This activity is often called “Minefield.” I’ve changed the title to something less violent and more treatment-oriented. Call it whatever seems appropriate for your group. This is one of my favorite group session activities. I love the metaphoric possibilities, the layers of meaning, and the fact that it works well in a small-ish group room.
Props: 3-4 blindfolds, about 10 sticky notes per participant, 2 lengths of tubular webbing (or rope), and as many obstacles as possible—tossables, rubber chickens, polyspots, inflated beach balls, whatever you’ve got.
Instructions: In advance, set up an obstacle course. At one end of the room, stretch out a length of webbing and at the other end stretch out the other webbing. The more space between start and finish, the more challenge involved in the activity. In between, distribute all the props (except the blindfolds) as obstacles.
Start off by briefly talking about obstacles to change, or recovery, or whatever is appropriate for your group. I think of this discussion as a chance to prime the pump, not exhaust the topic. Once a few obstacles have been identified and discussed, pass out about 10 sticky notes each and have the clients label each one with a different obstacle, preferably one that is true (or potentially true) for her or him.
Next, either 1.) Collect the sticky notes, briefly talk about the “interesting” ones, then use them to label the obstacles, or 2.) Have the clients label the obstacles themselves. Either way, look for potential metaphors. For example, in a substance abuse group, you are sure to get “using friends” as an obstacle, perfect to label beach balls. If bumped during the activity, the beach balls are likely to roll forward and be in the way again and again. Sound familiar?
There are lots of different ways to facilitate this activity. I prefer this variation, which minimizes instructions, maximizes client problem solving, and requires asking for help, often a challenge for teens in substance abuse treatment:
Explain the basics of the activity. I keep this very simple: The task is to get from the start to the finish line, while blindfolded, without touching any of the obstacles. Explain that if an obstacle is touch, there will be a setback of some sort.
Once the participants are aware of what they are agreeing to, ask for a volunteer willing to be blindfolded. Blindfold the participant, spin her a couple times, and then instruct her to start.
My clients (especially the ones most likely to volunteer to be first) will almost always attempt the task on their own. After a couple setbacks, the volunteer or another client will realize help is needed, a perfect opportunity to process in-the-moment. Sometimes, one person will become the helper; sometimes everyone will start shouting out directions, a real world parallel that my clients strongly relate to and another wonderful opportunity for in-the-moment processing! ("Everyone is always telling me what to do!")
The first time generally takes a while to complete because there are several issues to resolve—asking for help, improving the quality of help received, and both volunteer and other clients learning what kind of advice is useful. After the first volunteer has successfully completed the obstacle course, do it one or two more times. Next, have two or more volunteers go consecutively, alternating starting from opposite sides of the obstacle course.
Finally, consider moving the obstacles around. I usually do this only with the final participant, making barriers that have to be detoured around, then making another, and another. This sounds more mean that it is, because undoubtedly the helper or other observers will shout out what it happening and good spirited groups will enjoy the humor of it. Besides, my clients expect such things from me.
Comments: I present this activity as being about obstacles, but that’s something of a red herring. This activity is really about trust, support, and asking for help. Why not just frame it that way? Well, in my experience the self-discovery of needing help is much, much more powerful than me pairing the participants off into teams in advance.
Determine setbacks based on what is appropriate for your population. I usually have the participant answer a question relevant to the label, except if they touch a polyspot. I don’t use client labels for these. Instead, they are “relapses” and require the participant to start over.
I see activities like this one as opportunities for clients to practice real world skills. As such, I let them struggle with learning curves (i.e., I don’t suggest asking for help and I don’t suggest asking for only one person to provide that help). I also do these kinds of activities over multiple times, with a few variations along the way to keep things fresh, so that clients can improve their skills, and so they can even engage in some generalizing of those new skills.
Wednesday, November 24, 2010
Sunday, November 21, 2010
Perpetual Stuckness: The Role of Trauma in Adolescent Substance Abuse
According to the National Child Traumatic Stress Network (2008), one in four American teens will experience at least one potentially traumatic event by the age of sixteen. Although not all of these adolescents experience long-term traumatic exposure, those that do are highly likely to develop ongoing, significant drug problems and other mental health issues (Perry & Szalavitz, 2006).
In fact, in surveys of adolescents receiving treatment for substance-related disorders, more that 70% reported a history of traumatic exposure (National Child Traumatic Stress Network, 2008). The National Child Traumatic Stress Network (2008) also reported that up to 59% of all teens that warrant a diagnosis of post-traumatic stress disorder are likely to develop a co-occurring substance-related problem. As these statistics show, there is a clear and strong connection between substance abuse and a history of exposure to traumatic stress.
Adolescents can turn to a variety of potentially destructive behaviors in an effort to avoid or defuse the intense negative emotions that accompany traumatic stress. In addition to abuse of alcohol and other drugs, these behaviors can include sexual promiscuity, self-mutilation, bingeing and purging, and suicidality, among others (Perry & Szalavitz, 2006). In this paper, I shall examine the ways that trauma has shaped the cognitive scripts of substance abusing adolescents, resulting in these youth being “stuck” in cycles of maladaptive behaviors. As we shall see, these behaviors can frequently result in a state of perpetual stuckness.
Defining Cognitive Scripts
As a substance abuse counselor working with adolescents who have co-occurring disorders, I have observed that nearly all my clients with histories of traumatic exposure have predictable responses to stressful situations. These predictable responses can be thought of as cognitive scripts. 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, 1999, 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, 1999, p. 19). These processes begin at birth.
