Beyond Willpower: Nervous System Regulation for PAWS (Counselor CEU)

Foreign. I'd like to welcome everybody to today's presentation on healing the nervous system in addiction and post acute withdrawal syndrome. I'm your host, Dr. Donnelly Snipes. Today we're going to define addiction and pause. Examine the impact of addiction on the autonomic nervous system, including physical, interpersonal, emotional, cognitive, environmental and spiritual effects. And we'll highlight often overlooked treatment areas. Now, y' all know I have worked in co occurring disorders treatment since the last century. So I've seen a lot of different approaches. But I've also seen a lot of the things that we miss because we are focused too much on keeping people clean and maybe developing a few skills and not enough on healing the whole person and helping heal the body, which, you know, obviously we've got to start somewhere. But if we use a multifaceted approach, then people are often going to experience improvement in their symptoms a lot sooner. So addiction is continued use of a substance, behavior or a person to escape from pain in one or more pieces of life. Physical, interpersonal, emotional, cognitive, environmental or spiritual, despite experiencing problems in one or more areas of their life as a result of use. So if somebody is drinking alcohol and maybe they're using it, they're drinking alcohol in the evening because they had a hard day at work. All right, well, is it the best coping skill? No. But if they are not experiencing problems in one or more pieces of life as a result of their use, or if they start to experience problems like their significant other says, you know, you coming home and getting drunk every night really impacting the kids and they stop, then we're not looking at addiction, we are looking at heavy use. But the key features are using that causes problems in one or more pieces of life, including physical, and they continue to use despite those problems. Now, when I say pain in different pieces of life, it's important to recognize that withdrawal is also painful, emotionally, cognitively, physically. So it may not be what we think of as physical pain. Like you drink alcohol and it, you know, tears up your stomach. It may be psychological pain, it may be distress in some other form, spending more time, money or energy, thinking about getting, using or recovering from use. This is important too. We see it with chemical as well as behavioral addictions and giving up important activities or failing to meet responsibilities in one or more areas of life. Now spending more time, money or energy or, or giving up important activities. Obviously those are signs of problems or distress in one or more pieces of life. So this is, you know, really where we're looking at creating some sort of division between Recreational use, even heavy recreational use and addictive behaviors. Pause is what we usually call it. It's post acute withdrawal syndrome, and that is a great big old mouthful. Pause is a lot easier. And it's a constellation of symptoms that people experience as their nervous system and their gut microbiome and everything else heals. It's a constellation of symptoms that people also experience while their body's healing. Their neurotransmitters are kind of out of balance and they're trying to deal with traumas and resentments and anxieties and other things. So they got a lot of crap going on. They really do. Which would make just about anybody feel apathetic, exhausted, just feeling unwell. I just don't have any get up and go. I don't, you know, I just feel cravings for use. Well, the use generally supplied increased serotonin, increased dopamine, increased endorphins. So when you're feeling unwell, apathetic, unmotivated, it makes sense that your body's going, hey, I know how we can fix this irritability. When we're stressed, we trigger the stress response system. When the stress response system is triggered, we are triggering those irritability chemicals. We tend to be more easily agitated and, and remember going back to that bucket when we are in. Well, even when people are using and in early recovery, there's enough going on in the body, in the mind, in the relationships, that they have got that bucket filled up with stress. So it doesn't take much to overflow the stress bucket. And when people are in early recovery, not only is their stress bucket up here, you know, almost full, but you've taken away, or they've taken away the one tool that they've been able to use that's actually sort of numbed the pain so they didn't overflow. So yeah, we're going to expect more emotional ability, more irritability. Unfortunately, pause can last for one to two years post detox. And you're like, excuse me. Yeah, okay. But the good news is the good news, it doesn't let last in the same intensity and duration. People who experience pause the first three to six months, depending on what they used, how heavily they used, co occurring issues, etc, first three to six months can be pretty tough. It can be very gray. They can feel very irritable and feel like they've got more of a hair trigger, they dysregulate more easily. As their body starts to heal, those episodes of irritability go down because they've essentially drained some of Their stress buckets. So they've got a little bit more room to work with, but their body is still miscalibrated, their nervous system is still miscalibrated. So there's still a lot of stress on the system. And we're not going to get that stress bucket as low as we would like early on. It's going to be easy for them to fill it up and over overwhelm, over overflow. Okay, that's fine. But what we see with pause is as people heal, they're draining that bucket and the intensity, duration, and frequency of their paws. So symptoms goes down, the intensity, frequency, and duration goes down. So