The Origins of Addiction - from Dr. Vincent Felitti and the Adverse Childhood Study

In this film,  Dr Vincent Felitti, from Kaiser Permanente presents information from the ongoing 17,000 person Adverse Childhood Experiences (ACE) Study to challenge the conventional view that certain chemicals are intrinsically addicting.  He presents the evidence gathered in the ACE study to show that “addiction is not a disease, but is an unconsciously attempted response to minimize the effects of abnormal life experiences. Addiction can be seen as the unconscious, compulsive use of psychoactive materials in response to the stress of life experiences, typically dating back to childhood.”

Dr. Felitti discusses patients, including the woman who was the first person to draw his attention to the issue of using substances (in her case food), who are engaging in behaviors normally considered harmful in order to alleviate and protect from the pain of childhood experiences.  He primarily addresses food, alcohol, nicotine, methamphetamines and heroin addiction.  They are a few of the things that may be seen as public health problems but may often be “personal solutions to long-concealed adverse childhood experiences.  Describing bad habits as self-destructive behaviors hides their functionality in the life of a trauma survivor.”

As I think about how we try to address substance abuse, the heroin crisis, and human trafficking, I am drawn to the conclusion that we will fail in our attempts to resolve the crises until we begin to talk about the long held private conditions that lead to the public problems.  “These life experiences are very likely to be lost in time, and protected by shame, by secrecy, and by social taboos against exploring certain aspects of human experience.”  So many of us were raised in families and cultures where we did not discuss shameful family secrets.  As we grew up we were seen as the problem when the legacy of adverse childhood experiences presented as addictions and mental illness.

At this point in time treatment options are few and far between and minimally address the origins of the addiction.  By failing to address the adversity experience in childhood by so many people, we fail in our attempts to treat.  When treatment fails, we blame the person instead of recognizing that by “treating someone’s attempted solution, we may be threatening and causing flight from treatment” or forcing them to find another, possibly life-threatening, solution.

When these childhood experiences are named and validated as the source of long term difficulties in adolescence and adulthood we are removing the stigma and helping persons understand that it is not about having something wrong with them, but that something was done to them.  The next steps are to assist in finding healthier solutions and recognizing the strength and resiliency that helped them find solutions in the first place and survive in the midst of extremely adverse experiences. 

http://www.albertafamilywellness.org/resources/video/origins-addiction

Introduction to Excellent Website on Providing Trauma Informed Services to Women and Girls

Coalescing on Women and Substance Abuse – Linking Research, Practice and Policy


http://www.coalescing-vc.org/index.htm

This site captures material from historical and ongoing projects related to women’s substance use in Canada. The projects described here have been sponsored by the British Columbia Centre of Excellence for Women’s Health with the involvement of many partners. The site was first mounted to share the findings of the Coalescing on Women and Substance Use: Linking Research Practice and Policy project (2003-2008) a project that sparked short-term virtual communities of practice (vCoP) on six key topics related to women's substance use in Canada. Now material continues to be added from both virtual and F2F projects, for example on projects related to girls and heavy alcohol use, and on applying a gender lens to work on the National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada.

The aim of this site to share and promote action on promising approaches to responding to substance use by girls and women, on the part of service providers, researchers, health system planners and decision makers.

The following discussion questions found on the site can be used by direct services providers to reflect on their current practices and policies in providing trauma-informed services.

1. What have you noticed about the links among trauma, mental illness and substance use problems from your experience of supporting women with these and related challenges?

2. Does your service assume that violence has played some role in the woman’s/girl’s life, even if she has not identified abuse as a source of difficulty?

3. How does your service currently address the needs of girls and women experiencing trauma, substance use and mental health concerns?

4. Does your service provide training to women accessing services in skills useful to healing from trauma as well as substance use and mental health concerns - such as self-soothing, self-esteem, self-trust and assertiveness?

