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.

Understanding Obesity & Food Addiction

Something that I have learned over the years in my work as a Behavior Therapist and Addictions Specialist is that issues with food and eating are often lurking in the shadows of other problems, including alcohol dependence, drug abuse, problems with anger and impulse control, and difficulties with overwhelming emotions.

When I assess a new client in my Philadelphia or Chester County based office, I find it immensely important to understand their daily habits of living as they generally complete the picture in understanding the presenting issue and what is keeping it going. Lack of proper sleep, exercise and nutrition exacerbate mental and physical health concerns making them worse.  Energy drinks, take-out food, protein bars, pizza and coffee are not staples of a healthy diet. They do create poor eating and food habits and distance from what is normal and healthy via reinforcing impulsive and “on the fly” eating.

Most people want to be healthy, but struggle with making the changes needed to establish balance in their relationship with food and eating.  First, a person must understand their own tendencies with food along with how they deal with stress, emotions and people, as well as making sure there are no medical concerns (endocrine, etc.) which may be negatively impacting ones’ behavior with food.
I have found that obesity and food addiction are related much of the time.  I also find it curious, however, that issues with weight – obesity are not challenged and inquired about as much as one would think, despite the increase in health risks- That many people silently suffer food addiction.

Obesity
Obesity is at the forefront of today’s health concerns and warrants focus, because it is linked to many health problems. Did you know that that approximately 65% of adult Americans are overweight and 30% are obese? It is also estimated that roughly 80% of obese adults have at least one of more conditions such as: cardiovascular disease, diabetes, hypertension, sleep apnea, arthritis, and cancer. There is then another tier of problems which includes depression, substance abuse, and chronic pain that can develop as a result of those issues. Studies show that 25-50% of obese individuals binge eat and that there is a 75-95% recidivism rate to obesity among formerly obese individuals who have undergone treatment. Obviously, this points to a significant epidemic. It also raises a question, “What happened to our relationship with food?” “What went wrong?”

Food Addiction?
The medical community, insurance and food industries all encourage consumers to exercise “personal responsibility" when it comes to preventing obesity, addiction, and chronic health problems. Self-control, better choices, avoidance of over-indulging/over-eating, and staying away from packaged, high fat, carbohydrate, sugary foods is emphasized and encouraged. Seems simple, right? Being informed and then choosing? No!

Food, like alcohol and drugs, is biologically addictive. Food is a substance.

There are specific biological mechanisms that drive addictive behavior. Addictive behaviors are fueled via primitive neurochemical reward centers in the brain that override one’s ability to exert reason, self-control, manage cravings, stop eating and to recognize biological signals of true hunger, appetite, and satiation.

Liking vs. Wanting.  Research shows that obese individuals are similar to non-obese individual in their “liking” of foods, but that they have a stronger “wanting” / desire/ drive for the foods they want. They are also willing to go to great lengths to obtain and consume them. It is noted that this may be due, in part, to neurological changes that cause a blunted psychological reward response to food – Much like how a drug addicted person might crave their drug or “want” it very strongly, long after they stopped enjoying or “liking” it.


Craving vs. Addiction. We all crave certain foods from time to time. Women are notorious for craving chocolate.  Some other common cravings include fat, sugar, or carbs. Food cravings are important because they play a role in over or compulsive eating – as they serve as “trigger foods.” It is said that our industrialized society ripens the opportunity for obesity, due to the availability and exposure to addictive food substances: sugar, fat, sweeteners, refined carbohydrates, salt and caffeine -- eroding at self-control and ability to regulate consumption of these foods.  “Loss of control” is both a term and behavior associated with addiction.

Do You?...
* Eat when you're not really hungry or eat as a result of emotional triggers
* Feel guilt or shame after eating
* Eat alone, in secret or hiding the amount of food your eat from others
* Feel out of control and/or can't stop eating
* Crave certain foods only as part of binge eating
* Get a feeling of relief from emotions when eating certain foods

Evidence in Support of Food Addiction
According to a report from the National Center on Addiction and Substance Abuse (CASA) at Columbia University, up to one half of individuals with eating disorders (including bingeing) abuse alcohol or illicit drugs, compared to 9% of the general population. Conversely, up to 35% of alcohol and illicit drug abusers have eating disorders, compared to 3% of the general population.
A direct correlation has also been established between the dramatic increase of obesity and overweight population and the aggressive marketing, increased availability, and consumption of foods over the same period (similar to tobacco).

