Addiction and Mental Health

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Archive for the ‘Substance Abuse’ Category

Is Rehab Really Necessary?

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And How to Find the Right Rehab, if it is Necessary

By Julie Myers, PsyD, MSCP

Licensed Psychologist, Master Addiction Counselor, MS Clinical Psychopharmacology

 http://www.DrJulieMyers.com

It is my opinion that most people with substance abuse or dependency issues can recover with outpatient treatment from a licensed mental health professional or with the support of self-help groups.  However, in some cases, a Residential Treatment Center (RTC) may be necessary.

A licensed mental health professional, such as a psychologist certified in addiction treatment, can formulate an individualized treatment program equal to or better than many programs offered by “rehabs”.   A psychologist can provide individualized care to help identify behaviors and emotions that drive substance-using behaviors and can treat any underlying mental health conditions that likely exist.  Competent professionals can formulate an integrated, comprehensive program, which can include psychotherapy and referrals to psychiatric care, self-help meetings, group therapy, sober living homes, and other alternative treatments modalities.  The notion that everyone with substance abuse problems needs residential treatment is as unreasonable as stating that everyone with depression needs hospitalization.

Although outpatient treatment is preferable and sufficient for most people, there are those who may need a higher-level of care than outpatient treatment can provide.  In particular, some people may need a more restrictive environment, where there is no access to drugs or alcohol.  Sometimes, when a person is actively using and can’t stop, a Residential Treatment Center can provide the respite that a person needs from their access to drugs or alcohol.  They may also be indicated for those with severe forms of co-occurring psychiatric disorders that have not been adequately stabilized.

However, RTCs can vary greatly in their quality and level of care.  Some offer comprehensive, “gold standard” care, with evidence-based practice from qualified treatment professionals.   Others may offer little more than restrictive use of substances.  So the question becomes, how does one choose a Residential Treatment Center?   It may be difficult to determine which is the best RTC for themselves or their loved-ones, because they may not know the right questions to ask, and because many RTCs may be vague about what their programs include.

It would be helpful to have a set of key questions that someone seeking treatment could ask of the RTC about their program.  Recently, Dr. Donald Meichenbaum shared a letter with me, which he drafted for those seeking residential care.  This letter can be sent to the Director of an RTC that a person is considering.   This letter asks questions about the RTC’s program, questions that can help the consumer make an informed decision about that facility.   I have reposted his letter on my website, which you can find at http://www.DrJulieMyers.com.   I believe that this letter can help guide the consumer to find a residential treatment center that is right for them, should they need that level of care.

To find a list of Residential Treatment Centers, you can go to the SAMHSA government website located at:  http://findtreatment.samhsa.gov/

Copyright (2013) Julie Myers, PysD:  Psychologist in San Diego.  All Rights Reserved.

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Roadmap to Resilience and Recovery

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A Roadmap to Resilience and Recovery

by Julie Myers, PsyD, MSCP

Licensed Clinical Psychologist in San Diego

http://www.DrJulieMyers.com

Recovery from substance abuse is a process unique to each individual.   Despite those who believe otherwise, there is no single “right” path to recovery.  Instead, each person has a unique set of challenges and must address those challenges uniquely.  This is not to say that there are not techniques, tools, or methods that have been shown to be helpful in substance abuse treatment, but rather that because no one person’s history is exactly the same, no recovery will be exactly the same.  Each individual must find their own path.

However, finding that unique path can be overwhelming, particularly because of the amount of information available, from differing sources and viewpoints.  This can leave an individual confused and sometimes fearful about which path is best for them.  Sometimes, friends or family members, therapists, or self-help groups can help guide the individual.  But sometimes, what really is needed is simply a roadmap, outlining the options available to an individual in different domains.  Donald Meichenbaum has written such a roadmap.

