Episode #145

Bidirectional means “moving or taking place in two usually opposite directions.” This concept is super important to understanding how trauma and substance use connect. They don’t just intersect, they interact and drive the other. Research is clear about the bidirectional relationship. Most of our clients have had traumatic experiences. Some may have more severe or chronic trauma, but life is inherently difficult at times and so trauma is common. If trauma is common, then it stands to reason that substance use is also common. I want to share some of the research about the relationship between trauma and substance use.


 You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

Welcome back to the All Things Substance podcast. This is episode 145. It is officially September and its  one of my favorite months of the year. I love fall weather, even though today as I’m recording this, it’s currently 101 degrees up here in the north country.  By Wednesday it’ll be 67 it says, and down to the forties at night. It’s been a really weird summer with August being unseasonably cool, and we’ve been in the nineties for the last four days up here. 

This summer has been really busy. You might’ve missed hearing from me in the month of July. Well, that’s because I was running Charting the Course. Charting the course is the six week live taught program that I do for therapists, giving them the training that they need to feel confident and competent in working with substance use. It was a blast. I loved being able to work with the therapists in the group, and I’m excited to start our consultation calls in two weeks.

I’m gearing up for the last cohort of 2023 for Charting the Course. This will start on October 3rd. There are 10 spots and I would love to have you in it. I’ve even joined together with a colleague of mine, Dr. Jenny Hughes, to offer something really special. Jenny runs something called Brave, the Trauma Therapist Collective. Jenny has experience as a trauma therapist feeling unsupported and  was herself heading towards burnout and secondary traumatic stress due to doing the work of being a trauma therapist.

What she found was that having the support of other therapists helped bring her back from that, and it gave her a passion to do that work. As therapists, we really should have. A number of things in order to be good therapists, training isn’t enough, and having a full license isn’t enough either. What we need is excellent supervision, and most of us got mediocre supervision at best. We need colleagues that we can rely on. We need other people who understand what it’s like to do our work. 

Other people who know what it’s like to have to do notes when you’re exhausted, or having to rewrite diagnostic assessments every year or update treatment plans and make sure they’re signed and deal with productivity expectations, as well as the darkness of all of the things that we hear of how humans treat each other.

We keep hundreds of thousands of details of people, their family members, their pet’s names, their jobs, their likes and dislikes, things that trigger them, and things that help them calm down. We keep all of that in our head and we’re fucking good at our jobs. However, it takes a toll on us. This is where Brave the Collective comes in.

Jenny created a membership group built to support each other. In this group, there are expert trainings and consultation calls for those who wanna staff cases.  And there are practical techniques and tips that Jenny teaches you. So that you can protect yourself from burnout and secondary traumatic stress, or for those of you who are already there, help you come back from it.

Jenny is one of my very closest friends and colleagues, and we decided to put our programs together in a bundle so that you will have six months of BRAVE  and my course, plus the six months of consultation calls. You will get all of the training that you need to work with substance use and my support in addition to a community of other therapists doing hard work.

It may sound like you might not have the energy to do this, but I promise you it’s worth it. When we have support, it can be a huge deal. And that’s what I’m gonna be talking about for the next couple of weeks on the podcast.

One more business item before we get started today, Jenny and I ran our training Braving the Course on Monday, August 28th. We had a replay up and still do for those who wanna watch it, but as we got to talking and debriefing with each other, we talked about people who wanted to attend live, but just couldn’t on that day.

And we talked about people asking regarding CEUs and whether or not they could earn credit for the two hours of the training. Well, we got to talking and decided that we would try and experiment. We’re gonna run Braving  the Course one more time on September 18th. That’s a little less than two weeks on a Monday night at 6:00 PM Central time to 8:00 PM central time.

That’s seven for those in Eastern and five for those in Mountain, and four for those in Pacific time. We know that those in our international audience aren’t going to really be able to attend live unless you are all the way on the other side of the world in parts of Asia, Australia, New Zealand. We wanna offer this live so that people can attend and be there in person.

