 Welcome to today's presentation, everybody. We're going to be discussing the interplay between addiction and mental health and physical health. I just didn't want to make the title quite so long. Over the next 45 minutes or an hour, we're going to define co-occurring disorders, identify the impact of addiction on the individual, identify the impact of mood disorders on the individual, identify the impact of chronic illness or pain on the individual, and then explore the interplay between the three. Obviously, in this presentation, we're talking about the individual. We know that as a person's mental health or physical health decompensates, there will be effects in their relationships, which will have kind of reverberating effects, but we just don't have time to cover all of that in this hour. So right now, we really want to just look and understand the interplay and why it is so incredibly important to treat the co-occurring disorders concurrently, not prioritize and go, well, we'll treat this one, and then when that one's cured, we'll treat this one and go down sort of a linear thing, which takes me to my next slide. Shout out to my Hubean friends. People assume that time is a strict progression of cause to effect from a nonlinear, non-subjective point of view. It's more like a big ball of wibbly wobbly, time-yummy stuff. This is true about co-occurring disorders, too. It's not linear. You can't say this caused this and then this caused this. They have reciprocal effects and they feed back in on each other. Why is that important? Because, well, it's important for a lot of reasons. Number one, the cool thing is if you pull one string, for example, sleep, which is one of my favorite things in the world, and you start improving people's sleep quality, whatever you have to do to improve that sleep quality, is probably going to have positive effects in the other areas of life. Likewise, when people stop sleeping, maybe you're studying for final exam or you have a big project due at work, or you've got a little one at home and you're getting up every three or four hours to feed the baby, whatever the case may be. As our sleep goes down and our sleep quality goes down, it also has wibbly wobbly effects on all other areas of our life. You're never going to be able to watch Doctor Who again without hearing me say that. So why do we care? Co-occurring disorders, and I like the term multi-occurring disorders, but it doesn't really exist, so we'll stick with what exists. Co-occurring, things that occur at the same time, and there can be multiple co-occurring disorders, are the expectation not the exception, okay? We are not looking at someone who comes in and they just present with addiction and go, hey, you know, I have an addiction, but my mood is great, my self-esteem is great, I have no pain, I have no physical problems, my relationships are awesome, I just want to quit abusing alcohol. It just doesn't happen like that. So what we need to do is understand the person as a whole. A person who's sober, for example, but depressed is at risk for relapse into addiction. When you have someone in early recovery and they're not using alcohol, so they're clean, they may not have really mastered all of those new coping skills and coping tools yet, and that new lifestyle, and they're depressed. Now we know that people use addictions as a means of escaping from distress, so you take away that one thing that was working for them and you leave them in distress, what do you think is going to happen? A person who's actively using and we're working on a mood disorder is altering the balance of the neurotransmitters, they're still getting those dopamine rushes, they still have their neurotransmitters wonky, so it's going to be hard for their mood to improve enough where they can let go of that addictive behavior, so we need to treat them both. What are co-occurring disorders? Mental health addiction and physical health problems and their interaction, they must be treated concurrently. The MINCOF model highlights the interplay between mental health and addiction. He talks about having severe mental health, mild addiction, mild mental health, severe addiction, there are four quadrants. In any event, he does indicate that obviously we're going to focus a little bit more on the things that are more severe. If you have somebody with mild mental health and severe substance, they're probably going, if you have to choose, they're probably going to go into a addiction treatment facility as opposed to a mental health treatment facility, at least to start out with. Either place, my hope, my dream, and it's really still a dream at this point, is that the clinicians there are able to handle the dual disorders. This is a starting point for placement decisions. This is not saying that all we're going to address is the mental health and the addiction, because guess what? What happens when you get stressed out? Your immunity goes down, you get sick, you get aches in your back, you get headaches. We've got some chronic pain going on. Now, is it stuff we can address as stress goes down? Will some of that muscle tension go down and will the headaches maybe decrease and the gastric upset decrease? Sure. We need to understand that the physical, we're not just dealing with the head. We're dealing with the whole person. When you're stressed out, how does it impact your mood? I know when I'm stressed out, if I've got a lot of stuff going on, we just launched a podcast here and it's really exciting and there's a lot to do, so I haven't been sleeping as much and I've been a little bit stressed out. It's been harder to enjoy things that I would normally enjoy because I'm constantly thinking about the stuff that I've got on my to-do list to launch this project. My patience is not quite as good as it could be. Patience is not a virtue I have anyway, but I know that when I get stressed