I have spent my professional career immersing myself in understanding addiction through a mental health lens, and the farther along I go in this path I have come to agree with several professionals, innovators, and visionaries in the field that addiction is primarily a symptom, and specifically a symptom of trauma. As Dr. Gabor Maté stated at a conference, “Addiction is only a symptom, it is not the fundamental problem. The fundamental problem is trauma.” Now when I say trauma, most of us generally think of the big “T’s” of trauma, such as abuse, neglect, witnessing violence, feeling our life is in danger, and all of the criteria A of in the DMS 5 of Posttraumatic Stress Disorder; however, what about the little “t’s” which happen to people consistently. When I think of the little “t’s” of trauma, such as not feeling an attachment to our caregivers and experiencing toxic stress I tend to think of the saying, “death by a thousand cuts,” which are adverse childhood experiences and need to be acknowledged. The reason it is imperative to really understand how addiction is a symptom is before we can ask how to treat something, we have to understand what we are treating. When we understand addiction comes back to trauma people have experienced in their life and understand this, treatment can happen. To paraphrase Maté, most in the medical profession and the legal system do not understand addiction and treatment is not helpful and can in fact be harmful. The type of trauma I am going to speak of involves early childhood adversity and how when certain factors are present insecure attachment becomes a breeding ground for addiction to become a “substitute” relationship for individuals and attachment-sensitive counseling can be fundamental in the healing process for individuals diagnosed with a substance use disorder.
So, let’s talk about this. One model I love when understanding addiction is the biopsychosocial model of addiction—but what exactly does this mean? In my understanding, it means addiction is not always what it seems. There are hidden drivers, influences and motivations at work and underlying the disorder. Stress-specifically toxic stress, adversity, and trauma become the covert engines underneath many of the social, medical, and psychiatric crises we face. When we start to see this one thing becomes frightfully clear: trauma and addictive disorders are two of the most underdiagnosed disorders and this can be because most clinicians shy away from asking about sexual or emotional abuse, as well as substance use disorders. Oliver Morgan stated, “Perhaps the most powerful barrier confronting counselors and those struggling with trauma and addiction is the experience of shame and discomfort, of blame and societal judgment that surrounds both conditions. Safety to speak and inquire must precede honest truth-telling, and clinicians need to adopt making safety a priority.” One solution? Universal screening. After years of working in this field I am still shocked by how often trauma-related disorders are not even assessed. It is imperative to realize, as well, that both substance use disorders and diagnoses associated with trauma exist on a spectrum, and this perspective does not deny other factors--It does challenge, however, all the health and wellness-related fields to consider a new impact of stress and coping on living. When we understand that people who are addicted are traumatized people, we can take an approach that will help them heal that trauma rather than make it worse.
When it comes to different definitions about addiction, the DSM 5 evolved from the DSM IV by defining addiction as a spectrum disorder with specific emphasis on the substance taking over the person’s life. I don’t think this definition tells the whole story. My favorite definition of addiction has been from the Seeking Safety treatment manual stating addiction is the “chronic neglect of the self,” and with this definition it segues into the understanding addiction is an adaptive functioning to cope with the symptoms of trauma. I LOVE that. Substance use disorders have such a stigma and are still (wrongly) viewed as a choice or a morale defect; however, substance use is actually adaptive for individuals. Specifically, individuals that never learned how to regulate learn to regulate with substances; or if they have had adversity and insecure attachments, they finally find comfort in something, which tends to be a substance. Due to the fact substance use is adaptive it is essential to know when the substance is gone, they have taken away their biggest and most effective coping skill. For people whom have experienced trauma, substance use can have many meanings. Substance use can be a way of getting to sleep, numbing the pain, giving them control, helping them feel accepted by people, committing slow suicide, getting back at an abuser, crying out for help, showing others how much pain they feel, blotting out memories, accessing memories… and many more. The reason I like the definition about a chronic neglect of the self can be clients do not know how to care for themselves because they were never taught or they do not think they deserve to nurture themselves. Attachment-sensitive counselors can work with clients to explore how addiction evolved into a substitute relationship, and potentially how clients can learn to re-parent themselves.
Some alarming facts about trauma co-occurring with addiction are individuals diagnosed with both have statistically poorer treatment outcomes and higher rates of relapse. So how common are both disorders? Here are some statistics to shed some light on this?
· A Massachusetts study of adolescents and children in CD inpatient and intensive residential treatment found 82% had a history of trauma.
· Adolescents with alcohol dependence are 6-12 times more likely to have a childhood history of physical abuse and 18-21 times more likely to have a history of sexual abuse than those without substance abuse problems.
· In one study of juvenile detainees, 93.2% of males and 84% of females reported a traumatic experience with 18% of females and 11% of males meeting full criteria for PTSD. Males were most likely to report witnessing violence, while females were most likely to report being victims of violence.
· Individuals with histories of violence, abuse, and neglect from childhood onward make up the majority of clients served by public mental health and substance abuse service systems
· 90% of public health clients have been exposed to (and most have actually experienced) multiple experiences of trauma.
· 97% of homeless women with mental illness experience severe physical and/or sexual abuse, 87% experienced this abuse as children and as adults.
The reason why these statistics are so important is to dissect and understand the previously accepted theories of addiction are woefully inept in getting the whole picture. For example, the disease model speaks of the brain being hijacked, the choice model only speaks of it being a voluntary choice, and the learning model talks about what we see-because we are social creatures and we learn from modeling. And while there is validity in parts of the models, they do not tell the whole story. Oliver Morgan argues, “Why not view addiction as an attachment disorder?” This perspective does tell the entire story, and it removes stigma from addiction and increases empathy and understanding for clinicians and society as a whole.
