Category Archives: Psychological

Who needs a drink when you’ve got the Feel Stress Free app?

feel-stress-free-appSo managing all feelings, and particularly difficult feelings like depression and anxiety, was a big part of the early days and months of getting sober for me.  Even now I’m always on the look out for new sober treats and self-care tools to make this easier for all of us.  The new Feel Stress Free app released this year, is the second mindfulness app I have tried as I have talked on the blog before about Headspace.

For me psychological self-care and fitness is as important as physical fitness and self-care so this was a great addition to my sober tool-box particularly on the go when life gets tricky.  As you know I’m a District Nurse and some patient visits can be emotionally difficult so having an app in my pocket that I can tap into, potentially between patient visits if needed, is a much welcomed respite.  The apps image and sounds of a desert island, lapping waves and seagulls with background calming music was lovely every time.

This above image is the first screen that greets you once you have downloaded for free the Thrive’s Feel Stress Free Mobile App which is available for iOS and Android.  It works on a subscription basis,which can be purchased for one month, three months or a year. For one month it will set you back £4.99, for 3 months it will cost £3.33 each month and for a year it’s £1.99 each month.  I was lucky enough to get a month’s free trial from the developers 🙂

This is what their website says:

Be Stress Free has been created over two years of development and research to pro-actively prevent and manage stress and anxiety.

  • Keeps track of your mood over time
  • Enables you to train your thoughts so you can manage how you feel about different situations
  • Trains you in 4 relaxation techniques that give you control over your stress

Stressed or anxious? We can help! Using evidence-based techniques, we help you learn to relax and build your resilience to these common—yet hard to conquer—problems. Featuring our thought trainer, zen garden, and unique ‘message in bottle’ social feature, there’s plenty to explore!

I loved the zen garden and ‘message in a bottle’ social feature (that enables you to send a message of encouragement to others using the app) and fed back to the developers:

“Have recently spent a year training part time to be a child and adolescent psychotherapeutic counsellor at the University of Cambridge and one of the therapeutic tools we used was a sand tray!  It was lovely to be able to immerse myself in that way again and very valuable.”

I wasn’t the only reviewer who really liked this as Moonlolly in the City agreed: ‘If you swipe left, you go to a second island called the ‘Zen Garden’, a virtual Japanese rock garden used to aid meditation. Here you can design your own space and save your best designs.  I loved this part, probably because I’m a big kid – it was one of those absorbing exercises akin to adult colouring books. Totally on board with this.’

One of the things I liked about this app is it is designed by clinicians:

Dr Andres Fonseca – CEO, is a psychiatrist with almost 20 years of clinical experience. He believes the way mental health services work at the moment is very broken. Services are focused on intervening when people are in crisis, which is already too late. He believes therapeutic software that is fun to use is the way to help people Thrive.

A bit more detail about some of the key features:

Mood Meter

Start every day tracking your mood to receive the best recommendations to get through it. Based on your results the Mood Meter will recommend different activities. It will record your results on your progress so you can look back and see what works for you. It will learn itself what you find helpful and get better at advising you over time.

Thought Trainer

Our cognitive behavioural therapy based thought trainer is how we help you to re-frame your negative thoughts. We all have negative thoughts at times, but is there a better way we can think about things? That is what the thought trainer is here to do. It tracks how you feel, giving recommendations and helping you to see a positive in the negative. With everything tracked in Progress and the app learning more about you as you use it, the Thought Trainer will soon personalise itself to your experiences.

The evidence

Computerised Cognitive Behavioural (cCBT) therapy has accumulated 10 years of evidence. It has been shown to work as a self-directed treatment without intervention from a therapist. In 2016 Jill Newby and colleagues from St Vincent’s Hospital in Australia undertook a review of all the evidence of cCBT used for depression and anxiety showing it is a very effective technique and comparable to face to face therapy. Here is a link to the study.

Calm Breathing

This is the simplest technique, one that you can learn in the app and practice anywhere you are. It is based on the fact that increasing chest pressure by taking very slow and deep breaths, and then reducing by slowly breathing out, triggers a reflex. This reflex slows down your pulse and gives you a relaxed feeling in your body. As body and mind are connected this then results in relaxation in your mind. Give it a go for 3, 5, 7 or 10 minutes!

The evidence

Deep slow breathing is an essential technique incorporated in many relaxation exercises. It has been extensively examined in the literature in different setting. A good review of the evidence behind it and its uses can be found in General Principles and Empirically Supported Techniques of Cognitive Behavior Therapy, Chapter 14 by Hazlett-Stevens and Craske. You can read a preview of the chapter here.

Progressive Deep Muscle Relaxation

In this technique we also take advantage of the mind-body connection. We will teach you to contract and relax various muscles progressively allowing you to enjoy the difference between the tense sensations in the muscle and the relaxed sensations that come after you have let the tension go

The evidence

Since its description by Jacobson in 1938 this technique has a record of proven efficacy. There is a 2007 review of the literature that summarises all the available evidence up to that date which you can find here.

Self Hypnosis

Not for everyone but those of you who are able to reach a state of hypnosis can benefit greatly from this technique. We will try to teach you to put yourself into a hypnotic trance. If you are able to achieve it, he will help you teach yourself a word of phrase that will quickly bring you back to that state of relaxation whatever your circumstances.

The evidence

It has proven efficacy in anxiety related to many situations. It has been particularly studied in people going through different medical treatments like dialysis, chemotherapy, surgery and dentistry. There is a 2010 review that goes through all that evidence. The main issue with hypnosis is that the person must be suggestible to benefit from it. Here is a recent study on how suggestibility influences outcomes in using hypnosis to manage pain.

Meditation

Simple to learn but hard to master this is quite a powerful technique for relaxation.  It requires dedication and practice but if you persevere it can bring about the most benefits. You will need a quiet space and to achieve a sensation of comfort. You will be able todevelop a passive attitude that allows you to just watch your feelings, sensations and thoughts as they pass through your mind. You will also use word or phrase to help you refocus.

The evidence

This is probably the technique that has received the most attention recently. It requires practice to master but everyone can use it if they devote the time to learn it and practice it. There is a complete review and meta-analysis of all the evidence of meditation in the management of anxiety published in the British Journal of Psychology in 2012.

