Ellenhorn New Perspectives Series: Cultivating curiosity and motivation: cornerstones of change behavior in tri-occuring recovery

On May 2, 2022, Ellenhorn hosted the second of five talks in our 2022 New Perspectives on treatment series. This presentation was done by Zoi Andalcio, LMHC, Ellenhorn’s Director of IDDT Services and Katherine Clemens, LICSW, Ellenhorn’s Clinical Director.

Curiosity is something that we are all born with and is foundational to our cognitive development. As we develop from infants to adolescents to adults, however, our curiosity, or our intrinsic desire to know and understand, is subverted by multiple forces. This presentation will address the macro- and micro-level ways in which stymied curiosity results in an environment lacking in motivation to change, as well as examine mental-health treatment for “tri-occurring” recovery. Speakers discuss their own work with clients who are seeking recovery from tri-occurring challenges, as well as the ways in which they cultivate curiosity as essential motivation toward change.

2022 Shifting the Addiction Paradigm Conference Recordings

On April 1, 2022, Ellenhorn and the Menninger Clinic partnered to put on Shifting the Addiction Paradigm – a hybrid virtual/in-person conference aiding the shift toward humanistic and client-centered values in behavioral care. This year we were fortunate enough to have four presentations from experts in the harm reduction/addiction treatment field. You can view the presentations below.

Special thank you to our speakers, Ross Ellenhorn, Andrew Tatarsky, Sam Rivera, and Julie Holland, for all their hard work and wonderful presentations!

How We Approach The Co-Occurring Issues of Addiction and Mental Health Issues

In keeping with all treatment approaches at Ellenhorn, we take a whole-person approach to people with co-occurring issues. We believe addiction often must be approached seriously as a physical disease that can have significant and even life-threatening consequences. We also understand addiction as something deeply connected to the less-scientific concepts of hope, faith, connection to others, a sense of purpose and personal autonomy. Last, and specific to our program, we understand that the ravages of addiction and psychiatric issues often cause what we call psychosocial trauma.

Psychosocial trauma is the wound caused by the loss of social role, social status and identity suffered by people who spend a significant amount of time in treatment, and who are often removed from the world during this treatment. We believe that most of our clients, whether they engage in addictive behaviors or not, struggle with psychosocial injuries. These injuries cause them to disengage from others, to lose hope in their own future, and to lose faith in their fortitude to effectively face life challenges.

Taking seriously the impact of psychosocial trauma, we at Ellenhorn view what is considered the dual problem of psychiatric distress and addiction as, in reality, a tri-occurring problem that involves experiencing difficult psychological states, engaging in addictive behavior, and also suffering from psychosocial injury.

Many treatment approaches to co-occurring disorders only focus on the interplay between psychiatric issues and addiction, viewing the latter problem as a form of “self-medication” — a person’s attempt to manage psychiatric symptoms with harmful substances or other forms of addiction. In contrast, Ellenhorn takes the social injuries suffered by individuals who have been diagnosed and treated as mentally ill so seriously that we usually view addictive behavior and pain from these injuries as the key relationship in this triad, seeing psychosocial injury as often one cause of addictive behaviors, and in addition, as a very important factor in a person’s willingness to change this behavior. (Click here for Dr. Ellenhorn’s article on the concept of tri-occurring issues and the importance of community integration in mental health and addictions recovery.)

… Ellenhorn takes the social injuries suffered by individuals who have been diagnosed and treated as mentally ill so seriously that we usually view addictive behavior and pain from these injuries as the key relationship in this triad, seeing psychosocial injury as often one cause of addictive behaviors, and in addition, as a very important factor in a person’s willingness to change this behavior.

We are gratified that our tri-pronged approach is endorsed by current research on the most effective treatment for co-occurring issues of psychiatric experience and addiction.   The Substance Abuse and Mental Health Services Administration (SAMHSA) has conducted extensive research to determine which treatment model works best for people with co-occurring issues of mental illness and substance abuse.   SAMHSA found that Integrated Dual Disorder Treatment (IDDT) works best of all current treatment approaches, designating IDDT as SAMHSA’s evidence-based model.

What is IDDT?

IDDT stands for Integrated Dual Disorder Treatment.  IDDT teams are unique among co-occurring programs for at least three reasons: 1) They focus on helping people return to vocational, educational and family roles as a core source of recovery, rather than viewing these involvements as dependent on recovery; 2) They are interdisciplinary teams, in which all therapeutic work is integrated in a whole-person approach; and 3) They are mobile and outreach-oriented, conducting much of their work outside clinical settings. 

