In the expert opinion of Dr. Stephanie Covington, it's unwise to ignore trauma when treating addiction and co-occurring disorders. In fact, a failure to address PTSD will leave a person vulnerable to relapse and re-traumatization. In this episode, host William C. Moyers and Dr. Covington chat about the intersection between trauma and addiction, the high frequency of their combination and the best approaches for treating both. Read the podcast transcript below or listen and subscribe on iTunes, Google Play, Spotify or watch on YouTube. 0:00:13 William Moyers Welcome to Let's Talk, a new season of our award-winning series of podcasts produced and presented by Hazelden Betty Ford. I'm your host, William C. Moyers, we are glad you've joined us. Today our topic is the intersection between trauma and addiction and recovery from both. Dr. Stephanie Covington is a skilled clinician, an insightful author and an engaging public speaker, and our guest today. I've had the opportunity to hear Dr. Covington lecture several times over the years but this is the first time I've ever had the honor of interviewing her. Thank you, Stephanie, for joining us today. 0:00:52 Dr. Stephanie Covington Glad to be here, Bill, thank you. 0:00:53 William Moyers And I gotta ask you right off the bat: what is your interest in addiction and trauma and the intersection? Where does that come from? 0:01:01 Dr. Stephanie Covington Well, initially my interest in addiction came from my own experience. A recovering woman and early in my recovery I thought to myself, 'I wish one other woman could feel the way—feel the way I do.' And a series of events led me into the addiction field. And particularly focusing on women. And as I did that, I realized so many of the women I was seeing either in group in a treatment center or a private practice I had, had trauma histories. And I realized nobody was talking about that. And I began to explore more. And it was just—it was the evolution of my work really. And in those days, and now I'm talking about in the '80s, the addiction field did not wanna talk about trauma. I mean I can't even tell you the negative pushback I got. It was—it was fairly powerful. And the mantra in the addiction field was 'When you're clean and sober, you have a trauma history, you can deal with it a year from now.' Get a year of recovery and then deal with it. [shakes head] And I knew many people were never gonna get a year of recovery. 0:02:09 William Moyers Mmm. I wanna come back to that in a couple of minutes. Let me ask you first though—can you define trauma for us? 0:02:17 Dr. Stephanie Covington Sure well there're various definitions of trauma. I mean the one that mental health providers use in the DA Diagnostic Manual is that it's really a life-threatening event. And it's a life-threatening event in which can occur because you experience it or you witness or you hear about it happening to somebody else, or you get it because you're surrounded by trauma. And then there has to be a particular response. And the response it has to impact your relationships and your work life. And so, it's not just an event but it's a person's response. I think a simpler definition would be it's an overwhelming event that overwhelms a person's capacity to cope. Their physical and psychological coping skills don't work. Aren't working. Because of the overwhelming nature of the event. 0:03:10 William Moyers Why then has it taken us so long as professionals in the field to recognize the impact that trauma can have? And how it is so intimately connected to substance use disorder? 0:03:24 Dr. Stephanie Covington You know I've wondered that. I think it's a couple of things. I think one piece has to do with how the addiction field has evolved. You know? It evolved through people with lived experience and people who are paraprofessionals and dealing with trauma seems kind of scary if you haven't been "trained." [uses air quotes] I think also the belief that addiction is the primary issue as though that's the only issue, I think that theory has been problematic. And I think many people working in the field had trauma histories they never addressed themselves. And so it's pretty scary to think about working on trauma if that's part of your experience and the only way you manage it is to wall it off. So I think those are the things that have kept us as a field from being willing to really look at this and how important it is to understand this in terms of a person's recovery. 0:04:22 William Moyers And does trauma affect women the same way it affects men, the same way it affects children? 