Dealing with uncertainty is an unavoidable part of daily life. Because we can’t see the future, we can never be certain about what exactly is going to happen day to day. Research has found that people vary in their ability to tolerate uncertainty. That is, some people are okay with having a lot of uncertainty in their lives, and other people cannot stand even a small amount of uncertainty. Anxious people, particularly those adults who worry excessively, are more likely to be very intolerant of uncertainty. They will often try to plan and prepare for everything as a way of avoiding or eliminating uncertainty.
 
What’s Wrong with Being Intolerant of Uncertainty?
Obviously, it is normal, even common, for most people to be a bit uncomfortable with uncertainty. We prefer to know that the restaurant we are going to serves food that we like, that there will be people we know at the party we were invited to, and that our boss tells us exactly what he thinks about our work performance. This knowledge feels more comfortable to us than not knowing anything about the restaurant we are going to, being unsure about who will be at the party, and not knowing whether our boss thinks we are doing a good or a bad job.

Uncertainty as an allergy…
Being intolerant of uncertainty is a lot like having an allergy. If you are allergic to pollen, for example, you will sneeze and cough and your eyes may get red and teary when you are exposed to even a small amount of pollen. When people who are intolerant of uncertainty are exposed to a little bit of uncertainty, they also have a strong reaction: they worry, and do everything they can think of to get away from, avoid or eliminate the uncertainty.
But being very intolerant of uncertainty can cause problems, since it leads to a lot of time-consuming and tiring behaviors, causes stress and anxiety, and is the major fuel for worry.

What do people who are intolerant of uncertainty do?
If you can’t stand having uncertainty in your life, you are probably doing things that are designed to either remove all uncertainty in daily life situations or you are outright avoiding uncertain situations.
Some of the behaviors that people do when they are intolerant of uncertainty include:

• Seeking excessive reassurance from others: This might be asking friends or family their opinion on a decision that you have to make
• List-making: As a way of eliminating uncertainty, some people will make long and detailed “to do” lists, sometimes several lists every day
• Double checking: For example, calling loved ones repeatedly to “make sure” that they are okay, or re-reading emails several times to check that they are perfect and that there are no spelling mistakes
• Refusing to delegate tasks to others: Many people who are intolerant of uncertainty will not allow anyone either at work or at home to do certain tasks; this is because they cannot be “sure” that it will be done correctly unless they do it
• Procrastination/avoidance: Because being uncertain can cause anxiety, some people simply procrastinate or avoid people, places or situations. If you do not do something, then you don’t have to feel uncertain about it
• Distraction: Many people who are intolerant of uncertainty keep themselves “busy” most of the day, that way, they don’t have the time to think about all the uncertainty in life

You probably noticed that all of these behaviors require a lot of time and energy. Needing to be certain about everything can often take the fun out of life, since surprises or unexpected events become something threatening. Also, if you avoid or procrastinate, you might miss out on a lot of good opportunities in life simply because of a dislike of uncertainty.
Remember: Unless you can see the future, you will always be uncertain about some things.
 
Another problem with intolerance of uncertainty
If you can’t stand uncertainty and do everything you can to get rid of it, you might have noticed a problem: it is IMPOSSIBLE to get rid of all uncertainty in your life.
What this means for you is that all the work that you are doing to get rid of uncertainty is useless, it just doesn't work. If it did, you would probably not be struggling with anxiety and worry.
So, what is the solution?
If you can’t get rid of uncertainty in your life, the only way to manage your intolerance of uncertainty is by learning to be more TOLERANT of uncertainty.
 
How can I learn to become more tolerant?
Obviously, even if you agree that being more tolerant of uncertainty would be helpful, it is not easy to change an attitude. However, in cognitive behavioral therapy (CBT), we know that our thoughts, feelings and actions are all inter-connected, and that if you change one, you can change the others. So, the best way to learn to become more tolerant of uncertainty is to start acting “as if” you are tolerant of uncertainty. That is, you can change your behavior around uncertainty, using CBT and this will eventually help you to change your thoughts and feelings around uncertainty.
 
Learning to Act "As If"
 
Step 1: Make a list of behaviors
Start by writing down all of the things you do to try and feel more certain, or to get around or avoid uncertainty. You can use the sample of behaviors listed above as a guide. For example,

• Do you seek reassurance from others?
• Do you do a lot of double-checking?
• Do you look for a great deal of information before making a decision?
• Do you procrastinate a lot?
• Are there situations that you avoid?

A good way to compose this list is to be a detective in your daily life: notice when you are feeling anxious, and what it is that you do to try to feel less anxious. For example, if you have to buy a present for someone and you start to feel anxious about what to buy, what do you do? Do you call your friends and ask for advice about what to get? This reassurance-seeking behavior can then go on your list.

Step 2: Rank your behaviors according to anxiety
If you want to start acting “as if” you are tolerant of uncertainty, it is best to start small. That way, you are more likely to do it and to succeed. If you pick something too difficult, you might be unable to do it and you probably won’t want to try it again.
With this in mind, look at the behaviors that you have that might be easier to try to change. You can then rank your behaviors on a scale from 0 (“no anxiety at all”) to 10 (“extreme anxiety”) by imagining how anxious you would become if you could not do them.
 
Step 3: Practice tolerating uncertainty
Once you have a list of behaviors that you do to reduce or avoid uncertainty, then start picking small items that you can do to practice tolerating uncertainty. Try to do at least 3 things a week.
For example, you might try going to a restaurant and ordering a meal that you have never had, and then you might send a few emails without checking them first (and no cheating! Don’t send the email to yourself as well so that you can check it later).

Step 4: Write it down!
Keep a record of all the times you were acting “as if” you were tolerating uncertainty.
Write down:

• What you did
• How you felt while doing it (was it harder or easier than you thought?)
• What happened (did everything turn out alright?)
• If it did not turn out as planned, what did you do?

If you write things down, you will be able to see all the work that you did in facing uncertainty. As you keep practicing, you will find that the things you once thought were difficult have become much easier.

Step 5: Record what happened
If you are taking some risks and are not being 100% certain in your life, there is the chance that things will not go perfectly. For example, if you tolerate uncertainty and go to a movie without reading a review, you might not like the movie. If you go grocery shopping without a list, you might come home and realize that you forgot something.

When you allow some uncertainty in your life, sometimes things go wrong. For this reason, it is important to write down the outcome of your tolerating-uncertainty exercises, and what you did to cope. For example, if you forgot an item from the grocery store, what did you do? Did you pick it up the next day? Did you go back to the store? How horrible was the outcome?
Ask yourself the following questions:

• Did things turn out O.K., even though I was not 100% certain?
• If things did not turn out O.K., what happened?
• What did I do to cope with the negative outcome?
• Was I able to handle the negative outcome?
• What does this tell me about my ability to cope with negative outcomes in the future?

REMEMBER: Sometimes things will not go exactly as planned if you allow some uncertainty into your life. But this is not a sign of failure on your part. Most people who tolerate uncertainty learn that even if bad things happen, they can cope with them.
It is also important to realize that despite trying to make everything certain, things often didn’t always work out. It just took a lot more energy and time trying to be certain. By becoming more tolerant of uncertainty, you can let go of all of the problems associated with being intolerant, and you get to realize that you can deal with things, even when they don’t go perfectly.

Step 6: Build momentum!
When you feel comfortable with the small steps that you have taken to tolerate uncertainty, gradually try more difficult things.
Look for opportunities to tolerate uncertainty in daily life. For example, if someone asks you to pick up a bottle of wine for a party, try going to the store and buying a bottle without asking for anyone’s advice.
As you start acting more and more “as if” you are comfortable with uncertainty, it will get easier and become a part of your life. Think of it like building a muscle; you need to do your exercises every day if you want that muscle to get strong!
 
Thomas Kessler, LMFT, RAS
www.thomkesslertherapist.com
marintherapist@gmail.com

These disorders come in many forms, like a panicked feeling in social situations or constant anxiety about your health, your job, or your family. If you can’t seem to shake something like this, talk to a qualified psychiatrist. They can work with you to figure out what’s going on and help you manage it.   

Generalized Anxiety Disorder
You may have unnecessary fears about simple, everyday things, like money, health, family, or work. You expect the worst, even when there seems to be little to worry about. It may be hard to control this kind of worry for months at a time. It can affect your sleep and concentration, and it may leave you feeling restless, tired, and irritable.

Social Anxiety Disorder
This is not simply shyness -- you’re terrified of humiliating or embarrassing yourself in social situations. It typically starts in your teen years, and it can make social, professional, and romantic life almost impossible. You may feel powerless and ashamed. 

When You're Worried About How Much You Worry
These disorders come in many forms, like a panicked feeling in social situations or constant anxiety about your health, your job, or your family. If you can’t seem to shake something like this, talk to your doctor. She can work with you to figure out what’s going on and help you manage it.   
 
Panic Disorder
A panic attack is a sudden rush of intense anxiety that seems to come out of nowhere. It can happen anytime, even while you’re asleep. If you have them regularly and are very afraid of having another attack, you could have panic disorder. It typically starts in early adulthood, and women get it twice as often as men. Many of the same symptoms that accompany general anxiety such as a racing heart or pain in your stomach happen with a panic attack. But panic attacks are more intense, build quickly and then subside. Other symptoms include trembling, feeling like you can't breathe, being afraid you're going to die, a sense that you're going crazy.

Agoraphobia
In the past, this condition had been linked to panic disorder, but it’s now thought of as a separate disorder. You may stay away from public places where it seems hard to “escape,” like sports stadiums, the subway, or a shopping mall. In severe cases, it can be impossible for you to go outside your “safety zones” without serious anxiety.

Phobias
We all have things that scare us -- like spiders, heights, elevators, or the dentist -- but most people manage these fears. When a specific fear causes so much anxiety that it affects your daily life, it becomes a phobia.

I am Trained and use the Following Treatments in my practice.

Treatment: Cognitive Behavior Therapy (CBT)
Most anxiety disorders are treated in similar ways. For example, this kind of therapy helps you learn about your condition and do things -- like keeping a journal, meditation, or reflection -- to understand and change certain thoughts and behaviors. It can take 12 to 16 weeks to notice signs that you’re feeling better.

Treatment: Eye Movement Desensitization and Reprocessing (EMDR)
With this uncommon treatment, your therapist leads you through a series of side-to-side eye movements as you talk about a troubling thought or memory. This is like the natural rapid eye movement (REM) that happens when you dream. Research shows it works for post-traumatic stress syndrome, and some doctors use it to treat panic attacks and phobias as well.

Treatment: Exposure Therapy
The idea with this is to get rid of your fear by being around the thing that scares you in a planned, gradual way: The more you’re around it, the less anxious you’ll be about it. If you have social anxiety, it might be going to a restaurant. If you have an insect phobia, it might mean getting close to a picture of the bug and then actually getting near one.

Treatment: Acceptance and Commitment Therapy (ACT)
With this type of therapy, you work to be aware of and accept the negative thoughts brought on by your anxiety. You learn to think about them in a different way and commit to change any behaviors that interfere with your life.

Psychiatric Treatments

Treatment: Selective Serotonin Reuptake Inhibitors (SSRIs)
These medications affect the way your brain uses the chemical serotonin to send messages that control mood and anxiety. They’re used to treat all types of anxiety disorders, as well as many forms of depression.

Treatment: Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Similar to SSRI drugs, these medications affect chemicals in your brain -- serotonin and norepinephrine -- that are related to anxiety and mood. They’re sometimes used as a first treatment for generalized anxiety disorder.

Treatment: Benzodiazepines
These medications relax tension in your muscles and help calm other symptoms of anxiety, but they also can slow your thinking and make you sleepy. If you use them for a long time, you might gradually need higher doses to get the same effect, and you can become addicted.

​
Thomas Kessler, LMFT, RAS
www.thomkesslertherapist.com
marintherapist@gmail.com

These days it’s hard to find anybody critical of marijuana. The drug enjoys broad acceptance by most Americans — 63 percent favored ending cannabis prohibition in a recent Quinnipiac poll — and legislators on both sides of the aisle are becoming more likely to endorse than condemn it. However, there are increasingly alarming studies about what pot does to the human brain especially the adolescent brain.

One of the many things my teen clients have told me they like about getting high, was using pot alleviated their boredom — to one of curiosity, stimulation and enhancement of every day activities, thereby creating an atmosphere of a carefree and “relaxed” attitude. They report that marijuana transforms the mundane into something dramatic: family outings, school, work or just sitting on the couch become endlessly entertaining. My often response to their professed state of boredom is to define boredom as the inability to be with one’s self.

Like any mind-altering substance, marijuana produces its effects by changing the rate of what is already going on in the brain. In this case, the active ingredient delta-9-THC substitutes for your own natural endocannabinoids and mimics their effects. It activates the same chemical processes the brain employs to modulate thoughts, emotions and experiences. These specific neurotransmitters, used in a targeted and judicious way, help us sort the relentless stream of inputs and flag the ones that should stand out from the torrent of neural activity coding stray thoughts, urges and experience. By flooding the entire brain, as opposed to select synapses, marijuana can make everything, including the most boring activities, take on a sparkling transcendence.

Why object to this enhancement? As one client told me, using pot made his personal and professional life more engrossing and thus made him, he thought, a better person and employee. Unfortunately, there are two important caveats from a neurobiological perspective. Widespread cannabinoid activity, by highlighting everything, conveys nothing. When using marijuana the brain dampens its intrinsic machinery to compensate for excessive stimulation. Chronic exposure ultimately impairs our ability to imbue value or importance to experiences that truly warrant it. In adults, such neuro-adjustment may hamper or derail a successful and otherwise fulfilling life, though these capacities will probably recover with abstinence. But the consequences of this desensitization are more profound, perhaps even permanent, for adolescent brains. 

Adolescence is a critical period of development, when brain cells are primed to undergo significant organizational changes: Some neural connections are proliferating and strengthening, while others are pared away – called pruning. Although studies have not found that legalizing or decriminalizing marijuana leads to increased use among adolescents, perhaps this is because it is already so popular. More teenagers now smoke marijuana than smoke products with nicotine; between 35 and 45 percent of high school seniors report smoking pot in the past year, about 25 percent got high in the past month, and about 6 – 8 percent admit to using virtually every day.

​The potential consequences are unlikely to be rare or trivial.The decade or so between puberty and brain maturation is a critical period of enhanced sensitivity to internal and external stimuli. Noticing and appreciating new ideas and experiences helps teens develop a sense of personal identity that will influence vocational, romantic and other decisions — and guide their life’s trajectory. Though a boring life is undoubtedly more tolerable when high, with repeated use of marijuana, natural stimuli, like those associated with goals or relationships, are unlikely to be as compelling. 

Smoking marijuana changes what is happening in a user’s brain. For teenagers, the effects may be permanent. It’s not surprising, then, that heavy-smoking teens show evidence of reduced activity in brain circuits critical for flagging newsworthy experiences, are 60 percent less likely to graduate from high school, and are at substantially increased risk for addiction and alcoholism. Their motivation to accomplish any goals in life are can be significantly reduced. Recent data compiled from research conducted by neuroscientists is even more alarming: those who use THC, may be at increased risk for mental illness and addiction. The studies show alterations in cortical structures associated with impulsivity and negative moods.

Might the relationship between marijuana exposure and changes in brain and behavior be coincidence, as tobacco companies asserted about the link between cancer and smoking, or does THC cause these effects? Unfortunately, we can’t assign people to smoking and nonsmoking groups in experiments, but efforts are underway to follow a large sample of children across the course of adolescent development to study the effects of drug exposure, along with a host of other factors, on brain structure and function, so future studies will probably be able to answer this question. 

