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Addiction: Why Does Relapse Happen, & How Do You Prevent It? (Part 2) · RECOVERable: Mental Health and Addiction Experts Answer Your Questions

• 0:13
  SPEAKER_02: Addictive disorder doesn't only happen at a certain time in our lives.
• 0:17
  SPEAKER_02: It's one day at a time, one decision at a time.
• 0:20
  SPEAKER_00: Justly certified psychiatrist, addiction medicine physician, and certified physician executive.
• 0:26
  SPEAKER_02: And it really is an iterative, dynamic process.
• 0:29
  SPEAKER_02: You never really know which time will be the time that really works.
• 0:34
  SPEAKER_01: So if somebody's saying, you know what, I haven't had a drink in blank years.
• 0:37
  SPEAKER_01: I'm just gonna have some wine with dinner, that's a slippery slope.
• 0:45
  SPEAKER_01: We are returning with Dr.
• 0:47
  SPEAKER_01: Jocelyne Shutwall to continue this conversation about addiction, what it is and what it's not, and what we need to know so that we can deal with our own if we have it, and with people in our lives who we're trying to support.
• 0:59
  SPEAKER_02: Happy to be back continuing this conversation with you.
• 1:02
  SPEAKER_02: Thank you.
• 1:03
  SPEAKER_01: Yeah.
• 1:04
  SPEAKER_01: So when you defined addiction, you used the word relapsing, which makes me wonder is relapse to be or return to use to be expected, or is it that it might happen, it could happen, it sometimes happens.
• 1:15
  SPEAKER_01: Where does relapse play in addiction and recovery?
• 1:19
  SPEAKER_02: It's more likely than not that a person during the process of healing from addiction will have a relapse event.
• 1:27
  SPEAKER_02: And relapse really is data.
• 1:29
  SPEAKER_02: It tells us what are the things that made you go back to using that substance or that behavior to cope.
• 1:37
  SPEAKER_02: It tells us how stress shows up for you.
• 1:41
  SPEAKER_02: So a really good relapse prevention plan that somebody might develop with their clinician will often include all those data points.
• 1:51
  SPEAKER_02: And sometimes it is that on the path of healing, you discover what your triggers were.
• 1:57
  SPEAKER_02: Cause in the beginning, you may think these are three things that trigger me to use or cause me stress and make me go back to wanting to use.
• 2:05
  SPEAKER_02: But that in a relapse situation, you may learn, ah, okay, there's this fourth one too, right?
• 2:10
  SPEAKER_02: And what you can start to do as you're on this healing journey and gathering this data is that you become even better at assessing what could cause you to relapse and hopefully be able to do some preventative care or put in some structures in your life that keep you from relapsing.
• 2:30
  SPEAKER_02: So we really can use relapse as information on continuing our healing journey.
• 2:36
  SPEAKER_02: It becomes very important to share this with individuals who are on that healing path as well as their families so that we can take the shame out of relapse.
• 2:46
  SPEAKER_02: Because it's also very common to feel like relapse is a failure.
• 2:50
  SPEAKER_02: Yes.
• 2:50
  SPEAKER_02: Which it is not.
• 2:52
  SPEAKER_01: Both sides, right?
• 2:52
  SPEAKER_01: The person who relapsed and the people and the family members.
• 2:56
  SPEAKER_02: Yeah.
• 2:57
  SPEAKER_02: That everybody can say, oh gosh, well, you failed at that too.
• 3:00
  SPEAKER_02: And really, we all know from being like full human beings doing our work and living our lives, failure can be a great lesson.
• 3:10
  SPEAKER_02: So even if you want to use the term failure, it's really you're failing forward.
• 3:15
  SPEAKER_02: You learn something new in that, and then add that to your relapse prevention plan and your recovery plan and really learn from it.
• 3:23
  SPEAKER_02: Often I'll tell my patients like if you know something stressful is coming up, like for some people, this time of the year, the holidays are a stressful time.
• 3:31
  SPEAKER_02: And so you know you're going to be dealing with a situation which may be fraught with a desire to use, then you might want to create some little breaks in your day or have somebody who is a good source of support for you check in with you on an hourly basis if you're in the middle of a stressful family dinner that you haven't seen your family for a few months and you're going to be going, and this is the first time you've been in recovery.
• 3:57
  SPEAKER_02: So you know there's going to be little remarks or some other conversations that might be challenging.
• 4:03
  SPEAKER_02: And you can put some of those protective components in place to keep you from having another relapse.
• 4:10
  SPEAKER_02: But when you do and if you do, really using that as a data point is the most helpful way to look at it.
• 4:19
  SPEAKER_01: I love how much it reduces the shame.
• 4:21
  SPEAKER_01: From that discussion on what relapse is, help me understand.
• 4:23
  SPEAKER_01: Because I think it's difficult for people when someone goes to treatment, when someone goes and it's like, then they return to use and they go and they return to use and they go and they return to use.
• 4:33
  SPEAKER_01: And you think, like, what is going on here?
• 4:35
  SPEAKER_01: You've been in treatment seven times, but the eighth time they might not.
• 4:40
  SPEAKER_01: And that's hard to understand.
• 4:42
  SPEAKER_01: Like, what changes?
• 4:43
  SPEAKER_01: It can even be the same place.
• 4:44
  SPEAKER_01: So the program probably didn't.
• 4:46
  SPEAKER_01: Did the person?
• 4:47
  SPEAKER_01: Is it how do you explain that whole eventually something can still happen, even if you have failed multiple times prior?
• 4:54
  SPEAKER_02: Hope makes the world go around.
• 4:57
  SPEAKER_02: And we are all evolving human beings.
• 4:59
  SPEAKER_02: We're all dynamic.
• 5:01
  SPEAKER_02: Life is dynamic.
• 5:02
  SPEAKER_02: I even tell my clinicians today we are helping people.
• 5:06
  SPEAKER_02: We're helping them achieve recovery from trauma, from mood disorders, from addiction.
