This exercise is to improve communication by "Processing", which means that you can talk about an incident that occurred without becoming activated and getting back into the argument. It needs to be a conversation – as if you were both sitting in the balcony of the theater looking down on the stage where the action had occurred. This requires calm and some emotional distance from the incident.
BEFORE YOU BEGIN
Keep In mind the GOAL Is Greater Understanding – addressing the process and how the issue was talked about, without getting back into the fight. So, wait until you're both calm.
Assume that each of your realities has validity. Perception is everything. Don't focus on "the facts."
Pay attention to the common barriers to communication and their antidotes as you move through the process. The "Four Horsemen" references can help.
THE FIVE STEPS
Work through the Following Five Steps Together
Share how you felt. Some common words/phrase:
REALITIES AND VALIDATION
Subjective Reality and Validation:
Examples of Triggers:
Validation - does any part of your partner's triggers and story make sense to you?
Under ideal conditions, you might have done better at talking about this issue. What set you up for miscommunication? Share how you set yourself up to get into this conflict.
What set me up – Examples:
Read aloud the items that were true for you on this list. Specifically what do you regret, and specifically, what was your contribution to this regrettable incident or fight?
What Do You Wish To Apologize For?
I'm sorry that:
If you accept your partner's apology, say so. If not, say what you still need.
Share one thing your partner can do to help make discussing the issue better next time.
Then, while it's still your turn, share one thing you can do to make it better next time.
What do you need to be able to put this behind you and move on?
Be as agreeable as possible to the plan suggested by your partner.
STOP THE FOUR HORSEMEN WITH THEIR ANTIDOTES
Thom Kessler, LMFT, RAS
Potency of Marijuana
The marijuana today is not the marijuana of the 60’s, 70’s or even 80’s. Today, we see marijuana bud at 26% THC and many users are now using high THC concentrates such as butane hash oil (BHO), ear wax, dabs, budder, shatter, and edibles near 70%-90% THC.
According to the University of Michigan’s Monitoring the Future Survey, which has been tracking the trends of teen drug use since 1975, the average age of first intoxication is 12 years old. Neuroscientist and director at NIDA (National Institute of Drug Abuse) Nora Volker, MD reports that the teen brain is not finished developing until the mid-20’s. Studies show that if a teen is abusing drugs they are to 7-10 times more likely to develop a mental health disorder later in life and 4 times more likely to develop an addiction to their drug of choice.
As a result of man-made hybridized marijuana plants, i.e., cloning, hydroponics and sophisticated THC extracting devices, we live in a world that has easy access to very potent THC. Sadly, as a result, we are seeing serious mental health issues. We know that while the teen brain is still developing the impact of marijuana use can disrupt the development of the dopamine, anandamide and even the serotonin systems.
In the last few years those of us working with teens and young adults with cannabis disorders have seen a trend in side effects now resulting in panic attacks, anxiety, and psychosis leading to hospitalizations for some users. According to Neuroscientist Dr. Christine Miller, there is also a link to Schizophrenia. I am sure that most of the old pot users would have laughed at this back in the day.
The following has been taken from Dr. Miller’s presentation in Sacramento last year.
Hundreds of peer-reviewed, scientific articles show a correlation between marijuana use and psychotic outcomes such as schizophrenia, too numerous to list here. The question of whether marijuana is causal for psychosis has been answered in the affirmative by applying standard principles of causation used in pharmacological and epidemiological research. The increase in heavier dose use marijuana results in more users developing schizophrenia. Administration of the active ingredient (THC) in the clinic under controlled conditions causes psychotic symptoms
Self-medicating is not that likely, because many will try to quit to avoid the psychotic symptoms before they become too impaired but for others it may be too late. Marijuana use generally comes before the psychosis, not vice-versa.
In users who have schizophrenia, the age of onset is earlier than for non-users. The average onset of schizophrenia in men is 18 and 25 for women. Of all recreational drugs, marijuana use is the most likely to result in chronic psychosis.
