Whole Person Counseling: Addiction Assessment & Interventions

Foreign. I'd like to welcome everybody today's presentation on addiction assessment and interventions, A functional health approach for clinicians. I'm your host, Dr. Donnelly Snipes. Have you gotten stuck in a loop of feeling powerless? Because even if your clients are doing exactly what they're supposed to, many of them relapse. I know I struggled with this a lot when I was working in community behavioral health, especially my first four or five years. What I learned was that failure to address the recovery of the whole person leaves significant vulnerabilities for relapse. And that's really what we're talking about today. Just briefly, in case you haven't studied addiction a lot, I'm going to going to define addiction and pause. And then we're going to examine what I call the cci. The causes, consequences and interventions or in each of the pieces of life. Addiction is continued use of a person, place, substance, etc to escape from pain or distress in one or more pieces of life. And it is continued despite knowing that engaging in that behavior or using that substance is. Is causing problems as as a result of use. People spend more time, money or energy thinking about getting, using or recovering from use. Wow, there's a lot that goes in here. And this is where we can see a lot of the behavioral addictions in addition to a lot of the substance addictions, because there is the constant thinking about it. I don't want to go as far as saying obsessive nature, but the thoughts do take up a lot of people's time and giving up important activities or failing to meet responsibilities in one or more areas of life as a result of use. So it always comes back to that. These things are happening as a result of use. When people develop addiction, we're just going to use that term broadly. They can start out and a lot of people start out with recreational, occasional or light use. There are very few. There are some. But there are very few things out there that people get addicted to instantly. So oftentimes it starts out recreationally. Something they do makes them feel good, they enjoy it, helps them relax a little bit. No biggie. Eventually they start encountering stress in their life and they're like, hey, that thing over there helps me relax, helps me chill out. I'm going to use it well. As the stress increases and the use becomes more chronic, the body starts developing a tolerance to it. The body starts getting used to having it. It's like, well, I don't need to produce my own opioids. I don't need to produce my own Dopamine, because you're going to be flooding the system and you're going to be flooding me with it. So we start to see this tolerance and withdrawal develop. And people have physiological tolerance, and that's when their dopamine levels are lower than they should be. And that affects all of their other hormones and neurotransmitters. But we also see psychological withdrawal where a person really, really is craving something, really, really wants something because it helps them feel better. You could argue that that's neurochemical. However, a lot of the researchers, scientists, you know, those people talk about it as two different types of tolerance and withdrawal. So however you want to view it. But we do know that when people get used to having something, think about caffeine. I think most of us have been to a point at some time in our life where we've been addicted to caffeine. And if we stop using it, suddenly we start craving it, we start wanting it, we start missing it. It's the first thing when I get up in the morning, I get up and make coffee. There was a period there I wasn't allowed to have coffee, and I got up in the morning and I felt like I was missing something that was that psychological withdrawal. I was like, but where's my coffee? Then there was also the physiological withdrawal. Not having the stimulant in my system altered the levels of neurotransmitters. Eventually my system adapted. And that's what we see in recovery. Eventually, the system adapts, but in most addictions, it takes time. Post acute withdrawal syndrome can be categorized as either protracted withdrawal or prolonged withdrawal. Protracted withdrawal is withdrawal that happens, and then there's another withdrawal episode later. Why does this happen? For most people, protracted withdrawal is the result of in ingesting substances that are fat soluble, so they get stored in body fat. And then as the person loses weight, they start to have a release of those chemicals again. And so there can be a period, a week, a month, six months, even 18 months out, if the person suddenly loses a lot of weight, where they might start feeling like they're detoxing again or feeling like they're using again for a minute. And that's okay, but we want to prepare people for it. Opioids are really strong lipophilic as well as cannabis, those are two of the strongest. PCP is a close third. So those are three substances where we very often see protracted withdrawal. And people can feel like they're failing in recovery when they start having these intense cravings all over Again, we need to help them understand where it might be coming from. Cocaine and amphetamines are moderately lipophilic. Not nearly as much so as the other ones, but it can happen. So we don't want to invalidate people's experience and we do want to prepare them ahead of time that, hey, pause is a normal part of addiction recovery. And for most people, pause will gradually resolve over 18 months to two years. But it's not something that you're going to be finished with when you get out of a 28 day treatment. Don't fool yourself. Prolonged withdrawal is withdrawal that takes longer. It takes the body longer to adjust to not having the substance, and it takes the body longer to clear the substance. We see this very commonly in people with liver or kidney issues. So they've built up these levels of substance, their body, and it's going to take the body a while to clear it. When we're talking about substance as well as behavioral addictions, we also see prolonged withdrawal, prolonged symptoms of craving and irritability and impulsivity. Because the prefrontal cortex, the autonomic nervous system, the amygdala, the hippocampus, they