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Friday, June 23, 2017

Treating Substance Abuse with Co-occurring Disorders

substance abuse co-occuring disordersThe definition of recovery is "a return to a normal state of health, mind, or strength". It is becoming the norm for someone who suffers from substance abuse to also suffer from some sort of co-occurring disorder. It could be trauma, borderline personality disorder, a mood disorder, self-harm, amongst other things. Due to this increasing occurrence, it is has forced the treatment industry to evolve. 

Today, treatment often requires a multi-faceted approach. Let’s take a look at trauma as our first example. If a provider only treats the substance abuse, but does not treat the trauma an individual has suffered from, that person will not be able to make a full recovery, and it puts the patient at a higher risk for relapse. The reason being is that individuals with untreated trauma tend to unconsciously recreate the trauma in their lives. This means that if someone has untreated trauma, chances are they are going to put themselves in a situation that will not only cause pain of various types, but the individual will more than likely act out in certain behaviors that are not conducive to “a return to a normal state of health, mind, or strength.” They will be engaging in situations that put their newfound sobriety at risk.

The next example we can look at is some sort of co-occurring mood disorder alongside the addiction, such as bi-polar disorder. The same principle applies, if a provider treats the substance abuse, but not the mood disorder the individual will not be able to make “a return to a normal state of health, mind or strength.” People who suffer from addiction already suffer from extreme emotional swings due to the chemical imbalances in their brain. Couple that with bi-polar disorder and there is an extremely volatile situation that could quickly lead to relapse. In situations such as this it is paramount that they be under psychiatric care while being treated for their substance abuse. If the individual is not stable, how can they even benefit from substance abuse treatment? They won’t even be able to take in and apply what they are learning, nor will they be able to pursue the introspective practices necessary for substance abuse recovery. In the long term situation, an individual is at great risk for relapse if their mood is not regulated, because they run the risk of self-medicating with addictive substances.

If your loved one suffers from addiction with some sort of co-occurring disorder there are several things to look for when seeking treatment for them. Make sure the facility is adequately equipped to treat whatever co-occurring disorder is going on with your loved one. Ask specific questions pertaining to their treatment of the co-occurring disorder, and what the intensity of the treatment is. Furthermore, with someone who has a co-occurring disorder, it is absolutely vital they receive long term care. Substance abuse is a complex enough issue, couple it with a co-occurring disorder and treatment gets even more complex and intricate. Thirty days is simple not long enough to fully, effectively treat the issues at hand. A thirty day inpatient facility is a good start to get the ball rolling, but after care in a long term program is vital for recovery in situations with co-occurring disorders.

Saturday, June 10, 2017

Trauma Informed Care

trauma informed careThe awareness of trauma and stress related disorders and the importance of developing sound treatment approaches for these disorders has grown in recent years. It is essential for practitioners and agencies that deliver substance use and mental health treatment to enhance their understanding of the complexities of trauma related disorders and how to treat them. Furthermore, it is important that care providers deliver efficacious and empirically evaluated forms of treatment.

Trauma and stress-related disorders are among the most prevalent disorders treated by mental health professionals. Within the general population, a lifetime trauma incidence of 40% to 90% has been reported, and the overall lifetime prevalence for PTSD ranges between 7% and 12%. Needless to say, practitioners must ensure that they have the competency, training, and support to effectively treat trauma-related disorders.

Many studies have reported the efficacy for the psychological treatment for PTSD in conjunction with psychopharmacological treatment of PTSD. These studies have shown that psychological treatment is more effective in reducing symptoms of PTSD than medication alone. These studies have focused on several different modalities of treatment in order to determine which approaches seem to be most effective. Among the most researched and effective treatments for PTSD are trauma focused CBT (TFCBT), EMDR, Exposure based therapy, and Cognitive Processing Therapy. These approaches are widely used by practitioners in the treatment of trauma related disorders.

