helping clients identify triggers and develop needed coping skills. Seeking Safety has twenty-four modules on topics such as asking for help, coping with triggers, and detaching from emotional pain. Each group is structured to provide interaction and discussion but with a focus on current behavior, with in-depth discussion of personal trauma is relegated to individual sessions with trained therapists when needed. Studies on Seeking Safety have demonstrated reductions of trauma symptoms and substance use for women (Desai, Harpaz-Rotem, Najavits, & Rosenheck, 2008; Gatz et al., 2007) and men (Najavits et al., 2009). In the present study, gender-specific groups were conducted once per week, as this provides a “safer” venue for men and women to discuss personal trauma. In addition to Seeking Safety, clients received an array of other services, including case management, substance abuse treatment groups, individual counseling, and drug testing.
The sample as a whole was 71 percent female and 29 percent male. History of trauma, specifically physical or sexual abuse, was assessed on the addiction severity index (ASI; McLellan et al., 1992), a structured interview used to assess problems associated with drug and alcohol use. In addition, TSI was used to assess symptoms commonly associated with posttraumatic stress. The items form ten subscales, which combine to form three summary scales:
- The trauma summary scale, comprised of intrusive experiences, defensive avoidance, dissociation, and impaired self-reference subscales
- The self-summary scale, comprised of the impaired self-reference, sexual concerns, dysfunctional sexual behavior, tension-reduction behavior, and anger/irritability subscales
- The dysphoria summary scale, comprised of the anger/irritability, anxious arousal, and depression subscales
History of trauma differed by gender, with 11 percent of men and 51 percent of women reporting a history of sexual abuse and 22 percent of men and 69 percent of women reported prior physical abuse. Using LCA, three similar groups categorized on the basis of trauma symptoms emerged for men and women, but men and women were not equally represented in each of these groups. One group of participants (28 percent of the women and 33 percent of the men) had no clinical or problematic symptoms. A second group (41 percent of the women and 42 percent of the men) had elevated clinical symptoms in two areas that reflected trauma-symptoms: defensive avoidance (i.e., staying away from people and places that remind one of a traumatic event) and intrusive experiences (i.e., sudden disturbing thoughts or memories). Finally, 31 percent of the women and 16 percent of the men were characterized as having symptoms in the clinical range on almost all of the subscales on the TSI.
Thus, men and women fell into similar categories with regard to trauma symptoms. However, differences were found in the likelihood of men and women falling into those categories, with men were less likely than women to report either physical or sexual abuse or clinical-level trauma symptoms. While it is possible that this is an accurate reflection of the psychosocial concerns of these clients, other studies have shown that men are more reticent than women to report abuse (Sable, Danis, Mauzy, & Gallagher, 2006; Sorsoli, Kia-Keating, & Grossman, 2008). This reticence has been attributed to factors such as the stigma associated with male report of sexual abuse, the tendency of others to underplay the significance of abuse to men, and concern that others will think the male victim will become an abuser.
The second part of this study examined change in trauma-symptoms after six months in treatment. There was a significant increase in the number of participants who had trauma-related symptoms at intake and reported a reduction in clinical symptoms, or no clinical symptoms, at follow-up. There were also differences in patterns of change for men and women, as men were more likely than women to show a reduction in clinical trauma symptoms particularly among those initially classified as having severe symptoms at intake.
Further, some participants did not show a reduction in symptoms over time. The participants who were least likely to change were those men and women who had experienced sexual or physical abuse and had more clinical symptoms at intake. The focus of the program interventions in this study was the development of coping skills, with interventions largely provided in group format. Different types of trauma-focused interventions may be needed for clients with more intense or complex forms of PTSD. Cloitre et al. (2011) describe recommended interventions that vary by intensity that can be used to reduce trauma-symptoms; these interventions start with education about trauma and helping clients learn how to engage in greater emotional regulation, to more individualized interventions such as working with clients to develop a trauma narrative or engaging clients in cognitive restructuring for maladaptive schemas developed as a function of the experience of traumatic events.