Ellenhorn is a national leader in using evidence-based IDDT as the sole model for our co-occurring disorders program. Ellenhorn meets and often exceeds SAMHSA best-practice measures.

Ellenhorn delivers IDDT care through high-intensity multidisciplinary outreach teams that collaboratively provide integrated substance abuse, medical, mental health, family and psychosocial care from one source, outside institutional settings.  Our teams use non-confrontational therapeutic approaches to substance abuse, while actively helping people pursue vocational, educational and familial goals.

Why does focusing on work, school and family promote good outcomes?

Ellenhorn’s IDDT teams support clients in getting back on a life track – whether returning to school, finding employment, or engaging in healthy relationships with their families. Working closely with clients to create meaningful futures fosters real human connection and promotes a sense of hope, while profoundly addressing substance abuse, mental health and psychosocial recovery.

Too often, co-occurring programs focus most of their efforts on helping people understand how to recover, rather than helping them see why they should.   Along with family and social connections, work and school are the “why.”  These activities offer hope, a belief in one’s own future, and a path toward success.  For years, community mental health programs have endorsed this view, seeing psychosocial recovery not only as a behavioral target, but also as the means to help people recover. Decades of research on psychiatric outcomes support this approach. 

Repeatedly, addiction research shows that a sense of purpose and meaning are intricately intertwined with recovery.   When a person can see a road ahead, one in which he or she has a meaningful role in society, that person has a reason to be sober beyond sobriety itself. 

From day one, Ellenhorn’s IDDT teams keep each client’s future front and center, by simultaneously helping clients pursue career, education and familial goals as they receive treatment.  At Ellenhorn, we do not view moving ahead with one’s life as conditional upon abstinence from substances – as if it is a reward or the result of passing a test. Rather, getting on a life track is a major component of achieving sobriety.

A harm reduction outlook

To build a partnering relationship, we want to have honest discussion with our clients about current use.  That means we need them to trust that talking about use with us will not lead towards negative consequences.  We thus rarely expel people from our program if they engage in addictive behavior, and we often take a non-judgmental approach to their use.   We take, what is called, a “harm reduction” approach.

To put it plainly, we work with clients even if they are currently using substances or are engaging in other addictive behaviors. While we may help someone transfer temporarily to a higher level of care if their use is putting them in serious medical danger, our larger goal is to serve our clients, whether they are abstinent from addictive behavior or not. Our approach is to meet people where they are, without preconditions.

… we work with clients even if they are currently using substances or are engaging in other addictive behaviors.

Some forms of treatment rely on people “hitting rock bottom” as a motivation to finally make changes. Many treatments also make abstinence from addiction a precondition for care. We see grave problems with these approaches. For our clients, hitting rock bottom probably means not only facing difficult and stressful quality-of-life situations, but potentially destructive psychiatric experiences. For them, being terminated from treatment means that the part of them that needs psychiatric and psychosocial help is also being discharged.

Our approach, has as its goal to keep working with people while they use. By “harm reduction,” we refer to a way of approaching ongoing substance abuse in which those around the person try to reduce the risky consequences of that abuse.  If we can lower the chance of harm, we can keep clients in our program, and thus continue our relationship with them, which is a pillar of their recovery.

Why does an integrated treatment approach work?

All too often, dual diagnosis programs described as “evidence-based” offer techniques or interventions on a piecemeal basis: They supplement psychiatric work with a substance abuse add-on; or add a mental health component to substance abuse work. Yet evidence shows that this piecemeal approach has little effect.  Real co-occurring work takes as its premise that the two issues of substance abuse and psychiatric disturbance cannot be separated from one another.  As parts of a single complex syndrome, both problems must be treated simultaneously, using an integrated approach. This means that co-occurring treatment is not simply a matter of using the right technique. It requires a particular system of care, one that balances the two issues at once.  IDDT is this kind of system of care. 

But IDDT is much more than a way to combine substance abuse and mental health treatments.  It is a “whole-person” approach, whose practitioners view every individual as distinct, and who see behavioral challenges as emerging from complex and unique tangles of roots.  That is why Ellenhorn’s teams are made up of professionals with diverse expertise. 

Why does a mobile community-based approach work? 

IDDT is the only evidence-based treatment model for co-occurring disorders that works with people while they live in the community.  That means people receive IDDT right where their challenges are, while also developing competency and confidence in dealing with those challenges, pride in what they have achieved, and a motivating life-direction.