out, my patience will go down. It's harder to enjoy things. It's harder to concentrate sometimes because you've just got a million things running through your head and whether it's stressed out about a project at work or how you're going to pay the light bill, it's still stress and there's still thoughts running through your head. Problem solving and creativity. For many people, this goes down when they get stressed because they start feeling more boxed in. Sleep, even if you are sleeping enough hours, if you're in bed enough hours, your sleep may be restless. It may be great, but it may be restless. Energy levels, because you're exerting so much energy on whatever it is that's causing you stress and whatever whatever it is you're trying to deal with, your energy levels for everything else may go down. And after a while, you're going to start feeling kind of worn down. Your system adjusts to excessively high norepinephrine levels and says we can't run at this level up here. So we're going to take it down a few notches, even though there's still all this excess norepinephrine in the system. So it's important to understand that our body wants to protect itself and it's going to slow you down whether you like it or not after a period of time. Appetite changes, headaches, muscle aches. So you can see that something as simple as stress can have a lot of repercussions. Now if you add to that somebody who's already struggling to deal with life on life's terms or someone who has an addiction, guess what? They're just going to be like, yeah, I can't deal. Let me put my head back in the sand and I'll pull it out in a little while and see if maybe something's changed. People with addictions are trying to get some relief from emotional or physical distress. I get this. It's a survival mechanism. Nothing else is working. And at this point, they are just trying to survive. Unfortunately, whether the addiction is behavioral or chemical, you're creating an imbalance in the neurochemicals in the brain, which are going to keep you or going to exacerbate the anxiety and the depression. And if they're schizophrenia and bipolar and other stuff, it may exacerbate some of that too. But understanding that when those neurochemicals are out of balance, and I've used the analogy before of making a good marinara sauce, you have to have the parsley, the fennel, the oregano, the basil, all in the right combination in order for it to taste good. The same thing is true for the chemicals in your brain. You have to have the dopamine, the serotonin, the norepinephrine, the acetylcholine, and the glutamate, all in the right combinations to feel good. And your body has this predetermined recipe. It's just a matter of letting it create that recipe instead of trying to artificially bump one up with addictions or self-medication of some other sort. So mental illness effects. When somebody is, and I hate the term mental illness, I really do, because it sounds so pathologized. When someone is depressed, emotionally, they're going to feel depressed, and it's going to be hard to be happy. That's kind of part and parcel of the definition. Cognitively. I mean, we're just going to go through these symptoms. These are the DSM symptoms, difficulty concentrating, perception of hopelessness and helplessness, this victim mentality a lot of times feeling like they can't win. Nothing they do is going to do any good. Sleep disturbances, eating disturbances, restlessness and agitation, achiness and fatigue. So take all those symptoms and just think for a second, how would you like to feel like that 24 seven, you know, for 30 days, you know, hopefully not 365. Most people can't be that depressed for an entire year. But how, what would you do? How would it affect you? Would you want to escape? I know I would. Would you start getting some back aches and stuff when I don't sleep well, and I have difficulty concentrating, I tend to start to carry tension. I get achy and, you know, I don't want to go to the gym, but I also get achy from not moving around enough. Fatigue that is aside from not sleeping. People who have depression typically find that, I mean, they feel like their body weighs a thousand tons and just moving from one side of the house to the other. Just getting off the sofa is a huge big deal. I mean, my kids make fun of me now as I get older. I make more sounds every time I get up, you know, I've grown grimace. It feels more intense and it feels very heavy. Think about them carrying sort of the weight of the world on their shoulders. This is what it feels like physically too. Socially, so if you've got all that going on, do you really want to hang out with your buddies? I mean, if you've got some really good friends who can be there, be supportive and, you know, are doing all the right things, at least what you need at that point, you might, but sometimes it's just like I can't even deal with that. I hear that your heart's in the right place, but I don't have the energy to put on any kind of happy face or face at all right now. I just can't deal with people. Low self-confidence. Okay, if you're feeling this way for a while and you're starting to feel, you know, hopeless and helpless, you don't feel like you can break out of the depression, your self-confidence may start going down. And as your self-confidence starts going down, your desire to do stuff goes down, which then makes your self-confidence go down even more and you start withdrawing. Lack of energy or desire to interact and relationship deterioration. At a certain point, people, people are there. They want to be helpful. They want to be your friend. They want to be supportive, but at a certain point they've got to say, you know, there's nothing more I can do. And I can't allow myself to be in an environment that is quite that heavy all the time. So people start, healthy supports start to withdraw at a certain point. And