And you can track your progress:

Progress keeps track of everything you do in the app. It is what the app uses to give you better and better tips. If you are working with a therapist you can use Progress as your full-fledged therapy journal.

You can choose how long you want to do each exercise for, from a quick 3 minutes of deep breathing to 25 minutes of meditation, which is great if you want to fit a session into a busy day.  The app also remembers which exercises you’ve done before and how many times, encouraging regular use and making the whole experience feel very personalised.

Echoing the words of Moonlolly: if you’re going to invest in a mindfulness app, it’s worth bearing in mind that this is one of the first to have actual CBT therapy incorporated and be officially ‘clinically proven.’

So next time you’re feeling stressed or anxious rather than reaching for a drink, or thinking that a drink would help, why not try this?

Friday Sober Jukebox – Escape Velocity

escape velocitySo here we are again now heading into year 4 🙂

There are many things I still haven’t covered on this blog so until I run out of new things to share and say a post will keep appearing,  probably on a weekly or two weekly basis, depending on what’s going on.  Plus I know myself well enough now to know I won’t be able to keep my big mouth shut about any major news story that breaks in the alcohol and public health worlds!

So today is about psychological escape velocity (the minimum speed needed for an object to escape from the gravitational attraction of a massive body).  I had a headf*ck experience recently where I was given the opportunity to see photo’s of a house I lived in when I was a girl.  What was really spooky and serendipitous about this was it was via a nursing colleague who had lived in this house about 20 years after me, had taken photo’s and had recently been sorting through them and happened to have them with her in the office then and there that lunchtime!  Weird right?

What she didn’t know was that I have really distressing and traumatic memories of this house and time and have spent a good amount of time in therapy talking about it so seeing those images triggered an avalanche of memories.  What was so reassuring was that although the memories had only been experienced in the last 5 years (which fuelled a massive amount of drinking back then) my recall of that house was EXACTLY right.  Every detail that I had summoned from 40 years ago and discussed was spot on – so if my memory of the place was right so was my recall of the events.  This was a major revelation because at the time when I tried to tell someone I hadn’t been believed and I had therefore doubted my own experience and had questioned whether it was all just in my head – that my nightmare’s were just that horrors in my head not real life.  Although seeing the photo’s caused intense psychic tremors I was okay and I was able to regulate my emotions and handle the triggered distress.  This felt like massive progress to me and as if I had enough emotional and boundary depth to not be pulled back into the psychological pain of that time.  These events no longer defined me – I had reached my psychological escape velocity 🙂

When I told MrHOF he said this was not just the end of a chapter but the end of a volume in my life and he felt it was no co-incidence and a sign from the universe (because I believe in such stuff) that that experience and how I managed it marked closure both emotionally and mentally for me and that I wasn’t doing a geographical by planning our move to Australia.

That same day I was contacted by Regina Walker at The Fix who is a psychotherapist.  I was reading her writing archives when I came across an article about Dialectical Behaviour Therapy (DBT) a technique used in the UK mainly to treat those with borderline personality disorder.  Thanks to my research assistant experience with a Clinical Psychologist who worked with this client group it was something I knew about, knew it was a successful and valuable therapeutic approach and learned from this discovered article that it is being used and applied in addiction!

Here are the key excepts that link my experience recounted above and this technique (the whole article is well worth your time in reading):

The goal of DBT is to acquire skills to deal with the mental anguish the sufferer experiences and create a life worth living. The tools offered in DBT are meant to aid in the achievement of these goals.

DBT, for people struggling with substance abuse problems, is a way to achieve self-acceptance while simultaneously accepting the need for change. There are four basic aspects to DBT: mindfulness, interpersonal relations, emotion regulation, and distress tolerance.

The emotion regulation aspect of DBT teaches how to identify, regulate and experience emotions without becoming overwhelmed and acting on impulse. The skills aim to reduce vulnerability and increase positive experiences.

The fourth area of DBT is distress tolerance. This area is focused on the development of skills to cope with crises when emotions become overwhelming and the individual is unable to immediately solve the problem (a death, sickness, loss of job, etc.) but needs to persevere and live through the crisis without making it worse by impulsive actions (for example, getting high or drunk).

Dr. Linehan acknowledged that the self-harming behavior she saw in suffering patients made sense and had a purpose.  But she also recognised that this had to change and that the person had to accept themselves.

She referred to this as “Radical Acceptance”—acceptance of life as it is, not as it is supposed to be; and the need to change, despite that reality and because of it. These seem to be opposites: on the one hand, you have to take life as it is; on the other hand, that change is essential for survival. But for real change to happen, both self-acceptance, and acceptance of the need for change have to come together. This blending of two seemingly opposite views is called a dialectic—and it’s the vision behind the name of Dialectical Behavioral Therapy.

So after 3 years of living life sober, and ‘in the raw’ as Mrs D would say, I have both accepted myself and what happened to me as a child and shown myself self-compassion.  I have taken life as it is but recognised that change was essential for my survival.   My psychological escape velocity from my past, and as part of that alcohol, has reached a critical juncture 🙂

In the past those photo’s would have rocked my world in a very negative way and triggered the most almighty bender.  Now I just feel peaceful and content that I can trust myself to take care of myself as I tried to as a young girl.

Surrender

surrenderSo today my family & I fly to Australia for a month.  A hard earned & saved for treat for over 1000 days sober (1043 today to be exact!)  I can’t quite believe we’ve achieved this many days or this extended holiday.  As with my other breaks it will also be a cyber holiday so I’m leaving this post up until I return and linking a copy of my e-book here for you to download while I’m away should you want to:

Free ebook here 🙂

My online course is self-directed so remains available during this time but can I direct you to Udemy if you have any technical issues.  Equally any comments on the blog or emails sent to me during this time will not be responded to until my return at the end of August.