were all essentially damaged during the, the addiction. And it takes longer. The worse the damage is, the longer it takes to rebalance. It kind of makes sense. And people who have circadian disruption, this is a very common issue in addiction as well as in recovery. But every se cell in your body is on a circadian clock. And when people are not stabilizing, managing their circadian rhythms, guess what happens? Their body has less time to repair. Readjust, clear out the garbage. I've made the analogy many, many times that our body is like a factory during the day. It has the crew in there, it's working, it's helping you think, it's helping you move, go to the gym, whatever you need to do. That's wonderful. At night when we sleep, that's when the cleanup crew comes in. They come in and get rid of all of the byproducts that were created throughout the stress of the day. If that stuff doesn't get cleared out, then it stays on the factory floor and it makes everything harder to do the next day because essentially the daytime workers are tripping over all the trash from yesterday. So let's talk about the physical causes, consequences and interventions for addiction, physically autonomic service system dysregulation, and sympathetic dominance. Let's start there because that is really at the heart of what we're dealing with a lot of times. How can Ans dysregulation and sympathetic dominance cause addiction. Well, let me tell you, when you are stressed out all the time, or when you are a person who goes from flat to furious like that, it can feel overwhelming. There can be a strong desire to blunt that flat to furious or to blunt that distress so you're not feeling so bad quote all the time. And we see this in people with attachment disruption who've experienced adverse childhood experiences, who've had trauma. We see it in people even who are just experiencing chronic stress. Or over time, if your stress system is chronically on, it becomes much more powerful than your relaxation system. They can't balance each other out nearly as well. Or if you want to think about it this way, your workers make a whole lot more byproduct and junk during the day than the cleaning crew can even begin to handle overnight. So they start to get out of balance. This can cause people to feel bad and seek out ways to feel better because we don't want to feel bad. That is one of the ways it can cause addictive behaviors or the development of addictive behaviors. Now remember, some people go from go to recreational and maybe heavy use and then they back off and they never move that final step to addiction where it is causing significant problems in their life. But we do want to be aware now the consequences of nervous system dysregulation and sympathetic dominance or having an overly powerful stress response is that it alters the balance of our gut microbiome, of our neurotransmitters, of our stress hormones. It keeps us from being able to get good quality restorative sleep. So that cleaning crew can't even come in and do their job even if they wanted to, at least not nearly as effectively. And we've talked in multiple other videos about the long tail consequences of chronic stress on the entire body. You start to see more inflammation, you start to see more brain fog. Okay? These are all things that are going to be stressful. I know when I can't think clearly, I get irritable. I'm like, I've got to get all this stuff done and I can't even remember what I came into this room for. So we're seeing a bi directional interaction. Interventions for ans dysregulation, sympathetic dominance. Well, number one, we need to help people upregulate their vagus nerve. We need to help them learn how to downregulate their stress response. And I'm not saying change their emotions. I'm saying slow their breathing and their heart rate. That's ultimately what it comes down to. When they notice they're starting to get stressed, when they notice they're starting to have their heart beat faster, their palms are getting sweaty, they're grinding their teeth. Whatever stress looks like for the, for them, practicing square breathing, humming, bubble blowing, even just massaging the, the ear or right here on the face can help. But what we want to do is slow that breathing down. And the reason I give those that many suggestions is because there are a lot of people who have ans dysregulation who have a history of trauma. And doing somatic focused at work, like focusing on their breath or their heart rate can re trigger trauma. It can trigger dissociation. We don't want to do that. So what else can they do? Humming is great. Getting one of the pulse ox machines that you put on your finger and just slowing their breathing. They're not really focusing on it. What they're focusing on is that pulse ox machine. And they're seeing how quickly they can bring that number back down, which can give them a sense of confidence and competence in managing their stress system. So we want to help them learn how to downregulate. When they start getting distressed, we want to help them practice even when they're not distressed, down regulating. And one measure that we look at sometimes is called heart rate variability. But that gets into having a polar monitor or something else that a lot of people really don't want to get into. What I encourage people to do is just see how quickly, you know, pay attention to how quickly they can bring their heart rate back down to something reasonable. Hyper vigilant to threats and cues. When people are have experienced trauma, they may be hyper vigilant to threats and cues in the environment. And that's exhausting too. So again, what are they going to do? They're going to flee to or they're going to look for something to help them feel better. When they are hypervigilant, it increases that stress response. It increases sympathetic dominance. It says you need to be always on alert for threats. You, you're never safe is essentially what you're telling your body. When you're hypervigilant again, it's exhausting. Keeps you from getting good sleep, keeps you from maintaining your circadian rhythms, keeps you from keeping a balanced, sympathetic and parasympathetic nervous system. What do we do? Help people create environments that they feel safe. Help them develop