When examining obstacles in recovery, stress always rears its ugly head. An important line of research in addiction is on the behavioral and biological factors that result in increased vulnerability to relapse. This research has highlighted the role of stress, not only as a factor in initiating drug-seeking behavior and susceptibility to addiction, but also as a triggering factor for relapse. This article will look at the interaction between stress, impairment of the ability to self-regulate, and addiction. I will present evidence that childhood stress is highly correlated with addiction, along with the mechanisms of how stress creates the internal milieu for vulnerability to addiction. I will examine the evidence that stress leads to an increased probability for relapse. I will also address this risk factor with a model of resilience designed to restore the ability to self-regulate, and improved skills for coping with stress—which I refer to as “resilient recovery.”
Early Development of Addiction Vulnerability
High levels of early childhood stress alter and impair neural mechanisms of self-regulation and functioning. For example, stress caused by disruption of normal mother-child bonding and attachment affects an array of neural mechanisms. This literature is reviewed by Maté (2012), who notes that poor attachment with the primary caregiver impairs endorphin brain circuitry, including the dopaminergic and opioid systems. This impairment makes both reward and self-soothing more difficult. That makes such individuals more vulnerable to drugs that do what the organism has difficulty doing: triggering release of neurotransmitters that either reward or soothe.
Additionally, early maternal deprivation has been shown to permanently decrease the production of oxytocin, an endogenous chemical that modulates our emotional response and helps to regulate mood, anxiety, and aggression (Heim et al., 2009). On the other hand, positive nurturing experience—as exemplified in licking and grooming—results in reduced anxiety behavior as well as lower corticosterone response to stress (Pan, Fleming, Lawson, Jenkins, & McGowan, 2014). Good bonding and nurturing leads to increased nerve cell receptors for chemical neurotransmitters that serve as natural tranquilizers, thus making the brain more effective in dealing with nervousness and anxiety (Caldji et al., 1998). The interesting part of this study is that infants of low-nurturing mothers transferred to high-nurturing mothers were able to develop greater neural efficiency. This indicates that the effects had more to do with environment than genetics and suggests avenues to remediate the impairment.
In animal models of addiction, stress has been shown to increase self-administration of drugs of abuse. For example, it has been shown that early isolation in female rats produces heightened cocaine self-administration (Kosten, Zhang, & Kehoe, 2006) and social stress during rearing produces higher rates of responding for cocaine and alcohol (Miczek, Yap, & Covington, 2008). Similar results were found for amphetamine, where early life stress produced through maternal separation increased the reward enhancing properties of amphetamine (Der-Avakian & Markou 2010; Burke, Watt, & Forster, 2011). Introducing social defeat stress has been found to increase self-administration of cocaine and a cocaine-heroin mixture, although in this study it didn’t produce an increase in heroin administration (Cruz, Quadros, Hogenelst, Planeta, & Miczek, 2011). However, in another study, Martin and colleagues (2007) found that induced stress facilitated opioid self-administration in rats.
Early stressful experience has been shown to affect the serotonergic systems of the brain (Ichise et al., 2006). In a separate study, Macaque mothers of two- to six-month-old infants were exposed to stress associated with food uncertainty. These offspring showed a putative serotonin deficit, as well as smaller right hippocampal volume (Coplan et al., 2014). In a related study, the effect was a lifelong reduction in levels of serotonin in monkeys (Higley & Linnoila, 1997). These monkeys, as adolescents, were more aggressive and consumed excessive amounts of alcohol.
It has been shown that chronic stress selectively reduces hippocampal volume in rats (Lee, Jarome, Li, Kim, & Helmstetter, 2009). Structural neuroimaging studies of victims of child abuse have provided evidence of deficits in brain volume along with gray and white matter of several regions, most prominently the prefrontal cortex as well as the hippocampus, amygdala, and corpus callosum (Hart & Rubia, 2012). Similar studies of childhood stress and PTSD have demonstrated volume reduction in hippocampus and prefrontal cortex (Frodl, Reinhold, Koutsouleris, Reiser, & Meisenzahl, 2010; Tupler & De Bellis, 2006).