what we want to look for is gradual progress. And I always try to make the analogy with a physical condition. After somebody has a stroke, you don't expect them in a month to be up running a marathon again, probably not very likely. What we want to look for is gradual improvements in their symptoms. Same thing is true in post acute withdrawal. Some people really struggle with the apathy, with the cravings, with the frustration, and in their interpersonal relationships. A lot of times when their significant others see apathy, irritability, emotional ability, and just, you know, not being really motivated, significant others often assume that that means the person's using again. So we really need to do a good job of educating support people about post acute withdrawal. And could it mean they're using again? Sure it could. But we need to get the, we need to get fitcat facts in this context at this time. What do we know and what is the person doing? We don't want to accuse them of something that they're not doing. They're trying their hardest not to do. And how, how irritable do you get? I know I do. I get irritable if I know that there is a big piece of chocolate cake downstairs and I want it. And I know that, hey, it's after my eating window, can't have that chocolate cake. Do I tend to get a little bit more irritable? Yeah, because I want that chocolate cake. And chocolate cake is nothing compared to what a lot of people are addicted to. So think about how irritable they may feel when they're having these cravings, when they're experiencing this distress and they know that there's something they could do to make it go away, but they're choosing not to do it. They're doing the next right thing. We want to support that, no matter how cantankerous they are. Substance use and addiction impact the autonomic nervous system. A lot of People think it just impacts neurotransmitters. Well, no, it impacts the whole kitten caboodle. Your gut, microbiome, your nervous system, your vagus, everything. Substance use floods the body with a toxin. This is stressful. When your body is flooded with a toxin, it goes, oh crap, this is not suitable for survival. You know, things are out of whack. This is a problem. These toxins alter neurotransmitters in unnatural ways. All of a sudden your dopaminergic receptors are just being inundated with dopamine and your endorphins are being. Receptors are being inundated and they're just like, oh my gosh, I can't take it. This is too much. Think about the poor people that are working in retail on Black Friday. You know, kind of like that. It's just like, oh my gosh, I wanted customers, but not this many. Thank you. When the substance leaves the body, the autonomic nervous system cannot compensate as quickly just because the, the substance isn't there. The alcohol, the opioids, the testosterone, whatever it is, it leaves. And then the receptors are like, what happened? Wait a minute. I was just starting to get used to being overwhelmed and now all of a sudden all I hear is crickets. And it's a very stark contrast, which is when people start craving again. And this is obviously more pronounced in people who have addictions and they've become tolerant because it means that the receptors no longer are triggered by normal levels of dopamine, norepinephrine, endorphins. They get those normal physical physiological levels of those neurochemicals. They're just like, eh, whatever I'm not worried about takes a supra therapeutic dose, which is readminister. This substance. Now can the body heal and learn? Reawaken if you will? It's oversimplified, but reawaken those receptors certainly. But it takes the body a while, months sometimes to recognize, hey, I'm not going to be flooded anymore, so I can be a little bit more sensitive to what's going on. Engaging in addictive activities also floods the body with supranormal levels of dopamine, endorphins and possibly certain hormones they found with pornography and sex addiction, for example, that the combination, especially for, for men, the combination of the dopamine, the endorphins and testosterone, they actually enhance each other and make that rush, make that intoxication more potent than any of those neurochemicals could do individually. In any event, you're still flooding the body with supranormal levels. Yeah, you're not ingesting it in some way, but you're ramping it up in unnatural ways. These high levels of neurotransmitters alter other hormones and neurotransmitters, which create stress on the body. Anytime any system gets out of balance, it's stressful, and that will trigger the stress response. As the stress response is triggered, we start to see changes in motivation, changes in mood, we start to see epigenetic changes because stress triggers a whole different set of genes to be turned on in your DNA than no stress engaging in the behavior. Enough people can become dependent on it to have normal levels of hormones or and neurotransmitters or else they have cravings. People who engage in behavioral addictions, gambling, porn, sex, whatever, very often do have very legitimate physiological cravings in addition to psychological cravings because their hormones, their neurotransmitters, their nervous system, totally out of balance. Other stressors common to all addictions. So not only the use of the substance or behavior throwing the neurotransmitters out of whack, but other things that we see or my, in my experience, I've seen in most people that I have worked with with addictions, circadian rhythm disruption. Even the very few people who are keeping a steady sleep schedule, they're not sleeping as well because their neurotransmitters aren't there. Because their cortisol is too high, not enough melatonin, they're not getting good quality sleep. Gut microbiome disruption. Remember, the foods we eat are taken in and broken down by microbes