The Adolescent Mind: Intoxication, Trauma, and Attachment
Published in The Therapist: 2021 July/ August edition
Courtesy of California Association of Marriage and Family Therapists (CAMFT)
Adolescence is a turbulent time in the best of circumstances; riddled with pressures, paradoxes, conscious desires, and subconscious drives, adolescents are more mature than they’re often given credit for yet saddled with an undeveloped brain. Additionally they have a deep yearning to belong while simultaneously needing to differentiate. This need to be accepted while striving to be independent- at a time when they are still heavily dependent on adults- creates a lot of internal and external strain. All these double binds and dilemmas require an immense amount of resiliency and emotional support.
Dr. Kenneth Ginsburg, a specialist in adolescent medicine and co-founder of the Center for Parent and Teen Communication, proposed children and teens need “7 C’s” to foster healthy resiliency: competence, confidence, connection, character, contribution, coping, and control. Going deeper than resiliency, these 7 C’s also help shape one’s sense of self; or as John Bowlby called it, their Internal Working Model (Bowlby, 1969). It is the unique lens of how they see themselves and the world around them (Wallin, D. 2007, 26-28). Developing a healthy internal working model is no easy task; it requires a great deal of attention, attunement, and modeling on the caregiver’s part. If one develops a healthy internal working model they tend to feel secure in their worth, are able to take risks in relationships, face challenges in life head on, ask for help, and set healthy boundaries. In Attachment Theory, this is referred to as a Secure Attachment Style (Wallin, D. 2007, 48-49).
What is of particular interest to those working with teens who struggle with substance abuse and comorbid mental health issues, is what happens when an injured internal working model develops. This insecure attachment style is defined by negative core beliefs, difficulty building relationships, a perpetual lack of feeling safe or belonging, an aversion to asking for help (or a learned helplessness), and difficulty regulating emotions (Wallin, D. 2007). When the 7 C’s become compromised it weakens resiliency and leads to a significant predisposition to substance abuse and mental health struggles.
Jon Daily, an expert on the treatment of adolescent addiction, states in his book Adolescent & Young Adult Addiction: The Pathological Relationship to Intoxication and the Interpersonal Neurobiology Underpinnings, “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” (Daily, J. 2012, 23). Addressing this dysregulation is crucial to addressing mental health issues such as substance use disorders, disordered eating, self harm, as well as the mood disorders that tend to accompany them.
Dysregulation: Treat the Illness not the Symptoms
A patient with an infection typically has significant symptoms, but treatment is aimed at the source of the infection because symptom reduction alone will not heal the infection. If a teen is chronically abusing substances, cutting, restricting, purging, and/ or obsessively gaming, these indicate a glaring deficit in the ability to regulate emotions and impulses. Helping teens effectively regulate their emotions is critical in the stabilization phase of treatment but it’s important to not stop there. We must ask: why are they dysregulated in the first place?
Teens with substance use disorders 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 haven’t quite integrated a healthy lifestyle. Additionally, many weren’t well to begin with so getting them abstinent doesn’t mean getting them well.
Average teen development is a daily roller coaster as is, let alone when they’re pumping their brain and body full of chemicals. Therefore, abstinence is crucial in determining what symptoms are being driven by which sources. It is hard to diagnose a broken down car that’s underwater but if we dry it out we start to see what else might be going on. Beneath the addictions and the behaviors we can see a compromised ability to regulate emotions. Some of these are being influenced by the typical trials and tribulations teens face, but it can also be an indication of emotional struggles and stunting, which are often 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. Were we to make this a priority during the formidable years of development, the ripple effect would be considerable.
Dr. Alan Schore, a leader in the field of attachment and interpersonal neurobiology, has studied affect regulation for decades. His work has shown that the ability to regulate emotions does not just happen genetically like growth spurts and puberty do, rather it’s dependent on healthy consistent interactions with others. Despite our society’s obsession with independence and self sufficiency, a child raised in physical or emotional isolation will not develop to be a healthy well adjusted person.
Adolescent’s learning to identify, understand, and make sense of their biological, psychological, and social experiences, as well as how to respond to them, is critical for what Maslow referred to as “self actualization” (Maslow, A.H. 1943, 370-396). Interoception, the awareness of internal experience, whether it is hungry, angry, tired, or cold, is a crucial first step for achieving the ability to self-soothe (Porges, S. 2011). As Jack Kornfield often says, it is hard to tend to anything we are not aware of. If we’re not aware we’re cold then sickness is likely. If we’re not aware we’re hungry, starvation is a possibility. And if we’re not aware we’re angry, lonely, or anxious, how will they know how to tend to those emotions? Further complicating this process, awareness alone does not always bring about change; we also need to learn how to label, respond to, and manage our experience— to self-regulate.
