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I am a West Virginian and have worked in the substance abuse field for around 30 years. I didn’t start my career in mental health wanting to work with addictions, but as anyone who works in mental health will tell you, there is no way to avoid it, or at least no way to avoid it in West Virginia. Over those 30 years, I have learned that most of what we thought we knew about addictions is wrong or, more accurately, woefully incomplete. This is important because how folks attempt to address the problem comes directly from how they think about it. What causes addictions and substance abuse? What keeps it going? Why does it affect certain people and not others? Why do people have a hard time stopping? We need to answer these questions to ever have a chance of getting a handle on addiction in rural regions like Appalachia where there are problems with addiction.
Our views of addiction have developed over hundreds of years and have ended up becoming a mish-mash of moralistic and medical thinking. Add to this the current view that substances themselves are addictive and that our genes are a likely accomplice and you pretty much have the modern-day definition of addiction. Currently, most learned scientific societies and institutions define addiction as a chronic brain disease. Wonderful! Now all we have to do is find a cure for brain disease and we will be home free. So, how does one cure a brain disease?
Just as our view of addiction is a mish-mash from our past, so too is its treatment. We have moved from locking folks up in asylums and making them right through guided prayer to a process of detoxification, medically-assisted treatment, and on-going recovery. Medicine-assisted treatment (MAT) is a cleaned-up way of saying behavioral therapy with the help of pharmaceuticals. There have been improvements demonstrated by the current cures. However, you rarely hear any mention of preventing the problem before it gets started. I am happy for the folks who have been helped by current treatment methods, but it sure seems to me that we should be aiming a lot higher.
Throughout my career, I have witnessed many addiction treatments in action and have even participated in them directly. Generally, they are marginally successful. If one measures success as not using for six months or longer, then the picture looks a little brighter. However, if we want to see people restored to health and well-being, then it doesn’t look so good. Less than 10% of the people needing treatment for addictions in this country are actually receiving it, estimates say. There is not nearly enough capacity to treat everyone who needs it, and not many folks who need it can afford it. It is definitely a big problem. This, however, is only part of the problem. If treatment is all we needed, then you might think that in 10 years we would be able to take care of the problem. But the number of new people becoming addicted is growing much faster than they can be treated. In other words, there are more people coming into the system than are going out. This is a problem we all can understand. A parable illustrates this point well.
One afternoon, a group of townspeople sees a baby in the river. One person dives in and rescues the infant. But as he climbs ashore, one of the other townspeople spots another baby in the river in need of help. Then another. And another. Overwhelmed by the sheer number of babies, the townspeople grab any passer-by they can to help them.
Before long, the river is filled with desperate babies, and more and more rescuers are required to assist the towns people. Unfortunately, not all the babies can be saved. And, tragically, some of the brave rescuers occasionally drown. But they manage to mold themselves into an efficient life-saving organization and, over time, an entire infrastructure develops to support their efforts: hospitals, schools, foster care, social services, trauma and victim support services, lifesaving trainers, swimming schools, etc.
At this point one of the town citizens starts walking upstream.
“Where are you going?” the others ask, disconcerted, “We need you here! Look how busy we are trying to save these babies!”
The citizen replies: “You carry on here. I’m going upstream to find the bugger who keeps chucking all these babies in the river.”
This story really spoke to me when I first heard it years ago. At the time, I was working in substance abuse prevention at the local and state level. We had a team of 40-plus people working in nearly all 55 counties in West Virginia. Our primary work was helping communities develop prevention programs to deal with their problems . All the programs we were using were well researched and evidence-based. So, one would think, they would help deal with the substance abuse-problems and reduce the need for treatment. Some very positive things happened, but overall, I would have to say they were also only marginally successful. Why they were not more effective was certainly not because of the folks I was working with. They were all bright, caring, passionate, and resourceful people who knew the programs well and worked their tails off trying to make a difference.
I eventually discovered that a good bit of the failure was due to the nature of the programs we were using. It was not because they lacked sufficient research or evidence. The problem resided in the view the program developers had of addiction and thus how to address it. They all viewed addiction as a disease that primarily affected individuals, and the programs were all created in places quite different than West Virginia. This view, at best, is limited, which means that the programs they developed were likewise limited. If we seriously want to slow down and stop all the bodies being thrown in the river, then we are going to have to change the way we think about the problem of addictions.
