Across the addiction treatment landscape, a long-standing tension persists between two clinical imperatives: the drive to address the underlying trauma that so often fuels addictive behaviour, and the equally urgent need to establish sobriety as the foundation upon which any deeper healing can rest. For many clinicians, these goals have felt competing. In reality, they are sequential. This article argues that the sequencing of trauma and addiction work is not a theoretical nicety but a clinical necessity — and that understanding why requires a close engagement with the neuroscience of dissociation, the phenomenology of affect dysregulation, and the practical realities of how traumatised clients actually present in treatment.
1. The Dissociation–Addiction Link
To understand why stabilisation must precede trauma retrieval, it is first necessary to understand what dissociation is and what function it serves. Dissociation is not pathology in origin; it is survival. In early childhood, the capacity to mentally check out — to remove oneself psychologically from an unbearable physical reality — is a neurobiological gift. Children are born with this capacity, and for those who experience abuse, neglect, or chronic relational threat, it may become their primary means of enduring what they cannot physically escape.
The clinical complication arises in adolescence, when young people discover that certain substances, behaviours, and experiences can reliably reproduce this same dissociative state. Alcohol, drugs, self-harm, excessive screen use, disordered eating — all can function as what might be called evolved dissociation: externally induced states that mimic the internally generated checking-out the child once relied upon. The substance or behaviour becomes a vehicle for achieving the same neurological outcome: relief from intolerable affect.
This is not merely a metaphor. Bessel van der Kolk (2014) has documented extensively that at least half of all traumatised individuals attempt to manage their intolerable inner world through substance use, and that the absence of adequate psychoeducation around dissociation in addiction treatment may be a primary driver of relapse vulnerability. A client who does not know they are dissociating cannot interrupt the process. A client who does not understand the biological logic of their dissociation will continue to experience it as shameful weakness rather than adaptive response — and shame, as every trauma-informed clinician knows, is itself a powerful trigger for addictive behaviour.
2. The Somatic Landscape of Dissociation
Effective treatment of the dissociation-addiction cycle begins with helping clients identify the physical and somatic precursors to checking out. These are highly individual but frequently include: a distinctive pressure headache — described by clients as a tightening around the skull or a throbbing behind one eye — often followed by visual fuzziness or a loss of peripheral vision. The narrowing of the visual field is biologically coherent: when the nervous system registers threat, it focuses processing resources on what is directly ahead, eliminating peripheral data as extraneous. The client may describe feeling simultaneously hyper-focused and strangely distant, able to see the therapist’s lips moving but unable to register sound.
Other somatic markers include a heaviness or immobility in the limbs — the freeze component of the freeze response — and in some clients, a visual or phenomenological experience of darkness: a closing aperture, a dark curtain, or a sense of the room retreating. For clients on the more complex end of the dissociative continuum, there may be significant internal noise — other voices, competing internal commentary, or the pull of alternate self-states — that further disrupts the capacity for grounded engagement.
These phenomena are not incidental curiosities. They are clinical data. Frank Putnam’s Dissociative Experiences Scale (1997) offers a structured framework for eliciting them, and importantly, Putnam recommends administering it verbally rather than as a written form — precisely because the act of asking a question can itself elicit a dissociative response. Observing non-verbal reactions as the clinician reads each item (a glaze of the eyes, a drop of the chin, psychomotor slowing, a shift to flat monosyllabic answers) can reveal far more than any written self-report.
The clinical goal of this somatic mapping is not diagnostic but therapeutic: we are teaching clients to recognise their own early warning signals so that they can, in Dan Siegel’s phrase, ‘name it to tame it’ (Siegel, 1999). Simply naming the experience — ‘I notice I am beginning to check out’ — activates the prefrontal cortex and helps modulate amygdala arousal. The client begins to reclaim executive function at the moment it is most under threat.
