A Call to Addiction-Informed Care
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As a therapist and educator, I have noticed a recent increase in requests from agencies, organizations, institutions, individuals, and families to understand addiction and get help navigating a system that does not always take addiction/recovery into account when trying to help someone in active addiction. No doubt this increase is the direct result of America’s “addiction crisis,” but some fundamental lack of knowledge around the topic of addiction come up regularly enough to show that there is a deficit in this area of the conversation. This lack of knowledge, unfortunately, is what guides individual opinion, governmental policies, and treatment but also impacts the quality of services available. In an effort to raise awareness and fill in this deficit, I am calling for a new initiative, Addiction-Informed Care (AIC).
AIC is similar to Trauma-Informed Care (TIC), which is “an organizational structure and treatment framework that involves understanding, recognizing, and responding to the effects of all types of trauma (2017).” To define AIC, I would simply substitute the word addiction for the word trauma. TIC readily accepts that trauma is at the heart of addiction but addiction, as a cause of trauma, is not directly acknowledged. Trauma and addiction co-exist in a relationship together. They are inseparable because they are a part of the same process. Addiction causes traumas and traumas create addictions in a cause and effect loop. When bad things happen, people cope. But when the coping is done too much or is a toxic form, it creates a trauma because it creates a wound. Trauma is a wound (which might still be bleeding) and addiction is the pleasure that created/caused the wound. So, my theory is simple: Addiction is a trauma and trauma is an addiction.
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Definitions of addiction are explored below to help support my conclusion that addiction is really a trauma but my observation is that an addiction, fueled by our unmet needs, is present when a want is labeled as a need. I believe that people understand the active addictive process even when they say they do not. The best example is our relationship to sex. We often feel like we need to have sex when it is really a want. Yes, we need to have sex to perpetuate the species, but do we need to have it right now? Sex can also be painful and pleasurable at the same time but it is the relationship between the two that is intoxicating. If one understands being in a state of sexual arousal then he or she can understand active addiction. Imagine that you and your partner are in a state of arousal and in the preliminary stages of courting each other and you have to stop for some reason. Now, you can stop the sexual act but the passion is going to linger until satisfied. Why? Well, sex is deeply embedded in our brain and previous experiences of pleasure act similarly in the human body when triggered as they do in active addiction. This is the illusion of having a choice in the moment, but it is just a matter of where and when that the couple will have sex again. I believe that the main challenge to truly understanding addiction is the stigma of it and I believe that the main challenge to accepting that addiction is a trauma is that addiction is seen as a choice. In fact, addiction is directly related to trauma when we define a trauma as anything that still stays with you. And the addictive behavior is indeed something that sticks with you. Because they are rooted in our survival mechanisms, active addiction and symptoms of trauma cannot be turned off. They are always on even if they reduce in intensity for a time. Evolutionarily, it is extremely helpful for us to be unconsciously alert or remember positive or negative experiences, however, when the process intended to maintain the survival of the species becomes compromised by an addictive behavior, it can be devastating because of the sheer power of it.
What is often missed is that the addictive behavior or traumatic events are philosophically neutral. Over time, it is the individual’s relationship between pleasure and pain that is the issue. Our unmet needs or wants in our relationships are what fuel both traumas and addictions and are why I believe that we do not have an accurate definition of addiction currently. Furthermore, addiction has not been accurately conceptualized from a neutral point of view and the widespread application of this conceptualization has not been applied. So, if addiction as, in and of itself, is a trauma, then we can keep the definition of TIC the same and just add the word addiction to the end. But since addiction is not identified in TIC (nor is addiction accurately defined and widely understood) then this has to be done first.
Trauma and addiction are both rooted in our brainstem/survival mechanisms and they ride the pain/reward pathway when activated (Maté, (2010). This produces all human behavior because it informs our decision-making process. In the deepest recesses of our brain lies the reptilian fear/survival response which, when activated in a social context, manifests out of the range of normal behavior. For outside observers who are not in a primal state, the response appears to be out of place and gets misunderstood. When these responses (which create and motivate behaviors) extend beyond our personal lives, hospitals, the legal system, or policymakers it becomes problematic on a systems level. If we do not take into account or do not understand this primal response then the punishment for having an unconscious response to a perceived threat makes sense. The reality is that from a neutral standpoint, these reactions are not outside the realm of normal human behavior and addiction can be seen as more on a spectrum. In fact, they are a normal human survival instinct that has become extreme because, at some point, the individual learned that they had to be extreme in order to survive.