These impairments directly affect addiction liability by raising impulsivity, reducing the controlling and executive functions of the prefrontal cortex, and impairing the neurogenetic ability of the hippocampus. In addition, these impairments impact the autonomic regulating functions of the hippocampus and prefrontal cortex—key to managing stress and maintaining homeostasis.
Overall, traumatic and otherwise stressful childhoods have been shown to increase the risk of substance abuse (Dube et al., 2006). Using the Adverse Childhood Experience (ACE) questionnaire as an indication of childhood stress, Allem and associates found that a higher ACE score in Hispanic young adults was associated with an increased probability of binge drinking, marijuana, smoking, and other drug use (Allem, Soto, Baezconde-Garbanati, & Unger, 2015).
One side effect of adapting to a dangerous childhood environment is the expectation of danger, resulting in hypervigilance or a constantly activated nervous system. Early stress also shapes the sensitivity of the autonomic nervous system, increasing psychophysiological reactivity to stimuli. Porges (2007) refers to the establishment of neuroception, a subconscious system for detecting threat and safety that accompanies trauma. It helps explain autonomic reactivity when there isn’t any obvious threat. Taken together, these findings result in the impairment of autonomic self-regulation, which in turn makes recovery and abstinence more difficult.
And finally, childhood stress that impairs the functioning of the hypothalamic-pituitary-adrenal (HPA) axis also impairs the linked reward systems of the brain. Administration of most drugs of abuse has been shown in animals to activate the HPA axis. That may facilitate activity in the brain’s motivational circuits, which then facilitates drug reward and acquisition of drug-seeking behavior (Kreibich et al., 2009; Vendruscolo et al., 2012). Importantly however, with chronic administration of these drugs, there is a dampening of this reward effect (Koob & Kreek, 2007; Semba, Wakuta, Maeda, & Suhara, 2004).
Relapse Susceptibility with Stress
Chronic use of drugs of abuse has long been associated with exaggerated responses to stressors (Himmelsbach, 1941). This may be a factor in relapse liability.
In an animal study, oxycodone-addicted rats had their drug-seeking behavior extinguished by a long period of nonreward. The researchers found that stress was able to restart their drug-seeking behavior (Campbell, Kwiatkowksi, Boughner, & Leri, 2012). Another study found that physical stress produces a resumption of responding for morphine in animals whose morphine self-administration was extinguished (Karimi et al., 2014). The authors propose that stress partially exerts its effects on the reward pathway via glucocorticoid receptors in the basolateral amygdala.
There is considerable evidence that stress plays a significant role in addiction relapse (Sinha, 2007). Studies have found that stressful experiences increase craving. In a laboratory setting, craving in response to stress induction was predictive of treatment outcome in alcohol-dependent individuals (Higley et al., 2011). And in a cognitive behavioral therapy program, patients reporting greater stress experienced stronger and more frequent cravings. These stronger alcohol cravings were predictive of relapse (Law et al., 2016).
Neural circuits involved in stress and emotions overlap substantially with the brain systems involved in drug reward. Chronic alcohol use can result in neuroadaptive changes in stress and reward pathways. Such changes may alter an alcohol-dependent person’s response to stress, particularly with respect to stress and emotion regulation, and motivation for alcohol, which in turn may increase the risk of relapse. The overlap and disruption of reward, stress, and addiction neuropathways was evident in a longitudinal functional magnetic resonance imaging (fMRI) study that looked at cumulative stressful life events in adolescents. Higher cumulative stressful life events were associated with decreased response in the medial prefrontal cortex during reward anticipation and following the receipt of rewards. These decreases were associated with the severity of alcohol dependence (Casement, Shaw, Sitnick, Musselman, & Forbes, 2015). Preston and Epstein (2011) found a positive correlation between stress and craving for cocaine, heroin, and tobacco among methadone-maintained cocaine and heroin outpatients.
