Coping cards filled with coping statements can help you trade negative self talk with healthier, more positive replacements. Writing coping cards is an easy, no-cost intervention that might just help you. Read on to learn how to get started.

Negative self-talk doesn’t help. You can try to thought-stop but unless you’ve got a ready replacement, it probably won’t work (the mind’s not so good at staying quiet).

That’s why preparing coping statements and writing them onto coping cards that you carry with you makes sense.

Whenever negative self-talk gets you down, pull out your coping card and read your positive affirmations until you feel better.

It sounds too simple to work, but it does work, and since it’s so simple, you can make your own cards right now.

What Are Coping Statements?

Coping statements are truthful positive statements used to replace the negative and untrue thoughts that take-over when you feel anxious, stressed, angry and/or when facing other overwhelming situations.

For example:

• Replace, "I can't take it anymore." With, "This is uncomfortable, but I can handle it if I take slow and deep breaths."
  

Verbalizing your coping statements can help you calm down and stay in control. They offer reassurance that you can make it through any difficult period.

An example coping statement that a person with panic might use is:

• “I am safe and this will pass. I have survived this before. I am just going to let this pass through my body.”

Writing a Coping Card

It’s all well and good to write out coping statements – but who can remember to use them, or even remember them at all – in the heat of the moment?!!

• Because it is difficult to remember your coping statements once you start feeling overwhelmed, it is helpful to write out a number of statements on a small card that you can carry around easily in your wallet at all times.

With this card on your person at all times, you can pull it out and read the statements to yourself whenever you need to – no memory required.

You may want to write out different cards for different situations that provoke anxiety, or panic, or urges to drink – or whatever you struggle with. The cards work best when filled with statements that are specifically applicable to you and to the situations you face.

Tips for Writing/Using Effective Coping Statements

According to social anxiety specialist, Dr. Barbara Markway, Ph.D., to get the most out of coping statements, make sure to:

1. Write the statements in your own words – not in language you wouldn’t use or don’t feel comfortable with (avoid formal or academic language.)
2. Write statements that specifically target your problem – if you have anxiety about incontinence, write specifically about that.  
3. Write statements that are reassuring, but also realistic and truthful. If you struggle with pain, repeating, “I don’t feel pain” probably won’t help (you won't fool yourself.) A more accurate and thus more useful statement, might be, “This pain won’t last forever.”
4. Keep statements brief and easy to memorize – so you won’t have trouble remembering and repeating your statement when feeling overwhelmed (when you need them most.)

How to Use Your Coping Statements

Use your statements whenever you feel anxiety, panic, feelings of being overwhelmed, etc., coming on.

If using your statements to preempt negative thoughts in a crisis situation:

1. Read them out loud (if possible) and repeat them until you start to feel better.
2. If one statement in particular helps calm you most, just continue to repeat that statement to yourself – like a mantra.
3. Try to breathe slowly and deeply – into your diaphragm – as you read your statements.

Example Coping Statements

Need a little inspiration before getting started with writing your own coping statements?

Well then, review the following example coping statements, and get some good ideas for own unique and personalized coping cards.

Coping Statements for Anxiety

• Fighting this doesn’t help – so I’ll just relax and breathe deeply and let it float away.
• This feeling isn’t comfortable, but I can handle it.
• By relaxing through these feelings I learn to face my fears.
• I can feel anxious and still deal with this situation.
• This is not a real emergency. I can slow down and think about what I need to do.
• This feeling will go away.
• By staying present and focused on my task my anxiety will decrease.
• These are just thoughts – not reality.
• Anxiety won’t hurt me.
• Feeling tense is natural. It tells me it’s time to use coping strategies.
• Things are not as bad I am making them out to be.
• Don’t discount the positives.

Coping Statements for Fear - Preparing for Stress/Anxiety

Overwhelming anxiety and stress is not only unpleasant; it can also reduce your performance (think test anxiety!) Coping statements can calm you down and keep you at your best.

Researchers at West Virginia University found that coping statement training helped speech-anxious subjects reduce their public speaking anxiety – and the effects lasted beyond the training period.

• I’ve done this before so I can do it again.
• I’ll be glad I did it when this is over.
• I’ll feel better when I am actually in the situation.
• I’ll just do the best I can.
• By facing my fears I can overcome them.
• Worry doesn’t help.
• Whatever happens, happens. I can handle it.

Coping Statements for Feeling Overwhelmed

• Stay focused on the present. What do I need to do right now?
• It will soon be over.
• It’s not the worst thing that could happen.
• Step by step until it’s over.
• I don’t need to eliminate stress, just keep it under control.
• Once I label my stress from 1 to 10 I can watch it go down.
• Take a breath.

Coping Statements for Phobias

Researchers at the University of North Carolina at Greensboro found that coping statements helped subjects feel significantly less anxiety during hierarchical desensitization therapy (exposure therapy) and resulted in significant behavioral change (for the better.)

• I can always retreat out of this situation if I decide to.
• There is nothing dangerous here.
• Take deep breaths and take your time.
• This feeling is just adrenaline. It will pass in a couple of minutes.
• These feelings are not dangerous.

Coping Statements for Panic

• This isn’t dangerous.
• I will just let my body pass through this.
• I have survived panic attacks before and I will survive this as well.
• Nothing serious is going to happen.
• This will pass.

Coping Statements for Pain Management

The way you look at pain makes a significant difference.

In one study, published in The Journal of Pain Research, subjects faced an experimental pain task that measured their ability to tolerate discomfort. Half the study subjects repeated negative ‘catastrophizing’ statements during the pain task and the other half repeated positive coping statements during the task.

Subjects verbalizing positive coping statements during the pain task endured extreme pain for more than twice as long as subjects verbalizing catastrophizing statements.⁹

So consider trying out one or more of the positive coping statements from the experiment, such as:

• I can control the pain.
• One step at a time - I can handle this.
• I need to stay focused on the positives.
• It won’t last much longer.
• This isn’t as bad as I thought.
• No matter how bad it gets, I can do it.
• It will be over soon.

And definitely avoid using any of the catastrophizing statements that halved pain endurance, such as:

• I can’t stand this anymore.
• This is overwhelming.
• I can’t control this pain.
• This is worse than I thought it would be.
• I feel like I can’t go on.
• This is terrible.
• This is never going to get better.

Coping Statements for Disordered Eating

• Food is fuel. Food is medicine. Food makes muscles.
• Don’t think, just eat.
• I am not my illness.
• Strong, healthy, smart.

Coping Statements for Anger Management

• It’s not worth getting mad about.
• I won’t take this personally.
• I am in charge not my anger.
• I am going to breathe slowly until I know what to do.
• Getting angry isn’t going to help.
• I can handle this and stay in control.
• Remember to breathe. Remember to breathe.
• People aren’t against me – they’re for themselves.

Change Your Thoughts – Change Your Feelings

Your inner voice sometimes lies to you, and those lies can provoke powerful anxiety, anger, depression, panic and pain.

Fortunately, since you know that thoughts create feelings and behaviors, you can retake control over your wandering mind with coping statements that bring truth and positive thinking back to the forefront. And once you start thinking right – you’ll start feeling right.

If you struggle with overwhelming thoughts, coping statements can help you. They’re easy to create and they don’t cost you anything but a few minutes of your time. Why not give them a try?

Being passive in treatment yields poor results. You'll do better by learning how the process works and taking control of your treatment.

Here is a brief guide to help you get more active and involved in the diagnosis and treatment-plan process, read on to learn more about:

1. How clinicians come up with a diagnosis.
2. Why you need to be honest with your clinician.
3. What to do if you don't agree with your diagnosis.
4. Why you should guide the treatment plan (you have to state what you're actually willing/able to do).
5. How to prioritize and how to make a specific plan of action.
   

Diagnosis - Subjective Vs. Objective

Mental health and addiction are generally not objective in the way that most medical conditions are. If you have a broken leg, you could visit ten different doctors, all of whom will almost assuredly come to exactly the same diagnosis, prognosis, and course of treatment. Go see ten different dual diagnosis clinicians and there’s a very good chance you’d see a variety of diagnoses and a variety of treatment options and prognoses.

So there's no single right way.

Traditional dual diagnosis treatment has flaws:

• It tends to place the provider in the role of “expert” and the client into a passive role of recipient.
  
• Amongst “experts” is an ongoing debate as to whether substance abuse/addiction or mental health conditions should be treated first.
  
• In far too many practices, choice of treatment options rarely incorporates meaningful input from those being served.
  

Therefore, the more knowledgeable we are about the processes and our options, the better equipped we are to choose practitioners and approaches that best fit us.

Diagnosis Guides Treatment...So Be Honest!

Mental Health diagnoses are based on a biological/psychological/social (and sometimes spiritual) assessment, which is meant to be an holistic view of a person’s life – where we’re at and how we got here.

Diagnosis is important:

• Diagnosis dictates prognosis (likelihood of improvement) and treatment selection. Unfortunately, a very high percentage of clinicians rush this process. More accurate mental health diagnoses are achieved when we are forthcoming and candid in answering the myriad of questions posed in the assessment process.

So take your time:

• I urge my clients to take time to get comfortable and establish rapport before answering very personal questions. In most cases, a clinician has 30 days to complete this process. Take all the time you need and be aware of how your emotions in the moment may hinder you from being totally honest.