Plus I’d like to thank a member of the BFB Yahoo for this blog post they called Surrender and if you’d like to read more of their writing you can do so here (she’s on day 145 now!)  Over to them and see you in a month 🙂

Good morning BFBers

Today is day 30 for me. It’s been a ride and a half and I am so grateful for the support of this group. The longest I have ever gone without alcohol with the exception of three pregnancies and a few military deployments was 11 days out of the last 20 some years. Ridiculously, I used to congratulate myself on going more than 24 hours without a drink and never could have fathomed a whole month. Yet, here I am.  And I feel deep down that I will never drink again. I made myself a promise that if I could make it this first month that I would come clean and share my story here.  There are obviously years leading up to all of this, but this is how I came to SURRENDER.
Thirty days ago I drank an entire bottle of whiskey in an attempt to “feel better” after I had a series of unsettling events. I see it all now as what it was: a painful wake up call from God. The day before my last drink, I had worked a twelve hour shift in the ER, 10 of which were spent taking care of a patient who was an alcohol overdose who was found unresponsive by her family. She had aspirated (inhaled her vomit into her lungs), then had an anoxic (lack of oxygen) brain injury and a stroke as a result. She was 4 years older than me and will probably never wake up again. She left three kids.
Instead of coming home and recognizing that situation as a cautionary tale and using it to examine my own drinking, I did what I always did after a rough shift: I drank. I drank about 5 shots of whiskey and then restlessly went to bed at 0300. My sweet son who has a lot of sensory issues and learning disability had a giant meltdown about his socks the following morning which, in my probably still intoxicated state I did not handle well. I yelled at him which made it all worse and he went to school feeling misunderstood and sniffly.  I sat down after taking the kids to the bus feeling like an utter failure, trying to shake the images of my patient the night before. Her kids crying at the bedside, her slack jaw, the medications I was using to keep her alive, the rhythmic hiss and whoosh of the ventilator that was breathing for her.  So… I drank some more. A lot more.
I fell asleep, and was awakened by my phone ringing; the school calling to tell me that I had forgotten to get my 5 year old off the bus. I stumbled to my car, looking like God knows what and went into the office.  I could hear my words slurring, burst into tears when she came out of the nurses’ office and made some probably unintelligible statement to all of the office ladies that I wasn’t feeling well and had laid down and not heard my alarm. I have no idea why they didn’t call the police or why they let me take my daughter.  Unless the idea that I, a mom with three kids at that school who is active and “together” could have possible been severely intoxicated at NOON was just too difficult to imagine.  Maybe they truly believed that I did have the flu or something.. I drove home the 0.8 miles to our house (yes, I’ve measured just how far I drove drunk with my precious daughter in the car), remember trying to make her a PB and J. I took another shot to  manage the guilt I felt when I realized that instead of jelly, I had dumped out a jar of olives onto the sandwich and had to start over.  That was the last shot in the bottle, so of course I opened the second. I made her a sandwich and then I don’t remember anything after that.  Apparently, my subconscious knew that I was in trouble because I called my husband (I don’t remember) and told him he needed to come home right away because I was messed up.
The next thing I remember was lying in the tub vomiting up my guts, with my husband trying to get me up and out of the shower. Me crying that I just wanted to die and finally saying out loud to him over and over “I’m an alcoholic.” Then passing out again.
I finally woke up at 11 pm that night in my bed, feeling like I’d been hit by a truck. I had bruises on my entire body; my face was throbbing.  I looked down and realized that my left knee was completely dislocated. It was like looking at someone else’s knee. I literally felt nothing; just thought, “huh, pretty sure my knee cap shouldn’t be sticking out the side of my leg.” I stood up shakily and it popped back in. I hobbled to the bathroom to see my face. My lip was swollen, my right front tooth was broken and the whole side of my face was purple.. I have no idea how I sustained those injuries.  My first thought was of my kids. I asked my husband where they were and he told me “you made R lunch, called me and set her up with a movie. She was watching Strawberry Shortcake when I got home an hour after your call. The other two are fine. I was here when they got home.”
I see all of those things now as Divine providence. The school staff should have called the police. I was in a grey-out when I drove my daughter home and didn’t crash or hurt anyone. I could have killed both of us driving like that. I gave myself a concussion smashing my face into something because I was too intoxicated to stand. I knocked out my front tooth and tore a ligament in my knee.  I could have been more severely injured, passed out, aspirated and been just like my patient the day before.  It had been building for a while and my husband had never seen me like that. And though the signs were probably there if he had been looking, he never noticed. What a spectacular reveal!  Like whipping that curtain away from Oz, everything was out in the open, warts and all and now this is the new reality.
My thoughts during that first night were so full of shame that I just wanted to die. I was in severe physical and emotional pain. I didn’t want to see my kids in the morning, knowing that I had failed them so utterly.  Whatever any one tells you or what you want to believe, this disease is PROGRESSIVE…  over the last two months that I drank I had reached the point that I had become the clichéd slurring, falling down mother who endangered her child, and endangered other people on the road with me. I never would have imagined that a few ” You deserve it/ Mommy’s time out” glasses of wine (which became bottles which became day time drinking which became binge drinking vodka or whiskey because I had so much tolerance) after my children were in bed would swallow me whole; destroy my self-respect, make me a caricature, a failure and shatter every illusion of perfection or control I had ever clung to. And all of that happened in the span of two years. To anyone on the outside, I looked like a “together” mom of three adorable kids who is a damn good nurse, a tough lady with a great sense of humor who has survived a lot of tough times in life, the tall redhead with the quick wit who has a reputation for being able to handle anything.  Except I couldn’t handle alcohol anymore. And I felt like a fraud. If anyone knew….
If you are struggling with moderation, thinking you can control it, I am here to tell you that if you are truly an alcoholic, this disease will not allow you to do that indefinitely.  At some point, down the road, and I can’t tell you when it will be for you…Something will happen. That feeling of dread you have, that worry about being a news story, or being the next Diane Shuler… That is the voice of God telling you to STOP NOW.
That first morning, hurting and hungover, it was clear that I could either choose death or choose to accept  the idea that I could never, ever drink again.  I was living on grace and borrowed time. Because I should have been in jail or dead.  So I chose SURRENDER.  If you are reading this and haven’t gotten to that place yet, I beg you to accept that you may not be given the choice later.  So pick life.
Ironically, the last two days have been the hardest of these 30. I’m struggling with sleep again, feeling down and lacking energy. My anxiety is flaring and I had two panic attacks in the last few days where I honestly thought I was having a heart attack… But fortunately I’m able to recognize all of this as symptoms of PAWS. So, I’m pushing through, trying to rest when I need it, giving myself slack and working on doing a LOT of breathing and pausing.  The biggest thing I’ve learned in this last month is that just because I’m feeling something uncomfortable, I don’t have to fix it immediately.  I’m a person who hates unresolved things… always had to fix everything the very second that it cropped up. And if I couldn’t fix it, then I would just drink to feel better about it. Now, I’m finding that I don’t have to have knee-jerk reactions, don’t have to sacrifice my own well-being to make others feel better, or manage their emotions to the detriment of myself. I don’t have to “fix” it all right away. It can just BE for a while.
This of course makes me very uncomfortable and uneasy. But I have that little voice in the back of my head that says ” This sucks, but did you DIE?” Nope. Still alive and ticking. This month has been rough. Lots of firsts, some easy, some very difficult. But I’m still here, taking it a day at a time. Knowing that drinking just isn’t an option has freed me to get to the real work of unraveling myself.  Which is scary and some days like today I just don’t want to go there. The same stresses exist. I’m still suffering career burn out. I still have three kids and no local family support. My son still has very very bad days that throw everything into disequilibrium.  My husband still has PTSD and is too proud to get help. My marriage is still very rocky and probably even more so now that my husband who is a normie can’t understand what the big deal is and why I’m not just magically all better now I’m not drinking. If anything, all of this hurts a thousand times more because I’m not anesthetizing myself anymore. But I’m not drinking.
I know I can’t control and fix all of that so for THIS DAY, in this moment I will pause and  just be grateful that I’m sober.  I’m finding that though painful, this coming back to life is indescribably worth it.  I know that all of this hard work, these tough (often invisible) moments will be worth it. Because I am also open to the good things: laughter, joy; the million small details you can’t see when your edges are blurred.  I’m not sure I will ever come to a place where I can be “grateful” for being an alcoholic.  I still struggle with a lot of shame and regrets. But perhaps as this journey progresses I will eventually see it as a gift.
In the mean time, thanks for listening. Thanks for “getting” what it means to have the courage to unflinchingly take stock and face this disease.  And I hope you can be encouraged by reading my story.  Because if anyone as stubborn as me can finally learn to let go, there is hope for you.
Surrendering On