Finally, it should be noted that a consequence of stress and impaired stress coping is the shifting of neural control to the lower or survival centers of the brain. When this occurs, the recovering addict has greater difficulty accessing the newer learned behaviors developed during treatment. Instead, there is a regression to older learned mechanisms, along with increased craving. This downward spiral leads to a fallback to older habit patterns and relapse.
Previously I proposed the use of a readdiction liability test (Sideroff, 1980). This test was based on my research demonstrating psychophysiological conditioned responses to stimuli associated with addictive behavior (Sideroff & Jarvik, 1980). I suggested that a measure of an addict’s liability for relapse might be the way he or she responded, psychophysiologically, to drug-related stimuli. Based on the relationship between stress and relapse, this concept might be extended to include the measurement of psychophysiological stress reactivity.
Life itself is stressful. However, a person who has recently become sober is typically faced with a much larger scale of stresses. I’m reminded of what an ex-addict once told me. He said addiction is like a person driving down the highway in a station wagon and throwing all bills and unfinished business into the back of the car. Sobriety is like hitting the brakes and having everything from the back of the station wagon hurl forward into your lap. Programs designed to help addicts become more resilient can make them less vulnerable to the decompensating impact of life stresses.
A Model for the Restoration of Self-Regulation
The relationship between stress and addiction impels any treatment and recovery process to incorporate methods for restoring an addict’s ability to handle stress and self-regulate, which is at the core of resilient recovery.
I have described a nine-component model of resilience that addresses all factors contributing to optimal self-regulation and stress coping (Sideroff, 2015). This model is useful for recovering addicts. It focuses on three general areas: relationship; organismic balance and mastery; and process, or how one engages with the world. I will review each of these components.
1. Relationship with Self
In our therapeutic relationships we teach, encourage, support, and guide. But no approach can compete with the incessant voice in the addict’s head. This voice, developed during early childhood, undermines emotional healing. Thus the first component is the relationship with oneself. The goal is to help addicts shift from an internal voice or parent voice that’s critical, negative, and self-abusive to one that comes from a place of love, support, compassion, acceptance, and care.
To help develop a healthy parent voice or internal voice, I engage clients in a Gestalt therapeutic dialogue between their existing, and typically negative, voice and a newer, weaker—but healthy—internal voice. I help them determine what a healthy parent looks like, sounds like, and acts like and then how to find that part, no matter how tiny, within themselves. This is supported by identifying someone in their lives to model who has these qualities of love and acceptance. If they don’t have personal experience with such a person, we look to literature or movies for examples.
I have them switch chairs in the dialogue process to help distinguish the two voices. Usually I have to point out much of the inappropriate and critical or abusive messages of the old voice because they are so used to hearing these messages. This might include, “You don’t deserve because of all your mistakes,” “You should be better” or “You never get anything right.” My role is to help their new voice switch from being defensive to being assertive, by attacking and labeling the old voice as being wrong and inappropriate. In this process it’s important to point out that at first, the “feeling of what’s right” is tied to old patterns I refer to as “primitive Gestalts.” There is thus a tendency to trust these feelings and the old voice even though it is not accurate.
2. Relationship with Others
This is the ability to establish and maintain healthy relationships that are sources of support, acceptance, love, and healthy feedback. This means being able to identify appropriate people for a healthy relationship and letting go of those who do not treat them well or support them. It means being able to maintain a healthy boundary for emotional protection, while being assertive to get their needs met. And finally, it means being vulnerable under the right circumstances in order to receive nurturing and healing.
This process involves asking whether a relationship makes life more or less stressful. Is the feedback from this person helpful and supportive or critical and inappropriate? Do friends or relatives make unreasonable demands that make them feel guilty, adding stress to their lives? Do they feel like they’re walking on eggshells with some of their friends or relatives? Are they fearful of anger or of being rejected? It’s important to be able to say no and to set boundaries.
One of my techniques comes from the research of John Gottman, a psychologist who has worked extensively with couples and has found that successful relationships have a twenty-to-one ratio of positive to negative interactions. I’ll ask my clients to pay attention to the ratio of positive to negative comments and behavior, or what I refer to as the “Gottman ratio.” A ratio that drops below five-to-one indicates a relationship that is not healthy.