1. What percentage experience a psychotic outcome? The low to moderate-strength marijuana available in the last century was shown to trigger single psychotic symptoms (paranoia, racing thoughts, delusions, hallucinations) in 12% to 15% of users. Of those with such “prodromal” symptoms (denoting the period between the appearance of initial psychotic symptoms and the full development psychotic symptoms) about 35% can be expected to develop full psychosis, i.e. a constellation of symptoms occurring at once. For about half of these individuals, conversion to chronic schizophrenia spectrum disorder occurs irrespective of family history. The result for low to moderate-strength marijuana was about a 2.5-fold increased risk of schizophrenia, but for the high strength product available today, the risk for schizophrenia is 5-fold compared to non-users. That increase in risk translates into about one out of every twenty users if they don’t quit in time.
Is this impact limited to adolescence? Given that the brain continues to develop in males through the late twenties, it seems unlikely that the risk for chronic psychosis is limited to adolescent users. Furthermore, administration of THC to adults in a clinical setting results in psychotic symptoms.
Risks for anxiety, panic, and depression are increased by marijuana use: with some studies showing that correction for confounding variables lessens the association with anxiety and depression, while others report the effect remains.
Risk for suicidal ideation is increased on average 7-fold: even after correcting for a prior history of depression.
In 2014 the second year after legalization of recreational use of marijuana, Colorado experienced the highest suicide rate in state history. In 2014, there were 1,058 suicides among Colorado residents and the age-adjusted suicide rate was 19.4 per 100,000. This is the highest number of suicide deaths ever recorded in Colorado. These findings were included in The Office of Suicide Prevention in their Annual Report 2014-2015, Colorado Department of Public Health and Environment.
Particularly alarming, the Colorado media has reported sudden onset suicidal ideation or completed suicide in consumers of commercial edibles, but also reported following the smoking of potent marijuana. These responses can happen so quickly in individuals who were not previously suicidal that intervention may be impossible.
Lack of educational achievement and decreases in motivation has been contributed to an increase in the use of marijuana. The odds for marijuana users completing high school are reduced to about 0.37-fold that of controls accounting for demographics and other factors, marijuana use adversely affected college academic outcomes, both directly and indirectly through poorer class attendance Decreases in motivation with marijuana use have been documented in clinical studies of humans and animals.
IMPACT ON IQ:
Studies have shown that up to an approximate 7 point drop in IQ from childhood scores by age 38 in marijuana users who have been abstinent for 24 hours prior to testing; but only an approximate 5 point drop in those abstinent for a week prior to testing. A subsequent study of twins yielded mixed results, with an average decline of 4 points in marijuana users by late adolescence; however, restricting the comparison to the matched twins (thereby controlling for genetics and a myriad of environmental factors), the effect of marijuana largely disappeared. The limitation of this later study is that brain development is not complete by late adolescence, particularly the wiring of the all-important cortex is still ongoing through the late twenties There is no controversy, however, about the negative, real-time impact of marijuana use during tests of cognition and memory.
Thom Kessler, LMFT, RAS
Poor impulse control may be pre-wired in some teenagers. Researchers have identified brain networks that are linked to impulse control and drug addiction, which may exist even before someone is exposed to alcohol or drugs. Researchers at the University of Vermont performed a brain imaging study that included approximately 1,900 14-year-olds. They used a functional MRI, which permitted them to see how different parts of the brain work together. The teens were asked to perform repetitive tasks, and then were asked to stop mid-task, while the researchers measured their ability to do so. People who abuse drugs or alcohol tend to perform poorly on this test, according to research report notes.
The study identified teens who had previously been exposed to alcohol, illicit drugs or nicotine, and could recognize specific brain patterns linked with early experimentation with these substances. Teens who had poor impulse control, but did not have a history of substance abuse, had similar brain images to those teens who already had used these substances.
Lead researcher Dr. Robert Whelan reported that the findings suggest it may be possible to identify teens at risk of substance abuse, before they start. The study also included teens with attention deficit hyperactivity disorder (ADHD). The researchers found the brain networks of teens with ADHD were different than the ones associated with early substance abuse. People with ADHD are at increased risk of substance abuse and alcoholism.
Research findings are published in Nature Neuroscience.
Thom Kessler, LMFT, RAS
Drug and alcohol residential or outpatient rehab treatment is a place to go when an addiction has become a problem in your life, and you find yourself unable to stop. Whether the addiction is centered around alcohol and drug abuse or gambling, video gaming, Internet, sex and porn, etc. then perhaps residential or outpatient treatment is for you.
