by Hope Rehab Team
The Link Between Addiction and Trauma
For many clinicians, addictions work is trauma work. While not all substance users show a history of trauma, the link is significant and has been confirmed repeatedly in research over the years. Childhood trauma in particular seems to predispose humans for substance abuse, mental health issues and physical health problems later in life, as the Adverse Events in Childhood (ACE) study has clearly shown.
Research also indicates that women especially seem to be vulnerable to victimization and sexual violence, thus repeated trauma, at times preceding and at times as part of the terrible consequences of addiction.
Impact of Trauma
Trauma comes in many forms from non-intentional accidents to life threatening illnesses, crime or childhood physical, emotional or sexual abuse or neglect. Disregarding the nature of the traumatic event(s), all forms of trauma may negatively impact day to day functioning and survivors may experience the following common difficulties:
The single event or ongoing condition is extremely distressing and more than an individual can cope with, or integrate, and leaves the individual overwhelmed and emotionally unable to cope.
The individual experiences the event as a potential threat to his/her life or well-being, or the individual observes another person being exposed to a threat to life or well-being.
The individual experiences negative impact on their ability to function at work, at home and in relationships as a result of the traumatic experience.
How Common is Trauma?
According to the World Health Organization (WHO), traumatic experiences are common around the globe, although the nature of trauma and reactions to it may differ between countries or regions. For example, the Thai population exposed to the 2004 Tsunami showed little signs of lasting symptoms of trauma and most individuals exposed to this natural disaster did not qualify for a diagnosis of PTSD following this horrific event. In stark opposition to this, many New Yorkers exposed to the terrorist attack of 9/11 showed significant elevation of a diagnosis of post- traumatic stress disorder (PTSD).
Women and Trauma
While not everyone exposed to (a) traumatic event(s) develops PTSD, women seem especially prone: women are two to four times more likely to develop PTSD. The reasons as to why women are at such higher risk than men, and why some individuals in general are more prone than others in developing PTSD are manifold, and not fully understood. In general, mild traumatic brain injury (TBI), previous experiences of trauma, the nature and severity of the traumatic event(s) experienced, as well as already existing mental health problems such as anxiety or depression increase the risk for PTSD. Additionally, the nature of the traumatic event(s), availability or lack of a social supports, as well as personality factors such as being highly introvert may also contribute to the development of PTSD.
Among the different types of trauma, interpersonal trauma involving intentional injury appears to carry some of the greatest risk for PTSD. For women, rape, sexual abuse or other forms of interpersonal violence is on top of the list of traumatic events causing PTSD.
Consequences of Trauma
Individuals with PTSD experience intrusive, involuntary and highly distressing images or memories of the traumatic event(s), avoidance of anything that could potentially remind them of the event, as well as high anxiety and hypervigilance. Unfortunately, these symptoms of PTSD translate into multiple problems as it relates to all aspects of functioning. For example, PTSD sufferers often report feeling emotionally numb and disconnected from others and the world, including their loved ones and their children, and this may be especially distressing for women given relationships are central to their lives and their well-being. Other long-term consequences may involve distrusting others, low self-esteem, guilt and shame, as well as issues around power, control and safety.
Overlap Between Trauma and Addiction
Coping with these difficulties by using substances is not unusual. In fact, the overlap between trauma and addiction is staggering. The above mentioned Adverse Childhood Events (ACE) study, for example, showed that childhood abuse or neglect increased early onset use (early to middle adolescence) of alcohol or drugs significantly. Adverse childhood effects include physical, emotional and sexual abuse, as well as neglect and exposure to family violence, parental illness or crime. Individuals scoring higher than 5 on the ACE questionnaire were seven to ten times more likely than non survivors to report substance abuse later in life. Every additional point on the ACE questionnaire translates into a two to four fold increase in the risk of early onset substance use, as well as heightened vulnerability regarding suicide later in life.
Childhood trauma survivors were also shown at greater risk of depression and insomnia. The ACE study found that childhood trauma negatively impacts survivors 50 years later, and the above described mental health and substance abuse problems are often accompanied by social problems and physical illness. In short, adverse childhood experiences are a significant –and some argue THE main- factor in physical, social, emotional, and psychological health and well-being across the lifespan. Women reported more childhood trauma compared to men, except for physical abuse and physical neglect. Girls were found to be particularly at risk for child sexual abuse, and sexual abuse is related to increased risk of PTSD amongst other negative consequences.