The complexity and challenge of ‘dual diagnosis’

quadrant_dual_diagnosisSo this is an extra post squeezed in before I go away as it’s too important to miss!  It’s a great drug and alcohol findings research article about the complexity and challenge of dual diagnosis that I have written about before here.  To the left is an excellent diagram of ‘the quadrant model of dual diagnosis’.  It’s a lengthy read and I have shared it in full because it’s valuable and well researched.

With as many as three quarters of their clients suffering from mental health problems, deciding how to respond is a major concern for Britain’s drug and alcohol services. The issues are many, long-standing, and generally unresolved. Should substance use services take the lead in coordinating their clients’ care, or should this be taken on by psychiatric services? Is either willing and able to take on both issues and deal with mentally ill substance users, or would a better option be to create new integrated services?

People with coexisting mental health and substance use issues often have high support needs, and poor treatment outcomes. There are various barriers to the provision of appropriate support, but equally many opportunities and occasions to improve the lives of those affected.

Dual diagnosis: more complex than the name suggests

The term ‘dual diagnosis’ is used widely, but not often consistently. The World Health Organization defines it as “the co-occurrence in the same individual of a psychoactive substance use disorder and another psychiatric disorder”, whereas the UK National Institute for Health and Care Excellence (NICE) refers to “young people and adults with severe mental illness who misuse substances”. What these two definitions have in common is a leaning towards the severe end of experiences of mental health and substance use issues. The everyday use of the term dual diagnosis is much broader, describing the presence of coexisting mental health and substance use issues, where the person may or may not have a formal diagnosis of, or meet the formal criteria for, mental illness, substance use disorder or dependence. In fact, many people categorised as having a dual diagnosis do not have a diagnosis, and many people have more than the two problems or support needs that ‘dual’ diagnosis implies. Rather than thinking of people with dual diagnosis as having two support needs, it may be more useful “to acknowledge that they have complex needs”, both directly related to and extending beyond their substance use and mental health. It is because of this that some working in the field have advocated either moving away from the term dual diagnosis altogether, or adopting the broader, more inclusive, everyday interpretation of dual diagnosis to accommodate all who would benefit from treatment that considers their coexisting mental health and substance use problems (regardless of levels of severity or diagnosis).

Mental illness and substance use: which is chicken, and which is egg?

Dual diagnosis has been on the radars of researchers and clinicians for over thirty years. In terms of the complex relationship(s) between mental health and substance use (1,2,3,4) we now understand that (among other things):
Drinking and drug use can aggravate or exacerbate existing mental health problems or symptoms
• People may drink and take drugs to try to relieve the adverse symptoms of mental health problems (sometimes referred to as ‘self-medication’)
• Long-term, heavy drinking can cause damage to the brain which can impair cognitive functioning
• Drinking or taking drugs can induce temporary or longer-term mental health problems in some people, which may subside after the substance use has stopped
• Withdrawing from alcohol and many illicit drugs can produce or mimic symptoms of mental ill health

There has been somewhat of a preoccupation in the literature and in practice about understanding which comes first, the substance use issue or mental health issue – which is chicken, and which is egg? Though the answer to this question may have important implications for treatment, it would not necessarily be the most immediate or pressing concern for patients, and has arguably helped to foster a climate of fragmented services – with mental health and substance use services feeling ill-prepared or unwilling to treat patients where their own specialism isn’t seen as the primary treatment issue.

Which agency should take the lead?