3. Relationship with Something Greater
This is at the heart of the Twelve Step program. Fostering a spiritual path is one way to feel connected and not isolated. The two other ways this can be achieved is through giving service and developing a purpose in one’s life. I encourage my clients to find ways to serve. In addition, I work with them to find their passion and develop a purpose in their lives. Fostering this component of resilience creates a greater horizon in their lives and reduces the impact of daily hassles that can otherwise challenge one’s coping abilities.
4. Physical Balance and Mastery
It is commonly observed that addicts do not have a friendly relationship with their bodies. In fact, they are uncomfortable and don’t feel at home in their skin. Reasons for this include early trauma and abuse, which demand some sort of dissociation or disconnect from their body in order to survive and not be overwhelmed by emotional pain. This component addresses the deficit in coping and self-regulation. There are four main aspects: the ability to deeply relax, to feel comfortable and connected to their body, the ability to return to baseline following a stressful situation, and the ability to get restorative sleep. There is no substitution or shortcut for developing the ability to relax. As with any skill, it takes practice.
Left to their own devices, recovering addicts will resist training their body to relax. In fact, this is true for most people. As soon as they attempt the process, they are challenged by the discomfort they feel as emotions emerge, or by the judgments they make about the difficulties they are having. For some, the gap between ability to relax and the goal of deep relaxation is so great they feel hopeless about ever achieving this goal.
For these reasons it is important initially for the therapist to practice a relaxation process with clients. Part of this process is to help clients manage their discomfort, refrain from making judgments, and learn and practice the proper procedures. Biofeedback is a useful tool to support the ability to relax since it lets clients know when they are successful with concrete numbers that can’t be denied.
5. Mental or Cognitive Balance and Mastery
The normal cognitive distortions we all experience due to childhood lessons are magnified for the addict. In addition, as mentioned previously, specific deficits in brain function give addicts a tremendous cognitive disadvantage. For example, the prefrontal cortex, where decision making takes place, is typically underactivated in recovering addicts.
With this component, it is important for clients to accept that their perspective is frequently inaccurate, especially when they are evaluating their own behavior. An objective reality check whenever they are questioning their judgment is to have them imagine that the situation happening to them were happening to someone they like or look up to. Have them notice the difference in how they evaluate the situation based on whether it’s happening to themselves or another person.
This component is also about maintaining a positive attitude and expectation. This can be facilitated by helping addicts discriminate between lessons learned during their childhood and drug-related behavior and more recent positive results since becoming sober.
6. Emotional Balance and Mastery
Emotional reactivity negatively impacts resilience. Our brains get hijacked by our emotional unfinished business. When this happens, we feel helpless about our reactions, which typically include autonomic and neuromuscular activation. In addition, feelings not dealt with and needs not recognized unconsciously guide behavior, increasing the chances of mistakes, accidents, and undo pressure that exacerbates stress and emotional pain.
Clients need to accept that their feelings are neither right nor wrong but an organic part of life. They have to realize that when feelings come up, it’s an opportunity to address unfinished emotional business and get resolution. Learning to tolerate the discomfort of their feelings is a necessary step in the process of letting go and healing. Here is a four-step process designed to facilitate this healing process:
- Become aware of and accept the feelings that come up.
- Sit with them and recognize what they are about and whom they involve (an important cognitive component of the process).
- Encourage them to express the feelings within the context of acceptance. If they are angry or sad surrounding a particular relationship, acceptance doesn’t mean they like what is going on. It is simply an acceptance of reality; you can’t make people different than they are (and you certainly can’t change past events). Expression of anger, therefore, may uncover sadness or loss about what they want but don’t have.
- Let go. Once the feelings have been expressed, it is important to let go and not continue to expect the impossible.
Presence describes one’s ability to be in the moment, as well as the quality of the energy a person projects. In other words, there is a directional aspect to presence. The incoming aspect is about awareness and ability to notice and pay attention to your surroundings. This determines your ability to respond to events, as well as your awareness of internal cues, such as tension or fatigue, that need to be addressed. Presence is your ability to be in the moment, as opposed to being preoccupied or otherwise in your head.