• 5:10
  SPEAKER_02: However, if we don't attend to ourselves continuously, constantly in a dynamic way, we could be at the same place.
• 5:19
  SPEAKER_02: So nobody is immune.
• 5:21
  SPEAKER_02: A substance use disorder or an addictive disorder doesn't only happen at a certain time in our lives.
• 5:27
  SPEAKER_02: And so similarly, for somebody who's currently in the throes of a substance use disorder, you don't know what is the piece that will finally either click and stay in place.
• 5:39
  SPEAKER_02: It may be the way the treatment was approached this time.
• 5:43
  SPEAKER_02: It may be the person, the place they're at today in their life as they're approaching treatment.
• 5:48
  SPEAKER_02: And it really is an iterative, dynamic process.
• 5:51
  SPEAKER_02: So each time you're engaging in the act of achieving recovery, attempting to achieve recovery, hopefully they're learning something new, setting a more solid basis.
• 6:05
  SPEAKER_02: And at least in our, you know, clinical recovery community, we always say that you never really know which time will be the time that really works.
• 6:16
  SPEAKER_02: And our job is to provide evidence-based care, a supportive environment, and continue to build up the person towards healing.
• 6:27
  SPEAKER_02: And so whether in the beginning it's that harm reduction component of just making things less harmful and then gradually moving towards full sobriety, it's a journey and the journey never ends.
• 6:40
  SPEAKER_02: And even if today a person says, you know, I've been, I've been sober and in recovery for 10 years, they're still at risk of relapse.
• 6:49
  SPEAKER_02: So the risk never goes away.
• 6:51
  SPEAKER_02: For some people, this may sound very stressful or hopeless.
• 6:55
  SPEAKER_02: And in my mind, it's a very hopeful stance.
• 6:58
  SPEAKER_02: As much as you can grow and change at any point in your life, the more intentionality you bring to your life, the more likely it is that you'll continue to plot forward in a direction you want.
• 7:11
  SPEAKER_02: And so similarly with the recovery, you know, as long as you keep on showing back up to practice, to engage in positive healing behaviors, you have the hope to remain in recovery.
• 7:23
  SPEAKER_02: And even if you relapse, you can do it again because you've done it six other times.
• 7:29
  SPEAKER_02: Right.
• 7:29
  SPEAKER_02: So if you did relapse, that means you were also able to achieve recovery after that.
• 7:35
  SPEAKER_02: So each time, some people may practice yoga.
• 7:38
  SPEAKER_02: And in yoga, there's very much the philosophy of you have to just keep on coming back to the mat.
• 7:42
  SPEAKER_02: So it could be that I practiced yoga for 60 days and then I didn't for a week because work got really busy.
• 7:49
  SPEAKER_02: The whole mindful aspect of yoga is that you just keep on returning back to the mat.
• 7:55
  SPEAKER_02: And so similarly in this case, just keep on returning back to healing and recovery, keeping that front and center.
• 8:03
  SPEAKER_02: So if we relapse, then again, family members, clinicians, the person should know that they just have to have one day sober.
• 8:11
  SPEAKER_02: So even if you had a hundred and then you relapse, instead of saying, oh gosh, I lost those hundred days, let's get back to the first day.
• 8:18
  SPEAKER_02: It's one day at a time, one moment at a time, one decision at a time.
• 8:22
  SPEAKER_02: The more we start future tripping, the bigger it becomes.
• 8:27
  SPEAKER_02: All we have is the present.
• 8:28
  SPEAKER_02: And so making that decision in the present moment is what we can do.
• 8:33
  SPEAKER_01: So if you make the point that even 10 years into recovery, you are not out of risk or temptation.
• 8:41
  SPEAKER_01: So if somebody's saying, you know what, I haven't had a drink in blank years.
• 8:44
  SPEAKER_01: I'm just gonna have some wine with dinner.
• 8:46
  SPEAKER_01: I'm just at I when I'm golfing, I'm gonna have a beer or whatever, that's a slippery slope.
• 8:51
  SPEAKER_02: It can be, right?
• 8:53
  SPEAKER_02: It's a very personal decision and one that can be informed by how much work have you done on what was driving the behavior before.
• 9:04
  SPEAKER_02: We talked about trauma, I think, last week.
• 9:07
  SPEAKER_02: And so really thinking about trauma, if there is notable trauma in one's life and that the stress and sort of the traumatic memories were what were driving the self-medication with substances.
• 9:22
  SPEAKER_02: It may be that if we were able to engage in the act of recovery, but sort of let the trauma lay on the side, then it may become that even when you have that drink, it could be a really slippery slope because maybe the underlying things haven't quite been fully addressed and you sort of developed a very regimented life.
• 9:44
  SPEAKER_02: I just don't do that.
• 9:46
  SPEAKER_02: Just this is not who I am anymore.
• 9:48
  SPEAKER_02: I'm a person in recovery.
• 9:49
  SPEAKER_02: So just have a very regimented life.
• 9:51
  SPEAKER_02: And so then when you step out of that regimented component, quick slippery slope.
• 9:56
  SPEAKER_02: On the other hand, maybe if you have worked through more of that trauma, develop that greater level of self-awareness, emotion regulation, are mindful and intentionally you're having the one drink with the awareness of how you feel when the cravings come in or that compulsiveness and your level of self-awareness is higher.
• 10:19
  SPEAKER_02: You could do it possibly, right?
• 10:21
  SPEAKER_02: And there's still a risk, but you're taking a balanced risk.
• 10:26
  SPEAKER_02: So for every person, there's risks and benefits of anything we choose to do.
• 10:31
  SPEAKER_02: I am a strong proponent of bringing intentionality into life and making decisions sort of more obvious for oneself instead of just reacting to life.
• 10:42
  SPEAKER_02: And so this can be one of those things where as long as you're able to really take an intentional stance to say, okay, I'm gonna do this.