The risks of people with mental health issues developing substance use problems and people with substance use problems developing mental health issues are much higher than the risks of developing mental health or substance use issues within the general population. The high prevalence of coexisting mental health and substance use problems within mental health services is well-documented, with recorded prevalence rates in various UK studies at 32%, 36%, 44%, and 46%. Rates in substance use services could be even higher, with recorded rates of 75% in drug services and 86% in alcohol services. With so many people who are affected by dual diagnosis coming through the doors of both mental health and substance use services, clinicians face a difficult challenge. How can they best serve their patients given that they only hold one piece of the jigsaw?

An influential framework for determining the appropriate approach to treatment and care is the quadrant model, illustrated ( figure) in South Staffordshire and Shropshire Healthcare’s dual diagnosis policy. It describes four presentations of dual diagnosis based on levels of severity: mild substance use and severe mental illness; severe substance use and severe mental illness; mild substance use and mild mental illness; severe substance use and mild mental illness. The provisions for treatment described in the quadrant model focus on one service taking the lead (either substance use or mental health), and then this lead service coordinating care, and seeking advice and support from the other service (either substance use or mental health). This partly resolves where ultimate responsibility lies, but leaves unanswered other questions about the nature and practicalities of the relationship between mental health and substance use services (eg, information-sharing), and also leaves unstated the roles of other support and treatment services needed by people with coexisting mental health and substance use issues.

Department of Health guidance (published in 2002) recommended that mental health services take primary responsibility for people with severe mental illness, as they would be “better placed to offer services such as assertive outreach, crisis management and long term care than the substance misuse services”. For less severe cases not eligible for psychiatric care, substance use services are seen as taking the lead. We can be reassured to a degree that patients often improve after usual substance-focused treatments, possibly because at least some emotional problems are generated by substance use and associated lifestyles. This was why NICE recommended that alcohol services faced with seriously depressed or anxious patients should treat their drinking problems first, and consider referring the patient for specialist mental health care only if psychological conditions persist after three to four weeks of abstinence.

Despite this policy direction, there are many circumstances where people are unable to access mental health or substance use services. Sometimes those with low support needs can fall short of criteria for services, and not receive anything. Where which service should take the lead is unclear or is disputed, the result can be a stalemate where neither service can or will act. The danger of these barriers being unresolved is “service users being shifted between services and falling through the net of care”.

How can we prevent people falling through the gaps?

Coordination or joint working could be the answer. But a number of practical and cultural barriers make it difficult to achieve – sectors and services are guided by different policies, there is often a disconnect between available resources and service user or professional preferences for treatment and care, and there is a shortage of designated dual diagnosis funding. A dual diagnosis handbook published by social care organisation Turning Point suggests that “commissioners might want to explore concurrent funding streams – (eg, for mental health support services and substance misuse) – or look to share budgets to provide social care for vulnerable groups”.

In a recent piece for the Guardian, Professor Liz Hughes, who has extensive clinical and academic experience in mental health, substance use and dual diagnosis, warned that “the UK dual diagnosis scene is running on nothing but goodwill by a few enthusiastic champions”. The challenge is “being able to provide effective services to people with high needs, in a time of unprecedented crisis in mental health provision and loss of mental health expertise within the substance use sector.”

One potential source of new funding comes from the Government’s Life Chances Fund. In January 2016, Prime Minister David Cameron announced that “up to £30 million” would be available for “the development of new treatment options for alcoholism and drug addiction, delivered by expert charities and social enterprises”. This funding pot is based on the model of Social Impact Bonds, designed to leverage funding to service providers, and improve the outcomes of services by making funding conditional on achieving results, rather than inputs (eg, number of counsellors) or outputs (eg, number of counselling sessions). The independent Mental Health Taskforce to the NHS recommends that applicants should “demonstrate how they will integrate assessment, care and support for people with co-morbid substance misuse and mental health problems”.

Integrated services with staff trained and skilled specifically for dual diagnosis clients represent an alternative to independent working, or joint/coordinated working. This seems like the ideal solution on paper – clinicians in these services would have shared values, policies and processes, and there would presumably be no obstacles to information-sharing. However, the evidence about the effectiveness of integrated care has so far been inconclusive. This does not necessarily preclude the development of integrated services now or in the future, but does indicate that “the case for integration [may need to be] based on practice-based evidence rather than evidence-based practice”.

Unique opportunities (and challenges) in prison settings

Dual diagnosis is a common problem in prisons. “Nine out of ten people in prison have a mental health or substance abuse problem – often together – but most do not receive the right care”. Many prisons in the UK apply a “parallel approach” to dual diagnosis, where patient care is provided by more than one treatment service at the same time. The main advantage is that the patient receives specialist help for each of the different aspects of their problem. However, given the overlap of many problems, and the historic compartmentalisation of services (whereby substance use and mental health teams have tended to refer prisoners onto each other, rather than seeking to work together), the parallel approach has been perceived as fragmented care.

Overall, the evidence suggests that prison environments present an opportunity to provide integrated care to people with mental health and substance use issues. The recommendation is that more energy should be put into improving communication, information-sharing and referrals between services, and more research should be conducted into effective psychological interventions for prisoners with a dual diagnosis.

What treatments work?

Partly due to a lack of high quality trials, there has been no compelling evidence to support the use of any one particular psychosocial treatment over ‘treatment as usual’ for people with both severe mental illness and substance use problems (1,2). A recent review of psychosocial treatments for co-occurring cannabis use (the dominant drug problem in the UK among patients new to treatment) and mental health problems found poor results across the board, equivalence among therapies, and a failure to improve on usual treatments. When the authors looked beyond the trials where participants were randomly allocated (ie, beyond the most rigorous trials), they found some evidence for the use of motivational interviewing in psychiatric settings combined with cognitive-behavioural therapy, but little for cognitive-behavioural therapy alone.

Depression plus problem substance use is the most common combination encountered by substance use services. Experts disagree about the best general approach. An Australian study suggested that in some cultures this may differ for men and women – or at least, that for men an alcohol-focus may be a more acceptable and effective way of tackling their depression and drinking, while for women a focus on depression may be preferable. Given the difficulty of identifying which problem is primary, and the risks of getting this wrong (both could have equal weight and/or be independent of each other), guidelines from the British Association for Psychopharmacology say that “pragmatically, both disorders may have to be treated concurrently”. Their freely available resource offers extensive guidance on medication-based treatments for mentally ill problem substance users.

