Rates of adolescent substance use and abuse (SUA) are extremely high, as are rates of adolescent victimization and interpersonal violence in the United States. SUA is even more common among adolescents who have experienced victimization, violence, or other traumatizing experiences. One aspect of the relationship between SUA and trauma is that early trauma appears to interfere with the development of affect regulation. Increasing an adolescent’s ability to tolerate and regulate traumatic stress responses may reduce the need for other avoidant affect regulation strategies, such as SUA. Integrative Treatment of Complex Trauma for Adolescents includes interventions to help traumatized adolescents develop affect regulation skills. One important component of affect regulation development in ITCT-A is mindfulness training, which has been shown to reduce substance abuse-related problems as well as traumatic symptoms.

• Mindfulness
• Trauma
• Substance abuse
• Adolescents

Semple RJ, Briere J (2015) Mindfulness Training to Reduce Substance Abuse in Adolescent Trauma Survivors. J Subst Abuse Alcohol 3(2): 1033.

Mindfulness Training to Reduce Substance Abuse in Adolescent Trauma Survivors

Rates of adolescent substance use and abuse (SUA) are noteworthy in America. A national survey of drug use [1] found that an estimated 50% of adolescents in the United States have used illegal drugs before leaving high school. About 25% report having used drugs other than marijuana, such as cocaine, ecstasy, or hallucinogens. Although SUA continues to decline, more than 20% of high school seniors endorsed binge drinking within the previous two weeks (Johnston et al., 2014) [1]. Rates of adolescent victimization and interpersonal violence in the United States are also high and SUA is even more common among traumatized adolescents. For example, those with a history of physical or sexual victimization are three times more likely to report past or current substance abuse than those without a history of trauma (Kilpatrick, Saunders, & Smith, 2003) [2].

Trauma and SUA

The relationship between trauma and SUA has multiple components. One is that early trauma appears to interfere with the development of affect regulation. Consequently, traumatized adolescents may have fewer internal resources with which to manage emotional distress (Giaconia, Reinherz, Paradis, & Stashwick, 2003) [3]. Traumatized youth also may experience social marginalization due to poverty or various forms of discrimination, which increases both the likelihood of further exposure to trauma and the negative effects of victimization (Breslau, Wilcox, Storr, Lucia, & Anthony, 2004) [4].

Many substance using or abusing youth have experienced what is referred to as “complex trauma” (Briere & Lanktree, 2013) [5], often involving some combination of physical abuse, sexual abuse, emotional neglect, and/or psychological maltreatment, frequently in combination with additional, later traumas and social stressors. When such adversity is combined with limited internal resources with which to cope with distressing emotional states, adolescents may engage in a variety of maladaptive avoidance strategies, including SUA (Briere, Hodges, & Godbout, 2010) [6]. Although drugs or alcohol may temporarily numb the emotional distress, they typically create additional problems instead of providing long-term solutions. SUA may exacerbate the symptoms of posttraumatic stress; produce new difficulties, such as depression, anxiety, and even psychosis; encourage criminality in order to access additional substances, and interfere with the emotional processing of posttraumatic stress (Briere & Lanktree, 2014; Cohen, Mannarino, Zhitovasb, & Caponec, 2003) [7,8], leading to more chronic symptomatology.

Given this complexity, there are two interrelated goals when treating traumatized, substance-using adolescents. The first is to reduce trauma-related distress, and the second is to address problematic avoidance behaviors, including SUA. Axelrod and colleagues (2011) [9], for example, suggest that increasing the client’s ability to tolerate and regulate traumatic stress responses can reduce the need for other avoidant, affect regulation strategies, such as SUA.

