This post is the third in a four-part series about the connection between trauma and addiction written specifically for mental health and addiction professionals. The first instalment explored how substance use and addiction are common experiences for many people who have experienced significant trauma. The second instalment focused on the negative impacts our client’s experience when we miss the important connection between trauma and addiction.
Studies show that trauma occurred first for the majority of people who experience both PTSD and SUD. It is clear that not everyone who has experienced trauma moves into addictive patterns.
But the vast majority of individuals who experience addiction have experienced trauma and adverse childhood experiences.
The Need to Self-Medicate
Although it is important to acknowledge the strong correlation between trauma and substance use, it is also necessary to understand why this link is so pervasive. There is a theory that provides an explanation for this high rate of connection between trauma symptoms and SUDs that requires a closer look:
People are self-medicating their dysregulation and trauma symptoms with their use of drugs and alcohol.
Many clinicians recognize that addictive behaviour often begins as a coping mechanism for mental health and trauma symptoms. In the US, the Substance Abuse and Mental Health Services Administration recognizes the impact of trauma and how it increases the risk of substance misuse.
“A trauma-informed perspective views trauma-related symptoms and behaviors as an individual’s best and most resilient attempt to manage, cope with, and rise above his or her experience of trauma.” (SAMHSA)(1)
The more someone experiences the ongoing disruptions of trauma symptoms, the more likely they will gravitate to substances and behaviours that help them mood-alter and self-medicate.
Edward Khantzian’s Self-Medication Hypothesis
The Self-Medication Hypothesis (SMH) was developed over 30 years ago by Edward Khantzian and his colleagues at the Harvard Medical School. Over the years, this research has made a significant contribution to our understanding of substance misuse and addiction, especially as a way of medicating overwhelming emotions and experiences. His goal was to understand what drives substance use behaviour. He came to the conclusion that the heart of addictive disorders is suffering, not a “reward” or the seeking of pleasure – it is about self-medicating distress and painful feelings.
"Addiction problems are less a statement about pleasure seeking, reward, or self-destructiveness than they are about human psychological vulnerabilities."(2)
He believes that addiction is a combination of difficulties with emotional regulation, genetic vulnerability, and environmental influences. In developing the Self-Medication Hypothesis, Khantzian also observed that those with an addiction have difficulty regulating emotions including the overwhelming and intolerable feelings that trauma produces.
They also experience challenges with their sense of self-worth, their relationships, their behaviours, and how they practice self-care. He notes that the wide-spread availability of addictive substances as a way of relieving distress only re-enforces the use of drugs or alcohol. He sees addiction as a “self-regulation disorder” – substance users perpetuate their suffering as a means to control it and continued substance misuse only makes the challenges with self-regulation worse.
Addictive drugs do help relieve overwhelming distress, but attempts at self-medication are short-lived and often replaced by suffering associated with addiction.
Adverse Childhood Experiences (ACE) Study
The Adverse Childhood Experience Study (ACE Study) also supports the concept of substance misuse and other behaviours like smoking or disordered eating as ways of managing the overwhelming experiences of childhood trauma. In the 1990’s, Vincent Felitti and Robert Anda spearheaded a ground-breaking study of over 17000 participants aimed at identifying the association between adverse childhood experiences and the health or social problems experienced as an adult.(3)
They began by identifying ten specific categories of common childhood trauma that included physical, emotional, and sexual abuse, physical and emotional neglect as well as family dysfunction including divorce, addiction, violence, or incarceration. Adult participants were surveyed to determine how often they experienced these types of trauma in their childhood. They also documented how often a variety of social issues and well as physical or mental health concerns occurred for each participant.
The information they gathered from this extensive survey provides us with a clear picture of the negative impacts of painful life events in the lives of children. From this study, we see that adverse childhood experiences are vastly more common than previously thought.
Adverse experiences have a powerful and cumulative negative impact on adult health as seen in the increased rates of depression, substance abuse, sexual promiscuity, obesity, cigarette smoking, and suicide attempts reported by those who experienced more traumatic childhood experiences.
The ACE Study identifies the progression that leads to the health concerns and social problems seen in adults who have experienced childhood trauma. It demonstrates that children who experience one or more adverse childhood experiences (ACEs) experience emotional, social, or learning challenges. As a result, they adopt unhealthy and high-risk behaviours (including heavy substance use) as a way of coping which leads to social problems, health issues, disabilities, and early death.
Although the statistics from the ACE Study indicate that 33% of all participants reported no significant adverse childhood experiences, at least 17% reported experiencing three or more categories of ACEs. The statistics regarding the association between the number of ACEs experienced and the challenges experienced in adulthood are staggering.
Those who had experienced four or more ACEs were twice as likely to be smokers, seven times more likely to be alcoholics, and ten times more likely to have injected street drugs than someone with an ACE score of zero.
In fact, the highest risk of self-reported alcohol problems (30.7%) was reported by those who experienced four or more ACEs as well as a history of parental alcoholism.(4)
Self-Medicating Trauma Symptoms
Many clinicians agree that the symptoms of trauma and PTSD motivate people to use substances like alcohol or prescription drugs in an attempt to medicate their highly activated state. John Briere states that individuals with complex and chronic trauma histories are more likely to use drugs and alcohol as a form of emotional avoidance – substances are used to numb painful feelings associated with traumatic experiences or traumatic memories.(5)
Some may use substances for the purpose of falling asleep, reducing irritability, dampening an excessive startle response, or decreasing hypervigilance as well as helping with concentration.(6) It may also be used for stopping intrusive trauma-based thoughts or memories. Gabor Maté, author of “In the Realm of Hungry Ghosts”, calls addiction a “flight from distress”. He believes this:
Addiction originates with pain, especially the pain of early trauma and abuse – addiction is the emotional anesthetic.(7)
Part 4 in “Trauma and Addiction: The Link We Can’t Ignore” focuses on specific types of trauma symptoms and how substance use helps “manage” these symptoms: "Medicating Trauma Symptoms".
Here are all the posts in “Trauma & Addiction: The Link We Can’t Ignore (For Clinicians):
Intro to Trauma & Addiction Link (Clinician)
Part 1: The Problem (Clinician)
Part 2: The Negative Impacts (Clinician)
Part 3: Why People Use (Clinician)
Part 4: Medicating Trauma (Clinician)
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1 "TIP 57: Trauma-Informed Care in Behavioral Health Services." Substance Abuse and Mental Health Services Administration. SAMHSA, 2014.
2 Khantzian, E. J., and M. J. Albanese. Understanding Addiction as Self Medication: Finding Hope behind the Pain. 2008.
3 Dube, S. R., V. J. Felitti, M. Dong, D. P. Chapman, W. H. Giles, and R. F. Anda. "Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study." 2003. Pediatrics 111.3. 564-72.
4 Dube, S. R., R. F. Anda, V. J. Felitti, J. B. Croft, V. J. Edwards, and W. H. Giles. "Growing Up With Parental Alcohol Abuse." Child Abuse & Neglect”. 2001. 25:12:1627-640.
5 Briere, J., and J. Spinazzola. "Phenomenology And Psychological Assessment Of Complex Posttraumatic States." Journal of Traumatic Stress. 2005: 401-12.
6 Ouimette, P., R. H. Moos, and P. Brown. "Substance Use Disorder-posttraumatic Stress Disorder Comorbidity: A Survey of Treatments and Proposed Practice Guidelines." Trauma and Substance Abuse: Causes, Consequences, and Treatment of Comorbid Disorders. 2003.
7 Maté, Gabor. In the Realm of Hungry Ghosts: Close Encounters with Addiction. 2008.