Professional Voices—Lift Up The Hood

Professional Voices—Lift Up The Hood

By Dr. Richard Juman 11/20/14

Can resilience be taught as a skill that can be applied as part of addiction treatment?

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“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. 

[email protected]

@richardjuman

[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?]

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Dr. Richard Juman is a licensed clinical psychologist who has worked in the field of addiction for over 25 years. He has treated hundreds of patients as a clinician and also provided supervision, program development and administration in a variety of settings including acute care hospitals, long term care facilities and outpatient chemical dependency centers. Find him on LinkedIn and Twitter.

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