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Greetings Clients and Friends –

Winter can be long and tough to endure with its’ cold temperatures, gray days and snow storms. Winter nights can be especially dark with the skies shielded by clouds blocking the light of the stars and moon. It can feel like everything has come to a standstill – A barrenness to it all. However, that is simply not true.

Amidst the ice, snow and freezing rains is the spring that lies beneath preparing for its emergence with all of its newness.  We need the winter to allow nature to prepare for this amazing event. So, perhaps winter can also be amazing and have much to offer us.

Winter can bring an opportunity to retreat and to take time to reflect and quietly ponder things that are important. It can be a time of our personal dormancy as we regenerate and nourish ourselves preparing to blossom as we approach another beginning.

Nature has much to teach us.  If we pay attention, life starts to make more sense as everything is timed and orchestrated perfectly.

This issue of Living Well News is about the application of mindfulness in helping with improving mood and sense of well-being. We will examine the role of judgment and reactivity in challenging health and learn new skills to calm down.

Many of today’s problems are created by stress and confusion. We can see how problems can grow bigger and take on a velocity. Addiction, depression, medical issues and other stressors intermingle creating a unique display of behavioral difficulties and become more chronic in nature.

I hope that you find this information helpful. If so, feel free to forward to a family member or friend.

If you find that you can benefit from help with mood problems, give us a call at (610) 692-4995 or info@myintegratedtx.com.

Warm regards,
Paula Tropiano, M.A., L.P.C., CCDP-Diplomate
Director
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Do you, a loved one or someone you know suffer from depression? If so, you are aware that depression can be tough to live with – tough to understand and tough to treat.

For many people, depression is not just a single “episode”, but a long-term, chronic disorder requiring long-term management. Research tends to be more focused on resolving the first episode, rather than maintaining good health and developing positive habits of self-care after the depression has resolved. Unfortunately, relapses are very common.

Episodes of depression can become a learned habit.  Habits are developed through repetition and become deeply ingrained. Resolving depression becomes more challenging when depressive habits have become part of a person’s personality.   The depressive thinking, helplessness, body sensations, energy loss and shut down becomes part of the behavioral ritual when a stressor hits making intervention more difficult.

As an Addictions Counselor and Behavior Therapist, I see this a lot in my practice in Chestnut Hill, Philadelphia and West Chester, Pa.  Many of my clients have struggled with addiction(s), chronic medical illness, early life trauma, and unexpected life events, which have challenged their resilience and ability to cope in a helpful way. At times, stressors have compounded over time and have outstretched the person’s ability to move forward.

Some self help groups and organizations which tend positive support include:

National Alliance on Mental Illness (NAMI)

Depression and Bipolar Support Alliance (DBSA)

Each group has a local Philadelphia and Tri-state presence with regular support meetings.

It is important to identify and understand the depressive pattern and to construct a plan to dismantle the behavior chain as promptly as possible as it gets tougher as additional episodes occur, and the pattern reinforces itself. Being able to “head off” depressive episodes in their early stages is important in minimizing their impact and ceasing their progression.

Early intervention is paramount; this includes identifying the warning signs of relapse.

Some early warning signs of depression relapse include:

–    Becoming more isolated and withdrawn; not responding to emails or phone calls,

–    enduring some loss; personal or professional,

–    moving or changing jobs,

–    suffering through some disappointment, or

–    stress at work or home.

It is at this point that many people drift from their treatment providers, losing confidence in their ability to make progress. Termination of treatment is usually done unilaterally, with little or no response to outreach.

Sometimes people with a long history of depression or several relapses may have to stay on medication for several years. Developing a strong collaborative relationship with a prevention-minded primary care physician is a key part of the treatment plan.  Improving and optimizing health status is a foundational part of developing resilience.  The body must be as healthy as possible for the brain and mind to heal. Sleep, nutrition, and exercise are all part of improving one’s health.

What helps?

