Make sure it's going up. That's for him. Put your power point up over here. Where do I find it? I don't know where you're going. The one you're teaching. Just directly. Oh, no, you're doing video. I'm sorry. Yes. I'm sorry. Put your video up over there. Okay, so which one? The one from Vimeo or the one that's on the local drive? The one that's on the local drive. Hi, welcome to your course on co-occurring disorders and their impact on treatment. Okay, so. Brought to you by allceuse.com. I can't move it. I'm going to do that. Yeah. Cause you have it actually. For screen. So we're going to make sure we click optimize buttons. You want to open your other. Panels. Hi and welcome to your course on co-occurring disorders and their impact on treatment brought to you by allceuse.com. In this course, you're going to develop a broad biopsychosocial definition of co-occurring disorders. You're going to learn about the reciprocal interaction between mental health, physical health and addiction. We'll discuss the multiple contributing factors of boon disorders to include physical issues and issues stemming from addictive behaviors and explore ways to simultaneously address multiple disorders. This presentation is based in part on the following texts. Medication assisted treatment for opioid addiction in opioid treatment programs. It's a treatment improvement protocol or a tip that's produced by SAMHSA that you can order off the SAMHSA website. Strategies for developing treatment programs for people with co-occurring disorders. Also developed by SAMHSA. And treating adolescents with co-occurring disorders by Holly A. Hills and the Florida Certification Board. All of these can be found free online. So let's go ahead and get started. What exactly are co-occurring disorders? Well, what we're talking about in broad terms is mental health, physical health and behavioral or addictive behaviors and how they interact. They concurrently occur. You can't just have somebody with an addiction issue who doesn't also have some sort of concurrent depression. Now, whether it meets the category or the criteria for major depressive disorder, you know, that may not be. But we have to look at how the mental impacts the physical and vice versa and how addictive and behavioral disorders also impact both the mental and physical health of the individual. It's important to remember that the symptoms of each of these disorders can cause or worsen the others. But likewise, anything that improves in one area is probably going to have positive effects on the other areas. So if their physical health starts to improve, they may be able to concentrate more. They may be able to sleep better. They may be more likely to eat a little bit healthier, which will all have positive impacts on helping ameliorate any behavioral or addictive disorders. So I'm kind of getting ahead of myself here, but I want you to see that there is an interaction, there is an interplay, and we cannot stress enough that people need to pay attention to all of these. People are not just mental health or physical health. They're biopsychosocial individuals. So a general definition of addiction, let's start there, because that's the one that... Well, let's just start there. It's a substance or activity used to escape from pain, and that can be emotional or physical pain, despite negative consequences. So it's something that I do in order to escape from some sort of distress, and I keep doing it, even though it's causing me problems in my life, because the reward from escaping from the pain is greater, it's worth it to me to deal with all these negative consequences so I don't have to feel the pain. And I want you to consider addictions such as drugs, gambling, and sex. You have three very different addictive behaviors or addictions here, but they all kind of interact on the same or act on the same pleasure pathways, the dopamine pathways. And it's important to understand that regardless of how someone is activating those dopamine pathways, long-term excessive activation is going to lead to brain changes. So, moving on. How can each of the following symptoms contribute to physical or mental health issues? Tolerance or withdrawal? Well, when somebody experiences tolerance with an addiction, that means they need more of the same substance to get the same high, or they need to start combining substances or go to something stronger. Now, we know if this is happening, the body has adjusted to that substance, so you can see where there's a physical impact. Now, do you want to say it's causing physical health problems? I would say yes, but not everybody would go quite that far at this point. I want to understand, though, that once the body starts making changes to get... It sort of gets used to having the drugs in the system, so it quits doing the things it would normally do. Or it makes room in order to have the drugs, so people will start needing to have the substance or the activity in their life to feel normal. Now, when I say activity, remember in the last slide we talked about gambling and sex. Our pleasure pathways, our dopamine pathways are excited when we do things that produce pleasure. So whether it be taking drugs or alcohol, which obviously, you know, drugs cross the blood-brain barrier. I can't talk today. Anyway, and create a situation where the dopamine is released or sex or gambling when there is a tension and release or when there is a pleasurable outcome, the brain is flooded with dopamine and for lack of a more clinical term right now, happy chemicals. When the brain gets used to having the stimulus all the time, it's going to adjust, so in order to feel happy, people have to be engaging in the addictive behavior. That's why sometimes people wake up and they take a hair of the dog that bit them. It's so they can feel normal. I've worked with clients before who learn to do a job or learn to do something when they were high and they couldn't figure out how to do it when they were not high. They had to relearn the process. So tolerance or withdrawal tells you that the body is adjusting to having this substance or this activity, this excessive amount of dopamine in the system. Use of more of the substance or more of the activity for longer than intended. Well, when we talk about physical health, this may mean neglecting nutrition, may mean neglecting sleep, so those could be a problem. When we talk about mental health issues, if you're using this addiction, if you're using this activity for longer than intended, you're probably starting to neglect important things in your life, which eventually may lead people back to starting to feel depressed or anxious or empty or remorseful. A persistent desire or unsuccessful efforts to control use. I don't know about you, but if I've done something or if I'm trying to do something and I'm not successful at it, I get frustrated. And we know when we're talking about the diagnosis of depression, one of the key features of depression is a sense of hopelessness and helplessness. To control this addiction, you can see where we're headed toward a mental health issue. A great deal of time is spent in activities necessary to obtain, use, or recover from the effects of the addictive behaviors. So again, if you're spending a lot of time and you're spending more time than intended, you're probably starting to neglect other areas of your life. So those aren't creating pleasure for you anymore. Even worse, it could get to the point where there are people, places, things, situations in your life that you used to enjoy that now feel stressful to you because they're questioning your use or your engagement in the addictive behavior. Important social, occupational, or recreational activities are given up or reduced because of the addiction. We are to kind of hit that on the last slide, but as you start giving up your sober social supports, then if you have social supports, they're probably not the healthiest ones. Occupational activities are given up. If you start slacking at work, if you start being there just kind of in body, but not in mind or spirit, you can start losing jobs, you can start getting bad reviews, which can lead to depression, anxiety, stress, if you get fired, fear that you're going to get fired, whatever the case may be. When people start having problems at work, it generally impacts their mental health. And recreational activities are given up. Now you may be saying, well, recreation is recreation, so what? Recreation is where we rest and recharge. So if the person is not resting and recharging, they're experiencing stress at work at home and they've given up social supports and they're kind of out there on their own, you can see where life can start to get overwhelming really quickly because they are an island unto themselves. And addictive behaviors are continued despite negative consequences. And when we talk about negative consequences, we look at the health effects. Is it causing the person to get sick more quickly or more easily? Is it negatively impacting sleep? Has it caused something like hepatitis or HIV? Has it led to problems in relationships? Has it led to job loss? Home loss? Financial despair or destruction? Legal problems? Any or all of these are negative consequences that can occur because of any addiction, whether it be sex, drugs, gambling, shopping, you know, fill in the blank. So factors contributing to the appearance or the development or relapse of addictive behaviors. Physically, you know, we talked about these different symptoms. When the brain gets used to having basically too much dopamine in it all the time, it has to adjust. It tries to maintain what we call homeostasis.  The wonderful news is 99% of the time the brain can recover once the person quits using and quits flooding the brain circuitry with all of the happy chemicals all the time. Neurochemical imbalances or dysfunctional reward circuits can also contribute to the development of dysfunctional behavior. So what does that mean? That means somebody can be born with reward circuits or dopamine systems or serotonin systems that are not functioning quote normally. You can have a brain injury cause something like this or simply malnutrition and not getting enough sleep can cause the body to be depleted of all the necessary building blocks to make the happy chemicals to keep the system running. So there are a lot of physical impacts that we need to consider. One of the things that a lot of people are really willing to work on, motivated well motivated might be a stretch but they think it's easier to work on the physical aspects like getting more sleep regulating their circadian rhythms and eating more healthfully than it is to do the mental health work which in most cases is probably true because the mental health work can be exhausting and terribly emotionally distressful sometimes. So the good news is you can get people to start working on their physical health before or early on in treatment. Mental factors related to addiction that contribute to the development of worse addiction mental health problems and physical problems cognitive and affective distortions which impair the perceptions and compromise the ability to deal with feelings. In recovery we call this thinking thinking. When you start thinking of the world as a negative place, as a scary place as an uncontrollable place when you always see the glass as half empty when you're looking for people to do you wrong these are all the cognitive distortions that start to contribute to people feeling depressed, anxious hopeless and helpless. We need to address these because as people feel this way depression sets in, guess what? How do a lot of people with addictions deal with depression? They get high or they use their addictive behaviors. So we need to pay attention when we have someone who is starting to go down this depression or anxiety slope to make sure they don't go down too far because that can cause an addiction relapse. Exposure to trauma or stressors that overwhelm an individual's coping abilities. Well, we talked earlier about the fact that addictions are used to escape from pain. Now do people wake up in the morning and go, hey, I think I'm going to choose the most dysfunctional way to cope as possible? No. This is a last ditch effort to survive with the tools they have with the situation that they're in at this current time. So when someone is exposed to trauma or stressors that overwhelm their coping abilities they don't have the social supports they don't have the tools to deal with it they've got to make the pain stop. One of the ways to do this is to sort of numb it out with the addiction. Now when they sober up or quit engaging in the behavior that pain is still there. They still have the depression, the anxiety, the traumatic stress, whatever it is. So again, we have these things working together. Can they deal with it when they sober up? Probably not unless something radical has changed and they've developed coping skills overnight or gotten a sober support system. So they sober up or quit using the addictive behavior that pain is still there, guess what they do? Go back into the addiction until they can figure out a better way to cope and deal with the pain. And the presence of co-occurring psychiatric disorders in people who engage in addictive behaviors So if someone has a pre-existing mental illness they are going to be more likely or well, yeah, they're going to be more likely to develop an addiction. They did some studies and they found that in people with severe and persistent mental illness 50 to 75% of those people had an addiction during the course of their life. And vice versa, when we look at people who have an addiction, about 50% to 75% have a mental health diagnosis or a mental health disorder during the course of their life. These things don't, you know, you can see that they're kind of interwoven. One doesn't generally occur without the other. Socially, how does addiction impact a person? Well, it disrupts these social support systems and causes problems in interpersonal relationships which impact the development of resiliency. That's a really long way of saying it takes the healthy people the healthy relationships and disrupts them and it keeps people from developing good