And tell the truth (don't minimize):

• Substance abuse and addiction assessment are based on Chemical Use Assessments and hinge on accurate reporting. Don’t understate your drug & alcohol use. Minimizing and rationalizing are a big part of how we came to be in harm’s way.

Understanding the Results

A completed assessment uses five Axis of treatment to organize multiple conditions. They are:

1. Axis I – Addiction, substance abuse and most mental health conditions
2. Axis II – Personality disorders, pervasive developmental disorders
3. Axis III – Known medical conditions
4. Axis IV – Major life stressors – financial, relational, occupational problems, problems with primary support group
5. Axis V – Global assessment of functioning - A ridiculously subjective numerical scoring of a person’s overall functioning. It runs from 0-100. Yet you’ll almost never hear of a person below 25 and it would be an exceedingly rare person in need of more than very short term treatment if their score is much over 75

What If We Disagree with the Diagnosis?

Don't blindly accept a diagnosis:

• I encourage my clients to seek thorough explanations in layperson language (accept nothing less).
  
• I also urge them to listen for what resonates (sounds true and feels true). In most cases, accurately diagnosing a person with less than six months of abstinence from drugs and alcohol is largely a guessing game.
  
• It’s further problematic when clinicians get bogged down trying to determine which came first - the chicken and the egg scenario of mental health condition or substance abuse.

(Hint: happy, well adjusted people don’t often develop addictions).

• Seek a second opinion. Consult with your primary care physician (especially before taking psychotropic medications).

We can recognize that many of us were self medicating when we used. We can consider whether we were a mess before we ever took the first drink or the first hit. We can also acknowledge that conditions or at least temporary states of depression and anxiety are inevitable for those active in addiction or in early recovery.

It doesn’t mean you’re crazy. It means you’re an addict/alcoholic.

Work for a Treatment Plan You'll Actually Follow

The final piece of the assessment is recommendations for treatment and other services that may be beneficial. In the midst of being overwhelmed and at a low point in our lives; it’s very tempting to simply accept these as a set of directions and follow them accordingly.

I urge my clients to set their own agenda for a very simple reason – what they’re willing to do is vastly more important than what I think would work best. If your clinician is recommending something you know you’re not willing to do at this time, tell them. Anything else is a waste of your time and theirs.

Need help choosing options?

Try the Keep It Simple System (K.I.S.S.). Treatment isn’t really about what we want. It’s about what we need. Start with your physical health and move your way up Maslow’s Hierarchy. If the house is on fire it doesn’t make sense to water the lawn. Prioritize.

I’ve joked for years that I’m going to write a scholarly article “Clinical Applications of Common Sense.” I find it conspicuously lacking amongst a lot of my colleagues. In the absence of a psychotic disorder or otherwise extremely debilitating condition, sobriety should always be the highest priority in treatment. Continued drug and alcohol abuse compromises a person’s ability to retain the gains they might make in treatment. Revisiting the same topics and feelings without the willingness and ability to make changes is like tearing off a scab every week and wondering why it’s not healing.

Prioritize and Make a Specific Plan

If we’re going to move beyond a place of being chronically overwhelmed then we require fractionating and accountability. I often ask my clients, “How many dragons are we going to slay at once?” They’ve identified twenty (overwhelmed) and I want to get down to one (manageability attained through fractionating).

The next piece is developing a highly specific plan for how we get from where they are to where they want to be. Vague notions and ideas do not result in action. Who, what, where, and when do result in action and accountability.

We have every right to support and treatment. We have the right to work with clinicians and other providers who are “client centered.” If the provider is truly invested in empowering others then they practice their profession in such as way as to solicit and respect the identified goals of the client. Being passive as a recipient of services means that we get to experience what someone else thinks we need. We tend not to be invested in what others want for us. Reconceptualizing treatment is as simple as setting our own agenda and choosing what matters most.

Image Copyright: Ally Newbold

The 4 quadrant model provides a framework to help you understand what types of co-occurring disorder treatment you need most.

If you have a co-occurring disorder (a substance use disorder and a mental health disorder) this article will help you understand what types of integrated treatment you need.

OK – the experts recommend integrated treatment for co-occurring disorders, but what does this look like in reality? Where are you supposed to get treated and how are you supposed to pick and choose among all your options... how is this supposed to work?!?

• In severe cases, is it a psychiatric hospital you need or a residential addiction treatment program which specializes in care for those with co-occurring disorders?

• In milder cases, do you need outpatient addiction treatment with supplementary medication or general counseling combined with AA/NA or SMART Recovery in the evenings?

Getting appropriately matched integrated treatment greatly improves your odds of success, but how are you supposed to know what you need when faced with such an overwhelming array of options?

Well, for starters, this isn’t a decision you should make alone. You probably don’t know about all local programs and treatment options and you probably shouldn't build your recovery on the unstable grounds of self diagnosis. Find a professional you trust and get help designing a treatment program that makes sense – and if you can, get a loved-one involved in the discussion too.

But though you shouldn’t make this decision without help, getting educated always makes sense. At minimum it allows for an informed conversation with your healthcare team and at best it saves you from wasting your time on a treatment plan that won't work.

Read on to learn more about:

1. A system called the 4 Quadrant Model that provides a basic framework for matching disorder severity with appropriate treatment.
2. Treatment options for each of the 4 quadrants (for whichever of the 4 squares you fit into).
3. Assessment instruments you can use to assess the severity of your mental disorder and your substance use disorder.
4. An introduction to addiction treatment programs designed for co-occurring disorder clients.
   

The 4 Quadrant Model – an Intro

Professionals use the 4 quadrant model as a diagnostic tool to help determine correct treatment recommendations.

• As the name would indicate, the tool is based on a 4 box model, and every person with a co-occurring disorder will fall into one of the 4 quadrants.
• Once you identify your quadrant you can narrow your focus onto treatment options that make the most sense for you.
  

The 4 Quadrants Are:¹

1. Quadrant 1 – Less severe substance use disorder and less severe mental health disorder
2. Quadrant 2 – More serious mental health disorder and less severe substance use disorder
3. Quadrant 3 – More serious substance use disorder and less severe mental health disorder
4. Quadrant 4 – Severe mental health disorder and severe substance use disorder 

Matching Quadrants to Treatment

Quadrant 1²

People with low-severity substance abuse and low-severity mental illness can be treated:

• Within the primary healthcare system (such as by your physician).
  
• From either intermediate outpatient addiction treatment or intermediate outpatient mental health programs (for example, intensive outpatient programs).

In some cases, people in this quadrant might benefit from some integration of services between mental health and addiction treatment providers.

Quadrant 2

People with serious mental illness and milder substance use disorders are best served within the metal health system.

• You can access the mental health system through outpatient mental health centers (such as clinics) or more intensive residential or inpatient programs. Many mental health providers will also offer some addiction treatment, such as motivational interviewing or skills training. To find mental health services in your area, visit SAMHSA’s Behavioral Health Locator Tool.

Quadrant 3

People with more serious substance use disorders and less serious mental health disorders should receive substance abuse treatment as the primary focus of care.

• The types of treatment facilities capable of providing care for people in this quadrant are often referred to as dual diagnosis capable (DDC) or dual diagnosis enhanced (DDE). See below for more information on these types of specialty programs.

Quadrant 4

Serious mental illness and substance use disorders are typically treated in:

• Psychiatric hospitals
• Hospital emergency rooms
  
• Specialized long-term residential substance treatment programs, such as modified therapeutic communities (sometimes within the criminal justice system).

Evaluate Yourself

So what to do when facing substance use and mental disorders of unknown severities?

Well, again – since you can’t correctly match treatment without an accurate severity diagnosis for each condition, you should get a professional involved in the process. (Although you might wonder how you’d do this, any quality treatment program should insist on a comprehensive assessment before admittance, to ensure an accurate program fit.)

1. But for your own education, here are a couple of assessment instruments that may provide you with a better understanding of the seriousness of your 2 conditions.
2. Once you’ve diagnosed the severity of each independent condition you’ll know which quadrant you fall into – and thus what type of care you likely need.

The Global Assessment of Functioning Scale

One tool that a professional might use to determine the seriousness of your mental illness – and which you can use on yourself or a loved one, to get a basic idea of your situation – is called the Global Assessment of Functioning Scale.³

This scale is intended for adults over the age of 18. It provides you with a score from 0 to 100 that corresponds with the severity of your mental health disorder – the lower the score, the greater the disorder severity.