then environmentally, we don't think about this a lot, but the outside reflects the inside. Think for a second. For most of us at least, when we're stressed, when we've got a lot going on, when we are just, things are kind of chaotic mentally for us, because there's just so much going on. A lot of times everything in our environment kind of looks the same way. You know, if, if I've got a lot going on at the office, my tendency to put away my clothes after I wash them goes way down. But that's just me. Disorganization and lack of attention to other stuff, because there's so much energy going on with all these thoughts. And a lack of energy or desire to care for anything is just like, I don't have it in me. I don't have it in me to wash the dog. I don't have it in me to mow the lawn. These are all impacts of mental illness. So when you're feeling this way, when you're starting to lose your social supports, you're starting to lose your confidence in yourself. You've lost hope. You feel somewhat helpless. And you feel stuck. You can see where this may impact other things. It's going to, you know, you may start feeling gastrointestinal stuff. When we get upset, a lot of us take our stress and feel it in our bellies. Some of us feel it in our backs. Some of us feel it everywhere. It's important for people to understand where they feel their stress. But there is a physical aspect. And when you're achy and you can't get comfortable in your stomach hurts, do you really think you sleep that well? You see how the wibbly wobbly is folding back in. So how does mental illness impact addictive behaviors? Emotionally, addiction numbs or medicates the depression or anxiety for a short period. When someone is using or engaged in their addictive behavior, they are focused on that addiction. They are getting that dopamine dump, that behaviors getting rewarded. They are not in the other world. They are in the addictive world. Cognitively, addiction reinforces hopelessness and helplessness. A lot of the things that we talk about in addiction treatment, stinking thinking, refers more to a victim mentality. You did this to me. I'm going to blame. I'm going to manipulate. I'm going to lie. I'm going to feel bad and sorry for myself because I feel helpless and hopeless. Now, am I saying, well, people just need to have an attitude change? No. You know, we need to look and see what is it that is causing you to feel helpless and hopeless? And how can we go about supporting you and becoming hopeful and empowered? Physically, addiction helps people relax to get to sleep or it may keep them up instead of sleeping. So, you know, it depends on what your end goal is, which addictions you choose. Addictions to painkillers, to depressants, to sedatives, and a lot of your behavioral addictions tend to increase the relaxation, increase all those neurochemicals to help the body wind down. Then you have your stimulants, your cocaine, your methamphetamines that can help you help keep you up. So, if you're one of those people who is afraid to go to sleep or who doesn't want to go to sleep, the addiction can do that. The other benefit with stimulants is it increases the feeling of euphoria. So, it may be a trade-off. You know, I may not sleep too well, but I'm going to feel darn good while I'm awake. Thinking about our patients who abuse addictions or abuse amphetamines, the crash from that is just incredibly hard. So, as soon as those amphetamines are out of their system, they are depressed. What's going to happen? They're going to use again and they're going to feel happy, not as happy. They're going to feel happy and then they're crashed and they'll be even more depressed than before. And it's this downward peak and valley until they hit some semblance of bottom. Food is often used as a secondary self-soothing or addictive behavior. It can be the first thing that somebody uses in the development of addiction behaviors, addictive behaviors, or it can be something that they use as a drop-back in punt. We saw this a lot in residential treatment and I'm sure people still do see it where food is used as a comfort because they can't access sex, they can't access gambling, and they can't access their drug of choice. So, guess what? Food is the, you know, next best thing that they can access that is going to stimulate some of those reward pathways. In addictions, people often create a situation where their brain has adjusted to these higher levels of certain neurotransmitters. So, when they have a normal level, they don't feel normal at all. They feel like crap. It's important for people to understand, clients, family members, et cetera, because their brain can recover. But it's important for them to understand that, yeah, when you're not using, you are going to feel kind of bleh for a while. You may have a different, more clinical word than bleh, but you get the point. Physically, addiction helps soothe restlessness and agitation. Detoxin can intensify it. So, thinking about alcohol, or when we talk about some of your amphetamines, but let's take alcohol for this one. Initially, there's a relaxation, there's a loosening up, there's a disinhibition. As the alcohol wears off, there is an anxiety-provoking component. People start to feel restlessness and more agitated. So, what do they do? They pick up another drink. Hair of the dog that bit you, if you will. Aciness can be relieved or numb by certain addictions, especially in the case of opiates, but it may cause the body to stop making its natural endogenous opioids. So, if people start taking opiates in order to deal with achiness, you know, we're not talking post-surgical pain, we're talking back aches, muscle aches, spasms, they may get to the point where when they're not taking those, their body's not producing the natural painkillers, so their pain tolerance basically has gone through the floor and everything hurts and