Repeated similar experiences lead the brain to make generalized representations that form the basis of mental models used to “interpret present experiences as well as anticipate future ones” (Siegel, 1999, p. 29), suggesting that an individual is most likely to respond to life events in standard, predictable, and learned ways. These mental models can be conceptualized as cognitive scripts. Cognitive scripts are learned. For an individual who experienced a positive childhood environment, these scripts will be generally adaptive and flexible. However, “multiple exposures to interpersonal trauma… have consistent and predictable consequences that affect the many areas of functioning” (van der Kolk, date unknown, p. 6).
Perry and Szalavitz (2006) wrote, “The systems in your brain that get repeatedly activated will change and the systems in your brain that don’t get activated won’t change” (p. 29). However, they also stated that repeated activation of the stress response system could lead to “a cascade of altered receptors, sensitivity, and dysfunction” (2006, p. 24). In other words, over-activation of a system can result in becoming over-reactive, or what they described as sensitized.
Herman (1992) referred to this state as hyperarousal. She wrote, “Hyperarousal reflects the persistent expectation of danger… After a traumatic experience, the human system of self-preservation seems to go onto permanent alert, as if the danger might return at any moment” (p, 35). For individuals who have been sensitized, or are in a state of hyper-arousal, their cognitive scripts have become focused on stress and survival.
In my experience, substance-abusing teens with complex trauma generally have two basic cognitive scripts for dealing with life problems or stressful situations. They act up or shut down. Their use of illicit substances may be part of either script. With such limited options, these teens have no choice but to rerun their same maladaptive scripts, perpetrating already internalized beliefs that they are ineffective, incapable, and destined to remain stuck. Eventually, acting up and shutting down become so normalized that they no longer see these responses as problematic.
Trauma, Abuse and Neglect in Early Childhood
Research indicates that adolescents who enter substance abuse treatment are more likely than their peers to have experienced childhood abuse, neglect, and other significant family problems (Riggs, 2003). In fact, studies have found that these types of early childhood trauma are reliable predicators for substance-related problems in both adolescents and adults" (Romer & Walker, 2007, p. 245).
Adversity in early life alters the development of neural systems in a manner that predisposes individuals to disease in adulthood,” both physical and psychiatric (Romer & Walker, 2007, p. 149). In addition, “childhood adversity, in the form of trauma, neglect, deprivation, or abuse, may be especially harmful during critical periods in brain development… External stressors impact the structure, organization, and activity of the CNS [central nervous system]” (Romer & Walker, 2007, p. 350).
Several laboratory studies on the impact of neglect and early childhood stress have been conducted on rats. “Maternal care [in rats] alters the expression of genes in brain regions that subserve emotional, cognitive, and endocrine responses to stress (Romer & Walker, 2007, p. 161). This conclusion comes from a study that tracked levels of maternal care based on exhibited licking and grooming behavior, both natural variations and imposed differences.
When less maternal licking and grooming occurred, the rat pups exhibited increased fearfulness, heightened HPA (hypothalamus-pituitary-adrenal) axis responses to stress, and reduced performances on tasks requiring sustained attention or declarative learning. This was especially true when the rat pups were under stressful conditions (Romer &Walker, 2007).
The HPA axis is a neural system activated by stress that is “sensitive to environmental challenges and is activated in response to physical and psychological factors that threaten homeostasis” (Romer & Walker, p. 265, 2007). When activated, a chain of events occurs that leads to the release of cortisol, a hormone that increases both blood pressure and blood sugar levels, as well as having an immunosuppressive action (Romer & Walker, 2007), helping assure a quick return to normal functioning following stressful events.
According to Siegel (1999), the hippocampus is “the major center for conscious, declarative, explicit memory processing” (p. 178). He wrote that high levels of stress, especially when severe or ongoing, blocks hippocampal functioning and can even lead to “neuronal death” (p. 50) and decreased hippocampal volume. In other words, trauma can lead to a brain that is less capable of effectively responding to the stress caused by trauma. When this occurs, adolescents have begun experiencing stuckness. As we will see these adolescents are also likely to have these neurological challenges further compounded by developmental debt.
Experiencing Developmental Debt
When individuals already exposed to childhood trauma move into adolescence, they often face a cascade of problems, including a higher incidence of mental health disorders, school-related concerns, placement in separate classes, and increased association with peers who exhibit similar maladaptive issues (Romer & Walker, 2007). Coping with external stressors such as these, not to mention the original traumatic experience or experiences, “overtaxes the available resources allocated for developmental tasks” (Gil, 1996, p. 9) likely leading to what I conceptualize as developmental debt.
According to Gil (1996), trauma “interrupts and disrupts the developmental process” (p. 22). The National Child Traumatic Stress Network (2008) reported that “delays in the developmental processes that would normally enable them [adolescents] to better consider the consequences of their behavior, to make more realistic appraisals of danger and safety, to moderate daily behavior to meet long term goals, and to make increased use of abstract thinking” (p. 16) are compromised by traumatic experiences.
When this occurs, normal developmental tasks go uncompleted. As this developmental debt accrues, the individual starts to fall behind in normal social, emotional, and cognitive progress. Herman (1992) wrote, “The experience of terror and disempowerment during adolescence effectively compromises the three normal adaptive tasks of this stage of life: the formation of identity, the gradual separation from the family of origin, and the exploration of a wider social world” (p. 6).