Integrative Treatment of Complex Trauma for Adolescents

Although various empirical-based treatments for complex trauma in youth promote cognitive and emotional processing of trauma-related symptomatology, few are especially targeted to adolescents with problematic SUA. Of those that do, perhaps the best known are Seeking Safety, adapted for adolescents (Najavits, 2002) [10], and Integrative Treatment of Complex Trauma for Adolescents (ITCT-A; Briere & Lanktree, 2013) [5]. The focus of this article, ITCT-A seeks not only to help the adolescent process traumatic memories, but also to update and reframe his or her cognitions, increase interpersonal and social functioning, and deescalate triggered emotionality. Many of these interventions help the adolescent survivor develop affect regulation skills, so that he or she will be more able to tolerate intense emotional activation without using SUA. In support of this, ITCT-A has a separate, stand-alone treatment manual for working with traumatized youth who are also engaged in SUA (Briere & Lanktree, 2014) [7].

Mindfulness in ITCT-A

An important component of affect regulation development in ITCT-A is mindfulness training. Mindfulness has been defined as the learned ability to maintain a receptive, accepting, and nonjudgmental awareness of what is occurring in the present moment. Mindfulness is increasingly used as an empiricallybased intervention for children and adolescents to reduce symptoms and increase emotional stability (e.g., Semple & Lee, 2011) [11]. It teaches the youth to observe—in an objective, non-judgmental manner—that his or her thoughts, feelings, and bodily sensations are continually changing. Over time, he or she may come to realize that these events in the mind do not always reflect immediate reality—a process that is sometimes referred to as decentering or metacognitive awareness (Teasdale et al., 2002) [12]. The ability to be aware of one’s own thoughts as simply thoughts, and to not become as invested in them, has been shown to decrease anxiety, depression, low self-esteem, and posttraumatic stress, as well as reducing overall emotional reactivity in adults (Hofmann, Sawyer, Witt, & Oh, 2010) [13] and in youth (Zoogman, Goldberg, Hoyt, & Miller, 2014) [14]; all of which may lessen the need to engage in avoidance behaviors such as SUA (Bowen, Chawla, & Marlatt, 2011) [15].

Along with reducing dysphoria and posttraumatic arousal, ITCT-A uses a mindfulness skill for SUA-involved adolescents known as urge surfing (Bowen et al., 2011) [15]. This technique, adapted for trauma clients, allows the youth to apply mindfulness skills to manage trauma-related urges to drink or use substances. The need to engage in SUA or other behaviors is described as riding a wave. The trauma-related urge starts small, builds, peaks (usually within minutes), and then (if not reinforced) slowly fades. To the extent that the youth can experience such urges as transient intrusions—neither fighting against them nor acting upon them—he or she is better able to tolerate the strong emotions underlying the urge (e.g., desperation, anguish, or depression) and thereby avoid responding with SUA behaviors.

Mindful awareness also may operate as a form of therapeutic exposure (Germer, 2005; Semple & Madni, 2015) [16], since it allows the adolescent to remain present with whatever arises in awareness during triggered trauma memories, and to experience difficult thoughts and emotions with acceptance and metacognitive awareness rather than responding with emotional reactivity and avoidance behaviors (Semple, Lee, Rosa, & Miller, 2010) [17]. When thoughts and emotions are not suppressed (which may result in hyper-accessibility and continued intrusions), nor clung to (obsessed or ruminated about), they may become habituated and lose their power to produce distress. This type of mindful processing of traumatic material has been shown to reduce alcohol-related problems as well as traumatic symptoms (Smith et al., 2011) [18].

Caveats and contraindications

Mindfulness in ITCT-A is an optional module, because not all clinicians have training in this area or have an ongoing personal mindfulness practice. Although some mindfulness techniques, such as mindfulness-based breath training (see Briere & Lanktree, 2013) [5], can be used by most clinicians, more comprehensive mindfulness interventions typically require the clinician to have additional mindfulness training and practice.

There are some contraindications for mindfulness training, for example, if the adolescent is experiencing severe anxiety, suicidal depression, or is in the midst of a psychotic or manic episode. An evaluation should be conducted to assess the severity of symptomatology as well as the nature and severity of ongoing traumas that may be present in the youth’s environment. Nevertheless, there is little evidence that adolescents are unable to learn mindfulness, and much to suggest that, if used judiciously, it may be helpful for many trauma survivors (Semple & Madni, 2015) [19].

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