FREE HELP for Addiction Recovery

"How to stay clean, for an artist" Video#1

2017-06-07T02:39:00.001-07:00

howtofindhelpfordrugaddiction.blogspot.com

"How to stay clean for an artist" Video#1a

2017-06-07T02:36:00.001-07:00

howtofindhelpfordrugaddiction.blogspot.com

FREE HELP for Addiction Recovery Abstract

2013-03-07T12:04:00.000-08:00

*Brandon Dellario LMSW LASAC, recovering addict and alcoholic. Masters level specialist in addiction treatment, dual-diagnosis and other chronic mental health conditions. This page is presented by FREE HELP for Addiction Recovery Services (click here to learn more), online and telephone services. For information on services, please write to brandondellario@gmail.com

Addiction is a disease. The disease model of addiction is actually the medical model, also the most widely used model in treatment. Addiction is a funny kind of disease. Not funny as in W.C. Fields, but funny as in slippery. It is known to be sly. Addiction is not as easily seen as diabetes, but similar because it is progressive. Without treatment it is fatal, and not so fun on the way down.

Along with the sometimes physical, and always present strong psychological dependence of the disease, the denial aspect of addiction makes recovery tricky for an addict. It also makes the disease very difficult to treat, though there are therapeutic modalities known to be effective in treatment. Twelve-step mutual help programs, CBT & Smart Recovery and Motivational Interviewing in relation to the Stages of Change being among the top evidence-based treatments in the field. It is truly amazing to see the fitting therapy take hold of a resistant patient in treatment. However, addicts find their own special path of recovery in a variety of ways.

A program of recovery is needed to treat addiction, but it can only be selected and walked-out by the addict themselves. No one can do it for someone else. Once the addict surrenders to an effective program of daily living, there are no limits to the amount of freedom they can gain from any self-destructive behavior. Recovery is possible for anyone. If you can get this, buckle in and get ready for the ride of your life! After some sacrifice in working a program of recovery, you will be in the position to do whatever you want, and be effective at doing it too. You will be the one writing the movie script of your own life.

Brandon Dellario LMSW LASAC

UR Addiction Recovery: Maintaining Balance

2012-04-02T11:48:00.000-07:00

Maintaining Balance in Recovery

A Formal Expression Series (please leave comments regarding what helps you and others in recovery):
Brandon Bruce Dellario LMSW LASAC
When I see a baggy or anything that looks like drugs on the ground, I’ve been taught to immediately approach it, step on it and grind it into the ground. Most drugs will be destroyed this way.

   I really put some effort into it too. If I find drugs or alcohol somewhere in my house, car or anywhere I feel the need to dispose of it, I immediately take it to the toilet (without thinking) and flush it down. I will call my sponsor or another peer in recovery while on my way. If I give myself too much time in doing these things, I might be risking a desire to use
     There are many other things which can trigger a desire to use for me. Some movies and music can trigger an urge. I walk away or turn them off immediately. It’s just a sacrifice I make to stay clean. If I hear someone talking about specific drugs or details about using, this can be tough for me. I immediately start into the tools I have listed below. I get myself out of the situation without thinking of what others will think. If I’m in a meeting, I will cut off the person sharing and say “I’m an addict named Brandon and I have a desire to use” then share about it. If anyone is upset by my doing this, I don’t care. I know my life depends on this (sharing about desires to drink & drug). If the chair or someone else cuts me off, it may mean they don’t have experience with this situation. I will take someone aside and tell them about my desire to use. If the desire persists, I will do some fellowship or calls outside of the meeting.
When I do get a desire to use, there are four tools which help me most. Here is what I’ve learned.
#1. Pray. The prayer I repeat over and over when I have a desire to use is “please remove my desire to use.” I sometimes pray by talking to my higher power in my own way of speaking. Other times I will recite prayers I’ve learned. My grandsponsor told me that once he prayed the Serenity Prayer over and over in his mind for two days straight, in order to get through a difficult time. He has over 20 years clean, I’m working on 8 years clean. Prayer has worked for us and millions of others since the twelve steps were written in the 1930s. Mantras and meditation is also considered a part of this practice.
#2. Call. I call another recovering addict on my phone list and immediately tell them I want to use. I get very specific about what I want to do and what I am feeling. If I get to the bottom of the list after calling everyone and leaving whatever long messages I want, I will go straight back to the top of the list and start calling them all again. I am also praying while dialing each number. I do not want to go back to the misery of active addiction. I remember the terrible, painful feelings inside my heart. I lived in a dark and isolated place inside myself. Now I don’t have to isolate when I’m upset. I can call someone to experience the “unparalleled” help of one addict helping another. This is a twelve step recovery term. However, whether you identify yourself as a peer in recovery or not, you can be a useful person for someone to talk to on a bad day.
     Besides my regular meeting attendance, there are other times I need to talk to, call or fellowship with others who are doing good things in their life. Especially those who can identify with the things I could be going through. Peers in recovery help one another learn how to live clean. I’ve never experienced many of the things that I do today. I ask questions and ask for help from others now in learning these new things. Other people in recovery seem to understand me best in many ways. I can always go to them for help, or simply learn from them by seeing how they live. Many people in my life role model for me every moment of the day.
#3. Remember specific consequences I’ve endured from using in the past. I keep five or so of these detailed memories on hand. This tool helps me to remember why it is I don’t drink or use drugs. I've heard this called a "life line." In jest, I occasionally call it "negative visualization," but it really is a recall of negative imagery. Painful memories that resulted from my days of active addiction. Specific images, feelings, thoughts and general pain I experienced in past drinking and drug use. I can also use them to remember why I practice my good habits today (important to stay clean). I remember and think of as many of the bad memories as I can, or I know I am subject to romanticizing the past and glorifying my own use.
#4. Write. All I need is a pen and scrap paper. This is a great tool for getting ANYTHING out. I write very honestly, as if no one will ever read it. Sometimes I throw it away or burn it up afterward. I sometimes feel a large empty space inside where there use to be lots of pain. I know to fill it with good practices. I have been shown ways to fill that space today by journaling, writing from a stepworking guide or other literature, reading, meditation, volunteering in the community or in my twelve-step program, and helping my friends and family regularly.
#5. Remove the focus! Doing something off the wall like a spontaneous walk, or maybe a comfortable night on the couch can get me through a difficult day. I was told that I can do anything in writing the film of my life today. I'd rather be working out or writing a novel, but sometimes Rocky Road ice cream and a good movie is the call of the day. I can figure out a great deal of what's going on with me by using the HALT system (am I too Hungry, Angry, Lonely or Tired). I think of what I'm doing to take care of myself, and what I may be in need of just by remembering this tool.
     These are a few of the things that help me stay clean while regularly maintaining a program of recovery. Both the tools and the program fill me with joy today. Most of the time I know these practices to be the next right decision. They are a part of living clean and in recovery for me. Another reason I do these activities is because they feel great and remind me of how and why I stay clean. Not everyone does all of these things, but many people do many of them, even in non-twelve step programs such as SMART Recovery or various Faith-based programs for addiction treatment. In fact, twelve-step programs actually evolved from Faith-based programs, as did the twelve steps themselves.

UR Addiction Recovery: Self-care in Social Interaction

2012-04-01T11:27:00.002-07:00

Self-care in Social Interaction

A Formal Expression Series (please leave comments regarding what helps you and others in recovery):
Brandon Bruce Dellario LMSW LASAC

My Mother says that everyone is doing the best they can at all times. Although that might not seem to be true at times, I believe it to be.
When I feel as though someone is doing something which is unhealthy, it doesn’t feel good to see. This is a way to find what is right and wrong for myself. I look at the examples of others. If it looks like a behavior I want to exemplify, I can do likewise. If it looks like something to steer clear of, I do. It’s as simple as that. I have a rational mind and conscience to guide me on my path, along with consultation from healthy friends.
When I was a young man, I made many mistakes. I learned from my mistakes, which makes them very valuable to me. Though I can beat myself up over anything, mistakes are in fact helpful tools for education and growth. Remembering them also helps me to have empathy for the flaws of others. In this way I can love my neighbor, free myself from resentments and live in wisdom, forgiveness and respect. I like to think I only take action on the righteous judgments I make in life. Sometimes, I may need to love someone from a distance in order to establish a healthy boundary. This distance may also help them to help themselves. Here is what I’ve learned regarding my personal relationships in recovery.

When I came back to the twelve-step meetings (I had avoided like the plague previously), I had what they called “the gift of desperation.” I sincerely knew I needed to change my life and I couldn’t do it alone. I was ready to do what they told me to. My spiritual guides of the time let me know some simple tools for interactions with people who use:

#1. If using friends call or come around, I don’t let them in, literally or figuratively! I let them know I need to steer clear of people who use. I tell them I can’t talk or hang out for the time being. If they ask why, I tell them that it’s what I need to do for myself right now, because this recovery stuff is about me, not them. If they persist, telling me they are clean or don’t have anything on them, I tell them about the time and place of the next meeting. They can meet me in the meeting if wish to see me. It’s hard to turn away partners or friends that may have been there for you in the past. It has simply been necessary for me to stay clean, and I am willing to go to any lengths in order to do so.

#2. If I am forced to be around people who use regularly, I may ask myself why, and is it truly necessary. If so, I share about it regularly with mentors, especially my sponsor or spiritual guide, and ask for suggestions. This is a situation which might be quite difficult, but it can also be viewed as an opportunity to practice the tools I’ve been learning in recovery. I can pray, write about it, talk to friends about it, remember some of the consequences of my own use (where it took me and why I don’t want to go back), I can give myself a break by walking out of a stressful situation, or relieving myself in another healthy way. One tool I have found that's useful is to write down five to ten things I’m grateful for, and then just throw it away. This is a great recovery tool for feeling better. It is called a Gratitude List. I personally have a few other methods of removing the focus from the problem, such as: Movies; comics; music; art; exercise; milkshakes; driving; Nag Champa Incense; organizing and cleaning my room; working on fun little projects; singing; calling or writing friends; … I have even found it helpful to grab a hammer when I’m angry and beat on the ground outside for relief. An activity can be making a list of fun activities to do clean. The only thing I lost was the using. I fact, I have gained back everything else in life by giving up that using. Some say there are healthy and unhealthy ways of catharsis. Venting or blowing off steam. Many activities are healthy compared to using. For me, it’s not just a beer or a joint, it is a toxic poison. “I’m allergic” I sometimes say. This is not a lie. I am allergic. I will tell anyone I feel it is necessary to tell, the clerk at the local drugstore, the bartender at my regular restaurant, anyone. I can even tell my uncle not to serve me anything at his house if I feel safe there otherwise. But if anyone there is a drug or alcohol abuser, I usually leave and choose to avoid his house for a while. I do these things a bit proudly at times, but better safe than sorry. For me, the more barriers there are for me between living clean and using drugs, the better. And as they say in twelve-step meetings, “you can’t save your face and your ass at the same time.”

#3. If I know that someone is using, I do not make too much of a secret of it to others in meetings.
Many newcomers who come to meetings are still using off and on. We also know peers who relapse after significant periods of abstinence. Even people with years of recovery under their belt are susceptible to the tricky and baffling nature of this disease. It can be helpful for friends in recovery to know that a mutual friend needs support.
I can, and do, keep one’s anonymity to outsiders in the larger community. Especially if I know they value their right to anonymity. This can even be fun, keeping wild stories forever strickly confidential, or talking about things in our secret language.
In my regular life I don’t usually interfere in the lives of others unless I know someone is in danger. I will actually turn my head the other way when I know someone is using on my street for instance. Still, in the larger community, if someone interferes in my life (such as breaking into my house) or harms vulnerable people in some way, I will call the police today. I no longer live by the code of honor among thieves. I’m not a "buster" or "narc," but I am caring citizen, and sometimes a visit from the police might save someone’s life. I am personally grateful for almost every time I was busted or otherwise arrested by the police. Ninety-nine percent of the time it was an officer just doing his job, and actually saving me from myself. Some of these interactions with officers and others professionals I regard as direct blessings from my higher power.

#4. If I see someone in public that I know better than to be around, I have a few tactics:

a). ignore them completely. This may be rude, but I do have the right and my life may depend on it that day.

b). just say hi, make it very brief (like I’m in a hurry) or remember to not break stride.

c). dump recovery information on them, telling them about all the great things I’ve been learning until they are sick of hearing about it or ready to meet me at a meeting some other time. We do not hang out with people we know are using. Doing this is known as a twelve-step call and is not done alone. Even when done correctly it can be dangerous in ways.

d). I can lie :) I can tell them I am under surveillance, that the police are following me at that minute, or I myself am becoming a police officer. This is the one situation where I will advise someone to lie if they feel the need. Living by spiritual principles and being myself is enough for the rest of my behavior around others.

These everyday situations might actually be the difference between life and death for me, so I treat them as such. If I pick up again, I might not be able to stop until I am dead or in prison, and those might be the lesser of the evils that lurk on the downward spiral of active addiction. The disease of addiction is progressive. I am eligible for any of the terrible effects of life in the Gollum Monster. Everything that other addicts have done or experienced is waiting for me should I choose to pick up that first drink or drug. This is a major reason I stay clean and in recovery, maintaining the treatment of my disease. There is no cure, but there are some proven ways out of the dark. There are also great benefits along the golden road of recovery :)

UR Addiction Recovery: Slippery Places

2012-03-30T13:02:00.000-07:00

Get a Grip in Slippery Places

A Formal Expression Series (please leave comments regarding what helps you and others in recovery):
Brandon Bruce Dellario LMSW LASAC

This series of articles titled “UR Addiction Recovery” are my own personal experiences of life in recovery. The following stories exemplify behaviors which help me to stay clean,
many are techniques taught to me by old-timers in twelve-step meetings, others are professional mental health interventions I have found useful in my personal life. In this article I will focus on what I do given the many dicey situations presented to me in recovery. I vastly appreciate being clean. It has afforded me more benefits than I can name.
Along with working a twelve-step program in commitments with my sponsor, the following are tools that work for me. I do not suggest all of them to everyone. What works for me might kill someone else. As twelve-step literature states, tools that have worked for me at one point in my recovery don’t work in another phase of recovery. There are great lengths and sacrifices I make to stay clean, but it has become much easier to do over the years. Life can still be tough, but I get better at living it every day. Here is what I've learned so far.

          When I was thirty days clean, I shared at a meeting about wanting to go out and celebrate by dancing at the club. Thank God that my friend John Richards was there to let me know that it might not be a good idea. He told me if there was even the smallest percentage chance that I might use, or get something about using stuck in my head, then why risk it? He started calling me the birthday-boy jokingly from then on. John loved collecting stories from people when they came back from a relapse. I think this was his way of helping them look at what they did, or did not do. It was also his way of learning from them and avoiding problematic situations. Most relapse stories start with the same thing, “I quit going to meetings and . . .”
     After a couple years clean, I decided to attend karaoke at a local bar.
I did this with full accountability to my sponsor and other peer supports. I’m sure I even told my Mom about my plans to venture out of the regular routine. I wanted to do this as safely as possible. Under the advisement of friends in meetings,
I was told to go with other people in recovery and always give myself a way out of the situation. To me, this means having my car, and not being responsible to drive others who may not want to leave. To others “a way out” may mean having money for a cab or bus token.
It also helps me to have access to a phone in order to talk to another addict in recovery. I know to pick up the phone whenever I have a strong desire to use, but I can also call just to reach out for whatever reasons, including confusion, frustration, fun or friendship. Talking to another addict in recovery always stabilizes me in any situation.

Doing things in this special new way also means keeping aware of myself and my spiritual condition. If I’m not feeling comfortable in my own skin, it may signify it’s not the best night for me to go out, or it’s time to leave. I know there are specific situations that might cause this, such as being near or speaking directly to people who are inebriated. It can be shouting, fighting or the other chaotic characteristics of these “slippery” places. Other times it just happens with no apparent reason. I get “slimed.” This is a term for the way a using addict can effect a clean addict, just by being near. In this way I see the disease of addiction as having a slightly contagious nature.
The disease is very tricky to pinpoint and comes at me in subversive ways. If I’m around anyone using heavily, after a while, I get feeling a bit of anxiety or frustration. I can experience those types of stress, or I can start acting like an addict, without even using. Blaming others for my problems, acting out in anger, paranoia, lying, cheating, manipulation along with all the other negative aspects. I can slip into my old shoes very easily in certain circumstances around those living in active addiction. In this way, I believe the disease of addiction to be contagious to those who are predisposed to it.
If I do choose to attend functions where drugs like alcohol are present, it is best for me to plan a bit and be cautious. I can't control or moderate my drinking in the way some others can. I can't stop for long on my own, and I can't stay stopped without regular help of others. I have an actual allergic reaction to using (which is not always visable). For these reasons, I know I'm going to end up with unhealthy consequences if I use. I'm very happy to know this and enjoy my freedom from addiction today. I'm a grateful recovering addict/alcoholic.
I'm different from others, I'm in recovery :)

UR Addiction Recovery: Medications and Pain Management

2012-03-19T18:29:00.001-07:00

Medications and Pain Management for the Recovering Addict
A Formal Expression Series (please leave comments regarding what helps you and others in recovery):

Brandon Bruce Dellario LMSW LASAC

Every addict in recovery has their own particular path.
When it comes to addiction recovery, in relation to specific drugs that can or should be used for medications, opinions vary. Be it prescription or over the counter,
each recovering person makes decisions regarding their own recovery and the drugs they will ingest.
This is done with the guidance of a sponsor, peer or another accountability party, as well the supervision of a medical doctor. The doctor is the professional, and does have the final say, though doctors may not be informed regarding the disease of addiction and appropriate treatment medications or procedures. It is up to the doctor and the patient together to figure out the best course of medical treatment. As with most addiction treatment methods, this can only be done with the addict’s full disclosure.
I myself will tell the doctor immediately upon their entry to the room, “I want to let you know, I’m a recovering addict. There are certain things I do to manage medications, and I need your help in doing so. [Or, I will simply declare] I’m an addict and I know to tell you this before we proceed.”
    Over the years in my own recovery, I have undergone four surgeries. I've been on a variety of pain medications as well as several psychiatric medications. One might ask how someone who is on a medication be considered clean from drug use. Also, how can anyone in recovery insure they stay clean (meaning abstinent from drug misuse). The following is my personal experience which may differ from others. I mean only to share my own story with you as to allow others to find their own personal path in recovery. As they say in twelve-step programs, “take what you need and leave the rest behind.”
    Many people in addiction recovery find recovery-oriented programs necessary in order to stay clean. Early on in my recovery, I attended 6 or 7 twelve-step meetings per week. During my first year clean I attended over 300 meetings. It was in those meetings (including sponsorship meetings) I laid much of the groundwork for what I call my foundation in recovery. I still attend meetings regularly, but it was that first year I learned much of what I can and cannot do in order to stay clean. I learned that
With medications, we take the minimum amount needed to manage the pain or condition. We take meds only as prescribed, as directed and as needed.
    Of course, most psychiatric medications were nothing to worry about regarding abuse because they didn’t get me high. They just slightly change me in some way or another. On the other hand, there are many psychiatric medications that I abused in my using days, such as the many benzodiazepines commonly used to treat anxiety, and the myriad of stimulants used to treat Attention Deficit Disorder. I have had to turn down these medications down left and right from the many Dr. Feelgood PhDs out there. Alternatively, if I feel like I absolutely need one of those meds to treat my condition, I will accept the medication and consult my sponsor about the method I will (or will not) take it. I take these "controlled substances" or "drugs of abuse" only as medication, and only in a very special way now-a-days. Here is what I’ve learned from other addicts in recovery, as well as the particular ways of my personal sponsorship line in a twelve-step program regarding medication use:
·    Upon arrival,
I tell doctors, and occasionally nurses, that I am recovering from addiction.
·    Upon consultation I request information regarding the suggested medications, and I Inform the doctor if I feel the prescribed medication is dangerous for me to moderate (as a recovering addict). Working together, my doctor and I can figure out the best medication for me to take. Doctors know that I have a voice in my own treatment. I know better than to think I can control my own use of certain mind or mood-altering drugs.
·    If there is no alternative medication or treatment (which often times there is not),
I call a friend or family member and ask them to pick up the prescription with me and hold onto it. I then delegate that person, or another trusted person to dole out my medications as needed, specific to the dosage and time of day. I also do this with the many “non-narcotic” medications which are frequently prescribed. These meds can be every bit as mood and mind-altering as their more traditional counterparts.
Once I feel as though the pain is manageable without the next dose of my medication, I will cease to take it. After a short period of trial without the medication, I will ask my trusted friend to flush the medication down the toilet in order to eliminate any avenues of procurement. There is always a chance I will have desires to use. I continuously strive to avoid the people, places or things which might place me back in my old ways regarding drugs of abuse.

