Addressing Trauma in Clinical Work With Addiction

The importance of trauma-informed addiction approaches.

Reviewed by Monica Vilhauer Ph.D.

Key points

• Trauma is prevalent among individuals with addiction.
• A trauma-informed approach addresses both trauma and addictive behaviors simultaneously.
• Addictions counselors must be prepared to recognize, assess, and respond to trauma effectively.
• Emotion regulation and coping skill enhancement are critical components of integrated treatment approaches.

People with addiction are addicted to changing the way that they feel. Both drugs of abuse and addictive behaviors reliably and predictably change the way a person feels by stimulating the reward circuitry in the brain. Wright (2018) said, “using will make predictable what you are going to feel and when you are going to feel it” (p. 16). Both drugs of abuse and behavioral addictions induce pleasure (positive reinforcement), while also providing a temporary escape from negative mood states (negative reinforcement).

Due to the affect-altering properties of addictive behaviors, it is not surprising that those who have experienced trauma may be at higher risk of coping through drugs of abuse or behavioral addictions. Indeed, some individuals with trauma turn to addictive behaviors as a means of regulating their emotions (for example, a person who drinks heavily because, when intoxicated, they do not experience the trauma memories, psychological distress, or hypervigilance associated with posttraumatic stress disorder [PTSD]).

Trauma and Addiction

Scholars have found that experiences of trauma are higher among those with substance use disorders than the general population (Zhang et al., 2020). In a review of 80 studies, scholars found a robust association between childhood trauma and substance use in early adulthood (Sebalo et al., 2023). In addition to drugs of abuse, researchers also found associations between early trauma and compulsive behaviors like compulsive internet use (Hao et al., 2024) and gaming (Jhone et al., 2021).

There are many reasons why trauma can increase the risk of addictive or compulsive behaviors. Specifically, they can serve as a means of coping and emotion regulation among those who have experienced trauma (Felitti, 1998). Early trauma can cause disruptions in cognitive development and impaired executive functioning leading to impulsive decision making (such as engaging in addictive behaviors; Moh, 2023; Sebalo et al., 2023). Trauma can also cause attachment ruptures/failures leading to attempts to find secure attachment through addictive behaviors (Flores, 2004; Gill, 2018). And others have suggested that some individuals may use addictive behaviors as a means of reenacting trauma narratives and telling their trauma stories (Miller, 2002). Thus, the relationship between trauma and addictive behaviors is nuanced and can vary among individuals.

Trauma-Informed Care

It is therefore imperative that mental health professionals who work with individuals with addiction or compulsive behaviors are well-versed in trauma-informed treatment approaches. Specifically, trauma and addiction should be addressed simultaneously, as each condition affects and influences the other (SAMHSA, 2014). For example, using substances or engaging in compulsive behaviors could be motivated by the desire to escape trauma symptoms (negative reinforcement), and, on the other hand, substance use or engagement in an compulsive behavior may trigger trauma flashbacks or memories. Thus, it is beneficial to explore the relationship between trauma, addiction, and compulsive behaviors with clients to better understand how they interact.

Working from a trauma-informed lens in addiction treatment is not asking, “what’s wrong with you?” but rather, “what happened to you?” (Center for Health Care Strategies, 2025, para. 1). From this posture, clinicians can implement the four assumptions of the trauma-informed approach into their work (SAMHSA, 2014): realization (understanding the relationship between trauma and addiction and integrating that understanding into client conceptualizations); recognizing (assessing trauma with all clients with addiction and recognizing signs of trauma); responding (utilizing integrated clinical approaches that address addiction and trauma simultaneously); and resisting re-traumatization (avoiding practices that could re-traumatize individuals).

Importantly, there are many risk factors that increase a person's susceptibility to addiction, of which trauma is one. Thus, trauma is a critical piece of the puzzle, but not the whole picture—genetic predispositions, age of initiation, mental health conditions, and other environmental factors are important to consider as well. However, given the prevalence of trauma among those with addiction, trauma-informed addictions approaches often are warranted.

Trauma-Informed Addiction Approaches

Employing a trauma-informed approach to addictions counseling means utilizing clinical strategies that address both trauma and addictive behaviors simultaneously to holistically support clients. Rather than addressing one issue and then the other in isolation, a trauma-informed approach recognizes the bidirectional relationship between trauma and addiction and attends to both issues.

For mental health practitioners who are seeking to enhance their work with trauma and addictions, there are several approaches that can be utilized. Specifically, a manualized treatment like Seeking Safety (Najavits, 2002) could be a good starting place. This model of treatment addresses both PTSD and substance use disorders simultaneously. Additionally, Addictions and Trauma Recovery Integrated Model (ATRIUM; Miller, 2002) is a manualized model for clinical work with clients with a history of trauma and current addiction. Other approaches like Internal Family Systems, could be employed as a way to help clients recognize the part of themselves injured by past trauma and the parts that are trying to distract from the emotional pain through addictive behaviors (Schwartz & Sweezy, 2020; van der Kolk, 2014).

In addition, although important with all clients with addiction, it is crucial to help clients with trauma histories enhance both their emotion regulation skills and coping strategies. The goal is to increase clients' skills and self-efficacy in these areas so they respond to trauma symptoms (or other forms of distress) without turning to addictive behaviors. In a sense, clinicians are helping clients learn alternative, more adaptive, and goal-aligned ways to "change the way they feel" apart from drugs of abuse and/or behavioral addictions. As the addictions field continues to advance and expand, it is imperative that addictions counselors are trained to recognize, assess, and respond effectively to trauma in their work.