3. Dissociation as a Survival Strategy: Validation Before Interruption
A critical clinical error in addressing dissociation is to present it as a problem to be eliminated. For many trauma survivors, the capacity to check out is experienced as their most reliable internal resource — a kind of superpower, as clinicians often hear it described. Any suggestion that this resource might be removed will be heard as both a threat and a misrecognition of lived experience.
The therapeutic stance must therefore begin with genuine validation: acknowledging that dissociation was, historically, not merely useful but potentially life-saving. For a child who had no physical escape from a threatening adult, the ability to leave mentally was a form of agency — perhaps the only form available. Communicating this explicitly, and doing so in the past tense wherever possible to begin gently disentangling past from present, creates the relational safety necessary for the next step: introducing the concept of choice.
Many traumatised clients have never considered that dissociation could be optional rather than automatic. The idea that one might assess, in real time, whether checking out is in one’s best interest — or whether remaining present would actually be more empowering — can feel genuinely revelatory. It also addresses a paradox that must be communicated with care: whilst dissociation was protective in childhood, in adulthood it can function as a vulnerability. An adult in a dissociative freeze state cannot engage in self-advocacy; they cannot locate an exit, say no, or walk away from a dangerous situation. The very mechanism of protection becomes, in the wrong context, a mechanism of exposure.
This reframing is central to building motivation for change. When clients understand that staying present is not about strength or willpower but about self-protection, the rationale for affect regulation work shifts from therapeutic compliance to genuine self-interest.
4. Affect Regulation: Building the Toolkit
Once a client has some understanding of their dissociative process and is open to the possibility of alternatives, clinical work can begin on building a repertoire of affect regulation strategies. These must be practical, accessible, and genuinely effective — not exercises the client will abandon because they feel artificial or burdensome.
Aromatherapy is among the most physiologically potent of these strategies. The olfactory region of the brain is neuroanatomically adjacent to the areas governing sensory and emotional memory, meaning that scent produces an immediate and involuntary association response. For clients who identify a fragrance carrying positive associations, this can produce rapid re-grounding — a sensory shortcut to safety that bypasses the slower pathways of cognitive reassurance. Anchoring techniques — holding a meaningful object, a smooth stone, a crystal — serve a similar function, providing a physical tether to the present moment when the pull of dissociation is strong.
Mental grounding strategies — counting backwards, word games, positive affirmations — work by re-engaging the prefrontal cortex and restoring some degree of executive function. The 5-4-3-2-1 technique, developed within the Ericksonian tradition (Erickson, 1980), involves naming five things one can see, five things one can feel, and so on, counting down to one of each. By simultaneously engaging limbic and cortical processing, this technique facilitates what is sometimes described as the optimal window of arousal: the capacity to think and feel at the same time. This is the therapeutic window within which genuine processing becomes possible.
Breathwork carries particular clinical value because it requires no objects, no expense, and is available under any circumstances. For clients with limited resources or unstable living situations, this accessibility matters. Movement — not necessarily formal exercise, but simply moving to music — can release endorphins, restore a sense of bodily agency, and interrupt a freeze state that might otherwise escalate toward addictive behaviour.
5. The Full Spectrum of Addictive Behaviour
Effective trauma-informed addiction treatment requires clinicians to hold a broader conception of addiction than the conventional focus on alcohol and illicit drugs. Research consistently indicates that approximately 75% of individuals engaging in self-destructive behaviour do so through more than one method (van der Kolk, 2014). A client who discloses alcohol use may not spontaneously mention self-harm, disordered eating, compulsive sexual behaviour, excessive social media use, or gambling — all of which serve functionally identical purposes in relation to dissociation and affect regulation.
Self-harm offers a particularly clear illustration of the dissociation-addiction link. The act of cutting or burning produces both dissociation and endorphin release — a neurobiological reward that is immediate and reliable. However, as with other addictive behaviours, the relief is temporary. Once the endorphin surge subsides, the client returns to the same emotional baseline, typically with the addition of shame — itself a potent driver of further dissociation and further self-harm. The cycle is self-perpetuating.