The conditions of our lives are directly related to our health and sense of well-being. Creating conditions for our well-being and growth enhance self-esteem and satisfaction.

A few things that can help, include:

–    Seeking pleasurable emotions and sensations each day (through healthy means, of course!),

–    pursuing goals and activities that require full engagement,

–    doing things for other people,

–    being connected to good friends and a strong social support network, and

–    having a healthy partnership or marriage, affection, and physical intimacy.

Staying focused in the “here and now” rather than past, future, or other topics and places are what it means to be “mindful.”  Study after study has demonstrated that happiness and satisfaction come from the ability to “live in the moment” and “being in the moment” – Experiencing life in the moment versus living in the fiction and anxieties associated with thoughts of past and future.

To successfully prevent depression developing strength of focus and attention is most important.  Without mindfulness, there can be no treatment or progress for there is no presence in order to receive the help that is offered.

While it can be sad to leave summer behind, autumn brings with it gifts of its’ own; it’s vibrant tapestry of color, comforting foods, soups, chili and pumpkin pie, and the smell of fireplaces burning on a crisp evening.  Autumn, however, can be challenging on a health and energy level for many people.  As the days grow shorter, and there is less daylight, many people start to feel “down”, depressed or depleted of energy.  The transition into the colder months can be especially hard for people with mood problems, addictions, chronic pain and other persistent medical and mental health conditions. I hear this each year from clients and callers in my counseling practice in Chester County and Philadelphia, PA.

While season change can be tough, one doesn’t have to suffer. There are skills that we can use to reduce the likelihood of negative emotions and mood states – To prevent emotions from controlling our thoughts and actions.

Our ability to self-manage plays a key role in our physical and mental well-being; hence self-management skills are very important to our functioning. While some of these skills may seem like common sense or perhaps you are already doing them, you more than likely will find that you need to tend to a couple of them.

I use the Dialectical Behavior Therapy, Emotion Regulation skill for Reducing Emotional Vulnerability in my work with people with depression, anxiety, and other difficulties.

Marsha Linehan, Ph.D. pioneer of DBT uses the acronym of “PLEASE MASTER”  as a way of remembering these skills.

treat PhysicaL illness

balance Eating

avoid mood-Altering drugs

balance Sleep

get Exercise

build M A S T E R y

If we are feeling unwell, hungry and undernourished, fatigued, drinking too much alcohol, don’t move around or get much exercise or aren’t doing something in our day that gives us a sense of mastery or accomplishment, we are more likely to be vulnerable to negative emotions including low energy. We are also more apt to experience or see the negative rather than the positive in situations, less able to cope and manage interactions in a skillful manner.

Tips:

• If you are prescribed medication, take it as directed. Many people don’t. Symptoms tend to resurface under stress including season change. Issues that are persistent require ongoing treatment.
• Stay away from sugar, caffeine, excess carbs and processed foods. Try to eat organic and whole foods. It takes the body a lot of energies to metabolize unnatural foods and to work through the overstimulation and insulin spike ignited by sugars, caffeine and carbs.
• Don’t drink alcohol. Alcohol is a depressant. It also affects sleep.
• Build in an extra half hour of sleep at night – Get to bed earlier.
• Get outside and take a walk each day in the sunshine; even if its’ during lunchtime during the workday. Movement boosts endorphins and vitamin D (from sunlight) is related to mood, outlook and energy.
• Make sure you do something each day that makes you feel competent and in control of your life – Something that feeds your future. Taking care of the business of your life supports self-esteem and confidence.

Everything we do for ourselves counts – A lot. Through taking care of ourselves, we inoculate ourselves from negativity, ill health as well as being non-productive.

“It’s not selfish to love yourself, take care of yourself, and to make your happiness a priority. It’s necessary.” – Mandy Hale

When I started my practice Integrated Treatment Solutions in 2009, I did so out of professional conviction. My experience working in a variety of healthcare and drug and alcohol treatment settings led me to rethink my approach as a behavioral health professional. I could no longer only treat symptoms at the expense of being complete and addressing underlying issues. I realized that I was at a critical choice point and that working within a traditional clinical framework was preventing many clients from getting help – That was not going to work for me. I wanted to collaborate with clients in the exploration of their problems and see what made sense for them in their respective recoveries.

