Trauma-Focused Therapy in Addiction Treatment

How Trauma Shapes Substance Use

For many clients, substance use develops as an instinctive response to overwhelming internal states or unsafe environments. Unprocessed memories, chronic threat activation, and emotional numbing can lead people to reach for substances to self-regulate. Trauma therapy addresses the root mechanisms behind this pattern, making long-term recovery more attainable.

This work differs from cognitive restructuring approaches described in CBT for addiction, where the focus is on thoughts and behaviors, and from the values-driven orientation of ACT interventions. Trauma-focused therapy centres on restoring a sense of safety and reprocessing experiences that continue to shape current reactions.

The Trauma–Addiction Connection

Repeated exposure to threat — whether physical, emotional, or relational — can condition the nervous system to stay in survival mode. Clients may use substances to:

• numb distressing sensations or memories,
• disrupt hyperarousal (panic, agitation),
• counteract intrusive images or flashbacks,
• manage chronic shame from relational trauma,
• feel temporarily “more present” during dissociation.

Trauma therapy aims to reduce the physiological and emotional burden underlying these patterns, rather than tackling urges alone.

The Window of Tolerance

The window of tolerance describes the optimal arousal range in which clients can think clearly, process emotions, and integrate new learning. Outside this window, individuals may shift into:

• Hyperarousal — anxiety, agitation, reactivity, intrusive memories.
• Hypoarousal — numbness, dissociation, shutdown.

Maintaining work inside the window is essential for safe trauma processing. When clients frequently move outside it, clinicians may use regulation skills similar to DBT Distress Tolerance or grounding techniques before attempting deeper processing.

Phase 1 — Stabilisation and Safety

Trauma therapy begins long before processing traumatic memory content. The initial phase focuses on creating predictable routines and strengthening self-regulation. Key elements include:

• Nervous system regulation — breathwork, orienting exercises, somatic tracking.
• Environmental safety — reducing exposure to high-risk people or triggers.
• Affective stabilisation — mapping emotional warning signs and applying grounding techniques.
• Capacity building — preparing the client to stay within their window of tolerance.

During stabilisation, some clients benefit from learning skills described in DBT’s emotion regulation framework to reduce volatility before trauma processing begins.

Phase 2 — Trauma Processing

Processing methods vary but share a common purpose: helping clients re-encounter traumatic material gradually and safely so the nervous system can update its response. This may involve:

• Somatic approaches — tracking body sensations, completing defensive responses, releasing held tension.
• Narrative methods — reconstructing the story of what happened with emotional support.
• Exposure-based techniques — returning to avoided cues in controlled ways.
• Memory reconsolidation work — pairing reconnection with new emotional or cognitive experiences.

Some clients may transition to structured modalities such as EMDR treatment when bilateral stimulation and protocol-based memory reprocessing are appropriate.

Phase 3 — Integration and Rebuilding

Once processing is complete, the goal turns toward integrating insights and physiological shifts into daily life. Clients work to:

• strengthen new patterns of regulation,
• restore connection in relationships,
• develop identity beyond trauma,
• create routines that support sobriety and emotional health.

This integration phase may include values exploration similar to the work in ACT, reinforcing meaning and direction beyond symptom relief.

Red Flags and Clinical Risks

Trauma work carries inherent risks, especially if undertaken prematurely. Red flags include:

• severe dissociation or fragmentation,
• active self-harm or suicidality,
• unstable living environments that interrupt safety,
• recent heavy substance use that limits emotional containment,
• medical complications that could worsen under stress.

When these factors are present, stabilisation must continue until the client has sufficient internal and external resources. Pushing into memory content too early can worsen symptoms or increase relapse risk.

Competencies Required in Trauma-Focused Work

Clinicians conducting trauma therapy must have both technical skills and strong attunement. Essential competencies include:

• ability to maintain co-regulation during emotional intensity,
• knowledge of somatic responses and defensive activation patterns,
• competence in pacing and titration of traumatic material,
• capacity to monitor signs of hypo- or hyperarousal,
• skill in grounding, containment, and safety planning.

Phases of Trauma Therapy (Table)

Connecting Trauma Therapy With Other Modalities

Trauma-focused therapy does not exist in isolation. Clients may stabilize using DBT skills, explore long-term direction through ACT, or engage in targeted reprocessing using EMDR. Those wanting a broader overview can return to the psychotherapy hub.