The body remembers trauma/stress (van der Kolk, 2014) but it also holds on to peak experiences like sex. The act of using drugs is what is traumatic to the body and from an emotional perspective, just like an orgasm. From a biological standpoint, a drug is a toxin (for the purposes of this writing I am singling out substance addiction because it is the most obvious but the idea presents in any other addiction.) From a philosophical standpoint, the body is neutral once a toxin is introduced into it. The body will simply go through a process of elimination and detoxification to take care of it. The body rejects and expels the toxin that it sees as toxic. If it can get rid of it, it does. But when it cannot, symptoms arise which we bring to our family and professionals. The symptoms typically reported in addiction treatment by clients are intrusive thoughts, avoidance of remembrances, negative alterations in cognition and mood, and alterations in arousal and reactivity through being triggered. (What is a craving but another word for being aroused or triggered?) These are not addiction symptoms in a traditional sense, but rather, the symptoms of post-traumatic stress. When these symptoms/responses are socially enabled, they become stigmatized. This stigma directly gets in the way of people getting appropriate, respectful, and adequate healthcare. This is exactly what AIC and TIC stand to advocate against.
Furthermore, AIC would recognize that since our support systems do not understand addiction then recovery is not understood either. Here are two client cases that illustrate the lack of awareness. They are by no means abnormal. First is a middle-aged man with 15+ years sober from alcohol and a veteran. He struggled with high anxiety from his PTSD throughout his recovery. He was active in self-help group but his personal and work-life were stressful and his prescriber suggested medication. He was given benzodiazepine 1 year prior to seeing me. In treatment, he admitted that he was using alcohol again as a result of being given that medication. It took some investigating work to uncover that piece of the puzzle, but this was after losing his job, home, and marriage. He had not seen that his relapse and decline started once his body was re-introduced to an alcohol-like substance.
In another case, a person in recovery for 2 years was physically assaulted and in the hospital. There was a considerable medical need for pain relief and opiates were prescribed. Obviously, the addiction was triggered by the opiates but the aftercare plan did not include addiction care or a plan for recovery. She and her family were open about her addiction and tried to explain their concern for how to transition her back home without some addiction measures like detox or medication-assisted therapy. Even though she was taking the prescriptions as prescribed, the addiction was activated (fueled by active post-traumatic stress) and she struggled to regain recovery once released from the hospital. Luckily, they were a recovery-informed family and were able to get connected to services.
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Families, agencies, and communities are looking for support. There are grassroots organizations like Recovery Oriented Services (ROS), Peer Recovery Advocates, and Recovery Coaches that advocate for adequate care and governmental initiatives to help support educating and funding for the recovery community. However, all of these are moot if agencies and institutions do not understand how addiction is activated and what to do when it is. In both of the cases presented here, the re-introduction of a drug triggered addiction. I believe we must see the drug (and all addiction) as a trauma from the body/mind perspective because the body remembers (van der Kolk, 2014) and from this standpoint, addiction can be seen as a collection of toxic memories that fuel our unconscious behaviors. The great thing is that with this definition and philosophical understanding, addiction can be treated.
When considering how AIC would impact treatment providers, we first have to look at the definition of addiction to help guide our treatment. American Society of Addictive Medicine (ASAM) (2012) states, “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.” First, the word “primary” suggests that, in its presentation, addiction has taken over. This negates the survival response that has been triggered i.e. trauma. The idea of “disease” has long been discussed in relation to addiction but we are finding more and more about how emotions and stress trigger “disease” (Mate, 2003). Being triggered, sick, or in a state of dis-ease is going to create a lack of motivation due to impairment. Yes, being triggered impacts the individuals’ motivation, but that does not mean that people who are addicted lack motivation. Their motivation has been put on hold because they are in a state of survival.
Furthermore, Dr. Mohammad (2016) states “overstimulation of the reward circuitry factor significantly in addiction but it creates false memories of the experience. The brain regards the experience as ‘better than expected,” even when the experience wasn’t all that great. Because the memory is a permanent part of your mental makeup, anything and everything that reminds you of that memory also remind you that the experience was better than expected and triggers an instant desire to re-experience something that perhaps wasn’t anywhere as good as you remember (p. 56).”
