Getting to the Root of Addiction: An Integrated Approach

When I started my practice Integrated Treatment Solutions in 2009, I did so out of professional conviction. My experience working in a variety of healthcare and drug and alcohol treatment settings led me to rethink my approach as a behavioral health professional. I could no longer only treat symptoms at the expense of being complete and addressing underlying issues. I realized that I was at a critical choice point and that working within a traditional clinical framework was preventing many clients from getting help – That was not going to work for me. I wanted to collaborate with clients in the exploration of their problems and see what made sense for them in their respective recoveries.

These are some things about addiction and recovery that I have learned along the way and implement in my daily practice as an addictions specialist and behavior therapist…

Understanding addiction and moving into recovery is a process, not an event. Addiction recovery takes willingness, honesty, openness and time. Recovery is not linear. In fact, it can vary person to person.

The decision about one's relationship with substances is personal. Individuals use substances and engage in addictive behaviors for different reasons – Essentially, all behavior is purposeful. As human beings, we are always trying to accomplish something. Each person has his or her perspective and goals concerning their use, lifestyle and level of wellness desired.

As a co-occurring disorders specialist (previously referred to as dual diagnosis – addiction and mental health together) I counsel and treat clients presenting "clinical complexity." Many have been trying to gain clarity about their conditions and make progress for many years having been through many courses of treatment but continue to struggle with relapse or are "white knuckling" it through tough symptoms. Despite previous attempts at recovery and disappointments incurred along the way, they have stepped up again! I applaud their courage and determination.

I also believe that there is hope. Even after several attempts have been made.

It has become apparent to me that there are no failed clients only failed treatment. While addiction, depression, bipolar disorder, etc. tend to be fairly standard in their presentations, each person affected is different within the issue at hand. Each brings unique strengths, vulnerabilities and life experiences which need to be taken into account when planning treatment.

Treatment must be tailored to the individual – always.

People want to get well – not only sober. To feel at home in their bodies and positive about themselves, others and their relationships - To be able to trust themselves – their thinking, abilities and choices.

Many clients who approach treatment with me had been sober before – for long periods of time and yet continued to be in physical and or emotional pain. Many have made attempts at sobriety in traditional drug and alcohol rehabs and attended daily Alcohol Anonymous (AA) or Narcotics Anonymous (NA) meetings – Worked with a sponsor through the 12 Steps of AA or NA.

Symptoms from chronic pain, mood disorder, trauma, attention deficit (ADD) or chronic physical conditions/ diseases involving the autoimmune system, or unresolved post-surgical complications can surface when the person stops using substances - "breakthrough" symptoms can result in powerful triggers fueling drinking and drug use again. Inflexible personality traits or personality disorders can also serve as barriers to effective therapy and treatment. Trying to manage what is not known or understood is confusing and painful for people.

Unfortunately, situations presenting this level of complexity are not uncommon. There are often multiple problems occurring at the same time, playing off one another. The idea that addiction is a singular issue is often a false construct – An incomplete, inaccurate or an ill-founded psychological concept.

Addiction often travels with other issues – It is critical that all of the problem issues are identified, understood and addressed in order to move towards stabilization and recovery. Expecting a person to reduce their drinking or substance use or to completely abstain (depending on risk) is not realistic without a comprehensive and holistic approach offering precise diagnosis and a personalized plan.

No problem is about "one thing and one thing only."

 

Clients need and have the right to know exactly what the issues are and to be educated about them. Identification of the issues and a conversation about them needs to happen even if it means talking about conditions like borderline personality disorder (BPD), narcissistic personality disorder, Asperger's or anything that is tough to accept.

If difficult issues are NOT talked about, they will sabotage treatment and leave clients confused and defeated yet again, resulting in an increased sense of hopelessness and helplessness. When people are not informed they are deprived of the opportunity to move through their own process of "self-diagnosis", which means "Do I agree with this?" and "What does this mean to me?"

Knowledge is power.

 

Engagement and commit to change can only happen when clients are clear about what they are dealing with and have a sense of what to expect moving forward.

Effective treatment starts with a thorough bio- psychosocial assessment to obtain information about the major physical (bio), psychological, and social issues. A holistic approach posits that separate issues are often related. - No stone is left unturned in the interest of getting the "bigger picture" of what is going on.