As a general guide – scores greater than 50 correspond with less severe mental illness (quadrants 1 and 3) and scores of 50 or less correspond with more serious mental illness (quadrants 2 and 4).⁴

• 100 - 91 - You have excellent functioning across a range of everyday activities and no symptoms of any mental disorder. Other people interact with you by choice because of your positive personality. You never allow common problems to grow out of hand.
• 90 - 81 – You have no or very few symptoms of any mental disorder and a good level of functioning across a range of everyday activities. You have normal everyday problems but are generally satisfied with life and socially effective.
• 80 - 71 – You have some symptoms of mental disorder, but these symptoms are impermanent and they occur as a normal response to an environmental or behavioral stressor. Your symptoms cause you very little impairment in your general functioning at work/school and in relationships. An example could be feeling low for a few days after failing an important exam.
• 70 - 61 – You have lasting mild symptoms of a mental disorder but you still function well at school/work and you’re able to maintain relationships.
• 60 - 51 – You have moderate symptoms of a mental disorder or you have moderate difficulties with normal everyday activities and social functioning (for example, you have occasional panic attacks, some trouble keeping friends or you’re frequently in trouble at work or school.)
• 50 - 41 – You have serious symptoms of a mental disorder (for example, major depression, suicidal ideation, etc.) or you have serious problems with everyday social functioning (can’t get or keep a job, no social contacts).
• 40 - 31 – You have serious symptoms and at least some loss of contact with reality or you have major impairment in many areas of normal social functioning (for example, because of your mood disorder you don’t leave the house and you neglect all responsibilities and self care.)
• 30 - 21 – You have a serious loss of contact with reality which influences your behaviors, or you have serious inability to maintain normal communication or behaviors (very inappropriate acts, for example) or you have a complete inability to function in basically all areas.
• 20 - 11 – You are in moderate danger of hurting yourself or others or you sometimes don’t maintain even minimal standards of personal hygiene (use of toilet, for example) or you can no longer communicate at all.
• 10 - 1 – You are in serious and lasting danger of hurting yourself or others. You never maintain minimum standards of personal hygiene or you make serious suicide attempts.

Note – this scale is intended to serve as one diagnostic tool to be used in conjunction with other contextual behavioral and environmental information - and in combination with subjective common sense.

Evaluate Your Substance Use Disorder Severity

As a very general guideline:

1. People with low to moderate substance use disorders (abuse - not addiction, little compulsion, etc.) would qualify for less intense substance disorder treatment as in quadrants 1 and 2.
2. People with substance use disorders defined by addiction, compulsive use and loss of control would qualify for more intense addiction treatment, as in quadrants 3 and 4.

Take this quick self-test to gauge the severity of your dependence.

When making treatment recommendations, professionals generally use the American Society of Addiction Medicine’s (ASAM) Placement Criteria. By considering your situation against the following 6 placement criteria you may gain a sense of whether you need high or low intensity substance use disorder treatment.⁵

1.  Acute Intoxication and Withdrawal

A person needing medical management of withdrawal or intoxication requires more intensive substance abuse treatment than a person already detoxed and clean/sober.

 2. Biomedical Conditions and Complications

You require more intensive treatment if you have acute or chronic physical health conditions that complicate participation. For example, someone weakened after a pancreatitis attack or with poor liver function might require more intensive treatment (residential) than someone in good physical shape (able to travel to outpatient meetings).

3. Emotional, Behavioral or Cognitive Complications

In addition to co-occurring mental health disorders, people with diminished cognitive capacities may require more intensive treatment (cognitive deficits may be a transient side effect of withdrawal or abuse.)

4. Readiness to Change

A person very motivated to change may do well in a less intensive treatment environment, while a person with greater ambivalence about change may require greater structure and intensity to achieve the same outcome.

5. Relapse or Continued Use

If you can’t maintain even short periods of abstinence and acute intoxication interferes with your ability to participate in outpatient treatment, then you likely require residential treatment.

6. Recovery Environment

People lacking a safe and sober living environment typically require more intense treatment than people in supportive environments. 

Quadrant 3 Care - DDC and DDE Programs

Programs designed for people needing co-occurring disorder services are called dual diagnosis capable (DDC) and dual diagnosis enhanced (DDE) programs.¹

1. DDC Programs – These programs are set up to address the interaction between mental disorders and substance use disorders, even when focused primarily on addiction treatment. DDC programs offer treatment content that is adapted to the unique motivation, relapse prevention, recovery planning and treatment integration needs of clients with co-occurring disorders.
2. DDE Programs – Compared to DDC programs, DDE programs offer a higher level of treatment integration and can accept people for primary addiction treatment who have more serious mental health disorder symptoms or functional impairment.

To find DDC and DDE programs, you can use SAMHSA's Substance Abuse Treatment Locator Tool, which allows you to search for programs in a radius around your home. When using the tool, navigate to the advanced search and narrow the field by selecting programs that offer ‘a mix of substance abuse and mental health treatment services'.

Challenges and Special Considerations

Use the quadrant framework with a healthy-dose of common sense – especially when considering how fluid and changeable symptoms can be, even even short periods of time.

• You don’t stay as you are and if you did, treatment wouldn’t be much worth getting. As your mental health symptoms improve or your substance abuse declines, you will need reassessment to ensure that your treatment continues to match your needs.⁶
• In some cases, such as when dealing with substance-induced psychosis, suicide attempts or medication noncompliance, a person that’s initially classified in quadrant 4 could stabilize within hours or days and then no longer benefit from quadrant 4 treatment recommendations.⁴

Image Copyright: SAMHSA

Imbalanced gut bacteria may increase your risk of anxiety, depression, obesity and a host of other diseases. Learn how digestive bacteria can cause anxiety and find out how dietary changes can help you instill or protect an optimal balance of beneficial bacteria.

Use gut bacteria to protect yourself against anxiety, depression, obesity and a host of other mental health issues.

You already know that emotional states have gastrointestinal consequences: Stress causes you stomach pain, you feel butterflies in your stomach before a public speech... - but did you know that gut bacteria imbalances can also damage your mental health?

100 trillion bacteria call your gut home; you're carrying roughly 5 pounds of bacteria, viruses and other eukaryotes right now!¹ These microbes play essential roles in our body. Keep a good balance of beneficial gut bacteria and you protect health and well-being. Let bacteria slide out of balance and you put your physical and mental health at risk.

Read on to learn more about...

• The roles bacteria play in your gut
• Research that supports gut bacteria’s influence on anxiety, depression and weight management
• Diseases and conditions associated with gut bacteria imbalances
• How to promote healthy gut bacteria levels

What Gut Bacteria Do

Your gut (your digestive tract) is essentially a long tube that begins at the back of your mouth and continues to your stomach, small intestines, and to the colon and anus.

• Your gut is the only organ that has its own nervous system (with over 100 million neurons residing within the walls of the organ).
• You start out as a newborn with a sterile gut. By age 2 to 4 you have 100 trillion bacteria in your gut. Everyone has a unique mix of different bacterial populations. This mix is influenced by where you live, what you eat, your genetics, your experiences as an infant and other environmental factors
  
• Gut bacteria play an essential role in the manufacture of neurotransmitters - such as 95% of the brain’s serotonin. (Serotonin is an important messenger in the brain and in the gastrointestinal tract. Significantly, children who lack certain types of gut bacteria in early development will never produce as much serotonin, even in adulthood, as children with more diverse microflora.)²
• Gut bacteria help with the digestion and metabolism of food. They extract vitamins and maintain the gut wall - and once beneficial bacteria colonize the gut, they repel pathogens that would otherwise establish a foothold. They do this by optimizing pH and out-competing ‘invaders’ for nutrients.
• Gut bacteria communicate with dendritic cells of the immune system to quicken the response to harmful germs^{3 4}

We are composed of 30 000 human genes and carry roughly 3 million bacterial genes. Given this, is it any wonder that bacteria have such an influence on so many systems of the body, including cognition and emotional regulation?⁵

Research: Gut Bacteria’s Influence on Anxiety

Transforming Behavior with Bacteria

Using mice, scientists at McMaster University in Ontario demonstrated that altering gut bacterial levels with antibiotics changes behaviors and anxiety levels.⁶

After antibiotics and gut bacterial disruption, mice that were normally cautious became adventurous and less anxiety-prone. Or, in another experiment, the researchers demonstrated that by injecting normally active mice with bacteria from more passive mice, they transformed the active mice into timid creatures.

The researchers conclude that altering gut microflora with antibiotics or diet may cause emotional or behavioral changes; they suggest research on the use of probiotics as treatments for behavioral disorders.

UCLA Yogurt Study

UCLA researchers say eating probiotic yogurt twice daily for a month changes the brain’s response to threatening stimuli and induces structural changes in the cortex – dampening reactivity within areas of the brain that cause emotional spikes in response to bodily sensations.

Compared to subjects who ate no probiotic yogurt, subjects given a month of twice daily probiotic yogurt:

• Showed less neural-emotional response to pictures of threatening faces – particularly in areas of the brain that process and integrate bodily sensations into emotional and cognitive reactions.
• Had increased connections within cognition areas of the prefrontal cortex

So if a twinge in your gut spikes your anxiety, you may want to consider adding a couple of probiotic yogurts a day.⁷

Chronic Fatigue Anxiety Study

Subjects with chronic fatigue syndrome were given either probiotics supplements or a placebo for 2 months. After 2 months, those given the probiotics had significantly reduced anxiety scores as measured by the Beck Anxiety Inventory.⁸

Research: Gut Bacteria’s Influence on Depression

Early-Life Bacterial Deficits Create Life-Long Serotonin Deficits

Gut bacteria play an essential role in the production of serotonin and low serotonin levels are associated with an increased depression risk. In an animal model experiment, Irish researchers found that mice lacking certain gut bacteria during infancy never developed normal serotonin levels, even when they were colonized with essential bacteria later in life. A bacterial deficit in early-life caused an irreversible serotonin deficit through adulthood.⁹

Research: Gut Bacteria’s Role in Weight Management

Not convinced that gut bacteria play an important role in obesity? Then consider this - give a sample of your gut bacteria to scientists at The University of Florida’s Center for Biotechnical Research and they’ll predict your obesity or leanness with 90% accuracy.¹⁰

Danish Obesity Study

In a study of obese and non-obese people in Denmark, obese people were found to have less gut bacterial diversity than healthy-weight people - and over the 9 year study period, people with the least bacterial diversity gained the most weight.¹¹

Bacteria Change Leads to Weight Gain

In an animal model study, mice colonized with bacteria from an obese mouse gained weight more quickly than mice colonized with bacteria from a lean mouse.¹²

How Does Gut Bacteria Change Brain Function?