coping skills which would help them bounce back when life gets really tough. So where did I come up with all of these? Actually, the ASAM website the American Society of Addictions Medicine and the website is right here has these listed as contributing factors to addiction so I didn't just pull them out of the air I'm not just coming up with the fact that these things are interrelated on my own you can find them on the ASAM website and it's got a lot of other tools that you can look at that are really helpful to help people understand the interaction between bio, psychosocial and addiction. So we want to talk about how the symptoms of mental health disorders may impact physical health and addictive disorders we already know that when we have somebody with an addiction there's a chance that their addiction is going to make their mental health and their physical health worse probably a pretty darn good chance but let's take those and look at it from a mental health perspective if somebody has a mental health diagnosis how is it going to impact their physical health and their addiction. Now, we can kind of see how the addiction is probably going to get worse with the mental health but what about physical health? How does a mood disorder or a mental health disorder impact people's physical health? So we're going to take depression and anxiety first these are the most common ones. People who present in treatment whether they meet the criteria for a major depressive disorder or a persistent depressive disorder used to be known as dysthymia generalized anxiety we're going to see a lot of similar symptoms and this is something I want you to really look at because when we're talking about the mood disorders there are a lot of overlap in symptoms which could mean either a multiple disorders are co-occurring or we're not diagnosing correctly so we need to take a look at what symptoms are present and maybe address what's causing those symptoms I'll explain a little bit as we go through this so depression depressed mood or loss of interest or pleasure think back to a time in your life where you felt depressed or you just didn't care about anything you didn't have the energy to get off the sofa you were just like whatever it could be because you were exhausted it could be because you were sick it could be because you were actually clinically depressed when you don't have pleasure in anything it makes getting out of bed a real drag which leads us to our next symptom psychomotor agitation or retardation and I've always hated that phrase because you know we could say it a different way but it means you're either restless and fidgety or everything you do you're moving in slow motion so your motor skills you're either like really jittery and fidgety or it takes forever and when we talk to some people who have major depressive disorder they talk about how depression hurts and this is one of those symptoms that kind of falls under psychomotor agitation or retardation when you're really depressed sometimes your body feels like it weighs 10 tons so just getting up and walking to the kitchen is exhausting important to remember that just getting up and taking a bath takes more energy than they can possibly muster because their arms feel like they weigh 50 pounds think about this when we're thinking about the impact on physical health because people are probably going to go nah I don't have the energy to get up and eat right now or I don't have the energy to get up and bathe then we end up with people that are kind of sitting in the same place watching TV in their own filth for days on end this is when you really start to see what we would call somebody who's clinically depressed sleep disturbances that can mean sleeping too much it can mean not being able to sleep or it can mean not being able to stay asleep you fall asleep and then you wake up multiple times throughout the night so these sleep disturbances are a problem think about if you've ever been doing something whether you were in college and you just weren't sleeping enough or you had a new baby in the house or something was going on and you hadn't gotten enough sleep for a few days we're just talking a few days here we're not talking months how much harder was it to get things done how much more effort did it feel like it took to get up and how much less enthusiasm did you have for doing anything that wasn't mandatory so these sleep disturbances cause fatigue and loss of energy go figure and difficulty concentrating when we're sleepy when we're depressed it's hard to concentrate when we just don't care about anything it's hard to concentrate now in depression there are also types of guilt and worthlessness and eating disturbances guilt and worthlessness is pretty self-explanatory eating disturbances very much like sleep disturbances some people when they get depressed they don't eat at all other people when they get depressed may seek out comfort foods so they may eat an entire pizza or an entire gallon of ice cream or even not to that quantity eating good food and the only thing they're willing to eat is comfort food so in depression we start seeing a lack of enthusiasm to do things everything takes a whole lot more effort it's exhausting we can't sleep or we're sleeping too much we're just not feeling rested we're having difficulty concentrating life is just not very fun I think for a moment about how that might impact how we do it work how we interact with others what we do to rest and recharge yeah see all these things are probably going to the wayside because you just don't have the energy now why is anxiety on this slide well sliding over to the anxiety excessive anxiety or worry about a variety of things people with generalized anxiety disorder feel stressed out maybe anything from what some people refer to as being high strong to somebody feeling like their heart is just going to beat out of their chest like constantly now we're stopping short of panic attacks we're just talking about somebody who is palpably anxious so they too have psychomotor agitation they're restless, they're keyed up, they're on edge sleep disturbances not sleeping enough not being able to stay asleep most often which leads to fatigue and loss of energy they want to sleep they can't sleep, they can't stay asleep it's frustrating which again can get exhausting if you get frustrated that you're stuck in a circle difficulty concentrating for the same reasons, you're not getting enough sleep you're worried about stuff all the time you just can't focus there's just constantly stuff going on in your head which leads to irritability I know if I'm stressed out and I'm not sleeping enough and I'm exhausted and I can't concentrate yeah, I'm pretty irritable and I hold that irritability and that stress in my neck and in my back which is where we get muscle tension from so stay with me here so we have somebody who's worried constantly, stressed out can't focus negatively impacting work and relationships they're not sleeping well can't concentrate, they're irritable and they're in pain at a certain point that gets exhausting and they start to feel yep, you guessed it hopeless and helpless because it doesn't ever seem to stop they can't seem to get any relief which moves us over to depression this is important this is very very important in my opinion a lot of patients that I've worked with that have presented with depressive symptoms have concurrent anxiety and it's this anxiety that keeps them revved up and just constantly pedal to the floor running on high speed and burning themselves out that leads to the depression so in order to address the depression and address the anxiety they've got to be able to back off they've got to be able to wind down, rest and recharge now, if you can't do that if you feel stuck then you may look for a way to escape alcohol benzodiazepines, opiates when I've worked with patients before who were addicted to opiates one of the things that they regularly comment on is how much better they feel and how much more energetic they feel when they take opiates now opiates are depressants they slow you down they numb the pain too but they slow you down so let's think about that if something that normally makes people sleepy and slows them down makes a person feel their uber selves more energetic like a million bucks there's probably some anxiety going on somewhere and they're running on empty so we need to look at how to help them rest and recharge so opiates well just about any addiction can be used to try to numb or escape from depression and anxiety many many times depression and anxiety co-occur and when people are depressed and anxious they generally are not sleeping enough not eating well and letting themselves get well letting is kind of a bad word to use it sounds like it's a choice they are getting run down and exhausted which is going to start to impact their immune system and their ability to just kind of function okay so what if they don't have depression or anxiety are they in the clear I wish but no PTSD post traumatic stress a lot of our patients have traumatic incidents in their past whether it be growing up in a violent household or things they saw or experienced while they were in their addiction or maybe as part of their job people are exposed to trauma and stressors a lot now why does one person and this isn't on the slide but I'm going to take this little road take it with me for a few minutes why does one person experience a trauma and not have developed post traumatic stress and another person experiences the same exact thing maybe two cops that respond to the same scene but the second person develops post traumatic stress why is that well we don't know exactly don't you love that answer but we do know there are certain risk factors or protective factors depending on how you look at it for the development of post traumatic stress if the person feels similar or feels if the victim is similar to the responder or to the person witnessing the event then there's a good chance it will impact them more and they're at higher risk of PTSD so if a cop responds to a situation where maybe a three year old drowned and that cop also is a father then they're at higher risk than someone who is not a parent of developing PTSD now is it that simple oh no that doesn't explain it completely or even a whole lot other things to consider did they have good social support within 24 hours 24 hours is your crucial window 2 hours is your super crucial window for getting support after a traumatic incident if they had the ability to talk with colleagues or family members or the chaplain or somebody and get that social support then there's an improved chance that they won't develop traumatic stress disorder have they had mental health issues or stressors in the past 6 months or substance abuse issues if so then we know that they already may be kind of worn down so how similar they are whether they get social support and whether they have in the past 6 months a history of a bunch of stressors mental health issues or addictions so those are the things we really want to ask at the beginning when we're talking about whether somebody is going to develop a post-traumatic stress disorder or it's going to be acute stress and they'll deal with it and they'll move on in any event let's just talk about a traumatic event exposure whether it's pts post-traumatic stress or ptsd with the little disorder on the end somebody is exposed to a traumatic event I don't care who you are I don't care how similar or dissimilar you are to the victim it's going to impact you and it's going to take some emotional energy now if it develops into a disorder the person may have recurrent intrusive memories, nightmares or flashbacks so again we're disrupting sleep and maybe even some wake time which can cause a lot of anxiety if you're constantly worried that you're going to have a flashback if you're constantly trying to protect yourself from anything that might cause a flashback it's exhausting and it's going to take a lot of time out from experiencing positive things marked distress after exposure to related stimuli now if you experience an event or a trauma maybe through a car crash then things like driving on the interstate could be stimuli that remind you of the trauma so simple things in life or everyday things in life maybe simple is not the right word can start to cause a lot of stress and ongoing distress because everywhere you go there are reminders of the trauma which takes us to you start avoiding reminders if everywhere you go there are reminders of the trauma was one way to avoid these reminders engage in the addictive behavior because then you're focused on that addiction if it's internet porn if it's internet porn you are focused on that internet porn you're not focused on what's going on outside you don't have to worry about seeing something that remind you of the trauma some people get irritable develop aggressive or self-destructive or reckless behavior it's sort of a reaction to feeling helpless which can cause physical problems it can also cause stress and relationships which can lead to depression and anxiety hypervigilance when someone is hypervigilant they have this major startle response multiple times a day and it's exhausting see we're coming back to that exhausting word again many people who have post-traumatic stress develop some level of hypervigilance and the number, the frequency of these startle reactions are going to really sort of dictate how much energy is spent with this pts or ptsd every day so if you're getting stressed out and startled all the time every time a door opens or a cabinet closes too loudly or a door slams and you're jumping out of your skin it's going to start causing problems and concentration and sleep disturbances go figure so again we're seeing some of these symptoms overlap between depression, anxiety and post-traumatic stress all of these disorders or mental health issues can cause exhaustion can cause a person to not care as much about or not have as much energy to take care of themselves other features of pts inability to recall key features of the traumatic event that may or may not be important for people some people don't want to remember it may lead to persistent negative