Post on 25-May-2020
Running head: TRAUMA, ADDICTION, AND THE BRAIN
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Trauma, Addiction, and the Brain: Utilizing Brain-based Interventions to Heal the Effects of
Developmental Trauma.
A Literature Review
Presented to
The Faculty of the Adler Graduate School
________________________
In Partial Fulfillment of the Requirement for
The Degree of Master of Arts in
Adlerian Counseling and Psychotherapy
_________________________
By
Danielle Landa
_________________________
Chair: Jared Bostrom
Reader: Lisa Venable
_________________________
July 2018
TRAUMA, ADDICTION, AND THE BRAIN
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Trauma, Addiction, and the Brain: Utilizing Brain-based Interventions to Heal the Effects of
Developmental Trauma.
Copyright © 2018
Danielle Landa
All rights reserved
TRAUMA, ADDICTION, AND THE BRAIN
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Abstract
This paper will examine trauma experienced in childhood that causes brain changes correlated
with addiction vulnerability later in life. Limitations with historical treatment approaches will
also be discussed along with changes in the evolving understanding of addiction. Several
recommended treatment strategies will be included that have demonstrated to be efficacious in
addressing brain changes resulting from addiction and trauma.
Keywords: trauma, addiction, mindfulness, EMDR, attachment
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Acknowledgements
Sincere thanks to my family and friends for support, understanding, and space to
complete this project. Thank you to Jared Bostrom for the encouragement and guidance along
the way. Thank you, Lisa Venable, for being my reader, and for demonstrating the power of a
reframe through an Adlerian perspective in your group therapy course. To Christine Mannella,
for starting me on this journey, and to Jana Goodermont for leading with love.
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Dedication
This project is dedicated to my family. To my parents, Dan and Val, who have provided
me with the foundation of who I am today. To Kevin, for loving me even on my worst days, and
to Cole, Kaden, Trey, and Kaia, whom I love more than I can find the words to express, who
mean everything to me, and who put up with me being an incredibly busy mom for the past two
and a half years.
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Table of Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Attachment Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Attachment through an Adlerian lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Attachment and the brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Attachment and substance use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The ACE Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Trauma through an Adlerian lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Trauma and Brain Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Trauma and memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Amygdala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Hippocampus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Prefrontal Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Anterior Cingulate Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Corpus Callosum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Biopsychosocial Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Addiction through an Adlerian lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Addiction and the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Reward Circuit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Amygdala and Nucleus Accumbens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Hippocampus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Prefrontal Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Anterior Cingulate Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Trauma and Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Limitation of Behavioral Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Required Elements of Effective Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Window of Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Brain-based Therapies for Treating Trauma and Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AEDP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mindfulness Meditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mindfulness through an Adlerian lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mindfulness Meditation and Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mindfulness and the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Amygdala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Hippocampus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Prefrontal Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Anterior Cingulate Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
EMDR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
EMDR and Addiction Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
EMDR and the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adlerian Treatment of Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Implications for Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recommendations for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Trauma, Addiction, and the Brain: Utilizing Brain-based Interventions to Heal the Effects of
Developmental Trauma
According to JAMA Pediatrics, nearly 60% of children reported experiencing some form
of violence against them in 2011 (Finkelhor, Turner, Shattuck, & Hamby, 2013). Statistics vary
regarding the prevalence of childhood traumatic experience depending on the population
sampled and the type of trauma identified. Additionally, traumatic events are likely
underreported given the subjective nature of experience, and the fact that trauma survivors may
not speak up due to embarrassment, fear, or feelings of low self-worth. However, it is evident
that it is a problem that requires attention. Childhood trauma manifests in a variety of ways as
people go through life, and it has been documented that a significant number of traumatized
people will develop a substance use disorder (Mate, 2007). Research is plentiful regarding the
effects that childhood trauma has on the brain. The affected areas are those implicated in emotion
regulation, reward, and higher order functions such as planning and processing. It is clear that
these areas are negatively impacted by trauma--especially prolonged experiences such as neglect
or family violence. Damage to these areas can cause difficulties with impulse control, self-
esteem, and motivation. These changes are likely the cause of many diagnosed mental health and
substance use disorders.
Insecure attachment, which often results from childhood trauma, can also cause an
inability to effectively regulate emotions as well as it can impair relationship skills needed for
interpersonal connection. These deficits can leave an individual vulnerable to addiction and
other stress-related disorders. Earned secure attachment is possible to develop as an adult
through a strong therapeutic relationship. The therapist creates a right-brain to right-brain
connection with the client to help the client learn to self-regulate and to develop the areas of the
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brain related to attachment that are missing. The ability to self-soothe is a necessary foundational
skill in the process of addiction recovery.
Mindfulness meditation is one alternative therapy that has been proven to address the
underlying physiological deficits that have been caused by trauma and are associated with
addiction. Mindfulness has been scientifically proven to increase the grey matter thickness in the
areas of the brain that are damaged by trauma and improve the functional connectivity between
areas in the brain that help with concentration and emotion regulation (Ireland, 2014).
Specifically, these areas include: the hippocampus, the prefrontal cortex, and the anterior
cingulate cortex. Also, activity in the amygdala decreases and the connections that it has to other
areas of the brain weaken through the practice of mindfulness. These areas of the brain are all
involved in the addiction process.
Mindfulness-based relapse prevention is a component of some treatment protocols that
help those recovering from addiction become more aware of the way that their bodies respond to
various stimuli (Enos, 2016). Through this process, triggers are identified and brought into
greater awareness. Furthermore, meditators become proficient “urge surfers” when cravings
inevitably occur. Mindfulness is similar to the Adlerian perspective of being in the “here and
now” and also in reorienting the client to more useful behaviors.
EMDR is a front-line therapy that effectively desensitizes traumatic memories that cause
maladaptive behaviors in those who are affected. The adaptive information processing model is
the foundation upon which EMDR was developed (Shapiro & Laliotis, 2011). This model asserts
that early memories shape the way we respond to present situations and that the brain has an
innate desire to heal. EMDR has proven to be effective at reducing distress that can trigger
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substance use. Further, EMDR can be used to target and desensitize cravings and urges
associated with substance use as well as the feeling states that trigger use and relapse.
Trauma
“Trauma comes from the Greek word for wound, which vividly describes what it feels
like” (Najavits, 2017, p. 2). Traumatic experiences are those that are overwhelming and
frightening to the individual; however, it is important to understand that reactions to experiences
are not universal. The difficulty in diagnosing trauma lies in the subjective nature of experience
(what is traumatic for some is not traumatic for others), and the subjective nature of the
assessment methods (Dong Hoon Oh, 2012). Many people don’t realize that what they have
experienced is considered trauma. This is especially in family violence situations where this
lifestyle was “normal” for them, which amplifies the need for clinicians to screen for ACEs
within their practice. It is also important to remember that because traumatic interpretation is
individualized, to look for symptoms of traumatic stress rather than simply evaluate the
experience of the individual. According to the DSM-V, some of the symptoms of posttraumatic
stress disorder are: flashbacks, nightmares, persistent negative thoughts, hypervigilance, and
sleep disturbance (American Psychiatric Association, 2013). Although it is not currently a
formal diagnosis, this paper will refer to trauma as developmental trauma, which is the chronic
exposure to trauma (typically in the form of abuse) during the developmental years of a child
(DeAngelis, 2007).
During the process of normal learning, the sympathetic nervous system is activated which
signals the body to flee from a threat, followed by the activation of the parasympathetic nervous
system, which calms the body down so that learning can occur (Curran, 2017). In threatening
situations, the autonomic nervous system is activated, and the body responds by going into fight
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or flight mode (sympathetic stress response: mobilization) (Corrigan, Fisher, & Nutt, 2010).
However, if the situation is overwhelming or the individual is unable to flee, the body goes into
submission or freeze mode (parasympathetic stress response: immobilization). During this
response, the nervous system is completely activated while the body is immobilized, similar to a
car with the gas and brake pedals simultaneously pressed (Curran, 2017). It is in this state of
immobility where the body prepares to die as painlessly as possible and floods the system with
opiates. This experience that causes deep distress and overwhelm to the individual is the
experience of trauma.
National Geographic depicted the trauma response of polar bears who had been
inoculated by a tranquilizer dart (Curran, 2017). Once the polar bears began to collapse, their
bodies consistently completed the escape movements that they were making just before their
capture. The belief is that this sequence of movements is necessary in order to release the energy
from the body and reduce the traumatic effects of the event. The book, “Why Zebras Don’t Get
Ulcers” by Robert M. Sapolsky (2004) explains similar findings within zebra populations. The
author notes that when zebras escape an attack from a predator, they engage in the pattern of
movement that they were doing just before they were immobilized. Once this course of
movement was complete, they move on as if nothing had ever happened.
Similarly, if a person survives a traumatic experience, the energy generated during the
fight, flight, freeze or collapse gets stored in the body, which explains why some refer to the
language of trauma as body sensations and suggest that treating trauma is in treating the body. It
also explains the visceral reactions that some have during flashbacks of their original trauma that
are accompanied with the same body sensations that were originally experienced. Furthermore,
this energy storage can cause the individual to overreact in real time to non-threatening
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situations. Alternatively, these same individuals often dissociate and appear to not respond at all
when faced with an actual threat (Corrigan, Fisher, & Nutt, 2010). “Thus, threatening and
traumatic experiences result in a bewildering array of cognitive, emotional and physiological
symptoms: emotions of fear, shame and rage; numbing of feelings and body sensations;
overactivity of the stress response system; and painful, negative beliefs about the self that serve
to intensify the distressing feelings and body responses” (Corrigan, Fisher, & Nutt, 2010, p. 1).
This understanding of trauma energy storage in the body was the beginning of the
development of somatic experiencing that is explained by Dr. Peter Levine in his 2017 book,
Trauma and Memory: Brain and Body in a Search for the Living Past. Dr. Levine has had
tremendous success using somatic experiencing techniques to address the trauma symptoms
within the body of those who are suffering. Dr. Levine helps patients complete the movements
that were disrupted through the traumatic experience that were necessary for them to survive. For
example, one patient who he had worked with had lost function in one of his arms after trying to
start his lawnmower. The patient had visited several specialists and was preparing for a surgery
that would regain the mobility he had lost. However, the surgeon believed his symptoms were
due to an underlying trauma and referred him to Dr. Levine. Through their work together, it was
discovered that the man, who was a first responder, had come onto the scene of a fatal car crash
involving a young child. When he reached into the vehicle to grab the key, he realized the
fatality and pulled his arm back. This movement was repeated when he later tried to start his
lawnmower and it triggered a traumatic response creating the somatic symptoms. After
completing the somatic experience exercises with Dr. Levine, his mobility returned to his arm
without the need for surgery. These findings exemplify the importance of addressing the body
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sensations that accompany the traumatic memory in order to address the trauma in a holistic
manner.
