When the 4th and 5th steps are done without support for the symptoms of PTSD, they have the potential to retraumatize.
It is worrisome that a sex inventory is taken to find out how “we acted selfishly” when one-third of women and one-sixth of men have been sexually assaulted or raped.
Trauma is a current buzzword in the mental health world, and for good reason. Untreated trauma has measurable lasting physiological and psychological effects, which makes it a public health emergency of pandemic proportions. Trauma is an event or continuous circumstance that subjectively threatens a person’s life, bodily integrity, or sanity, and overwhelms a person’s ability to cope.
PTSD and Substance Use Disorder
Post-traumatic stress disorder (PTSD) is a condition caused by experiencing or witnessing a traumatic event. Symptoms include nightmares, flashbacks, anxiety, intrusive thoughts about the trauma, hypervigilance, and avoidance of triggers which remind you of the event. Substance use disorders (SUD) are frequently co-morbid (co-occurring) with PTSD. Many people with PTSD self-medicate with mind-altering substances to alleviate symptoms but getting high or drunk only works for so long. Substance use disorders often evolve from using substances as a maladaptive coping tool.
There are many physiological correlations between psychological trauma and SUD. For example, there are similarities in gray matter reduction for both the person with PTSD and the person with an alcohol use disorder. Although the neural mechanisms of addiction in PTSD patients are not fully understood, research has found that in the prefrontal cortex, dopamine receptors may be involved in both conditions. Memories related to fear and reward are both processed with the help of these specific receptors. It could be that the processing of traumatic memories affects the dopamine receptors, making them more sensitive to reward-triggering substances.
Sometimes, people with a dual diagnosis of addiction and PTSD find their way to 12-step programs like Alcoholics Anonymous. These programs are widespread, free, and require no commitment, which makes them more accessible than other types of treatment. AA’s worldwide membership and lasting existence has caused the program to be of interest to researchers for decades. Previous research has found positive correlations between AA participation and abstinence. There is less research on how 12-step programs interact with trauma recovery.
Studies on relapse factors have found that common predecessors to relapse in adults include anger, depression, and stress, among others. Recalling traumatic experiences, for someone with PTSD, can cause intense physiological and psychological reactions characterized by these same feelings: anxiety (stress), depression, anger, and frustration. It’s a combination that puts people with both trauma and addiction at a higher risk of relapsing.
Guilt, Shame, and AA
There are two sets of steps in 12-step programs that involve memory recall and direct involvement with others: Steps 4 and 5 and Steps 8 and 9.
Step 4 says: “Made a searching and fearless moral inventory of ourselves.” That step is followed up by sharing that inventory in Step 5: “Admitted to God, to ourselves and to another human being the exact nature of our wrongs.”
Later, Step 8 says: “Made a list of persons we had harmed, and became willing to make amends to them all.” To deal with that list, Step 9 directs people: “Made direct amends to such people wherever possible, except when to do so would injure them or others.”
The gist with these steps is that they look at both the resentment/anger the person feels towards others (which always involves taking responsibility for part or all of the event that caused the resentment and anger), and also the “harms” the person caused others. But there is no direct guidance on how to ensure a realistic and safe assessment of past events is made. The AA book presents this step as if someone with a substance use disorder has the tendency to blame others. People with PTSD are wracked with self-blame, and it is self-blame and shame which fuels many people’s addictions, but shame is not explicitly addressed in the steps.
Guilt is very commonly experienced by people with PTSD. Survivor guilt can be a bit of a misnomer; PTSD develops from situations that are subjectively experienced as traumatic, but these circumstances don’t have to involve death (although they certainly can and do for many people). Simply surviving can feel like something the person is not worthy of. They may feel guilt when they don’t stay in the pain and anxiety.
Shame is also common in trauma survivors, especially in people who have been sexually assaulted. Trauma survivors must restore a positive sense of self to find healing. Judith Herman, the author of Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror, explains that “the survivor needs the assistance of others in her struggle to overcome her shame and to arrive at a fair assessment of her conduct.” It becomes important, as the trauma reveals itself, to see it clearly for what it was so the person can integrate those experiences into their individual life stories.
AA literature is very focused on decreasing ego and on disrupting the selfishness of the person with the addiction. This is not necessarily a helpful baseline for traumatized folks; it can be harshly critical. The feeling of being judged can deepen the rift between the survivor and others. Herman writes, “Realistic judgements diminish the feelings of humiliation and guilt. By contrast, either harsh criticism or ignorant, blind acceptance greatly compounds the survivor’s self-blame and isolation.”
The primary text of Alcoholics Anonymous (the “Big Book”) suggests alcoholics review their past sexual life when creating a life inventory in Step 4. For the overall inventory, the book suggests that the reader completely disregard “the wrongs others had done” and to look only at “our own mistakes.” Even in situations where a person caused harm to the reader, the reader should “disregard the other person involved entirely” and find “where were we to blame?” These suggestions can be dangerous for survivors of intimate partner violence or child abuse who have been told that they were to blame for the abuse they suffered.
The book further details what to ask yourself when making an inventory of your sexual conduct:
“Where had we been selfish, dishonest, or inconsiderate? Whom had we hurt? Did we unjustifiably arouse jealousy, suspicion or bitterness? Where were we at fault, what should we have done instead?” It is worrisome that a sex inventory is taken to find out how “we acted selfishly” when one-third of women and one-sixth of men have been sexually assaulted or raped. An estimated half of women who experience a sexual assault will develop PTSD. One study found that 80 percent of women with SUD who seek inpatient treatment have been physically or sexually assaulted and nearly 70 percent of men have experienced either physical or sexual abuse.
How the 12 Steps Can Harm People with PTSD
Because remembering past traumas makes the brain’s reward center more receptive to the effects of drugs, Steps 4 and 5 need to approached with extreme caution for people who have experienced trauma. Ideally, these steps jumpstart healing; but when they are done without support for the symptoms of PTSD, they have the potential to retraumatize. As the person shares their trauma with someone else, hopefully the listener is compassionate and willing to point out where things were not the addict’s fault—at all. A child survivor of molestation had no agency in the assault, and it is unconscionable to tell that child, now grown, that they need to determine where they were at fault. It is not possible to “disregard the other person involved entirely” when an event only occurred because of the other person. Sometimes we need to recognize this fact and say to ourselves (or hear from someone else): “You had no part in this, you were a victim at that time.”
In Steps 8 and 9 we are to list and resolve harms done to others. If step 4 and 5 didn’t properly address where our fault doesn’t lie, we may be inclined to list abuses and harm done to us as wrongs we did. It says not to make amends if it will cause harm to others, but we need an additional specification not to make amends if it will cause harm to ourselves. If you owe an abusive ex-partner money, are you supposed to pay them back if you’ve cut off all contact? These are issues that require careful consideration. Sharing both lists with a compassionate person has the potential to help survivors recover. Sharing both lists with someone who is too harsh in their suggestions and assessments has the potential to push those in recovery back into active addiction.