The Space Between Stimulus and Response

Reflections on addictions counseling and creating change


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So what’s my “drug of choice”?

I have been fortunate, my life has never become unmanageable or out of control because of addictive behaviors.

As an adolescent, however, I developed moderately disordered eating. I believe these symptoms were triggered by other health issues I faced at the time. I avoided almost all fat in my diet, and restricted my caloric intake. I exercised more or felt guilty and awful when I could not motivate myself to exercise. I lost weight and briefly stopped menstruating. Further, I felt proud of myself on days that I rigidly adhered to these restrictions. My self-definition was largely based on body image, and comparison to others. These symptoms eventually abated on their own as I matured and entered a new school. As an adult, residual symptoms like attention to weight and calories/ quantity of food have largely been replaced with attention to being healthful. How does food nurture by body? How do I feel mentally and physically when I attend to my body through moderate exercise? Will I feel better or worse if I just sit here instead of moving around? Still, there are occasions when I find myself focusing on my physical appearance perseveratively, or I return to restrictive eating, eating… permissively, or under-exercising. Often these are times of vulnerability— emotional unfulfillment or stress.

I notice addictive roots in my attitude/behavior when I eat poorly, because the abstinence violation effect kicks in— “I didn’t any vegetables today and I had brownies and soda, so I might as well go all out. F@#$ it.” Or a bad day of shopping, trying clothes on in front of a mirror, and judging can become a trigger for other poor habits (eating junk or eating too much) that do not nourish me. Disappointment and guilt fuel negative behavior, rather than those behaviors that would get me back on track. Further, stressful days accompanied by consumption of high fat, high sugar foods (which trigger dopamine release) perpetuate my craving for these kinds of foods. I no longer seek out healthy foods. With respect to exercise, I also notice black or white thinking that can discourage healthy habits and keeping a routine— “If I went to the pool now, I could only swim for 25 minutes not 45, so I might as well not do it.” When I am at my best, I can use positive self-talk to counter these unhelpful attitudes. (“The really important thing here is that you stay in your routine of exercise, and that you allow yourself to exercise even if you can’t do it “perfectly.”) I also notice roots of obsession if I start checking my appearance in the mirror. I begin to notice how this one issue begins to define my sense of self for the day. I have to set rules for myself or I can tell these behaviors could take over. (“For whatever reason this is a vulnerable day, you need to take care of yourself, so you can’t look in the mirror any more. You only feel worse when you do this.”) These kinds of behaviors are harmful because I become estranged from my other healthier behaviors and because they fuel negative self-evaluation.

Though these behaviors are not pleasant, they are familiar. And as one might welcome back depression as “an old familiar friend,” I occasionally welcome back these old coping strategies when I am feeling vulnerable (down, anxious, tired, worn out, and so on). Eating poorly and not exercising are temporary periods when I release myself from high expectations (“who cares anyway”), though guilt sometimes follows. Further, rich foods are pleasurable and comforting in themselves— stimulating in both their scent and taste. On the other end of the spectrum, on days when I am restrictive, I feel a greater sense of control and self-discipline. Overindulgence and deprivation go hand-in-hand. Deprivation fuels desire and perhaps biological need, which can set off overindulgence. Overindulgence can create negative emotions that make it harder to get back on track. In trying to regain control and to assuage guilt we often overcompensate by depriving ourselves, and thus the cycle starts over.

While these behaviors are not helpful, they are infrequent and not pathological, and so I have not sought treatment. However, I do address perfectionism and self-image issues in periodical individual therapy. What I have found most helpful, as I said, is to focus on the standard of what is nourishing and healthy for body. I feel better about myself when I practice self-care, and when do what I need instead of what I want. I try to use positive self-talk to divorce myself from “the committee” of critics in my head and to reinforce moderation. And when I crave rich or unhealthy foods, I remind myself that a thought or feeling is temporary phenomenon, rather than truth or a call to action. I also find that a period of total abstinence from rich and innutritious foods is sometimes necessary to get back into healthful eating habits, and then I can typically return to incorporating these more luxurious foods into my diet. Further, after periods of uninterrupted balanced eating, I find I do not miss rich foods nearly as much. Time and self-care do ease craving and preoccupation. 