As a psychotherapist who specializes in treating clients with substance abuse and/or addiction, I’m unimpressed with many of the widely used arguments for the legalization of marijuana. “It’s natural!” So is arsenic. “It’s beneficial!” The best-documented medicinal effects of marijuana are achieved without the chemical compound that gets users high. “It’s not addictive!” This is false, because the brain adapts to marijuana as it does to all abused drugs, and these neural adjustments lead to tolerance, dependence and craving — the hallmarks of addiction.I have a difficult time listening to the astounding lack of skepticism about pot that is taking place in our current debate. Whether or not to legalize weed is the wrong question. The right one is: How will the increasingly use of marijuana affect individuals and communities? We are astoundingly naive about how the widespread use of pot will affect communities and individuals, particularly teenagers. 

Most drug legislation in this country had nothing do with scientific evidence of harm. Legalizing marijuana is inevitable, but don’t ignore the science on its dangers. Many people view marijuana as either benign or beneficial. Even many of those apathetic toward its potential health benefits are ecstatic about its commercial appeal, whether for personal profit or state tax revenue. In our rush to throw open the gate, we might want to pause to consider how well the political movement to legalize marijuana matches up with the science, which is producing inconveniently alarming studies about what pot does to the adolescent brain.

Though the evidence is far from complete, wishful thinking and widespread enthusiasm are no substitutes for careful consideration matches up with the science which is producing inconveniently alarming studies about what pot does to the adolescent brain. 


Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

​Addiction and sleep share a problematic bidirectional relationship where each influences the other. Many people treat sleep problems with drugs and alcohol, which can lead to addiction. People who are already addicted to drugs and alcohol undergo changes in their sleep architecture and sleep needs, forcing them to increasingly rely on their addiction in order to sleep. Once in recovery, one of the main reasons many people relapse is the discomfort and insomnia they experience, compounded by the long period of time it takes for the body to adjust back to normal sleep without drugs and alcohol.

Individuals with addiction experience sleep deprivation in two ways: they get less sleep than normal, but they also experience lower sleep quality, since they don’t spend the same amount of time in the various stages of sleep as a healthy individual would.

Unfortunately, sleep deprivation itself can lead to drug use, dependence and abuse. Only a quarter of adolescents, for instance, get the recommended 8 or more hours of sleep per night (adolescents need slightly more sleep than the recommended 7 to 8 hours for adults). Research shows these sleep-deprived teens are more likely to engage in risky behaviors, perform worse in school, and use drugs. Worse, those who regularly slept less than 6 hours per night were three times likelier to start using drugs than those who got sufficient sleep on a consistent basis. Experts believe this is due to the reduced ability to regulate your emotions and make good decisions when you’re sleep- deprived. Sleep-deprived people also have lower levels of dopamine, drawing adolescents towards drugs that can boost those reduced levels.

People who abuse drugs and alcohol often suffer from the following substance-induced sleep disorders during their addiction or into recovery. Such disorders are labeled as “substance-induced” because the substance abuse causes the sleeping problem and interferes severely enough with the individual’s normal life, often to the point of requiring medical intervention:

Insomnia describes difficulty falling or staying asleep. Because of the way drugs and alcohol affect the brain and body, nearly all individuals (97 percent) who abuse these substances experience poor sleep quality. Numbers vary, but severe insomnia is experienced by 17 percent of individuals with addiction, and moderate insomnia by 40 percent. While alcohol and drugs like cannabis can aid in initial sleep onset, they result in less restful sleep and an increasing dependence on the addictive substance.

Hypersomnia or excessive daytime sleepiness is the opposite of insomnia, although the two are often linked. Hypersomniacs sleep too much or too late, and they don’t feel refreshed upon waking. To counteract these effects, they try to sleep more, interfering with their life, or to induce sleep by relying on certain addictive substances.

Parasomnias such as sleepwalking, nightmares, or night terrors are more prevalent in individuals who abuse drugs, especially hallucinogens. Fear of these activities can create bedtime anxiety and insomnia, further lessening the individual’s overall amount of sleep.

Obstructive sleep apnea (OSA) describes a condition where the individual literally stops breathing during sleep because their airways have been blocked, whether due to obesity, the muscles relaxing in the back of the throat, or another factor. The brain briefly wakes them up to get them to start breathing again, disrupting sleep and lessening sleep efficiency. More than half of individuals with addiction also have sleep apnea. Alcohol causes the throat muscles to relax, worsening symptoms of sleep apnea, and the resulting lower levels of oxygen in the bloodstream worsen hangovers.

Restless legs syndrome (RLS) occurs when individuals are in a supine position, such as when they’re in bed. People with RLS experience an uncomfortable tingling or numbing sensation in their legs, accompanied by an uncontrollable, irresistible urge to move them in order to find relief. These symptoms are painful and disruptive when the individual is trying to fall asleep. RLS affects one- third of individuals with addiction.

Substance abuse is on the rise, and disrupted sleep, poor sleep, and sleep disorders are along for the ride Some people may rely on depressants like cannabis or alcohol to fall asleep, and eventually they can’t sleep without these substances. Others, who abuse stimulants like cocaine or amphetamines, experience such a boost in alertness that they feel like they don’t need sleep, and end up sleep deprived without realizing it. Once they come down, they may feel so fatigued that they take more drugs in order to stay awake.
This roller coaster of a sleep-wake cycle gets worse when you take into account that chronic drug and alcohol abuse disrupts sleep architecture and the way the brain experiences sleep. Below we’ll review how different drugs interfere with sleep.

Cocaine interferes with the brain’s ability to absorb dopamine, so it gets flooded with it and the individual experiences euphoria. Chronic cocaine use may increase the circadian rhythm and permanently damage the body’s ability to sleep well Even low doses of cocaine can increase wakefulness, decrease restorative slow wave sleep, and alter the amount of REM sleep, critical to cognitive processing. The energizing effect of cocaine causes insomnia, while withdrawal causes hypersomnia.

Amphetamines boost energy and can produce effects similar to cocaine. Amphetamine users share similar sleep problems to those who abuse cocaine, experiencing insomnia when they’re high, and hypersomnia during periods of withdrawal. Over time, chronic amphetamine abuse can disrupt the circadian rhythm.

MDMA (Ecstasy) is another energizing drug that reduces the serotonin nerve endings in the brain over time. Serotonin is involved in melatonin production, the hormone responsible for regulating sleep. Because of this interference with serotonin, MDMA abusers experience the effects of sleep deprivation sooner and more severely than others, especially in regards to cognitive functioning.

Hallucinogens mimic serotonin and stimulate brain activity, the opposite of what is supposed to happen when your body prepares for sleep. As a result, hallucinogen use can result in insomnia or delayed sleep.

While alcohol helps people fall asleep, their sleep isn’t as restful and they are more prone to nightmares, snoring and sleep apnea (because the throat muscles collapse), enuresis (nighttime urination), and night sweats. Alcohol also causes early waking – the alcohol makes your body temperature drop, inducing sleep, but once the alcohol wears off, your body responds with a rise in temperature, making you wake up. Alcoholics experience more alpha and delta brain waves than normal sleepers, interfering with their ability to sleep. They spend less time in REM sleep too, a stage of sleep critical for mood, motor skills, and concentration. Up to 20 percent of people use alcohol as a sleep aid, which over time can lead to dependence. The poor sleep from alcohol withdrawal can last as long as several months or even years, depending on the severity of the addiction.

Marijuana is another sedative like alcohol. It doesn’t impact total sleep quantity, but it does reduce REM sleep (especially THC strains) and users experience insomnia at double the rate of the general population. Less REM sleep means less quality sleep, and when users stop chronic use, they experience a REM rebound effect with especially vivid dreams for up to 2 months after quitting.

While behavioral addictions such as gambling, internet and smartphone addiction don’t have the same physical symptoms of drug addiction, they share many similarities, including negative symptoms such as sleep problems. Gamblers often experience poor and/or disrupted sleep as well as many mood or anxiety disorders that are comorbid with sleep disorders like insomnia. Addictive gamblers in particular have higher rates of daytime sleepiness to recreational gamblers. Sleep deprivation in turn reduces focus and makes gamblers more prone to mistakes and poor bets, which can result in negative behaviors or emotions. Smartphone addiction is correlated with higher rates of depression and anxiety, which often go hand in hand sleep problems. Finally, internet addiction is associated with higher rates of suicide, difficulty falling and staying asleep, daytime sleepiness, and hypersomnia.

Opioid Addiction and Sleep

About 2 million Americans are addicted to prescription opioids, according to the CDC, and overdose deaths from opioids have more than quadrupled in the past 2 decades. The most common opioids involved in death from overdose are methadone, oxycodone, and hydrocodone. 25 percent of people who receive opioids for non-cancer long-term therapy purposes end up becoming addicted.

Opioids are prescribed to help individuals with severe or chronic pain, since the body doesn’t create enough opioids naturally on its own to block intense pain. Opioids are depressants that attach to receptors in your brain to block pain, slow breathing, and create an overall sense of calm. They share a similar structure with the natural neurotransmitters in your brain, allowing them to attach to dopamine receptors, but because they are artificial and not quite the same, they can lead to negative outcomes when a person becomes addicted.

Opioids are addictive because, like cocaine, they flood the brain’s dopamine receptors and create a sense of euphoria when they’re not used as directed. The more a person abuses opioids, the worse their body becomes at producing opioids naturally, so their body becomes dependent on the opioids to block out lesser amounts of pain.

When a person is using opioids, they experience up to 30 to 50 percent reduction in REM and slow-wave deep sleep. REM, the dream state of sleep, is essential for memory consolidation and cognitive processing, while slow-wave deep sleep is what restores the body. Without sufficient amounts of either of these, an individual has trouble focusing, regulating their mood, and remembering things. Even individuals taking opioid medications as prescribed experience these adverse changes in sleep architecture so taking them in the long term can result in chronic fatigue.

Additionally, opioid addicts spend less time asleep overall, experience a higher number of transitions between sleep stages, and spend more time in light sleep. 30 percent of people with chronic opioid use also have central sleep apnea, which further disrupts their sleep, and some studies have linked RLS with opioid dependence.

For opioid addicts in recovery, withdrawal is especially intense. Their nervous system goes haywire, resulting in symptoms like anxiety, sweating, vomiting, diarrhea, muscle aches, and insomnia. Because their body and mind are weakened emotionally, energetically, and physically, it is even tougher for them to cope with the insomnia, and lack of sleep only exacerbates all the other symptoms. Yet sleep is critical for regulating mood, rebalancing the body’s hormones, and strengthening the immune system and restoring energy. Opiate withdrawal can last a week or longer, and symptoms such as these explain why relapse is so common.

Sleep Medication and Overuse

Prescription sleep aids use has increased significantly in the past 20 years, with 4 percent of Americans reporting having used them within the last month. These sedative- hypnotics, or “z-drugs,” include benzodiazepines, barbiturates, and hypnotics, and they all induce sleep. Benzodiazepines are anti-anxiety medications that increase drowsiness, while barbiturates cause a sedative effect by depressing the nervous system. The three most prescribed sleep medications are Ambien, Sonata, and Lunesta. Between 2006 and 2011, 38 million prescriptions were written for Ambien alone.
Most sleep medications aren’t approved for long-term use, because of how they interact with the brain and the dangerous side effects that can occur, such as driving while asleep. Scarily, even prescribed amounts as low as 18 doses per year result in a threefold increase of mortality rates.

Like opioids, prescription sleep medications are easy to become addicted to, in part because they work so well. Once the individual stops using them, they often have trouble falling asleep, so they start to use them again or increase their dose. They may even begin craving the medication, experience memory loss, or start seeking out prescriptions from multiple doctors in order to meet their higher dosage needs.

Recovering from sleep medication addiction requires tapering down the dose slowly and should be done under guidance from a doctor. Withdrawal can cause seizures.

Addiction Recovery

Recovery brings drastic changes to all aspects of an individual’s life, including their emotions, their focus, their behaviors, their routines, and their sleep. Their brain and body have developed a tolerance to the substance which resulted in adjusted sleep patterns or problems, and the sudden withdrawal wreaks havoc on the system as the body learns to adjust to a normal sleep cycle again. Meanwhile, the physical symptoms of withdrawal can be extremely painful or uncomfortable, and anxious thoughts often accompany the road to recovery.

Unfortunately, the lack of sleep associated with recovery worsens mood, increases depression and irritability, and makes it tougher to focus and make sound decisions. Life is suddenly and considerably more challenging. The individual feels terrible physically and emotionally, and their decision-making is impaired from the sleep deprivation. They may start to think they were better off with the substance, increasing their risk of relapse.

This is why it is important to include sleep as part of the overall treatment plan in the following sections we’ll discuss options for facilitating good sleep during recovery. Research shows that getting sufficient sleep aids recovery. Individuals who sleep well during recovery feel better overall and experience fewer cravings. Insomnia and recovery.

For most individuals in recovery, however, insomnia is a constant challenge. Insomnia is 5 times more prevalent in individuals in recovery than the general population, making it that much harder to return to sober life.

Alcoholics in recovery experience higher rates of insomnia, and have difficulty establishing a regular sleep cycle. As many as 75 percent of alcoholics’ experience insomnia during detox, and those with a sleep disorder are twice as likely to relapse than those getting restful sleep. Even if they sleep through the night, it doesn’t feel as restorative. The exhaustion is one of the main reasons for release. Insomnia is such a persistent problem for recovery that it’s included one of the acronyms for the 12-step program, HALT. HALT is the acronym for relapse risk factors, and stands for Hungry, Angry, Lonely or Tired.

Some addicts, such as cannabis smokers, used the drug specifically to help them fall asleep They’ve trained their mind to associate falling asleep with using marijuana, so they have trouble falling asleep without it. The resulting poor sleep during withdrawal causes 65 percent to relapse.

The bad news is that consistently good sleep is often one of the last things to return to an individual in recovery. Of course, that means the good news is that when you do find yourself sleeping better, that’s often one of the first signs you’re adjusted to sober life.

Treatments for Sleep during Recovery

Sleep is critical to a successful recovery. If you’re having trouble sleeping, you’re not alone. Fortunately, there are many behavioral changes and therapies you can try to get better sleep as you adjust to sobriety.

Natural Sleep Aids during Recovery

1. Having a solid support system in place is especially helpful during recovery. Being with people who love and care about you can help you stay on track, especially when you are feeling exhausted, depressed, or one of the many other uncomfortable symptoms of withdrawal. See if you can stay with friends and family during this time, or arrange regular check-ins and meetups with close ones.
2. Create and follow a consistent bedtime routine that helps you wind down and train your mind and body to prepare for sleep. Drink a warm cup of chamomile or lavender tea, take a warm bath, read a book, and stay away from electronics in the hour before bed. Avoid napping during the day and stick to a regular sleep schedule, even on your days off from work.
3. Improve your diet and exercise. Exercising improves mood and alertness, helping to offset the effects of sleep deprivation. Certain foods, like those rich in tryptophan, carbohydrates, calcium, and melatonin can help promote sleep. Avoid eating large meals or exercising later in the day as they can energize the body, upset the stomach, and make it tougher to fall asleep. Also avoid overly fatty, sugary, or spicy foods which can mess with energy levels and cause additional discomfort that makes it difficult to fall asleep.
4. Set up your bedroom to promote sleep. Remove electronics, and invest in products that help block out distracting noise and light, such as blackout curtains, eye masks, and white noise machines. Make sure your pillow and mattress provide proper support for your spine and lower back, and feel great to sleep on.
5. If you’re experiencing RLS as part of your recovery, a weighted blanket can help provide relief. Get a blanket that weighs 10 percent of your bodyweight plus 1 pound.

Cognitive behavioral therapy (CBT) helps patients learn to recognize their problematic or harmful thoughts and habits, and replace them with better thoughts and coping strategies. It’s often used to help individuals with a range of problems from anxiety and eating disorders to insomnia. CBT-I focuses specifically on helping individuals with insomnia adjust the thoughts and behaviors that prevent them from getting restful sleep.

Stimulus control therapy focuses on stimuli your brain has associated with not falling asleep, and retrains the mind to view them differently. For example, someone who works from their bed or watches a lot of TV may be encouraged to only use the bed for sleep and sex, or to stay out of the bedroom altogether except when engaging in those activities.

