Addiction and CoOccurring Disorder Diagnosis and Treatment Overview Counselor Continuing Education

Hey there everybody, and welcome to today's presentation on addiction and concurrent disorder diagnosis and treatment. I'm your host, Dr. Donnelly Snipes, and this is part of our Counselor continuing education series. In this video, we'll define addiction. We'll identify different types of addictions, explore different types of addictive thinking, identify reasons for engaging in addictive behavior, explore the impact of addiction on the individual, identify common concurrent or comorbid disorders, and finally, review common treatment strategies for people with addiction and concurrent issues. So we have a lot to cover. I want to start out by talking about what addiction is because a lot of clinicians when we go through graduate school have very little training on diagnosing or identifying or screening for or even treating addiction. So I think it's really important that we stay up to date on the information because there are a lot of people out there when you start including things other than substance use. There are a lot of people out there who are struggling with addictive behaviors. Addiction, as According to the ASAM and the DSM 5tr, addiction is a treatable chronic medical condition involving complex interactions among brain circuits, genetics, the environment and the individual's life experiences. So we're not dealing with something that is a moral issue. We're not dealing something with something that's purely genetic or purely biological. There's a lot of stuff and it requires a holistic approach. People with addiction use substances and or engage in behaviors that become compulsive and continue despite causing clinically significant distress or impairment in social, occupational or other areas of functioning. And this is a really important clause in this definition use. Whether we're talking about substance use or Internet gaming, or gaming, gambling, or just about anything that may be considered addictive is on a continuum. And there are a lot of people who engage in recreational use with no problems. And we don't want to pathologize that. So we need to make sure that we are identifying that these behaviors cause clinically significant distress or impairment in social, occupational or other important areas of functioning. So that is crucial. Key features of addiction. And I'm using the mnemonic TW crap out couldn't work in TW tolerance and withdrawal anywhere else. But in order to diagnose someone with an addiction, they need to have two of the following in a 12 month period. And I think this is really interesting because the criteria, the threshold for diagnosing addiction is actually pretty low. So most people, if any of these things are causing them clinically significant problems in one or more areas of functioning can meet the diagnosis for Compulsive use or addiction, you know, depending on whether you're using the DSM 5 TR or the ICD 11 but we'll talk about that later. Anyway, two of the following in a 12 month period. Tolerance needing more to get the same effect. Now this is not counted for medications when taken as prescribed, including opioids. Some people are on long term opioids because they have intractable pain. If they are taking them as prescribed then tolerance does not. We can't use that as a criteria. And I think it's also important to recognize that tolerance and withdrawal are not required anymore for a diagnosis of addiction. And that's really important because some substances, you may not develop a tolerance, some substances may not have a withdrawal syndrome. And when we start talking about behavioral disorders like gambling, we do see a behavioral tolerance, but we don't see the same type of physiological tolerance and withdrawal. So anyway, tolerance and withdrawal are not required, but they can be one of the two symptoms. Withdrawal Physiological, behavioral and psychological experiences when not under the influence of the chosen substance or activity or, or engaging in a substitute addictive behavior. Some people, if they're not able to access their drug of choice or their addiction of choice like gambling, will engage in something else, some other behavior in order to help them numb the pain, get that dopamine rush that they have developed the need for in order to feel like they can cope with life. So tolerance and withdrawal. And, and one of the things that we really want to consider with withdrawal is if they are engaging in those substitute activities, they may not have withdrawal symptoms. They may be self medicating with something else. But if they weren't doing that, then they may be experiencing withdrawal symptoms. The rest of the mnemonic crap out. The person experiences a craving for that substance or behavior. They're thinking about it a lot. They really can't get it out of their mind. They want it. They feel like they need negatively impacts relationships. They give up important activities as a result of use. So maybe they choose to stay home and participate in online gaming or gambling instead of going to their kids soccer game or instead of going to work. They engage in the behavior when they know it's physically hazardous. Drunk driving is a perfect example. Or drinking or using substances when you're on other prescribed medications or if you have diabetes. So if you're using, if you're doing something that you know could potentially cause you harm, that's a potential symptom. Obligations are unfulfilled. So this is similar to activities are given up. You know, they're not going to the gym anymore, they're not going to work, they're not fulfilling their obligations as a, an employee, as a spouse, as a parent, whatever. The amount of use is more than they intended. So they may intend to use for an hour or you have a drink and then before they know it, they've used way more than they intended. And the time spent