0:04:28 Dr. Stephanie Covington Well, it affects individuals differently. I think if we talk about women, there's certain traumas that women are more at risk of experiencing. Interpersonal violence, the violence that happens in relationships, women are at greater risk of experiencing than men are. The other thing for men there's a different level of shame for men. And I think it has to do with male socialization where we teach boys that you're supposed to be tough, you're supposed to withstand things, you're not supposed to show your feelings. All these things and then what if I'm a kid and I'm abused and I feel overwhelmed and I wanna cry, does that mean I'm not a man? So I think it's compl—it's a different level of shame for men. And for children, part of the challenge for children is is trauma impacts the brain. And for a child, their brain is still in development. So the impact on children particularly in terms of the brain is—is really dramatic compared to what might happen to someone who is an adult. So there are different ways that it can impact people differently. 0:05:36 William Moyers If somebody is impacted by trauma, either currently in their life or in their past, is it assumed that they're going to develop a problem with substances? 0:05:47 Dr. Stephanie Covington Not necessarily. I mean I—it's not a guarantee. But for many people who've experienced trauma, I mean one of the ways—what do you look for? You look for ways to cope. [Moyers nods] If your typical coping mechanisms don't work, gee, alcohol might work! [chuckles, raises glass of water] I can numb myself out with this. So, people pick up a drink, they use a drug, so we see some people who start using alcohol and other drugs as a way to manage their trauma symptoms. 0:06:16 William Moyers So you mean they're consciously or are they unconsciously using substance to manage that trauma? 0:06:22 Dr. Stephanie Covington A lot of times it's unconscious. [Moyers nods] It's very unconscious. Sometimes it's deliberate, sometimes it's 'I'm not feeing okay, oh this makes me feel better.' I don't think it's necessarily oh I have had trauma, therefore I'll drink. [chuckles] Or use. But I think it's about what can help me feel differently? I don't like how I feel. 0:06:42 William Moyers [nods] Hmm. And for somebody who struggles with trauma and also has a substance use issue, if you remove the substance use issue without addressing the trauma, what happens? 0:06:55 Dr. Stephanie Covington Usually there's relapse. It's a really interesting thing and a lot of addiction professionals don't like hearing this but if you have let's say post-traumatic stress disorder and you have an addictive disorder, and you treat the PTSD first, the addictive problem gets better. If you treat the addiction first, the PTSD does not get better. And so, all these years when we've heard well this is primary, well, this is primary and important, but this piece is also connected. And so now we talk about doing both. Working with both the trauma as well as the addictive disorder. 0:07:35 William Moyers But it's that chicken and egg that in reading your webpage, which is extensively sourced with information that even helped a layman like me to understand these issues, what I was immediately struck with is the chicken and egg approach. I mean, so how does somebody go and get help for trauma and substance use and how does a professional treat 'em? Do they treat one before the other? Both? How does it work? 0:08:02 Dr. Stephanie Covington Well, you know, number one if someone is looking for let's say a treatment program, whether it's outpatient or residential, you'd wanna be in a program that knows how to deal with both. And they will work with you as an individual to see how in-depth the trauma work may be. In the beginning of—of your recovery work. Sometimes you do both. Just right at the same time. Other times, there's an acknowledgment of the trauma and you learn coping skills. I mean think about it. If I've been using alcohol and other drugs as my primary coping skill, and you're taking those away for me 'cause I'm in a treatment program, what am I gonna do when I get home? You better teach me some new coping skills fast that are related to my trauma. That helped me when I have a trigger or a flashback or I have to have some new skills. 0:08:54 William Moyers Tell us about some of those coping mechanisms, some of those skills that somebody needs to help manage their trauma. 0:09:02 Dr. Stephanie Covington Well we teach people some very simple things. There are exercises, some of them have to do with breathing exercises. There are exercises about being in the here and now just like you and I sitting here. An exercise would be for me to say—what color are the walls? How many chairs are in this room? How many—you know, very here and—they're very simple, concrete things. And we have a variety of these exercises that we teach people and we have them sort of rate how did I feel before I did the exercise, how do I feel after I've done the exercise, and end up with three or four that really work well for you. They're different for different people, you know? 0:09:43 William Moyers But it can be more intensive as well, right? I mean you