Although not intended solely for those in recovery, Meichenbaum’s book, Roadmap to Resilience* remarkably address many of the key aspects that form the foundation of most recovery programs, addiction or otherwise.  His book is an easy-to-use, comprehensive resource packed with practical coping strategies, action plans, checklists, and thought-provoking inspiring quotations from those who have experienced adversity, even encouraging readers to submit their own experiences to the book’s website.  Dr. Meichenbaum gifts the reader with his 40 years of expert clinical experience and wisdom, all in one handy resource.

Roadmap to Resilience is organized by six domains:  Physical, interpersonal, emotional, cognitive, behavioral, and spiritual resiliency.  Resiliency — “the capacity to adapt successfully in the presence of risk and adversity” —  is at the core of addiction recovery.  Although the book’s target audience are those who have suffered trauma, the process of recovery requires similar attention to these six domains.  If resiliency is the ability of an individual to adjust to change and transform their lives, then almost anyone who has recovered from substance abuse has in some way been resilient.

This book is indeed a “roadmap”, rather than a directive.   It offers the reader a broad depiction of the choices available for recovery, but with enough detail to navigate and put into practice specific tools.  I would strongly recommend this book not only to anyone beginning their journey of recovery, but to anyone who wishes to bolster and improve their ability to successfully navigate their world.

*Meichenbaum, Donald (2012) .  “Roadmap to Resilience:  A Guide for Military, Trauma Victims and Their Families”, Institute Press, 211 pp.  Readers of Meichenbaum’s book can submit examples of resilience-engendering behaviors to the book’s Website at www.roadmaptoresilience.org. (See “Ideas for Resilience” and “Examples of True Grit” to read about stories of recovery.)  Dr Meichenbaum is one of the founders of Cogntivie Behavior Therapy and is presently Research Director of the Melissa Institute for Violence Prevention in Miami ( www.melissainstitute.org).

Copyright (2013) Julie Myers, PysD:  Psychologist in San Diego.  All Rights Reserved.

Written by Julie Myers, PsyD, MSCP

January 4, 2013 at 5:51 pm

Can You Think Your Way out of a Drink?

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How decision fatigue can affect your recovery

 

by Julie Myers, PsyD, MSCP

Licensed Clinical Psychologist in San Diego

http://www.DrJulieMyers.com

Recent research on the topic of willpower shows that we, as human beings, have limited decision making capacity.  That is, in any given day, we may simply run-out of the mental energy that is required to make decisions.  Researcher Roy Baumeister, PhD calls this depletion of mental energy “decision fatigue.”

Every day, we make hundreds of decisions, from large to small.   Even something as simple as eating breakfast may entail many decisions, such as what, where, and how much to eat.   We need to make decisions about our personal selves, our work, our relationships, how we move about and relate in the world, and how to resist a temptation.  The more decisions we must make, the more mental energy we use up.  Making decisions, particularly making good decisions, becomes harder over the course of a day as our mental energy wanes.

So why is this important for recovery from substance abuse?   Because the choice to not use is a decision Much of drinking/using is automatic, that is, we use simply because it is our habit to do so.  We step into the house after a long day, we have a drink or we get together with friends, we smoke a joint.  It may cross our minds not to use, but to not use requires a decision.  To say no, we must think about the consequences.  When our mental energy is low, we tend to act impulsively or do nothing different than usual.

We need to give ourselves the best chance at making good decisions, particularly when we are trying to change our relationship with drugs or alcohol.  Baumeister has shown that people with the best self-control set themselves up for success by conserving their mental energy.  For example, they may arise at the same time daily, eat the same breakfast, eliminate temptations, and delegate authority.   They don’t expend their mental energy on trivial decisions, instead preserving their mental energy for making important decisions.

If you want to give yourself the best chance of saying no to addictive substances or behaviors, here are eight simple tips to conserve mental energy for decision making success:

1.  Turn-on your brain. 
Become more aware of when and where you are most vulnerable to automatic use or when decisions are needed.

2.  Restore your mental energy with good sleep.
Make your important decision in the morning, when your mental energy is at its peak.

3.  Fuel your brain.
Your brain requires energy from food to make decisions.  When blood glucose drops, our decision making capacity decreases.  Keep your body fueled to increase your mental energy.

