Trauma, as defined by the Substance Abuse and Mental Health Services Administration, results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being.
Trauma may occur from a variety of events, and is solely defined by the subjective experience of the individual. Some people may respond to a specific event with higher resilience than others, and this influences the individual’s perception of the event. For example, when the terrorist attacks in New York City on 9/11/01 occurred, people throughout NYC responded differently to the traumatic event. Proximity to the event has influence, emotional connection to the event has influence, and the individual’s perception of a threat of injury, either physical or emotional, has influence. In any given building in NYC on that day, there would be a mix of responses from the individuals, from their symptoms of trauma, to their ability to easily resolve associated feelings, to other responses in between. The criteria for diagnosing responses to a traumatic event, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, include four clusters of behavior disturbances including:
- Re-experiencing = spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks or other intense or prolonged psychological distress.
- Avoidance = behavior attempting to avoid distressing memo¬ries, thoughts, feelings or external reminders of the event.
- Negative cognitions and mood = a myriad of feelings, from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event.
- Arousal = aggressive, reckless or self-destructive behavior, sleep disturbances, hyper-vigilance or related problems. This is the “fight” or “flight” associated behaviors.
Responses to a traumatic event vary greatly and may contain a combination of the above described behaviors. Even if a person’s behavior doesn’t meet criteria for a diagnosis, an individual’s response to a traumatic event may still have significant impact. A common reaction for a person who has experienced trauma and attempting avoidance behavior is to use substances such as alcohol or other drugs to cope with re-experiencing the trauma, negative cognitions and mood, and unpleasant arousal symptoms and behaviors. Often, medications (such as Xanax, Klonopin, etc.) are prescribed for someone who has heightened arousal symptoms or increased anxiety as a result of experiencing trauma.
The problem with using substances to cope without receiving appropriate mental health care is that the person does not learn how to use healthy coping skills to reduce arousal symptoms, and/or work through the re-experiencing symptoms without the use of substances. Because of this, over time, an individual instead learns to rely on substances, and this often develops into a substance use disorder. In time, the substance use disorder may progress from emotional reliance to emotional and physiological dependence.
If treated before substance use becomes misuse or dependence, an individual would benefit from education about trauma, medications, trauma therapy options (including self-help options, individual therapy, group therapy, holistic options, relaxation-training options, and more), and substance use/abuse/dependence. If a person becomes dependent on substances and also requires trauma therapy, it is usually best to address the substance dependence first, as this is the most dangerous ‘symptom’ and most critical need, along with the same education described above. It is best for a person to work on resolving the trauma after he or she has entered into recovery from substance dependence. If neither the substance use/dependence nor the trauma is addressed with treatment, the person continues the perpetual cycle of experiencing symptoms of trauma and using the most dependable coping mechanism he or she knows: to use a substance. If substance use alone is treated, the person continues to suffer from trauma symptoms, which is a risk factor in recovery from substance use. If trauma alone is treated while continuing to use substances, the individual does not have the opportunity to try new coping skills; this is because substance dependence precludes the person from practicing new coping skills and inevitable change. The recommendation for a person with both substance dependence and a trauma-related diagnosis would be to first treat the substance use disorder while acknowledging that the trauma-related disorder impacts substance use, and will need to be treated once recovery from substance use is obtained.