5. Has education (basic information about trauma and its impact) been offered to all staff at your service? Have clinical staff received training on specific modifications of existing services for trauma survivors?

6. What opportunities are there for building awareness/taking action to improve the response for girls and women with substance use problems and related trauma and mental health concerns?

7. Notice the language used within your context. What would happen if ‘symptoms’ were reframed as ‘adaptations’? How would things change at a practice and policy level if ‘disorders’ were considered ‘responses’?

8. Improving the system of care for girls and women requires a paradigm shift from “what is wrong with her?” to “what happened to her?” Consider what this shift might mean for your services or system.

9. How does your organization support efforts to minimize the possibility of re-traumatization?

10. In what ways are girls and women involved in the development of service policies and protocols?

11. How is diversity, such as one’s cultural background, considered in the trauma-specific services you offer?

Finding “A Woman’s Way Through the Twelve Steps”

When I first started working with survivors of intimate partner violence who were self medicating the pain of the violence there was a lot of criticism in the domestic violence community of the traditional 12 Step programs. This has continued over the years due to survivors continuing to be victimized within the 12 Step programs and the traditional approach maintained by substance abuse therapists who promote the 12 Step model. The empowerment model of domestic violence seems at odds with some of the steps which require a person taking a look at their “character defects” in order to take responsibility for their actions. Also, within the rooms of AA and NA, members can become emphatic in regards to beliefs that a person must be torn down before they can be built back up again. As we well know, survivors of violence have experienced that tearing down within their relationships and may find some interpretations of the 12 Steps to be another means of external forces exerting power and control in the life of the person using substances to cope.

The traditional approach to substance abuse treatment requires that the “addict” admit to having a disease, be willing to admit that they are powerless, take responsibility for their part of the problem and make sobriety a priority. In the trauma informed, empowerment model based approach, the advocate supports the survivor in making safety a priority and recognizing that the trauma the person has experienced has contributed to the increased use of substances or processes that mask the symptoms of the trauma. The survivor is also supported in knowing that they are not responsible for the trauma which led to the substance use.

Oftentimes, DV advocates are reluctant to address issues of substance abuse due to seeing the use as the person’s choice and her way of coping with her life. However, many times survivors see this as the only choice and an advocate can be of assistance in educating her as to other ways she can manage her life, increasing her self confidence and possibly leading her to the point where she can eventually see that there are other choices besides drinking or using drugs. It is not the role of the advocate to judge a survivor’s use of the substance, but be able to assist the survivor in maintaining safety and becoming personally empowered by having new choices available.

Another reason that DV advocates may be reluctant to address issues of substance use has to do with the lack of resources available to women to maintain their safety and sobriety and the fear of having a women revictimized within the recovery community. There are a few things that can be done to increase safety and make the 12 Step model more empowering for survivors. There are a number of different types of peer support programs for women in recovery but none are as prevalent and available as the 12 Step program. We have a number of women currently involved in the program coming into our agencies and it is valuable for us to have an understand of the model in order to converse with them about how recovery can be empowering.

First of all, in order to educate a woman about safety issues in regards to attending 12 Step meetings the following recommendations can be made:

1) Do not disclose where you staying to anyone in the group or reveal the name of your abuser.
2) If you go to a group and someone there knows the abuser, leave immediately and do not return to that meeting.
3) Try not to be predictable in which meetings are attended every week. A stalker may use a local meeting schedule as a way to follow a woman from meeting to meeting.
4) Do not accept rides from people you do not know or be the only passenger.
5) Attend “women’s only” groups as much as possible.


In A Woman’s Way Through the Twelve Steps, Stephanie S. Covington Ph.D. takes each of the 12 Steps and interprets them in a way that can be very valuable in working with survivors of trauma who are trying to find a way to manage their sobriety through the use of the support a 12 Step program can provide. In addition to the text, A Woman’s Way Through the Twelve Step, there is a workbook that can be used by someone working her way through the steps. See www.stephaniecovington.com for more resources.

