Self-Soothing Statements for the Human Condition

December 6, 2019 by

People can be burdened with two fundamental, often unconscious, beliefs: “I am a bad person” and “I am an incapable person.” As global statements, they are untrue. Only a very few of us can be perceived as evil, lacking such empathy that we take action without thought of human consequence. The rest of us, as humans, have brains that have evolved for us to be primarily good to each other, if only for survival reasons. Even if we make mistakes often – which, again, most of us don’t or we wouldn’t survive – we don’t make them all of the time.

The troubling nature of these beliefs is multiplied when they are paired with the just-world belief.

“The just-world belief holds that good things happen to good people, that bad things happen to bad people, and that the world should be a fair and just place. This belief emanates from the desire to find an orderly, cause-effect association between an individual’s behavior and the consequences of that behavior…this is a hard-wired, evolutionary need of humans to predict and control events in order to survive.” (65)
– Resick, et al., Cognitive Processing Therapy for PTSD: A Comprehensive Manual, 2017.

Anne's ringLook at the permutations of thoughts that can arise from the “I am bad”/”I do badly”/just-world belief scenario:

  • Something good happened. I must have done something right and deserve credit.
  • Something bad happened. I must have done something wrong, I am to blame, and I deserve punishment.
  • If I had just done something different, this bad thing wouldn’t have happened.
  • If ________ had only done something else, this wouldn’t have happened. (“hindsight bias”)
  • If I just could figure out what would have made a difference, I would feel more certain about why it happened and I would feel better.
  • If I do this and say this, and don’t do that and don’t say that, I can keep bad things from happening.
  • Why me?
  • Why not me? (“survivor guilt”)

A few weeks ago, one or more people came into my home, ascended the stairs to my bedroom, opened my jewelry box, and took a selection of rings, primarily the most valuable and beautiful. I experienced very human shock, fear, and grief. But part of the human condition is having things we love taken from us. Adaptively, we usually grieve, practice self-care, seek out and receive support, accept sad, unfortunate facts, and move ahead.

Instead, I descended into a hell of suffering. I had the experience of watching myself slip and tumble, being baffled by how this was happening, but being unable to do anything about it. Finding life enriched by giving and receiving counseling, I sought care from my in-person counselor and from online counseling via Talkspace. I worked and worked to become aware of my primary and secondary feelings, to sort through my thoughts as facts vs. beliefs, and to access my inner wisdom for guidance. (That’s the essence of the counseling protocols CBT, DBT, and CPT rolled into one.)

I think realizations usually dawn on people, but I actually had a eureka moment. On Thanksgiving, I worked out at my gym, then spent the rest of the day alone. In a moment of deep reflection, I realized I was thinking, “If I were a better, more capable person, this wouldn’t have happened. I should be better and I should have done better. Shame on me.”

Good grief! Who wouldn’t suffer from being told these things?! And in my own head! I had no idea how mean I was being to myself! No wonder I was suffering!

It is the human condition to think thoughts like these. But it is within our human capability to transform them.

I was asked by my Talkspace therapist, “What feelings are you trying not to feel?”

Repeating those beliefs to myself helped me avoid the fact I reject most often – “I am helpless to change what happened” – and the feeling I reject most often: sorrow.

For helpless sorrow, there is only one human, humane response: self-soothing statements of kindness.

  • Some things happen for no discernible reason.
  • Some things happen to me – both good and bad – that have nothing to do with me, who I am, or what I’ve done.
  • Some things happen to other people – both good and bad – that have nothing to do with them, who they are, or what they’ve done.
  • Some things happen that cannot have been predicted, prevented, or controlled.
  • For some things that happen, an alternative action may have had an equally negative or worse outcome.
  • I know this is a difficult time for me.
  • I am so sorry I’m going through this.
  • This is hard.
  • I’ve been through hard things before and I made it. I can make it this time, too.
  • I am here for me.
  • I am not going to leave me.
  • I have the skills I need to take care of myself. I can ask for help from others when I need it.
  • I can comfort myself.
  • I can help myself through this.
  • I can help myself do what I need to do.
  • I can care for myself.
  • I have hope for myself and wish the very best for myself.
  • Above all, I am kind to myself.

