Trauma and Addiction

Keith Loring, MD

“Every human has a true authentic self. Trauma is the disconnection from it and healing is the reconnection with it”

– Gabor Maté, MD

As Carl Jung said, “Until you make the unconscious conscious, it will direct your life

and you will call it fate.” Deep within each of us is our center, our authentic self, the essential part of us that is perfectly whole and unbroken, that holds all the wisdom, energy and intuition necessary to heal our earliest and deepest wounds to restore wholeness throughout our system and to create a life of awareness, connection and joy.

Addiction is a response to trauma, specifically early childhood trauma. In order to understand addiction, we need to understand the nature of trauma and its impact on human development. Seen through this lens, fully trauma informed, we are able to see those suffering addiction for what happened to them rather than what’s wrong with them. When we address what happened rather than what’s “wrong,” we see our patients for their possibility, not as victims. We are then able to offer solutions rather than solace. We meet them where they are, not where we think they should be. We become collaborators in their healing process, and we stop the fool’s errand of trying to fix them. That’s their job, not ours.

For most of the 25 years I practiced emergency medicine, I saw addiction as an unsolvable problem to be mitigated, or at best, be managed. Patients suffering addiction were often the most difficult. They were manipulative drug-seekers, or they were intoxicated, combative disruptors of the emergency department, who got in the way of taking care of those who were truly suffering. I became adept at catching drug-seekers early in their game and finding the most efficient ways of detoxing intoxicated patients and discharging them as soon as possible in order to minimize their impact on the operations of the ED. In essence, I was loaded to the brim with compassion and understanding – NOT! Not for my patients and not for myself. What I wasn’t willing to see in them, I was unwilling to see in myself— my own suffering.

About 15 years into my emergency medicine career, while holding leadership positions in two local emergency departments and their hospital medical staffs, at the San Francisco Emergency Physician’s Association and the (then) San Francisco Medical Society, and as a regional medical director for a large multi-contract emergency medicine partnership, my primary coping mechanism—an insatiable appetite for the circuit party scene— collided in spectacular fashion with the rest of my life. I was addicted to taking on those many roles and responsibilities in a desperate attempt to prove my self-worth. And I had become addicted to the dance parties and the drugs that fueled them as the only way to cope with the overwhelming and ever-growing pain on the inside.

That was the darkest and most transformational period in my life. My inner narcissist mounted a valiant effort to save face but failed. With him no longer in the lead, I got my life back, and began to recover my true self. Along the way, I have become well acquainted with the nature of human trauma, the colorful ways in which it is expressed, and the possibility that exists in every one of us, to move through and past our trauma, to discover that within our deepest suffering lies our greatest source of wisdom and compassion.

Coping with the Trauma Within

Trauma is not what happens to us, it is what happens on the inside as a result of what happens. The inner experience is the key. Trauma is anything that changes us in a way that makes our future responses to the world more limited, that causes a constriction. It interferes with our natural process of growth and development. We come out of trauma more limited than when we go in—limited self-awareness, limited flexibility in our future responses, limited capacity to self-regulate. We become disconnected from our body and our self. We are more likely to override our gut feelings, which are essential for survival. We are less able to stay in the present moment.

As infants and children, our inner experience is highly dependent on how well we are seen, heard and held by our adult caregivers. The difference between becoming traumatized and building resiliency depends entirely on the adult caregiving continued on page 16

environment in which we were held—or not. The more secure, attuned and compassionate the holding, the greater the likelihood that we will grow and develop into fully self-assured, fully self-regulated and compassionate adult human beings. The more problematic and insecure the holding, the more our natural process of development is impeded and the more we divert our energy toward automatic and instinctual ways of coping that work very well in the moment but become increasingly maladaptive later in life.

In other words, as children we don’t get traumatized because of our hurt, we get traumatized because we are alone with our hurt. That hurt can be from something as obvious and overt as emotional, physical or sexual abuse and it can be from something much less obvious such as having a depressed parent who is emotionally unavailable. Alone with our hurt, while completely vulnerable and helpless, our most evolved human response, reaching out for help, is not available. We cannot run away. And we cannot put up a fight. We are left with our most primitive survival responses, embedded in our reptilian brain— we are left to either freeze or fold, our defense mechanisms of last resort.

