“His insides are beginning to feel sickly. The pain of the world is a crater all these syrups and pills a thousandfold would fail to fill.” ― John Updike, Rabbit Redux
Most people who struggle with an addictive disorder find some type of stable recovery on their own—without treatment. In general, “spontaneous remission” from substance misuse is “the rule rather than the exception.” Yet many people, in sharp contrast, require multiple treatment episodes before they achieve recovery (unfortunately, many in this group never find stable recovery). What can be said about the differences between these two groups? And what can be changed about addiction treatment so that it does a better job of treating those who don’t get better on their own?
Trauma, frustration and pain are inescapable aspects of the human condition.
Examples of spontaneous remission from addiction are plentiful. People whose relationship to substances brings forward a “scary moment” where they find themselves too close to a certain kind of edge, back away and never get that close again. There are those who find their transformation through immersion into an alternative and healthier lifestyle. There are the people who connect on an interpersonal level with somebody—a romantic partner, a friend or a boss—in such a way that the addictive behavior is incompatible with, and ultimately not as strong as the relationship. And there is the more mundane paradigm of the college graduate who scraped by in high school and university despite eight years of heavy drinking, daily marijuana use and periodic binges with other drugs. Often, she will get her first job and gradually abandon a pattern of use that doesn’t work for the junior executive with an early-ringing alarm clock and a team of co-workers that depend on her in order to do their jobs.
What separates this cohort—people who only temporarily meet the criteria for substance use disorders— from their counterparts who require intensive treatment in order to reach the same goal? Why does addiction create a grip that some are able to break away from only after a long and oft-repeated struggle that includes multiple treatment episodes, while others with similar patterns of substance misuse manage to obtain a stable recovery on their own? There are many factors that play a role, but one strong possibility is that a history of trauma is one of the main variables that separates one group from the other.
I have noted elsewhere that the healthcare system leans toward symptom-focused care at the expense (pun intended) of treatments that look to underlying issues and foster lasting and less superficial change. The ubiquity of antidepressants is one example of this paradigm, as medications that can provide immediate relief by themselves do nothing to help patients extricate themselves from longstanding suffering. Our current system of care, although moving haltingly towards preventive care, still overwhelmingly focuses on treating symptoms. Rather than concentrate on “front-end” lifestyle issues such as diet and exercise, we treat symptoms on the “back end” with interventions and medication. And then we prescribe other medications to treat the side effects of our interventions.
Is trauma and the longstanding suffering that it imposes a core element in treatment-resistant addiction? Is the failure of many addiction treatment episodes a result of the fact that they are not long enough in duration and fail to address the trauma that may be a root cause of the addictive behavior? There is no quick fix for trauma, or any of the myriad complexities that combine to shape a human life, but that is often what you find when you “lift up the hood” and start exploring with a client whose addiction is longstanding and treatment resistant.
Trauma, frustration and pain are inescapable aspects of the human condition. Take “Harry Angstrom” the fictitious American everyman in John Updike’s famous Rabbit series, which was written by Updike as a barometer of experience filtered through decades of American life. Harry is an ordinary man in an ordinary town who discovers after his first heart attack that he has an ordinary heart: “…tired and stiff and full of crud. It's a typical American heart, for his age and economic status etcetera.” After a glimmer of greatness as a high school basketball star, Harry’s trajectory takes a sharp, downward turn with the first of multiple traumas to be contended with—the accidental drowning of their baby daughter by his wife. Harry’s life is full of trauma and micro-trauma, as he bears the guilt of fathering a daughter out of wedlock. He is also responsible for the death of a girl who is living in his house when it burns down. He alienates his only surviving child to the point where his son views him as a murderer. He suffers the loss of two careers and ultimately the respect of his family and the community. The “slings and arrows of outrageous fortune” that fall upon Harry, the “pain of the world” forming “a crater in his insides”— do they seem excessive or merely his fair share, similar to the allotment that many are confronted by? Consider the shared traumas that all members of a society are forced to confront, from the air raid drills of the cold war that Harry Angstrom grew up with, to the fear of terrorism that our youth are now confronted by.
The association between trauma, particularly trauma in childhood, and the likelihood of the later development of a diagnosable addictive disorder is well-established. Experiences such as neglect, abuse, domestic violence, a death in the family, incest, bullying and other “adverse childhood experiences” correlate highly with later addictive patterns and are especially powerful when multiple negative experiences have a compounding and multiplying impact. So the connection between trauma and the development of addiction is clear.