My work with trauma resolution has shown me that memories are anything but permanent. (At least our relationship with them is not.) Trauma resolution/healing is the process of moving traumatic active memories to long-term memory through a process of memory reconsolidation in the brain (Ecker, Ticic, & Hulley 2013). Stress, triggers, and disease are all based on previous experience i.e. “memory and related circuitry.” So, if “memory and related circuitry” are not being addressed in the treatment, can we say that we are truly addressing the condition of addiction? Since treatment acknowledges the role that addiction has in creating trauma, won’t it make sense to start there? To the larger point of this writing, if addiction is triggered by traumatic memory, then why are we as a society holding them accountable for an unconscious response and not looking at who or what triggered them? As Gabor Maté (2010) observed, “not why the addiction, but why the pain.”
Since addiction can be considered a trauma then why not look to trauma treatments that help address our “memory and related circuitry?” The specific methods of trauma resolution methods that I work with are Eye Movement Desensitization and Reprocessing (EMDR) (Shapiro, 2001), Progressive Counting (Greenwald, 2013), and Brainspotting (Grand, 2013). These have shown me that healing addiction is possible. Furthermore, it would be helpful for clinicians to recognize that if we focus on trauma work we are better able to treat all mental health disorders through these trans-diagnostic treatments (Greenwald, 2013) and particularly the condition of addiction (Marich & Dansiger, 2017).
AIC is based on mutual respect, understanding, equality, and freedom of choice. AIC is rooted in how neurological, biological, psychological, social and spiritual aspects of addiction impact our individual lives, communities, institutions, and systems. AIC recognizes that trauma and addiction are primal motivators for all human behavior, which can be linked to an abuse of power and a (conscious or unconscious) intention to cohesively control and stay in control. AIC actively engage to confront blatant disregards for facts and observable conclusions relating to all manifestations of addiction. AIC understands why people, institutions, and systems become abusive, coercive, and dysfunctional. Someone who is addiction-informed would have a thorough understanding of how addiction impacts an individual, communities, institutions, businesses, industries, systems, and the course of human history and development. Lastly, an addiction informed individual or system would advocate against the unwanted and unwarranted outcomes of individual opinions.
When we ignore a problem we tend to create more and over time ignoring the problem becomes the problem. Avoiding the link between trauma and addiction is to avoid our human nature. AIC is an important first step to admitting that the system has become unmanageable due to unmet wants and needs. However, we are the system. As individuals, we need to understand that when the solution has become the problem it is our responsibility to advocate against the injustices that have been created as a result. When we advocate and stand on the right side of history and humanity we engage in active healing. I believe that AIC activates healing and that healing is what we need if we are going to see a healthy culture or society.
Adam O’Brien LMHC, CASAC is the co-owner/clinician at Mutual Arising Mental Health Counseling, PLLC in Chatham NY. Full bio.
Ecker, B., Ticic, R., & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. New York, NY: Routledge.
Grand, D. (2013) Brainspotting: A revolutionary new therapy for rapid and effective change. Boulder, CO. Sounds True.
Greenwald, R. (2013). Progressive Counting: Within a phase model of trauma-informed treatment. New York, NY: Routledge.
Marich, J. & Dansiger, S. (2017). EMDR and mindfulness for trauma-focused care: New York, NY: Springer Publishing Company.
Maté, G. (2003). When the body says no: Understanding the stress-disease connection. Hoboken, NJ: John Wiley & Sons, Inc.
Maté, G. (2010). In the realm of hungry ghosts: Close encounters with addiction. Berkeley, CA: North Atlantic Books.
Mohammad, A. (2016). Anatomy of Addiction: What science and research tells us about the true causes, best preventive techniques, and most successful treatments. New York, NY: Perigee.
Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing: Basic principles, protocols, and procedures. New York, NY: Guilford Press.
van der Kolk, B. (2014). The body keeps the score: Brain, mind and body in the healing of trauma. New York, NY: Penguin Books.
http://www.traumainformedcareproject.org/ Retrieved on 10/31/17.