Researchers don't yet know exactly how gut bacteria influence our moods, but they’re pretty sure that the vagus nerve - a nerve-line which sends information from the gut to the brain - serves as one key pathway of influence.

Vagus Nerve Experiment

1. Mice fed a lactobacillus spiked diet became more adventurous and suffered less from stress. They also became more responsive to the neurochemical GABA (a chemical which is also targeted by medications like Xanax.)
2. However, when the scientists severed the vagus nerve, feeding lactobacillus to mice no longer caused any changes to stress, anxiety or GABA systems.¹³

Gut bacteria may also cause the release of chemical messengers from the gut into the bloodstream, and eventually into the brain.

What Is Gut Dysbiosis?

Dysbiosis - The condition of having an imbalanced microbiome; too much harmful bacteria and not enough beneficial bacteria.¹⁴

An imbalance in the gut impairs beneficial bacteria. Since beneficial bacteria play essential roles in digestion, immune system functioning and even mental health, this can lead to serious health conditions, like

• Obesity and other metabolic disorders
• Immune disorders
• Type 2 diabetes
• Endotoxemia
• Inflammatory bowel disease (IBS)
• Aggravated existing liver disease
• Food allergies
• Diminished mental health
  

How to Protect Healthy Gut Bacteria

100 trillion gut bacteria live and work in an average digestive system. They play important roles and when they get imbalanced we get diseases and mental health problems.

Given this, it makes sense to try to protect our microbiome - to encourage a good balance of beneficial bacteria. Here are a few general tips on maintaining good bacterial health:

• Avoid unnecessary antibiotic use and limit antibiotic use to short courses, whenever possible
• Encourage beneficial bacteria with a diet high in probiotics and prebiotics
• Avoid intestinal parasites and if exposed get treated promptly
• Be cautious with GERD drugs like proton pump inhibitors which drastically reduce stomach pH. This alteration in pH can lead to a dramatic change in gut flora and in some cases, growth of harmful bacteria at the expense of beneficial bacteria more accustomed to normal stomach pH levels.¹⁵
  
• Avoid excessive stress – animal research shows that long periods of stress lead to substantial declines in certain beneficial bacteria.¹⁶
• Breastfeed infant children
• Watch out for excessive hygiene and let small children get a little dirty every now and again – studies show that animals reared in sterile environments don’t develop the same healthy gut microflora as animals raised more naturally.¹⁷
• Make healthy eating choices – minimize consumption of high sugar, high fat and processed foods and maximize consumption of fiber-rich vegetables and fruits (see below for more on how diet influences your microbiome).

Dietary Choices for a Healthy Microbiome

People who consume high fiber, plant-based diets tend to have healthier microflora than people who consume a diet that’s higher in fats and simple carbohydrates (a junk-food diet!)

To encourage a healthy bacterial balance:

• Avoid a high fat diet – a high fat diet leads to the decrease or elimination of Bifidobacteria spp, a bacterium which plays an essential role in the protection of the gut barrier.
• Avoid a high sugar diet – too much refined sugar leads to excess bile production and creates a welcoming environment for the opportunistic pathogens C. difficile and C. perfringens (C. difficile is a super-bug that can cause symptoms ranging from mild diarrhea to life-threatening colitis.)¹⁸
• Eat more complex carbohydrates – Complex carbs encourage the growth of beneficial colonies of paratuberculosis and enterobacteriaceae and increase levels of Bifidobacteria spp
• Consider a high fiber vegetarian diet – high fiber consumption leads to significant fatty acid production (as microbes break-down these fibers.) This lowers pH and decreases pathogenic e-coli bacteria levels.¹⁹
  

Dietary Sources of Probiotics and Prebiotics

If you have gut dysbiosis, restoring a healthy gut microbiome should get you feeling a lot better.

One way to restore gut health is through the consumption of probiotic and prebiotic foods.

These foods are generally very healthy for all people, so with pre and probiotics you have very little to lose and potentially much to gain

Probiotic foods are foods high in beneficial bacteria. Some examples of probiotic foods are:

• Yogurt (buy one that indicates live active culture on the label)
• Kefir – a fermented dairy drink
• Sauerkraut
• Natto
• Miso
• Kimchi
• Fermented pickles

Prebiotic foods are foods high in the soluble fibers that feed beneficial bacteria – the idea is you can sustain a healthy microbiome by feeding it well. Some examples of prebiotic foods are:

• Bananas
• Honey
• Garlic
• Onions
• Leeks
• Whole grains
• Artichokes
• Asparagus
• Chicory

Are Probiotic Supplements Safe?

As an alternative to pro and prebiotics consumed through food, you can also take a daily dose through supplements.

According to The National Center for Complementary and Alternative Medicine (NCCAM) probiotics are generally well-tolerated and cause few side effects. There is little research evidence to support their long-term safety (or harm). People with pre-occurring serious health conditions may be at greater risk of serious side effects.²⁰

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Bi-polar disorder is a mental health condition that affects approximately 1% of the population, and most commonly emerges during adolescence or young adulthood. Bi-polar disorder is characterized by a continual cycling between states of mania, normalcy and depression; and the lows of the associated depression can be so severe that people with bi-polar disorder are almost 20 times more likely to commit suicide.

Additionally, people suffering with bipolar disorder are 3 to 7 times more likely to abuse alcohol or other drugs. People with bi-polar disorders generally abuse alcohol, sleeping pills and stimulants such as cocaine or Meth. Drugs and alcohol are abused to increase the natural high of the mania and as self medication during the depressive episodes. Concurrent use of alcohol or other illicit drugs greatly decreases the effectiveness of the available medications for bi–polar disorder, and can exacerbate the severity of the condition.

Bi-polar disorder can remain untreated for years, as people who abuse drugs or alcohol blame the abused substances for their mood swings; and because bi-polar sufferers so enjoy the high of the manic stage, they often resist treatment of the disorder.

Treatment For Bi-Polar Disorder and Alcohol or Drug Addiction

Because substance abuse both exacerbates the intensity of the symptoms of the disorder, and also reduces the effectiveness of the medications for bi-polar treatment, substance abuse in a bi-polar patient must be accurately diagnosed and treated at the earliest possible opportunity.

The treatment for someone with bi-polar disorder does not differ greatly from standard drug and alcohol rehabilitation, but this treatment must be administered with an awareness of the mental health condition and with appropriate treatment modifications as necessary. The most important first step is to achieve immediate cessation of drug or alcohol abuse, and immediate compliance with prescribed psychiatric medications.

Bi-polar disease can be managed through available psychiatric medications, and when taken as directed, these medications offer very effective symptoms management. When symptoms are controlled through these psychiatric medications, patients will benefit from therapeutic treatment of their substance abuse.

Where to Get Help

There are a number of options available for the treatment of concurrent bi-polar disorder and addiction, and therapeutic options include outpatient substance abuse treatment combined with psychiatric monitoring and prescribed medication, treatment in a rehabilitation center, with an appropriate awareness and modification of treatment for the concurrent disorder; or treatment in a mental health facility, with an appropriate modification to include the treatment of the substance abuse.

The relative severity of the concurrent problems will determine which option is most appropriate. Bi-polar suffers with serious dependencies and controllable symptoms will likely benefit from a rehabilitation center, while those with serious symptoms, and less serious addictions, may require mental health hospitalization.

That treatment occurs at all is of course the most important thing. The longer substance abuse is allowed to compound and exacerbate the symptoms of bi-polar disorder, the more difficult the ultimate treatment will be, and the greater the probability of an unfortunate ending.

Bi-Polar Addictions

The treatment of a bi-polar addiction is complicated but of paramount importance, and family should feel compelled to intervene should they suspect an undiagnosed bi-polar condition, non compliance of prescribed medication regimens, or the abuse of alcohol or drugs with a bi-polar diagnosis.

What Types of Therapy Work?

Individual Therapy

Individual therapy offers the bi-polar patient insight into both their mental health disorder, and how that disorder interacts with their substance abuse to compound the negative symptoms they experience. Therapy will work to educate the bi-polar addict on the consequences of using alcohol or drugs as a form of self medication, and to develop strategies that will empower the bi-polar addict to avoid temptations and triggers to use.

Peer Group Therapy

One of the hallmarks of bi-polar disorder is a reluctance to accept treatment and/or a denial of the existence of the disorder, and as such a peer group session with other bi-polar substance abusers can serve to induce a better self awareness of the condition, and a greater acceptance of the necessary treatments.

Bi-polar substance abuse peer therapy illuminates the behaviors, sensations and emotions common to concurrent addiction and bi-polar disorder; and through peer group sharing, stories and strategies, bi-polar addicts gain strength and awareness from others like themselves, and increase their motivations to live sober, and appropriately medicated.