• People who are addicted to food tend to exhibit many of the same characteristics as those addicted to alcohol and drugs:Exhibit behavior in times of transition or stress
• Common family history
• Common brain chemistry (decreased sensitivity of dopamine-reward system)
• Low self-esteem, depression, anxiety, impulsivity
• History of sexual, physical, or emotional abuse
• Obsessive preoccupation, cravings, and secretive rituals
• Experience mood altering effects from use of substance

- National Center on Addiction and Substance Abuse (CASA) at Columbia University
There is help available – One does not need to suffer.  Counseling for eating disorders coupled with professional nutritional guidance and self- help programs such as Overeaters Anonymous and Eating Disorders Anonymous are the basis of a well-structured plan.  If you are concerned about your relationship with food and eating but not sure if you are addicted and or not quite sure if you are ready to make any big changes, help is still available. Effective counseling allows room to sort through issues and make new choices.

Recovery - Healing: Forbearance and Resulting Gifts - Part #4

Recovery & Healing: Turning “Crisis into Opportunity"

Part #4: Forbearance and Resulting Gifts

Our world has become fast, furious and bottom line oriented. Technology tools like texting, emailing, Face-Time, SKYPE, on-line shopping and others set an expectation that we are all accessible 24/7 with no "wait time." Our expectations for quick response can be almost addictive and our dependency on these technologies an addiction. Regardless, we have become "trained" to expect immediate response - It is easy to lose sight of process and that all things take their own time.

Healing is a process not an event. Recovery and healing from addiction, depression, chronic pain, distress/ burnout and other medical issues take time. These issues tend to take longer in the making and therefor are not quick to resolve -- Paying attention to the nuances of these conditions and healing is important to be able to recognize progress and sustain motivation. This is where forbearance comes into play.

Forbearance is a form of patience - tolerance or self-control, especially in not responding to provocation. Forbearance requires refraining from action: the fact of deliberately not doing or saying something when you could do or say it. This is not the same as shutting down or repressing one self, but consciously choosing to suppress action in favor of the overall good of the situation. Forbearance is necessary in life and a quality that comes with maturity and wisdom. As we get older we often come to see that we have little control over many things that happen, and that we need to find other ways to cope which go beyond "grinning and baring" or resisting and pushing through circumstances. Through forbearance we often learn more about ourselves and the process of life.

Forbearance is another learning that sounds simple but is not easy! But it is worth developing as we learn to understand ourselves, our behavior patterns, assumptions, and motivations. We also learn about others, and the overarching process of how things work in the world and how the pieces come together in their own timing. This helps with learning to be more relaxed and present in the moment and not be over-focused on the future at the expense of living more fully right now. We also learn to be more patient and accepting of ourselves and others, and be the kind of people with whom others feel safe and enjoy spending time. And, of course, our efforts and goals have more opportunity to be completed.

In order to get and to stay well staying centered, in the moment, organized and balanced is required. This may sound immensely simple but again, not easy! In behavior therapy we learn how to develop skills to focus and be more mindful (less reactive), process difficult emotions, tolerate and cope with distress and to advocate for ourselves in a graceful and effective manner. By increasing our life skills in these areas we decrease the stress and pressure on our bodies, freeing up energy for improved functioning and well-being. We establish the roots of health and wellbeing - http://myintegratedtx.com/our-philosophy/ .  

Recovery and Healing: Crisis Meets Opportunity - Part #2

Crisis Meets Opportunity

What can be more traumatic than addiction? To become aware of being out of behavioral control and attached to a substance and or process to the point of sheer destruction of one's life? Sounds pretty scary - Not to mention the "ripple effect" of such a crisis, on others connected to the individual, family, workplace, etc. This can make for a highly complex issue leaving people feeling confused, overwhelmed and powerless. However, whether one is dealing with addiction, depression, pain issues or the like, deep within the situation there is a way through it - solutions, and a gem of opportunity waiting to be discovered.