it's really achy and it's really uncomfortable. That's something that we see a lot when people are detoxing from methadone, especially if they're going cold turkey, because their body hasn't been back into gear yet. Addiction to stimulants may be used to self-medicate fatigue, but can cause rebound exhaustion. Think about times when you've been tired and, you know, I'm not talking about just kind of, wow, I'm talking about I cannot put one foot in front of the other tired. If you've drunk a lot of coffee, you may feel awake for a little while, but when that caffeine wears off, there's just huge crash. Take that, multiply it by like 50 or methamphetamine. Socially, addictions may be used to help people loosen up, feel like they are part of a group, make it easier to interact with others. So the addiction, if someone is withdrawing from their friends or their friends are withdrawing, remember going back to the mental illness, it may help them feel a little less depressed, a little less anxious, it may help them feel more sociable, more confident, and it may provide an alternate peer group that is more tolerant of the depressive behaviors. What we are saying is not that the primary diagnosis is mental illness, what we're saying is that mental illness, addiction, and physical illness all reciprocally impact each other and are equally important in treatment. Environmentally, in addiction, there's little concern for the environment unless the person's trying to hide the addiction. For example, if they're trying to prove that they are not an alcoholic or if they're trying to prove that they don't have some other problem going on, they may become more attentive to cleanliness and organization. As the addiction develops, that typically goes away by the time somebody is hitting whatever their bottom is. Generally, they're not trying to pull the wool over anybody's eyes anymore, they just want people to leave them alone. Hi, how are you? So what are the benefits to addiction? Numbing, relaxation, euphoria. When people start using whatever it is that they become addicted to, and remember it can be behavioral or chemical, there is recreational use of just about anything, whether it's legal or not is a whole different story. Why did they initially start using it? I think back to friends that I've had and family members that I've had that when they get stressed out or after a long day at work, they go out and have a few drinks to relax. Are they addicts? No. So what are the benefits? When people start using addictive behaviors, they're trying to relax, they're trying to feel a little bit better. As they progress in their addiction, their thinking may change. Physically, in their addiction, they may be able to temporarily increase their energy or feel like they're improving their sleep or relaxation through basically chemical means, if you will. This happens before the addiction develops. These are effects from everything. These are effects that people may seek out when they begin a pleasurable behavior. How does it become an addiction? Well, it becomes an addiction when that behavior starts being used in order to cope with, escape from, or numb out the stress of some sort. Socially, addiction may give people a new peer group. It may not be a healthy peer group, but it may give them a new peer group. So when people start out using, maybe they're drinking with their friends in high school, not addicts, just recreational users, they start drinking more in college. They may start feeling like they have to go out more. As they use, they start getting the neurotransmitters in their brain wonky, for lack of a more clinical term, and that intensifies the need to use again. They're creating a self-perpetuating cycle. Addiction is real. It's not just willpower. When people start using, tolerance and withdrawal are very, very real, very, very biological effects of addiction. So if somebody's created that, then they have altered the neurochemicals in their brain, and this is where we get to the point when you're talking with physicians, which came first, the depression or the substance abuse. It doesn't really matter. We got to treat them both now because they're both presenting. Like I said at the beginning, if we only treat one, then we're setting the person up for a relapse. In long-term treatment, when you're looking on the long haul, if the person had relatively balanced neurochemicals from jump and their brain chemicals and their mood and everything else got out of whack from use, then it follows that with time and treatment, their brain can recover and the mood disorder will remit. Whether the person needs to be on a short course of antidepressants or anti-anxiety medications in order to help them get through that brain adjustment phase is between the person and their physician and psychiatrist. But it is important to understand that addiction can cause depression and depression can precipitate addiction. So addiction causes neurotransmitter imbalances. As depression and anxiety worsens, the need for the addiction and numbing increases and life starts to revolve around using. People want to feel good again. And like I said, it's a high and in substance abuse treatment, we talk about chasing the high because the first high is the highest high. And then every high after that, it peaks and then crashes lower and then peaks, but the peak is lower this time. You're not feeling as good. The brain is adjusting and starting to try to adjust to those floods of dopamine and rewarding neurochemicals. This leaves people not feeling normal when they're not using. So they go back to the addiction, which leads them to lying and manipulation in order to keep the addiction. Because right now at this point, if they've created this situation, the addiction, the behavior, the substance is what's keeping them feeling okay. It's numbing the pain right now. And when they