Establishing safety in the healing process for clients recovering from substance use disorder

By Rebecca Knowles, OTD, OTR/L, RYT Reviewed by Unyte Clinical Team

Rebecca Knowles, OTD, OTR/L, RYT, is an occupational therapist specializing in sensory processing and mental health. She describes how combining pain management, lifestyle modification, and sensory strategies through a biopsychosocial, trauma-informed lens can help people in recovery.

According to the Centers for Disease Control and Prevention, overdosing continues to be a leading cause of death in the U.S. In 2019, the World Health Organization (WHO) reported about 36.3 million people worldwide suffered from drug use disorders, and a 2021 article in The Lancet reported that over 500,000 deaths since the mid-1990s were attributed to opioids. 

This epidemic has become more prevalent in recent years, as drug-related deaths increased by almost 30 percent in 2020, aligning with the peak of the COVID-19 pandemic. Individuals with high incidence of adverse childhood experiences (ACEs) are also more likely to develop addiction and other mental health challenges as adults.

Providers working with clients with substance use disorder may benefit from a bottom-up approach that considers the impact of trauma on substance use.

In my experience, most of the clients I’ve worked with are polysubstance users with psychiatric comorbidities, so if they present with an opioid use disorder, there are often related changes with other substances and mental health conditions, and almost always a trauma history.

Many individuals with opioid-related challenges also have pain-related conditions, and started using prescribed opioids before their disease progressed to full-blown addiction and illicit substance use. In these cases, it’s important to address their underlying pain through a biopsychosocial lens. The combination of pain management strategies, including changing the association and relationship to the pain is important.

Challenges in the healing process for people with opioid use disorder

With all substance use disorders (SUD), lifestyle modification is a significant challenge. People with SUDs often need to change many aspects of their life, from their work and social communities, relationships with family members, recreational activities, establish basic self-care and activities of daily living (ADL) routines, and sleep hygiene, which is often overlooked. 

Reframing opioid use

When supporting clients who believe that opioid use is a beneficial part of their lives, it’s important to approach from a place of understanding using therapeutic modes of empathizing and collaborating. An approach based on cognitive behavioral therapy (CBT) can help change their beliefs and associations with use, but only when grounded in bottom-up approaches, such as sensory processing, mindfulness and social engagement that help them feel safe — in their bodies, not just mentally or emotionally — and calm without the drug. 

Remember that many people with SUD have spent much of their lives in a fight-flight-freeze state and have been using substances to numb. Feeling calm and relaxed may feel uncomfortable for them at first. Support them with bottom-up strategies to better access homeostasis without substances.

How to plan your first sessions together

When starting out with a client with SUD, the first session can vary greatly depending on the evaluation. I start with a thorough evaluation, including an occupational profile and variety of assessments, often the Pittsburgh Sleep Quality Index (PSQI) and A/A Sensory Profile. I then use motivational interviewing techniques to help identify goals and establish a baseline. Beyond that, the first few sessions are all about the relationship and establishing safety and trust.

Establishing safety for the client is an essential step in setting a foundation for healing. When clients experience dysregulation in their nervous system, they can be stuck in a defense loop that prevents them from progressing in their recovery. Bottom-up therapeutic interventions, such as the Safe and Sound Protocol (SSP), are often used to help repattern the autonomic nervous system, complementing CBT and other top-down modalities.

Integrating nervous system regulation in the healing process

Watch this video to learn about the impact of the Safe and Sound Protocol when used in treatment, as described by Deirdre Stewart, Vice President of Trauma Resolution Services at The Meadows, a leading national provider based in Arizona that provides support for people seeking to overcome addiction and heal unresolved emotional trauma.