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Thursday, October 12, 2017

Reflecting About EMDR & Substance Abuse Treatment

EMDR substance abuseFor as long as I have been working in the field of substance abuse treatment there has always been a concern that a client may not be able to stay sober if they start to deal with their deep emotional issues. There are those who say “NO WAY” and those who say “If they don’t they CAN’T stay sober”. I have found that I rest somewhere between these two extremes.

While working here at Canyon Crossing, I've noticed that someone who has been doing well in treatment begins their trauma work with EMDR, and will appear to become less stable in their recovery. When they start dealing with that old trauma (that they used drugs/alcohol over for years), they start to have more cravings; when they were not having any cravings before they started to process these feelings. This is perplexing to the client, and creates some confusion and concerns for them. It is important that the client understand that this is a normal response to digging deep and dealing with old trauma, because this trauma is a huge relapse trigger and it is better to deal with it in a safe environment instead of on their own after treatment when they don’t have the built in support that treatment gives them.

One of the great things I like about working at Canyon Crossing is that I can do this deep work with the clients. I trust that the environment they live in is secure enough to support them while they deal with resolving their trauma, cravings, and painful history. The high accountability and structure that Canyon Crossing provides is a perfect place for these women to stay sober and work through their deep history of trauma with EMDR in order to achieve long term sobriety.

Janet E. Bontrager

Monday, October 2, 2017

Risks and Benefits of Psychotropic Medications

risks benefits psychotropic medicationsIt is not uncommon for clients in treatment to have resistance towards being prescribed psychotropic medication due to such factors as side effects, risk of becoming dependent on the medication, having to take the medication for the rest of their life, etc. As a result, there is a movement towards using alternative forms of treatment (i.e., biofeedback for ADHD, holistic medicine, hypnotherapy, EMDR).”

With many illnesses, the benefits of medication must be weighed against potential risks and side effects. Ultimately, the patient must be informed of the risks and benefits and make a decision whether to pursue a medication management program or not. Part of the provider’s responsibility is to educate the patient on the pros and cons as well as possible alternative forms of treatment that do not include the use of psychotropic medication.

The decision to have a life free of the devastating effects of mental illness and addiction versus experiencing unpleasant and/or potentially life altering side effects is a decision that must be made by the patient after a thorough process of informed consent. This is when the benefits of psychotropic medications must be considered.

The success rates of being treated with psychotropic medications can often be quite high. Some studies have indicated that antidepressants can be up to 70% effective even with the first medication trial. Sometimes, patients initially experience unwanted side effects with one medication but will find relief from the use of another medication. In such circumstances, the benefits of the medication must always be balanced against the possible consequences of not taking the medication.

In the case of chronic depression, it may be necessary for one to be treated with antidepressants long term. For many, illnesses of this nature are chronic, lasting years. Research has shown that if left untreated the effects of the illness can have detrimental effects on the brain. Those who aren’t treated effectively for depression actually have lower brain volumes due to the increased number of circulating stress hormones. These hormones cause cell damage and death, while antidepressant medications have a neuro-protectant effect that prevents this type of cell damage and assists with neuro-genesis. Specifically, the antidepressant medications known as SSRIs aid in transforming stem cells in the brain into mature brain cells that ultimately replace damaged cells in the hippocampus.

In general, psychotropic medications are especially effective with biologically based disorders such as schizophrenia and, in some cases, bipolar, mood disorders, and anxiety disorders. Medications have proven to reduce the negative symptoms of these disorders, increase overall functioning, increase the effectiveness of other therapeutic approaches, and tend to be very cost effective.

The primary categories of psychotropic medications include antipsychotics/neuroleptics, mood stabilizers, antidepressants, antianxiety medications, stimulants, narcotic and opioid analgesics, antiparkinsonian medications, and hypnotics. These medications have shown to have the following positive effects when treating mental illness: stops or reduces psychotic symptoms, produces mood stabilizing effects, relieves anxiety, decreases suicidality and other self-harm behaviors, prevents psychotic states, reduces depression, can produce calming and relaxing states, increase attention span while reducing impulsivity, can control acute pain, can aid in substance use detoxification, can treat neurological disorders, and assists with sleep disturbances. These are only some of the many potential benefits of psychotropic medications.

