TRAUMA-RELATED SUBSTANCE ABUSE

Prevention providers and treatment specialists, both, have long known of the correlation between experiencing a traumatic event and the subsequent use and abuse of alcohol or other drugs, as well as the connection between trauma and relapse. But while the research is replete with extensive studies on trauma, studies on the concept of a link between trauma and substance abuse are more recent.

The Council, in leading a one-year review of the research, found that victims of trauma are 4-to-5 times more vulnerable and likely to experience alcohol or substance abuse than the general public. Studies after the World Trade Center disaster, studies of the Columbine incident, Oklahoma City bombing, of war veterans and PTSD, and numerous studies of other catastrophes have demonstrated that there is a very strong relationship between experiencing a traumatic event and the subsequent use and abuse of alcohol, cigarettes, street drugs, and misuse of prescription drugs.

These findings hold true across categories of trauma - natural disasters, war, accidents, experiencing terrorism, being a victim of crime or violence, experiencing child abuse or sexual abuse, or with a personal loss - health, possessions or death.

Often the most natural thing to do is to cope with or "self-medicate" the grief, fears and anxieties with these substances. Yet, from virtually every perspective the use of substances following trauma is contra-indicated unless under strict medical protocol. In fact, often, the consequences of substance abuse re-traumatizes the person, or subjects the person to secondary trauma.

The research speaks to ways to mitigate the effects of trauma and reduce the probability of substance abuse post-trauma. Prevention experts and counselors can best accomplish this by helping victims of trauma with: (1) spirituality, self-actualization, personal growth, and by reviewing purpose and meaning in life, (2) teaching positive coping skills, (3) building resiliency, (4) enhancing protective factors, (5) reducing risk factors, (6) encouraging family and community support, (7) and by the provision of education and intervention services, support groups, and counseling as needed.

Substance abuse may not develop immediately after the traumatic event. It may not develop for 6-to-18 months - or even years after a traumatic event. In either case - from a prevention or a treatment perspective, educators and counselors both need to mitigate the effects of trauma - and do everything possible to minimize the use of substances after a traumatic incident.

DEFINING STRESS

Any true understanding of trauma and the effects of trauma must be based upon a solid understanding of stress. One definition of stress describes it as a powerful internal communication to raise awareness and increase energy.

Stress is triggered by excessive internal, external or environmental demands or stimulation. The experience of stress can be looked upon as existing on a continuum from mild stress to traumatic stress. Mild stress stimulates the central nervous system, the immune system, the adrenal system and the cardiovascular system and results in increase of blood flow to major organs and muscles, neurotransmitter release, and production of CRF hormone. The effect on the body is increased concentration, energy and memory. Mild stress therefore can result in increased performance and efficacy.

Prolonged stress however, can deplete the body’s capacity and result in negative consequences. It seems to impair the immune system's capacity to respond. Prolonged stress not only makes people more vulnerable to catching illnesses but can also impair their immune system's ability to respond to its own anti-inflammatory signals that are triggered by certain hormones, possibly altering the course of an inflammatory disease.

http://www.apa.org/releases/chronicstress.html Traumatic stress is stress resulting from exposure to, or witnessing of events that are severe and/or life threatening. The extent of traumatic stress experiences varies by duration of exposure and number of exposures. Additionally, the amount of stress incurred will vary according to the availability of resources and coping skills.

DEFINING TRAUMA

Individuals who have experienced a traumatic event often suffer psychological stress related to the incident. In most instances, these are normal reactions to abnormal situations. Individuals who feel they are unable to regain control of their lives, or who experience the following symptoms for more than a month, should consider seeking outside professional mental health assistance. A traumatic event is defined by psychiatric professionals as "an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of self or others."

CATEGORIES OF TRAUMATIC EVENTS / RESULTING TYPES OF TRAUMA

Traumatic events are often referred to as disasters or crises. Such events that are considered traumatic fall into two general categories: natural and man-made.

Natural crises include those disasters that are created by the forces of nature such as tornados, hurricanes, fires, earthquakes, floods, and tsunamis. These disasters may be unpredictable or there may be some advance notice giving people time to take precautions or vacate. Natural disasters are generally considered "uncontrollable" in terms of their occurrence although there may be some control over their impact.

Man-made disasters or crises include building/structural collapse, medical/food tampering, chemical attacks/dispersement, ethnic cleansing, riots and wars, suicide, murder, and crime and violence. When the cause is viewed as man-made, the reactions may be more emotionally devastating. This is likely because the disaster is viewed as within the control of individual persons, and therefore avoidable. It is not only the acts themselves, but the threat of these acts which may have psychologically traumatizing impact. Society at large is at risk due to close proximity of persons in public and working spaces such as office buildings, public transportation and public events. Globally, especially since the events of 9/11, people around the world have begun to see themselves as vulnerable.