Sleep restriction therapy sets strict bed and wake times for an individual, and they’re only allowed to stay in bed during those prescribed times, regardless of how much sleep they get. The idea is the body and brain eventually learn to sleep during the appropriate schedule.

Sleep hygiene is about promoting sleep-healthy behaviors, such as avoiding caffeine later in the day, exercising regularly, eating healthier foods, and avoiding blue light in the hours before bed from electronics like TV or computers.

Sleep environment improvement focuses on making the bedroom conducive to sleep, such as keeping it dark with blackout curtains or eye masks, cooling the temperature to somewhere in the mid-60 degrees Fahrenheit, and removing stimulating electronics.

Relaxation training techniques include meditation, deep breathing exercises, muscle relaxation, and visualization strategies to calm the mind and body to prepare for sleep.

Remaining passively awake helps the mind stave off anxiety or stress about not being able to fall asleep, and instead become comfortable just lying in the bed, allowing sleep to come naturally instead of worrying about it.

Biofeedback monitors the patient’s heart rate and muscle tensions so they and their therapist can observe biological reactions that may be inhibiting sleep.

Because of the tendency towards addiction, over-the-counter sleep aids are not recommended for individuals in recovery. Both over-the-counter and prescription sleep aids can create side effects and dependency that interfere with recovery or adjusting back to sober sleep.
​
Melatonin can be helpful as a sleep aid and is generally considered safe, but individuals should still consult their medical professional first, just to ensure they experience no adverse effects based on their individual addiction. The side effects of melatonin on teens in puberty also hasn’t been fully evaluated.


Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

Your Brain
Your brain is who you are. It’s what allows you to think, breathe, move, speak, and feel. It’s just 3 pounds of gray-and-white matter that rests in your skull, and it is your own personal “mission control.” Information from your environment—both outside (like what your eyes see and skin feels) and inside (like your heart rate and body temperature)—makes its way to the brain, which receives, processes, and integrates it so that you can survive and function under all sorts of changing circumstances and learn from experience. The brain is always working, even when you're sleeping.

The brain is made up of many parts that all work together as a team. Each of these different parts has a specific and important job to do. When drugs enter the brain, they interfere with its normal processing and can eventually lead to changes in how well it works. Over time, drug use can lead to addiction, a devastating brain disease in which people can’t stop using drugs even when they really want to and even after it causes terrible consequences to their health and other parts of their lives.

Drugs affect three primary areas of the brain:

• The brain stem is in charge of all the functions our body needs to stay alive—breathing, moving blood, and digesting food. It also links the brain with the spinal cord, which runs down the back and moves muscles and limbs as well as lets the brain know what’s happening to the body.

• The limbic system links together a bunch of brain structures that control our emotional responses, such as feeling pleasure when we eat chocolate. The good feelings motivate us to repeat the behavior, which is good because eating is critical to our lives.

• The cerebral cortex is the mushroom-shaped outer part of the brain (the gray matter). In humans, it is so big that it makes up about three-fourths of the entire brain. It’s divided into four areas, called lobes, which control specific functions. Some areas process information from our senses, allowing us to see, feel, hear, and taste. The front part of the cortex, known as the frontal cortex or forebrain, is the thinking center. It powers our ability to think, plan, solve problems, and make decisions.

How does the Brain Communicate
The brain is a complex communications network of billions of neurons, or nerve cells. Networks of neurons pass messages back and forth thousands of times a minute within the brain, spinal column, and nerves. These nerve networks control everything we feel, think, and do. Understanding these networks helps in understanding how drugs affect the brain. The networks are made up of:

• Neurons 
  Your brain contains about 100 billion neurons—nerve cells that work nonstop to send and receive messages. Within a neuron, messages travel from the cell body down the axon to the axon terminal in the form of electrical impulses. From there, the message is sent to other neurons with the help of neurotransmitters.
• Neurotransmitters—The Brain's Chemical Messengers 
  To make messages jump from one neuron to another, the neuron creates chemical messengers, called neurotransmitters. The axon terminal releases neurotransmitters that travel across the space (called the synapse) to nearby neurons. Then the transmitter attaches to receptors on the nearby neuron.

• Receptors—The Brain's Chemical Receiver 
  To send a message, a nerve cell releases a chemical (neurotransmitter) into the space separating two nerve cells, called the synapse. The neurotransmitter crosses the synapse and attaches to proteins (receptors) on the receiving nerve cell. This causes changes in the receiving nerve cell, and the message is delivered. As the neurotransmitter approaches the nearby neuron, it attaches to a special site on that neuron called a receptor. A neurotransmitter and its receptor operate like a key and lock, in that a very specific mechanism makes sure that each receptor will forward the right message only after interacting with the right kind of neurotransmitter.
• Transporters—The Brain’s Chemical Recyclers 
  Once neurotransmitters do their job, they are pulled back into their original neuron by transporters. This recycling process shuts off the signal between the neurons.

How do drugs affect your brain?
Drugs are chemicals. When someone puts these chemicals into their body, either by smoking, injecting, inhaling, or eating them, they tap into the brain’s communication system and tamper with the way nerve cells normally send, receive, and process information. Different drugs—because of their chemical structures—work differently. We know there are at least two ways drugs work in the brain:

• Imitating the brain’s natural chemical messengers
• Overstimulating the “reward circuit” of the brain

Some drugs, like marijuana and heroin, have chemical structures that mimic that of a neurotransmitter that naturally occurs in our bodies. In fact, these drugs can “fool” our receptors, lock onto them, and activate the nerve cells. However, they don't work the same way as a natural neurotransmitter, and the neurons wind up sending abnormal messages through the brain, which can cause problems both for our brains as well as our bodies.

Other drugs, such as cocaine and methamphetamine cause nerve cells to release too much dopamine, which is a natural neurotransmitter, or prevent the normal recycling of dopamine. This leads to exaggerated messages in the brain, causing problems with communication channels. It’s like the difference between someone whispering in your ear versus someone shouting in a microphone.

The “High” From Drugs/Pleasure Effect
Most drugs of abuse—nicotine, cocaine, marijuana, and others—affect the brain’s “reward” circuit, which is part of the limbic system. Normally, the reward circuit responds to feelings of pleasure by releasing the neurotransmitter dopamine.Dopamine creates feelings of pleasure. Drugs take control of this system, causing large amounts of dopamine to flood the system. This flood of dopamine is what causes the “high” or intense excitement and happiness (sometimes called euphoria) linked with drug use.

The Repeat Effect
Our brains are wired to make sure we will repeat healthy activities, like eating, by connecting those activities with feeling good. Whenever this reward circuit is kick-started, the brain notes that something important is happening that needs to be remembered, and teaches us to do it again and again, without thinking about it. Because drugs of abuse come in and “hijack” the same circuit, people learn to use drugs in the same way.

After repeated drug use, the brain starts to adjust to the surges of dopamine. Neurons may begin to reduce the number of dopamine receptors or simply make less dopamine. The result is less dopamine signaling in the brain—like turning down the volume on the dopamine signal. Because some drugs are toxic, some neurons also may die.

As a result, the ability to feel any pleasure is reduced. The person feels flat, lifeless, and depressed, and is unable to enjoy things that once brought pleasure. Now the person needs drugs just to bring dopamine levels up to normal, and more of the drug is needed to create a dopamine flood, or “high”—an effect known as “tolerance.”

Long-Term Effects
Drug use can eventually lead to dramatic changes in neurons and brain circuits. These changes can still be present even after the person has stopped taking drugs. This is more likely to happen when a drug is taken over and over.

What is drug addiction?
Addiction is a chronic brain disease that causes a person to compulsively seek out drugs, despite the harm they cause. The first time a person uses drugs, it’s usually a free choice they’ve made. However, repeated drug use causes the brain to change which drives a person to seek out and use drugs over and over, despite negative effects such as stealing, losing friends, family problems, or other physical or mental problems brought on by drug use—this is addiction.

What factors increase the risk for addiction?
Although we know what happens to the brain when someone becomes addicted, we can’t predict how many times a person must use a drug before becoming addicted. A combination of factors related to your genes, environment, and development increase the chance that taking drugs can lead to addiction:

• Home and family. Parents or older family members who abuse alcohol or drugs, or who are involved in criminal behavior, can increase young people’s risks for developing their own drug problems.

• Peers and school. Friends and acquaintances who abuse drugs can sway young people to try drugs for the first time. Academic failure or poor social skills can also put a person at risk for drug use.

• Early use. Although taking drugs at any age can lead to addiction, research shows that the earlier a person begins to use drugs, the more likely they are to progress to more serious use. This may reflect the harmful effect that drugs can have on the developing brain. It also may be the result of early biological and social factors, such as genetics, mental illness, unstable family relationships, and exposure to physical or sexual abuse. Still, the fact remains that early use is a strong indicator of problems ahead—among them, substance abuse and addiction.

• Method of use. Smoking a drug or injecting it into a vein increases its addictive potential. Both smoked and injected drugs enter the brain within seconds, producing a powerful rush of pleasure. However, this intense "high" can fade within a few minutes, taking the person down to lower levels. Scientists believe that this low feeling drives individuals to repeat drug use in an attempt to recapture the high pleasurable state.

Can you die if you use drugs?
Yes, deaths from drug overdose have been rising steadily over the last decade. In 2015 alone, more than 52,400 people died from a drug overdose. More than three out of five drug overdose deaths involve some type of opioid, either prescription pain reliever, heroin, or man-made opioids like fentanyl. Among young people, just over 4,200 deaths from a drug overdose occurred that year. Young males were two times more likely to die from a drug overdose than were females. Learn more about drug overdoses in youth.

In addition, death can occur from the long-term effects of drugs. For example, use of tobacco products can cause cancer, which may result in death.

Are there effective treatments for drug addiction?
Yes, there are treatments, but there is no cure for drug addiction yet. Addiction is often a disease that is long-lasting (sometimes referred to as chronic). As with other chronic diseases, like diabetes or heart disease, people learn to manage their condition. Scientific research has shown that 13 basic principles are the foundation for effective drug addiction treatment.

Types of Treatment
Treatment will vary for each person, depending on the type of drugs used and the person’s specific circumstances. Generally, there are two types of treatment for drug addiction:

• Behavior change, in which people learn to change their behavior
• Medications, which can help treat addictions to some drugs, such as tobacco, alcohol, heroin, or other opioids

Length of Treatment
Like diabetes and even asthma, drug addiction typically is a long-lasting disorder. Most people who have become addicted to drugs need long term treatment and, many times, repeated treatments—much like a person who has asthma needs to constantly watch changes in medication and exercise. The important point is that even when someone relapses and begins abusing drugs again, they should not give up hope. Rather, they need to go back to treatment or change their current treatment. In fact, setbacks are likely. Even people with diabetes may go off their diet or miss an insulin injection, and their symptoms will recur—that’s a cue to get back on track, not to view treatment as a failure.

Motivation for Treatment
Most people go into drug treatment either because a court ordered them to do so or because loved ones wanted them to seek treatment. The good news is that, according to scientific studies, people can benefit from treatment regardless of whether or not they chose to go into treatment.

How do I know if someone has a drug problem?
There are questions people can ask to gauge whether or not a person has a drug problem. These may not mean that someone is addicted but answering yes to any of these questions may suggest a developing problem, which could require followup with a professional drug treatment specialist. These include:

1. Have you ever ridden in a car driven by someone (including yourself) who had been using alcohol or drugs?
2. Do you ever use alcohol or drugs to relax, to feel better about yourself, or to fit in?
3. Do you ever use alcohol or drugs when you are alone?
4. Do you ever forget things you did while using alcohol or drugs?
5. Do family or friends ever tell you to cut down on your use of alcohol or drugs?
6. Have you ever gotten into trouble while you were using alcohol or drugs?

Important Resources
If you, or a friend, are in crisis and need to speak with someone now:

• Call National Suicide Prevention Lifeline at 1-800-273-TALK (they don't just talk about suicide—they cover a lot of issues and will help put you in touch with someone close by)

If you need information on drug treatment and where you can find it, the Substance Abuse and Mental Health Services Administration can help.

• Call Substance Abuse Treatment Facility Locator at 1-800-662-HELP
• Visit the locator online at www.findtreatment.samhsa.gov

Drug Facts

• Drugs, Brains, and Behavior: The Science of Addiction
• Research Report Series: Comorbidity: Addiction and Other Mental Illnesses
• The Brain: Understanding Neurobiology Through the Study of Addiction, Educator Curriculum
• The Brain: Understanding Neurobiology Through the Study of Addiction, Teen Activities

Treatment

• DrugFacts: Treatment Approaches for Drug Addiction
• Principals of Drug Addiction Treatment: A Research-Based Guide

​
Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

When nicotine enters the body, it initially causes the adrenal glands to release a hormone called adrenaline. The rush of adrenaline stimulates the body and causes an increase in blood pressure, heart rate, and breathing. 

Most of the harm to the body is not from the nicotine, but from other chemicals in tobacco or those produced when burning it—including carbon monoxide, tar, formaldehyde, cyanide, and ammonia. Tobacco use harms every organ in the body and can cause many problems. The health effects of smokeless tobacco are somewhat different from those of smoked tobacco, but both can cause cancer.

Secondhand Smoke
People who do not smoke but live or hang out with smokers are exposed to secondhand smoke—exhaled smoke as well as smoke given off by the burning end of tobacco products. Just like smoking, this also increases the risk for many diseases. Each year, an estimated 58 million Americans are regularly exposed to secondhand smoke and more than 42,000 nonsmokers die from diseases caused by secondhand smoke exposure. One in four U.S. middle and high school students say they've been exposed to unhealthy secondhand aerosol from e-cigarettes.

The chart below lists the health problems people are at risk for when smoking or chewing tobacco or as a result of exposure to secondhand smoke.

Nicotine and the Brain
Like other drugs, nicotine increases levels of a neurotransmitter called dopamine. Dopamine is released normally when you experience something pleasurable like good food, your favorite activity, or spending time with people you care about. When a person uses tobacco products, the release of dopamine causes similar effects. This effect wears off quickly, causing people who smoke to get the urge to light up again for more of that good feeling, which can lead to addiction.

A typical smoker will take 10 puffs on a cigarette over the period of about 5 minutes that the cigarette is lit. So, a person who smokes about 1 pack (25 cigarettes) daily gets 250 “hits” of nicotine each day.

Is Nicotine Addictive?
Yes. It is the nicotine in tobacco that is addictive. Each cigarette contains about 10 milligrams of nicotine. A person inhales only some of the smoke from a cigarette, and not all of each puff is absorbed in the lungs. The average person gets about 1 to 2 milligrams of the drug from each cigarette.

Studies of widely used brands of smokeless tobacco showed that the amount of nicotine per gram of tobacco ranges from 4.4 milligrams to 25.0 milligrams. Holding an average-size dip in your mouth for 30 minutes gives you as much nicotine as smoking 3 cigarettes. A 2-can-a-week snuff dipper gets as much nicotine as a person who smokes 1½ packs a day.