It seems likely that many patients with depression would benefit more from addressing this directly at the same time as addressing problem substance use. One medication-based strategy was tried in a US study which selected alcohol-dependent patients whose depression was judged independent of their drinking. It found that combining sertraline for depression with naltrexone for drinking substantially and significantly promoted abstinence compared to either alone or to placebos, and also helped more with depression. This is, however, not a universal finding. Prompted by that study, researchers in New Zealand tried adding the similar antidepressant citalopram to naltrexone in the treatment of dependent drinkers suffering what for three-quarters was judged to be major depression independent of their drinking. In this case adding the medication led to no significant overall benefits in respect either of depression or drinking.

Establishing what works for patients with a dual diagnosis is not easy given the wide spectrum (and combination) of substance use and mental health problems that exist. The label of dual diagnosis itself can facilitate or impede access to treatment, and its subsequent success. Where dual diagnosis is associated with negative stereotypes it can be stigmatising for services users. Where the term is associated predominantly with severe mental health or substance use issues, it can exclude people with lower level issues who would still benefit from treatment tailored to their coexisting issues. Where the term can be powerful is in raising awareness of the gaps in support for people with complex and coexisting difficulties. Where it can also be beneficial is in promoting a language which emphasises the importance of collaboration between mental health and substance use services.

Where do we go from here?

Progress, a group of consultant nurses and expert practitioners working in the National Health Service (NHS), runs a website offering useful resources about dual diagnosis for service users, carers and professionals. This includes the stories of David, Martha, ‘God’ and Jason (based on the experiences of people with mental health and substance use issues), and information about how to find a member of Progress working near you.

NICE is in the final stages of producing guidance to improve services for people (aged 14 and over) with severe mental illness and substance use problems, not just for their immediate mental health and substance use support needs, but those relating to physical health, social care, and housing. The expected publication is November 2016, but draft guidance is available here. Recommendations include collaboration between services in mental health, substance use, primary care, and social care, as well as organisations in the community and the voluntary sector, and the agreement of a protocol for information-sharing between all relevant services. It also recommends that people with coexisting mental health and substance use issues should be encouraged to stay in contact with services, and be involved (along with their family and carers) in developing their own care plan, which should take into account how their abilities, strengths and past experiences can help support engagement and recovery.

Dual diagnosis is not a single entity but a label for differing constellations of troubling substance use and psychological problems. Present gaps in resources, knowledge and evidence about dual diagnosis are putting a strain on clinicians, and risking many patients getting lost in the system. Historically, the values and treatment approaches of substance use and mental health services haven’t always been aligned. One potentially “binding philosophical strand” going forward is the increasing importance of recovery within both services, with opportunities to define what recovery means for people under the umbrella of dual diagnosis, and create new shared values around these aims.

Completely agree with all of it and look forward to see the new NICE guidelines! 🙂

Ask Alanis Morissette: how can I stop drinking so much?

Alanis-Morissette-LFrom The Guardian in April’s Ask Alanis Morissette’s column: how can I stop drinking so much?

I started drinking at university, and 25 years later, I still drink daily and often too much. Most would consider me successful: I have a PhD, a great job, a nice house, a solid marriage, and good health. So why drink? The short answer is, I enjoy it. But I frequently feel tired (or have a hangover) the next day. I still go to work, exercise, and do everything I normally do – including drink at the end of the day. How do I stop?

Perhaps you drink to release stress at the end of the day, or as a kind of congratulations, or a way to rebel in the face of too much responsibility? I would recommend investigating other ways to reward yourself to see if, in fact, alcohol has more of a hold on you than you think. Would a massage or a bath or a homemade lemonade do the trick? If that sounds like a big shift, then you may need more support. There are many forms this could take, from seeking rehab, to reading self-help books, to attending a local group, or a combination of all three.

For me, alcohol served as a brilliant secondary addiction to stave off the effects of my three primary addictions, which were love, food and work. Anyone who overworks, is overly generous with their time, energy or money, is overly responsible (might this be you?), or has a background including trauma, can rely on substances of many kinds to reduce this stress.

The thing about alcohol that can be so compelling is that it works. It gives us an hour or two of calm, or invigoration, or whatever we might be turning to a drink for. However, it offers this only temporarily, and as you mentioned, there is a fallout – involving health, wellbeing and, often, relationships. If attempting to replace the alcohol ritual with something healthier proves to be too challenging, I recommend identifying what your primary addiction(s) might be, and getting help with those.

Addictions don’t go away on their own. We either choose actively to recover, or these same processes and substances that seemed to keep us afloat will eventually end our lives, in the most extreme cases. I have been in recovery myself for many years now, and there have been many gifts on the road. I wish you well in shifting your habit, or with your own recovery.

Friday Sober Jukebox – Broken Stones

sally bramptonSo with a week to go before I hit 1000 days I’ve become very reflective and the recent news that Sally Brampton walked into the sea not to return made me both profoundly sad and introspective.  This image is taken from her blog and I believe it is her sat on the stones and pebble beach near where she lived.  I used to love reading her column in The Sunday Times Style as she was so full of wisdom and compassion.  Her own ongoing struggle with depression and her past battle with alcoholism was known and added to, not took away from, her ability to offer comfort and advice.

She renounced alcohol in 2003.  ‘It would take three years and a 28-day spell in rehab for alcoholism, as well as attendance at AA meetings, for Sally to recover completely.’ (Daily Mail)

This is the post that remains on her website and resonates so strongly for me:

This is where I write about pretty much everything I love; usually emotion, because I think that’s where we all connect. I write about depression because I have depression, and I think it’s good to talk about it. Sharing can bring us out of the dark and into the light. That’s why I wrote a book about it; Shoot the Damn Dog, and I am pleased and honoured that it helps so many people, who write to me sharing their experiences. I wish I could reply to every letter, but I simply can’t, because there are so many, but sometimes, it’s just good to get our thoughts down on paper. It makes us feel less alone and I hope it helps you as much as it helps me to know that we are in this together, and that there are people who truly understand.”

Obituaries were written by The Guardian, The Telegraph and The Independent.