TRAUMA, STRESS, AND SUBSTANCE ABUSE

The fact that there is a connection between trauma and substance abuse has been known for decades. The stress-reduction model of substance abuse posits that the distress experienced by trauma is either managed or "self-medicated" by some people by intake of alcohol, tobacco, or other drugs.

In fact, stress - and especially trauma - is considered a major contributor to substance abuse initiation, continuation, and relapse. Studies have consistently shown that there is a greater likelihood of alcohol and drug abuse when stress is high, and now research supports the theory that trauma is one of the pathways into addiction.

Survey results (funded by grants from NIDA) demonstrated increases in the use of tobacco, alcohol, and marijuana among the residents of Manhattan five to eight weeks after the terrorist attacks on the World Trade Center (WTC).

Research demonstrated that in the 4-to-8 month post-trauma period after the Oklahoma City bombing, it was found that 16% of Oklahoma City bombing survivors had used alcohol to cope, and 40% used medication to cope.

Estimates of lifetime substance abuse are from 21% to 43% for persons with PTSD (for persons without PTSD, lifetime substance abuse is estimated from 8% to 25%.)

Men and women reporting sexual abuse have higher rates of alcohol and drug use disorders than other men and women; twenty-five to seventy-five percent of those who have survived abusive or violent trauma also report problems with alcohol use; and ten to thirty-three percent of survivors of accidental, illness, or disaster trauma report problematic alcohol use, especially if they are troubled with persistent health problems or pain. In other research sexual abuse in childhood was found to be the strongest predictor of later alcohol and drug abuse.

In a research document called "Stress and Substance Abuse: A Special Report," the NIDA highlighted numerous studies elucidating a scientific basis for the clinical observations that people exposed to stress, stressors and life crises are likely to abuse alcohol and other drugs, and are more vulnerable for self-administration. High stress was found to be predictive of continued drug use, and stress was found to be the number one cause of relapse for recovering individuals.

SUBSTANCE ABUSE IS CONTRA-INDICATED

Self-medication with substances is contra-indicated for survivors of trauma. Use of alcohol, cigarettes, street drugs or a mis-use of prescription drugs is a negative coping mechanism. While it seems to provide some immediate relief from either anxiety or pain, in reality it complicates and confounds the healing and recovery process:

     o First, substance use only provides temporary relief, if any at all; it often blocks necessary psychological processing and can prevent or delay the natural completion of the grieving process;

     o Second, it often results in lower functioning capacity resulting in poor choices and poor decisions and even behavioral dysfunction;

     o Third, rather than calming nerves, alcohol and other drugs can actually increase both anxiety and fears, they intensify and exaggerate emotions so they come out drug-affected... and long term use can even cause emotional stagnation;

     o Substances can disrupt sleep, especially stage four or deep sleep, and they can increase nightmares and make them more vivid and believable.

     o A person who abuses substances can easily be re-traumatized because of impaired decision making, furthering a use-abuse-trauma-use cyclical dynamic.

Even the most minor use of these substances, unless by physician’s prescription and under a strict medical protocol, can actually make the symptoms of trauma -- especially the more severe symptoms associated with Post Traumatic Stress Disorder -- much more serious.

The healing process is most effective when done in the company of safe, supportive others, and not with the use of substances.

TYPES OF TRAUMA

In general, trauma includes the following types:

Natural Disasters - Includes natural disasters such as tornados, hurricanes, fires, earthquakes, typhoons, floods, and tsunamis. These disasters may have low predictability (such as fires and earthquakes) or there may be some advance notice giving people time to take precautions or vacate. The occurrence of natural disasters is generally considered to have no or little controllability although there may be some control over impact.

Personal Loss - The most prevalent type of trauma is that of the loss of a person who has played a key role in the person’s life. Losses may also include pets, jobs, or any familiar object or environment. This includes loss due to death, divorce, and separation. Separations can be marital, parental, siblings, or other important support persons. Intensity of this trauma varies by the intensity of the relationship with the person, object, or life situation. Repeated personal losses without sufficient recovery time complicates and intensifies the reaction.

Health Trauma - Includes trauma due to the onset of a disability or illness.