global beliefs about oneself in the world that the world is a dangerous place that they are worthless that there's undue guilt which takes us back to addiction that stinking thinking because they feel like they can't control anything in their world it also leads us back to some of the characteristics of depression the negativity and the sense of hopelessness and helplessness persistent negative trauma related emotions fear anger and guilt people who have post-traumatic stress disorder may tend to be more unhappy and you know I don't really blame them because they can't sleep and they're constantly being haunted by nightmares and flashbacks and it seems like they can't control what's going on one of the things that I encourage my patients to do very early on if they've got post-traumatic stress or anything I ask them what is the survival value of this symptom because our body does things to help us so once you wrap your head around the survival value then you can start to deal with it now for example hyper-vigilance the survival value is to protect the person so they don't encounter that trauma again so they're not put in a position of threat or danger again now hyper-vigilance means you're startled and you're on edge in situations where you don't need to be when someone starts to understand okay this symptom this reaction is designed to keep me safe but I'm safe and I don't need to startle then they can start dealing with those reactions and talking themselves down more quickly when something startles them or triggers that hyper-vigilance reaction feeling alienated from others detachment or estrangement sometimes it can be because others just don't understand other times it can be because they don't want to get emotionally involved or emotionally connected to anyone else because they don't want to get hurt again maybe they lost somebody in a trauma so these are all things that we want to consider how is the mental health disorder affecting their social supports their ability to sleep good nutrition taking care of themselves enjoyment of daily activities and is the pain such that they just have to escape they can't tolerate the pain anymore which may lead to addictive behaviors schizophrenic disorders well people with schizophrenia have delusions hallucinations disorganized speech grossly disorganized or catatonic behavior and negative symptoms so we're not going to talk a whole lot about this because schizophrenia is not nearly as prominent as depression anxiety and PTSD in the general population but it's important to recognize that people with schizophrenia may live in a very scary world and you can't convince them delusions and hallucinations are egocentonic you cannot convince them that the sky is blue if they think it's purple you cannot convince them that the squirrels are safe and are not going to hurt them if they think that's true it's important to remember this so we have to join them in their world and experience it for what it is is it a safe place or is it a scary place a lot of people with schizophrenia have difficulty forming any sort of supportive relationships which is one of our greatest buffers against stress so you take somebody who lives in a scary world and doesn't have a whole lot of social support they're probably going to feel stressed out exhausted on top of that if they're taking antipsychotic medications and even some of our atypical antipsychotics our second generation they have some extreme side effects weight gain lethargy, exhaustion all of these may contribute to feelings of depression, frustration hopelessness and helplessness when we come back from the break we're going to talk a little bit about personality disorders and how they also impact the person and the development of mood disorders physical maladies somatization and it may worsen addictive disorders this Halloween one thing you don't have to be afraid of is leaving a flame unattended instead of putting a candle into your jack-o'-lantern you can build a safe circuit to replicate the effect with candle flicker LEDs and the best part is this project will automatically turn on when it gets dark out and turn off again when the sun rises welcome back to co-occurring disorders and their impact on treatment part 2 last section we were talking about how co-occurring disorders means physical mental health or addictive disorders and how they interact with one another we also talked about the fact that addictive disorders are a person's last-ditch effort to survive pain then we moved on to looking at some of the symptoms of addiction and how they can actually contribute or worsen disorders that are mental health disorders or physical disorders then we moved on to talking about some mental health disorders how they can make addictions worse they can also contribute to the development of physical problems so we see how all of this is kind of folding in on one another and we cannot just separate one from the other in this section we're going to move on we're going to continue to talk about mental health disorders and how they may impact addiction and addictive behaviors as well as physical health but we're also going to look at things like personality disorders and autistic disorders so personality disorders distorted thinking patterns and problematic emotional responses are two of your key features of all of the personality disorders in many of the personality disorders you have people they have a preoccupation with fantasies of unlimited success or power basically they can't like themselves for who they are they feel like they need to be something more so they create this grandiose concept of themselves which is easily shattered very very easily shattered which can cause them to act out behaviorally in addiction or become very depressed these distorted thinking patterns can also cause people to quickly shift from over idealizing to devaluing others in themselves so let's talk about others first certain personality disorders whether we're talking about dependent personality disorder borderline, narcissistic they may see people and think this person is the greatest person in the world now sometimes as in with the person with narcissistic personality disorder they may over idealize someone who is dependent on them they are going to think very very highly of someone who thinks equally as highly of them as they think of themselves so over idealizing is creating this all or nothing sort of situation this person is just the greatest thing in the whole wide world or they're the scum of the earth now how do we switch well in a lot of the personality disorders it comes when there's a threat to the person's ego whether with the case of narcissistic personality disorder if they feel like someone is criticizing or judging them all of a sudden that person may be persona non grata likewise with borderline personality disorder if the person feels like someone is getting ready to abandon them or is judging them they may also just switch to looking at all the faults and trying to focus on all the reasons this person is just the worst person in the whole world unfortunately this behavior also applies to themselves so they may think that they are all that in a bag of chips and some more on some days but as soon as they do one thing wrong or they're confronted with the fact that they are not all powerful and all wonderful they may crash and see themselves as complete failures or completely worthless and unlovable think about how much energy that takes to go every day either just completely idolizing somebody or thinking they're the scum of the earth that means you're probably not going to have stable social supports it's exhausting to have to be on guard and be that attentive to whether somebody is looking to cross-eyed and it's also exhausting and frustrating for people to go from thinking that they're all that to thinking they're the scum of the earth and they're worthless and useless and not good people so you can see where we're starting to develop a mood disorder on top of the personality disorder remember the last section we talked about all behaviors have a survival mechanism so we need to ask ourselves in what way is this behavior protecting this person from destruction either emotional destruction or physical destruction and we know with personality disorders a lot of the trauma or problems can be traced back to early childhood which is why they start relatively early in young adulthood you know we're not going to diagnose a personality disorder before the age of 18 but we can start seeing some symptoms early on most people with personality disorders have a very troubled past in what way are these current behaviors or did these behaviors in the past protect them now a lot of times if you look at it in terms of how did it protect a 5 or a 6 year old it makes perfect sense but then when you say well this person is 25 it doesn't make sense but it does because that person is still stuck back being that 5 year old they haven't developed further coping skills from the time that they were their coping skills were overwhelmed they were traumatized for whatever reason their development got kind of stuck or derailed the good news is you don't have to take 20 years to get somebody caught up once the 25 year old adult sees you don't need to behave this way anymore you don't need to protect yourself anymore you can make other choices it is possible to start to arrest some of those personality disorder behaviors now there's a lot of controversy about whether you can quote recover from a personality disorder there's also a lot of controversy about whether you can quote recover from an addiction because both addictions and personality disorders are characterized by behaviors that are pervasive throughout multiple areas of a person's life but in my opinion behaviors characteristic of personality disorders and behaviors characteristic of addiction serve a survival mechanism and if you can help people understand the function and find a different way to meet that need you can help them change their behavior now whether you want to qualify that as recovery or not is something else but I'll leave that for you to chew on for a moment problematic emotional responses affective instability due to marked reactivity of mood translated it's really easy for this person to get upset it doesn't take a whole lot to set them off which means they're happy one moment they're angry the next they're depressed the next moment it's exhausting to even think about imagine living it imagine if every stimuli or lots of stimuli in the environment were setting you off every time you turned around you were feeling a different emotion it would be exhausting inappropriate intense anger or difficulty controlling anger when we talked about anxiety and generalized anxiety and feeling keyed up and on edge we talked about irritability well effective instability reactivity of mood not being able to feel like you can depend on other people and going back and forth trying to decide whether you are the greatest thing in the world or worthless it's exhausting which can lead to difficulty concentrating and just irritability and this irritability can grow and explode into inappropriate intense anger it's just like screw it I can't take it anymore yeah you see where we're going the other characteristic with personality disorders not all but some is they don't experience genuine remorse for the harm that they cause others a lot of times it turns into a look what you made me do not I'm sorry I hurt your feelings it's you made me do this to you if you would have then I wouldn't have had to so there's no remorse there's a lot of blaming a lot of externalizing a lot of manipulation in order to try to make people fall in line and in order to try to control their very tenuous environment over or under regulated impulse control now this can be having to have everything just so and having to have routines and not being able to divert from those routines or it can be somebody who's just totally impulsive all of the time and either way that can cause problems in relationships that can cause problems at work that can cause extra stress and can put you in some pretty risky situations and finally interpersonal difficulties people with personality disorders have a hard time forming relationships because they go from idealization to devaluation they are irritable they may be impulsive or they may be rigid so they have frantic efforts to avoid real or imagined abandonment they're difficult to be around so guess what a lot of people don't want to be around them which makes them even more stressed and even more desperate to hold on to people they have unstable and intense interpersonal relationships well if you're afraid you're going to be abandoned all the time and if you need someone or someone's in your life to tell you that you are all that in a bag of chips and constantly build up your ego then if you find someone like that you're going to hold on to them really really tight which leads to these intense interpersonal relationships these people tend to fall in love really quickly and really intensely and then again just like everything else as soon as something starts to go sideways it turns to hate there's no middle ground there's no compromise there's no work it out it's intense and it's my way or the highway some need to be taken care of by others they're influenced by other people's suggestions and opinions now in some cases that may mean they are chameleon like in other cases it may mean anytime anyone has a dissenting opinion they're going to be kicked to the curb because the person with the personality disorder generally has feelings of inadequacy and are hypersensitive to negative evaluation remember I said a few minutes ago looking at your cross-eyed they may take any look any smirk anything that they perceive as a slight and blow it way out of proportion and run with it so it's always extremes and most of the time the negative extremes are a protective mechanism because they are afraid of being judged most people with personality disorders have a very unstable if any at all sense of self so they rely on other people to tell them how wonderful they are or how worthy they are and if other people aren't telling them