“Always deal with the alligator closest to the boat” – as mental health professionals, it’s an excellent reminder to deal with the most urgent problems first. That’s why we turn off a running faucet before cleaning up the water that has overflowed. Or why first-responders make sure people are safe before figuring out the cause of an accident.
It’s also a phrase I’ve heard from people who work in the field of addiction disorders. Many want to approach working with those who have identified both trauma and addiction as “problems” they need to address similarly. Often, addiction is seen as the “alligator closest to the boat”.
While treating addiction can be a very urgent issue for some, it isn’t always helpful to see it as the only problem to focus on in the early stages of recovery.
There is an abundance of research revealing an important connection between traumatic experiences and the development of addiction disorders.
In North America, about 7% of the population will experience PTSD in their lifetime, but 36-50% of people receiving treatment for substance use disorders fit the criteria for PTSD.
People with PTSD are four times more likely to develop problems with substance use than those without.
Even those without PTSD may still be experiencing the impacts of trauma that increase the risk of substance misuse or other behavioural addiction.
If you’re interested in reading more evidence for the strong connection between trauma and addiction, you can read this series Trauma & Addiction: The Link We Can't Ignore. It provides a more detailed look at the statistics and research that shows a clear pathway demonstrating trauma increases the risk of developing addiction disorders.
This series also covers some of the reasons we need to pay attention to this clear connection:
Trauma and addiction lead to more significant adverse outcomes: greater overall substance misuse, earlier age of problematic use, more mental health issues, and increased self-harming behaviours.
Those dealing with co-occurring trauma and substance misuse often receive less benefit from addiction treatment programs. Trauma symptoms can interfere with the ability to benefit from treatment for substance use disorders fully.
Trauma and substance use negatively impact each other – one problem often feeds the other. When self-regulation and healthy coping are disrupted by trauma, it creates a desire to self-medicate.
When we understand the link between trauma and the development of substance use disorders or other addiction disorders, it raises some vital questions. What are the best ways to move forward with treatment? Which of these issues should get treated first? Which one should be the focus when a person is trying to move into recovery?
Historically, there has been minimal overlap between the health and mental health programs that treat trauma and those that treat addiction disorders. Even now, it would not be uncommon to find trauma treatment programs that do not provide services to those in active addiction.
It is not uncommon to have addiction treatment programs providing little or no treatment for underlying trauma or other mental health issues such as anxiety or depression.
Too Little Help For Those With Both Trauma and Addiction
Although there’s a growing awareness of trauma as a significant contributing factor for those who are experiencing substance use disorders and addiction, there is often far too little practical help for someone who is desperately trying to stop their spiralling addiction. Many factors contribute to this:
1. There is often too little support for historical trauma in the addiction treatment system.
I was initially trained as a trauma therapist when I started my counselling career. When I transitioned into working in a residential treatment program, the director gently reminded me that my focus was to be on addiction because the centre didn’t treat trauma. We continue to have a good laugh at this – he now runs an outpatient addiction treatment centre and is actively exploring options for bringing more trauma-focused work into the program.
2. Many of the staff working in addiction treatment programs lack the clinical training in trauma including recognizing and treating trauma symptoms.
It's a sad reality that a significant number of common signs of trauma are seen as being “resistant” to treatment or that someone “hasn’t hit their bottom yet”. Or that strong craving to use can be the result of trauma symptoms like anxiety, flashbacks, or anger that surfaces when the person is no longer medicating those symptoms with a substance or behaviour.
3. Mental health clinicians often are inadequately prepared to deal with active addiction.
Historically, addiction treatment programs have been run by those who are in recovery themselves while mental health issues (including trauma) are the domain of those trained in clinical counselling programs – and there has been too little focus on developing training and programs that approach working with both trauma and addiction in an integrated manner.
4. There are common practices in many treatment programs (both addiction treatment and trauma treatment) that create an environment of shame and fear.
This only adds to the challenge and stigma of addressing trauma and co-occurring addiction disorders.
5. Treatment providers often believe people are unable to begin addressing their trauma in helpful ways while still using substances.
There is also the belief that someone should not attempt to address their trauma history until they have had a period of abstinence or sobriety: "always deal with the alligator closest to the boat". But asking someone to give up one of their most effective means of coping with trauma symptoms without providing awareness and tools to address the trauma is a set-up for failure. Many are unable to do this simply because they lack the support and tools to cope with their trauma symptoms effectively in any other way – not that they don’t want to be sober “badly enough” or they haven’t “hit their bottom yet.”
6. Treatment that lacks the awareness and support needed to address both trauma and addiction disorders can create frustration and hopelessness in the treatment process.
Those with co-occurring trauma and addiction are more likely to drop out of treatment and continue using, or they relapse shortly after completing a treatment program if both issues are not addressed as part of the treatment plan.
So which issue should we focus on when someone is experiencing the symptoms of both trauma and addiction disorders? The simple answer is this: both.