For those of you who are able to make it in person, we will be offering two free CEUs for everyone who is there live and remains for the entirety of the training. I’d love to be able to offer CEUs for this training when people watch it on a video. However, the rules about CE vary from state to state and board to board. In order to do something like this off the cuff, I have to obey a certain set of rules from a particular board. 

It’s complicated, but it is legit. It’s just that I have to be able to verify attendance at the training and for the entire training. In order to do that, I have to be able to verify that, and the only way for me to do it is to have you there live.

So I know that not everyone will be able to attend this, but I wanna invite you anyway, if you can figure out a way to clear your schedule on September 18th, which is a Monday at 6:00 PM Central time, it’ll be on Zoom and we’ll run from six to eight. And you will get a certificate with two CEUs. 

If you are not already signed up head over to betsybyler.com/braving-the-course, braving dash the dash course. You sign up there and you’re registered. You’ll get the link to the zoom room the day before the training. For those of you who are already signed up, you don’t need to do anything further since you’re already signed up. You just need to show up live. We are so excited to offer this opportunity to you and to offer you two free CEUs.

In the next couple of weeks as we’re leading up to Braving the Course and talking about the bundle that includes membership in the Brave Trauma Therapist Collective and a spot in Charting the Course, which is my program, plus the six consultation calls. Afterwards, we’re gonna be talking about trauma and substance use.

I think if we all stop to think about it, we know that trauma and substance use are highly related. It seems like a given, but I thought today I would go over some of the research to show us that truly substance use is showing up  in our offices. We just maybe don’t think of it that way.

Trauma comes into our office, whether you are a specific trauma therapist or not. For those of us who are specializing in trauma like myself, I may end up seeing more significant and severe trauma. But I remember before I ever specialized in it, most of my folks had trauma. I definitely had people who had been through natural disasters, traumatic death, sexual assault, assaults of other kinds, childhood neglect, domestic violence.

All of those things showed up in my office even when I hadn’t said that I could manage that. The thing is that we know that trauma is directly correlated and responsible for the development of a number of mental health issues. We also know that one of the outcomes of trauma is increased risk for problematic substance use.

So let’s talk about that. About 20 years ago, the ACEs study came out. This is the Adverse Childhood Experience study that was completed in 1998. It took us a while as a community to get all of the research out, but it became a hot topic. I recall going through trainings about ACEs. This study told us what we suspected, but it wasn’t something that we had the research on. If you haven’t had a chance to hear about the ACEs study, that’s the Adverse Childhood Experience Study, Google that, and I’ll put links as well on the show notes and take a look because it is fascinating.

What they found is that when people had experienced traumatic things within the first 18 years of life, such as physical, emotional, and sexual abuse, neglect, loss of a parent, witnessing intimate partner violence and living with a family member with mental illness, they found that. The more of those a person experienced, the risk of alcohol and other drug use in adulthood increased dramatically.

They found that adults endorsing four or more of those experiences were three times more likely to experience alcohol problems in adulthood, and those endorsing three or more ACEs were three times more likely to engage in problem gambling.

We also know from research that traumatic experiences in early childhood have a huge effect on the development of the brain  and that a number of these changes in brain development can make people more susceptible to problematic substance use. Part of that is the dysregulation of the stress system.

When people go through trauma, their stress system gets overloaded, and they’re constantly on guard. We know that because that’s one of the hallmarks of PTSD, is the hyperreactivity. The hyperawareness. What we know about people who are constantly in a state of chronic trauma or constantly in a state of chronic hyperawareness, is that their body’s alarm system doesn’t really know when to shut off.

Like a motion detector light that goes off every time a leaf blows through it, rather than when something the size of a human goes through it. They’re constantly on or ready to be on immediately. The stress system is supposed to prepare us to respond to danger, but it over identifies danger and makes people unable to determine what danger really is.