mindful awareness of the situations. When you start feeling hyper vigilant, you feel like that bunny rabbit or that squirrel that's just constantly looking for the next predator. Okay, when people become aware that they're feeling on edge, that's okay. Recognizing it and then engaging in grounding activities. Five things that I see, four things that I hear, three things that I smell, two things that I feel, and maybe one thing that I taste. Or maybe they can look around and say, who, what, when, where? Who am I? What am I doing right now? Where am I? Why am I doing this? Whatever this is right now. The goal is to get people grounded in the moment. And when they're grounded in the moment, it does two things. It helps them anchor to the facts in this context at this time, or fitkat. It also turns their attention, intentionally turning their attention away from that feeling of fear to focus on the present moment. When we do that, when we engage our prefrontal cortex and say, no, we're going to focus on this right now, the hippocampus and the amygdala go, oh, okay, well, there must not be that much of a threat then. So we start to see the heart rate come down. So that distraction that people experience when they're engaging in grounding activities can be super helpful. I've already mentioned sleep and circadian rhythm difficulties, and we'll throw in sleep apnea here. How can they cause addiction? Well, there's a lot of people that have sleeping difficulties. When we don't sleep well, we don't clear out adenosine. We feel sluggish a lot of the time. We've got brain fog. People are more likely to gravitate toward some sort. Some sort of stimulant to help them stay awake during the day, and some sort of depressant to help them sleep at night. Behavioral addictions can also happen. Pornography and sex addiction, for example. For people who have sleep difficulties, they may think, well, if I can just orgasm, it'll help me sleep. If I can just do this, it will help me sleep. So again, they're looking for something maybe not chemical, maybe, maybe neurochemical. They're looking for something that is going to help them get to sleep. And eventually they may start becoming dependent on it or they develop a tolerance. It doesn't work as well anymore, and they need to intensify it or combine it with something else. That is the definition of tolerance. The consequences of sleep and circadian rhythm difficulties, we already talked about that earlier. Nighttime cleaning crew can't come in and do their job. So that's going to increase stress and brain fog the next day as stress goes up and becomes more permanent and as the junk builds up in the system because the cleaning crew can't come in and clean it out, we start to see more systemic inflammation, which is, guess what? Stressful increases that sympathetic dominance even more. When people use substances, they may alter the tension in certain muscles in their airways that can contribute to sleep apnea. Likewise, stress is a very common contributor to worsening of sleep apnea symptoms. There is a really strong correlation between sleep apnea and people with ptsd, irrespective of their gender or weight. And they're starting to recognize that because we hold tension up here, it actually impacts our airway and can increase apnea. So the interventions rule out sleep apnea. That's a first thing that we want to do. If we have a patient presenting that says they snore like a freight train, we need to refer them for a sleep study or at least back to their primary care to get that looked at. We need to educate them about sleep hygiene, all of the things that they need to do in order to get better quality sleep. And I have several videos on that, so I'm not going to go into great detail. But, you know, some of the things that we don't frequently think about are getting allergens out of the room. And I say that as I put my hand on my cat, who's on my desk and just flaring my allergies like crazy, but he's so cute. Keeping allergens out of the bedroom can be really helpful. Nasal irrigation can be very helpful for people who have allergies. Making sure that they're getting turning off the blue light two hours before bed. There's lots of things that they can do and circadian rhythms. I have a little, little mnemonic for that. It's leap light. You want to have bright light during the day and dim light at night. Just like the sun is supposed to cue our body when we're supposed to be awake, when we're supposed to be asleep. Eating is the second thing. Eating is a. And I'm probably going to not say this right, zeitgeber, it's a German word that says timekeeper, and it helps anchor our circadian clock. So if somebody eats at roughly the same time each day, it doesn't matter if they're eating one meal or three meals or four meals, but eating at roughly the same time each day helps their body organize its routines and the ebb and flow of different hormones and neurotransmitters. A stands for activities. We want to have, you know, a relatively predictable set of activities Some people like a lot more spontaneity. I get that. So a wind down routine can be very helpful. Just like with kids, they come home from school, they play, they eat dinner, they take a bath, you read a book with them, you tuck them into bed, that's their nighttime activity. And that's another one of those time anchors that can really help maintain the circadian rhythm. S stands for stress. Don't do things that are stressful within two hours of bed, don't pay the bills, don't have a discussion with somebody unless you absolutely have to. Try to keep the last two hours of your evening relaxed. Reading, watching a show you like, doing arts and crafts or whatever it is your hobby is something that is pleasant but not stressful. And T stands for temperature. Cool when we're sleeping and warm when we're awake. Just like bears hibernate when it's cold and they're awake when it's warm outside. Same thing for us, basically. So light eating activities, stress and temperature can hugely, hugely help the body recalibrate itself so it can more effectively and efficiently repair itself. We want to look at nutritional deficiencies and gut dysregulation. Stress impairs the gut and when people have a disrupted gut microbiome, they may feel icky, they may