There have been several “truths” I have learned about addiction over the time I have worked in the field. These are a few:
- Addiction comes about through a highly complex interaction of our biology, psychology, and sociology. It never boils down to just our genes or our brains or our family. It is all of them all at once, all the time, and more.
- People can heal from addiction, but there is no one single way. It usually takes a village and many approaches.
- One cannot adequately understand a person’s addiction without understanding the context within which they live.
- People who are addicted are generally in pain, and their behavior is intended to relieve themselves of this pain.
No one factor alone will cause addiction. However, there are contexts that give rise to more addictions than others. Essentially, certain contexts create more people vulnerable to addictions than others. By context, I mean the physical and social environments in which people live, work, and play. Usually, this is their community.
The big questions to me are 1) which communities are most vulnerable in the U.S. and 2) why are they more vulnerable than others?
Question #1: Vulnerability
In August 2016, the Appalachian Regional Commission released a report they commissioned from the Walsh Center for Rural Health Analysis entitled, “Appalachian Diseases of Despair.” The study looked at the impact on deaths related to the three main diseases of despair. The three diseases are
- Alcohol, prescription drug and illegal drug overdose.
- And alcoholic liver disease/cirrhosis of the liver.
The deaths from these three diseases of despair was 37% higher in Appalachia than the rest of the nation, and this number is growing significantly faster in Appalachia than in the rest of the country. Deaths for people in the 25 to 44 year age range was 70% higher than the rest of the country. Interestingly, this higher rate of death doesn’t necessarily correlate with economic conditions, at least at the national level. So other factors are in play.
When comparing the sub-regions in Appalachia, the greatest number of deaths occurred in the North Central and Central sub-regions. That is all of West Virginia and Eastern Kentucky. Many of the counties in the North Central and Central sub-regions are designated by the ARC as distressed counties and these counties had disease rates 34% greater than the non-distressed counties in Appalachia.
More evidence of Appalachia’s high addiction rates is found in the annual Gallup-Sharecare Well-Being Index, which looks at interrelated elements such as financial security, physical health, and the strength of community and social relationships. The two states with the lowest well-being in the country are West Virginia and Kentucky.
Question #2: Coal Connection
The second question is why communities in Central Appalachia are so vulnerable to addiction. The ARC report and many others point to a host of issues such as poverty, unemployment, violence, poor health, school failure, etc. But these answers seemed turned upside down. Are they saying that poverty causes this vulnerability? It seems much more likely that these problems, just like the diseases of despair, are symptoms and outcomes rather than its causes. What is it that creates this vulnerability? Obviously, something deeper is happening here.
Years ago, my organization attempted to quantify which West Virginia counties had the greatest substance abuse problems. To find the answer, we gathered data from economics, health, mental health, education, criminal justice, and others. As a way to make sense of what we were seeing, we put this data on county maps of the state and color-coded them by county based on the rates of each of these problems areas. There were separate maps for the counties with the highest rates of poverty, unemployment, family violence, arrests, and others. There were a few “outlier” counties, but by and large, most of the counties with the highest rates of problems overlapped closely. The counties with the highest rates of poverty also generally had the higher unemployment, worse health outcomes, lower educational attainment, more family violence, etc. This did not surprise those of us who knew the state well, because all one had to do was spend a little time in these counties before you knew they were struggling.
I pondered our maps trying to figure out what set these apart from the rest of the state. Then it occurred to me that there was coal mining in most of these counties. I put together another color-coded map marking the counties that currently or historically mined coal. The counties in this map, by and large, overlapped with the counties that were experiencing social and economic difficulties.
I was not surprised, but perplexed. What was there about coal mining counties that grouped them with these other problems? I was aware that folks who were struggling with addictions most often came from families and communities who were also struggling with addictions, but this was usually accounted for through family dynamics. In other words, dysfunctional families begat dysfunctional kids who became dysfunctional adults who begat more dysfunction. However, the explanation did not really explain anything other than it was a problem of the people themselves and that is usually where the explanation ended. There was nothing about how the dysfunction got there in the first place or what kept it going. The only thing this explanation was good for was more subtly and “scientifically” blaming the people for their problems. But that explanation is bogus. What was happening here was different.
Within a year, I discovered an article entitled “Intergenerational Transmission of Trauma across Three Generations” by an Israeli researcher named Rachel Lev-Wiesel. She did extensive interviews with three generations of three different families who were from different cultures. The older generation in each of the three families experienced three different kinds of group trauma. She wrote:
“Trauma included experiencing the Holocaust, being placed in a transit camp following immigration from Morocco, and being forced to dislocate as the result of a war. The representatives of successive generations were administered qualitative, open ended interviews regarding their life as survivors or victims, or as the second/third generation of survivors/victims. A content analysis revealed that the intergenerational transmission of three types of trauma was perpetuated across three generations.”
