Key practices for Co-occurring care: (Paula DeSanto’s perspective)
- Trauma informed and treatment - understanding of the ACE study and the need to help build people's faith in a nurturing universe
- Person-centered - taking the time to understand what each person needs and tailoring the services to the needs of each person
- Emotion based skills training that focuses on experiencing emotions, cultivating gratitude and positive experiences, forgiveness, acceptance, and effectiveness
- A culture that promotes safety, authenticity, and engagement as a priority focus. Re-training some LADC's that they are clinicians, not probation officers
- Integration of neuroscience across all interventions emphasizing neuroplasticity, brain training, and the neurological impact of both addiction mood/stress
- Pharmacological interventions to reduce relapse
- Emphasis on effectively treating people with borderline personality disorders - focus on building trust, locus of control, skill building, and behavioral reinforcement
- Mindfulness Training - gateway to self-awareness and self-regulation
- Stage matched and how to work with people who are actively using including effective risk management
Person-Centered Wisdom – Dr. Gabor Mate’ (Excerpts from his book, In the Realm of Hungry Ghosts)
The teachings of the heart, the revelations of the soul all assure us that no human being is ever beyond redemption.
– Gabor Mate’
How to support this possibility is the ultimate question?
- Numerous studies indicate that stress and trauma are common factors associated with substance use as a means to self-regulate negative or painful emotions.
- Early stress is not just a potent indicator of addiction because it impairs brain development and emotional growth, but because it deprives faith in a nurturing universe.
- Attunement literally means being “in tune” with someone else’s emotional states. It is not a question of parental love, but of the parent’s ability to be present emotionally in such a way that the infant or child feels understood, accepted, and mirrored. It is deeply instinctive and easily subverted when the parent is stressed, depressed, or distracted. Attunement is especially likely to be lacking if parents missed out on it in their own childhoods.
- Poorly attuned relationships provide an inadequate template for the development of the child’s neurological and psychological self-regulation systems.
Engagement as the top priority
- Human beings have an ingrained opposition to any sense of being forced - an automatic resistance to coercion.
- When encouraging change in another, the conversation needs to open not as a demand, but as an invitation that can be refused.
Providing the island or relief so people have the space to think – understanding the power of the environment
- If emotions are brought toward a healthy balance, people have a chance to think. This requires a supportive and safe environment where a need to soothe pain does not constantly drive a person’s motivation.
- Free choice comes from thinking; it does not come from emotions.
- If we create environments that are safe and predictable and relationally enriched, then all of the other factors in treating co-occurring disorders will be so much more reasonable.
- The power of an enriched environments to induce positive brain development has been demonstrated repeatedly (Dr. Marion Diamond -Berkeley)
Teaching mindfulness as a gateway to self-regulation
- Brain research shows that mindful awareness provides a gateway to self-regulation and a key to unlocking automatic patterns.
- A teaching in Buddhism -- the way to deal with the mind is not to attempt to change it, but to become an impartial, compassionate observer of it.
- A battle against any part of ourselves leads to inner discord and more distress. Reflection on the addicted brain, not willful resistance to it, is the way to tame it.
Embracing Harm Reduction
- Harm reduction approach accepts that many people have too much pain in their lives and too few internal and external resources to completely give up substances. The focus is less on abstinence, and more on helping people feel better, bringing them into a therapeutic relationship with care givers, offering them a sense of trust, removing judgment from our interactions, and giving a sense of acceptance. The value of our clients is not based on them pleasing us.
Providing brain training to promote neuroplasticity
- It is essential to have an understanding of how the nervous system works and the basic neuroscience of addiction.
- The work of Dr. Jeffrey Schwartz (UCLA) has shown that in the brains of people with OCD, new circuitry can be successfully established that overrides ill-functioning circuits and he suggests that the methods used can be adapted to the healing of addictive compulsions.
- The brain remodels itself throughout life. However, every treatment that “exploits” the power of the mind to change the brain involves arduous effort.
Recovery defined: Being free of internal compulsion and living according to the principles we believe in.
Self-Regulation defined: Maintaining a reasonably stable internal environment regardless of what is going on in the external environment.
Practice what we preach:
- This work can be intensely satisfying or deeply frustrating depending upon our own state of mind.
- We need to be very loving, very accepting, and very patient. If we are, people will have a much higher probability of getting better.
- Heavy workloads and overwhelming needs can keep us from recognizing all the beauty that comes from our contributions.
- Thank you for all your sincere and heartfelt efforts to help those in need.
Advice for Clinicians by Dr. Mark Willenbring (October 2014 Blog - Substance Matters)
- There is no ONE RIGHT WAY to overcome addictions. There are many different pathways. Our job is to help each person find his or her own best way.
- A skilled clinician is usually effective no matter the specific technique, as long as the clinician is focused on the patient, not the technique or path. Focus on general skills, such as empathy, reflective listening, unconditional positive regard, and instilling hope. There is no evidence that a specific technique is more effective than another, except in specific circumstances. The relationship is more important.
- Be client oriented. Take them where they are. Find out what they want, help them clarify their goals and how to reach them. Help them learn skills to achieve their goals, while also gently helping them realize that the ideal goal (use without consequences) is out of reach.
- Be patient and let them teach you about their disorder and its nature. Recovery is a two-steps-forward, one-step backward process. Trying and failing is a necessary step for most people, and the important thing is to accept that, learn from each step back, and then look forward. Persistence is the key.
- Never use the words denial, codependency, or enabling. Don't threaten, cajole or berate. Don't share your own experience unless it is (very) clearly in the best interests of the patient (it usually isn't).
- Never question their motivation to get better. I've never met an addict who liked being addicted. They all want to feel better, but sometimes it takes a while to figure what the way forward is.
- Accept that you can't help everyone. Why should we be able to universally help everyone with a complex human affliction? Be humble, but hopeful and available. Never blame the patient/client for the failure of our treatments, which are modestly effective at best. People die from addiction, and too often we can't stop it or know how to help them.
- Use common sense guided by compassion.
- Apply “evidenced-based” (evidence is thin) practices, but ultimately we’re all making it up as we go
- Think long-term: Quantitative, reoccurrences as learning opportunities, stay with clients no matter what and maintain hope.
- Address anxiety, insomnia and pain aggressively.
- Better is better. Accept improvement.
- Keep working, and trying, stay hopeful, alive and open hearted. This is most important of all.