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Personal biases and process addictions.

I am finding that process addictions and other compulsions blur in my mind. After all, process addictions (and substance addictions) are maintained through obsession and compulsive behavior in the face of adverse consequences. The Diagnostic and Statistical Manual of Mental Disorders now groups compulsive and formerly impulse-control disorders (body dysmorphic disorder, trichotillomania, hoarding, and excoriation) as Obsessive Compulsive and Related Disorders. These disorders seem to be united by tension and anxiety followed by gratification or relief by compulsive behavior. It seems to me that other possible behavioral addictions like work or exercise could be driven more by anxiety in the absence of the behavior, rather than the perpetuation of brain reward. Further, it seems to me compulsive behaviors grounded in anxiety instead of pleasure would manifest in the brain differently. As with substance addiction, research indicates that changes in reward-centers of brain perpetuate compulsive behavior in many process addictions too, including overeating , pathological gambling , and internet addiction . There is simply less research on workaholism and compulsive exercise for comparison.

 

I suppose this distinction is not all that important. Like other classmates who have commented on workaholism, I am hesitant to recognize a disorder that is not clearly supported by literature/research. Our textbook points out that work addiction has “no recognized diagnosis in current diagnostic manuals,” and that “there is little data available on the prevalence of workaholism.” The text mentions compulsive exercise, but does not dedicate any section of the text to it. Further, I worry about medicalizing activities that are within the scope of everyday behavior. This conversation seems theoretical. However, with a client, I know she does not need to be labeled with a disorder in order to work on problems in her life. I would want to help any clients reduce or eliminate behaviors (“disordered” or not) that are narrowing the scope of meaning in their lives and creating harmful consequences. I am sure that some of my biases are still unknown to me, but I make great efforts to see how dysfunctional behaviors develop out of needs, and in this way I can cultivate empathy for clients with diverse problems. Suggesting that someone has problems, but not a disorder, might imply that they are less ill. However, I think a problem should be measured, not by a label, but by the degree to which it interferes with one’s life, and the degree to which it can or cannot be explained by other problems.

 

Working in substance addiction now, I will say that there are times when I think “Can’t you see how much this is hurting you? How can you not want to give it up?” In those cases it does help to remember that I am seeing a symptom of a disorder rather than a intrinsic trait. It also helps to remember that all perpetuated behaviors have gain, and until you can help someone achieve these gains in other ways, change can be hard.

 

As I am new to the field, my beliefs are often in a state of flux. When I learn something new, I tend to see problems within this framework, when of course they are likely to be much more complex. Then I sometimes lose emphasis on some ideas as I adopt others. For example, I was just reading about sensation seeking traits of boredom susceptibility, adventure seeking, experience seeking and disinhibition. Accordingly, I started to see a lot of addictive behavior as the need for intense and novel stimulation. Given this tendency, I think it is necessary for me to ask myself “what am I leaving out?” and “is the client receptive to this idea?” I also think it is important for me to continue exposure to many concepts and theories. What we know and understand depends heavily on research and culture; this is perhaps why continued education is so important in our field.

 

Working in addiction, I have a lot of respect for my clients, in terms of their strengths and what they have lived through. It hurts me to know how that there is so much stigma attached to labeling someone an addict. One thing that does worry me is that I am interested in brain physiology, and I often explain addiction as a brain disease. I’ve read an article on the Americanization of mental illness, which suggests that approaching illness as a psychosocial problem rather than a brain-disease may not serve to reduce stigma, as commonly thought. We may actually treat people more harshly, and see them as more impaired with the later explanation. I have seen this too with clients who learn that their brain has been changed by use. Despite also hearing about brain plasticity, my clients who are ambivalent about change hear it as damning that their brains have been harmed, and this can reduce motivation (black or white thinking— “the damage is already there, so I might as well continue use”). This is a reminder to me that we have to explain well to clients the biopsychosocial influences in the development of addiction and other illnesses.


