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Thursday, December 28, 2017

Dual Diagnosis or Co-Occurring Disorders

dual diagnosis cooccurring disordersDual diagnosis or co-occurring disorders (CODs) refers to one or more disorders relating to the use of alcohol and/or other drugs, as well as one or more mental health disorders. Examples might include Major Depressive Disorder with cocaine addiction; alcohol addiction with Panic Disorder; Borderline Personality Disorder with substance use. There is no single combination, rather there is great variability among combinations of disorders.

More than half of all adults with severe mental illness are further impaired by substance use disorders. Compared to patients who have a mental health disorder or substance use disorder alone, clients with CODs often experience more severe and chronic medical, social, and emotional problems. The existence of two or more disorders causes potential for both substance use relapse, as well as worsening of the psychiatric disorder.

Addiction relapse often leads to psychiatric deterioration, whereas worsening of psychiatric problems often leads to addiction relapse creating a dangerous cycle. Relapse prevention must be specifically designed for patients with co-occurring disorders.

Both substance use and mental health disorders are rooted in biopsychosocial systems.  Sometimes the mental disorder occurs first, which can lead the individual to self-medicate with alcohol or drugs, providing temporary relief. Sometimes, substance use occurs first, which can lead to symptoms indicative of one or more mental health related issues. Mental Health Disorders & Addiction are both dynamic processes, with fluctuations in:

• Severity
• Rate of Progression
• Symptom Manifestation
• Differences in speed of onset

Furthermore, both disorders are greatly influenced by several factors:

• Genetic Susceptibility
• Environment
• Pharmacological influences

Certain individuals have a high genetic risk for these disorders, whereas others may develop them due to environmental situations. It is also important to note that some drugs are more likely than others to cause psychiatric disorders. A common example includes methamphetamine induce psychosis or schizophrenia.

To provide appropriate treatment for CODs, the Substance Abuse and Mental Health Services Administration (SAMHSA) recommends integrated treatment for individuals suffering from CODs. Integrated treatment occurs when a person receives combined treatment for mental illness and substance use from the same clinician or treatment team. Integrated treatment helps individuals develop hope, knowledge, skills, and the support they need to manage their problems and to pursue meaningful life goals.

• Specific methods of integrated treatment include
• Screening, assessment, and referral.
• Mental and physical health consultation.
• The use of a prescribing onsite psychiatrist.
• Medication and medication monitoring.
• Psycho-educational groups.
• Psychotherapeutic groups.
• Individual Therapy Sessions.
• 12-step Based Program and/or spiritual support.
• Peer/Community Support.

When all components of integrated treatment are present, the likelihood of relapse in either mental illness and/or substance use disorders diminishes significantly. Long term recovery from the devastating effects of CODs is available and possible with integrated compassionate care.

Marie Tueller, MED, LPC

Thursday, December 7, 2017

The Influence of Sober Support Networks

importance of sober network
One of the important things to understand about addicts and alcoholics is that drugs and alcohol served a purpose in their lives. It helped the person cope with stress, trauma, and bad feelings or circumstances. It was a friend and it was always there for them. When an addict gets clean and sober they don’t have the skills to cope because they have been using drugs and alcohol to handle all the aspects of their life that they couldn’t. This concept creates a big loss in their life, and the drugs and alcohol have to be replaced with something.

What Alcoholics Anonymous (AA) learned in the 1930’s is that if the alcohol was replaced with a spiritual life, a life lived with the support of other alcoholics, and a way to come to terms with their inner selves they could stay sober. They could do something that the medical field had been unable to do with any consistent success. They needed each other and they needed a Higher Power of their own understanding. This was the beginning of what we have now come to understand as sober support networks.

When a person can learn to ask for help from another alcoholic/addict they have learned a vital skill that will save their lives when things get hard. And, things get hard the minute they are sober/clean. Because they have relied on alcohol/drugs to cope, it will take an outside source to introduce new ideas and skills to use to cope with life. A support network consists of sober individuals who are also learning how to stay sober/clean or who have been sober for a long time and are willing to share with the newcomer how they stayed sober. A sponsor can influence a newcomer and teach them what it takes to stay clean and sober by sharing their experience strength and hope. An AA group or Narcotics Anonymous (NA) group will become a safe place to find support. Treatment centers are a good start and will educate the newly clean/sober individual about sober networks and how to use them to be successful. A sober support system will also be a place of accountability in order to learn how to show up for themselves and others.

