The pain that came first: what trauma and addiction ask of us

A man in his fifties came to my clinic with headaches he had carried for three years. The imaging was clean. The bloodwork was clean. He had been through the standard workup twice already at other hospitals, and he recited it to me the way people recite an address they have given too many times. Near the end of the visit we came to the line on the intake form about alcohol. He gave me a number, paused, revised it upward, paused again, revised it upward once more, and laughed at himself.

I asked him when the drinking had started to matter. He gave me a year. Earlier in the visit he had mentioned, almost as an aside, a scar on his forearm and the accident that put it there. Same year.

The headache was real. I want to be clear about that, because patients with headaches spend half their lives being told their pain is imaginary. But sitting there with his chart, I had the strong sense that the headache was the smallest thing he had brought into the room.

For most of the last century, psychiatry filed trauma under the heart. A wound of the mind, a bad memory, something to be talked through. Twenty-first-century neuroscience has redrawn that picture almost completely. Trauma is a bodily event. It reorganizes the machinery.

In brains shaped by deep trauma we see the amygdala — the threat detector — running chronically hot, so that ordinary stimuli produce responses sized for emergencies. We see the hippocampus reduced in volume, which matters more than it sounds, because the hippocampus is part of how a memory gets filed under past. When that filing fails, the memory does not stay where it belongs. It keeps arriving as the present. We see the prefrontal cortex underactive, so the capacity to stand above one's own reaction and look at it calmly is weakened exactly when it is most needed. We see the HPA axis stuck slightly open, cortisol running a little high for years. We see vagal tone drop, the parasympathetic brake worn thin. And we see the default mode network — the circuitry that keeps the running story of who you are — settling into abnormal patterns.

Add all of that together and it produces one sentence, though the body never says it in words: I am safe nowhere.

Bessel van der Kolk, who has probably done more than anyone to make this visible, spent a career cataloguing what helps. Medication helps. Cognitive behavioural therapy helps. EMDR helps. Body-based work, breathing, yoga — all of it helps. And then, near the end of The Body Keeps the Score, he keeps circling back to something harder to put in a protocol: that recovery which lasts almost always involves meaning, and often involves the frankly spiritual.

I used to find that a slightly embarrassing sentence to read in a medical text. I don't anymore, and the reason is neurological rather than devotional. What trauma destroys is not primarily a memory. It is trust — in the world, in other people, in oneself — and those convictions do not live at the level where argument reaches. The world is not safe. No one will protect me. I am worthless. Nobody talked those beliefs into a person, so nobody can talk them out. For anything to change, trust of the same depth has to settle back in.

Addiction has the same shape, seen from another angle.

We now understand the addicted brain reasonably well. Dopamine signalling goes strange: responsiveness to ordinary daily life falls, while responsiveness to the one thing climbs. The decision circuits of the orbitofrontal cortex are damaged, which is why the entirely accurate judgment this is destroying me so reliably fails to stop the hand. Tolerance grows. And the small pleasures — a meal, a walk, a joke — go grey. This is what makes the moral framing so useless. The circuit on which willpower runs is itself the circuit that has changed.

But the neurology is not the whole account, and Gabor Maté has spent thirty years saying so in one line.

The first question is not why the addiction. It is: why was this person already in so much pain?

Take the substance away and the pain is still there, waiting, exactly where it was. This is why detox without anything else so often fails, and why the most durable recovery programme of the last century did not come out of medicine at all.

Alcoholics Anonymous began in 1935 as two men trying to stay sober. Ninety years later it is the largest self-help movement on earth. Its architecture is unmistakably spiritual: an admission of powerlessness, a turn toward something greater than the self, a searching inventory, amends to those harmed, and finally the obligation to help the next person in the same trouble. For decades physicians were sceptical, partly for good reasons — it is hard to run a trial on a fellowship. Then in 2020 a Cochrane review of twenty-seven studies found that AA and twelve-step facilitation performed as well as established treatments like CBT, and better on the specific measure of continuous abstinence.

I want to be careful about what that does and does not show. It is a finding about a programme, not a measurement of God. Nobody scanned grace. But it does mean the spiritual architecture of those steps cannot be dismissed as decoration on top of the real treatment, because when you compare it with the real treatment it holds up.

And the steps map onto things I have circled for years. The surrender of the first step loosens the grip of exactly the self-referential network that will not stop talking. The turn toward a greater power in steps two and three points the reward circuitry at something that does not require escalating doses. The twelfth step, helping another addict, switches on the reward system of giving — which, as it happens, is one of the better-documented findings in the whole field. That mapping is a plausible reading, not a proof. I offer it as a neurologist who finds the correspondence hard to ignore.

There is one more thing Christianity brings here, and it is not a technique. At the centre of the faith sits a man who went through betrayal by his closest friend, a rigged trial, torture, public humiliation, and execution — and did not sidestep any of it. For someone carrying deep trauma, the recognition that runs through that story is not an argument. It is closer to being met: whatever I went through, he went through first. He is not being told about this.

I cannot measure that. I have watched people to whom it made a difference, and I have watched people to whom it made none, and I am suspicious of doctors who tidy that up in either direction. What I will say is that recovery, when it comes, is never just the relief of symptoms. It is someone becoming a different person than the one who walked in — a fundamental re-recognition of the self, the slow return of trust, meaning found somewhere it had not been before. Theology has an old word for that. Neurology has a newer one: deep restructuring. Two vocabularies, one event, and neither of them owns it.

The man with the headaches came back. I did not preach at him; that is not my job, and it would not have worked. I asked him the second question instead — not why the drinking, but what happened the year the drinking started. He was quiet for a while. Then he told me, and it took the rest of the appointment, and we ran late.

The headaches, for what it is worth, are somewhat better.

📖 These reflections draw from my books. Start with The God Neuroscience Found on Amazon, or see all my books on my author page.

These essays are personal reflection at the intersection of neuroscience and faith — not medical advice.