Kenneth Anderson performed an invaluable service in The Influence recently by reviewing the literature on trauma, PTSD, and substance use disorders/addiction.
What he showed us was remarkable: Trauma research is actually the study of resilience.
But I can only agree with some of his conclusions. Here are three of the most important pieces of information he supplied:
- Fewer than 15 percent of people who experience the most extreme traumas (rape and physical assault) develop PTSD. The figure for military personnel with combat experience is shockingly low (2 percent). Those who experience extreme events such as major hurricanes and similar disasters develop PTSD at a rate of around 5%. Human resilience is the dominant result to emerge from research on people’s reactions to traumatic events.
- People with PTSD have a heightened likelihood of developing a substance use disorder. Nonetheless, Anderson noted, “the vast majority of people with substance use disorders do not have PTSD.”
- In the absence of PTSD, studies of other sorts of less-severe trauma show mixed results. Of course, the most famous of these is Vincent Filetti’s work at Kaiser, the Adverse Childhood Experiences (ACE) Study, which found far more frequent addictive substance use based on the number of traumatic life events people experienced in childhood: emotional, physical, or sexual abuse; physical or emotional neglect; violence, alcoholism and drug abuse, incarceration, or mental illness within the family; and having been raised by anyone other than two biological parents.
But another study, a prospective study (which means identifying children’s trauma independent of their memories, then following their lives going forward) found no relationship between trauma and addiction. As Anderson describes,
“Interestingly, however, these results were not replicated in a prospective study by Horwitz et al. 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.”
What could account for this monumentally significant difference in results and therapeutic implications of Filetti’s versus Horwitz’s work? The differences are due to the perspectives: In Filetti’s study, we know of people’s trauma because they recall it. Horwitz et al., on the other hand, are studying whether people recall and focus on their seemingly evident trauma.
As Anderson correctly divines, people who don’t focus on their abuse experiences are actually more likely to overcome them: “This suggests the possibility that people who forget childhood abuse have better adult mental health than those who recall it.”
If so, then what does this say about treatment whose main goal is to recall traumatic memories (and, in worst-case scenarios, to implant them)? What does it say about an entire addiction treatment system that has come to explain people’s addictions as being due to trauma and then focusing treatment on that trauma à la Gabor Maté?
But Anderson only partly grasps the wrongheadedness of the emergent trauma-based addiction treatment movement. He critiques Maté primarily because of Maté’s unsupported contention that the 12 Steps of AA are great for resolving trauma. As Ken puts it, “Gabor, you can’t cure it by appealing to the Easter Bunny.”
True. But Maté’s very idea of treatment as rekindling memories of traumatic experiences, and his insistence that such experiences produce permanent brain damage, exacerbate and prolong the effects of trauma, and addiction along with it.
People seem blinded to the fatalism, the powerlessness, that is fundamental in Maté’s message—the AA-ness of it. As Maté forcefully declared in 2012 (he has since seemingly been trying to temper this message):
“The principles of the 12 steps are essential: the recognition of the powerlessness over addiction. You gain power and end your denial by acknowledging your powerlessness.” [My emphasis]
Maté arrives at his dysfunctional views because he relies on ACE without any further consideration of the overwhelming evidence indicating that resilience—not addiction—is by far the most common response to trauma. That is, the dominant tendency is towards recovery through a person’s life development. As my fellow Influence columnist Maia Szalavitz powerfully put it:
“Most people with addiction simply grow out of It: Why is this widely denied? The idea that addiction is typically a chronic, progressive disease that requires treatment is false, the evidence shows. Yet the aging out experience of the majority is ignored by treatment providers and journalists.”
And not just them, Maia!
Maté is, understandably, guided by his experience with the Portland Hotel Services population for whom he served as medical director. PHS clients (with whom I have visited) are heavily skewed towards the chronically mentally ill and homeless, the extremes of those with traumatized life histories, a group that requires a multitude of supportive services, who haven’t been able to right themselves.
God bless Maté for helping to provide such services. Even for this hurt group, however, the basic PHS model is that they can progress, as they often do, when provided with housing, purpose, work, and care. What an inspiration for all of us in the field!
But trauma-based theory and treatment reverses this seeming miracle: those whose life conditions readily predict recovery and flowering instead become weighed down by their otherwise remediable unhappiness and misfortune. As one correspondent of mine who realized this wrote:
“I’ve had an aversion to Dr. Mate since reading Hungry Ghosts. Everyone in the addiction community was raving about his work but I knew his theory left me quite hopeless and without solutions. He posits that stress while a mother is pregnant affects the developing brain and is “the single most important biological factor in determining whether or not a person will be predisposed to substance dependence.”
I dug up the original research which is condensed in a tidy little book—How Children Succeed by Paul Tough. It turns out that stress does affect the brain but for some reason Mate leaves out the most beautiful discovery in this research: “Parents and other caregivers who are able to form close, nurturing relationships with their children can foster resilience in them that protects them from many of the worst effects of a harsh early environment.