Clinicians should also hold in mind the role of cognitive distortions in maintaining these cycles. Many trauma survivors carry core beliefs — ‘I am damaged’, ‘I deserved the abuse’, ‘I am fundamentally bad’ — that are not simply negative thinking but the logical conclusions of a child’s attempt to make sense of maltreatment within an attachment relationship. Taking ownership of abuse, as children frequently do, is a strategy for preserving attachment to a caregiver upon whom they depend. These beliefs, unaddressed, fuel the self-medication that addiction represents, and the shame that perpetuates it.
Alexithymia — the inability to identify and articulate emotional states — is also common in this population. Where a child was not permitted to express needs or feelings, or where no adult modelled the language of emotional experience, the client may arrive in treatment genuinely unable to name what they are feeling. This is not resistance; it is an absence of vocabulary they were never given. Part of treatment involves building this vocabulary with patience and without judgement.
6. The Cyclical Nature of Trauma and Addiction
J. Eric Gentry (2002) describes a feedback loop that many clinicians will recognise: re-traumatisation leads to self-medication through addictive behaviour; addictive behaviour impairs judgement and insight; impaired judgement places the individual in unsafe situations; unsafe situations increase the likelihood of re-traumatisation. The cycle is vicious, and it is structural — not a failure of willpower but a logical consequence of the client’s neurobiological state and available coping resources.
What this framework clarifies is why attempts to address trauma narrative directly, in the absence of established stabilisation, so often produce the opposite of the intended effect. As Gentry (2002) further notes, as addicted survivors begin to abstain from substances, the intrusion, avoidance, and hyperarousal symptoms of traumatic stress frequently intensify. The addiction has been functioning as a chemical barrier between the client and their traumatic material. When that barrier is removed, the material surfaces — and if the client has not yet developed adequate affect regulation capacity, the most available response to overwhelming affect remains the addictive behaviour. The relapse is not failure; it is the clinical information that stabilisation is not yet complete.
7. The Treatment Framework: Stabilisation Before Retrieval
7.1 Sobriety First
The foundational principle of trauma-informed addiction treatment is that sobriety must precede trauma narrative work. Attempting to address, for instance, childhood sexual abuse on the third day of a client’s sobriety is not only clinically futile but potentially harmful. A client who is still in active withdrawal or early recovery does not yet have the neurobiological stability — let alone the affect regulation skills — to engage with traumatic material safely. To proceed is to risk overwhelming the client in a way that drives them back to the very behaviour treatment is attempting to interrupt.
This is not to suggest that sobriety alone constitutes adequate preparation. The question of readiness for trauma retrieval is more complex, and involves the quality of stabilisation as much as its duration. Some clients establish solid sobriety and develop robust affect regulation resources within months; others vacillate in and out of abstinence over years. The clinical decision about when to transition into retrieval work must be made on the basis of the individual client’s demonstrated capacity to tolerate affect without recourse to addictive behaviour — not on the basis of elapsed time alone.
7.2 12-Step Programmes: Usefulness and Limitations
Twelve-step programmes offer genuine and significant value in the early stages of recovery: reducing isolation, providing a structured social network, and helping to replace the people, places, and routines associated with addictive behaviour. For many clients, the sense of community and mutual identification experienced in these meetings is therapeutic in itself.
However, clinicians working with trauma survivors must hold a nuanced view of the 12-step framework. The language of powerlessness — foundational to the model’s first step — can be experienced as re-traumatising by clients for whom loss of power and control was the central feature of their abuse. The fourth step’s focus on ‘character defects’ risks activating the very shame-based cognitive distortions that are already among the client’s most significant vulnerabilities. Reframing ‘character defects’ as ‘areas for growth’, and ‘powerlessness over addiction’ as ‘powerlessness over the neurobiological sequelae of trauma’, can make the model more accessible without undermining its structure.
Clinicians should also be alert to the possibility of clients using meeting attendance itself as an avoidance strategy — attending multiple meetings daily as a way of not engaging with other responsibilities or therapeutic work. The 12-step programme is one component of a broader package of care, not a substitute for it.