Early childhood trauma, and again I am not necessarily speaking of the big “T’s” which are important to consider—such as emotional abuse, chronic neglect, caregiver substance use or mental illness, exposure to violence; but the little ones. The chronic little “t’s” can add up very quickly without adequate adult support and it creates toxic stress. Toxic stress becomes a response when a child experiences frequent, prolonged adversity. Children do not yet know how to emotionally regulate and they need an adult caregiver to “co-regulate” with them, and often they do not receive the kind of support they need to learn this fundamental skill.
Why does toxic stress then lead to substance use? Individuals reach for substances as comforts when they do not get comforts in the “normal” places. We as humans seek to be soothed, and it is human nature to reach for other things to support us in times of trouble. When there is not a relationship present, we settle for something else. This then becomes the beginning of “substitute relationships.” When we are diagnosing trauma, it is important to consider several factors which impact how an individual experiences trauma. Such as:
· Age of the person
Developmental and psychological history
Timing of traumatic occurrences
Temperament
Source of the trauma
Previous exposures
Length of the exposure
Perceived sense of control
Perception of the event’s meaning
Level of perceived life threat
Availability and use of supports
All of these together equate to the symptoms we see
Again, speaking of trauma, these incidents are too large to discuss in the scope of this blog; however, I’m including these to consider in the screening process to be considered:
Acute childhood illness, medical intervention, and extended hospitalization
Motor Vehicle, occupational, and household accidents
Repeated traumatic exposure
Unrecognized societal traumas (preverbal or neonatal trauma)
Delayed on-set trauma
Cultural trauma
When we talk about trauma, the real issue we are discussing is adversity. I found this quote striking: “It is easier to build strong children than to repair broken men.” Transitioning to adversity, which is a form of trauma: Adversity can affect the individual who grows up in a toxic family environment with childhood or teenager maltreatment that can predispose for poor health outcomes and addiction susceptibility, or co-occurrence with mental disorders.
Evidence from a wide variety of sources indicates that America’s addiction health crisis—and specifically its current prescription drug and opioid crisis—has roots in childhood and later adversity.
Childhood adversity is a premier predisposing risk factor for vulnerability to substance-related addictive disorders.
Individuals with a history of adversity do not approach involvement with substances and compulsive behaviors from a neutral position. Those living with significant stress bring that history. Those who experience later adversities can use addictive relationships for coping and comfort. Those relationships can be difficult to renounce.
With that being said, who here has heard of the ACE’s study? Evidence from a wide variety of sources indicates that America’s addiction health crisis—and specifically its current prescription drug and opioid crisis—has roots in childhood and later adversity. This insight does not deny that other factors, such as genetics, temperament, or comorbid mental illness, are important, but it does insist that developmental trauma, toxic stress, and social ecology are major players in public health. The evidence also indicates that improvements in the nation’s health and addiction crisis must involve intervention and prevention regarding adverse childhood experiences. Childhood adversity is a premier predisposing risk factor for vulnerability to substance-related addictive disorders.
Early childhood adversity, abuse, neglect are capable of impairing the function of reward and stress response systems.
Long-term treatment of addiction must consider any underlying psychological dimensions that a person in distress was attempting to ameliorate when they started on the road to addiction.
“…without exception, people who have had extraordinarily difficult lives. And the commonality is childhood abuse. In other words, these people all enter life under extremely adverse circumstances. Not only did they not get what they need for healthy development, they actually got negative circumstances of neglect…that’s what sets up the brain biology of addiction”
And for someone much more knowledgeable and articulate than me, please watch this TED talk:
With all of this being said—what would it be like to think about addiction as an attachment disorder? When we think about attachment to caregivers: Attachment is a fundamental mainspring driving human development. When all goes well, the individual becomes securely attachment and capable of moving out into the world on his or her own. But things do not always go so well. When a child, primed and ready for connection, encounters indifference, neglect, preoccupied caregivers, a lack of adequate care--or worse, hostility, manipulation, relationship challenges, or outright victimization, then she or he becomes burdened with deficits and imperatives to cope in any way possible or crumble.
Substance-related and addictive disorders may be seen as potential outcomes when attachment processes go awry or attachment needs remain unmet (Fishbane, 2007; Flores, 2004).
Disconnection creates fertile ground for the emergence of addiction and other troubles later in life.
Unfulfilled interpersonal needs can be shifted toward bonding and relationship-building with a drug, an activity, or a behavior that partially fulfilled the role of a substitute (Morgan, 2019, P. 104).
Daniel Seigal spoke of attachment as a “feeling felt,” and when it is absent, there can become rupture. Before I go too far down the rabbit hole, I have been in several trainings where parents can quickly become frightened of harm they have caused, but just know it is not about the rupture of the attachment so much as the repair, and there has been significant research on “good enough parenting.” With that being said: Mary Main identified disorganized/unresolved attachment and while this group makes up to maybe 15-25% of the population, they tend to be 80% of individuals diagnosed with substance use disorders.
Children that are raised in challenging homes and toxic environments learn to anticipate stress, danger, and the need for protection. They wake up every morning with neural fists raised and ready. When this happens, something happens to the brain where the individual cannot think long-term. They cannot active the pro-con list most of us do before making a decision. I have seen this with clients so frequently. They are constantly in survival mode and their brain literally does not function the same way as those not growing up in an adverse environment. When it comes to treatment: Attachment-based deficits help us to understand the prevalence of a number of contemporary social and clinical dysfunction from divorce to child maltreatment, from physical illness to addictions.
I know a lot was just covered and I am going to leave you on a cliff hanger… stay tuned for the next blog about what attachment-sensitive counseling means and why EMDR is so effective in treating both trauma-related diagnoses and substance use disorders.