talked about some things that somebody can do in their home office or if they're riding a bus or walking down the street. But what about some of those intensive therapies and how does that work? 0:09:56 Dr. Stephanie Covington Well, there's a missed understanding. People think that having complete memory is part of the healing process. So you don't really have to work with people to have complete memory of an event. Sometimes you know the way I was originally trained was that if I was gonna work with a trauma survivor, I'd work with them multiple times a day for many years. Very few people get that service. Nor do they need that service. And so, some of the more intense interventions we really do reserve for when people are more stabilized in recovery. But the initial work is pretty—you'd be amazed how powerful it is for people to do really simple things. 0:10:42 William Moyers How about the role of the Twelve Steps play? Certainly they're integral to recovery for millions of people. Is there an applicability when it relates to trauma? 0:10:54 Dr. Stephanie Covington Well, yes and no. I mean, the Twelve Steps are wonderful tools for living. They're really wonderful. When we come to trauma, there're a couple of problematic areas. One is you can go to meetings for years and some—and no one will ever say trauma. So you might think well I guess that hasn't—doesn't relate to anybody in this room. No, not necessarily. They just may not be sharing it. The other thing particularly for women is sometimes going to co-ed meetings it's that old thirteenth step. [Moyers nods] It's not necessarily a really safe place for a newcomer for a woman. So there—those are some of the things to think. But there's nothing contraindicated in the Twelve Steps. You know, a number of years ago I wrote that little book A Woman's Way Through the Twelve Steps. [Moyers nods, smiles] And many of the women talked about trauma and how they've used the steps with their trauma. So there's nothing contraindicated, but I wouldn't rely on the Twelve Steps for my trauma healing. 0:11:54 William Moyers I wanna come back to your authorship in just a moment. But just quickly, to continue on this train of thought, what about the role of medications? Is there pharmacology that applies to addressing trauma? 0:12:09 Dr. Stephanie Covington Well, it depends on the person. You know. What happens for people who are trauma survivors sometimes they have anxiety disorders, sometimes they're depressed, there are a variety of mental health symptoms that are often are related to trauma. And sometimes those need to be medicated in order for someone to sustain the recovery or be involved in a group process. So there isn't like a pill you take for trauma. But there are things available for some of the symptoms that are related to having the trauma history. 0:12:39 William Moyers You've been intimately engaged in this issue of trauma and helping women and men heal from it. Since the 1980s. and in your—in your books and in your lectures, in your presentations. Talk about your—the evolution of our field and particularly the evolution of your perspective, as it relates to identifying, recognizing, and treating trauma. From the '80s to now. 0:13:06 Dr. Stephanie Covington Well in the '80s, as I mentioned [laughs], when I would talk about this in a lecture, talk about—I mean people were angry at me. I mean, furious. I would come off a podium and people would say I was gonna be—people were gonna die because of what I was saying. I mean just all these things that weren't true of course. And then, probably one of the most sort of touching things was in the middle to the end of the '90s, a man who very had—well two men actually really were adamant high up in the field about this, about why I was wrong. We were all at a conference and they gave—both came up and gave part of my introduction, they both said they were wrong. That they had been unwilling to look at this and that—and you know that's a big deal for somebody to get up. [chuckles] If you're a "name." [uses air quotes] And you know they admitted they were wrong. So, it's been an evolution. 0:14:02 Dr. Stephanie Covington [continued]Now, I would say in the '90s, we began to sort of acknowledge it. But didn't do anything about it. [Moyers nods] 'Oh yeah, our clients often have trauma.' And then now, what's been evolving slowly is people realizing that becoming trauma-informed, understanding trauma is absolutely I believe an ethical issue for treatment providers. That it's really important that they understand trauma. What this means in their clients' lives. And then how does that relate to their history of addiction which is different for different people. But to ignore that, I don't think is okay at this point in time. I just don't think that that's good treatment. 