Cognitive Therapy

Cognitive behavioral therapy is an important part of any addictions treatment, and is especially crucial to the overall success of any treatment for a bi-polar addict. Behavioral teachings will enable the addict to recognize their cues to abuse, and learn strategies that will help them to avoid these triggers; and will also help them to recognize the behaviors that may indicate a worrisome turn in the symptomology of their bi-polar disorder. Effective cognitive training can help to improve psychiatric medication compliance, reduce the temptations of alcohol or drug abuse, and greatly increase the probability of a stable, sober and happy future.

Family Involvement

The probability of continuing sobriety is increased through ongoing therapy and medication compliance. A family support system, educated in both the disorder and the effects of the concurrent addiction, can prove very beneficial, and can help to ensure continuing therapy and compliance with prescribed medications.

Family should be included in the therapeutic process, should receive education on both addictions and bi-polar disorder, and should learn effective strategies that allow them to assist and support a bi-polar sufferer in substance abuse recovery. Bi-polar sufferers are notoriously poor at self diagnosing their ascension into mania, and the signs that indicate a fall into depression; and as such it can be very beneficial for the bi-polar addict to learn to trust and rely on the judgments of friends and family, on when additional therapeutic intervention may be necessary.

Drug, Alcohol and Bi-Polar Education

Through learning more about the effects and triggers of the disorder, and also the effects of addiction and triggers to abuse, bi-polar addicts are empowered to avoid future dependency, and remain compliant on their psychiatric medications.

It's tough to make an appropriate decision about treatment when you can't understand the terminology used by drug treatment facilities!

While searching for a drug or alcohol treatment facility for a person with a dual diagnosis, you will often encounter the terms inpatient (hospitalization) and partial hospitalization (residential treatment). These terms used by drug and alcohol treatment facilities refer to a level of care and staffing, and have nothing to do with leaving the hospital, in either case.

Deciding on appropriate care for a dual diagnosis patient is tough enough, and confusing terminology certainly does not make the process any easier!

Hospitalization (inpatient)

Facilities that offer true hospitalization or true inpatient care will offer medical care around the clock; 24 hour a day nursing care, and 24 hour a day access to doctors when needed.

Medical detox will occur in a hospitalization setting, for safety, and in some cases psychiatric patients will need hospitalization for stabilization of symptoms before proceeding to lesser intensity partial hospitalization care.

Full hospitalization for dual diagnosis patients generally occurs for only a very brief period, a mater of days, and as soon as psychiatric symptoms have stabilized to the point where the patient can participate safely in a traditional drug treatment environment, they will be moved.

Partial Hospitalization (Residential Treatment)

The vast majority of drug and alcohol rehabs are partial hospitalization facilities. Patients reside within the facility 24 hours a day, but medical nursing services will not be offered around the clock. These services are offered in emergency situations.

Dual diagnosis patients need only a partial hospitalization environment, as long as their symptoms are stable, they are not a danger to themselves or to others, and they are lucid enough to participate effectively in the therapies of drug or alcohol treatment.

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Treat the disease, not the symptoms. Dual diagnosis addicts use manipulation as a way to continue to drink or drug, and family can only influence change through tackling the real root of the problem, and by being tough...tough love

Addicts are master manipulators, and dual diagnosis addicts are no different. Manipulation is part and parcel with denial, and is a defense mechanism essential to continuing to use or to drink. All addicts use manipulation to protect their use, they’ll do almost anything to protect their use!

Although dual diagnosis addicts do use manipulation as a strategy to continuing intoxication, the co presence of another disorder makes it much tougher for family to deflect this manipulation, and thus much tougher for family to act in constructive and supportive ways.

Family can exert a great influence towards getting a dual diagnosis patient both off drugs or alcohol, and towards better mental health as well, but they can only exert this positive influence if they retain a clear view of the situation…and this is very tough to do!

Why Tough Love Is the Best Love

No one enjoys seeing a loved one in pain, and our first and very natural impulse is always to do whatever we can reasonably do for them…whatever they ask of us. Problematically, what the dual diagnosis addict will ask of us is often completely at odds with an end to pain, and actually far more likely to create more pain through continuing and increasing drug and alcohol use.

Family will often coddle a dual diagnosis addict, accepting explanations for poor behaviors and life choices that they would never accept from another family member. Family will often do more than simply accept poor behaviors; they will tacitly support these behaviors through continuing financial or other support.

A dual diagnosis addict may offer a million explanations as to why they cannot go to treatment, why they cannot work, why they cannot handle their responsibilities, and the truth is they are very likely struggling to fulfill these tasks. However, when family indulges and accepts poor behaviors, and cleans up any and all messes made by the dual diagnosis addict, they create a situation very unlikely to induce positive change.

Addicts not faced to live their true reality are not addicts very likely to ever get better.

Dual diagnosis addicts coddled and supported by the family and not compelled to take steps to better their addiction and psychiatric issues tend to get increasingly isolated in the home. They do not work, they do not participate in outside activities, and they develop erratic sleeping patterns. They tend to develop lifestyles well fit to getting drunk or high, and not much else. Family that supports such a lifestyle does little to help the dual diagnosis addict get better.

To influence positive change, family must create a situation in which the dual diagnosis must face the consequences of their poor behaviors. Where family support is contingent on the fulfillment of certain agreed upon requirements (attending treatment, for example) and where the manipulations of the addict are minimized.

Treat the Disease, Not the Symptoms

Families, acting out of the best of intentions, too often spend enormous resources and energy fighting the symptoms of the disease, yet never tackling the disease itself.

Families try getting them into new living arrangements, try taking them on vacation, try buying them a car so that they can get around better…none of these things solve the root cause of all other difficulties.

You cannot expect lasting change through a symptoms management approach to the problem. The problem is from within, and altering external factors cannot change what emanates from within a sick person. Things cannot get better until the addiction is tackled as a primary cause of all other difficulties. (Addiction must be tackled however in a manner cognizant of the challenges facing a dual diagnosis patient.)

Tough Love is Tough

Family does not indulge a dual diagnosis addict out of any motivation other than concern and a misguided direction of natural compassion. It feels normal and right to try and “rescue” someone obviously hurting. Family can exert a great influence towards change, but only through tough love, love that is not easy and doesn’t always feel good. You have to be firm, tackle the real cause of the problem, and stop all behaviors that allow the addict to continue to use or drink without facing up to the consequences of these actions.

Psychiatric challenges do cause a predisposition to addiction. It’s not fair, but it’s reality, and you have to move forward with the hand you’ve been dealt. Dual diagnosis patients can and do get better, but they need to face their reality, and they need to become active participants in their recovery.

Tough love isn’t easy, but it works, and it makes things better.

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Drug rehab is a great step forward, yet it's only the beginning of the recovery journey - and the months and years after rehab present some pretty significant challenges to the dual diagnosis addict in recovery. Family can help, but they have to be tough.

Family can do a lot, and after rehab (or other drug treatment) family support can make all the difference. Enabling never helps, and family needs to learn effective supportive strategies, strategies that ensure ownership over the recovery process remains firmly on the shoulders of the dual diagnosis addict. You can help, but you can’t do it for her!

Support, Not Enabling

There is a fine but certain line between family support and enabling behaviors, and when a loved one suffers a dual diagnosis (mental heath challenges with addiction) determining where support ends and enabling begins can seem an impossible task!

Dual diagnosis patients, especially those newly in recovery, do face significant life and sobriety challenges and family social support can be of fundamental importance. Family support behaviors that go beyond assistance and allow the recovering addict to regress in the process of recovery are enabling behaviors, and do nothing to help alleviate the pains of a dual diagnosis addiction.

Structure

In addition to continuing aftercare therapy, what dual diagnosis addicts in recovery need most - are structure and proactive support.

Many addicts (while using) live very unstructured, ruminating and unproductive lives; lives not fit for much beyond lengthy periods of daily intoxication. One of the most significant things family can do for the dual diagnosis addict in recovery is simply to promote a minimum structuring of daily life.

The addict in recovery will no longer be permitted to live free from responsibilities and enjoy financial and other support. They will be required to actively participate in the world as they are able, and they will benefit from this enforcement of structure. We all need things to do and places to be, and none of us excels blowing in the wind. Structure helps, and it helps the dual diagnosis addict enormously.

Contingent Support

No more free lunch!

Tough love can be pretty tough! It's not often what feels right, and it can be awfully tough to follow the brain when the heart screams help.

But for most families, the initial periods of sobriety and recovery follows a lengthy period of active use, and most families will have first-hand experience on the manipulations of the using addict. Addicts by nature manipulate to protect their lifestyle and their drug or alcohol use, and newly in recovery dual diagnosis addicts will very likely continue to try the same manipulations that have long worked well for them.

Family can exert an enormous positive influence simply through discussing contingent support in a calm and reasoned manner with the in recovery addict, and then ensuring that they abide by any pre agreed upon arrangements. 

Family may decide that a dual diagnosis addict in recovery may receive familial financial support as long as they are attending aftercare treatment. This type of arrangement can work well for all involved, and family can influence continued growth through positive and constructive support. But the addict in recovery must live up to their end of the bargain…no excuses – no more manipulations.

The support of an educated and caring family does wonders for a dual diagnosis addict or alcoholic in new recovery, but just as the addict learns of a new way in rehab, the family must also take on new roles if they truly wish to promote lasting change.

Tough love and support are rarely easy, never intuitive, but they are needed - and they can really help.

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Hope is vital. Without hope, family gives up and the dual diagnosis addict lose necessary and beneficial support. Learn why treatment works, and why you have to keep hope alive!

