Trauma is the Gateway Drug – an ACE’s Informed Approach to Substance Abuse Treatment

by Wayne Munchel, LCSW   2 Comments

“We treat people’s solutions as problems.” Vincent Felitti MD, eminent author of the original ACE’s (Adverse Childhood Experiences) study, often makes this point when discussing how we focus on eliminating people’s desperate means of coping, without recognizing their adaptive functions. When addressing substance abuse (the most common method of tolerating overwhelming fear and pain) do we commit the same error of attempting to control the “solution” while largely ignoring the underlying core problems associated with traumatic exposures? For many people struggling with addictions, substance abuse represents their survival.

The linkage between ACE’s and trauma and substance abuse disorders (SUD’s) is compelling. In his paper, Origins of Addiction, Felitti reports that people who experience 4 or more ACE’s are 500% more likely to abuse alcohol. People who report five ACE’s or more are 7 to 10 times more likely to report illicit drug abuse. A jaw-dropping data point indicates that individuals who survive 6 or more ACE’s are 46 times more likely to be IV drug abusers than people who report no ACE’s. Trauma truly is the “gateway drug” to addictions.

Kanwarpal Dhaliwal and the youth at RYSE (Richmond Youth Services) have amplified the ACE’s pyramid to include the toxic impacts of social conditions and local contexts such as poverty, racism and historical trauma. This expanded view helps us recognize that it’s not just what has happened to you, but what environmental stressors and social conditions you are born and raised in. As attention has turned to the “opioid crisis,” it would seem to be no coincidence that the communities most affected are beset by high rates of unemployment, poverty, and social isolation. In contrast to the reductive medical model, the ACE’s trauma-informed approach encompasses neighborhoods as much as neurons, and it relates to zip codes more than just genetic codes.

Some substance abuse programs and mental health agencies have begun integrating the ACE’s questionnaire into their initial assessments. What might be the potential impacts of incorporating enhanced ACE’s informed perspectives into treatment?

  • Asking about childhood maltreatment, listening and offering empathy represents a significant intervention in itself. Simple, straightforward human compassion for “what has happened” to people, acknowledging human suffering and distress can be healing.
  • Inviting people who abuse substances to be “compassionately curious” about themselves and to connect the dots between their unseen wounds and their attempts to cope with overwhelming distress can provide relief and self-understanding. (“I use substances for understandable reasons, I’m not just crazy or stupid.”) This is often a long-term, life-time process.
  • Instilling hope for a better future is an essential ingredient for recovery. “What can be hurt can be healed” seems to illuminate this pathway much more than “you have an incurable, life-long brain disease.”
  • Empowering people to take responsibility for owning their own stories and writing (and rewriting) new chapters. Talk of genetic predispositions and chemical imbalances can engender passivity and resignation.
  • Supporting meaning making and setting the stage for post-traumatic growth.
  • Emphasizing the central need for social supports and human connection. In his enlightening TED talk, Johann Hari asks this challenging question: “What if the opposite of addiction is not sobriety, but the opposite of addiction is connection?” A key aspect of reducing substance abuse is how well we can help people develop their social networks and resilience.
  • This reminds us all that unless we also vigorously address issues such as social justice, poverty and racism, our progress will be limited.

Utilizing this broader, trauma-informed lens often seems at odds with the dominant medical model approach to addiction as a disease. Framing problems such as addiction as solely problems within an individual’s disordered neural circuitry are favored. We prefer our solutions to be fast-acting, cheap and to avoid discomforting questions about social conditions. In his book “In the Realm of Hungry Ghosts,” Gabor Mate makes the following observation: “We keep trying to change people’s behaviors without a full understanding of how and why those behaviors arise.” A trauma informed approach to substance abuse and dependence brings the potential of deep healing, not just for individuals but our communities as well.

{ 2 comments… read them below or add one }

don cook September 7, 2017 at 6:02 am

Hi: All of those points i employed 12-13 years ago when working at a methadone clinic; the result was my 50+ patients having the lowest relapse rate in the clinic, and telling me things they never had told anyone before… never heard of ACE. May You all have Peace!

Donald J. Cook, LMFT

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Karyn Dresser September 11, 2017 at 5:24 pm

Here here! So agree with Mr. Munchel. In my view, anyone working with young adults and/or those with addictions ought have training in psychological trauma treatment!

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