TFCBT combines trauma-sensitive interventions with cognitive behavioral techniques, family approaches, and humanistic principles. EMDR is a treatment approach that facilitates the accessing and processing of traumatic memories and seeks to bring these memories to a more adaptive resolution. Exposure therapy involves gradually exposing the client to the feared object and/or situation without any danger as a way to overcome stress-related symptoms. Cognitive Processing Therapy (CPT) is also considered to be a best practice model. CPT is an adaptation of cognitive behavioral therapy and incorporates trauma specific cognitive techniques to assist clients in moving past erroneous beliefs and maladaptive thoughts.

While applying evidenced-based treatment approaches to trauma services is absolutely necessary, there are additional things to consider when working to develop a trauma informed approach to treatment. To become trauma informed, practitioners and agencies not only need to be aware of evidence-based and efficacious forms of treatment, they must demonstrate an understanding of and competency in working with trauma exposed clients. Training of all staff within an agency as well as ongoing training for practitioners is essential in order to deliver sound and effective services. Ongoing supervision, training, and an emphasis on creating an environment of safety, trust, choice, collaboration, and empowerment are necessary components of creating competency and effective treatment of trauma related disorders.

When delivering treatment for PTSD, physical and emotional safety are the foundation for effective therapeutic work. This includes providing a safe physical environment, education, and information about the pervasive effects of trauma. Trust is an essential part of emotional safety when treating trauma. This includes establishing and maintaining appropriate boundaries, honoring confidentiality, consistency, clarity, and predictability. These components are absolutely necessary when delivering trauma treatment and creating a safe environment in which to procure services.

Cultural awareness and competency are also important to consider when utilizing various techniques to establish trust and safety. For example, practitioners must have knowledge of culturally appropriate nonverbal cues and norms that enhance safety and trust within that particular culture. Agencies and practitioners must be aware of culturally appropriate interventions and ways in which to communicate trust and safety in a culturally sensitive manner.

A competent treatment approach and a trauma sensitive environment also places value on client choice and one’s ability to have a voice in his or her recovery process. Emphasizing choice and supporting the client’s unique voice, allows the client to assume an active role in his or her treatment. This involves mutual collaboration between the client, practitioner, and/or agency in which a cooperative relationship is built based on the value of each individual’s unique experience and expertise. The practitioner’s experience and expertise are not valued over the client’s unique experience and expertise, rather both engage in a mutual exchange of respect and trust.

Finally, empowerment is a key component to effective trauma treatment. This concept argues that clients should be actively involved in the planning, delivery, and evaluation of services. A practitioner can empower clients by providing resources, information, education, and engaging them in interventions. It is important to build on a client’s strengths and his or her inherent resiliency as a means to empower him/her in the recovery process.

In addition to implementing evidence-based treatment, and adhering to principles of safety, trust, choice, and empowerment, trauma informed practitioners and agencies must be aware of the specific challenges and risks associated with trauma treatment. These challenges include but are not limited to personal attitudes, resistance, developing appropriate policies and procedures, and the potential for staff members to suffer from vicarious trauma. Trauma-informed clinical and staff support has been recognized as a primary protective factor for trauma reactions experienced by providers. Specifically, trauma sensitive coaching and staff support must include the same principles necessary for effective trauma treatment: safety, trust, collaboration, choice, and empowerment.

As awareness continues to grow regarding the complexity and pervasive effects of trauma, it is imperative for practitioners and mental health agencies to develop an understanding of and competency in trauma informed practices. This not only includes ongoing training and the implementation of evidence based practices, but a sensitivity to and awareness of the key components that comprise an effective therapeutic relationship based on safety, trust, collaboration, and empowerment.

Marie Tueller, MEd, LPC
June 8, 2017 

Sunday, June 4, 2017

The Importance of Accountability in Recovery

accountability in recoveryIndividuals who suffer from addiction, more times than not, have no idea about being responsible for their behaviors and choices in life. When someone enters into recovery, it is paramount that they recreate themselves. Their previous way of living has been ineffective, and has caused chaos and harm in their own lives as well as the lives of others. Addiction centers in the mind. Therefore the importance of teaching these individuals to change the way they view things, and thus them changing their own behavior, is crucial for long term recovery.

