Some addiction mavens—notably Gabor Maté, author of In the Realm of Hungry Ghosts—claim that trauma is at the root of all substance use disorders, and that everyone with an addiction needs trauma-informed care.
Others—such as Influence columnist Stanton Peele, author of Love and Addiction—dismiss the idea that trauma lies at the heart of addiction, claiming that trauma-informed care prevents recovery by convincing people that they are powerless.
What does the evidence tell us about who is right? Let’s answer six simple questions to find out.
1. What is trauma?
Not every negative life event qualifies as trauma. The DSM 5—the American Psychiatric Association’s diagnostic bible—defines trauma as follows:
Exposure to actual or threatened death, serious injury, or sexual violation, in one or more of the following ways:
Directly experiencing the traumatic event(s)
Witnessing traumatic event(s) in others
Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or unintentional
Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (for example, first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related
2. What is PTSD?
According to the DSM 5, a diagnosis of post-traumatic stress disorder (PTSD) requires that the person was exposed to a trauma as defined above and that subsequently the person showed symptoms from every one of the following four categories for more than one month:
The traumatic event is persistently re-experienced in at least one of the following ways: Recurrent, involuntary, and intrusive memories; Traumatic nightmares; Flashbacks; Intense or prolonged distress after exposure to traumatic reminders; Marked physiologic reactivity after exposure to trauma-related stimuli.
Avoidance of at least one of the following: Trauma-related thoughts or feelings; Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).
Negative alterations in thoughts and mood (two required): Inability to recall key features of the traumatic event; Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., “I am bad,” “The world is completely dangerous”); Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences; Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame); Markedly diminished interest in (pre-traumatic) significant activities; Feeling alienated from others (e.g., detachment or estrangement); Constricted affect: persistent inability to experience positive emotions.
Alterations in arousal and reactivity (two required): Irritable or aggressive behavior; Self-destructive or reckless behavior; Hypervigilance; Exaggerated startle response; Problems in concentration; Sleep disturbance
3. How often does trauma lead to PTSD?
The large majority of adults who are exposed to a traumatic event do not develop PTSD, although some traumatic events are more likely to lead to PTSD than others.
According to Norris (1992), only 7% of adults over age 18 who are exposed to trauma will develop PTSD (including delayed-onset PTSD). Rape is the trauma most likely to lead to PTSD—but even so, only about 14% of rape survivors developed it. Combat is the listed trauma least likely to lead to PTSD: a mere 2% of combat survivors developed PTSD. Details of the Norris research are given in Figure 1.
4. What’s the relationship between addiction and PTSD?
How many people with a substance use disorder (the DSM term for “addiction”) also have clinically diagnosable PTSD?
Mills et al. (2006) examined data from the Australian National Survey of Mental Health and Well-Being and found that only 5.9% of people with a substance use disorder (past year prevalence) also have PTSD (past year prevalence). In other words, 94.1% of people with a substance use disorder do not have PTSD.
Rates differ by substance; those with an opioid use disorder are far more likely to have PTSD than those with an alcohol or cannabis use disorder. Details are given in Figure 2.
It’s also important to turn the question around, to ask how many of those people with PTSD have a co-occurring substance use disorder.
According to Mills et al. (2006), 34.4% of people with PTSD (past year prevalence) also have a substance use disorder, with alcohol being the most common (24.1%). By way of comparison, SAMHSA estimates past-year prevalence of substance use disorder in the general public at 8.4%. (Interestingly, Mills found that the past year prevalence of PTSD in the general public in Australia was 1.3%, whereas the past year prevalence in the US is estimated—by Kessler et al., 2005—at 3.5%.)
So it’s fair to say that although people with PTSD are much more likely than the rest of us to have a substance use disorder, the vast majority of people with substance use disorders do not have PTSD.
5. What’s the relationship between addiction and (non-PTSD) trauma?
Trauma is also associated with mental health conditions other than PTSD, including mood and anxiety disorders. So do people who have experienced trauma in adulthood but not developed PTSD—including people with other trauma-related mental health conditions—experience substance use disorders more than the general population?
On this question, the evidence is contradictory.
Breslau et al. (2003) found no significant increases in the incidence of substance use disorders in civilian adults in Michigan who were exposed to trauma but did not develop PTSD. Fetzner et al. (2011), on the other hand, found adult trauma exposure without PTSD still led to significant increases in alcohol use disorder.
What about traumatic experiences in childhood? Again, the evidence is mixed.The Adverse Childhood Experiences (ACE) Study (1998) surveyed 13,494 adults about seven categories of traumatic experiences which they recalled undergoing, as well as their current health status. The more categories of adverse childhood experiences the subjects reported undergoing, the worse they reported their adult physical health, mental health, and substance use status.
For example, those who had had experienced four or more categories of childhood trauma were 7.4 times more likely to consider themselves alcoholic and 10.3 times more likely to inject drugs than those who reported zero categories. Details are given in Figure 3.
Interestingly, however, these results were not replicated in a prospective study by Horwitz et al. (2005). In this study Horwitz used court records to identify victims of child abuse and tracked them down as adults 20 years later. There were 641 subjects in the study; but the study showed that these adult victims of child abuse were no more likely to have substance use disorders than matched controls from the general population.
This poses a question about adult memories of childhood abuse. Dr. Linda M. Williams (1994) interviewed 129 adult women with documented histories of childhood sexual abuse in their medical and other records. She found that 38% did not recall the abuse. Women who were younger at the time of the abuse and those who were molested by someone they knew were less likely to recall the abuse. This suggests the possibility that people who forget childhood abuse have better adult mental health than those who recall it—and it would be valuable if someone conducted a study to see if this were the case or not.