For many, medications are appealing because they often produce quicker results than alternative treatments. For those who are significantly and chronically depressed, sometimes the trajectory of “feeling better” through alternative treatments isn’t fast enough and they are at risk for suicide or other dangerous behaviors while experiencing significant impairment in functioning. Medications can often provide faster relief and stabilization for those who present as a danger to themselves or others. Medication can help these individuals live better longer lives with fewer effects that can cause detrimental consequences.

This is not to say that there aren’t significant risks associated with the use of psychotropic medications. In 1990 a survey was conducted to explore the general public attitude toward psychotropic medications. The survey found that the majority of the population views psychotropic medication with suspicion for the following reasons: 1) they can cause unwanted side effects and dependency, 2) their effects are restricted, i.e. they only treat the symptoms of the illness and not the cause, and 3) they can be ineffective, having either no effect or effects of a doubtful or temporary nature.

For some, medication may be a way to find quick relief without having to do “the work” that is required to not need medication. It’s simply easier to just take a pill than it is to change certain behaviors, thought patterns, and maladaptive coping mechanisms. What many patients do not realize is that medications often only treat the symptoms of the illness and not the main cause. Alternative approaches such as therapeutic interventions and psychosocial treatments address the cause of the illness thereby producing lasting change and relief; however these approaches tend to be more costly, time consuming, and require work.

Medications often produce unpleasant and even dangerous side effects including but not limited to mania, psychosis, hallucinations, depersonalization, suicidal ideation, heart attack, stroke and sudden death. Frequently, psychiatrists cannot predict what side effects a patient will experience due to the fact that it is unknown how exactly many of the medications work. In fact, many psychotropic drugs have been exposed as chemical toxins with the potential to significantly harm and/or kill those who take them.

Due to the potential risks associated with medication management treatment, the American Psychological Association actually recommends that, in most cases, alternative interventions such as psychosocial therapy should be the first intervention that is considered, especially for children and adolescents who tend to be much more susceptible to the adverse side effects of medication. Clearly, such interventions are much safer and, often, more effective than the use of psychotropic medications. In fact, when medications are deemed to be necessary they should be used as adjuncts to behavioral and therapeutic treatments.

Due to the many risks and unpleasant side effects of psychotropic medications, it is important to consider alternative forms of treatment for mental health issues. Therapeutic interventions and psychosocial treatments provide guidance, support, education, and positive coping skills to manage and treat mental illness. Therapeutic interventions should be given consideration as a first option to treat mental illness. While they tend to take longer than psychotropic medications for improvements to be noticed, they have solid grounding in empirically based research and are safer than medications.

Some empirically based alternative forms of treatment include, but are not limited to, behavioral therapy, cognitive behavioral therapy, EMDR, holistic treatment, psychotherapy, biofeedback, and dialectical behavioral therapy. These treatments utilize tools that can increase positive behaviors, correct negative thoughts, heal past trauma, facilitate a return to normal functioning, teach healthy ways of interacting, develop a deeper understanding of one’s self, and skills training such as emotional regulation and distress tolerance. Research has found support for the use of these interventions as first-line modes of treatment. Through various controlled trials and meta-analysis, researchers have observed sustained significant effects on behavioral problems, mood disorders, and other mental health issues as a result of using these alternative forms of treatment.

Other forms of treatment such as yoga and meditation are being explored as interventions that can lead to improvement in overall mental health. Yoga practices incorporate mental, physical, and spiritual healing to develop self-awareness, grounding, calm the nervous system, and build balance, flexibility, and strength. A few studies involving control groups have demonstrated yoga’s overall benefit on positive self-regard, perceptions of wellbeing, and emotional regulation skills. Yoga has further been identified as a tool for treating trauma. In fact, the Trauma Center at Justice Resource Institute has developed a form of yoga for traumatized youth in inpatient and residential treatments. 

While psychotropic medications certainly can be beneficial for those suffering from mental illness, they are not without their risks. One must carefully consider potential side effects and long-term effects of medications before making a decision regarding an appropriate course of treatment. A thorough analysis of potential benefits versus potential risks must take place in addition to careful consideration of alternative forms of treatment. In many cases, such alternative forms of treatment, while slower to produce results, can lead to lasting change by treating the core causes of the patient’s condition rather than simply relieving the symptoms.