7.3 Therapeutic Relationship as Clinical Foundation
For clients whose earliest attachment relationships were characterised by threat, inconsistency, or betrayal, the therapeutic relationship is not merely the medium through which healing occurs — it is, itself, a primary site of healing. The experience of being consistently received, accurately attuned to, and genuinely witnessed by another person can begin to rewire the relational expectations that trauma has encoded.
This places particular demands on the clinician. Charlie Whitfield’s distinction between asking ‘Do you use drugs?’ and ‘How do you use drugs?’ (Whitfield, 1987) captures something essential: the question of function — what the client gets from their addictive behaviour, in what contexts, with what emotional antecedents — is as clinically significant as the question of frequency or quantity. Exploring what relationships support sobriety and which increase vulnerability to relapse is equally important, and involves mapping the client’s relational world with honesty and care.
Clinicians should be thoughtful about availability: making oneself completely accessible can foster unhealthy dependence and, paradoxically, replicate the experience of inevitable rejection when availability inevitably has limits. The therapeutic aim is to build a genuinely relational resource whilst simultaneously supporting the client in developing other sources of connection and support.
7.4 Trauma Retrieval: Timing and Readiness
Trauma retrieval work — the deliberate processing of traumatic memories and narratives — should occur only after stabilisation is well established, affect regulation capacity is demonstrated, and the therapeutic relationship is secure. In many cases, this means months or years into the treatment process. This is not delay for its own sake; it is the clinical prerequisite for retrieval work to be safe and productive rather than retraumatising.
A crucial point about retrieval work is that it cannot safely be attempted within a brief therapeutic frame. Safety planning, psychoeducation, affect regulation work, and the establishment of relational resources can all be delivered meaningfully in shorter-term work. Trauma narrative processing cannot. Clinicians working in time-limited settings must be honest about this, and must resist the temptation — whether client-driven or service-driven — to enter retrieval work before the necessary foundations are in place.
Trauma is not stored in the language part of the brain (van der Kolk, 2014). This has direct implications for how retrieval work must be structured: it requires visual and visceral approaches that can access somatic memory, and it requires keeping the client within the optimal window of arousal throughout — neither flooded with affect nor so dissociated that processing is impossible. The dual awareness of thinking and feeling simultaneously is both the goal and the prerequisite of effective trauma processing.
8. The CARESS Model: A Practical Framework
For clients in early recovery who are managing impulses toward addictive or self-destructive behaviour, the CARESS model offers a structured, non-confrontational framework that honours the function of addictive behaviour whilst introducing alternatives. The model addresses three components: Communicate Alternatively, Release Endorphins, and Self-Soothe.
The foundational philosophy of CARESS is that clients do not continue engaging in self-destructive behaviour because they are irrational or self-defeating; they continue because the behaviour delivers something real and neurobiologically significant. Rather than using a no-harm contract — which clients may sign with conscious resentment and subsequently breach, adding shame to the cycle — CARESS asks: what is the client getting from this behaviour, and how might they obtain the same neurobiological effect without the self-injury?
The Communicate Alternatively component addresses the communicative function of many addictive and self-harming behaviours. As van der Kolk’s research using PET scanning demonstrates, traumatic experience is stored visually and viscerally rather than linguistically (van der Kolk, 1994). Many clients do not have a verbal narrative for what has happened to them — either because the memory is pre-linguistic, or because a perpetrator’s injunction not to disclose has shaped how the experience is encoded. Offering alternative means of expression — drawing, writing, sculpting, recording audio — acknowledges this reality and provides an outlet that does not require the client to produce a verbal account they may not yet have.
Release Endorphins addresses the neurobiological reward function of addictive behaviour. Cutting, drinking, bingeing — all produce endorphin release. Replacing this with brief physical movement, genuine laughter, or physical warmth (hugging a cushion, wrapping in a blanket, contact with a pet) can produce a physiologically comparable effect without self-injury. Critically, the model excludes strategies such as rubber band snapping or ice immersion that have appeared in some clinical literature — these are, in effect, new forms of self-harm, and are inconsistent with a genuinely self-compassionate approach.
