In my last post, I looked at cognitive scripts and the concept of stuckness. In this post, I’ll look more closely at how this concept is particularly relevant to youth with a history of trauma, abuse or neglect.
More than eight million American children suffer from serious, diagnosable trauma-related mental health problems (Perry & Szalavitz, p. 3); adolescents with impaired stress response systems resulting from long-term traumatic exposure are most likely to develop ongoing, significant drug problems (Perry & Szalavitz, p. 189) and other mental health problems (Perry & Szalavitz, p. 246). Additionally, surveys of adolescents receiving treatment for substance abuse found that more that 70% reported a history of trauma exposure, while other studies have found that 57% of adolescents in treatment come from homes where violence occurred frequently, and 40% reported being physically abused (Lawson & Lawson, p.176).
These statistics clearly show that there is a strong connection between substance abuse and a history of traumatic stress. In addition to substance abuse, adolescents with such histories often turn to a number of potentially destructive behaviors in an effort to avoid or defuse the intense negative emotions that accompany this traumatic stress. These behaviors often include engaging in risky sexual behaviors, self-mutilation, bingeing and purging, and suicidal behaviors. This serve to further traumatize these youth, reinforcing their already maladaptive cognitive scripts. Understanding the connection between substance abuse, trauma, and this cascade of chaos is important if we wish to assist our clients in moving forward.
Trauma in Early Childhood
As I’ve written before, nearly all my clients have predictable cognitive scripts. This is especially true with trauma survivors. When faced with even small life challenges, these youth predictably act up, shut down, or use. Hebb wrote, “…any two cells or systems of cells that are repeatedly active at the same time will tend to become ‘associated,’ so that activity in one facilitates activity in the other” (qtd. in Siegel, p. 26). In other words, “Experience, gene expression, mental activity, behavior, and continued interactions with the environment are tightly linked in a transactional set of processes” (Siegel, p. 19).
These processes begin at birth. Repeated similar experiences lead the mind to make generalized representations that form the basis of mental models used to “interpret present experiences as well as anticipate future ones” (Siegel, p. 29-30), suggesting that an individual is most likely to respond to life events in standard, predictable and learned ways.
Perry and Szalavitz stated that repeated activation of the stress response system cleads to “a cascade of altered receptors, sensitivity, and dysfunction” (p. 24). In other words, over-activation of a system can result in becoming over-reactive, or they as described it “sensitized” (Perry & Szalavitz, p. 36). A common causation of this sensitized state is childhood neglect, abuse and other early childhood trauma. In these cases, that trauma becomes part of the individual's mental models. In other words, traumatic stress leads to the expectation of more traumatic stress, which becomes a self-fulfilling prophecy. After all, expecting stress is stressful all by itself.
When individuals exposed to childhood trauma move into adolescence, they face a new cascade of problems. These can include a higher incidence of mental health disorders, school-related concerns, placement in separate classes, and increased association with peers who exhibit similar maladaptive issues. This cascade of problems frequently results in youth with limited academic success, a continued escalation of behavioral problems, social marginalization, interactions with deviant peers, and a significantly increased likelihood of substance abuse. In addition, the neurobiological changes cataloged above increase the likelihood of developing anxiety disorders (Romer & Walker, p. 350) and substance-related problems (Romer & Walker, p. 446).
Simply put, not only are these youth stuck with maladaptive cognitive scripts, they are these stuck in a seemingly endless cascade of chaos. For these adolescents, school failure, negative peer relations, environmental stressors, mental health disorders, and substance abuse are all likely to co-evolve. An additional factor in this co-evolution is brain development. For an adolescent already suffering the negative impacts from early childhood trauma, the additional impact caused by these environmental problems would likely contribute to his cascade of problems.
A former client, “Andrew,” illustrates this. By the age of three, Andrew’s parents were both heroin dependent and the family lived in a car. It is reasonable to make two assumptions here. First, the environmental stressors caused by addicted parents and homelessness had already negatively impacted Andrew's brain development. Second, with both parents heroin dependent, Andrew likely had a genetic predisposition for addiction.