and repackaged into hormones and neurotransmitters. And what we need to survive, if those microbes are disrupted, killed off, become imbalanced, then we're going to have a hard time making those hormones and neurotransmitters. We need to feel good again. Just like the nervous system can retune itself, the gut microbiome can repopulate itself when people are eating a healthy diet. And this is one of the areas that we really need to focus on, in my opinion, more effectively in I in outpatient treatment programs, educating people about the importance of nutrition, as well as in some residential programs. Um, one of the residential programs that I worked at, they had really good food, but in terms of being anti inflammatory, not so much. It was very southern, very high fat. Yeah. Not a lot of color, not a lot of fiber, so it wasn't anti inflammatory. And the body, when it's recovering from addiction, has a lot of excess Oxidative stress that needs to be cleared out. Remember, oxidative stress are the byproducts of living. But when we're stressed, we produce more byproducts, we produce more trash. And generally if you're eat not eating an anti inflammatory diet and doing all the things that you need to do to be healthy, which most people in addiction are not, then that oxidative trash builds up and we need to help people get it out of their system. So an anti inflammatory diet is helpful. That all that means is having a diet that's rich in fiber, that's colorful and that minimizes overly processed foods. Ideally it has a good dose of omega 3s but you know, the first three definitely. And that can really help the gut microbiome heal because guess what? Those foods and fiber feed the microbes. If you give them healthy microbes, the food they need, then they will repopulate. We also see alteration of thyroid and gonadal hormones and neurotransmitters. I've said it before, I'm going to say it again probably a hundred times. They act as a unit. Estrogen, testosterone, make certain neurotransmitters more available or less available depending on their levels. Oxytocin is also implicated. We have, and then we have all of our neurotransmitters. When one of them gets out of whack, all of them get out of whack. So if somebody is experiencing and you know, we're thinking addiction recovery as well as pause during those periods, they're experiencing deficits, insufficient amounts of dopamine and endorphins compared to what their body expects. So that throws the system out of whack until it rebalances increased pain. Believe it or not, when we're under stress, we tend to start feeling increased pain over time. Initially in the acute stress response, cortisol secreted. And cortisol is an anti inflammatory. It also brings along endorphins to help us not feel the pain as much because it wants to help us fight or flee. But if we continue that stress over a long period of time, then the receptors in our body become less sensitive to cortisol. Cortisol loses its ability to suppress inflammation. Endorphins lose their ability to suppress pain as much. So people actually feel more pain. And when we're in pain, that's distress and it impacts how we feel, it impacts our motivation, impacts our sleep and hyper vigilance. A lot of people who are in early recovery are hypervigilant. They in their addiction, they became hypervigilant becoming suspicious, trying to protect their addiction, being aware of everything around them. If they were un in unsafe environments, they were trying to be aware of everything around them. In recovery, people sometimes become hypervigilant to triggers for use. They are constantly scanning to see if they're safe, see if there, there's anything around them that's going to trigger them to use. Other people are just plain hyper vigilant because of trauma histories that are now not being met, self medicated or suppressed. But there's a lot of hypervigilance, the stress response, because especially combined with continued use of substances for a period of time, the person often develops sympathetic dominance which doesn't just magically go away when the substances are cleared because neurotransmitters, hormones are still imbalanced. Stress is still there. When we're stressed, our body doesn't really rationalize. You know, I'm stressed for this reason, so I don't need to pay attention to that. No, our body is like, I'm stressed or I'm not stressed. And when we're stressed, we tend to be more hypervigilant to, to anything. We tend to be scanning for more threats in the environment. We tend to interpret things cognitively and I'm jumping ahead of myself through a more negative lens. So paying attention to this in treatment, making sure that people are going to bed and getting up at about the same time. Most residential treatment programs are really good about this. However, IOP programs and outpatient programs, obviously we don't have any control over when people go to sleep and get up. So we need to educate them about the importance of circadian rhythms and how to set them, making sure that they are in a dark, quiet, cool, safe environment. The gut microbiome, we can educate people in outpatient and we need to work with our dietitians in residential to, to make sure that we are creating within budget, of course, a meal plan that can support the rehabilitation of the gut microbiome. You don't need any fancy things. I mean ideally if you can get some yogurt in there, that'd be fabulous or kombucha or something. But that's usually not available. Sometimes yogurt may be available in some of the, in some of the treatment centers and that's fabulous if you're an iop. What I've done before, or even outpatient. What I've done before is have spend a group educating about nutrition and then we create together a list of foods that they want to start including in their daily consumption. Each person's going to have