Teens with a history of trauma exposure often become so focused on day-to-day survival that the emotional and cognitive resources normally allocated to developmental tasks are simply unavailable (Gil, 1996). With each uncompleted developmental task, the individual falls farther behind, further increasing the likelihood of even more life problems (Riggs, 2003) and the possibility that these life problems will negatively impact multiple areas of his or her life.
Bronfenbrenner (1979) identified four dimensions of influence upon adolescents: family, school, peers, and work or play. When an adolescent experiences disruption in any of these dimensions, a ripple effect is likely to occur with negative impacts in the other worlds. For adolescent survivors of trauma, the likelihood of problems rippling out into in all four dimensions seems especially high, resulting in these adolescents moving ever deeper into a cycle of stuckness, where childhood adversities, school failure, negative peer relations, environmental stressors, mental health disorders, and substance abuse all start to co-evolve. For an adolescent already suffering the negative impacts on the brain due to early childhood stressors, the additional impact caused by this developmental debt would ever further contribute to his cascade of problems.
Jittery and Paranoid is My Normal
A former client, Andrew, effectively illustrates this co-evolution. Andrew’s parents were both heroin dependent and the family was homeless, living in a car. It is reasonable to make two assumptions at this point. First, the environmental stressors caused by addicted parents and homelessness had already negatively impacted his hippocampus and general brain development. Second, with both parents being heroin dependent, Andrew was born with a high genetic predisposition for addiction.
At age four, Andrew witnessed the death-by-overdose of both parents. With no relatives willing to provide care, he entered the foster care system. Between the ages of four and fifteen, he had over a dozen different placements. Andrew reported, “I was moved around so much that I stopped unpacking my suitcase.” Not surprisingly, his behavior became increasing problematic. He reported first use of alcohol at age ten and first use of marijuana shortly thereafter. At thirteen he went to detention for the first time. At fifteen, he ran away from the group home where he was living.
When I met Andrew at sixteen years old, he had just moved into a transitional living program after being homeless for almost a year. He reported two recent assaults and had mental health diagnoses that included post-traumatic stress disorder, conduct disorder, attention deficit/hyperactivity disorder, and major depressive disorder. I added additional diagnoses for alcohol dependence, cannabis dependence, amphetamine dependence, and opiate abuse. In addition, Andrew exhibited difficulty remembering details, time frames, and other factual information. He 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.”
Andrew clearly exhibited what the National Child Traumatic Stress Network (2008) defined as chronic trauma: “the experience of multiple traumatic events” (p. 14). The Network continued, "Complex trauma is a term used by some experts to describe both exposure to chronic trauma—usually caused by adults entrusted with the child’s care, such as parents or caregivers—and the impact of such exposure on the person. Children and adolescents who have experienced complex trauma have endured multiple traumatic events (such as physical or sexual abuse, profound neglect, or community violence) from a very young age" (p.15).
I propose that it is complex trauma that lead to Andrew’s cascade of problems and developmental debt described above. Erickson (cited in Gil, 1996) wrote that the primary developmental task for adolescents is to create a sense of ego identity. He stated that adolescents must create “some central perspective and direction, some working unity, out of the effective remnants of childhood and the hopes of anticipated adulthood” (cited in Gil, p. 45, 1996). For Andrew, this did not happen. He certainly had the ruins of childhood, but he had no direction and no hopes for adulthood. As a result, his already existent developmental debt may have been destined to deepen, resulting in the creation of an existential vacuum.
Frankl (2006) defined an existential vacuum as “a feeling of emptiness and meaninglessness” (p. 141). Such a vacuum is likely to lead to depression, aggression, and addiction (Frankl, 2006). In his autobiography of addiction, Sheff (2007) wrote, “Using is such a fucking ridiculous little circle of monotony. The more I use, the more I need to kill the pain, so the more I need to keep using. Pretty soon it seems like going back, facing all my shit, well, it’s just too goddamn overwhelming. I’d rather die than go through it” (p. 146).
Regarding his use, Sheff continued, “I don’t care. Isn’t that the greatest gift in the world—just not to care? I feel so grateful for it. That’s nothing I ever knew sober” (p. 60). It seems clear that Sheff’s addiction is an attempt to fill this his own existential vacuum, at least temporarily, even if in a maladaptive and unsustainable manner. I believe this is also true for most adolescent survivors with substance-related disorders.
Addicted to Chaos
Working with adolescents that have co-occurring disorders, I see a lot of clients with a history of complex trauma. Like Andrew, these adolescents often appear to be stuck in an endless cycle of chaos, often seemingly of their own making. 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 hyperarousal response. According to Perry and Szalavitz (2006), the brain changes related to hyperarousal “may make some trauma victims more prone to stimulant addiction” (p. 190).
Based on how stimulants affect the brain, it seems likely to me that stimulant use may be an attempt to recreate the feelings of trauma from the pasts. By using stimulants, adolescent trauma survivors may be attempting to artificially stimulate the production of those neurotransmitters that they have become physically accustomed to being present. Perhaps these individuals are, in fact, using stimulants to avoid withdrawal caused by a decrease in their accustomed level of dopamine and noradrenaline caused by their history of complex 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.
This type of risky behavior helps assure the perpetuation of chaos in the lives of these teens. Self-sabotaging behavior functions differently. In this case, when things are going well for these clients, they do something to create chaos or stress: the client about to graduate from an inpatient program acts out and has her graduation canceled; the court ordered client who cusses out a judge during a hearing; the client who gets arrested for dealing, but insists he did not use so his treatment should not be affected.
