Substance use disorder and trauma exist in a reciprocal relationship, and distinguishing the origin of one from the other is often impossible. One does not wake up one day with the thought, “perhaps I will derail my life with substances.” The behaviors associated with substance misuse are expressions of deeper underlying emotional trauma; the substance misuse is just one way of managing pain. Many individuals begin using substances to manage the psychological effects of childhood abuse, interpersonal violence, neglect, discrimination, grief, or other adverse experiences. As substance use progresses, however, individuals may experience additional traumatic events directly related to intoxication, withdrawal, impaired judgment, unsafe environments, criminalization, and the destabilization of relationships and housing. Treatment must therefore address not only trauma that preceded substance misuse but also the trauma that occurred during active use and as a consequence of addiction, therefore furthering the cycle of trauma and substance misuse.
Research on trauma-informed care recognizes problematic behaviors, like addiction, as adaptive attempts to survive overwhelming circumstances rather than simply as evidence of pathology or resistance. Levenson (2017) explained that trauma-informed practice emphasizes safety, trust, collaboration, choice, and empowerment while avoiding the repetition of coercive or disempowering interpersonal dynamics. These principles are especially relevant to substance use treatment, where individuals may have experienced stigma, forced treatment, criminalization, involuntary withdrawal, or exclusion from services because of relapse. These individuals have been re-victimized by antiquated systems that focus on sobriety as a precondition of care. An effective approach must therefore reduce immediate behavioral risk while creating opportunities to process the emotional, relational, and existential effects of substance-related trauma.
Two approaches, integrated deliberately, offer a promising response to this challenge: experiential therapy and dialectical behavior therapy. Their integration can help clinicians and families alike feel hopeful about the potential for effective, holistic recovery.
Women, specifically, seeking treatment for both trauma symptoms and substance use, demonstrate elevated vulnerability to suicidal ideation and suicide attempts, illustrating the potential severity of the interaction between trauma, addiction, and emotional distress (Resko et al., 2018). Substance-related trauma may also be cumulative. An individual may survive numerous overdoses, assaults, betrayals, or losses without identifying any single experience as the primary trauma. Instead, the person develops a broader expectation that the world is dangerous, relationships are unreliable, and personal needs or emotions cannot be tolerated.
Recognizing systemic and cultural contributors to harm underscores the importance of cultural competence, encouraging clinicians to feel responsible and capable of delivering respectful, inclusive treatment.
Experiential therapy is a broad theoretical cluster of clinical orientations that emphasizes present-moment awareness, direct emotional experience, embodiment, creativity, relational contact, and learning through action. Experiential therapies have decades of research embedded within their structured approaches. Whether through equine therapy, dance and movement therapy, expressive arts, or other modalities, experiential work can tap into deep emotional connections. Rather than relying exclusively on intellectual discussion, experiential interventions invite people to notice how trauma is carried through emotions, physical sensations, interpersonal patterns, avoidance, and identity.
From an experiential perspective, substance use can be conceptualized as an interruption of contact with emotional experience. Substances may numb grief, suppress fear, reduce physiological arousal, create a temporary sense of connection, or provide distance from shame. Although this strategy may initially protect the person from overwhelming experiences, it limits the person's ability to identify, tolerate, express, and integrate emotion. Treatment, therefore, seeks to expand awareness and help the person remain in contact with internal experience without becoming overwhelmed or returning to substance use.
Experiential work also carries risks when used prematurely or without proper assessment. Reenactment, imagery, role play, or intense emotional activation can destabilize individuals who lack grounding skills, remain in unsafe environments, or are experiencing acute withdrawal, suicidal ideation, psychosis, or severe dissociation. When integrating experiential therapy with DBT, clinicians must carefully evaluate individual readiness, ensure safety, and proceed collaboratively. Trauma-informed experiential therapy must be paced, with clients maintaining control over exercises to prevent re-traumatization or destabilization.
When applied to addiction, DBT conceptualizes substance use as a maladaptive strategy for regulating overwhelming emotions, escaping distress, or managing interpersonal conflict. Treatment, therefore, extends beyond reducing use and focuses on helping individuals build more effective alternatives through mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. The dialectical balance of acceptance and change is especially relevant in substance use treatment, as people are supported in acknowledging the function that substances have served while also accepting responsibility for changing behaviors that threaten recovery. DBT also addresses relapse directly by identifying high-risk patterns, strengthening commitment to abstinence or harm-reduction goals, and treating lapses as opportunities for behavioral analysis and renewed engagement rather than as evidence of treatment failure.