A concept that may have explanatory power with respect to the difference between those who are eventually able to find recovery without treatment and those who require intensive treatment is the concept of resilience, or grit, a big part of which is the ability to withstand “failure, adversity and plateaus in progress.” Does the power of adverse childhood experience manifest itself in the diminution of grit? Does a robust, innate, natural resilience serve as an inoculation against the impact of trauma later in life for certain people? Can grit be taught as a skill that can be applied as part of addiction treatment?
A variety of approaches that integrate trauma and addiction treatment have been developed. In Women and Addiction: A Trauma-Informed Approach, Dr. Stephanie Covington points out that addiction treatment tended to work on substance misuse as a “single-focused intervention…and assumed that the other issues would either resolve themselves through recovery or would be dealt with by another helping professional at a later time,” a paradigm that, as discussed above, might not provide for a treatment of sufficient duration or depth to promote lasting recovery. Dr. Covington notes that “the vast majority of addicted women have suffered violence and other forms of abuse” and that “a history of being abused drastically increases the likelihood that a woman will abuse alcohol and other drugs.” She argues that addiction treatment programs for women should “become integrated, incorporating what we have learned from relational-cultural theory (women’s psychosocial development), addiction theory, and trauma theory.”
Dr. Lisa Najavits, the author of Seeking Safety: A Treatment Manual for PTSD and Substance Abuse, describes a similarly problematic paradigm.
Dr. Najavits notes that many people with substance use disorders also suffer from PTSD, most with “a history of trauma and often multiple traumas, such as child abuse, rape, criminal assault, serious accidents, natural disasters, and combat. Yet, traditional treatment has not attended to these issues.” She points out that “when a client has PTSD, getting clean and sober is a bigger hurdle and such traditional methods may not work as well,” and argues that “treating both PTSD and substance abuse at the same time appears to help clients with their substance abuse recovery, rather than derailing them from attaining abstinence.” However, Dr. Najavits is clear that “opening up the 'Pandora’s box' of trauma memories may destabilize clients when they are most in need of stabilization” and that “clients themselves may not feel ready for trauma processing early in substance abuse recovery.” She describes her integrated model as a “present-focused therapy to help people attain safety from trauma/PTSD and substance abuse” (seekingsafety.org).
Some clinicians who work with adolescents who have experienced both trauma and addiction also argue that it makes sense to incorporate the assessment and treatment of both issues in order for therapy to be most effective.
The Adolescent Traumatic Stress and Substance Abuse Treatment Center reports that “approximately 25% of children and adolescents will have experienced at least one traumatic event by the age of 16,” that “experiencing trauma at an early age increases the risk of substance abuse later in life,” and also that “adolescents who abuse substances are at a significantly higher risk for experiencing trauma and developing Post-Traumatic Stress Disorder.” They recommend that both trauma and substance use are assessed, that “interventions designed to target multiple maladaptive behaviors resulting from trauma and substance abuse will be most effective” and that “a complete inventory of an adolescent’s specific problem behaviors as well as signs and symptoms of trauma and substance abuse should be incorporated into an individualized treatment plan when administering psychological services.”
Is trauma a factor with strong explanatory power in regards to the question of why some people require multiple treatment episodes for addiction while others find a stable recovery on their own? Would proper assessment of trauma history and accurate diagnosis of trauma in every addiction treatment episode and the incorporation of evidence-based care for trauma and PTSD make a difference for many people who enter our treatment programs? Please share your thoughts.
Richard Juman, a licensed clinical psychologist who has worked in the integrated health care arena for over 25 years, providing direct clinical care, supervision, program development and administration across multiple settings, is also former President of the New York State Psychological Association.
[Professional Voices is designed to provide a forum for clinicians to exchange ideas about good treatment and highlight concepts, techniques and interventions that have proved important in their work with clients. What do you think are the essential elements of effective psychotherapy in addiction treatment?]
Does compulsive sexual behavior, commonly known as sex addiction, alter brain activity similar to drug addiction? Why yes, according to a study published in the journal PLOS ONE.
The University of Cambridge research team, lead by neuropsychiatrist Dr. Valerie Voon, used functional magnetic resonance imaging (fMRI) to observe the brain’s response to videos depicting explicit sex. They compared the brain activity of 19 men affected by compulsive sexual behavior (CSB) with the brain activity of the same number of healthy volunteers, or the control group.
In a detailed questionnaire and psychiatric interview to determine those with CSB, the men in the CSB group reported spending 25% of their time online viewing porn, more than five times that of the control group. “The patients in our trial were all people who had substantial difficulties controlling their sexual behavior and this was having significant consequences for them, affecting their lives and relationships,” said Voon in a press release. “In many ways, they show similarities in their behavior to patients with drug addictions. We wanted to see if these similarities were reflected in brain activity, too.”