Self-sabotaging incidents such as these are fairly common among adolescents in substance abuse treatment. I have always attributed them to a mix of poor decision making skills, an unconscious desire to stay in counseling, and a fear of success. Perhaps, though, these behaviors should be viewed as relapses. In the above cases, the clients did not use drugs, but they certainly did get a jolt of stress-related neurochemicals.
For years I have referred to these clients as “chaos junkies”—a term most adolescent clients 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, another example of a maladaptive cognitive script. Could there be something more happening here, though? Could these youth be addicted to chaos? More precisely, could these youth be physically dependent upon the chemicals released due to the stress caused by complex trauma, chaotic lifestyles, and unhealthy environments?
If this is true, then I believe these individuals are not simply stuck in chaos. Rather, their brains have become wired in such a way that they are now creating their own trauma.
Perpetual Stuckness
Thus far I have examined traumatic experiences as causal pathway for substance abuse in adolescents. While this appears to be the primary causal pathway, it is also possible for substance abuse to lead to trauma (National Child Traumatic Stress Network, 2008). As we have already seen, it is not uncommon for substance-abusing youth to engage in high-risk behavior such as prostitution or drug dealing.
For Andrew, drug dealing supported his substance abuse. It also led to several physical assaults and to him being the perpetrator of violence. Andrew also acknowledged frequently trading sex for drugs and engaging in various criminal activities. High-risk behaviors such as those seen with Andrew can serve to re-traumatize these adolescents. In other cases, such high-risk behavior could be the cause of the initial trauma (National Child Traumatic Stress Network, 2008). Either way, these adolescents find themselves in a cycle of stuckness.
Paradoxically, even though risky behavior is evident in the lives of most adolescents with complex trauma, these teens are generally risk-adverse. Indeed, it seems possible that their risky behaviors are often ineffective attempts to avoid risk. In my experience, youth that engage in high-risk activities can be so distracted by these behaviors that they simply do not have time to think about their past trauma.
On the other hand, adolescents obsessed with safety often resort to substances and other maladaptive, risky methods of finding it. Still other teens lead lives that are so constricted that they barely even participate in existence. For these cases, trauma has “cast the victim into a state of existential crisis” (Herman, 1992, p. 51) where all choices lead to further stuckness.
Jon, a client with a significant trauma history, vividly described his existential crisis caused by intrusion. “Lots of times I feel like I’m living in some kind of black hole. I’m alone, but not really, because everything is there, because I just can’t escape shit, ever, no matter how much I try. It’s black, because that’s what black holes are, right? But, black is really all the colors at once, every single fucking one of them. And that’s too many colors if you ask me.” Being faced with all the colors at once immobilized Jon in a dark, lonely, constricting vacuum.
Herman (1992) wrote, “By avoiding any situation reminiscent of the past trauma, or any initiative that might involve future planning and risk, traumatized people deprive themselves of those new opportunities for successful coping that might mitigate the effect of the traumatic experience” (p. 47). Many adolescents avoid those past experiences by escaping into addiction. While escape may temporarily possible, as we saw with Sheff’s statement, it ultimately only perpetuates the problem, because the only escape is into an existential vacuum filled with all colors.
For adolescent survivors, it is likely that few adaptive cognitive scripts were ever modeled. Through modeling or other methods, an individual learns a certain response and starts putting that behavior into practice. As we have seen, if an individual repeats the behavior enough times, it becomes an integrated part of that person’s cognitive scripts. This is, of course, the basic idea of brain development: “Neurons that fire together wire together” (Siegel, 1999, p. 26). For these teens, what has wired together is inherently problematic.
Rose (1998) wrote that most youth with life problems “seem to have dedicated and rigid strategies of dealing with problems and are disinclined to look at other possibilities” (p. 177). These rigid strategies have been born from a life of traumatic stress. Looking at other possibilities requires a willingness to try something new, to take risks, and as we have seen, these adolescents are—at their core—risk adverse. For a teen who has had much unpredictability, even the most painful known option can feel far less risky than any unknown one. For adolescents like Andrew and Jon, who have had lives filled with traumatic stress and unpredictability, even the most painful known option can feel fall less risky than any unknown one. Andrew said it this way: “What I like about shooting [meth] is that I know what to expect. I use. I get high. No surprises.”
Chemical Constriction
Andrew stated once, “When I smoke weed, all the bad feelings go away. I don’t want to do stupid shit. I don’t want to think about the past. I don’t care about the future. As long as I’m high, everything’s gonna be okay.” This statement by Andrew perhaps points to a simple truth for these adolescent survivors of complex trauma. Ultimately, substance abuse is a form of constriction.
A vacuum filled with all the colors is overwhelming, but a vacuum filled with no thoughts can seem promisingly safe. Herman (1992) wrote, “When the victim has been reduced to a goal of simple survival, psychological constriction becomes an essential form of adaptation. This narrowing applies to every aspect of life—to relationships, activities, thoughts, memories, emotions, and even sensations” (p. 87).
While in treatment, Andrew lived in a group home with a drug testing policy. Continued use could have resulted in losing his placement. Yet, he continued. Some chemical dependency counselors would say Andrew was in denial, or perhaps resistant to treatment. I believe such an assessment would be both simplistic and pessimistic, and so I offer a different possibility: Andrew was not resistant and was not in denial. In fact, he readily acknowledged the problems in his life, including his addiction. He was, however, stuck. His lifelong cascade of problems had impacted his brain’s architecture in ways that had shaped his behavior, determined his cognitive scripts, and assured his stuckness.
