therapy notes

The Link Between Trauma and Substance Use: Why We Self-Medicate

Shayan Salar, LCSW, LCADC · 9 min read

Trauma and substance use are so often treated as two separate problems, addressed in two separate places, by two separate specialists. But in the room they rarely look separate. For many of the people I work with, the drinking or the using did not start as a problem at all. It started as a solution, a way to manage something that had become unbearable, and only later became a problem of its own.

Understanding that link changes everything about how the work is approached. Holding both clinical mental-health and addiction credentials, I treat trauma and substance use as connected rather than as two conditions that happen to share a person, because that is almost always how they actually operate.

Two problems, or one?

Clinically, we call it comorbidity: trauma and substance use disorders co-occur at strikingly high rates. But the language of two overlapping conditions can obscure what is usually a single, connected picture. When someone drinks to quiet a nervous system that has been on alert since childhood, or uses to blunt memories that arrive uninvited, the substance use is not a coincidence sitting next to the trauma. It is a response to it.

In short, the substance is often doing a job, and that job is usually managing pain the trauma left behind.

The self-medication hypothesis

The psychiatrist Edward Khantzian gave this idea its clearest form with what he called the self-medication hypothesis. His observation was that people do not choose substances at random. They tend to gravitate toward the one whose effect answers their particular pain: some reach for alcohol or opioids to quiet hyperarousal, dread, and the feeling of never being safe, while others use stimulants against emptiness, fatigue, or depression.

Seen this way, substance use stops looking like a simple failure of willpower and starts looking like an attempt to cope, an attempt that works, in the short term, which is exactly why it takes hold. It is a deeply human thing to reach for relief. The trouble is the cost of that relief compounds over time.

What the research shows

The connection is not just clinical impression. The landmark Adverse Childhood Experiences study, run by the CDC and Kaiser Permanente, found a strong dose-response relationship between childhood adversity and later substance use: the more categories of adversity a person experienced growing up, the sharply higher their risk of alcohol problems and drug use as adults. Trauma does not guarantee addiction, but it is one of its most consistent predictors.

Alongside that, rates of co-occurring PTSD and substance use disorder are high in both directions: people with trauma histories are more likely to develop substance problems, and people in addiction treatment carry trauma histories at rates far above the general population. The two travel together often enough that treating them as unrelated is usually a mistake.

Why substances work, until they do not

Trauma leaves the nervous system dysregulated: too activated, too numb, or swinging between the two. Substances are effective, fast-acting tools for changing that internal state. A drink genuinely does take the edge off hyperarousal. That is not a delusion; it is pharmacology, and it is why the pattern is so hard to simply decide your way out of.

The trap is that the relief is temporary and the system adapts. Tolerance builds, so more is needed for the same effect. The substance that quieted the anxiety begins to generate its own, and the thing that once soothed the pain becomes a second source of it. Now there are two problems where there was one, and they feed each other. This is often the point at which what looked like high-functioning drinking stops feeling under control.

Why treating one in isolation often fails

This is the practical heart of it. If substance use is managing untreated trauma, removing the substance without addressing the trauma leaves the original pain fully intact, and often intensified, because the coping tool is now gone. That is one of the most common paths to relapse, and it is frequently misread as a lack of motivation rather than what it usually is: unfinished trauma work.

The reverse can also go wrong. Diving straight into trauma processing while someone is still actively and heavily using, without stabilization or pacing, can flood a system that does not yet have the resources to handle it. Neither problem waits politely for the other to be solved first, which is why sequencing them in separate silos so often disappoints.

In short, the substance and the trauma are usually one system, and treating half of it tends to leave the other half to pull things back.

What integrated treatment looks like

The alternative is integrated, trauma-informed treatment that works with both at once. In practice that means understanding what the substance is doing for you before focusing only on removing it, building the capacity to tolerate difficult states so the substance is needed less, and working with the underlying complex trauma at a pace the system can handle. A harm-reduction stance makes this possible without demanding total abstinence as the price of even starting.

Because I hold both an LCSW and an LCADC, I can do this work in one place rather than sending you to one provider for the drinking and another for the trauma, hoping the two halves talk to each other. Anxiety, depression, and other patterns usually belong in the same conversation, since they are frequently part of the same story. You can read more about how I work.

There is a way through

The most important thing to know is that this is treatable, and that the connection between trauma and substance use is a reason for hope rather than despair. It means the using is not evidence that you are broken or weak; it is evidence that you were trying to survive something. When the trauma underneath is addressed, the job the substance was doing gets smaller, and change that felt impossible through willpower alone becomes genuinely possible.

If you recognize yourself here, reaching out is a strong move. If you are having thoughts of harming yourself, please treat it as urgent: in the US you can call or text 988 for the Suicide and Crisis Lifeline, and the SAMHSA National Helpline offers free, confidential support 24/7 at 1-800-662-HELP (4357). If you drink heavily every day, do not stop abruptly without medical guidance, as withdrawal can be dangerous.

Frequently Asked Questions

Why are trauma and substance use connected?

Trauma changes how the nervous system manages stress and emotion, and substances are often an attempt to manage what trauma left behind: anxiety, hyperarousal, numbness, or unbearable memories. The two are so frequently intertwined that in many cases the substance use began as a solution to the trauma before it became a problem of its own.

What is the self-medication hypothesis?

The self-medication hypothesis, developed by psychiatrist Edward Khantzian, proposes that people do not use substances randomly but tend to choose ones whose effects relieve their specific emotional pain. For example, some gravitate toward alcohol or opioids to quiet hyperarousal and anxiety. It frames substance use as an attempt to cope rather than simply a lack of willpower.

Does trauma cause addiction?

Trauma does not guarantee addiction, but it is a major risk factor. The large ACE study found a strong dose-response relationship between adverse childhood experiences and later substance use: the more childhood adversity someone experienced, the higher their risk. Addiction is multi-causal, but trauma is one of the most consistent contributors.

Why doesn't treating addiction alone work for everyone?

When substance use is serving to manage untreated trauma, removing the substance without addressing the trauma leaves the original pain intact and often intensifies it. This is a common path to relapse. For many people, lasting change requires working with the trauma the substance was managing, not just the substance itself.

What is integrated treatment for trauma and substance use?

Integrated, or dual-diagnosis, treatment addresses trauma and substance use together rather than in separate silos or one after the other. Research supports treating co-occurring conditions concurrently with a trauma-informed, appropriately paced approach. It recognizes that the two problems are connected and works with them as a single, related picture.

Do you treat trauma and substance use together online?

Yes. I hold both clinical mental-health and addiction credentials, LCSW and LCADC, and work with co-occurring trauma and substance use via secure telehealth across New Jersey, Pennsylvania, Florida, Texas, and Maine. Because these problems are connected, I treat them as connected rather than sending you to two separate places.