that they may try to do that for themselves they may build themselves up but that's a very, very fragile facade and as soon as it starts to crumble they go into protective mechanism they go into the scared pit viper sort of position another issue that people face is autistic disorders now I initially started to do this fetal alcohol spectrum disorders because we have a lot of people with addictions who were born into families where there were addictions and the mother drank when she was pregnant this is a huge, huge issue over in Britain right now not as much here we have a little bit more education about fetal alcohol spectrum disorders but I tend to think there's a lot of FASD that goes unreported here so you know I'm not sure whether we're comparing apples to apples anyhow children with autistic disorders in general and remember in the DSM-5 we went to autism spectrum disorders have poor sleep wake cycles now thinking back to when we were talking about depression and anxiety sleep disturbances this is common in mood disorders people with autistic disorders even if they have even if they're older may still have poor sleep wake cycles so we don't want to just say children we want to say anyone with an autistic disorder may have attentional deficits which makes it harder to focus and concentrate which may make it harder at work it may make it harder to integrate into social relationships it may make a lot of things more challenging add to that some impulsivity difficulty waiting difficulty waiting your turn to talk difficulty taking turns when playing games difficulty in delaying gratification which when we're talking about addictions somebody needs to make the pain stop and they want to make it stop yesterday they don't want to wait for coping skills which take a while they want it to stop now difficulty adapting to change insistence on sameness and inflexible adherence to routines or rituals people with autism may need that structure in order to feel safe in order to be able to feel like they've got some control over their environment this can make it again very difficult to deal with life on life's terms because life is not same it is very flexible and can be exhausting to the person with autism learning difficulties and inability to appreciate cause and effect and here I'm going to go off on a little FASD side road for a second learning difficulties you know we got that inability to appreciate cause and effect when I work with people that are in the criminal justice system and I see somebody who has had repeated offenses they don't ever escalate it's always petty theft petty theft, petty theft, petty theft and I think you know why is this person continually getting caught for petty theft people with FASD can't forecast the consequences of their actions they can't learn from consequences and go oh if I do this I'm probably going to get arrested likewise they tend to follow a lot more they tend to be much more suggestive so if you have some but are suggestible so people with FASD tend to make poor choices if they fall into the wrong crowd because they're just they're trying to fit in and since they can't see the consequences of their actions if you tell them to go jump off a bridge they just might do it we need to be aware of this because it's even more important in the recovery process when we're working with someone with autistic disorders working with someone who can't anticipate cause and effect to make sure that they're in a safe sober environment where they're not going to get taken advantage of people with autistic disorders may have poor understanding of social expectations they may have difficulty reading nonverbal behaviors so they may not be able to understand are you happy, are you sad are you what is it that you're trying to communicate with your behaviors which leads to deficits in nonverbal communication behaviors they can't interpret other people's nonverbal communication they may not have their own because we mirror our nonverbal behaviors we've learned that as we've grown up you know what does a happy face look like what does a sad face look like and if we can't the person who can't interpret those signals is going to have a hard time creating those signals in a way that's meaningful and hyper or hypo reactivity to sensory input let's start with hyper reactivity remember we talked about hyper vigilance with PTSD it can be exhausting everything around you just seems 10 times louder brighter, stronger than everything else when I was pregnant and a lot of people have this situation when they're pregnant my sense of smell was bionic, I swear I could walk into a room and the slightest offensive odor would turn my stomach about living like that constantly where it's not just smells it's sights, it's sounds that are constantly bombarding and you can't necessarily filter them out and they seem way more intense everything is more intense on the other side there's hypo reactivity to sensory input and these are the people where it doesn't seem like anything phases them loud noises don't seem to bother them it's dark it doesn't phase them in any event I want you to put yourself in the position of someone who has some or all of these symptoms difficulty adapting to change inability to appreciate cause and effect you keep making the same mistakes over and over again and you don't understand why poor understanding of social expectations difficulty communicating with other people and either hypo or hypo reactivity to sensory input it can be very difficult to deal with life on life's terms if that's what your life is like now is it impossible no I know a lot of people that have some level of autism that function quite well but they do have to be more careful and cognizant of taking care of themselves and what situations they put themselves in so autistic disorders can lead to problems with independent living making decisions following through keeping on a schedule employment and social integration and we talked about all those on the last slide so I'm not going to belabor them concurrent secondary disabilities depression anxiety and addictive disorders frustration at feeling hopeless and helpless people with autism is not that they don't realize what's going on around them many people with autism are actually very perceptive and it's frustrating to them that they can't integrate socially or they have difficulty with employment because they have hopes, aspirations, dreams those sorts of things as well so depression and anxiety can be high and addictive disorders obviously as a way to escape from the depression, the anxiety the excessive sensory input those things that would be frustrating depressing, exhausting anxiety provoking okay is that all the mental health disorders? no, not by a long shot but we hit the highlights ADD, ADHD would be another one that you would want to consider and giftedness may be another one you want to consider because people who are gifted often see the world differently than other people but there are a lot of gifted people who integrate quite well so those I didn't hit on in this particular presentation but do be aware that any difference mental health difference that people experience make it more difficult to integrate socially to develop fulfilling relationships and may make life seem a little bit more overwhelming so let's move to physical health disorders we're going to talk about some basic issues there obviously we have medication side effects and a whole host of other disorders conditions and issues that we're not even going to talk about today but we're going to hit the highlights chronic pain, this is a big one when you're in chronic pain it makes everything seem a lot harder some days hormone imbalances and this can be anything from testosterone and estrogen to thyroid hormones malnutrition sleep deprivation and just frequent illness if you're somebody who gets sick a lot or maybe someone who has something like hepatitis it may make it more difficult some days than others because you don't feel well where does chronic pain come from? nah, who knows injury, it can be an injury you got yesterday or it can be an injury you got when you were playing football in high school but if it causes you pain most days then it can be considered chronic pain are we talking a level of pain that's negligible barely noticeable to excruciating that's something very, very different fibromyalgia this can be excruciating pain in multiple areas of the body and most days so people with fibromyalgia obviously may find it more difficult to do things to do things on a daily basis fibromyalgia is also worsened by stress so if someone is under a lot of stress or anxiety they may hurt more so if you're under a lot of stress and anxiety and you hurt more it may get pretty depressing because you may feel like you're never going to be able to be pain free and happy people who have migraines can be very debilitating they can negatively impact relationships your ability to function take your kids to soccer the light sensitivity can be completely debilitating sometimes and just the level of pain makes it impossible to concentrate and even something like scoliosis which is a curvature of the spine can cause back pain or stress or just aging and other things and can cause a significant amount of pain in the neck back and shoulder region other physical disorders and I know pregnancy is not a disorder but when you're pregnant some people, not everybody you know I was very lucky with my pregnancies I loved being pregnant I didn't experience back pain I didn't experience difficulty sleeping I didn't experience the nausea and the vomiting that a lot of people do but if you experience those things it's also going to make it harder to sleep so you're going to get exhausted and you see where we're going you get run down you start feeling depressed yada yada yada vitamin D deficiency or seasonal affective disorder they are not one and the same but when people start to experience a vitamin D deficiency because they're not exposed to enough sunlight or they're not getting enough vitamin D in their diet most of it we get from sunlight they may start to feel depressed so this is a really really easy fix people if you have a patient who is feeling depressed make sure they get a physical some of these things can be ruled out or very easily treated seasonal affective disorder is also partially the result of the vitamin D deficiency but also partially the result of circadian rhythms getting kind of messed up because if there's not a lot of sunlight or if the days are really short you wake up and you go to work it's dark if you're in an office that doesn't have windows work all day and leave and it's dark your body doesn't know when it's supposed to be awake when it's supposed to sleep when it's supposed to eat which can lead to feelings of depression it can negatively impact sleep patterns etc seasonal affective disorder again there's some pretty easy interventions for it that are natural number one making sure that you get up and have a routine so your body knows how to take number two taking advantage of any sunlight that may be there number three talking to your doctor and making sure that your vitamin D levels are adequate and number four making sure that you have exposure to between 14 and 16 hours of a day of daylight bulbs and these are pretty bright harsh bulbs I'll tell you I've got them in my living room but they do make a significant difference especially on those days where it's just gray um and maybe gray for days or weeks on end sometimes um those are some pretty easy interventions to put in there is it going to do everything no is it going to help probably so but it's important for people to recognize what's causing it and understand the importance of maintaining proper circadian rhythms then we move to thyroid or hormone imbalances hypothyroid will lead to symptoms of depression depression and hypothyroid are very difficult to differentiate unless you have a blood test again go to the doctor get a panel done make sure that everything your vitamin D levels your thyroid and your hormones are where they're supposed to be hormone imbalances I've all heard about premenstrual dysphoric disorder well what is that? that's when the hormones change and it negatively affects mood can you fix this not necessarily but the doctor can work with you on ways to moderate the impact of hormone changes and ways to maybe deal with some of the anxiety and depression with it sleep deprivation and insomnia now whether it's because you've got a new baby in the house because you've got chronic pain because you're sick, because you're stressed or maybe you're just traveling a lot or working a lot if you're not getting enough sleep your body can't rest repair and recover therefore some of those neuro chemicals that are required to be feeling happy and energetic and dealing with stress they're not going to be able to be built they're not going to be able to replenish so we need to give ourselves down time now some people say well you don't need that much sleep how much sleep you need is kind of up to you but we all do need rest and recharge time time where we're doing enjoyable things and we're not taxing the problems of our body so we're going to take another break here and then we're going to move into how do we treat co-occurring disorders we understand now that as physical health problems get worse it may contribute to depression and anxiety it also may contribute to the need or the desire to escape or to self-medicate in the next section we're going to look at how can we start addressing those do we do it one at a time or all at once and how much is too much to address at once welcome back to co-occurring disorders and their impact on treatment part 3 so for the rest of this presentation we're really going to talk about treatment implementation so we're going to start out with a case study which should sound familiar if you've worked in a residential or a detox facility our client we're going to call him Jim Bob he comes in he has a blood alcohol content of .23 and you know if you haven't worked in a substance abuse or a detox facility you might be thinking wow that's pretty high but that's actually not that high for a lot of people who