take that away, it's way more agonizing than before. A, because the neurochemicals are out of balance and the person may have biological reasons for depression. But B, there may be social, environmental, financial, and cognitive reasons for depression that have developed as a result of the continued use. Physically addiction disrupts circadian rhythms through too much or too little sleep. And you know how much, you know, I said before how much I love sleep and how important I think circadian rhythms are because your body regulates your neurochemicals. You know, serotonin is excreted when you start relaxing, which serotonin is converted to melatonin, which helps you sleep. If you start messing that up and having serotonin too high at certain levels or too low, sleep is going to be affected. If you don't have enough serotonin, you can't make enough melatonin, your sleep is not going to be good. Addiction by the same mechanism can alter hunger cues and can cause health problems, which lead to chronic pain. Socially addiction becomes the person's best friend. You know, those people turned on them and wanted them to give up the addiction. They were judgmental, they were hateful, they, you know, in the addict's mind, tough love is not love at all. It is betrayal. So the addiction becomes the person's best friend because the addiction is not going anywhere and it always numbs the pain. Now, after a while, they may need to add a little bit to it because they've developed a tolerance, but it starts being pretty much the go-to. They begin spending time only with using peers or alone. Using peers get it. And being alone, they don't have to answer to anybody. When we're, when we talk about people in recovery, we want people to spend time with people in recovery because those people have also been the using peers before and, you know, you can't con a con. So having people in recovery also in your lifestyle as you recover is important. Loss of healthy relationships because people who are not struggling with issues of addiction and mental health don't get it. They don't understand the draw of the addiction most of the time. And trying to help families understand why people can't just stop is a huge challenge. And if they get it, then they may understand and they may understand relapse. They can also lose healthy relationships because they don't want to want to be around people who might take away their addiction. So they're going to push them away. So some people may choose to leave because they just don't understand or the person with the addiction may push people away because they don't want to give up the addiction. Environmentally, again, the inside and the outside often reflect what's going on. Addiction may take precedence over environmental cleanliness or safety and may cause feelings of depression. So where does chronic pain come in? Well, you know what? A lot of people experience chronic pain and it can be from an injury. It can be from a disease or it can be from stress, chronic migraines. You name it. It's not for me to say who has chronic pain, fibromyalgia. It's not for me to say whether your pain is intense enough and chronic enough. If it is disrupting your life in one way or another, we're going to talk about chronic pain because it's having a negative impact on your life, which can cause mood problems, which can cause you to want to escape through addiction. Think about the last time you were in a lot of pain. About three weeks ago, I had a double ear infection and I don't get in ear infections but I have no tolerance for your pain at all. I was trying to work. I couldn't focus. I was trying to find my own number for the doctor. I couldn't even remember what to Google. I could not focus because I was in so much pain. It causes a difficulty concentrating, so I don't want to say childbirth because a lot of times it's not that bad. But think about a time you were in chronic pain. How able were you to concentrate? How able were you to look at the silver lining of everything versus being, oh, crap, it's a rainy day and it's hot outside. I just washed the car. A lot of times when people are in chronic pain, their mood is lower. We know that serotonin is involved in pain tolerance, so when people have chronic pain, we may look for death serotonin imbalances, which can also contribute to depression. These negative perceptions just reinforce it. If you get up and you're curmudgeonly all day long, you're going to see the negative. So you've got someone and, you know, sometimes I don't blame people. I would hate to be in that kind of pain all the time. Rheumatoid arthritis, oh my gosh, I can't imagine. Um, my hands get sore after gardening, you know, during planting season. I can't imagine living with that 24, 7, 365. I know what it does to my mood. I know what it does to my ability to be just sadly cheerful. Our clients are the same way, which impacts their relationships. If every day they get up and they hurt, at a certain point, nobody wants to hear about it anymore. They're like, yeah, we know you hurt. Well, what else is now? So they're not getting the sympathy. They're not getting the support that they may feel like they need. They're not able to sleep as well. You know, if you're in chronic pain, it's hard to get good quality sleep and stay asleep. Fatigue, again, from not sleeping well. Your body requires energy to maintain muscle tension. And a lot of times when people are in chronic pain, they also have muscle tension. So they're using a lot of energy for negative cognitions, muscle tension, and then just trying to cope with and find workarounds for that pain. Socially, if you hurt, it's hard to want to go out and do stuff with friends, even if, you know, you've got a headache. I'm not even talking of migraine. You just got a headache. Do you really want to go out and walk around at the mall? Not so much. Friends, like I said, may