Assumptions are dangerous.  Illnesses presented as being "treated" such as autoimmune disease, diabetes, depression or conditions that tend to be minimized like, Lyme disease, premenstrual dysphoric disorder (PMDD), or sleep problems can fuel addiction and its ‘problem behavior. Medical treatments often need to be reevaluated to determine if they continue to be effective.

People are not always consistent with or misuse medications. Many do not have a trusted primary care physician. There are oversights and misunderstandings that can happen which have the impact on any health problem.

So, the solution to the problem is only as good as it's' conceptualization. To be inaccurate or incomplete is time, energy and resource draining.

An integrative approach to addictions treatment and its' co-occurring disorders is collaborative, thorough, health and well- being oriented – Not just about "one thing" or symptom oriented.

Treatment for Drug and Alcohol Addiction - Rehabilitation or Habilitation?

Many years ago, when I was working as an Addictions Therapist in an Intensive Outpatient Program someone said something in a group setting that was quite insightful and ingenious as it related to treatment and recovery - “I have been in and out of treatment and have been in treatment in several inpatient and outpatient programs and just now seeing that I don’t know how to live and I am terrified!” This person went on to say that it often assumed that just because people are grown-ups, that they do not always have the skills to live effectively - That somehow the drugs or alcohol curtailed functioning and the goal was to restore it. But, as he said , “When I try to remember how to live, there is not anything to recall. It is not that I am ignorant, but I never learned anything about how to manage myself and my life in a way that worked for me! Addicted people are not in need of rehab but we often need habbing! In a way, addiction fills a gap and it is my way of coping in the world. Sometimes I am aware that I am digging my heels into the ground, because I don’t know how to move forward and I’m scared.”

It is often assumed that adults know how to do things and are skilled enough to be effective in life and that somehow it was lost along the way and needs to be rehabbed to get that knowledge and skills back. This is not always the case. As a Behavior Therapist and Addictions Specialist, I am aware that despite my clients success in other areas of their lives that they are are starting form scratch in some fundamental areas. knowledge and skills are being taught and learned for the first time or in such a way that they as recovering people (can be applied to recoveries from addiction, depression, chronic pain, etc.) can learn and integrate new material in order to apply it to their lives in an effective manner. This, in turn, reduces stress and confusion, while building more productive coping skills and ultimately makes way for eradicating relapse behavior. It may seem too basic, but not any less important. Sometimes the obvious is easily overlooked; we judge what we think we ought to know. However, life requires a lot of teaching and learning – since managing ourselves, relating to others, organizing, and problem-solving are not necessarily skills that are totally inborn. We learn them.

I think of the man who shared his insight about needing habilitation at times and his complete honesty and candor. He was able to get beyond the human ego and self-examine in such an open way. He also made a lasting impression on others and gave permission to be human and to accept imperfection and the need to learn. He also reminded me to be aware of the danger of assumptions and how they can negatively impact the delivery of quality treatment that is appropriately tailored to the individual.

Hence, rehabilitationis a process of rebuilding and taking a foundation and restoring it. Conversely, habilitation is development from the ground up – the putting into place for the first time. Although adults have life experience and points of strength – perhaps successful in business, popular with friends, a strong athlete – they may have significant skill gaps or other issues, medical or otherwise, which they have been subconsciously trying to compensate for or work around. This impacts the ability to manage themselves and their thoughts, emotions and behavior which negatively impact one’s ability to function and be effective in life.

Hence, although there is a strong genetic component, addictive behavior can be utilized as a coping strategy, although not a healthy one. Repeated use of substances can become habituated behavior and ultimately grow into an entrenched and highly destructive disease that when not treated gets worse and become terminal.  Comprehensive and effective treatment matters.

Next week we will talk about what makes for Successful Drug and Alcohol Treatment with focus on assessment and choice of treatment with emphasis on dual diagnosis/ co-occurring disorders.

Building Cooperation – The Importance of Taking Turns

Early on in life our parents, teachers and other family members teach us the importance of “taking turns” – an important lesson because it’s learning the value of patience and courtesy. Knowing how to take turns becomes even more important as we move forward in life as adults, as we build relationships and alliances with others that we need in order to sustain. But adult “reason” can get in the way of this – making some people, events, and things more important or convenient. This can be hurtful.