Family watching a loved one succumb to addiction often feels powerless to exert change, and when a psychiatric condition complicates things, family often feels helpless to make things better.

While it's true that a dual diagnosis complicates treatment, treatment still works and works quite well, and there is always hope for a better tomorrow.

It's not going to be easy, recovery from addiction never is, but it's possible, and it's the only acceptable outcome.

Hope

Hope is an intangible. Hope is hard to measure, hard to quantify, and hard to put into practice; yet without a belief that change is possible, family cannot do much of value.

It's natural to get discouraged after your efforts are rebuffed and you cannot seem to influence positive change. The things that work are not always intuitive nor what feel good, but if family does get informed, and does start to act in a concerted manner to exert change, the odds are high that a dual diagnosis addict will also take some steps towards recovery. And this is fantastic, because once walking that path, the road to health is open and wide, and there is a great chance that addiction can be overcome.

Here are three reasons why treatment works for dual diagnosis patients…three reasons why families need to keep hope alive.

1. Enforced sobriety

Many dual diagnosis patients take drugs or alcohol as a way of self medicating the negative symptoms of their psychiatric condition. Intoxication can bring a temporary reprieve from these negative symptoms, but over time, using drugs or alcohol always exacerbates the severity of the mental health challenge.

There is real therapeutic power in a period of enforced sobriety. A few weeks away from drug or alcohol abuse can improve mental health symptoms substantially, even without any of the additional and beneficial therapies of drug treatment. Sobriety reduces the assault on the chemicals of the mind, and allows for a natural healing of psychiatric symptoms.

Sobriety without therapy is probably not going to be enough, but it does make a real difference, and it is a real start to recovery.

2. Medication

Whether or not the dual diagnosis addict has been diagnosed and medicated while still using, the corresponding use of drugs or alcohol greatly reduces the efficacy of these otherwise very effective psychiatric medications.

Addicts using don’t often take medications on schedule and most of these drugs do not work well when taken with other intoxicants.

Getting into treatment, getting sober and receiving appropriate medication can greatly reduce symptoms severity, and can get the dual diagnosis addict feeling better and thinking more clearly.

With a reduction in symptoms severity, the addict in recovery can participate more intensely in the recovery process, can take ownership over the process, and can experience in part what getting sober and getting healthy feels like.

Getting sober and getting medicated can get the addict in recovery feeling so much better that they once again want sobriety as a lifestyle, and have them once again hopeful for a life free from the pains of abuse, and the clouding of mental illness.

3. Inspiration from Others

Recovery at its best doesn’t happen alone.

Dual diagnosis addicts are often trapped within a web of hopelessness and irresponsibility, and without transitioning to a belief in recovery and an ownership over the process, sustained betterment is unlikely.

A dual diagnosis is tough, and it's unfortunate that anyone must endure the trial-but equally-there is no point in wishing away what life brings. Recovery is possible.

Recovering in a group with others also facing similar life challenges can inspire, and the authentic inspiration of witnessing other dual diagnosis addicts get better is not easily mimicked outside of the group recovery environment.

You can’t say it's impossible when you watch someone else that you know suffers as you do get better. You can’t say you can’t do it when others do.

A period in a residential rehab brings many things to the table, and sobriety and professional therapy (medication) help greatly, but unless that recovering addict can be made to believe in the possibility of a life without abuse, and believe that they must ultimately choose to participate in this recovery, all else is irrelevant. Group therapy in rehab brings the hope towards recovery, hope that is so desperately needed.

Recovery and Hope

No one says it's going to be easy and no says it's fair either – but recovery is possible. Keep hope alive, believe that it is possible (it is) and work towards getting the dual diagnosis addict into a program where they will get sober, get medicated; and hopefully, get inspired.

Family can do a lot, and they can take steps to get a loved one into appropriate treatment, but at the end of the day recovery happens from within, and without belief, determination and inspiration, recovery can’t hold.

Help them find the inspiration they need. Help them get into a group recovery environment.

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Are you self-medicating to cope with stress, anxiety or depression? If abstinence is impossible right now, consider a harm reduction approach to limit the consequences of your self-medication choices.

A lot of the people I treat for depression, anxiety, and stress management tell me that they’re becoming concerned about their use of “drugs, alcohol, pot, and cigarettes.” All of these are drugs and yet they’re distinct categorically in the mind of the user. They represent very different threats to the individual. It’s telling that the order in which they’re presented is consistently the order in which they do the most amount of damage in the least amount of time.

Assessing the Situation

When the subject of self-medication comes up, rather than give an opinion on whether someone may be developing a pattern of abuse or addiction; I encourage folks to do some self screening:

• Do you tend to take things to extremes/have an addictive personality?
• Are you depending on a substance to cope with stress and/or negative emotions?
• Do you tend to make high risk choices while under the influence?
• Do you have a family history of alcoholism or addiction?

The next issue to consider is willingness. For those who are unwilling to explore life without substances, I advocate minimizing potential harm. In simple terms, what are we willing to do to reduce risk?

Understanding Harm Reduction

Harm reduction can be conceptualized as removing vices in the order in which they make life most unmanageable.

Self medicating is based in the belief/experience that dealing with life without substances and established forms of coping (no matter how unhealthy) is either undesirable or impossible.

The intersections of harm reduction and self medicating have not been meaningfully explored as combined approaches.

Self-Medication - Addiction and Other Risks

We’re still ignoring the progression of self medication, experimentation, and substances that carry high risks when abused:

“Soda pop and Ritalin…
alcohol and cigarettes
and mary jane to keep me insane,
doing someone else’s cocaine.” 

- Green Day “Jesus of Suburbia”

Taking Stock of What We Use & Why

If we want to lower our risks, we must recognize that morality and legalities do not belong in the criteria of what’s safe (body and mind) and what isn’t. Alcohol is completely legal for those over 21 and it not only kills people every day, it’s also amongst our most abused and addictive substance.

If we’re going to make changes to our drug use, we need to stop using categorical approaches like “meds”, “drugs”, “drinking” or “smoking.” These distinctions are arbitrary and make it far easier to rationalize why it’s okay to continue using them. Look at each of the substances as what they are – chemically mood altering substances.

Be brutally honest:

Pros:

• What’s the overall effect of the drug?
• What do I enjoy most about using it?
• What do I gain from the use?

Cons/Risks:

• Is the substance addictive?
• What are the possible drug interactions and side effects?
• How is impulsivity, decision making and regulation of emotion and behavior affected?
• Does the drug have the potential to kill (overdose, poisoning)

Self-Medicating without Substances

Instead of simply considering what to eliminate or reduce (which leads to a feeling of denying ourselves) we can also consider what to add. Seeking outlets for stress and negative emotion can be combined with activities and pursuits we enjoy. If we want a safe chemical to use; we’re free to try adrenaline. Skydiving is comparable to stimulant use at about the same cost and with far fewer (statistical) risks.

Choosing the Lesser of Evils

When we are completely honest with ourselves, we know that using any mood altering substance involves ingesting toxins and compromising our health. Measuring the pros and cons gives us a clear view of what we’re seeking and how it can be attained with the least amount of harm. In the grand scheme of things, nicotine, caffeine, and marijuana are as close as we can come to safety without abstinence.

Marijuana?

I recognize that for some folks, abstinence from Marijuana is not a choice that they’re willing to make. In these cases, while I don’t recommend using cannabis, I see that it is far less dangerous than using alcohol or other drugs.

The real challenge in using marijuana is that once we’ve medicated or used recreationally, the temptation becomes stronger for some to then ingest another substance to heighten the experience. However, this dynamic is far more common with alcohol due to the impact on our inhibitions. The best approach is to make these decisions before using pot and resisting any temptations that may arise afterwards.

Building a Satisfying Life

The greatest opportunity is to invest in not only the emotional health we want, but in our lives holistically. We all know that drugs simply offer instant gratification. The challenge is to consider what would be far more gratifying in the long term. To work toward these ends is the most important piece of achieving emotional maturity and ultimately toward having the life we most want.

When they are a danger to themselves or to others, can you have them committed? Will the state do what you cannot, and force someone in need of treatment to get help?

It seems obvious sometimes, obvious to everyone but the addict that they are placing their life in danger through their abuse, neglecting their basic needs for food and shelter and badly in need of help.

Sometimes, despite our most determined efforts, we just can’t get them to see reason and can’t get them to concede to a need for treatment. Surely when things get as bad as this we can have them temporarily committed for their own safety and wellbeing?

Unfortunately, the State is very unwilling to intervene except in real emergencies, unwilling for a couple of basic reasons.

Why the State Won't Often Intervene...

Civil Rights

Firstly and historically, it used to be quite easy to have a relative committed  for mental health or substance abuse needs, and in retrospect, civil rights advocates argue that it was far too easy to have someone committed against their will and consent, and for an indefinite length of time as well.

In response to many real abuses of individual rights on cases of questionable merit, the state in the second half of the last century moved progressively away from easy familial commitment of people in need of mental health or substance abuse treatment. The state would intervene only when there was a clear and imminent danger to self or others, and the standard of proof required to meet these criteria was quite high.

In retrospect, and in the guise of civil liberty, the state moved too far away from involuntary commitments and a great many people in real need of temporary psychiatric or substance abuse care were not compelled to get it, and a great many tragedies ensued as a direct result.

