Media depictions of trauma often show clients coached to dig deep into their memories, cry, scream, or otherwise somehow “get it out.” The experience looks horribly painful, but is supposed to be cathartic, meaning it lets you have a crisis and then let the pain go.
Traditional approaches to substance users, from 12 Step programs to rehabs, have a lot in common with this approach. Telling your story in meetings, digging deep into your history (including sexual history, which for many of us includes rape and abuse), and sharing it with others is often mandatory (or “suggested.”)
Is this the best way to approach a person whose substance use has been driven by trauma? The real masters of trauma treatment would tell you, “No.”
The Best Approach
Dr. Peter Levine, one of the world’s foremost experts in trauma and founder of the Somatic Experiencing Trauma Institute,1 focuses not on the story of “what happened” but on the physical and mental symptoms that follow. As Dr. Levine emphasizes, trauma is “the debilitating symptoms that many people experience in the aftermath of a perceived life-threatening or overwhelming situation.”2 What happened doesn’t matter: the symptoms of trauma, such as acute fear of danger, fear of going outside or people, flashbacks and nightmares, panic attacks, and inability to connect with other people, are what needs to be addressed in any sort of treatment.
These symptoms read like a list of triggers to drink or use, leading to the chicken and egg nature of trauma and substance problems.
Trauma is resistant to treatment because it changes the brain. According to Bessel Van der Kolk, MD, trauma changes the brain at levels below the cognitive level, where thinking occurs. First, at the level of perception, trauma causes people to see threats where others see manageable situations.3 Second, the brain’s “filtering system” goes haywire, making it difficult for people to distinguish between what matters now and what does not.3 It becomes difficult to “engage with ordinary situations.”3 Third, your sense of yourself, including your ability to feel pleasure or connection to others, becomes dampened.3 This is a defense mechanism to survive a terrifying situation, but it Post Traumatic Stress Disorder it lingers on.3 Dr. van der Kolk points out that many people use drugs to deal with this loss of self. Since these reactions happen at a deeper level of the brain than the cognitive, thinking part, you can’t just “think” your way out of it.
Many of us have been frustrated by concerned people, including therapists, suggesting we just “make a decision” not to feel the way we feel. If it were that easy, we would have done that already! That’s why sometimes even the most evidence-based approaches like Cognitive Behavioral Therapy (the basis of SMART Recovery, an international non-12 Step group whose facilitators are trained and certified) can fall flat when a traumatized person is not able to turn off the terror response long enough to access the cognitive part of the brain.
Trauma is also locked in the body. Levine, Van der Kolk, and others have written extensively about how using physical techniques, not talk therapy, can help patients more. In books such as In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness4 by Peter Levine, and The Body Keeps The Score5 by Bessel van der Kolk, these techniques are explored in detail.
The key takeaways for people suffering with trauma and substance use all at the same time are:
- Talking it out may not help. It may even hurt. Forcing yourself to re-experience the events can be retraumatizing and make symptoms worse, not better.
- Go easy on yourself. Your body may hurt. Chronic pain is a common symptom. If you can, try gentle, restorative yoga (please avoid those classes that look more like yoga inspired aerobics!). A hot bath with Epsom salts can help. While it seems like “processing” the trauma would relieve the physical tension, sometimes it works the other way around.
- Do not attempt to justify how you feel. Trauma is individual. You don’t have to prove to anyone (not a sponsor, not a counselor, not a family member) that what you went through was *bad enough.* Focus on your healing, not others’ judgment.
- Allow yourself to set boundaries. When I was a rape survivor fresh out of crisis, I was not comfortable with being touched or with going to meetings with men. You have the right to protect yourself.
- Avoid anything that forces you to tell your story in environments where you are not able to be comfortable and honest. You do not have to “share” in meetings, work with a sponsor immediately (or at all), or answer questions from family members or friends. It can be hard to draw these boundaries and sometimes you may be in situations where you have no choice, but a firm “No” works more often than you may think.
Setting boundaries can be very difficult because once someone has been identified as an “addict,” often that person is denied freedoms and privacy that would be taken for granted in regular life. Historically, cruel and humiliating interrogations and punishments have been inflicted on addicted persons in an attempt to “break down denial” make them see the consequences of their actions. More treatment programs are now learning that these techniques can be extremely harmful. Treatment should be healing, not re-traumatizing.
Look for future articles about how to choose a treatment center or program that is truly trauma-informed. And remember, your own instincts are not necessarily wrong because you have used substances problematically. If you are being forced to relive traumatic experiences in a way that brings on flashbacks, physical symptoms or terror, you have the right to just say no.
2 Levine, PA. (2005) Healing Trauma. Boulder, Colorado: Sounds True, Inc.
4 Levine, PA. (2019) In An Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley, CA: North Atlantic Books.