This got my attention. Traumatic events experienced by grandparents get passed down to future generations. Could this be what was happening in Central Appalachia? Could this link the current opioid epidemic, as well as other substance abuse problems, to the thing all these counties had in common: coal mining?
Since I first read that article approximately 10 years ago, a lot more research has been done that supports Lev-Wiesel’s original piece. This research was coming from all around the world and from different cultural contexts. Even though it has been called by various names, historical trauma has so far been identified among groups of people who have experienced deliberate inflicted trauma in the forms of genocide, slavery, war, and colonization. There is documentation that it has been experienced by North American Indians, Holocaust survivors, Alaskan natives, Australian aboriginal people, Palestinians, Canadian indigenous people, African-Americans, Romanians, Japanese-Americans, and many others. Research has begun uncovering the complex and diverse impacts on numerous groups of people around the world as well as in the United States.
In this growing body of research, essentially none of it has focused on Appalachia. Given the numerous biological, psychological, and social problems experienced by people in the region and the documented vulnerability to substance abuse, it seemed worthwhile to look into. To understand how historical trauma made it into Central Appalachia first requires an understanding of the history of the region.
An excellent, well researched description of how this happened in one valley on the Kentucky-Tennessee border was given by John Gaventa in his 1980 book, Power and Powerlessness: Quiescence and Rebellion in an Appalachian Valley. Gaventa points out that for nearly a century before the late 1800s, rural communities within Central Appalachia lived an agrarian existence. They developed slowly in relative isolation and were “scarcely influenced by the rapid industrialization to the east, north, and west.” However, the region had vast natural resources that were desired by industrialists, so the industrial colonization of Appalachia began. It occurred through multiple processes over a relatively short time beginning with land acquisition. As Cratis Williams put it, “The industrialists invaded Appalachia and exploited it as if it were a colony imbedded within the nation itself and left its people demoralized and in poverty.” Ron Lewis made the case that the region became the “frontier of American industrial capitalism” during this period of time. As an example of the extent of land acquisition, he points out that by the 1970’s, two thirds of the privately held land in West Virginia was controlled by natural resource corporations from outside of the state.
Following land acquisition came the economic boom. Railroads were built in the area, followed by tents and other company housing along with coking furnaces, iron works, planing mills, lumber mills, stores, and saloons. Timbering and coal mining started in earnest. In the Clear Fork Valley described by Gaventa, within a two to three year period the area was transformed from a relatively self-sufficient agricultural community of approximately 60 families to a city of 5,000 people with 57 industries operating or planned and six banks. Between 1880 and 1920, the population of the coalfields of Central Appalachia exploded, and nearly 80% of the population lived in company-owned towns.
Along with this economic boom came “the development of social stratification and the establishment of absentee, concentrated economic control of resources and the means of their extraction.” The colonizers built the buildings and infrastructure of the town and created the social institutions necessary to maintain them. In Lewis’s words, the coal mine operator became not only the employer, but “also filled the roles of landlord, merchant, postmaster, provider of entertainment, and sanitation officer.” In addition, the companies provided fire and police protection along with “medical, spiritual, entertainment, and educational services.” The industrial colonization brought with it a worldview and ideology promoting the virtues of civilization over the culture that previously existed in the mountains, thus imposing new values and beliefs on the population that simultaneously degraded the traditional culture of the people of Appalachia. Companies further exercised domination by imposing their control on the socializing agencies of government, churches, and schools, thus permanently shrouding inequalities to ensure unquestioning participation by the non-elite in the new order. As the typical economic cycle of boom and bust proceeded over the years within the region, communities suffered and deteriorated. In a short time, the citizens of Appalachian had lost their land, their way of life, and their ability for self-determination. Mining camps became what Ron Lewis called, “the rural equivalents of the ethnic ghettoes which served as transitional communities for foreign immigrants in the cities.” The industrial colonization of Central Appalachia clearly meets the criteria of historical trauma. The nature of the trauma has been chronic and the associated stress nearly constant.