Here is a very brief review of the steps and how they can be interpreted and used within the empowerment model I encourage you to read the book yourself since I cannot possibly cover all of the points here. . It is important to note that the steps are a process that can take years and should not be rushed. It is often recommended that the first three steps take a year or more and that the remaining steps be done as the person is ready. By using a workbook and a facilitated group, however, the steps can be done in a shorter period of time and then done more comprehensively at a later date.

• Step One – We admitted were powerless over alcohol – that our lives had become unmanageable.
This step is primary about becoming aware of how life has become unmanageable due to the use of the substances. We know as advocates that trauma may be the source of the unmanageability and we want to remind survivors that they are not responsible for the abuse in their lives. By acknowledging their lack of power in some areas of their lives (i.e. the actions of their abuser) they can then become free to act in areas where they do have power.

• Step Two – Came to believe that a power greater than ourselves could restore us to sanity.•
Step Three – Made a decision to turn our will and our lives over to the care of God as we understood Him.
These two steps generate a lot of resistance for survivors and advocates alike due to the suggestion that life will be better if we just had over power and control to another outside entity, This can raise fear and trepidation for someone who wants to regain power and control over her own life, especially when religion has been used as an excuse to perpetrate ongoing abuse.


Stephanie Covington encourages us to consider the use of the group as a higher power, particularly a group of women who have had the same struggles and who have found their way to empowerment, safety and sobriety. She also encourages women to find their own definition of God/Goddess/Higher Power and recognize that we do not need to be held to the constraints of a childhood religion that does not empower women.

• Step Four – Made a searching and fearless moral inventory of ourselves.
This step has been a block for most persons involved in 12 Step programs due to the fear of facing some of the demons of the past. The main points to remember are that this inventory is a process and not an event. It takes as long as it takes and not everything needs to be addressed in the first inventory. Also, Stephanie Covington encourages women to do an inventory of “Assets and Strengths” and “Challenges and Limitations” rather than the traditional inventory of “character defects.”

• Step Five – Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
Done with an empowering approach this step can provide what many of our survivor support groups do. It helps the person put an end to secrecy, helps them find that other people feel the same, assists with self-acceptance and self forgiveness and starts the survivor on the road to celebration and gratitude for their assets and strengths and the support they receive from a community of women.

• Step Six – Were entirely ready to have God remove these defects of character.
This step provides the opportunity for a survivor to use “letting go” rituals to release some of the challenges and limitations she may believe about her life. By this time she may have learned enough about how the trauma has affected her that she will be able to release some of the coping skills that are no longer needed due to the development of new strategies.

• Step Seven – Humbly asked Him to remove our shortcomings.
This step is about relinquishing those former coping skills and recognizing how there is strength available to move forward. The word ‘humbly” often gets confused with humiliation. However, in this step humility means having a strong sense of who we are, realizing our limitations and acknowledging our strengths.

• Step Eight – Made a list of all persons we had harmed and became willing to make amends to them all.
This step is about relationships and the power of being able to recognize what we are responsible for and what others are responsible for. It is helpful to have a sponsor or therapist work with the survivor on this step as it is very easy to get off balance and start taking responsibility for the actions of others.

• Step Nine – Made direct amends to such people wherever possible except when to do so would injure them or others.
Personal responsibility can be a key to empowerment. The 12 Step program encourages direct and honest amends and this can only be done after the strong, balance approach in Step Eight. It is also mentioned that amends can be “living amends,” treating some with more respect or kindness than in the past. It also requires a willingness to accept whatever the person’s reaction may be to the amends. This about making amends, not necessarily about receiving forgiveness.

• Step Ten – Continued to take personal inventory and when we were wrong promptly admitted.
This step encourages staying present in the moment. As in Step Four, it is recommended to use the balanced approach of making an inventory of “Challenges and Limitations” and “Strengths and Assets.”