feel pain, they may feel depressed. They've actually shown that our mood and our impulsivity can be directly impacted by our gut microbiome. So if somebody's gut microbiome is out of whack, or if they've got nutrient deficiencies that are, or nutrient excesses that are increasing their anxiety or their depression, guess what? That can be a vulnerability for developing addiction. As far as consequences of nutritional deficiencies, well, your body takes all these nutrients in and uses them in order to make the hormones, the neurotransmitters, repair the tissues, etc. So if you're not giving the body the building blocks it needs, can't do the job. If the gut is out of whack and the microbes in there aren't able to break down the raw materials you give, it still got a problem. When we're stressed, we also see the mucus lining of the gut start to become thinner and, and some of the toxins from the gut leak into the system called leaky gut. All of those increase inflammation, increase stress, increase irritability. That can make somebody more likely to seek out relief. What do we do in treatment? Refer to a dietitian. If you're not a dietitian, if you believe that they have significant nutritional Issues. It's also helpful just to educate them about eating a colorful diet. Three colors on the plate at every meal. Condiments and skittles don't count because a lot of our colorful foods are high in fiber, which is a prebiotic that helps nourish those gut microbes. Encourage them to consider eating fermented food, whether it's kimchi, kefir, yogurt, sauerkraut, all of those have prebiotics, probiotics in them that can help repopulate the gut microbiome. So prebiotics are fiber and probiotics are the microbes themselves. We want to increase that. We are not telling people what to eat, but we are educating them that making these slight adjustments to their diet can help reduce inflammation, can help give their body the building blocks it needs. Getting adequate protein intake is also very important. Generally the guideline is about 0.6 grams of protein per pound of body weight. Most of the time in early recovery, first couple of months, I don't want people to get overly concerned or focused on one particular thing. That's why I focus on try to have three colors on your plate at each meal. Try to get some fermented foods in your diet. A few times a week can go a long way, end of story. And obviously referring them to a dietitian or their primary care, if I think there's a problem. They can also be tested at their doctor for their levels of B vitamins, iron and vitamin D. All of those have been shown to be directly correlated to mood and impulsivity. So helping people have an informed conversation with their doctor to make sure that we're not missing something that's going to leave them vulnerable to relapse blood sugar regulation. When our blood sugar gets out of whack and we start feeling foggy headed or shaky or exhausted, you know, what do a lot of us do? A lot of times people try to self medicate if they're starting to feel exhausted. After they eat a high carb meal, they often pound back some caffeine. Not recommendation. That's not a recommendation. It's just a real realization when we're stressed. Every time our body senses stress, it dumps more blood sugar into our system. Eventually our receptors, our insulin receptors start to become tolerant or resistant, if you will, to being bombarded all the time. So we end up with a lot of blood sugar in our bloodstream, but it's not getting into the muscles where it needs to be. So people's A1C starts going up and we start seeing Metabolic disorders. Blood sugar regulation can be a risk factor for relapse especially. And when blood sugar is out of control, it makes everything harder. Our brain, our prefrontal cortex, where we do most of our functional higher order thinking is heavily, heavily dependent on blood sugar. So if we're not regulating blood sugar or if it's there, it's right outside the cell door. But the cell can't get it inside, it ain't going to do us any good. So we're going to have brain fog and it's going to tend to make everything seem a lot harder and more stressful. Blood sugar regulation most of the time is a discussion that is best had between the patient and their primary care or a nutritionist. But it is something we want to educate people about. These are the symptoms of hypoglycemia, hyperglycemia. This is what happens when we're stressed to your blood, to your blood sugar. Children who have ADHD or who are gifted, even adults who have ADHD or who are gifted because their prefrontal cortex works so hard, a lot of times they go through blood glucose a lot faster than others. And they found that in order to help them sustain attention and focus, having a snack mid morning can be really, really helpful. Well, think about patients that you've worked with in residential or iop. Do you have, do you see them starting to lose focus and attention about halfway through the second group? Well, that's maybe what could be going on. So do we need to alter the structure of our programs to make sure that our patients bodies are able to support their learning and recovery process? Altered immune systems either a reduced immunity or increased inflammation and pain. You know, when you're sick you tend to want to feel better. Some people will kind of overdo it a little bit on some of the medications, on some of the stimulants. Now that generally won't cause addiction per se, but it is a risk factor. Especially if somebody has an addiction to stimulants and then they start taking decongestants for a cold, it's a huge risk factor. Not saying that they can't do it, but we need to recognize the potential dangers there. When people have a reduced immunity, they get sick easier. When they have increased inflammation and pain, well, they hurt more. Life feels more difficult. It is more difficult because it hurts to move. And all of that impacts our, our thinking. Just last week I hurt my back when I was cleaning up after the storm. And the two days that I was in the most pain, I couldn't think clearly. To save my life. The pain wasn't like oh my gosh, I, it's excruciating, I need to go to the hospital. But I'm sitting up here on the computer trying to do work and it's just that overriding