The Body Keeps the Score, a book by author Bessel van der Kolk (2015), details brain
imaging results of people who are experiencing flashbacks to trauma. Functional MRIs show a
heightened level of activity in the right brains of these individuals, especially in the right
amygdala--which he refers to as the brains “smoke detector” given its function for detecting
threats. The left brains show a significant decrease in activity during a flashback. Without the
left-brain function, a person experiencing a flashback has a reduced capacity to identify what
they are experiencing since the left side of the brain is needed for organization of thoughts. It
also houses Broca’s area that is implicated in the processes of language production and
comprehension (Alamia, Solopchuk, D’Ausilio, Bever, Fadiga, Olivier, & Zenon, 2016).
Because this, too, goes offline during flashbacks, a person is often left speechless and frozen
during the experience. This can retraumatize the individual as it perpetuates feelings of
overwhelm and powerlessness. Additionally, this lack of access to speech and thought
processing experienced during flashbacks explains why talk therapy is ineffective for treating
trauma.
Other brain regions that go offline during a flashback experience are the dorsolateral
prefrontal cortex (DLPFC) and the thalamus in both the right and left hemispheres of the
brain. The thalamus receives input from the environment and sends information to the amygdala
and to the frontal lobes (van der Kolk, 2015). The thalamus is responsible for filtering
information that comes into the brain. When it goes offline such as during a traumatic
experience, the filter is gone, and the individual becomes flooded with sensations and emotions.
The DLPFC is referred by Dr. van der Kolk as the “timekeeper” of the brain as it is responsible
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for putting time on our experiences. Specifically, the relationship between present experience
and our past, and the way that this perception may affect the future (van der Kolk, 2015). The
lack of functioning in these areas during a flashback explains why trauma memories continue to
be fragmented, feel as though they are not in the past, and are accompanied by strong somatic
sensations. When the memory comes up, the individual can’t access the part of the brain that is
associated with logical reasoning or cognitive thinking and therefore, feels as though they are
reliving the memory. It is for this reason, Dr. van der Kolk explains, that it is necessary to bring
these areas of the brain back online in order to successfully integrate the traumatic memory.
Attachment Theory
Attachment describes the emotional bond that forms between a baby and their adult
caregiver. Attachment can be secure or insecure based on this early relationship. A relationship
that results in an insecure attachment style is a form of trauma that can affect the individual well
into adulthood. A healthy attachment style is necessary to develop in order to maintain healthy
relationships with others as well as with the self.
Attachment theory was first developed by John Bowlby to understand the relationship
between a parent and child based on the way that the child reacted when they were separated
from their caregiver. Bowlby was working with children who were considered maladjusted
“affectionless children” and began to study the early interactions within their families as a means
for understanding their behavior (Bretherton, 1992). He later began working with children who
were hospitalized and kept away from their parents during their stay. These children, he noticed,
experienced significant and unnecessary distress as a result of this separation. (It is through his
efforts that treatment protocols have evolved within the hospital setting to allow parents and
children to remain together).
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Mary Ainsworth joined his research team in 1950 and went on to study mother child
bonds in Uganda before moving to Baltimore, where she continued to work with mother-baby
dyads. Eventually she developed her study that is referred to as the “strange situation” that was
designed to assess the correlation between a mother’s responsiveness to her baby with the baby’s
reaction to being separated and reunited with her (Bretherton, 1992). Patterns were recognized
within these babies that were consistent with the level of responsiveness of the mothers. For
example, mothers who were less responsive to the baby’s cues had babies who protested or
avoided them upon their return. This behavior was in contrast to babies with mothers who were
more responsive. When their mothers returned, they sought comfort from her and then moved
on to explorative play. The former group of babies were later determined to be insecurely
attached, while the latter, secure.
These patterns of attachment were also identified within adult test groups who were
analyzed to determine their patterns of attachment through their adult relationships. Adults were
interviewed about their recollections of their early attachment relationships. Patterns also
emerged within these interviews and three categories were identified: autonomous-secure,
preoccupied, and dismissive (Bretherton, 1992). Interestingly, the babies of these mothers were
found to be securely attached, ambivalent, or avoidant, respectively. This pattern demonstrates
the transgenerational learning of attachment and the importance of education and intervention to
interrupt maladaptive interaction patterns.
Through this research, it is understood that attachment is developed in the early years of a
child’s life through the responsiveness or attunement (ability to read and respond to the baby’s
cues) of the primary caregiver to the child. As the caregiver interacts with the baby, the baby
connects through their right brain with the right brain of the caregiver (Curran, 2017). Because
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the baby’s brain is underdeveloped, it relies on the caregiver to regulate their own emotions, and
also co-regulate the baby’s through attunement and activated mirror neurons. Affect regulation
involves the balancing of positive and negative emotions as it works to boost positive emotions
and reduce negative ones (Lipton, & Fosha, 2011). Simply put, when the baby cries, the mother
responds with a tone of voice that is higher pitched than her usual tone to match the baby’s
tone. Essentially, this validates the baby’s experience. The mother then begins to lower her tone
of voice which demonstrates an alternative response to the baby that is calm. This helps the baby
calm down as it is connecting with the mother, responding to her cues, and reducing its own
affective response. Similarly, when the baby is happy and the mother responds with enthusiasm,
the baby’s response becomes synergistic as it is amplified by the mother’s excitement. These
interaction patterns stimulate the development of the baby’s new neural pathways and are the
“scaffolding” upon which the baby’s right brain is built (Cihan, Winstead, Laulis, & Feit, 2014).
When attunement is consistent and affect regulation results, the baby develops secure
attachment. A secure attachment system helps a child develop a feeling of safety within the
world that deactivates their attachment seeking system. There are times when the parent
responds incorrectly to the baby’s cries which creates a rupture in the parent-child relationship
(Lipton, & Fosha, 2011). However, secure attachment is still able to form under these
circumstances provided the attachment figure repairs the rupture by soothing the baby. The use
of mindfulness is helpful with attunement: to pay attention to both the inner experience of the
parent as well as the experience of the child without judgement. This helps with the co-
regulation process that is imperative within the mother-baby dyad. With the attachment seeking
system calm, the child learns to explore the world through curious movement and learns to
regulate his or her own emotions.
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When a parent fails to respond to the baby’s cries, or doesn’t attune appropriately, the
baby doesn’t learn to calm down or that the attachment figure is safe. This is often the case
when a parent is experiencing depression or other mental illness. The parent has likely suffered
their own attachment injuries and is too preoccupied with their own pain to respond effectively
to their baby. Chronic misattunement leads to increased stress levels in the infant who develops
an insecure attachment style. A baby with insecure attachment has an activated attachment
seeking system that consistently tries to reach out to the caregiver but is not soothed. Over time,
the baby either becomes anxiously attached, disorganized, or avoidant (Lipton, & Fosha, 2011).
These early interaction patterns create an internal experience that is known but not
remembered by the individual because the hippocampus, which is not developed until after the
first year and a half of life, has not retained the events that connect to the feelings of the
experiences. Jack De Stefano and Shawna Atkins (2017) clearly state in their article,
Nonsuicidal Self-Injury, Interpersonal Neurobiology, and Attachment: Implications for
Counselors and Therapists, that the interpersonal environment has a direct effect on the
development of the baby’s brain. Specifically, they state that if the caregiver does not provide
appropriate attunement to the baby, the baby’s hippocampus and cortex will be underdeveloped,
while the amygdala will be hyperactive and the baby’s stress response will be chronically
activated (De Stefano & Atkins, 2017). These deficits compromise the baby’s ability to regulate
its emotions and self-soothe which lasts into adulthood and can lead to symptoms of depression
and other disorders.
It is important to identify an adult’s attachment style as it can provide insight into the
unconscious attachment patterns that are driving the relationship behavior. As explained earlier,
a baby who developed anxious attachment will most likely become an adult with an anxious
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18
attachment. The anxiously attached adult seeks closeness with their partner and is distressed by
separation. Additionally, this type of person has a highly activated attachment system that can
cause them to appear overly needy which can push their partner away. The avoidant attachment
style is developed in a child with a caregiver who is distant or emotionally unavailable. This
person develops a discomfort with closeness and will struggle in relationships with others who
try to become close to them. Disorganized attachment develops when the attachment figure is
abusive to the child. Babies learn early on that the attachment figure is needed for survival.
When that person is also the source of their fear, the child is forced to ignore their own feelings
and experiences in order to avoid upsetting the attachment figure in an effort to keep them
close. As an adult, this attachment system can cause attraction to a partner who is abusive, or the
person might become abusive themselves (Schwartz, 2016). Understanding the way in which we
relate to others through our attachment patterns brings conscious awareness to our behavior
which is the first step in being able to make a change.
Having an insecure attachment system creates problems in relationship with the self and
with others. Insecurely attached people have trouble regulating their emotions and managing
strong affect making it difficult to relate effectively with others. An inability to manage strong
emotions increases the risk of the individual being traumatized at some point in their lives as
they are more likely to become overwhelmed by an upsetting event. Considering that several
people can have a similar traumatic experience with only some of them becoming traumatized, it
is important to realize that those who have the most trouble managing strong emotions are more
likely to develop symptoms of PTSD (Lipton, & Fosha, 2011). Furthermore, insecurely attached
people will often end up with people who are similar to their early attachment figures as it is
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19
what is familiar to them. Some people believe that it is out of a need to work through unfinished
business of their childhood.
Attachment through an Adlerian lens. An Adlerian perspective of attachment would
consider the fictional final goal of an adult with an insecure attachment. The belief is that the
child who grows up with an insecure attachment system due to the inability to gain the attention
or affection of their attachment figure is attracted to a person who is also inattentive or
unaffectionate. This attraction is explained by the mistaken belief that the person will feel whole
inside if they could earn the affection, love, and attention of the new person in their life. The
reality is that even if the new person were to evolve and grow into the most loving and
responsive human, it would not erase or fill the void of the missing love from the early
attachment figure.