slightly different foods. Some one person may like blueberries, another person may like blackberries or, or whatever. And I encourage them, we go through color by color and I encourage them to identify foods that they like. We go through different fibrous foods and I encourage them to identify foods they like. Not necessarily making a full menu, but, but this way they have a list of foods in each group that they can pluck off of as they're eating. A healthier diet. That is the easiest change for a lot of people, especially, especially if they're an Iop and they're cooking for a family. It may not be super easy to switch from mashed potatoes and chicken nuggets every night to, you know, this colorful diet. But we can talk about ways to sneak it in, have their doctor test them for the balance of their nutrients, their, their homocysteine, which will help measure vitamin B12 utilization, their thyroid hormones and ideally gonadal hormones. That's expensive, so a lot of people won't do that. But. And C reactive protein, that's another great one to test because that measures inflammation. And as we start to see reduced inflammation, we should see C reactive protein go down. Those aren't necessary tests if the person can't afford it or it's not part of your treatment program. But those are excellent markers that we can go by to identify the body's healing. Some people may not have had normal levels or healthy levels of thyroid or gonadal hormones even before they started using. Maybe they had pcos or estrogen dominance or something. That's not going to go away when they heal from the addiction. Underlying pathologies are likely still going to be there and inhibit their recovery. So. So again, I think it's really important that we understand what's going on under the hood and fix the things that can be fixed and learn how to manage the things that can't. Interpersonally, people experience reduced self esteem. They feel guilty for using. They feel helpless that they can't stop on their own. All right, well, we need to help people in recovery recognize that you didn't become addicted overnight. You're not going to feel better, 100% better overnight. So looking for those small steps forward, a reduction in frequency, intensity or duration of any of those symptoms, because sometimes it's going to wax and wane. Maybe the. On Monday, it's a really short episode, but it's intense. On Tuesday, it's a longer episode, but it's not as intense. So you want to see those improving over time. So those episodes of pause are, are more tolerable. We want to encourage them to look at their successes that they're having now. Yes, they need to deal with the failures, the things they feel guilty for, all that stuff that happened in the past. But help them broaden their vision to see not only what they've got to work on, but what's going well. And that can help provide a little sense of personal empowerment and interpersonal distress. A lot of people in addiction recovery are. They feel guilty, they feel they have resentments, and they have a lot of people who have resentments toward them. They may have difficulty because they have high emotional ability and are easily disregulated. They may have difficulty effectively assertively communicating. So all of those things are things we need to work on with people in early recovery. One of the places I usually start is emotional regulation. If you're getting ready to interact with somebody who either you have a resentment toward or you know they have a resentment toward you, okay, notice how you feel down, regulate. Try to get into your wise mind so your heart's not racing. And then we practice hearing what the person has to say, accepting constructive feedback. Hopefully it's constructive, accepting feedback without becoming defensive and responding in turn. Those can all be super helpful if they have a strategy, if they have tools to start repairing relationships, they may also feel a lot of people with addictions have abandonment histories, so they may feel anxious even about establishing new relationships with people in their support groups. So we do want to help them learn what a healthy relationship looks like, learn about boundaries, and have them really process you. This relationship that you're developing with your sponsor or with this other person, you're starting to feel anxious about it. You're starting to be anxious that they're going to abandon you. What are the facts in this context at this time that you have that either support that belief or tell you that that's your mind and prior experiences telling you that you, quote, should anticipate the worst emotional distress. I brought it up a bunch. I didn't figure it was really worth going into a. In depth in early recovery. And, and even through pause, through the first two years people have that easy disregulation. They. Their stress bucket stays pretty full. They often are still hyper vigilant. So they're viewing the world through more of a pessimistic lens. And it's important to help them develop tools to activate positive feelings as well as to tolerate distress and manage their other symptoms that arise when. When they feel a feeling cognitively. People with addiction and post acute withdrawal have brain fog early in recovery. It's almost constant as recovery progresses as sleep improves, as the nervous system starts to heal and inflammation goes down, brain fog will improve negativity. Because of that hypervigilance and our body's tendency to to focus on threats, people can have more of a negative perception about things. Stinking thinking if you will. Acknowledging that and helping people develop cognitive restructuring tools. Looking at again fit cat the facts in this context at this time, what do I know about this situation and what are look looking at both sides, the benefits and the drawbacks or what's what