• 10:50
  SPEAKER_02: This is sort of the risk, these are the potential benefits, you make the decision and stay aware of where you go next.
• 10:59
  SPEAKER_02: And you possibly could have that glass of eggnog.
• 11:01
  SPEAKER_02: But for somebody else, it may be like, it might not be worth it.
• 11:04
  SPEAKER_02: Not worth the risk, right?
• 11:06
  SPEAKER_02: And if you haven't had an addictive disorder or an addiction previously, but you're now maybe stepping into retirement, have a big life transition, that could be a point where you're now at higher risk because suddenly you've been filling your time with your work.
• 11:22
  SPEAKER_02: You have meaning and purpose that you're deriving from it.
• 11:25
  SPEAKER_02: And suddenly you're gonna have all this open time.
• 11:28
  SPEAKER_02: The things that made you feel good about life, the things that gave you purpose and meaning, what you were doing are no longer there.
• 11:35
  SPEAKER_02: And suddenly that can be a time somebody may start with compulsive behavior of any kind.
• 11:41
  SPEAKER_02: And so that's really where that intentionality component comes up for me, where we have to be intentional at every major transition.
• 11:50
  SPEAKER_02: Cause instead of you being the person who's making the choices, it could be that you just slip down a slope and start engaging in things that are not healthy, whether it's a diagnosable condition or not.
• 12:05
  SPEAKER_01: So we're both using the word recovery.
• 12:08
  SPEAKER_01: What is the difference between recovery and sobriety?
• 12:11
  SPEAKER_02: Recovery is more holistic in a simple way.
• 12:14
  SPEAKER_02: Sobriety is one act.
• 12:17
  SPEAKER_02: Sobriety is I am not using these substances, or I'm not, you know, using any substances for a lot of people.
• 12:24
  SPEAKER_02: I think if you think about the AA philosophy, Alcoholics Anonymous, it's very much that you will not put anything that is mind altering.
• 12:33
  SPEAKER_02: I I can argue that 16 different ways because what is mind altering?
• 12:38
  SPEAKER_02: Interesting.
• 12:38
  SPEAKER_02: Right, is a big question.
• 12:40
  SPEAKER_02: Um, you can actually alter your mind by breathing.
• 12:43
  SPEAKER_02: If somebody's heard of Wim Hof, um, he's a breathing practitioner.
• 12:48
  SPEAKER_02: And so he teaches you how based on how quickly or slowly you breathe, how shallow or deep the breaths are, you can alter your mind.
• 12:56
  SPEAKER_02: Hypnosis is a way of altering the mind.
• 12:58
  SPEAKER_02: So there's, but I think really just talking about substances, it becomes sobriety becomes about not using substances.
• 13:07
  SPEAKER_02: That doesn't talk about did you address the underlying issues?
• 13:10
  SPEAKER_02: I think recovery is a more holistic term.
• 13:13
  SPEAKER_02: Um, I would use recovery for mental health conditions or substance use conditions.
• 13:19
  SPEAKER_02: I would also use recovery sometimes from just recovering from the chaos of life.
• 13:24
  SPEAKER_02: Uh and so in that way, recovery is a much broader concept that talks about how you become in alignment with who you are, your values, your purpose.
• 13:36
  SPEAKER_01: This is uh another searched question on the internet.
• 13:39
  SPEAKER_01: What is a functional addict and how do you know if you are one?
• 13:43
  SPEAKER_02: What people would typically call a functional addict is someone who is able to continue to appear to meet their role obligations.
• 13:51
  SPEAKER_02: I think, you know, role obligations are that you're a parent, you're continuing to check the boxes of doing the things parents do, attending your kids' PTO meetings, taking them to their activities.
• 14:02
  SPEAKER_02: You're continuing to meet what is required of you at your job, in your relationships, you show up.
• 14:07
  SPEAKER_02: However, it may be that you internally might still feel out of control.
• 14:13
  SPEAKER_02: You may yourself still have those compulsive behaviors, but it's the type of thing where the addictive disorder is definitely running, or the I should maybe should say just say addictive behavior is continuing to run, but that functional impairment hasn't quite obviously shown up.
• 14:32
  SPEAKER_02: These are people who may also say, I'm not really an addict, or I'm don't really have a substance use disorder.
• 14:38
  SPEAKER_02: What are you talking to me about?
• 14:40
  SPEAKER_02: And these are also people who sometimes will come to us for treatment.
• 14:43
  SPEAKER_02: And if they see that they have a use disorder on their medical chart, they'll say, excuse me, I didn't come for that.
• 14:49
  SPEAKER_02: I'm not like those people.
• 14:51
  SPEAKER_02: And so that very much can be a sense that I still have control over this, I can still live my life.
• 14:59
  SPEAKER_02: And so really it is maybe a bit of a gray zone where the person hasn't quite gotten to the place where there's an obvious functional impairment, but the people who may be close to them, or sometimes they themselves might know that there's the substance use disorder sort of brewing underground.
• 15:18
  SPEAKER_01: So I would think that saying to yourself or anyone who will listen, you know, I've never had an OWI and O UI, I've never missed a day of work.
• 15:26
  SPEAKER_01: I'm fine.
• 15:28
  SPEAKER_01: And that's not necessarily meaning you don't have an addiction that would you could benefit from treating.
• 15:34
  SPEAKER_02: Yeah, I think that's a that's a good way to put it.
• 15:36
  SPEAKER_02: Also because when it comes to a substance use disorder, there's still the biologic impact of it.
• 15:44
  SPEAKER_02: You could still have the brain changes, right?
• 15:47
  SPEAKER_02: And it may be that you're having to now work extra hard amount of energy that's going into your brain, the amount of effort you're putting day-to-day to hold things together, as we call it.
• 15:58
  SPEAKER_02: Okay.
• 15:59
  SPEAKER_02: Right?
• 15:59
  SPEAKER_02: You're just trying to, you're working extra hard.
