Motivation and emotion/Book/2022/Childhood trauma and subsequent drug use

Childhood trauma and subsequent drug use:
How does childhood trauma influence subsequent drug use?

Multimedia presentation (3 min)

Overview

Figure 1. People may abuse substances to deal with their childhood trauma

Society tends to perceive drug use as a voluntary behaviour, invalidating potential causes of drug addiction (see Figure 1.). What if I told you that some people are more likely to use drugs because of childhood experiences? Childhood trauma is an unfortunate reality in our society, one that has substantial negative consequences on those exposed to it. Unprocessed trauma often results in maladaptive coping strategies throughout one's lifespan, leading them to self-medicate for emotional relief. A common way to cope with adverse psychological and emotional trauma is through drug use. A preliminary step in the treatment of trauma-induced drug use consists of understanding its motivational processes.

This chapter defines childhood trauma and drug use, then explains the theoretical underpinnings of trauma-induced drug use. The motivational aspects of how childhood trauma might motivate drug use are analysed. Lastly, current treatment approaches are discussed.

Focus questions:

• What is childhood trauma?
• What are theoretical underpinnings of childhood trauma-induced drug use?
• How does childhood trauma influence drug use?
• What are the strategies for treating trauma-induced drug use?

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What is childhood trauma?

Figure 2. Childhood trauma negatively impacts a child's emotional well-being

The American Psychological Association (APA) defines a traumatic life event as:

"One that threatens, injury, death, or the physical integrity of self or others and also causes horror, terror, or helplessness at the time it occurs. Traumatic events include sexual abuse, physical abuse, domestic violence, community and school violence, medical trauma, motor vehicle accidents, acts of terrorism, war experiences, natural and human-made disasters, suicides, and other traumatic losses (American Psychological Association, 2008)."

When these events are experienced by a developing child, this constitutes as childhood trauma. It refers to negative events that threaten or cause harm to a child's emotional and/or physical wellbeing (see Figure 2). Since children are still developing, childhood trauma can have lasting effects on a child's physical, mental, and emotional well-being which often transfer into adulthood. Childhood trauma exposes children to become insecurely attached and develop poor self-regulation skills (Ford, 2009). These emotional regulation deficits stunt children’s ability to develop healthy emotional expression. Therefore, emotional dysregulation as a consequence of childhood trauma, has been highly linked to substance use with heavy consumption in adulthood (Dass-Breilsford & Myrick, 2010; Mandavia et al., 2016).

Terr (1991) introduced two types of childhood trauma:

• Type I - results from a single event such as an accident, witnessing a crime or rape.
  • Individuals affected by Type I trauma especially if the incident occurred after the age of 3, are thought to remember the incident and experience perceptual symptoms such as visual hallucinations as a consequence of the trauma.
• Type II - results from repeated exposure of extreme traumatising events such as re-occurring abuse.
  • Individuals affected by Type II trauma, are proposed to repress the event using denial and dissociation methods to avoid the trauma exposure.

Case study Elena is a 7-year-old girl who repeatedly watched her father physically and sexually abuse her mother since she could remember. Recently, her father physically abused Elena for the first time and this left a bruise on her face. The school got involved and Elena's father was sent to prison. Elena now lives with her mother who is severely depressed. Elena has been struggling to remember what her father did to be in prison. According to Terr (1991), is Elena struggling with Type I or Type II trauma?

Figure 3. Methylenedioxymethamphetamine (MDMA) - A form of illicit drug

What constitutes drug use?

Drugs have been used medically and recreationally throughout history with early civilisations consuming natural substances for healing and religious rituals. Typically, when people discuss drug use, they are referring to illicit substances. Drug misuse is defined as the recreational use of alcohol, illicit drugs and analgesics which can lead to emotional, physical, and social harm (Degenhardt & Hall, 2012). People often use drugs to numb psychological distress and as an escape from reality (Jouhki & Oksanen, 2021). Illicit substances (see Figure 3.), alcohol and tobacco are among the largest contributors to the global burden of disease and mortality.