present in detox so he's 40 year old male with a blood alcohol content of .23 polysubstance dependence of alcohol and opiates which we know both of those are depressants and you combine them and it's .27 so it's really dangerous to combine alcohol and opiates anyway so he's abusing both of these right now he's also got persistent depressive disorder which used to be called dysthymia generalized anxiety and chronic back pain he started using the opiates to deal with his chronic back pain found out that he felt pretty good when he was taking them which probably because he was dealing with his generalized anxiety and the alcohol is probably being used to mask his persistent depressive disorder but we'll look at that as we get more into the treatment aspects he was referred to residential after a three day detoxification so he shows up in residential he's only had three days to detox from a blood alcohol of .23 now the first thing that tells me is Jim Bob's been drinking for a while so it's going to take him a while to get out of the fog he may not have alcohol in his system anymore but all of those brain chemicals are wonky and it's going to take him a while to rest and recuperate so we know that Jim Bob is going to have probably difficulty concentrating and he's going to be in a fog for the next two to three weeks at best we might be looking at longer depending current medications on top of the opiates and alcohol are sertraline for depression and anxiety and ibuprofen for pain so the doc decided to keep him on the sertraline and switched him from opiates and ibuprofen to just ibuprofen alone so that's also probably going to impact his early recovery because when one is taking opiates the body quits producing the endogenous opioids your natural painkillers so what normally his body would normally take care of and go we got this, we're going to numb the pain the body's not making those anymore so it's going to hurt and he's going to be achier and things are going to seem worse right now which is going to make sleeping harder concentrating harder and probably have a negative impact on his mood so he's not concentrating he's in a fog and he's working against him and some of you are going wow wouldn't want to be him well I wouldn't either but we want to put ourselves in his position and go okay what does Jim Bob need to make it through not the next three weeks but to make it through until tomorrow what can we do to help him develop some sense of control and hope because we want to start dealing with the hopelessness and helplessness and we haven't even talked about what causes his persistent depressive disorder or his generalized anxiety yet we haven't dealt with those cognitive issues we're just looking at physical issues right now that are probably going to make treatment and recovery a challenge in the first couple of weeks so our treatment priorities first address medical issues like I said in one of the other slides sometimes it is easy-peasy you can send somebody to the doctor and they find out the thyroid imbalance they can get on medication for that they can go to a pain management physician maybe get some nerve locks or something that is non-opioid based there are a lot of different techniques and interventions that can be used to help people deal with some of the physical causes or things that would exacerbate physical depression that would exacerbate depression the other thing we want to look at is making sure that Jim Bob is getting enough sleep which is going to go partly with the pain management but partly with dealing with the anxiety so the doc may start him on a short course of psychotropic the sertraline is what he has been on and he is going to stay on for a little while hopefully that will do enough to help him out through this early detox period other things that we want to look at is nutrition I am not talking switches diet up completely all I am talking about is making sure that he is getting enough protein, enough carbs enough fats and drinking enough water he needs to start flushing some of those toxins out of his system and giving his body the building blocks to make the neurotransmitters that he is going to need for recovery we don't want to switch somebody to a super healthy diet and eat crap because we know that they are not going to stick with it probably we don't want changing their nutritional habits to be painful or seen as unpleasant so where I used to work the ladies that cooked in the kitchen they were wonderful cooks but they cooked southern let me tell you what just about everybody who worked there put on 15 pounds within the first year because they had a lot of seasoning but the food was relatively nutritious we had a registered dietitian overseeing everything there was always a protein there was always a vegetable now it was drenched in butter but there was always a vegetable so we want to do what we can to get the healthy food in their system without making them sort of balk at it so nutrition helping make sure they are eating consistently throughout the day partly goes to circadian rhythms your circadian rhythms do more than just make you sleep they also tell your body when it's time to eat and when it's time to be awake and all that other kind of stuff so what can we do for circadian rhythms well the first thing is just like we used to do if you're a parent and you've had a child there needs to be some sort of a wind down routine because that tells the body to secrete melatonin which will help you get sleepy yep, believe it or not, you actually make melatonin so how do we do that in residential we had a wind down routine they would come back from a meeting they would do chores they would have snack time watch TV and then it would be lights out at 10 o'clock after a while the body starts to expect that just like with small children they come home from school take a book or take a bath then read a book and wind down for a few more minutes and then go to sleep it's queuing the body in that okay this is the routine that means sleep is on the way does it mean you have to go to bed at the same time every night no, ideally yes you would want to in order to give yourself the best chance of rapidly resetting these cycles the visual cues and the activity cues is if you're off by a little bit one night you come home from work and you're really sleepy it's like 6 o'clock and you go through your wind down routine and it's 8.30 and you go to sleep the next night you're doing pretty good didn't have such a hard day and you don't end up starting your wind down routine until 8 or 8.30 and you don't go to sleep until 10 as long as you're within a reasonable window I mean you don't want to stay up to 3 in the morning but hopefully in early recovery they're not doing that the circadian rhythms also need to have the wake up cue so when people get up out of bed sitting around in the dark doing whatever is not and kind of slowly edging out into the morning is not going to reset that circadian rhythm they need to get up they need to get dressed and they need to turn on the lights that doesn't mean they have to start doing chores or going out and doing groups or whatever the case may be not everybody likes to hit the ground running when they wake up in the morning but there needs to be light and there needs to be movement of some sort and getting out of the PJs that's another cue when you put on your street clothes that it's time to be awake these are all really basic life skills that people can undertake and will help them start feeling better as they start having more quality sleep now I'm not expecting Jim Bob to sleep through the night for at least a week or so with his anxiety and his pain and everything else but when he's asleep he can sleep pretty well and we start training him, his body to sleep at night and be awake during the day in a week or three he'll probably start getting more satisfying restful sleep which will help a lot of things alright so once we hit the basic physical things and you notice I didn't mention exercise in here Jim Bob is not ready to exercise most people in early early recovery are not ready to exercise if they are like walking whatever the doctor approves of is great but most people aren't wanting to go out and start running 5Ks and exercise isn't something that a lot of people like to do I usually leave that up to the client whether they want to start exercising early on in their recovery or whether that's something I suggest they try a little bit later and we usually work it in with animal assisted therapy because that's a whole lot more fun to go out and play ball with a dog than it is to go out and go on a power walk for 30 minutes or something so anyway now a lot of the thinking errors, cognitive distortions thinking thinking negative attributions all that stuff we talked about in the mood disorders, personality disorders and even addictive behaviors come back to a couple of things number one cognitive mistakes irrational thoughts, cognitive distortions and number two low self esteem you will find I have never found let me put it that way in the almost 20 years that I've been working in co-occurring disorders I have never met a patient who walks in and would have what I would call a high self esteem they have some stuff they have some issues and whether that predated the addiction or it's a result of everything they did in their addiction doesn't really matter right now their self esteem is low at best and usually in the crapper so we need to start helping people realize that they are worthy for who they are not what they can do for people and they don't need someone else to tell them you're okay they can do that I always make the joke and it's getting to the point now that most people don't get it because you know I'm that old but Saturday Night Live used to have somebody called Stuart Smalley and he would look in the mirror and he would say I'm good enough I'm smart enough and gosh darn it people like me and most of my clients look at me and if they remember the skit they're like yeah I'm not going to do that and if they don't remember the skit they just look at me like I'm crazy but it's all good we want people to start figuring out what's good about them so there are a lot of self esteem exercises you can do we're not going to go into that class but that is something that people can start working on early and recovery writing down one or two nice things that they do each day or making a gratitude list focusing on things that are good about them there are a lot of different ways people can improve their self esteem one of the things that we do at the end of the day is a daily summary and I make people and make is actually the word I want to use I make people identify three accomplishments or successes for the day that helps people see that they are good and they are able to accomplish things and there is something to this whole recovery thing and they can do it and even on the bad days people struggle but they can find three accomplishments even if it's just getting up, sticking with it and staying sober alright a little bit more difficult than the self esteem is helping people address irrational beliefs and this can be a bit of a challenge for people when they first start doing it because we talk about those automatic beliefs and it's sort of is not tangible but I encourage you to give your clients a list of cognitive distortions and irrational thoughts and have them keep it with them so when they start having a bad moment they can go down that list and go are any of these thoughts cognitive distortions or irrational the next exercise we are going to talk about is cognitive processing therapy which is a little bit easier for people to grasp onto but the ABC's the cognitive behavioral therapy is really the yardstick by which everything else has been measured and built so A is the activating event what was it that happened B comes right after A and you almost don't even realize it then comes C the consequences so the activating event somebody cuts you off in traffic the consequence you get upset in between somebody cutting you off in traffic and you getting upset you had a whole litany of beliefs that you didn't even realize it happens in like a millisecond they were rude they are not paying attention they could have killed you whatever the case maybe you have all these beliefs so the next step something happens you get upset before you start acting on it determine which beliefs are factual and accurate was the person really being a jackass or were they maybe you were in their blind spot maybe they weren't paying attention we all make mistakes we're not perfect once you determine and eliminate any beliefs that are not factual and accurate then evaluate your options for your energy when we're talking about getting cut off in traffic is getting all upset and screaming at them through your car with the windows rolled up is that going to do any good and I challenge anybody to say yes so you're just using a whole lot of your energy for no benefit what are your other options let it go take a different route if you don't like traffic how else can you use that energy that would be more productive to you another way to look at it is do you really want to give that person power to make you upset and generally when you put it that way to somebody who has an addiction they'll say oh no nobody takes my power that's how you can look at it the short short version of this if something happens you get upset ask yourself is this worth my energy and if the answer is no then move on figure out how you're going to move on but you don't have to act on every feeling cognitive processing therapy sometimes we have irrational beliefs something happens we get upset and we think the sky is going to fall so you ask yourself what is the evidence for this belief what is the evidence against this belief and we're talking about evidence not feelings we're talking about evidence is the source of the evidence reliable if it's your three year old what do you want if it is some scientist with three PhDs well okay maybe they might know if the sky is falling is the belief based on fact feeling or habit one that gets tricky is it fact if it is okay great is this belief based on a feeling you just have this