Chain analysis is one of the most useful DBT interventions for substance misuse. Rather than labeling relapse as a moral failure, the counselor and client examine the sequence of vulnerabilities, prompting events, interpretations, emotions, urges, actions, and consequences surrounding the episode. This analysis identifies specific points at which skills or environmental changes could interrupt the sequence. A recurrence of substance misuse following a trauma reminder might reveal that the client experienced an argument, intrusive memories, shame, physiological arousal, an urge to escape, contact with a former using peer, and eventual substance use. Each link becomes a potential target for treatment. This experience moves the locus of responsibility from the individual choice, rather, to the systemic events that lead to a need for one to access substances to manage pain. By understanding the broader context of use, the clinical process becomes about changing systems and environments, rather than perpetuating shame as a framework of moral failure.
Research within the counseling profession has found that DBT is associated with meaningful improvements among adolescents receiving partial hospitalization services, including reductions in clinically significant symptoms (Lenz & Del Conte, 2018). Although this research was not limited to substance-related trauma, it supports the feasibility of DBT in intensive counseling settings serving highly dysregulated clients. The broader clinical rationale for DBT is especially strong when trauma symptoms coexist with self-harm, suicidality, impulsivity, unstable relationships, and substance misuse.
DBT's emphasis on stabilization is consistent with trauma treatment guidelines that prioritize careful assessment and evidence-based intervention. The American Psychological Association (APA, 2025) identifies several trauma-focused psychotherapies as having strong support for adult posttraumatic stress disorder. DBT alone is not equivalent to a complete trauma-processing protocol. Still, its behavioral and skills-based components can create the stability necessary for clients to participate safely in trauma-focused work. Specialized adaptations of DBT have also incorporated trauma processing after clients demonstrate sufficient control over immediately dangerous behaviors.
Experiential therapy and DBT can be integrated through a phase-based model. The purpose of integration is not to combine techniques indiscriminately but to use each approach for the clinical tasks it addresses most effectively. DBT provides structure, behavioral assessment, crisis management, and skills for tolerating emotional activation. Experiential therapy provides methods for accessing, expressing, and integrating emotions and relational experiences that may not change through behavioral analysis alone.
The first phase focuses on physical safety, overdose prevention, suicide assessment, withdrawal management, housing stability, interpersonal safety, and development of a collaborative treatment plan. Counselors assess substance use patterns, trauma symptoms, dissociation, medical needs, medication, recovery supports, and current exposure to violence. Harm-reduction strategies may be necessary even when abstinence remains a longer-term goal.
DBT skills are emphasized during this phase. Individuals learn to recognize triggers, tolerate cravings, ground themselves during trauma responses, reduce access to lethal means, and seek support before a crisis escalates. Chain analysis is used to understand relapse, self-harm, treatment avoidance, or dangerous relationships. The counselor consistently validates the survival function of substance use while helping the client identify its current costs.
Trauma processing begins only after the person demonstrates sufficient stability to remain present without becoming dangerously dysregulated. Readiness should be evaluated collaboratively rather than determined solely by a fixed period of abstinence. Some clients may need integrated trauma and substance use treatment because postponing all trauma work leaves the primary trigger for continued use unaddressed. For this fact alone, families and referring clinicians should be wary of treatment programs that only treat substance use disorder and do not have qualified clinical staff beyond substance abuse counselors.
Experiential interventions can be used to explore grief, shame, fear, anger, betrayal, and identity, among other issues. A client who survived an overdose might engage in an imaginal dialogue between the part that wanted relief and the part that feared death. A parent who lost custody may use chair work to express grief while differentiating responsibility from global self-condemnation. A client who witnessed a peer's death might use psychodramatic or expressive methods to process survivor's guilt and unfinished communication.
The APA's (2025) treatment guideline indicates that trauma-focused interventions should be selected based on available evidence, client characteristics, clinical expertise, and client preference. Therefore, experiential processing should not be presented as a substitute for established trauma-focused protocols when a client meets criteria for posttraumatic stress disorder and desires one of those treatments. Instead, experiential and DBT methods can support engagement, stabilization, emotional access, and integration as part of a broader evidence-informed plan.
The final phase moves beyond crisis reduction toward the development of a meaningful recovery identity. Participants examine relationships, values, work, education, spirituality, community, sexuality, recreation, and future goals. DBT describes this process as building a life worth living, the ultimate aim of the model. Experiential methods allow individuals to rehearse new roles, grieve lost possibilities, communicate with important people, and embody identities that are not organized around substance use or trauma.