using is excessive. They think, hey, I'm going to spend an hour doing this. But when we start looking at the time, the amount of time that they're thinking about it, that they're obtaining the substance or you know, driving to the activity or whatever it is, actually engaging in the activity and then recovering from the activity, we include all of that in the time spent on that particular addiction. So again, you only need two symptoms that are causing clinically significant impairment in a 12 month period. Types of addiction. I have not listed them all because there are a lot of different things that people will come up with in order to escape pain, in order to feel something, in order to get a dopamine rush. So don't think that these are the only things. But we know that these are very common things. Substance use or misuse, sex addiction, pornography addiction, gambling. And this can include stock trading. Some people become addicted to it. And with the upsurgence of crypto and options and other things, there are, there is something that can be traded pretty much any hour of the day, any day of the week. Where it used to be you could only trade when the stock market was open. Now not so much. And it can be a form of gambling for some people. Gaming, adrenaline. Some people are what we call adrenaline junkies. They're trying to feel something and there could be an underlying neurochemical imbalance there. But yeah, we'll get to that. And Internet. And this is different than gaming. This is different than gambling. This is just surfing the Internet or being on social media. It's something that they feel they need to do in order to escape, in order to numb their brain. So they may sit there for hours on end scrolling through feeds. Along with this, we start to see addictive thinking develop. When people are using an addiction that is their best coping skill they have or the one that's most effective to help them numb the pain or escape. Until now they're trying to survive. So they are often going to become very defensive if somebody tries to point out that it might be a problem. It's like, I can't give that up. You know, don't tell me I've got a problem. This is Helping me survive. So addictive thinking can incom incorporate blame. If you didn't xyz, then I wouldn't have to use if you didn't xyz, then I wouldn't have to gamble all the time. So they try to blame somebody else in order to give themselves permission to do it. A lot of people with addictions have a lack of time, perspective and fail to plan for the future. They get involved. Remember I said it takes a lot more time than they intended. They get involved doing something and they fail to plan. They fail to recognize, hey, I need, I actually have three hours of homework to do tonight or I have to get ready for work or whatever it is. Selective effort. People with addictions are going to devote a lot of time and effort to obtaining, engaging in and recovering from those addictions because that is what is again, numbing the pain. And for some people, it makes them feel. When they develop tolerance, if they're not using, they don't feel normal. And when they're using, it helps them feel normal. And I use the word normal because that's the one that they often use. It makes them feel what is normal for them? Justification. This kind of goes with blame. And a lot of times people will justify. You would use if you were in my shoes. You don't have it as bad as I do, so I have a right to use. They may minimize the impact that the substance or the addiction is having on their life. They minimize the impact on their schoolwork, on their relationships, on their health. They may engage in emotion based reasoning and emotion based thinking. I hurt, therefore I must use. I. I hurt, therefore I must make it go away. I don't feel normal, therefore I must use. They're not using a lot of higher order thinking and coping skills and problem solving. They have a feeling and they want to address that feeling. They want to make that feeling go away without addressing or thinking about is that feeling and a fact. Because feelings are not facts. Is that feeling representing a fact or is it just representing a feeling? And some people have difficulty when they're in their addiction with their inner critic. They may have started using to kind of silence the inner critic. When they sober up, that inner critic is even louder. And it tells them that they are not good enough, they're not smart enough, they can't do this, they can't recover. So when somebody hears that, they may feel hopeless and helpless and guess what? Start using again. I just, I can't deal. It's overwhelming. I don't feel empowered. I don't Feel safe. Personalization is also common in addictive thinking, where the person with the addiction takes the blame for things and says, oh, well, you're blaming me for this. You're angry. So, oh, everything's always my fault. There's a lot of cognitive distortions, but that personalization is often what we realize later is a projection. They feel like it's their fault, so they're assuming that everybody else is blaming them. And that, again, often elicits blame in them. If they feel like they're being blamed, they're going to respond in kind. Magnifying and minimizing. Magnifying the problems in their life and minimizing the resources, the strengths, the abilities that they have. A need for control is very common in people with addictions. They need to control what's going on around them so they can protect their addiction. But they also may need to control what's going on around them because of whatever that is that they are trying to escape from, which is often trauma, perfectionism. A lot of people, when they start recovery, think that they have to do it perfectly. Relapse is unacceptable. Slips are unacceptable. And that sets them up for failure because they feel like if they can't do it perfect, why do it at all? That also