Image is an enlargement of a photo taken in 2007 of one of my missing rings: 14 karat gold, heavy band; oval pink tourmaline, estimated 9 x 6 mm; small diamond on either side of stone; scrollwork wire around setting of stone; custom designed by Virginia artist Kirk ______ (unknown last name).

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, clients, family members, or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Filed Under: Addictions Treatment, CPT

Evidence-Based Care for Substance Use Disorders: Year 1 Outcomes

December 4, 2019 by

After a year of providing evidence-based counseling and case management services to people with substance use disorders and co-occurring mental disorders in the New River Valley and Roanoke Valley of Virginia, I wanted to share my outcome data with you.

For context, to protect clients’ privacy, I have a direct-pay private practice. I currently limit my caseload to 20 clients. My results are reported from a case study level, not a research data level. There was no random selection and no control group. Data analysis is limited by the reports offered by my electronic health record, analysis by hand rather than with software, and by my limited human power to follow up with clients after termination. Enrollment is open and data is based on clinical observations and client self-reports. I count all clients who enroll, not just those who continue.

Since the defining symptom of substance use disorder is persistence in use despite negative consequences, my primary criterion for measuring treatment success is the absence of negative consequences. Conducting urine drug screens can cause harm, toxicology reports are frequently false – even up to 20% – and performing them as a counselor may constitute violation of the American Counseling Association’s Code of Ethics. For those taking medication for opioid use disorder, urine drug screens are not associated with health outcomes. I do not perform urine drug screens.

From October 1, 2018 through October 1, 2019, I enrolled 56 clients.

  • 7% no-showed for the first appointment. In addiction treatment settings, the no-show rate can range from 29% to 42%. (Molfenter, 2013)
  • 20% did not return for a second appointment. In addiction treatment settings, rates for not returning for a second appointment can range from 15% to 50%. (Molfenter, 2013)
  • 73% attended from 2 to 150 individual, group, partner, and/or family sessions.
  • Of the 73% who continued in treatment, 72% have experienced no additional negative legal, employment, educational, and/or health consequences since beginning receipt of evidence-based treatment.
  • Of the 73% who continued in treatment, 34% enrolled in Cognitive Processing Therapy (CPT) for relief from trauma symptoms. 70% of people with substance use disorders have experienced trauma. ((Khoury, 2010) I am trained in CPT, a protocol for PTSD recommended by the American Psychological Association and the Veterans Administration.
  • 67% of the clients with severe substance use disorders who opted to – rather than attend residential treatment – remain in situ and engage in the trio of recommended evidence-based treatment protocols -1) medical care, 2) counseling with cognitive behavior therapy, motivational interviewing, and contingency management, and 3) social support – have been in remission for 6 months or more. Return to active use rates after exiting rehab can be 70% or more.

I welcome speaking with groups or organizations about this work. If I can be of service to you in anyway, please do not hesitate to contact me.

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, clients, family members, or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Filed Under: Addictions Treatment

Using Evidence-Based Treatment to Achieve SUD Remission Efficiently

November 25, 2019 by

The defining symptom of substance use disorder is persistent use despite negative consequences. A person is in remission when substance use no longer results in negative consequences for self, others, or society. For some substances, no safe level of use exists without negative consequences. Some people need to abstain entirely to prevent negative consequences.

In individual terms, remission can be stated this way: “What _________ did for me, I can now do for myself. I may want _________ but I no longer need it. In the few instances when I can’t do what I need for myself, I can get it done without involving _________ and without creating negative consequences for myself, others, or society.”

According to Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health released in November 2016, an evidence-based treatment plan to achieve remission from substance use disorders includes, in priority order: medical care, individual counseling with cognitive behavior therapy (CBT), and support. Additionally, research reports that self-care practices – adequate sleep, nutrition, and physical motion foremost – are fundamental to achieving remission. Inadequate self-care, external stressors, and inadequately managed internal distress are correlated with unintentional returns to use.

Individual counseling assists those seeking remission from substance use disorders to acquire skills in attention management*; emotion regulation; thought-sorting; challenging situation identification, evaluation, and response; pattern identification and replacement with conscious choices; anticipation-reward experiences; and social connection. Skills-focused group counseling – not general group counseling – can also be of assistance.