But the most poignant was the page dedicated to her in The Sunday Times Style magazine a few weeks ago which shared some of her gems of wisdom from her column that ran for 8 years to ‘celebrate her infinite wisdom.’

Sally Brampton RIP 2016

This tune played recently on my rounds and it felt apt – the lyrics, the images of the beach and sea and so I share it here in memory of Sally.

Rest in Peace.

 

There’s no such thing as an addictive personality

the conversationAnother excellent piece from The Conversation in March looking at the topic of addictive personality.

“Life is a series of addictions and without them we die”.

This is my favourite quote in academic addiction literature and was made back in 1990 in the British Journal of Addiction by Isaac Marks. This deliberately provocative and controversial statement was made to stimulate debate about whether excessive and potentially problematic activities such as gambling, sex and work really can be classed as genuine addictions.

Many of us might say to ourselves that we are “addicted” to tea, coffee, work or chocolate, or know others who we might describe as being “hooked” on television or using pornography. But do these assumptions have any basis in fact?

The issue all comes down to how addiction is defined in the first place – as many of us in the field disagree on what the core components of addiction actually are. Many would argue that the words “addiction” and “addictive” are used so much in everyday circumstances that they have become meaningless. For instance, saying that a book is an “addictive read” or that a specific television series is “addictive viewing” renders the word useless in a clinical setting. Here, the word “addictive” is arguably used in a positive way and as such it devalues its real meaning.

Healthy enthusiasm … or real problem?

The question I get asked most – particularly by the broadcast media – is what is the difference between a healthy excessive enthusiasm and an addiction? My response is simple: a healthy excessive enthusiasm adds to life, whereas an addiction takes away from it. I also believe that to be classed as an addiction, any such behaviour should comprise a number of key components, including overriding preoccupation with the behaviour, conflict with other activities and relationships, withdrawal symptoms when unable to engage in the activity, an increase in the behaviour over time (tolerance), and use of the behaviour to alter mood state.

Other consequences, such as feeling out of control with the behaviour and cravings for the behaviour are often present. If all these signs and symptoms are present then I would call the behaviour a true addiction. But that hasn’t stopped others accusing me of watering down the concept of addiction.

The science of addiction

A few years ago, Steve Sussman, Nadra Lisha and I published a review examining the relationship between eleven potentially addictive behaviours reported in the academic literature: smoking tobacco, drinking alcohol, taking illicit drugs, eating, gambling, internet use, love, sex, exercise, work and shopping. We examined the data from 83 large-scale studies and reported a prevalence of an addiction among US adults ranged from as low as 15% to as high as 61% in a 12-month period.

We also reported it plausible that 47% of the US adult population suffers from maladaptive signs of an addictive disorder over a 12-month period and that it may be useful to think of addictions as due to problems of lifestyle as well as to person-level factors. In short – and with many caveats – our paper argued that at any one time almost half the US population is addicted to one or more behaviours.

There is a lot of scientific literature showing that having one addiction increases the propensity to have other addictions. For instance, in my own research, I have come across alcoholic pathological gamblers – and we can all probably think of people we might describe as caffeine-addicted workaholics. It is also common for people who give up one addiction to replace it with another (which we psychologists call “reciprocity”). This is easily understandable as when a person gives up one addiction it leaves a void in the person’s life and often the only activities that can fill the void and give similar experiences are other potentially addictive behaviours. This has led many people to describe such people as having an “addictive personality”.

Addictive personalities?

While there are many pre-disposing factors for addictive behaviour, including genes and personality traits, such as high neuroticism (anxious, unhappy, prone to negative emotions) and low conscientiousness (impulsive, careless, disorganised), addictive personality is a myth.

Even though there is good scientific evidence that most people with addictions are highly neurotic, neuroticism in itself is not predictive of addiction. For instance, there are highly neurotic people who are not addicted to anything, so neuroticism is not predictive of addiction. In short, there is no good evidence that there is a specific personality trait – or set of traits – that is predictive of addiction and addiction alone.

Doing something habitually or excessively does not necessarily make it problematic. While there are many behaviours such as drinking too much caffeine or watching too much television that could theoretically be described as addictive behaviours, they are more likely to be habitual behaviours that are important in a person’s life but actually cause little or no problems. As such, these behaviours should not be described as an addiction unless the behaviour causes significant psychological or physiological effects in their day-to-day lives.

Agreed and feel like this would be a useful discussion, for me not about booze but about some of my new reciprocities and the Shutterstock image that was used in the original article of syringes filled and labelled with the words ‘internet, news, social media’ seemed particularly pertinent to me!

Edited to add 19th May 2016:

This article nails pretty accurately many of the other substances, habits and behaviours I’ve struggled with since getting sober

7 Types of Addictions in Sobriety

Friday Sober Jukebox – Slow Emotion Replay

slow emotion replaySo today’s post  falls on Good Friday 🙂  Here’s wishing you all a Happy Easter!

As you know I’ve been studying child and adolescent counselling as a post graduate for the last 18 months and it’s a while since I’ve made any reference to that.  That’s mostly because what I’m exploring in personal therapy and in group isn’t for this space but I’ve had a big aha moment recently that I wanted to share.

We often out here in the sober blogosphere talk about the inner critic – that voice that for me was soul destroying when I was drinking and although it is much less present it is still there.  Well we’ve recently had to video a 30 minute counselling session with a peer and our assignment is to critique our performance!  As you can imagine this is uncomfortable stuff but offers up such valuable insights both personally and in our learning about the therapeutic process.  As part of that I’ve been learning about Kleinian & Rogerian theory.

Melanie Klein was a psychoanalytic therapist and “Klein stresses Freud’s concept of transference, meaning the conscious but also unconscious expression of past and present experiences, relationships, thoughts, phantasies and feelings, both positive and negative, in relation to the analyst.” (source)

She also talked about other psychoanalytic defences such as splitting (splitting a person into good and bad objects) and projective identification and that these can be projective and introjective phantasies operating together.