The Chinese have been aware of this phenomenon for thousands of years. In Chinese the word for crisis consists of two characters: one meaning danger, and one meaning opportunity. Why? Because crisis always feels dangerous and can indeed be dangerous. However, it is often our response to sudden or unwanted events which impact outcomes and the future; but that can be tough to see in the moment when paralyzed by fear. Our fear of danger may be necessary for self-protection in some cases, but can distract us and impair our ability to see through presenting situations and identify important information and solutions. We often miss themes and patterns that are embedded in such circumstances which are clamoring for our attention and trying to provide guidance for us to find our way. Hence, the interpretation of the Chinese proverb also says that it is the rare person who can see the opportunity within a crisis.

In talking health and wellness, we need to recognize that our symptoms are messages communicating our needs, fears and wants. As a trusted mentor once said, "It is easy for human beings to mislabel experiences as symptoms." It is natural to not want to be uncomfortable and when we do feel uncomfortable we may be apt to view our unwanted experiences as symptoms to be cured. But, when this type of thinking occurs, we miss the learning and information we need to create more productive conditions to move forward, to learn about ourselves and our needs.

Recovery and Healing: Turning “Crisis into Opportunity" - Part #1

Greetings Readers - 

Welcome to the Living Well Weekly Blog! I’m Paula Tropiano, Counselor and Behavior Therapist practicing in Chestnut Hill, Philadelphia, and West Chester, PA. Over many years of practice, I have learned that no problem is about one thing and one thing only. Most difficulties are accompanied by others, but rooted in a common issue, functioning as the “eye of the storm.” So, whether the presenting problem is addiction, dual diagnosis, mood problems, impulse control, stress/ burnout, ET al., or even difficulties with relationships and work, there are often underlying habits of thinking, emotions and or a medical issue(s) that need to be addressed.  Problems often play off of one another and be confusing then after years of building beneath the surface they intersect and then surface with the force of the “perfect storm” resulting in crisis. But, there is hope!

In my practice, Integrated Treatment Solutions, we aim to get to the behavioral “roots” of presenting challenges, including persistent conditions that impact human health, performance and well-being.  It is our goal to empower our clients to be effective in each area of their lives – To shift obstacles into challenges to be overcome, resulting in improved functioning and new opportunities.  

This Blog entry has four parts which will be posted over the month of May. Healing: Turning “Crisis into Opportunity"– is focused on healing and how presenting crisis can be leveraged to create increased opportunity for well-being - To define the difference between the notion of a "Cure" vs. the deeper lasting changes which come with true healing; to learn the difference between reacting and responding - And, ultimately, identify opportunities for growth, acceptance, and health within the crises that life presents.

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

Your input and comments are welcome.

Looking forward to the conversation!

Warm regards,

Paula Tropiano, LPC, CCDP-Diplomate

Getting Unstuck, the Importance of Perspective

One of my clients recently asked me "How can you deal with the intensity of treating addiction every day?" Given the fact that I work with people with chronic, often tough to treat conditions, this is certainly not the first time that I have been asked this question. But relayed the same usual simple response - "Where there is crisis there is opportunity." This is certainly not my quote, but part of a more comprehensive and profound set of teachings originating from ancient Eastern philosophy. However, as a clinician as well as a person on the journey of life I find the message to ring true. It is the opportunity for new possibilities packaged within the presenting crisis that I find exciting and keeps me engaged in the facilitation of the change process!

However, what does a person do when the reality of crisis sets in? When a long-term job or relationship has been lost? Or, pain fails to subside after a surgery? Or, upon diagnosis of a potentially life threatening health issue? It is normal to want things restored back to balance and back to the way they were, but everything changes and nothing ever stays the same. Our response to crisis can either move things along following the natural flow of how the universe works or our fears and resistances can prolong our discomfort and create suffering, keeping us stuck. The way we perceive and interact with the events in our lives can deeply impact our experience and ability to move forward.