So sometimes they’re constantly aware and ready for fight, flight, or freeze. And for others, they’re so overloaded that they just see nothing as dangerous and they numb out or dissociate in order to deal with it. All of this during childhood is going to affect the ability to regulate emotions. It’s going to affect cognitive development and executive functioning.

We also know that it can disrupt the regulation of oxytocin, which is a hormone implicated in attachment and emotional intimacy. It can also mess with serotonin, which is a neurotransmitter linked to mood resulting in attachment issues and feelings of depression. So what does this all have to do with substance use?

Well, the main reason that people end up using substances in a problematic way.

So the main reason that people use substances is because of the immediate effect they get from it. This happens even in what I would call normal or recreational substance use. Most people know how it’s going to affect them and they’re using it because of that. Sometimes folks are strictly based on the taste and that’s all they’re after.

Other times, people are wanting to relax or have fun, and they know that having a drink or two or three is gonna do that. That’s super normal. If a little bit is good, in that sense of helping someone relax, wouldn’t more be better? So we have a bunch of people who have been through trauma, and we know that trauma doesn’t discriminate, but race, sex, gender, socioeconomic status, culture, et cetera.

We do know that there are higher rates among certain people groups, but trauma affects everyone. Substances are available to everyone. It is something that you don’t need another person to engage in the activity. You can figure out a way to find substances for yourself. It’s always going to work and it’s always available. You can always find something to use. It’s far more reliable substances, I mean, than people. It’s no wonder that when people experience trauma, substances are often involved. 

So when someone has experienced trauma and they have a dysregulated stress system, drugs and alcohol can offer relief. It can help take down that chronic hyperarousal and anxiety that they feel. Depressants like alcohol, benzodiazepines, opioids,  and cannabis or T H C helps slow things down. When you are dealing with a chronically overstimulated stress system, that can be like a breath of fresh air.

The number of folks who have experienced trauma and never used substances to cope, I believe, is extremely small. I’m not saying that everyone who has had trauma has used substances to cope, but I’m saying that the majority of them most likely have. It’s understandable. It’s problem solving. And for a lot of folks, trauma was experienced early in childhood because children are the most vulnerable.

Certainly there’s trauma that happens as an adult. There are lots of folks I see who grew up in relatively safe, good enough homes and experienced something traumatic as an adult. Even those folks, in my experience at one time or another, used substances to manage it. Maybe not long term, maybe they didn’t get into problematic using, but they found that substances are there and they’re effective and they’re immediate.

Depressants aren’t the only type of drugs or alcohol that people like to use in order to deal with their traumatic experiences. For some people, their response to trauma isn’t to be  hyper aware, but instead it’s to be numb, to dissociate,  to be below the window of tolerance, so to speak. And in that case, stimulants are the way to go. Cocaine, amphetamines, synthetics, all have stimulating effects that help bring up energy and alertness. It allows them to feel something.

We know from the research that individuals with trauma histories are more vulnerable to addiction because of the mood modifying properties of the substances and the rewarding behaviors. It’s actually not just the reward system that gets impacted. There are a couple other areas of the brain that get impacted that make this a triple whammy when it comes to risk for developing problematic substance use.

And those have to do with the ability to form habits around certain behaviors. So we’ll think of that as opera conditioning and that additionally, the use of substances over time causes the brain to be less able to manage stress. And in a system where somebody has experienced trauma, they are already less able to manage stress and more vulnerable to the damage from that. Substances make that even more significant.

When we look at who the experts are that are talking about trauma, one of those is the National Child Traumatic Stress Network, or NCTSN.  The National Child’s Traumatic Stress Network has put out tons of resources about trauma If you’ve never gone to their website, it is a wealth of knowledge and I would totally recommend going to check it out even if you don’t work with kids.

What they found is that one in four children and adolescents in the United States experiences at least one traumatic event before the age of 16. So that’s one in four that experience at least one before the age of 16, one in eight, then develop post-traumatic stress disorder at some point in their lives.