In my work with others, we term these skills “awareness skills.” Here’s an awareness skills self-assessment you can take to learn more about them. The “Self-Care Checklist for People with Substance Use Concerns, pages 28-29 in Help That Helps: A Kind, Research-Informed, Field-Tested Guide for People with Substance Use Concerns may also be informative.

Individuals can work on each skill separately. They can also seek out activities that work multiple skills at the same time to increase the potential for achieving remission efficiently. In the chart is a selection of activities with correlated skills. “X-” indicates the activity may be only somewhat helpful. Blank spaces are left to fill in with individual choices.

Important: None of the activities is an evidence-based treatment for substance use disorder. Further, proficiency with one skill may be necessary but not sufficient to achieve and maintain remission. The goal is to intentionally find activities that provide practice in the skills reported by research to help people achieve and maintain remission.

*”Attention management” is defined as having the intention to gain the strength and power to choose to what one gives one’s attention. In contrast, “distraction” with whatever is available keeps one’s attention a flabby victim of circumstance.

Of possible further interest

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, clients, family members, or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Filed Under: Guide

Outplaying the Game of Abstinence Solitaire

October 23, 2019 by

It would be easier to not use substances if wishing to use them would go away.

I think I’ve been on a personal, anti-wishing campaign since I began to abstain from alcohol nearly seven years ago. The neuroscience of addiction explains, however, that shutting down the brain structures and functions that long for alcohol would shut down the same networks that bond and attach to the ghost child I could never conceive and to my mother, gone seven years now. It is my humanity, not a pathology, that wishes for the substance that lifted me up and relieved me of my anguish, as if I were held in my mother’s arms.

Outplaying abstinence solitaireUsing the proverbial metaphor of life as a card game, wishing to return to use is a card I’ve been dealt. It’s a fact. What other cards are on the table? Medical care and medications are the first line of treatment for substance use issues. Let’s say I’ve got that. Given that each week holds 168 hours, even if I could schedule 40 hours of medical appointments, counseling sessions, and supportive meetings, that leaves 128 hours. We’re told we can’t recover alone, yet’s who’s going to staff my alone time? How can I help myself play what’s essentially a game of abstinence solitaire during all those hours I’m solo?

Based on my personal and professional experience, knowledge of counseling protocols, syntheses of literature reviews of research, and my desire to help people who want to or are mandated to abstain from substances, I’ve devised two “card decks.”

The first deck, entitled “Why Some People Return to Substance* Use After Abstinence: The Cards on the Table,” lists forces at play for many people with substance use concerns. For short, I call this the “fact deck.”

  1. Many memories of positive experiences of substance use: experience of substance ≠ experience of consequences of substance use
  2. Few memories of experiences of negative consequences of substance use: experience of substance ≠ experience of consequences of substance use
  3. Abstinence anhedonia: Inability to feel pleasure during abstinence comparable to pleasure experienced using substances
  4. Automaticity overpowers autonomy: Unskillful attention management; unskillful emotion regulation; unskillful thought-sorting; environmental cues
  5. Experience of substances and substance use outcompetes experience of available life offerings (“Is this all there is?!”)
  6. Experience of substances relieves inner experience better than other available options
  7. Deprivation effect, up arrow: Abstinence may be experienced as deprivation, result in unremitting feelings of panic or rage, and cause bingeing to compensate.
  8. Deprivation effect, down arrow: Abstinence may be experienced as deprivation, result in unremitting feelings of hopeless despair, and cause a sense of helpless return to use.
  9. Mysterious brain changes inexactly defined despite the best efforts of the best minds and hearts among researchers, treatment providers, journalists, and those in remission.

The second deck is entitled, “How I Can Help Myself Abstain from Substances*: Outplaying the Hand I Have Been Dealt.” I call it the “action deck.” It provides corresponding counter-plays.