ache that every time I moved and my brain was so focused on that that my stress response apparently was so high that my body was shunting blood sugar away from my prefrontal cortex and into the rest of my body so I could protect myself from any predators that may come along. That's that amygdala and primitive part of the brain. We want to help people stay as healthy as possible, encourage them to practice good hand washing, social distance when necessary, all those things. Eating a good healthy diet helps maintain their immunity in terms of inflammation and pain, Helping them develop skills and use guided imagery for pain. Encouraging them to talk with their doctor or physical therapist about tens units, massage, exercise, stretching. There are a variety of non chemical strategies to help manage pain. And when people aren't in as much pain, they're going to sleep better. Life is not going to seem so overwhelming, they're going to have less brain fog. We know that autoimmune disorders are worsened by stress. So if somebody is engaging in addictions then and they have an autoimmune disorder then that can likely maintain or worsen the autoimmune disorder. Because every time they use it's a stressor on the body. Every time they detox or the substance leaves their system, it's usually a stressor on the body. So then they start having cravings and they use again a stressor on the body. So you've got stressors coming and going in addiction which is only going to worsen autoimmune conditions. Helping them recognize the connection between stress and their autoimmune disorders and identify ways that they can eliminate unnecessary stress and manage unavoidable stress. There's an alteration of go nadal hormones in people with chronic stress and for some that can make them want to numb that out or that can make them seek out behaviors like sex, pornography, etc that may help them feel something. They're like I should feel something here. Or they may have hypersexuality so they're just driven for it. Either way, you know, if it becomes an addiction then we've got a whole host of other problems. The other consequences of altered gonadal hormones. When we're stressed, our gonadal hormones, our sex hormones get altered. It's just part of the stress response. The consequence is as Gonadal hormones get altered. It also alters our neurotransmitters, our gut microbiome, our inflammation, our pain perception, etc, all of which are risk factors for relapse. There's not a lot that as counselors we can do about gonadal hormones. Encouraging again, patients to have a frank conversation with their primary care physician if they believe that their hormones are out of balance. If it's not totally out of balance, then they may need to recognize that again, stress management is going to be a huge part of, of their recovery process. To turn the intensity down, it's kind of like you have a factory that has been running wide open and the machines are starting to break down. It's just, it's not working well. In order to continue without having to shut the factory down, we need to back off. We can't accept as many orders. We need to take the load off of the workers and the machines and everything else until we can get everybody unburned out, if you will. Hypertension and cardiovascular disease are common consequences of addiction and they're also common consequences of chronic stress. Recognizing how that is impacting the person and how any medications they're on may be impacting them is really important in treating addiction. A lot of blood pressure medications can be very, very sedating. A lot of statins, cholesterol medications can are associated with symptoms that are very similar to depression, fatigue, brain fog, low motivation, etc. Encouraging them to be aware. When did you start taking that medication and when did your symptoms start? If there's no clear definition, then okay, talk about it with your physician and tell them why not? Well, you might want to talk with your doctor about the meds you're on, but you might want to talk with, with your doctor about, with the medications you're on and your symptoms, such as fatigue and dry mouth and whatever the symptoms are so they can start seeing a connection. And then we start having cravings due to neurotransmitter destabilization. Well, when we flood the system through our behaviors or through substances with something that is addictive, it naturally triggers the dopamine and the endogenous opioids and all the feel good chemicals to just skyrocket. Well then when it leaves it, it's just a, a way up and then a crash. Kind of like a, a kid on Halloween after they've gone trick or treating. Just up and down with the blood sugar. Same sort of thing with our neurotransmitters. When we're dealing with addiction, those neurotransmitters are destabilized. It's going to take a while, months, even, maybe even up to two years in some cases for the receptors for those neurotransmitters to start becoming receptive again and basically for the NER nervous system to heal. It will heal. People do get to a place where they feel what they define as normal for them again. And that's, that's great. We need to recognize also that stress in general, addiction withdrawal and detoxing and nervous system remodeling, yeah, that's all stressful. Most of the people we're dealing with in addiction recovery also have other stuff that they need to process and all of that stuff is stressful. And when we're under stress, emotional stress, interpersonal stress, etc, it's going to increase that sympathetic nervous system. One of the things that I found most helpful working with my patients is educating them about stress management. Not as much about addiction and pharmacology and all this other stuff, but helping them see how everything in their life until now may have built on this stress, chronic stress load that they're carrying. And this is what it's doing to their body, which is triggering the desire to escape, it's triggering the fatigue, it's causing them to feel less motivated and flat. Okay, so there's a lot of stuff we've got to deal with. But one of the things that they are empowered to work on is some of this physical stuff. Sleep, circadian rhythms, nutrition. There are some very basic steps that people can take