Attachment and the brain. Bruce Perry and Maia Szalavitz explain in their 2008 book,
The Boy Who Was Raised as a Dog, that the stress response is interconnected with the reward
circuitry of the brain. Further, when a child’s attachment seeking system is activated, the stress
response is also activated. When the baby’s caregiver responds to the baby’s cries, the baby
feels pleasure through the reward circuitry in the brain as the level of distress is reduced. This
repeated interaction between being responded to and soothed is how people learn that nurturing
is connected to pleasure which wires them for future human connection (Perry & Szalavitz,
2008). In children who have misattuned or abusive caregivers, the stress response is not calmed
through the reward pathway and pleasure is not experienced. They do not learn to value
nurturing relationships and human connections as their brains are not wired to do so. Those who
do not find comfort in human connection may be more likely to seek pleasure through artificial
means such as drugs and alcohol.
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Attachment and substance use. Insecure attachment can lead to problems with
substance use. The inability to regulate psychological distress is a primary reason believed to
cause the increase in substance use in insecurely attached individuals (Cihan, et al.,
2014). Problems specific to this population include but are not limited to: distress that
accompanies painful relationships, an inability to manage strong affect, or the need to escape the
discomfort of intimacy with others. Neuroscience has provided brain imaging scans that
demonstrate that attachment disorders have a negative impact on brain structures (Cihan, et al.,
2014). Because of the disease model of addiction, it is accepted that these brain changes are at
the root of addiction and must be addressed in order to reduce the addictive behaviors. “If
substance abuse is rooted in an inability to enter into satisfying interpersonal relationships, self-
regulate affect, and develop positive means of coping with stressors, then popularized CBT
techniques may miss the mark on long-term resolutions” (Cihan, et al., 2014, p. 535).
The caregiver-infant relationship also produces neurochemical changes during the
attachment interactions that are positive in the brains of both individuals. “As caregiver-infant
interactions progress, neural pathways are strengthened, and the resulting neurotransmitter
“high” becomes an expected and necessary part of daily life” (Cihan, et al., 2014, p.
533). Without this natural high that occurs in the brain, some individuals resort to the use of
substances as a means to experience the positive neurochemical release that they are
missing. Because of the immediate gratification that accompanies the release of drug-induced
neurotransmitters in the brain, individuals will often choose the path of substances as the fastest
or easiest way to feel better.
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21
The ACE Study
Nadine Burke Harris explains in her 2015 TEDTalk titled, How childhood trauma affects
health across a lifetime, that childhood adversity dramatically increases health risks throughout
life. Her information is based on a study conducted in the 90s by Dr. Vince Felitti of Kaiser
Permanente and Dr. Robert Anda of the Center for Disease Control. Together, these doctors
studied over 17,000 patients. The objective was to identify a correlation between childhood
adversity and health risks such as heart disease and cancer. The patients were screened for
ACE’s or Adverse Childhood Experiences using a 10-question survey that asked for a yes or no
answer to questions that identified adverse conditions under which they lived. Specifically, the
questions screen for physical, emotional, or sexual abuse, physical or emotional neglect, living
with a parent with a mental illness, having parents that separated, having a parent incarcerated,
living with domestic violence, or living with a parent with a substance use disorder. This
information was cross-referenced with the health outcomes that were experienced within this
same group and the results were overwhelming. They found that almost 70% of them had at least
one ACE and over 10% of them had 4 or more. The health risks were exponentially higher as the
ACE scores increased. Furthermore, functional MRIs showed anatomical differences in the
amygdalae and the prefrontal cortex in the brains of those with several ACEs compared to those
with zero or one. These differences are believed to be due to the chronic overactivation of the
autonomic nervous system that creates an environment of toxic stress within the body and also
leads to a reduction in immune and hormone function.
Children who are developing under these conditions experience a disruption in the
development of their nervous systems as they are chronically on alert for threats of danger. This
overactivation impedes their ability to be in the window of tolerance where learning and mood
regulation are integrated (Corrigan, Fisher, & Nutt, 2010). The inability to regulate emotions
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22
causes further distress and social isolation for children who often turn to drugs or alcohol at an
early age as a desperate attempt to self-regulate or escape. Dr. Felitti states, “Until we treat the
underlying ACE trauma, nothing will change, and a high percent of people will continue to die
early. These abuses create the top ten causes of death in the U.S.” (Felitti, 2014, p. 1).
Trauma Through an Adlerian Lens
Rudolf Dreikurs was ahead of his time when he said that “children are expert observers
but they make many mistakes in interpreting what they observe” (Dreikurs & Soltz, 1964, p.
15). The truth behind this statement is largely due to the underdevelopment of a child’s brain
and the lack of wisdom due to life experience and world view that is limited. Children often
believe that they are to blame for the maltreatment they are experiencing and develop mistaken
beliefs that they are not worthy of love or that they aren’t good enough. Other mistaken beliefs
that are commonly observed in children who are abused are that “big people overpower and hurt
little people” or “men or women are not safe”. Adler believed that gender guiding lines are
developed during childhood (Griffith & Powers, 2007). That is to say that children learn what it
means to be a man or a woman through their interactions with their parents or caregivers. When
the caregivers are not safe, children might accept this as a general truth about adults and grow up
to be attracted to an adult partner that is also unsafe. These are Adler’s “guiding fictions”
(Griffith & Powers, 2007, p. 41) that are subconscious but have tremendous influence over
decisions that are made throughout life.
Children who are living in chaotic environments also develop various survival strategies
that are necessary to keep them as safe as they can be. For example, they are often hypervigilant
to environmental signals of danger as they must always be on alert for threatening situations. In
abusive environments, children learn to dissociate from their own bodies to escape the pain and
discomfort of abuse. Adler referred to these maladaptive strategies as “safeguarding tendencies”
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23
(Griffith & Powers, 2007, p. 89) that are used to avoid the underlying pain or fear that the
individual is experiencing. Safeguarding becomes part of a person’s lifestyle and is reflected in
their interactions with others and themselves. The safeguarding that they learned to keep them
alive is often the problem interaction patterns that are causing them the most distress as adults. It
is important to validate their experience and help them understand that they did the best that they
could with the wisdom of a child and that those survival skills aren’t needed or useful when they
are in a safe environment. However, it is also important to assess for safety in the person’s life
as they may currently be in an adult relationship that is abusive.
Trauma and Brain Development
Alfred Adler wrote that “The style of life and a corresponding emotional disposition exert
a continuous influence on the development of the body” (as cited in Ansbacher & Ansbacher,
1956, p. 226). He explains that the emotions are expressed through the organs of the body and
that the organs often show symptoms due to psychological stressors experienced by the
individual. Adler referred to this as “organ dialect” or “organ inferiority”. Interestingly, Adler is
also quoted as saying that, “someday it will probably be proved that every organ inferiority may
respond to psychological influences and speak the language. . . a language expressing the attitude
of the individual toward the problems confronting him” (Griffith & Powers, 2007, p. 75).
Neuroscience has proven his theory through the use of both functional MRIs and
diffusion tensor imaging to measure volumetric changes that occur within the brains of various
populations. For example, studies that are done in adult populations who endorse a history of
childhood maltreatment are compared with adults who did not have those experiences. Various
areas of the brain are identified within the test groups to be anatomically different--in many cases
smaller, and hypo functioning, compared to the control groups. These areas are also the areas of
the brain that are implicated in the addiction process. A reduction in the functioning of these
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24
areas creates a neurological vulnerability to addiction that is necessary to address as part of a co-
occurring disorders treatment plan.
Trauma and memory. Many theories attempt to describe the phenomenon behind
trauma memory storage. One such theory suggests that due to the overwhelming sensations that
accompany trauma, the trauma memory becomes split off from conscious processing and thus is
stored elsewhere in the brain (Dekel & Bonanno, 2013). This faulty storage results in
unpredictable recall of traumatic sensations in the present moment. It has also been believed that
trauma memories have a rigidity around them that keeps them fixed during recall whereas
normal memories change and fade with time (Dekel & Bonanno, 2013). However, a study
conducted on post 9/11 survivors suggests that trauma memories can adapt and change under
certain circumstances. Certain therapies, such as EMDR, help process the trauma memories and
allow them to be stored within the prefrontal cortex of the brain where it is understood to be in
the past. It is important to be able to put trauma memories in the past to alleviate the
disorganized, fragmented storage that causes unpredictable and emotional recall.
The hippocampus stores memories of experiences and is not developed until 18 months
to 3 years of age. Because of this, experiences prior to this development are remembered
through body sensations or “recorded experientially” and are stored in the right brain (Lipton, &
Fosha, 2011). Children who are traumatized before the hippocampus is online do not have
language associated with their experience but can have a felt sense that something bad
happened. This further demonstrates the importance of addressing the body when working with
trauma.
The amygdala. The brain has three regions that are considered the “triune brain”: the
frontal lobes, the limbic system, and the brain stem (Fisher, 2011). The amygdala is part of the
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25
limbic system that is associated with emotional learning and memory (Dong Hoon Oh, 2012).
The role of the amygdala is to alert the rest of the body when danger is present. In people who
have experienced trauma, the amygdala becomes hypervigilant and perceives small threats as
large ones. For example, a person may hear a rude comment directed at them. Although this is
not life-threatening, the amygdala responds as if the person has been confronted by a hungry
tiger. Adrenaline is pumped into the brain and body, and oxygen is sent to the hands and feet to
enable the body to run; thus, leaving less oxygen in the brain to help with rational thinking, and
sending the individual into “fight, flight, or freeze” mode (PMSL Training, 2015). This is
referred to as an “amygdala hijack” and if the process is not interrupted within 10 seconds, it will
take the body approximately 18 minutes to break down the adrenaline that is released (PMSL
Training, 2015).
Studies have shown an increase in amygdala volume in children who have experienced a
traumatic event while a decrease in amygdala volume has been identified in adults who
experienced trauma as children (McCrory, De Brito, & Viding, 2010). Additionally, one study
indicated that a reduction in amygdala volume correlated to an increase in alcohol craving
(Wrase, Makris, Braus, Mann, Smolka, Kennedy, Cabiness, Hodge, Tang, Albaugh, Siegler,
Davis, Kissling, Schumann, Breiter, & Heinz, 2008). These discrepancies are not completely
understood, however, it is suggested that structural changes in the brain are dependent on the age
of the individual at the time of the trauma, as well as the duration and the severity of the
trauma. Other factors to consider are the child’s connections with other caring people, the
amount of control that they had over their environment and the predictability of the abuse (Perry
& Szalavitz. 2008). Despite the variability in experience and anatomical differences, the fact
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26
remains that exposure to recurrent trauma during development increases the activity of the
amygdala that creates hypervigilance which continues into adulthood.
