Louise Stanger is a speaker, educator, licensed clinician, social worker, certified daring way facilitator and interventionist who uses an invitational intervention approach to work with complicated mental health, substance abuse, chronic pain and process addiction clients.
Over the last couple years, more and more treatment centers have started saying they specialize in “Trauma Informed Therapies.” I marvel over this, as clearly indigenous to substance abuse, mental health and chronic pain is, in fact, trauma. To better understand the link between trauma and addiction, I collaborated with my colleague and friend Dr. James Flowers, CEO of Driftwood Recovery in Austin, TX.
Let's take a look at this. Larke Huang, Director of the Office of Behavioral Healthcare Equity at the Substance Abuse and Mental Health Administration, defines trauma broadly as “a stress that causes physical or emotional harm which you cannot remove yourself from.” Trauma is subjective, meaning what matters most is the individual’s internal beliefs and their innate sensitivity to stress, not whether a family member or therapist or other outsider deems an experience traumatic. We all know people who were in the same combat zone, present at ground zero, have seen a life-threatening event, or who have been bullied and persecuted, etc. will have differing responses. There is a link between emotional trauma (i.e. the increase in the number and frequency of events) and a link to substance abuse.
In the Journal of Alcoholism: Clinical and Experimental, a study was published which showed a link between childhood trauma and alcoholism. For example, a study of children who lived near ground zero were more likely to experience trauma the more exposure they had to a life-threatening event (such as knowing someone who dies or fearing for their life), which correlated with a higher likelihood they were to use alcohol and other drugs. Furthermore, the study reports that “a child with four or more adverse childhood experiences is five times more likely to become alcoholic and 60 percent more likely to become obese, and a boy with 4 or more of these adverse experiences is 46 times more likely to become an injection user than others." The researchers of the Adverse Childhood Experience, which followed 17,000 Kaiser patients, further found that the effects of trauma are cumulative and that one of the most destructive forms is "chronic recurrent humiliation,” a big term for name-calling or ridicule.
That being stated, trauma can occur in many ways. As Dr. Flowers points out, trauma can stem from abuse or neglect or frightening experience such as witnessing a murder, a car, boat or airplane accident, school bullying and shootings, sudden life changes or near- death experiences. It also can have happened in homes where there was an alcoholic parent. Or growing up in an environment where the expression of how one feels was not cultivated.
The definition of trauma grows broader if you include responses to powerful one-time events, such as: accidents, natural disasters, crimes, surgeries, deaths and other violent events. It also includes responses to chronic or repetitive events such as child abuse, neglect, combat, urban violence, concentration camps, battering relationships and enduring deprivation.
Joe Allen, a psychologist at the Menninger’s Clinic, wrote a book in 1995 titled Coping with Trauma: A Guide to Self-Understanding in which he emphasizes again there are two components of trauma -- the objective i.e. what happened (ex: my father killed himself, my baby died of SIDS, I witnessed a murder, my boyfriend beat me, my mother said I was no good, I survived Hurricane Katrina, etc.) and the subjective experience (ex: how do I perceive the occurrence?). Per Michele Rosenthal, a behavioral health specialist and researcher, “fear drives all post-trauma behaviors; healing focuses on resolving the fear.” And all behavioral health care centers must focus on healing and not tearing down.
While experiencing trauma does not guarantee that a person will develop an addiction, research clearly suggests that trauma is a major underlying source of addiction. For example, the National Center for Post-Traumatic Stress Disorder and the Department of Veterans’ Affairs have found that veterans who witnessed many violent acts, including the deaths of other soldiers and civilians in combat, physical pain sustained from injuries, or strenuous combat fatigue, are at a much higher risk to experience a substance abuse or mental health disorder stemming from their PTSD. Here are a few statistics that correlate trauma with substance abuse or mental health disorders:
- Survivors of illnesses, accidents, and natural disasters report between 10 to 33 percent experience alcohol abuse.
- Sources estimate that 25 to 75 percent of persons who survive abuse experience addiction.
- A diagnosis of PTSD (Post Traumatic Stress Disorder) increases the risk of developing alcohol abuse.
- Female survivors who do not experience PTSD face an increased risk for addiction.
- Male and female sexual abuse survivors experience a higher rate of alcohol and other drug abuse.
In addition to the link between trauma and addiction, neuroscience helps us further understand the relationship:
- The section of the brain related to the threat center, or amygdala, may become overactive after experiencing a traumatic event -- constantly seeking out and assessing threat. This will cause the person to become excessively fearful and anxious.