In my experience I have seen little success for the addict/alcoholic that doesn’t fully integrate a 12 step (or other of their choice) support network. I have seen addicts replace their drugs with food/relationships/work and their lives become unmanageable because they have resisted using a support network. Most of them either live miserably or relapse on their drug of choice. Without a support network they don’t have a place to learn how to cope with life without their drug. A sober/clean life is better than any addict can imagine alone but with a sober support network the possibilities become endless.

Janet E. Bontrager B.A. Primary Therapist

Thursday, November 30, 2017

Medication Assisted Treatment

medication assisted treatmentThe opioid crisis is in full swing, and is not showing signs of slowing down any time soon. As a result of this epidemic sweeping our nation, healthcare providers have been scrambling to come up with new ways to treat the issue. One of the solutions healthcare professionals came up with is Medication Assisted Treatment, or MAT for short. This method of treatment certainly has its benefits, but it can also have severe drawbacks, if not used appropriately. MAT is a method of using medication to treat opiate addiction, and other disorders, in the course of rehabilitation. For this article we will focus on opiate treatment.

One of the main medications used to combat the opiate epidemic is Suboxone. Suboxone is what’s known as an agonist. Suboxone binds to the same receptors in the brain as opiates like heroin, and oxycodone. There are two separate schools of thought for administering Suboxone. The first, is that it is used in a short taper to help ease the individuals detox symptoms from opiates. This is particularly beneficial because most addicts have a great fear of opiate detox, as it is excruciatingly painful. Often times, an opiate addict wont even attempt to get clean because of the detox symptoms; and providing this as a method of detox greatly eases the symptoms, thus motivating the individual to enter into recovery.

The second school of thought, is long term suboxone maintenance. This essentially is the idea that if someone is on suboxone long term, it will keep the individual from wanting to abuse opiates. The reason behind this thinking is two fold: first suboxone simulates the effects of opiates, thus cravings are reduced. The second, is that due to subxones method of action, it is very hard to become intoxicated on opiates whilst on it. However, the main drawback of this type of treatment is that so many providers use it as a sort of band-aid. They give the patient the medication, and send them on their way. This is not an efficient form of substance abuse treatment - because it does not treat the underlying causes of the addiction. No actual treatment of the addiction is involved. If curing the opioid epidemic was as simple as taking a medication every single day, it would have stopped long ago. Due to no actual treatment of the addiction, many individuals on suboxone maintenance will simply stop taking the drug, and begin abusing their opiate of choice again. Long term suboxone maintenance, however, can have its place in opiate addiction treatment. For example: If an individual simply cannot stop relapsing, suboxone combined with actual addiction treatment can be a powerful combination. The reason being is that the individuals cravings can be somewhat managed long enough for them to actually engage in the treatment of the addiction. Once the individual is stable, the provider can then begin slowly tapering them off the medication. It should be noted that since suboxone acts the same way as an opiate does, there are detox symptoms from it as well, when it is used long term.

The second medication commonly used in MAT with the opioid epidemic is Vivitrol. Vivitrol is an agonist- meaning it is a blocker. It blocks the opiate receptors in the body, making it very difficult to become intoxicated on opiates while it is in the system. It is a once monthly injection as well, so taking it daily, or suddenly stopping the medication to abuse opiates is not an option. Vivitrol is a valuable tool, in that it is not an opiate like suboxone, and it is time released, so the individual does not have the option of simply stopping, and using opiates. However, it too is not a cure-all. Like suboxone, it has it’s place, so long as the individual is receiving actual addiction treatment alongside of it. Since it is not an opiate, there are no withdrawals from the medication, and it is not a substitute like suboxone. All of these make it the more desirable option when it comes to using MAT in the treatment of opiate addiction.

In conclusion, MAT in the treatment of opiate addiction is certainly beneficial, however, it is not a cure all for the addiction. If you or your loved one is interested in MAT, be sure to get informed, and seek treatment in addition to the medication.

Disclaimer: The information presented her is only for informational purposes. This is not in any way shape or form medical advice. Before making any decisions, always consult a licensed medical professional.