The hippocampus. The Hippocampus, also part of the limbic system, plays an important
role in learning and memory and is activated during novel experiences. More specifically, it
allows the brain to differentiate between past and present memories (McCrory, De Brito, &
Viding, 2010). Additionally, the hippocampus aids in the regulation of amygdala activity
(Curran, 2017). Animal studies show a reduced capacity of hippocampal functioning resulting
from exposure to chronic stress (McCrory, De Brito, & Viding, 2010). Neuroimaging in humans
has revealed shrinkage in grey matter areas of the hippocampus in patients diagnosed with PTSD
(Wlassoff, 2015). This loss of volume is associated with depression, the inability to keep
traumatic memories in the past, and the experience of flashbacks when current situations are
similar to the original trauma. Equally problematic is the way that the stimuli become
overgeneralized, creating situations where a person experiences an extreme stress response to
many triggers that faintly resemble the original.
In addition to the processing of learning and memory, the hippocampus is one of the
primary sites in the brain where neurogenesis (growth and development of nervous tissue) occurs
(LaDage, 2015). Chronic stress down regulates the process of hippocampal neurogenesis
resulting in fewer new neurons that are produced in the brain. This is explained through the
stress response system which is activated as a result of an environmental stimulus. The
hypothalamic-pituitary-adrenal (HPA) axis releases cortisol as part of the fight or flight
response. Cortisol is a glucocorticoid that directly affects hippocampal neurogenesis (LaDage,
2015). This reduction in new neurons correlates to a reduction in spatial learning, which results
in cognitive deficits and reduced memory capabilities commonly experienced by individuals who
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27
are exposed to chronic stress and developmental trauma. These deficits decrease the ability to
learn from mistakes and implement more adaptive behavior.
The prefrontal cortex (PFC). The prefrontal cortex is the region of the brain that “is
responsible for regulating emotional responses triggered by the amygdala” (Wlassoff, 2015, p.
1). This area is also known as the “thinking center” of the brain, and is responsible for activities
such as self-awareness, problem solving, and planning (Psych Central, 2017). Neuroimaging
reveals decreased grey matter in this area of the brains of patients with PTSD. Studies also
indicate that childhood maltreatment is associated with hypoactivity in certain brain regions
including the prefrontal cortex (McCrory, De Brito, & Viding, 2010). This reduction in volume
and functionality of the prefrontal cortex explains the emotional dysregulation that is often seen
in trauma survivors as it is also where the executive functions develop. “Executive functions
refer to a set of skills responsible for top-down regulation of behavior, that is, they are skills that
give individuals cognitive control of their actions, including their thoughts and emotions” (Dias,
Trevisan, León, Prust, & Seabra, 2017, p. 383). One model explains that the scope of executive
functions can be divided into three categories: inhibition, which includes the inability to inhibit
inappropriate behaviors and the inability to focus attention; working memory, which is needed
for reasoning and decision making; and cognitive flexibility, which allows a person to generate
alternate possibilities and viewpoints (McCrory, De Brito, & Viding, 2010). A reduced capacity
to function in these areas creates vulnerabilities related to social connection, behavior control,
school performance, substance use, and relationship skills.
The anterior cingulate cortex (ACC). The ACC is located behind the prefrontal cortex,
is situated on top of the corpus callosum, and is responsible for the regulation of emotion, mood,
and impulses. Stroop tests, which measure implicit cognitive function, also indicate that the
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28
ACC is implicated in the process of assessing conflict and driving avoidance behavior (Braem,
King, Korb, Krebs, Notebaert, & Egner, 2017). Damage to this area of the brain can lead to
impulsivity and a reduced ability to regulate or tolerate painful emotions as it becomes
underactive in people who have experienced trauma (Psych Central, 2017). “ACC, like the
hippocampus, might be vulnerable to prolonged glucocorticoid exposure resulting from chronic
stress, which in turn may decrease its ability to exert negative feedback control over HPA
(hypothalamic-pituitary-adrenal axis) activity” (Braem, King, Korb, Krebs, Notebaert, & Egner,
2017, p. 140).
The corpus callosum. Dr. Jill Bolte Taylor (2012) explains that the brain is distinctly
divided into two hemispheres and that each hemisphere functions uniquely from the other. The
right hemisphere works by thinking in pictures, learns through body movements, and is in the
present moment. By contrast, the left hemisphere operates in a linear manner and is concerned
about the past and the future (Taylor, 2012). This hemisphere focuses on details, categorizes
them and organizes them to imagine all future possibilities based on those details. Dr. Taylor
states that this hemisphere thinks in language and that it works to connect the internal experience
of an individual to the outer world and that it defines our separateness from others. The corpus
callosum is situated between these two hemispheres and is comprised of millions of axonal fibers
that are utilized for interhemispheric communication within the brain (Carrion, Wong, & Kletter,
2013). “Specifically, the medial and posterior areas of the CC contain interhemispheric
projections from brain structures that mediate the processing of emotional stimuli and memory –
core processes that are disturbed in PTSD” (Carrion, Wong, & Kletter, 2013, p. 57).
Diffusion tensor imaging has been used to study the brains of adolescents who were
exposed to repeated trauma during their development. A reduction in white matter in the corpus
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29
callosum was found in these individuals which compromises the integrity of their
interhemispheric communication abilities (Rinne-Albers, Werff, Hoof, Lang, Lamers-
Winkelman, Rombouts, Vermeiren, & Wee, 2016). Reduced functioning in the corpus callosum
correlates to a reduction in emotion and mood regulation and an increase in other
psychopathological disorders (Rinne-Albers, et al., 2016). These studies also revealed that there
are critical periods during brain development where the child is especially vulnerable to the
effects of abuse. These windows are during the early years and again during adolescence. To
demonstrate the effects of abuse during the adolescent years, a similar study was conducted on
the brains of over 800 adults who had not experienced early life trauma but were victims of
verbal abuse from their peers during their adolescent years. Brain scans revealed structural
changes in various areas of their brains as well, including a reduction of white matter within the
corpus callosum (Hurtful Words, 2011).
Addiction
According to the Surgeon General’s report, “substance misuse is the use of alcohol or
drugs in a manner, situation, amount, or frequency that could cause harm to the user or to those
around them” (HHS, 2016, p. 1-1). Additionally, over 100,000 annual deaths in the United
States are caused by the misuse of drugs and alcohol. (HHS, 2016). Substance misuse that is
maintained over time can lead to a substance use disorder which, when severe, is more
commonly referred to as addiction.
Addiction was originally believed to be a matter of will-power and was linked to a
character flaw within the individual. It is now understood that addiction is a disease that causes
changes in both the structure and function of the brain and requires a holistic understanding of
the problem. As an addiction progresses, the individual will often experience consequences due
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30
to their substance use such as job loss, relationship struggles or trouble with the law. Despite
these consequences, the substance use may continue due to the physiological processes that
occur within the brain as well as the individual’s genetic make-up and social environment.
Biopsychosocial Model
The biopsychosocial model incorporates biological, psychological, and social dimensions
of human functioning to provide a holistic framework that guides treatment within the field of
mental health as well as other medical disciplines (Pilgrim, Kinderman, & Tai, 2008). “At a
practical level, it is a way of understanding the patient’s subjective experience as an essential
contributor to accurate diagnosis, health outcomes, and humane care” (Borrell-Carrio, Suchman,
& Epstein, 2004, p. 576). This model asserts that in order to effectively heal an individual, one
must consider all aspects of their functioning, rather than simply managing their symptoms.
Addiction Through an Adlerian Lens
According to Adler, addiction is a form of neurosis and is a symptom of a discouraged
individual who is lacking social interest (Ansbacher & Ansbacher, 1956). Further, he believed
that over indulgence in substances is a means to avoid pain and discomfort often rooted in
inferiority feelings. In line with the biopsychosocial model, Adler endorsed a perspective that is
“an integrated, holistic model of human nature, psychopathology and treatment” (Pienkowski,
nd, p. 1) when treating addiction that is built upon a supportive relationship between the therapist
and the client.
Addiction and the Brain
The brain registers pleasure the same whether it is stimulated by a natural cue or a
synthetic substance (HHS, 2016). Dopamine is flooded into the synapses of the brain, and the
feeling of happiness is experienced. A person can experience this release of dopamine through
natural means such as eating or accomplishing a goal. However, drugs and alcohol create a short
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31
cut to this dopamine surge that is with little effort and in greater amounts. Functional MRIs
allow researchers to look closely at brain activity and adaptations. Over time, neural adaptations
occur that further the addictive process as the circuitry becomes linked in a manner that
perpetuates drug-seeking behavior. The areas of the brain implicated in the addiction process
are: the reward circuit, the amygdala, the nucleus accumbens, the hippocampus, the prefrontal
cortex, and the anterior cingulate cortex.
The reward circuit. The brain’s reward circuit is responsible for identifying rewarding
stimuli and signaling the individual to continue to engage in rewarding activities and is
implicated in the process of drug-seeking behavior (Eisch, 2005). The reward circuit is also
referred to as the mesolimbic dopamine pathway as dopamine is the primary neurotransmitter
that is released in these areas in response to pleasurable stimuli (Advokat, Comaty & Julien,
2014). Dopamine is primarily produced in the VTA when it is activated by a stimulus and is
then sent to the nucleus accumbens, the amygdala, the prefrontal cortex, and the hippocampus
(Advokat, et al., 2014).
The reward circuit can be activated to varying degrees depending on the stimulus. Food,
sex, affection, and praise are examples of stimuli that activate the reward circuitry in the brain
and release dopamine that in turn produces a rewarding feeling such as happiness. Drugs and
alcohol also activate the reward circuit. When a person uses drugs or alcohol, the natural stimuli
often lose their appeal as they don’t activate the reward system to the heightened degree that the
synthetic stimuli do. This helps to understand the addictive process and the disregard that the
addicted person often has for other people who are affected by their use.
The amygdala and nucleus accumbens. The amygdala is one of the most common
areas of the brain discussed with regard to trauma. Trauma causes the amygdala to be
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32
hypervigilant to environmental stimulus, causing the individual to overreact. Also, the amygdala
releases dopamine into the nucleus accumbens when it is activated by either positive or negative
stimulus. The nucleus accumbens is a key component in the addiction process as it is the brain’s
pleasure center. Drugs activate the nucleus accumbens by flooding it with dopamine. This
dopamine surge is higher than is achieved through natural events such as eating. The higher the
dopamine surge, the greater the likelihood that it will become addictive.
If childhood trauma causes the amygdala to flood the nucleus accumbens with dopamine
over prolonged periods of life, it is possible that this predisposes a person to substance misuse
given the need to continue this flood of dopamine to achieve homeostasis in the brain. It is
difficult to find research that directly answers this question. What is known, however, is that an
overactive amygdala contributes to emotion dysregulation that often underlies substance use
problems. Further, the neural networks activated through trauma are related to those activated
during substance use.
