Janette, a 46-year-old woman who was recently divorced from her third husband, walked into a community mental health center with slurred speech, unable to make decisions, exhibiting extremely poor self-care and diminished expectations. All of her husbands were drug addicts; and the last one also was a sex addict (a term that was not readily used in the therapeutic process at the time). Janette was treated with antidepressants, and although she responded positively to the medication, she demonstrated a long-standing anxiety disorder. She fretted and worried about every minor and major detail in her life. Everything was a potential problem. Treatment with anti-anxiety medication improved her functionality. It was noted at the time of her intake that she was raised in a physically threatening, alcoholic home; and for a period of two years, experienced sexual abuse by two perpetrators who were friends of her parents.
Thomas started experiencing panic attacks shortly after he began recovery from his compulsive overeating. He was raised in an alcoholic family with a schizophrenic mother who subjected him to extremely cruel physical punishments. Food had always been his self-medication. Without the sugar, and without any recovery from the emotional pain in his life, his underlying fears quickly rose to the surface. He was hospitalized three times for what would ultimately be diagnosed as panic attacks characterized by intense anxiety, often accompanied by a feeling of impending death, heart palpitations, shortness of breath and sweating. He was never asked about his experiences growing up.
Both Janette and Thomas sought help in traditional settings that were not familiar with the dynamics of trauma or addiction. Although both experienced a stabilizing effect when treated for their presenting symptoms, the underlying issues were neither identified nor addressed. Ultimately, until the role trauma played in their belief systems and defense structures is recognized, the prognosis for a long-term favorable outcome is limited. Their trauma history will most likely continue to contribute to maintaining self-defeating belief systems and low self-esteem, resulting in poor decision-making and lack of healthy relational skills. That combination will, in turn, work against both of their potential for recovery from anxiety and depression, as well as Janette’s capacity to make healthier partner choices.

Familial trauma

When people think of trauma it is common to think of the trauma experienced by our soldiers in Iraq and Afghanistan, or the thousands of people who are survivors of natural disasters, such as hurricanes, tornadoes or tsunamis. Shoot­ings on our college campuses or in corporate offices leave behind many trauma survivors. However, the majority of people who experience trauma will experience a more subtle, chronic form that most often occurs within their own family ­system.
Blatant forms of trauma in the family include being subjected to and/or witnessing physical and sexual abuse. Trauma also occurs in more subtle forms—for example, living with fear on an ongoing basis, such as the fear of not knowing if or when a parent is coming home; or the fear that comes with listening to one’s parents argue night after night; or the fear of not being able to rely on a parent attending a significant event. To live with chronic fear during the vulnerable childhood and adolescent years—when one is developing beliefs about oneself and the world at large—is traumatic to emotional, psychological and spiritual development.
For those who are familiar with the early years of the adult children of alcoholics (ACoA) movement, this work offered a model and a language that enabled people to understand their childhood experiences; and created a process for healing to occur. Post-traumatic stress disorder (PTSD), once called delayed stress, is what the “adult child” dynamic encapsulated. It offered a framework for how the vulnerability of children who live with chronic stress and loss, self-protect against their pain with a host of different defenses, while learning faulty beliefs and developing cognitive distortions in the process. PTSD then described the resulting consequences, which often would not present as problematic until many of these individuals were of adult age.
When intervening with those who were raised with addiction in the family, it is critical to address issues of chronic stress, chronic abandonment, and in some cases, blatant violence, all of which are aspects of trauma.
A 1999 report from the National Center on Addiction and Substance Abuse at Columbia University stated, “There is no safe haven for the abused and neglected children of drug- and alcohol-abusing parents. They are the most vulnerable and endangered individuals in America.” The report further noted that substance abuse causes or exacerbates seven out of 10 cases of child abuse or neglect, and that children whose parents abuse drugs and alcohol are nearly three times more likely to be abused, and more than four times more likely to be neglected (Reid, J., Macchetto, P. & Foster, S., 1999).
Callee, a 23-year-old client told me, “As I was growing up I really remember wanting only one thing, and that was to do it differently than how it was being done around me. Two days before my 23rd birthday, with my husband in jail for a drinking and driving charge, I looked into the passive eyes of my child, whom I had just thrown across the living room floor, and I felt my world and sanity crumble. I was doing it exactly as they had done.” Callee was raised with both substance abuse and physical abuse, and at a young age was quickly repeating her family script.
The culminating act of abuse is when someone is killed, but for many family members the physical abuse is not the hitting, slapping or punching someone until they bleed or are bruised; rather, it may be the shoving, pinching, slamming someone up against the wall until their teeth rattle or terrorizing car rides.
Also traumatic to a child’s development is the witnessing of abuse. Jake shared, “When I was about 10, Dad would regularly come home drunk about three in the morning and drag my 13-year-old brother out of bed. He’d be yelling things at him, slapping him about the face, making his nose bleed. Sometimes he’d beat him with his fists. My brother would be bleeding and crying and Dad would hold him up to the mirror and say, “Is this what a man looks like?” The tears and fear that filled my brother’s eyes were my tears and fear. I always wondered when Dad would come home and if it would be my turn for him to make me a man.”
While there is no substantiated causal relationship, addiction and sexual abuse frequently coexist in the same family. Children are primed for victimization as they:
• Are starved for attention—perpetrators are known to groom their victims, to initially engage a child under the guise of friendship and give them positive attention.
• Are less likely to speak up for fear of not being believed. They already live in a family system where the truth is not supported.
• Give others the benefit of the doubt.
• Don’t trust own perceptions.
• Have difficulty identifying their feelings, making it less likely they can use their feelings as cues and signals to propel them to action that may mobilize assistance.
• Are already confused about what constitutes appropriate boundaries.
• Are already experiencing shame (from the addicted family system), which then accompanies the added shame from the sexual abuse, fueling powerlessness rather than action (reaching out for help).