Whether a person smokes tobacco products or uses smokeless tobacco, the amount of nicotine absorbed in the body is enough to make someone addicted. When this happens, the person continues to seek out the tobacco even though he or she understands the harm it causes. Nicotine addiction can cause:

• tolerance: Over the course of a day, someone who uses tobacco products develops tolerance—more nicotine is required to produce the same initial effects. In fact, people who smoke often report that the first cigarette of the day is the strongest or the “best.”
• withdrawal: When people quit using tobacco products, they usually experience uncomfortable withdrawal symptoms, which often drive them back to tobacco use. Nicotine withdrawal symptoms include:
  • irritability
  • problems with thinking and paying attention
  • sleep problems
  • increased appetite
  • craving, which may last 6 months or longer, and can be a major stumbling block to quitting

How E-cigarettes Affect the Brain
Research so far suggests that e-cigarettes may be less harmful than cigarettes when people who regularly smoke switch to them as a complete replacement. But since they are so new, we do not know for sure. And, nicotine in any form is a highly addictive drug. Health experts have raised many questions about the safety of these products, particularly for teens:

• Testing of some e-cigarette products found the aerosol (vapor) to contain known cancer-causing and toxic chemicals, and particles from the vaporizing mechanism that may be harmful. The health effects of repeated exposure to these chemicals are not yet clear.
• There is animal research which shows that nicotine exposure may cause changes in the brain that make other drugs more rewarding. If this is true in humans, as some experts believe, it would mean that using nicotine in any form would increase the risk of other drug use and for addiction.
• Some research suggests that e-cigarette use may serve as a “gateway” or introductory product for youth to try other tobacco products, including regular cigarettes, which are known to cause disease and lead to early death. A recent study showed that students who have used e-cigarettes by the time they start 9th grade are more likely than others to start smoking traditional cigarettes and other smoked tobacco products within the next year.
• The liquid in e-cigarettes can cause nicotine poisoning if someone drinks, sniffs, or touches it. Recently there has been a surge of poisoning cases in children under age 5. There is also concern for users changing cartridges and for pets.
• Some research shows that secondhand e-cig vapor pollutes the air quality with particles that could harm the lungs and heart.
• Some research suggests that certain brands of e-cigs contain metals like nickel and chromium, possibly coming from the heating of coils.

Regulation of E-cigarettes
Yes. The U.S. Food and Drug Administration (FDA) announced in 2016 that the FDA will now regulate the sales of e-cigarettes, hookah tobacco, and cigars. Therefore:

• It is now illegal to sell e-cigarettes, hookah tobacco, or cigars in person or online to anyone under age 18.
• Buyers have to show their photo ID to purchase e-cigarettes, hookah tobacco, or cigars, verifying that they are 18 years or older.
• These products cannot be sold in vending machines (unless in an adult-only facility).
• It is illegal to hand out free samples.

FDA regulation also means that the Federal government will now have a lot more information about what is in e-cigarettes, the safety or harms of the ingredients, how they are made, and what risks need to be communicated to the public (for example, on health warnings on the product and in advertisements). They will also be able to stop manufacturers from making statements about their products that are not scientifically proven.

Regulation does not mean that e-cigarettes are necessarily safe for all adults to use, or that all of the health claims currently being made in advertisements by manufactures are true. But it does mean that e-cigarettes, hookah tobacco, and cigars now have to follow the same type of rules as cigarette manufacturers.
​
Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.


Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

​Today’s teens are growing up in an environment with pressures, stress and priorities vastly different from when we were their age. If you’re concerned that your son or daughter might be using drugs or alcohol — or if you know they are — it’s important that we, as parents, consider why. Some teens turn to drugs and alcohol for a variety of reasons, like fitting in, socializing, experiencing life transitions or dealing with emotional and psychological pain. Here’s why it’s important for you to recognize why kids might be drawn to substances and what you can do about it.

Keep in Mind:

• Young brains are more vulnerable to drugs and alcohol. Research shows that the teen brain doesn’t fully develop until 25. Drugs and alcohol can alter this development, potentially affecting brain structure and function.
• If there is a history of addiction in your family, if your child has mental health or behavioral issues, has suffered trauma or has impulse control problems, then your child has a much greater risk of developing a substance use problem. Be aware of these elevated risks and discuss it with your child regularly, as you would with any disease.

FITTING IN
Many teens feel like an outsider and long to be included and liked by their peers. This need can be so strong that they engage in drinking or drug use to help make friends, fit in, be accepted or get in with a desired crowd. Drugs might provide an instant “in” with what may seem like a desirable social group.
​
If the kids your teen wants to hang out with are drinking or doing drugs, he or she may feel the need to participate as well, or risk being left out.

What Parents Can Do:

• Get to know your kid’s friends and their parents – and talk with those parents especially when they are hosting parties and find out who is supervising, their stance on substances, will they be serving alcohol, etc.
• Encourage your teen’s friends to hang out at your house: give them a private space if possible but keep an eye on them.
• Talk to your teen about why it’s so important to fit in with this particular group. Explain to your child that real friends don’t make you do things you aren’t comfortable with. Tell stories (either from your own life or from history, books, movies, the news, etc.) of people who chose not to go along with the crowd — and achieved great things because of it.
• If you feel your child is risking his or her health or safety, let her know that you are concerned and get help.

SOCIALIZING
Many teens use drugs and alcohol to overcome insecurities, let their guard down and feel socially confident with others. Some see “partying” as a way to instantly bond with a group of kids, uniting with them in opposition to the “rules” of school, work — and parents.
Drugs may make teens feel that they are really open and relating to each other. Kids may come to believe that drugs are necessary to achieve close interaction with one another.
Some teens use drugs or alcohol because they’re curious or bored and see it as something to do or experiment with.

What Parents Can Do:

• Find activities for your teen to socialize in a healthy, safe and supervised environment. Communicate your expectations and rules for when your teen goes out with friends, and include regular check-ins by texting or calling. Set and enforce curfews.
• Encourage — and help — your child to socialize with friends in a public place instead of in someone’s empty home.
• If your child is socializing at someone else’s home, know where he or she will be. Call the parents in advance to verify the occasion and location and that there will be supervision. Ask your child to call or text you halfway through the night (and set consequences if he or she doesn’t). If the activity seems inappropriate, express concern and keep your child home.
• Assure your child that he or she can call you to be picked up whenever needed, no questions asked. Some families even agree on a code word for the child to text their parents to discreetly say, “Come get me.”
• If your teen is staying over at a friend’s house, be sure to check in with them and speak with the parents who are hosting, if possible.
• Supervise any parties in your home to make sure there is no alcohol or other drugs – and make sure your teens know the rules ahead of time. Learn about the social hosting laws in your state and what they can mean for your personal liability in the event of underage drinking in your home.
• When your teen arrives home after a night out with friends, look her in the eye, smell her clothes and hair and ask her about her night. Although be aware that some ways that marijuana is used, like vaping and edibles, make it harder to detect.
• If you sense your teen has been drinking or using drugs, be sure to have a conversation the next morning when he or she is sober.

LIFE TRANSITIONS
Periods of transition in teens’ lives — like moving, divorce, puberty, changing schools, an illness or death in the family — can often be a time of upheaval, leading many teens to attempt to find solace in alcohol or drugs.

What Parents Can Do: 
Pay even closer attention to your child’s behavior during—and AFTER—transitions, such as:

• Ramp up the monitoring and communication.
• Encourage an open dialogue with your teen about his experiences.
• Set aside regular one–on–one time with your teen to bond and have fun together.

EMOTIONAL AND PSYCHOLOGICAL PAIN
Some teens use alcohol or drugs to dull the pain in their lives. When they’re given a chance to take something to make them temporarily feel better, many can’t resist.

Some teens turn to drugs or alcohol to deal with the pressures of everyday teen drama or to escape from family problems, stress or issues with school or grades.

The pressures kids feel from social media – feeling left out, fear of missing out, feeling like everyone else has a perfect life – can become too much for kids.

Loneliness, low self-esteem, depression, anxiety disorder and other mental health issues lead many teens to use substances.
Furthermore, many of these issues occur in combinations, each compounding the intensity of the others.

What Parents Can Do:

• Keep an eye on how your child is coping. Does he or she seem withdrawn or uninterested in the usual activities? These are signs that your child might be hiding something or need some guidance.
• Remind your child that you are there for support and guidance – and that it’s important to you that she or he is healthy and happy and makes safe choices.
• Offer empathy and compassion. Let your child know you understand. The teen years can be tough. Acknowledge that everyone struggles sometimes, but alcohol is not a useful or healthy way to cope with problems. Let your child know that he or she can trust you.
• If you notice extreme and lasting changes in mood, behavior, grades, attention span, or if your son or daughter seems depressed or not herself, etc., take your child to a doctor or therapist for a professional health assessment to find out what’s causing the problem.
• Model healthy coping skills. Show your kids how to learn from mistakes and disappointments. For example, after a long day, instead of drinking a glass of wine or beer, try stretching or deep breathing. Promote healthy coping skills for managing stress: exercise, take a walk, practice yoga, meditation or mindfulness.
• Brainstorm together healthy ways to help your child manage the stress in her/his life. (Ex: More sleep, yoga, recreational sports, volunteering, etc.) Let your child offer suggestions and help him/her think through the ideas. Help teach your teen social coping strategies. Explain to your child that it’s okay to make mistakes – that’s how we learn. At the end of each day, call attention to all that she has accomplished. Be sure to point out these positive efforts.
• Remind her that you care deeply about her health and well-being and love her no matter what.
• If your child is suffering, reassure her that you will seek out appropriate professional help and then do just that.

How to Talk with Your Son or Daughter about Drugs and Alcohol
Productive communication with your teen or young adult about alcohol and drugs doesn’t always have to feel like you’re giving the third degree. Remain calm, relax and follow the tips below to ensure that your child hears what you have to say — and visa versa.

• Try to be objective and open. If you want to have a productive conversation with your child, do your best to keep an open mind and remain curious. Your child is more likely to be receptive this way.
• Ask open-ended questions. These are questions that elicit more than just a “yes” or “no” response and will lead to a more engaging conversation. For example, instead of asking, “Do your friends smoke marijuana?” you can try, “What do your friends think of the new marijuana laws?”
• Let your teen know they’re being heard. Use active listening and reflect back what you are hearing — either verbatim, or just the sentiment. For example, you can say, “I’m hearing that you feel overwhelmed, and that you think drinking helps you relax. Is that right?”
• Think about activities that can be healthy, fulfilling substitutes to their substance use or ways to help them learn coping skills to that are more effective than substance use in addressing underlying problems.
• If your child’s interested in drinking or using drugs, ask why. This gets your teen to think about her future, what her boundaries are around drinking – and some of the possible negative consequences (she may be late to practice, do something stupid in front of her friends, feel hung over). It will also give you insight into what’s important to her.

Adapted from Partnership for Drug-Free Kids

Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

Teen Instagram star Essena O’Neill amassed a large following just based on photos of her life. Recently, after reaching nearly a million followers, the 19-year-old decided to tell her fans the secret behind her success: Self-doubt and addiction to her screen.

So, just like most people eventually do with a bad habit, she decided to kick it to the curb.

“Social media, especially how I used it, isn’t real,” she said in a video announcing her decision. “It’s contrived images and edited clips ranked against each other. It’s a system based on social approval, likes, validation in views, success in followers. It’s perfectly orchestrated self absorbed judgement. I was consumed by it.”

She has since edited the original captions on her Instagram photos, explaining the real work that went behind seemingly “candid” shots (“A 15-year-old girl that calorie restricts and excessively exercises is not goals,” one edited photo reads). She also deleted her YouTube account and started a website dedicated to mindful use of social media.

O’Neill’s story is one of many about the false illusions and negative feelings caused by social media, highlighting a growing, under-addressed health problem for young people. An extensive new survey from Common Sense Media found that teens spend nearly nine hours a day using their devices.

Technology certainly has the power to inspire positive change, but overindulgence can have dangerous consequences. Here are just a few ways excessive screen use can take a toll on teens’ well-being — and a few tips to keep in mind:

Too much tech can lead to weight gain.

Technology has a way of usurping physical activity, and it may show in teens’ health. One study found that increased screen time was associated with larger waistlines in adolescents, Scientific American reported. Swapping social media scrolling with some adventures outdoors can improve every aspect of someone’s health — and it feels way better than a Facebook “like.”

Excessive social media use is a sign of loneliness.

Social media has a way of prompting FOMO in real time, simply with a scroll through a newsfeed. A 2014 study found that excessive Facebook use may be a sign of loneliness. Not only that, research shows the popular social media site can make people feel sadder and less satisfied with their life.

It also leads to social comparison.

Research shows the reason why people feel so bad when they use social media is because of a subconscious process called social comparison, or stacking up their own life against someone else’s. This can result in the user feeling less satisfied with their own life. A friendly, gentle reminder for anyone who thinks someone’s life is better than their own: An Instagram filter often acts as a rose-colored lens. Social media is often used as a highlight reel, not an accurate portrayal of someone’s reality.

Screens make multitasking super tempting.

The recent Common Sense Media survey also reveals a growing trend with multitasking, saying many young adults felt comfortable engaging with multiple tech mediums while doing their homework. Studies show multitasking can ruin a person’s productivity on tasks in the long run. As tempting as those puppy videos in the background might be, it may be wiser to compartmentalize the two activities.

They may also hurt teens’ grades.

Limiting excessive tech use may also boost test scores. A recent study from the London School of Economics revealed that students saw remarkable improvement in test grades after smartphones were banned from the classroom, CNN reported. Knowledge is power.
Overall, excessive online media can jeopardize teens’ health.
Smartphones can cause the perfect storm for health implications. Research shows that adolescents’ media consumption — in addition to lack of sleep and physical activity — puts them in jeopardy for psychiatric conditions just as much as their high-risk peers who abuse alcohol, skip school or engage in other potentially dangerous behaviors.

Mindful use of technology is possible, and probably the most effective antidote when it comes to screens’ negative effect on well-being.  Just like with most things, moderation is essential. The body and brain depend on it.

​
Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

​When nicotine enters the body, it initially causes the adrenal glands to release a hormone called adrenaline. The rush of adrenaline stimulates the body and causes an increase in blood pressure, heart rate, and breathing.

Most of the harm to the body is not from the nicotine, but from other chemicals in tobacco or those produced when burning it—including carbon monoxide, tar, formaldehyde, cyanide, and ammonia. Tobacco use harms every organ in the body and can cause many problems. The health effects of smokeless tobacco are somewhat different from those of smoked tobacco, but both can cause cancer.

Secondhand Smoke
People who do not smoke but live or hang out with smokers are exposed to secondhand smoke—exhaled smoke as well as smoke given off by the burning end of tobacco products. Just like smoking, this also increases the risk for many diseases. Each year, an estimated 58 million Americans are regularly exposed to secondhand smoke and more than 42,000 nonsmokers die from diseases caused by secondhand smoke exposure.2 One in four U.S. middle and high school students say they've been exposed to unhealthy secondhand aerosol from e-cigarettes.

The chart below lists the health problems people are at risk for when smoking or chewing tobacco or as a result of exposure to secondhand smoke.

Nicotine and the Brain
Like other drugs, nicotine increases levels of a neurotransmitter called dopamine. Dopamine is released normally when you experience something pleasurable like good food, your favorite activity, or spending time with people you care about. When a person uses tobacco products, the release of dopamine causes similar effects. This effect wears off quickly, causing people who smoke to get the urge to light up again for more of that good feeling, which can lead to addiction.

A typical smoker will take 10 puffs on a cigarette over the period of about 5 minutes that the cigarette is lit. So, a person who smokes about 1 pack (25 cigarettes) daily gets 250 “hits” of nicotine each day.
Is Nicotine Addictive?

Yes. It is the nicotine in tobacco that is addictive. Each cigarette contains about 10 milligrams of nicotine. A person inhales only some of the smoke from a cigarette, and not all of each puff is absorbed in the lungs. The average person gets about 1 to 2 milligrams of the drug from each cigarette.

Studies of widely used brands of smokeless tobacco showed that the amount of nicotine per gram of tobacco ranges from 4.4 milligrams to 25.0 milligrams. Holding an average- size dip in your mouth for 30 minutes gives you as much nicotine as smoking 3 cigarettes. A 2-can-a-week snuff dipper gets as much nicotine as a person who smokes 11⁄2 packs a day.