The hippocampus. The hippocampus is involved in the addiction process as it is
activated to remember novel experiences (Kantak, 2007). As drugs are introduced into the
reward pathway, the hippocampus records the environmental cues and feelings associated with
the drug. This memory storage of environmental cues contributes to cravings and compulsion
associated with substance use. Additionally, this memory storage is implicated in the relapse
potential of an individual in recovery. Specifically, a relapse can be initiated through exposure
to visual cues such as a hypodermic needle or a glass of wine.
The prefrontal cortex (PFC). Dysfunction within the prefrontal cortex contributes to
the lack of impulse control and the denial of the addiction that is common among substance
misusers. Further, the PFC modulates the planning and anticipation of reward and also inhibits
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33
inappropriate actions (van der Kolk, 2015). Once the brain has been introduced to illicit
substances, the prefrontal cortex is hijacked to focus on obtaining more of the drug. The PFC
receives messages from the nucleus accumbens that stimulate craving for the drugs that
previously activated the reward pathway (van der Kolk, 2015). This repeated pattern strengthens
neural connections between these two regions that further influence addictive behaviors.
The anterior cingulate cortex (ACC). The anterior cingulate cortex helps to regulate
mood and emotion as it integrates interhemispheric cerebral information. A decrease in ACC
functioning is associated with mood dysregulation which often leads individuals to use
substances as a means to ease discomfort. Reduced function in the ACC can also affect impulse
control that can lead to difficulty in abstaining from drugs and alcohol (Congleton, Holzel, &
Lazar, 2015).
Trauma and Addiction
According to Recovery.org (2015), between “25 and 75 percent of people who survive
abuse or violent trauma develop issues related to alcohol misuse”. (The range in this percentage
exemplifies the difficulty of quantifying the prevalence of trauma). The most common reason in
the literature that explains the high incidence of use in trauma survivors is the need to self-
medicate. Trauma survivors self-medicate for a variety of reasons: to avoid feeling unsafe or
threatened, to soothe pain, to suppress traumatic memories, or reduce anxiety, to list a few. Put
another way: “to feel something, to feel nothing, or to feel different” (Curran, 2017). Prolonged
substance use results in dysregulation of the brain’s reward pathway and a down regulation of
dopamine receptors (Eisch, 2005). The reduction in the dopamine receptors occurs as a result of
too much dopamine in the brain and is the brain’s attempt to regain homeostasis. However,
fewer dopamine receptors means that it takes more of a stimulus in order for the individual to
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34
experience feelings of happiness. This contributes to the anhedonia often expressed by prolonged
substance users. Additionally, disruption of the brain reward circuitry is also caused by chronic
stress placed on a developing child. “Many clinical characteristics of addictive illness can be
linked to the acute activation and chronic disruption of brain reward circuits” (Dackis & Miller,
2003). Children who are subjected to chronic stress during their development are
physiologically vulnerable to addictive behaviors as adults.
Another possible reason for the high prevalence of addiction in trauma survivors resides
in the body’s response to stress. Laboratory studies reveal important relationships between stress
and addiction that may provide insight into this correlation that is seen in human populations
(Eisch, 2005). Stressful environments that were created in the laboratory varied from
maltreatment to deprivation to isolation and ranged from acute to chronic stress (Eisch,
2005). Each stressful situation correlated to an increase in drug taking behavior.
One relationship that was discovered from this research is that stress and abusive
substances cause similar changes within the reward pathway of the brain. The areas highlighted
were the ventral tegmental area, the nucleus accumbens, the prefrontal cortex, and the
connections within these areas that transmit information bidirectionally (Eisch, 2005). As
Hebb’s axiom states, “neurons that fire together, wire together” (Brown & Milner, 2003). If both
the use of substances and exposure to stress activate the body’s stress response as well as the
reward pathway, it is possible that these neural pathways become deeply connected through
either experience. “This suggests that exposure to either drugs or stress may ‘prime’ the brain
for the next exposure to either stimulus” (Eisch, 2005, p. 31).
Another relationship that was discovered between stress and substance misuse is that
early exposure to stressful situations correlated to the increased incidence of drug self-
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35
administration and also the increased effect of the reward (Eisch, 2005). Exposure to stress on a
developing brain has proven to be detrimental. The brain develops in a use dependent manner
which means that it forms in response to both the positive and negative experiences of the
individual (van Duiven, 2009). Particular vulnerabilities are within the sensitive periods that
occur in the early years and again during adolescents. (Sensitive periods are times when the brain
is especially vulnerable to change and has a heightened ability to learn). Because these sensitive
periods occur during childhood, it is particularly damaging for children in abusive environments
as it alters their brain development, creating an increased risk for substance use. Additionally,
these brain changes create a heightened sensitivity to the effects of illicit substances. “A current
working hypothesis in the field is that stressful experiences produce long lasting increases in
stress hormones as well as dopamine, which thereby make the subject more vulnerable to the
rewarding aspects of drugs of abuse” (Eisch, 2005, p. 34). This increase in the rewarding effects
of drugs can increase the likelihood of addiction as great pleasure is experienced by the
individual in association with the drug.
The final relationship discovered between stress and substance misuse from this study
indicated that a future stressful experience increased the likelihood that a relapse would occur
after a period of abstinence. It was noted that more predictable stressors were less threatening to
a relapse while, conversely, more intense stressors were more likely to impose a relapse situation
(Eisch, 2005). Neuroadaptations identified after cessation of drug exposure included a reduction
in dopamine activity and in increase in activity within the HPA axis (Eisch, 2005). This
reduction in dopamine and increase in the stress response can trigger cravings that occur on a
physiological level. These findings highlight the neurological vulnerability developed through
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36
exposure to stress and illicit substances and the need to address these brain areas in humans who
are seeking treatment for co-occurring disorders.
An interesting difference that was discovered between a stress-induced relapse and a
drug-induced relapse was that the stress induced relapse (in this case, a shock to the animal’s
foot) was activated through a dopamine surge reliant on the amygdala while a drug induced
relapse activated a dopamine release through the nucleus accumbens (Eisch, 2005). While both
elicited a relapse in the animal, the activation of the reward circuitry began in different locations.
Further, the stress-induced relapse was reliant on the amygdala which has been shown to be
hypervigilant in those who have experienced chronic stress. It is possible that humans who have
been exposed to chronic stress are more susceptible to a stress-induced relapse than a drug-
induced relapse. Further study is needed to identify this correlation in human subjects.
One human study did identify an increase in mesolimbic dopamine activation in response
to evocative cues related to drug use in populations of adults with cocaine use history who report
child abuse experiences (Regier, Monge, Franklin, Wetherill, Teitelman, Jagannathan, Suh,
Wang, Young, Gawrysiak, Langleben, Kampman, O’Brien, & Childress, 2017). Participants
were treatment-seeking adults for cocaine dependence. They were screened for experiences of
abuse in childhood that were either physical, emotional, or sexual in nature. The study utilized
fMRI to monitor reactions in the brains as the subjects were exposed to video cues relating to
cocaine use as well as neutral cues. The results indicated a heightened dopaminergic response
within the brains of those who reported a history of abuse. Further, the degree of activation in
their brains was correlated to the severity of the early life abuse (Regier, et al., 2017). This study
exemplifies the connection between the human stress response system and the reward system as
predicted in the laboratory studies.
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37
Limitation of Behavioral Treatments
Many of the addiction treatment facilities available today are based on the principles set
forth in the original treatment facilities of the 1960s that viewed addictions as character disorders
(U.S. Department of Health and Human Services, 2016). These treatment programs utilize
cognitive behavioral therapy and skill building to address thoughts and cravings associated with
substance use. While these are useful tools, they do not address the biopsychosocial conditions
that create vulnerabilities to addiction in those who have experienced developmental trauma. If
the activity of the amygdala is not reduced and the brain’s neural networks are not rewired for
more adaptive thinking patterns, the adaptive information processing model asserts that the
individual will continue to react in the present based on their past maladaptive experiences. This
continued pattern of reactivity, emotion dysregulation, and maladaptive coping strategies
perpetuates pathological conditions and addictive habits. Thus, if the underlying neurobiology is
not addressed and treated, the addicted person might continue to be physiologically drawn
toward the use of substances. A life tied to fighting internally against cravings and urges is a life
of survival and is not a life of purpose and meaning.
Required Elements of Effective Treatment
Through the biopsychosocial model, it is evident that substance use treatment requires a
holistic approach. Neuroscience has proven that anatomical changes occur in the brains of those
who are exposed to recurrent trauma. The disease model asserts that addiction is a medical
condition that incorporates biological, neurological, genetic, and environmental factors. A
holistic approach to chemical health treatment must address the underlying causes that are
driving the addictive behavior. In order to do so, it is important to first be thorough in the
diagnostic portion of clinical work. Tools such as the ACE inventory can help identify early life
trauma. Other screening tools such as the Vulnerable Attachment Style Questionnaire can help
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38
identify insecure attachment patterns. Once trauma is identified, it is important to utilize brain-
based therapies that heal the effects of the trauma on a physiological level. Some brain-based
therapies include: Accelerated Experiential Dynamic Psychotherapy, Mindfulness Meditation,
and EMDR. These brain-based therapies create space for the individual to learn to function
within their window of tolerance, where they can think and feel at the same time, and where they
can thrive.
The window of tolerance. The fluctuation between hyper and hypo arousal states results
in mood dysregulation that is difficult for individuals to tolerate. The “window of tolerance”
model was developed to help explain the space between these two responses where emotions can
be felt and experienced at the same time and information can be integrated (Corrigan, Fisher, &
Nutt, 2010). For trauma survivors, this window can be small, and the object of therapy is to
function at the outer edges of each end in order to foster growth. The outer edges mark the range
that is uncomfortable for the client, yet still tolerable. In this growth area, patients are able to
think and feel simultaneously which allows them to process thoughts, feelings, and emotions,
while facilitating their ability to develop self-regulation skills. People strive to be within the
window of tolerance on their own, and trauma survivors often use maladaptive coping strategies
such as drugs, alcohol, or compulsive activities in an effort to do so (Corrigan, Fisher, & Nutt,
2010). Specifically, alcohol use is often associated with chronic hyperarousal states in an effort
to reduce the emotional state down towards the window of tolerance, while drugs such as cocaine
or amphetamines are often used to counteract hypo arousal and bring the emotional state up. It is
important to note, that depressed individuals who use stimulants have an increased risk of
suicide, as it is believed that the stimulant can provide the individual with a burst of energy that
is sometimes used to complete a suicide (Corrigan, Fisher, & Nutt, 2010).