• 16:01
  SPEAKER_02: It's like a duck in a pond, like they seem like they're just gliding, but they're working super hard under the surface.
• 16:08
  SPEAKER_02: So that can be one of the big tells of what can be considered functional addiction or a person who's functioning with addiction.
• 16:17
  SPEAKER_01: Are 12-step programs like Alcoholics Anonymous mandatory for sobriety?
• 16:22
  SPEAKER_02: They are not mandatory for sobriety.
• 16:26
  SPEAKER_02: They have been obviously around for many, many decades and are seen to be highly effective for people who are enrolled in them, but we do understand that they're not for everybody.
• 16:38
  SPEAKER_02: And so, again, going back to, you know, a very personalized plan and the need to see what works for your own personal philosophy, the way you like to engage with care, um, and and what is important to you.
• 16:51
  SPEAKER_01: So you work in a treatment center.
• 16:53
  SPEAKER_02: I do.
• 16:54
  SPEAKER_01: When people come, is there generally a, okay, I have reached this point and I really need help right now?
• 17:01
  SPEAKER_01: Or are some of the people still, I don't think it's a big deal, but my blank does.
• 17:06
  SPEAKER_01: My boss, my wife, the police.
• 17:08
  SPEAKER_01: Both.
• 17:09
  SPEAKER_01: Yeah.
• 17:09
  SPEAKER_02: We do get people who self-refer and, you know, say, I this is ruining my life.
• 17:15
  SPEAKER_02: I need to get this under control, or this may ruin my life.
• 17:18
  SPEAKER_02: And there's a lot of people who come in and say, well, other people think this is a problem.
• 17:22
  SPEAKER_02: Uh, we'll also get individuals who may have had an intervention from their family, which, you know, I know there's reality shows about, but there can be sometimes less dramatic ways of intervening too.
• 17:33
  SPEAKER_02: But they might have an intervention.
• 17:35
  SPEAKER_02: And so then they're choosing to come.
• 17:37
  SPEAKER_02: We are a voluntary facility, and so obviously everybody who's coming is coming in with some level of willingness.
• 17:44
  SPEAKER_02: There can be an internal drive, but there can also be sort of that external motivation for somebody.
• 17:50
  SPEAKER_02: Both are okay.
• 17:51
  SPEAKER_02: Yeah.
• 17:52
  SPEAKER_02: Most people have a mix of both present.
• 17:55
  SPEAKER_02: I think everybody who comes into treatment may have some part of them that says, I'm not really sure how much of a problem this is.
• 18:04
  SPEAKER_02: And I think most people, even the ones who are saying, I don't have a problem at all, will have some times where they're able to recognize that, okay, well, it may be a problem.
• 18:14
  SPEAKER_02: And so I think there is, it's it's a pretty wide birth, and usually there's a blend of both of those feelings.
• 18:21
  SPEAKER_01: I think I've always assumed it was more external.
• 18:24
  SPEAKER_01: Somebody says you have to do this.
• 18:25
  SPEAKER_01: You have to do this if you want to keep your job, if you want to stay in this marriage, if you want to have access to the children, whatever it might be.
• 18:31
  SPEAKER_01: It's not, it's about, is it about even?
• 18:34
  SPEAKER_02: Um, oftentimes I think by the time they come to us, it it seems to be pretty even.
• 18:39
  SPEAKER_02: Um and and I think of the the people who come with that internal motivation um often are hurting.
• 18:47
  SPEAKER_02: Yeah.
• 18:47
  SPEAKER_02: Right.
• 18:48
  SPEAKER_02: That's what we were talking about last week, too.
• 18:50
  SPEAKER_02: That it's not a pleasant condition to be dealing with.
• 18:54
  SPEAKER_02: You are hurting in some ways.
• 18:55
  SPEAKER_02: And even if every moment of every day you're not fully aware that that's going on, when you pause and sit with it, it feels uncomfortable.
• 19:06
  SPEAKER_02: And that's why often you might not sit and pause and think about it.
• 19:09
  SPEAKER_02: And so having supportive others who are able to say, you know, I got this, I got the kids while you go get better, or I'll, you know, you can take this leave from work, we'd really actually encourage you to take this leave from work because you're such an amazing employee.
• 19:24
  SPEAKER_02: And we want you to be able to be your full self.
• 19:27
  SPEAKER_02: I think having more family members like that, and we haven't talked much about workplace and substance use.
• 19:33
  SPEAKER_02: And I wish if employers were more willing to be open and supportive to really get their people the help so that they can be their best selves.
• 19:44
  SPEAKER_02: I think if you have an employee assistance program or even HR being more supportive around people getting care is very important.
• 19:54
  SPEAKER_02: I mean, one would say that the ADA mandates it, right?
• 19:58
  SPEAKER_02: But then culture is obviously a much stronger driver of whether people seek care or share that they need care than just the laws.
• 20:07
  SPEAKER_01: Oh, I think you think you're gonna lose your job if you say, I need care.
• 20:10
  SPEAKER_02: Yeah.
• 20:11
  SPEAKER_02: Yeah, I think definitely that that that is that is a lot of people's experience, right?
• 20:18
  SPEAKER_02: That why don't you just toughen it up?
• 20:20
  SPEAKER_02: You have no willpower, you can't stop this.
• 20:22
  SPEAKER_02: Right.
• 20:23
  SPEAKER_02: And again, I think back to that like moral failing component.
• 20:27
  SPEAKER_02: Um, so maybe one of the myths that I did not mention in the time that you asked me is the myth that you can stop an addiction with willpower.
• 20:36
  SPEAKER_04: Right.
• 20:36
  SPEAKER_02: Gosh, it's hard to stop eating a cookie with willpower for people who don't have, you know, an addictive relationship with food because sugar is so like hits your dopamine circuit so hard.
• 20:50
  SPEAKER_02: Uh and really that's the piece that willpower for all of us, we have limited willpower.