Limited Resources

The second fundamental problem state agencies face when dealing with requests for involuntary treatment is a real lack of resources to treat all people in society in need of mental health and substance abuse care, within their budgetary and personnel constraints. Essentially, unless these agencies are given greater funding they cannot meet the treatment needs of all those people who would benefit from involuntary care.

The regulations do vary by state though, and to get more information about the requirements for involuntary temporary commitment in your area you should visit or call the state court mental health department to learn more. It is worth looking into, and in some cases you may find that the state will do what you cannot, and compel needed treatment on an otherwise unwilling participant.

Imminent Danger Tough to Prove

In recent years, many states have moved back slightly towards making it easier for people in real danger to be treated without their consent, but the requirements for involuntary commitment remain very high, and most addicts, even those who are most certainly harming themselves as a consequence of their abuse, will not meet the stringent guidelines for involuntary commitment.

The regulations vary by state, but in general, to be involuntarily committed a person needs to present with an imminent (and provable based on recent actions) danger to themselves or others, or through their neglect of basic necessities (that cannot or are not being met by family) be placing themselves in immediate and direct harms way.

It can be very tough to prove that an addict or alcoholic is placing themselves imminent danger, chronic and long term danger is easy, but imminent danger is tough, and as a result few people with substance abuse problems will meet the minimum standards for involuntary commitment.

Pragmatic and in-depth approaches are what it takes to overcome panic attacks.

To the uninitiated, panic attacks look like inconsolable hyperventilation. To the person experiencing one, it feels like a heart attack.

Physical pain, extremely rapid heartbeat, a sense of imminent dread, the feeling of having a huge weight on one’s chest and numbness in the limbs are common symptoms. Attacks tend to last 10-15 minutes but as anyone who’s had one will tell you; it feels like an eternity.

A person who experiences a panic attack will inevitably develop fear of when the next episode will strike.

Medication, Coping and Internal Conflict Resolution

Medication used on an as needed basis is commonly offered to those who experience panic attacks. Ativan, Xanax and Klonpin are heavily prescribed and often without warning for their addictive qualities or concern for the danger of combining them with even small amounts of alcohol. Taking these meds in the midst of a panic attack is akin to taking antacids for heartburn – it’s reactionary and does nothing to prevent the next occurrence.

Panic attacks are generally the culmination of repressed fear and anxiety. Overcoming them requires not only healthier coping, but also resolution of internal conflicts and locating the origins of specific fears. This is no small undertaking. Most folks who come into treatment have experienced numerous episodes and their willingness to go to these lengths is born of desperation.

Avoiding Perpetuates the Problem

Those who experience panic attacks tend to avoid people, places, and things associated with past attacks. I worked with a man years ago who only came into treatment because he ran out of grocery stores within a 60 mile radius of his home. Each time he had an attack in public, he simply wouldn’t return to that location. Avoidance resolves nothing. It simply provides a false sense of security in which we falsely view the specific experience as causal.

Agoraphobia was the catalyst for his panic attacks. Feeling exposed and vulnerable in public places spiked his anxiety to unmanageable levels. Living in a rural area made leaving home a necessity and so ultimately his fears were not avoidable at all.

Perspective Is Vital

Old adages ring true, “It’s all in how you look at it.” In public places, my client was “white knuckling it.” He was simply forcing himself to get through what he feared by maintaining tunnel vision and moving through it as quickly as possible. What he wasn’t noticing was that for the most part, he wasn’t exposed at all. No one was staring or even taking an interest in him. They were attending to their own needs.

The difficulty was that he was viewing the world through the eyes of a child. My client’s trauma history occurred primarily around age eight. He found that when he was triggered, he no longer felt like a competent adult, but rather like a very small and frightened boy

Learning Effective Coping Strategies

You can manage panic attacks by learning coping strategies, such as:

1. Mindfulness

By implementing basic grounding strategies (using our five senses to stay in the here and now) he was able to manage his emotions as an adult. When he feels like an adult, he knows that he has the ability to protect himself and that he can leave any situation if it becomes unmanageable. He is able to consider problems and process information rationally and effectively.

2. Managing the Physiological Response

Like all people who live with anxiety, my client wanted to feel like he was in control. I urged him to notice the physical manifestations of his fears and to see this as the foundation of self control. By slowing his breathing, releasing physical tension, and walking at a relaxed pace, he was able to feel far more comfortable and calm. Maintaining awareness of the stress in his body made managing his thoughts and emotions vastly more manageable.

3. Managing Negative Self Talk

He learned that managing his self talk was something that made everything easier. When he was overwhelmed, his subconscious mind ran his self talk and he would revert to catastrophizing (making things seem worse than they are). By consciously choosing to talk to himself (in his mind in public and out loud when alone) he was able to talk himself through things the way he would help a friend who was feeling anxious.

Get on the Same Page with Yourself

Try to find the root causes of your anxiety.

My client learned that his fear of having conflict with others had everything to do with being conflicted internally. He referred to “keeping things on the back burner.” These were issues he’d not been able to resolve and in talking about them with me, he realized that each time he placed something on the back burner; he wouldn’t return to it until it boiled over. In this way, he was only addressing things when he felt compelled and was overwhelmed while trying to do so.

Having a manageable life requires dealing with things as they happen. By pushing things to the back of his mind, he was giving himself things to feel anxious about later. Coping with the feelings he had in the moment ensured that he would not develop further resentments and it allowed him to work through old issues one at a time by choice instead of necessity.

He Found Success - You Can Too

According to the postcards I receive, my client has not experienced a panic attack for years now. Clients who present with severe and persistent anxiety are sometimes given poor prognoses and the focus of treatment is geared toward minimizing rather than overcoming. Anxiety disorders are not genetic and can be overcome given holistic treatment.

Image Copyright: Litherland

Psychosis: it affects 3%, but if you spot and treat it in the pre-illness phase you can stop the symptoms before they even get started. Learn the warning signs of the prodromal phase.

If you act quickly enough, you can sometimes stop psychosis before it even really grabs a toehold.

First episodes of psychotic mental illnesses, like bipolar disorder, major depression and schizophrenia often occur during adolescence or early adulthood.¹

When people initiate psychosis treatment before full onset, in the pre-illness or prodromal phase, the prognosis is much better. In some cases, early intervention can stop the progression of psychosis before it gets to the acute or full symptomatic phase.

Unfortunately, loved ones often misinterpret the early warning signs of psychosis as typical emotional and behavioral changes of adolescence and early adulthood and so miss a valuable opportunity to really help.

Read on to learn how to identify psychosis in the prodromal stage and to learn why early intervention is so important.

What Is Psychosis?

• Psychosis is a disruption in brain function that results in a loss of contact with reality.

• Psychosis can occur as a syndrome within mental illnesses such as schizophrenia, schizoaffective disorder, delusional disorder, brief psychotic disorder, bipolar disorder and major depression. Drugs and certain physical illnesses can also cause psychosis.

• The primary symptoms of psychosis are delusions, hallucinations and disorganized thoughts, speech or behaviors²

The Importance of Early Intervention and Treatment for Psychotic Mental Illness

• At some point in life, about three people in a hundred are going to experience a disorienting and scary first episode of psychosis.
• Unfortunately, few people initiate treatment soon enough – at the point where treatment can do the most preventative good.

Psychosis always requires professional treatment so there is no point in waiting to see if things get better on their own. Without treatment symptoms will likely worsen, and the earlier you initiate treatment the better the ultimate prognosis – in fact, in some cases, early intervention not only reduces the severity of a psychotic episode it stops symptoms entirely so that full psychosis never occurs. ³

Early psychosis intervention can help a person avoid or minimize many of the consequences of untreated psychosis, such as:

• An increased risk of depression and anxiety – psychotic symptoms can cause a great deal of worry, a loss of social support systems, increased drug and alcohol abuse, a loss of functioning and other behaviors that up a person’s risk for secondary mental illnesses
• A loss of self confidence and self esteem
• An increased risk to develop a substance abuse problem (from self-medication with drugs or alcohol)
• An increased risk of self harm and suicide
• Decreased ability to function on the job or at school
• Disrupted social relationships ⁴
  

How to Spot Psychosis in the Prodromal Stage

Most people will go through a prodromal stage prior to a first onset of psychosis. This prodromal stage can vary in length but typically lasts for several months. During the prodromal stage, a person will start to experience subtle and gradually worsening symptoms.

If you initiate treatment in the prodromal stage you can stop things before they reach the acute psychosis phase. Without intervention, a person in the prodromal phase will eventually progress to acute psychosis and experience symptoms that are severe enough to disrupt the ability to function on a day to day basis.

The trick is in distinguishing the signs of early psychosis from the normal developmental changes of late adolescence and early adulthood.