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Brain-based Therapies for Treating Trauma and Addiction
Trauma and addiction are often co-occurring, and it isn’t always clear which is the cause
of the other. What is clear is that both trauma and addiction cause physiological changes in the
brain that create vulnerability to further addictive behavior and further trauma. Brain-based
therapies are necessary to address the physiological effects of trauma at the root. Brain-based
interventions discussed in this paper are: accelerated experiential dynamic psychotherapy,
mindfulness meditation, and EMDR.
Accelerated Experiential Dynamic Psychotherapy (AEDP)
AEDP is a form of psychotherapy that asserts that earned secure attachment can be
achieved in adulthood through the therapeutic relationship under the right circumstances (Lipton
& Fosha, 2011). It is based on the belief that, neurobiologically, human brains strive toward
healing, the right brain is shaped through the early attachment relationship and can be further
shaped through right brain connection with an attuned therapist (Lipton & Fosha, 2011). The
therapist uses right brain to right brain communication to maintain attunement with the client to
foster the development of affect regulation. The therapist establishes a sense of togetherness
with the client by demonstrating that he or she is in the experience with the client. Insecure
attachment can cause significant feelings of aloneness that can be combated by this
approach. The goal is to create emotional safety for the client to experience the body sensations
together with their emotional experience. The therapist co-regulates the emotions of the
therapeutic dyad as the client learns to develop their own self-regulation skills, much in the way
that they would have in their early interactions with their caregiver.
The therapeutic stance is one of acceptance of all feelings to create a space for the client
to examine their experience throughout the therapeutic process as explained through the use of
“metaprocessing” (Lipton & Fosha, 2011). The belief is that learning takes place through the
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40
reflection of the therapeutic experience which is occurring in the present and experienced in the
right brain and integrates the felt experience of being understood and attuned to into the left
hemisphere (Lipton & Fosha, 2011). This process mimics the early interactions between the
mother-baby dyad that are crucial for the development of emotion and mood regulation.
Neuroplasticity allows this interaction to develop new neural pathways in the brain and
strengthens areas that were underdeveloped as a child.
The corpus callosum, the prefrontal cortex, the insula, and the anterior cingulate cortex
play a primary role in attachment (Lipton & Fosha, 2011). These same brain areas are engaged
during the use of meta-processing in therapy. Metaprocessing incorporates both left brain and
right brain experiences that are needed to heal. Through this psychologically safe environment,
it is believed that the areas of the brain that were underdeveloped can thrive. It is written that
trauma weakens the bridge between the felt experiences in the right brain and the ability to
reflect on them coherently in the left brain (Lipton & Fosha, 2011). This reduction in
interhemispheric communication is possibly due to the reduced size and functioning of the
corpus callosum. The AEDP model has two parts: to heal the hurt and pain of the self, and to
develop the latent resilient parts of the self.
Mindfulness Meditation
The formal practice of mindfulness meditation is an ancient tradition thought to originate
from the Buddhist culture (Wolfe & Serpa, 2015). It has been used for centuries to calm the
brain and body and is becoming increasingly popular in mainstream culture. It is a way of being
in the present moment, fully aware of the senses, including thoughts and feelings, and without
judgement. It is often practiced with a focus on breathing and an acceptance of circumstances as
they are. As thoughts enter the mind, they are non-judgmentally dismissed and the attention is
returned to the breath. Mindfulness must be accompanied by kindness or compassion in order to
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41
avoid detachment or sentimentality (Wolfe & Serpa, 2015). Having compassion for the self and
others or a kindness towards one’s experiences combined with the act of being mindful is the
process that leads to the reduction of suffering.
Mindfulness can be used informally as a means of managing emotions and stress. It is
the act of noticing one’s experience internally as well as externally without judgement that
allows one to remain in the window of tolerance for longer periods of time. Further, noticing
one’s experience without judgment activates the neocortex which sends messages to the
amygdala to calm down and reduces the possibility of the amygdala hijack mentioned
previously.
Research has demonstrated the positive effects of mindfulness in the areas of symptom
reduction, biological markers and neuroplasticity (Wolfe & Serpa, 2015). Specifically,
mindfulness has proven to reduce symptoms of depression, anxiety, and pain as well as increase
quality of sleep and overall quality of life--which is one of the main goals for treatment of
individuals with post-traumatic stress disorder according to Dr. Bessel van der Kolk
(2015). Biological markers such as a reduction in cortisol levels have also been observed in
meditators, as well as improvements to immune function and anti-aging functions.
Mindfulness through an Adlerian lens. Adler is quoted in an article by Powers and
Griffith (1996, p. 3) as saying, “the cure or reorientation is brought about by a correction of the
faulty picture of the world and the unequivocal acceptance of a mature picture of the
world”. This idea of reorienting is also found in the practice of mindfulness as it distances a
person from their feelings and allows them to view them objectively. This provides them with
the opportunity to reorient themselves and respond more appropriately to situations. The
Adlerian approach to treating PTSD focuses on the “here and now” which is also a strategy of
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42
mindfulness and mindfulness meditation. During mediation, the person focuses on the present
moment without judgement, notices thoughts and feelings, and simply accepts them.
Additionally, the mindfulness practice of integrating kindness and compassion is supportive of
the Adlerian practice of social interest. As we choose compassion towards ourselves and others,
we let go of judgment and anger and embrace loving kindness. This practice fortifies peace and
understanding which are the underpinnings of social interest and Gemeinschaftsgefūhl.
Mindfulness meditation and addiction. The science behind mindfulness reveals
improved function in areas of the brain that are implicated in the addiction process and it is
beginning to be used as part of addiction treatment programs such as mindfulness-based relapse
prevention programs (MBRP). These programs aim to teach clients to use mindfulness to help
identify triggers, body sensations, thoughts, and feelings that may stimulate their substance use.
This process of identification sets clients in motion towards creating space to respond to these
sensations rather than impulsively reacting with substance use (Enos, 2016). Urge surfing is
another way that mindfulness is applied to the substance use population. When cravings occur,
clients are instructed to imagine that they are riding the craving as if they were riding on a wave.
They become kindly aware of the cravings and feelings that come up, without judging them, and
ride them out to sea.
It is also possible to use mindfulness in clients who are actively using. For many,
substance use has been their only source of relief from painful feelings of rejection and shame.
Teaching the practice of loving compassion and acceptance of all of life’s circumstances could
be the first step in freeing them from negative feelings that are perpetuating their substance
use. “People with addictions tend to be rather diffuse in their ability to stay present and often
ruminate about negative things, which fosters more negative feelings and compulsive
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43
behaviours. Mindfulness training insulates one's thoughts to be more present, positive, and life-
affirming” (Prousky, 2012, p. 53).
Mindfulness and the brain. The practice of paying attention to the present moment with
the stance of loving kindness wires new neural pathways through the process of neuroplasticity
(Wolfe & Serpa, 2015). This repetition and creation of new neural pathways makes it easier for
a person to respond with kindness and compassion to their circumstances as the circuitry
becomes stronger with practice. Mindfulness meditation is similar to the practice of executing
fire drills to prepare for an actual fire. Over time, the process becomes automatic when the fire
drill sounds and everyone knows what to do and where to go. Similarly, as the brain becomes
more accustomed to responding to circumstances with kindness, a new situation that would have
triggered strong negative emotions in the past is less likely to do so in the present.
The amygdala. The amygdala is part of the limbic system that gathers information from
the environment and prepares the body to react to it. An overactive amygdala sends the body
into fight, flight, or freeze mode unnecessarily and can keep the body in a constant state of
stress. Daily meditation has resulted in a decrease in brain cell volume of the amygdala and also
in its activity (Wolkin, 2015). Reducing the activity of the amygdala has an overall calming
effect on the individual as it provides space to think about their feelings and distance from them
enough to feel less affected by them. Mindfulness meditation has also demonstrated reductions
in the connections between the amygdala and the rest of the brain. This reduction is a result of
the decreased activation of neural networks. These networks weaken as the new ones related to
compassion strengthen. Reducing the reactivity and connections of the amygdala also allows
more time for the thalamus’ signals to reach the prefrontal cortex which increases the chance for
a calm and rational response to occur.
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44
The hippocampus. The hippocampus is also part of the limbic system and is associated
with emotion, memory, and the development of resilience (Congleton et. al., 2015). Studies have
indicated that those with a history of stress-related disorders such as PTSD or depression tend to
have smaller hippocampal regions. Functional MRIs following mindfulness practice revealed an
increased grey matter density in this area. This increase in grey matter can improve the overall
function of the hippocampus, which is needed to regulate the reactivity of the amygdala.
The prefrontal cortex. The prefrontal cortex is located behind the frontal lobe and is
associated with the executive functions (Wolkin, 2015). This area of the brain gives humans the
ability to think critically and respond peacefully when it is well-developed. After an eight-week
mindfulness study, the prefrontal cortex showed an increase in the thickness of the grey matter
(Ireland, 2014). Connections between the prefrontal cortex to the amygdala are weakened
through the regular practice of mindfulness meditation allowing connections to strengthen with
other areas involved in higher order functions such as attention and concentration (Wolkin,
2015). As the connections between the prefrontal cortex and the amygdala weaken, there is less
emotional reactivity experienced by the individual. As this neural connectivity weakens, the
communication from the amygdala to the prefrontal cortex in drug and alcohol seeking behavior
is subsequently reduced.
Studies that scanned the brains of meditators with 40,000 hours of mindfulness practice
found that the prefrontal cortex had gone back to its original size, indicating that after prolonged
practice, the improvements become automatic and require less effort (Ireland, 2014). These
studies also found that the brains of meditators in a resting state looked similar to those in a
meditative state, and that the positive effects on the brain are permanent.
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45
The anterior cingulate cortex. The anterior cingulate cortex is associated with the
unpleasantness of pain and learning from past experience (Congleton et. al., 2015). Damage to
this area can reduce mental flexibility and can cause a person to hold on to old ways of doing
things even when they are no longer useful. The reason for this could be the reduction of
interhemispheric communication that occurs through this brain region. Studies of meditators
show improved function in the ACC and also show high performance on tests of self-regulation
and focus. Eight-week mindfulness studies showed a significant increase in the grey matter
density in this area and an improvement in the functional connectedness it has to other areas of
the brain.