Andrew was incapable of making more adaptive choices. His brain was not physically able to complete such a task. Does that mean he was beyond help? I do not believe so. For adolescents like Andrew and Jon, remaining stuck is a safe, tempting possibility, but it is not destiny. Substance-related disorders and complex trauma are frequently an intricate, co-evolving, cascading cycle of stuckness. Helping adolescents overcome this stuckness requires challenging them to risk developing new cognitive scripts, so that they are able to move beyond their perpetual stuckness and see all the colors, not just black.
References
Frankl, V. (1984). Man’s Search for Meaning. New York: Simon and Schuster.
Herman, J. (1992). Trauma and Recovery. New York: Basic Books.
Gil, E. (1996). Treating Abused Adolescents. New York: Guilford Press.
National Child Traumatic Stress Network (2008). Adolescents and Substance Abuse. Retrieved October 5, 2010, from http://www.nctsnet.org/ncct/nav.do?pid=ctr_top_adol
Perry, B. & Szalavitz, M. (2006). The Boy Who Was Raised as a Dog. New York: Perseus Books Group.
Riggs, P. (2003) Treating Adolescents for Substance Abuse and Comorbid Psychiatric Disorders. Science & Practice Perspectives, 18-28. Retrieved October 5, 2010, from www.drugabuse.gov/PDF/Perspectives/vol2no1/03Perspectives-Treating.pdf.
Romer, D. and Walker, E. (Eds.). (2007). Adolescent Psychopathology and the Developing Brain. New York: Oxford University Press.
Rose, S. (1998). Group Therapy with Troubled Youth. Thousands Oaks, CA: Sage Publications.
Sheff, N. (2007). Tweak. New York: Simon and Schuster.
Siegel, D. (1999). The Developing Mind. New York: Guilford Press.
Van der Kolk, B. (n.d.). Developmental trauma disorder: A new, rational diagnosis for children with complex trauma histories. Psychiatric Annals.
In fact, in surveys of adolescents receiving treatment for substance-related disorders, more that 70% reported a history of traumatic exposure (National Child Traumatic Stress Network, 2008). The National Child Traumatic Stress Network (2008) also reported that up to 59% of all teens that warrant a diagnosis of post-traumatic stress disorder are likely to develop a co-occurring substance-related problem. As these statistics show, there is a clear and strong connection between substance abuse and a history of exposure to traumatic stress.
Adolescents can turn to a variety of potentially destructive behaviors in an effort to avoid or defuse the intense negative emotions that accompany traumatic stress. In addition to abuse of alcohol and other drugs, these behaviors can include sexual promiscuity, self-mutilation, bingeing and purging, and suicidality, among others (Perry & Szalavitz, 2006). In this paper, I shall examine the ways that trauma has shaped the cognitive scripts of substance abusing adolescents, resulting in these youth being “stuck” in cycles of maladaptive behaviors. As we shall see, these behaviors can frequently result in a state of perpetual stuckness.
Defining Cognitive Scripts
As a substance abuse counselor working with adolescents who have co-occurring disorders, I have observed that nearly all my clients with histories of traumatic exposure have predictable responses to stressful situations. These predictable responses can be thought of as cognitive scripts. 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, 1999, 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, 1999, p. 19). These processes begin at birth.
Repeated similar experiences lead the brain to make generalized representations that form the basis of mental models used to “interpret present experiences as well as anticipate future ones” (Siegel, 1999, p. 29), suggesting that an individual is most likely to respond to life events in standard, predictable, and learned ways. These mental models can be conceptualized as cognitive scripts. Cognitive scripts are learned. For an individual who experienced a positive childhood environment, these scripts will be generally adaptive and flexible. However, “multiple exposures to interpersonal trauma… have consistent and predictable consequences that affect the many areas of functioning” (van der Kolk, date unknown, p. 6).
Perry and Szalavitz (2006) wrote, “The systems in your brain that get repeatedly activated will change and the systems in your brain that don’t get activated won’t change” (p. 29). However, they also stated that repeated activation of the stress response system could lead to “a cascade of altered receptors, sensitivity, and dysfunction” (2006, p. 24). In other words, over-activation of a system can result in becoming over-reactive, or what they described as sensitized.
Herman (1992) referred to this state as hyperarousal. She wrote, “Hyperarousal reflects the persistent expectation of danger… After a traumatic experience, the human system of self-preservation seems to go onto permanent alert, as if the danger might return at any moment” (p, 35). For individuals who have been sensitized, or are in a state of hyper-arousal, their cognitive scripts have become focused on stress and survival.
In my experience, substance-abusing teens with complex trauma generally have two basic cognitive scripts for dealing with life problems or stressful situations. They act up or shut down. Their use of illicit substances may be part of either script. With such limited options, these teens have no choice but to rerun their same maladaptive scripts, perpetrating already internalized beliefs that they are ineffective, incapable, and destined to remain stuck. Eventually, acting up and shutting down become so normalized that they no longer see these responses as problematic.
Trauma, Abuse and Neglect in Early Childhood
Research indicates that adolescents who enter substance abuse treatment are more likely than their peers to have experienced childhood abuse, neglect, and other significant family problems (Riggs, 2003). In fact, studies have found that these types of early childhood trauma are reliable predicators for substance-related problems in both adolescents and adults" (Romer & Walker, 2007, p. 245).
