Understanding Substance Use, Relationship Violence, Sexual Assault, and Trauma: How Therapy Can Help

People rarely come to therapy with problems that fit neatly into one category.

Someone may begin therapy because they are drinking more than they would like, only to discover that alcohol has become one of the ways they cope with anxiety or painful experiences. Someone else may initially seek counseling for depression before recognizing that an unhealthy relationship has contributed to the way they feel. Trauma can affect sleep, relationships, emotional regulation, substance use, self-esteem, and the way we perceive safety.

During my clinical mental health counseling training, I studied crisis intervention involving substance use, intimate partner violence, sexual assault, childhood sexual abuse, and trauma. One of the things these subjects have in common is that effective counseling requires more than simply identifying a problem. Therapists also need to understand where someone is in the process of change, what risks may be present, how trauma is affecting them, and what kind of support fits the individual person.

The concepts below are based primarily on Crisis Assessment, Intervention, and Prevention by Jackson-Cherry and Erford (2014).

Substance Use Is More Complicated Than “Just Stop”

Historically, alcohol problems have been understood through several different models.

Jackson-Cherry and Erford (2014) discuss perspectives including moral, biological and genetic, social learning, psychological, medical or disease-based, and multi-causal models of substance use.

One influential framework was Jellinek's model of alcoholism, which conceptualized problematic drinking as progressing through four stages:

Prealcoholic → Prodromal → Crucial → Chronic

Within this framework, alcohol use may begin as a way of relieving tension. As the problem progresses, alcohol can occupy a larger role in someone's life, with increasing physical, psychological, and social consequences (Jackson-Cherry & Erford, 2014).

I think the broader lesson is more useful than memorizing the stages.

Problematic alcohol use often doesn't appear overnight.

For some people, drinking begins innocently enough:

"It helps me unwind after work."

"I sleep better after a few drinks."

"It makes social situations easier."

"It takes the edge off when I'm anxious."

Over time, however, the relationship with alcohol can change.

Therapy can provide a place to examine that relationship without immediately reducing someone to a label.

Therapists May Ask About Alcohol Even When It Isn't Why You Came to Therapy

Assessment is an important part of counseling.

Jackson-Cherry and Erford (2014) discuss brief screening questions that clinicians can use to identify whether alcohol use may warrant further assessment.

This doesn't necessarily mean a therapist thinks someone has an addiction simply because they ask about drinking.

Alcohol and other substances can affect mood, anxiety, relationships, sleep, impulsivity, and the way someone responds to stress. Understanding someone's substance use therefore provides another piece of the larger clinical picture.

A therapist may ask questions about:

• how frequently you drink or use substances

• how much you typically consume

• whether your use has increased

• whether you've tried to cut down

• whether alcohol or drugs have affected relationships or responsibilities

• what you tend to be feeling before you use them

Sometimes the most useful question isn't simply "How much are you drinking?"

It is:

"What is alcohol doing for you?"

Understanding the function of a behavior can be an important step toward changing it.

You Don't Have to Be Completely Ready to Change Before Starting Therapy

One of the most useful concepts in substance-use counseling is that people differ in their readiness to change.

Jackson-Cherry and Erford (2014) discuss the stages-of-change framework developed by Prochaska and DiClemente.

For example, someone in the precontemplation stage may not believe their substance use is a problem.

Someone in the contemplation stage may recognize that something isn't working but feel conflicted about changing.

They might think:

"I know drinking is hurting my relationship, but it's also the only thing that helps me relax."

"Part of me wants to stop, but another part doesn't."

"I know this can't continue forever, but I'm not ready to give it up."

That ambivalence matters.

Therapy doesn't necessarily have to begin with a demand that someone immediately change everything.

Instead, treatment can meet the person where they are.

Jackson-Cherry and Erford (2014) also emphasize that movement through stages of change is not always linear. Someone may make progress, experience setbacks, return to an earlier stage, and move forward again.

Change is often messy.

That doesn't mean it isn't happening.

Intimate Partner Violence Can Happen in Many Kinds of Relationships

Another major area of crisis counseling involves intimate partner violence, commonly abbreviated as IPV.

IPV is not limited to heterosexual married couples.

Jackson-Cherry and Erford (2014) emphasize that intimate partner violence can occur across different sexual orientations and relationship structures.