To the average person, these measures may seem extreme. However, we are dealing with a disease which is more than elusive. In my recovery, I have found it is best to lean into what other recovering people tell me about making appropriate decisions. It is not an easy way to go about things, but is a part of the path I've been given in freedom from active addiction. My own ways of doing things never kept me clean, no matter how hard I tried and no matter what I did. I now know to ask the people who have been there and helpful professionals for suggestions.

What are the mental health issues related to cocaine addiction and withdraw?

2012-03-18T21:41:00.000-07:00

Cocaine-induced Disorders with Onset During Withdraw:
Mental Health Informed Addiction Information
Brandon Bruce Dellario LMSW LASAC

     This is a report on cocaine-induced disorders with onset during withdraw. Cocaine is known to elicit a very strong psychological dependency. There are many symptoms of post-acute withdraw from cocaine.
To examine the forms of depression, anxiety and psychosis that come of it, we will take a general overview of the cocaine dependent population with and without previous mental illness. We will also look at some treatment modalities available for those in recovery from this substance use disorder.

Etiologies
“Regular users of stimulants seem to experience withdraw symptoms upon cessation, but they do not have a clear cut, easily observable syndrome as can be seen with opioid, sedative, or alcohol withdraw. The typical symptoms include dysphoria, fatigue, insomnia and psychomotor agitation . . . Cocaine users may develop a variety of psychiatric symptoms including anxiety, agitation, paranoia, and psychosis. Cocaine-induced psychosis and paranoia appear to be a relatively common experience for users, . . . As with other substances, those who abuse or are dependent on stimulants are at increased risk of a variety of psychiatric illnesses including depression, bipolar disorder, anxiety disorders, personality disorders, and schizophrenia, though a cause and effect relationship has not been established.”(Rastegar, 2005 pgs. 147 & 150)

     Detoxification from cocaine dependence is best done through an inpatient program at a drug rehabilitation treatment facility. Yet many of those addicted to cocaine go in and out of withdraw regularly when they run out of drugs and money to buy them. This is observable in the devastating effects of people going through cocaine-induced withdraw who trade or sell all their possessions, sell their bodies, live homeless, live well below poverty, steal (sometimes by force), and so on. These are some of the easily recognizable effects of drug addiction on society, but what about the finer, psychological symptoms of someone going through this painful process. The DSM-IV TR describes three diagnostic criteria for drug withdraw:

“(a) development of a substance-specific syndrome as a consequence of cessation of (or reduction in) substance use that has been heavy and prolonged; (b) the substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and (c) the symptoms are not a result of a general medical condition and are not better accounted for by another medical or mental disorder.”(DSM-IV TR, 200?)

Characteristics
     There are several specific diagnostic categories within individual substance use disorders. There is also a range of dual-diagnosis categories, some with the mental disorder being the primary diagnosis and some with the substance-related disorder being the primary diagnosis. Understandably, these are confused from time to time. The ways these disorders are determined have many dimensions. Firstly, if a psychiatric disorder was present before the substance related disorder, the psychiatric disorder is considered the primary, and vice versa. If the patient is still using drugs when seen by a psychiatrist, it is not viable to diagnose the psychiatric disorder until there has been a period of abstinence. However, it is proven that if there is the possibility of a dual diagnosis, it is effective to prescribe the proper medications right away to aid the person in their recovery. So, many doctors will diagnose prematurely in order to lubricate the recovery process, affording the patient with all of the services available to them, including medications necessary.
     I was personally invested in a similar situation as a young man with a substance abuse history, along with a new psychiatric diagnosis in 1996. Through the years, I have discovered some things about my dual-disorder diagnosis. I had emotional and behavioral issues as a youngster, which I now view as symptoms of my vulnerability to mental illness. This predisposition caused onset of mental conditions once I experienced times of physical and emotional trauma in my adult life. Also, my social and self-medicating drug abuse spiraled into exacerbated mental health challenges thereafter.
     For whatever reasons, I was determined to drink and use drugs even from the early age of 10. It could have been “the gene,” the nature theory people argue for in the (medical) disease-model of addiction, which does exist in my family. It may have been the traumatic environmental stressors I experienced, or a combination of both. In any case, the drugs gradually exacerbated my mental symptoms over the years, while also exacerbating the addiction itself. Cocaine itself made me crazy, during and after using it. It has been a long, hard road in my recovery from substance abuse, mental disorders and the difficulties that come from the combination.
     Cocaine, like any drug of abuse, is sometimes used to self-medicate. This is a topic of dispute in research. Some findings show that certain populations are self-medicating in some situations, and not in others. Whether or not someone starts off using cocaine to self-medicate or not, it is my opinion that with prolonged use, addicts eventually get to the point of self-medicating with cocaine to kill the pain of addiction. Though cocaine-induced disorders are plenty and varied, the disorders that come with onset of withdraw (cocaine withdraw syndrome), comes in three phases:

Table 1. The first phase of cocaine abstinence

First Step: Agitation, Dysphoria Depression, Anorexia, Craving

Second Step: Fatigue, Depression, Hypersomnia

Third Step: Strong fatigue, Somnolence, Hyperfagia

Table 2. The second phase of cocaine abstinence

First and Second Step: Normalization of sleep and of mood, Anxiety, Irritability

Third Step: Anhedonia, Strong Anxiety and Craving

     “The third begins several weeks or months after cessation and it is dominated by an intense craving. The withdraw syndrome in cocaine addicts is characterized by a hedonic dysregulation . . . clinical evidence has shown that hedonic dysregulation in cocaine-dependent patients is responsible of dysphoria, apathy, irritability, depression, and suicidality.”(Barbaro, 2007 pg. 37) These disorders occurring upon withdraw are the opposite effects that a cocaine user seeks in using the drug. This is known as “reflective withdraw,” where the natural states the person is trying to relieve by using the drug are reversed and magnified during withdraw. Another cocaine-induced disorder which is common among stimulant abuse is known as “crack bugs” or “meth bugs.” This is a form of psychosomatic dermatitis, or more specifically, a skin allergy developed with abuse of cocaine or methamphetamine, where the addict actually feels as though they are covered with bugs. Although these states “are not medically dangerous,”(Barbaro, 2007 pg. 40) they are intense and can be overwhelming for the cocaine-dependent person beginning their recovery. Some have found relief from the itching sensations with use of the over-the-counter allergy medication Cetirizine. Though there are serious side effects involved with use of allergy medications, and any use of medication should be concurrent with doctors orders.

Psychosocial Considerations
     One Spanish study on “psychiatric co-morbidity in young cocaine users: induced versus independent disorders,”(Herrero, 2008 pg. 2) discovers some psychosocial demographics of young cocaine users (18 – 30 year olds). Of the 139 subjects studies, 85% had never been married, almost 93% were schooled beyond primary education, 14.4% were university students, around 45% were employed, nearly 54% lived with friends (23.7% of whom were squatters), 32.4% were living with their parents, 11% lived with their significant other, 3% lived by themselves, About 22% of them had been to jail or prison. More men were single, lived with their parents and had a criminal record. This study also found that this large population of cocaine using young people with psychiatric co-morbidity “never sought treatment for their substance abuse nor for associated psychopathology.”(Herrero, 2008 pg. 7)
     A Yale study on mood disorders among cocaine using-methadone patients found that treatment completion could be loosely associated with ethnicity. In their sample of 67 patients with a mean age of 37 years old, they found that African-American ethnicity was a positive predictor of treatment success. Also, those who were not able to speak English fluently in this U.S. study (i.e. Hispanics) “participated less in group discussions. Perhaps these patients were consequently less engaged in the treatment and more likely to drop out.”(Rosenblum, 1999 pg. 8)
(This article is continued in the posting below)

Barbaro, G., Nava, F., Barbarini, G., Lucchini, A. (2007). Management of Medical Disorders Associated with Drug Abuse and Addiction, Nova Science Publishers, Inc., New York, NY.

Herrero, M.J., Domingo-Salvany, A., Torrens, M., TeresaBrugal, M. (2008). Psychiatric comorbidity in young cocaine users: induced versus independent disorders. Addiction, 103 (2), 284-293.

Inaba, D., Cohen, W. E., (2007). Uppers, Downers and All Arounders, CNS Productions Inc., Medford, OR.

Rastegar, D.A. (2005). Addiction Medicine: An Evidence-Based Handbook, Lippincott Williams & Wilkins, Philadelphia, PA.

Rosenblum, A., Fallon, B., Magura, S., Handelsman, L., Foote, J., Bernstein, D. (1999). The Autonomy of Mood Disorders Among Cocaine-Using Methadone Patients. The American Journal of Drug and Alcohol Abuse, 25 (1), 67-80.

If someone is having mental health issues related to cocaine withdraw, what effective treatments are available?

2012-03-17T21:30:00.000-07:00

Treatment for Cocaine-induced Disorders with Onset During Withdraw: Mental Health Informed Addiction Treatment
Brandon Bruce Dellario LMSW LASAC

“Most people with dual diagnoses report the onset of substance-use disorder later than the onset of other mental disorders. Prospective studies confirm this temporal order, but with some mental disorders (e.g. anxiety and depression) the risk relationship is recipricol, with these mental disorders predicting increased risk of later substance abuse, and vice versa.
”(Emmelkamp, 2006 pg. 12)

     The most effective treatment techniques for cocaine induced disorders with onset during withdraw, may include a combination of psychosocial and pharmacotherapy treatment. Methods of psychosocial treatment can be self-help groups, individual and group counseling, and behavioral approaches. Some of these evidence-based practices are 12 step programs and other mutual-help groups, Cognitive-behavioral therapy (CBT), Contingency management, advice, counseling and residential treatment.
     Pharmacotherapy is the use of specific agents to aid in treatment. Evidence-based medications such as disulfiram, topiramate, modafinil and long-acting amphetamines may be helpful in reducing cocaine use.(Rastegar, 2005 pg. 151) Many medications are used by doctors to treat this population including; stimulants like modafinil (Provigil), antiepileptic drugs like topiramate (Topamax), both used to treat stimulant cravings. Bromocriptine (Parlodel), amantadine (Symmetrel), levodopa combined with carbadopa (Sinemet) these are dopamine agonists used to suppress withdraw symptoms and initial stimulant cravings. Antidepressants, Antipsychotics (neuroleptics), Sedatives, and nutritional approaches are all used to treat the depletion of dopamine and neurotransmitters which are caused by cocaine dependence.
     The depression, mood disorders, anxiety, sleep disturbances and psychosis that come as a result of this drug-specific addiction need to be attended to in residential treatment, and throughout after-care treatment.(Inaba, 2007 pg. 469) There are differences in the distinction between powder cocaine and crack cocaine use. Crack is associated with differing degrees and progression of abuse and dependence, along with a greater number of symptoms and higher levels of anxiety, depression, paranoid ideation and psychoticism.(Herrero, 2008 pg. 1)
“A wide range of drug–induced psychiatric symptoms often accompanies stimulant abuse. Acute paranoia, schizophrenia, major depression, and bipolar disorders are often the initial presentations by a stimulant addict, particularly at the end of a long run. These symptoms require psychiatric intervention to prevent harm and to assess whether they are caused by the drug itself or whether the mental illnesses are preexisting and will remain a problem after detoxification and initial abstinence. Besides psychiatric symptoms, other key effects to watch out for in cocaine or amphetamine abusers who are detoxifying are prolonged craving, anergia (exhaustion), anhedonia (lack of ability to feel pleasure), and euthymia (a feeling of elation that occurs three to five days after stopping use). Euthymia makes users feel that they were never addicted and that they don’t need to be in treatment. Anergia and Anhedonia begin to overtake the euthymia about two weeks after starting detoxification, and these findings, particularly the total lack of ability to feel pleasure, often lead to relapse.”(Inaba, 2007 pg. 469)

     Cognitive-Behavioral Therapy (CBT) is a great option for those seeking treatment for cocaine-induced disorders. CBT Integrated treatment of the substance abuse and mental health treatment is preferred with clinicians working side-by-side to work with the client in a holistic manner, systematically identifying, exploring and addressing problems that are presented while the client comprehensively improves skills and supports. The objective of CBT is to;
“help clients negotiate and maintain behavior change related to their problematic drug/alcohol use. In line with this, clinicians using C-BIT [CBT] encourage clients to develop “healthy” alternatives to drug/alcohol misuse, and to recognize the relationship between substance use and mental well-being . . . [CBT] aims collaboratively to identify, challenge and undermine unrealistic beliefs about drugs or alcohol that maintain problematic use, and replace them with more adaptive beliefs that will lead to strength and behavior change, . . . it seeks to facilitate an understanding of the relationship between problem substance use and mental health problems, . . . it teaches specific skills for controlling and self-managing . . . the early warning signs of psychosis, and for developing social support for an alternative lifestyle.”(Graham, 2004 pg. 15)

     CBT consists of screening and assessment, engagement and building motivation to change, negotiating behavior change, relapse prevention and relapse management, skills building and working with families and friends. CBT works to help people identify beliefs, stressors, feelings, thinking patterns/styles and thoughts in evaluation and maintenance of problems. This can help people who have the psychosis and emotional disorders that come with withdraw from long periods of cocaine abuse.
     In a mixed substance abuse sample, CBT was compared to a combination of motivational interviewing and CBT. It measured alexithymia (difficulty expressing feelings), non-supportive networks of friends and antisocial personality disorder. It found that patients with high difficulty in these areas were better off with standard cognitive behavioral therapy treatment. Patients low in alexithymia were better off with the combined motivational/cognitive behavioral therapy approach. Hostility and low motivation at preset were factors that had equally moderated treatment effects.(Emmelkamp, 2006 pgs. 117 & 118)
     Specific treatment facilities carry heavy responsibilities. There are several approaches to treatment program evaluation. One of these that is compatible with evidence based practice is called ‘empowerment evaluation.’ It includes the following:
1)    [Continuous] Improvement of services.
2)    Community ownership of evaluation data.
3)    Inclusion (all stakeholders in the community are included in the process).
4)    Democratic participation (requires “authentic collaboration” and transparency).
5)    Social Justice (fair and equitable allocation of resources and services).
6)    Community knowledge (members of the community are experts on their own groups, recognizing that lived experience knowledge is equal to science-generated knowledge).
7)    Evidence-based strategies (empirical science should be adopted in accordance with local context and community norms).
8)    Capacity-building (empowerment evaluation provides skills to stakeholders which increase their capacity to improve circumstances in the community).
9)    Organizational learning (openness to change, continual striving for improvement, promotes problem solving skills and systems thinking).
10)    Accountability (heightens a programs sense of responsibility to the public as well as the agency itself).(Eliason, 2007 pg. 79)

Eliason, M.J. (2007). IMPROVING SUBSTANCE ABUSE TREATMENT, An Introduction to the Evidence-Based Practice Movement, Sage Publications, Thousand Oaks, CA.

Emmelkamp, P.M.G. (2006). Evidence-Based Treatment for Alcohol and Drug Abuse, Routledge, New York, NY.

Graham, H.L., (2004). Cognitive-Behavioral Integrative Treatment (C-BIT), John Wiley & Sons Ltd., West Sussex, England.

Herrero, M.J., Domingo-Salvany, A., Torrens, M., TeresaBrugal, M. (2008). Psychiatric comorbidity in young cocaine users: induced versus independent disorders. addiction, 103 (2), 284-293.

Inaba, D., Cohen, W. E., (2007). Uppers, Downers and All Arounders, CNS Productions Inc., Medford, OR.

Rastegar, D.A. (2005). Addiction Medicine: An Evidence-Based Handbook, Lippincott Williams & Wilkins, Philadelphia, PA.

When addiction counselors, therapists and other human services professionals develop a drug problem, what can we do to help?

2012-03-16T18:06:00.000-07:00

Mental Health Professionals and Substance Abuse:

“Is there a relation between social work and drug abuse among professionals?”

Brandon Bruce Dellario LMSW LASAC

Taking the ecological model into account, we are presented with a situation where mental health professionals live daily with factors which contribute to substance abuse vulnerability.

“An ecological model of causation, which seeks to understand the transactions between the person and the environment, offers a more robust model for describing the addictive process and its effects (Rhodes, 1996).” The term ‘substance abuse’ is identified here as an issue regarding negative professional consequences such as impairment (Siebert, 2003).

There are obvious realistic concerns regarding substance abusing social workers and the clients they serve. The problem itself could be born out of the social worker’s stress in work with a particular population, possibly even a substance abusing population, where their own substance abuse vulnerability turns to onset. Somehow, in a variety of circumstances, a tendency to misuse alcohol and or other drugs is born. The possibility of that substance abuse being related to counter-transference from the client must be investigated.

Several state chapters of the National Association of Social Work (NASW) have created committees to tackle this matter. The Peer Consultation Committee of the NASW’s New York City chapter provides prevention, education, advocacy, intervention, consultation and referral information to a social worker with a substance abuse problem or to a co-worker of that social worker. One of the problems of a situation like this is the inclination for everyone involved to simply ignore the ‘elephant in the room.’ Colleagues and employers are all too often aware of substance abuse problems within the agency, but do nothing in the way of interventions, warnings or sanctions. (Fewell, 1993)

Theories

“Alcohol and other drug use impairs job performance (Fewell, 1993).” This being a factor in a social worker’s employment leads one to the conclusion that proactive steps should be taken. Many social workers are in recovery themselves, from past personal substance abuse or from having a substance abusing loved one. These workers are more perceptive in spotting the early warning signs of substance abuse in others. In fact, it can lead to anger, depression and anxiety for colleagues of the substance abusing social worker, thereby affecting the job performance of others at the agency.