As adults we are more apt to apply judgment as to why some things are more important than others.  We can slight people without knowing because our reasons seem just, so it is easy to assume they should be accepted by others. When we do this, we block other people from having experiences that they need to feel valuable and “part of.” We also block people from truly being known and appreciated outside of the roles that we tend to put them in.

A couple of types of situations  come to mind.  One is the position of “mother.”  I have many clients in my West Chester and Chestnut Hill, Philadelphia, PA based counseling practice who are mothers. Their lives are busy with raising children and taking care of their families. They are the nurturers and always aiming to make things better for the people they love. Through their commitment to their families they often sacrifice of themselves.  Over the course of years as children grow older and grow up mothers can continue to be viewed as the “givers” and not receive as much.  Mothers may not be asked questions about themselves – How they are doing; what is going on in their lives, opinions, and thoughts, etc.. It is easy to overlook that “mother” is also a woman, friend, sister, professional, essentially a person with needs, wants and dreams of her own.

Imbalances can happen with friends, too.  For instance, in a friendship between two young women one can be the talker, entertainer, and center of attention while the other can be quieter and go with the flow, but seems to be the “supporter’ or audience for the other. Over the course of years this imbalance can take its’ toll.  Perhaps the “go with the flow” friend, realizes that she is no longer amused with her entertaining – high energy friend who seems to dominate conversations and require constant attention.  She decides to move on in search of more equitable companions.
There is a time to turn the table and start giving back – Striking balance. This is important in all types of relationships, including friendships, coworkers, spouses, and siblings.

As much as we might not want to take turns and do what we feel is wanted or suits us, taking turns is necessary to relationships. At times we must let go of what we want for the greater good of relationship and of the other person. People can get stuck in roles within families, couples, friendships, workplaces and communities and not have enough room to be more of who they really are.  Often, when people are stuck in roles they may either clamor or become withdrawn.  Sometimes people do not know what is going on inside of them, but something seems off and there is dissatisfaction and conflict.  Roles prevent people from growing – and, we are designed to grow. One cannot have a relationship with a “role” only with a person.

Stepping back and looking at your most important relationships, what do you see? How are you with taking turns? Is there someone or some people in your life with whom you could have a better relationship?

We invite you to explore your relationship skills. Are they working for you? Is there room for improvement? Do you have a friend or family member who might need a refresher?

Improving Relationships Through the Power of Validation

Human emotions are complex. They are also unique to each and every person. This means that each person experiences emotions differently.  If a group of five people who were sad were asked to describe their experience of sadness, we would more than likely get five different responses. Why?  Because emotions are private experiences.  Emotions are part of a complex tapestry including human temperament, life experiences, relationships, and perceptions. No two people are completely alike.

In my counseling and therapy practice in Chestnut Hill, Philadelphia and West Chester, Pennsylvania my clients tell me about their feelings and emotions and how they were responded to by the people in their lives. Since I work with issue involving, addiction, codependency, depression, chronic pain, etc., learning self- care and self- advocacy is of primary focus.  In order to build these important skills one needs to learn how validate themselves. This is harder than one might imagine, especially if the person has been exposed or is living in an invalidating environment.

So, what is validation?  Validation is to recognize and accept another person’s thoughts and feelings, regardless of whether or not you feel that they should be experiencing them. Validation helps us to develop a sense of self-worth. People who are validated feel reassured that they will be accepted and loved regardless of their feelings, while those who are not validated are more vulnerable to emotional and behavioral problems and relational difficulties.

We can validate another person by paying attention and reflecting back what we heard them share with us, asking questions, and identifying with them. This helps all of us feel “part of” and less alone. We can easily overlook the fact that ignoring others or neglecting to acknowledge them is indeed invalidation.  This is why childhood neglect is considered abuse.

Here are a few everyday ways of validating one another. These can be built into how we communicate over the course of time and help improve relationships.