6. What does all this mean for treatment?
For the small minority of people with substance use disorders who also have PTSD, should both of their conditions be treated at the same time?
Some therapists have speculated that that therapies which involve PTSD patients reliving trauma, such as exposure therapy, would make substance use worse. Others have speculated that people who use drugs would be unable to benefit from treatment because of their substance use. However, clinical evidence has shown these fears to be unfounded myths.Foa et al. (2013) conducted a trial of prolonged exposure therapy for PTSD (with naltrexone or placebo) compared to treatment as usual (with naltrexone or placebo) for men and women with alcohol dependence. All four groups showed large reductions in both drinking and PTSD symptoms—however, the only significant differences between groups were greater reductions in drinking by the two naltrexone groups.
Unexpectedly, none of the groups showed significantly greater reduction in PTSD symptomatology than the others.McGovern et al. (2015) compared integrated cognitive-behavioral therapy (ICBT)—a treatment developed specifically for co-occurring substance use disorder and PTSD—against treatment as usual in subjects (both male and female) with both alcohol and drug use disorders and PTSD. Both treatment modalities resulted in large reductions in substance use and PTSD symptomatology. However, the only significant difference was greater reductions in drug use by the ICBT group—there were no significant differences in alcohol use or PTSD symptomatology; both groups showed equal improvements in terms of these two measures.
SAMHSA’s registry of evidence-based treatments lists five treatments for co-occurring substance use disorder and PTSD. Four of these treatments, the Boston Consortium Model, Helping Women Recover and Beyond Trauma, Living in the Face of Trauma (LIFT), and the Trauma Recovery and Empowerment Model (TREM) are exclusively for women. The fifth treatment, Seeking Safety, has been tested with both all-male and all-female subjects.
Interestingly, all five interventions using all-female subjects performed significantly better than treatment as usual in terms of drug use, alcohol use, and PTSD symptomatology. But when Seeking Safety was tested with all-male subjects, it showed significantly better outcomes only on drug use. This suggests that current therapies for co-occurring PTSD and substance use disorder might be more effective for women than for men—and this is another question deserving of further research.
Finally, should people with a substance use disorder seek out an underlying trauma or a repressed memory as the cause? The answer to this is an unqualified no! If you find a therapist who promises to cure your addiction by recovering repressed memories of childhood trauma, run—do not walk—the other way.
As Dr. Scott Lilienfeld (2007) points out, recovered memory therapy can easily induce false memories, lead to increased suicidal ideation, psychiatric hospitalization, and even induce multiple personality disorder. There is no evidence that this therapy recovers true memories rather than implanting false ones, no evidence that it is beneficial, and much evidence that it is harmful.
If you believe that you have PTSD, you should of course seek medical advice. Good therapies for PTSD, as discussed by Schnyder et al. (2015), are time-limited (often eight to 16 sessions), conducted with guidance of a therapy manual, and delivered by therapists specially trained in the specific technique. Good PTSD therapies help to reduce unhelpful strategies such as rumination, hypervigilance for threat, thought-suppression, and excessive precautions. Finally, good PTSD therapists will only give you treatment for PTSD if there is a genuine diagnosis. If you are diagnosed with both substance use disorder and PTSD, consider one of the evidence-based therapies discussed earlier in this article.
But if you are one of the 94% of people with a substance use disorder who do not have PTSD, you should not seek out treatment for PTSD, even if you—like most people—have suffered some trauma in your past.
There is simply no evidence that PTSD therapy will be helpful to you, and it might even be harmful. Since these therapies were designed specifically for PTSD and have never been tested on people without PTSD, we simply don’t know what effect they might have if misused. Good therapists stick to therapies which are proven effective for the conditions which they are treating. If you have co-occurring depression, anxiety, social phobia, etc. rather than PTSD, then you will benefit from seeking out evidence-based treatments for these conditions, in addition to utilizing evidence-based strategies to change your substance use.
If you have a history of trauma but not PTSD, a good therapist will acknowledge and respect that without doing you harm by dwelling on it.
So who is right about trauma and substance use disorder: Stanton Peele or Gabor Maté? Although each makes an important contribution to the discussion, ultimately they are both more wrong than right.
Peele’s concern that adopting the role of trauma victim will only serve to make addictions worse is correct. However, evidence-based therapies do not teach one to adopt the role of a victim; rather they teach here-and-now coping skills to make one a highly functional survivor.
Meanwhile Maté’s thesis that all addiction stems from trauma is simply not supported by the evidence, which suggests that some, but not all, addiction is trauma-related. Moreover, Maté spends three chapters of his book, In the Realm of Hungry Ghosts, arguing that spirituality and 12-stepping are the cure for trauma…without citing a single scientific study to back his claims.
So yes, Stanton, there is PTSD—and no, Gabor, you can’t cure it by appealing to the Easter Bunny.
Editor’s note: Stanton Peele’s response to this piece can be found here.
Kenneth Anderson is the founder of the HAMS harm reduction program for alcohol, and the author of How to Change Your Drinking: A Harm Reduction Guide to Alcohol. He has worked in harm reduction since 2002, including “in the trenches” doing needle exchange in Minneapolis, serving as online director for Moderation Management, and working as director of development at the Lower East Side Harm Reduction Center. You can follow HAMS on Twitter: @Harm_Reduction.