Again, this type of self-regulation develops within the context of consistent, predictable, and attuned care giving (Siegel, D. 1999). The ability for adolescents to manage their own distress comes from repeated childhood experiences of a loved one recognizing they’re overwhelmed, helping soothe them, and teaching them to soothe themselves; this is co-regulation (Siegel, D. 1999). Through co-regulation there are learned experiences that they’ll be ok and asking for help is actually beneficial, and they’ll learn how to self-soothe, and eventually, help soothe others; thus, nurturing their internal working model and expanding their tolerance for stress (Siegel, D. 1999). For babies, being hungry, tired, or scared is barely tolerable; and can quickly lead to a meltdown. However, if the caregiver can notice the distress and help bring relief, consistently and predictably, the child learns to tolerate the experience better over time and in turn build a healthy Window of Tolerance for both excitatory and inhibitory stress (Ogden, P., Minton, & K., Pain, C. 2006).
Examined at a deeper level, these regulatory regions have a direct impact on key neuromodulators; which are neurotransmitters that regulate (up and/or down-regulate) other neurotransmitters. Some of these crucial neuromodulators consist of oxytocin, opiate endorphins/ dynorphins, dopamine, norepinephrine, and serotonin to name a few (Panskepp, J. & Biven, L., 2012). Anyone who works in the substance abuse field should be quite familiar with these neurotransmitters as key chemicals released by various drugs and may already be drawing connections to the relevancy of these systems, especially in teens who become dysregulated.
But again, how do they become dysregulated? Starting to ask this question means understanding substance use disorders better. For this dysregulation to occur to the extent that it creates dysfunction, there has to be repeated disruptions along the timeline of development that makes teens predisposed to poor emotional regulation and subsequently substance use disorders.
Predispositions to Dysregulation and Substance Use Disorders
Those battling substance abuse and addiction have biological, psychological, and social deficits coupled with genetic predispositions that create powerful drives; it’s no wonder relapse rates are in the 80-90 percent range (Gust, D., Walker, S., & Daily, J. 2006). It is my belief that, aside from denial, dysregulation is the number one reason for relapse. Rarely do I hear of people relapsing due to cravings alone ( I would even argue cravings are a form of dysregulation). Rather, it is more common relapse is fueled by an attempt to numb, avoid, or enhance how they feel. This is a very human response- one we all have to battle daily- but some populations struggle with dysregulation more. Some research points to genetics (Flagel, 2011) and some to temperament (Milivojevic D. et al. 2012), but I believe a history of trauma, especially unresolved or unexplored trauma, to be a more significant predictor of emotional dysregulation, and subsequently substance use disorders- it’s as significant a factor as a family history of addiction.
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 Study has backed up with research (ACES Study, 1998, 2018). Trauma leaves imprints that create an internal storm of restlessness, irritability, and discontent. It damages trust and safety and disrupts the building blocks of their sense of self, especially if experienced during their developmental years. If this occurs, a child’s sense of self gets developed around the trauma, leading to an insecure attachment and stubborn core belief systems that don’t always respond to cognitive approaches and 12-step programs. In her 2017 book, The Trauma Heart, Judy Crane 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” (Crane, J. 2017). As in a frantically woven fabric, trauma and intoxication are overlapping braids of the same strand.
Trauma: Covert, Overt, & Developmental
It is a natural response to repel from traumatic material. Unfortunately, the avoidance why so many people carry unresolved imprints of trauma. Additionally, there is a societal misunderstanding and stigma around the word. Nobody wants to talk about it, and certainly not teens. Sure, teens want to differentiate, but they don’t want to be ostracized. If they come from homes that discourage sharing emotion and vulnerability, or that punish them for it, this fear is intensified. As if that isn’t enough, due to the lack of education and understanding, most people aren’t even aware they have been through trauma. In fact, when I ask clients if they have experienced trauma, they say no much more often than yes. Many immediately think of war time experiences or extreme forms of abuse and assume they are trauma-free if they haven’t endured that type of suffering.
But trauma is less about the event and more about the imprint it leaves. Doctors do not judge a concussion based on what hit the head, they judge it based on the residual symptoms. Trauma can be covert or overt, intentional or unintentional, shocking and subtle. When I began educating people on this instead of simply asking about it, many started realizing the extent of their pain. However it also led me to another barrier, minimization. The worst childhood trauma history I ever heard was immediately minimized by the client demurring that others have had it worse. Trauma is inherently belittling and creates a fierce aversion to being pitied, so they often quickly reject the identification of painful experiences as traumatic for fear of feeling weak and 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- an environment where only shame thrives, not healing. Trauma is extremely prevalent, yet our “don’t talk about it” society, which prioritizes perseverance and grit, discourages any kind of honest acknowledgment of reckoning- so much so that many teens keep their trauma a secret well into adulthood.