It’s estimated that 29% of adolescents, nearly one in three, have experimented with illegal drugs by the time they complete eighth grade and 41% of them have consumed alcohol. And that’s just experimentation. We know even further, that one in five American adolescents between 12 and 17 engages in abusive/dependent or problematic use of illicit drugs or alcohol. So one in five of those who have been using are doing so in a.

In surveys of adolescents who are receiving treatment for substance use, more than 70% of them had a history of trauma exposure. And teens who had experienced physical or sexual abuse were three times more likely to report past or current substance use than those without a history of trauma.

Trauma and substance use have a bi-directional relationship. By this, I mean that trauma is a risk factor for substance use, and that substance use is a risk factor for trauma. Let me be super clear that this is a statement that is being made by experts, not something that I just came up with. I also wanna be super clear that we are not blaming people using substances for their trauma.

When traumatic events happen and assault is perpetrated, it is never the victim’s fault. We know that when substances are involved that bad things can happen.  When I was last doing, charting the course, we talked about this as a group, how we had clients whose experiences around drugs and alcohol led them to believe that an assault that they experienced wasn’t actually assault because substances were involved and they felt like that meant it was their fault and they couldn’t say it was assault. As much as we try to put that to rest and to tell people that, no, that’s not the case, just because you were drinking or smoking or whatever, doesn’t make an assault not an assault. But it is super common.

Substances are a way that people let their guard down, and there are people in the world who prey on those who are vulnerable and indeed want to give them substances to make them vulnerable. So it is a bi-directional relationship. Trauma is a risk factor for substance use, and substance use is a risk factor for trauma.

Another place that you can find expert information is the International Society for Traumatic Stress Studies, ISTSS. They found increased rates of substance use among people who have experienced trauma regardless of age. For instance, up to 80% of Vietnam vets seeking PTSD treatment have alcohol use disorders. Women exposed to traumatic life events show an increased risk for alcohol use disorder. Men and women reporting sexual abuse have higher rates of alcohol and drug use disorders than other men and women.

 In their studies, adolescents with PTSD are four times more likely than adolescents without PTSD to experience alcohol abuse or dependence, and six times more likely to experience marijuana abuse or dependence, and nine times more likely to experience hard drug abuse or dependence.

So let’s think about substance use and whether or not you see clients with substance use. I think the majority of therapists, if they were asked, do you work with substance use? I think people would say, no. Some people might say, well, it depends. Sometimes I do, but I don’t specialize in it. What I have been saying, and if you’ve been around me for any length of time, you know that I say this a lot, is that we all work with substance use.

 I would venture to say that there is not a single clinician with any time under their belt at all that has never had someone abusing substances in their office. Whether they knew they were or not  we can’t know, but substance use and problematic substance use is everywhere.

And it is not because we are somehow deviant people. It is just because we are all moving from day to day. And people are trying to survive and manage their lives and the pain and the hurt of being in relationship with others, of dealing with loss, of dealing with other kinds of threats and pain.  If you have ever decided to take an extra drink or smoke extra or whatever, just to forget, then you know what that feels like.

The issue comes when people don’t see when their use is crossing the line from normal and recreational to problematic. See, everybody thinks that they’re gonna know when that happens. Like somehow it will come to them and they will be able to tell. And the truth is that’s not what happens. Most people aren’t thinking about their use like that in the beginning.

They’re not like, okay, so if I wanna be a normal drinker, how can I do that and where’s the line? When do I need to stop so that I don’t become an alcoholic? Or when is it too much? Now, every now and again, somebody has a consequence. Like they go into a blackout and something terrible happens, or they have a really big social consequence and they’re like, oh shit, I acted like a fool and I need to scale it back.

Most people though, who are using in a problematic way, they drifted there. It’s sort of like getting on a slow moving river on a raft and falling asleep and waking up three hours later and you’re miles away. That is what substance use usually is like. Once in a while we get somebody who jumps all in feet first. Most of the time though, it’s not what happens.