Victimization - A physical or emotional trauma that results from abuse or neglect. This includes: physical abuse, sexual abuse, and neglect. Victimization can be repeated, prolonged, or a single event. These may subject the individual to a prolonged period of perceived or actual life threatening situations which increases the intensity of the event. Victims may blame themselves for behaviors prior to or during the trauma, increasing the perception of controllability.

Criminal Violence - Victims are subjected to an individual event such as robbery or homicide, and criminal assault in which they experienced a lack of control over their belongings and/or bodies and may be subjected to a life-threatening situation. Re-victimization may compound reactions.

Wars and Terrorism - These are intense, massive in scale, and long term in nature, exposing victims to repeated life-threatening situations. Additionally, persons may have engaged in perpetuating violence against others. This may intensify the response to trauma because the perpetration can be seen as counter to the self-image. It may be particularly distressful if it comes to be viewed as an unavoidable and uncontrollable occurrence.

COMMON REACTIONS TO TRAUMA

Everyone reacts to trauma. Both the mind and body react to the experience of crisis. These reactions in general can best be described as: 1) physical reactions, 2) affective reactions, 3) cognitive reactions, and 4) behavioral reactions.

Physical Reactions to Trauma: Immediate reactions of the body are attempts to provide the body with increased attention, energy, and strength. The expenditure of the body’s resources takes a toll which can lead to physical exhaustion and physical problems.

Common physical reactions may include: vascular changes (increased blood flow); cardio-vascular changes (increased heart rate); increase in adrenalin; gastro-intestinal problems (diarrhea, constipation, nausea); allergies; skin rashes; somatic complaints (headaches, body aches, muscle aches); and fluctuations in blood pressure.

Affective Reactions to Trauma: These reactions encompass the emotional responses to trauma. Frequently a sense of shock or numbness is noted as an initial emotional reaction: anxiety, denial, helplessness, panic, anger, numbness, diminished sense of being, emptiness, lack of enjoyment, shock, fear, hopelessness, despair, frustration, survivor guilt, uncertainty, overwhelmed, lack of enjoyment.

Cognitive Reactions to Trauma: These reactions include the thinking about trauma or the level of capacity to think in an effective manner: poor attention span, flashbacks, nightmares, impaired judgment, self-blame, confusion, diminished concentration, difficulty in decision-making, impaired memory, sense of powerlessness, obsessive thoughts or memories.

Behavioral Reactions to Trauma: These reactions are related to actions taken or avoided during trauma: irritability, unresponsiveness, over-protectiveness, sleep disturbances, withdrawal, eating disturbances, anger outbursts, crying, diminished levels of activity, exaggerated startle response, communication change, alcohol and/or drug abuse, antisocial acts, disorganization, hyper-arousal, change in sexual behavior, excessive use of sick leave, hysterical reactions, isolation from others, fatigue, neglect of health and daily activities, avoidance of situations.

THE PREVENTION OF TRAUMA-RELATED SUBSTANCE ABUSE

Stated simply, there are three levels of recovery from trauma. People will ultimately stay the same, get better, or become worse. While most persons will have decreased functioning for a period of time following a traumatic event, they often return to their former level of functioning after 18-to-24 months.

As prevention providers, there are two distinct goals to strive for:

     (1) to mitigate the negative effects after experiencing a traumatic event, and

     (2) to reduce the probability of the use, abuse or misuse of substances after a traumatic event.

To accomplish these, there are three universal objectives :

     (1) use a holistic prevention framework, that is: promoting health-enhancing behavior and reducing health-compromising behaviors to be supportive of, or contribute to a post-trauma elevated self level.

     (2) to return persons (at least) to the pre-trauma level of functioning; 

     (3) to prevent the onset of substance use, or relapse into active addiction..

In this regard, research clearly demonstrates the primary tools of prevention are: (1) teach positive coping skills; (2) foster (internal) resiliency characteristics; (3) enhance protective factors (including family, friends and support groups), (4) reduce risk factors, (5) encourage personal growth, self-actualization and spirituality, (5) and most importantly, develop and integrate effective substance abuse educational program(s) and/or intervention program(s) for the population defined as survivors of trauma.

FACT SHEET: TIPS FOR HELPING ADULTS AS VICTIMS OF TRAUMA

The following are findings that can help you to cope with the physical and emotional distress you may be experiencing as the result of a traumatic incident.

Avoid the use of drugs or alcohol, including over-the-counter drugs to numb the pain. It can exacerbate distress and complicate or delay your recovery. Take prescription medicine only as recommended.

Use this as an opportunity to strengthen the connection or to reconnect with your church or synagogue or mosque, with friends and family, and with other community resources that can be a very valuable source of support. Don’t isolate yourself... reach out instead!