Finally, a small group of men and women had their symptoms worsen over time. This was most likely to occur for adults who initially reported no clinical symptoms and no history of trauma. We offer two possible explanations for these findings. First, it is possible that these clients were in denial or at least not inclined to report their trauma experiences honestly at the start of treatment, but felt more willing to do so as they grew comfortable in the program. Alternatively, these participants may have been accurate in their self-reported history of no physical or sexual abuse and may have been poorly matched to the trauma-informed treatment programs offered to them, such that being in treatment with others who were affected by trauma may have been nontherapeutic. Prior research suggests the providing high-intensity treatment to individuals with lower treatment needs may be detrimental to those clients (DeMatteo, Marlowe, & Festinger, 2006). Thus, just as participants who enter treatment with higher clinical needs may need more intensive interventions, participants without trauma symptoms may be negatively affected by an intense program and benefit more from a substance abuse intervention that does not focus on trauma.
Participants in substance abuse treatment are likely to have experienced trauma. Clients are also likely to vary in the nature and severity of those traumatic events, their expression of trauma symptoms, and their responsiveness to trauma-informed interventions. While there are many determinants of clients’ trauma experiences, gender is a significant contributing factor. Men and women tend to report different types of traumatic experiences. Men also tend to report fewer trauma symptoms than do women, even when both have experienced similar traumatic experiences. The reasons for this are not fully understood. We do know, however, that men have greater difficulty than women talking about their trauma experiences and staff members also have more difficulty talking to men than to women about their prior traumas (Lab, Feigenbaum, & De Silva, 2000). Finally, the studies reported here focus on gender as a binary factor; however, gender identity is considered today to be a more complex phenomenon, yet rarely assessed in its complexity in studies of substance abuse treatment (Flentje, Bacca, & Cochran, 2015). While more research is needed, it is clear that careful assessment of trauma-related needs, and matching clients in substance abuse treatment to interventions based on those needs, is important.
Briere, J. (1995). Trauma symptom inventory professional manual. Odessa, FL: Psychological Assessment Resources.
Clark, C., & Young, M. S. (2009). Outcomes of mandated treatment for women with histories of abuse and co-occurring disorders. Journal of Substance Abuse Treatment, 37(4), 346–52.
Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B. L. (2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress, 24(6), 615–27.
Danielson, C. K., Amstadter, A. B., Dangelmaier, R. E., Resnick, H. S., Saunders, B. E., & Kilpatrick, D. G. (2009). Trauma-related risk factors for substance abuse among male versus female young adults. Addictive Behaviors, 34(4), 395–9.
DeMatteo, D. S., Marlowe, D. B., & Festinger, D. S. (2006). Secondary prevention services for clients who are low risk in drug court: A conceptual model. Crime & Delinquency, 52(1), 114–34.
Desai, R. A., Harpaz-Rotem, I., Najavits L. M., & Rosenheck, R. A. (2008). Impact of the Seeking Safety program on clinical outcomes among homeless female veterans with psychiatric disorders. Psychiatric Services, 59(9), 996–1003.
Douglas, K. R., Chan, G., Gelernter, J., Arias, A. J., Anton, R. F., Weiss, R. D., . . . Kranzler, H. R. (2010). Adverse childhood events as risk factors for substance dependence: Partial mediation by mood and anxiety disorders. Addictive Behaviors, 35(1), 7–13.
Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: The adverse childhood experiences study. Pediatrics, 111(3), 564–72.
Elliott, D. E., Bjelajac, P., Fallot, R. D., Markoff, L. S., & Reed, B. G. (2005). Trauma‐informed or trauma‐denied: Principles and implementation of trauma‐informed services for women. Journal of Community Psychology, 33(4), 461–77.
Flentje, A., Bacca, C. L., & Cochran, B. N. (2015). Missing data in substance abuse research? Researchers’ reporting practices of sexual orientation and gender identity. Drug and Alcohol Dependence, 147, 280–4.