Repeated drug use often leads to substance use disorder (SUD) which commonly constitutes addiction. According to the 5^th edition of the Diagnostic Manual of Mental Disorders (DSM-5), substance induced disorders occur when the substance use leads to intoxication, addiction, withdrawal and induced psychological disorders such as psychosis and depressive disorders (American Psychiatric Association, 2013). Hence, the use of drugs is commonly looked down upon and seen as the self-endangerment of an individual's well-being and sanity. So, what motivates individuals to partake in such self-endangering behaviours?

Case study Elena is now 15 years old and still has no contact with her father. The more time that passed, the less she thought about what had happened. When those thoughts did arise, she would find herself in a state of panic. This scared her and led her to smoke marijuana every night for the past year before bed because that is when she feels most vulnerable. Recently, the marijuana has not been working as well as it used to so she turned to something stronger - oxycodone. Is Elena using drugs to escape her reality?

What are the theoretical underpinnings of trauma-induced drug use?

Drug use constitutes a dangerous behaviour that is commonly performed recreationally with large negative consequences. Although drug use is often initiated by peer pressure within social situations (Degenhadt & Hall, 2012), psychological trauma can be a precursor for drug use throughout the lifespan. Trauma-exposed individuals are likely engaging in drug use as a maladaptive coping strategy to experience an emotional relief (Sheerin et al., 2016). Focusing on trauma-induced drug use, this part of the chapter will discuss the theoretical concepts surrounding the motivation behind trauma-induced drug use.

Attachment theory

Human beings who are exposed to adverse events in childhood and experience an insecure childhood, develop insecure patterns of attachments. Attachment theory was introduced by Bowlby (1958), who proposed that the physical attachment between the child and primary caregiver, leads to four attachment styles in adulthood (see Table 1). Emerging literature focusing on recurring childhood abuse and emotional neglect proposed that experiencing such adverse events in childhood can inhibit secure attachments and induce problematic behaviours (Schindler & Broning, 2015). For example, researchers studying neglected children found that trauma-exposed children in foster care, display behavioural and emotional problems and frequently possess insecure attachments and a need for control (Prather & Golden, 2009).

Insecure attachment styles commonly co-occur with other mental health issues. Research suggests that mental health issues, such as anxiety and depression, increase the probability of drug misuse (Mandavia et al., 2016). With an increase in insecurity, individuals experience difficulties in regulating stress and emotions. This dysregulation acts as a risk factor towards drug use (Schindler, 2019). Based on attachment theory, substance misuse can be understood as “self-medication” and therefore a compensation technique for lacking attachment strategies (Schindler, 2019). Taken together, attachment theory proposes an interesting take on the impacts of childhood trauma and subsequent drug use.

Table 1. Attachment styles

Attachment styles	Description
Anxious	Individuals hold a negative self-image and often worry that others will abandon them.
Avoidant	Individuals hold low investment in relationships and possess problems with intimacy.
Fearful	Individuals fear intimate relationships and possess low self-esteem.
Secure	Individuals feel trust and a sense of safety within close relationships and are capable of forming lasting relationships.

Figure 4. Man depicted relieving his emotional distress for a short-term reward

Extrinsic motivation

Extrinsic motivation refers to an individual’s engagement in a behaviour due to external outcomes and the pursuit of an instrumental goal. Research investigating the triggers of substance use has suggested that stronger extrinsic motivation may predict an increase in drug use (Moore & Hardy, 2020). In this theory, individuals are motivated to use drugs due to the presence of an extrinsic reward relieving their emotional distress (Takano et al., 2021). Operant conditioning incorporates similar principles, where we see the motivation of certain behaviours occur due to rewards and punishments. Similar to extrinsic motivation, negative reinforcement may also explain trauma-induced drug use where an unpleasant stimulus is removed, increasing a behaviour (Staddon, 2003). In childhood trauma-induced drug use, the unpleasant stimulus is the emotional distress which is removed through the short-term reward elicited by the consumption of drugs (see Figure 4; May et al., 2020). This process increases drug use behaviour following childhood trauma.

Test your knowledge on theory! 1 Attachment Theory suggests that individuals with insecure attachment patterns are less likely to turn to drugs in adulthood True False 2 Which of the following theories proposes that individuals turn to drugs to alleviate the distressing emotions caused my childhood trauma? Attachment Theory Extrinsic motivation The amygdala Emotion Regulation

How does childhood trauma motivate drug use?

