Adolescence is a turbulent time in the best of circumstances, riddled with paradoxes and pressures, subconscious drives, and conscious desires. Adolescents are more mature than they are often given credit for, yet at the same time operating with an undeveloped brain. Additionally, at this time they feel a deep drive to belong while simultaneously needing to differentiate. This need to be accepted while striving to be independent (and still heavily dependent on adults) can create a lot of strain both internally and externally. All these double binds and stressors require an immense amount of emotional support and resiliency.
Kenneth Ginsburg, MD, MSEd, a specialist in adolescent medicine and cofounder of the Center for Parent and Teen Communication (CPTC), proposed that children and teens need “Seven C’s” to foster healthy resiliency:
In fact, beyond resiliency the Seven C’s help shape individuals’ sense of self, or their unique lens of how they see themselves and the world around them (Wallin, 2007); what psychologist and psychiatrist John Bowlby called individuals’ “internal working models.” Developing a healthy internal working model is no easy task, as it requires a great deal of attention, attunement, and modeling on the part of caregivers. If individuals develop healthy internal working models, they tend to feel secure in their worth and are able to take risks in relationships, face challenges in life head on, ask for help, and set healthy boundaries. In attachment theory (Bowlby, 1969) this is referred to as a “secure attachment style” (Wallin, 2007). What should be of particular interest to those working with teens who struggle with substance abuse and mental health issues is what happens when an injured internal working model develops. What follows as a result are negative core beliefs; difficulty building relationships; perpetually feeling unsafe and out of place; an aversion to asking for help (or a learned helplessness); and difficulty regulating emotions—that is, an insecure attachment style (Wallin, 2007). When the Seven C’s become compromised, resiliency is weakened, which leads to a significant predisposition to substance abuse. Jon Daily, LCSW, CADC-II, who was an expert on the treatment of adolescent addiction, stated in his book Adolescent and Young Adult Addiction, “Clinicians treating young people with addictive disorders have become increasingly aware that affect dysregulation and an inability to turn to others for emotional soothing and comfort significantly contribute to the onset of drug use, continued drug use, and relapse” (2012). Addressing this dysregulation is crucial not only to addressing the symptoms of substance use, but also ensuring quality long-term recovery.
If patients have an infection, like the flu or organ failure, they will certainly have significant symptoms, but treatment will be aimed at both symptom reduction and the source of the infection. Symptom reduction alone will not repair the infection. If teens are chronically abusing substances, cutting, restricting, purging, or obsessively gaming, that indicates a glaring deficit in their ability to regulate emotions and impulses. Of course helping teens effectively regulate their emotions is critical in the stabilization phase of treatment, but it is important not to stop there. Treatment providers must ask why they are dysregulated in the first place.
Teens with substance use disorders (SUDs) do not always return to wellness simply by becoming drug free. In fact, what usually occurs is a period where they may feel worse; that painful stage where they have given up the unhealthy people, places, and things, but have not quite integrated a healthy lifestyle. Additionally, many teens were not well to begin with, so getting them abstinent will not necessarily mean getting them well. Average teen development is a daily roller coaster even when they are not pumping their brains and bodies full of chemicals. Therefore, abstinence is crucial in recognizing what symptoms are being driven from what. It is hard to diagnose a car that is underwater, but if we drag it out and dry it up we start to see what else might be going on. Beneath the addictions and behaviors we can see a compromised ability to regulate emotions. Some of these are being influenced by the typical trials and tribulations teens face. However, it can also be an indication of emotional struggles and stunting, which often get overlooked unless glaring and obvious. Children and teens are measured in many ways throughout their development, but our society drops the ball on measuring emotional regulation and preparedness. We might wonder what kind of ripple effect our society might see if we made this a priority during the formidable years of development.
Allan Schore, PhD, a leader in the field of attachment and interpersonal neurobiology, has studied affect regulation for the last two decades (“Biography,” 2021). His work has shown that the ability to regulate emotions does not just happen genetically like growth spurts and puberty. Rather, he and many others have discovered that the ability to regulate emotions is dependent on healthy and consistent interactions with others. Children raised in isolation, whether physically or emotionally, will not develop to be healthy, well-adjusted people . . . despite our society’s obsession with independence and self-sufficiency.