Link Between PTSD and Substance Abuse Greater in Women
Perhaps not surprising given these findings, the association between PTSD and substance use in general is found to be stronger for women than in men. Studies found 30-59% of women with substance use problems also have a diagnosis of PTSD, and women with PTSD were found to be more likely to develop poly-drug dependencies and severe alcohol abuse. Nearly 80% of trauma survivors reported drinking alcohol or using cocaine for the first time after a traumatic event. Among women entering alcohol and substance use treatment, 73 % reported having been raped, and almost half of these women experienced multiple rapes across their lifespan.
Women using multiple substances were most likely to become the victims of assault, although findings also suggested a risk of violence as a result of alcohol or marijuana abuse alone. The experience of multiple traumas across the lifespan seems particularly high for sexual abuse survivors. One study found that 80% of sexual abuse survivors were subjected to further trauma and violence. Re-victimization means sexual abuse survivors often end up experiencing more traumas in the course of their adult lives, and re-victimization is linked to high anxiety levels, depression and other mental health problems, as well as heavy drinking or drug use.
Some research indicates that substance use may in fact precede trauma: A study with adolescents found that substance use made for greater possibility of being exposed to trauma and with that, the possibility of developing PTSD. These studies also showed that substance using adolescents were twice as likely as their non-using counterparts to develop PTSD as a result of exposure to trauma, perhaps as less able to draw on helpful coping strategies or support. In short, while traumatic experiences make women more vulnerable to coping with substances, using substances also makes them more vulnerable to repeated victimization and traumatic experiences.
The Why and How of Trauma
Although the exact mechanisms are still unknown, research has brought about some answers as to why and how traumatic experiences –particularly those experienced early in life –are linked to addiction and mental health difficulties later in life. In general, for our brain to grow and develop in a healthy fashion, we need nurturing, consistent and predictable care from a caregiver attuned to our needs. For example, childhood trauma is linked to high levels of the stress hormone cortisol in the body, which is known to cause problems with dopamine and serotonin functioning. These neurotransmitters are important for good brain health and healthy functioning, and they are also involved in regulating mood and behaviours. Cortisol impacts the hippocampus and the limbic system, regions in the brain associated with learning, memory and processing emotions. Impairment in this region of the brain may result into difficulties learning and memorizing, and into problems regulating emotions and controlling our impulses.
Childhood trauma is also linked to increased inflammation in the body, and inflammation can create problems in both the physical body and our psychological health. High inflammation is not only linked to a multitude of serious medical problems such as cancer, but research also found a link to suicide. This inflammatory response in the body was also observed to have impact on the brain and brain chemicals, causing an increase in some while decreasing others. In short, childhood trauma leads to alterations in emotion regulation, impulse control and brain functioning that may decrease individuals’ ability to cope with stress. Together with an increased sensitivity and reduced resiliency to stress, these consequences may create pathways to addictive behaviours.
Differences Between Women and Men
Once addictive substances have become part of an individual’s coping mechanism, women in particularly seem prone to descending rather swiftly into full addiction. In general, women’s use of substances differs quite significantly from mens’ use. Women report initially using substances often as a way of coping with mental health problems such as depression, or as a response to interpersonal problems or escalating life stressors. These factors also play a role in relapse for women. In contrast, men appear to experience the aforementioned difficulties as a consequence rather than a precursor to substance use. While individuals with mental health problems are generally more vulnerable to developing substance use problems, women seem particularly prone to silently self-medicate when suffering various mental health difficulties. For example, one study found that women diagnosed with Major Depression (MDE) were not only 7 times more likely than women without MDE to have alcohol dependence. Men suffering from depression on the other hand were found not at greater risk for the development of alcohol dependence as compared to men not experiencing depression. In regards to problematic alcohol use, women tend to drink in isolation, or in response to being pressured by their alcoholic partners. For men, problematic alcohol use appears to happen mainly in the context of social situations and to augment positive emotions.
Women’s substance use also appears to progress much faster than men’s once initiated, and their use seems to have a greater negative impact on their ability to function. Women in general tend to become addicted quicker than men and experience more negative physical health consequences than men.
Women substance users appear drawn to legally available substances when initially using, such as alcohol and prescription medications like opioids or benzodiazepines, but they tend to add illegal substances to the mix once their use becomes heavy. One study found a link between greater severity of childhood sexual, emotional or physical abuse to frequency and amount of cocaine used in cocaine dependent women, as well as higher relapse rate in women. This association was not evident in men, perhaps speaking to the greater impact interpersonal violence has on women compared to men.
