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we'll have a guest speaker on May 4, on her own eating disorder

A Foundation for Understanding Addiction and Self-Defeating Behaviors
Liz Sutherland, ND

these lectures to be her understanding of
the etiology of repetitive entrenched behavior
a basic framework

CHILDHOOD PSYCHOLOGICAL DEVELOPMENT
enter world in complete emotional fusion, symbiosis
identity developed in reaction to others
often in rxn to their anxiety and emot needs

DEVELOPMENT OF TRAUMATIC RESPONSE
factors that influence the imprinting of trauma
no such thing as a life without negativity
probably there is an optimal intensity and duration of "negative" experiences
tolerances vary among individuals
need both neg and pos to establish identity
family my have drama, fighting, etc and still yield healthy children
child never doubts parents love-->unlikely to exhibit self destructive behaviors

something happens that we cannot grasp with our minds
point when focus of our awareness begins to move from inner to outer
normal and natural process but something is happens in a jarring/traumatic way

(abuse, sexual, disaster, neglect, disappearing parent)-->"crazymaking"
child whose mother disappeared-->OCD, lack of trust in world, need to control
always expects to be left behind
sometimes event that mars a childhood may need seem like big deal to others
some traumatic things can be devastating, others can leave one with a vulnerability
trauma can cause a loss of connection with onesself

trauma "movie" replays in our lives as if it were real time
as if everyone in our lives were those original people who impacted us

SIGNIFICANT FACTORS IN DEVELOPMENT OF ADDICTIVE/SELF-DEFEATING ADULT PROBLEMS
1) inappropriate balance of neg and pos in early envir, intensity, duration, not mitigated
2) nobody says anything about it, no one says "this must be very upsetting for you"
may happen preverbally, no one helps us create a narrative to explain
kids left with primitive fear, not verbalized
impulse remains to avoid that feeling in future
there was no help

DEVELOPMENT OF DEFENSES
something terribly upsetting happens-->develop defenses
fx: protection, safety, survival, not feeling pain, externalize problem
children tend to take the blame for whatever happens, assume responsibility
core or essence is bad (this is what we don't want to feel)
spiritual interp: loss of conxn with divine self within
social interp: loss of conxn with who we would have been, who we could be
disconnected from self
fx: to maintain global stability of the system (which is us)
cannot just take away coping mechanism that provides global stability

WHEN GOOD DEFENSES GO BAD
from this place we function in reaction to others
present in seen in terms of the past
limits our experience of life
no freedom to act without being reactive
confuse memories with perception

APPEARANCE IN ADULT
some defenses more flexible than others
highly developed hypervigilance
not allowing oneself to get close to another person
alcoholism
drug addiction
eating disorders
religion
self cutting
staying in an emotionally abusive or otherwise impossible relationship
etc
all used to "control their demons"

THE AIM OF ADDICTIVE BEHAVIOR
"to heal by avoiding pain"
there is something life affirming about the pursuit about the addictive behavior
but unfortunately the behavior may be destructive

another theory:
keep doing the destructive thing until we reach a sort of critical mass
and then maybe we can do what we couldn't do as children
and escape from the pain

HOW TO HELP
by understanding that something happened
usu when they were small, that they just couldn't contain
couldn't express, and nobody helped
just the recognition that this person went through something horrible
is affirming, "I know you are trying to heal yourself."
"No wonder you feel this way"
(emotions are not the problem)

"I know you don't want to deal with this issue right now but I want you to know that I'm very concerned about this behavior"

we try to heal what they're doing in the present to protect themselves from re-experiencing the past

quality of Doc-Pt relationship determines outcome
be prepared to live with the questions
it takes strength to hear, esp if pt has a lot of shame
be in zone of uncertainty, unknowing
we must let go, as practitioners, of the idea that we can control anything
don't try to have all the answers

be compassionate and restrain your judgment
but be present
ok with her to cry with patient
**"Did anyone help you deal with that at the time?"
Did anyone acknowledge that you were going through something painful?