For individuals, learning to identify, understand, and make sense of their biological, psychological, and social experiences—and how to respond to them—is critical for what Maslow referred to as “self-actualization” (1943). Interoception, which is people’s awareness of their internal experiences (e.g., being hungry, angry, tired, or cold), is a crucial first step for achieving the ability to self-soothe (Porges, 2011). It is often hard to tend to anything we are not aware of. For example, if we do not have the awareness we are cold, then sickness is likely to occur. If we do not have the awareness we are hungry, starvation is a possibility. Emotionally, if we do not have the awareness we are angry, lonely, or anxious, how will we know how to tend to those emotions? Further complicating this process is the fact that awareness alone does not always bring about change; individuals also need to learn how to label, respond to, and manage their experiences (i.e., self-regulate).
This type of self-regulation develops within the context of consistent, predictable, and attuned caregiving (Siegel, 1999). The ability of adolescents to manage their own distress comes from repeated childhood experiences of loved ones recognizing the children in question are overwhelmed, helping soothe them, and teaching them to soothe themselves—this is called “coregulation” (Siegel, 1999). Through coregulation there are learned experiences such as that things will be okay, that asking for help is actually helpful, how to self-soothe, and eventually how to help soothe others. This is building the internal working model and expanding these individuals’ tolerance for stress (Siegel, 1999). As babies, being hungry, tired, or scared is barely tolerable, initiating a rapid meltdown. However, if caregivers can notice the distress and help bring relief, children learn to tolerate the experience better over time. Pat Ogden, PhD, in her coauthored book Sensorimotor Psychotherapy (Ogden, Minton, & Pain, 2006), referred to this as our “window of tolerance,” which is our own unique window for how we tolerate stress, both excitatory and inhibitory.
Teens with substance use disorders (SUDs) do not always return to wellness simply by becoming drug free.
So how does a compromised window of tolerance develop? Or how do teens end up completely lacking the ability to even identify how they are feeling (i.e., alexithymia), let alone know how to tend to it? This is not a simple answer; there are biological, genetic, epigenetic, cultural, economic, and social issues at play. However, there is a large body of research showing that early trauma and stress has profound effects on emotional development. In fact, trauma not only impedes emotional development, but it actually stunts the physical and structural growth of key regulatory regions in the brain (van der Kolk, 2014). Examined at a deeper level, these regulatory regions have a direct impact on key neuromodulators, which are neurotransmitters that regulate (up regulation and/or down regulation) other neurotransmitters. Some of these crucial neuromodulators consist of opiate endorphins/dynorphins, dopamine, norepinephrine, and serotonin to name a few (Panskepp & Biven, 2012). Anyone who works in the substance abuse field should be quite familiar with these neurotransmitters as the key chemicals drugs release, and should already be drawing connections to the relevancy of these systems, especially if they become dysregulated. But how do they become dysregulated? When I started asking this question, I started understanding addiction better. What I discovered is that for this dysregulation to occur to the extent that it creates dysfunction, there have to be repeated disruptions along the timeline of development that makes teens predisposed to poor emotional regulation and subsequently SUDs.
Addicts have biological, psychological, and social deficits, coupled with genetic predispositions, that create powerful drives, so it is no wonder relapse rates are so high (Gust, Walker, & Daily, 2006). Denial aside, it is my belief that dysregulation is the number one reason for relapse. Rarely do I hear of people relapsing due to cravings alone. It is more common that it is a response to some emotional experience and an attempt to numb, avoid, or enhance how they feel. This is a very human response and one we all have to battle daily, but some populations struggle with dysregulation more. Temperament certainly has its place in this discussion.