Trauma and addiction treatment must be culturally responsive. Behaviors identified as avoidance, mistrust, or noncompliance may reflect realistic responses to discrimination, coercive systems, or previous mistreatment by providers. Counselors should examine how race, culture, gender, sexual orientation, poverty, disability, immigration experiences, and criminal-legal involvement affect the person’s exposure to trauma and access to recovery resources.
Counselor competence is another concern. Experiential interventions can appear simple yet require advanced skills in monitoring arousal, dissociation, group dynamics, boundaries, and emotional containment. Similarly, isolated DBT worksheets do not constitute comprehensive DBT. Counselors should accurately represent their training, seek supervision, and refer people when their needs exceed the counselor's competence or the setting's capacity. When blending modalities with DBT and omitting the entirety of a DBT treatment protocol, the approach is best described as DBT-informed, as this integration represents a departure from the DBT model's fidelity.
DBT currently has the stronger and more standardized research base of these two approaches. Its treatment structure, behavioral hierarchy, skills modules, and chain-analysis procedures are clearly defined and can be evaluated across clinical settings. DBT is particularly applicable when substance-related trauma is accompanied by emotional dysregulation, self-harm, suicidality, impulsivity, or unstable relationships.
Experiential therapy offers a strong conceptual fit for the embodied, relational, and identity-based dimensions of substance-related trauma. Its methods may reach emotional experiences that individuals cannot access through cognitive discussion or behavioral education. However, experiential therapy encompasses a diverse collection of practices, making the overall evidence base difficult to evaluate. More rigorous research is needed to identify which interventions are most effective, for whom, at what stage of recovery, and under what conditions.
These principles are not abstractions at New England Medical Group. NEMG's programs are built on the premise that runs through this article: substance use is treated by treating what lies beneath it. The clinical team includes licensed mental health professionals precisely because trauma work requires qualified clinicians, and care follows the phase-based logic described above. Safety and stabilization come first, with DBT-informed skills work building the ground on which deeper processing can stand. Trauma processing is introduced when readiness has been collaboratively established, not according to a fixed timetable or a mandated period of abstinence. The experiential dimension is not theoretical either: NEMG's programming includes psychodrama, expressive arts, music therapy, and canine therapy, each introduced with the pacing, consent, and clinical oversight the phase-based model requires. Throughout, the relationship remains the vehicle: at the partial hospitalization and intensive outpatient levels of care, daily clinical contact gives the team the continuity to recognize when a person is ready to go further and when the work should slow down.
People with substance use disorders may carry trauma that occurred before substance misuse, during active addiction, and as a consequence of substance-related behaviors and environments. Treatment that focuses only on stopping substance use may leave grief, shame, fear, relational injury, and traumatic memories unresolved. At the same time, trauma processing without sufficient stabilization may increase dysregulation, relapse, self-harm, or disengagement from treatment.
DBT and experiential therapy offer complementary responses to this clinical challenge. DBT provides a structured framework for reducing dangerous behaviors, analyzing relapse, tolerating distress, regulating emotions, and developing a meaningful life. Experiential therapy provides methods for accessing embodied emotion, processing unfinished experiences, reconstructing identity, and transforming the person’s relationship with shame and grief. When integrated through a trauma-informed and phase-based model, the approaches can address both the immediate behavioral risks and the deeper emotional consequences of substance-related trauma. Continued research is needed, particularly on standardized experiential interventions for individuals with co-occurring trauma and substance use disorders. Nevertheless, a careful integration of DBT and experiential therapy offers a clinically coherent framework for helping people move from survival and avoidance toward emotional integration, accountability, connection, and sustainable recovery.
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Andrew Lapin, M.S.,M.A., LMHC, serves as the Vice President of Clinical Services for New England Medical Group, where he provides clinical leadership across behavioral health programming, supervision, treatment development, and quality of care initiatives. With more than 15 years of experience in human services and mental health care, Andrew brings a clinically grounded and systems-focused approach to building programs that are ethical, effective, and responsive to the needs of clients and families.
Andrew’s clinical philosophy is rooted in the belief that lasting healing requires more than symptom management. His work emphasizes addressing the core issues of trauma, attachment, emotional pain, and relational disruption that often underlie addiction, maladaptive coping, and behavioral health challenges. He is committed to integrated, evidence-based treatment that helps clients understand the function of their symptoms while developing healthier, more sustainable ways of relating to themselves and others.
Andrew is a Licensed Mental Health Counselor and is currently pursuing doctoral study in Counselor Education and Supervision, further strengthening his work as a clinician, supervisor, educator, and behavioral health leader