We can use a model to help conceptualize the process of recognizing there is a alcohol and or drug abuse problem or any other forms of addiction and how to take action to do something about it. This model is called the, “Stages of Change” model, which describes common stages or phases individuals go through in changing behavior: Pre-contemplation, Contemplation, Preparation, Action, Maintenance. It is an important and necessary part of psychotherapy addiction assessment.
This is the first stage where a person doesn’t see that they have a problem, and therefore, are not yet thinking about changing their behavior. The person is in ‘denial’ about their problem, and isn’t aware that change is needed. In fact they do not see themselves as having a problem. It is everyone else in their life that views them as having a 'problem' or the people in their life are the 'problem.' Sound familiar? At this stage, the person needs help in seeing that they have ongoing drug or alcohol abuse/dependence or other forms of addictive behavior such as gambling, sex, or the Internet to name just a few of the common seen addictions in life. This is where I begin my non judgmental and non confrontational style of psychotherapy.
My approach utilizes Motivational Interviewing skills, which is a process whereby I create an alliance with my patients by working with them in a non-judgmental, non shaming therapeutic style. The goal is for the patient to create their own insight by helping them to see the discrepancies between the reality of their situation - the negative consequences caused by their addiction and their statements of denial. The idea is for the patient to gain insight by considering the possibility that perhaps a problem does exist – all change is intrinsic – meaning we change from within. We do not change by someone telling us that we have to change because we have a problem. Or that we have to change or else…….Few people like to be told what to do - no matter what the issue and pushback is the norm.
While a ‘confrontational’ style of intervention is commonly known to the public, thanks to the promotion of reality television shows, research shows that this approach in the long term is rarely successful. Instead, I prefer an alternative style of intervention using positive reinforcement a style referred to as Systemic Intervention. In a Systemic Intervention the focus is not just helping the identified patient (IP) into recovery but helping the entire family or system enter into recovery. I have often conducted ‘interventions’ regardless whether the ‘IP’ decides to come in with their family. The family suffers from the consequences of addiction just as much as the person who is struggling with their addiction. The family is often overlooked in the process of getting treatment for the abuser.
This is the stage where a person understands that they have a problem, and considers doing something about it. Still, at this stage, the person hasn’t yet made a commitment to change. They may not know what steps to take and need help in formulating a reasonable, doable plan that fits their situation. I help them in coming up with a plan by collaborating with the patient. It has to be a plan that they can buy into - that fits their needs. At this stage, I also help the patient and their family members to support the person by helping them to deepen their understanding of the pros of leading a clean and sober life - alice free from their addiction, the consequences of their addiction and that help is available to them if they chose to accept help.
At this stage the person has made a decision to change their behavior and face their addiction. Regardless whether the addiction is centered around abusing drugs and alcohol or any other forms of addiction including, sex and love addiction, porn, Internet, video gaming or gambling. This is a stage where people often need help in deciding what to do. Every person struggling with some form of addiction is different and ‘one size’ treatment does not fit all. This is a stage where I work closely with the individual and the family and help them to choose what is the best course of action for them to take. What may work for one person may not necessarily be the right course of action for another. At this stage we begin the process of preparing and planning what to do. Because there is the real possibility of not following through with intentions and plans, this is the stage where a person needs a lot of encouragement and support to help them follow through with their intention to seek help. There is always the risk of falling back to an earlier stage in the model.
The person now has made a commitment to make a substantial change and follows through with their plan. Plans from the Preparation stage are put into action, e.g., attending a 12 step group, going into residential or intensive outpatient treatment and or meeting with a therapist who specializes in addiction. The best approach to successful treatment is to include all of the above.
This is the stage where it is acknowledged that the person has truly committed to maintaining the change in their behavior and is living clean and sober - a life free from their addition (s). What we call maintaining ones recovery. This takes work, dedication, commitment and constant vigilance. Applying relapse preventions skills are necessary until the person has had some years under their belt living free from their addition the risk of relapse remains high. Maintenance is an ongoing stage and usually the risk of relapse has diminished substantially after the first year and especially if the patient has been taught relapse prevention skills. Often, over the years due to the positive experiences of living clean and sober the risk of relapse can diminish greatly. However, even after years of sobriety, the risk for relapse can always be there. Support from family and clean and sober friends is always helpful. If relapse occurs at any time after being free from their addiction - for any length of time, taking the necessary steps to get back into recovery should happen as quickly as possible. Relapse should not be looked at as a failure. For some it’s part of the journey of recovery and living clean and sober. If relapse is treated quickly and without shame, the relapse process can be studied and used to strengthen an individuals recovery program.