gut feeling sometimes we have this feeling what's the evidence for this belief I have none what is the evidence against this belief well I still have none I just feel like something bad is going to happen is the source of the evidence reliable well if generally when you get a sick feeling in the pit of your stomach something bad happens you might go yeah you know 70% of the time spot on you go back down to is the belief based on fact no it's just a feeling I have in the pit of my stomach okay so feelings aren't all that reliable so we want to just pay attention to that or habit sometimes we have thoughts or beliefs just out of habit we expect someone to act a certain way or we expect something to turn out a certain way so if it's an expectation based on prior experiences you might call that a habit so then you've got to ask yourself okay do I want to go into this and get all riled up expecting the worst because that means I'll probably create it create the self-fulfilling prophecy alright so we've looked to see if there is evidence the source of the evidence is reliable and identified whether our beliefs are based on fact feeling or habit then we say are we thinking in all or none terms if you're thinking we'll go back with that sick feeling in the pit of your stomach that means something horrible is going to happen well that's kind of an extreme reaction little bad things happen all the time so if you're expecting that then you're probably going to blow things out of proportion are you focusing on the entire event or just one bad aspect so if maybe you go out on a vacation and during your vacation you lose your passport and you come back and you say that was the worst vacation ever I lost my passport you're focusing on that one aspect you were gone for two weeks you did other stuff but this this passport is the only thing you're remembering and then you ask yourself is the distress from this belief worth my energy is it worth dwelling on what could happen or the fact that I've got a sick feeling in the pit of my stomach or the fact that it was I lost my passport only the individual can decide this for themselves but I encourage you to encourage them to write all seven of these down on an index card or in their phone and keep it with them at all times so when they start spiraling out of control into the what ifs and catastrophizing they can check themselves most of our clients will find that once they start becoming aware of these irrational beliefs they naturally start stopping them for example I started using the verbiage that or stopped using the verbiage that so and so or such and such made me angry there was a difference in my approach to life because I realized that nothing can make me angry something can trigger an anger reaction but then I choose what to do with it I can let it go in which case you know I hardly noticed the blip I'm not going to deal with it or I can nurture it and blow it out of proportion but I am responsible for my own feelings once clients wrap their head around this they will find that life is a lot easier the other concept they need to wrap their heads around which is a little bit harder is understanding that when something happens with someone or when they don't get along with someone it's often more about that someone and that someone's feeling about themselves than it is about them so if somebody gets upset with you yeah look at what your pardon it was but there was probably some of their stuff in there too so not to take everything personally because it's not all about you the next thing which again is another easy one exceptions and connections exceptions are when the behavior doesn't occur so remember we talked at length so far about how all these things are interconnected so if you say alright Jim Bob on those days that you are not as depressed you know because the persistent depressive disorder is kind of like Eeyore it's kind of always there but when you are not as depressed what is different and Jim Bob might say well generally I've slept more and I'm not in as much pain okay so what do we need to do to help you sleep more and deal with your pain those are things that are easier to deal with than the fact that you're still upset because you didn't have the childhood you wanted there's a whole other existential issue we need to focus on later find exceptions when you are not using when you are not drinking when you are not using pills what are you doing instead because those we want to do that more so if you don't drink when you are at the gym if you don't drink when you are with your kids if you don't drink when you're at church those exceptions are this is what we want you to start focusing on doing more for right now once you develop stronger coping skills you'll have a wider repertoire of things that you can do when you start to get upset but for right now let's just focus on doing things that conflict with using where you can't do one and the other at the same time this will help patients start finding hope and strength they will start seeing that there have been times in the past when they haven't used it may have only been for two hours or a day or maybe even a week but they did it and all I'm asking them to do is go for two hours or a day or maybe a week now I'm not asking them to go for forever I'm asking them to do what they need to do hour to hour minute to minute until they start feeling a little bit better and the pain starts to subside which takes us to finding motivation in motivational interviewing there are activities called decisional balance exercises which are wonderful but you've got to remember that motivation is activity specific I may say I want to be happier well I'm really motivated to be happier but I may not be motivated to do everything it takes to be happy when people come into recovery they say I want to be sober and I say okay that's great so what are you willing to do to be sober I had a client come in one time it was in a drug court program and she comes in she doesn't know me from Adam's house cat and she sits down and I introduce myself and she says hi doesn't introduce herself and she says I said okay and she repeated herself she said I don't care what you say I am not going to those meetings they don't work and she went off on this diatribe for probably 30 seconds or a minute about her impressions or feelings about 12 step meetings and I sat there and I listened and when she was finished I said okay meetings aren't going to work for you so what are you going to do instead because I don't care about what you're not going to do what I need to know is what you're going to do instead and she just had this dumb founded look on her face for a minute because nobody had ever listened to her or listened to her preferences they'd always tried to shove her into this pre-formatted treatment and that wasn't going to work she made it abundantly clear to me that was not going to work so I asked her what was going to work and that was a whole new concept that she might actually know what works best for her nobody had ever treated her like that so we want to help our patients find motivation but we have to help them understand that motivation is activity specific getting healthier getting in shape means going to the gym it means eating a healthier diet two things at least sleep most people are not going to be motivated to do all three at once so you say which one are you motivated to do they go into great detail on how to do these decisional balance exercises in tip 35 but we're going to go over a couple examples of them just so you can see how to break it down with your clients so they can understand and increase their own motivation clients to learn how to set their own goals to learn how to identify their own exceptions and to learn how to maintain their own motivation they don't need me I'm going to teach them some skills right now but six months or a year from now I'm hoping that they have these skills and they don't need to have someone else kind of prompting them to do the next right thing so motivation is the key to change you don't do something if we're not motivated you don't get off the couch to go to the kitchen to get something to eat unless you're motivated to get something to eat as simple as that you don't get up and go to work unless you're motivated to go to work now some days we don't want to go to work but we know that in the big schema things what we want for our life means that we have to go to work so that's the motivation motivation is multi-dimensional there's physical motivation pain versus pleasure I'm not going to do things that hurt I'm going to go for things that make life better make me feel better I'm going to go for things that help me get energy they don't drain my energy and that increase my comfort not cause me discomfort emotional motivation happy and sad if I'm going to do things that make me happy not things that make me sad cognitive motivation is looking at the right and wrong or confusion and clarity so when you do something doing it because it's the right thing to do is one motivation another cognitive motivation is doing something because it'll help you kind of get focus on what's going on you know we talked about our clients at this particular period are probably having difficulty focusing and concentrating so they may be motivated to make lists they may be motivated to write things down they may be motivated to do something a little bit different because their life right now is very chaotic and they figured out that doesn't work they want something a little bit more clear a little bit more focused then we have social motivation are you going to get acceptance from your peer group for this behavior do we always do things to get acceptance from our peer group no most of the time we do but sometimes the right or wrong may win out but so we want to look at social acceptance we want to encourage people to be around peers that are going to support their decision to be clean and sober take their medication live a healthier lifestyle whatever the case may be and social motivation can also be in terms of reinforcement and punishment your peer group is going to be more supportive of the things that they want you to do versus the things they don't want you to do and then there's environmental or situational and there are a lot of things here financial motivations housing motivations sometimes people do things just so they won't be kicked out of their house employment motivations sometimes they do things just so they can not lose their job because they don't want to be kicked out of their house because they're broke so you see how all this kind of there are a lot of different types of motivation that we can look at and we can harness to help people remember why the pain is worth it because sometimes recovery sucks there's just no way to say it nicely the best thing about recovery is you start to feel feelings and the worst thing about recovery is you start to feel feelings but helping them maintain their motivation to push on through is something that we can do motivation is dynamic and fluctuating when the going gets tough people want to get going when it starts to become uncomfortable people start going do I really want to do this so we need to make sure that they've got the motivation to say yes not only do I want to do this I can do this motivation can be modified we can make people more motivated or people can make themselves more motivated by really taking a look at the reasons why they want to do things and we can increase the rewards too in terms of offering certain token economies or certain rewards for periods of sobriety or periods of medication compliance and motivation is behavior specific if you're using motivation to encourage somebody to do something that is a complex task it's probably not going to be nearly as effective as if you use motivation or you focus the motivation on a specific task for example when I was program director I loved being program director that was great I loved working with the clients I loved creating organizational plans I even really enjoyed writing manuals and going through audits what I didn't like doing was performance evaluations not because I had conflicts with my staff I had a great staff I just didn't like doing them and I have no idea why but I didn't so I had to work to increase my motivation on that specific task because I would get up and I would go to work and I would work at 10 or 12 hour day and not blink an eye but I would manage to avoid doing those silly performance evaluations so motivation is behavior specific so there's a particular behavior you need to hone in on that so let's talk about physical health first your decisional balance exercises are broken down like this you want to look at the benefits and the drawbacks of the new behavior versus the old behavior and sometimes it's a little clearer and sometimes it's a little bit muddy but the easiest for most clients to break it down in terms of the different dimensions of motivation so for example the benefits of improving nutrition the physical benefits and this is you want to have your clients fill this in you don't want to fill this in for them because it needs to come from them what do they see as the benefits the physical benefits to improving nutrition weight loss, lower cholesterol reduced need to take blood pressure medication more energy whatever they find emotional benefits have improved nutrition they may find that their mood improves because they're providing their body to building blocks it needs to make the neurotransmitters to feel good cognitive benefits have improved nutrition there may not be any it may help them think a little bit clearer I know when my blood sugar gets low I get kind of foggy they may or may not come up with that that's okay you're not going to have motivations in every single area social benefits have improved nutrition maybe some of their friends are trying to eat more healthfully maybe it's something that they want to teach their children they want to teach their children good eating habits encourage them to think about what are the social benefits for them and their family, for them and their friends and for them and just society in general how does improved nutrition affect