Do We Overstate the Role Trauma Plays in Addiction?

the scream
Feb 24 2016

Do We Overstate the Role Trauma Plays in Addiction?

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 Addictiondismiss 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.

Fig 1 Ken

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.

Fig 2 Ken

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.

Fig 3 Ken

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.

Conclusion

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.

  • I’m not in the same league as the people mentioned in the article so my two cents worth may be worthless. I’ve spent decades trying to understand my issues and my history that includes the abuse of my family members. My abuse was not sexual, it was psychological. My family is pretty messed up but I have realized that so many others are also and statistics say that 80% of families in the west are dysfunctional in some way and that 30% of that 80% are severely dysfunctional. If that is true and if it’s true that we are all different and react differently to different events then trying to straighten this out would be too great a task for our society to complete unless we stop it before it happens, or we will just keep going around in circles. When does therapy stop?, a great question to ask at this point. If we believe that most of our issues are based on our lifestyles, and I do, then that would be the place to start the nip it in the bud approach or at least slow the damage down considerably. For me, changing the fundamental way that I think has been the most help in not trying to figure the trauma out as I don’t think I ever will. The cost of trying not to live a crazy life has been expensive in more ways than loss of revenue. I believe in Harm Reduction, and all it’s many forms, and have for a while now because I doubt we’ll ever be able to go back and correct “The” problem, at least for the majority of us. We have so many people, so many damaged people and for so many reasons and not enough people on the same page in any recovery modality to attack the problem in mass, so I think we will now have to allow that people are going to do something to try an alleviate whatever the problem (unbalance and pain) may be. Kind of like a placeholder until we can all see through the fog of the suppression of truth that has kept us all in a state of confusion and distrust.

    • Kenneth Anderson

      Yes!

  • Rebecca Bee

    I appreciate your article and your comprehensive review of scientific studies on this topic. Intuitively, I always felt that the proposed link between “trauma” and substance abuse was overblown. “Got a drinking problem – go to talk to a trauma therapist” should not be the go-to therapy plan, especially with such weak evidence linking the two issues. It does make sense in a minority of cases as you point out, but it is definitely not appropriate for everyone. Thanks for explaining the science.

  • Gary Thompson

    State sponsored trauma leading to an increase of harm mostly to non overdose patients. Also increases drug use and abuse, loss of trust in medical profession, addictions, harm reduction workers. No one says a word, living in denial makes you physically and emotionally ill. My letter Emergency Medicine News Dec. 2015
    http://journals.lww.com/em-news/Fulltext/2015/12000/Letter__Flaws_in_Toronto_s_Opioid_Overdose.14.aspx

    My response Can. J. Public Health 2013;104(3):e200-4
    ‘Development and implementation of an opioid overdose prevention and response program in Toronto, Ontario.’ http://static.smallworldlabs.com/hsf/user_content/files/000/000/169/355cc02324a166bb8abf31174c141f69-cjph-20131043200-4.pdf

    One of my articles in the 2015 AHA & ILCOR CPR guidelines
    https://volunteer.heart.org/apps/pico/Pages/PublicComment.aspx?q=891

    All 70 references from 2015 CPR guidelines on opioid overdose and comments ALL SAY RESCUE BREATHING NO MENTION ANYWHERE CHEST COMPRESSIONS
    https://aliascpr.wordpress.com/2015/12/13/2015-ilcor-and-aha-references-opioid-od/

    Deputation Toronto Board of Health https://youtu.be/QhsDjmI9H9c read ‘show more’

    Spreading deadly misinformation chest compressions only has and continues to backfire in a thousand ways you could never dream up, nature of the creature. There is no medical evidence for the Public Health protocol, it’s contraindicated.

    Signs of OD and proper treatment, rescue breathing any respiratory emergency
    https://www.youtube.com/watch?v=35lBf5s-iro
    https://www.youtube.com/watch?v=wsN0ijLnK2k

    Public Health Ontario training video http://www.youtube.com/watch?v=zlbkU5IK5Do
    Training Power Point Slide 23 https://www.cpso.on.ca/uploadedFiles/members/Meth-conf-POINT-PP.pdf
    Naloxone Training Video https://vimeo.com/68067103 Listen 9:20 secs signs of respiratory emergency

    No mention anywhere respiratory assist You would think it brutal to withhold the air from anyone.

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  • Dan Howard

    Easter bunny? This level of disrespect and snarkiness can only reflect on the writer. Does the recovery-modality war
    have to look like the Republican primaries?

  • Paul Regier

    While i appreciate the dissociation of PTSD and non-PTSD trauma (something that needs to be done more), the role of non-PTSD trauma, particularly a history of maltreatment, in addiction is not overstated. In the population I’m studying, for instance, the rate of past abuse is over 50%. NIDA – https://archives.drugabuse.gov/NIDA_Notes/NNVol13N2/exploring.html – points a high percentage of individuals having a history of abuse. The number will vary depending on the population studied, of course, but estimates are 1/3 to 2/3 of individuals in treatment (another important distinction) for addiction having a history of abuse.

    To your point about needing research on recall of previous maltreatment linked to drug use: This has been done – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3852601/ – and the researchers found a significant correlation of recall and drug/alcohol issues.

    • Kenneth Anderson

      Thanks for the link to the memory study–this is important and I will be using it in the future. And it is not surprising to see high rates of trauma history in clinical samples–this is why I choose to focus on community samples–clinical samples are very atypical of people with addictons in general.

  • I very much appreciate this review and not just because it confirms my own observations. I believe that most of the variance in addiction is explained by genetic factors. This is not to say that psycho social factors are irrelevant but that the traditional emphasis on seeking “underlying psychological factors” is often misleading and counterproductive.

  • atropos_of_nothing

    Rehab, 1998. All-women’s facility. Every member of the staff save one was, herself, a recovering addict. The exception was the “counselor” (he claimed to have lost a brother to addiction). Mondays, Wednesdays, and Fridays we’d all file in and spend two hours listening to this guy try to harangue and wheedle memories of sexual abuse out of us. Because there’s no other way we could have possibly gone down the path that led us here, you see. ALL of us had been abused, he said, some of us just needed help remembering it.
    We learned pretty quickly that if we told him a sick enough story, with enough of those horrifying details that made his eyes gleam just so, he’d have to transfer us over to the therapy group on the shelter side, the counselor for which was actually legitimate, effective, and not a creepy pervert who liked to listen to young women talk about being touched as small children.

    • atropos_of_nothing

      Where I was going with that was, the trauma model of addiction is just one more draw for the kind of sorta-qualified predator who likes easy pickings.

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