In addition to the more blatant forms of abuse, these children are often subjected to covert forms of sexual abuse; being called sexual names such as, “whore,” “slut,” or being asked if he or she got “laid” last night and then being laughed at in a humiliating tone; or being exposed to drunken nudity, which often reinforces negative statements to a child about his or her own body.
Even more prevalent is emotional and spiritual abuse within the addicted family. This may consist of verbal abuse, name calling, blaming or severe and cruel criticism. It is living with ­broken promises, lying and unpredictability—not knowing what will happen next. With this type of trauma comes a myriad of feelings, such as:
• Fear—of being with an under–the-influence driver; of divorce, or no divorce; that someone will get seriously hurt or die.
• Sadness—for the parent not showing up; for what the parent said or didn’t say to the child.
• Anger—for broken promises; for the message that the parent’s using is more important than the child; that the parent does not try to quit or is not able to quit.
• Embarrassment—for outbursts in front of friends; for the unkempt appearance of the parent; for what the parent said or did in public.
• Guilt—for thinking that they are responsible for their parents’ behavior; for having negative feelings for someone they are supposed to love.
• Confusion—about why this is all happening and who is at fault.

Children learn to tolerate the hurt. With continuing exposure, they come to expect it, often developing a greater tolerance for hurtful behavior. They succumb to the dysfunctional family rules—Don’t Talk. Don’t Feel. Don’t Trust. Don’t Think. Don’t Question—all in an attempt to cope. It is the Don’t Talk rule, the rule of silence, when people just pretend things are different than they really are that sits on top of all of the pain and dysfunction. There is no doubt that these are children raised with chronic stress.

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Stress responses and trauma

The experience of stress can either promote growth or cause serious damage. There are three types of stress: positive, tolerable and toxic. Positive stress is associated with moderate short-lived physiological responses, such as the stress that comes with meeting new people, handling frustration, coping with parental limit-setting, etc. Positive stress is an important and necessary aspect of healthy development.
Tolerable stress is associated with physiological responses that could actually disrupt brain architecture, but are relieved by supportive
relationships, among other protective factors. These are stress situations such as the death or illness of a loved one; a frightening
accident; or a natural disaster. Certainly, these types of experiences can have long-term consequences, and they often become traumatic, particularly when coinciding with toxic conditions in childhood, which are traumatic in and of themselves. However, such stresses are emotionally and mentally tolerable when they are time-limited and the child has access to supportive people to provide buffering protection.
Toxic stress, the most threatening, is associated with strong and prolonged activation of the body’s stress management systems in the absence of the buffering protection of support. Toxic stress emerges in the face of loss—conditions of extreme poverty; continuous family chaos; persistent emotional, physical and/or sexual abuse; chronic parental depression; persistent parental substance abuse or other manifestations of addiction; and ongoing emotional or physical neglect. Without the protective factors that allow children the space to disengage, they become trauma victims.
Stereotypically, when we think of trauma, what comes to mind are public catastrophic events than can overwhelm an adult. What distinguishes childhood trauma from occurrences like combat stress is simply that the injuries occur to children. “Dear Lord, be good to me,” reads the epigram for the National Children’s Defense Fund. “The sea is so wide and my boat is so small.” A child’s personality and neurology—the little boat he or she must navigate in—are still developing.
For children, home is supposed to be safe. In times of trauma, the natural response is to run. This is not just about running from, but also of running toward. Trauma survivors typically run toward home, but where can a child go when the trauma is in his or her home? When it is not safe psychologically or physically to be the person you are, to own your truth, and what you see and how you feel, then you move into various trauma responses—you fight, you flee or you freeze.
Today we know the body cannot tell the difference between an emotional emergency and physical danger. When triggered, it will respond to either situation by pumping out stress chemicals designed to impel someone to flee to safety or stand and fight. In the case of childhood problems, where the family itself has become the source of significant stress, there may be no opportunity to fight or flee. For many children, the only perceived option is to freeze and shut down their inner responses by numbing or fleeing to the inside.
When young children get frightened and go into flight, flight or freeze, they have no way of interpreting the level of threat or using reason to modulate or understand what is happening. The brain’s limbic system becomes frozen in a fear response. The only way out is for a caring adult to hold, reassure, and restore the child to a state of equilibrium. When primary caregivers are not available to soothe and reassure, the child is left to live through repeated ruptures in his developing sense of self, his fundamental learning processes and his relational world.
By virtue of their extraordinary vulnerability, children are at special risk for trauma. Childhood injuries, even when mild by some people’s experiences, can have long-lasting effects because they occur while the very structures of the body, brain and personality are being formed.