from the first day they're in detox to start healing their body as they're healing their mind, their relationships, etc, interpersonally. Causes of addiction low self esteem and self efficacy. People who don't feel good about themselves or they're afraid of rejection. They may pre party before going out to loosen up. They may drink or use while they're with others in order to feel like they belong. They may be more readily or more susceptible to engaging in following the crowd kind of behaviors that may spiral over time. The consequences of low self esteem and self efficacy in people who develop addictions is that a lot of times it makes them feel worse about themselves. Then they start feeling guilty, they start feeling ashamed, they start feeling powerless and helpless, which is going to spiral downwards and increase their stress response. It's vital that we help people work on their self esteem, that is their ability to accept themselves and see themselves as worthy and as human beings. Separate what they've done, their behaviors or what they can do, their behaviors from who they Are seeing themselves as inherently acceptable. And I encourage them to look at a picture of an infant, a picture of a dog, a picture of, you know, some of these other things that most people look at and go, yes, that thing is lovable. And then back up a little bit and go, why? They can't do anything for you. You know, it's an infant, it's just sitting there, it's going to cry, it's going to wake you up in the middle of the night. But is it lovable? Yes. Why? Because it is. And really driving that point home. Setting smart goals, very specific, very short term, measurable goals to help them track their progress and in recovery is also important that increases efficacy. Helping them see when they are able to more effectively down regulate their heart rate. Helping them notice when they're getting better sleep. Helping them notice when their energy level is improved even a little bit. The lack of awareness and the chameleon esque issue that a lot of people with addictions deal with. Many of them were raised in an environment where you don't talk, you don't trust and you don't feel. So they're not aware of necessarily how they feel. They're so focused on pleasing others to avoid rejection or punishment that they don't know. So they change to be whatever they think you want them to be. Encouraging them to identify, spend time with themselves, which sounds really weird, Getting to trying things out. What hobbies do you like? What do you like to do? And encouraging them to become more mindful about their thoughts, wants and needs. They don't necessarily have to communicate them right away. That's a whole different terrifying step. But becoming more aware. A lot of people with isolation and abandonment fears again try to numb that pain or try to do things in order to feel loved. We also see a lot of people lately with isolation and abandonment fears who start developing compulsive sexual behavior and compulsive porn use because it is easier to engage in that behavior and get the reward of the orgasm without having to actually engage with a real person which feels too threatening and that can quickly spiral out of control. Unfortunately, when people are isolated and fearing abandonment, they often don't have any support system, let alone a healthy support system. Sometimes because they never learned how to develop a healthy support system, they may appear narcissistic. Some people are like, nobody's going to protect me. I've got to protect me. It's all about me. That's not necessarily being narcissistic as much as being self protective based on what they've learned the other way is codependent, where the person believes that the only way people will love me and people won't abandon me is if I rescue them, if I make myself indispensable to them. So we want to look at what are their behaviors saying when we see some of these unhealthy relationship dynamics and help them identify what they're doing, why they're doing it, and alternate strategies to help them improve their relationships both with themselves and with others. A lot of people who are irritable and argumentative may have difficulty downregulating. That's one of those signs that somebody has a dominant sympathetic nervous system. And in those people, they may always be on guard. It's exhausting. So you can see how that easily could develop into somebody trying to seek solace in behaviors or addictions. When people are irritable and argumentative, yeah, guess what? It's harder to maintain healthy relationships. And a lot of times they feel guilty afterwards for being irritable and argumentative. Helping people understand irritability as a response to a perceived threat and respond appropriately, helping them learn to listen without defensiveness and communicate assertively. I have entire videos on both of those topics because there's a lot to unpack there. Understanding, viewing every behavior, every choice as a communication can be revolutionary to a lot of people. Instead of doing something and then feeling like they failed at whatever they're going to do, we need to look at what they did and understand why they did it and then modify the treatment plan in order to help them not do it again. Some people with addictions are overly self focused. It's what about me? Why me? Why is this all happening to me? Maybe they have a lack of self awareness. Maybe they are seeking and many times they are seeking someone to rescue them. It depends on the patient, depends on the situation. Helping people step back and recognize, what was my part in this? Yes, this crappy thing happened. Why me? It feels like everything is happening to me. I get it. We all feel that way sometimes. Helping them step back and say, what parts of this am I responsible for? And what parts of this do I have the ability to address? And what parts of this were completely out of my control? You know, we don't have control over the weather. We can't directly control other people. Encouraging people to look beyond me or in some cases beyond you and see the big picture. What was my part? What was your part? What else? And who else played a part? And what do I have the ability to address Helps increase sense of empowerment. And improving