Preventing and responding to relapses – central to recovery from substance use disorders – are a primary focus of outpatient alcohol and drug rehabilitation as well as of continuing care. Understanding what triggers them is an important part of dealing with relapses effectively. Of the three categories of triggers – exposure to psychoactive substances, environmental cues, and stress – the last is perhaps the one most complex to address. The stress created by the emergence of memories of traumatic experiences is a particularly problematic issue.
The familiar quote, “God never gives you more than you can handle” is not, in fact, found in the Bible. Rather, it is a “meme” resulting, I believe, from wishful thinking. Most of us have unfortunately had one or more experiences of encountering something that is psychologically more than we could handle at the time.
Here is how I think that this situation evolves into a relapse trigger: When an event is psychologically devastating, one’s defenses lock up the memory of the experience so that it is kept out of conscious awareness. If this memory is not psychologically processed at a later time, it can endure in this locked-up state indefinitely. If later stress weakens the locking-up defenses, people often find that using a variety of substances – such as alcohol, tranquilizers, and opioids – can shore up those defenses and keep the painful awareness at bay.
If the person has a genetic predisposition to developing a substance use disorder, the temporary relief afforded by the substance develops into a separate problem in its own right, thus complicating the trauma disorder. When the traumatized person addresses the substance use disorder by abstaining from the substance, he or she is likely to have experience that triggers the traumatic memories that emerge through the cracks in the defenses. Because these memories have not been processed, they return into awareness with all of their original painful intensity. The person is unprepared for the resurgence of the painful memories, which act as a relapse trigger for a return to the use of the substance. The temporary relief of the trauma pain comes, however, at the expense of sobriety.
The best approach to this combination of problems is for the person to receive treatment for the trauma disorder at the same time as the substance use disorder. Significant progress has been made in treating trauma disorders over the past 40 years, because of the attention paid to combat veterans and survivors of childhood physical and emotional abuse. The treatment is primarily through psychosocial interventions. Moving at a slow pace is critical for success. The good news is that the prognosis for recovery from the combination of substance use and trauma disorders is better than at any time in the past and improves as clinicians gain more experience and support groups grow.