• 20:57
  SPEAKER_02: Um, that's really where also then Marikondo uh minimalism comes from, like reduce the number of decisions you have to make.
• 21:05
  SPEAKER_02: Um, but willpower isn't not the answer.
• 21:08
  SPEAKER_02: And so I think at workplaces, too, if we can make it more normalized that this is a health condition, let's do early intervention, let's seek support, let's take time away and get well.
• 21:21
  SPEAKER_02: Um, that would be very amazing.
• 21:24
  SPEAKER_01: To the get well point, what are the most effective treatment options for addiction?
• 21:29
  SPEAKER_02: Addiction treatment is multipronged.
• 21:34
  SPEAKER_02: So you definitely need, you know, some level of biologic treatment that can be helpful for something like opioid use disorder.
• 21:42
  SPEAKER_02: We haven't talked a lot about opioids in the time we've spoken, but they are some of the most addictive substances from just how much of a dopamine stimulation can be had from them.
• 21:53
  SPEAKER_02: But for that specifically, there's methadone, there's buprenorphine, which are types of medication treatments.
• 22:00
  SPEAKER_02: They're called medications for opioid use disorder or MOUD.
• 22:04
  SPEAKER_02: They used to be called MAT, which was medication assisted treatment before.
• 22:08
  SPEAKER_02: But the more current terminology is MOUD, which is medications for opioid use.
• 22:13
  SPEAKER_02: Disorder.
• 22:14
  SPEAKER_02: There's another medication called naltrexone that can be used in opioid use disorder, also alcohol, and does help in multiple other areas, including food addiction in some ways.
• 22:26
  SPEAKER_02: So people who have compulsive eating.
• 22:28
  SPEAKER_02: And so naltrexone can be another form.
• 22:30
  SPEAKER_02: Both buprenorphine and naltrexone come in long-acting injectable medications, which means you can get one injection for a month or longer.
• 22:39
  SPEAKER_02: And that can be a nice way to have a medication on board for those conditions without having to make the decision daily to take it.
• 22:48
  SPEAKER_02: And then you definitely need continued what is called psychosocial treatment, which is developing connection with others, engaging support, being able to have a supportive social network because often people who use are either isolated or the people that they're connected with are also using.
• 23:09
  SPEAKER_02: So finding healthy or healthier connections and community, which is where I think that AA component or smart recovery, some of those peer support models of recovery become very valuable because oftentimes people can then find others who are in recovery or at least in sobriety to hang out with, have social connections with, and realize that it can be done.
• 23:35
  SPEAKER_02: You see like 10 other people who are from your neighborhood or, you know, in similar profession as you who have achieved sobriety and that can be very helpful.
• 23:45
  SPEAKER_02: I'm a physician.
• 23:46
  SPEAKER_02: And so there's a specific physician-focused AA.
• 23:50
  SPEAKER_02: And so when you go to those Caduces AA meetings, they're all fellow physicians.
• 23:54
  SPEAKER_02: Right.
• 23:54
  SPEAKER_02: And so you suddenly see, oh, it's not just me.
• 23:57
  SPEAKER_02: There's so many of us who are in recovery.
• 24:00
  SPEAKER_02: So I think there is this element of being seen and supported.
• 24:03
  SPEAKER_02: If you have other physical health conditions like pain or you're in distress for something else, that also needs to be treated often alongside.
• 24:13
  SPEAKER_02: So taking care of your physical health can be part of that recovery component and getting treatment for addiction.
• 24:21
  SPEAKER_02: We see that a lot of people will give up their normal primary care visits or their executive physicals, et cetera, while they're in their throes of using because everything else sort of disappears.
• 24:32
  SPEAKER_02: And so being able to go back to care and learning to love yourself and know that you deserve the care is important.
• 24:40
  SPEAKER_02: And as a psychiatrist, I can't finish the list without mentioning that other mental health conditions which are co-occurring, like depression, anxiety, PTSD, other trauma activation, ADHD, all of those also need to be treated at the same time so that the drivers of addiction can be addressed.
• 25:00
  SPEAKER_02: So it is a multi-pronged approach and something that really needs a holistic understanding of the person, their life, and everything else that pours into them being well.
• 25:12
  SPEAKER_01: So if someone is making the decision to at least explore the possibility of treatment and recovery, where do you start when you need all of that?
• 25:21
  SPEAKER_02: Our healthcare system makes it challenging.
• 25:23
  SPEAKER_02: It does indeed.
• 25:24
  SPEAKER_02: Because whether you have access to care of any kind, and with the evolving situation right now, when it comes to healthcare, it could become even more challenging than it has been.
• 25:36
  SPEAKER_02: But we, as one of the countries that doesn't fund healthcare publicly, we have our own challenges from that.
• 25:43
  SPEAKER_02: But I think a short answer would be start where you can, start where you're already connected.
• 25:49
  SPEAKER_02: So if you're already connected with your primary care doctor, start there.
• 25:53
  SPEAKER_02: It may be that sometimes people may find that their primary care doctor doesn't really do that type of care.
• 26:00
  SPEAKER_02: Then let's get a referral.
• 26:02
  SPEAKER_02: But really being able to see a practitioner who, especially if we're talking about addiction recovery, is able to see a licensed addiction counselor, a social worker, a primary care doctor, addiction medicine physician, psychiatrist, like wherever you can get in, start there.
• 26:21
  SPEAKER_02: Because I believe that even making one appointment with a healthcare professional is a way that you are caring for yourself and showing up.
• 26:30
  SPEAKER_02: And as long as we keep that channel of communication about our health open, we're more likely to achieve something than not.
• 26:37
  SPEAKER_02: AA and AA can be an easy initial step.
• 26:41
  SPEAKER_02: That could be a way to start too.
• 26:43
  SPEAKER_02: Because you can go there and there's other people who have had their own paths.
• 26:48
  SPEAKER_02: And so being able to connect with somebody else who can say, you know what, this is what I did.