• Listen with empathy and genuine concern, being careful to stay in the moment. Display interest and engagement through verbally and non-verbally: Nod and maintain eye contact, and use verbal replies such as “Yes" and "I understand."
• Be responsive by reflecting back what the other person has shared. For example, “It sounds like you were very hurt that your friend didn't call you back." Check for accuracy by asking "Is that right?"
• Observe and articulate the individual’s unspoken feelings and emotions, based on what he or she says as well as nonverbal cues. Ask if your observations are accurate. For example, “So you are frustrated when your friend does not communicate directly with you about plans - That when she doesn't call by a certain time that it means that she cannot follow through.  You cannot accept that way of interacting.  Is that correct?”
• Communicate that you are aware of the "bigger picture" of the person's feeling or emotion.  Acknowledge that his or her current emotions are understandable within the context of his or her past experiences and/or present circumstances. For example, “Considering that you grew up in an alcoholic home with little stability, it is understandable that you would feel anxiety when cancels plans with you and  things are uncertain.”

We can validate one another quite readily if we pay attention and seek out opportunities to do so. Validation strengthens relationships, communities and reduces conflict.

What is your experience with validation?

The Importance of Receiving Graciously

Not long ago, I was privy to a conversation between two women who met up with one another at a professional event in Philadelphia, PA.  It was apparent that they had not seen one another for a long time as they hugged and expressed excitement about running into each other.  One woman commented to the other on how healthy and happy she looked, saying “You look really great! And that dress is lovely.” The other woman replied, “Actually, I gained so much weight…and, this dress?  It was a bargain at TJ Maxx…$10.00.  Can you believe that?” The woman who gave the compliment stepped back and was quiet. There was an awkward pause between them. Where does one go after that?

Most of us were taught to say “Thank you” when receiving a compliment. However, debunking a compliment or acknowledgement can come about quite naturally – Out of habit. One might feel uncomfortable with the attention, not want to appear selfish  or feel self-conscious when noticed and in turn think it is okay to  not take the compliment.  It can, however, present a problem for the “giver” of the compliment. Rejecting the compliment actually discounts the observations and intentions of the giver.  It says, “You are wrong. I don’t want your compliment. I am not open to you.  I don’t like myself.” It is a block to connection and relating. Rejecting an acknowledgement such as a compliment or act of kindness can be experienced as very invalidating by the other person.

So many acts of kindness are rejected in this manner – Whether it is an invitation to lunch, holding the door for someone, not allowing a birthday gift to be given…There are so many examples both large and small of heart centered generosity gone awry.

Deep down inside, each one of us wants to receive. I hear what people want everyday in my counseling practice in Chestnut Hill and West Chester, PA. That is just human nature. “Give and take” is built into our primal template of survival skills. We give in order to belong and to build cooperative relationships with others as well as to plant the seeds for being able to take later when we need to. Without the dynamic of give-and-take, civilizations would crumble and cease to exist. Give and take is a necessity. Giving and receiving has a deeper meaning and is more intentional rather than transactional. Receiving is about connecting.

Receiving is different than “taking” in that it involves being aware of the giver, what is being given, as well as the intentions of the giver. It requires being able to receive and truly say “Thank you” and take in the emotions that come along with generosity, such as gratitude, happiness and, at times, awkwardness. Receiving with accountability builds true relationships – allowing for vulnerability and intimacy.

Many of the worlds religions emphasize  “One must receive for the sake of giving.” If no one chooses to receive or cannot receive graciously, then no one can give nor can be acknowledged or known. It diminishes the possibility of the wholehearted connection which we claim to want the most.

How are your receiving skills?

Improving Relationships through Listening

Have you ever been talking with someone and, before you can even finish your sentence, they interrupt to share their own thought or finish yours? Or perhaps you are in the middle of making an important point and their attention is pulled away as they check their ringing cell phone, send an email, or reply to a text message. We’ve all watched someone we are talking to nod and even mutter “uh huh” – knowing they didn’t really hear a word we just said.

People notice and can feel when others are not paying attention. These are conversations that leave people feeling unheard and unimportant, and they happen to all of us. In fact, most of us are guilty on a regular basis of listening to others in this same way. Listening with all of our attention is a discipline that needs to be practiced. It is also a skill that pays big dividends in both personal relationships and business endeavors. After all, every part of life is about relating.