The issue with addiction is that the substances being abused are only the tip of the iceberg. What about the lying, stealing, manipulating, and other destructive behaviors that accompany addiction? Many people are aware getting the drugs and alcohol out of the system is only the beginning. If it where that simple there would be no need for treatment centers or recovery programs. Recovery is about taking responsibility for one's actions, both past and present. In order to do this the behaviors mentioned above must be confronted, and the individual must learn that behaving in their previous manner will get them nowhere in life and will more than likely lead them to relapse.

Bringing about this change is not easy, but it starts with learning to hold oneself accountable. Since the individual entering recovery has no idea how to do that, it is important that others around them do so until they learn personal accountability. This is where long term treatment comes into play; especially a facility that believes accountability is crucial to one's long-term recovery. The process usually involves their peers as well as the staff confronting the behaviors in a direct, yet therapeutic manner. If someone is simply told they are not behaving appropriately, but is not explained to why, nor given an alternate method of handling the situation the individual will not internalize the importance of changing themselves.

When an individual learns personal accountability, they are able to handle life successfully. They no longer engage in harmful behaviors, they are able to have effective meaningful relationships with others, and they are able to face situations in an appropriate manner, handling them without the need to rely on others.

Friday, May 26, 2017

The Healing Forces of Nature

ecotherapyMatsumura (2016) stated, “ecotherapy changes cognition, emotion, and physiology that are positively valued and/or enhance effectiveness and adaptive capacity (p.3).” By incorporating nature into therapy using rocks, shells, or plants or collaboratively agreeing with the client to have their therapy session on a walk in the forest there could be a substantial increase in the level of therapeutic transformation in the client. While I was at colloquium I took a workshop on the use of nature for therapy. The first exercise we were asked to do was to notice the emotional climate and shift that happens in each of us as we move from an enclosed space to walking outdoors. Then the Eco therapist asked each of us to pair up with one other person and find anything in the natural environment surrounding us such as the rocks, flowers, creek, or even just one small patch of grass. Once this is done I was to lead my partner with her eyes shut to a big rock I had chosen near the creek for my partner to sit, take in, and be aware of their emotional atmosphere in the here and now. This was to take place for 7 minutes, then we would switch and do the same thing. After both people have played the part of the therapist and client they take 7 minutes to discuss what happened for them in the time they sat with the chosen natural object. This exercise gives the client time to pause and be mindful of her natural surroundings and allow the answer to come. In the business of everyday life, it is easy to become overwhelmed. If we stop and listen through interactions in the natural world conclusions can unfold right before our eyes.

Another therapeutic exercise may simply be taking the client on a walk and asking them to become aware of everything in their environment and let it speak to them. For instance, the therapist asks the client to scan from left to right and point out what they notice then define why they noticed it. For instance, the roots of the trees are connected to one another which seems to make them stand up stronger. The therapist can use this as a means to explore how this relates to the client personally. Thus, the very essence of ecotherapy is utilized for highlighting the positive impact that nature creates within the human psyche while bridging the gap within the whole person (Matsumura, 2016).

Matsumura, J.L. (2016) Ecotherapy as a Tool for Mental Wellness. Vermont Connection 37103-110

Friday, May 12, 2017

Behavioral Modification for Treatment of Addiction

behavioral modification addiction treatmentBehavioral modification is a type of psychotherapy that focuses on the reduction or elimination of unhealthy, destructive habits and behaviors, to be replaced by healthy and appropriate behaviors. Behavioral modification first made its appearance in psychotherapy in the late 1800’s and early 1900’s, with the introduction of Ivan Pavlov’s work with dogs. In the course of his famous experiment, “Pavlov’s Dogs,” he discovered that the dogs could be conditioned to respond to a stimulus that wouldn’t normally elicit such a response. He paired a neutral or “unconditioned stimulus” (ringing a bell), to a “conditioned stimulus” (food), and found that after pairing these for a while, the conditioned stimulus (food) could be removed from the equation and the dogs would salivate after merely experiencing the unconditioned stimulus (ringing a bell). This became known as classic conditioning, and is found to not only apply to dogs, but humans as well. Just as Pavlov’s dogs were conditioned to respond to a stimulus, humans can be conditioned and shaped by our environments and the rewards within them. Behaviors that produce a reward become reinforced, while behaviors that do not produce a reward are often discontinued.