Whether a person smokes tobacco products or uses smokeless tobacco, the amount of nicotine absorbed in the body is enough to make someone addicted. When this happens, the person continues to seek out the tobacco even though he or she understands the harm it causes. Nicotine addiction can cause:
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• tolerance: Over the course of a day, someone who uses tobacco products develops tolerance—more nicotine is required to produce the same initial effects. In fact, people who smoke often report that the first cigarette of the day is the strongest or the “best.”
• withdrawal: When people quit using tobacco products, they usually experience uncomfortable withdrawal symptoms, which often drive them back to tobacco use. Nicotine withdrawal symptoms include:
  
  • irritability
  • problems with thinking and paying attention
  • sleep problems
  • increased appetite
  • craving, which may last 6 months or longer, and can be a major stumbling block to quittingHow E-cigarettes Affect the Brain Research so far suggests that e-cigarettes may be less harmful than cigarettes when people who regularly smoke switch to them as a complete replacement. But since they are so new, we do not know for sure. And, nicotine in any form is a highly addictive drug. Health experts have raised many questions about the safety of these products, particularly for teens:

• Testing of some e-cigarette products found the aerosol (vapor) to contain known cancer-causing and toxic chemicals, and particles from the vaporizing mechanism that may be harmful. The health effects of repeated exposure to these chemicals are not yet clear.
• There is animal research which shows that nicotine exposure may cause changes in the brain that make other drugs more rewarding. If this is true in humans, as some experts believe, it would mean that using nicotine in any form would increase the risk of other drug use and for addiction.
• Some research suggests that e-cigarette use may serve as a “gateway” or introductory product for youth to try other tobacco products, including regular cigarettes, which are known to cause disease and lead to early death. A recent study showed that students who have used e-cigarettes by the time they start 9th grade are more likely than others to start smoking traditional cigarettes and other smoked tobacco products within the next year.10

• The liquid in e-cigarettes can cause nicotine poisoning if someone drinks, sniffs, or touches it. Recently there has been a surge of poisoning cases in children under age 5. There is also concern for users changing cartridges and for pets.
• Some research shows that secondhand e-cig vapor pollutes the air quality with particles that could harm the lungs and heart.11
• Some research suggests that certain brands of e-cigs contain metals like nickel and chromium, possibly coming from the heating of coils.12Regulation of E-cigarettesYes. The U.S. Food and Drug Administration (FDA) announced in 2016 that the FDA will now regulate the sales of e-cigarettes, hookah tobacco, and cigars. Therefore:

• It is now illegal to sell e-cigarettes, hookah tobacco, or cigars in person or online to anyone under age 18.
• Buyers have to show their photo ID to purchase e-cigarettes, hookah tobacco, or cigars, verifying that they are 18 years or older.
• These products cannot be sold in vending machines (unless in an adult-only facility).
  
• It is illegal to hand out free samples.
  
  

FDA regulation also means that the Federal government will now have a lot more information about what is in e-cigarettes, the safety or harms of the ingredients, how they are made, and what risks need to be communicated to the public (for example, on health warnings on the product and in advertisements). They will also be able to stop manufacturers from making statements about their products that are not scientifically proven.

Regulation does not mean that e-cigarettes are necessarily safe for all adults to use, or that all of the health claims currently being made in advertisements by manufactures are true. But it does mean that e-cigarettes, hookah tobacco, and cigars now have to follow the same type of rules as cigarette manufacturers.

Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and


Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

Deaths from fentanyl and other synthetic opioids (not including methadone) rose a staggering 72 percent in just one year, from 2014 to 2015 and continue to rise. Government agencies and officials of all types are rightly concerned by what some are describing as the third wave of our ongoing opioid epidemic.

As a concerned psychotherapist and addiction specialist, working with individuals and families — the following are the most important things to understand about fentanyl.
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1. Fentanyl is 50 to 100 times more potent than heroin or morphine. It is a schedule II prescription drug typically used to treat patients with severe pain or to manage pain after surgery. It is also sometimes used to treat patients with chronic pain who are physically tolerant to other opioids. In its prescription form, fentanyl is known by such names as Actiq®, Duragesic® and Sublimaze®. Fentanyl is measured in micrograms not milligrams, which should give you an idea of how strong this synthetic opiate is.
2. It is relatively cheap to produce, increasing its presence in illicit street drugs. Dealers use it to improve their bottom line. According to a report from the Office of National Drug Control Policy, evidence suggests that fentanyl is being pressed into pills that resemble OxyContin, Xanax, hydrocodone and other sought-after drugs, as well as being cut into heroin and other street drugs. A loved one buying illicit drugs may think they know what they’re getting, but there’s a real risk of it containing fentanyl, which can prove deadly.
3. Naloxone (Narcan) will work in case of overdose, but extra doses may be needed.Because fentanyl is far more powerful than other opioids, the standard 1-2 doses of naloxone may not be enough. Calling 911 is the first step in responding to any overdose, but in the case of a fentanyl-related overdose the help of emergency responders, who will have more naloxone, is critical.
4. Even if someone could tell a product had been laced with fentanyl, it may not prevent their use.Some individuals claim they can tell the difference between product that has been laced with fentanyl and that, which hasn’t, but overdose statistics would say otherwise. Some harm reduction programs are offering test strips to determine whether heroin has been cut with fentanyl, but that knowledge may not be much of a deterrent to a loved one who just spent their last dollar to get high. I recently received a sample of Xanax that someone bought on the dark web. I sent it in to my toxicology lab and came back laced with Fentanyl.
   
5. ​Getting a loved one into treatment is more critical than ever.

If you need help in determining a course of action, feel free to call me.

Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

We all have stress in our lives. When it comes to your teens, you know that school (like homework, competitive sports, tests, SATs, college applications) combined with juggling social media and after-school activities is one of the biggest sources of stress. As parent’s you want to make sure that it doesn’t lead them to unhealthy behaviors to help cope.

Stress can be a motivator, but it also can produce negative feelings and, unfortunately, increase the possibility that a teen will use drugs*. When people are under stress, the brain releases cortisol, the stress hormone. Over time and under chronic stress, parts of the brain that are related to memory or learning are negatively affected by the presence of cortisol. Interestingly, some of these areas of the brain are the same parts impacted by drug use and addiction. In reality, your child’s brain is still developing until age 25 to 28 (depending on which study you reference) and stress can damage parts of the brain that can make your child more vulnerable to drug addiction, in the same way that early use of drugs can.

It’s not a new concept that stress can lead to drug use and addiction — far from it — but it’s something that many parents don’t necessarily associate with school and the good intentions that they have for their kids. Abusing drugs not prescribed to them, like prescription stimulants, act on the “reward center” in your child’s brain, releasing euphoric chemicals like dopamine and serotonin. In time, they can cause the brain to rely on drugs to keep those chemicals flowing. While drugs might make your child temporarily feel respite, in the long run, misusing drugs actually makes stress more pronounced.

Unfortunately, those exposed to chronic stress are more likely to use substances in an attempt to relax or “power through” the stress, so it’s important that your child knows how to use healthy coping mechanisms instead to deal with the pressures he or she faces.
​
For example, some teens when they become stressed out and anxious, may turn to abusing prescription stimulants not prescribed to them — also known as “study drugs,” instead of coping in healthy ways. These are medicines that are used to treat Attention-Deficit Hyperactivity Disorder (ADHD) such as Adderall, Concerta, Vyvance and Ritalin — but are abused to pull all-nighters and cram for exams. Most don’t see this behavior as risky.

But what happens when high school and college kids (who don’t have ADHD) take prescription stimulants that are not prescribed to them? Is this safe or are there real dangers? According to Dr. Nora Volkow, Director of the National Institute on Drug Abuse (NIDA), the data is showing that overall stimulant medications do not improve your cognitive performance. If you have someone that is performing optimally, and you give them a stimulant, the performance may deteriorate.” “If you’re giving stimulant medications to a kid that doesn’t have ADHD, at the time in their life when their brain is developing very rapidly that may interfere with those developmental processes.”

* For the purpose of this blog - alcohol is considered a drug.


Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

This fact sheet was created using a 2104 report from the National Institute of Drug Abuse (NIDA) and The Surgeon General’s - Call to Action to Prevent and Reduce underage Drinking.

The short- and long-term consequences that arise from underage alcohol consumption are astonishing in their range and magnitude, affecting adolescents, the people around them, and society as a whole. Adolescence is a time of life characterized by robust physical health and low incidence of disease, yet overall morbidity and mortality rates increase 200 percent between middle childhood and late adolescence/early adulthood.

This dramatic rise is attributable in large part to the increase in risk-taking, sensation-seeking, and erratic behavior that follows the onset of puberty and which contributes to violence, unintentional injuries, risky sexual behavior, homicide, and suicide. 

Alcohol frequently plays a role in these adverse outcomes and the human tragedies they produce. Among the most prominent adverse consequences of underage alcohol use are those listed below:
Annually, about 8,000 people under age 21 die from alcohol-related injuries involving underage drinking. Approximately:

• 1,900 (38 percent) of the 8,000 deaths involve motor vehicle crashes,
• 1,600 (32 percent) result from homicides, and
• 300 (6 percent) result from suicides

Underage drinking:

• Plays a significant role in risky sexual behavior, including unwanted, unintended, and unprotected sexual activity, and sex with multiple partners. Such behavior increases the risk for unplanned pregnancy and for contracting sexually transmitted diseases (STDs), including infection with HIV, the virus that causes AIDS.
• Increases the risk of physical and sexual assault.
• Is associated with academic failure.
• Is associated with illicit drug use.
• Is associated with tobacco use.

• Can cause a range of physical consequences, from hangovers to death from alcohol poisoning.
• Can cause significant alterations in the structure and function of the developing brain, which continues to mature into the mid- to late twenties, and may have consequences reaching far beyond adolescence.
• Creates secondhand effects that can put others at risk. Loud and unruly behavior, property destruction, unintentional injuries, violence, and even death because of underage alcohol use afflict innocent parties. For example, about 45 percent of people who die in crashes involving a drinking driver under the age of 21 are people other than the driver. Such secondhand effects often strike at random, making underage alcohol use truly everybody's problem.
• In conjunction with pregnancy, may result in fetal alcohol spectrum disorders, including fetal alcohol syndrome, which remains a leading cause of mental retardation.
• Is a risk factor for heavy drinking later in life, and continued heavy use of alcohol leads to increased risk across the lifespan for acute consequences and for medical problems such as cancers of the oral cavity, larynx, pharynx, and esophagus; liver cirrhosis; pancreatitis; and hemorrhagic stroke.

There Is a High Prevalence of Alcohol Use Disorders Among the Young.

Early alcohol consumption by some young people will result in an alcohol use disorder-that is, they will meet diagnostic criteria for either alcohol abuse or dependence and the highest prevalence of alcohol dependence is among people ages 18-20
In other words, the description these young people provide of their drinking behavior meets the criteria for alcohol dependence set forth in the most recent editions of the Diagnostic and Statistical Manual of Mental Disorders - DSM-V.

Early Onset of Drinking Can Be a Marker for Future Problems, Including Alcohol Dependence and Other Substance Abuse.

Approximately 40 percent of individuals who report drinking before age 15 also describe their behavior and drinking at some point in their lives in ways consistent with a diagnosis for alcohol dependence. This is four times as many as among those who do not drink before age 21.

The Negative Consequences of Alcohol Use on College Campuses Are Widespread.

Alcohol consumption by underage college students is commonplace, although it varies from campus to campus and from person to person. Indeed, many college students, as well as some parents and administrators, accept alcohol use as a normal part of student life.

​Studies consistently indicate that about 80 percent of college students drink alcohol, about 40 percent engage in binge drinking, and about 20 percent engage in frequent episodic heavy consumption, which is bingeing three or more times over the past 2 weeks.16 The negative consequences of alcohol use on college campuses are particularly serious and pervasive. For example:

• An estimated 1,700 college students between the ages of 18 and 24 die each year from alcohol-related unintentional injuries, including motor vehicle.
• Approximately 600,000 students are unintentionally injured while under the influence of alcohol.
• Approximately 700,000 students are assaulted by other students who have been drinking.
• About 100,000 students are victims of alcohol-related sexual assault or date rape.

Problems among underage military drinkers include: serious consequences (15.8 percent); alcohol-related productivity loss (19.5 percent); and as indicated by AUDIT scores, hazardous drinking (25.7 percent), harmful drinking (4.6 percent), or possible dependence (5.5 percent).

Children of Alcoholics/Addicts Are Especially Vulnerable to Alcohol Use Disorders.

Children of alcoholics/addicts are between 8 and 10 times more likely to become alcoholics than children from families with no alcoholic adults and therefore require special consideration when addressing underage drinking. Adolescents can be predisposed to develop alcoholism / addiction. They are at a greater risk to develop an addiction later in life if they use alcohol or drugs. According to recent research, if one parent has an addiction in the family, that child now has a 45% risk of developing an addiction, if they use alcohol or drugs. If both parents suffer from the disease of alcoholism/addiction or have family members with an addiction, their child now is at a 90% risk of developing an addiction later in life. Research also indicates that the onset of addiction in an adolescent is 8 times greater then in an adult over the age of 25.

Notes R. E. Dahl, "Adolescent brain development: A period of vulnerabilities and opportunities," (Keynote address) Annals of the New York Academy of Sciences 1021 (2016): Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control (NCIPC). Web Based Injury Statistics Query and Reporting System (WISQARS) 2004; R. Hingson and D. Kenkel, "Social health and economic consequences of underage drinking" in: Reducing Underage Drinking: A Collective Responsibility (Washington, DC: National Academies Press, 2014), 351-382.; D. T. Levy, T. R.. Miller, and K. C. Cox, Costs of Underage Drinking (Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention, 1999); National Highway Traffic Safety Administration (NHTSA)., Traffic Safety Facts 2002: Alcohol, DOT Pub. No. HS-809-606 (Washington, DC: NHTSA, National Center for Statistics and Analysis, 2003); G. S. Smith, C. C. Branas, and T. R. Miller, "Fatal nontraffic injuries involving alcohol: A metaanalysis," Annals of Emergency Medicine 33 (2014):659-668.

M. L. Cooper and H. K. Orcutt, "Drinking and sexual experience on first dates among adolescents," Journal of Abnormal Psychology 106 (2013):191-202; M. L. Cooper, R. S. Pierce, and R. F. Huselid, "Substance use and sexual risk taking among black adolescents and white adolescents," Health Psychology 13 (2012):251-262.

R. Hingson, T. Heeren, M. Winter, et al, "Magnitude of alcohol-related mortality and morbidity among U.S. college students age 18-24: Changes from 1998 to 2001," Annual Review of Public Health 26 (2015):259-279.

J. A. Grunbaum, L. Kann, L., S. Kinchen, et al, "Youth risk behavior surveillance-United States, 2003," MMWR Surveillance Summaries: Morbidity and Mortality Weekly Report Summary 53(2):1-96, May 21, 2004. Errata in MMWR Morbidity and Mortality Weekly Report 53(24):536, June 25 2012; 54(24):608, June 24, 2013.

S. Shiffman and M. Balabanis, "Associations between alcohol and tobacco," in Alcohol and Tobacco: From Basic Science to Clinical Practice, NIAAA Research Monograph No. 30, NIH Pub. No. 95-3931 (Washington, DC: U.S. Govt. Print. Off., 2010), 17-36.

S. A. Brown, S. F. Tapert, E. Granholm, et al, "Neurocognitive functioning of adolescents: Effects of protracted alcohol use," Alcoholism: Clinical and Experimental Research 24 (2012):164-171; F. T. Crews, C. J. Braun, B. Hoplight, et al, "Binge ethanol consumption causes differential brain damage in young adolescent rats compared with adult rats," Alcoholism: Clinical and Experimental Research 24 (2014):1712-1723; M. D. De Bellis, D. B. Clark, S. R. Beers, et al "Hippocampal volume in adolescent-onset alcohol use disorders," American Journal of Psychiatry 157 (2012):737-4744; H. S. Swartzwelder, W. A. Wilson, and M. I. Tayyeb, "Age-dependent inhibition of long-term potentiation by ethanol in immature versus mature hippocampus," Alcoholism: Clinical and Experimental Research 19 (2014):1480-1485; H. S. Swartzwelder, W. A. Wilson, and M. I. Tayyeb, "Differential sensitivity of NMDA receptor-mediated synaptic potentials to ethanol in immature versus mature hippocampus," Alcoholism: Clinical and Experimental Research 19 (1995):320-323; S. F. Tapert and S. A. Brown, "Neuropsychological correlates of adolescent substance abuse: Four-year outcomes," Journal of the International Neuropsychological Society 5 (1999):481-493; A. M. White and H. S. Swartzwelder, "Age-related effects of alcohol on memory and memory-related brain function in adolescents and adults," in Recent Developments in Alcoholism, Vol. 17: Alcohol Problems in Adolescents and Young Adults: Epidemiology, Neurobiology, Prevention, Treatment, (New York: Springer, 2005), 161-176. U.S. Department of Transportation Fatality Analysis Reporting System 2004.