The researchers found that certain brain regions that are also activated in drug addicts responding to drug stimuli were more active in the brains of the men in the CSB group compared with the control group. “There are clear differences in brain activity between patients who have compulsive sexual behaviors and healthy volunteers,” Voon said. “These differences mirror those of drug addicts.”
The study suggests there could be a shared brain network associated with many compulsive disorders, whether they involve drugs or sex.
However, Voon emphasized that the study’s results do not necessarily mean that pornography is inherently addictive. “Much more research is required to understand this relationship between compulsive sexual behavior and drug addiction,” Voon said.
Are you a driver of large trucks, a bus driver, a commercial pilot, a railroad engineer, or a worker on a pipeline? Are you a family member of a person who works in these areas? Do you know the rules regarding alcohol, prescription medications, and drug use on the job and off? Do you know the consequences if someone tests positive for drugs or alcohol?
All the above jobs are covered under rules set down by the US Department of Transportation (USDOT). You can check the rules yourself: They are Federal Regulations 49 CFR Part 40. They are written in simple, easy to understand language. What I’d like to do is review the rules and procedures for you and to share some working perspectives on them.
In very simple terms, you shouldn’t use illegal drugs at all. You shouldn’t drink on the job and before starting on the job. And you shouldn’t use prescription medications on the banned list unless you have previously notified your employer and that it won’t interfere with your work. If you work for a company or agency, you are supposed to be regularly trained in the rules. If you work alone as a truck operator, you are supposed to be trained by a third party administrator. You can look up in the regulations to find the specifics of your occupation. The common theme is: don’t use illegal drugs and don’t drink on or before the job.
In all cases, you will be randomly tested every two years for illegal drugs. You must consent to take this test. Refusal to take the test constitutes a DOT violation. The tests are highly accurate, even more than state tests for drugs and alcohol. Don’t expect the tests to be inaccurate!
If you test positive for illegal drugs or alcohol use, it will be up to your employer to decide whether you stay working at that position. If, for example, you are a truck driver and have an accident on the job and test positive, you will be taken right off your truck. At minimum for all covered occupations, you will be removed from any work in a safety sensitive position. For truck drivers, that will also include maintenance and mechanical work. The same is true for airline mechanics as well. Unless covered by contract, your employer may choose to terminate you right then.
Once you are removed from work, you must see a Substance Abuse Professional (SAP). There are national directories of SAPs, such as SAPList.com. Your employer may have a list of SAPs. The SAP will schedule an appointment for you. The SAP is usually a therapist or psychologist who has successfully completed the SAP training. I am writing this as a SAP who is also a psychologist and who has worked in the field for many years.
The SAP’s job is to assess you. The SAP will have received a written notice of your DOT violation. This notice will include the type of infraction and the date of infraction and its attestation by a Medical Review Officer (MRO.) The MRO is a physician certified to assess the testing of your sample. The SAP may contact the MRO to review her/his findings.
When the SAP contacts you to make an appointment, s/he will ask you how you intend to pay for her/his services. You should be prepared to answer this question so that the assessment can proceed.
In terms of payment, your employer may choose to pay for the assessment. Your Employee Assistance Program may have that as a benefit. Your health insurance may cover it as a benefit. I would advise you to find out beforehand whether you are covered or not. If you are covered, make sure you have the authorization number for your assessment. If you are not covered, the SAP will charge you directly. It is customary that you pay the SAP in full on the initial visit and SAPs will insist on this. The SAP will not be moved that you do not have the money to pay for this. The SAP knows upfront that you are supposed to know you are not to use illegal drugs or drink on the job.
There are several reasons payment is expected upfront. The first is that the SAP wants to know that s/he will get reimbursed. Many people do not finish the assessment or treatment process. The SAP does not want to have to bill you or send the bill to collections. S/he may ask for a non-refundable pre-payment of a set amount to ensure that you make your appointment.
The second reason is that once you start with a SAP, you cannot switch to another SAP. I am writing this in bold so that you remember it: In simple terms, you cannot SAP-shop. So, let me go over the assessment procedure with you.
The SAP will schedule an appointment when s/he hears the issue and is assured of payment. When you come in, the SAP will review the process with you.
S/he or he will ask you to sign a statement of understanding after this explanation. This statement will include the fact that the SAP will be in contact with your Designated Employee Representative (DER) if you work for a company or agency. You should already know who your DER is. Often it is someone in the Human Relations Department (HR). If the person is not there, your HR department should tell you who s/he is. I am writing this again in bold so that you take it seriously: If you are taking a prescription medication, you should tell your DER or Third Party Administrator (TPA) when you first get it. It should be on record. Any changes should be on record.