What emerges from Gaventa’s account of the colonization and subsequent domination of the Clear Fork Valley shows a pretty clear example of how trauma and chronic stress find their way into the daily lives of people a community. This particular story is unique to the area in and around Middlesboro, Kentucky, but it is quite similar in overall theme to most coal mining areas in Central and North Central Appalachia. Life in the coal camps continues to the present day as do the traumas in the forms of mine disasters, environmental degradation, and social fragmentation. This scene has repeated itself across Central and North Central Appalachia for four generations or more. Coal mining communities today do not experience the same situation or context as their ancestors, but they clearly show the consequence of such a history. (Though Appalachia is the region I know best, it is by no means alone in experiencing historical trauma. The research on this theory has delved more deeply into the experiences of Native Americans and African Americans.)
In Appalachia, the stories and consequences have clear common themes. The evidence for this plainly shows up in the region’s indicators of social, economic, and health issues. In the Gallup-ShareCare Well Being Index (2016), Central Appalachia has the lowest overall well-being of any region in the nation, and it has been like that since the survey started in 2008. Similarly, these Appalachian counties consistently rank in the lowest quartiles within their states for both health outcomes and health factors. The conditions described in this survey have been going on in the region for at least a century.
Appalachians never asked for addictions and its associated problems. It was all bestowed on us as a direct consequence of the massive group trauma brought about by industrial colonization.
The historical pattern of industrial colonization in Central and North Central Appalachia is a clear example of how a unique form of historical trauma develops in communities and creates a context that significantly degrades well-being, compromises people’s abilities to exercise self-determination, and leaves the population vulnerable to a host of problems in the present including substance abuse and addictions.
We now know where the most vulnerable communities in the country are located and we have some pretty solid evidence what got them started down that path.
I can partially go along with the idea that addiction is a chronic brain disease. It is true that addiction affects our brains and the rest of our bodies.. However, to attribute this brain disorder to messed up brain chemistry, faulty genes, poor learning, inability to control impulses, inability to connect with others, poor coping skills, inability to deal with stress, etc. seems “bass-ackwards.” I’ve worked with quite a few addicted people, and all of them had experienced some form of trauma at some point in their lives, and all of them were in pain. Whether it was physical pain or emotional/psychological pain makes no difference. To your brain, it is all the same.
Appalachians never asked for addictions and its associated problems. It was all bestowed on us as a direct consequence of the massive group trauma brought about by industrial colonization. Under this colonization, a large percentage of the people of Central and North Central Appalachia were seriously wounded. Under the imposed social order, the population’s wounds got infected, abscessed, and became chronic. The wounds were passed down from one generation to the next. The imposed context continually wounded people who, over time, showed the wear-and-tear that comes from this.
The context became physically and socially toxic. It was diseasing and killing the community. This should not come as a surprise, because it happens all over the world. Anytime one group of people colonizes another group, there will be trauma and it has consequences that can last for generations. What has been wrought through industrial colonization has, over time, taken a great toll on the people and made them quite vulnerable to the things that ease their pain.
The current opioid epidemic is not surprising when you see it in its proper historical context. If you take any group of humans and force them into a wounding environment, as Appalachians were, they will become traumatized and seek relief. Any one of us would do the same because it is part of our nature as humans. The seeking of relief by this large chunk of Appalachians did not go unnoticed by other industries, particularly the pharmaceutical companies, who have been all too happy to help out with the relief seeking…at a price of course. They have flooded North Central and Central Appalachia with billions of pain killers.
An online source defines colonization as, “the action or process of settling among and establishing control over the indigenous people of an area.” In Appalachia, we are clearly experiencing colonization by opioids. Appalachians are being thrown in the river at an astonishing rate, a rate that has overwhelmed our ability to handle.
Question #3: What’s Next?
Now we have a different way to think about addictions, so I hope we can apply this new thinking to creating new ways to handle it. We can no longer view addictions as a problem of an individual, and we can also no longer avoid the tight relationship between addiction, poverty, unemployment, financial stability, health, violence, and all the rest. They are all inextricably connected to the lives of a community. It is a challenge for us all. Maybe if we start looking for answers to one last question, we might just stumble onto something that could work.
And here is the last question:
How can Appalachian communities – and others affected by historic trauma – heal from these wounds and go about the business of creating the kind of communities they really want? Answer this question, and we will go a long way toward solving the problem of addiction.
Wayne Coombs is a native of West Virginia, where he was a counseling professor at Marshall University and director of research and development at the West Virginia Prevention Resource Center. He currently lives in Johnson City, Tennessee.