These are some things about addiction and recovery that I have learned along the way and implement in my daily practice as an addictions specialist and behavior therapist…

Understanding addiction and moving into recovery is a process, not an event. Addiction recovery takes willingness, honesty, openness and time. Recovery is not linear. In fact, it can vary person to person.

The decision about one’s relationship with substances is personal. Individuals use substances and engage in addictive behaviors for different reasons – Essentially, all behavior is purposeful. As human beings, we are always trying to accomplish something. Each person has his or her perspective and goals concerning their use, lifestyle and level of wellness desired.

As a co-occurring disorders specialist (previously referred to as dual diagnosis – addiction and mental health together) I counsel and treat clients presenting “clinical complexity.” Many have been trying to gain clarity about their conditions and make progress for many years having been through many courses of treatment but continue to struggle with relapse or are “white knuckling” it through tough symptoms. Despite previous attempts at recovery and disappointments incurred along the way, they have stepped up again! I applaud their courage and determination.

I also believe that there is hope. Even after several attempts have been made.

It has become apparent to me that there are no failed clients only failed treatment. While addiction, depression, bipolar disorder, etc. tend to be fairly standard in their presentations, each person affected is different within the issue at hand. Each brings unique strengths, vulnerabilities and life experiences which need to be taken into account when planning treatment.

Treatment must be tailored to the individual – always.

People want to get well – not only sober. To feel at home in their bodies and positive about themselves, others and their relationships – To be able to trust themselves – their thinking, abilities and choices.

Many clients who approach treatment with me had been sober before – for long periods of time and yet continued to be in physical and or emotional pain. Many have made attempts at sobriety in traditional drug and alcohol rehabs and attended daily Alcohol Anonymous (AA) or Narcotics Anonymous (NA) meetings – Worked with a sponsor through the 12 Steps of AA or NA.

Symptoms from chronic pain, mood disorder, trauma, attention deficit (ADD) or chronic physical conditions/ diseases involving the autoimmune system, or unresolved post-surgical complications can surface when the person stops using substances – “breakthrough” symptoms can result in powerful triggers fueling drinking and drug use again. Inflexible personality traits or personality disorders can also serve as barriers to effective therapy and treatment. Trying to manage what is not known or understood is confusing and painful for people.

Unfortunately, situations presenting this level of complexity are not uncommon. There are often multiple problems occurring at the same time, playing off one another. The idea that addiction is a singular issue is often a false construct – An incomplete, inaccurate or an ill-founded psychological concept.

Addiction often travels with other issues – It is critical that all of the problem issues are identified, understood and addressed in order to move towards stabilization and recovery. Expecting a person to reduce their drinking or substance use or to completely abstain (depending on risk) is not realistic without a comprehensive and holistic approach offering precise diagnosis and a personalized plan.

No problem is about “one thing and one thing only.”

Clients need and have the right to know exactly what the issues are and to be educated about them. Identification of the issues and a conversation about them needs to happen even if it means talking about conditions like borderline personality disorder (BPD), narcissistic personality disorder, Asperger’s or anything that is tough to accept.

If difficult issues are NOT talked about, they will sabotage treatment and leave clients confused and defeated yet again, resulting in an increased sense of hopelessness and helplessness. When people are not informed they are deprived of the opportunity to move through their own process of “self-diagnosis”, which means “Do I agree with this?” and “What does this mean to me?”

Knowledge is power.

Engagement and commit to change can only happen when clients are clear about what they are dealing with and have a sense of what to expect moving forward.

Effective treatment starts with a thorough bio- psychosocial assessment to obtain information about the major physical (bio), psychological, and social issues. A holistic approach posits that separate issues are often related. – No stone is left unturned in the interest of getting the “bigger picture” of what is going on.