K. L. Jones and D. W. Smith, "Recognition of the fetal alcohol syndrome in early infancy," Lancet 2(7836):999-1001, 1973.
J. D. Hawkins, J. W. Graham, E. Maguin, et al, "Exploring the effects of age of alcohol initiation and psychosocial risk factors on subsequent alcohol misuse," Journal of Studies on Alcohol 58 (2013): 280-290; J. E. Schulenberg, K. N. Wadsworth, P. M. O'Malley, et al, "Adolescent risk factors for binge drinking during the transition to young adulthood: Variable- and pattern-centered approaches to change," Developmental Psychology 32 (1996):659-674.Alcohol Research & Health, Alcohol and Disease Interactions Vol. 25, No. 4, 2001.
American Psychiatric Association (APA), Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (Washington, DC: APA, 2004); American Psychiatric Association (APA), Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision(Washington, DC: APA, 2000).

B. F. Grant and D. A. Dawson, "Age at onset of alcohol use and its association with DSM-V alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey," Journal of Substance Abuse 9 (2014):103-110.

In college studies, binge drinking is usually defined as "five or more drinks in a row for men and four or more drinks in a row for women" (National Institute on Alcohol Abuse and Alcoholism [NIAAA] National Advisory Council). The definition was refined by the NIAAA National Advisory Council in 2004 as follows: "A 'binge' is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gram percent or above. For the typical adult, this pattern corresponds to consuming 5 or more drinks (male), or 4 or more drinks (female), in about 2 hours." It is a criminal offense in every State for an adult to drive a motor vehicle with a blood alcohol level of 0.08 gram percent or above.

National Institute on Alcohol Abuse and Alcoholism (NIAAA), A Call to Action: Changing the Culture of Drinking at U.S. Colleges(Bethesda, MD: NIAAA, 2002).

R. Hingson, T. Heeren, M. Winter, et al, "Magnitude of alcohol-related mortality and morbidity among U.S. college students age 18-24: Changes from 1998 to 2001," Annual Review of Public Health 26 (2005):259-279.

The Alcohol Use Disorders Identification Test (AUDIT), which was developed by the World Health Organization, consists of 10 questions scored 0 to 4 that are summed to yield a total score ranging from 0 to 40. It is used to screen for excessive drinking and alcohol-related problems. Scores between 8 and 15 are indicative of hazardous drinking, scores between 16 and 19 suggest harmful drinking, and scores of 20 or above warrant further diagnostic evaluation for possible alcohol dependence.

R. M. Bray, L. L. Hourani, K. L. R. Olmsted, et al, 2005 Department of Defense Survey of Health Related Behaviors Among Military Personnel (Research Triangle Park, NC: RTI International, 2006).
M. Russell, "Prevalence of alcoholism among children of alcoholics," 
in Children of Alcoholics: Critical Perspectives (New York: Guilford, 1990), 9-38.

J. E. Donovan, "Adolescent alcohol initiation: A review of psychosocial risk factors," Journal of Adolescent Health 35 (2004):529e7-529e18.

B. F. Grant and D. A. Dawson, "Age at onset of drug use and its association with DSMIV drug abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey," Journal of Substance Abuse 10 (1998):163-173.


Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

​The term dry drunk is a slang expression infamously known in the sober community. It describes a person who is ‘dry’ and no longer drinks or abuses drugs, but continues to behave in dysfunctional ways. While in their active addiction they often experienced negative trains of thought, attitudes, feelings and actions. Simply removing alcohol or drugs without changing these underlying factors is likely to produce what is often referred to as a ‘dry drunk syndrome’. Another catchphrase used in the sober community is “untreated alcoholism.” Both terms refer to the same symptoms, and these risky conditions can traditionally mark the initial stages of relapse.

The dry drunk syndrome is best described as someone who fits one or more of the following conditions. A person with chemical dependency issues who has given up alcohol and drugs, but has made no internal emotional or behavioral changes. Essentially, the only difference in these individuals is they are abstinent and are no longer abusing a substance.

It is important to recognize an individual’s old ways of thinking and acting. A lack of progression continues despite being abstinent from alcohol and drugs. Sober alcoholics and drug addicts not in recovery often rely on commonly distorted ways of thinking, which create their negative thoughts and often linked to their depression and anxiety. Negative thoughts are accompanied by negative feelings. Many practice isolation behavior and find life generally difficult, experiencing a sense of uneasiness and restlessness with life.
An alcoholic / addict who has not worked on their underlying emotional issues or behaviors will continue to experience negative attitudes and behaviors. These symptoms despite being abstinent impact their quality of life and often the people around them.

The dry drunk may display superiority or low self-esteem issues. Superiority or grandiosity basically means a return to a self-centered, ‘the world revolves around’ me attitude. Chemically dependent people are self-centered in the extreme, as any therapist or psychiatrist is quick to observe. With grandiosity, one is setting themselves up to be the center of attention; either superior to everyone around them, or by playing the victim. Either way, they distance themselves from the people and world around them.
Self-esteem issues are found in the core belief of how one view themselves internally. People with untreated alcoholism often feel that they are not ‘good enough’ by comparing themselves to others and are plagued with ANTS – Automatic Negative Thoughts.
The following are examples of behavior that are common with people with untreated alcoholism.

The dry drunk may display impulsivity. One of the most common attitudes or observable behaviors of people with addiction problems is poor impulse control and impatience. They tend to do what they want, when they want, with little regard for self-harm or the hurt caused towards others.

When impulsivity is combined with grandiosity, attention-seeking behavior accelerates rapidly. Warped expectations that characterize virtually every alcoholic and drug addict feed this impulsiveness. Chemical dependency instills a taste for immediate relief. Years of alcohol and drug abuse almost mold it into addiction’s nature.
The dry drunk may display negative judgment. This may be one of the most destructive mental aspects of addiction. Alcoholics and addicts tend to exhibit particularly negative perspectives about themselves, others and the world about them.

People who judge another as being ‘better than or less than,’ create a situation where their internal condition is manipulated in much the same way a drink or drug functioned. On the other hand, if a person judges others or themselves as ‘falling short or less than,’ they can feel bitter and cultivate resentment.

In both cases, people with chemical dependency are at risk of separating themselves through mental isolation. This is another reason why drug addiction and alcoholism are commonly referred to as mind-powered diseases.

The dry drunk may display complacency. This is not only an attitude of somebody with untreated alcoholism, but is a red flag warning sign of someone who dangerously treading the path to relapse. An important facet of being in active recovery is just that - being active. It does not matter how quickly an alcoholic or drug addict progresses in recovery, just that progress is being made. It is easy to regress into laziness or disinterest, and return to addictive behaviors.

The dry drunk may display negativity in general. If negativity sets in, it is very important to determine if any underlying issues are present. What’s going on beneath the surface? Is it anger and resentment, or is some person, place or thing not working out? Excessive anxiety and worry begin to seep into various threads of life. In these situations, old defense mechanisms can begin to show up such as minimizing, rationalizing and denying problems.
One of the most common reasons for relapse is stress caused by anxiety. High stress consumes mental and emotional energy. It is virtually impossible to retain feelings of happiness and serenity when anxiety permeates life. Some destructive behaviors and actions that can result from the dreaded dry drunk thinking are restlessness, irritability and discontent.

Little things may start become annoying. One begins to look for differences in the people around them, which can cause a feeling of separation. This is often the first stage in the relapse process. It is also the trickiest a person fails to recognize that ‘separation mentality’ is present.

Feelings of being bored or dissatisfied with life begin to creep in. One becomes easily distracted from productive tasks. Nothing is exciting and what is referred to as the “pink cloud” is over. The initial euphoria of becoming abstinent is replaced with disillusionment. People may start to wonder why they got sober in the first place.
It is my belief that for those in long-term recovery, complacency is the biggest demon one must fight. On the flip side, I believe the most viable asset one can have in recovery is persistence. When life appears to be working well, the temptation is to lose focus on growing in recovery.

Many sick people stop taking medication once they start feeling better, only to see their illness reemerge. The same principle holds for those on the sober path. Don’t stop taking the medication offered through recovery.

Another risk experienced by the dry drunk is they begin to engage in ‘euphoric recall.' Euphoric recall only remembers the good times when using drugs and alcohol. People remember how much fun they had when using, how much more social, clever, witty and awesome they were. It really is a journey into the past’s fantasyland.

At the same time, the alcoholic / addict also chooses to ignore all of their misery that resulted from alcohol and drug abuse. They tend to forget the times where they made a total fool of themselves at parties or social events. Perhaps they ignore memories of legal troubles.

A simple risk-benefit exercise can end the process of euphoric recall quickly. Writing and remembering the negative consequences, and most alcoholics and drug addicts have a laundry list of negative consequences is helpful.

Engaging in magical thinking is when unrealistic expectations and fanciful dreams begin to appear. This characteristic is similar to euphoric recall, but not necessarily confined to past events. Magical thinking can involve unrealistic expectations, unreasonable goals, and simply believing that things will occur if they are wished for hard enough. One example of magical thinking might be thinking that if I stay sober, my girlfriend will come back to me.

Becoming clean and sober is definitely a step in the right direction; however, there is a good chance that wreckage of the past will take time to heal and resolve. This starts to move into the realm of having unrealistic expectations. People who are newly sober want things to happen quickly. However, without daily action and continual self-improvement, not much will change.

Final Thoughts on Dry Drunk Syndrome.

Looking back at the list of attitudes and the actions dry drunk syndrome can generate, it is easy to see how this condition is nothing more than regression to thoughts and behaviors exhibited during active alcoholism and drug addiction. Life becomes more stressful. The craving for alcohol and drugs can begin to grow. This increases the dry drunk’s irritability and demanding behavior and often makes others around the dry drunk feel that they were more tolerable when they were drinking!

If one can recognize the dry drunk symptoms, then the problem can be met head on. If the symptoms are not recognized and acknowledged they become a significant problem, and relapse may just be around the corner.

Below are some of the thoughts, feelings and behaviors that I have observed in my clients and that they have shared with me over the years.

1) Thoughts About Associated Pleasures:They start thinking constantly about pleasures associated with drinking. Though you are aware that you have had problems with alcohol, still you imagine that drinking was a pleasant experience.

2) Fear About Well Being: They feel a lack of confidence and extreme anxiety in life without alcohol. If there is any stress, they seem to want a quick fix.

3) Loneliness Leading to Depression: They experience intense loneliness they miss the days when they were drinking with their friends, and even when they were drinking alone. All of their highs had been in relation with alcohol and drugs. They had cut themselves off from many social relationships to be with their bottle or pills. Now they are alone but without their ‘medication’.

4) Irritation and Anger: They consider staying away from drinking or drugging a major sacrifice. They think everyone and everything else should conform to their expectations. This, naturally, does not happen and this leads to stress, anger and frustration.

5) Impatience: Things cannot happen soon enough for them. They can’t wait to get their suspension order revoked, or the promotion that was delayed.

6) Compulsive Behavior: They try many other mood-altering activities. They may talk continuously in the presence of others or keep absolutely quiet. They might make impulsive and impractical purchases to impress friends or family. They might take to gambling or some other route of escape from reality.

7) Self Pity: This is the biggest and most negative hole many can get into. There is a negative thought they have been singled out for injustice.

8) Tunnel Vision: They try to drown themselves in work they become the workaholic and escape from social or family obligations. Or they shy away from responsibilities at work and try to integrate themselves with another aspect of life. They do not look at the facets of their life with balance.

9) Denials and Over Confidence: They deny that they have to make lifestyle changes. They deny that they have to change their attitude to life. They do not want to discuss their problems. They boast that they have kicked their habit. Quite recklessly, they often will even say that they can drink without getting addicted again. They fail to see that this may be the ultimate setup for failure.

It is important to point out here, that not all people that embrace recovery are members of a 12-step program. I have many clients past and present that now live their life in recovery, that did not attend a 12-step program. Instead through psychotherapy they have learned to understand what their underlying issue was that caused them to self medicate with their drug of choice – their co-occurring disorder.

To date I have never had a person walk through my door that was not self medicating an underlying psychological issue. Whether the issue is centered on depression, anxiety, trauma, self-esteem issues or a painful childhood it is important to treat the co-occurring disorder if one is expected to give up their drug of choice. In addition to weekly therapy, all my clients have completed a specially designed version of step work that is psychological based to address their co-occurring disorders.
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Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

Millions of American teens report experiencing weeks of hopelessness and loss of interest in normal daily activities, and many of these depressed teens are making the problem worse by using marijuana and other drugs. Some teens use marijuana to relieve the symptoms of depression (“self-medicate”), wrongly believing it may alleviate these depressed feelings. In surveys, teens often report using marijuana and other drugs not only to relieve symptoms of depression, but also to “feel good,” or “feel better,” to relieve stress, and help them cope. 

However, recent studies show that marijuana and depression are a dangerous combination. In fact, using marijuana can worsen depression and lead to more serious mental health disorders, such as schizophrenia, anxiety, and even suicide. Weekly or more frequent use of marijuana doubles a teen’s risk of depression and anxiety. Depressed teens are more than twice as likely as their peers to abuse or become dependent on marijuana.

Alarmingly, the majority of teens who report feeling depressed aren’t getting professional help. They have not seen or spoken to a medical doctor or a psychotherapist about their feelings. For parents, this means they need to pay closer attention to their teen’s behavior and mood swings and recognize that marijuana and other drugs could be playing a dangerous role in their child’s life.

Research conducted by NIDA has shown

• Depressed teens are twice as likely as non-depressed teens to use marijuana and other illicit drugs.
• Using marijuana can cause depression and other mental illnesses.
• Teens who smoke marijuana at least once a month are three times more likely to have suicidal thoughts than non-users.
• Teen girls who use marijuana daily are more likely than girls who do not use marijuana to develop depression.
• Two million teens report feelings of depression and loss of interest in daily activities during the past year.

Depressed teens are more than twice as likely as their peers to abuse or become dependent on marijuana.

Marijuana use can worsen depression and lead to more serious mental illnesses such as schizophrenia, anxiety, and even suicide.
The percentage of depressed teens is equal to the percentage of depressed adults, but depressed teens are more likely than depressed adults to use marijuana and other drugs.

Drugs and Depression
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According to recent national surveys, two million youths (8%) felt depressed at some point in the course of a year. Another survey of high school students shows that percentage even higher (29%).
There are indications that many teens are using drugs to “self-medicate” (deal with problems of depression and anxiety by using drugs to alleviate the symptoms). Many teens say they use drugs to “make them feel good” or “feel better.”

However, research shows that using marijuana and other illicit drugs puts a teen at even greater risk for more serious mental illnesses. A teen who has been depressed at some point in the past year is more than twice as likely to have used marijuana (25%) as teens who have not reported being depressed (12%). Similarly, 35 percent of depressed teens used an illicit drug (including marijuana) during the year, compared to 18 percent of teens who did not report being depressed.

Depressed teens are more likely to engage in other risky behaviors, as well. They are more likely than non-depressed teens to report daily cigarette use (5% vs. 3%) and heavy alcohol use (5% vs. 2%).

Link Between Marijuana Use, Depression, and Other Mental Health Problems

Teens who use marijuana can end up making tough times worse. Mental health risks associated with recent and long-term marijuana use include schizophrenia, other forms of psychosis, and even suicide. Recent research makes a strong case that cannabis smoking itself may be a causal agent in psychiatric symptoms, particularly schizophrenia.