could be a. An excuse, a barrier, a bluster that they put up. If I can't do it right, I might as well not do it at all. It gives them an. Again, an excuse to not try. So we need to help people look at progress, not perfection. And finally, a lot of people with addictions feel powerless in life and to change. So we want to help people start feeling more empowered. Maybe they've tried to change their situation. They've tried to address their symptoms. They've tried to stop using before, and it hasn't worked. It's important that as clinicians, we go, okay, what can we learn from those experiences and that we earnestly hold the belief that change is possible? What are the motivations for addictive behavior? Escaping from traumatic memories. Very common for a lot of people. Whether it is childhood trauma that they are those memories they're trying to escape from, or victimization or war, or even coming home and finding your significant other in bed with somebody else. I mean, that's a traumatic memory. That's like, whoa. So people may use in order to try to numb or escape those memories. They may try to escape from abandonment anxiety. And a lot of times abandonment anxiety starts in childhood because they didn't have a secure attachment. But then when they get into relationships, they constantly Fear abandonment, or if they're not in a relationship, they fear that they won't be able to cope because they don't have somebody to help them. They may be trying to escape from the pressures of daily life. They don't have good coping and life skills. They don't know how to use their resources and supports. And life just is overwhelming. It's. We in. In recovery, we talk about dealing with life on life's terms. Well, they don't agree with life's terms. They don't feel like they can handle that. And for some people, they, again, they don't. They've never had the support and they've got so much else going on. You look at what's going on in their head and yeah, it's overwhelming. So we need to look at that. And they may be trying to escape from physical pain, physical pain as a result of autoimmune issues, as a result of an injury, whatever the case may be. Some people may start using in order to distract themselves. And that doesn't just apply to medication. They may be using other activities in order to try to escape that physical pain. They may use in order to numb or control their emotions. A lot of people with addictions have very poor emotional intelligence. This is not saying that they're stupid by any means. They're very bright people. They have not been taught how to identify their emotions, how to regulate or tolerate and then regulate their emotions. So when they feel something, it's just like, oh my gosh, this is overwhelming. I need to make it go away. So they try to numb it or control it. And some people use to help their attention. If they have a history of trauma or if they have adhd, particularly those two examples, they may be hypervigilant or they may have difficulty with what we call sensory gating. They may have difficulty filtering out un unnecessary stimuli. So they have difficulty paying attention. And they may gravitate towards substances that will help them control their attention. Some people use, and this is kind of like escape, but a little bit different to silence. They use to silence that inner critic that I talked about that is so nasty to a lot of people. We tell ourselves things that we would never tell anybody else. And sometimes we have memories of abusive or neglectful caregivers telling us things that we would never tell anybody else. So and those memories get programmed into that inner critic. People may use to silence that. And some people who are having psychotic breaks maybe use to silence the voices. And that's a very small proportion of the people with addictions. But it is important to recognize that for some people, using is how they've been self medicating until now. And for some people, the medications that are used to treat psychotic disorders have so many side effects that they, on their own, you know, doctors wouldn't recommend it, but on their own they decide to not use their medication and instead self medicate through something that has lesser side effects in their, in their mind. Some people use for recreation, they're just, they're, they're bored and they need to use. Now unfortunately, when the brain starts getting used to having that, that dopamine, those endorphins surging then when they're not using and it takes more to get that same feeling of relaxation and recreation. If they're using for recreation and it's not causing problems in one or more areas of life, then we need to recognize that continuum. We need to respect the continuum. If they're using it to recreate, to wind down, but it is taking four, five, six hours a day and they're not getting other obligations done, then it's becoming a problem, even if they're defining it as recreation. And some people do use for revenge. Look what you made me do. If you wouldn't, and this goes back to the blaming, if you would do this, then I wouldn't have to do that, or if you wouldn't do this, then I wouldn't have to do that. And it's a, it's an aggressive measure to try to punish someone else when it doesn't seem like they've been able to communicate or effectively punish or control that other person. We need to recognize we can't control other people. So what is the impact? And I went through all that initial stuff, for those of you who are not super familiar with addictions, to kind of get into the mindset of someone with addictions and it's important to recognize that it is almost never in, in my clinical experience, people almost never just have an addiction. They have an addiction and a mood disorder, they have an addiction and something else. So it's important for us to recognize that we have to treat the person biopsychosocially in order to help them prevent relapse. So