Consider this irony:  In the United States, we spend significant resources on temporary ways to help people, provided in artificial surroundings that remove people from life challenges.  But we spend minimal resources on supporting these people once they leave institutional care (whether a hospital or residential setting) and must face the challenges of real life. Ellenhorn IDDT teams step into the gap, providing flexible levels of support so people with co-occurring issues learn to deal successfully with the stresses of life, thereby forming the foundation of lifetime recovery. 

Treatment in the community not only helps people meet their challenges, it also enables them to find sustainable natural supports for sobriety.  There is mounting evidence that recovery from addiction happens when people mend and form connections — to people and to their community – and when they develop a sense of purpose. These resources are only temporarily provided within institutional settings.  They are readily available in the community. 

The Ellenhorn treatment approach for co-occurring disorders is guided by this core belief: Being engaged in meaningful relationships and having a sense of a future are powerful determinants in a person’s desire to recover. Hope and connection are our targets.

VIDEO: Laurie Damsky, PMHNP appears as guest on Recovery X

On July 23rd, 2018, Laurie Damsky, PMHNP, appeared as a guest on Recovery X with Dan Sevingy. Laurie and Dan talk about what Ellenhorn does, mainly surrounding addiction, and how it is unique, more effective, and better for the client as a whole than other treatment models. The use of the PACT model, IDDT, A4CIP, and why Ellenhorn does what it does are all topics that are explored in depth in this interview.

“[Addiction and mental health issues] are not separate, they are completely intwined with each other.”

To learn more about any of the topics covered in this interview please visit our website, www.ellenhorn.com. Here you will find more detailed information about all of the topics Laurie and Dan covered in their conversation together. For questions about admissions, please contact Laurie Damsky, PMHNP through email at ldamsky@ellenhorn.com or by phone at 617-491-2070.

Laurie Damsky, PMHNP-BC of Ellenhorn – Integrated Dual Diagnosis Treatment (IDDT)❌ WANT TO HELP US SAVE LIVES? ❌We offer addiction sufferers and their families with free addiction recovery resources, like educational videos and one-on-one help finding treatment.You can help educate and save lives by donating to the show here:➡https://pages.donately.com/recoveryx/donate$1 or $1,000. One-time or Monthly.It all helps!Thank you for your support of the causeMentioned in this episode:Ellenhorn – https://www.ellenhorn.com/Laurie Damsky, PMHNP-BC – ldamsky@ellenhorn.comAssociation for Community Integrated Programs – http://a4cip.org/

Posted by Recovery X – Addiction Recovery Experts on Monday, July 23, 2018

You’re not the only expert in the room: Therapeutic Collaboration

At Ellenhorn, we place collaboration in therapeutic relationships front and center. In such a relationship, therapist and client work to achieve goals the client identifies as important, and that both agree they have the power to reach.  This is very different from a relationship in which the clinician, as an expert, figures out what is wrong with the client and prescribes a particular treatment protocol to fix it.

You can’t really talk about a collaborative therapeutic relationship without talking about a “treatment contract” that provides a sense of where client and clinician are going.  With that in mind, we call our plan the “Roadmap to Recovery,” and we’ve built this therapeutic contract to be collaborative.  The graphic below presents a picture of how we think about the Roadmap to Recovery.

Roadmap To Recovery

“If everything goes well here, what will your life look like six months from now?”  That’s the question we typically ask while building our Roadmap.  The answers form the “dream” at the top of the graphic.  Once we understand their dream, we work with clients to mobilize their strengths, and to remove as many barriers as we can, in order to achieve it.

That simple idea makes our Roadmap different from a typical treatment plan in which symptom reduction or behavioral change is the goal.  We work on symptoms and behavior with our clients, but only in pursuit of larger life-goals. Thus, the typical fodder for clinical interventions is not our central target.  The dream is our focus for our clients, the destination we share.  Most often, psychiatric issues emerge as barriers to reaching this destination, and together we work to remove these.

“Collaborative therapeutic relationship”: the words have a nice ring to them.  And they do point to humane and decent sentiments.  But collaboration is more than a nice value.  The collaborative relationship is scientifically proven to be the most effective kind of relationship in facilitating change.

This pie chart captures a surprising fact:  A hefty 30 percent of client change results from “common factors” in the relationship between client and therapist, that is, behaviors and attitudes exhibited by therapists, independent of the therapeutic approach they use, that promote change in clients.  As shown here, common factors are doubly powerful as change-drivers compared to specific therapy models.