how they interact with society and environmental you know we talked about improved nutrition is not going to affect housing at all will it affect how you do your job at work maybe, maybe not there's been a lot of research that's shown that kids focus a lot better on their interest so possibly it may improve your work product but that might be a stretch for some of our clients to believe and endorse but we can look at the financial aspect of improved nutrition especially if they're not having to take as much medication you know then we want to go over to the drawbacks and yeah we talk about those why because we need to remove the barriers and the drawbacks to this behavior change all of these are barriers so we need to figure out how to deal with them physical drawbacks of improving nutrition you're going to have cravings there's just no two ways around it if you've been binging on chocolate, refined sugar and caffeine those are my three you're going to have cravings emotional drawbacks some people get really cranky when they can't have their chocolate, refined sugar and caffeine you may also get headaches so how do you deal with those one way could be to gradually change your nutrition so you're not quitting cold turkey there are a lot of ways but you want to encourage your clients to figure out how to eliminate these barriers cognitive barriers to improve nutrition now one of them maybe they don't know what good nutrition is because they've never been taught how to eat healthfully a good friend of mine who's a registered dietician said you know don't worry so much about serving sizes and how many servings in the food pyramid and this and that instead of using a big plate use a salad plate and make sure you have a minimum of three colors on your plate at every meal if you do that you're probably going to be just fine and I find that works really well with clients because it takes away the anxiety of worrying about you know how much is a serving and okay I need six to eleven servings of which food group there's too much to remember anybody can say small plate three colors social drawbacks to improve nutrition well you know it's going to make having pizza every night kind of not the thing to do and we can also go with financial a lot of the less healthy foods are cheaper which is unfortunate so you've got to think about financially you may have to plan for eating a little bit healthier thankfully most of this is covered on food stamps are weak or what have you so it doesn't matter that much to most people whether they're eating you know peanut butter or potato chips okay so the benefits to your change we want to increase those the drawbacks to your change we want to get rid of those now we go and look at the benefits to staying the same why because you don't do things unless there's a benefit and if we don't address that issue then we are going to set our clients up to have a motivation lapse so let's look at what are the benefits for the current eating habits physically it tastes good it's easy you know sometimes maybe they're eating fast food every night which means they don't have to spend time preparing food it's easy it's quickly accessible it tastes good emotionally it may be more of a comfort food but by the same token it also may be a stress reliever because they're not having to prepare a whole meal so these are things that we also need to work on sort of eliminating what are the benefits to eating poorly how can you get around those people instead of going and buying you know a family meal at a fried chicken maybe you can get a frozen dinners for everybody a little more healthy probably doesn't cost anymore you can just pop them in the oven you don't have to worry about making multiple things you can also cook ahead so you know prepare pasta and you can make multiple different things off of it over the course of a couple of days cognitively yeah probably not a whole lot of things we need to address that we haven't social benefits of current eating habits the kids like it kids like to eat hot dogs grilled cheese and pizza for every meal if they could probably oh and chicken nuggets that's another big one but when you think about that there's a whole lot of different colors there so we want to go back to those colors does that mean they can never have hot dogs grilled cheese chicken nuggets and pizza no they can have it we just need to encourage them to have it in moderation and you know maybe as part of the three colors environmental nah probably not going to be a lot of benefits in the current eating habits except for maybe you don't have to do dishes if you're eating fast food you just throw the dish and throw the stuff in the trash yes you're going to have to do dishes it's just one of those things you can't get around drawbacks to maintaining current eating habits this is a motivator so we want to focus on why would you want to do this you see how we're going physically drawbacks to the current eating habits you're putting on weight you're needing more blood pressure medication it's not as healthy kids are learning poor eating habits a lot of people find when they start eating healthier and drinking more water they can think more clearly there's a hypothesis that it's because not only does the body have more building blocks to make what's necessary and vitamin B12 and all that kind of stuff but you're also flushing more of the toxins out of the body whatever kind of gets you through the day drawbacks to current eating habits social drawbacks there may not be any unless your friends are all health nuts and you're the one that's out there eating fast food all the time and environmental drawbacks well you can think about all the waste from the fast food that you're eating that is going into the trash you can think about the amount of money you're spending on fast food if that happens to be what you're eating it really depends on the client and the client's situation this is a great activity to do in group because one client will think of probably 20% of the things to go on here so if you have five clients you're going to come up with a whole lot more and you know maybe 100% but you get my thought process that multiple heads are going to have multiple ideas about what the benefits and drawbacks are and they can share with one another so let's talk about mental health same thing changing thinking patterns benefits to changing thinking patterns physically you're going to be less stressed emotionally you're going to be less depressed cognitively you'll be able to concentrate and focus a little bit more if you're less stressed and less depressed socially if you change your thinking patterns and you don't see the world as so negative if you're not depressed all the time it's going to be a lot more fun to be around people and people are going to want to be around you more and environmentally things go a lot easier work will probably seem easier if you are not constantly waiting for the sky to fall worried about everything depressed all the time whatever the thinking patterns maybe the drawbacks to changing thinking patterns it's hard there really are no physical drawbacks I can think of emotional drawbacks is it's hard it's frustrating because these thinking patterns are ingrained so it takes time to change that goes with cognitive as well one of the things to encourage your clients to do is to be kind to themselves you know you're not going to get it every time you're not going to change it every time if you can change it 20% of the time the first week that's phenomenal socially changing thinking patterns are there any drawbacks well if you start expecting or stop expecting people to let you down then you may actually trust in somebody which may make you more vulnerable to getting hurt yeah that's true but how can you deal with that and one of the things that we want to encourage our clients to do is start developing healthy boundaries whole another class environmental drawbacks to changing thinking patterns there's not a lot that I can think of now remember I'm the one person in the group so I'm probably coming up with 20% of the reasons here so we look at the benefits of maintaining current negative sort of paranoid depressive worried stressed out thinking patterns physical benefits none I can think of emotional benefits it's what you know it's easier because it's what you know is it what you want to continue to do? probably not so how do you deal with that because it's it is a change cognitively again it's what you know so this your current thinking patterns are going to be your automatic reaction it's going to take some time to change that automatic reaction it's going to take some practice the good news is with time in practice you can change your thinking patterns so it's not a process it's pretty much automatic social benefits to maintaining current thinking patterns your current social circle probably supports those thinking patterns which means you have to look at your current social circle and go is this the best recovery environment for me? which takes us to environmental current thinking patterns that are negative stress depressed high strong worried all the time people who feel like that generally don't have a lot of energy to clean house to do other things because they're so spending so much energy internally that their external environment tends to kind of become chaotic and then we go over to the fourth quadrant the drawbacks of maintaining current thinking patterns physically when you're negative and depressed at this time you store stress and it hurts you can give yourself headaches migraines back aches poor sleep the list goes on we know that when people are stressed over a period of time that their immune system also goes down which means they get sick more often and I don't know about you but I'd rather be just about anything than sick emotional drawbacks to current thinking patterns well they're keeping you stressed and depressed cognitive same thing social drawbacks to current thinking patterns they're keeping away people who are positive and optimistic and may be able to help you feel happier and environmentally drawbacks to current thinking patterns is that your environments probably in as much chaos as your thoughts are in your own head another mental health issue that we want people to work on early in recovery is developing social supports so we want them to look at the benefits and drawbacks in addiction recovery from jump we start talking about changing people places and things which is true it needs to happen but that is scary as all get out from most of our clients because they don't feel worthy they don't even like themselves so they can't expect other people to like them which is why we start with self esteem work so early in the process so figuring out how to make friends and not only make friends but make friends when you're not drunk or high is scary it's terrifying so we want to start with the benefits and sometimes when we talk about making a change or doing something that's really hard or really scary we still go through it the same way but then we will revisit the benefits of the change at the end so developing positive social supports physical benefits there may not be any you may experience some less stress which means less neck head pain that sort of stuff that sort of far removed emotional benefits definitely stress reduction and a feeling of not being isolated and all alone cognitively positive social supports can generally help you by acting as a good sounding board and giving you suggestions and sort of being a second head you know how they say two heads are better than one socially positive social supports are great because you're surrounding yourself with people who are positive positive begets positive you know it's not like a magnet positive doesn't attract negative when we're talking about relationships positive attracts positive so environmentally you may have more energy to keep your environment in a little bit more of a you know and you may also have things in your environment that start to be happy you might start noticing things in your environment for me my kids have been laughing at me lately I saw this meme on Facebook and it was a hamster in a sweater and it's just like the cutest thing I've seen in my entire life so now it's my lock screen on my phone and whenever I start having a moment I look at my screen and it makes me smile because it's a hamster in a sweater and you're probably rolling your eyes right now thinking I've lost my mind but it's okay laugh with me laugh at me as long as you're laughing I'm happy and that's part of having good sober healthy social supports people realize that it's okay to be different it's okay to be happy even if other people you know aren't I mean I'm not going to be yucking it up at a funeral or something but just because my roommates had a bad day doesn't mean I have to get all grumpy too alright so let's move over to the drawbacks of new friends physically again not a whole lot emotionally it's scary to put yourself out there put yourself to new people put yourself in new situations so this is something that you can work on in therapy with rehearsals you can work on practicing introducing yourself you can go in groups to new situations so it's you're not going in there by yourself I hate going into new situations all by myself I'm kind of a chicken that way so I make somebody else go with me and it makes it a whole lot easier emotionally the drawbacks to developing new friends is that the current negative unhappy dysfunctional friends might not want to hang around with y'all you've got to decide whether you're okay with that and how you're going to deal with your current friends as you start making healthier sober social supports alright what are the benefits to maintaining your current friends well you know them they anticipate them even if they are mean, nasty, negative whatever the case may be you know what to plan for and you can kind of deal with it they may not be building you up but you've figured out how to keep them from tearing you down cognitively it's less to think about because you know what to expect um we like to keep our current friends it hurts to have to end a relationship or to put distance between