Assumptions are dangerous.  Illnesses presented as being “treated” such as autoimmune disease, diabetes, depression or conditions that tend to be minimized like, Lyme disease, premenstrual dysphoric disorder (PMDD), or sleep problems can fuel addiction and its ‘problem behavior. Medical treatments often need to be reevaluated to determine if they continue to be effective.

People are not always consistent with or misuse medications. Many do not have a trusted primary care physician. There are oversights and misunderstandings that can happen which have the impact on any health problem.

So, the solution to the problem is only as good as it’s’ conceptualization. To be inaccurate or incomplete is time, energy and resource draining.

An integrative approach to addictions treatment and its’ co-occurring disorders is collaborative, thorough, health and well- being oriented – Not just about “one thing” or symptom oriented.

Many years ago, when I was working as an Addictions Therapist in an Intensive Outpatient Program someone said something in a group setting that was quite insightful and ingenious as it related to treatment and recovery – “I have been in and out of treatment for most of my life. I have been in treatment in several inpatient and outpatient programs. I am now seeing that I don’t know how to live and I am terrified!” 

This person went on to say that it often assumed that just because adults are grown-ups, that they do not always have the skills to live effectively – That it was assumed that the drugs or alcohol curtailed functioning and the goal was to restore it. But, as he said , “When I try to remember how to live, there is not anything to recall. It is not that I am ignorant, but I never learned anything about how to manage myself and my life in a way that worked for me! Addicted people are not always in need of rehabilitation but we often need habilitation! In a way, addiction fills a gap and it is my way of coping in the world. Sometimes I am aware that I am digging my heels into the ground, because I don’t know how to move forward and I’m scared.”

It is often assumed that adults know how to do things and are skilled enough to be effective in life – That somehow the “know how” was lost along the way presenting the need to get that knowledge and skills back. This is not always the case. As a Behavior Therapist and Addictions Specialist, I am aware that despite my clients success in other areas of their lives that they are are often starting from scratch in some fundamental areas. Knowledge and skills are being taught and learned for the first time or in such a way that they as recovering people (can be applied to recoveries from addiction, depression, chronic pain, etc.) can learn and integrate new material in order to apply it to their lives in an effective manner.

Building new skills reduces stress and confusion, while building more productive coping skills and ultimately makes way for eradicating relapse behavior. It may seem too basic, but not any less important.

Sometimes the obvious is easily overlooked; we judge what we think we ought to know. However, life requires a lot of teaching and learning – Managing ourselves, relating to others, organizing, and problem-solving are not necessarily skills that are totally inborn. We learn them.

 I often think of the man who shared his insight about needing habilitation noting and respecting his complete honesty and candor. He was able to get beyond the human ego and self-examine with such transparency. He also made a lasting impression on others and gave permission to be human and to accept imperfection and the need to learn. He also reminded me to be aware of the danger of assumptions and how they can negatively impact the delivery of quality treatment that is appropriately tailored to the individual.

Hence, rehabilitation is a process of rebuilding and taking a foundation and restoring it. Conversely, habilitation is development from the ground up – the putting into place for the first time. Although adults have life experience and points of strength – perhaps successful in business, popular with friends, a strong athlete – There may be significant skill gaps or other issues, medical or otherwise, which the person has been subconsciously trying to compensate for or work around. This impacts the ability to self – manage and regulate thoughts, emotions and behavior.  The absence of such skills negatively impact one’s ability to function and be effective in life.

Although there is a strong genetic component to addiction, addictive behavior can be utilized as a coping strategy, although not a healthy one. Repeated use of substances can become habituated behavior and ultimately grow into an entrenched and highly destructive disease process that when not treated gets worse and can become terminal.  Comprehensive and effective treatment matters.

Next week we will talk about what makes for Successful Drug and Alcohol Treatment with focus on assessment and choice of treatment with emphasis on dual diagnosis/ co-occurring disorders.