physical HPA axis dysregulation, when people use it alters their neurochemistry, it alters their stress response, even if they're using is producing an adrenaline rush. We've talked about that before. The HPA axis engages for fight or flee, but it also in engages for euphoria. So when they're feeling super Excitement, they're having that rush of those excitatory neurochemicals. And when that is sustained for too long, it can result in HPA axis dysregulation. We also recognize that a lot of issues, especially trauma related issues, will result in HPA axis dysregulation that people may try to numb with addiction. So we need to look at the HPA axis. That is, you know, a baseline issue that I go over with people that I work with. The microbiome is also altered, which impacts mood, reward salience, impulsivity and liver function. Well, we know that using especially substances can impact liver function. So that's one of those things. But if people are using and engaging in behavioral addictions, the stress of those addictions, the stress of the alterations will also alter the microbiome and may cause systemic inflammation and impact liver function with reward salience. This is particularly true about substances, including food. But if the body gets used to having a particular substance ingested, then when they don't have it, you know, talking about that tolerance and withdrawal, when they are starting to experience withdrawal symptoms, when they have that substance again, that substance is increasingly rewarding. It's like, okay, you know, it's almost like the life breath the person has. And interestingly, they're finding that the microbiome is also involved in people's impulsivity. So we want to look at obsessive compulsive behaviors, we want to look at emotional dysregulation, we want to look at addictive behaviors and ask ourselves, you know, what part of that is has an impulsive component to it. Regardless of the, whether it's an addiction or a mood issue, we often see increased inflammation and inflammatory disorders. As inflammation goes up, depression and anxiety go up. As depression and anxiety go up, inflammation goes up. We're not sure, you know, which one came first, chicken or the egg, but we know that they tend to be very strongly correlated with one another. And people who use substances, engage in addictive behaviors often have poor coping and distress tolerance skills, hence the reason they're using, which means they often also have difficulty with sleep. And this can be because they are too stressed out. It can be because of a trauma history, it can be because of the effect of a substance or a behavior that they're engaging in. There's a lot of reasons their sleep and their circadian rhythms can get out of whack. However, it is vital that we recognize the importance of sleep in recovery. And, and I can't stress that enough, we're not taught that at Least we weren't, I don't know, 20 some odd years later. If you're being taught more about the biological impact on mood. But sleep is crucial in and, and circadian rhythms are also crucial in maintaining the health of the hypothalamic pituitary adrenal axis, the HPA axis, the hpg, which is the hypothalamic pituitary gonadal axis, and the hpt, which is the hypothalamic pituitary thyroid axis. All of those axes are involved in the stress response as well as the relaxation response. They need to turn off, they need to turn down for the relaxation response to kick in. And we need to recognize the impact of inadequate quality sleep and inflammation on, on the person and on the development of their symptoms affectively. A person with an addiction often is struggling with anger, guilt, resentment, anxiety, depression, despair and loneliness. And when we look at people who develop addictions, a lot of times they had one or more of these that were just overwhelming, that contributed to the increased use. They may have been using recreationally and then, you know, life threw them a whole bunch of, of lemons. We do want to recognize this and identify, not help them develop their emotional intelligence. How do I identify these feelings? How can I tolerate and cope with these feelings? But we also need to look at the underlying issue. What is causing these feelings? Is it something, an event that happened right now, or is it stuff from the past that is currently negatively impacting you in the present cognitively? People with addictions and most mental health disorders experience brain fog. It is difficult to concentrate, they're not sleeping well, adenosine is building up, their neurotransmitters are kind of out of balance, norepinephrine may be low. They're going to experience brain fog, which can be exasperating because with brain fog it's just hard to think. Like it's hard to drive through the fog. It's hard to think through the fog. And pessimism. There's a lot of pessimism because most people by the time they've come to treatment have tried to quit on their own and have been unsuccessful, or they have tried to heal themselves on their own, address their trauma or their depression or their anxiety, and it hasn't worked. So they started self medicating. So they're pessimistic that true recovery is actually possible. Environmentally. We need to examine financial instability as a result of spending too much on the addiction or failing to go to work and housing instability as a result of financial instability. If people don't have the ability to meet their basic needs. Food, shelter, safety, medical care and dental care. It's going to negatively impact their ability to successfully move into recovery and relationships. People with addictions and psychiatric disorders often struggle in relationships with feelings of shame and low self esteem. There may be conflict because the other person doesn't understand what is causing or maintaining those behaviors and those feelings. They may feel isolated because they don't