• Step Eleven – Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
– “Prayer is an act of either reaching out to a Higher Power or going inward to a deeper knowing. Just as we described God our own way in Step Three, we can also come to prayer however we like.” Stephanie Covington

• Step Twelve – Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all of our affairs.”
This step is an invitation to continue practicing the principles of the 12 Step program and inviting others to explore the support of the program.

This review is not necessarily a recommendation of the 12 Step program but is more of a means to help advocates be more informed about the model. Given how it is often the only type of support a survivor has for her recovery from substance use, it is valuable to be able to talk to survivors about how it can be used in an empowering way.

The Fallacy of Co-Dependency and Addiction in Regards to Seeking Safety

I was having a conversation with a program director yesterday and it was brought up that there is still language in the mental health community in regards to intimate partner violence survivors being labeled as “addicted” to their abusers. This led to a discussion regarding co-dependency, addiction and being a person living with an abusive partner in her life.

The definition of addiction, “the state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming, as narcotics, to such an extent that its cessation causes severe trauma,” does a disservice to the survivors for whom we advocate and does not address the cycle of violence and the desire for the woman to manage her life in a way that keeps her and her children safe. According to the definition of addiction, separation from the habit causes trauma due to the loss and the physical effects of separation. Certain habits, skills, and coping mechanisms may be developed in a relationship in order to attempt to manage the abuser and the violence but these are in no way a sign that the person is addicted to the abuser. If anything, she is addicted to maintaining her safety and is hyper vigilant of the abuser’s activities in order to maintain that safety. This hyper vigilance is a result of complex trauma, not of an addiction.

The term “co-dependency” over the years has evolved and is often used when describing a victim of intimate partner violence who remains living within the cycle of abuse. As a movement, domestic violence advocates work hard to keep from labeling victims with descriptors that blame the victim. The original concept of codependency was developed to acknowledge the responses and behaviors people develop from living with an alcoholic or substance abuser. Like the term “addiction” however, “co-dependency” does not take into consideration the hyper vigilant behavior that arises from the complex trauma of abuse. Someone who is labeled co-dependent is attempting to control another person’s behavior in order to feeling in control and may blur boundaries in order for that to occur. However, a victim of violence has had her boundaries violated by another and has developed behaviors in order to maintain her safety. Again, these behaviors are not due to co-dependency but are survival skills developed while experiencing trauma.

When we think about what trauma does to the brain we understand a little more about how addiction and co-dependency differ. When the brain experiences a traumatic event the “doing” center of the brain, the amygdale, is activated into fight, flight or freeze mode. The pre-frontal cortex or frontal lobe, the “thinking center” assesses the danger and will tell the “doing” center to back down and resume normal activity. However, after many traumatic incidents (complex trauma) the “thinking” area of the brain will stop assessing, assumes the person is always under attack, and will not stop the “doing” center from going into fight, flight or freeze. Therefore, the person is in a heightened state of anxiety and hyper vigilance most of the time and develops strategies to manage that state that would seem foreign and/or maladaptive to the rest of us. To the victim, these strategies feel like the only way to maintain safety. This is not about being co-dependent or addicted it is about wanting to be safe.

While the trauma is occurring and the survivor is developing her skills to maintain safety she may be unable to focus on skills and behaviors for daily living. As stated above, the “thinking” area of the brain has allowed the “doing” center to take over. What we see as manipulative, co-dependent, or addictive behaviors are actually necessary skills to maintain safety and until the chemicals that have flooded the “doing” center of the brain find a healthy way to release and the “thinking” brain can function normally again, these skills will remain as the primary method of maintaining safety. This work cannot occur while trauma is still occurring and requires safe, healthy relationships with advocates and therapists who understand what is happening from a trauma-informed viewpoint. There are many modes of treatment that work to return the brain and body to balance and I recommend that you search out therapists in your area who understand trauma and trauma treatment.