In behavioral modification, it is emphasized that just as people learn maladaptive, undesirable behaviors; they can unlearn these behaviors as well. This method of treatment has proven highly effective in the treatment of substance use, as well as with personality disorders, as these disorders are often characterized by maladaptive inner experiences and behaviors.

The following are techniques that can help accomplish the reduction or elimination of undesirable behaviors: aversive conditioning, modeling, extinction, and token economies. All of these techniques basically involve behavior being reinforced or eradicated.

Aversive Conditioning pairs the undesirable behavior (e.g. not following treatment guidelines) with an unpleasant stimulus (writing guidelines multiple times), with the goal being for the unpleasant stimulus to decrease or eliminate the undesirable behavior.

  • Modeling involves the watching and imitating of others, and explains why our environments so greatly contribute to behavior. In this technique, a client who would like to improve communication skills could do so by observing the communicative skills of therapist or more advanced peers. 

  • Extinction is a technique that involves completely removing any reinforcements from unwanted behavior. For example, when a person is acting out in attention-seeking behaviors, those behaviors are completely ignored. Once the behavior no longer elicits a reward or reinforcement, it eventually ceases or becomes extinct. 

  • Token economies involve positive reinforcement and rewarding positive behaviors with “tokens.” These tokens can be used to purchase a special treat or privilege, and promote learning that when behavior is appropriate, it is met with a reward and when behavior is not appropriate, there is no reward. 

  • Behavioral modification is a short-term therapy that aims to improve the quality of an individual’s life by the teaching adoption of new skills and confidence, and at the same time, the reduction of problematic behaviors. The techniques are very straightforward and easy to understand. As aforementioned, this type of therapy can prove highly beneficial to those with substance use and mental health disorders. 

Benefits of Behavioral Modification

One of the greatest benefits of behavior therapy is that it helps people to improve upon their quality of life. When a person gains confidence and begins to utilize newly acquired skills, they may implement that confidence to make other changes in their lives. For example, a person who has suffered debilitating social anxiety may develop confidence through the ability to communicate effectively and learn that they no longer need to drink or use drugs to have the confidence to engage with others. People who have experienced anxiety resulting from debilitating phobias can learn to overcome these fears without the use of “liquid courage.” The results can be truly life-changing. 

Behavioral modification can help people learn to reduce and manage unhealthy impulses, compulsive behaviors, and emotional outbursts. It can help improve upon current coping skills and adopt new ones. In addition, it can also teach people how to function better in social settings.

Compared to other types of psychotherapies, behavior modification is a relatively short-term, and therefore cost-effective treatment. Treatment goals can often be reached in as little as several weeks, rather than several months or a few years. The techniques and strategies used in behavior therapy are also fairly straightforward and easy for most clients to understand and learn, making it applicable to people from all backgrounds, with all education levels.

Thursday, May 4, 2017

Addiction and Trauma

addiction and traumaDrug and alcohol addiction is a multi-faceted disease. Many factors can impact an individual’s susceptibility to addiction, including physiology, genetics and environment. Due to this there is a direct link between preverbal or childhood trauma and addiction. In a study done on an abstract group of women with substance use disorders, sixty percent of them had a history of childhood sexual abuse, fifty five percent of them had a history of childhood physical abuse and forty five percent of them had a history of emotional neglect or abuse. These statistics show a strong correlation between childhood abuse and the development of addiction as a mitigating behavior. When trauma occurs in childhood it adversely impacts the brains normal development. The human brain adapts and responds to its environment. In relation to addiction, an individual is born with the genetic predisposition for this disease and the environmental stimulation the individual is exposed to can activate this gene and alter the neural pathways causing synapses to develop. These neural abnormalities occurring in brain structure of individuals who experience childhood trauma are thought to negatively impact emotional development, social capacity, and proper cognitive ability.