  1. Many memories of the positive experience of substance use: Fact. Nothing to do but accept.
  2. Few memories of the experience of negative consequences of substance use: Fact. Nothing to do but accept.
  3. Abstinence anhedonia: Fact. BUT research suggests I can have a direct impact on anhedonia and apathy by deliberating discovering and “dosing” myself with multiple, small, anticipation-reward experiences.
  4. Autonomy vs. automaticity: Use of awareness skills can effectively overpower automaticity: attention management; emotion regulation; thought-sorting; outmaneuvering or avoiding environmental cues
  5. Experience of substances and substance use outcompetes life: I must honor my preferences and collect an adequate number of ways which, enough of the time, together, have more value than the value offered by substances. (synergy = whole greater than sum of parts)
  6. Experience of substances outcompetes relief of inner experience: I must keep experimenting with other ways to experience relief and increase my ability to tolerate distress.
  7. Deprivation effect, up arrow: Feelings of panic or rage: I must find what I can, and add what I can, to have enough experiences enough of the time to help my life feel enriched enough, not impoverished by scarcity.
  8. Deprivation effect, down arrow: Feelings of hopeless despair: I have to find what I can, and add what I can, to have enough experiences enough of the time which help me feel reassured and encouraged enough.
  9. Mysterious brain changes: Fact. Nothing to do but accept.

*”Substance” is defined as any substance with which use or overuse can cause negative health consequences. Problematic substances may include nicotine, caffeine, alcohol, marijuana, methamphetamine, opioids, other drugs, and food. One would not abstain from food, however.

I can envision these cards as screens in a mobile application.

(In another life, I was part of technology startups and this is what’s left of our attempts to create software applications for people in recovery. Potential referrers wanted clinical trials to prove efficacy and our attempts to gain funding failed. I cringe at the stigmatizing language I used in 2013 and am part of an initiative to change that.)

Because the magnitude of each factor might vary for each individual, the size of each card could be customized. Individuals could add or delete cards as well. The point is that I’ve created a simple, static version of a complex, dynamic system.

If you would like to try your hand at playing abstinence solitaire, here are .pdfs of the “fact deck” and the “action deck.” Once I printed the pages, I used scissors to snip the cards apart. I played the fact deck first, arranging the cards in the order of their impact on me.

Seven years ago, the deprivation effect cards would have been in the upper row. Today, an hour with a glass of wine might outcompete the many lonely, child-absent, partner-absent, elderly-parent-caregiving hours I’ve currently got going.

I have to outplay the hours that drain and demoralize me. Using the “action deck,” I play the synergy card. I work on creating enough small, meaningful experiences, enough of the time, to keep myself on the ground above a chasm of longing.

From using the fact and action decks, I’ve realized that many of my efforts to help myself with abstinence have been attempts to move cards glued to the table by reality. I’ve wasted time and energy on what I can’t do. I can shift my efforts to what I might be able to influence.

Some of the fact cards seem like wild cards, ones that might play me rather than me playing them. I have done everything that research and logic suggest to do, yet there they are.

Here’s how I see to play this. First, I acknowledge non-judgmentally and kindly that I really wish I didn’t have to play this game at all. However, given the current state of beliefs, policies, and laws about substance use, I simply may be required to abstain or risk losing what’s precious to me. So. Let me really look at the cards on the table. What’s really on the table? And the game is abstinence solitaire? Let me strategically and skillfully play the cards I’ve been dealt.

Fact Deck (.pdf)

Action Deck (.pdf)

Insider’s Guide to Early Abstinence may be helpful as well.

The abstinence solitaire card decks are supplements to the guide Sanjay Kishore, M.D. and I have co-authored, Help That Helps: A Kind, Research-Informed, Field-Tested Guide for People with Substance Use Concerns. A .pdf of 107 pages, Help that Helps is a self-guided program – tested and refined by real people with real substance use issues – for people with substance use challenges who need or want to abstain.  Caveat: Any self-help guide is to be used in tandem with medical care.

Last updated 10/25/19

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, clients, family members, or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Filed Under: Addictions Treatment, Guide

Chanel Miller Is With Us

October 16, 2019 by

I am recommending Chanel Miller’s Know My Name: A Memoir to my clients who have experienced trauma, to their partners, parents, and family members, and to anyone who wants to better understand trauma and how to begin to heal from it.

I concur with Laura Norkin, Deputy Editor of InStyle, who posted on Twitter, “Very few stories, in this seemingly endless trauma vortex, are actually worth dipping back into your own PTSD spiral in order to read. This is one – because she talks about climbing back out.”