get tired of hearing about the pain or may feel taken advantage of if you're always needing them to do stuff, not saying that you don't need them to do stuff. You know, sometimes that's just where you are. It is hard for a lot of support people to really get in the shoes of the person with chronic pain and understand how bad that pain is. It's a give and take. You know, some people find this little niche and they exploit it. Other people really need the help. Environmentally, the environment may be in disarray. The person, if every day you get up and you hurt and it hurts to do anything, it can be very frustrating. I know when my grandfather started developing Parkinson's, he loved to make miniatures. He made miniatures on wooden doll furniture and stuff. Beautiful, beautiful stuff. He prided himself on that. Now, my grandfather was an active alcoholic. He had PTSD. He had chronic depression. He had a whole bunch of stuff going on. When he started to have Parkinson's and he couldn't manipulate the machines and do the fine work anymore, he got drastically depressed because he was like, I can't see well enough to read anymore. He only had a sixth grade education. Reading in and of itself wasn't something he often did for pleasure. Even when he could, he had to wear glasses. Those didn't work as well. He couldn't do anything with his hands. His memory started to go. It started to kind of fold in on itself. So then you have to step in and go, okay, hold up. Where can we find a place that we can make some meaningful interventions that you're willing to work on? So chronic pain, addiction and mental illness. Emotionally, if someone's in chronic, if someone's in chronic pain, they may take opiates. They may have to take opiates because of the pain. And I'm not saying opiates are bad. Opiate addiction is bad. But opiates can be used appropriately. But they can intensify depression. And like I said earlier, they can cause the body to quit producing its own natural painkillers. So if the person stops taking the opiates, there's going to be an adjustment period unless they're weaned off of them. Negative feelings can be numbed with addiction. So if you're in physical or emotional pain, it can be numbed. Pognitively, chronic pain creates an environment for the stinking thinking. I can't do it. I don't, there's nothing else I can do. And people get stuck on focusing on all the things they can't do. All the things they used to be able to do, but they can't do any more because of their pain. Or all the things that other people can do that they can't do because of their pain. And those are all true. You know, I'm not going to argue with you. They can go jet skiing. And you can't because you've got rheumatoid arthritis in your hands. And that sucks. It's not fair. What can we do instead? Because you can't change that. So let's talk about what other things would you enjoy doing? That doesn't always, that line of thought doesn't always work for everybody because some people are not ready to go there and go, okay, let's look at the things I can do. And that's where clinical skill comes in, figuring out where the person is, figuring out what they want, what gives them hope. They're still hanging on for some reason. They're still here and they're actually taking the proactive step to be in your office. So there's some little glimmer of hope in there that things can get better. What does better look like to them? And then we can start working backwards, identifying the things that are most important to them first. Because like I said, once you start making changes in the system, that wibbly, wobbly, timey-wimey stuff, everything starts impacting everything else. So a positive change in one area produces positive changes in other areas. It's also important to remember that if people are not motivated to work on something, it's not going to help. And dealing with their depression, that's a big goal. They may be motivated to work on their depression because they don't want to feel like this anymore. But the interventions that we put forth that, okay, well, we may need to look at doing this, this, and this, each intervention has its own level of motivation. Some people may be really motivated to counseling three times a week, but not so motivated to start exercising. So one of the things that you want to consider is where is the person's motivation? We want to set them up for success. We don't want to say, well, you have to start with the cognitions, and then we'll start working on the stuff you want to work on too. So a question comes in, do we see different approaches or success depending on what part of the system is someone presents in? And this is where I go back to my dream of co-occurring disorders is that wherever someone presents in a system, and tip 42 that Sampsa put out actually talks about this, that at any point in the system, whether it is child welfare, whether it is school, work, hospital, physical health, drug treatment, crisis center, there should be a broad approach, a biopsychosocial approach to identifying the person's problems. And so there's no wrong door. Wherever they enter the system, people are going to understand how pain, how physical illness, addiction, and mental illness can all affect each other and can all promote or mitigate one another. So yeah, I mean we do see different, definitely different approaches. I don't know that I would say different successes because right now from what I've seen in most cases, most places are still maybe co-occurring enhanced, but they're still, if they are co-occurring enhanced, they're still only addressing mental health and addiction. They're not even considering this physical aspect over here, but they're running on parallel tracks. Instead of talking about relapse as a return to old behaviors and triggers as triggers for depression, triggers for anxiety and triggers for addiction, they talk about substance abuse triggers. And then there's a whole different group on dealing with depression. So the approaches are different and from a theoretical point of view, each one of your approaches may be different than mine. I tend to be much more cognitive behavioral, mindful, you know, that sort of approach as opposed to maybe experiential. We know that only about 20% of what happens and the success rate of the interaction with the therapist is due to our techniques. 