Question 1

Why are substance use disorders (SUDs) and PTSD often co-occurring?

Lisa Najavits · Accepted Answer

It’s natural and understandable that people who are in emotional pain from trauma will reach for comfort, escape and soothing. Substances and other addictive behaviors (food, internet, gaming, etc.) can provide these in the short term – though in the long term they clearly create more suffering. This pathway – when PTSD occurs first, then SUD – is called self medication because the person turns to a substance to “medicate” their pain from PTSD. But it’s useful to remember that it can go the other way too: SUD can lead to PTSD, as in drink driving accidents, violence associated with the drug trade, or being assaulted while intoxicated. Whatever the pathway, the key step is to get help to break the downward spiral of PTSD/SUD.

Question 2

What drives and sustains addiction in the traumatised person?

Lisa Najavits · Accepted Answer

Often they need coping skills and support they don’t yet have. Addictive behavior may feel like the only solution to them. The good news is that treatment can help people learn to address the trauma without turning to addictive behavior. It’s like a lightbulb going on when they recognize the connection between trauma and addiction. It’s healing just to see that – it frees them from some of the shame and self-blame they typically feel. A recent article I wrote for counselors on this topic is: Najavits, L.M. (2022). Trauma and Addiction: A Clinician’s Guide. In Evidence Based Treatments for Trauma-Related Psychological Disorders (2nd edition), edited by U. Schnyder and M. Cloitre. New York: Springer.

Question 3

I have observed the increase of prescribed medication for opiates and other symptoms related to substance use disorder and trauma. What has been your experience working with people who appear to be over medicated and trauma?

Lisa Najavits · Accepted Answer

Overmedication is indeed an issue. Overdoses on opioids has been a public health tragedy for a while now, with over 100,000 overdose deaths just last year. There’s now greater awareness in the medical field to promote safe levels of prescriptions and to warn people about potential for addiction when using opioids related to medical care. People with PTSD are especially vulnerable to developing substance use disorder so being careful about prescriptions is all the more important for them.

Question 4

Does addiction need to be resolved before trauma is addressed?

Lisa Najavits · Accepted Answer

That used to be the standard approach but no longer is. The problem is that people often can’t successfully address addiction while trauma issues are still present, so they get caught in a heartbreaking “catch-22”, unable to break the cycle. The current approach – and backed up by research – is that people can address both trauma and addiction at the same time. But it’s all about how it's approached. It’s important not to simply have the person dive into the painful trauma narrative without adequate preparation, coping skills, readiness and Informing them about different ways of approaching the trauma work. My most recent book (Finding Your Best Self: Recovery from Addiction, Trauma or Both) goes into detail on these issues and also gives guidance on how to choose treatment and what kinds of questions to ask providers. It has 35 short chapters addressing trauma and addiction and was designed as self-help or for families, peers or professionals. I mention it because all too often people still hear old messages about how treatment should occur. There’s a real need for education on these topics.

Question 5

When treating comorbid PTSD and addiction, how can clinicians balance a compassionate approach with the need to enforce treatment expectations and boundaries?

Lisa Najavits · Accepted Answer

This is so important. In the Seeking Safety model for trauma and addiction, we focus on support and accountability as the two key processes in treatment – both are crucial. Sometimes in response to the person’s trauma history there is a lot of support and compassion but low accountability. And the opposite can occur in response to a person’s addiction – a lot of accountability but low compassion. Balancing support and accountability is key to help the client grow and to preserve the clinician’s own well-being.

Question 6

What misunderstandings underlie stigma and how can we create a more compassionate world?

Lisa Najavits · Accepted Answer

That is a big, important question and I surely wish I knew the answer! I don't know that anyone actually does. Certainly we can say that there is a need for more love and understanding. But the challenge is how that translates into action that is sufficient to help overcome the myriad of enormous issues that people face, including stigma. Each of us is hopefully trying to do our part in whatever ways we can within the domains we inhabit, however large or small that may be. As Mother Teresa famously said, “Not all of us can do great things. But we can do small things with great love.”

Question 7

What is the Seeking Safety therapy model for treating trauma and addiction?