as adult still can create a narrative to contain the experience
be the person who recognizes the pain
generalities (I was abused) don't help
details trigger feelings
writing about it can move it out of the trauma part of the brain, too
turn it into a memory
something terrible that happened in the past that isn't going to happen again
it pts want to they can read it to you
write for 20 minutes, often numb at first, capture the feeling
talk to family about it

CORE OF HOW TO COMMUNICATE WITH AN ADDICT
practitioner enforcement of giving up addiction-->more relapses
**don't argue the reasons why the patient should give up the behavior
because the pt will have to express the other half of the ambivalence
"He only beats me on Mondays"
talk about the reasons why they do the destructive behavior
and let them discover and express the reasons why they'd like to change it

develop relationship and let patient make the connections
only works if pt agrees to enter therapeutic relationship with us
depth over time
more about dancing than wrestling
directly engaging and pointing out their shit gets a defensive response
people do not change because we want them to or tell them to
they may be fully aware of the harm done
we are responsible for the quality of our presence and for doing our best
a prayer offered by one doctor:
**"Thankyou for the opportunity be present to witness your self healing."
be aware of your own junk: know your triggers, decide if you can work with someone
ask open ended questions, get patient to think, reflect, consider
let's explore what this means to you
expressed compensation mechanism is just one option among many
value in acknowledging what the addiction is doing for patient
don't frame behavior as wrong/bad: it's protective on some level
something is stuck (in an orbit)

COMPLEX CASES
addiction often associated with depression and chronic pain
assorted pathologies both mental-emotional and physiological
denial: they don't think they have a problem
vs desire to change: but are they able?
be really happy and surprised if pts do what you ask
degree of identification with addiction influences ability to adjust
we have models to understand, be compassionate, and to offer treatment
compassion is essential because shame is a strong component of addiction
maintain the person's dignity

PREDOMINANT MODEL OF ADDICTION
substance abuse as disease
characterized by neurotransmitter imbalance

CHILDHOOD TRAUMA ANOTHER LOOK
defenseless child with messed up parent
"this is how it is"
try to take the messed up away by doing same
or absorb it by osmosis
mess can be personal or generational, miasmatic
mess expressed in 10,000 ways
tx: pay attention to yourself
your way of being may not be the only option
just because I think something doesn't mean it's accurate
tx: have a practice, become aware of voices in head
voices that speak in 2nd person are internalized from someone else
"you piece of shit" "if only you were more x" "you're just y"
become aware of who you are when you're triggered
big picture, and then in the moment
triggered = getting close to the thing we think we need to protect
we are not our personality
**affirmations are valuable because they raise internal objections
then we have something to work with
regard negative self talk as "flatulence" and just let it go
tx: ask our bodies, ask our selves: what is the deeper truth? what is going on for you?
compassionately, as with patients

get to place she calls core self, divine
there we have the resources we thought we didn't have

***********************************************************************
begin week 6

GOAL FOR TXING MENTALLY ILL
help them learn how to live with their illness
she doesn't think we cure
more we go in the direction of health
help pt recognize warning signs of impending manic/depressive crisis
body cues, pain, anxiety
what do you do when you're on the verge?
a plan for who to contact
must have a treatment team: psychiatrist, psychotherapist, psycopharmacologist, social worker, etc etc etc

KNOW YOURSELF
know your triggers, what throws you off balance

SUICIDE
attempts may be artifacts of "mood stabilizing" drugs

RESOURCES
www.amenclinics.com for a treasure trove of evaluation form, site slow to open
http://www.bipolarhappens.com/ health cards system for txing bipolar
An Unquiet Mind by Kay Redfield Jamison
Hurry Down Sunshine: A Father's Story of Love and Madness, by Michael Greenberg
Unstuck, Your guide to the Seven Stage Journey Out of Depression by James Gordon
Opening Up The Healing Power of Expressing Emotions, by James Pennebacker, on therapeutic writing