“Temperament” refers to our natural inborn traits and is biological rather than learned, beginning as early as the womb. Many child development specialists classify temperament into three main categories: easy and flexible (40 percent of the population), slow to warm/fearful (15 percent of the population), and difficult and feisty (10 percent of the population). Several research studies have found those individuals with a slow to warm/fearful or difficult and feisty temperament are most at risk for addiction (Milivojevic et al., 2012). However, more prevalent than temperament, I find trauma to be one of the biggest predictors of dysregulation (and subsequently SUDs). I believe a history of trauma—especially unresolved or unexplored trauma—is as significant a factor as a family history of addiction when it comes to predisposing individuals to emotional dysregulation and substance abuse.
Not everyone who experiences trauma gets “traumatized,” but if that trauma is left unresolved in the brain and body it can wreak havoc, as the adverse childhood experiences (ACE) study (Felitti et al., 1998) has backed up with research. Trauma leaves children and teens restless, irritable, and discontent. It also damages trust and safety, and disrupts the building blocks of their sense of self, especially if experienced during their developmental years. If this occurs, their sense of self gets developed around the trauma, leading to insecure attachment styles and stubborn core belief systems that do not always respond to cognitive approaches and Twelve Step work. In her book The Trauma Heart, Judy Crane, LMHC-QS, CAP, ICADC, CSAT, states, “Unresolved or unexplored trauma is the number one cause of relapse . . . I believe that trauma creates such despair that there are only three choices: relapse, go crazy, or suicide. Relapse is the healthiest choice and this is where chronic relapse occurs. There is a fourth choice: trauma resolution, a painful but amazing journey of healing” (2017).
I believe, like a frantically woven fabric, trauma and intoxication are overlapping braids of the same strand. In the pursuit to understand addiction, and further understanding trauma, I bumped up against three primary reasons why it often goes untreated.
First, the natural response to trauma is to repel from it. Nobody wants to talk about it, and certainly not teens, especially if they come from homes that discourage vulnerability or the sharing of emotions, or worse, are punished for it. There is often the fear of “betraying” perpetrators, who are commonly family members that teens still have to live with or see at family get-togethers.
Second, most individuals do not even realize they have trauma. Due to the lack of education and understanding about trauma, most people do not have the awareness they have been through trauma. In fact, if I just ask my clients if they have experienced trauma, they say “No” much more often than “Yes.” Many think of trauma as wartime experiences or extreme forms of abuse without knowing that trauma is less about the specific event and more about the imprint it leaves. Similarly, doctors do not judge concussions based on what hit the head, but more on the residual symptoms. Trauma can be covert and overt, intentional and unintentional, shocking and subtle. When I started to educate people on trauma, prior to assessing, is when many started realizing the extent of their pain and subsequently began having more compassion for their suffering.
Third, a common survival response to trauma is minimization. The worst childhood trauma history I ever heard was immediately followed up with a minimization about how they should not complain because others have had it worse. Trauma is inherently belittling and creates a fierce aversion to being pitied, so there is often a quick response to not identify painful experiences as traumatic in fear of feeling weak, pathetic, or “being a victim.” Additionally, teens are consumed with belonging and any experience that might exclude them from the pack often gets placed in the shadows—unfortunately an environment where only shame thrives. Despite trauma being extremely prevalent, we are a “Don’t talk about it” society, built on the bootstraps of perseverance and grit so much so that many teens keep their trauma a secret well into adulthood.
Trauma is no stranger to the addiction field, but for a long time it was mostly posttraumatic stress disorder (PTSD) that patients were primarily being screened for. While PTSD is quite prevalent in the SUD community, with lifetime rates of SUDs in individuals with PTSD between 36 and 52 percent (SAMHSA, 2020), not everyone with trauma fits nicely in the DSM’s criteria. Thanks to pillars in the psychology community like Dan Siegel, MD, Bessel van der Kolk, MD, Bruce Perry, MD, PhD, Stephen Porges, PhD, and Peter Levine, PhD, who have committed their life’s work to researching, treating, and educating on the topic, we have a much better understanding of trauma and implementation of trauma-informed care.