0:14:49 William Moyers So Dr. Covington, are you suggesting then that clinicians who are in the process of being trained and getting their licenses, that a component of the curriculum needs to include issues like trauma? 0:15:05 Dr. Stephanie Covington Absolutely. It should be in the curriculum for Master's level students, it should be in the curriculum for PhD's in Psychology, it should be in addiction counselor education, absolutely. It really—it needs to be there as a critical piece of understanding human behavior. And because it's so pervasive in our society. I mean I think that's the thing we have to acknowledge Bill is that we're not talking about five, ten, twenty percent of the population that comes in for addiction treatment. You know. We're talking about the vast majority. 0:15:43 William Moyers Really? 0:15:43 Dr. Stephanie Covington And—yeah, oh absolutely. Absolutely. I mean the people with the highest rates of trauma in their lives are the men and women in our criminal justice system. Now of course many of 'em are there because we have criminalized addiction. But many are there and they have extremely high rates of violence and trauma in their lives. People who come into treatment for addictive disorders, again, very high rates of abuse and trauma. Starting in childhood. So, um, this—we need to understand what this means in someone's life. [Moyers nods] 0:16:18 William Moyers Tell us about what you have coming in 2021. In terms of new products and updates to what you've been presenting to the public for a long time. 0:16:31 Dr. Stephanie Covington Sure. Well, a couple things. We have Helping Men Recover which we wrote the men's version we have women and a men's version. We'll have a new edition of that coming out the end of '21. And we'll also have Healing Trauma and Exploring Trauma are two brief interventions for men and women. Brief interventions. And I've just rewritten those and expanded those to include the transgender non-binary community. So those are the three new things that'll come out in 2021. 0:17:04 William Moyers And that transgender component why—why is that so critical now? 0:17:11 Dr. Stephanie Covington Well, I think we're you know—I've sort of made my career, if you will, thinking about being gender-responsive with people talking about oh it's only women. Expanded that to what does it mean with men. But, you know, the binary model isn't the model in today's world. We have to think about gender on a continuum. People express themselves in a variety of ways. And when we don't share—talk about that and help people feel included in our treatment interventions, how are they gonna benefit from what we're trying to offer? So, and this is in a population with very high levels of trauma in their lives. And so, it's really important that the interventions reflect that. Reflect this population. 0:17:56 William Moyers [nods] Last question for our podcast. I know a lot of people will be tuning in because they're professionals, they know your work, they wanna hear what Dr. Covington has to say. As it relates to their professional careers. But, I know that we get a lot of people who tune into these Let's Talk podcasts who are struggling mightily in the moment. And they find that connection through a podcast like this. What is your message to women and men, children and families, who are wrangling with trauma in their own lives? What's your message for them? 0:18:29 Dr. Stephanie Covington I think what's really important is to understand that there's help. That the challenges that you're facing because of experiences you had, they weren't your fault. And there're people there who can help you. Healing is possible. For many people they don't—they believe well what happened happened in the past. I just have to grin and bear it. Nobody knows blah blah blah. It's not true. Help is available. And healing is possible. And there's a—there's a very different way to live once you understand what's happened, its impact on you, and then have some new coping skills. It's a new life, really. 0:19:06 William Moyers Thank you for ending on a message of hope and help and healing. Thanks, Dr. Covington for your insights and your time. [turns to camera] And thanks to all of you for tuning into this podcast. If you liked it, make sure to tell your family and friends, colleagues and fellow travelers, to check out our podcast too. And if you didn't like this podcast, shoot me an email and tell me why. What we can do differently. On behalf of my colleagues and the Executive Producer, Lisa Stangl, we hope you remain safe and healthy and resilient in these challenging times. And remember it is never too early or too late to ask for help if you or a loved one, a family member, a friend or a colleague, is struggling with trauma, depression, or other mental health challenges, addiction, or a substance use issue. As Dr. Covington said there is hope, there is help, there is healing. It is okay to reach out and ask for help. Take good care. See you soon.