Marie Tueller, MEd, LPC

Friday, September 8, 2017

Cognitive Behavioral Therapy

cognitive behavioral therapyAlbert Ellis, the founder of Rational Emotive Behavior Therapy (REBT) is among the most influential psychologists, and has profoundly impacted the treatment of mental illness and substance use disorders. His psychological theory is an important contributor to Cognitive Behavioral Therapy (CBT). Ellis asserted that one’s beliefs strongly impact emotional functioning, which in turn directs behaviors. Specifically, he believed that irrational beliefs lead to negative emotions, which then lead to self-defeating behaviors. He focused on several common irrational beliefs or cognitive distortions that lead to emotional dysfunction and maladaptive behaviors and emphasized the importance of disputing these irrational beliefs through a variety of practical applications.

The tools laid out by REBT, to dispute irrational beliefs and thereby increase positive mood and decrease unwanted behaviors, have been especially impactful when treating addiction and co-occurring disorders. This treatment approach is highly intuitive and accessible to most individuals. It is especially useful because it provides simple understandable rationale for emotion and behavior along with solution focused coping mechanisms that one can apply to disrupt unhealthy modalities of thinking, feeling, and behaving, which is the root of most psychological, behavioral, and emotional problems.

This model is well researched, evidence-based, widely accessible, and can be applied to a vast range of psychological problems, which makes it especially useful. It can be easily and intuitively understood, thereby allowing what may have once seemed to be an insurmountable and complex issue to become something more manageable and treatable.


Marie Tueller, MEd, LPC

Thursday, August 31, 2017

EMDR Therapy and Complex Trauma

emdr therapy traumaEye Movement Desensitization and Reprocessing (EMDR) became the preferred treatment approach for people suffering from PTSD trauma and single incident trauma (car accidents, rape, etc.) from the very beginning due to the positive research that was conducted and the evidence that it made a difference in the lives of the people who participated in this treatment. It was proven to reduce a person’s strong emotional reactions to their past trauma in a relatively short period of time, sometimes as few as 1 – 5 sessions for any one single incident. Since this model of treatment is so effective with single incident trauma and PTSD it has been applied to other populations of clients which are helped with EMDR therapy as well. In Jim Knipes book, EMDR Toolbox: Theory and Treatment of Complex PTSD and Dissociation, he states this “emotional disturbance and behavior problems in the present often have their origins in prior events that were not life-threatening, but were very damaging. This is true not only for children who have had active exposure to adverse events (“trauma of commission”) but also for children who had “traumas of omission” – failure to receive adequate nurturing, mirroring, engagement, or guidance during childhood” (Knipe, 2015, p. 5).

The most important aspect of the above quote is that clients who come to Canyon Crossing for addiction treatment may also be suffering from past trauma, and may not be aware of how their present is being effected by their past. This is the one major plus in applying EMDR to an addict’s/alcoholic’s treatment. With EMDR, we can effectively separate their emotional responses to their past from their present circumstances, which make it easier to deal with their addiction and enter into a recovery that feels positive. For instance, when a person gets clean/sober and is encouraged to trust their peers and staff members, many times there is a strong resistance to trust and the client doesn’t always know why. Often times it comes from a past experience where they were hurt, disappointed, or in danger because they trusted someone (who was untrustworthy) and they don’t want to risk getting hurt again. With EMDR we can process and resolve these past incidents in order to help the client with the healing process and help them to trust the program and the staff. EMDR works well within a whole treatment approach that includes 12 step meetings, structured living, peer groups, and talk therapy. I’m pleased to be a part of this team and to bring EMDR to this population.


Janet E. Bontrager B.A.

References:
Knipe, J. (2015). EMDR toolbox: Theory and treatment of complex PTSD and dissociation. New York, NY: Springer Publishing Company.

Thursday, August 24, 2017

Co-Occurring Anxiety Disorders

Anxiety disorders are characterized by feelings of excessive fear and anxiety that can result in behavioral dysfunction and physiological reactions. There are six categories of anxiety disorders:
co occurring anxiety disorders

  • generalized anxiety disorder
  • stress-related anxiety
  • panic disorder
  • social phobias
  • anxiety induced by medical illnesses
  • anxiety symptoms that are part of a primary mental disorder


While the anxiety disorders tend to be highly comorbid with one another, they differ in the specific triggers or situations that induce anxiety, the resulting behaviors, the content of associated cognitions, and the duration of symptoms.

The etiology of anxiety disorders also varies depending on the specific diagnosis, however it is generally understood that most mental health issues are a result of a complex interaction between environmental factors, genetics, cultural influences, psychological composition, and biological influences. Some anxiety disorders appear to be more strongly linked to biochemical and genetic factors while others are primarily linked to cognitive bias and/or environmental influences.