Adversity in early life alters the development of neural systems in a manner that predisposes individuals to disease in adulthood,” both physical and psychiatric (Romer & Walker, 2007, p. 149). In addition, “childhood adversity, in the form of trauma, neglect, deprivation, or abuse, may be especially harmful during critical periods in brain development… External stressors impact the structure, organization, and activity of the CNS [central nervous system]” (Romer & Walker, 2007, p. 350).
Several laboratory studies on the impact of neglect and early childhood stress have been conducted on rats. “Maternal care [in rats] alters the expression of genes in brain regions that subserve emotional, cognitive, and endocrine responses to stress (Romer & Walker, 2007, p. 161). This conclusion comes from a study that tracked levels of maternal care based on exhibited licking and grooming behavior, both natural variations and imposed differences.
When less maternal licking and grooming occurred, the rat pups exhibited increased fearfulness, heightened HPA (hypothalamus-pituitary-adrenal) axis responses to stress, and reduced performances on tasks requiring sustained attention or declarative learning. This was especially true when the rat pups were under stressful conditions (Romer &Walker, 2007).
The HPA axis is a neural system activated by stress that is “sensitive to environmental challenges and is activated in response to physical and psychological factors that threaten homeostasis” (Romer & Walker, p. 265, 2007). When activated, a chain of events occurs that leads to the release of cortisol, a hormone that increases both blood pressure and blood sugar levels, as well as having an immunosuppressive action (Romer & Walker, 2007), helping assure a quick return to normal functioning following stressful events.
According to Siegel (1999), the hippocampus is “the major center for conscious, declarative, explicit memory processing” (p. 178). He wrote that high levels of stress, especially when severe or ongoing, blocks hippocampal functioning and can even lead to “neuronal death” (p. 50) and decreased hippocampal volume. In other words, trauma can lead to a brain that is less capable of effectively responding to the stress caused by trauma. When this occurs, adolescents have begun experiencing stuckness. As we will see these adolescents are also likely to have these neurological challenges further compounded by developmental debt.
Experiencing Developmental Debt
When individuals already exposed to childhood trauma move into adolescence, they often face a cascade of problems, including a higher incidence of mental health disorders, school-related concerns, placement in separate classes, and increased association with peers who exhibit similar maladaptive issues (Romer & Walker, 2007). Coping with external stressors such as these, not to mention the original traumatic experience or experiences, “overtaxes the available resources allocated for developmental tasks” (Gil, 1996, p. 9) likely leading to what I conceptualize as developmental debt.
According to Gil (1996), trauma “interrupts and disrupts the developmental process” (p. 22). The National Child Traumatic Stress Network (2008) reported that “delays in the developmental processes that would normally enable them [adolescents] to better consider the consequences of their behavior, to make more realistic appraisals of danger and safety, to moderate daily behavior to meet long term goals, and to make increased use of abstract thinking” (p. 16) are compromised by traumatic experiences.
When this occurs, normal developmental tasks go uncompleted. As this developmental debt accrues, the individual starts to fall behind in normal social, emotional, and cognitive progress. Herman (1992) wrote, “The experience of terror and disempowerment during adolescence effectively compromises the three normal adaptive tasks of this stage of life: the formation of identity, the gradual separation from the family of origin, and the exploration of a wider social world” (p. 6).
Teens with a history of trauma exposure often become so focused on day-to-day survival that the emotional and cognitive resources normally allocated to developmental tasks are simply unavailable (Gil, 1996). With each uncompleted developmental task, the individual falls farther behind, further increasing the likelihood of even more life problems (Riggs, 2003) and the possibility that these life problems will negatively impact multiple areas of his or her life.
Bronfenbrenner (1979) identified four dimensions of influence upon adolescents: family, school, peers, and work or play. When an adolescent experiences disruption in any of these dimensions, a ripple effect is likely to occur with negative impacts in the other worlds. For adolescent survivors of trauma, the likelihood of problems rippling out into in all four dimensions seems especially high, resulting in these adolescents moving ever deeper into a cycle of stuckness, where childhood adversities, school failure, negative peer relations, environmental stressors, mental health disorders, and substance abuse all start to co-evolve. For an adolescent already suffering the negative impacts on the brain due to early childhood stressors, the additional impact caused by this developmental debt would ever further contribute to his cascade of problems.
Jittery and Paranoid is My Normal
A former client, Andrew, effectively illustrates this co-evolution. Andrew’s parents were both heroin dependent and the family was homeless, living in a car. It is reasonable to make two assumptions at this point. First, the environmental stressors caused by addicted parents and homelessness had already negatively impacted his hippocampus and general brain development. Second, with both parents being heroin dependent, Andrew was born with a high genetic predisposition for addiction.
At age four, Andrew witnessed the death-by-overdose of both parents. With no relatives willing to provide care, he entered the foster care system. Between the ages of four and fifteen, he had over a dozen different placements. Andrew reported, “I was moved around so much that I stopped unpacking my suitcase.” Not surprisingly, his behavior became increasing problematic. He reported first use of alcohol at age ten and first use of marijuana shortly thereafter. At thirteen he went to detention for the first time. At fifteen, he ran away from the group home where he was living.