feel like they're understood and or they may isolate themselves because they're like, y' all are just too much stress, there's too much drama. I just, I want to be alone. And there may be paranoia, paranoia that somebody's going to find out about their, their disorder, they're going to find out about the addiction. And, and so we need to destigmatize as much as possible. There's a lot of stuff we're going to talk about in addressing all of these things, but we can't just pluck out the addiction from this list and say, we're going to treat this. We need to address the person. We need to address the situation in general. Addiction begins for recreation. People experiment when they're in high school or college and they're like, oh, this is pretty cool. Then something happens and they may start to use more frequently, more heavily for self soothing, to help them relax in the evening or to help them cope with a particular particularly stressful situation. As that happens, they may begin increasing the frequency, intensity or duration of their use. So they are starting to develop a habit, if not a tolerance and to that particular behavior or substance. And when they're not using, then they may sober up, if you will, and look around and recognize, oh, I failed to go to work, I disappointed my kids, I did this, I did that. They feel even worse about themselves. So what do they do? They start using again. And they may use to cope with cravings and other withdrawal symptoms. When they start using frequently, if they're not using, if they're not engaging in that habit, that behavior, using that substance, they will have cravings. Their brain's going, something's not right here. Our dopamine is low. Dopamine levels are lower than they should be. So they may start having behavioral, physiological and emotional withdrawal symptoms, common concurrent issues. And I'm not going to go through all of these in depth, But I think it's important to recognize that if somebody presents in your office with adhd, we need to screen for trauma, we need to screen for addiction. Doesn't mean they're going to have it, but because these things co occur so frequently even if they're not presenting for addiction treatment, we need to understand that addiction often co occurs with other stuff and failure to address the addiction usually results in failure of the person to achieve their maximal recovery. So adhd, screen for trauma, screen for addiction, screen for substitute addictions. When you're not using or engaging in your addiction of choice, what do you do? When I worked in residential, people would turn to gambling, sex or food, usually in the residential treatment center. And yes, they weren't supposed to be having sex, they weren't supposed to be gambling, and we had way too much highly palatable food that they could use in order to numb feelings. But when that craving is strong enough, when that dopamine is so low and they're going, I got to make this feeling stop or I've got to silence those voices or the inner critic, there's a lot of motivation there. It's important to recognize this and help people recognize. Smoking is another one. People who were in residential would often start, this was when our facility was a smoking facility. They would start smoking a whole lot more, they would start eating a whole lot more. It was not uncommon for somebody to put on 10 or 15 pounds in 45 days. Adverse childhood experiences often co occur with addictions as well as mood disorders and trauma. So recognizing that every person you deal with, whether you're a physical health doctor or you are a mental health professional, every person you deal with should be screened for adverse childhood experiences and trauma, anxiety and depression. Whether it existed prior to the addictive behaviors or developed as a result of the addictive behaviors, it exists. If we don't treat it, it is a relapse trap. Bipolar disorder, very common, just like I mentioned, for people with psychotic disorders. Very common for people with bipolar disorder to be medication non compliant because they miss the highs. They don't miss the lows, they miss the highs. So they will not take their prescribed medication and instead they will try to self medicate their depression and trigger as many hypomanic or manic episodes as possible. And that's not healthy, obviously not recommended, obviously, but it is something we see. So if you're working with somebody who has bipolar disorder, monitoring medication compliance is important as well as monitoring addictive behaviors. When people are in a manic or hypomanic episode, they are much more impulsive and much more likely to engage in problematic addictive behaviors, whether it's gambling or sex or porn. One of the early warning signs for a lot of people that they're getting ready to enter into a manic or hypomanic episode is hypersexuality. Note that. Recognize that that may be a clue that may be a symptom of their bipolar disorder. And it's important to help them develop tools to cope with any symptoms or breakthrough symptoms that they experience as a result of their bipolar Cardiovascular disease. Extremely common in people with addictions. Whether it is cannabis or alcohol or smoking or other things, A lot of addictions negatively impact the vasculature in the body and contribute to heart and lung diseases. It contribute to high blood pressure. So again, if you're a medical professional, recognize that there may be underlying addictions that may need to be addressed. And again, all of these, there is a high likelihood of a history of trauma. So always screen for addiction. Always screen for trauma, chronic illness and pain. Another medical doctor issue. Although some people may come to counseling to figure out how to deal with the depression or the anxiety from the chronic disorder, we need to see how they're coping, what they're doing to cope. And again, screen for trauma and