Treatment for anxiety disorders varies depending on the specific diagnosis. In some cases, medication that directly alters the neurochemical processes associated with anxiety is indicated. In other cases, psychotherapy or a combination of pharmacological and therapeutic interventions is more effective. In order to determine the most effective mode of treatment, a provider must conduct a thorough evaluation that includes differential diagnosing, ruling out certain conditions and causes, and identifying any comorbid disorders that might better explain the anxiety symptoms.

There are several things to consider when determining the possible etiology of anxiety disorders including genetic, biological, environmental, and temperamental factors. Additionally, some anxiety symptoms can be explained by a medical condition, medication and/or substance use. In other cases, certain underlying traits may predispose individuals to anxiety symptoms in addition to environmental risk factors such as childhood maltreatment, adversity, abuse, family dynamics, and substance use. Genetic and physiological factors also play a role in some anxiety disorders. For example, one-third of the risk of experiencing generalized anxiety disorder is genetic, heritability for agoraphobia is 61%, and there is an increased risk for panic disorder among children of parents with anxiety, depressive, and bipolar disorders. It is well understood that most disorders are a result of a complex interaction between genes and environment.

The brain regions typically associated with anxiety include the amygdala, pre-frontal cortex, and structures within the limbic system. The amygdala is a key structure in managing fear and anxiety responses. Individuals with anxiety disorders often show heightened responses in the amygdala when presented with anxiety cues. The orbital frontal cortices (OFT) have also been implicated in anxiety disorders. Individuals with anxiety disorders have shown an increase in overall chemical concentrations in the OFC, thus lending further support to the neurobiological explanations for anxiety.

Some of the primary mediators of anxiety symptoms exist within the central nervous system and include norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA). Brain imaging has demonstrated reduced serotonin receptor binding and smaller temporal lobe volume in individuals with panic disorder. Research also suggests that abnormalities in serotonin levels and dopaminergic transmission are implicated in obsessive-compulsive disorder (OCD). Additionally, brain imaging has shown increases in blood flow and metabolic activity in the orbitofrontal cortex, limbic structures, caudate, and thalamus in individuals suffering from OCD. This indicates that symptoms of OCD may be a result of impairment in the brain structures that mediate strong emotions and the autonomic responses to those emotions (Baxter et al., 1992).

Psychological theories are also used to explain the etiology of anxiety disorders and typically consider cognitive, emotional, behavioral, and internal constructs as important factors that influence the development and expression of anxiety related symptoms. Cognitive theories state that anxiety is a result of an individual’s negative interpretation of anxiety related cues, cognitive distortions, and possibly a hypersensitivity to internal cues. Individuals with an anxiety disorder may overestimate the potential for danger and/or anticipate the worst-case scenario causing them to avoid certain situations and triggers. Behavioral theories view anxiety as a learned or conditioned response resulting from past associations between specific stimuli and anxiety responses. As a result, an avoidance response or a fear-based response becomes linked to these situations.

There are also considerable cross-cultural and gender differences in the prevalence and expression of anxiety disorders. For example, the female to male ratio for anxiety disorders is 3:1. The prevalence of GAD, panic disorder, and social anxiety in Asian, Latin American, and other non-western cultures is significantly lower relative to predominantly Caucasian American cultures. Explanations for these cultural variations include possible cultural and gender related differences in risk factors for the development of anxiety disorders, culturally specific concerns, beliefs, and evaluations of symptoms. 

Treatment for anxiety depends on the specific type of anxiety disorder, so it is important to conduct a thorough assessment in order to make an accurate diagnosis before considering specific interventions. The duration of anxiety disorders is also quite variable. Some individuals may only require short-term treatment while others may need years of ongoing treatment. It is also important to recognize that anxiety and stress are normal parts of daily living and should only be treated when the symptoms become excessive and interfere with normal functioning.

Medications such as SSRIs, venlafaxine, and busprione have been shown to be effective in the treatment of Generalized Anxiety Disorder (GAD), however many experts recommend psychotherapy as the primary modality of treatment for this disorder. While benzodiazepines can be an effective anti-anxiety medication, this class of medications poses significant risks for those including increased depression and risk of dependence. They should only be used if other medications prove to be ineffective and provided that the individual does not have a history of substance use or depression. If an individual is suffering from situational or stress related anxiety, medication may not be indicated, and if it is, it should only be prescribed on a short-term basis. 

