The Link Between Trauma and Substance Misuse
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Many clients who struggle with substance misuse have experienced childhood or adult trauma. This is not to say every client who has had one or multiple past traumas will misuse substances. When treating clients with trauma, it is important to remember these experiences create a vulnerability in some individuals.
The more adverse childhood experiences (ACES) one has, the more that individual is vulnerable to mental health issues, which include substance misuse. According to the Centers for Disease Control and Prevention, “ACEs are linked to chronic health problems, mental illness, and substance use problems in adolescence and adulthood. ACEs can also negatively impact education, job opportunities, and earning potential.”
This demonstrates the significance of recognizing and treating childhood trauma. If childhood trauma has not been resolved or recognized, therapeutic work can be done to help individuals heal as adults.
What are Trauma and Post-traumatic Stress?
Not all people who experience trauma develop post-traumatic stress disorder but they are affected in some way. Trauma as defined in The Diagnostic Statistical Manual Fifth Edition Text Revision (DSM-5-TR), diagnosis for post-traumatic stress is based on the following criteria:
- Exposure to actual or threatened death, serious injury, or sexual violence. In one of the following ways;
- Directly experiencing the traumatic event
- Witnessing, in person, the event as it has occurred to others
- Learning the traumatic event occurred to a close family member or friend
- Experiencing repeated or extreme exposure to aversive details of the traumatic events
In a 2014 research study by Debell et al., it was found, “Of the different PTSD symptom clusters, this review found most evidence for associations between alcohol misuse and both avoidance/numbing symptoms and hyperarousal symptoms. Given that comorbidity appears to be common, the evidence from this systematic review supports the use of routine screening for comorbidity in populations who are known to have PTSD or alcohol misuse.”
Research suggests it is the direct first-hand exposure to trauma that correlates the most with substance misuse. In a 2021 study by Levin et al., “Our findings indicate strong associations between all types of trauma and the development of several substance and behavioral addictions. Furthermore, we found that while across interpersonal trauma types (comprising sexual, weapon and physical assault), direct exposure was most highly associated with addiction-related outcomes.”
Directly witnessing a trauma can result in harm. As the above criteria for post-traumatic stress states, trauma can be experienced first-hand by your client or your client can be a witness to trauma. Witnessing a trauma does not lessen the effects for some people. Clients may feel an increased sense of helplessness and guilt, especially if they were unable to intervene and stop the events.
Fight, Flight, or Freeze Response
Trauma elicits the survival response of fight, flight, or freeze. To protect ourselves, the brain activates a person to confront, run, or become immobilized in order to endure a traumatic event.
It is not uncommon for children who witness or are a victim of trauma to freeze as part of a survival response. This occurs because children lack the physical strength and cognitive skills to fight off their attacker or comprehend a traumatic event. Adults also enter a freeze response to protect themselves at times.
After the traumatic event has passed, a heightened state of arousal can remain activated. This makes it difficult for clients to feel relaxed and they are easily triggered by the same or similar stimuli. Some clients report feeling on edge or ready to fight. Other clients feel numb for the majority of the time until they experience a trigger that re-activates their system again. Lastly, some clients withdraw to avoid or leave situations that remind them of the initial trauma.
There is no right way to respond to trauma or danger. Counselors need to educate clients about all reactions to trauma. A part of treatment will be to normalize this human response to survive traumatic events without judging one response as superior to another.
The Importance of a Thorough Evaluation
When a client presents with trauma experiences, it is essential to inquire about past and current substance misuse. You will want to ask about past hospitalizations, detoxifications, substance misuse, treatment groups (mandated or self-referred), withdrawal symptoms, periods of abstinence, and/or individual therapy.
It is important to have a list of various substances to ask the client about usage. This helps counselors remember all the different types of substances people can misuse. Remember to examine not only illegal drugs but also those that are legal and/or prescription drugs. Ask when your client began using substances, how often, when the last use was, and the current usage. At times, substance misuse and legal issues coincide. Question if the client has had any legal problems.
If your client presents with a substance misuse disorder, you will want to do a thorough trauma history. Ask about any and all instances of neglect, emotional/verbal, physical, or sexual abuse. The first session is not a time to get in-depth with every instance of abuse unless it concerns current abuse or neglect. Counselors are mandated reporters and, as such, need to report any suspicion of abuse for children, dependent adults, the elderly, or persons with disabilities.
If the abuse reported is in the past, a good start is to note the type of abuse, at what age the client was when the abuse started, when it ended, and who was involved. As trust is built in the therapeutic relationship, the client will feel safer sharing past instances of abuse.