addiction. Eating disorders, very common. Substitute addictions, very common concurrent addictions with, if you want to call it an addiction with substance addictions, screen for them. Recognize a lot of people with eating disorders will misuse substances in order to maintain weight. A lot of people with food addiction. Also, there's a hot, really high correlation between alcoholism and food addiction. Different video, have it on the YouTube channel, but be aware of that. So screen. A lot of people with eating disorders have trauma. So screen liver diseases. We already talked about that. Very common, especially in people who use substances. And it's not just alcohol. Any substance that is used to excess is really hard on the liver and can contribute to liver diseases. Malnutrition. Some people, when they're in an addictive state or when they're in a depressive state, don't eat good, don't have good nutrition. Okay, so that's one potential cause of malnutrition. Other people may be eating a very healthy diet. Thank you very much. But the substances they're using, particularly substances, may prevent adequate absorption of those nutrients. There it the substances are contributing to systemic inflammation, which are contributing to poor absorption. If somebody is. You're seeing them for a mood disorder or. Or psychiatric disorder or an addiction, screen for nutritional deficiencies. If people do not have the building blocks to make the neurotransmitters to heal their body, no amount of talk therapy is going to make those building blocks. So we need to make sure that they have access to those things. Refer to a physician or a nutritionist, dietitian when necessary. We also see a lot of overlap with obsessive compulsive disorder, ptsd, complex PTSD and sleep disorders. So let's talk about treatment issues and strategies. What do we do? I've talked about a lot of things and it may seem overwhelming to you that, oh my gosh, you know, I always just treated the, treated the depression or treated the anxiety or addressed the addiction. Now you're telling me I have this whole buffet of things that need to be treated. And the answer is yes, but the answer is also do it in a stepwise, a stepwise pattern. You don't have to address everything all at once. Matter of fact, don't, because that's likely not going to be sustainable for the person. Identify two or three things that they can work on. What are they most motivated to work on or most willing to work on? Start working on those. Those will produce positive changes in everything else most, most of the time. And then once they get those behaviors solidified or address those issues, then they can identify two or three more and just start kind of knocking off the issues two or three at a time until the person has achieved what they define as recovery and a rich and meaningful life. These are not in any particular order, although I, I tend to like to start with the base of Maslow's hierarchy and address the physiological issues, sleep and circadian rhythms. People who are not getting adequate quality sleep are at much higher risk of inflammation, depression, immune system problems and addiction. Educating them about the importance of these things is really important, but also recognizing that many of these issues, sleep and circadian issues, are due to trauma and are due to other things. We also want to screen for sleep apnea. Sleep apnea is far more common in people with addictions and people with trauma histories than in the general population. And sleep apnea will really screw with your sleep quality and your circadian rhythms. If somebody has sleep apnea or you think they do make the referral they really need to get that treated. Nutrition, we are not nutritionists or dietitians. Have them keep a nutrition log on an app, on their phone, or on their mobile device so they can figure out am I getting enough of what I need? And refer them to their physician. So important to identify some of these underlying issues like hyperthyroid, hyper or hypothyroid anemia, vitamin D deficiency, hormone insufficiencies. All of those things can be identified in a decent physical with blood work. And the doctor can help assess because remember I said the person may be eating a great diet, but it's not getting absorbed because they've got inflammation in their gut for some reason. We need to address autoimmune and chronic conditions, make sure they're working with their medical treatment provider to develop a treatment plan. But then we can help them maintain mo motivation for that treatment plan and, and help them deal with depression, the anxiety, the guilt, the grief, the anger over having a chronic condition, over experiencing flare ups and surges. We want to address pain and that's one of those things that Jaco tells you to address anyway. So it's important to screen for pain, chronic pain, acute pain, and make referrals as appropriate. But just like other chronic conditions, somebody who has chronic pain may need to develop unique coping skills. They may not have figured out what helps them manage their pain, what helps them tolerate their pain and use their energy to move towards a rich and meaningful life. They may feel pain and just kind of get stuck in that quagmire. And we need to screen for post acute withdrawal. And anybody who's got an addiction, behavioral or chemical, has been altering their neurochemicals, they've been altering their neurochemistry and their neurocircuitry. We know this. And when they are not doing that anymore, when they're not causing incredible surges of dopamine and norepinephrine and, and stuff in their brain, the brain is going to go, excuse me, we're a little light on the dopamine. And people will experience that the body doesn't respond immediately to the person not using. So they will experience cravings, they will experience fatigue and lethargy and brain fog and you know, all of the things that we talk about