That means abusive relationship dynamics can occur among straight, gay, lesbian, bisexual, transgender, and other partners.

The relationship also does not necessarily have to involve marriage.

This matters because people sometimes dismiss their own experiences because their relationship doesn't fit the stereotype they associate with domestic violence.

Someone may think:

"We're not married, so I don't know if this counts."

"We're both men. I don't think anyone will take this seriously."

"They've never actually hit me."

"Most of the time they're wonderful."

Abuse can be complicated, and recognizing it is not always easy.

Why Someone May Feel Like They're “Walking on Eggshells”

Jackson-Cherry and Erford (2014) discuss a cycle of violence, including a tension-building phase.

During this stage, the abusive partner may become increasingly hostile, insulting, threatening, or physically intimidating.

Meanwhile, the other partner may become increasingly focused on preventing an escalation.

They may become especially agreeable.

They may avoid certain subjects.

They may monitor the other person's mood.

They may try to keep everything calm.

They may think carefully before saying something because they don't know how their partner will react.

This is often described as walking on eggshells.

From the outside, someone might ask:

"Why don't they just stand up for themselves?"

But within an abusive dynamic, being compliant may represent an attempt to prevent something worse from happening.

Understanding the pattern can sometimes help clients recognize that their behavior developed for a reason.

Therapy Can Also Involve Assessing Safety

When intimate partner violence is disclosed, therapists may need to consider more than the emotional health of the relationship.

They may also need to consider physical safety.

Jackson-Cherry and Erford (2014) describe lethality assessment as an important part of responding to intimate partner violence.

Factors that may be relevant include:

• how severe the violence has become

• previous incidents

• stalking or obsessive behavior

• previous homicidal or suicidal threats

• substance-use problems

• criminal behavior

• major external stressors

• access to weapons

• perceived threats to the relationship, such as separation

• attempts to prevent a partner from contacting emergency services

The purpose of asking these questions is not to frighten someone.

It is to understand the level of danger accurately enough to discuss an appropriate safety plan.

Someone experiencing abuse may also minimize what is happening because they have gradually adjusted to increasingly concerning behavior.

Talking through specific events with another person can sometimes make patterns easier to recognize.

After Sexual Assault, the First Goal May Simply Be Safety and Stabilization

People sometimes imagine that therapy after sexual assault means immediately recounting everything that happened.

That doesn't necessarily have to be the first step.

Jackson-Cherry and Erford (2014) discuss Psychological First Aid, or PFA, as an important framework for responding to someone following sexual assault or another traumatic experience.

The eight core actions include:

1. Contact and engagement

2. Safety and comfort

3. Stabilization

4. Information gathering

5. Practical assistance

6. Connection with social supports

7. Information on coping support

8. Linkage with collaborative services

Notice that the first task isn't intensive trauma processing.

It is establishing safety and helping the person regain some stability.

A therapist may therefore begin by asking:

"What do you need right now?"

"Do you feel safe?"

"Is there anyone you trust whom you'd like to involve?"

"Is there something practical that needs to be addressed first?"

"Would you rather talk about what happened, or would that feel like too much right now?"

Jackson-Cherry and Erford (2014) emphasize allowing the individual to help determine how the conversation proceeds, including respecting someone's desire not to talk.

That element of choice is particularly important when the traumatic experience itself involved a loss of control.

Trauma Doesn't Always Look Dramatic

People respond to sexual assault and other traumatic events differently.

Some reactions are outwardly expressive.

Someone may cry, become angry, talk rapidly, or show intense distress.

Others may become remarkably quiet.

They may appear emotionally numb.

They may describe something horrific with very little visible emotion.

Neither response tells us how deeply someone has been affected.

Jackson-Cherry and Erford (2014) describe several trauma-related reactions that can overlap with symptoms of Post-Traumatic Stress Disorder (PTSD), including:

• sleep disturbances

• hypervigilance

• withdrawal

• emotional numbness

• decreased involvement with the outside world

• nightmares

• flashbacks

• intrusive thoughts

Hypervigilance, for example, means remaining unusually alert to potential danger.

Someone might constantly scan their surroundings.

They may sit facing the door.

They might startle easily.

They may become uncomfortable in crowds.

Their mind may continually ask:

"Am I safe?"

