When I was a rookie addictions counselor, I had repeated run-ins with clinical supervisors. The conflicts centered around the abuse histories of men and women at the treatment centers where I worked. My bosses were fearful of delving into trauma. They’d say things like, “No, don’t talk to them about trauma. Don’t open any wounds. We aren’t equipped to close those wounds. Teach them about AA. If they need therapy, put it in their aftercare plans. Don’t dredge up any ghosts.”
Trauma wasn’t new to me. Raised by parents who survived the Holocaust, I grew up listening to heroic escape odysseys and horrific encounters with violence and death. Also, before becoming a clinician, I had been a journalist. As a police reporter, I chronicled the dark side of human experience by interviewing numerous police officers, victims and offenders about traumatic events that took place in the communities I covered. Later, in my clinical internships, I conducted detailed psychosocial assessments, exploring themes of trauma, abandonment, and loss.
Since narrating one’s story is a critical part of early recovery, I couldn’t understand when I began my work as a counselor how I was supposed to avoid asking about clients’ traumatic pasts.
I began to explore and treat trauma “undercover,” utilizing astute and insightful senior colleagues outside of my work settings for informal supervision.
Today, the addiction field has finally embraced the notion that underlying trauma must be addressed for a person to recover. I am privileged to be asked frequently to present on trauma around the country. I share clinical vignettes to illuminate the link between trauma and addiction and illustrate pathways to healing. As part of my presentations, I facilitate demonstration psychotherapy groups, called “fishbowl groups,” offering clinicians attending the conferences a rare opportunity to experience the healing power of group. I invite nine people to participate in the groups, while other attendees observe. I encourage members of the demo groups to self-disclose about the family-of-origin dynamics and transgenerational themes that commonly lead to countertransference reactions in their work with patients. Very often, clinicians will make speakable in these groups traumas heretofore unprocessed.
In one powerful demo group, an African American female counselor courageously and tearfully shared about a torturous memory of being raped and left stranded. Barely a teen at the time, the woman recalled that a police officer remarked to her that how dare she select a holiday on which to be raped, burdening police with her needs. The young girl was turned away from the police station. She carried the secret of the assault and the brutal encounter with police until her demo group experience. The group, and other attendees later, offered her overwhelming support. Many cried with her.
In my private practice, I lead 15 psychotherapy groups per week—women’s, men’s and mixed-gender. I am privileged to watch group members work through trust and attachment issues and let go of daunting, haunting past memories.
Group therapy is an effective modality for treating eating disorders, chemical dependency, and “process addictions,” such as sex, gambling and internet addictions. It also is a treatment of choice for psychological trauma. Acutely painful psychological states related to feelings of being trapped, disconnected, socially isolated, and alienated have been clinically observed in addicted, eating-disordered and traumatized populations. Many people with eating disorders, chemical dependency histories and process addictions are, in fact, trauma survivors seeking relief, escape, or pleasure through addictive behavior. Unprocessed, untreated trauma contributes to both the development of an addiction or eating disorder or to relapse once a recovery process has begun.
Tian Dayton, a clinician and researcher specializing in treatment trauma, refers to trauma as “unmetabolized pain that sits within the self, leaking out in all the wrong places.” Trauma survivors often self-medicate with alcohol, drugs, food, sex, gambling, the Internet, shopping, spending, work, frenetic activity, or other “excessive behaviors,” she reports. They engage in addictive behavior to ease the emotional pain caused by trauma and then to numb themselves from the trauma created by addiction. Often, by the time they present for help, they have long buried their feelings, avoided sharing their feelings, or pretended their feelings don’t exist. “Trauma, by its very nature, renders us emotionally illiterate,” notes Dayton
Trauma creates what Dayton describes as “a cauldron of pain that eventually boils over…. (The) pain feels overwhelming. The person in pain reaches not toward people, whom he or she has learned to distrust, but toward a substance…. Addicts may initially feel they have found a solution, but the solution becomes a primary problem…. The longer traumatized people rely on external substances to regulate their internal worlds, the weaker those inner worlds become…. Emotional muscles atrophy…. Personality development is truncated or goes off track. Thinking becomes increasingly distorted and secretive as addicts strive daily to justify to themselves and others a clandestine life. Authentic, honest connection slowly erodes as relationships turn from sources of support to targets of deception and means of enabling.”