I can control and what I can't control. Too often they just focus on what they can't control instead of what they can. And executive functioning deficits. When we are stressed, our prefrontal cortex takes a hike. So the more stressed we are, the less able we are going to be to problem solve, learn things, remember things, focus, organize all of those executive functioning skills. That's okay. Encourage people to learn strategies to deal with that. Like I said, some things we can't make, we can't fix right away or maybe not ever. If they have adhd, you may not ever be able to fix that. So how can they learn to live with that so those symptoms don't cause additional stress? If they're having problems focusing, for example, making sure that when they are trying to focus, they minimize distractions, maybe even up to and including being in a room by themselves with the blinds closed. With my son we always had to have the blinds closed because he would get distracted by the birds or, or by the trees or anything else. So when he was doing his schoolwork, we had to have those pulled down. When we were talking to him and asking him to do something. As a child we had to insist on eye contact. If he wasn't looking at us, then it was a pretty good chance he wasn't focusing on us. So using tools to address those executive functioning deficits and help people learn how to manage and live their richest, most meaningful life even though they're having difficulty concentrating, even though their memories in the crapper right now, that's where writing things down comes up. Go old school environmentally. A lot of people with addictions start having financial instability, may they may have housing instability if their significant other finds out and they say you're out of here. And they experience a lot of distress and use triggers when they go out. Somebody who has been abusing alcohol, you know, they're clean, they're sober, they go to Walmart and there's a full aisle of cold beer and wine. You know, it's a trigger. Yes, it's there. No, we don't expect it to go away. But recognizing that that is a trigger for them, it's. There's a little voice in the back of their head that goes ah, look at that right there. You remember that and it starts romanticizing and remembering the good things about using. Same thing is true for people who watch porn. You know, just being around a computer can be triggering for them. So we need to be sensitive to the fact that a lot of people in recovery have a lot of very generalized triggers for for use and those can relate directly to use like the computer for the person who used porn or they can relate to the traumas and stressors that led up to the use. We can't possibly identify every trigger for any person, but helping them develop tools to become mindful of triggers and strategies to manage them because they're going to come up. So when this happens, what are the three things that you can do to help keep your keep yourself safe, sane and sober. Nearly all people in early recovery, even to the middle phases of recovery, have sympathetic dominance. This is because their stress response stress system has been on for so long. Every time the stressor would leave their body, they'd use again or they wouldn't use again and the body would be going I'm out of balance. I'm out of balance. It's stressful. It was stressful either way. Using or detoxing, always stressful. So the body got stuck in sympathetic dominance. As a result, some people most but developed glucocorticoid resistance and may be tempted to engage in alternate endorphin behaviors, substitute addictions to give them energy or help them feel better. When I worked in residential oh my gosh. This was so prevalent. Gambling, sex and high sugar foods. That's one of the first things I did when I took over the residential wing was to get rid of the pastries. We since we were a nonprofit, the grocery stores would donate their day old breads and pastries to us and they were available to 24,7 to the residents to snack on between meals. And so their blood sugar was just incredibly, incredibly all over the place. And that was increasing their inflammation which was working against their healing process. And it was also a way they were self medicating. Instead of learning to deal with the distress in a constructive way, they were self medicating the glucocorticoid resistance. That is what we call it when cortisol loses its ability to suppress inflammation. And inflammation runs rampant. And then we start seeing all these other symptoms like sleep disruption, triggered eating, cravings, irritability, these endorphin behaviors they engage in, as I mentioned, whether, whether it's gambling, sex or eating, especially eating high, high processed foods, further tax the autonomic nervous system and delay recovery. We gotta cut that out. We've got to help people learn to live healthfully. Recovery requires the person to feel safe and empowered, which means they've got to get all control of that nervous system. If they stay stuck in fight orf flight, if their sympathetic system stays engaged, they're not going to feel safe, they're not going to be able to relax and good, get good sleep. Many people have stuff they need to deal with that they were, that they were using the addiction to escape from or that occurred during the addiction. I, I haven't yet encouraged some, somebody in treatment that didn't have stuff to deal with. And that stuff is emotionally, cognitively, interpersonally, painful, distrustful. And yeah, that increases sympathetic activation, increases inflammation. So we have to help them deal with that. And most treatment programs are pretty good at helping people deal with their, their stuff. When the sympathetic nervous system is triggered, people don't feel safe. The relaxation part of your nervous system, the parasympathetic it