There has been a call to the NASW for employee assistance programs, in-service education, workshops for affected colleagues and information packets on intervention. Normally, even when a substance abusing worker is approached by a co-worker, it is ineffective. Although there are steps one can take to be as effective as possible in helping a fellow worker. Firstly, it is important to remember that confrontation is therapeutic and is done in the best interests of the individual. It is done firmly, though not in anger. It is suggested that this approach be direct, in order to aid the person in looking at the effects on themselves and the people around them. The focus must remain on identification of the alcohol or other drug problem as to not slip into the other surrounding issues or reasons for poor job performance.

Ethical Issues

Of course, with the client's health at stake, the intoxicated mental health professional must be immediately suspended from work and later informed of treatment options. The NASW Code of Ethics does not speak directly to the issue of substance abuse among social workers, but the NASW is taking steps toward helping substance abusing social workers to find recovery. Substance abuse issues involve different intervention strategies than other mental health intervention procedures. An adequate understanding of effects of substance abuse must be present for an intervention to be done properly.

It is also necessary that the problem be obviously that of substance abuse, not merely a suspicion of substance abuse. The profession of social work has a future challenge in the respects of education and training of practitioners to work with substance abusing populations. These areas of education will also help social workers better understand how to deal with substance abuse issues in the workplace, and in their own personal life. (Fewell, 1993)

Fewell, C. H., King, B. L., Weinstein, D. L. (1993). Alcohol and other drug abuse among social work colleagues and their families: impact on practice. Social Work, 38, 5, 565.

Rhodes, R., Johnson, A. D. (1996). Social work and substance abuse treatment: a challenge for the profession. Families in Society, 77, 3, 182-186.

Siebert, D. C. (2003). Denial of AOD use: an issue for social workers and the profession. Health & Social Work, 28, 2, 89-98.

When a parent struggles with drug addiction.

2012-03-15T13:02:00.000-07:00

Parental Substance Abuse: Family Assessment & Treatment

Brandon Bruce Dellario LMSW LASAC

The issue of substance abuse disorders within a family, and its effect on family systems, is a testament to the usefulness of ecological theory in social work practice. “An ecological model of causation, which seeks to understand the transactions between the person and the environment, offers a more robust model for describing the addictive process and its effects

(Rhodes, 1996).” When a parent is a problem user, their self-destruction can no longer be called a victimless situation. Parental substance abuse can become toxic to the family as a whole. Children are often victims of abuse or neglect. Additionally, children have an increased risk of being prenatally exposed to alcohol and other drugs (Young, 2007). Spouses, significant others and other adult family members of the using parent may also become candidates for physical and mental abuse.

When a parent, caregiver or guardian is substance abusing, it can be devastating to a family’s health. Some of the consequences are damaged relationships related to areas of imprisonment, institutionalization, abuse and neglect, injury, illness, disease, death… as well as lack of trust, care, commitment, responsibility, respect… Addiction and other substance abuse disorders erode at the place where supportive families stand and grow.

When an individual is assessed and treated for a substance abuse disorder, there is normally little or no attention paid to their family. Family therapy is normally used for substance abusing adolescents but not for adults. Thus, another way the family of a substance abusing parent is left to fend for itself, yet again. There may be an assessment or treatment referral for family members if the courts or human service agencies are involved and deem a situation worthy of investigation. However, individuals who go inpatient at treatment facilities are treated with the medical disease model of addiction, which helps patients to primarily focus on their own behavior. Some treatment centers have family days for education, support and family involvement, but it is actually only a small percentage of the activity involved in a treatment program.

Assessment

Social Workers have an opportunity to assess a using parent and the family as a whole in everyday practice, although not as much work is usually done with the family unit. The National Study on Child and Adolescent Well-Being (NSCAW) has child welfare workers who use the Composite International Diagnostic Interview-Short Form (CIDI-SF) to assess substance dependence of caregivers. It is used for both open and closed cases for the year prior to data collection. The CIDI-SF is used to find statistics of caregivers in America who fit into the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis for substance abuse disorders. “It was found that child welfare workers failed to identify a substance abuse problem in 61% of the caregivers who actually met DSM criteria for alcohol or drug dependence (Young, 2007).” Moreover, the courts and the addiction treatment system do not report on the needs of the family when serving the client.

Social workers are in an integral and personal position to the client and family. Additionally, social workers need to stay aware of issues that may be resulting in harm to anyone. The Child Welfare System (CWS) identifies parental substance abuse issues only when they lead neglect or abuse of children. Early screening and assessment is extremely important to intervention. It can lead to programs like family drug treatment courts, and programs that have services for children of problem users (Young, 2007).

Social workers can orchestrate initial sessions with families through: Establishing a personal relationship and confidentiality; defining the presenting problem as a family problem; asking open-ended questions which support clarification of family and individual needs, wants, perceptions, choices, hopes, expectations, concerns, reservations and roles; explanation of the nature of the helping process; role-modeling open communication; appropriate self-disclosure; establishing an empathetic relationship; and active, effective listening (Way, 2009)

Workers can gain awareness of client and family issues by asking themselves questions like the following: How was this client referred? What is the impact of this problem on the family? How does it affect family dynamics? How do they manage pressures? What are this client’s and family’s strengths? How have they dealt with similar situations in the past? What are the family boundaries and maintenance of those boundaries? To what degree do individual family members exhibit differentiation? Does everyone in the family feel free to be themselves? How are decisions and disagreements managed? Who is the disciplinarian? What are this client’s and other family member’s goals? Are these goals connected to the presenting problem or other problems? To what degree are these goals connected to a crisis? What do this client and family anticipate in working on those goals? What are the established supports and barriers (Way, 2009).

Biegel, D.E., Ishler, K.J., Katz, S., Johnson, P. (2007). Predictors of burden of family caregivers of women with substance use disorders or co-occurring substance and mental disorders. Journal of Social Work Practice in the Addictions, 7(1/2)

Gruber, K.J. (2001). In-home continuing care services for substance-affected families: the bridges program. Social Work, 46, 3, 267-278

Rhodes, R., Johnson, A.D. (1996). Social work and substance abuse treatment: a challenge for the profession. Families in Society, 77, 3, 182-186.

Springer, D.W. (2002). Families helping families: implementing a multifamily therapy group with substance abusing adolescents. Health & Social Work, 24, 3, 204-208

Young, N. K., Boles, S.M., Otero, C. (2007). Parental substance use disorders and child maltreatment: overlap, gaps, and opportunities. Child Maltreatment, 12, 2, 137-149.

Way, I. (2009). SWRK 6610: social work practice with individuals and families. Western Michigan University School of Social Work, Fall 2009, Thursdays 10am-12:20pm, 1087 CHHS, Kalamazoo, MI.

When parents struggle with drug addiction, what effective help is available?

2012-03-14T13:19:00.000-07:00

Parental Substance Abuse Treatment: Family Treatment
Brandon Bruce Dellario LMSW LASAC

There are several essential factors regarding family recovery, in treatment planning for a substance abusing parent. Once a substance abuse disorder has been diagnosed in a parent, client-specific treatment methods can be found.

There are helpful instruments such as The Interpersonal Support Evaluation List (ISEL) which measures the adequacy of the client’s social support network. Family involvement in a using parent’s treatment “can have a positive impact on client outcomes such as abstinence, reduced relapse, general functioning, psychiatric symptomatology and client treatment engagement (Biegel, 2007).” Successful treatment methods focus on the particular issues surrounding a client and family, tailored to the individual family members, addressing behavioral problems of children and development of the parental support systems. Social Workers can provide information to the family about the problem and strategies of addressing it (Biegel, 2007).

Multifamily Therapy Group (MFTG) involves individual family therapy sessions as well as weekly multifamily therapy group sessions involving four or five families at a time with a maximum of 15 group members. MFTG includes techniques and interventions from solution-focused therapy, structural family therapy, interactional approach and mutual aid approach. MFTG is a future-oriented, strength-based approach which encourages goal development, partnership with the client and collaboration with possible resources (Springer, 2002). Behavioral Couples Therapy is an evidence-based treatment useful for substance abuse disorders to increase functioning of relationships between couples. The mental health treatment of a Psychoeducational Intervention has also proven effective with improving family relationships in this category, be they spouse or parent. It helps families to understand substance abuse related behavioral issues through education. Family education and other outreach programs like family support groups are important to a family’s recovery, although they have been under utilized in the field of substance abuse treatment (Biegel, 2007).

Many patients who receive treatment for substance abuse disorders also have mental health issues, whether they are drug-induced or otherwise present. The term for this is dual-diagnosis or co-occurring disorder. This information is valuable to the social worker who works with problem users. Both disorders must be taken into account in a treatment intervention. There is a program currently utilized for co-occurring disorders by Community Mental Health and Substance Abuse Services (CMHSAS) called Integrated Dual-Diagnosis Treatment or IDDT. Welcoming, engagement and motivational interviewing with individuals at various stages of change are some of the essential ingredients of IDDT. CMH hosts a program for families of dual-diagnosis individuals which also serves as a support group for those families. It is called Families In Action. Social workers can look to these programs for information and referral when working with families of people with co-occurring disorders.

When social workers are faced with families of substance abusing parents, workers must be aware of the natural supports already in place for the individual, the family and supports for them within the community. It may be easier for someone to utilize a support that they normally use, have some previous experience with, or is provided at no expense to them. A friend, a known social worker, or just a convenient place they like to go where supportive people gather might be a great familiar resource.

Most urban areas have self-help, mutual-help, support groups or 12 step programs where peers help each other deal with situations of any kind. For substance abusers there are a variety of meetings one can attend such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, Dual Recovery Anonymous, Smart Recovery and so on. For loved ones of substance abusers there are programs like Alanon, Naranon, Co-dependents Anonymous, Adult Children of Alcoholics, and so forth. These links to the recovering community can be a valuable resource to the parent or anyone looking for help with a substance abuse disorder, personally or within the family. They are often assigned as a part of a continuing care plan at discharge from substance abuse treatment. These programs are also widely known to be a key ingredient for effective recovery maintenance.

There are many additional options following inpatient treatment. Studies have found that involving families in an individual’s treatment and maintenance can drastically reduce the likelihood of relapse. The family is in a central position for support and encouragement. A clinical social worker with specialized training in substance abuse can be very effective in aiding the family to find help. The worker can directly provide, arrange or refer the family to ongoing assistance for the problems caused by a parent’s past or present substance abuse. Today there are number of strategies for the continuum of care such as family-centered home-based services, outpatient treatment, counseling, help-lines, support groups, parenting classes, and advocacy. These services can be utilized to provide an atmosphere of recovery and education which may in-turn foster healing for the family as a whole.

One family-centered home-based service named the Strengthening Families Program, a part of the Detroit Safe Haven program, has been found effective for treatment of the issues surrounding the family of a substance abusing parent. This and other similar programs are focused on long term support “to improve family communication, organization, expressiveness, and cohesion; increase parenting efficacy and parent-child bonding; and improve the child’s school performance, positive behaviors, and association with positive peers (Gruber, 2001).”

Families of parents in recovery have a broad spectrum of critical areas that a social worker can look to in developing an intervention. Person-centered assessment and treatment planning methods, used in conjunction, can establish a blueprint for a client to follow. As a using parent finds their particular path to a healthy lifestyle, they can take more steps out on their own, gaining self-efficacy and competence in their own recovery. A comprehensive, recovery support network lays the foundation for the individual and family to gain wholeness.

Gruber, K.J. (2001). In-home continuing care services for substance-affected families: the bridges program. Social Work, 46, 3, 267-278

Rhodes, R., Johnson, A.D. (1996). Social work and substance abuse treatment: a challenge for the profession. Families in Society, 77, 3, 182-186.

Springer, D.W. (2002). Families helping families: implementing a multifamily therapy group with substance abusing adolescents. Health & Social Work, 24, 3, 204-208

Young, N. K., Boles, S.M., Otero, C. (2007). Parental substance use disorders and child maltreatment: overlap, gaps, and opportunities. Child Maltreatment, 12, 2, 137 149.

Way, I. (2009). SWRK 6610: social work practice with individuals and families. Western Michigan University School of Social Work, Fall 2009, Thursdays 10am-12:20pm, 1087 CHHS, Kalamazoo, MI.

When teenagers struggle with drug abuse or addiction, what can we do to help?

2012-03-12T12:34:00.000-07:00

Teen Substance Abuse: Observations & Treatment
Brandon Bruce Dellario LMSW LASAC

Teens can find substance abuse treatment in different ways for various reasons. One of the biggest motivating factors for young adults is our legal system. A study in 2002 showed most adolescents (53%) seeking treatment were referred by the criminal justice system, 17% were self referral, and 11% were referred by schools.

(1)
For some, the courts are the only encouraging thing they have found to quit using. Since youth may only be exposed to the juvenile justice system for a brief period, “. . . it is best to focus on pretreatment services such as assessment, engagement, and getting the youth to commit to changing their behavior.”(3) It is very important to keep them occupied and motivated by continuing contact with a support network and writing assignments while they are awaiting a treatment program. Continuity of treatment can have a major effect on teen recovery.

“Adolescents ages 12 to 17 admitted to substance abuse treatment increased 65% between 1992 and 2002.”(1) All other admissions increased only 23% in the same period.(4) They are coming into treatment as poly-drug abusers. 48% of these admissions reported the use of alcohol and marijuana.(1) Cocaine is also on the rise with youth. Many youngsters see cocaine as harmless or fashionable. MDMA (Ecstasy), GHB, Rohypnol, ketamine and other synthetic “club” drugs are very popular among young people today. Michigan is one of the highest ranking states for illegal prescription drug abuse amongst teens. One study shows that “12% of Michigan teens abuse prescription drugs.”(2) These “scripts” are hazardous when used without a doctor’s supervision, especially when mixed with alcohol and other drugs. For teens, prescription drugs are easy to get and mistaken as being safe.

Treatment plans for teens should include focus on, “sequence of interventions, length of treatment, voluntary versus mandatory treatment, and pretreatment services.”(4) With sequential treatment, youth receive services from one system at a time. Whomever the patient comes into contact with first determines the severity of his or her symptoms. The service provider makes a determination about what services the teen should receive and in what order. This kind of treatment works well for the young person in the juvenile justice system with mental health issues.(4)

Length of treatment is an important factor when considering a program for an adolescent. While there are in-patient programs which give the client months or even years to gain recovery, outpatient programs don’t always have a long-term benefit. A lengthy outpatient program can have a negative impact on a teenager.(4)

When it comes to voluntary versus mandatory treatment, adolescents like to feel they have some say so in their own treatment process. Most don’t respond well to being told what to do. Perceived choice is a successful method in working with teens, especially those in the criminal justice system. They feel better about making a personal decision to change their behavior, as oppose to listening to someone else. Perceived choice accelerates the teen’s motivation and commitment. It’s a motivational enhancement approach. In such a case, the counselor shows empathy, points out discrepancies in the child’s lifestyle, and negative consequences of behavior, all in a non-judgmental and non-confrontational approach.(4)

“High school and college students with substance use disorders are different from their adult counterparts, with their problems stemming from various causes. Stronger peer influences, physical and mental development issues, the presence of other disorders, and diverse value sets all need to be considered when treating youth with substance use disorders. Because of this, young people in treatment for substance use disorders need more specialty support than others.”(4)

Therefore, programs in the treatment center should be specifically designed for teens. Distinctive programming for their individual needs include: Family programming, psychiatric services, recreational activities, coordination of care, and other health care services. Effective treatment programs for teens implement 9 elements listed below:

1) Assessment and matching - where a youngster’s needs are matched to services and amount needed.

2) Comprehensive and integrated treatment approach - holistic approach to all an adolescent’s problems. 3) Family involvement in treatment - engaging the patient’s family in his or her recovery.

4) Developmentally appropriate programs - programs that address a specifically teenage circumstance.

5) Engaging and retaining teens in treatment - ways treatment can make sense to teens.

6) Qualified staff - staff with specialized training and experience.

7) Gender and cultural competence - addresses the important differences among patients.

8) Continuing care - support networks, relapse prevention, and follow-up plans.

9) Treatment outcomes - analysis in the success of treatment programs.(4)

Like other addicts in recovery, teens participate in 12 step programs. Alcoholics Anonymous, Narcotics Anonymous and Celebrate Recovery to name a few. We created a questionnaire and gave it to 4 teens in the program of Narcotics Anonymous. The age of first use ranged from 8 to 16 years old. The reasons they think they used were primary named as peer pressure and to cover emotional problems. All of them obtained drugs and alcohol from family members. When we asked them about treatment, 2 of them had some form of treatment experience. They were both open-minded to the idea of treatment when referred to treatment by friends or the court. They both had peers of a similar age with them while in treatment.

http://alcoholism.about.com/od/teens/a/blsam040901.htm

About.com: Alcoholism & Substance Abuse

http://www.adolescent-substance-abuse.com/blog/labels/teenagers.html

Adolescent Substance Abuse Knowledge Base

http://www.ncmhjj.com/curriculum/juvenile/mod_03_E_07.htm

The National GAINS Center for People with Co-Occurring Disorders in the Justice System

http://www.recoverymonth.gov/2006/kit/html/Targeted_Outreach/yoouth.aspx

National Alcohol & Drug Addiction Recovery Month, September 2006

1A Addiction treatment program for teen dual-diagnosis populations.