Gatz, M., Brown, V., Hennigan, K., Rechberger, E., O’Keefe, M., Rose, T., & Bjelajac, P. (2007). Effectiveness of an integrated, trauma‐informed approach to treating women with co‐occurring disorders and histories of trauma: The Los Angeles site experience. Journal of Community Psychology, 35(7), 863–78.
Keyser-Marcus, L., Alvanzo, A., Rieckmann, T., Thacker, L., Sepulveda, A., Forcehimes, A., . . . Svikis, D. S. (2014). Trauma, gender, and mental health symptoms in individuals with substance use disorders. Journal of Interpersonal Violence, 30(1), 3–24.
Kilpatrick, D. G., Ruggiero, K. J., Acierno, R., Saunders, B. E., Resnick, H. S., & Best, C. L. (2003). Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: Results from the National Survey of Adolescents. Journal of Consulting and Clinical Psychology, 71(4), 692–700.
Lab, D. D., Feigenbaum, J. D., & De Silva, P. (2000). Mental health professionals’ attitudes and practices towards male childhood sexual abuse. Child Abuse & Neglect, 24(3), 391–409.
Marsh, J. C., Cao, D., & D’Aunno, T. (2004). Gender differences in the impact of comprehensive services in substance abuse treatment. Journal of Substance Abuse Treatment, 27(4), 289–300.
McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., . . . Argeriou, M. (1992). The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9(3), 199–213.
McGovern, M. P., Lambert-Harris, C., Alterman, A. I., Xie, H., & Meier, A. (2011). A randomized controlled trial comparing integrated cognitive behavioral therapy versus individual addiction counseling for co-occurring substance use and posttraumatic stress disorders. Journal of Dual Diagnosis, 7(4), 207–27.
Messina, N., Calhoun, S., & Braithwaite, J. (2014). Trauma-informed treatment decreases posttraumatic stress disorder among women offenders. Journal of Trauma & Dissociation, 15(1), 6–23.
Najavits, L. M. (2001). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY: Guilford Press.
Najavits, L. M., Schmitz, M., Johnson, K. M., Smith, C., North, T., Hamilton, N., . . . Wilkins, K. (2009). Seeking safety therapy for men: Clinical and research experiences. In L. J. Katlin (Ed.), Men and addictions: New research (pp. 37–58). New York, NY: Nova Science Publishers.
Rosenberg, L. (2011). Addressing trauma in mental health and substance use treatment. The Journal of Behavioral Health Services & Research, 38(4), 428–31.
Sable, M. R., Danis, F., Mauzy, D. L., & Gallagher, S. K. (2006). Barriers to reporting sexual assault for women and men: Perspectives of college students. Journal of American College Health, 55(3), 157–62.
Sorsoli, L., Kia-Keating, M., & Grossman, F. K. (2008). “I keep that hush-hush”: Male survivors of sexual abuse and the challenges of disclosure. Journal of Counseling Psychology, 55(3), 333–45.
Stewart, S. H., & Conrod, P. J. (2008). Anxiety disorder and substance use disorder comorbidity: Common themes and future directions. In S. H. Stewart & P. J. Conrod (Eds.), Anxiety and substance use disorders (pp. 239–57). New York, NY: Springer.
Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of twenty-five years of research. Psychological Bulletin, 132(6), 959–92.
Wu, N. S., Schairer, L. C., Dellor, E., & Grella, C. (2010). Childhood trauma and health outcomes in adults with comorbid substance abuse and mental health disorders. Addictive Behaviors, 35(1), 68–71.
Editor’s Note: This article was adapted from an article by the same authors previously published in the Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation provides the original source of the article:
Cosden, M., Larsen, J. L., Donahue, M. T., & Nylund-Gibson, K. (2015). Trauma symptoms for men and women in substance abuse treatment: A latent transition analysis. Journal of Substance Abuse Treatment, 50(3), 18–25.