These reactions can be exhausting.

Therapy can help someone understand why their mind and body are reacting this way and gradually develop new responses.

Trauma Can Affect the Way We Relate to the World

One of the more difficult aspects of trauma is that the original event may end while the person's nervous system continues behaving as though danger is still nearby.

Someone may withdraw from activities they once enjoyed.

They might stop socializing.

They may feel emotionally detached.

Sleep may become difficult.

Certain environments may suddenly feel threatening.

These responses can make someone wonder why they can't simply move on.

A trauma-informed perspective asks a different question.

Instead of:

"Why are you still reacting like this?"

we might ask:

"What did your mind and body learn from what happened?"

That opens the door to understanding rather than judgment.

Childhood Sexual Abuse Can Show Up in Many Different Ways

Childhood sexual abuse is another area in which responses can vary considerably.

Jackson-Cherry and Erford (2014) discuss possible differences in the way children may express distress. Some children may externalize, meaning their distress becomes visible through aggression, acting out, risky behavior, or other behavioral changes.

Others may internalize, with symptoms appearing more as anxiety, depression, withdrawal, or self-harming behavior.

There is significant overlap, and no one pattern applies to every child.

Other possible behavioral changes discussed by Jackson-Cherry and Erford (2014) include:

• attempting to run away

• restlessness

• extreme compliance

• regressive behaviors

• separation anxiety

• developmentally inappropriate sexual language or behavior

• behavioral changes involving peers

The broader takeaway is that traumatic experiences do not always appear as someone explicitly saying:

"Something traumatic happened to me."

Sometimes distress appears first through changes in behavior.

Treatment Should Fit the Person, Not the Other Way Around

There is no single psychotherapy approach that makes sense for every person.

This is especially true with children.

Jackson-Cherry and Erford (2014) discuss Cognitive Behavioral Therapy and other approaches used with children who have experienced sexual abuse, while emphasizing the importance of considering developmental level and the particular difficulties the child is experiencing.

For some younger children, play therapy may be useful because they may not yet have the verbal or cognitive abilities required for more conversation-heavy forms of psychotherapy.

This illustrates a principle that applies to adults too:

The therapy should adapt to the client.

Not every person communicates the same way.

Not everyone responds to the same intervention.

Not everybody needs to process trauma at the same pace.

And not every therapist will be the right therapist for every client.

Good treatment involves understanding the individual person and selecting interventions that make sense for their needs.

Therapy Can Help You Understand the Pattern Beneath the Problem

Substance use, unhealthy relationships, trauma reactions, and difficulties regulating emotions can sometimes look like unrelated problems.

Often, however, there are connections.

Alcohol may be helping someone avoid painful memories.

Hypervigilance may have developed because being constantly alert once helped someone survive an unsafe environment.

People-pleasing may have begun as a way to reduce conflict with an unpredictable partner.

Emotional numbness may represent a mind trying to protect itself from overwhelming feelings.

Recognizing the reason a pattern developed does not mean we have to keep it forever.

It simply gives us a better starting point for changing it.

This is one of the things I find valuable about psychotherapy.

Rather than simply asking:

"How do we get rid of this symptom?"

therapy can also ask:

"Where did this come from?"

"What purpose has it served?"

"Is it still helping you?"

and finally:

"What might work better now?"

Healing Doesn't Have to Follow a Straight Line

Whether someone is changing their relationship with alcohol, leaving an unhealthy relationship, recovering from sexual assault, or working through childhood trauma, progress is rarely perfectly linear.

People can move forward and backward.

They can understand something intellectually before they are ready to act on it.

They can feel better for several weeks and then unexpectedly struggle again.

That doesn't necessarily mean therapy has failed.

As the stages-of-change model discussed by Jackson-Cherry and Erford (2014) illustrates, change itself can involve movement, ambivalence, setbacks, and renewed attempts.

Therapy can provide a place to understand those patterns without turning every setback into evidence that someone is incapable of changing.

The goal isn't perfection.

It's gradually developing greater awareness, more choice in how you respond, healthier ways of coping, and a life that feels increasingly like your own.

Reference

Jackson-Cherry, L. R., & Erford, B. T. (2014). Crisis Assessment, Intervention, and Prevention. Pearson Higher Ed.

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