Paul Dent: How trauma can lead to addiction

Addiction in all its form is now considered a major public healthconcern given its negative impact on health and negative social, and economic consequences (Levin et al. (2021). Trauma is often found to be linked with maladaptive coping issues leading to the development of addictive disorders.

This resists the notion that processes giving rise to addictive behaviour have a simple explanation. There is no one cause with genetic and other biological factors contributing as well as many social, psychological, and environmental factors. All play a part in whether someone descends down a pathway of substance abuse.

Other characteristics may be involved such as an inability to deal with stress that has been associated with addiction, but there is little evidence to support an "addictive personality" type that makes one more likely to self-medicate to solve problems.

Although addiction may be perceived as a societal problem that is spiralling out of control and has major implications for healthcare providers, this is a superficial notion and does not address the true issue. In reality, addiction is the symptom, not the root cause as many self-medicate to deal with the underlying emotional pain of past traumatic events. Perhaps a more relevant question, according to addiction expert Gabor Mate, is not why the addiction, but what's the pain and past traumatic event(s) driving it? (Mate & Levine, 2011)

Research has shown that, over the past 20 years, there is a strong relationship between Adverse Childhood Events (ACE) scores and addiction(Zarse et al., 2019). For instance, people encountering four or more ACEs are three times more likely to experience alcohol problems in adulthood (Dube et al., 2002), and those encountering three or more ACEs are more than three times more likely to engage in problem gambling (Poole et al., 2017)

(ACE’s or potentially traumatic events encountered later in life can have the potential to cause stress thereby overwhelming one’s ability to cope initiating suicidal ideation or driving towards nihilistic thoughts. As means of coping, self-medication may be sought in the form of drugs, alcohol or gambling leading to a negative feedback loop which is self-perpetuating and may lead to the development of addictive behaviours (Levin, 2021)

Trauma as an emotional response:

Few people can go through life without encountering some kind of trauma which is a person’s emotional response to a distressing experience. Traumatic events tend to be sudden, unexpected and can involve a serious threat to life with little degree of control of the unfolding events. This contributes to a questioning of one’s safety within the world, often undermining the previous sense of safety that had been established. In reality, nothing may have changed but it leads to vastly differing view of the world with a sense that catastrophe could strike at any time.

Acute trauma may be brought on by intense distress in the immediate aftermath of a one-off event and the reaction is of short duration. Common examples include a car crash, physical or sexual assault, or the sudden death of a loved one. Military combat maybe be seen as acute though if experienced over a number of months then it can be described as chronic which can arise from harmful or intensely stressful events that are repeated or prolonged. This can also develop in response to persistent bullying, neglect, abuse (emotional, physical, or sexual), and domestic violence.

Complex trauma develops through repeated or multiple traumatic events with the perception of escape - a key feature of the experience. This can undermine a sense of safety by inducing a state of hypervigilance and constant monitoring of one’s world for the possibility of threat.

Secondary or vicarious trauma arises from exposure to other people’s suffering. This is often suffered by those professionals that are involved in law enforcement or respond to injury such as first responders. Such individuals, over long periods of time, may be at risk of compassion fatigue, avoiding investing emotionally in others in an attempt to protect themselves from experiencing distress.

Sufferers of long-term trauma may develop emotional disturbances, such as extreme anxiety, anger, and sadness. Compassion fatigue may exhibit along with disassociation. PTSD (post-traumatic stress disorder) is very typical resulting in flashbacks or intrusive violent thoughts. Much of this is due to the amygdala become hyperactive leading to an increase in stress hormones. This results in one permanently living in defence mode, ever-vigilant to the possibility of threat. This may have the effect of ongoing problems with sleep or physical pain, and feel a diminished sense of self-worth.

Positive psychological changes after trauma are also possible if difficulties are acknowledged and people see themselves as survivors rather than victims. This process can build resilience, and have an effect on the development of coping skills and a sense of self-efficacy. It is possible to undergo post-traumatic growth and build stronger relationships, thereby gaining a deeper appreciation for life.

Trauma leading to addiction

Individuals suffering from trauma can be vulnerable to addiction as a means of regulating mood, dealing with intrusive thoughts, as well as high levels of arousal which can be caused by elevated stress hormones (Levin et al., 2021; van der Kolk, 2015). Self-medication leads to addictive behaviours facilitating a state of numbness, rather than dealing with the root issue. This can offer a reprieve from chronic hyperarousal and anxiety. Self-medicating with alcohol, benzodiazepines, opioids, and cannabis products initiates a calming intoxication effect, thereby slowing down the central nervous system, hence, "depressants".

in addition, self-medication may lead to rewarding behaviours, changing the way individuals feel by producing pleasure and reducing negative reinforcement (Griffiths, 2005). Gambling (especially with electronic gambling machines) encourages the player to forget about everything other than the machine (Schull, 2012).

Others may experience trauma differently depending on the type and duration of trauma, age of occurrence, and biological characteristics of the individual). Some individuals, rather than obtaining a state of hyperarousal, protect themselves during prolonged traumatic experiences by dissociating or employing depersonalization strategies (van der Kolk, 2014). These individuals may feel chronically numb, disengaged, and lacking in emotion.

Healing addiction and trauma

In light of this complex relationship, the conceptualization and treatment of addiction require a trauma-informed perspective to address both the experience of trauma and addictive behaviours concurrently. Being "trauma-informed" is to recognize the pervasiveness of trauma and seek to be responsive to this reality, aware of trauma's many personal and societal consequences.

Foreseeing how trauma survivors may respond to words and actions, and creating a world that does not cause further harm. Being trauma-informed means helping to construct a world that can foster growth, resiliency, and healing.

Merely stating the intention to be trauma-informed is however not enough to guarantee good outcomes. Further, given the diversity of traumatic experiences and trauma survivors, it is hard to define a narrow set of behaviours that will be appropriate in all circumstances. A better approach is to use a set of guiding principles which can be flexibly applied to unique situations and people.

Understanding the importance of this topic, the Substance Abuse and Mental Health Service Association (SAMHSA) has created guidance for a trauma-informed approach to care (2014). Their work provides some key definitions as well as a set of core principles, including Safety; Trustworthiness and Transparency; Collaboration and Mutuality; Empowerment, Voice, and Choice; Peer Support; and Cultural, Historical, and Gender Issues.

A trauma-informed treatment approach looks at an individual's experiences and past traumas to better understand and address their current physical and emotional challenges. This approach prioritizes creating a safe and supportive therapeutic environment where the client feels comfortable to share openly. A truly trauma-informed approach remembers that it’s not just the clients but members of staff, trauma survivors and leadership who are vital. Over time, across unique situations these core principles can transform and heal relationships, organizations, and perhaps those you have experienced trauma.

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