in the post acute withdrawal video and these things can go on in some cases for up to three years, but the symptoms are worst right at the beginning in early recovery and get much milder, milder and fewer and farther between. So people have fewer episodes, if you will, as they get more sobriety, more clean time, more recovery under their belt. We need to treat for mental health disorders, mood issues, including bipolar. We need to monitor compliance with any prescribed medications, especially for people with bipolar disorder or psychotic disorders. We need to address PTSD and cptsd, even if you don't think it meets the threshold for diagnosis. If somebody has a trauma history, we need to explore how that trauma may be impacting them in the present and help them develop tools to feel safe and empowered in their skin. Right now we need to examine personality disordered behavior and I'M very passionate about this because I see a lot of emotional dysregulation, a lot of manipulation, a lot of what we would normally identify particularly as cluster B type personality disorders in early recovery. This is the person's HPA axis being out of whack. This is the person not having tools to deal with the emotions. So they're experiencing those physiological symptoms that they may have been medicating, if you will, self medicating until now. So I tend to stay away from any actual diagnosis of a personality disorder until the person has at least a year of recovery under their belt. But I do want to look at the behavior and explore what might be causing this and how might this be related to untreated trauma or the after effects of long term addictive behavior? Post acute withdrawal and psychotic disorders obviously also need to be addressed and treated. We need to identify grief and loss issues. Now I put this outside of mental health disorders because grief is not a disorder. Yes, I know DSM5TR added prolonged grief disorder. But that aside, grief itself is not a, is not a disorder. And we need to explore grief and loss issues unrelated to the addiction. Things that happened in their life before they started using or even while they were using that were not related to the addiction. Maybe they had a parent die or a house burned down or something. We need to address those issues. And we also need to address grief and loss and guilt related to the addiction relationships, for example, that they lost as a result of using money, experiences, time, jobs that they lost as a result of using cognitive functioning. We need to explore, and this is another one that I'm passionate about, explore their temperament. And you can have them go online to the Kircy Temperament Sorter or whatever. But that's the shortest one. They don't need to do the full mbti. Extroverts tend to think while they talk. They tend to draw energy and motivation from being around others. They will do really well in group therapy and support groups. Introverts, not so much. They like to. They tend to like to do a deep dive on things. They like to know a lot about a particular topic. They tend to be overwhelmed in large groups. It's just there's too much going on. So those people would do better in one on one counseling. Would do better in small groups in 12 steps. We call these like big book studies. They're not going to benefit nearly as much from groups of 12, 15, 40 people. Sensing and intuitive people. The sensing people tend to focus on the details and they miss the big picture. They're so busy planning out their schedule and their recovery, they miss the fact that this is all to help them have a happier, rich and meaningful life. So they get stressed about doing tasks instead of experiencing life. Intuitors on the other hand, are the big picture people and they can start focusing on the feelings of recovery and how much better they feel in these broad strokes. But they miss the details. They miss, okay, when am I going to go to my meeting or when am I going to go to counseling? When am I going to do my journaling? Both people have potential relapse traps in their in their recovery plan that we need to address. Just temperamentally thinking and feeling really talks about how people are motivated. Thinkers are motivated more by facts. Feelers are motivated more by fact, relationships and how something makes them feel. So this is really helpful when you're doing motivational enhancement activities and then judging and perceiving. Judgers tend to be and this tends to refer reflect more on time management. Judgers tend to be very structured, very deadline oriented and may not make use of opportunities when they come up because it's not in the plan. Perceivers get really bored with plans really fast and they will start to kind of go off and do their own thing. So when you're talking about a long term recovery plan, the perceivers need a lot more wiggle room. Maybe they know they need to go to three support group meetings a week. Okay, well they can figure out what days they want to go to those and where they want to go to those. The judger will know exactly what meeting at what time and it's it's on their day planner. We need to recognize these unique issues for different people and help them figure out how can I create a relapse and recover prevention and a recovery plan that I'm most likely to follow through with. We need to help people develop mindfulness skills. A lot of people in with mood disorders, with psychiatric disorders, with addictions, with trauma don't have a lot of mindfulness. They have either been intentionally trying to numb things out so they didn't feel, they didn't notice, or they never learned how to be mindful. And in order to keep relapse from sneaking up on them, they need to be consistently aware of their thoughts, wants, feelings and needs. Mindfulness skills is one of the most important skills in my opinion for relapse prevention. If people aren't aware of what's going on in themselves, then