• 26:52
  SPEAKER_02: Maybe we can try that.
• 26:54
  SPEAKER_02: So trying something is important.
• 26:57
  SPEAKER_02: AA being alcoholics anonymous, NA being narcotics anonymous.
• 27:00
  SPEAKER_02: Yeah.
• 27:01
  SPEAKER_01: Two questions from the internet that are frequently searched.
• 27:04
  SPEAKER_01: And I put these together because I think that the way they're worded differently is worthy of a discussion in and of itself.
• 27:10
  SPEAKER_01: You gave a lot of advice in part one about how to have a conversation.
• 27:13
  SPEAKER_01: So the first is what's the best way to talk to a loved one about their substance use or addiction?
• 27:18
  SPEAKER_01: The second is how do I confront my loved one about drugs?
• 27:23
  SPEAKER_02: Love those questions.
• 27:25
  SPEAKER_02: I think let's talk about the difference between the two.
• 27:28
  SPEAKER_01: That's why I put them together.
• 27:29
  SPEAKER_01: I think.
• 27:30
  SPEAKER_02: Yeah.
• 27:30
  SPEAKER_02: So the first one, obviously, you know, we can all hear that it's a person wanting to more maybe compassionately talk about the substance use.
• 27:39
  SPEAKER_02: The second one takes a stronger stance and says, you know, I need to show this person.
• 27:45
  SPEAKER_02: And for the word confront.
• 27:46
  SPEAKER_02: Yeah.
• 27:47
  SPEAKER_02: Um, as a clinician, I don't have that strong of a reaction to confront, but I do understand that lay people, which is non-clinicians, would.
• 27:55
  SPEAKER_02: As a psychiatrist, we think about in psychotherapy, confrontation is bringing to awareness anything that is out of awareness.
• 28:03
  SPEAKER_02: And that's why I smile at the question.
• 28:05
  SPEAKER_02: Yeah.
• 28:06
  SPEAKER_02: That if we think about confrontation in that way, which is bringing to awareness something that has been out of awareness, then heck yeah, let's go ahead and confront.
• 28:14
  SPEAKER_02: Yeah.
• 28:15
  SPEAKER_02: Um, so again, doing that with a compassionate stance and taking, taking the approach of curiosity, believing that we don't know it all.
• 28:26
  SPEAKER_02: And we talked last time about comparing our insights to other people's outsides.
• 28:31
  SPEAKER_02: So in this case, the family member who's asking about the confronting the use of drugs is comparing their inside.
• 28:39
  SPEAKER_02: Well, I don't feel like using these substances.
• 28:41
  SPEAKER_02: I feel totally fine, but that person's use.
• 28:45
  SPEAKER_02: Um, and that can be less helpful.
• 28:47
  SPEAKER_02: That makes it that, you know, if you are taking a blaming approach or just talking about what you consider negative behavior, you're very likely to cause the person to shut down or then confront you with something you're doing.
• 29:02
  SPEAKER_02: Yeah.
• 29:02
  SPEAKER_02: Right.
• 29:03
  SPEAKER_02: It's like you're saying, well, you have these two glasses of wine, and the other person may say, Well, you have the six cookies.
• 29:08
  SPEAKER_02: Like, let's talk about who has a bigger problem.
• 29:12
  SPEAKER_02: And so I think taking that more curious, compassionate approach to say, I don't understand everything.
• 29:18
  SPEAKER_02: This is what I'm seeing.
• 29:20
  SPEAKER_02: So, again, speaking objectively to the behavior you're seeing, the fact-based components and saying, This is what I'm seeing.
• 29:28
  SPEAKER_02: I know I don't understand everything.
• 29:30
  SPEAKER_02: Tell me a little bit about what you think is going on.
• 29:34
  SPEAKER_02: Or being able to say, help me understand what this helps you with.
• 29:39
  SPEAKER_02: Because we do need to take the approach that any human being will only engage in a behavior because it's helping them in some way.
• 29:47
  SPEAKER_02: It's fulfilling some need.
• 29:48
  SPEAKER_02: So trying to understand what it is that it's fulfilling takes a more compassionate and holistic approach to it to say, you know, you're such a wonderful human being.
• 29:59
  SPEAKER_02: You have all these wonderful skills.
• 30:01
  SPEAKER_02: I love you so much.
• 30:02
  SPEAKER_02: I've known you my, you know, these many years.
• 30:04
  SPEAKER_02: And I've seen in the last six months that every time we meet, you have like three to four drinks.
• 30:11
  SPEAKER_02: I'm getting a little worried about it, but help me understand what I'm not understanding, or tell me what does this, what role is this playing?
• 30:20
  SPEAKER_02: And the person may say, Oh, well, I had a really stressful week.
• 30:22
  SPEAKER_02: These are actually the only six times that I drank.
• 30:26
  SPEAKER_02: And maybe that goes in a different direction.
• 30:28
  SPEAKER_02: It may also be that they under-report to you, but at least it gets them engaged in the conversation.
• 30:35
  SPEAKER_02: And so once we've opened that channel of communication, there's hope for a more robust, more authentic, more real conversation.
• 30:43
  SPEAKER_01: So as we talk about compassion and curiosity, there's there are going to be people who listen to this and think, that's great.
• 30:49
  SPEAKER_01: That's really good advice.
• 30:50
  SPEAKER_01: I wouldn't have gotten there on my own, or I need that reminder.
• 30:53
  SPEAKER_01: Then there are people who say, like, wow, you're just being way too soft on them.
• 30:57
  SPEAKER_01: If I come at it that way, nothing's going to change.
• 30:59
  SPEAKER_01: So is that approach soft or is that trauma-informed?
• 31:05
  SPEAKER_02: I would call it trauma-informed.
• 31:07
  SPEAKER_02: It may also be a softer approach.
• 31:10
  SPEAKER_02: Um, and I would say that for most people, let's start there, because we don't really know what the person's experience is.