Here’s what to look for:

1. Feeling Off or Wrong in Some Way

In the prodromal phase people often start feeling as if something there is something wrong with the way their brain is working. They may:

• Start having trouble doing school work or on the job
• Start feeling unusually sensitive to sounds, smells, light and touch (not like being touched by others)
• Start feeling like they have special powers or abilities

2. Feeling Muddled or Confused

• Having trouble paying attention or thinking clearly
• Forgetting things or getting lost easily
• Having trouble reading longer sentences
• Having trouble understanding what others are saying
• Getting mixed up when speaking or writing

3. Social Withdrawal and a Reduction in Self Care

• Suddenly caring less about your appearance/personal hygiene
• Withdrawing from friends and family (spending a lot of time on your own in your room, for example)

4. Behavioral Changes

• Sleeping or eating a lot less or more than normal
• Feeling very tired all the time
• Not interested in activities or hobbies you used to find enjoyable

5. Fear and Anxiety

• General fear and anxiety without apparent cause
• Feelings of suspicion and paranoia – worrying that others are thinking badly about you or want to harm you in some way
• Feeling fearful around people - maintaining vigilance

6. Hallucinations

• Feeling like someone else is planting ideas in your head
• Seeing or hearing things that aren’t real
• Feeling like your brain is ‘tricking’ you in some way

7. Emotional Changes

• Feeling depressed
• Experiencing extreme mood swings⁵

After You Notice the Warning Signs… Then What?

Whether for yourself or for a loved one, once you spot warning signs of a problem the next step is to make an appointment for a mental health assessment from a doctor or mental health professional experienced in early psychosis identification.

Treatment for early psychosis typically consists of medication and counseling, and since the earlier you start the better the outcome, it’s important to take action as quickly as you can.

Image Copyright: Indrani Soemardjan

Create wellness sheets and have a reminder of what you need to do every day, and once in a while, to keep yourself feeling good and to prevent worsening psychiatric or emotional symptoms.

You know that certain behaviors keep you feeling good and that certain activities and habits lead you to places you'd rather avoid.

But you're only human(!) and when life gets busy or stressful, when symptoms flare up or even when you just start feeling really great for a while it's all too easy to forget those habits and behaviors that maintain wellness.

You already know what works - the trick is making sure you incorporate these positive habits into your daily life - that's what's hard, and that's where wellness sheets can make a big difference.

These activity plans were developed by other people with psychiatric or emotional symptoms and they are proven to help you maintain better mental health.

They don't cost you anything but a few minutes of your time and they put you in control of the maintenance of your own well-being.

Writing Out Wellness Sheets

Wellness sheets remind you, on a daily basis, of what you must do every day and what you might want/need to do some days, to maintain wellness and to prevent the onset of unwanted emotional or psychiatric symptoms.

There are 4 steps to developing your wellness sheets:

1. Brainstorm activities that you know or think make you feel good
2. Write out descriptive words that describe how you act and feel when you are feeling good
3. Make a list of a few simple activities that must be done on a daily basis to maintain good mental health
4. Make a list of activities that might need doing on a daily basis to maintain good mental health.

Brainstorm Activities That Help Maintain Wellness and Prevent Worsening Emotional or Psychiatric Symptoms

To get the ball rolling, take 10 or 15 minutes to fill a paper with activities that you know, or think, help you feel good. Don't be too selective at this stage as you're just providing yourself with inspiration for the steps to come. Some examples might be:

• Walking the dog
• Making sure to eat breakfast
• Taking some time to call a friend each day
• Limiting the time you spend watching TV
• Getting your hair done
• Tidying up your home environment
• Getting your homework finished up early

Write Out Words That Describe How You Act and Feel When You're Feeling Good

As part of a daily practice of incorporating wellness activities into your daily lifestyle you need to get into a habit of monitoring your emotional states so you know when you need to pay extra attention to making some time for yourself.

You can help yourself in this practice by writing out a list of  words that describe how you act/feel when you're at you're best and by comparing your mood and behaviors daily against your optimal self.

Some examples of words that you might use to describe yourself when you're at your best are:

• Cheerful
• Energetic
• Motivated
• Talkative
• Interested in the lives of people around me
• Relaxed
• Mindful

Make it individualized and true - there aren't any right or wrong answers here, and then compare how you're feeling each day against how you feel when you're at your best. When there's great divergence, you know you need to take some extra time to focus on wellness activities.

Make a List of Things You Must Do Each Day to Maintain Wellness

The experts say that when you find yourself feeling worse you can often trace the start of a downward spiral back to not taking adequate care of your emotional or physical health - to forgetting to do something that must be done to maintain good health on a daily basis.

To help avoid this, make a very short list of essential activities - things you must do each day to keep yourself feeling good (don't make your list too long or complicated or you'll never be able to complete all list items each day...this is just the daily essentials here.)

For example, every day I must:

• Talk to a friend or a family member each day on the phone or in person
• Get out of bed before 9 am
• Eat 3 meals
• Take a shower soon after waking
• Leave the house for some outside time for at least 30 minutes per day
• Take medication
• Do at least 20 minutes of meditation or relaxation exercises
• Spend at least 20 minutes doing something fun

Reminders -  Make a List of Things You Might Need to Do Each Day to Maintain Wellness

Some wellness promoting activities are done only occasionally, like visiting your doctor or therapist, and others, like doing laundry, need doing regularly, but not daily.

Getting behind on chores and obligations leads to increased stress and aggravation and forgetting important occasional activities can reduce quality of life.

For your daily reminder sheet make a list of chores, activities and obligations that you need to keep on top of to maintain wellness.

For Example:

Today, Do I Need To?

• Make or attend a doctor or dentist’s appointment?
• Do laundry or clean my living space?
• Complete a work or school task?
• Go to a support group meeting?
• Spend time with a loved one?
• Buy food for the house?
• Go to an exercise or yoga class?

Daily Attention Makes a Big Difference

Remember to consult your daily wellness activities and reminders lists every day and remember also to edit your lists whenever appropriate, adding activities that help and erasing activities that no longer provide you with much of a boost.

By thinking hard about what you need to do each day to stay happy and healthy and by structuring these activities into a daily routine you can do a lot, by yourself, to maintain wellness and to prevent worsening emotional or psychiatric symptoms.¹

Image Copyright: Mr. Pessimist

People with co-occurring disorders need treatment which integrates substance abuse and mental health therapies at the same time. Read on to learn more about 8 elements of effective co-occurring disorder treatment programs.

So you or someone you love has a mental illness and drinks or uses drugs to excess. You would be right in thinking that a co-occurring disorder complicates treatment, but you might be surprised at just how commonly addiction and mental illness co-exist and you’ll be pleasantly surprised to learn how well addiction treatment can work – even for those with co-occurring disorders.

People with co-occurring disorders will benefit greatly from addiction treatment, as long as treatment integrates substance abuse and mental health therapies at the same time.

1. Untreated addiction will always lead to drug or alcohol abuse which will inevitably derail mental illness remission.
2. Untreated mental illness will invariably lead to symptoms which make substance use relapse very likely
   

So when searching for co-occurring disorder addiction treatment, finding an integrated treatment program is essential. But what does an effective integrated addiction treatment program look like and how does it differ from conventional treatment?

According to the experts at The National Alliance for Mental Illness (NAMI), here are some elements of effective integrated treatment programs.

Elements of Effective Integrated Addiction Treatment Programs for People with Co-occurring Disorders

Effective Programs Work to Build Trust between Client and Caregiver

Effective treatment occurs in stages and the building of trust between the client and treatment staff is of utmost importance. Once clients trust caregivers they are more likely to become actively involved in their own recovery program.

Outreach Programs Improve Retention and Overall Success

Integrated treatment tends to take longer and it needs to be more comprehensive – and one aspect of this comprehensiveness is taking treatment beyond a main central facility and extending services into a client’s home environment – to see what is really going on and to provide the services that are necessary ay any given time.

Home visits and other outreach services also serve to strengthen the therapeutic bond between caregiver and client. Programs which use outreach interventions to engage with clients have much better retention rates than programs which are confined to a central location. Outreach might involve home visits to the client’s residence and/or other out-of-building meetings.

Effective Programs Often Incorporate Motivational Interviewing

Clients can often enter into treatment lacking confidence in their ability to change and may be battling some ambivalence about treatment and abstinence. Motivational interviewing is an evidence based intervention that helps people overcome ambivalence to change, take more ownership over treatment decisions and become more actively involved and committed to meaningful change.

Effective Treatment Programs Offer Counseling

Whether individual, group or family based, all effective treatment programs for those with co-occurring disorders offer at least some counseling. Counseling teaches coping, behavioral and cognitive skills and is an essential element of dual diagnosis treatment.

Effective Programs Help Clients Build Positive Social Relationships

Negative peer relationships (drug using friends or drinking buddies, for example) can damage recovery efforts while positive and supportive social relationships reduce the odds of relapse. Effective programs help clients identify and end dangerous social relationships and help clients develop the skills needed to build new or strengthen existing healthy relationships.

Effective Treatment Is Extended and Open Ended

Dual diagnosis treatment can take months or even years. Protracted treatment allows for a natural rate of progress and protects greatly against early relapse. Every person is different and every person’s treatment schedule will differ. Although 28 days of treatment to a ‘cure’ may sound attractive it is not likely realistic or desirable.

Effective Treatment Is Comprehensive

When mental illness intertwines with substance abuse, treatment cannot focus solely on internal changes – it must help the client make changes and progress in all areas of life. To do this, effective treatment programs provide intervention and support in areas such as social relationships, living arrangements, employment skills, handling leisure time and dealing with stress and anger.

Effective Treatment is Culturally Aware

Caregivers must be able to understand, relate to and communicate effectively with the client for any chance at real success. It is important that people receive integrated treatment within a program that is culturally sensitive. Cultural sensitivity is of paramount importance to many people from certain groups, such as women with small children, teens, homeless people, African Americans or Hispanics and others. ¹

Image Copyright: Giampalo Macorig