Lisa Najavits · Accepted Answer

Seeking Safety is an evidence-based, present-focused counseling model to help people attain safety from trauma and/or addiction. It can be conducted in groups (any size) and/or with individuals. It is an extremely safe model as it directly addresses both trauma and addiction, but without requiring clients to delve into their detailed trauma narrative, thus making it relevant to a very broad range of ﻿clients and easy to implement. It is for all genders, adults or adolescents, for any length of treatment, any level of care (e.g. outpatient, inpatient, residential). It has been successfully used for decades across all types of traumas and all types of addictions, and for those who may have problems in both areas (trauma/addiction) or just one or the other. It has also been successfully implemented for many years across vulnerable populations including homeless, criminal justice, domestic violence, severely mentally ill, veterans and military, and others. Any provider can conduct it even without training; however, there are also options for training. It has also been delivered successfully by peers in addition to professionals. It has been translated into numerous languages. The Seeking Safety book provides client handouts and guidance for clinicians. Seeking Safety has 25 topics that can be conducted in any order and as few or many as time allows. Examples are: PTSD: Taking Back Your Power, Honesty, Asking for Help, Setting Boundaries in Relationships, Compassion, Creating Meaning, Integrating the Split Self, Taking Good Care of Yourself, Detaching from Emotional Pain (Grounding), and Life Choices. The website www.seekingsafety.org has a lot of additional information on the model, including over 65 published research articles on it. It is also a highly cost-effective model https://www.treatment-innovations.org/cost-benefit.html And here is a podcast overview I did about the model: https://www.voiceamerica.com/episode/133186/dr-lisa-najavits-treating-ptsd-and-substance-use-disorders - .YdbMROVxIxE.mailto

Question 8

What changes would you like to see to mental health services and treatment for trauma and addiction in the future?

Lisa Najavits · Accepted Answer

I hope to see greater focus on (1) peer support; (2) augmenting mental health services with apps; (3) creating as many methods as possible for low-cost, accessible treatment options. Most people with trauma and addiction don’t go to treatment, for a variety of reasons. We need to take treatment to them, any way that we can.

Question 9

How is treatment adapted for intergenerational trauma? What are the most urgent and emerging barriers to equity and access, and how to overcome them?

Lisa Najavits · Accepted Answer

Intergenerational trauma is sadly all too common. The goal is to enhance treatment opportunities to break the cycle across generations. Over the past several decades there has been progress in terms of greater awareness of trauma (such as in the media and in treatment programs), and in the development of trauma informed care. Equity and access are also crucial issues and it will take a lot of effort to keep reaching the people who need to be reached. Often the people who are the most traumatized are the least likely to get high quality care. There are significant workforce issues with underpaid providers, lack of enough providers, and at times burnout and systems issues.

Question 10

What do you think is the appeal of somatic, body based approaches such as yoga for healing trauma?

Lisa Najavits · Accepted Answer

Both trauma and addiction have strong mind/body linkages. For some people it can be very helpful to focus on the body as part of their recovery, whether through yoga, exercise, equine therapy, dog therapy, drumming, energy therapies, or other methods. However, it’s key to remember that there is no one way to heal – some people prefer verbal methods like individual or group counseling. Some like community based support such as 12-step or SMART recovery. The best advice is to try a variety of methods (as long as they’re reputable) and find a good fit. Within a few sessions, notice whether it feels helpful – if not, keep looking.

Question 11

What is your opinion on exposure-based therapies for trauma in the context of comorbid SUD?

Lisa Najavits · Accepted Answer

There has been some important research in the past 10 to 15 years looking at this question. The bottom line is that exposure based therapies do not do better than non-exposure based methods for people with PTSD and SUD (see the article below for details). In fact, quite a surprise, they don't do better than substance abuse treatment per se. Yet past focused models can be helpful for people who want to explore the past and who are ready for it. However, it is important not to give the message that it is required for healing as it is not. There are many different pathways. In addition, it's useful to understand that research on exposure based models consistently excluded complex clients such as those who are currently suicidal, violent, homeless, or psychotic, and for a very long time excluded people who had SUD. Exposure based models are also known to have issues with dropout. There is always a need for more research and hopefully there will be more on this topic too. I am appreciative of past focused models and in fact have a book coming out next year called Creating Change which is a past focused model for PTSD/SUD. It takes a different approach than classic exposure therapy. See https://www.treatment-innovations.org/creating-change.html for more. Najavits, L. M., Clark, H. W., DiClemente, C. C., Potenza, M. N., Shaffer, H. J., Sorensen, J. L., Tull, M. T., Zweben, A., Zweben, J. E. (2020). PTSD / substance use disorder comorbidity: Treatment options and public health needs. Current Treatment Options in Psychiatry, 1-15. Najavits, L. M. (2015). The problem of dropout from "gold standard" PTSD therapies. F1000Prime Reports 2015, 7(43), (doi:10.12703/P12707-12743).

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