When I met Andrew at sixteen years old, he had just moved into a transitional living program after being homeless for almost a year. He reported two recent assaults and had mental health diagnoses that included post-traumatic stress disorder, conduct disorder, attention deficit/hyperactivity disorder, and major depressive disorder. I added additional diagnoses for alcohol dependence, cannabis dependence, amphetamine dependence, and opiate abuse. In addition, Andrew exhibited difficulty remembering details, time frames, and other factual information. He 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.”
Andrew clearly exhibited what the National Child Traumatic Stress Network (2008) defined as chronic trauma: “the experience of multiple traumatic events” (p. 14). The Network continued, "Complex trauma is a term used by some experts to describe both exposure to chronic trauma—usually caused by adults entrusted with the child’s care, such as parents or caregivers—and the impact of such exposure on the person. Children and adolescents who have experienced complex trauma have endured multiple traumatic events (such as physical or sexual abuse, profound neglect, or community violence) from a very young age" (p.15).
I propose that it is complex trauma that lead to Andrew’s cascade of problems and developmental debt described above. Erickson (cited in Gil, 1996) wrote that the primary developmental task for adolescents is to create a sense of ego identity. He stated that adolescents must create “some central perspective and direction, some working unity, out of the effective remnants of childhood and the hopes of anticipated adulthood” (cited in Gil, p. 45, 1996). For Andrew, this did not happen. He certainly had the ruins of childhood, but he had no direction and no hopes for adulthood. As a result, his already existent developmental debt may have been destined to deepen, resulting in the creation of an existential vacuum.
Frankl (2006) defined an existential vacuum as “a feeling of emptiness and meaninglessness” (p. 141). Such a vacuum is likely to lead to depression, aggression, and addiction (Frankl, 2006). In his autobiography of addiction, Sheff (2007) wrote, “Using is such a fucking ridiculous little circle of monotony. The more I use, the more I need to kill the pain, so the more I need to keep using. Pretty soon it seems like going back, facing all my shit, well, it’s just too goddamn overwhelming. I’d rather die than go through it” (p. 146).
Regarding his use, Sheff continued, “I don’t care. Isn’t that the greatest gift in the world—just not to care? I feel so grateful for it. That’s nothing I ever knew sober” (p. 60). It seems clear that Sheff’s addiction is an attempt to fill this his own existential vacuum, at least temporarily, even if in a maladaptive and unsustainable manner. I believe this is also true for most adolescent survivors with substance-related disorders.
Addicted to Chaos
Working with adolescents that have co-occurring disorders, I see a lot of clients with a history of complex trauma. Like Andrew, these adolescents often appear to be stuck in an endless cycle of chaos, often seemingly of their own making. 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 hyperarousal response. According to Perry and Szalavitz (2006), the brain changes related to hyperarousal “may make some trauma victims more prone to stimulant addiction” (p. 190).
Based on how stimulants affect the brain, it seems likely to me that stimulant use may be an attempt to recreate the feelings of trauma from the pasts. By using stimulants, adolescent trauma survivors may be attempting to artificially stimulate the production of those neurotransmitters that they have become physically accustomed to being present. Perhaps these individuals are, in fact, using stimulants to avoid withdrawal caused by a decrease in their accustomed level of dopamine and noradrenaline caused by their history of complex 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.
This type of risky behavior helps assure the perpetuation of chaos in the lives of these teens. Self-sabotaging behavior functions differently. In this case, when things are going well for these clients, they do something to create chaos or stress: the client about to graduate from an inpatient program acts out and has her graduation canceled; the court ordered client who cusses out a judge during a hearing; the client who gets arrested for dealing, but insists he did not use so his treatment should not be affected.
Self-sabotaging incidents such as these are fairly common among adolescents in substance abuse treatment. I have always attributed them to a mix of poor decision making skills, an unconscious desire to stay in counseling, and a fear of success. Perhaps, though, these behaviors should be viewed as relapses. In the above cases, the clients did not use drugs, but they certainly did get a jolt of stress-related neurochemicals.
For years I have referred to these clients as “chaos junkies”—a term most adolescent clients 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, another example of a maladaptive cognitive script. Could there be something more happening here, though? Could these youth be addicted to chaos? More precisely, could these youth be physically dependent upon the chemicals released due to the stress caused by complex trauma, chaotic lifestyles, and unhealthy environments?
If this is true, then I believe these individuals are not simply stuck in chaos. Rather, their brains have become wired in such a way that they are now creating their own trauma.
Perpetual Stuckness
Thus far I have examined traumatic experiences as causal pathway for substance abuse in adolescents. While this appears to be the primary causal pathway, it is also possible for substance abuse to lead to trauma (National Child Traumatic Stress Network, 2008). As we have already seen, it is not uncommon for substance-abusing youth to engage in high-risk behavior such as prostitution or drug dealing.
For Andrew, drug dealing supported his substance abuse. It also led to several physical assaults and to him being the perpetrator of violence. Andrew also acknowledged frequently trading sex for drugs and engaging in various criminal activities. High-risk behaviors such as those seen with Andrew can serve to re-traumatize these adolescents. In other cases, such high-risk behavior could be the cause of the initial trauma (National Child Traumatic Stress Network, 2008). Either way, these adolescents find themselves in a cycle of stuckness.
Paradoxically, even though risky behavior is evident in the lives of most adolescents with complex trauma, these teens are generally risk-adverse. Indeed, it seems possible that their risky behaviors are often ineffective attempts to avoid risk. In my experience, youth that engage in high-risk activities can be so distracted by these behaviors that they simply do not have time to think about their past trauma.