Research shows that teens who smoke marijuana at least once a month in the past year are three times more likely to have suicidal thoughts than non-users during the same period. Yet another study found that marijuana use was associated with depression, suicidal thoughts, and suicide attempts. One 16-year study showed that individuals who were not depressed and then used marijuana were four times more likely to be depressed at follow up. Another study conducted over a 14-year period found that marijuana use was a predictor of later major depressive disorder.

An extensive analysis of longitudinal studies on marijuana use and risk of mental illness later in life showed that marijuana use increases the risk of developing mental disorders by 40 percent. The risk of psychosis increases with frequency of marijuana use, from 50 to 200 percent among frequent users. The authors conclude, that “there is now sufficient evidence to warn young people that using cannabis could increase their risk of developing a psychotic illness later in life.”

Other studies also show a strong relationship between marijuana and schizophrenia. A study from New Zealand showed “a clear increase in rates of psychotic symptoms after the start of regular use” of marijuana. Another 21-year longitudinal study showed that marijuana use was associated with psychotic symptoms and suggested a causal relationship. A study published in Schizophrenia Research found that cannabis use seems to be a specific risk factor for future psychotic symptoms.

Another study of young adults from birth to age 21 found a relationship between early initiation and frequent use of cannabis and symptoms of anxiety and depression, regardless of a history of mental illness.

Teens who smoke marijuana when feeling depressed are also more likely to become addicted to marijuana or other illicit drugs. Eight percent of depressed teens abused or became dependent on marijuana during the year they experienced depression, compared with only three percent of non-depressed teens. Overall, more teens are in treatment for marijuana dependence than for any other illicit drug.

Depressed Teens More Likely To Use Drugs than Depressed Adults

The percentage of teens reporting being depressed is similar to the percentage of adults reporting depression. Depressed teens, however, are more likely than depressed adults to use drugs. In the course of a year, seven percent of adults reported feeling depressed, compared to eight percent of teens.

But a quarter (25%) of depressed teens used marijuana in the course of a year, while only 19 percent of depressed adults did. Additionally, 35 percent of depressed teens used other illicit drugs (including marijuana), compared to 28 percent of depressed adults.

Girls at Greater Risk

Teen girls are especially at risk. In fact, three times as many girls (12%) as boys (4%) experienced depression during the year. Another study confirms that girls are more likely than boys to report feelings of sadness or hopelessness (37% vs. 29%).

Substance abuse can compound the problem. Girls who smoke marijuana daily are significantly more likely to develop symptoms of depression and anxiety: their odds are more than five times higher than those of girls who do not smoke marijuana.

Parental Involvement

Parents should not dismiss changes in their teen’s behavior as a “phase.” Their teen could be depressed, using drugs – or both. Parents can help their teen understand the risks of marijuana use, and should be on the lookout for signs of depression.

It’s been shown that parents who make an effort to understand the pressures and influences on young people are more likely to keep their teen healthy and drug-free.

Teens who report having conversations with their parents about alcohol and drug use are more likely to stay drug-free, compared to teens who do not talk about substance abuse with their parents.


Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

Addictive behavior can be recognized as a progressive loss of control over drug use, and can be reflected in behaviors such as "doctor shopping," or seeking multiple prescriptions for opioids from different doctors, difficulty functioning in important life areas such as at work or in important relationships, and escalating use of opioids despite the devastating impacts, both physical and psychological. If you or someone you are close to is suffering from these signs and symptoms, seeking a prompt evaluation by an addiction treatment professional is a good place to start.

Waiting for a loved one to hit bottom, we risk missing a chance to save a life. As knowledgeable consumers of medicine in the Digital Era, we have the power to make safer and more informed choices about pain treatment, and we can recognize the signs of a plan of pain management that is headed towards addiction and destructive consequences in a loved one.

The staggering statistics are all over the media. Drug overdoses are claiming more lives than auto accidents, with opioids as the main driver of the climbing death toll. The Centers for Disease Control and Prevention estimate that 78 people die every day from an opioid overdose, an unprecedented toll in the history of the health impact of drug abuse. With proper treatment, however, many recover from opioid addiction. With as much public awareness that has developed about the potential for opioid addiction and overdose, the rates of treatment initiation and recovery ought to increase dramatically, if this information is put to use by consumers of medical care.

Research studies have found medication-assisted treatments for opioid addiction, such as suboxone and methadone, to be highly effective in helping people recover from addiction and preventing overdose deaths. There are many reasons these medication-assisted treatments are underutilized, including limited availability of the medicines, cost and trained prescribers. Perhaps equally problematic is the skepticism that patients and health care providers have about the use of these medicines in treating addiction. Concerns about replacing one addiction with another are also common.

The desperation to avoid withdrawal contributes to excessive use, overdose and even criminal activities in the pursuit of more of the drug. Medicines such as Suboxone and Methadone are used to treat opioid addiction by stopping the cycle of highs and withdrawals while providing a stable dose of a replacement drug that acts on the same area of the brain. This restores the stability of the addict's brain chemistry, relieves cravings and helps the person become functional again, and to be productive and have meaningful relationships.

As scientific data concerning chronic pain treatment has accumulated, the benefits of opioids when prescribed for pain that extends beyond three months have been called into question. What's more, the repeated use of opioids has been found to worsen pain in a sizable group of patients, a condition known as "hyperalgesia." This can create a vicious cycle in which the pain sufferer takes larger doses of opioids to try and eliminate a pain condition that was itself worsened by opioids in the first place. As the pain progressively intensifies in response to escalating doses of opioids, the risk of addiction and overdose worsens.

Because opioids also affect the respiratory centers in the brain, which regulate breathing, at too high a dose, or when combined with other sedatives, respiratory depression and death can occur. This is now the too-often heard story of a fatal overdose.

New guidelines for opioid prescribers who are treating chronic pain, released in March by the Centers for Disease Control, recommend consideration of alternative treatments to opioids rather than starting with opioids as a "go-to" pain management strategy. As these guidelines are being implemented, we are not powerless against the devastating disease of opioid addiction. If a doctor prescribes opioids for your pain management, make sure you ask questions about the risks – and alternative treatments.

If you have a history of addiction, even if unrelated to controlled substances, or if you suffer from a mental health condition like depression, you are more vulnerable to becoming addicted to opioids. Adolescents also have an increased risk. But even those who are not at especially high risk can develop an opioid addiction; no one is immune.

Recovery from addiction can be achieved through a combination of behavioral therapies and effective medicines. Studies support the use of a variety of approaches including psychotherapy, exercise,
Addiction is not a simple problem with a simple solution. Many have tragically lost the fight, yet I have worked with and heard powerful stories from those who not only survived, but also have created rewarding and meaningful lives in the aftermath of their battle with this disease.

A licensed therapist who has been trained and certified in addiction can be a tremendous source of help.

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Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

Below I have broken down my approach to couples work in the following sections. I do believe that “one size does not fit all,” so within this framework I also incorporate other modalities of therapy. However, couples therapy is very specific and separate form individual therapy. Couples come to me for guidance and suggestions so I am very active in session. I meet with couples for at least 60 minutes – many times for 90 minutes. Research has shown that after the first 40 minutes the efficacy of therapy goes up significantly. I will meet with the couple and then schedule separate sessions with each partner for further assessment. After most sessions I assign “homework” for each partner to work on – sometimes together and sometimes apart.

Research Based Methods:
I use several principals when working with couples. The first principal I use is to utilize proven research-based methods to treat couples. What this means is utilizing clearly thought-out, scientifically grounded approach to the challenges that the couple are trying to address in their relationship. For example one proven research finding and one that you might have felt intuitively: Healthy relationships require that we honor and support one another’s differentiated experiences. Healthy relationships emerge from integration. Integration in a relationship entails the honoring of differences and the compassionate communication that links two individuals together as a whole. Integration is the source of the idea that “the whole is greater than the sum of its parts.”

Assessment:
When I first meet with a couple I am assessing the health of the relationship and evaluating the full nature of what is exactly going on and then deciding on a course of treatment, while taking into consideration the expectations of each individual in the relationship. This process is a collaboration of goals to repair and or improve the health of the relationship.

It is necessary to understand each partner’s inner world. This means sensing each individual’s subjective inner experience, making sense of their world – their feelings, thoughts, hopes and dreams.

Process Past Regrettable Incidents:
When a “regrettable incident” has occurred and stored in our memory, it can be both at an implicit and explicit level and can alter how we feel about another person in ways that may persist for long periods of time following the experience. It is crucial to repair the rupture. We do this by processing not only the rupture but also the cause of the rupture and its unintended consequences.

Gentle Conflict Management Skills:
Often the challenges to the couple’s relationship are the four ways in which they relate to each other: criticism; contempt; defensiveness; and stonewalling. The first two, criticism and contempt are used as active weapons against each other; the second two are used as isolating and protective shields.

Strengthen Friendship and Intimacy:
There are so many ways in which we can connect in a close relationship as a couple. It is important that we honor our differences while promoting compassionate communication as we cultivate an integrated relationship. We learn to foster and nurture intimacy. If you think about friendship and intimacy, you may notice how close relationships require that you honor differences and promote respectful, caring communication. Each person in the relationship is unique, and each person can be connected to the other without losing his or her own identity.
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Couples therapy is an opportunity to learn the tools that will help each of you to find shared meaning, and bring more kindness and compassion into your relationship and into your lives.


Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

Do you or a loved one struggle with addictions to street drugs, prescription drugs, or alcohol? Have you or your loved one repeatedly entered treatment programs only to relapse time and again? Stop blaming yourself, as it may be because you or your loved one are not getting the necessary treatment for concurrent or underlying mental health conditions.

Going in and out of treatment can be expensive, but may not address a person’s whole well being if the focus is not on treating the symptoms of deeper problems. Many problems present themselves in conjunction with other issues, making treatment of dual diagnosis necessary for a full recovery. I help by treating my clients holistically to increase their harmony and understanding of themselves.

What is Dual Diagnosis?

A dual diagnosis treatment plan should offer the healing for substance abuse problems, mental health disorders, and/or eating disorders that occur at the same time, which are called dual diagnosis or co-occurring conditions. Some people may suffer from depression, anxiety, trauma, schizophrenia, or paranoia, and drink or abuse drugs in order to self medicate. Alternatively, some people who are addicted to drugs or alcohol subsequently suffer a mental disorder. Eating disorders are often the result of a mental disorder, and many people with an eating disorder also succumb to substance abuse. Some people also have multiple mental disorders that require concurrent treatment.

What are the Symptoms of Dual Diagnosis?

The main sign that a person might have co-occurring conditions is continually relapsing after undergoing a treatment program. Recognizing other signs and symptoms can be difficult, as one condition can often mask another, which is why it is important that a therapist understands how to screen for dual diagnosis. The therapist should look at an individual’s family history, treatment history, and how he or she feels while clean and sober in order to develop an accurate diagnosis. You want to watch for the typical symptoms and signs that include substance abuse, depression, anxiety, bipolar disorder, trauma and an eating disorder.

I believe treatment for dual diagnosis should treat all co-occurring conditions simultaneously. This approach helps my clients to finally gain control over their problems. Often, substance abuse and addiction occur at the same time as a mental disorder, like anxiety or depression. If the mental issues are not also treated, then the risk of relapsing is very high. Additionally, eating disorders and substance abuse also have a high rate of co-occurrence. Sometimes, people also exhibit more than one mental disorder. When only one of the problems is addressed at a time, a person is vulnerable to setbacks. I approach dual diagnosis treatment by integrating various therapies in order to concurrently treat all conditions so my patients can fully recover.

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Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

From the moment our children are born and the doctor takes them to be weighed, measured and bundled, their health becomes one of our very highest priorities. As parents, most of us are instinctively attuned to every sneeze, scratch and sleep disruption. We are careful to never miss a check up or ignore a cough. Yet even as we worry over immunizations and stock up on hand soap for flu season, how often do we take the time to sit back and ask ourselves: how emotionally healthy are our children?

According to The American Academy of Pediatrics (AAP), "An estimated 21 percent of children and adolescents in the U.S. meet the diagnostic criteria for a mental health disorder...Yet, due to a shortage of pediatric mental health care providers, only 20 percent of these children receive treatment." In June, the AAP release a toolkit along with other resources to help pediatricians more effectively identify and manage mental health issues in children.

As important as it is this to get this message to pediatricians, it is just as important to help parents, who may have trouble identifying that their kids are hurting. On Dec. 4, I will be hosting the free Webinar, "How to Raise Emotionally Healthy Children" to help parents, caretakers, teachers, and professionals learn valuable tools for dealing with their children's emotional struggles.  As parents in today's culture, we find ourselves encouraged to center our daily lives on our kids. Yet as we focus our attention on carpools, homework and play dates, we run the risk of becoming dangerously distracted from what's most important: how our children feel. While setting our schedules to make our children a practical priority is an act of genuine caring, nothing is as valuable or has the positive impact as staying attuned to a child's feelings, asking her how she is and allowing her to open up about her thoughts, impressions and fears.

In general, many of our children's emotions get overlooked, as we tend to pay more attention to how they are behaving than how they are feeling. By maintaining an awareness of our children's psychological state and keeping in mind the following parenting principles, we can become more attuned to our children and learn ways to raise an emotionally healthy child.

Don't ignore signs that your child is struggling 

Be aware of behavioral changes that could indicate a child is struggling. If a teacher tells us our child has had trouble getting along with other kids in class, we shouldn't just shrug it off as being out of character and hope for the best - just as we shouldn't chuckle at how silly our child looks while throwing a temper tantrum. What may start off as small behavioral patterns can elaborate into later behaviors that are concerning. For instance, an exaggerated focus on food or video games can be signs a child is using these things to cut off pain. If left unaddressed, these patterns can lead to obesity or an addiction to drugs and alcohol. And the fits that seem kind of cute coming from a 4-year-old will seem far less charming from a 14-year-old.

Don't trivialize how your child is feeling 

It is all too easy for parents to fluff off our children's moods, chalking them up to developmental stages like the terrible twos or teenage rebellion. Though these stages do contribute to emotional behaviors, it's important to learn to sensitively relate to our children while they are in these states, and teach them how to cope with their emotions.
When we notice an emotional change in our children, it's important to try to understand what specifically is impacting them and to respond accordingly. Perhaps something has scared them that they themselves haven't made sense of or that they aren't comfortable talking about. For example, a friend of mine recently noticed his typically outgoing, independent 13-year-old daughter becoming quiet and anxious about being away from him and her mother. It was weeks before my friend realized that his daughter had been deeply shaken after a student at her school lost her parents in an accident.

As we let our children know we are interested in or concerned about their specific struggle, we invite them to investigate their own emotions and to better comprehend their source. By being open and nonjudgmental, we encourage our kids to be honest with us. When they do open up, it is important to react with both compassion and strength. Offering both of these responses helps demonstrate a constructive attitude that our kids can adopt toward themselves and thereby develop a resiliency that will serve them well in future struggles.

Be sensitive and attuned, not reactive or parental 

From the moment they speak their first words, it's essential to encourage our kids to talk to us. When it comes to influencing our kids, just making rules never works, but maintaining an open and equal sense of communication does. However for this to work, we must be accountable: we have to live up to our word in order to gain our children's trust. If we invite our children to talk to us honestly, then are defensive or erratic in our responses, we give them very good reasons NOT to tell us what's really going on in their lives.

For example, a friend of mine noticed his 6-yeard-old son acting oddly angry and rebellious at the dinner table. Doing his best to react sensitively, he took the boy aside and asked if something had upset him that day. His son replied that his feelings had been hurt when his dad didn't play baseball with him that evening, as he usually did when he came home from work. Inadvertently, my friend reacted defensively: he said that he'd had to work late that day and besides, he hadn't promised to play catch with his son, and then he drove home the fact that just because he was disappointed was no excuse to misbehave at dinner.

Later that night my friend realized that his response had been insensitive. He immediately approached his son and initiated a second conversation with him. He told him that he knew that playing baseball together in the evening meant a lot to him. He said that it was one of his favorite times of his day and that he had also missed playing it that evening. He communicated to his son that he not only understood the boy's disappointment but also shared it. Then he encouraged his son to talk to him the next time he felt bad, so they could avoid a scene like the one at the dinner table. He also reassured his son that he would really listen to what he was saying about himself and not respond the way he had during their first conversation. Both father and son went to bed that night feeling happy and on good terms with each other.