2012-03-09T20:48:00.000-08:00

Treatment Program for Marijuana-dependent Teens who display symptoms of Schitzophrenia: The We Recover for Life Program
Brandon Bruce Dellario LMSW LASAC

Abstract
     In recent years, it has become apparent that many people suffering from the disease of addiction have also been diagnosed with mental illness.
     In one study it was found that 23% of people diagnosed with serious mental illness have substance abuse or dependence disorders (Inaba, 2007). Other studies show this number to be closer to 60% or 80%. We term these individuals “Dual Diagnosis” or, with “Co-occurring Disorder.” But, what is the relationship between substance abuse and psychosis? “Cannabis use in particular is widespread, both in the general population but especially so amongst people with serious and enduring mental illness, particularly psychotic illness” (Macleod, 2007).
     Sadly, many of the people suffering from dual diagnosis, put themselves into dangerous situations which can be very destructive for a person in such a vulnerable condition. “Substance abuse is associated with an increased risk of motor vehicle crashes, emergency department admissions, and suicide” (Griswald, 2007). Marijuana use in general can impair brain activities. Like short-term memory, judgment, learning ability, coordination, and the ability to follow moving objects are all impacted. It can also decrease testosterone and sperm production or harm the heart, lungs and immune system (Gignac, 2005). The drug buying and selling environment is condusive to high-risk sexual practices, disease, violence and other unsafe conditions. Substance abuse often counteracts and even mixes poorly with psychiatric medications. This population also spends a large amount of their income on drugs, (Inaba, 2007) occasionally stealing or selling themselves for money. These factors result in a poor environment for rehabilitation and an increase of psychotic breakdowns.
     The population of people suffering from Dual Diagnosis can be divided into several groups. There are patients in the private system (with upper echelon insurance), and those in the public system who are either compliant or non-compliant with the programs offered by the community. There are high functioning subjects who take an active role in their own recovery, and there are severely dysfunctional patients who have trouble living in or out of the psychiatric hospital. Rich or poor, man or woman, old or young, the reality is, everyone is at a different level of sickness and we must focus on a small cross-section of this large population if we are to find and offer solutions of resolve.
     “Earlier treatment potentially could avert lifelong disorders“ (Griswald, 2007). This program will focus on all males age 17-26 who abuse Marijuana and have been diagnosed with schizophrenia. 60% to 75% of adolescents with mental illness also suffer from substance use disorders (Griswald, 2007). This may be explained by environmental factors like poor parenting, parental substance use and childhood mistreatment, “and psychological dysregulation (i.e., delayed development of behavioral, emotional, or cognitive regulation)”(Griswald, 2007). Many studies show that young men who use marijuana have an earlier onset of psychotic disorders. “Male cannabis users were found to have their first psychotic episode a mean of 6.9 years earlier than male nonusers, . . . (and) early onset is associated with a poorer prognosis of the disorder” (Veen, 2004). Since there is only a small number of cannabis-using women with schizophrenia, it’s hard to examine the interaction effect (Veen, 2004). Young male schizophrenics abuse cannabis much more than females and older males with schizophrenia (Veen, 2004).

Research
     “While drug use is a concern to the general public, it is of particular concern in adolescents with psychiatric disorders“ (Gignac, 2005). Marijuana is the most popular drug of misuse and abuse in early adulthood (Gignac, 2005). “Recent studies suggest drug abuse and addiction are developmental disorders“ (Griswald, 2007).
     The 2 questions raised are: 1) Is schizophrenia and cannabis use related? 2) What can be done to provide prevention and treatment for our current generation of young people?
     “The ability of cannabis use to precipitate unusual thoughts or perceptions in users is not, generally, in question. These effects are typically acute, that is they disappear on sustained abstinence from cannabis. However, regular cannabis users excrete detectable drug metabolites for up to a month after abstinence and ‘acute’ (i.e. self-limiting) psychoactive effects may also be apparent over a long period” (Macleod, 2007). In addition, contemporary studies have proved over and again that marijuana abuse is involved in early onset of schizophrenia and other psychosis. Whether cannabis use is a cause or an effect, remains to be determined (Veen, 2005). “It is possible that cannabis makes manifest schizophrenia in young subjects who are genetically at risk for developing the disorder. According to this point of view, which has recently gained support from studies in the Netherlands and Sweden, some of the individuals would never have developed schizophrenia had they not used cannabis (Veen, 2004).
     It doesn’t appear that these young schizophrenics are self-medicating when they abuse cannabis. “If such use genuinely reflected self-medication then one might predict that it would increase following periods where users felt worse. Instead, lower (rather than higher) depressive symptom scores at one assessment were associated with higher subsequent use of cannabis. Scales on the psychotic symptom scale showed a similar, albeit weaker relation” (Macleod, 2007).
     A German study from Charite-University Medicine, Berlin found that long-term cannabis consumption can cause neurotoxic damage in nerve growth factor serum levels. “Nerve growth factor (NGF) is a apheliotropic neurotrophic protein that is implicated in development, protection and regeneration of NFG-sensitive neurones” (Jockers-Scherubl, 2005). They also found that cannabinoids affect catecholaminergic neurotransmission with exposure in the perinatal period, and reduce dopamine transmission in the frontal cortex. Data suggests that long-term abuse (2 or more years), and early adolescent use are contributing factors to psychosis when measured up to schizophrenics without a chronicle of marijuana abuse (Jockers-Scherubl, 2005).

Schizophrenia
     Specifically, schizophrenia is a disease with no etiology which can only be measured in clinical practice (Pull, 2007). The definition of Schizophrenia is: “Any group of psychotic disorders usually characterized by withdrawal from reality, illogical patterns of thinking, delusions, and hallucinations, and accompanied in varying degrees by other emotional, behavioral, or intellectual disturbances. Schizophrenia is associated with dopamine imbalances in the brain and defects of the frontal lobe and is caused by genetic, other biological, and psychosocial factors”(Dictionary, 2000). Some of the distinguishing traits are hallucinations and delusions, disorders of thought, speech, behavior, emotions and affect, cognitive deficits and avolition (Pull, 2007). 80% of schizophrenics experience hallucinations and 90% have delusions (Pull, 2007).
     Schizophrenia is anhedonic, which means that patients loose feeling or pleasure from things like enjoying sunsets, eating, drinking, singing, being massaged, or being with friends (Pull, 2007). Some of the cognitive deficits include decreased, “attention, memory and problem solving, …complex conceptual reasoning, psycho motor speed, new learning and incidental memory, and both motor and sensory perceptual abilities” (Pull, 2007). These factors will have to come into play in the treatment of schizophrenics. Avolition, or, the lack of will, may also be a barrier as to involving patients in goal-oriented activities (Pull, 2007).
    “There have been many attempts to classify the courses of schizophrenia, but there is no universally accepted classification in this field. . . . studies of the course of schizophrenia indicate that there may be very different types of course, ranging from complete cure to severe disabling chronic forms. Some patients experience only one episode of illness, others have several episodes, and still others suffer from chronic symptoms”(Pull, 2007).
     In treating schizophrenia, a “true team approach” (Kaplan, 1989). is crucial. “Members of the team must understand what other clinicians and therapists are attempting to do” (Kaplan, 1989). For instance, if medications are affecting the patients ability to get up early enough for an activity, the prescribing physician should relay that information to the activity coordinator. Or, vice versa, “certain types of environmental effects may necessitate dose adjustment” (Kaplan, 1989).   As well as a synergistic relationship between treatment modalities where, “. . . one modality may be indirectly exerted through another, as when family therapy serves to enhance compliance with medication” (Kaplan, 1989).
    The recommended length of stay for schizophrenics in acute treatment varies from practitioner to practitioner. They range from 1 week up to 6 months (Pull, 2007). One study suggests that patients who respond well to treatment show, “an amelioration of non-specific symptoms, such as sleep disturbance or anxiety and agitation, but also of positive symptoms within the first two treatment weeks” (Pull, 2007). There are treatment resistant schizophrenics, but those include all patients who do not endure the side effects of pharmacologic interventions (Pull, 2007). The majority of patients show a partial reaction in remittance of one of their symptoms, like fewer hallucinations or delusions, while other symptoms persist (Pull, 2007).

Treatment Program
     With these findings in mind, we have devised a treatment program for these young, male schizophrenics. We will provide residential treatment for male schizophrenics, ages 17-26, for the treatment of marijuana dependence. This treatment will last from 2 weeks to 3 months depending on the opinions of our trained staff of psychiatrists, psychologists, counselors and administration.
     Our Mission Statement: We wish to help and support addicts with psychosis to find relief of their symptoms through abstinence from all drugs outside of the necessary medications taken as directed. This is the first step toward recovery. Recovery being the recuperation of an individual to an acceptable state of health or well-being. We work to put our patients into activity with the recovering community and public agency programs that will aid them in transition to living on their own.
     There are many 12-step programs which aid people in recovery from drug and alcohol addiction, as well as mental illness and every other kind of disorder. Narcotics Anonymous, Alcoholics Anonymous, Cocaine Anonymous, Dual Recovery Anonymous, Schizophrenics Anonymous and Celebrate Recovery. Peer support groups like “Recovery Group” at the Pathways Drop-in Center, 119 W. Vine St. in Kalamazoo, MI USA. This is a meeting specifically for people with mental illness or dual-diagnosis. Depression Bi-polar Support Alliance (DBSA) is an international peer-run organization for groups of mutual supporting peers in mental health recovery. There are many other community-inclusive programs for people in recovery worldwide. Also programs funded and supported through the various branches of Community Mental Health, Recovery Innovations of Arizona (RIAZ), The Appalachian Consulting Group and the Recovery Institute of Kalamazoo, MI (RI), to name a few. RI offers groups for aspiring artists, poets and musicians in recovery, groups for peers who are breaking stigma and improving mental health awareness in the community (such as Power Group), groups for peers who are teaching and learning from computer trainings, groups for those who wish to return or are currently attending high-school/college. Education in recovery tools, Wellness Recovery Action Program (WRAP), peers offering peers person-centered planning, self determination, techniques for self awareness & self monitoring, writing, yoga, exercise and health. Anything that fosters our patients to become part of our community and benefit their own recovery path.

Modalities
     Our patients meet with one of our 5 counselors to plan the next weeks daily activities outside of the treatment center. They have the choice in-between ten 12-step meetings per week, or some combination of 12-step meetings and community inclusive programs. This is what we focus on directly after detox, in conjunction with other in-house treatment strategies. “Adolescents who benefit most from mutual help groups generally have severe substance involvement and feel they cannot stop or cut down on their own, . . . Groups counter their feeling of being alone, help them see that recovery is possible, and offer support” (Griswald, 2007). One study showed that, “individuals who attended group meetings 1 or more times a week for the first 6 months had lower rates of substance use 4 years and 6 years later, even after controlling for concurrent participation” (Griswald, 2007).
     The Substance Abuse and Mental Health Services Administration (SAMHSA) defines substance abuse as, “. . . regular use or abuse with several and more severe consequences” (Griswald, 2007). Substance use disorders are, “maladaptive patterns of use accompanied by clinically significant impairment or distress” (Griswald, 2007). Although criteria have not yet been established for adolescents, kids who start using before they are 18 are eight times more likely to develop substance dependence as adults (Griswald, 2007). Since substance use, abuse, dependence and induced disorders are all a problem in relation to psychosis, Our program will assess and cater to all substance use issues in our dual-diagnosis patients. We try to determine whether the psychosis or substance use disorder is primary by re-assessing the patient at one month clean (Griswald, 2007). Psychiatric medications are prescribed, reduced or eliminated by our 3 psychiatrists directly following detox whenever appropriate. “Although abstinence from substance use should proceed the use of psychotropic medication, there is a risk that untreated psychiatric illness will impede treatment initiation, precipitate early dropout, or interfere with achievement of abstinence” (Griswald, 2007).
     We use cognitive-behavioral therapy techniques with our in-house treatment program. It has received the highest level of evidentiary support (Vaughn, 2004). “. . . cultural factors such as discrimination, acculturation, and ethnic pride influence treatment outcome” (Griswald, 2007).    Every patient in our program will have an individualized, diversity-informed plan worked out with their counselors in one-on-one therapy. Our well trained staff who specialize in adolescent rehabilitation, will account for the important factors in developing a confidential individualized treatment plan. We incorporate motivational interviewing while accounting for cultural factors, age, sexual orientation, family history, peer attitudes, involvement with the justice system, lethality assessment, readiness to change, social and psychological functioning, “behavior factors such as verbal or physical aggression, academic difficulties, impulsivity, hyperactivity, depressed mood, and poor social skills” (Griswald, 2007). This helps us listen and encourage adolescents while creating an environment of positive change (Griswald, 2007). We look at the positives and negatives of their drug use, look at consequences, set goals while observing their current situation (Kouimtsidis, 2007).
     Our counselors will express empathy, work with resistance instead of against it, and communicate free choice, self-efficacy and personal responsibility (Kouimtsidis, 2007). “Essentially this approach [motivational interviewing] aims to work with the clients perception of substance use rather than imposing the therapist’s external view of reality” (Kouimtsidis, 2007). Our program will involve the patient's voice in their own program, through person-centered planning and self-determination. We will assess and refer them to a case worker in the community while they are a resident. We screen for substance use disorders using the CRAFFT questionnaire (reliable tool for adolescent substance abuse screening) (Griswald, 2007). We will screen for mental illness using the GAIN (Global Appraisal of Individual Needs) assessment tool (Anon., 2006).
     In our 50 minute group therapy sessions, we employ the Socratic method of question and answer. In this modality, patients are given the chance to reflect and find their own answers when given a series of questions by our counselors. “It allows clients to develop an awareness of their own beliefs and behaviors. By asking such questions clients develop an insight into their thought processes and how these influence their emotions and behavior. Accordingly the client becomes aware of inappropriate beliefs and is helped to challenge them and change the behavior” (Kouimtsidis, 2007). We use two other methods of therapy in our group sessions. One is the Downward arrow exercise where the client is asked variations of the question, “what does that mean to you,” or “if that were true what would it mean” (Kouimtsidis, 2007).    Another is Imagery, where the patient is asked to remember and, in effect, re-live certain problematic experiences, “. . . so as to identify the emotions, thoughts and context associated with the problematic event or experience” (Kouimtsidis, 2007). Some of the topics of discussion in our groups are: Depression; anxiety; self-esteem; anger/aggression; impulse control; relationships; compliance with treatment; risky behaviors; criminal behavior; sleep management; trauma and abuse. (Kouimtsidis, 2007).
     Activities that our clients participate in are: Daily journaling (Daily thought record); distraction chores like cleaning the house, laundry, gardening, mowing the lawn, etc.; physical exercise activities like hiking, swimming, lifting weights, yoga and frisbee; relaxation training in breathing and guided meditation. We also have a recreation area for movies, music, board games, ping-pong, billiards, and general socializing on the couches.
     Family therapy is a crucial part of our treatment plan. Parents are screened for substance abuse, referred to treatment if needed, and educated about substance abuse and psychosis. We work with parents to keep alcohol and medications locked away in the home if the patient is living with them or spending any amount of time there (Griswald, 2007). Parents will be invited to attend family days in our facility where we have lunch, speakers, information and to spend personal time with their loved one. We use the proven, “emphasis on educating the patient and family members about the nature of schizophrenia and available treatments” (Kaplan, 1989), as well as medication management and substance misuse information. We talk about the common symptoms, signs and prognosis of schizophrenia and the patients relationship with family members, peers, lifestyle, work, school, etc. Our family therapy employs the systems-strategic method of demonstrating the ability of the family to modify it’s rules and reactions, even through direct conflict with the patient. (Kaplan, 1989). Through sessions, our families will learn problem-solving skills, how to cope with stress, rehearsal behaviors, modeling, feedback, social reinforcement, expression of feelings, naming feelings, active listening, requests for behavioral change, and reciprocity of conversation (Kaplan, 1989).

Evaluation
     We will evaluate our clients success by keeping track of them by phone and contacting their case workers every 6 months post-treatment. Upon discharge, every patient will fill out a personal evaluation form to assess their own performance, as well as their perceptions of the strengths and weaknesses of our in-house structure.

Conclusion
     “Peer groups play a vital role in promoting abstinence as well as abuse” (Griswald, 2007). We work to place our patients in contact with peers who are living a new way of life in recovery. In treatment, they live among other males in their age group. They are also encouraged to seek out more peers in the recovering community, outside of the treatment center, while steering clear of people who use. “Triggers” can be people, places, things, and high risk situations which are conducive to relapse.
     Continuing care is what we aim for during our entire program. We aid our patients to be ready to actively pursuit their own recovery in the community. Yifrah Kaminer, M.D., M.B.A., co-director of research in the division of child and adolescent psychiatry at the University of Connecticut Health Center’s Alcohol Research Center, suggests, “Aftercare, more appropriately termed continued care, he said, can help prevent relapse and chronic disease. Unfortunately, he said, responsibility for continued care often is left to unmotivated clients who typically receive only passive referral to mutual help groups” (Griswald, 2007).
     The expected outcome of our program for patients is involvement in the recovering community (12 step programs such as Dual Recovery Anonymous, Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous and the like), activity in other community inclusive programs, and with aid from public social service agencies such as Community Mental Health, The Department of Human Services, Social Security Administration . . . Our patients will become aware of their peers and peer groups in the community who support each other, develop friendships and learn how to stay clean together, all while actively participating in these programs offered by the community.

Inaba, D., Cohen, W. E., (2007). Uppers, Downers and All Arounders, CNS Productions Inc., Medford, OR

Macleod, J., (2007). Cannabis use and symptom experience amongst people with mental illness Psychological Medicine, 37, 913-916

Gignac, M.D., Timothy E. Wilens, M.D. and Joseph Biederman, M.D., (2005). Assessing Cannabis Use in Adolescents and Young Adults: What Do Urine Screen and Parental Report Tell You? Journal of Child and Adolescent Psychopharmacology, Vol. 15, #5

Veen, N., Darryl Wade and Marie-Odile Krebs, (2005). Cannabis Use and Schizophrenia. The American Journal of Psychiatry, Feb. 2005: 162, 2, pg. 401

Veen, N., Jean-Paul Selton, Ingeborg van der Tweel and Wilma G. Feller, (2005). Cannabis Use and Age at Onset of Schizophrenia, The American Journal of Psychiatry, March, Vol 161, Iss. 3; pg. 501

Jockers-Scherubl, M., Uta Matthies, Chronic cannabis abuse raises nerve. Psychopharmacology, 17; 439
Pull, C., (2007) www.netlibrary.com

Dictionary, The American Heritage Dictionary of the English Language, Fourth Edition (2000). published by Houghton Mifflin Company

Griswold, K., M.D., M.P.H.; Helen Aronoff, M.D., M.A.T.; Joan B. Kernan, B.S.; and Linda S. Kahn, Ph.D. (2007). Adolescent Substance Use and Abuse: Recognition and Management, State University of New York at Buffalo School of Medicine and Biomedical Sciences (www.aafp.org/afp.)

Kouimtsidis, C., Martina Reynolds, Colin Drummond, Paul Davis and Nicholas Tarrier, (2007). Cognitive-Behavioral Therapy in the Treatment of Addiction, John Wiley & Sons, Ltd.

Vaughn, M., Matthew O Howard, (2004). Adolescent substance abuse treatment: A synthesis of controlled evaluations, Research on Social Work Practice, Sept., Vol.14, Iss.5; pg.325, Thousand Oaks.

Kaplan, H., MD, Benjamin J. Sadock, MD, (1989). Comprehensive Textbook of Psychiatry/V, Williams & Wilkins, Vol. 1, 4th edition

Anonymous, (2006). Only half of adolescent facilities conduct mental health assessments, Alcoholism & Drug Abuse Weekly, July 24, v18 i29 p1(4)

Can alternative therapeutic techniques be used for addiction treatment?