The developmental difficulties causes by trauma can be exhibited in many ways. Often children who have experienced trauma exhibit symptoms of Attention Deficit Hyperactivity Disorder, or severe anxiety, when in reality they are experiencing a normal physiological response to trauma. Due to this they are often misdiagnosed and incorrectly medicated. Later in life many of these individuals end up self-medicating. This mitigating behavior is extremely dangerous for individuals predisposed to alcoholism. This is especially true because when individuals are using drugs and drinking heavily they often expose themselves to traumatizing environments on a daily basis. When the body is abused physically, sexually or emotionally, neurochemicals are released in the brain activating the amygdala and throwing the mind and body into the “Fight, Flight, or Freeze response. Individuals who are repeatedly exposed to trauma have a lower threshold for these neurochemicals and can be thrown into this response by far more mild experiences. This perpetuates drug and alcohol abuse as a way to cope with constant agitation and fear.

When individuals enter recovery, they are faced with the challenge of feeling all the built up emotional and physical stress on their body by the trauma they have endured. Trauma and Post-traumatic Stress Disorder cause a range of problems from sleep deprivation, to night terrors, and somatic issues. In order to treat this, individuals need a multi-faceted treatment strategy - including 12 step based programs, clinical trauma work, and development of spiritual coping tools. Long-term treatment is the most effective in this area because it allows the individual time to emotionally and somatically regulate, before diving into clinical trauma work. In doing this work individuals gain an understanding of their disease, learn and practice tools in order to self-regulate, learn and implement the principals of 12 step recovery, and begin to heal spiritually, physically and emotionally. Working through trauma therapeutically allows individuals to form internal and external emotional boundaries, learn to form safe and healthy interpersonal relationships and feel safe in their body instead of being a state of disassociation. All of these aspects allow for long-term, sustainable recovery.

Friday, April 28, 2017

Gender Specific Addiction Treatment

gender specific addiction treatmentThere is no denying the benefits of substance abuse treatment when the individual applies what they learn while in treatment. However, for the addict in early recovery, the challenge of staying focused on themselves and applying the tools they learn is immensely difficult. This arises for several reasons. It could be they are not interested in recovery, or that they have an intense fear of facing the reality of who they have become. However, there is another distinct reason, that is more common than one might believe. Studies show that the number one thing addicts cross addict to in early recovery is romantic relationships.

There are several reasons why an individual may chose to distract themselves with a romantic relationship while in early recovery. The first is the most obvious one. People with addiction have repeatedly gone against their moral compass while intoxicated. They would do things while intoxicated that they would have never done if sober. When the addict sobers up most come to reality with the actions they have taken while in their addiction. Taking a hard look at oneself is not an easy thing to come to terms with. Therefore the addict in early recovery will chose to engage in a romantic relationship for the sheer purpose of focusing on another person instead of focusing on themselves. This is obviously inherently selfish, as well as unhealthy. In order for someone to successfully recover from addiction they must repeatedly take a hard look at themselves, and be willing to continue to amend their behaviors.

Another reason is because addicts, by default have a low self-esteem. Due to this, the addict will become involved in romantic relationships, because they derive a sense of validation and worth from the relationship. Building a sense of self-esteem and self-worth takes time, and is not an easy task. There are many things the addict must face and overcome to do so. Since people with addiction tend to avoid their problems and want instant gratification, they will usually try to find another way to achieve their goal - which almost always ends up in avoiding the problem, or dismissing it outright. Therefore it is not surprising that the addict in early recovery will use romantic relationships the same way they used substances. Substances provided a way for them to avoid dealing with reality, and to escape pain. It is the same with unhealthy relationships in early recovery. They will use the relationship as a source of self-worth, thus avoiding both the true work needed and the pain of growing. This is particularly dangerous because they do not do the necessary therapeutic work needed to recover from addiction. Furthermore, the addict in early recovery tends to have enmeshment issues, and will often times establish their identity based on another human being. 

Hence why gender specific programs are becoming more and more of a mainstay in the treatment industry. If an individual chooses to attend a gender-specific program, they will not have the opportunity to distract themselves with a romantic relationship. These programs also offer a more comfortable environment for the individual to become vulnerable with both their peers and staff. For example, not many men care to open up and be emotional around women, because it might make them feel week. Or vice versa. Not many women would feel comfortable talking about abusive relationships they have had with men, in a room full of men. Gender specific treatment not only removes the distractions, but also allows the individual to learn how to form true friendships with their fellows, and gives the addict a safe place where they feel comfortable opening up and being their true self.