On the other hand, adolescents obsessed with safety often resort to substances and other maladaptive, risky methods of finding it. Still other teens lead lives that are so constricted that they barely even participate in existence. For these cases, trauma has “cast the victim into a state of existential crisis” (Herman, 1992, p. 51) where all choices lead to further stuckness.
Jon, a client with a significant trauma history, vividly described his existential crisis caused by intrusion. “Lots of times I feel like I’m living in some kind of black hole. I’m alone, but not really, because everything is there, because I just can’t escape shit, ever, no matter how much I try. It’s black, because that’s what black holes are, right? But, black is really all the colors at once, every single fucking one of them. And that’s too many colors if you ask me.” Being faced with all the colors at once immobilized Jon in a dark, lonely, constricting vacuum.
Herman (1992) wrote, “By avoiding any situation reminiscent of the past trauma, or any initiative that might involve future planning and risk, traumatized people deprive themselves of those new opportunities for successful coping that might mitigate the effect of the traumatic experience” (p. 47). Many adolescents avoid those past experiences by escaping into addiction. While escape may temporarily possible, as we saw with Sheff’s statement, it ultimately only perpetuates the problem, because the only escape is into an existential vacuum filled with all colors.
For adolescent survivors, it is likely that few adaptive cognitive scripts were ever modeled. Through modeling or other methods, an individual learns a certain response and starts putting that behavior into practice. As we have seen, if an individual repeats the behavior enough times, it becomes an integrated part of that person’s cognitive scripts. This is, of course, the basic idea of brain development: “Neurons that fire together wire together” (Siegel, 1999, p. 26). For these teens, what has wired together is inherently problematic.
Rose (1998) wrote that most youth with life problems “seem to have dedicated and rigid strategies of dealing with problems and are disinclined to look at other possibilities” (p. 177). These rigid strategies have been born from a life of traumatic stress. Looking at other possibilities requires a willingness to try something new, to take risks, and as we have seen, these adolescents are—at their core—risk adverse. For a teen who has had much unpredictability, even the most painful known option can feel far less risky than any unknown one. For adolescents like Andrew and Jon, who have had lives filled with traumatic stress and unpredictability, even the most painful known option can feel fall less risky than any unknown one. Andrew said it this way: “What I like about shooting [meth] is that I know what to expect. I use. I get high. No surprises.”
Chemical Constriction
Andrew stated once, “When I smoke weed, all the bad feelings go away. I don’t want to do stupid shit. I don’t want to think about the past. I don’t care about the future. As long as I’m high, everything’s gonna be okay.” This statement by Andrew perhaps points to a simple truth for these adolescent survivors of complex trauma. Ultimately, substance abuse is a form of constriction.
A vacuum filled with all the colors is overwhelming, but a vacuum filled with no thoughts can seem promisingly safe. Herman (1992) wrote, “When the victim has been reduced to a goal of simple survival, psychological constriction becomes an essential form of adaptation. This narrowing applies to every aspect of life—to relationships, activities, thoughts, memories, emotions, and even sensations” (p. 87).
While in treatment, Andrew lived in a group home with a drug testing policy. Continued use could have resulted in losing his placement. Yet, he continued. Some chemical dependency counselors would say Andrew was in denial, or perhaps resistant to treatment. I believe such an assessment would be both simplistic and pessimistic, and so I offer a different possibility: Andrew was not resistant and was not in denial. In fact, he readily acknowledged the problems in his life, including his addiction. He was, however, stuck. His lifelong cascade of problems had impacted his brain’s architecture in ways that had shaped his behavior, determined his cognitive scripts, and assured his stuckness.
Andrew was incapable of making more adaptive choices. His brain was not physically able to complete such a task. Does that mean he was beyond help? I do not believe so. For adolescents like Andrew and Jon, remaining stuck is a safe, tempting possibility, but it is not destiny. Substance-related disorders and complex trauma are frequently an intricate, co-evolving, cascading cycle of stuckness. Helping adolescents overcome this stuckness requires challenging them to risk developing new cognitive scripts, so that they are able to move beyond their perpetual stuckness and see all the colors, not just black.
References
Frankl, V. (1984). Man’s Search for Meaning. New York: Simon and Schuster.
Herman, J. (1992). Trauma and Recovery. New York: Basic Books.
Gil, E. (1996). Treating Abused Adolescents. New York: Guilford Press.
National Child Traumatic Stress Network (2008). Adolescents and Substance Abuse. Retrieved October 5, 2010, from http://www.nctsnet.org/ncct/nav.do?pid=ctr_top_adol
Perry, B. & Szalavitz, M. (2006). The Boy Who Was Raised as a Dog. New York: Perseus Books Group.
Riggs, P. (2003) Treating Adolescents for Substance Abuse and Comorbid Psychiatric Disorders. Science & Practice Perspectives, 18-28. Retrieved October 5, 2010, from www.drugabuse.gov/PDF/Perspectives/vol2no1/03Perspectives-Treating.pdf.
Romer, D. and Walker, E. (Eds.). (2007). Adolescent Psychopathology and the Developing Brain. New York: Oxford University Press.
Rose, S. (1998). Group Therapy with Troubled Youth. Thousands Oaks, CA: Sage Publications.
Sheff, N. (2007). Tweak. New York: Simon and Schuster.
Siegel, D. (1999). The Developing Mind. New York: Guilford Press.
Van der Kolk, B. (n.d.). Developmental trauma disorder: A new, rational diagnosis for children with complex trauma histories. Psychiatric Annals.
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