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Two diseases, one approach?
Much has been written about treating dually diagnosed clients, and I won't pretend to have the inside track on best practices. But I have noticed that some interventions are helpful with addictions as well as with depression, and I present them here for your consideration.
Does it matter which came first?
Depression can lead to addiction. The euphoria associated with alcohol and drug use is very seductive to the depressed person. “Take me away.” “Make the pain stop.” “Let me forget about the guilt for my past behavior.” “Help me stop fearing tomorrow.” All offer compelling reasons to escape today's reality.
Isolation is another symptom of depression. The lack of social supports can open the door to substance abuse. Some depressed people are attracted to the “faux-sociability” of the local barroom, using liquid courage to engage with others.
Self-medicating the depression with alcohol is, of course, a short-lived solution, because alcohol is a central nervous system depressant on its own. When the bar is closed, when the new best friends are gone, when morning's reality comes streaming through the window, the depression is worse than ever. The cycle has begun and addiction becomes part of the pathology.
Addiction can lead to depression. As previously stated, alcohol is a depressant. Using intoxicants plays havoc with our brain chemistry, most notably the production of serotonin and dopamine. Most addicts have experienced the post-binge depression. Longer-term, the loss of relationships, employment, opportunities and self-esteem can be, well, depressing.
Cognitive restructuring
Errors in thinking are common in all of us and, as Albert Ellis so often demonstrated, we need to identify these errors and to challenge our “irrational beliefs.” But these are learned skills; they take time to master.
I encourage my clients to challenge their assumptions and to adopt healthier ways to view the world. For example, a client who is overwhelmed by negative circumstances might benefit from learning and reciting the Serenity Prayer-as often as is necessary.
The prayer is on a wall in my office. I ask clients to read it out loud. As they read, “God grant me the serenity to accept the things I cannot change,” I often say, “Stop,” because most of our troubles are simply things we must accept as they are. Granted, some things we must attempt to change, but most situations are beyond our control.
There are many truths found in 12-Step recovery that translate to everyone on this planet. For example, we all should live one day at a time. “This too shall pass” is another axiom from AA that reinforces this concept nicely.
I encourage clients to think of their “acceptance muscle,” a muscle like any other that gets stronger the more one uses it. It's a learned skill that takes practice and improves with use.
Other cognitive distortions as harmful to the addict as to the depressed person include: “I'm a loser.” “I'm a screw-up.” “No one likes me.” “I'll never get better.” These ideas present a wonderful opportunity to shed light on the client's past accomplishments and to deliver heartfelt praise for what the client is doing today to help himself.
“Awful-ization” is another trap clients seem to embrace. This is the unrealistic belief that the outcome of a certain event is going to be terrible. I often ask, “What's the worst that could happen?” When we examine the worst-case scenario, we see that the world will continue to spin and life will somehow go on, even if the situation ends up as feared.
Lastly under the heading of cognitive interventions, I teach my clients visualization/relaxation techniques so they can lower their anxiety long after our relationship has ended. Such mindfulness skills are easy to learn and easy to implement into one's daily life.
These cognitive restructurings are as important to the person in recovery as to the person fighting depression.
Behavioral modification
“Bring the body, the mind will follow” is a favorite saying in AA, because it reinforces the concept of doing the next right thing, whether you want to do it or not. Getting well (from addiction or from depression) requires action. Whether it's going to the next AA meeting or simply getting out of bed in the morning, sometimes our clients need to “act first and think later.” One of my favorite posters reads:
“You are what you do. The rest is just talk.”
An AA-ism that works well for mood disorders is the acronym H.A.L.T., which stands for Hungry, Angry, Lonely and Tired. If my client is any two of those, it's time for action. If hungry, eat something. If angry, talk about it. If lonely, pick up the phone or socialize with others. If tired, take a nap. Bottom line: We can help ourselves to avoid relapse to depression or substance abuse.
 Brian Duffy, LMHC, LADC-I |
Exercise is something I always recommend to clients. In the spirit of AA's “Progress, not perfection,” I encourage clients to walk instead of taking public transportation, and to breathe deeply along the way. Although a health club is often beyond the financial means of our clients, there are many affordable ways to improve oxygen flow to the brain. This, of course, leads to improved production of “feel-good” chemicals such as serotonin, dopamine and adrenaline.
An often overlooked stress reducer is the shedding of tears. Men are particularly reluctant to cry, although the benefits of doing so are well documented. If a client is hesitant to cry in front of others, I'll encourage him to bury his head in a pillow and wail-to cry uncontrollably. It works!
We often see clients turn night into day. They stay up late to play video games and then wonder why they can't get out of bed in the morning, or why they can't sleep when they suddenly go to bed at a reasonable time. Resetting one's Circadian rhythm is not an easy thing to accomplish, but it's simple: It's a matter of forcing oneself to go to bed and to arise at the same reasonable time each day, with no naps in between. We humans need structure and regimentation, yet we so often resist adherence to those principles.
Although there are too many opportunities for behavioral change to mention in this article, the most obvious potentially harmful behaviors include gambling, isolation, overeating, nicotine consumption, promiscuity, caffeine consumption and shopping. Even healthy activities such as work and exercise can be overdone, leading to a relapse to substance abuse and/or depression.Finally, let's consider behavioral changes that, in my experience, are pivotal in treating addictions and mood disorders. I'm talking about one's ability to socialize and to have fun. Although they don't have to be done concurrently, it so often works out that way-to the benefit of our clients.
An Irish proverb: It is in the shelter of each other that we live.
People with substance use and mood disorders seem to do better when they're able to make friends (with safe, sober people). But learning how to socialize and to have fun is often a difficult challenge. Many clients need help in identifying what fun might look like, and they need guidance on how to meet and engage with others.
Conclusion
Research suggests that substance use and mood disorders are best treated separately but concurrently. Fortunately, there are some cognitive restructurings and behavioral modifications that can have a favorable impact on both addiction and mood disorders.
Brian Duffy, LMHC, LADC-I, is a Mental Health Counselor at SMOC (South Middlesex Opportunity Council) Behavioral Health Services in Framingham, Massachusetts. He wrote on the effects of talk therapy and journaling in the September/October 2010 issue. His e-mail address is bduffy@smoc.org. Addiction Professional 2011 May-June;9(3):26-28