The Stigma of Addiction and Trauma for Women
Added to this, research found that women tend to be more harshly judged and stigmatized for their substance misuse, including by loved ones, family members and friends. Women may therefore experience greater negative consequences admitting to unmanageable substance use and to seeking treatment, and this is especially true for mothers, pregnant women or women with other caretaking responsibilities. Studies also revealed that women experience more physical, psychiatric and social consequences of alcohol or drug use compared to men. For example, substance using women typically run the risk of heightened victimization and therefore repeated trauma. Victimized women showed a greater frequency in binge drinking than alcohol using men, and unfortunately binge drinking in turn was associated with increased risk for rape and other forms of sexual violence towards women. Women substance abusers are perhaps more likely to experience sexual violence, particularly if involved in the sex trade, while male substance users may be more exposed to physical violence as a result of their illicit use. Substance use may also pave the way to violence in other ways, as female victims of sexual violence report their perpetrators were under the influence during the assault. They also reported impaired judgment on their part as to decisions about safety of their company as a result of intoxication.
The latter has an impact on treatment: Female victims of violence tend to experience trauma at hand of people known to them, most often men they date or are in close relationship with. Male substance users, in contrast, tend to experience crime at the hand of strangers. This interpersonal violence at the hands of people women trusted often translates into a profound mistrust towards others. They may therefore present as very guarded towards peers and helping professionals alike, and establishing the therapeutic alliance that is so crucial in helping individuals to move towards greater health and healing may be extremely difficult with female substance users. Such traumatic experience may also make it difficult for survivors of interpersonal violence to engage with and fully immerse in a recovery community, whether during rehab or afterwards as part of their ongoing recovery plan. This is particularly painful for women, who tend to be more relationship focused and oriented than men: while women survivors may really long for human connection, they are at the same time very afraid to get close. The latter can translate into the often observed help seeking-help rejecting cycle clinicians observe in survivors of interpersonal trauma. In this regard, it may prove crucial to include loved ones in their treatment, as involving trusted family and friends may create safety, comfort and trust.
Women, Trauma, and Addiction Treatment
Unfortunately, research findings indicate that women survivors of interpersonal violence tend to leave conventional treatment programs early, and they are also less likely to remain sober following discharge. In contrast, female trauma survivors entering gender-specific programming were found twice as likely to complete treatment.
Treatment providers can consider the following points in creating a therapeutic environment that may make it more likely for female substance users and trauma survivors to remain in treatment, and to benefit from treatment long-term:
Creating safety is an absolute must for female trauma survivors, and this speaks to safety in regards to the therapeutic environment, but also more importantly to relationships between staff and clients, and relationships among members of the recovery community. An awareness as to a trauma survivors’ triggers can help in knowing what changes to make environmentally, and how to best support them. For example, incidents of stealing, not uncommon in rehab settings, may strongly trigger survivors of trauma and abuse, given the implied invasion of private space and disregard for boundaries. Such event can leave survivors of interpersonal violence triggered for days and weeks, leaving them hypervigilant, anxious, and unable to sleep or participate in programming.
Apart from PTSD, many female trauma survivors show psychiatric problems that often preceded or triggered their substance use in an attempt to cope. Similarly, female trauma survivors are prone to experience physical problems such as chronic pain as a consequence of child or adult trauma. When these issues remain unaddressed, women may be at higher risk for relapse in an attempt to cope with pain or mental health symptoms. As such, treatment providers may be well advised to offer integrated treatment that addresses all of these issues.
As many women have experienced violence at the hands of men, gender specific group programming may allow for a safe space for women to explore the impact of trauma and connect with others with similar experiences. Women may also need opportunity to connect safely with their bodies, as they have known them to be the source of shame and pain. Mind-body approaches, such as mindfulness, movement or yoga can offer such opportunities when delivered in gentle, non-competitive and supportive ways. It goes without saying that such trauma and gender specific services ought to be facilitated by highly trained female staff members.
Women tend to have more economic challenges and face greater judgment and stigma than men, especially if they are pregnant or mothers. They also face greater barriers to treatment if actively parenting children, or if responsible for elder care within their family network. Ideally, this can be taken into account in the development of gender-specific programming, so women can enter treatment without guilt and worries about existing care arrangements for their loved ones. For existing treatment providers, addressing such issues during the intake process and assisting women in problem solving these issues may remove otherwise insurmountable barriers to treatment.
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