is unable to turn down the sympathetic nervous system, the prefrontal cortex, where we do our reasoning and our rational thinking. You know, is this the best choice for me at this time? That disengages the focus is on the threats. People become more irritable or prone to dysregulation, even about the little things. Behavior tends to be emotion driven and impulsivity increases. All of these things we need to recognize and educate the person about as well as their supporters. Educate their supporters that this is going to happen. There are going to be some bumpy moments and it's important that their supporters don't take it personally if their loved one has a moment. You know, gets, gets a little snippy for a second. Now obviously not tolerating verbal, physical abuse. That's not okay. That's not okay. No matter what reasoning you may have behind it. Not okay. But if somebody is more withdrawn, more feel, seeming more tired, more irritable, not taking it personally, not assuming they're using, acknowledging it and saying, you know what, it seems like you're, you're feeling very stressed right now. What is it that you need to do in order to deal with that? If somebody's in a 12 step program, they may say I really need to go to a meeting. If somebody is in a different type of recovery, okay, what do they need to do? Because sitting there in their irritability is probably not helpful. What are they doing to help them keep themselves safe, sane and sober? When people have sympathetic dominance, they also have imbalanced attention to the perception of threats. Encouraging the person to acknowledge the threats. I'm not going to invalidate that and acknowledge what's going well, yeah, this is out here you have pending charges that you've got to deal with. That's true. And you're in treatment. You've been clean and sober for three months and blah blah, blah. So let's look at the balanced picture. Help them become more mindful to their hypervigilance when they're feeling sort of restless, on edge. Help them develop skills to downregulate grounding skills. Looking around the room and identifying five things that are brown or identifying five things they see, four things they hear, three things they smell, two things they can feel. Whatever grounding skills work for them to bring their attention to the present moment and, and facts in the present moment. You know, I may feel anxious and unsafe right now. Let me look around. Well, my cat is sacked out on my desk. My dog is sitting right behind me, also sacked out. There's nobody else in the house, you know, so I'm looking at mindfully, I'm in the present moment and I'm verifying my feelings of if I feel unsafe. I'm verifying that against the feeling facts of in this context at this time, am I unsafe? And we need to regularly have people do that. There is a lot of mind reading that goes on in treatment programs, whether it's in IOP groups or in residential groups or the day room or whatever. That's something that we need to check because mind reading and hypervigilance often go hand in hand when it comes to relationships. Paying attention to you feel like so and so is being judgy of you. Okay, tell me what it is that they did or said that makes you feel that way. All right. And let's look at that and then let's talk with them about did they mean it that way? A lot of times because everybody on the wing or in the unit is feeling like crap on a cracker. Then a lot of times they may have unpleasant non verbals and micro expressions. It may not even have anything to do with the person, which is where we really start checking that mind reading and that hyper vigilance to non verbal cues that that trigger stress and Abandonment fears in so many people. Continued sleep disruption even if circadian rhythms are somewhat stabilized because their neurotransmitters are still out of whack. And in a lot of residential programs, the people are, are sleeping two, four, eight to a room which can leave people feeling unsafe. Or, or you may have somebody in the room that snores like a sailor. There are a lot of reasons. So we need to look at sleep hygiene. If the person is at home, they're an outpatient or iop again encouraging them to really focus on their sleep quality. How quickly do they get to sleep? How long do they sleep before they wake up? Is it fragmented sleep where they keep waking up and tossing and turning? Or are they out like a light? What is their sleep like? If they continue to have difficulty, refer them back to their primary care. And who may be able to refer them for a sleep study. A lot of people with trauma histories have. And a lot of people with addictions have trauma histories. So a lot of people with trauma histories or intense chronic stress have sleep apnea because stress keeps all of these muscles up here too tight and that ends up causing problems at night. That's what they hypothesize at least. Emotional numbing or dysregulation and vacillating back and forth between both. The flat to the furious, the flat to the frantic. Very common. Helping people develop skills to down regulate when they dysregulate. Understanding tools they have to put the brakes on. I'm not invalidating how I feel. I'm recognizing I'm angry and I'm recognizing that anger isn't going to solve anything. I need to get into my wise mind to figure out how to solve it. So how do I down regulate my stress response so I can engage my thinking mind in terms of emotional numbing? We want to help people start engaging in behavioral activation. Things that used to bring them joy, have them just start doing them. It can be really hard to do some of these things because, you know, going on a walk in nature pales in comparison to the high they used to get from xyz. That's true. But let's go on a walk in nature if that's something you used to enjoy doing. And let's notice how it makes you