Children who experience trauma are unaware of the impact this event has later in life. As a result, they may turn be more likely to drug use to self-medicate against the unbearable pain and distress caused by unresolved and unprocessed traumatic experiences (Marcenko et al., 2000). To combat the issue and establish treatment strategies for childhood trauma-induced drug use, it is important to understand the relationship between trauma types and later drug use.

Childhood trauma types most relevant to drug use

Adverse childhood experiences play a role in maladaptive coping mechanisms. Nonetheless, it is important to address the types of childhood traumas that affect this behaviour to successfully treat it. A study conducted by Dube et al. (2003) assessed several adverse childhood events such as sexual abuse, domestic violence, emotional neglect, incarcerated family member and parental drug use. Through self-reports asking participants to indicate their drug taking behaviour, results revealed that 50% to 66% of serious drug use problems were caused directly by the experience of at least one of these adverse childhood events. The strongest predictor remained childhood neglect. The consequences of childhood neglect include the development of insecure attachment styles, leading to subsequent drug use (Prather & Golden, 2009). An additional type of childhood trauma that heavily influences drug use is childhood sexual abuse (Liebschutz et al., 2002). Childhood sexual abuse is more commonly related to substance use in adulthood in comparison to an adulthood sexual abuse life event. This could be explained by the emotional, physical, and potentially repetitive damage caused while the child is still developing. Subsequent drug use extrinsically motivates individuals to drown out this damage, allowing for a short-term fix for the constant distress.

Limited contextual ability

Experiences of events that are traumatic for children, are typically less traumatic for adults. A key explanation for this is that children lack the ability to make contextual inferences about the event, leaving them relatively helpless (Lubit et al., 2003). This lack of contextual ability in children, likely hinders them to process these experiences effectively. The most destructive properties of childhood trauma include their inability to engage in a normal developmental experience. This affects a child’s capability to express and regulate emotions following trauma-exposure, creating a negative effect on the individual’s identity. Thus, trauma-exposed children possess a higher vulnerability to traumatisation in the future (Lubit et al., 2003).

The psychological impact that childhood trauma has on a developing child, affects how a child learns to adapt and cope (Marcenko, 2000). When compared to adults, children are much more vulnerable due to the basic structures of their personality still being shaped. Their view of the world as a safe or dangerous, controllable, or uncontrollable place is still developing, placing their self-perception and development at risk when exposed to trauma (Lubit et al., 2003). Their limited contextual ability therefore affects how they will grow to perceive the world and themselves following the trauma, placing them at a higher risk of dug misuse (Marcenko, 2000). For instance, a child with severe attachment issues due to a physically abusive parent, may turn to drugs to counteract the insecure relationships maintained throughout adulthood – avoidance of loneliness.

Figure 5. The processes of learned helplessness

Learned helplessness

The excessive arousal and subsequent psychic numbing of trauma-exposed people, can lead to a state of learned helplessness, making it difficult for the individual to circumvent dangerous situations such as drug use (Lubit et al., 2003). Learned helplessness represents a state of being that arises following the experience of a repeated and uncontrollable stressful situation (see Figure 5; Seligman, 1972). This theory of learned helplessness offers a framework for understanding childhood trauma and subsequent drug use. Children experience a sense of helplessness when exposed to traumatic events. Whether this is caused by a natural disaster, or they are victimised or shamed by an adult figure (Kelley, 1986). Self-blame presents as one of the most common attributions experienced by children following a trauma leading to feelings of helplessness and inadequacy (Kelley, 1986). A coping response for these attributions includes drug use to cope with the aversive experience (Filipas & Ullman, 2006). Research has merely scratched the surface on learned helplessness on this topic, with a promising framework for understanding the motivation behind childhood trauma-induced drug use.

Case study Elena is now 25 and has developed a severe oxycodone addiction. She keeps telling herself that she will quit and get therapy but relapses immediately. Besides, her mother has been telling her that this is her own doing. Elena starts blaming herself for what happened to her dad especially when she is sober, motivating her to get high again. What is Elena experiencing?

What are the strategies for treating trauma-induced drug use?