I have been doing this work for a long time, or at least I feel like it’s a long time. It’s 20 years this year. And what I have noticed about people’s substance use is that it typically starts out with normal experimentation, just like other kids and for those people where it kicked over into problematic, there was a triggering event.

It could be small, it could be big, but once that domino gets pushed over, things pick up speed. And sometimes the triggering event was just the beginning. And then because substance use increases the risk for trauma. Traumatic things happen, and it keeps the substance use moving right along.

You do not have to specialize in substance use in order for it to show up in your office.  I guarantee you that if you aren’t really screening for substance use, that there are people in your practice who are using and you just don’t know it. We hide the things that cause us shame, and most folks who are using problematically are feeling shame about that.

I’m not suggesting they need to feel shame, just that it’s just our default. I get it. I get why therapists get concerned about substance use and about screening for it. I think there are valid reasons that people give for not wanting to ask about substance use. I think it’s important though, that we do, and that’s gonna be what we talk about next week.

Next week, I wanna share with you the top five reasons that I believe that therapists don’t ask about substance use. And I wanna give you the top five reasons that I believe you should.

Here’s the thing that I’m bringing to you today. If you are a therapist, then trauma shows itself in your office whether you specialize in it or not. That people who have experienced trauma are many times more likely to have used substances to cope. That trauma increases vulnerability to addiction and problematic substance use, and that therefore, there are people that you see that are problematically using substances and they need your help.

To me, substance use is so common that saying that you don’t work with it would be like saying that you don’t work with people who have anxiety. It’s so incredibly common. We’re not talking about addiction, full-blown addiction being incredibly common, although among folks with trauma, that’s a super high number. That the number of folks in active addiction, whether it be to substances or gambling, the majority of them have significant trauma. We know that from research and surveys. That is a huge number.

So I’m not saying that everyone who has trauma in your office is at high risk for addiction or using in a way that is into the addiction area, but that there are folks in your practice who are using substances problematically. Your job is not to get them sober. Your job is to help them find healing and freedom and living the life that they want.

Substances are going to fuck that up, especially if they’re not being honest with you and themselves about it. It’s gonna get in the way. I do get it though. I really do get why therapists don’t talk about substance use and why they’re hesitant. . And that is gonna be the topic of our next podcast.

In closing for today, please don’t forget about braving the course, which is going to be live the week after next Monday night, September 18th at 6:00 PM Central Time. I am so excited to do this training live again with my friend Dr. Jenny Hughes, and also to offer two free CEUs for you. All you need to do is register and show up live. If you have not registered, you can do so at betsy byler.com/braving-the-course and that’s B R A V I N G Braving the Course.

I can’t wait to see you there. If you have any questions, please feel free to email me. You can always shoot me an email at betsy@betsybyler.com and if you are not already on our mailing list, then you probably aren’t getting these updates, and you can certainly go to my website and register as well. I’d love to keep you up to date on all the things that we’re doing.

Thank you so much for listening. I love being able to share information with you. Thank you for your patience with my break in July, but I’m back and we’ve got good things coming this fall on the podcast in training series and a number of exciting projects that I am really pumped to be a part of.

Thank you so much everyone. I hope that as I’m recording this, you are having a good Labor Day weekend here in the US and that it’s not as hot where you are. I’ll see you on the next podcast, and until then, have a great week.

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.


Helpful Links

Braving the Course Registration betsybyler.com/braving-the-course

Home of the Brave Trauma Therapist Collective braveproviders.com

Charting the Course betsybyler.com/course

Traumatic Events and Substance Use Disorders in Adolescents – PMC

Substance Abuse and Trauma. – Abstract – Europe PMC

The adverse childhood experiences questionnaire: Two decades of research on childhood trauma as a primary cause of adult mental illness, addiction, and medical diseases –