4.  Employ relaxation strategies.
A calm state increases our decision making capacity.  Relaxation techniques, such as slow breathing or meditation, will help to decrease the stress response.

5.  Conserve your mental energy.
Decrease the number of decisions you must make in a day by creating healthy habits.    Delegate some decision to trusted others.  Reduce situations where you need to make decisions, such as shopping.

6.  Reduce temptations
Move temptations out of your reach, when you have the mental energy to do so.

7.  Recharge your mental energy throughout the day.
Exercise has been shown to increase mental energy.  Exercise regularly, on a set schedule.  Even 5 minutes of daily exercise will help recharge your mental energy.

7.  Reduce the number of times that you need to say no.
By planning ahead, you can avoid those situations in which your habit to use requires mental energy to say no.   If you know when you are most vulnerable and plan ahead, you will need to make fewer decisions about whether or not to use.

By employing the strategies above, you will give yourself a better chance for recovery success by reducing your decisions fatigue.  

If you would like to read more about this topic here are two books you might enjoy

Willpower: Rediscovering the Greatest Human Strength by Roy F. Baumeister and John Tierney (2012). 

       The Willpower Instinct: How Self-Control Works, Why It Matters, and What You Can Do To Get More of It by Kelly McGonigal (20

Copyright ( 2012) Julie Myers, PysD:  Psychologist in San Diego.  All Rights Reserved.

Stopping a slip from becoming a relapse

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Stopping a slip from becoming a relapse

by Julie Myers, PsyD, MSCP

Licensed Clinical Psychologist in San Diego;  http://www.DrJulieMyers.com

For many with serious substance abuse problems, any drug or alcohol use can be problematic. These people must abstain.  If they drink or drug again, they can slip into full-blown relapse, even after months or years of abstinence.  For some, even a brief lapse may generate so much self-doubt, guilt, and a belief about personal failure, that the person gives up and continues to use.  This tendency is referred to as the abstinence violation effect.

So does this mean that even a brief lapse must lead to a full-blown relapse?  Does it mean a person must continue to drink or drug until the use returns to the initial level?   Is spiraling out of control inevitable?   Simply put, no.  A lapse need not become a relapse.  After a slip, you have not unlearned all that you have learned.  You have not unchanged all that you have changed in your life to support your recovery.  You do not have to start counting again from day one.

If you view your lapse as a mistake and as a product of external triggers, rather than as a personal failure, research shows that you will have a much better chance of return to abstinence quickly.  Your lapse becomes a tool to move forward and to strengthen your motivation to change, your identification of triggers and urge-controlling techniques, your rational coping skills, and the lifestyle changes needed to lead a more balanced life.

Does this mean that a person should view these lapses as a good thing?   Of course not!   Clearly, if one wants to abstain, lapses are not preferred.  But by recognizing that mistakes can happen and learning how to quickly right oneself, long-term abstinence can be achieved.   Lapses may occur, but relapse is not inevitable.

Copyright ( 2012) Julie Myers, PysD:  Psychologist in San Diego.  All Rights Reserved.

Taking Control of Cravings

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Taking Control of Cravings

by Julie Myers, PsyD, MSCP

Licensed Clinical Psychologist in San Diego;  http://www.DrJulieMyers.com

 

Cravings for drugs or alcohol are controlled by a variety of brain chemicals, including norepinephrine, dopamine, and glutamate.  Many people describe their cravings as coming out of nowhere, as if these chemicals pop into their brains and create a cravings spontaneously.

These chemicals and the manifestations of cravings are actually triggered by stimuli from external environmental cues and internal mood states, particularly anxiety, irritability, and dysphoria.  Environmental cues can include familiar people, places or things, for e.g., being in a favorite place that you used to use.  Environmental triggers are often easier to identify than internal mood states, particularly if the moods are subtle.  For example, a mildly irritating discussion may be enough to trigger a craving, although it may be difficult to identify this discussion as the trigger.