they can't address it before it comes becomes a crisis. We need to address cognitive distortions that's true. Regardless of the issue you're dealing with. And we need to help people develop coping strategies. I have several videos on improving emotional intelligence, but basically we're helping them get back to basics and identify what emotions look and feel like in themselves and what triggers those emotions get to know themselves. Then they're going to develop skills to tolerate those emotions even if they can't make them go away. To tolerate and say, okay, this, this feels awful and it won't crush me. And tools to regulate those emotions. Once you get into your wise mind, okay, how can you improve the next moment? How can you. If it's good, if whatever's going on is good, how can you keep it going and Address Learning Disabilities A lot of people who develop mood disorders, low self esteem, addiction, have undiagnosed learning disabilities that contributed to the development of their problem when they were in school because they struggled a lot more than some of their peers and they didn't receive the support that they needed in the environment. We need to make sure they have access to medical and dental care, financial resources, and safe and stable housing resources. As clinicians, most of us, this is considered outside of our scope of practice, but it's important that we make referrals. United Way 211 is a good place to start. Your social services department is a good place to start. I encourage a lot of therapists if you're working in a particular area, if you're doing telehealth, it's a lot more difficult. But if you're working in a, in a city, in a town, in a community, identify and make a resource list for people that you can give to them to help them figure out where to find these resources. Now not everybody is going to be able to follow through. Sometimes calling and making an appointment is overwhelming to the person. So we need to make sure that once they have the resources, they can actually use them. But it is important that medical care, physiological issues, addressing nutritional, hormonal health, pain issues, those are all important. And they've also found that there is a strong correlation between poor dental health and microbiome dysfunction as well as mood disorders. So dental care is also important. Financial resources and housing that's safe and stable to be in recovery, to be able to live that rich and meaningful life, people need to not be worried every night that when they try to go to sleep that they're not safe or worried every day that they aren't don't know how, that they don't have somewhere to sleep that night. And finally, relationships. We need to Help people work on self esteem. Help them learn about their inner child and how those experiences from childhood may not have actually been dealt with. So they have a lot of fear memories from the past or anger memories from the past that they need to deal with. We need to help them identify their attachment style and if it's insecure. Learn how to develop a secure attachment with themselves first as well as with other people. What is, what is a healthy relationship with a secure attachment look like? A lot of people need help developing assertive communication. They've either been taught to be passive or aggressive. They need help with relationship skills like boundaries and social anxiety. They may need to explore their relationships with supportive people and harmful people. Make a list of who's in which, which area and which relationships do I want to use my energy to try to nurture and or repair. In terms of treatment objectives, this is something I learned after grad school, but I found it to be invaluable. When we teach people about something, it's important that they first learn about it. So learn about depression. Learn about addiction in general. What are the symptoms and what causes it? Okay, now that I know in general, let me look at my experience. Let me learn about my depression or my addiction. All right, great. I figured out what's going on with me. Now what do I do? Learn about strategies to address specific symptoms like fatigue or craving or depression or anxiety. Okay, so there's strategies to address that. Now which strategies would work for me? Because each. Every strategy doesn't work for every person. It's important for them to think about what has worked for me in the past, even if for just a little period of time. And might something similar to that work for me in the present? And how can I make it work better? Once they've identified what causes what their symptoms are, what may be causing their symptoms, they've identified strategies to address it. Then they need to practice those chosen strategies in session. If they're in counseling or in a safe setting. If they're trying to do self help, not just go out willy nilly and start trying to use them at work and at the grocery store and everything until they're comfortable with it, and then practice chosen strategies in real life. Addiction rarely occurs by itself. Addiction has helped the person survive until now. The underlying pain, emotional pain, physical pain and skill and lifestyle and resource deficits must be adequately addressed to prevent relapse. Think again about Maslow's hierarchy. If the body isn't healthy, if the body isn't working, then the person's going to have difficulty finding the energy to do the things they need to do to nurture relationships and to feel safe and to develop self esteem. So we need to look at the person in totality. But remember, as I said earlier, don't try to fix everything at once. This took a long time to develop. Identify two or three things that the person can work on right now, and once they address those issues, then two or three more things, because we want to make sure that they have success in treatment instead of feeling like it's failed them yet again.