I am putting this in bold and underlining it because it is crucial: If you are in a state that has legalized marijuana or has permitted medical marijuana, and you use it, you are still in violation of USDOT regulations.
The SAP will explain to you that you should know that this contact is required and is NOT subject to your consent. And, as you will see, the SAP’s contact with whatever program s/he sends you to is also not subject to your consent. If the SAP needs to talk with your physician, that is upon your consent and covered by HIPAA privacy rules.
The SAP will review the concerns about your violation. USDOT considers the violations serious and that you are putting the public—who is the real “client"—at risk. The SAP will also explain that the assessment process is something for which s/he is responsible as well.
The SAP will customarily give you a standardized test about drug and alcohol use. S/he will use the results to guide the resultant intake interview. The SAP will then ask you questions about your violation, your personal life, and substance use and abuse, both past and present. S/he will often review medical issues with you as well.
I am writing the next part in bold letters so that you don’t miss what I’m saying: The SAP, both through training and experience, has heard every kind of story about how any violation has occurred. Don’t try to con the SAP. That makes her or him suspicious of you. Remember: you are supposed to know that you are not to use. I have heard stories about how meth was put in beer or that someone took their wife’s medication by mistake. In one year, I heard from four violators that meth was accidentally put in their beer.
The SAP will then make a considered judgment about the kind of treatment you need. The SAP’s judgment is final and cannot be appealed. The SAP will have familiarized herself/himself with treatment centers in your area, including costs. If there are none, s/he will find others elsewhere. You will have to find out whether your insurance covers them. The SAP may try to accommodate some of your financial and work needs, but s/he is not obligated to do so. If your insurance or employer doesn’t cover treatment, you will be expected to pay for it yourself even though you may not have the money to pay. That is not the SAP’s primary concern. You can do the program when you have the money. You will not be able to work in any DOT safety sensitive position until you do so and have received a successful reassessment from the SAP.
The SAP will then contact the treatment program if s/he thinks it’s warranted. Many treatment programs are familiar with DOT violations. The SAP will tell the treatment worker what s/he expects to be addressed in treatment; the program may have additional requirements as well. Generally, programs also test you for drugs while you are in attendance. You will have to find out whether such drug testing is covered by your insurance or yourself.
As I have said earlier, the SAP does not need your consent to talk to the treatment facility. Again the bold for emphasis: The facility may have its own procedures and ask that you sign a release so that they can talk to the SAP. Make sure that you do because the SAP will not proceed until s/he knows that s/he can talk to the facility and follow your progress. That is your responsibility.
If the SAP recommends a program, then s/he will monitor your progress. S/he may also be in communication with your DER throughout. At the end of your program, the SAP will review your progress with the program. If additional work is needed mid-stream, it will be part of your plan. S/he will then schedule a reassessment of you. At that time, the SAP will decide what you must do next in terms of your follow-up. That follow-up will likely include more randomized drug and/or alcohol testing and attendance in sobriety groups.
As mentioned, the SAP may want to talk to your doctor. One client I assessed drank several six packs of beer every night for back and neck pain. I spoke to his doctor and he was given appropriate treatment for his condition—so that he wouldn’t have to use and abuse alcohol.
Your DER will get this report. The EAP or insurance company may also want a copy of the report. It is yours and the DER’s responsibility to do the follow-up. If you do not complete the program, the DER will receive a report of non-compliance. The SAP’s assessment is not a fitness report, not a return to work report, but a report of your drug use and treatment. The employer will decide to do what s/he wants to do regarding your employment or work assignment. If you don’t complete the SAP’s recommendations and you want to work in a USDOT covered position, you must tell the prospective or new employer that you have a violation and must complete the program before being allowed to work in any USDOT safety sensitive position.
To repeat, because this is so important, you shouldn’t be using or abusing. You should make sure you are regularly informed of USDOT regulations. You should comply willingly with the testing procedure. If you are a partner or spouse of a USDOT covered person, you should know what the rules are and make sure your person is not abusing substances. If that person is the main source of your livelihood, she or he is putting your welfare at risk. I would certainly ask the DOT covered partner what their training has been and what are the results of their randomized drug and alcohol tests. The goal is not to have a violation and not to see a SAP.
Richard Zimmer, PhD is a licensed psychologist, a SAP—a Substance Abuse Professional—and an anthropologist. He practices in Santa Rosa, California.
Behavioral and Emotional Addictions