Researchers have gone deeper into the question of what promotes change, examining which common factors are most important.  As the next chart shows, a collaborative approach is the winner (surrounded by its sister, alliance, and its cousins of empathy, genuineness and positive regard).

When we at ellenhorn are able to form a collaborative relationship with our clients, discussions with them that otherwise would place significant power in the hands of clinicians, take on an egalitarian hue.  No longer are we assuming that our formulations, diagnoses and prescriptions are the unquestionable guides for treatment.  Instead, we engage in a conversation with our clients in which we look at how psychiatric experiences, along with other factors that play a role in all our lives, may hamper our work to reach their dream.  This approach levels the playing field, giving the client significant voice. It doesn’t silent our opinions; rather, it gives us the ability to say what we think is happening without our opinion carrying more weight than theirs.

At ellenhorn, I’m allowed to have my own experience,” says one client.   “No one is trying to convince me, or pathologize my disagreements with them, saying ‘You’re in denial’ or ‘You won’t get well if you don’t see you are sick.’”

There’s a lot of room on the team for different voices,” she continues. “It’s a polyphony, rather than a unified front.  And I have a central voice in this polyphony. That’s a big relief for me, since I’m no longer judged as just a patient with no agency or input.  I can voice my doubts and express sadness, and have appropriate feelings about what’s happened, without feeling like someone is diagnosing me.

When this client gives an example of the times when she most felt the effects of our collaborative relationship, her answer points to an important and unique way we work:

“I’ve never had a group of friends who all saw me at the same time in my own environment and saw what was going on, and then approached me with that shared knowledge.  At ellenhorn, for the first time I have multiple people seeing and communicating with each other about how I am doing outside of therapy.  That’s the most important factor.  It’s really important that there are all these multiple views that can be checked with each other, and are windows into my world.”

This client felt the strength of our collaboration outside our offices, in her own home.  Her response captures another important factor in change: a person’s life outside therapy, or “extra-therapeutic events.” As the chart above indicates, they embody 40 percent of the factors that either produce or block change.

As the most robust community integration program in the U.S., we focus on these outside-the-office issues.  We do so collaboratively, combining the two most prominent supporters of change into one.  That means we put a lot of energy into issues other than a client’s purely psychiatric symptoms, working alongside our clients in the community to both deploy their strengths to reach their dreams, and remove barriers to these dreams.  “I was afraid of the visibility an outreach team would impose,” our client says. “But it turns out that it’s this very visibility that has made my time with ellenhorn so productive.   Allowing myself to be seen and known and even seen in different psychological states —  these things have to be seen literally by someone.  And having them seen in my own environment, without people judging me, makes feel like I don’t need to hide anymore.” 

Community integration programs, especially ones as comprehensive as ours, are often called “hospitals (or residential programs) without walls.” The concept of “without walls” sounds innovative, accessible, hospitable.  But walls don’t only keep people in; they also keep people out.  When mental health workers serve people in the community, they’re given access to their clients beyond the usual barriers of privacy the rest of us enjoy. When professionals walk through the doors of their clients’ homes to treat them, they wield significant power based on their ability to survey the most private parts of people’s lives.  But when we focus on having a collaborative relationship with our clients, that potentially coercive and monitoring spirit gets turned on its head.  Instead of entering a home from a position of power, we enter it with our eyes on where the client wants to go, and how we can help them get there.  Our client beautifully captures this union of collaboration and treatment in the community:

“Even though my entire history says I would find it threatening, I can now say that people coming into my apartment doesn’t feel threatening at all: it’s actually felt very freeing to have somebody come over and just check in and see what I’m doing. That would never happen in any other context.”

Ross Published on The Fix: “Adverse Adult Experience” in Co-Occurring Disorders

For many years, substance use disorders and mental illness were generally construed as issues that were best treated separately. It was common that patients in psychotherapy for mental health issues, upon revealing significant substance use problems, would be referred out for substance use treatment and told to return when their substance use issues were treated—presumably rendering them “ready” to do the work of psychotherapy. As our understanding of the interconnection between “psychiatric” and “addiction” issues has improved, the treatment system has begun to change. But has that change gone far enough? Here, Dr. Ross Ellenhorn advocates for a broader view of both our understanding and treatment of the inextricable connection between mental health, addiction and the life circumstances into which they are embedded…

Read more from our Founder/CEO, Dr. Ross Ellenhorn on The Fix by clicking the following link: https://www.thefix.com/role-adverse-adult-experience-co-occurring-disorders