80% of it is relationship. So if you're listening to your client and you're helping them understand the function of what's going on and where these symptoms are coming from, a lot of times I find, and again, it's my style, so it may not, you may not have the same reaction, but I find that when I educate my clients about, let's look at why this is happening. Let's look at all the possible reasons you may be having problems sleeping or all the possible reasons that your mood may be not great right now. It gives them hope because it helps them understand that the first time may not work. And so if they've gone to counseling before, you know, maybe they learned something, maybe they didn't, but we can try now and looking at everything that's going on for them and understanding the interaction. They want to survive, their brain wants to survive and their body wants to survive. So it's our job to help them figure out how to make that happen. Socially, addiction can help people not care that they don't have healthy relationships. It's like, you know, it's just me and Jim Beam, y'all can go away. Environmentally, a depressing environment may intensify feelings of hopelessness, which can be self-medicated with addiction. If you're in chronic pain and you're feeling negative and you are having difficulty, you've got a lot of fatigue, you're self-medicating, you can see how chronic pain can contribute or exacerbate depression, which can contribute to or exacerbate addiction. So finally, I want to kind of look and I'm big on charts because I'm visual. When people are depressed and in chronic pain, it's hard to feel pleasure about a lot of stuff because it hurts. Depression hurts and chronic pain obviously hurts. Opiate addiction, for example, would numb some of that hurt, some of the emotional hurt as well as some of the physical hurt. So if you've got a client who presents with these three diagnoses, let's look at what may be going on. Depression causes sleep disturbances. Chronic pain causes sleep disturbances. Opiates help people sleep. You know, it seems like a survival sort of thing is going on here. Now, remembering that the opiates are causing their own set of problems, I'm not saying this is a great solution, but I want you to understand the motivation behind it. Depression, there's a sense of hopelessness and helplessness. Chronic pain, same thing. I can't get the pain to stop. I wake up, I just wish I could wake up one morning and get out of bed without feeling like somebody is stabbing me in the foot or whatever the case may be for your clients. Difficulty concentrating. True in depression, true with chronic pain. Low self-esteem, not feeling good about who you are. When you're depressed, you know, if the self-esteem problems probably started before the depression, but let's just say it's because of the depression. When you're depressed, you don't have the energy to get out and do things. You may start feeling guilty. You may start feeling like you are not the parent you want to be. You're not the spouse you want to be. You're not the employee you want to be. You're not the person you want to be. So self-esteem goes down. Chronic pain is the same. Sometimes you feel like, you know, the talents you did have were stripped from you. Or, you know, because this ongoing chronic pain, you don't feel like you're able to be useful, which may contribute to feeling less than good about yourself. Depression causes pain. You know, we know that people have aches, pains, joint aches, but we also know that, especially if the depression is caused by low serotonin, that somebody, people may have a lower pain tolerance. In chronic pain, you've got pain. With opiates, if the person is taking opiates and abusing opiates, sometimes they report they feel like they're uber selves. That was one of my client's terms. Okay. It was actually anxiety reducing because he didn't care about anything. It was kind of his, you know, well, you get the idea. He didn't care. When he took the opiates, when people stop feeling the pain, the physical pain, and when they're taking the opiates, they may stop caring so much that they may not care about their self-esteem. They're just kind of in this la-la land. It does numb the physical pain. But it also, in most people, increases fatigue, which depression and chronic pain do, too. So if your client presents with all three of these, you know, I'm going to look at all the symptoms that the person's presenting with, and I'm going to say, okay, what do you, what do you feel like would be the first thing that we need to work on? If they want to work on their sense of hopelessness and helplessness, then let's talk about how to do that. If they want to work on their sleep disturbances, again, let's talk about it. But when you set it out logically for clients, a lot of times they will say, okay, when we do treatment planning, you know, or, or you can say, look at this list and prioritize the three most important things on this list to address. And then let's talk about how we could improve those in ways that have worked in the past. Let's go from a strengths-based perspective, ways that have worked in the past for you to address this. You know, when you've been feeling down, when you've started to have a depressive episode, what have you done that has helped you feel better? And what's been going on during that time that was contributing to you feeling