As parents, we should do our best not to react defensively to our children or try to talk them out of their reality. Instead, we should apologize that their feelings were hurt and help them make sense of their unique perspective and experience. Then we can share our own feelings about how they acted and enjoy an equal, honest level of interaction. If we do slip up and react in a way that is insensitive or inappropriate, it is important to go back and undo the damage that we have done to our child's trust in being able to communicate with us.

Invite them to spend time with you 

When it comes to spending time with our kids, quality is much more important than quantity. It is advisable to set aside a specific time in which we engage in activities directed by our children; a realistic time period during which we offer our kids our uninterrupted attention and let them know they are a priority. Letting our kids decide what we do does not mean allowing them to set unrealistic expectations about activities that cost too much in time or money. Rather it is an opportunity to share an activity with our children and create a situation in which they can talk to us.

We can learn about them from what they suggest we do or games they opt to play. Parents, who take the time to sit with their young children, while they play with dolls or action figures, are often surprised to hear Barbie saying the very things that Mommy does or Spiderman acting in ways that Daddy does. Games that involve make believe or pretend can be very telling when it comes to kids. And we shouldn't be surprised when one character reflects the role - and consequently, the thoughts, feelings and behaviors - of our own children.

If they won't talk to you, help them find a situation they trust 

Many parents wonder what to do when their kids will not open up to them. This is especially true of parents with teenage children. Yet, even if our kids refuse our offerings, it's important to keep putting ourselves out there and to keep letting them know we are there whenever they want to talk. If we are consistently there for our kids, we never know when they may come around.

If our children do not feel comfortable talking to us, we must remember that there is no shame in helping them find someone they do trust who they can open up to. Each of us can think of someone in our lives who meant something to us as a kids - a warm uncle, a dear grandmother, an outgoing teacher or a trusted therapist. Parents aren't always the easiest people for children to talk to, especially if their struggles involve their parents in some way. Letting our kids know they can talk to someone besides us can help secure their trust in us and will encourage them to deal with whatever they are feeling outwardly with someone they feel comfortable to confide in.

If they are in real trouble get them the help they need 

If a child shows an unusual amount of anxiety, fear, anger, stress or pain, it is important to get him the help he needs. As parents, we must not be too prideful when it comes to raising our kids. How our children feel should always outweigh how we are viewed as their parents. The best thing we can do for our children is to be selfless in our commitment to getting their emotional needs met.

Take care of your emotional health 

Although it's important to prioritize our kid's needs, it's equally important to remember that little affects our kids more than how we ourselves are feeling. Children are naturally highly attuned to their parents' moods. Putting on a brave face or denying our frustrations will never fully mask what we are feeling, and these feelings, which our children undoubtedly perceive, are sure to impact them.

Therefore, taking care of our own mental health is a key factor in helping our kids feel happy. No matter how much we fuss over, worry about or take interest in them, if we are not feeling content and fulfilled in ourselves, we are very likely doing more bad than good in terms of our children's emotional well being.

That is why we, as parents, have to ask ourselves: How am I feeling? Am I getting enough support in my own mental health? How do the answers to these questions influence the way I am caring for my children? Am I focusing on them too much or too little? Am I putting too much pressure on them, looking to them to meet my needs instead of the other way around? Am I relating to them in a personal way? Although we may falsely label such self-reflection as selfish, looking deeper into ourselves and focusing on what lights us up is truly beneficial to the spirits of our children.

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Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

Anticipating an initial session can create anxiety in many people and knowing what to expect can help alleviate that anxiety. This is why I offer a 30 minute telephone consultation before people come to my office. I listen to what your presenting issue is and provide you with an understanding of my approach to therapy. After our phone conversation if you feel we both feel we might be a good fit you fill out paperwork that is provided on my web site, so that we do not use valuable session time to complete paperwork.

In the first few sessions we are getting to know each other informally. I have found that no matter how knowledgeable or experienced a therapist may be there is little, if any therapeutic progress without a strong therapeutic alliance between the client and their therapist. You must feel safe, comfortable, not judged and hopeful that you have found a place where you can truly begin to understand issues that have been causing you challenges.

My process involves asking general questions about why you decided to obtain treatment as well as background information. Questions will include your relationship and work history, medical history, assessment of your symptoms and other psychological history, previous psychotherapy experiences, and questions regarding your cultural background and family, to name a few.

After a few sessions I share my initial impressions in order to determine if I correctly understand you. I also will begin to outline what your treatment plan might be, usually within the first one to three sessions. I will encourage you to think up some of your own goals for therapy. I believe goal setting should be collaboration between my clients and myself. I also encourage questions regarding my professional background, my experience working with your issues and any questions you have regarding the psychotherapy process.

As treatment progresses, one thing to keep in mind is that psychotherapy requires client engagement. In order for treatment to work for you – you must be engaged, or involved, in your treatment. The client and psychotherapist are both active participants, as opposed to the client being the passive recipient of treatment. The more engaged you are, the more you will get out of the process.
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Psychotherapy can seem daunting initially, however, many clients feel more comfortable once they have had their first session. You are there to be heard, assessed, and engage in treatment so that you and the your psychotherapist can work together to help you feel healthier overall.

One in 4 people deals with mental health issues which impacts people emotionally, cognitively, their relationships, the workplace — and also medically. “Mind your Health” by keeping mental health in the forefront.


Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

Adolescence for many people is a wonderful, challenging time of life. On the one hand, it’s a time of emerging independence and identity, exploring new freedom and contexts. However, the changes during this time are many, and this can also bring about different challenges and struggles for teens. This is also a time when teens can experience a mental health condition being triggered, and also might begin using substances, which can lead to teen addiction and/or substance abuse.

Right now in the United States, about 1/5 teenagers has a diagnosable mental illness, such as Teen Anxiety, Teen Depression, Teen Bipolar Disorder, or Teen Eating Disorder. Of these, around 70% will wait between 8-10 years before telling anyone and/or receiving any sort of diagnosis and treatment. This delay between onset and treatment is one of the greatest vulnerabilities for teens, as symptoms continue to worsen over time, gradually affecting almost all areas of the teens’ lives. For instance, around 50% of teens with a mental illness drop out of school and about 70% of teens in juvenile detention have a mental illness and sadly, suicide is the 3rd leading cause of death for teens. Moreover, the likelihood of a teen abusing substances is drastically increased for those suffering with a mental illness, which often complicates teens’ symptoms and overall health, even further.

Types of Treatment
The most common types of adolescent mental health and substance abuse treatment include talk therapy approaches and medication, and most instances employ some combination of the two. Some of the different types of treatment I make available include: individual therapy sessions, family therapy, 12-step program therapy, peer group therapy, psychotherapy, behavioral therapy, and support groups. All of these therapeutic offerings can prove extremely helpful and truly life changing for teens, regardless of how intimidating things may seem, at the start.

Teen Treatment Statistics for Mood Disorders
Teen Mood Disorders are defined as a psychological illness that’s connected with a teen’s moods, and are characterized by a persisting low mood, which doesn’t alter, even over time. The most prominent cause for Teen Mood Disorders is a chemical imbalance in the brain, which causes disruption of properly functioning neurotransmitters. Mood Disorders affect about 11% of youth in the United States. Some examples of the most prevalent Mood Disorders among teens include Teen Bipolar Disorder and Teen Depression. Teen Treatment Statistics for Anxiety Disorders Teen Anxiety Disorders affect about 8% of teens ages 13-18 in the United States and are characterized by a constant state of anxiety, fear, and worry, which persists regardless of circumstances. Teens that have an Anxiety Disorder are so overwhelmed by their racing minds and anxious feelings that it disrupts nearly every aspect of their lives. Some of the most common types of Teen Anxiety Disorders include: Teen Generalized Anxiety Disorder, Teen Phobia, Teen Social Anxiety, Teen Obsessive Compulsive Disorder, and Teen Panic Disorder. Addiction Treatment Statistics Adolescence is also a time when many teens begin experimenting with alcohol and other substances and this can unfortunately lead to Teen Addiction.

Teen Substance Abuse and Addiction is especially dangerous because teens’ brains are still developing; therefore, substances can have more serious and/or even permanent effects on teens’ brains. Because of this, often teens vastly underestimate the potential risk of trying a substance even once, as they don’t usually understand the full ramifications. There’s also a strong correlation between teens with addiction suffering from a mental illness, and vice versa. In fact, the majority of teens who receive treatment for addiction also show symptoms for a Co-Occurring Disorder, such as Teen Depression or Teen Anxiety. In these cases, it’s common for teens to turn to substances in order to self-medicate for the uncomfortable symptoms they’re experiencing or in other cases, a mental illness can actually be triggered by use of a substance.

Technology and Teen Mental Health
As technology such as the Internet and social media continue to have an increasing presence in teens’ lives, it’s important to observe the relationship between teens’ use of technology and how it might be contributing to mental illness symptoms. While the Internet and social media can obviously serve helpful and positive purposes in teens’ lives, they can also be a vulnerability for teens to develop bad habits and/or even addictions, which have significant negative effects on their lives. For instance, teens can form an addiction to always checking their cell phones and/or investing too much of their self-worth in the way they are judged in their online profiles. This kind of constant obsessing over looking at a phone can create anxiety and chronic stress, which can be especially harmful for teens that are already struggling with a mental illness.

Getting Treatment
When considering the current environment and statistics of teen mental health in the United States, it’s imperative to recognize that there is treatment available for teens struggling with mental health and/or substance abuse disorders. As our knowledge and understanding of mental health and addiction continues to grow, so too does our ability to treat it effectively, which means helping teens gain substantial relief in a relatively short amount of time and it’s very possible for them to go on to live their healthiest, happiest lives. Even in circumstances where symptoms are advanced and teens are feeling overwhelmed, treatment will help. Feeling better is possible. And reaching out for help is truly the most important step.

If you are a parent or loved one of a teen who is struggling with a mental illness or addiction problem, please reach out and ask questions, get information, and don’t wait. Often in addressing the teen mental health state, experts continue to emphasize that the most important factor in treating adolescent mental health and substance abuse disorders is to decrease the time between onset and treatment, so that teens are not struggling alone for so long.

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Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

Speaker/Listener ExerciseFind a quiet, distraction – free space in your home to sit across from one another and take turns sharing about the stressors in your day.

TAKE TURNS AS SPEAKER AND LISTENER

Speaker: talk about your stress in detail for 10 minutes. The topics must be about situations outside the relationship. This is not the time to discuss how worried you are about your financial life or your partner’s lack of organization and/or to complain about your partner.

Listener: provide support to your partner. This is not the time to try and solve your partner's problem. Clearly understanding the issues and feelings must precede any advice.

GIVING SUPPORT MEANS:

• Show genuine interest; maintain eye contact, and ask questions.
• Be an ally for your partner; show empathy.
• Communicate understanding: “Wow! That would bother me too."
• Show solidarity: "this is our problem and we will face it together."
• Don't side with the "enemy" even if you agree with them. You can still empathize with your partner’s reaction to a bothersome person or situation. Focus on what your partner is feeling, not whether he or she is “correct” about the situation.
• Provide affection and comfort: "let me hold you. I'm here for you."

Show that you empathize and care:

• "Tell me more about that."
• "Wow! No kidding!"
• "That's so sad."
• "That would've worried me too."
• "I'd be annoyed too."

Don't: Stonewall, ignore your partner, fail to respond, get defensive or criticize.

ASK QUESTIONS
The Listener should ask The Speaker if they feel heard and understood. Example: "anything else? I want to make sure I get it." 
If the Speaker says yes then you can ask if he or she wants help problem solving. 

If the Speaker does not feel understood, and ask more questions.

• What's most upsetting to you about this?
• What's the worst thing that could happen?
• Is there anything I can do to support you in this?
• What do you need right now?
• What don't you like about this?

SWITCH ROLES AS THE SPEAKER AND THE LISTENER

Repeat steps two and three. 

Make a commitment to have a stress reducing conversation five days a week for 15 to 20 minutes each day.


Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

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.

• Criticism
• Contempt
• Defensiveness
• Stonewalling

THE FIVE STEPS
Work through the Following Five Steps Together

1. Feelings: Share how you felt. Do not say why you felt that way. Avoid commenting on your partner's feelings.
2. Realities: describe your "reality." Take turns. Summarize and validate at least a part of your partner's reality.
3. Triggers: share what experiences or memories you've had that might've escalated the interaction, and the stories of why these are triggers for each of you.
4. Responsibility: acknowledge your own role in contributing to the fight or regrettable incident.
5. Constructive Plans: plan together one way that each of you can make it better next time.

FEELINGS
Share how you felt. Some common words/phrase:

• I felt……… defensive
• not listened to
• my feelings were hurt
• totally flooded
• angry
• sad
• unloved
• misunderstood
• criticized
• not cared about
• worried
• afraid
• unappreciated
• alienated
• overwhelmed
• tired
• frustrated
• I was right and you were wrong
• taken for granted
• out of control

REALITIES AND VALIDATION

Subjective Reality and Validation:

1. Take turns describing your perceptions, your own reality of what happened during the conflict. Describe only what YOU saw, heard and felt, not what you think your partner meant or felt. Avoid attack and blame. Talk about what you might have needed from your partner. Describe your perceptions like a reporter, giving an objective moment by moment description. Say "I heard you say," rather than "you said." This leaves room for your partner to correct anything that they heard or misunderstood.
2. Summarize and then validate your partner's reality by saying something like, "it makes sense to me now why you saw it this way, and what your needs were." Use empathy by saying something like, "I can see why this upset you." Validation doesn't mean you agree, but that you can understand even a part of your partner's experience of the incident.
3. Do both partners feel understood? If yes, move on. If no, ask, "what do I need to know to understand your perspective better?" After summarizing and validating, ask your partner: "did I get it?" And "is there anything else?"

TRIGGERS

1. Share what escalated the interaction for you. What events in the interaction triggered a big reaction for you?
2. As you rewind the videotape of your memory, stop at a point where you had a similar set of feelings triggered in the past. Now tell the story of that past moment to your partner, so your partner can understand why that is a trigger for you.
3. Continue to share your stories – it will help your partner to understand you. As you think about your early history or childhood, is there another story you remember that relates to what got you triggered you, and further explains your "enduring vulnerabilities"! Your partner needs to know you, so that your partner can be more sensitive to you.

Examples of Triggers:

• I felt judged. I'm very sensitive to that.
• I felt excluded. I'm very sensitive to that
• I felt criticized. I'm very sensitive to that
• I felt disrespected
• I felt powerless
• I felt out of control
• I felt ashamed
• I felt lonely…

Validation - does any part of your partner's triggers and story make sense to you?

TAKE RESPONSIBILITY
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:

• I've been very stressed and irritable lately.
• I've taken you for granted.
• I've been running on empty.
• I've not been emotionally available.
• I've not shared very much of my inner world.
• I've needed to be alone.
• I've been very preoccupied.
• I haven't felt very much confidence in myself.
• I've been overly sensitive lately.
• I've not expressed much appreciation toward you lately.

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:

• I overreacted
• I was really grumpy
• I was defensive
• I was so negative
• I attacked you
• I didn't listen to you
• I wasn't respectful
• I was unreasonable…

If you accept your partner's apology, say so. If not, say what you still need.

CONSTRUCTIVE PLANS
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

• Criticism – – Use Gentle Startup
• Defensiveness – – Take Responsibility
• Contempt – – Describe your Own Feelings and Needs
• Stonewalling – – Do Physiological Self Soothing

Thom Kessler, LMFT, RAS
Thom@thomkesslertherapist.com
415-454-8931

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.
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The following has been taken from Dr. Miller’s presentation in Sacramento last year.

PSYCHOSIS:
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.

ANXIETY/DEPRESSION:
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.

SUICIDE:
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
Thom@thomkesslertherapist.com
415-454-8931