- The brain’s center for processing memories, the hippocampus, may become under active. Rather than storing new memories, it may get hung up on the memories of trauma and play them on repeat, making disturbing and uncomfortable recollections.
- The brain’s cortex, the center of executive control, becomes caught up in survival instincts. These instincts are like paradoxical distortions -- they decrease your ability to inhibit or control certain behaviors.
Therefore, physical pain (acute or chronic) brought on by a traumatic event (not just emotional) may also be a trigger for substance abuse disorders. The human body operates in tandem with the brain and nervous system, therefore, the common denominator between chronic pain and trauma is the nervous system. Trauma can make the nervous system persistently reactive. The more reactive the nervous system, the higher level of pain we physically experience. Once an acute painful injury or illness occurs, people with an already reactive nervous system are more prone to develop chronic pain.
Research shows how chronic pain may stem from childhood or adulthood trauma and can fuel an addiction. Per papers published in the US National Library of Medicine and the National Institutes of Health, here are a few statistics:
- With or without back surgery, nearly 76% of patients with chronic lower back pain report having had at least one trauma in their past.
- Upwards of 90% of women with fibromyalgia syndrome report trauma in either their childhood or adulthood.
- 60% of those with arthritis report a traumatic history.
- 66% of women with chronic headache report a past history of physical or sexual abuse.
- Among men and women, 58% of those with migraines report histories of childhood physical or sexual abuse or neglect.
- Women with chronic pelvic pain also report high rates of sexual abuse in their past, upwards of 56%.
As we often say when we talk about substance abuse -- I have never met anyone who said they want to become an alcoholic or addict when they grow up. As such, addiction pops up more like a survival instinct to numb painful memories. The places you have been, the things you have witnessed, the abuse - physical or emotional - among other experiences, shape who we are and may awaken an addiction as a means of coping. Addiction becomes a friend, a good intention that goes bad. As behavioral health clinicians, our question must not be: what is wrong with this person? Instead, we must ask: what happened to this person?
Therefore, when we think of trauma as both objective and subjective, it becomes indigenous to substance abuse, process disorders, mental health and chronic pain. Solid assessments must be done and much can be uncovered with family mapping. The key is two-fold: behavioral health care providers must remain open to what our client say (start where the client is) not what we think of them or their situation. Secondly, clinicians must provide experiences which allow for clients to communicate with their body, not necessarily communicating through talking. It’s a process of observing how the body responds to different stimuli.
Hence, all therapeutic interventions must be trauma-informed, focusing on strength and resilience. Some interventions may be more specific to somatic experiences such as EDMR, Challenge by Choice, outdoor activities, psychodrama, art expression, mindfulness, massage, acupuncture, seeking safety etc. SAMSHA. Therapeutic interventions may also offer a multitude of resources including but not limited to an Addiction and Trauma Recovery Integration Model as well as Trauma, Recovery Mental Health and Recovery (TAMAR), etc.
We must integrate substance abuse, mental health and chronic treatment in the behavioral health care field. Trauma as it exists is in the eye of the beholder and goes together with addiction, mental health, chronic pain, etc. Let us not see this as something out of the ordinary, rather, let's make it part and parcel of our behavioral healthcare treatment protocols. If we can do this so can you!
To learn more about Louise Stanger and her interventions and other resources, visit her website.
Resources
What Is Psychological Trauma? https://www.sidran.org/resources/for-survivors-and-loved-ones/what-is-psychological-trauma/
Allen, Jon G. Coping with Trauma: A Guide to Self-Understanding. Washington, DC: American Psychiatric Press, 1995
Sack, David. Emotional Trauma: An Often-Overlooked Cause of Addiction. Psych Central 2012
Rosenthal, Michele The Trauma _Addiction Connection (March 30, 2015 ) in Behavioral Health, Living in Recovery, Living with Addiction
For statistics related to lower back pain and trauma, visit the US National Library of Medicine: https://www.ncbi.nlm.nih.gov/pubmed/8118090
For statistics related to chronic headache and trauma, visit the US National Library of Medicine:
For statistics related to pelvic pain and abuse in women, visit the US National Library of Medicine:
SAMSHA Addiction and Trauma https://www.samhsa.gov/nctic/trauma-interventions
Trauma and Recovery
SAMSHA’ Concept of Trauma and Guidance for Trauma Informed Approach http://store.samhsa.gov/shin/content/SMA14-4884/SMA14-4884.pdf
Women and Addiction http://www.stephaniecovington.com/assets/files/CovingtonSARC5.pdf
Resilience to meet the Challenge of Addiction Psychobiology and Other Considerations