• 31:18
  SPEAKER_02: We often don't even know what their life experience is, even if they're your child.
• 31:25
  SPEAKER_02: Absolutely.
• 31:26
  SPEAKER_02: Even if they're your partner.
• 31:28
  SPEAKER_02: Um, when I do intakes with patients and I used to do outpatient work before I joined this treatment center, um, I would say often that I knew my patients better than I knew my best friend.
• 31:40
  SPEAKER_02: Interesting.
• 31:41
  SPEAKER_02: And it's because a big part of my clinical work is trying to facilitate somebody's story and helping them sort of uncover or share what what the internal kind of thought process is as they're going through life.
• 31:55
  SPEAKER_02: And we very rarely, if ever, have those type of conversations with our loved ones.
• 32:02
  SPEAKER_02: Even where we talk to them pretty deeply about things, they're not sitting with me on a weekly basis, sharing what went on and how they thought through things.
• 32:13
  SPEAKER_02: So, really, like there is that level of awareness that one can develop about another person.
• 32:19
  SPEAKER_02: So, really realizing that even my best friends who I've known since I was in middle school or high school, that as well as I know them, and I might say, you know, this is how she'll behave in this situation, I still didn't know them as well as I knew my patients.
• 32:35
  SPEAKER_02: I think for me, that's what really got me down this path on facilitating somebody's story that we do not know a lot.
• 32:45
  SPEAKER_02: And so start with curiosity, start with compassion.
• 32:51
  SPEAKER_02: And it may be that there are some people out there who do need the kind of stronger boundaries or do need the confrontation.
• 33:02
  SPEAKER_02: But if we start at a place of compassion, then maybe we'll uncover that.
• 33:06
  SPEAKER_02: We'll uncover that they do need kind of a more stern approach to the situation.
• 33:12
  SPEAKER_02: And it's best to start with the compassion and curiosity because then you're not shutting down the conversation prematurely and making it that then the person just doesn't want to engage with you anymore.
• 33:24
  SPEAKER_01: That feeling I'm in trouble or I'm being judged because you would be.
• 33:28
  SPEAKER_02: And people have so much self-stigma already.
• 33:31
  SPEAKER_02: Yeah.
• 33:32
  SPEAKER_02: There's so much self-judgment and self-stigma.
• 33:35
  SPEAKER_02: And that sometimes can be the reason they're not seeking support or care.
• 33:38
  SPEAKER_02: Because they're like, I already feel so shitty about myself.
• 33:42
  SPEAKER_02: I don't now want Terry to feel badly about me too.
• 33:45
  SPEAKER_02: Right.
• 33:45
  SPEAKER_02: Um, and there can be this component of like building on shame.
• 33:49
  SPEAKER_02: Like, I have enough shame of my own.
• 33:51
  SPEAKER_02: Please don't pile yours on.
• 33:52
  SPEAKER_02: Right.
• 33:53
  SPEAKER_02: Uh, because then that might become too much.
• 33:55
  SPEAKER_02: Another thing that we haven't quite talked about that I would want to mention is that a person with a substance use disorder is at an elevated risk of suicide, right?
• 34:05
  SPEAKER_02: Or a suicide attempt.
• 34:07
  SPEAKER_02: Um, because there is that inability to cope with what life has put in their plate.
• 34:13
  SPEAKER_02: And it could be either because we have limited or like a narrow range of coping strategies.
• 34:20
  SPEAKER_02: It could be that the situation has overwhelmed your capacity to cope.
• 34:23
  SPEAKER_02: And that's really what trauma is.
• 34:26
  SPEAKER_02: And so when a person is using substances, we already know they're in that state of overwhelm.
• 34:32
  SPEAKER_02: So when we pile on our shame on them or pile on our judgment, we may actually push them further out into that overwhelm.
• 34:42
  SPEAKER_02: And so that again is another reason to let's start with compassion and curiosity.
• 34:48
  SPEAKER_01: Another of the most searched questions on the internet.
• 34:50
  SPEAKER_01: What if I'm worried about my drinking, but I don't think I'm an alcoholic?
• 34:54
  SPEAKER_02: If you're worried about your drinking, it's good to take stock of it.
• 34:59
  SPEAKER_02: Right.
• 35:00
  SPEAKER_02: Um, you don't have to have an alcohol use disorder, as it's called, to consider not drinking or reducing your drinking.
• 35:09
  SPEAKER_02: Though often when people start to get into a place of worrying about their drinking, it may be that it is moving in that direction or has moved further along than you believe it is.
• 35:22
  SPEAKER_02: Um, there are questionnaires like the cage questionnaire that one can take.
• 35:27
  SPEAKER_02: C-A-G-E.
• 35:28
  SPEAKER_02: Yeah.
• 35:29
  SPEAKER_02: Um, that one can take that will help you assess if that's, you know, something that's a little bit further along.
• 35:36
  SPEAKER_02: You can obviously talk to your clinician about it.
• 35:40
  SPEAKER_01: So uh somebody can ask themselves questions, ask a clinician questions, um, do an online assessment.
• 35:48
  SPEAKER_01: What are the signs for us to look at in ourselves and each other?
• 35:53
  SPEAKER_01: It's like these are indications that your use of whatever behavioral or or substance might be creeping up on being a problem.
• 36:04
  SPEAKER_02: To identify when things are moving into the region of being a problem is often when you start feeling that you are over-relying on that, on that behavior, that solution.
• 36:18
  SPEAKER_02: Uh, we talked about, you know, all of us doing as human beings different things to cope with stress or life's chaos.
• 36:25
  SPEAKER_02: And so when you start overusing one tool, that can definitely be a flag that, gosh, I always do this.
• 36:33
  SPEAKER_02: It could be that, you know, every time you have a stressful situation, you go for a run.
• 36:37
  SPEAKER_02: Like if you're running eight times a day, that might be a problem.
