November 2023 – Vol. #21, No. 8

Welcome to the November edition of Tips and Topics and a happy Thanksgiving to all in the USA.

In SAVVY, when clients present with mental health problems and are also using alcohol and other drugs, there could be three diagnostic possibilities. When mental health clinicians are not savvy about addiction and vice versa, misdiagnosis is easy to do.

In SKILLS, assessment guidelines on timelines and drug-free periods can help tease apart what is going on in the relationship between substance use and mental health signs and symptoms.

In SOUL, I invite you to ponder what you might say at the Thanksgiving dinner table when someone says: “Let’s share what you are grateful for this year.” Try out Marshall Rosenberg’s modified 3-step process.

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY

Recently a friend introduced me to his 36 year old daughter who had just started seeing a therapist for anxiety. I talked briefly with the young woman who knew I am a psychiatrist and she was surprisingly quite open saying, unsolicited, that she was a “functional alcoholic”.  She has quite a demanding job with much responsibility and is doing well in her work.  But she went on to tell me that she often opens a bottle of wine at night and ends up drinking the whole bottle. She felt a good connection with her therapist who is doing cognitive behavioral therapy (CBT) with her.

It wasn’t my place to do a clinical evaluation, but her drinking raised a red flag for me and got me wondering:

• Did her therapist do a substance use history?
• Are they even knowledgeable about addiction and have the skills to explore addiction?
• If they do discover her drinking, will they know how to engage her into a change plan for risky drinking; or will they explain away the drinking as a symptom of anxiety disorder?

Unfortunately too many mental health trained clinicians are not savvy about addiction, believing that substance use is just a self-medication coping skill for unresolved mental health issues.     

Tip 1

Risky substance use can be a self-medication coping mechanism. But it can be an indicator of a co-occurring substance use disorder that needs evaluation.

When clients present with mental health problems and are also using alcohol and other drugs, there could be three (not mutually exclusive) diagnostic possibilities:

• The person may be attempting to self-medicate a psychiatric disorder with substance use.
• The mental health problems may be signs and symptoms of the addiction illness e.g., depression because of the crash after a cocaine binge or mood swings because they are getting high on uppers and downers.
• The person may indeed have both a co-occurring mental and substance use disorder.

Tip 2

It is easy to label people with mental health signs and symptoms as having a mental disorder and prescribe medication. It is better to medicate diagnoses not signs and symptoms.

• When mental health clinicians are not savvy and skilled in addiction diagnosis and treatment, the tendency is to fall back on what you know; and not know what you don’t know. A client presents with anxiety and gets an Anxiety Disorder diagnosis and prescription. Similarly with a presentation of depression (Major Depression) or mood swings (Bipolar Disorder).
• On the other hand, it is also easy for addiction counselors, not savvy and skilled in mental health, to see all substance use as a Substance Use Disorder needing addiction treatment. 

This is why all behavioral health professionals need to be savvy and skilled in co-occurring disorders.  Using assessment guidelines can help prevent:

• Misdiagnosing everyone who uses substances and has mental health problems a co-occurring disordered client.
• Misdiagnosing a mental disorder for people with mental health signs and symptoms who are actually suffering from a Substance Use Disorder with mental health manifestations of addiction; or a Substance Induced Disorder.
• Misdiagnosing a substance use disorder for people using substances who are actually self medicating a Mental Disorder.

SKILLS

Of the three diagnostic possibilities in SAVVY Tip 1 above, it is not always clear which applies to any one client. Here are some assessment guidelines to help make a hypothesis on what might be going on:

Tip 1

Examine timelines to see if addiction problems preceded mental health problems.

• Did the client first start experiencing mental health issues before problems with substances?
• If the mental health problems appeared first and the client started using substances to cope, begin working on the mental health problem rather than sending the client to addiction treatment. Notice what happens to the substance use. The client could be self-medicating a mental disorder.
• If the addiction illness came first, you might begin with a focus on the addiction; then observe what happens to the mental health problems.
• If mental health signs and symptoms persist with effective addiction treatment and/or if substance use problems persist with good mental health treatment, this may indicate co-occurring addiction and mental disorders.

Tip 2

Review the time relationship between substance use and mental health signs and symptoms.

• If the client was using substances at the time of, or not long before, the acute mental health presentation, you could be looking at a possible Substance-Induced Mental Disorder directly related to the pharmacological effects of the substances being used at the time e.g., a methamphetamine-induced depression, or an alcohol-induced anxiety disorder.
• Check for any drug-free periods in the person’s life. Ask what happened to the mental health signs and symptoms during those drug-free times. Did mental health problems still persist strongly even though the person was abstinent? Perhaps this indicates a Mental Disorder rather than a Substance-Induced Disorder.
• If the psychiatric problems dissipated after drug-free periods of weeks to months, then it could be that the mental health problems were substance-induced.
• If a person could stay abstinent for a period of weeks to months and mental health signs and symptoms dissipated, but substance use flared back up, this could indicate a Substance Use Disorder and inability to stay abstinent.
• If mental health problems persist and substance use flares back up, this may be a person suffering from co-occurring disorders.

In your clinical decision making, these guidelines are prompts to use. This is not a computer algorithm that spits out the diagnostic answer without using your clinical judgment.

SOUL

Over thirteen years ago, I wrote in the March 2010 SKILLS about how to make expressions of appreciation powerful. 

As I write this during Thanksgiving week in the USA, I invite you to ponder what you might say at the Thanksgiving dinner table when someone asks: “Let’s share what you are grateful for this year.”

There’s nothing wrong with:

“It’s been a tough year, but I’m glad you are here with me.”

“I’m grateful for all my friends”

“I love my job.”

But if you want to get in touch with what you really are grateful for and why, think first about your feelings and needs that were met. And then share your more in-depth expression of gratitude.

Here is Nonviolent Communications Marshall Rosenberg’s four step process that I first wrote about in February 2007 modified for expressions of gratitude:

Step 1.  Observing means to state what you are seeing, hearing, experiencing for which you are grateful.

Examples:

(a) “This year I’ve had work, relationship and health disappointments.....”

(b) “When I think about all my friends......”

(c) “I love my job…….”

Step 2.  Feeling means to state how you feel succinctly about that observation.

Examples:

(a) “This year I’ve had work, relationship and health disappointments and feel glad.....”

(b) “When I think about all my friends I feel tearful......”

(c) “I love my job and feel excited…….”

Step 3. Needing means to then state what human need(s) was fulfilled by the situation.

Examples:

(a) “This year I’ve had work, relationship and health disappointments and feel glad because you have been with me met my need for nurturance and support.”

(b) “When I think about all my friends I feel tearful and touched because they have all met my need for honesty and consistency.”

(c) “I love my job and feel excited because I need the autonomy and creativity this job allows.”

This may all sound a bit stilted and formulaic. I’m not suggesting that every expression of gratitude has to be a rigid 3-step process.  But if you really want to understand the fullness of your gratitude, tuning into your feelings and needs will deepen your gratitude.

Have a great Thanksgiving dinner......and gratitude sharing.

UNTIL NEXT TIME

Thanks for joining us this month. See you in late December.

David