Stop Treating Solutions like Problems - An ACE's Informed Approach to Substance Abuse Treatment

“We treat people’s solutions as problems.”  Vincent Felitti MD, eminent author of the original ACE’s (Adverse Childhood Experiences) study, often makes this point when discussing how we focus on eliminating people’s desperate means of coping, without recognizing their adaptive functions.   When addressing substance abuse (the most common method of tolerating overwhelming fear and pain) do we commit the same error of attempting to control the “solution” while largely ignoring the underlying core problems associated with traumatic exposures?  For many people with struggling with addictions, substance abuse represents survival.

The linkage between ACE’s and trauma and substance abuse disorders (SUD’s) is compelling.  In his paper, Origins of Addiction, Felitti reports that people who experience 4 or more ACE’s are 500% more likely to abuse alcohol.  People who report five ACE’s or more are 7 to 10 times more likely to report illicit drug abuse. A jaw-dropping data point indicates that individuals who survive 6 or more ACE’s are 46 times more likely to be IV drug abusers than people who report no ACE’s.  Trauma truly is the “gateway drug” to addictions.

Kanwarpal Dhaliwal and the youth at RYSE (Richmond Youth Services) have amplified the ACE’s pyramid to include the toxic impacts of social conditions and local contexts such as poverty, racism and historical trauma.  This expanded view helps us recognize that it’s not just what has happened to you, but what environmental stressors and social conditions you inhabit.  As attention has turned to the “opioid crisis”, it would seem to be no coincidence that the communities most affected are beset by high rates of unemployment, poverty, and social isolation. In contrast to the reductive medical model, the ACE’s/trauma informed approach encompasses neighborhoods as much as neurons, zip codes more than genetic codes.

Some substance abuse programs and mental health agencies have begun integrating the ACE’s questionnaire into their initial assessments.  What might be the potential impacts of incorporating enhanced ACE’s informed perspectives into treatment?

  • Asking about childhood maltreatment, listening and offering empathy represents a significant intervention in itself. Simple, straightforward human compassion for human suffering and distress can be healing.
  • Inviting people who abuse substances to be “compassionately curious” about themselves and to connect the dots between their unseen wounds and their attempts to cope with overwhelming distress can provide relief and self-understanding. (This is often a long-term, life-time process.)
  • Instilling hope for a better future is an essential ingredient for recovery. “What can be hurt can be healed”, seems to illuminate this pathway much more than “you have an incurable, life-long brain disease.
  • Empowering people to take responsibility for owning their own stories and writing (and rewriting) new chapters. Talk of genetic predispositions and chemical imbalances can engender passivity and resignation.
  • Supporting meaning making and setting the stage for post-traumatic growth.
  • Emphasizing the central need for social supports and human connection. In his enlightening TED talk - Johann Hari asks this challenging question; “what if the opposite of addiction is not sobriety, but the opposite of addiction is connection? A key aspect of reducing substance abuse is how well we can help people develop their social networks.
  • Reminding us all that unless we also vigorously address issues such as social justice, poverty and racism – our progress will be limited.

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Wayne Munchel posted:

Hi Lisa - I appreciate this dialogue. 

While I understand that addiction = brain disease is the prevailing model, I'm very skeptical. (no bio-markers)  We know that trauma profoundly changes brain architecture (it precipitates a disease?)  I prefer to think of drug dependence as normal reactions/adaptations to abnormal experiences, and like Felitti, believe that this damaging coping behavior cannot be addressed effectively without addressing the underlying severe distress, pain & fear.

You won't be surprised to hear that I also don't regard most mental disorders as brain diseases, but also as different methods of coping & sequelae to traumatic experiences.

So we do agree that it's a more hopeful message (?) but disagree if it's factually correct?  Thanks   

I love it - respectful dialogue - thank you, Wayne - I appreciate it, too. I very much agree with your statement, "and like Felitti, believe that this damaging coping behavior cannot be addressed effectively without addressing the underlying severe distress, pain & fear." I also would agree with your message as being more hopeful -- I have found a similar message works with the people with whom I work.

I do think it's important the person with an SUD understands the nature of their disease / disorder - and to your point, mental illness and addiction are now both referred to as disorders (but in the case of an SUD, defined in the details as a brain disease). So I don't think it's necessarily productive to hammer home, "it's a disease," because like other chronic diseases, remission is entirely possible and people go on to live healthy, enthused lives.

I do think it's helpful for people to understand the disease concept and the complexities of what goes into a person developing an SUD, however, so they can appreciate the complexities of what it will take to help them treat their SUD (as you know, there is NO one-size-fits-all treatment protocol). I think NIDA's Principles of Effective Treatment does an excellent job of laying out the wide range of treatment options a person may find helpful for their situation.  And I absolutely agree that treatment protocols need to raise awareness / screen for ACEs and share the ACE Study findings for the very reason you pose the question, "When addressing substance abuse (the most common method of tolerating overwhelming fear and pain) do we commit the same error of attempting to control the 'solution' while largely ignoring the underlying core problems associated with traumatic exposures?"

Bottom line...I'd say we're more in agreement than disagreement

Thanks for the dialogue!

Hi Lisa - I appreciate this dialogue. 

While I understand that addiction = brain disease is the prevailing model, I'm very skeptical. (no bio-markers)  We know that trauma profoundly changes brain architecture (it precipitates a disease?)  I prefer to think of drug dependence as normal reactions/adaptations to abnormal experiences, and like Felitti, believe that this damaging coping behavior cannot be addressed effectively without addressing the underlying severe distress, pain & fear.

You won't be surprised to hear that I also don't regard most mental disorders as brain diseases, but also as different methods of coping & sequelae to traumatic experiences.

So we do agree that it's a more hopeful message (?) but disagree if it's factually correct?  Thanks   

Wayne Munchel posted:

Lisa - thanks for letting me know how you've been using it.  IMO it's much more a matter of distress than disease.  I think that's an important distinction.

Wayne - Are you speaking of substance use disorders as "much more a matter of distress than disease?" If so, there is a range within SUDs, with substance dependence (commonly referred to as addiction) being the most severe and a brain disease. Three of the five key key risk factors for developing addiction are childhood trauma, mental disorder, and social environment. The "lesser" SUDs (commonly referred to as alcohol or other drug misuse or abuse) are not brain diseases and certainly distress / stress like that which can occur with ACEs contributes to the substance misuse/abuse. Regardless - I love this point of yours to answer your question, "What might be the potential impacts of incorporating enhanced ACE’s informed perspectives into treatment?"

  • Instilling hope for a better future is an essential ingredient for recovery. “What can be hurt can be healed”, seems to illuminate this pathway much more than “you have an incurable, life-long brain disease.

 

If I've misunderstood what you mean, I apologize. Thanks again for a great article - it's resonated with several of my social network connections.

Couldn't agree more, Wayne! I've been using the ACE questionnaire in my coaching work with family members of persons with substance use disorders -- for their own score and for their loved one's. It helps them better understand how ACEs may have contributed to their loved one developing an SUD, which can help them appreciate what they're loved one will need to do to treat their brain disease. And they can see how they may have been affected by ACEs themselves (either in the current relationship or previously in their family of origin), which helps them appreciate they need their own healing, as well.

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