those communication skills, helping them learn to pause before they speak can be a really important intervention. People with poor communication skills tend to alienate their support systems or they don't get what they need because they're not telling people what they need. They're assuming the other people are going to read their minds. Then they feel abandoned, they feel let down, they feel disappointed. Improving those communication skills is huge. Tell me what it is you need. Don't expect me to know. Unstable boundaries in each piece of life. Physical, interpersonal, emotional, cognitive, and environmental. We want to help people feel safe. When people don't feel safe, then they're stressed out and they tend to be more at risk for addictive behaviors. When people don't feel safe, they have unstable boundaries. They are more often either victimized because they let people walk all over them, or they are abandoned because they're boundaries are so rigid, they push people away. Helping people learn what boundaries are and how to effectively set and maintain them and the fact that they don't, they're not static. I may feel very comfortable with Jill today, but then she may do something that I feel was very threatening. So I may say, you know what, Jill, I don't want you to have a key to my house anymore. You know, we. We've lost that trust. So I'm going to push. Push back on that boundary. That is okay. Unstable relationships are common cause of distress for people. And we see this a lot. People get into a fight with their significant other that then they end up going to a bar and having some drinks or, or what have you to take the edge off. In people with addictions, there's often this push, pull. I want you to love me, but I don't want you to get so close that you're going to take away my addiction. Or I want you to love me, but I'm afraid you're going to abandon me. So I want to keep you at arm's length. Chaos as the norm or as a deflection. I see this a lot because it's a lot easier if you grew up in chaos to keep that chaos going. Because that's what you know. A lot of people with addictions, when there's silence, when they're alone with themselves, is some of the most painful, overwhelming time, because then they start hearing their own thoughts. What is the purpose that this person is creating chaos or deflecting attention? And what can we do to help them feel safe? There's a lack of earned trust in relationships both ways. Person with addiction may not trust others because they have been abandoned and abused so many times. People who are. Who love them or support them may not trust the person with the addiction because they have been abandoned and abused so many times. So we need to help people define what does trust look like and what can I do to start reap or what can we do to start rebuilding trust in this relationship? Objective, observable, measurable things. People who supported someone who has an addiction may have relapse expectations. Heck, sometimes people with addictions have relapse expectations. They're like, I've done this before, but I don't think it'll stick. Which can make relationships more difficult if the person in recovery feels like everybody around them is just waiting for them to screw up. We need to help people. Codependence Anonymous can be helpful working through codependency, helping people really explore the facts in this context at this time. Yeah, John seems to be kind of scatterbrained this week. Is it that he has relapsed or is it. Fill in the blank. What else could be causing John to be scatterbrained? What are the facts in this context at this time? Let's not assume that John has relapsed until we have facts. There may be lack of recovery for the family unit. I saw this a lot when I was in community behavioral health. People grew up in an environment where there was rampant addiction. They learned that as a coping behavior, as a normative behavior, they go to treatment, they develop an addiction, they go to treatment, they make wonderful strides. 30, 30 days, 90 days, they get out of treatment and they go back to an environment where everybody else is at the same place they were 90 days ago before they went to treatment. And a lot of times they get sucked back into that vortex. So we need to encourage recovery for the family unit and an understanding of what addiction is as a neuro by neurobiological issue that impacts all pieces of life. And addiction can cause ace adverse childhood experiences for children in the family. But a lot of people who've experienced adverse child experiences often develop addictions. There's a really high correlation. Adverse childhood experiences are traumatic. The person needs to identify what happened in their family of origin that caused them to feel unsafe and powerless. What they need to do now to feel safe and empowered. And generally there's some inner child healing work that's got to go along with that down the road. A lot of people with addictions dysregulate. They go from flat to frantic or furious like that. That is that nervous system kicking in, helping them Understand that it's not a character flaw, it's a neurochemical or a nervous system imbalance that they're going to be able to help work to rebalance, but they're going to be more likely to have a hair trigger, if you will, going from flat to frantic. The more stressors that they've got going on already. Think about stress like a bucket. And if they've already filled their bucket up almost to the brim with water, then anything that happens is going to start that bucket overflowing. How can they empty or at least partially drain that bucket in recovery? Anxiety, anger, resentment, guilt, shame, jealousy. All of these are responses to a threat or a perceived threat. Helping people identify what's triggering that feeling for them and develop skills to down regulate, explore what's going on, what triggered the feeling, what the response options are and act accordingly. So the mnemonic is idea. Identify the feeling, downregulate, explore what triggered it and the options, and then act accordingly. A lot of people with either prior to addiction or with addiction, their dopaminergic system is just broken and they feel apathetic, they feel low motivation, they feel lack of, they're exhausted