Many in the field refer to trauma as “Big T” and “Little T,” but I do not endorse referring to trauma as “little.” Again, it is less about what hits the head and more about the resulting injury; a point proven by an extremely prevalent type of trauma found amongst teens (and addicts in general) called “attachment wounding” or “relational trauma.” These are subtler than “Big T” shock traumas, yet usually more prolonged, and teens rarely have the insight, understanding, and language to put words to these experiences. However, these “Little T” relational traumas are a significant factor influencing dysregulation.
Overt shock traumas are quite easy to recognize: abuse, neglect, witnessing violence, and being a victim to violence, to name just a few. The covert relational traumas, however, are more abstruse and often unintentional. They are rooted in our everyday experiences such as growing up with emotionally unavailable or misattuned parents, stealthy discrimination, feeling misunderstood and out of place, even growing up with a chronically ill or sick family member. Covert traumas are rooted in pervasive and persistent relational and attachment wounding, often the most difficult and stubborn traumas to treat. If there was a primary strand in a braid that the other two get entangled around, it is attachment trauma. These experiences allow single strands to transform into bonded braids, and to call them “little” is an injustice.
Attachment traumas are critical to understand given the relationship they have to our resiliency. Perhaps in the future some questions pertaining to these kinds of ACEs will make their way on to the ACE study score sheet. Our early attachment experiences set the tone for our internal working model, our window of tolerance, and our neural plasticity. These building blocks of our sense of self are the very foundation of our resiliency, even influencing the likelihood of being exposed to and of bouncing back from overt shock traumas.
Teens should be learning about themselves; the world; how to make friends; hobbies; their worth; and their principles and values. Their brains—and its billions of neurons—should be blooming, firing, and initiating huge growth. However, if children and teens experience these traumas during their crucial developmental years (i.e., developmental trauma), it has profound effects on them. Their internal working models get formed around the pain, presenting as a myriad of mental health disorders. Their nervous system stays active in a fight-flight-freeze state and their window of tolerance becomes compromised. We can see the inhibited growth of key regions in the brain that regulate emotion and decision making (Siegel, 1999). At neurochemical levels, we can even measure how trauma disrupts the release and restoration of key mood stabilizers like opiate endorphins, dopamine, serotonin, GABA, norepinephrine, and many more (van der Kolk, McFarlane, & Weisaeth, 1996; van der Kolk, 2014).
Sir Isaac Newton proposed that for every action in nature there is an equal and opposite reaction. This law applies to human nature as well. If we have deficits, we seek balance; if we are in danger, we seek safety; if we are cold, we seek warmth; and if we are depleted in certain neurotransmitters, we seek it out in other ways. This inherent tendency to seek balance, to chase pleasure and avoid pain, that very biological drive within us, has helped us survive as a species for a very long time, but is also deeply rooted in addictive tendencies. Addiction, simply put, is the extreme manifestation of the normal human condition. So, if at a young age teens are lacking certain biological regulating chemicals and have excess stress hormones, nervous systems operating in overdrive, psychological struggles, and social difficulties, we can see why teens would be drawn to the biopsychosocial rewards of intoxication and continue onward to oblivion and beyond. The good news is these systems have plasticity—the ability to be reshaped—especially at a young age. Furthermore, with an understanding of how intertwined trauma, attachment, and intoxication are, we can now use this information in treatment. If a primary source of the deficits facing teens battling addiction are rooted within the context or absence of understanding relationships where it feels safe to ask for help, then one of the most important aspects to healing will be within the context of nurturing relationships where they feel felt, understood, and encouraged to ask for support.