At age four, Andrew witnessed the death-by-overdose of both parents. With no relatives to provide care, he entered the foster care system. Between four and 15 he had over a dozen different placements. Andrew reported, “I moved around so much that I didn’t even unpack my suitcase.” Not surprisingly, his behavior became increasing problematic. He reported first use of alcohol at age 10 and first use of marijuana shortly thereafter. At 13 he went to detention for the first time. At 15, he ran away from the group home where he was living.
When I met Andrew, he was 16 years old and had just moved into a shelter after being homeless for almost a year. He reported two recent physical assaults and had mental health diagnoses that included PTSD, Conduct Disorder, ADHD and Major Depressive Disorder. He also had diagnoses for Alcohol Dependence, Cannabis Dependence, Opiate Abuse, and Amphetamine Abuse. In addition, Andrew exhibited difficulty remembering details, time frames, and other factual information. Andrew reported using because “it makes me feel normal,” even though he acknowledged amphetamines made him “jittery and paranoid.” With a blank look he continued, “I guess jittery and paranoid is my normal.”
Being Stuck
Working with teens that have co-occurring disorders, I see a lot of clients with a history of trauma. Like Andrew, these adolescents frequently appear to be stuck in an endless cascade of chaos. Here are two additional examples:
• “Carl” is 16 and a convicted felon for multiple car thefts. He suffered physical and emotional abuse from his father starting around age four. At age six his mother died. All three older brothers have drug problems; two of them are currently in jail. Carl has diagnoses of Cocaine Dependence, Cannabis Abuse, Alcohol Abuse and PTSD.
• “Melissa” is 15. She grew up subjected to significant neglect at the hands of her mentally ill mother and was sexually abused by several of her mother’s boyfriends. In addition to diagnoses of Amphetamine Dependence, Alcohol Abuse and Cannabis Abuse, Melissa has a history of disordered eating, suicidal ideation and self-harming behaviors.
Most of my clients don’t have histories as intense as Andrew, Carl or Melissa. however, the majority of them have experienced neglect, parental substance abuse, or other traumatic stress. In my experience, the more severe the history of trauma, the more likely the client will be using stimulants. Stimulants replicate trauma by releasing dopamine and noradrenaline, which are released during the hyper-arousal response. “Brain changes related to hyper-arousal may make some trauma victims more prone to stimulant addiction” (Perry & Szalavitz, p. 190). If this is so, then are these adolescents attempting to recreate the feeling of trauma from their pasts? This likely isn’t their overt intention. However, as Melissa said, “I only feel normal when I’m on meth.” Her brain has changed to make this hyper-arousal her normal state of being.
Melissa’s entire life has contributed to a trauma-focused development of her brain. By using meth, she artificially stimulates the production of those neurotransmitters that she has physically become accustomed to being present. For Melissa and others, perhaps the absence of stress-induced neurotransmitters should be considered a type of withdrawal. Perhaps, these youth are using stimulants to avoid withdrawal caused by a decrease in their accustomed levels of dopamine and noradrenaline caused by the past trauma.
Likewise, perhaps the extreme behavior many of these youth engage in—auto theft, prostitution, drug dealing, risky sex, graffiti, running away, assault, and more—is also a way to increase levels of dopamine and noradrenaline, thereby avoiding withdrawal from stress-related neurotransmitters.
For years I have referred to these clients as “chaos junkies”—a term these youth readily understand and frequently acknowledge as true—but always thought of this as a psychologically based behavioral pattern, a repeating of life strategies that had been modeled in chaotic family environments. Could there be something more happening here? Could these youth actually be physically addicted chaos? More accurately, could these youth be physically dependent upon the chemicals released as a result of the stress caused by their chaotic lifestyles and environments?
This isn’t true for all my clients, but I definitely believe some of them—such as Carl, Melissa and Andrew—are addicted to the cascades of chaos in their lives. If our goal as a substance abuse counselors is to help these adolescents create more adaptive cognitive scripts, then part of my work must to help them resolve their addictions to chaos.