EMDR
Eye movement desensitization was developed by Francine Shapiro who realized the
desensitizing effects that eye movements had on troubling thoughts as she was walking in the
park (Rosen, McNally, & Lilienfeld, 1999). Her eyes began involuntarily shifting right and left
and she realized that her level of distress decreased through this process. Following her
discovery, she began testing this process on her friends and colleagues. Inspired by the results,
she conducted a study on patients with post-traumatic stress disorder (PTSD) as part of her
doctoral dissertation (Rosen, McNally, & Lilienfeld, 1999). The results of her 22-patient study
were astounding. Dr. Shapiro renamed this therapy to add reprocessing to include the part of the
therapy that changes the negative thinking patterns, and EMDR has since been deemed a front-
line approach for treating trauma-related illnesses.
EMDR is based on the adaptive information processing (AIP) which asserts that new
experiences and information are understood within the context of old memories and beliefs
(Shapiro & Laliotis, 2011). Further, this information processing system is adaptive and strives
towards the reduction of distress and more adaptive thinking patterns. Specifically, “what is
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46
useful is incorporated, what is useless is discarded, and the event serves to guide the person
appropriately in the future” (Shapiro & Laliotis, 2011, p. 193).
The AIP model is also guided by the belief that instability and pathology are a result of
unprocessed distressing memories that, once integrated, result in a reduction of symptoms
(Shapiro & Laliotis, 2011). Memories that are integrated whether they are positive or negative
get stored appropriately in the brain and are usually forgotten. However, events that overwhelm
the system with negative emotions do not get processed effectively and get trapped in the right
hemisphere of the brain in fragmented pictures along with the original body sensations (Shapiro
& Laliotis, 2011). These body sensations become activated in the present when an experience is
similar to the original and the old feelings flood the system creating a visceral response that is
seen as an overreaction to the situation.
EMDR is an eight-phase approach to treating trauma. The first two phases revolve
around installing the resources a client needs in order to maintain stability once the trauma
network is accessed. These phases are called client history and preparation. During these
phases, the therapist establishes rapport with the client and develops an understanding of the life
experiences that are the underpinnings of the current distress as indicated by the adaptive
information processing model.
An important skill to develop in this phase is to use breathing to access the
parasympathetic nervous system. Deep, diaphragmatic breathing has been demonstrated to bring
the PNS online which in turn calms the body down (Klotter, 2009). An easy way to help clients
engage in this breathing technique is to suggest that they exhale for twice the amount of time as
they inhale. For example, if they inhale to the count of 4, they would exhale to the count of 8.
An important side note is that when working with clients who have OCD, it is best to vary the
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47
numbers as they count in and out to avoid activating an OCD response to the breathing as this
would be counter-productive.
Resourcing is also an essential goal of the preparation phase of EMDR therapy (Shapiro
& Laliotis, 2011). Through resourcing, the therapist works to install the necessary supports,
cognitions, and calming strategies that the client will need in order to remain stable while
processing the traumatic memory. Specifically, the client will develop their container and their
comfortable place. The container exercise asks that the client visualize a container that can hold
anything that they do not yet have the resources to manage. The therapist guides the client
through an imagery exercise aimed to build the container and fill it with whatever they need to
put in there. Comfortable place is used to help the client connect to an inner calm that can be
accessed whenever it is needed. This, too, is accomplished through guided imagery. The
therapist helps the client make this place as real and vivid as possible by incorporating sights,
sounds, smells, and positive feelings. In both of these instances, the theratappers are turned on to
install the positive feelings and experiences that are noticed through the process. For example,
the therapist will ask the client how it feels to put everything in the container. Often, the
response is that they feel relieved. The therapist helps the client identify where they feel that
relief in their body and, if possible, to identify the color that they see with it (engaging as many
of the senses as possible). The client is instructed to focus on that feeling of relief that is
associated with putting everything away and imagine it getting as big as possible while the
tappers are turned on for the equivalent of about two full breaths.
Other important resourcing techniques to be done before any processing are the
installation of nurturing, protective, and wise figures (Curran, 2017). Installing nurturing figures
requires that the client list people that represent nurturing to them. These people could be real or
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48
imagined; they could be television characters or animals. The important part of this exercise is
that they identify the nurturing qualities that are associated with these beings. These qualities are
“tapped in” with the theratappers for the length of two or three deep, diaphragmatic breaths. It is
important to keep the repetitions short in this phase as the client’s brain could jump to a negative
thought and that is not part of the resourcing phase (Curran, 2017). This exercise is also done
with the protective and wise figures to install the protective feelings and wise counsel that were
missing during the traumatic experience. During the processing phase, these resources are drawn
upon to help support the client when they feel distressed. It is important to understand that some
clients remain in the resourcing phase for a year or more and that it is better to “over-resource”
then “under-resource” (Curran, 2017).
The third phase of EMDR therapy is when the trauma network is accessed. It is
suggested that the clinician help the client begin with the earliest or worst trauma. In this phase,
the client is asked for the subjective unit of distress or SUDs that they feel as they think of the
worst part of the memory on a scale of 1 to 10 (Curran, 2017). Additionally, the client is asked
to identify the negative cognition that is associated with this memory such as, “I am not good
enough”, or “I am to blame for my abuse”. They are then asked to list the preferred cognition
such as, “I am enough”, “I did the best I could”, or “I am not responsible for other people’s bad
behavior” and the validity of this cognition on a scale from 1 to 7. To add some clarity, the
practice of identifying the SUDs and the VOC was implemented during the clinical study that
Francine Shapiro did in order to prove the efficacy of EMDR as it was necessary to establish
criteria to demonstrate a reduction in distress and a reprocessing of the memory (Curran, 2017).
However, asking the client for the validity of the cognition often confuses them and gets them
back into their left brain which shuts down the trauma network. The desensitizing that occurs in
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49
phase four requires that the trauma network be activated. Therefore, it is ok to forego the
preferred cognition at this point (it will often emerge through the processing) and begin
processing as soon as the trauma network is activated (Curran, 2017). The network is activated
when the client tears up or looks visibly flooded while describing the original memory. At this
point, initiate the alternating bilateral stimulation and allow the client to process the memory.
While the client is processing, the therapist is instructed to slightly vary the rate of the
ABS. This keeps the hippocampus online which is necessary to keep the amygdala from firing
(Curran, 2017). The therapist reminds the client of their body being in the room to create the
dual awareness that helps the client stay grounded in the present as they revisit the trauma
memory. The therapist also reminds the client that this is only a memory, that it is over, and that
they are safe now. The therapist checks in with the client periodically by stopping the ABS and
asking what they notice, what has come up, or what they are saying to themselves now as they
think of the original memory. Whatever comes up, the client is encouraged to “go with that” and
continue to process.
Interestingly, other memories will often emerge as the client processes the original
memory. Typically, the memories that come up share the same negative cognition that was
associated with the original memory. This subconscious process reveals the reality of the
adaptive information processing model as it demonstrates that experiences are connected through
the context of memory networks that are similar. More compelling is the similarity between the
negative cognitions that link our memories and Adler’s concept of private logic. Adler
recognized that people don’t remember everything that ever happens to them. However, he
noted that they tend to remember that which fit their private logic. That is to say that people
collect memories that “prove” their original beliefs about themselves. EMDR brings this
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collection of memories together through the processing phase and insight is developed as people
begin to recognize their faulty thinking patterns and where they originated.
If the client gets stuck in the memory, the therapist can ask, “what does the child need to
get through this” which helps the client connect to their nurturing, protective, or wise figures to
help them continue to process. Clients are always allowed to stop if they need to and go to their
comfortable place if the experience feels too overwhelming.
Sometimes body sensations are experienced during the processing of a
memory. Interestingly, these body sensations are often a result of something that is needed
during the processing. For example, if a client states that they are feeling tightness in their
throat, it could be that there is something that they need to say to someone in their memory. The
therapist will instruct them to “go with that” and often times, the sensation will diminish once
they “said” what they needed to.
Eventually, the new more adaptive cognition emerges, and the SUDs is reduced to a 0 or
1. Ideally, the SUDs needs to be a 0; however, for some clients, a 1 is the lowest it will ever be
and if they express that this is an acceptable SUD, it is acceptable to move on. At this point the
EMDR moves into phase five: installation. In this phase, the client holds the positive belief with
the original memory and utilizes the ABS to “tap it in” to their neural network. This is believed
to create the new neural pathways that are associated with the adaptive thinking. The therapy
then moves into phase six which is the body scan. The therapist asks the client to scan their body
to check for any sensations that are unpleasant such as tightness or pain. If anything is still there,
they focus on that area and continue to process. Once the body is showing no sign of distress, the
client is directed back to their comfortable place through guided imagery and then the attention is
brought back to the room. This is phase seven of the EMDR therapy: closure. Closure focuses
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51
on discussing what occurred during the session. Phase eight happens in the following session
when the client is asked to revisit the memory that was processed and list the SUDs and VOC of
the preferred belief. If the SUDs have elevated, the client goes back to phase four and processes
the memory again.
EMDR brings forward subconscious thinking patterns based on memories that are linked
together that drive maladaptive behavior. This process of making connections demonstrates the
brain’s desire and ability to move towards wholeness as it is done automatically and without
direction. The connections that are made provide insight into beliefs and behaviors that might
not have been discovered through talk therapy. Equally important, EMDR activates the thalamus
that is deactivated during trauma and is needed to effectively integrate the trauma memory
(Bergmann, 2008). Further, the desensitization to the original trauma memory calms the brain
down as the memory is moved out of the limbic system and into the prefrontal cortex where it is
now understood to be in the past (Curran, 2017). It is then that a client can begin to develop new
adaptive coping strategies to deal with the challenges of life.
EMDR and addiction treatment. Bessel van der Kolk reports several cases in which
spontaneous termination of addiction occurred following the completion of EMDR therapy in his
book, The Body Keeps the Score (2015). The belief is that through the desensitization and
reprocessing of trauma memories, the need to self-soothe no longer exists, the person is able to
be present and connect to their embodied experience, and they are able to develop adaptive
coping skills and thinking patterns once the trauma memory has successfully moved to the
prefrontal cortex. That said, specific therapies have been developed that utilize alternating
bilateral stimulation to target specific situations related to addiction: triggers and urges, and
feelings associated with substance use.
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DeTUR is a therapy that uses ABS to process the urges and cravings that are associated
with the substance use. This process accesses internal resources that the client already has and
processes them to strengthen neural connections associated with positive states. Additionally,
the DeTUR protocol targets the client’s triggers and processes them until their “level of urge”
(LOU) is a 0 or 1. The positive feeling state is then linked with the trigger and anchored in the
body through the use of ABS.