• 36:40
  SPEAKER_02: Yeah.
• 36:40
  SPEAKER_02: You can get shin splints, you, you know, move into the direction of orthorexia.
• 36:45
  SPEAKER_02: There can also be um signs if your behavior is changing and it's impacting relationships.
• 36:52
  SPEAKER_02: So if the thing that you're doing is impacting relationships, if it's keeping you isolated, you're not fulfilling the roles that you want to in your life, those are all good ways to assess that things are heading into a problem.
• 37:07
  SPEAKER_02: We talked at the beginning about workaholism.
• 37:09
  SPEAKER_02: That's another thing.
• 37:10
  SPEAKER_02: If you start avoiding, you know, going to family events or engaging with friends just for the sake of work, or you're at an event and you're constantly just working, that again could be a sign that your life is now becoming more one-dimensional, or your coping is becoming one or two dimensional.
• 37:31
  SPEAKER_02: And so I think those are the easiest ways from a behavioral standpoint to see that there's a problem.
• 37:37
  SPEAKER_02: And then internally, there's that distress component that we talked about.
• 37:41
  SPEAKER_02: It's like, oh, if I can't engage in it, then I'm feeling distress.
• 37:44
  SPEAKER_02: Right.
• 37:45
  SPEAKER_02: Or when I engage in it, I'm feeling shame and distress.
• 37:48
  SPEAKER_02: Right.
• 37:49
  SPEAKER_02: Those are, again, other ways that you can see that this might be a problem.
• 37:54
  SPEAKER_01: When you're dealing with addictions, substance use disorders, others, and mental health conditions, commonly they overlap.
• 38:02
  SPEAKER_01: So how does treatment work?
• 38:04
  SPEAKER_01: Is there an order of operation?
• 38:07
  SPEAKER_01: Does it all have to happen at the same time?
• 38:09
  SPEAKER_01: What's most effective?
• 38:10
  SPEAKER_02: Um, as with a lot of things, it depends on the person and what they're showing up with.
• 38:15
  SPEAKER_02: Co-occurring treatment is best, addressing both things.
• 38:19
  SPEAKER_02: A clinician who is highly skilled ideally should be facilitating your story and bringing to awareness that there's a couple of things happening at the same time.
• 38:30
  SPEAKER_02: Though sometimes it is that one may cover the other, right?
• 38:34
  SPEAKER_02: There's a presenting issue that's more urgent and showing up right now.
• 38:39
  SPEAKER_02: And then as you settle that a little bit, you might notice sort of like playing whack-a-mole that something else has popped up or come to awareness.
• 38:48
  SPEAKER_02: And so it is a dynamic process.
• 38:51
  SPEAKER_02: It is important to consider the person as a whole person and do holistic treatment.
• 38:58
  SPEAKER_02: Interestingly, you know, the mind and the body don't know that insurance companies or the healthcare system divide them up.
• 39:06
  SPEAKER_02: Yes.
• 39:06
  SPEAKER_02: So the mind and body sort of does its thing all together.
• 39:10
  SPEAKER_02: Uh, and that's really where even though your primary care doctor might say, Oh, well, you know, this is a mental health thing, go to your mental health clinician.
• 39:18
  SPEAKER_02: Right, your body doesn't know that because your brain's part of your body.
• 39:22
  SPEAKER_02: Yeah.
• 39:22
  SPEAKER_02: And so it just both affect each other.
• 39:25
  SPEAKER_02: And so keeping awareness of both while doing treatment is important.
• 39:30
  SPEAKER_02: And in that same way with mental health, insurance companies and others might divide it into addiction and mental health.
• 39:37
  SPEAKER_02: And it's all the same.
• 39:38
  SPEAKER_02: So again, facilitating one story, considering what's going on.
• 39:42
  SPEAKER_02: And obviously, you'd address whatever is more urgent first, but hopefully with awareness that all things need to happen eventually or in some way consistently as possible.
• 39:55
  SPEAKER_01: Okay, so we've covered a lot in the last two episodes.
• 39:59
  SPEAKER_01: And as we wrap up this whole conversation, as a clinician, as a psychiatrist, as someone who works with people in addiction and with mental health conditions, what are you hoping that someone takes away from this conversation for themselves or for someone that they love and care about who is dealing with an addiction?
• 40:17
  SPEAKER_02: The thing I hope that people take away from our conversation is that addiction and mental health conditions are multifactorial, that what we don't know, we just don't know.
• 40:29
  SPEAKER_02: We cannot ever guess another person's experience.
• 40:33
  SPEAKER_02: The only way to know is to ask.
• 40:36
  SPEAKER_02: And healthy, supportive, kind communication is really what we need.
• 40:43
  SPEAKER_02: And to not make it extremely complicated for themselves.
• 40:49
  SPEAKER_02: Love, support, compassion, curiosity, start with that.
• 40:55
  SPEAKER_02: Start with why you're worried about your loved one.
• 40:58
  SPEAKER_02: Start with why you're worried about yourself and build out from there.
• 41:03
  SPEAKER_02: Because really, if we can connect around that, that we both want this situation to be better.
• 41:08
  SPEAKER_02: We both want our family to be in a better place.
• 41:12
  SPEAKER_02: We both love each other.
• 41:15
  SPEAKER_02: And that's really where the worry or the fear comes in, then that is a place we can hopefully move forward in a more positive direction from.
• 41:24
  SPEAKER_02: But love really does make the world go round.
• 41:28
  SPEAKER_01: I appreciate your perspective and all your expertise.
• 41:31
  SPEAKER_02: And your time.
• 41:32
  SPEAKER_01: Thank you so much, Terry.
• 41:33
  SPEAKER_01: It was delightful to be here.
• 41:34
  SPEAKER_01: Thank you.
• 41:35
  SPEAKER_01: And I really appreciate it as well.
• 41:36
  SPEAKER_01: And we will be back next week with the beginning of a look at another topic in the addiction and mental health field.