So does this mean that you are at the mercy of the environment and your own internal mood states?  Absolutely not!   It means that you can minimize your cravings by employing ways to control your environment and modify your mood.  You have the power to choose what people, places and things you expose yourself to that might trigger a cravings.  You also have the power to recognize and change your own reactions, thereby changing your mood state.

The first step is to identify your specific triggers.  Try keeping a simple log of your cravings.  What environmental cue did you encounter?  What were you feeling?   Sit down and write it down.   Think about it backwards, from the time that the craving hit, backwards until you can identify something you believe triggered that craving.

If you can identify your triggers, you have taken the first step to taking control of your cravings.

Copyright (2011) Julie Myers, PysD:  Psychologist in San Diego.  All Rights Reserved.

Written by Julie Myers, PsyD, MSCP

December 4, 2011 at 9:22 pm

How the Benefits of Recovery Expand

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How the Benefits of Recovery Expand

by Julie Myers, PsyD, MSCP

Licensed Clinical Psychologist in San Diego;  http://www.DrJulieMyers.com

When you begin to contemplate changing your addictive behavior, you may think about all the problems that your behavior has caused.   There may be a single negative event (such as a DUI) or an accumulation of events and problems.  These problems may be enough to motivate you to change, but for sustained motivation, you may want to consider the positive change that may happen.

Try this simple exercise.  A cost-benefit-analysis1  is a simple way to start thinking about the benefits of changing.   First, draw a line down the middle of a sheet of paper.  On the left side, list all of the benefits of your addictive behavior, for e.g., “It’s fun”, “It helps me sleep”, “It makes me more social”.   Now, on the right side, list all the negatives (costs) of using, for example “Hangovers”, or “My spouse is mad at me”, or “Legal issues”.   If your costs outweigh the benefits, you may be ready to change your addictive behavior.

Now, try expanding this simple exercise by adding two more columns on another page:  “Costs of Quitting” and “Benefits of Quitting”.   For example, costs may include losing friends or being bored.  The benefits may be something simple, such as “I’ll have more money”.

Something interesting happens the further you move forward in recovery:  The costs of quitting diminish.  Things that once seemed so important to you may lose their significance or you find new ways to satisfy your need.  For example, you may believe that you won’t have any way to calm yourself down, relax, or relieve your depression if you don’t use.  But as you learn to identify your thoughts, emotions, and behaviors, you will find new and more enduring ways to relax and deal with emotions.  Another commonly held belief is that you won’t have any fun, you will be bored.  But as the brain becomes accustomed to less intense rushes of dopamine (which most drugs of abuse and some maladaptive behaviors supply in overabundance), you will learn new ways to find enjoyment.

Even more interesting is how the benefits of stopping expand in unexpected ways.   The simple benefits of  “feeling better” or “having more time” lead to even more benefits.  For example, feeling better may mean that you feel good enough to enjoy the sunrise or climb a mountain.  You might not have predicted that you could find the time to go back to school, play basketball with your kids, or even read a book.  But the benefits of quitting are real, and in the end, more deeply satisfying than your maladaptive behavior.   As you move forward in your recovery, make note of all the things you discover that you can now do and enjoy, which you couldn’t do before.

1For a great examples of this exercise, go to http://www.SMARTRecovery.org/resources/toolchest.htm

© (2011)  Julie Myers, PsyD

Written by Julie Myers, PsyD, MSCP

August 21, 2011 at 4:24 pm

Therapeutic alliance as a predictor of outcome in treatment of cocaine dependence: A Review

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Therapeutic alliance as a predictor of outcome in treatment of cocaine dependence

by Barber, et al.

A Review by Julie Myers, PsyD, MSCP

Licensed Clinical Psychologist in San Diego

There has been an increasing interest in outcome measures in therapy.  Although there is a school of thought that technique is the primary predictor of outcome, some therapists believe that it is the therapeutic alliance that is the major predictor of outcome.  The study by Barber, et al. examines outcome measures in drug treatment.