The Feeling State Addiction Protocol asserts that positive feelings and body sensations
can become linked in our brains to positive events just as traumatic events can be linked to
negative feelings (Miller, 2012). Thus, it is the desired feeling state associated with the
substance use that drives impulsive behavior. Further, once the feeling state has been developed,
it is activated by the anticipation of the substance through environmental cues. This treatment
targets the positive feelings that are desired through the use of substances, assesses the feeling
state on a 0-10 scale, and processes using ABS until the level is down to 0 or 1 (Miller, 2012).
EMDR and the brain. EMDR began with the use of alternating bilateral eye
movements but has adapted to incorporate other forms of alternating bilateral stimulation (ABS)
using theratappers or music tones after experiencing success using these methods with blind
patients (Rosen, McNally, & Lilienfeld, 1999). In order to resolve traumatic memories, the right
side of the brain must be activated while the left side of the brain is also online to add logical,
adaptive reasoning to the original memory. It has been speculated that the alternating bilateral
stimulation works because it distracts the client enough to be able to work through the memory
without becoming flooded by it. Another possibility is that the bilateral stimulation functions to
increase the interhemispheric communication that might have decreased due to a weakened
anterior cingulate cortex. Additionally, the ABS causes new neural networks to fire that are
TRAUMA, ADDICTION, AND THE BRAIN
53
associated with positive, more adaptive thinking patterns (Curran, 2017). Finally, EMDR
activates the thalamus, or the brain’s filter, that was deactivated during the trauma (Bergmann,
2008). This activation is necessary in order to integrate the original memory with logical
reasoning.
Alternating bilateral stimulation activates interhemispheric communication that facilitates
the desensitization and the processing of trauma memories (Propper & Christman, 2008). “This
allows you to get to the root of the problem and reshape your brain, not just mask your
symptoms” (NeuroDevelopment Center, 2013).
Adlerian Treatment of Trauma
Blackburn, O'Connell, and Richman (1984) discuss PTSD from an Adlerian perspective
in their article, Post-Traumatic Stress Disorder, The Vietnam Veteran, and Adlerian Natural
High Therapy. The focus is on the fact that the combat veterans have survived the trauma and
that they are experiencing a sense of deep discouragement. The treatment lies in uncovering
mistaken beliefs and reorienting the client to more useful goals. Adler believed that people’s
maladaptive behaviors were symptoms of deeper problems. Identifying the mistaken beliefs and
the source of discouragement that has set in following a trauma is the beginning to healing the
individual in a holistic manner.
The Adlerian Style of Life Tree (Stein & Lalonde, 2003) depicts the foundational
influences that collaborate to create the individual’s lifestyle. Thus, through the use of creative
power, each child does his or her best to make sense of the world with what he or she has; often
with the use of inefficient tools. If we accept this, it would only make sense to address all
problems at their roots.
TRAUMA, ADDICTION, AND THE BRAIN
54
Discussion
Brain-based interventions for the treatment of trauma and addiction provide a promising
future for those afflicted with substance use disorders, or who have been impacted by trauma.
Utilizing these therapies stimulates the growth of new neural pathways in areas of deficit caused
by trauma. Functional MRI studies demonstrate that the areas of the brain that are implicated in
the addiction process exhibit reduced functioning and volumetric properties in those who have
been exposed to developmental trauma. Studies also show a correlation between increased grey
matter density in the areas involved in emotion regulation and a reduction in symptoms
(Boukezzi, El Khoury-Malhame, Auzias, Reynaud, Rousseau, Richard, Zendjidjian, Roques,
Castelli, Correard, Guyon, Gellato, Samuelian, Cancel, Comte, Latinus, Guedj & Khalfa, 2017).
The medical model identifies various disorders through their diagnostic criteria and
therapy is then focused on symptom reduction. While it is necessary to teach clients new skills,
it is also necessary to treat the underlying physiology that is causing the symptoms as understood
through the disease model. In order to identify the underlying causes, it is necessary to carefully
screen for developmental trauma and attachment injuries. Those who have experienced
developmental trauma will likely have reduced functioning in the areas of the brain that are
needed for emotion regulation as well as other higher order thinking. This reduction in
functionality is correlated to an increase in the risk for further trauma as well as substance
misuse. To teach emotion regulation skills is useful and necessary; however, that alone is similar
to subscribing a statin drug for high cholesterol without suggesting that the patient also change
their diet.
Brain-based therapies are those that improve the structure and function of the brain.
These therapies develop new neural connections that are associated with increased emotion
regulation, reduced reactivity, and improved impulse control. Specific areas of the brain that
TRAUMA, ADDICTION, AND THE BRAIN
55
show improvement are: the amygdala, the hippocampus, the anterior cingulate cortex, and the
prefrontal cortex. Not only is the functionality within these regions improved, but the
connections between them are altered in a way that further improves emotion regulation and
executive functions.
Mindfulness is an on-going practice that will further develop positive neural connections
within the brain, resulting in the ability to remain in the window of tolerance for longer periods
of time. The more a person can function within this window, the more they can learn, grow, and
thrive as an individual. EMDR brings the areas of the brain back online that were not available
during the traumatic events, which is needed in order to fully integrate the trauma memory into
the brain.
Developmental trauma will more than likely result in an insecure attachment style of the
adult. This style of attachment hurts the person’s ability to connect with safe people and form
secure, lasting, relationships. Without this ability, the individual is often in painful relationships
that might be abusive in nature. Because of this, it is necessary to identify the attachment style
and provide corrective emotional experiences that allow new growth to develop earned secure
attachment as an adult. Accelerated experiential dynamic psychotherapy is one that supports the
development of secure attachment through the client/therapist relationship. This dynamic offers
a supportive, right brain-to-right brain connection, between the two, that is similar to the early
connection between a baby and the primary caregiver. This connection helps the client learn to
regulate their emotions as well as develop safety within the context of a relationship.
One of the primary reasons that people who have experienced developmental trauma
misuse substances is to avoid feeling pain. This pain can be from flashbacks of trauma, shame
they are experiencing as a result of the trauma, frustration resulting from emotion dysregulation,
TRAUMA, ADDICTION, AND THE BRAIN
56
or feelings of low self-worth, for example. Therapies that reduce flashbacks, by effectively
integrating them into the brain as past memories, reduce emotional reactivity, and alter brain
pathways to improve impulse control and higher-order thinking are needed in order to heal the
problems at their source. This can calm the inner world of those who are suffering. This internal
change could reduce the need for substances and improve the desire for connection in the world
which supports a meaningful life of purpose.
Implications for Practice
The subjective nature of trauma requires that clinicians proactively assess for experiences
that have traumatized their clients. Further, it is necessary to screen for various types of addictions
as clients are often unable to identify that they have a substance use problem or an underlying
mental health disorder. It is necessary to conduct a thorough diagnostic assessment including the
use of tools that effectively screen for trauma, attachment patterns, and substance use. Screening
tools such as the ACE inventory help identify any developmental trauma that has been
experienced. Further, the AUDIT or CAGE-AID can screen for substance misuse. It is also
important to identify the style of attachment. The Vulnerable Attachment Style Questionnaire
(VASQ) is a screening tool used for this purpose. The focus of the therapist is to gain the clearest
picture possible of what it was like to grow up in the environment of the client and what sense they
made out of it. Early Recollections can also help with this as well as the Mistaken Beliefs
Questionnaire.
If a client reports a history of trauma, it is necessary to screen for dissociation, as EMDR
is not suitable for those who are dissociated. If the client is a candidate for EMDR, the therapist
begins with extensive resourcing to develop the client’s ego strength in order to process their
targets later in therapy. The installation of comfortable place, container, protective, wise and
nurturing figures, is an important part of the resourcing phase. Additionally, positive feelings that
TRAUMA, ADDICTION, AND THE BRAIN
57
accompany growth throughout the therapy process can be “tapped in” to help develop neural
connections in the brain that are associated with positive feelings.
Mindfulness can be used in this stage as a means to help the client begin to activate their
“noticing brain” that practices paying attention on purpose to their circumstances without
judgment. AEDP can also be used to begin to establish a connection within the context of a safe
relationship. The therapist helps the client notice the relationship through metaprocessing, which
is the practice of paying attention to thoughts and feelings associated with feeling heard, safe, and
understood. This helps the client begin to develop trust within a safe relationship, which is the
beginning of repairing their early attachment injuries. EMDR can be used early in therapy to target
cravings, and urges, if the client is using substances.
Once the client has developed ego strength and is connected with resources outside of
therapy such as support groups or friends and family who are available, it is time to process their
trauma targets if they want to do so. In this phase, it is important to help the client continue to
monitor their inner experience and to keep them grounded. The sessions always include container
and comfortable place and a check in to notice any body sensations that may be problematic.
As therapy progresses, it is also important to monitor substance use. Initially, it is possible
that their use could increase as old feelings are coming to the surface. However, the practice of
mindfulness, and the use of the container, can help the client learn to navigate difficult emotions
without the use of substances. Further, re-administering the substance use screening tools at
various intervals can provide encouragement to the client if they begin to notice that their use is
decreasing over time.
Recommendations for Future Research
Research is limited within the co-occurring disorders population as most studies screen
out people who have chemical health problems. In order to understand the lasting effects of
TRAUMA, ADDICTION, AND THE BRAIN
58
brain-based therapies in this population, it would be beneficial to include these participants. For
example, mindfulness is being utilized in substance use treatment programs to help identify
triggers, and ride out cravings; however, research does not appear to be available to identify
whether the changes in the brain, due to meditation, reduce or eliminate the need for the
substance altogether. If studies show permanent changes in the brain due to meditation, further
studies would be helpful to identify the lasting effects these changes have with relation to
substance use. Additionally, sample sizes tend to be small. Larger studies with varied
populations would help to further the understanding of brain alterations resulting from alternative
therapies as well as establish a larger control group to exemplify the differences between various
treatment methods. Finally, EMDR studies are often limited to fMRI studies that identify brain
areas activated during aversive visual stimulation. Larger studies are needed within the co-
occurring disorders population as well as those with PTSD to identify brain changes after EMDR
is complete.
Conclusion
Trauma experienced in childhood causes brain changes that correlate to addiction
vulnerability later in life. Neuroimaging has demonstrated a reduction in functioning and
volume in the areas of the brain that are implicated in the addiction process. Utilizing brain-
based therapies such as accelerated experiential dynamic psychotherapy, mindfulness meditation,
and EMDR correlates to improved function in these brain areas. The biopsychosocial model
asserts that a holistic approach is necessary to meet the unique needs of the individual which is
further supported by Adler’s belief in holism. Treating the effects of trauma at their root
provides the best possibility for helping those with addiction develop a life of meaning and
purpose.
TRAUMA, ADDICTION, AND THE BRAIN
59
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