feel. Let's focus on what it feels like to feel calm, to feel content, to feel however they're feeling. There is increased ruminations common when we're stressed. Not. And those ruminations are often not on good things. They are on. What if this happens? What if that happens. Am I going to be able to stay sober? Blah blah. Their mind can just spiral out of control. Developing skills to manage ruminations can be really helpful for a lot of people. There are different tools that people can use. Writing them down on a piece of paper and then coming back to them 30 minutes a day. And it's their worry time. Some people will say, I just don't pay attention to them. When I start having them, I actively turn my attention to something else that works for me really well. If I'm worried about something, I will actively turn my attention to something else that and focus on it. Like planning my spring garden or well, usually planning my spring garden because that's one of my favorite activities. They may have difficulty controlling negative thoughts. Again, same process, rigid thinking. When you're not engaging your prefrontal cortex, you're going to be stuck in that box. This is what I've always done. This is the only thing I know how to do. So getting back into that wise mind can help. Seeking support from other people or input from other people can help you identify. Even if you can't get out of the box, they can help you identify strategies that are outside of the box that you may be able to use. And increased impulsivity. Making sure that people are checking in with themselves frequently throughout the day to and being mindful of how impulsive they feel. Do they feel like they have no filter? They have a thought and then they engage. If so, what can they do to address that impulsivity? Sometimes it's a change of scenery. Mistakes. In early recovery, circadian rhythms get disrupted because people are exhausted, especially in the first three months. So they want to take naps. They want to sleep all the time. The first week or so. You know that acute detox period, a lot of people sleep a lot. But after that it is important to try to maintain your circadian rhythms. Does that mean you have to forego naps? Not at all. Means you need to keep your naps less than 45 minutes, preferably less than 30, but definitely less than 45. A lot of times that can help people get through the day and with less stress. And quite honestly, short naps actually increase some focus chemicals like norepinephrine. But paying attention to their circadian rhythms and minimizing long naps. Super important nutrition. Avoid that junk food. Avoid inflammatory foods. Encourage people to eat healthy foods. Apples, bananas, whole grain foods, oatmeal. And I have a lot of videos on anti inflammatory nutrition. But ultimately three colors on your plate at every meal and at least one of them that's high in fiber, like some sort of grain or legume. Blood sugar management we almost never pay attention to this. If the person is not diabetic, it go, it goes under the radar. They estimate that 54% of Americans are either insulin resistant, pre diabetic or diabetic. 54% of Americans. That's not looking at people who have had chronic stress. Stress. When that stress response kicks off, what happens to our blood sugar goes through the roof? Our body gives us this surge of glucose to help us fight or flee. So people who have had chronic stress, especially those in early recovery who are undergoing a lot of acute stress, often have blood sugar spikes and may be insulin resistant. Insulin resistance Diabetes leads to systemic inflammation. We need to get it under control. Oral hygiene. One study found that over 60% of people in addiction treatment reported poor oral hygiene. Now these are just the people who are reporting that they've got some kind of tooth problem or mouth problem, dry mouth, cavities, gingivitis, something like that. Those are only the people who it was bad enough that they said, I got to see a dentist. A lot of people because of a variety of factors, not the least of which is ongoing sustained systemic inflammation, have problems with oral hygiene. Our mouth is a gateway to getting bacteria into our system and increasing systemic inflammation. It's an overlooked treatment area. Encouraging people to not only brush but also floss is going to be super important in recovery. Vagal tone enhancement have people monitor when possible their heart rate variability. If you can have them, if you're facility can get a couple of Polar H10 straps, you don't have to get super fancy with it. There's an app that they can use that the person can use to monitor their heart rate variability. You get a snapshot once a day. And so if you've got 30 people in the program, you have 10 straps. It doesn't take long to get each person's HRV measurement a few times a week. You don't need to do it every single day. But what you want to do is see improvements in their heart rate variability because that will show that their parasympathetic nervous system is actually starting to get stronger. And that's what we want. We ignore pain management. We say, unless they're complaining about it, we're not going to address it. We need to address it. Even if they're not feeling pain right now, they need to have skills and tools to manage pain because pain increases stress. Manage pain when they're out of treatment, when they're in post acute withdrawal when before their body has fully started responding to those endorphins again, helping them develop guided imagery. Transcutaneous electronic nerve stimulation, otherwise known as TENS units Massage, heat, cold, stretching. There are a variety of different techniques that can be used, depending on the type of pain, to help the person manage it. Non pharmacologically, but just ignoring pain. Unless they can distract themselves to