Damaged “survival bonds” are the major trauma underlying addiction, says Dayton, referring to relationships with primary caregivers. And subsequent traumas add on layers of complexity and severity. “…Ruptures in early parent/child bonds are some of the most traumatic because our dependency and risk for survival are at their highest in infancy and childhood…. If someone has experienced a rupture in a ‘survival bond,’ subsequent bonds may be harder to form and subsequent ruptures may be more devastating because they return us to the pain of the original one.”
Group therapy provides a therapeutic context in which to conquer the shame, secrecy and stigma that frequently silence and marginalize traumatized and addicted individuals. Groups offer a rare opportunity for people to overcome, in a safe setting, impairments in attachment and relational capacities, develop trust, and achieve a sense of intimacy and belonging. Group members find commonalities with others whose traumatic experiences may be both similar and dissimilar in terms of the particulars. They build their own resilience and self-esteem by observing and recognizing others’ strengths and resiliencies and by sharing their coping skills with others. They learn to value themselves when they feel accepted and affirmed by valued others. The concept is reminiscent of a phrase often shared in 12-step fellowships: “Let us love you until you learn to love yourself.” Members tend to develop a sense of pride as they contribute to others’ healing. And the experience of connection in the group often empowers people to seek out affirming relationships in 12-step fellowships and in the outside world. Group therapy therefore functions as a bridge to new community.
The term, “trauma,” may be broadly applied. It includes personal trauma and community catastrophes. Atrocities include many things—sexual and domestic violence, combat violence, state-sponsored violence, political terror…. Judith Herman, in her book Trauma and Recovery refers to commonalities “between rape survivors and combat veterans, between battered women and political prisoners, between the survivors of vast concentration camps created by tyrants who rule nations and the survivors of small, hidden concentration camps created by tyrants who rule their homes.” Traumatic events involve threats to life or bodily integrity, or a close personal encounter with violence or death.
The fundamental stages of recovery identified by trauma theorist Judith Herman are all amenable to the group format. The three stages are establishing safety, constructing the story, and restoring connections with family and community. With some therapy groups, there is mutual member support outside the group along the way as members make contact by phone or in person and engage socially or may, for example, attend 12-step meetings together.
Co-existing PTSD symptoms are common in addictive populations, and group therapy can offer support. There are three main clusters of such symptoms: intrusion, or re-experiencing; constriction, or avoidance; and hyperarousal.
- Intrusion – Long after the danger is gone, traumatized people may relive the event as if it were recurring in the present. They may try to return to a normal life, but the trauma repeatedly interrupts. This can happen both as flashbacks during waking states and as traumatic nightmares during sleep.
- Constriction – Since reliving a traumatic experience evokes intense emotional distress, traumatized people may go to any length to avoid it. Herman explains, “The effort to ward off intrusive symptoms, though self-protective in intent, further aggravates the posttraumatic syndrome, because the attempt to avoid reliving the trauma too often results in a narrowing of consciousness, a withdrawal from engagement with others, and an impoverished life. It is like going into a state of surrender. There are alterations of consciousness, which are at the heart of constriction or numbing.” There may be amnesia for important aspects of the trauma; diminished interest in significant activities; feelings of detachment from others; a limited range of affect; and feelings of a foreshortened future.
- Hyperarousal – After a traumatic experience, the human system of self-preservation seemingly goes onto permanent alert, as if the danger might be back at any moment. Included in the hyperarousal cluster are sleep difficulties, irritability, trouble concentrating, hypervigilance, and a heightened startle response.
Lillian Rubin authored a book, The Transcendent Child: Tales of Triumph over the Past, based on life-history interviews with four men and four women with heart-wrenching childhood stories. Rubin found that children who “transcend” painful pasts typically “disidentified” with their family and their family’s way of life. They became adept at “finding and engaging alternative sources of support.”
At any point in the lifespan, therapy groups can be powerful sources of support.
“Creating a protected space where survivors can speak the truth is an act of liberation,” declared Herman.
Marcia Nickow is Clinical Director of SunCloud Health Outpatient Treatment Center, leading clinical supervision groups and overseeing multidisciplinary teams at three locations. She is an addictions psychologist, group psychotherapist and trauma specialist. Nickow runs 14 weekly ongoing psychotherapy groups in her downtown Chicago private practice while also treating individuals and couples and supervising trainees