When considering treatment strategies for childhood trauma-induced drug use, it is important to consider that both disorders need to be addressed simultaneously. The traumatic event often triggers the onset of post-traumatic stress disorder (PTSD), with the symptoms prompting a drug dependence causing SUD (Dass-Brailsford & Myrick, 2010).

Two types of treatment for treating trauma-induced drug use include cognitive behavioural therapy (CBT) and eye-movement desensitisation reprocessing (EMDR; see Figure 6).

Figure 6. Talk therapy for childhood trauma-induced drug use

Cognitive behavioural therapy

CBT focuses on cognitive restructuring of dysfunctional cognitions such as emotional numbing and reexperiencing, whilst reducing anxiety and the avoidance surrounding trauma memories (Dass-Brailsford & Myrick, 2010). It has been applied to the treatment of PTSD symptoms with promising results. For instance, a 20-week intervention splitting CBT into two intervention approach: CBT for substance abstinence and following with CBT for PTSD treatment, resulted in simultaneous improvements in both SUD and PTSD (Triffleman, 2003). Thus, CBT presents a promising treatment approach for childhood trauma-induced drug use.

EMDR

A study conducted by Perez-Dandieu and Tapia (2014), examined the effects of EMDR therapy in chronically drug dependent patients struggling with PTSD. Using a small sample of twelve individuals, EMDR therapy was implemented with the results indicating a reduction in PTSD symptoms with no change in addiction symptoms. Nonetheless, if the drug use is triggered by trauma symptoms, it can be suggested that rehabilitation may be more successful following EMDR. Moreover, more recent research investigating treatment options for childhood trauma-induced drug use, has tested the efficacy of trauma-focused and addiction-focused EMDR intervention in combating both disorders simultaneously with promising results (Carletto et al., 2018). Presenting preliminary results, this study proposes a combined trauma-focused and addiction-focused EMDR intervention as an effective treatment for trauma patients struggling with SUD.  

One crucial clinical barrier includes that inquiring about one’s trauma history whilst the individual is actively taking drugs may lead to disingenuous or incomplete information making treatment more difficult (Dass-Brailsford & Myrick, 2010). Research suggests that some clinicians prioritise the treatment of drug use over the treatment of trauma due to the difficult nature of treating both simultaneously (Blakey & Bowers, 2014). Thus, when drug use is trauma-induced, it makes the treatment particularly difficult.

Case study At the age of 26 Elena was connected with a social worker who introduced her to Angela, a clinical psychologist specialising in trauma and EMDR therapy. Elena was still struggling with addiction but was able to openly discuss and understand her trauma for the first time. The more she opened up, the less distressing emotions she was experiencing while sober, the more she wanted to be sober. Today, Elena is 32 years-old and 5 years sober, working as a social worker and helping teenagers with addiction.

Conclusion

Drug use can be heavily influenced by childhood trauma. This chapter discussed the key theoretical underpinnings of childhood trauma and subsequent drug use. Firstly, the most prominent theory for childhood trauma-induced drug use is attachment theory which suggests that individuals who misuse drugs are motivated by insecure relationships triggered in childhood. Extrinsic motivation proposes that individuals are motivated by the extrinsic reward elicited through drug consumption to relieve a distressing emotional state. Childhood trauma types play a role in later drug use with the most prominent being neglect and sexual abuse. This alone is not a predictor, a child’s limited contextual ability hinders their capacity to process a traumatic event, affecting how they learn to cope and therefore turn to drugs. Learned helplessness also offers a framework demonstrating how children may blame themselves for the trauma and turn to drugs in adulthood to cope. It comes as no surprise that individuals self-medicate to cope with an adverse memory which is unprocessed and/ or repressed. The clinical barriers in the treatment of childhood trauma-induced drug use includes the complexity of treating both simultaneously. Nonetheless, the most prominent treatment methods include CBT and EMDR with both demonstrating promising yet preliminary interventions and results. Research has only scratched the surface of motivational processes behind childhood trauma-induced drug use with enough evidence supporting a significant correlation.

See also

• Childhood trauma and emotion (Book chapter, 2018)
• Protection motivation theory (Wikipedia)
• Recreational drug use (Wikipedia)
• Safety as a psychological need (Book chapter, 2018)

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External links

• Drug abuse (healthdirect.com.au)
• What is childhood trauma? (blueknot.org.au)