Trauma is no stranger to the substance use disorder (SUD) field, but for a long time addicts were primarily screened for post-traumatic stress disorder. While PTSD is about three times more prevalent in the SUD community than in the general population, not everyone with trauma fits nicely in the DSM-V’s criteria. Thanks to pillars in the psychology community like Dan Siegel, Bessel Van Der Kolk, Bruce Perry, Steven Porges, Peter Levine, and others who have committed their life’s work to researching, treating, and educating on the topic, we now have a much better understanding of trauma and more effective implementation of trauma informed care.
Many in the field differentiate between “Big T” and “little t” trauma but I don’t believe it’s a helpful distinction. Again, it’s less about what hits the head and more about the injury, a point proven by an extremely common type of trauma found amongst teens- and addicts in general- called attachment wounding, or relational trauma. These relational traumas are more subtle than “Big T” shock traumas yet are usually more prolonged, and since teens rarely have the insight, understanding, and language to put words to these experiences they are a significant factor influencing dysregulation.
Overt shock traumas- abuse, neglect, witnessing or suffering violence- are quite easy to recognize. The covert relational traumas, however, are more abstruse and often unintentional. They’re rooted in our every day experiences such as growing up with emotionally unavailable or mis-attuned parents, being subjected to stealthy discrimination, feeling misunderstood and out of place, even growing up with a chronically ill family member. Covert traumas are rooted in pervasive and persistent relational and attachment wounding, and they’re often the most difficult and stubborn traumas to treat. If there was a primary strand entangled in the braid of trauma and intoxication, it’s these attachment traumas. To call them little is an injustice.
Our early attachment experiences have biological, psychological, and social ripple effects. by impacting neural plasticity and neurochemical regulation, they set the tone for our internal working model, and shape both our window of tolerance and social skills. These building blocks of our sense of self are the very foundation of our resiliency, even influencing the likelihood of being exposed to, and bouncing back from, overt shock traumas. Attachment traumas are critical to understand given the influence they have on our bio-psycho-social development; so it would be useful for questions pertaining to these adverse childhood experiences to make their way on to the ACES score sheet.
Teens should be learning about the self and the world, making friends and developing hobbies, discovering their worth, principles, and values. The adolescent brain, and it’s billions of neurons, should be blooming, firing, and initiating huge growth. But when a child experience these traumas during their crucial developmental years (developmental trauma), it has a profound impact. Their internal working model gets formed around the wounding, and this later presents as a myriad of mental health disorders. Their nervous system stays dysregulated fluctuating between a sympathetic Fight/ Flight and a dorsal vagal Freeze/ Collapse; they’re not able to stay in their ideal ventral vagal, or social engagement, zone; presenting as any number of DSM-V diagnoses (Porges, S. 2011).
With today’s technology, we can see hot areas in the brain that should be cold and cold areas that should be hot (Amen Clinics, 2009). We can see inhibited growth of key regions in the brain that regulate emotion and decision-making (Siegel, D. 1999). We can even measure how trauma disrupts the release and restoration of key mood stabilizers like opiate endorphins, dopamine, serotonin, GABA, and norepinephrine at the neuro-chemical lelel (van der Kolk, B.A., et al. 1996) (van der Kolk, B.A. 2014). Trauma- even covert attachment trauma- has profound impacts on the developing mind.
Newton’s Third Law
Sir Isaac Newton proposed 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 will seek restoration. When we are in pain we seek relief, when we are cold we seek warmth, and when we are depleted in certain neurotransmitters we seek that chemical out in other ways. This biological drive to seek balance, to chase pleasure and avoid pain, has helped us survive as a species for a very long time, but it is also a driving force in addictive tendencies.
Addiction, simply put, is the extreme manifestation of the normal human condition. So when teens lack certain biological regulating chemicals while experiencing excess stress hormones, a dysregulated nervous system, psychological struggles, and social difficulties, it’s obvious why teens would be drawn to the bio-psycho-social rewards of intoxication and continue on into oblivion. The good news is that these systems have plasticity, the ability to be reshaped, especially at a young age. Furthermore, with a solid understanding of how trauma, attachment, and intoxication intertwine, we can now apply this information to treatment. If the deficits teens are facing is rooted in the context, or absence of, connected and understanding relationships, then one of the most important aspects to healing will be within the context of nurturing relationships where they feel seen, understood, and unrestrained 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 unearthed some interesting discoveries. The study found found that within the first year of sobriety 64 percent of the participants relapsed and that within one-to-three years 34 percent relapsed. The relapse rate continued to drop significantly as participants reached three-to-five years sober- 14 percent which remained unchanged at the five-to-eight year follow ups.