2012-03-07T20:03:00.000-08:00

Expressive Arts Therapy: Art Therapy for Addiction Treatment
Brandon Bruce Dellario LMSW LASAC

“In contrast to the impact of dysfunctional and broken families, parental drug and alcohol abuse, or neglect, art education may seem inconsequential. Yet, evidence suggests this may not be so.
”(Venable, 2005)

    There are many professional journal articles on expressive arts therapy in regards to addiction and substance abuse treatment. However, few studies have the in-depth, qualitative research and evidence-based information clinicians now need on this subject. Most published research on art therapy has been in its use with children, not adults. Also, art therapists generally categorize their practice as more of a humanist venture than a science. Some postulate that all research regarding therapy can only be understood in subjective experience and documented as such.(Kellman, 2008) Clinical diagnoses, along with other black and white scientific terminology which liken human conduct to that of a lab rat, appear to be on their way out, at least in this small gamut of the social science spectrum.
     Current substance abuse treatment is widely known for its small percentages of successful outcomes and high drop-out rates. Research shows that specific individual needs need be addressed in the substance abuse treatment population. These needs can vary from client age, gender and ethnicity to medical, mental health and resource concerns. The need for alternative treatment modalities is obvious and many are looking to avant-garde therapeutic models for the answers. Authors whom I have found most prolific on this subject of expressive arts therapy for substance abuse treatment are Karen Sharf Phd from the New York University School of Social Work, and Julia Kellman, author for The Journal of Aesthetic Education. These two scholars have a firm grasp on this small but developing field. The previous introduction and following body is in-part based on, and greatly inspired by their unique voices.
    Substance abuse prevention and treatment are essential areas of concern in the United States itself. Every dollar spent on substance abuse treatment and prevention saves taxpayers $7 to $9, which otherwise would have been spent in the criminal justice system toward drug-related crimes. While the US government spends 12 billion dollars annually on the “war against drugs,” it most greatly utilizes a punitive system for drug crimes which constitutes 60%-80% of the 1.8 million people currently incarcerated.(Sharf, 2004) Additionally, this figure (60%-80%) is the same percentage of Americans with mental health challenges who suffer with substance abuse disorders. That being said, it is evident that the disease of addiction and other substance use, induced and abuse disorders are of prime concern to the domain of human services and contemporary society at large.
    Expressive arts therapy is a continually growing and vastly dynamic field of therapeutic treatment. Addiction recovery and therapy itself have both been known colloquially as “an inside job.” Some theories regarding the etiology of substance abuse view addiction as a “self-destructive behavior that is reflective of internal struggles.”(Sharf, 2004) Art therapy has been known to help those who suffer with post traumatic stress disorder (PTSD). 25%-50% of female substance abuse patients who find their way to treatment suffer with PTSD.(Sharf, 2004) The number of chronic substance abusers who have experienced some form of trauma is far too high to ignore. Some statistics say 80% or more. Art therapy, while known to support clients on a path of recovery, has also proven to “reduce professional ‘burnout’ often associated with the treatment of substance abuse.”(Sharf, 2004) Clinicians can use various art therapy techniques which focus on issues of countertransference.
    A key factor in clinical use of expressive arts therapy directed toward addiction treatment include the formation of a therapeutic alliance, which can involve a clinician’s use of:   Empathy; active listening; open-ended questioning; unconditional positive regard; creating an environment of safety, security and acceptance; informed consent regarding roles, contract and confidentiality; establishment of trust which is often equivalent to the client’s length of treatment; and the client’s expression of drives and associated wishes.(Sharf, 2004) Many of these necessary factors actually become easier to accomplish when art materials are present. In fact, once a client has drawn, painted or otherwise expressed a part of themselves tangibly, its’ reality cannot be ignored. The subject can more easily become present in discussion, and that previously expressed part of themselves is more difficult for the client to ignore or disregard.(Sharf, 2004)
    Three of the biggest evidence-based modalities for substance abuse treatment are 12-step mutual-help programs, cognitive-behavioral therapy (CBT), and motivational interviewing (relative to the appropriate stage of change). In spite of the overwhelming popularity of these addiction treatment methods and the myriad of techniques within, related expressive art therapies are almost non-existent.(Sharf, 2004) There are visualization, meditation and similar therapeutic activities involved in CBT. There are also scattered projects regarding visual representations of the 12 steps and so on which have become somewhat popularized.
Still, why this historical lack of creative energies concerning substance abuse treatment modalities? Is it because of the stereotyped population of non-compliant, low-motivated and often involuntary substance abusing clientele (insert other cliché terms for “we’re doing something wrong with this person”)? This population is known as being difficult to work with among clinicians, and clients do require knowledgeable professional care, but does that mean we can’t utilize creative freedoms within treatment? The challenges professionals often face with treatment of substance abuse populations may have less to do with a, “problematic population,” and more to do with the traditionally rigid approaches most commonly used. Albeit the disease of addiction is cunning, baffling and powerful…   progressive, incurable and fatal… we do know from documented treatment outcomes, therapy can help. How can we incorporate creative freedoms into an individual program of recovery?
     Creative freedoms have certainly been left out of many public schools in contemporary America. Were the arts disposed of, thrown to the wayside in our narrowed aim at a media propagated, corporate identity and political profit margin? Were they disregarded as something un-needed, or simply left alone for too long and forgotten? Many people feel they are personally energized by using their imaginations in day-to-day activities. Some folks have great fun being creative which sparks interest, shortens long days, and makes life worth a struggle. Struggles can be common in recovery from the disease of addiction. What can we do to make our own or the struggles of others bearable?
     Natalie Rogers expresses radical artistic notions in her book, The Creative Connection: Expressive Arts as Healing. She calls the arts, ancient forms whose practice bring balance and harmony into our world. It sounds like they must be invited and utilized to be effective. Rogers incorporates the person-centered or client-centered approach in art therapy. This approach was created by her father, Carl Rogers, whose teachings are widely hailed and frequently used in the mental health field today. In fact, Rogerian therapy and principles of practice are the essential methods in the recovery of our mental health system. This is a system transformation which materialized in the late twentieth-century and continues today across the country. It, like Rogerian theory, is focused on client respect, worth, dignity, potential and the facilitation of growth.(Rogers, 1993) Although there are many bridges to cross in implementation, its growth has been quick and expansive. This “recovery transformation of the mental health system” involves programs for peer support services, person-centered planning, self-determination, supported education/employment and various other services aimed at supporting self-direction. What better way to allow a client self-direction than offering them alternatives to how they may express themselves in treatment?

Check out these amazing Expressive Arts Therapy Videos (listed below), studies show that many of these alternative therapeutic techniques we seldom hear about are indeed evidence-based:

Bill T Jones with Bill Moyers: Still Here (choreography and dance with terminal patients)

Gabrielle Roth: The Wave (The 5 rhythms of movement)

Gabrielle Roth: I Dance the Body Electric (conversation about her work)

John Fox/John Graham Pole: Healing Words, Art and Medicine (creative expression at Shands Hospital, Florida)

Of Sound Mind and Body (survey of music and vibrational healing)

Sharry Edwards: Sonic Apothecary (Bioacoustic Sound)

Kurt Toftin: Shakespeare Behind Bars

Natalie Rogers: Creative Connection

Shands Hospital Arts in Medicine Program, Florida: Color My World

Francis, D., Kaiser, D., Deaver, S. (2011). Representations of attachment security in the bird’s nest drawings of clients with substance abuse disorders. Art Therapy: Journal of the American Art Therapy Association, Vol. 20, #3, 125-137.

Hanes, M. J. (2007). Face to face with addiction: the spontaneous production of self-portraits in art therapy. Art Therapy: Journal of the American Art Therapy Association, Vol. 24, #1, 33-36.

Kellman, J. (2008). A place for healing: a hospital art class, writing, and a researcher’s task. The Journal of Aesthetic Education, Vol. 42, #3, 1-14.

Kellman, J. (2008). HIV, art, and a journey toward healing: one man’s story. The Journal of Aesthetic Education, Vol. 39, #3, 33-43.

Rogers, N. (1993). The creative connection: expressive arts as healing. Science & Behavior Books, Inc., Palo Alto, CA.

Sharf, K. (2004). Art therapists’ perceptions of their work with patients in treatment for substance abuse: a qualitative investigation. New York University School of Social Work.

Venable, B. (2005). At-risk and in-need: reaching juvenile offenders through art. National Art Education Association, Vol. 58, #4, 48-53.

Walker, G. (2011). HOL 5500: Introduction to expressive arts. School of Holistic Health, College of Health and Human Services, Western Michigan University, Summer I, 2pm-4:30pm.

1A Addiction & dual-diagnosis treatment, art therapy intervention.

2012-03-07T19:29:00.000-08:00

Art Therapy Intervention for Dual Diagnosis Treatment:
Recovery Map
Brandon Bruce Dellario LMSW LASAC

“Art therapy can often assist a chemically dependent individual to work through defense mechanisms that distort his or her sense of self and life circumstances.
”(Hanes, 2007)
     Therapeutic theories and techniques are significant to the method one administers an art therapy activity. I myself have schooling and 5 years of professional experience in the field of mental health and addiction treatment. I am also an artist who works in 2 dimensional media. For the purposes of imagery to display my subjective experience in the following project, I will not refer to myself as “this clinician, practitioner, worker” or otherwise. I will steer clear of clinical language unless necessary, in which case I will explain its’ meaning. This I do in the spirit of humanizing the catalog of my own social science practice. It also serves the purpose of de-mystification of the process involved. Names and other identifying information of participants will be kept confidential.
     Let’s begin with the project at hand. There are some art therapy activities using 2D art materials we have learned about such as: Bridge drawings; abstract drawings of emotional states, memories and self-portrait; experimental, multi-media watercolor painting; and sandbox drawings in representation of the found object’s placement on a surface.(Walker, 2011) In speaking with a colleague about this project, I came to understand the boundaries and freedoms in creation of an expressive arts therapy project. She gave me an idea that I used in the first portion of an art, drama and movement activity. My population is adults in substance abuse recovery. I chose 2 men in their late thirties and early fourties, both clean, living in an adult foster care home. One man in his 4th year of recovery, one in his first year. I will refer to them as 4 and 1 in the rest of this paper. They both are dual diagnosed (mental health and substance abuse recovery). I chose not to focus on their specific mental and emotional conditions, in fact, we did not speak of any clinical diagnoses.
     Pulling markers and paper out onto the table instantly drew them in. I simply asked them to draw the disease of addiction. The purpose of this activity was to get them thinking about what it is they are recovering from. It only took them 5 minutes or less to put it down on paper. 4 drew a red face looking straight at the viewer, speaking negative messages. 1 drew a spiral which he described as “going down.” I explained to them that this was a warm-up exercise to get the creative juices flowing. We started to converse about the art pretty naturally at this point which made it a great ice-breaker.
Materials/Method
     Next I gave them another sheet of paper, provided a number of different colored markers, pencils and pastels and asked them to draw a map of their disease and recovery. I explained to them that this activity is a take on the expressive arts activity called “life map.”(Walker, 2011) I let them know they could do this however they wanted, and could use varied lines, colors, numbers, symbols and words to describe parts of the map. The purpose of this exercise was to allow the participants to look at their own path into and out of addiction. The expected outcome was that the participant would find their inner thoughts and feelings regarding addiction and where they find themselves now in recovery. The term ‘addiction’ can of course be interchanged with ‘substance use’ or ‘abuse’ where appropriate. These two (1 & 4) took more time in drawing the maps and thinking about them as they worked. 4’s map looked like many of the maps my fellow students did in our art therapy class, a single line with a beginning and ending. 1’s map was just a large spiral, but this time in red as oppose to black, and with a line going from the center to the outside.
In the final part of this activity, I asked them to physically walk out their map with us following behind them. I again told them they could do this however they wanted, while giving them some examples of how others have expressed themselves in doing it in the past. 4 wanted to start. We placed our hands on his shoulders as he walked us along in baby steps. He was so very animated with jumps, crouches and other unique movements, as well as telling us the story in a dramatic fashion all the while.

Evaluation
     “Art therapy can provide numerous benefits for clients with chemical dependency and for their families. Art therapy offers a an approach for bypassing denial and other defenses commonly used by substance abusers – this helps to open avenues for the identification and communication of feelings (Albert-Puelo & Osha, 1976/1977). Naumberg (1966) has emphasized that putting mental representations in graphic form presents a space for the expression of the client’s important qualities, strengths and struggles. In substance abuse treatment, this material becomes available for processing and creates an opportunity for the art therapist to facilitate the eventual transformation of mental representations that lead to maladaptive behaviors. Addressing relationship issues arising from insecure attachment is an important aspect of this process because of the ability to seek support from significant others is crucial to recovery.”(Francis, 2003)
     The jist of 4’s story revolved around one of his first best friends who treated him very poorly. He went on to talk about this for over an hour afterward. It must have unlocked the memory of things he hadn’t thought of in a great while. He was not overly emotional or torn about the subject, but seemed glad to put this piece into the puzzle.
     1 didn’t seem to want us touching him, so he asked to simply explain his map to us, although he was very engaged in the activity. He told us about the woman that he once loved long ago, and eluded that there was a painful ending to that relationship. Then he spoke of his new life in recovery as if things are pretty good now in his life.
     I remembered to take time to listen to each of them and ask questions, as to give them time to process what was going on. The content of our project outcome made perfect sense to me. These are two men who are healing, focused on good decisions and have begun to put their lives back in order. I could see it helped them to organize some thoughts, if not more. They also thoroughly enjoyed themselves. I gave them a pack of the markers and asked them to keep up the art. I look forward to using similar art therapy techniques in the future with clients who are in earlier stages of change, such as the pre-contemplation and contemplation stages where one might not be actively making changes or at least not by personal choice. I believe, as with many therapeutic techniques therapists and counselors use, these and other expressive arts therapy techniques proplerly utilized can lead a client to their own inner truth.

1A Addiction & dual-diagnosis treatment, art therapy program.

2012-03-07T18:54:00.001-08:00

Art Therapy Program for Addiction & Mental Health Recovery:
Art Expression Group
Brandon Bruce Dellario LMSW LASAC

    Art Expression Group is an art course for people in recovery from addiction and or other mental conditions.
The program runs for eight weeks. Each week new art mediums and techniques are introduced to the group. The subject of group projects will also change from week to week, allowing group members to open up conversations regarding recovery while developing artistically. The group will be instructed by an artist who also is a certified counselor or therapist. The group could also be coordinated by both an artist (as art instructor) and a counselor/therapist (as group facilitator), but the lead facilitator of the group must be a certified counselor/therapist.
    Group A meets on Mondays from 3pm to 4:30pm. Group B meets on Wednesdays from 3pm to 4:30pm (Group B is for overflow purposes if necessary). Each group member will be evaluated on their performance in class. Members who successfully complete all eight classes will graduate and receive a letter of recommendation from the Art Expression Program Coordinator. This letter of recommendation can be used to pursue employment, education, art business and the like.
A graduation ceremony and art show reception will be held at the facility one week after the last class, 3pm to 4:30pm. The art will remain displayed at the facility for one month afterward. Our program does not claim responsibility for any damages/theft of art from the facility or otherwise. It is the responsibility of the group member to take care of their own art in class, and pick-up soon after the art display.

Art Expression Program Curriculum:

Firstly the art media is set up for the group as directed by the group facilitator. Throughout the course, portions of class time will allow open discussion related to recovery, the art project and art in general. Each individual class starts with set up (10 minutes), then specific instruction regarding the art medium (15 minutes), followed by an art-making icebreaker (15 minutes), an art project (40 minutes) and cleanup (10 minutes). The week’s icebreaker and art project have one of a variety of subjects on recovery. The classes are scheduled as follows:

Week #1
    Introduction to the course: Coordinator and facilitators will introduce themselves, their own professional background and what the program will look like in the future.
Art Medium: Pencil, Conte & Charcoal
    Instruction: Sketching techniques
    Icebreaker: Who or what are your 5 greatest supports? How do you use those supports? What are the barriers to your own personal recovery? How do you think you can remove those barriers? Draw one of each.
    Art Project: Bridge to Recovery

Week #2
Art Medium: Chalk Pastel
    Instruction: Techniques in use of chalk pastel
    Icebreaker: How are actions and consequences related? What actions lead to health, happiness and serenity? What actions lead to sickness, depression and insanity? Draw one action and one consequence that you have experienced.
    Art Project: Gay Walker’s “Life Path”

Week #3
Art Medium: Pen & Felt tip markers (fine and wide tipped, Sharpie and Crayola)
    Instruction: Free draw
    Icebreaker: What are some of your own personal values? What is it about these values that attract you? What do they do for you? How are they different or similar to the values of others? What are some definitions of the terms “principles” and “values?”
    Art Project: Draw the 12 Steps

Week #4
Art Medium: Oil Pastel
    Instruction: Techniques for use with oil pastel
    Icebreaker: What is your personal definition of spirituality? How does it help you in your life? How is spirituality, in a broad sense, different from the disease you suffered from (addiction or chronic mental condition)?
    Art Project: Paint the Disease

Week #5
Art Medium: Magazines, Glue and Masks
    Instruction: Techniques of collage
    Icebreaker: What are some of the faces you show to the world and why? What are some feelings you have behind those faces and why? How are they alike or different?
    Art Project: Masks

Week #6
Art Medium: Acrylic Paints
    Instruction: Acrylic painting techniques
    Icebreaker: What is an example of an affirmation? What are some things you tell yourself to help you through the day? What are some things you’d like to tell yourself in the future? How do affirmations help an individual in life?
    Art Project: Pet Rock

Week #7
Art Medium: Watercolors
    Instruction: Watercolor painting techniques
    Icebreaker: What are some ways you help others? What are the things you enjoy about helping others? What are the pitfalls of helping others? What are the ways you avoid those pitfalls? What are the ways people help you? What are the difficult things about accepting help? What are some ways to avoid those difficulties?
    Art Project: Boundaries

Week #8
Art Medium: Choose your own medium
    Instruction: Ask instructor and classmates for suggestions regarding your medium of choice.
    Icebreaker: What tools are the most helpful to you? Calling/sharing/fellowship with others? Groups? One on one? Prayer/meditation/relaxation? Reading/writing? Singing/dancing/art-making/music/cooking/sports? Out of these last eight weeks, what are the new tools you have gained? How do they help you? How will you remember to use them when necessary? Who will help you to stay accountable (mentor, sponsor, spiritual guide, pastor, etc.)? Tell us about your plan for regular maintenance of recovery (replacing bad habits with good habits regularly)
    Art Project: Self-care

Art Expression Program Rules & Contract

5 Rules of Group Sessions:

1.    Group members must agree to treat one another with respect and dignity at all times.
2.    Group members must agree to remain focused on the instruction and group project during class, and to engage in casual conversation related to recovery or art-making only while working on class projects (as dictated by facilitator).
3.    Group members must not bring drugs of abuse, paraphernalia or weapons into the facility.
4.    Group members must speak to facilitator privately if experiencing problems in or out of the group.
5.    Group members must have fun making art J

Group Member Signature:_____________________ Date:_____

If a group member is having difficulty in class, the coordinator will discuss the situation with the member in private and offer individual guidance and referral. If problems persist and agreed-upon alternatives have not been followed through by the group member, a written warning will be given to them.
If the issue continues to rise, and there continues to be no commitment to change by the group member, they will be dropped from the Art Expression Group. At this time, the coordinator will meet with them privately for guidance and referral purposes. They will be allowed to try the program again during the next program session if there was no threat of physical harm to anyone related to the program or facility.