The legacy

Most children growing up in troubled families learn to function by developing a false sense of self, adapting to the needs and demands of the family system. The family legacy then continues as family members act out and cause spiritual and emotional bankruptcy. Most who are raised in a family with addiction or other painful circumstances are determined not to repeat history, and genuinely believe they are going to be able to do it differently.
While a trauma survivor may no longer be subjected to abuse, he or she may not have found a therapeutic avenue through which to resolve his or her pain. Survivors often try to cope and quiet the pain by using substances, such as alcohol, cocaine, methamphetamine, heroin or even food. Often their use of a medicating substance or high-risk behavior is in response to an anxiety disorder or depression. It is
common to see both addiction and co-occurring disorders among those with greater trauma histories. Addiction, depression and/or anxiety are common flight or fight responses, and certainly freeze responses among this population.
Another dynamic characteristic of trauma is the fact that it repeats itself generationally. While the names change, the stories of repetitive partnering with an addict are nearly universal. This is referred to as trauma repetition.

Usually something that took place in childhood and started with a trauma; reliving a ‘story’ from the past; repeatedly engaging in abusive relationships; or repeating painful experiences, including specific behaviors, scenes, persons and feelings (Carnes, P., 1997). It is often repeating what you know, the familiar or what you believe you deserve. It may be an attempt to change the outcome of an old family script. Ulti­mately, it is as futile as attempting to survive the sinking Titanic by repeatedly changing your seat as the ship is going down.

The evidence

For more than a decade, the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente in San Diego, along with leading researchers, have been conducting an ongoing study, the Adverse Childhood Ex­periences Study (ACE), to examine the childhood origins of many of our leading health and social problems. The ACE score is used to assess the total amount of stress during childhood and has unequivocally demonstrated and quantified for the first time that which we have observed clinically—as the number of adverse childhood experiences increase, the risk for the following health problems increases in a clear and progressive fashion (Anda, R. & Felitti, V., 2003):
• Alcoholism and alcohol abuse
• Depression
• Illicit drug use
• Risk for intimate partner violence
• Smoking
• Suicide attempts
• Multiple sexual partners
• Health-related quality of life—specific health issues of liver disease, chronic obstructive pulmonary disease (COPD), ischemic heart disease (IHD) and sexually transmitted ­diseases (STDs).
In his book, The Truth about Depression, Charles Whitfield, MD summarizes 251 peer-reviewed published reports that examine the relationship of childhood trauma to subsequent depression and other mental illness. Of the 209 studies that linked depression with having a history of childhood trauma, the reports found that among those with a history of childhood trauma, depression was from 1.6 to 12.2 times more common than was found among the controls. Further, an additional 70 published studies from the community on nearly 70,000 trauma survivors and controls showed up to a tenfold increase in depression; and two prospective studies following 11,000 people for up to 20 years revealed an increase in depression of up to tenfold (Whitfield, 2003).
In his book, The Truth About Mental Illness, Whitfield cites a total of 153 data-based research studies that document the firm association of the link between alcohol and other drug problems and having a history of repeated childhood trauma (Whitfield, 2004).

The possibilities

The possibility for recovery from trauma begins with identifying whether or not there is a primary disorder and the potential for co-occurring disorders and multiple manifestations of addiction. In addiction treatment programs, it means recognizing family treatment is not merely an educational process, but that family members have the right and need the opportunities to heal from their ­familial pain.
For the primary clinician, it means asking clients about their original family history, asking pointed questions about the use of alcohol and other drugs, and exploring the possibility of other addictive disorders. It means asking about the possibility of physical or sexual abuses, and recognizing the impact of toxic stress, chronic loss situations and less than nurturing environments. And, in this process of asking, we as treatment professionals need to demonstrate a willingness to identify and address trauma as a clinical issue.
In some situations it is easy to not recognize the role past trauma continues to play in someone’s life. Or it may be easy to discount the role of trauma because the trauma itself or its apparent consequences may not seem to be as severe as someone else’s experience. But no one person’s losses negate anybody else’s experience. The prevalence and impact of traumatic experiences are not to be underestimated. Everyone deserves a life of choice versus living a script written by a dysfunctional family system.

Claudia Black, PhD is a well-known and respected educator and author of more than 15 books in the field of addictive disorders. She is Senior Clinical and Family Services Advisor for Las Vegas Recovery Center specializing in the treatment of chronic pain and substance abuse, and Senior Editorial Advisor for Central Recovery Press, publishing materials on addiction, recovery and behavioral health care topics. For more information contact lasvegasrecovery.com; centralrecovery.com; or claudiablack.com.