A 2007 study examining relapse rates followed 1,162 participants over the course of eight years (with a 94 percent retention rate) and discovered some interesting findings in regards to relapse. The researchers found that within the first twelve months 64 percent of the participants relapsed, and within one to three years 34 percent of participants relapsed. However, relapse rates dropped significantly if they reached three to five years sober (14 percent relapse rate) and that rate remained unchanged at five to eight years abstinent as well. After discovering the likelihood to maintain abstinence goes significantly up after three years sober, the researchers sought to analyze what treatment methods led to the best results. They found there was not any one specific type of treatment that correlated strong enough with predicting abstinence. However, the one connecting variable that predicted reaching three or more years abstinent was participants had integrated into some sort of community that supported their recovery. Whether it was a Twelve Step group, a Buddhist group, a religious group, a yoga community, a therapy group, an alumni group, or others, those participants who integrated into a supportive community had the best chances of maintaining abstinence (Dennis, Foss, & Scott, 2007). Therefore, it can be posited that in the fight against addiction, relationships are one of our greatest assets.
We are in the midst of an addiction epidemic. Overdose rates have been exponentially increasing since the late 1970s (Jalal et al., 2018). The current drug of choice changes, but that is simply a distraction from the bigger issue: an ingrained, societal “relationship to intoxication” (Gust & Smith, 1994). The drive to alter our experience is universal and intensified for those with certain predispositions. As Judith Grisel, PhD, stated in her book Never Enough, “The solution is not to be found on the supply side, but rather depends on a change in demand, and that’s likely to be an inside job. We are social creatures raised in contexts that profoundly influence the structure and activity of our neurons. It follows that the answer to the addiction crisis is not solely in the brain, but must include the context” (2019).
Our society is not lacking in resourcefulness, but if we really want to help teens with SUDs we have to look at the glaring deficits in resiliency, where these deficits originate, and teach them how to access and repair them.
What Dr. Grisel is proposing is not just a hypothesis; we have scientific evidence that supports her claims. Interpersonal neurobiology—the study of relationships and how they influence our brains, bodies, and minds—backs up her declarations with hard science. According to Allan Schore, PhD:
Intimate contact between the mother and child is mutually regulated by the reciprocal activation of their opiate systems . . . increasing pleasure in both brains. In these mutual gaze transactions, the mothers face is also inducing the production of not only endogenous opiates but also regulated levels of dopamine in the infant’s brain. It is established that opioids enhance play (social) behavior and increase the firing of dopamine neurons. In this manner, the organization of the developing brain occurs in the context of a relationship with another self, another brain (2003).
While every drug releases its own unique chemicals at their peak, they all release a few of the same chemicals: opiate endorphins, dopamine, and oxytocin (Daily, 2012). Subsequently, at the peak of a genuine and attuned moment where we feel felt and understood, our body releases these very same chemicals (Siegel, 1999). Through healthy and connected relationships, teens can access the very chemicals being sought through substances and addictive processes. These chemicals not only release reward chemicals, but as I mentioned previously, they are key neuromodulators and mood stabilizers. This attuned moment will help us feel more regulated, even in the presence of danger and the absence of any actual solution.
Our society is not lacking in resourcefulness, but if we really want to help teens with SUDs we have to look at the glaring deficits in resiliency, where these deficits originate, and teach them how to access and repair them. If we are asking them to let go of their attachment to intoxication, it is necessary to offer them healthier attachments, teach them how to attach to others in a healthy way, ensure those around them know how to provide a secure base to attach to, and foster a society that encourages connection over stoicism and intoxication as self-care. Adolescent SUDs should be seen as a single strand of a larger braid: a braid of dysregulation held together by trauma. Insecure attachment styles are more than just “styles,” they are the modus operandi as a result of trauma. If we expect to properly treat this precious population and truly battle our societal addiction epidemic, it will require untangling these strands of intoxication, attachment, and trauma, not just with those we work with but also within ourselves. A healthier us will ultimately result in a healthier them.
Curtis Buzanski, LMFT, LAADC, is a licensed therapist and addiction counselor. He first entered the addiction field in 1997, shortly after entering recovery himself. He has a private practice in Fair Oaks, California, where he primarily specializes in treating trauma and substance abuse as well as other mental health issues. Aside from holding a master’s in counseling psychology from the University of San Francisco, he is trained in EMDR and the comprehensive resource model. In addition to his private practice, Buzanski provides clinical supervision at a dual-diagnosis intensive outpatient program and has been a consultant for programs and facilities.