Thursday, November 9, 2017

Family Therapy

family therapyFamily therapy is a relatively new form of treatment, first introduced in the 1950’s. Based on the assumption that psychological issues are the result of unhealthy interactions with others, Freud’s psychoanalysis and Roger’s client-centered therapy launched individual therapy in a whole new direction that included the influence of familial relationships, eventually giving birth to family therapy (Nichols, 2017). Carl Rogers believed that individuals are born with the innate drive towards self-actualization, but this drive is subverted by the desire for approval, which leads to conflict (Nichols, 2017). Actual founders and significant pioneers of family therapy are among Virginia Satir, Carl Whitaker, Jay Haley, Lyman Wynne, Ivan Boszormenyi-Nagy, and Salvador Minuchin (Nichols, 2017).

In working with families or individuals, therapists will at times encounter situations that involve domestic violence and/or sexual abuse. If the therapist has any suspicion of abuse of children, the elderly, or any vulnerable population, the therapist has a “duty to warn,” or a duty to report these suspicions to the appropriate authorities immediately.

In assessing a family for treatment, the therapist should be mindful of culture, as well as how assumptions related to culture may be driving forces behind some of their problems, particularly when it comes to gender roles and assignments (Nichols, 2017). If working with a culture outside of their own, the therapist would best serve their clients by developing cultural sensitivity, through educating themselves as to the experience and traditions of that culture (Nichols, 2017).

The first interview of the family is aimed at developing a hypothesis of the contributing factors of the presenting problem, as well as building a therapeutic alliance (Nichols, 2017). In the early phase of treatment, major conflicts will be identified, the hypothesis will be refined, and family members will be challenged to identify their own roles in the family problems. When one person is presented as the specific problem, the family therapist will challenge the linear thinking by finding out how other people are involved, and what roles they may have played in the manifestation of the problem (Nichols, 2017). In this phase, it is important for the therapist to be aware of both process and content, for as much can be learned by how people talk to one another, as can be learned by the content of the message (Nichols, 2017).

The middle phase of treatment will be aimed around helping family members develop more constructive ways to interact with one another. Here, the therapist will take a less active, observant role and encourage interaction amongst family members. This helps family members learn to use their own resources to work together, rather than relying solely on the therapist (Nichols, 2017). Once the presenting problem has improved, the family understands what was and wasn’t working, and has a fundamental knowledge of how to avoid similar problems in the future, the therapy may be successfully completed (Nichols, 2017).

Family therapists tend to think in terms of circular causality, rather than linear causality, by examining the interactive cycles of relationships. Instead of thinking solely in terms of cause and event (linear thinking), family therapists consider the influence people have on one another in a cyclical focus (Nichols, 2017). It is truly a dynamic process that looks beyond personalities to patterns that connect them and how family problems may be a product of the relationships that surround them (Nichols, 2017).

Nichols, Michael P. (2017).  Family Therapy: Concepts and Methods.  (11th ed.). Pacific Grove, CA: Brooks/Cole. ISBN 9780134300740

Wednesday, October 25, 2017

Dialectical Behavior Therapy in the Treatment of Addiction

dialectical behavioral therapy addictionA main goal of dialectical behavior therapy is to improve emotional regulation and reactivity to external stimuli. These skills can be especially impactful for people with substance abuse disorders, as they tend suffer from intense mood fluctuation and sensitivity. Many people with substance abuse disorders are also impacted by borderline personality disorder. DBT has been proven to be one of the most effective methods of treatment for BPD, due to its behavior and thought modification. DBT also focuses on reducing stress, learning how to manage every day life, and interpersonal skills. All of these things combined make long term sobriety more accessible.

Dialectical behavior therapy helps clients identify triggering thoughts and situations. For example, a boss being unhappy with ones work performance. The client will then assess whether this situation warrants the extreme emotional reactions they are experiencing. The client implements evidence-based thoughts to counter act their “triggering thoughts”. Clients learn and implement self-soothing exercises and coping skills to aid with emotional regulation.

Dialectical behavior therapy is an extremely effective form of therapy due to the diversity of areas in which it can be implemented. DBT can be used in group therapy, in the form of skill building, or in training groups. This is where clients can learn life skills and interpersonal effectiveness. Individual therapy is also an area where DBT can be used. Clients share personal experience and then use/implement new coping strategies in order to handle life more efficiently. Both of these methods are extremely important in the treatment of substance use disorders because clients are generally learning for the first time how to live as a responsible adult. Clients with substance use disorders also need to learn new coping skills, rather than turning to drugs or alcohol to sooth intense emotions and stress.

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