depressed, blue, however you're feeling? So let's look at the exacerbating and mitigating factors. Figure out what they've done before. Increase that. Figure out what makes it worse. Figure out how to get rid of that. Breaking it down in a method that is, it's not linear, but is concrete for a lot of clients, gives them hope and empowers them because they can say, okay, the first step I've got to do is this. And if I do this, then likely we'll see these following effects, positive reinforcement. The next step that I want to take is such and such. Break it down so it's meaningful to them and it focuses on what they're motivated to work on because they're going to do that more than if they, if you focus on what you're motivated for them to work on. So addiction, mental health and physical illness all impact mood and the neurotransmitters, eating, which is prompted by neurotransmitters, sleeping, which is prompted by neurotransmitters and can be made worse by chronic pain, motivation and relationships. Addictions may temporarily address the issue, but it also intensifies all of the above problems when the person is not actively using. Comprehensive treatment of the whole person is vital. For example, if they are experiencing a lack of pleasure and they want to address that, we need to look at addressing the neurochemical imbalances. Now that can be through sending them to their doc from eds, sending them to a nutritionist for nutritional advice, increasing activity levels, resetting circadian rhythms. That's a whole different presentation. But we need to figure out how to help them start addressing that imbalance. Help them find alternative coping strategies besides the addiction. This is where the exceptions come in. When you haven't been depressed in the past, what have you been doing? And when you've started to get depressed, what has worked besides the addiction? Identify cognitive issues that may be maintaining the negative mood. Again, that's a whole different presentation. Understanding cognitive distortions and irrational thinking patterns and helping our clients understand that the way we perceive things and our negative self-talk or our positive self-talk can really impact our mood and how we deal with things. Identify physical issues such as chronic pain or hormone imbalances that are contributing to this lack of pleasure. Testosterone imbalances, thyroid imbalances, estrogen imbalances. Get it ruled out by a doc first. Identify anything, vitamin D deficiencies. All of these can contribute to a lack of pleasure. The effects of addressing lack of pleasure, just this one little part of that whole list, improve motivation. If you start feeling pleasure and reward from things, it's like, oh, getting out of bed wasn't such a bad thing today. Improved ability to focus. For me, that's huge. I hate it when I can't concentrate. I walk into a room and I'm like, why was it that I came in here? Improved ability to focus is great for people because a lot of times that helps them accomplish tasks that they want to, which is empowering. And improved mood. As you start to get everything kind of back in order or in order, maybe it never was, mood will start to improve. Now, I personally don't believe there is a magic pill that people can take to make them happy. But a combination of things may be necessary and some people may need psychopharmacology to help them with preexisting chemical imbalances. Another example, simple one, sleep disturbances. Address neurochemical pain or other issues causing sleep disturbances. If their serotonin is too low, so they're not getting enough melatonin and they're not able to sleep well, that could be something that maybe be able to be addressed by the doctor. Pain doesn't have to be opiates. You know, there are a lot of medications for pain besides opiates and there are a lot of treatments such as massage, yoga, exercise, dare I say it, that can help address pain, acupuncture, acupressure, and address other issues. One thing that I have a lot of my, I encourage every patient to do, not everybody does, is keep a notebook or their smartphone, but preferably a notebook and a pencil beside their bed. So if they have thoughts running through their head constantly, turn on the light, write them down and then lay back down because if they don't write them down where it's concrete, then they're going to worry, they're going to forget them and they're going to keep tossing them around in their head all night long. Create an effective sleep routine. That means do the same three or four things every night before bed to cue your body in that, hey, it's time to start secreting all these relaxation hormones. It doesn't mean you have to go to sleep at 10 o'clock every night, but it's ideal that most nights you do roughly the same thing every night before bed, just like we do with our children. You know, we get them home, we have playtime, we feed them, we bathe them, we read them a story, cuddle for a little while, and then it's bedtime. Create your own sleep routine. The effects of this less fatigue, well, yeah. More time for the body to repair. So all those things that you deplete during the day with stress and oxidative damage and all that other stuff, it gives your body time to focus on that instead of thinking and remembering and doing all the stuff we do when we're awake. Improve concentration. Most people concentrate better when they're awake and well rested than they do when they're not. And it also gives you more energy to interact with others because paying attention to nonverbals and interacting and listening and doing all that stuff actually does require energy. It's not effortless and it requires more effort for some people than others. So you can see that you can start pulling any one of those threads in that ball of yarn and it will have positive effects on every other area of the person and the person's life.