TX
encourage: exercise, avoid drugs/alc, stick to tx plan
follow up if pt skips appts
simplify, say no, take time
socialize, don't isolate
eat well
sleep
structure your time, plan your day
time important decisions
don't equate yourself with this condition

*********************

EVALUATING AND TREATING THE SUICIDAL PATIENT
goal: delay the desire
goal: set the threshhold higher for wanting to leave this world
homeopathy mb effective, open doors, "indispensible" at liberating stuckness
deep healing and transformation may be possible but don't promise it at the outset
be realistic
you are a unique human being with your own structure and function
let's work together to provide you with the most optimal movement/flow
within your own structure and function

BEHAVIOR
ranges from fleeting thoughts to execution
many pts who suicide have seen doc recently
many docs unaware of pts intentions or previous attempts
often doc and pt had long relationship centering on physical ailments

RISK FACTORS (document them, ask about them, trust your gut instinct)
previous suicide attempt is good predictor
FHx also predictive
80% of successful suicides are male
women 25-44 attempt more often and fail
white
most successful in elders: over 65
widowed or divorced, living alone, no kids under 18 in house
gay youth
stressful life events, something unbearable
access to firearms

psych disorder esp: depression, substance abuse esp alcohol
major depression, substance esp alc, schiz, panic, borderline
schizo pts more likely to suicide during period of remission
in adolescents: impulsive, aggressive antisocial, family violence, disruption
depressed pts often feel better once they've decided to suicide
or is it that antidepressants allow pts to take action?

hopelessness more predictive than depression
anhedonia, insomnia, severe anxiety, impaired concentration
panic attacks, psychomotor agitation

BE BOLD, TALK ABOUT IT, ASK QUESTIONS
pts who contemplate suicide have ambivalence about it
we can talk about it
suicide mb the only thing they can think of
show that you care, you won't cause a suicide

*assess if pt is at immediate risk (24-48 hour period)
this is more reliable than predicting longterm risk
Do you have a plan to end your life? the means? a gun? drugs?
Have you imagined your funeral and how people will react to your death?
Have you practiced your suicide? (gun to head)
Have you changed your will or life insurance policy, given away possessions?
Onset of suicidal thoughts? frequency?
How much control do you have of your suicidal ideas?
What stops you from killing yourself?
Precipitating stressor? do you feel you are a burden? is life worth living?
What makes you feel better? worse?
*review risk factors
*screen for alc abuse (cut down, annoyed, guilty, eye opener)
http://counsellingresource.com gives more questions

interview family or SO
synthesize and formulate a tx plan

relate to pt first
if pt is immediate risk you are obligated to contact immediate family
unless the family is the problem, or the ideation is fleeting
if pt has lethal means, poor support, poor judgement
AND cannot make a safety contract
(imminent danger and can't take care of self)
-->hospitalize even if involuntary

PROBLEM WITH HOSPITALIZATION
it may make things worse
no continuity
mb coercive
if invoke system protocols, involve family
keep supporting by making sure referrals are good

NO HARM CONTRACT
not legally binding
does not substitute for through assessment
serves mainly to solidify therapeutic relationship
pt agrees not to harm self for brief and specific time
agrees to contact physician if anything changes
doesn't count if pt is altered, intoxicated, too depressed to care
doesn't count if pt has made serious attempts in the past
pt must be seriously and diligently evaluated over time
if family is available ideally they should be involved in formation/implementation
for pts who promise not to suicide, ask family to remove all lethal means
and implement monitoring system
if family is not available, conservative action is warranted
assess: impulse control, judgment, degree of socail support

THE LAW
standard of care is based on "foreseeability"
there are no standards for prediction of suicide
foreseeable and preventable not the same
document everything including family interactions, tx plans and implementation

SUICIDE RESOURCES
American Assoc of Suicidology http://www.suicidology.org/web/guest/home
http://counsellingresource.com gives more questions

IF PT IS SUCCESSFUL IN SUICIDE
to to funeral
contact family
follow up
respect if they are not interested

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