And Carl Rogers (1902-1987) was a humanistic psychologist who agreed with the main assumptions of Abraham Maslow, but added that for a person to “grow”, they need an environment that provides them with genuineness (openness and self-disclosure), acceptance (being seen with unconditional positive regard), and empathy (being listened to and understood). (source)  Self-actualisation was the title of my 2 year post so ties in nicely 🙂

I am going somewhere with this I promise!  So we can not only project parts of ourselves that we don’t like outwards onto others but we can also internalise them.  And one of the strengths I was complimented on by my tutor during the review of the footage was my therapeutic presence (as indicated by Roger’s above).

So fast forward to some processing going on while running and some of the feedback I’ve had during personal therapy recently and the penny dropped.  For us to heal we have to provide a positive therapeutic presence for ourselves just as we do for others.  We have to internalise the ability to be kind to ourselves and when we are in a place of emotional distress rather than reverting to the introjected bad, & for me punitive position (which is usually the voice of someone else not my own), it’s important to recognise that and acknowledge it and be gentle.  We do this in the early days of getting sober but as time goes on that critical voice finds new outlets and new ways to punish us and we have to see it for that.

So this The The song span round while I was on the same run and felt very appropriate:

In the words of Matt Johnson ‘I don’t even know what’s going in myself’ and ‘You’ve got to find your own salvation’.  I’m working on both of those now …… slow emotion replay indeed.

Braving

brene brown courage worksSo I’ve posted this today because it’s my wedding anniversary 🙂  And for me Brene Brown’s work resonates with both my personal journey and my journey as part of a marriage partnership so it feels wholly appropriate to discuss braving.  This was a free online talk she gave at Oprah’s Super Soul Sessions that was part of the launch of her new Courage Works.  I am a massive fan of Brene and have written about her work on shame before here.

So she was discussing the anatomy of trust – a BIG word and as part of the discussion she broke it down and provided an acronym to give the word some form which is braving.

Now you’re probably wondering – what has that got to do with this blog?  Well a big part of the recovery journey for me has been about self-trust.  And as Brene says self-trust is braving self love and self respect, which to me means self-care and that is a HUGE part of the recovery journey.

As she says we have to trust ourselves above everyone else because

“You can’t ask people to give you what you don’t have”

I never trusted myself as a drinker because once I’d had one drink all bets were off and my self-trust has been massively restored through sobriety.

So here is the lovely pdf she designed to explain braving and a worksheet for rumbling with self-trust

BRAVING_Download

Rumbling_with_Self-Trust

I really really like this (along with everything else she does!!)  but this bit really rang loud bells “Did I choose courage over comfort? Did I choose what’s right over what’s fun, fast, and easy?”  Boundaries, reliability, accountability, integrity, non-judgement, generosity towards self and others and the vault of friendship are all hugely important to me and were seriously eroded by alcohol leaving me with guilt and shame.  It wasn’t that I was a ‘bad’ person it’s just that my sensitivity to alcohol meant that it co-opted my normally reliable self and destroyed my boundaries and integrity (particularly with myself).  Now that I’m present all the time that isn’t under threat EVER – not with myself, MrHOF or the kids and that makes me feel so proud.

She also talks about marble jar friends – ‘sliding door’ moments of trust where before with booze I couldn’t be sure I would do the right thing but now it has been made much easier.  Plus I have so many marble jar friends out here in the sobersphere I wouldn’t give you or my sobriety up for anything, much like MrHOF, who is ever so grateful we married a month after Valentine’s Day as it has it’s own alternative celebration you may have heard of 😉

I was drinking a bottle and a half of wine a night after my husband walked out

wine binThis was in The Telegraph in December and much like Xmas can be a flash point for relationships (like a husband walking out)  so can Valentine’s Day so this article felt appropriate for today.

Champagne used to be the highlight of my Christmas,  but this year I raised a glass  of non-alcoholic wine – something I never thought would happen. I used to believe that alcohol helped me cope with a difficult marriage; now I think it kept me there.

My husband was unfaithful for eight years.  I felt worthless. I was taking antidepressants, knocking them back with a bottle of  wine every day. We worked in the same law firm, but he struggled and was asked to leave. I became the main breadwinner. I thought if I tried hard enough, it would be all right.

I was desperate to save our marriage.  I’d always taken alcohol  a little bit further than my friends. It was the means by which I was able to feel confident in social situations. The first time I drank, I got drunk. I was 15 and it was at a friend’s party. Her mother was ladling out home-made punch – I thought it was fruit juice. 

You kid yourself it’s fine because you’re not sitting on  a street corner. I’d entertain friends; the wine would flow and flow, and once I started  I couldn’t stop. The next day friends would say, ‘I’ve got  a serious hangover.’ Not me.  The more I drank, the more  I was able to drink. Four years ago, after 26 years, my husband left.

After the divorce, I gained two stone.  I could drink a bottle and a half of wine a night. My personal trainer said, ‘All the exercise in the world won’t help if you drink all those calories every night.’ She was right. I was frightened about my health, but I couldn’t stop.  

My son had always liked that I was good fun, but that changed last summer. He lives in New York, had recently got engaged, and invited me to hear him sing solo in his choir. I flew out from London, and went out with a friend the night before the concert.

The next day I went to the wrong concert hall, and missed it. I claimed it wasn’t because I was drunk.  He replied, ‘But you were. All you want to do is drink all day.’  I felt deeply ashamed. The turning point was when I went away with him, his fiancée and her parents, and I could see that he was on edge in case I drank.  I thought: enough. 

I had the details of a counsellor who offered a cognitive behavioural therapy-based programme for women worried about their drinking, but I hadn’t contacted her because that would mean I was an alcoholic. When I rang, she said, ‘You’ve done the hardest thing, and now it will be fine.’ 

She changed the way I see alcohol. I started asking, ‘Would this situation have been better or worse with alcohol?’ Giving up had always felt like deprivation but I realised that everything I’ve regretted, from staying too long in a miserable marriage to upsetting my son, was because of drinking.

Recently, I attended his wedding. People said, ‘Why don’t you have a glass of champagne?’ I said, ‘I could. But I don’t need it any more. I’m having a great life without it.’

If booze has become your bad lover – maybe it’s time to kick him into touch too? 🙂