something they want to do, just ignoring pain and say, well, suck it up, buttercup, that's not real helpful. And we need to pay attention to those substitute addictions, including nicotine emotionally. Many programs do not do a good job teaching integrated mindfulness. They don't do a good job starting each IOP session with a mindfulness activity or start having the people in residential treatment engage in mindfulness activities before each meal. There are ways we can teach people to integrate it into their lifestyle, but we have to prompt them, we have to help them learn to integrate it. It's not something that just comes naturally. And as I mentioned, behavioral activation, super important. Doing things that help people laugh, even if that's putting on inane YouTube videos in the day room. So, you know, there are lots of YouTube videos that are funny and not triggering cognitively. In recovery, we often tend to reinforce focus on threats and powerlessness. We focus on, these are your triggers, these are, this is, you're powerless over this, you're powerless over that. We need to expand the vision. Yes, there are threats out there, but what else is going on? These are the threats and these are your strengths. These are the things that are going well. These are the things that, you know, balance it out so they recognize that it's not just, you know, a minefield in trying to live. And what do they have the power to control? Yes, this you cannot control, but this you can, you cannot control how alcohol affects you, but you can control whether you walk into that bar. Overload. Especially in early recovery, when people are tired, stressed out, having difficulty focusing, they've got brain fog, and you sit them in group all day long and talk at them, they're not going to pick up any of it. If you're expecting them to engage in a lot of things that require cognitive activity, a lot of them are not going to remember it. So being cognizant and compassionate in how much information people have to process, recognizing boundary violations and cognitive boundary violations, telling people, this is what you need to do, this is what you should do. This is the right thing to think. Yeah, not helpful. Environmentally, there's a lack of empowerment triggers we want people to look around their environment, whether they're living at home or in a facility, and feel empowered. Hey, I can do this. Look at all the people that have succeeded. Look at how far I've come. Whatever those empowerment triggers are, journals can be helpful, Pictures can be helpful. People telling their story, people who are in long term recovery telling their story can be helpful. We want to have that prominent. We want to make sure they feel safe. You know, again, if you're sharing a room with four other people and you can't lock your stuff up, you may not feel safe. So talking with people about what helps them feel safe. Having a place where people who are introverts can go for alone time, downtime, whether it's a picnic bench outside or a library where nobody's going to come up and bother them, they need time where they can be unbothered every day and spiritually. An insistence on a focus on a higher power is not trauma informed. I'm sorry, it's just not. A lot of people feel very abandoned by their higher power and they feel very abandoned by their parents. And it's just a replication of that abandonment and telling them to focus on that entity. Being that they feel abandoned them may not work for them in early recovery. You can look at good orderly direction as. And if you look at that G O D God is the plan to get you to the destination of your rich and meaningful life. I make the analogy. It's like asking Google Maps for directions. I'm here at this point and I want to get to this point. Good orderly direction helps me get there. Good orderly direction improves parasympathetic nervous system activity because it helps people feel grounded and empowered, which reduces inflammation and improves mood and cognition. So the parts of good orderly direction. The mnemonic is perfects prudence. People need to have patience. That means not impulsivity and wisdom. Have patience, get the information you need and then make a wise decision. So prudence, endurance of distress because it happens. So helping people recognize that they can endure stress, they're distress tolerant and they have skills for down regulation, respect for self and other. Helping them focus on what I'm thinking, what I'm doing, is it demonstrating respect for me and for those that I care about. Same thing with forgiveness of self and other and compassion for self and other. When people are letting go of anger, when they are being more forgiving and compassionate, it reduces stress. It helps reduce sympathetic activation, truthfulness with self and other, well, it's a whole lot easier to relax when you're not having to remember your lies. And it's a whole lot easier to heal when you're being truthful with yourself about what you need and selflessness which is defined as helping others to the extent that you can without hurting yourself. And that's the part that a lot of people forget. So spiritually helping people focus on being prudent, enduring, respectful, forgiving, compassionate, truthful and selfless. Well that's great because those are things that are within their control and they are. There's an overarching premise that helps them use them in life. Addiction is very stressful on all pieces of life. So is pause and recovery. Stress is a trigger for relapse. Reducing stress promotes autonomic nervous system healing and downstream improvements in all pieces of life. Thank you all for being here today. I hope you are having just an amazing Wednesday day before Thanksgiving if you're in a country that celebrates the Thanksgiving and I hope you have a safe, sane and sober holiday.