Trauma-informed care in substance use treatment: what it is and is not

Trauma-informed care is a way a program or service is run, based on an understanding of how trauma can affect people. It is a framework developed by the Substance Abuse and Mental Health Services Administration (SAMHSA), the US federal agency for behavioral health. It matters in substance use treatment because, in SAMHSA's words, trauma is especially common in the lives of people with mental and substance use disorders.

What SAMHSA means by trauma

SAMHSA's 2014 concept paper defines individual trauma as resulting from an event, series of events, or set of circumstances that a person experiences as physically or emotionally harmful or life threatening, and that has lasting adverse effects on the person's functioning and mental, physical, social, emotional, or spiritual well-being. The definition centers on the person's experience, so the same event can affect people differently.

SAMHSA's current trauma page adds that traumatic experiences are associated with behavioral health and chronic physical health conditions, especially when they occur in childhood, and that substance use, mental health conditions and other risky behaviors have been linked with traumatic experiences. The National Institute on Drug Abuse (NIDA) notes that one analysis found over 30 percent of adults with a substance use disorder had childhood trauma. These are associations, and having a history of trauma does not mean a person will develop a substance use disorder. The wider overlap of conditions is covered in co-occurring mental health conditions.

The four Rs

SAMHSA describes a trauma-informed program, organization or system as one that realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in the people served, families, staff and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures and practices, while seeking to resist re-traumatization. These are often shortened to realize, recognize, respond and resist.

The six principles

The 2014 concept paper states that a trauma-informed approach reflects adherence to six key principles rather than a prescribed set of practices or procedures. The six are:

1. Safety: staff and the people they serve feel physically and psychologically safe.
2. Trustworthiness and transparency: decisions are made with the goal of building and keeping trust.
3. Peer support: peer support and mutual self-help are treated as key to establishing safety and hope.
4. Collaboration and mutuality: partnering, and leveling power differences between staff and the people served.
5. Empowerment, voice and choice: a belief in the primacy of the people served to heal and promote recovery from trauma.
6. Cultural, historical and gender issues: moving past stereotypes and biases, offering gender-responsive services, and recognizing and addressing historical trauma.

SAMHSA's current web page on trauma-informed approaches lists the first five of these. It also states SAMHSA's commitment to reducing and ultimately eliminating seclusion and restraint in services for people with mental or substance use disorders.

Trauma-informed care versus trauma-specific treatment

Because the framework is defined as principles, it describes how a service operates rather than naming a therapy. It is not itself treatment for trauma symptoms. Trauma-specific treatments are the separate interventions designed to address trauma and its effects, and a trauma-informed program may offer them or refer a person to them.

A program can be trauma-informed without delivering any trauma-specific therapy, and a clinician can deliver such a therapy in a setting that is not trauma-informed. It is worth asking a program exactly what it does. Approaches that may be part of a plan are covered on pages such as cognitive behavioral therapy and mindfulness-based approaches.

What it can look like for a person entering care

SAMHSA does not provide a checklist of procedures, so what follows is a reading of the principles, not a standard every program meets. A program applying them might explain what will happen at each step, so that nothing is a surprise (trustworthiness and transparency). It might offer choices about things such as how an assessment is done or which staff member is involved (voice and choice). It might involve people who have lived experience of recovery (peer support). Staff might treat power differences as something to reduce, not use (collaboration and mutuality).

It can also mean attention to the physical setting and to how staff speak and behave, because safety in SAMHSA's definition covers both physical and psychological safety. Someone who finds a setting unsafe, rushed or controlling can say so, and ask what the program does about it. The first conversation with a service is described in what happens when you ask for help.

What the evidence shows, and its limits

The principles are widely adopted, but the research is less settled than the framework's reach suggests. SAMHSA expects its grant recipients to use funds for programs, practices and policies that incorporate trauma-informed approaches, which reflects policy commitment. That is different from proof of better outcomes.

SAMHSA's 2014 literature review on trauma-informed care in behavioral health services is candid about the research on trauma-specific interventions. It lists limitations such as study attrition, inadequate handling of missing data, publication and investigator bias, difficulty generalizing from one population to another, inadequate follow-up, and a shortage of high-quality randomized controlled studies. For some models the studies did not find significant differences from active comparison treatments. That review concerns trauma-specific interventions, and this page found no comparable summary in the sources opened for trauma-informed organization as a whole.

Another limit is scope. The framework is not a substitute for assessment and treatment by qualified clinicians, and it does not replace care for substance use itself; see psychoeducation for how learning about these links can fit into a plan.

Questions to ask a clinician

• How does this program take trauma into account in everyday care?
• Will I be asked to describe past events right away, or can the pace be my choice?
• Do you offer trauma-specific treatment, or refer elsewhere, and what is the evidence for it?
• How are staff trained, and how do you handle it if something feels unsafe to me?
• Who coordinates care for substance use and for trauma-related symptoms?