In my experience, teens without a history of significant trauma do not typically identify stimulants as a drug of choice. They may have tried meth, crack or Ecstasy, but only in limited amounts. In fact, it seems to me that stimulant dependence or abuse in adolescents could be considered indicative of trauma. Unfortunately, for these youth, this sign—as well as others—is often missed. Andrew, Melissa, and Carl all came into treatment with long lists of diagnoses such as Conduct Disorder, Major Depressive Disorder, Bipolar Disorder, and Attention Deficient-Hyperactivity Disorder, among others.
While it is possible that those other issues might be present in some cases, without addressing their obvious trauma-laden histories that positive growth seems unlikely. Acknowledging, understanding and addressing the traumatic histories of these youth allows for the possibility of getting unstuck. First, though, it is important to further explore why these youth stay stuck.
Staying Stuck
Thus far, I’ve looked at traumatic experiences as causal pathway for substance abuse in adolescents. While this appears to be the primary causal pathway among adolescents and adult, it is possible for substance abuse to lead to trauma. For Melissa, prostitution helped pay for her expensive drug habit of meth and cocaine. It also led to multiple sexual assaults. For Carl, a severe lack of impulse control and untreated Attention Deficient-Hyperactivity Disorder was at the root of repeated auto thefts, high-speed car chases with the police, and stimulant dependence. It also led to repeated jail sentences. For Andrew, drug dealing supported his substance abuse. It also led to several physical assaults.
These high-risk behaviors clearly re-traumatize the youth. In other cases, such high-risk behavior could be the causation of the initial trauma. Either way, it is easy to see that these youth are stuck. As stated already, Andrew currently lives in a group home. This group home has a drug testing policy and continued use will result in him losing his placement. Yet, he continues to use. Some chemical dependency counselors would say Andrew is in denial, or maybe he’s resistant to treatment, but either way until he “hits his bottom” nobody will be able to help him.
I believe this assessment of Andrew is both simplistic and pessimistic, and so I offer a different analysis: Andrew is not resistant and he is not in denial. In fact, he readily acknowledges the problems in his life. But, he is stuck. His lifelong cascade of problems has impacted his brain’s architecture in ways that have shaped his behavior and determined his cognitive scripts. Andrew knows no responses to his world but acting up, shutting down or using. Furthermore, I believe his brain is not physically capable of making other choices. Helping Andrew become unstuck requires discovering ways to assist him create, practice and then apply more adaptive cognitive scripts.
Writing New Scripts
Evans and Sullivan wrote, “Survivors frequently have excellent artistic abilities, a reflection of their extensive use of right-hemisphere survival strategies” (p. 143). If this is true, then experiential learning—including initiatives, games, art therapy, music therapy, games, and other activities—could be a vital clinical approach for working with trauma survivors. Ross and Bernstein support this conclusion. They wrote, “[G]ames and activities offer youth a workshop for discovering and developing new ways to manage obstacles” (qtd in Rose, p. 24).
Active, experiential learning achieves this goal by not only providing participants the opportunity to try new behaviors, but to also practice them in a safe, supportive environment. In addition, these interactive approaches provide opportunities to increase problem-solving skills, self-efficacy and openness to taking good risks, so that the participants are willing to implement these newly developed, more adaptive scripts.
For adolescents struggling with both substance abuse and traumatic stress, remaining stuck in chaos is a safe, tempting possibility. Melissa stated once, “When I smoke weed, all the bad feelings go away. I don’t want to cut. I don’t want to purge. As long as I’m high, everything seems okay.” As we’ve seen, substance-related disorders and traumatic stress are frequently an intricate, co-evolving, cascading series of obstacles. Helping youth get unstuck from this loop requires challenging these adolescents to risk developing new cognitive scripts.
Works Cited
Lawson, G. & Lawson, A. (1992). Adolescent Substance Abuse. Gaithersburg, ME: Aspen Publishing.
Perry, B. & Szalavitz, M. (2006). Boy Who Was Raised as a Dog, The. New York: Basic Books.
Romer, D. & Walker, E. (2007). Adolescent Psychopathology and the Developing Brain. New York: Oxford University Press.
Rose, S. (1998). Group Therapy with Troubled Youth. Thousand Oaks, CA: Sage Publications.
Siegel, D. (1999). Developing Mind, The. New York: Guilford Press.