Inpatient or Outpatient Treatment?
Once having made a decision to get treatment, where to go needs to be decided, including whether to go to an inpatient facility or an outpatient facility—the two main settings for treatment.
Inpatient Residential Treatment.
Inpatient rehabs are also referred to as residential treatment centers. This choice may be best for persons who are moderately to severely affected by their addiction. This type of treatment costs more compared to the outpatient treatment because residential costs and other expenses are included. Inpatient rehab provides an environment away from many triggers, e.g., people, places, and things, and an environment of continuous care.
In looking at substance abuse several questions to consider:
Are you using alcohol or drugs on a daily basis or are active in your addictive behavior and are not able to remain addiction free for 24 hours? If the answer is “Yes,” then inpatient treatment is most likely indicated.
Do you experience severe withdrawal symptoms if you try to abstain and stop drinking or using drugs, e.g., convulsions, seizures, blackouts, delirium tremens (DTs) (body tremors, confusion, disorientation, stupor, hallucinations)? If “Yes,” then a medical detoxification facility is required prior to entering residential treatment. These days many high-end residential treatment centers operate their own medical detox centers. Alcohol and some drug withdrawal can be fatal is not managed medically. One of the main reasons people continue in their addiction is the fear of withdrawal and the physical and emotional pain that accompanies the withdrawal stage.
Intensive Outpatient Treatment (IOP)
With an outpatient program, people visit the treatment center on a weekly basis for counseling and treatment (for example, 3 -4 x / week for 12 weeks). This type of treatment is less costly compared to the inpatient treatment because the client does not incur residential costs. There are several new studies out that indicate IOP is just as effective as inpatient treatment depending on the severity of the addiction.
One last word on rehab. There are many studies that show rehab does not work for many people especially if they enter into a residential treatment center for the minimum 30 days. There are several reasons for why people relapse after a 30 day stay. One reason is that 30 days is often not enough time but due to the expense of rehab and the time it takes out of ones life, 30 days is all people can afford. Ideally 90 days is preferred. If you end up choosing a 30 day program then there should be a thorough aftercare plan provided before discharging. A thoughtful and well planned aftercare plan should include outpatient treatment, membership in a 12 step group and a sponsor. A significant cause for relapse is the transition back into the 'real' world, which can be overwhelming to most people. The reality is anyone can stay clean and sober in a residential system where you are in an environment, which is highly structured from the time you wake up in the morning until you go to bed at night. That coupled with the fact that it difficult to obtain drugs and alcohol or gamble or engage in any other risky addictive behaviors in a confined, monitored environment. Difficult but not impossible.
Because I also specialize in relapse prevention, I work closely with patients that recently have completed residential treatment and people who are currently in an outpatient setting, helping them to understand the risks of relapse and how to avoid situations that can lead to relapse.
Rehab is an expensive investment. As in any investment it is important to take great care in protecting your investment. Which is why treatment does not end after one completes a residential or outpatient program. Weekly and daily maintenance is a must to minimize relapse. The first year is the most difficult year in the maintenance stage. Again, many studies have shown that the first year is the most important year. Once a person successfully maintains their recovery from their addiction for one year, the odds greatly improve in maintaining their recovery and the risk of relapse drops significantly. I have helped many of my clients successfully navigate their first year of recovery by teaching them relapse prevention skills, cognitive behavior skills and treating their underlying cause of addiction. Many people who suffer from an addiction are merely attempting to self medicate their depression, anxiety, trauma and their core belief issues that they are not good enough. If these issues are not successfully addressed in therapy with a psychotherapist who understands and has been trained in co-occurring disorders the likelihood of relapse remains high. However, this does not have to be the case.
Thom Kessler, LMFT, RAS
Marriage & Family Therapist and Registered Addiction Specialist