Substance abusers are often difficult to engage in treatment, yet the therapeutic alliance has rarely been studied.  This study is the first to examine the self-reports of the therapeutic alliance as a means to predict the outcome of cocaine treatment.  Because there is a high drop-out rate for cocaine dependence (50-80 % dropout within 3 months), the research also attempts to distinguish between intent-to-treat and completer samples to see if the alliance early in treatment predicts treatment outcome.

The study used a sample size of 252; many co-occurring disorders were excluded.  Clients were randomly assigned to three different treatment techniques:  Cognitive therapy (based on Aaron Beck), dynamic therapy (support-expressive therapy), and 12-step drug counseling.  A fourth treatment group was added later in the study, which used 12-step group drug counseling only.  In addition to the targeted technique, all treatment groups were mandated to attend group drug counseling 2 times per week for initial two weeks, then once per week for four months.  Therapists in the different treatment groups were not similarly trained; drug counselors had the least training.

Both patient and therapists completed two alliance scales, the Helping Alliance (Haq-II) and the California Psychotherapy Alliance Scales (CALPAS).  In addition, patients were administered measures of functioning.  Statistical analysis of the results looked at a number of different relationships, including the prediction of outcome from alliance given symptom improvement, completer sample, and the number of sessions.

The results did not find a strong relationship between the outcome measures and the therapeutic alliance.  The alliance didn’t predict drug outcome at six months, although at one month there was stronger correlation; the therapeutic alliance was a better predictor of outcome for depression scales.  Results also showed that the therapist’s rating of alliance was less predictive than patients.  Measures were similar across completer and intent-to treat samples.  The only strongly conclusive results were that the shorter the lag time between assessment and outcome measures and the longer clients remain in treatment, the better the outcome associations.   These results do not seem to be particularly surprising to me.  The authors state that a “good therapeutic alliance with the therapist, as viewed by the patient early in treatment, is important in predicting outcome when it is embedded in a long term relationship with that therapist.”

The authors state that there are several possible reasons for the weak predictive results, including the choice of the outcome and alliance variables, the nature of the patient population and/or disorder, and the restriction of range in the measures of alliance.  Although these seem likely influences on the results of the study, I found there to be several other possible explanations.

If a study is not well designed, all of the statistical analysis in the world will be meaningless.  In my own graduate-level econometrics classes, I was taught that when designing a study, the researcher must be careful not to examine too many variables, otherwise it becomes a study that is “hunting for” statistical significance, which biases and invalidates the results.  In my opinion, this study threw too many variables into the mix, both in the design of the study and in the statistical analysis.  A far more rigorous study would have chosen one or two associations to measure, then designed the groups with stricter protocol.

In my opinion, the addition of the fourth group-counseling treatment group invalidated the results, not only because of the late introduction of the treatment, but because of the cross-over between the different treatment samples in this group counseling.  Although the researchers attempted to make the treatment samples significantly different from one another, using different therapy methods and different therapist qualifications, for therapists and counselors who do not use 12-step methods, the mandatory attendance in a 12-step group treatment adjunct to therapy may harm the therapeutic alliance.  Cognitive therapists, in particular, may have little or no belief in the 12-step method.  From my understanding, when therapists do not believe in the methods being used, outcome is compromised.

This study may be better used as a guide to setting up treatment protocols to assess therapeutic alliance than it is useful for the results of the study.  Significant changes that I would suggest are:  less lag-time between assessment of outcome and therapy, more clearly defined and independent treatment protocols, and fewer measurements of outcome.  Although the large sample size was a positive aspect, a smaller sample would not compromise the results.

– Julie Myers, PsyD, MSCP

http://www.DrJulieMyers.com

References:

Barber, J., L. Luborsky, P. Crits-Christoph, M. Thase, R. Weiss, A. Frank, L. Onken, R. Gallop (1999),  Therapeutic alliance as a predictor of outcome in treatment of cocaine dependence.  Psychotherapy Research 9(1), pp. 54-73.

Written by Julie Myers, PsyD, MSCP

July 23, 2011 at 7:32 am