we would say, “Now is not the time to deal with the trauma. Keep it on the shelf until the patient’s abstinence is stable.” As a young therapist I would confer with my preeminent psychiatrist and psychologist colleagues and say, “Doc, that’s fine with me, but tell me, what shelf? Where is this shelf?” Meanwhile, intense trauma-based emotions are spilling out for patients who are no longer self-medicating. So, how do we work with trauma when we take away the patient’s primary coping method, when abstinence/recovery expose the pain connected with it?
My philosophy is that as clinicians, we do not seek to explore trauma with clients who are newly abstinent. Nevertheless, when the patient brings trauma to us—meaning, to the treatment environment—we need to acknowledge it and help the patient contain it. To use a Native American metaphor, we don’t rush the river. But, when the river starts flowing, we need to be able to contain it.
In terms of trauma, the patient’s trauma-driven emotions are the river. My experience in this field for over twenty-five years suggests that the majority of people admitted for addiction treatment, 80 to 90 percent in the case of women, have experienced trauma. It’s also true that a high percentage of men have been abused. In early recovery, we do not go looking for trauma with the patient. The patient brings the trauma to the therapist. When the patient brings the trauma to the treatment setting, as professionals we are obligated to deal with it and be able to contain it.
It is also helpful to be aware of the link between addiction and trauma from a multi-generational perspective. My framework for understanding multi- or intergenerational trauma is this: That which is not transformed is transmitted. Specifically, trauma that is not transformed or healed well enough within one generation will be transmitted to the next generation. For instance, often you have a patient in your practice with addiction and over-reactive/aggressive behaviors whose parents and grandparents were substance abusers and were also abusive. These previous generations never transformed their own issues and therefore transmitted those issues intact to the next generation.
Multigenerational trauma can manifest itself in different ways, so allow me to provide another example.
Your maternal grandfather is a raging alcoholic, so your mother decided she would never drink, and perhaps she kept that commitment. In this case, active addiction was not transmitted to the next generation. However, if your mother does not engage in the work necessary to transform the dysfunctional thinking, distorted beliefs, and unhealthy ways of dealing with emotions that go along with growing up in an addicted family system, all these are passed on to the next generation. That which is not transformed is transmitted.
Touching Suffering—the Interactional Challenges of Trauma
Trauma changes the structure of the brain at the point where the prefrontal cortex, the emotional brain, and the survival brain converge. The prefrontal cortex is the part of the brain in charge of executive functioning, notably rational thinking and decision-making. This was the last part of the human brain to evolve, and it does not develop fully until sometime between the ages of eighteen to twenty-five. The emotional brain encompasses the midbrain, where memories and emotions are recorded and stored. The survival brain is the so-called “reptile brain.” This was the first part of the brain to evolve. It is the most primitive part of the brain and plays an important role in the regulation of essential basic functions including heart rate, breathing, sleeping, and eating.
For seven years I was Vice President of Treatment Services at the Betty Ford Center in Rancho Mirage, California, where I presented lectures on trauma. The audience often included doctors who were among our patients. Some of these physicians would come up after the lecture and tell me, “I never made that correlation (between trauma and the three primary parts of the brain). Never.” A couple of them were psychiatrists who said, “I am going to look at my patients completely differently from now on.”
I know from the experience of supervising counselors for many years that some clinicians can be intimidated by working with trauma. Sometimes it happens that patients are ready to share their trauma, but their therapists are not ready to work with it because they haven’t had enough training or haven’t done enough of their own personal work. These clinicians will tend to steer patients with trauma back to the more strictly cognitive realm because that is where they (the clinicians) are more comfortable. When this occurs, the patients’ need to begin to address their trauma has effectively been blocked, and they come out of their sessions more confused than when they went in, and in more pain—which they will act out. Especially in inpatient treatment environments, this acting out frequently takes dramatic, emotionally labile, and staff-splitting forms.
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