yourself and someone but at the end of the day you have to ask yourself physically emotionally, cognitively is the energy that I'm putting into this friendship or surviving in this friendship worth it or is it just dragging me down which takes us to the drawbacks of maintaining your current social relationships and then finally of course we had to look at sobriety now sobriety is a bunch of different things not just not using and I'll say that again sobriety is not just not using it's a whole different way of thinking a different way of approaching life it's characterized by honesty courage, discipline, integrity you know all kinds of stuff that are not prevalent in an addictive lifestyle so right now we're just looking at stopping using but we need to encourage people to recognize that that's just being clean that's not being sober so what are the benefits to not drinking well physically it's better for your health you're not going to put yourself in situations where you're getting into bar brawls um legally you may not be getting as many DUIs socially it might be kind of scary so we're going to save that for right now cognitively benefits to not using is you'll actually remember what you did the night before drawbacks to stopping physically you're going to have cravings and physically the detox from alcohol is not the most pleasant in the world because after that depressant effect wears off there's an anxiety effect where people feel their anxiety going up which is often why they have another drink but if you're detoxing you can't so the physical drawbacks from alcohol are unpleasant and they can be life threatening so if you're detoxing please from alcohol please make sure to have your clients detox under medical supervision emotional drawbacks to stopping you're going to have to feel feelings oh crap that can be a benefit or a drawback kind of depending on the day but we need to encourage clients to be aware that you're going to start feeling some stuff and it's not going to be pretty but you can do it cognitive drawbacks you're going to start remembering all the stuff you did when you were drunk and having to make amends you know all the stuff that people experience in early recovery the good news is thousands of people have done it and made it through and dealt with the stuff so your client can too and having faith in your client that they can do it will help them have faith in themselves benefits to continued use no cravings occasionally you'll be numb cognitively you're not going to remember what you do so you're not going to feel as guilty unless you start to sober up socially you get to keep all the same dysfunctional friends and environmentally you may not be able to stay at your house anymore you may be living out of your car but you don't have as many responsibilities now I say that kind of ingest we want to encourage clients to really get honest about the reasons they use alcohol the main benefit is generally dealing with emotions so we need to make sure right here we help them figure out when they start feeling feelings how do they deal with it and then the drawbacks to continued use this is usually the easiest one for them to fill out because they're in that early recovery stage and they're like oh I'm not going to do that again and these are all the reasons why encourage your clients to not just talk about this in group but to write give them worksheets that look like this and encourage them to fill them out so when they start having a weak moment going why am I here they can look back at their decisional balance exercise and go okay that's right I really do want to start living a happier healthier life this just sucks right now so treatment priorities cognitively when people start feeling those feelings they need to work on developing mindfulness what does that mean well the first thing is understanding the function of the feeling just like our reactions and all of our quote symptoms our functional and self-preserve geared toward self-preservation our feelings function to protect us we have the fight or flight reaction when we are faced with a threat we size up the threat and we decide I can take it I'm going to fight or oh crap I can't I'm going to flee now you break that down you've got anger versus anxiety or stress understand the function of the feeling when they start to feel a dysphoric feeling is it anger is it anxiety and then depression is out here where is the body saying I've got no more I've got no more gas I just can't do it anymore and if they're starting to feel depressed that means they need to figure out how to reduce some of that stress so what is the function of this feeling why is it making them feel angry, anxious or helpless and hopeless break it down to those four very rudimentary feelings and then distract don't react just because they're feeling it doesn't mean they have to act on it just because they're depressed doesn't mean they have to cut doesn't mean they have to drink doesn't mean they have to cry doesn't mean they have to put a fist through a wall whatever they typically do they're feeling a feeling because it's their body's way of saying dude you gotta do something what are they gonna do they need to take this time to say alright I need to distract for a second because when you have this fight or flight reaction or fight, flight or forget it and I'm paraphrasing there but when you have that reaction that's basically an adrenaline reaction a primitive reaction and we wanna let that go by we wanna let that adrenaline get out of our system so we can think clearly and make a decision in our rational mind make one that is based on higher order thinking that humans are capable of so distract don't react how can they distract themselves when they start feeling feeling the blank again, have them keep it on index cards three things I always say three options when I am angry I can when I am anxious I can and when I am depressed I can so that's nine things all together those are things they can do to distract themselves until they can figure out what they're actually going to do about the situation and then finally mindfulness and this is an overarching activity the mapping activity I love doing this activity I give people a map which is why it's called the mapping activity hey go figure on one end of the map I put a star that's their destination and they can call it whatever they want recovery, happiness eating I don't care and on the other end of the map we're going to put you are here now just like back in the olden days before we had google maps we had you would get maps from triple A and they would tell you where all the road construction was and all the potential barriers to your travel and tell you different alternate routes google now will tell you what three routes you have which one's the fastest and whether it's clear when you get to a barrier a traffic jam, something like that it will either tell you this is still the fastest route you just have to sit through it or would you like to detour now good orderly direction is a term we use in recovery talking about in the big scheme of things because people with addictions and anxiety want this pain to stop now so good orderly direction says this may not be my favorite thing to do right now but a month from now is this getting me closer to where I want to be a month from now six months from now five years from now so they need to identify their potential barriers to reaching whatever their destination is where are the traffic jams where are the roadblocks they need to figure out what alternate routes to take if there is a roadblock and how to do it safely you know you don't want to just without a GPS go driving take an exit off the interstate and randomly go driving around until you find your way back to your path you want to have an alternate route mapped out for yourself ahead of time or develop the method for tolerating the roadblock and to sit in traffic drives them absolutely bonkers but sometimes that is still the fastest route so how do you tolerate sitting in traffic how do you tolerate this roadblock it's unpleasant how do you get through it instead of trying to make it go away and probably making things worse the mapping activity gives a real perspective for the recovery process and you want to have them identify pit stops along the way if you were actually driving the route you would stop to pee stop to eat so what pit stops are they going to take along the way where they give themselves an atta girl or an atta boy and what does that look like a relapse in any of the disorders can trigger a relapse in any of the others when you're in pain it may make you start feeling depressed again because you're like oh crap here we go again with this which may make you want to use again and you know any permutation of that it's important to identify the most salient factors to address first for example pain contributes to sleep problems depression and addiction so we know that pain is one of these common threads that if we improve that we're going to have an improvement in sleep which will also probably help kickstart the body's building of endogenous opioids and the pain management system and all that kind of stuff another example is anxiety contributes to pain because you store stress and exhaustion depression and again addiction because people when they get stressed out want to have a drink or something to help them relax so if we help people deal with their anxiety we also are going to be impacting the physical and the addiction aspect of their recovery one way to get at what the common thread is for some of your patients if there's not one that's really obvious is to say what is one thing you need right now to start getting better and they may just say something like I need a break and you're like okay so I hear you're overwhelmed that tells me anxiety so how can we help you get a break make a practical plan for time management delegating and handling some of those other issues practical counseling is not magic it's practical solutions to real life problems nutritional and medicinal interventions will take one to six weeks to take effect make sure your patients know this that way they don't start getting frustrated when after two days they're not feeling better quite honestly with most of your medications the first two days you're going to feel worse because your body is adjusting to it so you may have some flu like symptoms they need to know that too otherwise you may have some high rates of medication non-compliance please do not treat the addiction and expect the mood disorder to spontaneously remit if we treat this addiction then the depression is going to go away it's not that simple you know the body is going to be able to more effectively make serotonin and the dopamine pathways will and the motivation pathways may start to recover but there's a lot of cognitive errors and a lot of stuff that people have to deal with so we need to treat both of them likewise you can't treat a mood disorder and expect the addiction to spontaneously remit well if I treat your depression then you won't need the alcohol or the binge eating anymore well that may be true but if the person is still drinking while you're treating the depression then they're still keeping their neurotransmitters wonky so we need to treat both of them it's not nearly as true anymore thank goodness but when I first started working in the field I worked with several psychiatrists in a substance abuse treatment facility who said no a person has to have six months of clean time before I will even consider prescribing an antidepressant so basically you ended up with somebody who was really depressed and clean and they don't stay clean for very long if they're in that much emotional pain so not that we can make doctors to prescribe anything but it's important to educate the clients and the physicians if necessary that we have to address both things simultaneously and just as as one gets worse the others will too as one gets better the others will too which is awesome because we can focus on what clients are willing to change gradually other things will start to improve if a client is not willing to stop using but they want to improve their depression and work on their marriage okay we'll work on those things and in the back of my head I know that part of improving their depression and working on their marriage is stopping using but I'm not going to say that right now because they need to come to that realization for themselves that things are not going to get better as long as one of those pieces is still wonky so addictions impact the person physically, socially, emotionally and cognitively physical health problems can contribute to anxiety and or depression anxiety and or depression can trigger an addiction relapse physical pain can also increase depression, irritability and disrupt sleep creating relapse triggers for both mood disorders and addiction a biopsychosocial approach helps people deal not only with the addiction which is a means of escaping the pain but also with the causes of the pain itself whether that pain is emotional or physical remind patients that their motivation will differ between presenting issues and over time so it's important for them to stay aware mindful of their level of motivation for the change behaviors that they're undertaking when one disorder gets worse it may need more attention so maybe if the pain whatever is causing the pain starts to get worse it may require more time and attention but that doesn't mean to forget about everything else if you start forgetting about everything else then those cognitive habits and other habits may creep back in so you may need to give it more attention but don't forget about the other two areas if you've watched and participated in this program for CEUs log into the classroom at allceuse.com and take the quiz if you've watched and participated in this presentation and want CEUs but have not yet registered you can purchase access to the quiz and certificate on our website at allceuse.com this presentation was recorded as part of a live interactive webinar if you are watching it on replay please remember you can always contact Dr. Snipes on her personal chat page at purechat.me slash qtvx