The Self-Soothe component offers a range of genuinely comforting activities — breathwork, a warm bath, time in nature, meditative music — that activate the parasympathetic nervous system and help restore a more regulated physiological baseline. The practical implementation of CARESS involves the client gathering everything needed for all three components into a physical box, with a timer. When an impulse arises, the client goes to the box. The full CARESS process takes thirty to forty-five minutes — a duration chosen deliberately to carry the client past the neurological peak of the craving, which typically subsides within approximately twenty minutes.
Critically, the model does not prohibit the addictive behaviour at the end of the process. The client retains the right to engage in it. This removes the power struggle that is so often counterproductive with trauma survivors, for whom experiences of coercive control are central to their histories. In practice, clients frequently report that completing the CARESS process means they no longer feel the impulse — not because they were prohibited from acting on it, but because they have cared for themselves.
9. Grief, Loss, and Parts Work
Clinicians accustomed to framing recovery as unambiguous gain may underestimate the extent to which giving up an addiction involves loss. The substance or behaviour has, for many clients, been their most reliable source of relief, comfort, and even pleasure. It has served a genuine relational function in their internal world. To relinquish it is, in some sense, to lose a relationship — and loss requires grief.
A parts perspective — drawing on frameworks including Internal Family Systems and ego state therapy — can be useful here. There may be a part of the client that is committed to recovery and a part that remains loyal to the addictive behaviour, not out of weakness but out of an older, deeper logic. Holding both parts with compassion, rather than enlisting the ‘recovery part’ against the ‘addicted part’, is both more honest and more effective. Goodbye letter exercises, written over time and across multiple drafts, can allow clients to honour the function the addiction has served whilst articulating, in their own words, what it is costing them.
10. Core Principles: A Summary
The argument of this article can be distilled into a set of clinical principles that are, at their core, about sequencing and respect. Stabilisation before retrieval is not a conservative or cautious approach; it is the approach most likely to produce genuine and lasting change. The principles are:
Reframe symptoms as adaptive rather than pathological — the question is always ‘what happened to this person?’ rather than ‘what is wrong with them?’. Establish sobriety and stabilisation as the necessary preconditions for any trauma processing work. Build affect regulation capacity before attempting to access traumatic material. Honour the function of addictive behaviour whilst consistently introducing the possibility of alternatives. Use the therapeutic relationship as a corrective attachment experience, with careful attention to both availability and appropriate boundaries. Recognise that trauma is held in the body and that effective intervention must be visual and visceral, keeping the client within the optimal window of arousal. Introduce choice and agency at every point, understanding that the restoration of choice is itself one of the primary therapeutic objectives for trauma survivors. And recognise that recovery involves grief — and that grief requires space, validation, and time.
The aim, ultimately, is to help clients arrive at a place where their affect regulation capacity is sufficient to meet whatever life brings — including the inevitable recurrence of difficult feeling — without requiring them to choose between their pain and their safety. This is what stabilisation makes possible. And it is why it must come first.
References
Erickson, M. H. (1980). The collected papers of Milton H. Erickson on hypnosis. Irvington.
Gentry, J. E. (2002). Compassion fatigue: A crucible of transformation. Journal of Trauma Practice, 1(3–4), 37–61.
Putnam, F. W. (1989). Diagnosis and treatment of multiple personality disorder. Guilford Press.
Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. Guilford Press.
Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to shape who we are. Guilford Press.
Siegel, D. J. (2010). Mindsight: The new science of personal transformation. Bantam Books.
van der Kolk, B. A. (1994). The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Review of Psychiatry, 1(5), 253–265.
van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.
Whitfield, C. L. (1987). Healing the child within: Discovery and recovery for adult children of dysfunctional families. Health Communications.
Whitfield, C. L. (1995). Memory and abuse: Remembering and healing the effects of trauma. Health Communications.