Information for the Agency & Facilitator

    The facilitators of the Art Expression Program will direct students who arrive early to set-up materials for the day’s work. This will give students competence, promote self-efficacy and build on their familiarity with the media/art room. The art room must have a space for display of art, storage of materials, adequate furniture, a nearby sink and space for students to express themselves in. The environment must be safe and secure. This room is a sanctuary to the students. Its’ character is of importance to the functioning of the group. Ideas involving alternative expressive art therapy models must be carefully designed, orchestrated and submitted to the program director for approval.
    The classes are conducted by an artist/mental health professional that plays the role of instructor and facilitator. With the supervision of a mental health professional, an outside instructor can donate time to come in and teach a certain media or technique if the group so desires. Decisions regarding this program’s evolution will be made by the class, but only when approved by the group coordinator and program director. No oil painting or other hazardous materials will be used in this program.
An art-making icebreaker follows the initial instruction, after which an art project is introduced to the group. The group sessions will involve art instruction regarding a variety of different materials which are easy to control and clean up. Some are listed here: pencils, erasers, felt tip pens, markers (Sharpie), a variety of colored markers (Crayola), conte crayons, charcoal, chalk pastels, oil pastels; acrylic paints, watercolor paints, brushes, mugs for water, rags, pallets; scissors, tape, glue; newsprint, typing paper, quality sketching paper, water color paper, canvas/wood/masonite, stones, masks; smocks, plastic or cloth covers for table, storage bins, containers; proper safe and secure work space with running water and necessary furniture.
The group facilitator can offer alternatives to group members who wish to create something outside of the weekly project or art medium. No more than two classes can be used to work on something outside of the weekly project.
The facilitator can ask open-ended questions of the members to facilitate their art making or group discussion. The facilitator must also promote and maintain and atmosphere conductive of recovery. If a group member is acting inappropriately, it is a great opportunity for the facilitator to reach out by pulling that person aside casually, asking them to meet for a one-on-one meeting, or referral to a worker or agency who might be able to help. 911 should be called if there is a serious threat of physical harm.

1A Addiction treatment program

2012-03-06T18:41:00.000-08:00

Substance Abuse Treatment Program: SOBER Group
Brandon Bruce Dellario LMSW LASAC

“The effectiveness of treatment is positively related to the length of time that clients spend in treatment.”(Prendergast, 2000) This document is a proposal for a fifteen week outpatient substance abuse treatment program.
The group’s name is S.O.B.E.R. (surrender and open-mindedness bring everything to recovery). The purpose of SOBER is to support and encourage those with substance use disorders to live clean, productive and responsible lives. The population served at our outpatient clinic all fall within the contemplation or pre-contemplation stages of change. The target population for the SOBER treatment program is adults, eighteen to eighty, who have shown a significant history of substance abuse as measured by the SASSI instrument, without signs of non-substance-induce mental illness. Clients who present with signs of mental illness will be referred out to agencies who can provide them with necessary services.
Around 75% of our clients are mandated by the courts to participate in treatment which make them overwhelmingly a non-voluntary clientele. We at Plainwell Psychological Associates will take these factors into account when working with the clients of the SOBER treatment program in relation to formulation of a sound therapeutic contract. There will be no reaquirements to attend 12 step meetings outside of group since this has been shown to have a negative effect on treatment outcomes.(Magura, 2000) 12 step attendance is however encouraged throughout our program. We treat clients according to their individual social, cultural and environmental factors. As interns will be facilitating this program and related groups, there will be no charge to our clientele.
The first five weeks of SOBER involve didactic groups for psychoeducation on addiction recovery. The next four weeks are spent as therapeutic process groups where members share their individual experiences in recovery. The last three weekly groups are focused on maintenance of ongoing recovery. This is followed by three individual sessions with a counselor for client aftercare.
The didactic sessions, while allowing for some group discussion, will focus on the provision of addiction recovery information. This fills the requirement of our substance abuse population’s great need for education regarding the disease of addiction and addiction recovery. During this time we also focus on related topics including boundary setting, developing new relationships, developing healthy habits along with support and encouragement. We at Plainwell Psychological Associates are 12-step oriented. We seek to integrate our clientele with the local 12-step meetings and the recovery community at large. We do this by making a suggestion to our clients to attend three 12-step (or other mutual help group) meeting minimum per week throughout our fifteen week treatment program.
The four week process group focuses on the individual experiences, strengths and weaknesses of each group member. After five weeks of getting to know one another through attending group, group members begin to get comfortable with each other. This is advantageous to the therapeutic process for comfort levels in sharing personal information in process group, as well as receiving help from and offering help to other regular group members. The last three groups are geared toward detailed work on the supports and barriers each group member carries. Finally, the three individual sessions following group treatment are for personal work with a counselor regarding the clients’ specific needs in their personal ongoing recovery.

Organizational Aspects
Information about SOBER will be dispersed through other local agencies such as Kalamazoo Community Mental Health and Substance Abuse Services, Drug and Alcohol Courts and Community Healing Centers. SOBER pamphlets will be placed in waiting areas in these agencies, as well as sent to individual workers and probation officers inside each agency. When a patient is referred from an agency, they will be further informed about SOBER through an initial meeting with one of our counseling interns. This is where clients are given all the information about our program (including consumer rights), sign needed documentation and meet with at least one of our program facilitators.
At SOBER, the client comes first. We gear our program toward the Carl Rogers person-centered approach. This is a recovery-focused model which is becoming more utilized by our contemporary American mental health care system. Our SOBER client-centered approach puts our customers in the driver’s seat, while providing rough guidelines for appropriate behavior. Clients gain more personal experience, competence, self-efficacy and self-accountability when expected to make their own decisions. “The consumer should be paramount, people expect providers to systematically determine and respond to consumer needs.”(Wilkerson, 2000)
Within our small clinic, we will need to organize the required time allotments on the calendar in scheduling time for group in the large meeting room. This may prove difficult, as we have no system for this in place as of yet. Once we establish the system of reserving the large meeting room, we will need to have an agency meeting where the scheduling process will be announced to all staff. At this time we can announce the proposed times for SOBER group sessions to look for scheduling conflicts.
Another challenging area might be finding enough interns at Plainwell Psychological Associates to put in the hours necessary for SOBER to stay afloat. We will approach individual interns and ask them what their schedules look like. We will also ask them to take their SOBER program co-ordination responsibilities to their field supervisor and field liaison for final approval. It looks as though we will have to discontinue SOBER through the summer months when interns are not available. If after evaluation, SOBER is shown to be an effective program, our funding sources may pick it up for year-round activity.

Group Members
Given the population of Plainwell, MI and surrounding areas, we have come up with a general expected client population of local, white males between the ages of 18 and 64. Most of these local men are employed by farms and factories in the area, around 60% of them are married with children. These men have historically come to treatment because of DUIs and other substance abuse charges. They are normally court-ordered to treatment with us. This makes many of them involuntary. We have very few that are beyond the contemplation stage of development.
When the individual group member first comes in and is informed about the SOBER program, they will also be given a needs assessment, a mental status exam and testing through use of the SASSI instrument. This will tell us the level of the specific substance use disorder which requires treatment. This instrument will be the major criteria of inclusion or exclusion depending on the results which will be discerned by individual program facilitators. Aside from agency policy regarding clientele, and exclusion of those with a severe and persistent unrelated mental illness, the SASSI instrument is the only criteria of inclusion or exclusion needed for participation in the SOBER program. Our program will be run charge free by the unpaid labor force of interns. Since interns are only at our agency from September to April, with very few here in the summer months, the SOBER program will not be operating during the months of May through August.
The people we serve are our primary stakeholders. We will provide them with healthy, safe evidence-based treatment in a timely manner. If they are not able to find transportation to appointments, we will provide transportation. The SOBER program will be sensitive to individual differences and show respect regarding individual client needs, cultures and backrounds. We actively engauge clients in design, delivery and evaluation of services. Our clients make many key decisions regarding their own treatment plan while receiving informed choices.(Wilkerson, 2000)

Group Session Focus & Dynamics
The clients involved in the SOBER program will be predominantly involuntary. This raises issues regarding low-motivation, denial, and refusal to participate in group sessions. For this reason, group sessions will be organized appropriately with a defined structure. “Drug dependence treatment produces improvements in drug-use-related behaviors (e.g. use by injection, crime) and in positive social functioning (e.g. employment, family relationships, psychological adjustment).”(Prendergrast, 2000)
The 15 sessions will be 45 minutes in length. We have agency rules which all group members must abide by. Some of these which most pertain to SOBER participants are: 1) No weapons, drugs of abuse, or drug paraphernalia on the premises; 2) Clients must not attend sessions while intoxicated; 3) Clients in group sessions make an agreement that “what is said in group, stays in group.” There are no specific SOBER program rules aside from the following other than the guideline which states that any member who misses more than 3 group sessions is automatically dropped from the SOBER program.
In our history of treating involuntary clients with substance abuse disorders, we have some realistic expectations of client/leader interaction. Our group leaders are trained in Mandt, Motivational Interviewing and Person-centered Planning. These group leaders are our intern staff who are educated and experienced in methods of working with resistant and low-motivated clients. We have made this foresight into the SOBER program because so many of our previous and current substance abuse group members have a history of physical and verbal abuse. A client acting out in these issues comes into play within the group and challenges group sessions. These type of traumatic issues coupled with the frustration clients sometimes feel when they are court-ordered to treatment can be explosive. We at the SOBER treatment program and Plainwell Psychological Associates have a firm grasp on all that is needed in treating this population safely and securely with a minimum of negative consequences.
Our goals will all correlate with the SOBER mission statement which is, “. . . a program to aid clients in finding their own inner wisdom and strength to achieve sobriety.” Thus, group didactic sessions will focus on education of lifestyle changes which will support individuals in their own recovery path. Process sessions will explore individual changes along with supports and barriers to change. Frankly, our group goals will center on sobriety and ongoing recovery from substance abuse.

Evaluation
     Our program, SOBER, will utilize a meta-analysis, “to examine the relationship between selected program factors and client outcomes. . . . it is the most systematic and comprehensive assessment of the impact of selected program factors on client outcomes conducted to date.”(Magura, 2000) In the beginning, the formative stage of evaluation, we will utilize The Rehabilitation Accreditation Commission (CARF) accreditation standards for substance dependency programs. We will match up our program very tightly to these standards of practice. SOBER will utilize only evidence-based practices to treat our clientele, such as Cognitive Behavioral Therapy (CBT).
     After the first three groups have finished and been discharges from the fifteen-week SOBER program, we will begin an evaluation of the effectiveness of the program at our clinic. In this summative stage of evaluation, we at the SOBER program will employ Archibald Cochrane’s evidence-based approach of randomized control trials (RCTs) with the use of instruments such as the Addiction Treatment Inventory (ATI) “designed to measure key structural, organizational and service delivery variables of substance dependency programs.”(Magura, 2000). The ATI evaluates program variables for the practical measurement of change. It was designed to be used regularly, so we will use this instrument as a yearly evaluation of the SOBER program in relation to its effectiveness regarding client outcomes. This will be done in relationship to our three quarterly contacts with clients during their aftercare.(Prendergast, 2000)
     In the final, ascriptive, stage of evaluation for the SOBER program, we will hire an outside party to come into our work week and evaluate the program. We will require that the evaluator pursuit information regarding all criteria which make up our program, with special regard to its effectiveness in treating our clientele.

Cochrane, A. L. (1972). Effectiveness and Efficiency: Random Reflections on Health Services. Nuffield Provincial Hospitals Trust, London, England.

Magura, S. (2000). Introduction: Program Quality in Substance Dependency Treatment. Institute for Treatment and Services Research at National Development and Research Institutes, Inc., New York, NY.

Prendergast, M. L., Podus, D. (2000). Drug Treatment Effectiveness: An Examination of Conceptual and Policy Issues. Drug Abuse Research Center, Neuropsychiatric Institute, University of California, Los Angeles, CA.

Rogers, C. R. (1977). Carl Rogers on Personal Power: Inner Strength and its Revolutionary Impact. Delacorte Press: New York, NY.

Wilkerson, D., Migas, N., Slaven, T. (2000). Outcome-Oriented Standards and Performance Indicators for Substance Dependency Rehabilitation Programs. Commission on Accreditation of Rehabilitation Facilities (CARF), Tucson, AZ.

SA Tx, Clinical Treatment Practices in Substance Abuse: Prospecting Solutions Through a River of Denial -Brandon Dellario LMSW LASAC

2011-12-04T16:51:00.000-08:00

"In the film, 'Mad Max, Beyond Thunderdome,' Mel Gibson finishes a steel cage match by taking down a killer named Blaster. When Blaster is defeated on the dirt, Gibson rips off his helmet and reveals the notorious Blaster to be a sweet, smiling little boy. Blaster’s keeper, Master, was using him as a tool to rule and destroy. Maybe Master is similar to the disease of addiction, and Blaster likening our own true-self, a child hiding deep inside." prose selection by Brandon Bruce Dellario

As a treatment practitioner and peer in the mental health system, being a peer professional may be advantageous in helping clients. It can also have its’ barriers. Peers have a way of relating and communicating hope with one another which is fundamental to a recovery process. People feel more included when they know others are in it together with them. I am a proud member of our community as a peer, and blessed to speak of it as a professional. Although, because of the various people I come into contact with, it is especially important for me to work and live with great professional integrity regarding boundaries.

The following is my experience in working with those commonly labeled “low-motivated” or “resistant” clients. Although clients are often called names such as, ‘problematic,' we as practitioners know there is no such thing as an untreatable client or condition, only improper practices or treatment modalities. While clients do not always follow up on the demanding though agreed upon commitments of a treatment plan, this is not our responsibility. We the professionals are the party responsible for seeking out solutions. So what are professionals able to do regarding a client who presents an, "insufficient instigation to change?"

“Lack of motivation for change or motivational ambivalence is widely regarded as a primary obstacle in treating substance abuse and dependence and is related to the high rate of treatment dropout. The substance abuser experiences insufficient instigation to change, and makes little or no correction in changing his or her substance-abusing behavior despite adverse consequences of continued substance abuse.”(Emmelkamp, 2006 pg. 43)

In the beginning of my experience as a peer professional, I worked only with individuals who came to groups regularly and actively participated in their own recovery process. Two years later, I began recovery coaching as a peer support specialist in substance abuse treatment and providing resource information to clients of a treatment facility. I loved the job and planned to go on in the field, but I was faced with some new challenges. There were those who were very resistant to, or displeased with the treatment services being offered them.

Starting work at the treatment facility, I had some useful information from 12 step programs, my education and employment trainings. I put these tools to use when working with people who (for whatever reasons) did not want to hear what the professionals had to say, nor anything related to the topic of ‘recovery.’ I began to back off when appropriate. I asked them to tell me their own goals, supports, barriers and ideas about aftercare. Still, I grew further confused about giving a “resistant” client a safe, comfortable atmosphere, while attempting the sorely-needed confrontational styles of counseling in a chaotic group setting.

Focusing on the clients’ needs in appropriate self-disclosure, I began asking clients for permission to share some of my own experience. Peer Support Specialist positions are especially conductive to this type of dialogue, though every clinician has struggles or victories they can use in relating to clients. Everyone is a peer in some way or another. Some of these similarities may be fitting to vocalize sparingly with clients for various reasons. Practitioners can share a bit of themselves while focused on the wellbeing of clients, in careful recognition of radical differences which may exist.
After all, we each have our own idiosyncratic paths in life. In 12 step programs they say, “What works for you might not work for me,” in distinguishing this truism. As the old saying goes, you don’t know what it’s like to be someone else until you’ve walked a mile in their moccasins. In summation, we may only seek to understand what another person’s life is like, while observing a relationship to anyone as simply another human being, not un-like ourselves. We are all equals in what my sponsor calls our larger "human family." Everyone is someone's brother or mother or daughter and so on. At times, I think of myself as any person's spiritual sibling on a strictly human-level.

Mental health professionals are not here to tell others what to do. I am not sponsoring clients, nor am I to be in any kind of intimate relationship with them. I stay accountable to my supervisor in spotting potential difficulties in this area. Yet, clients get very personal, sharing the honest details of their lives in groups and one-on-one with professionals. This can easily draw a professional into an empathetic relationship with the client, and become frustrating when a client will not acknowledge behaviors which appear unhealthy. Whether it is a refusal to change or addiction protecting itself with denial, recovery decisions are ultimately the client’s choice. Practitioners merely do the next right thing to support and encourage them by providing an environment for change. Consequentially, the clinician’s role in a person’s life is an awesome responsibility with no picture perfect answers.

I do often find it challenging to work with those who would rather not be there. Some of the people we serve get drunk and high right before we see them which make it especially hard to conduct sessions. With these people we do what we can. It may be allowing a client the opportunity to do certain things for themselves. Answers may come from asking questions about client behavioral consequences. In my professional practice, I seek to steer clear of personal enabling or actions of co-dependence. For other practitioners, it’s a challenge to simply remain open-minded in supporting a client who seems bent on self-destruction. In this situation we remember it is our job treat whatever mental health conditions are presented, regardless of our opinions on a clients persona or personal choices.

Whatever the case, we can help even those who don’t even want help with suitable models of therapy. Betty Ford is famous for popularizing this idea. Though some clients may need to exhaust their resources or suffer devastating consequences before gaining abilities to see what is happening in their life, let alone ask for help. I was once lost in the woods myself, and no matter how lost someone might seem, there is always hope. There have been single weeks where I’ve seen people go from a huge resistance to change, to a gigantic surrender to a program of treatment and recovery.

It’s good for me to remember this, that although someone may be resistant to help, it doesn’t mean we cannot help them. I have been taught great, simple techniques for helping people find their own inner wisdom. These are the motivational interviewing and peer support practices of asking the client honest, open-ended questions. These questions are best asked without a motive of leading the client to a certain conclusion. My motivations as a professional are not always best for the client. Sometimes I look for things like goals, barriers and supports and ask questions about them, but most of the time, people just like someone to talk to and listen to them. At other times I have found it useful to employ a didactic or assessment instrument to grease the conversational wheels.

I am always learning more about when to bite my tongue and attentively listen to the people I serve. This is called “Active Listening.” I have been trained to wait 3 seconds after someone speaks to respond, this insures that they are done speaking and ready to listen to my response. I can look for and point out strengths, without co-signing poor decisions practice unconditional acceptance of all behaviors, or just be there (which is all people need sometimes).