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How I can help Sahira now, how I’d like to help her in the future…

I am fortunate in that I have some work experience with people coping with addiction. I have been privileged to learn from more experienced clinicians, as a co-facilitator of an intensive outpatient treatment program (IOP). The IOP focuses on early recovery skills including identifying internal/external triggers for use, exercising environmental control to reduce contact/influence of triggers, dealing with cravings, the relapse process, post-acute withdrawal syndrome (what the brain and body go through as they recover), dealing with feelings, building new social networks, replacing using activities, and structuring time. Our approach draws heavily from CBT— replacing unhelpful behaviors with those that are more adaptive and identifying the belief systems that underlie these behaviors. One of my strengths for assisting Sahira is my knowledge of this evidenced-based practice for addressing substance use.

I also tend to be compassionate and empathic over judging. A non-judgmental stance would be important for developing a rapport with Sahira, and for helping her to overcome shame and guilt for the choices she has made during active addiction. Without trying to be too personal, I’ll disclose that I am adopted. I share this because I think this experience has helped me to realize that genetics are only a small part of the equation that determines who we are. Our environments and experiences are huge determinants of who we will become. I believe that different environment and different experiences could have made me someone else (anyone else). I do not judge individuals with addiction because I know that I could have found myself in the same place if circumstances had been different. There are always opportunities to recognize our humanness, and how our needs as people make us more alike than different.

As part of our program, we look at the losses and gains for use (decisional balance) and we discuss readiness to change (stages of change). These are Motivational Interviewing approaches, yet I am less familiar with practicing all the components of this technique: expressing empathy, rolling with resistance, developing discrepancies and supporting self-efficacy. I feel comfortable with my ability to empathize with clients and to affirm positive behaviors. However, I do want to build on skills for eliciting change talk and for reflecting on what I see and hear from clients. Specifically, I often find myself asking closed-ended questions, when I would generate more meaningful conversation with open-ended questions. I could also improve on skills relevant to self-efficacy— assisting clients with generating small, realistic goals that can be tackled between sessions, and on helping them to generate possible solutions to problems.

My clients often utilize 12-step programs, yet I have only been to several meetings. I do not know the ins and outs of stepwork or the culture well. I would like to become more familiar with AA, NA and other derivatives. The principles of 12-step programs sometimes differ from my training as a clinician, but there is no question that they are programs that my clients value. They assist individuals in building new sober support networks that help them to remain abstinent, reducing their exposure to triggers and reducing isolation. Clients undergo self-exploration through the 12 steps. They learn from the behaviors modeled by others who are more established in recovery. They feel empowered and comforted to when they learn that this illness affects many people. Further, it seems valuable that individuals enter the rooms of AA/NA as equals. Addiction does not discriminate on the basis of sex, race, religion, education or wealth.

In a nutshell, I feel comfortable with my skill in delivering Rogers’ Three Conditions for growth— genuineness, unconditional positive regard and empathy. However, I would be a better clinician if I developed more specific knowledge of interventions including Motivational Interviewing, support groups, and perhaps mindfulness-based cognitive therapies, like Dialectical Behavior Therapy and Acceptance and Commitment Therapy. I would like to develop greater skills in working with depression, anxiety and trauma too, as they are so often co-occuring in clients with substance use problems.


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Humbled and in awe.

I am two weeks into Addictions Counseling I. And I can say that the more I learn, the more I humbly understand how little I know. For example, I have already been given a more concrete framework for motivational interviewing than I have ever had before. Topics we have covered so far, like the biopsychosocial model of addictions etiology, are also a reminder that people (and all living things) are so nuanced and complex.

And don’t even get me started on brain physiology! Like the universe, it seems to have infinite complexity. I am in awe of it. When we think about neuradaptation— tolerance and withdrawal— we recognize that it is a sign of dependence/illness, but this adaptation also highlights the strength and beauty of our bodies. Our brains adapt to maintain homeostasis, to keep us alive. Maybe this is a crazy thought, but I wonder if it can foster just a little bit of acceptance of (not resignation to) the disease of addiction and the desire to take care of ourselves.


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Welcome!

I’m Meg Davis, a first-time blogger, student, and mental health counselor in training. I work for a community mental health counseling and substance abuse treatment agency. Through this blog, I hope to connect with all of you. I’ll also be sharing reflections as we move through the topics of Addictions Counseling I. I’m especially interested in learning about these topics as they relate supporting others as they create change in their lives. I’m also interested in these topics in relation to self-growth and my evolution as a counselor. Thanks for visiting!