Eat balanced and regular meals as much as possible, even if your don’t feel like it. Good nutrition is very important when you are feeling stressed. Try to also regulate your sleep into a regular, balanced routine.

Exercise regularly within your ability. It can help work off some physical stress symptoms, leaving you feeling calm and better able to relax. If you are feeling lethargic, it can help energize you and clear your mind.

Structure your time and set priorities. Maintain your basic routine, but give yourself permission to skip the extras for a while.

Don’t make any major life changes or decisions. Do make as many small daily decisions as possible to reassert your sense of control.

Don’t try to avoid or deny reoccurring thoughts or feelings about the incident even negative feelings. They are normal and talking about them with people who understand and support you will help them decrease over time.

Do things you enjoy -- find hobbies. Take mini-breaks, go-out to dinner, take ten minutes alone on a walk, tune into nature, watch a movie, creative arts, pets, music, massage, etc.

Talk with people you trust: your family, friends, co-workers. Don’t be afraid to reach out. But don’t be afraid to set limits with others when you don’t feel like talking. You don’t have to discuss the incident or your feelings when you don’t want to.

Don’t label yourself as "crazy." Remember that you are having normal reactions. Write down your thoughts and feelings. This can be especially helpful if you have trouble sleeping or when you wake from a troubling dream.

Put things in proper perspective. Many people suffer a traumatic event at some point in their lives. But there is hope for recovery - for a future that is bright and healthy although different. Many have survived and overcome difficulties of enormous magnitude, and have demonstrated both gratitude and greatness as a result of their pains, struggles and difficulties.

Identify positive coping skills that you have used in the past to deal with other crises or trauma and use them.

Ask for help when you need it. If you are having trouble coping on your own, help is available from many sources. In the workplace, you may be able to get assistance from your co-workers, the human resources department, or the company Employee Assistance Program. For others, professional assistance from a counselor may sometimes be necessary. Finally, there are many community-based support groups - for bereavement, for cancer survivors, for the divorced or separated, for single parents, etc. This does not imply weakness or "inability to handle my problems." Simply, we all do better with a little help from our friends!

FACT SHEET: TIPS FOR HELPING CHILDREN AS VICTIMS OF TRAUMA

Children are just as affected as adults by a disaster or traumatic event. As with adults, the extent of effects falls along a continuum. Without intending to, we, as parents, may send our children a message that it is not all right to talk about the experience. This may cause confusion, self-doubt, and feelings of helplessness for a child. Children need to hear that it is normal to feel frightened during and after a disaster or traumatic event. When you acknowledge and normalize these feelings for your children, it will help them make peace with their experience and move on.

Following exposure to a disaster or traumatic event, children are likely to show signs of stress. Signs include sadness and anxiety, outbursts and tantrums, aggressive behavior, a return to earlier behavior that was outgrown, stomachaches and headaches, and an ongoing desire to stay home from school or away from friends. These reactions are normal and usually do not last long. Whether your child is a preschooler, adolescent, or somewhere in between, you can help your child by following the suggestions below:

Preschooler

     o Stick to regular family routines.

     o Make an extra effort to provide comfort and reassurance.

     o Avoid unnecessary separations.

     o Permit a child to sleep in the parents' room temporarily.

     o Encourage expression of feelings and emotions through play, drawing, puppet shows, and story telling.

     o Limit media exposure.

     o Develop a safety plan for future incidents.

Elementary Age Children

     o Provide extra attention and consideration.

     o Set gentle but firm limits for acting out behavior.

     o Listen to a child's repeated telling of his/her trauma experience.

     o Encourage expression of thoughts and feelings through conversation and play.

     o Provide home chores and rehabilitation activities that are structured, but not too demanding.

     o Rehearse safety measures for future incidents.

     o Point out kind deeds and the ways in which people helped each other during the disaster or traumatic event.

Pre-adolescents and Adolescents

     o Provide extra attention and consideration.

     o Be there to listen to your children, but don't force them to talk about feelings and emotions.

     o Encourage discussion of trauma experiences among peers.

     o Promote involvement with community recovery work.

     o Urge participation in physical activities.

     o Encourage resumption of regular social and recreational activities.

     o Rehearse family safety measures for future incidents.

It is important to remember that you do not have to "fix" how your child feels. Instead, focus on helping your child understand and deal with his or her experiences. Healing is an evolving state for most children, but some may need professional help.

If signs of stress do not subside after a few weeks, or if they get worse, consider consulting a mental health professional who has special training in working with children. In time and with help, your children will learn that life does go on.