These are especially helpful when a client is resistant. For instance, if a client were to tell me that she thinks, “recovery sucks,” I can open-mindedly ask her questions about her views without judging them as ‘right or wrong.’ Or I could say, “You have a very strong character, don’t you?” “You know, you’re right, I bet there are many big challenges for anyone in recovery” or, “I admire your honesty, thanks for sharing your opinion!” These example techniques of Motivational Interviewing called Rolling with Resistance. My way of following this technique is to think of the client as a friend, while responding as such (but with professional practices and boundaries). We can always relate to someone on a human level, regardless of how different we may be. I work on giving clients the benefit of the doubt in relation to their own perspectives of circumstances. People are their own greatest authority. If there is something they are lacking or could do better with, I must also recognize that what they are currently doing is working for them in some way or another, for reasons I may not be aware of. In any situation, there may be present behaviors or circumstances which help the client in their recovery. I ask them about their own concerns, and express those concerns back to them using reflective statements.

Sometimes I work with people in dual diagnosis recovery, recovering from co-occuring substance abuse and mental health conditions. Although there can be a world of difference between individual clients in dual recovery, these are yet additional factors to consider when working with people in recovery. In substance abuse treatment it is especially important to look at each client individually considering there are a variety of problems facing each client in various environments. For dual recovering clients, struggles may include these general reoccurring problems, “. . . low self-efficacy, primary negative symptoms of severe mental health problems, such as loss of motivation, energy and drive, apathy and difficulty in experiencing interest or pleasure, and secondary negative symptoms, such as depression and the side effects of medications.”(Graham, 2004 pg. 9) Further individualized factors to consider when working with clients are age, sex, sexuality, gender, financial, legal, physical, religious and cultural differences which must be taken into account when appropriate. Empathy and open-mindedness to possible solutions are readily at hand when professionals remain aware of these diversities. Motivational Interviewing has proved to be a valuable technique in behavioral interventions for those with dual diagnosis.(Barbaro, 2007 pg. 26)

“Social workers must be concerned with his or her own values, and control for inappropriate intrusion into practice situations. This is known as Value Suspension.”(Barlow, 2009 CD-ROM) It is important for me to keep my own opinions to myself when working with someone. We all have different perspectives from living out our own experiences. Telling someone else what to do, or talking about something I have no training or personal experience with is counterintuitive. Normally, very few situations call for sharing my personal ideas with someone I am helping. I can appropriately self-disclose some personal experience, share some psychoeducation or maybe even make a suggestion. However, as a mental health professional, my focus should be on supporting the client in their own personal path of recovery which will take whatever direction that they, the client choose.

Asking someone open-ended questions will guide them to understand themselves and find what they want to get out of recovery. This is what is most important. Personally, It has been some work in getting myself out of the equation in practicing this ethical principle. I struggle at times and have a long way to go with practicing selflessness in service to anyone in need. Although more and more often I find myself listening to what clients have to say while attempting to understand. In following some rhetorical colloquialisms, I cannot ‘walk in someone else’s shoes,’ but I can ‘put myself in their shoes.’

“The simplest and most straightforward form of treatment is to screen patients for tobacco, alcohol and other drug use and to counsel those in whom you believe this is a problem. This generally takes the form of giving advice on the health effects of the drug, assessing the patient’s readiness for change, and providing information and assistance on treatment options.”(Rastegar, 2005 pg. 27)

An important streamlined-statement on interventions, making assessment and psychoeducation sound like the go-to models of treatment. However, notice the language in this treatment recommendation, ‘. . . counsel those in whom you believe this is a problem . . . the patient’s readiness for change, and providing information and assistance on treatment options.’ This sounds like treatment is more about attending to the needs of the patient and less like pushing people into what I want them to do. Now, I don’t have to agree with something I think may be problematic for clients. In fact, I have a responsibility to be honest about treatment and whatever information I have. Though I don’t want to direct energy into commanding others to perform, or make it sound like there is only one way to recover.

Although most people who suffer with substance abuse disorders eventually find great value in a program of recovery. There are occationally clients I work with who seem able to stop using drugs on their own. There are those who have the capability to remain abstinant for years without aftercare, outpatient treatment, long-term maintainance, mutual-help groups, relapse-prevention programs or treatment of any kind. I can’t tell who those people are, and even if I could, it’s not my place to tell anyone else if they are or are not an addict/alcoholic. This identification is strictly up to the client to make such a determination. Professionals can point out probable or actual consequences of a client’s behavior. Some use testing instruments to measure the possibility of a substance use disorder, then present evidence to a client. If clients identify with abusing substances, they can use the resources provided for treatment. Even if they don’t identify themselves as having problematic behaviors, they can still use resources provided toward a new way of life however they choose.

There are many different treatment techniques that substance abuse counselors use with clients. Most use a combination of various treatment approaches involving 12-step, cognitive behavioral, motivational enhancement, therapeutic community, or psychodynamic. One method that has been found ineffective in evidence-based treatment is the delicate practice of Confrontation. “. . . It results in resistance and treatment dropout . . . [but] there is still a widely held belief among counselors that client denial must be ‘broken down’ for treatment to work.”(Elliason, 2007 pg. 16)

I know that it’s not up to me to ‘convince’ someone they have a problem, or break denial that I feel may be present. I am personally a peer in addiction recovery. Drinking and drugging was my only solution to the confusion. Little did I know that it was also my greatest source of it. I held onto drinking and drugs with a death grip. I had periods of clean time during those 12 years of regular use, but I never saw a real way out until I opened up to a therapist about my drug problem. He followed a simple substance abuse assessment, asking me about every single year of my drug use, and other life difficulties I was experiencing at the time. He left it up to me to put the pieces of the puzzle together. I did! At first I got very frustrated, then called my friend to pick me up for a mutual help meeting the next day. Thank God for that counselor’s educated treatment methods. He gave me the opportunity and room to look at what I was doing to myself for the first time ever.

It seems that many styles of Confrontation can work to aggravate someone’s refusal or denial, fueling them with justification, possibly causing them to retreat further into rationalization. Some people know they have a problem, but continue to drink and use drugs. Some have tried to stop so many times on their own and failed, they may believe it’s impossible to stop. This situation is a great chance for me to tell my story. I let them know I have been clean for years, and if the past millions of recovering people can do it, they can too. It’s not always appropriate for me to tell my story or share my personal experience, I spend time weighing the positives and negatives of sharing before I do. Firstly, I focus on the client’s needs to see what will best suit them at the time. Secondly, I can postulate on whether or not they would be open-minded to my self-disclosure. Then, if they do seem to want inspirational words about something outside their own life, I can ask permission to share my experience on the subject. I also like to make it clear that none of us knows everything in recovery. We each have our own path and a personal mentor/sponsor is the best person to ask for the final word on any subject.

Many people in recovery don’t name specific drinks and drugs they used in the past, others do name them for identification purposes. In fact, sometimes substances themselves may not be discussed at all throughout an entire group meeting. I sometimes bring this, 'no-substance-label,' philosophy into my work as a recovery coach because it displays that we are not fighting a substance, but a disease inside us. Normally people in society do know various drugs to be different and have different effects, but for myself they all go to the same place starting with the first. As an addict and alcoholic, all drinks and drugs put me on a downward spiral of destruction. One of anything will take me to unhealthy places I never want to go again.
At times, I simply inform clients on the devastating effects of prolonged drinking, drug use and lifestyle issues. I do this in hopes they will stop the progression of their own unhealthy behaviors by beginning a program of recovery. As treatment practitioners we have only to focus on doing the next right thing, making a good decision as best we can, the rest works out for itself.

References

Barbaro, G., Nava, F., Barbarini, G., Lucchini, A. (2007). Management of Medical Disorders Associated with Drug Abuse and Addiction, Nova Science Publishers, Inc., New York, NY.

Barlow, D.H. & Durand, V.M. (2009). Abnormal Psychology: An Integrative Approach (CD-ROM). Belmont, CA: Wadsworth Cengage Learning.

Eliason, M.J. (2007). IMPROVING SUBSTANCE ABUSE TREATMENT, An Introduction to the Evidence-Based Practice Movement, Sage Publications Inc., Thousand Oaks, CA.

Emmelkamp, P.M.G. (2006). Evidence-Based Treatment for Alcohol and Drug Abuse, Routledge, New York, NY.

Graham, H.L., (2004). Cognitive-Behavioral Integrative Treatment (C-BIT), John Wiley & Sons Ltd., West Sussex, England.

Inaba, D., Cohen, W. E., (2007). Uppers, Downers and All Arounders, CNS Productions Inc., Medford, OR.

Rastegar, D.A. (2005). Addiction Medicine: An Evidence-Based Handbook, Lippincott Williams & Wilkins, Philadelphia, PA.

McKinney, R. (2009). SWRK 6330: Advanced Seminar in Culture, Ethnicity, and Institutional Inequality in Social Work Practice. Western Michigan University, Spring Semester, 4422 CHHS, W 2-4:30.

MI Tx, Clinical Treatment Practices in Mental Health Recovery: Trauma-informed Treatment of The Sanctuary Model -Brandon Dellario LMSW LASAC

2011-12-03T06:30:00.000-08:00

“We’ll use humor to heal pain and suffering. Doctors and patients will work side by side as peers. There will be no titles, no bosses. People will come from all over the world to fulfill their dream of helping other people. There will be a community where joy is a way of life, where learning is the highest aim, where love is the ultimate goal.” quote taken from the words of Dr. Hunter “Patch” Adams, UFO Landing artwork by Brandon Bruce Dellario

After reading Sandra Bloom’s, Creating Sanctuary, and taking a look at my agency, I feel like I was placed in a crystal ball of wonder. What are the ways my agency meets the expectations of The Sanctuary Model of Trauma-informed Treatment? What are the barriers that would impede its implementation? Firstly I think of greeters. They are the security guards and reception staff that handle daily operations. Even though these employees are the first to welcome recipients of services, they are often not trained to work with our clientele in manners of health care hospitality. Since many clients seeking treatment can be in sensitive states of a healing process, all health care workers are of great service when responsive to issues of welcoming. So how can we better provide a healing environment?

The Sanctuary model is based on the inner-workings of a scaled down community, and we know that each part affects the whole. This is a premise of systems theory, that the whole is greater than the sum of its parts. The ecological systems model developed by Urie Bronfenbrenner regards the client as a part of their larger holistic environment. Reflection on Sanctuary findings leads us to the affirmation that all staff and clients, from the director to the suffering child, should be considered and treated as an integral part of the therapeutic community.

Relationships within an agency can have a synergistic effect on the total outcome of operations. Those who have suffered through traumatic experiences could be dealing with conditions which make it difficult for them to “fit in” around public places like a mental health agency. Most adults have been through some form of trauma, and every one of us has our own creative ways of dealing with it. However, we live in an imperfect world. People have problems, no matter what their lifestyle appears to be. Everyone has bad days where they act rudely or make other kinds of mistakes. Staff and clients alike may have problems whose symptoms ripple out into the rest of an agency. Scaled-down communities can be a healing synergy of support, or a dysfunctional cycle of toxins stemming from the interaction of the individual in the agency, environments outside the agency, feeding into the family, or vice versa.

In Creating Sanctuary, Bloom illustrates, “Our [American] society appears to be in the grips of a post-traumatic deterioration that could also end in self-destruction, just as it does with patients who remain locked in the patterns of the past.”(Bloom, pg. 9) Perhaps we can parallel this to our slowly recovering mental health system, en route to solutions. What questions shall we ask in observation of a deteriorating culture (such as that of the United States mental health system, or simply the environment of a small agency)? Apparently many questions of ‘what is working and how can we implement its usage more often?’ Within the questions lie the answers.

“ . . . the individual cannot deal with the traumatic experience because it continues to pose some kind of life threat and the culture (dysfunctional community) cannot or will not help the person come to terms with the experience. [due to the problems posed by the dysfunctional community] The person is unable to establish a coherent and consistent sense of identity because the traumatized self is directly in conflict with the normal self. [due to the problems posed by the dysfunctional community] He or she is unable to establish a comprehensive and flexible meaning system or philosophy of life because they harbor too many internal contradictions. Under these circumstances (of the dysfunctional community) dissociation becomes a way of life and the disintegration of the person continues.”(Bloom, pg. 32)

Bloom states,“The person is unable to establish a coherent and consistent sense of identity because the traumatized self is directly in conflict with the normal self.” Recently, a personal colleague pointed out that in professional mental health settings, the professionals are set apart from the clientele and thus restricted in their ability to relate because they have two different identities: professional versus client, or because of roles such as ‘normal’ versus ‘mentally ill.’ Could this be one of the problems posed in the system, or even posed by our mental health system?

Our agency is sincerely dedicated to furthering our clients recovery. We continue to demonstrate cutting edge recovery education and practice. We have been engaged in the process of creating an atmosphere of recovery for years, and it is coming along very well. We have several peer-professional employees and volunteers in varied positions throughout our agency. Peers in every staff position. This has several beneficial impacts on our small society. When someone works with a peer, they are sometimes given the hope that someone else is in it together with them, may identify to some degree with struggles, and possibly have some degree of personal success in recovery. Regardless of who, how, where, what and why specifics, peer-professionals are trained to work with clients in ways which have yielded some of the very highest rates of treatment effectiveness ever recorded. Peer support has become an integral part of the transformation of our national mental health system. Leading us in the conversion from a ‘stabilization’ view of client status, to a more client-centered and strength-based recovery focus.

Our agency is rising to the challenge posed by our emerging peer professional staff and other agencies on the cutting edge of these incredible person-centered services. Recovery of the system, to provide emerging services, available to persons engaged in personal change. Possibility of health and change are integral to a healing process. Possibly a substitution of spirituality for clinical dissection of the illness? Yet, are we ignoring the reality of the severity of our system’s failures or flaws? Do we minimize or overlook new challenges that would be better addressed head on?

As a peer professional, I have personally experienced stigma in the way of being a recovering person who is occasionally viewed as ‘different’ in some ways from other professional employees who do not regard themselves as peers. As a peer, I find that I must have acceptance of the fact that most people are not as entrenched in the recovering community as myself. However, all people who work in the field are better informed on the healing electricity pulsating from those who are in recognition of recovery in their own life, community and agency. It’s not especially hard for a professional to identify and celebrate recovery, it’s what we work for. How does our agency’s culture reflect our needs for recovery celebration and gratitude? Does it help or hinder those points?

Bloom tells us that problems must not go unresolved in the therapeutic community. They somehow must surface and be dealt with, be they small, unnoticed relationship struggles or larger systemic flaws. People at our agency, whether they be peers or practitioners, are always gaining in recovery wisdom and reduction of the associated stigma suffered by those who acknowledge personal flaws. The Sanctuary Model is inspiration for all communities to stand up and say, ‘there is something wrong here, now let’s look at it so we can move on.’ Personally, I am on fire with gumption to stick up for and role model what I see to be right, point out what I see directly to an individual by taking them aside. When I feel like a situation is problematic, I look to the NASW Code of Ethics to find what may be out of place. Thanks to Bloom’s research we know how damaging the, ‘elephant in the room,’ can be where a concerned voice is unheard. That voice could be an important part of communication which all too often goes unidentified. Clients and co-workers alike, we all need to have a safe place to express ourselves, where it’s okay to talk about professional, personal or social problems.

There is a systemic dissociation in place of treatment essential empathy wherever trauma effects are seen as, ‘people getting what they deserve,’ in light of personal decisions. Stigma asserts clientele to be experiencing problems which we as professionals would never or could never experience, for whatever imaginary reasons. All persons involved in our mental health system should be aware that they are eligible too. Eligible to experience any human problem, become a problem or to live in proven solutions. Everyone is susceptible to the ‘sore thumb’ coping mechanisms that stick out among our idiosyncratic teachers, given the right set of circumstances. Those teachers being the people who have endured the trauma that often times goes ignored or passed over by in objectification of the patient. We are all in this together, thoroughly inseparable. A problem experienced by one person affects everyone and ought to be treated as such.

In Creating Sanctuary, Bloom argues for self expression through the arts. “Creative expression is the voice of our nonverbal self.”(Bloom, pg. 53) Our agency produces and supports a myriad of programs for artistic endeavors, community activities including fitness and recreation, all complimented by alternative, self-directed treatment techniques. Though many peer-professional staff members are involved in these groups themselves, maybe there is another side of stigma that draws a boundary between recovering persons and those who would like to be involved in recovery activities, but are not self-identified peer staff. Everyone needs healing and community inclusion in some form or another. Where does self-care for the practitioner fit into a regular week on the job? Existent or non-existent? Observation of systems theory again suggests possible solutions. New systems can experience difficulties in implementation without holistic and balanced interventions regarding all persons, staff and clients alike. Our agency is beginning to attack this barrier by forming groups that are open to anyone, encouraging all staff to become active participants in wellness activities. Though it can be hard for anyone to serve dual-roles on the job, this avenue may prove advantageous for practitioners and their practice, lessen burnout rates, etc. Regardless, vital questions remain of what healing paths are offered to our healers in this time of systemic transformations? Group and community involvement is essential to self-development in trauma recovery for those in recovery. How might this staff involvement in the agency’s culture work for: Clients (first and foremost); client families; agency functioning; practictioners who have personal and job-related stressors such as counter-transference; staff job performance; the community and society at large?

“The social group apparently has the obligation to provide a mechanism for conscious integration after any kind of dissociative experience, . . . When done properly, the social group provides various, often ritualized, ways for the victim to put their experience into words using language.”(Bloom, pg. 69)

Overall, our agency is catching up to the healing system portraiture of The Sanctuary Model. A small opus of recovery atmosphere is developing inside and all around us. Recovery Innovations of Phoenix, AZ, The Appalachian Consulting Group and Community Mental Health are a few of the organizations at the forefront of this movement for the rebuilding of agencies and employee training nationwide.

Trauma-informed Treatment: Informational Article on the film "Girl Interrupted" -Brandon Dellario LMSW LASAC

2011-12-02T14:03:00.000-08:00

The film, Girl Interrupted, is a poignant comment on recovery in America’s mental health system and in the family. The two primary characters are played by Winona Ryder and Angelina Jolie.

Winona plays a young woman who tries to commit suicide. Her therapist takes this as a sign of her instability and recommends her to a nearby mental hospital (Claymore). It is there she meets Angelina's character who makes herself out to be a wild, self-destructive woman. 'Angelina' considers herself to be mentally ill for a reason, and revels in it as a gift that makes her special. This rubs off on 'Winona.' When they become friends Winona indulges in the acting out right along beside her.

Angelina adapts to her environment in the way of aggressive dominance over the other patients. She has a strong spirit and appears to be self-directing, but underneath her personal qualities of rage, she has a poor relatedness with society and a weak competence in self care which manifest themselves as an unhealthy goodness of fit in the ward regarding her hositility.

When Winona arrives at Claymore, she attempts to build relatedness with the other patients by offering laxatives to Daisy, and befriending women she sees as having disempowerment in their lives. As things get hectic, she attempts to match these women with her own maladaptive actions, but actually, this is a way of seeking competence in a world she blames as unfair.