all the time. Some of this could be from circadian disruption, from poor nutrition. Some of it could just be that those dopamine receptors aren't working the way they're supposed to. Encouraging activities that might make them feel somewhat better can be really helpful. This is called behavioral activation. What is it that you can do that will give you a little bit of success or contentment? They may not love it, but encouraging them to do positive things each day. Depression and grief. I often talk about them together because they go hand in hand. Grief process involves anger, denial, anger, depression and acceptance. A lot of people who develop addictions are trying to numb a grief that they're feeling, a loss that they've had. And almost everybody I've worked with that develops addictions has some stuff they need to grieve. We need to help them understand that grief is not just about death. It's about loss of dreams, it's about loss of time. It's a lot about loss of hopes or friendships and helping them process each one of those cognitively. There is a lot of brain fog in people with addictions, which leads to slow processing and impaired recall, which can make them more susceptible, more vulnerable to relapse. Encouraging them, providing supportive tools to help them remember things, encouraging them to give themselves plenty of time. And we need to do that when we're in group to make sure that we're not. We're giving them plenty of time to think about it, formulate their answer and respond, which is probably going to be slower for them than for us. Attention deficit difficulty, Learning new things, Problem solving deficits, Time management difficulty, Difficulty planning, poor memory. All of these are executive functioning deficits. When we're stressed, blood sugar and energy is going to fight or flight and it's starving the prefrontal cortex, which is where all this other stuff happens. Helping people learn to down, regulate, mitigate, mitigate unavoidable stress and avoid or minimize unnecessary stress can help them rebalance that energy system. In terms of poor memory. Encouraging people to write things down, don't expect yourself to remember everything right now. Negative self perpetuating thoughts. I encourage my clients, when they have them, they feel like it, jot it down and then they can go back later and restructure it, or even right then and restructure it. Or they can ask themselves, would I be holding this over my best friend's head? Would I be saying this to anybody else? A lot of times the answer is no. So then the question is, what would you say to somebody else? And helping them identify and address faulty beliefs. To identify and address thinking errors which are common in all of us, not just people with addictions, I use the mnemonic feel. What are the facts in this context? What are alternate explanations besides it's my fault or the world is ending? What are exceptions to when this happens? If I'm thinking that every person is dangerous or things always happen bad to me, what are the exceptions? And based on the facts, the explanations and the exceptions, what is the likelihood that my catastrophic vision for what's going to happen is actually going to happen? Housing instability, job instability, financial instability, all are triggers for for stress. Those are all extremely stressful and can lead people to feeling helpless and hopeless and turn to addictions for numbing. Likewise, once they develop an addiction, they become more housing unstable, job unstable, and financially unstable. Making sure that they're getting the bottom level of that Maslow pyramid met, their basic needs met is essential to helping them feel safe enough to and allow their body to recover, as well as to do the hard cognitive work that goes along with mental health recovery. There's also an increased lack of safety as a result of generalized triggers. They go to the grocery store and there's wine, there's beer, there's this. They go to work. If they've got porn addiction and there's computers everywhere, there's lots of triggers around. We need to help people Learn how to manage their emotional response, their stress response. When they're exposed to triggers. We can't possibly identify every trigger out there. So they need to develop skills and tools for down regulating so they feel safe in going about their daily life. And finally disarray. Their lawn's not mowed, there's weeks of dishes not done, there's clutter around that adds stress to many people and it's important. That's one of those mitigatable stressors. When people are in active addiction, they're not worried about these things, so they go undone, which makes it harder to engage in recovery activities. Because there are these stressors in their environment. The clutter that is outside is representative of all the clutter that's going on inside, encouraging them. Basic, basic sorting, getting boxes or bins for sorting, rinsing off dishes, whatever they can do to minimize disarray. And spiritually, there's a sense of disconnection and not belonging anywhere. A loss of faith in self, others and the universe, including their higher power. And a loss of hope for change and a rich and meaningful life. We need to help them define what does connection look like? What would it look like if you belonged? Where might you be able to start creating that sense of belonging? What is, what do you want to believe about yourself, others and the universe? And is there any evidence that that actually exists right now? And in terms of change and a rich and meaningful life, what do you have right now that is important in your rich and meaningful life? They're not going to have everything. And how. What, what's the progress that you've made toward change? Even if it's day one in detox, that is a huge step. So there is hope for change because you came, you're trying to. That is huge. Addiction and pause impact all pieces of life. Recovery is almost never linear. It ebbs and flows. As clinicians, we must recognize and address the whole person causes of or triggers for addictive behaviors using whole person interventions. This will help people move past the fundamental cognitive behavioral therapy or interpersonal therapy and heal the body in addition to the other pieces of life.