Know My Name by Chanel MillerAlthough I learned in 2016 that “Emily Doe’s” victim impact statement had been published on BuzzFeed, I was not one of the 15 million+ who read it.  While clinicians term the primary symptom of post-traumatic stress disorder (PTSD) “avoidance,” having experienced trauma myself, I was simply being merciful, willing to do anything to protect my broken heart and wild mind from further tragedy.

When I learned through The New York Times that “Emily Doe” had identified herself as Chanel Miller and written a memoir, again I hesitated.

I am so very sorry for what has happened to the narrators of trauma survivor stories. Many survivors can only record that miserably electrified, detailed memory set that comes with trauma. The narrator and the listener or reader re-experience the trauma in excruciating detail, became overwhelmed with horror, and stay stuck in anguish. “This shouldn’t have happened,” If only I had or hadn’t…,” and “I don’t know what to do except endure” are beliefs often underpinning many experiences of trauma.

They were part of mine as well. But these beliefs are so much less a part of how I think about the traumas I experienced. I was taken through Cognitive Processing Therapy (CPT) by a local psychologist about two years ago. Based on the findings of neuroscience about the traumatized brain, paired with cognitive theory, CPT helps people use their own tender hearts and wise minds to directly help themselves. Even today, I tear up with compassion for myself when I remember the dawning realization that how I was thinking about myself as a result of what happened was causing my suffering. My poor self! I was writhing and whimpering from my own mean thoughts! I had no idea I was doing to myself what I would never even consider doing to anyone else.

I rarely think in self-cruel ways now and can catch myself pretty quickly when I do. PTSD can be a tough disorder, but I have few symptoms because I treat myself kindly. As a counselor, I was eligible to train in CPT and became a rostered provider of CPT. I attempt to pass the kindness forward.

Still, I protect myself as much as I can from situations in which I feel helpless and sad. In sum, PTSD results from feeling unrelentingly overpowered and helpless. To quote CPT founder Dr. Patricia Resick at a seminar I attended, “At essence, PTSD is unfelt sadness.”

Wondering if her memoir might be helpful to clients, however, I listened to Chanel Miller tell her own story.

Chanel Miller states openly that she engaged in therapy and thanks her therapist in the acknowledgements. I don’t know if she engaged in CPT, but she takes herself through a similar restorative process.

Yes, as she recalls and recounts the details, downward trajectories threaten downward spirals. But she challenges what she’s telling herself about herself throughout her story.

As I listened to her memoir, I heard her record realities, feel feelings as a result, becomes aware of associated thoughts, and differentiate between thoughts that are about facts and thoughts that state beliefs. She then challenges those beliefs with the facts as she sees them and as those who love her see them. She comforts herself as she can, but even when she simply has to get back in bed, she continues to seek to affirm the reality of her own self.

Again, as I see it, it seems that the inner narrative she discovers, composed of facts and realities, revives and restores her to stability, even through the punishing experience of the trial and sentencing. It’s harrowing! But she uses the very skills that brain researchers – as currently formulated by CPT – reveal are helpful: have an on-going, compassionate, interested, inner conversation, feel and name feelings, become aware of thoughts associated with the feelings, identify the thoughts that are misbegotten beliefs, meticulously dismantle those beliefs with facts, and free yourself.

I felt and thought infinitudes while I listened to Chanel Miller’s story, but I only cried three times, once when she recounted something loving her mother said, once when she recounted something bold her father said, and finally when she was thanking the Swedes in her acknowledgements. I am so very sorry for her pain, but I am uplifted and strengthened by her compassion and bravery.

BuzzFeed published all 7,000 words of Emily Doe’s/Chanel Miller’s impact statement and, I too, cannot make a selection from her memoir to quote. William Zinsser asked writers to ask, “Is every word doing new work?” For those of us with trauma stories, perhaps as yet unspoken or unwritten, Chanel Miller’s words help do the work with us and for us.

CPT is the counseling protocol recently featured on This American LIfe. It is a recommended treatment for PTSD by the Veterans Administration and the American Psychological Association (APA).

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, clients, family members, or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Filed Under: CPT
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