Many people with traumatic histories have co-occurring addictions, which present a complex tangle of challenges for treatment providers. Until very recently, the prevailing wisdom among addiction professionals held that addicts needed to experience a period of abstinence before addressing the underlying trauma. The dilemma has been that abstinence was frequently unachievable or that even when addicts could remain abstinent, the symptoms of untreated post-traumatic stress would often surface, causing suicidal thoughts and attempts; self-injury; immobilizing depression; and often correlated loss of support networks, livelihood and loved ones.
Or, as one addiction went into remission, another would become more acute, as with the young female crack addict who stops using, begins to gain weight and sees symptoms of anorexia emerging, or with the alcoholic male who gets sober, leaves his long-term relationship and begins to act out sexually with multiple partners.
Conversely, in the mental health field, the belief has historically existed that addictive behaviors were “medicators” for the traumatic symptoms, and that if the trauma were treated, the maladaptive attempts to self-soothe would be alleviated. This approach did not recognize the primary nature of addictive disorders.
This linear, either/or conceptualization has limited our ability to recognize the need for a radical paradigm shift until recently, when brain research has begun to tell us why our traumatized clients can’t remain clean and sober, or abstain from sexually compulsive behaviors, or adhere to a meal plan and maintain weight gain. We have begun to ask the right questions: How can we accurately assess and match treatment needs for clients experiencing a wide range of shifting clinical symptoms? What is the hierarchy for the client’s needs? And, most saliently, what is the synergistic interplay of trauma and addiction?
The dilemma of treating co-occurring addiction and trauma has been confounding. Advances in neurobiology have given helping professionals the data to evidence what we’ve known anecdotally: People who suffer from addiction and trauma have neurological, interpersonal, cognitive and affective deficits that are compounded by the synergy that occurs with dual disorders.
Trauma and addiction both generate belief structures associated with being an outcast, not belonging, being inherently damaged. The world is experienced as a dangerous place, trust is too risky, and on a deep intrapsychic level a chronic chasm is formed between self and others. Defenses are constructed to protect the split, and survival depends on hiding the true self and its needs, causing impenetrable isolation and loneliness. It is into this living tomb that we are invited when we begin working with the synergy of addiction and trauma.
In addition, the categories currently in use (post-traumatic stress, which is a natural and predictable response to a traumatic event, and post-traumatic stress disorder, which is the cluster of symptoms that occur when trauma has not been adequately resolved) have been expanded to include complex PTSD through the work of Christine Courtois and her identification of the far more challenging client who presents with multiple traumatic exposures and a resulting labyrinthine clinical presentation. These clients are often acute and chronic, presenting for repeated treatment episodes over the course of their lives. The comorbid disorders and the paucity of internal and external resources for these clients contribute to the preponderance of treatment challenges.
Clients with addictive disorders and trauma often present with a constellation of diagnoses that have become treatment-resistant over time. In addition to drug and alcohol addiction, sex addiction, eating disorders and self-injury (one, several or all of which may be present in varying levels of intensity at different times), there is frequently the presence of a co-occurring mood disorder, anxiety disorder, and often features of or possibly a fully developed personality disorder.
Trauma creates an abiding belief that “I do not belong” and “My needs can’t be met.” The cycle of mistrust, self-protection organized around rejection of others, and the profound internalized rejection of the self forge an almost impenetrable defensive structure that in turn embeds the cycle ever more deeply.
Illustrative case study
I first met Ramona at a treatment center she’d been referred to that specialized in residential extended care for trauma and co-occurring disorders. She came to us from a primary facility, where she had completed treatment for addiction, an eating disorder and complex PTSD.
We met for our first session in my small and narrow office, which I had been using temporarily. My chair was placed between Ramona and the door. I remember spending our first hour together feeling as though I was in an enclosed place with a trapped, wild animal. Ramona kept her eyes on the floor and glanced furtively at the door once or twice. She answered questions with three-word sentences and flew out of the office when the session ended.
It was early 1999, and I knew nothing about the biology of trauma, fight, flight, the freeze response or tonic immobility, but I remember talking in a consistently low and even voice, making slow and measured movements only when absolutely necessary and wondering afterwards who I had actually been trying to reassure, Ramona or myself.