Winona heightens the stress in her awkward relationships with other patients, and rebels against authority figures. Later these perceived dominant actions awaken her to a mis-aimed self-direction. Winona escapes The Claymore Mental Health Facility with Angelina and finds Daisy hanging from a rope, she then returns to the hospital and opens her mind to the ways of recovery. Winona does what she can to find a goodness of fit in the hospital with her precious life future in mind. She fends off invitations to run away with her boyfriend, and refuses to participate in Angelina’s rebellion any longer.

Daisy is a perplexing character in this film. When Winona first sees her, Daisy stares her down out of the security of her room’s door jam. Daisy’s abrasive actions initially appear unwarranted as she angrily orders people around and locks the ward out of her room. This is displacement of emotions onto others, because of what we find out later to be Daisy’s victimization by her father in an incestuous relationship, which may have been all she’s known from him since childhood.

Trauma Specialist Dr. John Briere, Keck School Professor of Psychiatry and Psychology, University of Southern California, says that, “severe trauma associated with severe abuse causes repression.” Trauma Specialist Dr. James Henry, College of Health and Human Services, Western Michigan University found similarities,

“In a 1993 study of 450 adults in psychotherapy, 60% reported a period in their lives before age 18 where they had no memory of abuse. Those that could not remember were more likely to have greater current psychological symptoms, were molested at an earlier age, had been victims of extended and violent abuse, had been abused by more than one person, and feared disclosure.”(Henry, 10/16/08)

It is obvious that Daisy has trouble expressing herself, resorting to the compulsive eating habits and laxative abuse which make up her eating disorder. This is one of the many possible coping mechanisms that are characteristic of people suffering post traumatic stress disorder (PTSD). Daisy’s denial is abruptly challenged when Angelina tells her that everyone knows about Daisy having sex with her father. Daisy calmly walks up the stairs like a zombie without a spark of regard toward Angelina’s words. The next day they find her dead from her suicide, hanging in the bathroom. The record player repeating song lyrics such as, “I died the day you took your love away.” Daisy’s inability to communicate to others and take part in the therapeutic community was a contributor to her tragic act, as were her toxic friends. Sandra Bloom states that trauma recovering patients,

“. . . were trying to ‘get attention’ because their transcendence was dependent on a response from the social group, a shared experience of pain that would allow them to find a place back within the human community. They were desperately trying to engage the rest of us in a transformative ritual. It was the social group that needed to respond to their performance in a healing way, and it’s this response that we had repeatedly failed to give, creating instead a society that revolved around unconscious and repeated trauma instead of change, transcendence and transformation.”(Bloom, pg. 193)

The staff at the film's inpatient mental hospital (Claymore) did demonstrate a trauma informed environment of healing overall. They took the patients on small trips into the community and gave them access to outdoor environments. “We learned that human beings need settings that maintain a connection with the natural . . .”(Bloom, pg. 126) Patients had their own rooms and communal settings for fraternization. They also had lots of staff interaction,

“. . . patients and staff needed frequent opportunities to connect with each other. We needed the freedom to make our own choices about who we would connect with most strongly, and we needed other people to comfort us when we became very emotionally upset. But we also recognized that we needed other people to help us understand when we have crossed the line into too much connection, into over involvement with others.”(Bloom, pg. 127)

Staff showed values of compassion, empathy and education to the Claymore patients while working together to show distinctive boundaries, without abusing their authority.

“We evolved a position that simultaneously condemned the [destructive] behavior while supporting the person involved in the behavior. . . We each learned how to mediate these situations individually by demonstrating verbally and nonverbally that we understood that this escalation indicated that the patient did not feel that he or she was heard, at that we were willing to listen. Usually this was effective in bringing about a change in the dramatic scene.”(Bloom, pg. 143 & 152)

Winona’s Family was stereotypical of the stigma presented by society, in regards to perceptions of mental illness. According to Saterian theory, the way a family communicates self-esteem is a key concept. Winona’s mother and father want her to go to college like their family friend’s children. This is a classic example of the way American society classifies success or safety/security in financial and occupational directions. Winona’s desire to become a writer, or to more or less find an unconventional path in life, was not supported by her family. In fact, it was seen as a stain on their otherwise upper social class status. As was the suicide attempt.

Winona’s mother had an emotional breakdown as a result of hearing Winona’s diagnosis of borderline personality disorder. With her, ‘whatever I can do for you, just ask,’ personality, she could be seen as 'the placator.' This is a familial role of one who serves others with perceived selflessness. Winona’s mom also lived the role of ''the victim' in this situation. She acted overwhelmed by Winona’s suicide attempt, but avoids the subject by burying it whenever possible, which places her in the familial role of 'distracter.' The main 'distracter' is a family role played by Winona. Winona's character plays the role of 'the family clown' (or family problem) and reacts to them as such. Winona’s father plays the family role of 'the computer' in the ways he appears emotionally disengaged, however, his starring family role is that of 'the blamer.' He criticized Winona for falling asleep during her graduation day by commenting that she was, ‘pulling some kind of stunt.’ He portrays a displeased authoritarian figure in these roles.

Bloom, S. (1997). Creating Sanctuary. New York, NY: Routledge.

Henry, J. (2008). SWRK 6310 Lecture Notes. Western Michigan University, Fall Semester, 2008.
*The premise of this paper was developed by Dr. James Henry.

Recovery from Trauma & Attachment Disorders: Informational Article on the film "Good Will Hunting" -Brandon Dellario LMSW LASAC

2011-12-02T10:24:00.000-08:00

In the film Good Will Hunting, Matt Damon’s character (Will) is a man who was physically and mentally abused by his foster parents as a child. This first disrupted attachment relationship primed him adversely for his future relationships.

When a child’s needs aren’t met, he doesn’t cultivate attachment seeking behaviors, his behaviors develop in the way of meeting his own needs.(Richardson, 9/25/08) The abuse that Will suffered creates a spiral of terror, avoidance, loneliness and isolation. This insecure attachment creates a complex trauma referred to as the “Cycle of Doom.”(Richardson, 9/25/08)

Will grew course in ways of fighting, vulgarity, and heavy drinking. These traits were also fostered by his close friends in this Boston neighborhood. He was close to them, but not anyone else. Essentially, Will’s self-development was interrupted early in life without anyone to form healthy relatedness with.

Later, Will is discovered to be a mathematical talent and is thrown into a world of new relationships. He meets a young woman, a math professor and a therapist. All whom he gets to know and like, but acts distant and pushes them away whenever cornered. This dominant action of Will’s is a normal reaction for someone who has been dis-empowered in the past.

These three new relationships of his take a downturn, until his best friend tells him that he owes it to him (Will's friend played by Ben Affleck) to do well for himself, and be all that he can be with his abilities. This triggers something in Will to try something different. He sees his therapist who asks him about the abuse he’s been through. Will tells him he knows he has problems with attachment and fear of abandonment.

This therapist (played by Robin Williams) tells Will over and over again that, “it’s not your fault.” Will starts crying and seems to have a breakthrough in his recovery. The next time he meets with the therapist, Will tells him he is going to try one of the jobs he was offered by the math professor, he’s going after the young woman he was afraid of getting involved with. This is an example of Will’s growth, “[an] innate capacity and need to form attachments with others (relatedness).”(Henry, 9/11/08)

By the end of the film, Will and the therapist became very close, like father and son. They helped each other heal from past scars, and move out of fear. They start to take new risks which they agree are an examples of new-found competence in life.

Will begins the healing process by taking the first steps with new relationships. Gaining healthy attachments which allow him to foster esteem for himself and others, he can move on to higher echelons in the hierarchy of needs.

According to Maslow's hierarchy of needs, when an individual has needs filled they can progress. Once fulfilled, one can move from basic health needs to needs of safety and security, then on to social needs and needs of esteem, where an individual is able to achieve needs of self-actualization. Like Will moving from emotional reactivity, violent behavior and other previously needed defense mechanisms, to affiliation with a mate, concrete thought and abstract thought.

*Bibliography posted with related articles published in this blog. The premise of this paper was developed by Dr. James Henry.

Recovery from Trauma: Informational Article on the film "Seabiscut" -Brandon Dellario LMSW LASAC

2011-12-02T09:07:00.000-08:00

“Trauma [is] a central organizing principle of human thought, feeling, belief and behavior that has been virtually ignored in our understanding of human nature. Without this understanding we cannot hope to make the sweeping changes we need to make if we are to halt a universal post-traumatic deterioration.”(Bloom, pg. 9)

SEA BISCUIT, this film places one innevitably lost in empathy for Toby McGuire’s character and his four-legged partner Sea Biscuit. 'Toby' was left by his parents, mistreated by his first boss and beaten senseless in the boxing ring. This likens horse Sea Biscuit’s toxic stress decided in his former trainer’s abusive tactics. Toby and Sea Biscuit equally react to life in ways that seem unhealthy to others. Toby lived a depressing life. He had trouble forming relationships with women and other jockeys. Sea Biscuit was very violent and unpredictable. This points to the fact that they both had problems resulting from attachment disorders. These present as dysfunctional behaviors, moods and relationships with others which stem from abuse or neglect at a young age.

In Toby’s youth, he was thrown into a foreign world without any family. Thus creating an, “. . . anxious/ambivalent, insecure attachment. Distressed upon separation. Angry and approaching, but resistant.”(Richardson, 9/25/08) Sea Biscuit was caught in the fight, flight or freeze response triggered by his trauma. “Problems arise only when this reaction is evoked in the absence of any threat.”(Bloom, pg. 18) Sea Biscuit was ‘fear conditioned’ which created his ‘chronic hyperarousal.’ Sandra Bloom speaks to the effects of such trauma in her book, Creating Sanctuary.

“. . . most psychiatric disorder is the culmination of ‘normal reactions to abnormal situations,’ situations largely created by the failure of our social systems to provide traumatized children with the protection and care to which they have a right.”(Bloom, pg. 11)

When Sea Biscuit’s future owner asks his trainer how to find a winning race horse, he tells him a great horse is one that won’t back down from a fight. This was something that trainer saw in Sea Biscuit’s eyes in spite of his limp and awkward running style. He appreciated Sea Biscuit’s spirit as a horse who had potential to show self efficacy (capacity for beneficial change in a therapeutic intervention). This trainer put the horse into an environment of sanctuary and matched him with the jockey counterpart (the part of Toby McGuire). Once taken off the track and his vicious, “Cycle of Doom,”(Richardson, 9/25/08) Sea Biscuit’s life struggles crystallized from learned helplessness into a racing competence on the open trails of the wood.

“Learning is dependent on the ability to categorize incoming material. We can categorize information, and make new categories only when we are in a state of relative calm and attentiveness . . . Learning is also dependent on the state of consciousness we are in when the learning occurs.”(Bloom, pg. 24)

McGuire’s character blossomed into a competent jockey and a responsible young man. His new relationships with Sea Biscuit, the trainer and the owner’s family was somewhere Toby fit in to form relatedness with his environment. However, his traumatic past rears it’s head in the way of troubled decision making abilities. He reacts to another jockey cutting him off in the race by shooting ahead while losing his momentum, and the race.

“When severely stressed, we are unable to think clearly, to consider the long-range consequences of our behavior, to weigh all the possible options before making a decision, to take the time to obtain all the necessary information that goes into making good decisions. As a consequence, our decisions are inflexible, oversimplified and often very poorly constructed. At such times we minimize the effort we put into problem solving because our body has oriented us towards taking action, not towards thinking calmly about the situation.”(Bloom, pg. 23)

Eventually, learning and growing in his own new recovery environment. Toby’s character overcomes his emotional memory and makes the corrective moves in order to win the race. The neuroscientist Le Doux states that, “. . . emotional memory appears to be permanent and quite difficult, if not impossible, to eliminate, although it can be suppressed by higher centers in the brain.”(Bloom, pg. 28) This is an illustration of how the brain damage from trauma can be overcome, and once again how recovery is always possible. A victory of the Pre-frontal cortex over the Brain Stem (where the amygdala, nondeclarative, implicit, or procedural memory lies). This happens, “. . . in development when the child begins to understand speech.”(Bloom, pg. 27) Toby’s character grows into an adult, who triumphs over the painful situations of his youth. In the same way he always nurtured his boyhood dreams and aspirations. This is a primary example of the integration of different aspects of Toby's life and personality, into one unified whole.

Bloom, S. (1997). Creating Sanctuary. New York, NY: Routledge.

Griffin, S. (1998). Denial. The Sun, 9-13.

Henry, J. (2008). SWRK 6310 Lecture Notes. Western Michigan University, Fall Semester, 2008. *The premise of this paper was developed by Dr. James Henry.

Richardson, M. (2008). SWRK 6310 Lecture Notes. Western Michigan University, Fall Semester, 2008.

Ecological Systems Theory: Informational Article on the film "The Chumscrubber" -Brandon Dellario LMSW LASAC

2011-12-01T11:28:00.000-08:00

The film The Chumscrubber is a story of highly privileged teenagers and their families living in the suburbs of Los Angeles. This story is a strong example of how viewing a person within their environment holds undeniable relevance.

The primary assumption of ecological theory is that the person and environment are inseparable and must be considered jointly. It forms a unitary system where the person and environment shape each other. The main character, Dean, has a friend named Jack who he finds dead from apparent suicide. Dean was not very well adjusted to begin with. Jack was his only friend. At school Dean gets picked on and harassed about Jack’s suicide. Jack was a drug dealer. Dean is threatened by bullies to steal Jack’s drugs, or they will kill his younger brother.

At home, Dean has a fairly stable family compared to other parents and adults in the community, though his father psychoanalyzes him, and his mother has a hard time keeping the home afloat. The other adults in the neighborhood are phony to each other and their children. There are also numerous parental problems presenting themselves as dysfunction. These families display inbalance in the parental disconnection, indecisiveness, ambivalence and sometimes overzealous behaviors.

The children are stressed by their parents, but given zero discipline or structure, and no open lines of communication. If they want something from an adult they simply state that it is, “for school,” and they are free to do as they will. When bullies end up kidnapping a child, all adults ignore what is going on because they choose not to believe it is true of their children. This fuels the bullies criminal energies. This relationship between the bullies and the parents requires an element of reciprocal causality. Reciprocal Causation happens when one bad decision precludes another in it's effect.

Reciprocal Causality is the participation of an individual in their environment as to the “. . . interactive, cumulative effects”(Green, pg. 271) … of adapting to and creating the conditions in which they live.

Dean has trouble trusting people which is heightened when he is tricked by the lead bully's girlfriend repeatedly. He has trouble trusting his father who is continually publishing Dean’s problems in pop-psychology books and giving him medications. He has a decent relationship with his mom, yet she flip-flops back and forth between being his friend and his mother. He is otherwise isolated.

However, Dean is a self-controlled person who isn’t easily swayed. He refuses to become a part of the bully’s games. He determines his own environment by listening to his family and not reacting to the threats of the bullies. He chooses not to live in fear. Then finally confronts the bullies at the film's end, and talks the kidnapped boy out of killing them.

Dean shapes a life for himself in the way of cynicism and opposition to a world lacking any definition of reality. He retains his principles in the midst of savage artificialism. These strong values of Dean’s are actually shaped by the toxic environment he adapts himself to by establishing a boundary and working against the grain. This environment actually aided to develop this character's character. The symbol of a zombie warrior in an apocolyptic world (the Chumscrubber video game character), seems to be a metaphor for Dean's survivalist behavior in a socially toxic suburban environment.

Green, R., Human Behavior Theory and Social Work Practice. (coursepack)

Kotlowitz, A. (1991), THERE ARE NO CHILDREN HERE. New York, New York: Doubleday

Development of the Self: Informational Article on the work of Sam Keen & Mark Epstein -Brandon Dellario LMSW LASAC

2011-05-13T20:18:00.000-07:00

Sam Keen has an interesting viewpoint on finding your own meaning and purpose in life, which is the essence of existentialism. “I started giving workshops to help people discover their own stories or 'scripts.' I later came to call this 'writing your own autobiography.'”(London, pg. 59)

This self-determined discovery of meaning and purpose can be a valuable virtue in mental health interventions. Clients gain control of their recovery when discovering they are the best experts on themselves. In understanding where we come from, we have the power to know where we are going, and change that direction if need be.

Keen strongly believes in models of social ecology, observing how, “Cultures that have a unifying cultural narrative are stable in some ways, but they are resistant to change.”(London, pg. 60) Keen then Illustrates how we don't possess unifying myths today, but we can create new stories from experience that may get us back into the natural order of harmony with the world.

Sam Keen displays how the dominant American secular myth is, “a blind faith in the free market economy, in technological fixes to the world’s problems [and] . . . once the flow of information is complete, everyone will be wealthy.”(London, pg. 59) Thus challenging our notions by waking us up to the fact that we may be on the wrong path. “To maintain our sanity today... we need a ‘spiritual bullshit detector.’”(London, pg. 58) Keen takes on Buddhist perspectives, “Desires are endless, I vow [Sam vows for himself] to put an end to them,”(London, pg. 63) Additionally expressing how American society tells us we can satisfy all our desires, and have it all.

Sam Keen believes we get a glimpse at the essential truth of who we are by confronting the depths of our own ignorance. He calls this, “the paradox of self-knowledge.”(London, pg. 58) Keen believes in recognizing your fears, facing them, building self-esteem by doing things you think you can’t, and relating to others in a community of friendships. Though this theory does line up with our western independent-self ideology.

Similarly, Buddhist Psychiatrist Mark Epstein has faith in the notion of loving others before you can love yourself, but states that, “The Western notion of what it means to have a self is flawed.”(Griffin, pg. 68) Epstein illustrates how according to Buddhist philosophy, the perception of 'self' is an illusion, and observation of 'the feeling of emptiness' as the key to happiness. He states, “. . . the sense of being not quite real enough, is a tiny insight into something that is true: that the self we think should be so clear and big and obvious is really not who we are.”(Griffin, pg. 68)

“People who have [the previously stated] 'little flash of insight' are on the way to understanding the Buddhist concept. But it gets contaminated very early on with a sense of unworthiness. There is a lot of fear, a lot of judgments, and a lot of thinking, ‘I don’t know who I really am.’ Then you get what is called low self-esteem.”(Griffin, pg. 68)

This idea is a radical challenge to our American notions of the self. People being a part of the larger community, as oppose to an autonomous self-seeking unit. As a young man, this writer always held ideas of freedom as doing what I wanted when I wanted. Though creature comfort freedoms are nice to have, today I am learning that true freedom is gained through taking care of responsibilities. I have a responsibility to myself and others in the world. A personal commitment to respect, peace and other values that promote health, gaining self-esteem and integrity along the way. In following principles such as these, I am including myself in the group, community and life in general. We are one community, greater than the sum of our parts.

Griffin, J. (1998). THE PARADOX OF SELF. Common Boundary, 28-31.

Henry, J. (2008). SWRK 6310 Lecture Notes. Western Michigan University, September 11, 2008.
*The premise of this paper was developed by Dr. James Henry.

London, S. (1999). on the Flying Trapeze. The Sun, 6-15.