When treating any mental illness, it is important to conduct a thorough evaluation in order to make an accurate diagnosis. Anxiety symptoms can result from a variety of factors including environmental or situational causes, medical conditions, substance use, medication side effects, or other mental disorders. It is therefore essential for a provider to determine the main cause of the anxiety symptoms and treat the primary causes and conditions.

When an individual presents with anxiety symptoms the following conditions should be ruled out before implementing a course of treatment: trauma or stressor-related anxiety, Substance/Medication-Induced Anxiety Disorder, Anxiety Disorder Due to Another Medical Condition, a medical illness, or Adjustment Disorder With Anxiety. Common issues that may cause anxiety include substance use particularly alcoholism and stimulant use, heart conditions, CNS diseases, hypoglycemia, hyperthyroidism, steroids, caffeine use, and other medications (Preston & Johnson, 2014). It is important to assess for any medical conditions, medications, and/or substance use issues that could be causing anxiety related symptoms.

Additionally, various mental illnesses can also cause anxiety related symptoms. Anxiety frequently accompanies mental health issues such as depression, schizophrenia, substance use, and organic brain dysfunctions. Anxiety disorders also have a high comorbidity rate with one another and require careful assessment to determine accurate diagnoses. Some anxiety disorders are frequently associated with a range of other mental health disorders. It is important to consider the presence of and possible relationship between the anxiety symptoms and other mental disorders.

Once an accurate diagnosis has been made, then a course of treatment should be determined in collaboration with the individual and other providers if necessary. For many mental disorders, therapeutic approaches are the first recommended course of treatment or a combination of pharmacological treatment and therapeutic interventions. Psychotherapeutic approaches such as behavioral modification, graded exposure therapy, psycho-education, skills training, and cognitive behavioral therapy are often effective in treating anxiety. If the anxiety symptoms are acute and/or likely to be of short duration, medications are not always indicated and, if they are, they should only be prescribed for a short period of time. If the anxiety is situational, a result of a specific crisis, or due to typical life stressors, then the anxiety is likely to resolve once the situation or stressor has passed without therapeutic or pharmacological intervention.

Some anti-anxiety medications can offer quick symptomatic relief and reduce suffering, however they do not necessarily “cure” the disorder. In order to achieve long-term recovery, the primary source of the anxiety must be altered. Therapeutic techniques have proven to be effective in addressing the main cause of some anxiety symptoms while facilitating lasting relief. If medication is indicated,it is important to educate those seeking treatment on the risks and benefits of medications including the differences between short-term and long-term use of medications.

Education and skills training such as meditation, mindfulness strategies, and distress tolerance techniques as well as CBT and behavioral interventions are quite effective approaches to the treatment of anxiety. Specific therapeutic techniques might include behavioral activation, physical and cognitive relaxation strategies, thought stopping techniques, and training in how to identify triggers, automatic thoughts, cognitive distortions, and methods to develop reassuring cognitions. These interventions have proven to result in significant reduction in anxiety symptoms particularly for pervasive chronic anxiety characteristic of GAD. The effectiveness of CBT based interventions lends additional support to the overwhelming evidence that many forms of anxiety are associated with cognitive distortions, hypersensitivity to internal cues, and a tendency to interpret events negatively.

When developing any course of treatment it is imperative that a provider view the individual and his or her symptoms within the larger context of culture and gender. Cultural variations in cognitions, beliefs, and unique ways of understanding physiology and psychology may affect the presentation, risk factors, course, and interpretation of anxiety symptoms. Similarly, gender frequently influences the expression of anxiety as well as the presence of co-occurring disorders. For example, women with social anxiety disorder report a greater number of comorbid depressive, anxiety, and bipolar disorders, whereas men are more likely to have conduct disorder or a substance use disorder as a means to manage anxiety symptoms. As a result, culturally sensitive interventions and gender-related diagnostic issues must be considered when formulating a treatment plan. This includes assessing the culture that the individual identifies with as well as determining the degree to which the individual endorses specific cultural practices and beliefs.

It is clear that the etiology of anxiety disorders, like most mental disorders, is complex and varies depending on the specific disorder. Dynamic interactions between neurological, biological, and environmental factors shape and influence the expression of anxiety related symptoms. These etiological factors have important implications for diagnosing and subsequent treatment planning. Some anxiety disorders are rooted in neurological and/or biological dysfunction and therefore respond well to medical and/or psychopharmacological treatments, while other anxiety symptoms can be linked to cognitive and/or behavioral abnormalities and require therapeutic interventions.

Marie Tueller, MEd, LPC