After discovering that the likelihood of maintaining abstinence goes up significantly after three years of sobriety, the researchers analyzed which treatment methods led to the best results. While they couldn’t find any one specific type of treatment that predicted long-term abstinence, the one connecting variable for success was when participants had integrated into a community- whether it be 12-step, a Buddhist group, a religious group, yoga, a therapy group, or alumni groups- those that integrated into a community had the best chances of maintaining abstinence (Dennis, M., Foss, M, & Scott, C. 2007). Thus, we can posit that in the fight against mental health and addiction, community and relationships are some of our greatest assets.
Relationships as Medicine
We are in the midst of an addiction epidemic. Overdose rates have been increased steadily since the late 1970’s. (Jalal, et al. 2018) The current trending drug changes, but the bigger issue is an ingrained societal “relationship to intoxication” (Gust, D. 1994). The drive to alter our experience is universal; but it’s intensified for those with certain predispositions. As Judith Grisel stated in her 2019 book Never Enough: The Neuroscience and Experience of Addiction, “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” (Grisel, J. 2019).
What Dr. Grisel is proposing is not just a hypothesis. Interpersonal neurobiology- the study of relationships and how they influence our brain, body, and mind- backs up her claims with hard science. As Alan Schore so eloquently describes it: “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” (Schore, A. 2003).
While every drug releases its own unique chemicals, at their peak they all release a few of the same: Opiate endorphins, Dopamine, and Oxytocin (Daily, J. 2012). At the peak of genuinly attuned moments during which we feel seen and understood, our body releases these same chemicals (Siegel, D. 1999). Subsequently, through healthy and connected relationships teens can access the very chemicals being sought through destructive means. These are not only reward chemicals, they’re also, as I mentioned earlier, they are key neuromodulators and mood stabilizers. So an attuned moment will help us feel more regulated; even in the absence of a solution to the issue at hand.
If we really want to help teens with comorbid substance use disorders we have to look at the glaring deficits in resiliency and teach them how to access and repair them. If we are asking them to let go of their attachment to intoxication, self harm, or disordered eating, we must offer them healthier attachments. We must teach them how to attach to others in a healthy way and foster a society that encourages connection over rugged self-reliance and intoxication as self-care.
Adolescent substance use disorders should be seen as a single strand within the larger braid of dysregulation entangled with trauma. An insecure attachment styles is more than a “style,” it is the modus operandi that results from trauma. If we hope to treat this precious population and truly battle our society’s addiction epidemic, we must untangle these strands of intoxication, attachment, and trauma, not just within our clients, but also within ourselves. A healthier Us will ultimately result in a healthier Them.
Crane, J. (2017) The Trauma Heart. Deerfield Beach, Florida: Health Communication, Inc
Daily, J. (2012) Adolescent and Young Adult Addiction: The Pathological Relationship to Intoxication and the Interpersonal Neurobiology Underpinnings. Fair Oaks, CA: Jon Daily, LCSW, CADC-II/ Recovery Happens Counseling Services
Grisel, J. (2019) Never Enough. New York: Doubleday
Gust, D. (1994) Effective Outpatient Treatment for Adolescents. Fair Oaks, CA: New Directions Program Corporation
Gust, D., Walker, S., & Daily, J. (2006) How to Help Your Child Become Drug Free. Shingle Springs, CA: FinishLine-Print Specialists
Ogden, P., Minton, & K., Pain, C. (2006) Trauma and the Body: A Sensorimotor Approach to Psychotherapy. New York, NY: W.W. Norton & Company, Inc.
Panskepp, J. & Biven, L. (2012) The Archeology of Mind: Neuroevolutionary Origins of Human Emotions. New York, NY: W.W. Norton & Company, Inc.
Perry, B.D., & Szalavitz. M. (2006) The Boy Who Was Raised as a Dog. New York, NY: Basic Books
Porges, S. (2011) The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. New York, NY: W.W. Norton & Company, Inc.
Schore, A. (2003) Affect Dysregulation & Disorders of the Self. New York, NY: W.W. Norton & Company Inc.
Siegel, D.J. (1999) The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. New York, NY: The Guilford Press
van der Kolk, B.A., et al. (1996) Traumatic Stress. New York, NY: The Guilford Press
van der Kolk, B.A. (2014) The Body Keeps the Score. New York, NY: Penguin Books
Wallin, D. (2007) Attachment in Psychotherapy. New York, NY: The Guilford Press
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