What a relief! There is hope!”
For reasons that cultural historians will study, our era is intent on performing a modern anti-miracle by convincing ourselves that our misfortunes doom us when, all around, when we look, we see that the opposite is true. When I spoke at the Ibogaine conference in Tepoztlan I asked, as I always do, what the hardest substance addiction to quit is. People shouted in unison, “smoking,” “nicotine,” “cigarettes.”
When I then asked, “How many of you have quit smoking,” scores raised their hands. I continued, “And how many of you relied on therapy to do so?” As always, never more than a couple (the same is true when there are hundreds of ex-smokers in the audience) raised their hands. And this in a group many of whose members view a drug as a panacea for addiction!
Anderson recognizes that trauma theory is doing more harm than good:
“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.”
“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.”
Puzzlingly, he then concludes that my rejection of the overall usefulness of trauma-based theory and practice in the addiction field—since effective treatment (involving cognitive restructuring and coping skills training) for the tiny population of PTSD sufferers has shown benefits—makes me just as misguided as Maté. (Note to Ken: Of course I know of horrible cases of trauma, cases that defy humanity and belief.)
But appropriately targeted PTSD treatment for this small number of sufferers is not the situation we face in the contemporary American addiction field.
Rather, it has become almost pro forma for therapists and public health specialists to declare that addiction and substance use disorders are all due to trauma, and to focus on such events in people’s lives to explain and deal with their substance use problems. Which, as Anderson points out, is harmful.
But what is more distressing about the effects of trauma theory is its impact on overall policy and mental health practices, because it diverts our attention, even among liberals, from the real social causes of trauma and addiction, and from our baked-in social problems.
I turn to the distinguished Harvard historian and social critic, Jill Lepore, for her trenchant historical and public health analysis of our inability to prevent child abuse, even as we have become preoccupied with it. Her analysis can also be applied in every regard to our failure to stop (or reduce) addiction, which, as I have written for The Influence, is trending in the opposite direction.
Lepore traces our failure to successfully address child abuse to President Richard Nixon’s vetoing a program the US Congress passed to improve children’s lives across the board, which was then replaced by a child-abuse-oriented program. The results are deplorable:
“Between 1970 and 2000, the number of infants murdered, per hundred thousand infants in the population, rose from 5.8 to 9.1 (that is, a 50% increase). Other measures are even more troubling. Today, the United States has one of the highest rates of childhood poverty of any nation in the developed world.”
Lepore specifically addresses Felitti and trauma assessment in lieu of a social commitment to rectify poverty and socially-based trauma:
“The murky science of risk assessment relies on attempts to quantify “trauma” and “adversity,” which, on the one hand, are meaningful clinical concepts but, on the other hand, are proxy terms for poverty. (And, worryingly, the study of trauma has both a dubious intellectual history and an abysmal track record, not least because of its role in the sexual-abuse scandals of the eighties and the recovered-memory travesty of the nineties.)” [parentheses in original, my bolding]
[Re: ACE, the instrument for measuring negative childhood experiences.]
“The noble dream here is that, if only child-protective agencies collected better data and used better algorithms, children would no longer be beaten or killed. Meanwhile, there is good reason to worry that the ACE score is the new I.Q., a deterministic label that is being used to sort children into those who can be helped and those who can’t. And, for all the knowledge gained, the medicalization of misery is yet another way to avoid talking about impoverishment, destitution, and inequality.”
For preventing both violence against children and addiction in our society, both of which are especially present for those deprived of social resources, we are barking up the wrong tree, led by Maté and his ilk.
Lepore focuses on poor teen parents, white as well as black. The parents in the template legal cases she reviews were themselves the children of poor, deprived youths. This cycle is never-ending in the US. To take two examples, a generation apart:
- (2016) “The staggering problem of chronic unemployment among minority men . . . .[expresses itself when] in Los Angeles and New York City about 30 percent of 20- to 24-year-old black men were out of work and out of school in 2014. The situation is even more extreme in Chicago, where nearly half of black men in this age group were neither working nor in school.”
Does anyone reading this expect to see child abuse and murder—or addiction—decline in a society in which the gap between the haves and have-nots, white and black, is expanding exponentially?
Stanton Peele is a columnist for The Influence. His latest book, with Ilse Thompson, is Recover!: An Empowering Program to Help You Stop Thinking Like an Addict and Reclaim Your Life. He has been at the cutting-edge of addiction theory and practice since writing, with Archie Brodsky, Love and Addiction in 1975. He has since written numerous other books and developed the online Life Process Program. His website is Peele.net. Dr. Peele has won career achievement awards from the Rutgers Center of Alcohol Studies and the Drug Policy Alliance. You can follow him on Twitter: @.