The primary concern in the beginning of therapy is to decrease or maintain sobriety with the client and to obtain a clear picture of one’s mental health. It is not uncommon for clients to uncover anxiety, depression, post-traumatic stress, or other symptoms as they are achieving sobriety. Some researchers suggest reducing post-traumatic stress symptoms first to assist with sobriety. Counselors will need to lean on their expertise when treating trauma symptoms or substance misuse.
Patock-Peckham et al., 2020 states,
Recalled childhood trauma (sexual and emotional abuse) may contribute to PTSD symptoms and dysregulated drinking. In conclusion, our data suggest that reducing PTSD symptoms may assist individuals in regaining control over their drinking.
Why Does Trauma Lead Some Clients to Misuse Substances?
When trauma occurs early in life, the brain is more susceptible because a child’s brain is not fully formed until their mid-twenties. The developing brain is vulnerable to trauma and can experience changes that contribute to impulsiveness and poor decision-making. When trauma in children is not recognized, some of these children become misdiagnosed as attention deficit disorder rather than trauma disorders, such as post-traumatic stress. This delay in proper treatment can lead to further harm to a child’s brain.
De Bellis and Zisk report in their article, “The Biological Effects of Childhood Trauma,”
These investigations strongly suggest that childhood maltreatment interferes with executive or control circuits, whose dysregulation is an important contributor to adolescent and adult mental health and substance use disorders. Thus, childhood trauma can have detrimental effects on the brain networks that establish an individual’s ability to think, and regulate their sense of self, motivations, and behaviors.
Children who experience trauma lack coping skills and are in emotional pain. Often the adults around these children have not learned how to cope in healthy ways, they cannot teach what they do not know. These symptoms can lead people of all ages to utilize and get caught up in the cycle of substance misuse.
When substance misuse and post-traumatic stress disorder coincide, it is known as a dual diagnosis or co-morbidity. Tull, Weiss and McDermott 2015 report:
Posttraumatic stress disorder (PTSD) is associated with a high level of functional impairment, comorbid psychiatric disorders, suicide, and various physical health problems. A growing body of research also shows that individuals with PTSD are at elevated risk for engaging in a number of impulsive and risky behaviors, including substance abuse, risky sexual behavior, non-suicidal self-injury, and eating disordered behavior. The presence of these behaviors among individuals with PTSD may lead to more extensive and worse functional impairment, as well as complicate the treatment of PTSD.
Often to escape the painful feelings of trauma and to decrease their symptoms, clients misuse substances in an attempt to self-medicate. McCauley et al state:
The comorbid presentation of PTSD and SUDs is remarkably common, and in comparison to patients presenting with either PTSD or SUD alone, PTSD/SUD patients often report greater functional impairment and experience poorer treatment outcomes—including treatment failure and dropout. Several mechanisms have been posited to explain the co-occurrence of PTSD and SUDs, including the self-medication hypothesis, the high-risk hypothesis, the susceptibility hypothesis. The majority of research to date supports the self-medication hypothesis.
Future Trauma & Substance Misuse
When a person experiences trauma, their nervous system can become inhibited through emotional numbing or depression symptoms. Some clients seek out exciting stimuli or sensations to feel something or feel alive. For some people, they find excitement in using various substances, but for others, it can be putting themselves in risky situations, which could lead them into further traumas.
Other clients may feel depressed or numb, not able to recognize the danger of a situation. Clients who have not processed or healed their trauma may experience trauma as their normal experience, and this leads them to be re-traumatized.
Those who are actively using substances become vulnerable to trauma happening to them. When a person is misusing substances, their emotional and behavioral regulation is compromised. Poor judgment and decreased inhibitions can cause poor decision-making, and people find themselves in at-risk situations.
Lisa Hutchison, LMHC
Writer & Contributing ExpertLisa Hutchison, LMHC, is a licensed mental health counselor for the Commonwealth of Massachusetts. She works for professionals who want to treat and prevent compassion fatigue. With over 20 years of psychotherapy experience, she helps her clients assert themselves, set boundaries, and increase their coping skills. Her specialty is decreasing stress, anxiety, and depression while increasing realistic methods of self-care for those who help others. Ms. Hutchison’s psychological advice has been featured in Reader’s Digest and the Huffington Post. Her articles have been published in numerous magazines, including Grief Digest and Today’s Caregiver.
Lisa is the bestselling author of I Fill My Cup: A Journal for Compassionate Helpers and a faculty member writer for NetCE. Her latest continuing education unit publication is “Setting Ethical Limits for Caring and Competent Professionals.” She has taught creative writing in colleges and presented on boundaries for the compassionate helper; the use of expressive art to heal grief, anxiety, and depression; inspirational and motivational topics; and creative writing techniques.