In short, how does one develop or hone the skill of listening? Here are a few points to bare in mind in becoming a more skilled listener:

• Giving the other person your undivided attention. This may included putting your cell phone away, closing your laptop, stepping away from the crowd, turning off the television, music etc. and tuning in to the person with eye contact.  Removing barriers to being present helps with focus.

• Stay focused.  We are conditioned to drift.  There are often many things competing for our attention. Focus is a skill to be built – It is not automatically “there.” When talking with another person be mindful of the thoughts and inner and outer distractions that can negatively impact connecting.  When distracted gently pull your attention back to the person talking – Even if you need to do it over and over again.

• Being aware of the impact of judgment. Defending one’s self  from what is not wanted to be heard or felt or blocks our ability to listen and attend to the relationship. This includes blaming the other person or situation when uncomfortable or distressed- projecting unwanted feeling onto others. Part of this is the experience of how we believe others see us.  When self perception is distorted a person can become distracted and emotionally deregulated.  Working with human judgment and learning to appraise ourselves and others accurately allows for more connection and compatibility.

• Maintain open body language. Body language is non verbal and actually that more significant part of communication than what is verbal. Non- verbal being roughly 55-65% of communication. Remember words and actions need to line up – This is often considered “Walking the talk.” Alignment of verbal and non-verbal communication fosters connection and trust with others. Make sure you are open and receptive – No crossed arms, furrowed brow, abrupt movement, eye rolling – darting or similar behaviors.

When we become skilled listeners, we provide people around us with a gift that they have rarely been given in their lifetime. For when we truly listen we take others in, learn about them, and acknowledge that they exist. When we listen we also learn more and allow ourselves to truly know others and to challenge our assumptions. Listening facilitates change.

Do you tend to hear people or really listen?

Quote: “Since in order to speak, one must first listen, learn to speak by listening.”  

 ~Rumi

Improving Relationships: Skills that Work

As a licensed therapist, coach and addictions specialist I counsel and treat clients with some pretty serious conditions, including, alcoholism, sexual compulsivity, road rage, bi polar disorder, and personality disorders, such as borderline personality disorder and narcissism. Much of the time these issues (and others) may be occurring at the same time and make for immense complexity.

However,  over the many years of practice, I continue to find it curious that despite the crisis, physical and emotional challenges and other problems at hand, that the conversation always comes back to relationships, communication and the development of connection and intimacy. Even in the face of chronic pain, depression and job loss the underlying concern is  often “I don’t think my spouse loves me” or “I am afraid of being left behind” or something similar.

The number one reason why people seek counseling is related to their relationships. Whether it’s due to an intimate couples’ problem, social isolation, family or work related conflict; relational concerns always take precedence – even over finances. It doesn’t matter what the presenting concern seems to be – addiction, eating disorder, pain, depression, etc. – at the end of the day the conversation comes back to connection, love, and belonging. These are not lofty needs or desires, but are necessary for our health, well-being, and survival. But, in today’s world of technology, pressed schedules, increased consumerism, family difficulties and economic pressures, the simple things that have served as the foundation for human health and happiness have been strained and minimized. It’s no wonder chronic disease is on the rise with 25% of American facing such challenges.

Many years ago an author by the name of Robert Fulghum wrote a book All I Really Need to Know I Learned in Kindergarten http://www.peace.ca/kindergarten.htm. In his own simple and elegant manner the author provided practical guidelines for successful living and loving through looking back on what is taught to children in kindergarten, as they learn to take care of themselves and socialize with one another – The importance of respect. Sounds simple, right? However, sometimes the simplest of things are not so easy. What happens when those basics either get lost or are not learned? These relational deficits leave a large gap in one’s ability to relate and have needs met, leading to immense dissatisfaction and suffering – For everyone.

This next grouping of blog postings is focused on getting back to the basics of relating effectively with others; highlighting the importance of our ability to listen, understand, and to develop collaboration and cooperation in order to construct safe, balanced relationship dynamics that are healthy and satisfying.

As you read the blog, you may wish to ask yourself how you rate in these areas and or how others around you rate. Through increasing your skills it becomes easier to discern what healthy relating looks like and how it feels verses poor relational fit.  You will also learn how to build a healthy and satisfying network of supportive relationships in your life in order to feel more balanced, connected and competent.

We hope you find this information useful and encourage you to forward the blog onto a family member or a friend.