These are completely automatic and largely unconscious reactions. We learn to tune out, withdraw, distract, numb, repress or depress our feelings in response to stress. We become defended against vulnerability, which is essential for human connection. We disconnect from ourselves and from the world around us. We adopt shame-based beliefs, that we are not worthy, not loveable, or worse. As children, when bad things happen to us, we automatically believe it is because there is something wrong with us. There is no middle ground or nuance available to us. It’s too overwhelming to acknowledge the truth—that our caregivers are too overwhelmed and are incapable of keeping us safe and nurturing us the way we need. It is far less overwhelming to take on shame than experience the full emotional impact of realizing we are not safe or safely held. Faced with existential crisis, we default to shame. It is never a conscious choice, but it is a brilliant survival strategy. In this way we stay attached to the adults in our world and survive, but it is at the cost of our authenticity.

Addiction: A Self-Defeating Solution

Among the strategies we adopt to cope with this predicament is the process of addiction. Addictive behavior is aimed at alleviating the suffering of being stuck in a lonely and dangerous place, full of anxiety and shame. This strategy too is never a choice; it’s automatic and unconscious. However, it is always only a temporary solution that over time, like an overzealous fire hose, can cause a lot of collateral damage and eventually becomes its own source of suffering. And despite the mounting damage and suffering, you can’t give it up.

All the while, the pain of unresolved trauma remains undischarged, held in the body and buried deep within the psyche until we either die from our defense against it or we discover our inner capacity to consciously and courageously revisit, sit with and authentically discharge it, each of us in our own unique way, with willingness, curiosity and courage. The unresolved pain held within the entire mind-body system must be addressed. The only way past it is through it. There is no other way. That, in a nutshell, is the process of recovery. It’s heroic work; the true hero’s journey, an inward journey that every human being has the capacity to undertake. Our job as physicians is to recognize that capacity in ourselves and therefore in others. Where we have compassion for ourselves, we automatically have compassion for those with whom we work.

Healing and Recovery

From a neuropsychological perspective, the implication of understanding addiction as a response to trauma, as an unconsciously learned behavior, is profound. A person suffering addiction is no longer a victim of their genes fated with a diseased brain and broken psychology that are irreparable and at best manageable. The brain of a person suffering addiction is perfectly intact. It developed in response to its biopsychosocial and spiritual environment. It does perfectly well what it learned to do, with brilliance, tenacity and resilience. It’s just that the behaviors that these qualities serve are self-destructive, antisocial, and can eventually become anti-survival, pushing the brain and body past the point of no return.

The good news is that an intact brain is reprogrammable. Adult human neuroplasticity allows for ongoing personal transformation and growth throughout one’s lifespan, provided there is safety. In the words of Stephen Porges, “Safety is not the absence of danger, it is the presence of connection.” The work of recovery from addiction—recovery from trauma—is the work of reconnection. When a human being is held in compassionate connection, their brain will re-tune and rewire, turning its intelligence, tenacity and resilience away from defense toward growth and restoration.

Consider this as we engage in relationship with our patients: Seek to understand them for what happened to them, not for what’s wrong with them. All wounding occurs in relationship; therefore, all healing must occur in a relationship that holds a person in a way they weren’t when they were wounded. What do we do to hold our patients in a way that they feel truly held, seen, heard and understood? Such that they sense from us that they are safe and worthy of healing? Such that they have full agency

to look inward and tap into their inner resources for healing? Our patients co-regulate with us—they take their inner cues of safety from us. When we see them for what is wrong with them, they sense it and see themselves as judged, as victims. When we are truly curious to see them for what happened, they will sense it and feel understood and seen for their possibility. So it’s our job to do our own deep work of self-discovery, to be self-aware, to show up fully self-regulated and present in order for them to learn how to do so as well. To do this we need to open our eyes, ears and hearts to a trauma informed view of all mental and bio-physical illness, a view that necessarily recognizes that the mind and the body are inseparable and that the source of healing comes from within. From this perspective, difficult patients transform into human beings with amazing histories of challenge, difficulty, and survival. Each suffering in their own unique way and worthy of support and guidance toward healing. The vast armamentarium of tools we have at our disposal—the medicines we prescribe and the procedures we perform—become far more effective when we understand that the source of healing lies within those we serve.

For a deeper dive into the topics of trauma, addiction, and healing I recommend the following: In The Realm of the Hungry Ghosts: Close Encounters with Addiction - Gabor Maté, MD The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma - Bessel Van der Kolk, MD In An Unspoken Voice: How the Body Releases Trauma and Restores Goodness – Peter Levine

The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication and Self-Regulation - Stephen Porges

Keith Loring, MD, is board certified in both emergency medicine and addiction medicine. He practices addiction medicine at HealthRight360 and is a certified Compassionate Inquiry Practitioner, a fully trauma informed approach to counseling, recovery coaching and therapy developed by Gabor Maté, MD. https://compassionateinquiry.com/practitioners/ He has been a member of the SFMMS for many years, serving in various capacities and currently is an alternate delegate to the CMA HOD.