There is also the aspect of presence that has to do with what one projects out into the world. It’s sometimes referred to as charisma. This determines whether others are attracted to or repelled by you; whether they feel comfortable or a bit nervous around you.
An impaired sense of personal safety results in fear of being at the contact boundary. This results in being less responsive and less able to engage with others and the world.
The therapeutic relationship is the most effective context for helping recovering addicts address both aspects of their presence. This relationship offers a safe laboratory for experimentation. At some point in my sessions, I will have clients pause and take a moment to notice their surroundings. I will coach clients by having them report what they see in the room or have them close their eyes and tell me what I’m wearing.
To address clients’ energy and how they project this out into the world, I work with them in front of a mirror. I might have them notice their posture such as slumped shoulders. I might then have them exaggerate this posture and notice that this actually creates greater depression, lack of energy or negative self-assessment. As part of this evaluative process, I will also have them notice their facial expression and ask them what this expression says to the outside world.
This would be followed by having them adjust their posture, straighten up, and hold themselves high. While holding this posture, I’ll have them walk around the room and notice their feelings and sense of self. I will bring their attention to their breathing and have them adjust into a more supportive breathing pattern, and adjust their facial expression to a more positive one. These tools for self-adjustment help empower clients.
Flexibility is at the heart of the ability to adapt, to learn from new experiences and not be stuck in outmoded ways of doing or thinking. If you’re flexible, you can adjust and become comfortable with new and unexpected circumstances, rather than react with distress. Old patterns constrain our flexibility as they limit what’s okay. In fact, it’s addicts’ frozen adaptation to their childhood environment that interferes with a healthy adjustment to the present.
I like to educate clients on research about brain plasticity to promote their belief that change and flexibility are possible. At the same time, it’s important for them to “stalk their pattern” as I refer to increasing awareness of engaging in their old outmoded patterns. Visualization exercises to imagine acting and thinking in new ways are helpful as “dress rehearsal.” Their homework is to do some of their daily routines differently, such as using their other hand to brush their hair and their teeth. Doing this literally develops new neural pathways.
9. Power: The Ability to Get Things Done
This is the ability of the recovering addict to engage with the world to set and reach a new set of goals. It involves being persistent and holding the tension of uncertainty in their bodies without running or otherwise avoiding the constructive process. Most significant is an understanding of the learning and growth process: they need to accept and tolerate the inevitable awkwardness and mistakes of new learning. Success in this area contributes to a sense of confidence. Most important, it contributes to their trust in themselves rather than dependence on others, or manipulation, and a greater feeling of control, which has been shown to mitigate the effects of stress.
Childhood dangers and trauma lead to a growing inability to maintain and regain autonomic stability and balance and produce brain impairment and damage. This also affects reward mechanisms of the brain. These factors conspire to impair the efforts of treatment and leave addicts more vulnerable to relapse triggered by stress.
With a focus on restoring the ability to self-regulate, health professionals are helping clients gain foundational abilities that result in them being able to cope better with the inevitable stresses of life, as well as feel more comfortable in their own skin and be more available and responsive to other treatment approaches. In other words, it leverages the treatment process.
At the heart of managing stress is component four in my resilience model: physical balance and mastery. And at the heart of this is practicing techniques—such as meditation and biofeedback—that restore the ability to deeply relax. However, as I show in my model, the process of restoring and maintaining balance and resilience requires all nine of my resilience components.
There are no short cuts in the treatment and recovery process. It is a chronic brain disorder with linked psychological factors that serve to keep addicts behind the eight ball. What I’ve attempted to show in this article is that stress along with its resultant autonomic dysregulation and impairment is of central importance in the establishment of addiction and pivotal in vulnerability for relapse. Thus a dedicated track in treatment focused on stress coping, the reestablishment of self-regulation ability, and an overall development of resilience can support all other aspects of treatment and increase the chances of long-term recovery.
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