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You know that sinking feeling when you wake up with a hangover and think: “I’m never doing this again”? We’ve all been there. But what happens when you follow through? Sonia Kahlon and Kathleen Killen can tell you, because they did it! They went from sisters-in-law, to Sisters in Sobriety.
In this podcast, Sonia and Kathleen invite you into their world, as they navigate the ups and downs of sobriety, explore stories of personal growth and share their journey of wellness and recovery.
Get ready for some real, honest conversations about sobriety, addiction, and everything in between. Episodes will cover topics such as: reaching emotional sobriety, how to make the decision to get sober, adopting a more mindful lifestyle, socializing without alcohol, and much more.
Whether you’re sober-curious, seeking inspiration and self-care through sobriety, or embracing the alcohol-free lifestyle already… Tune in for a weekly dose of vulnerability, mutual support and much needed comic relief. Together, let’s celebrate the transformative power of sisterhood in substance recovery!
Kathleen Killen is a registered psychotherapist (qualifying) and certified coach based in Ontario, Canada. Her practice is centered on relational therapy and she specializes in couples and working with individuals who are navigating their personal relationships.
Having been through many life transitions herself, Kathleen has made it her mission to help others find the support and communication they need in their closest relationships. To find out more about Kathleen’s work, check out her website.
Sonia Kahlon is a recovery coach and former addict. She grappled with high-functioning alcohol use disorder throughout her life, before getting sober in 2016.
Over the last five years, she has appeared on successful sobriety platforms, such as the Story Exchange, the Sobriety Diaries podcast and the Sober Curator, to tell her story of empowerment and addiction recovery, discuss health and midlife sobriety, and share how she is thriving without alcohol.
Your sobriety success story starts today, with Kathleen and Sonia. Just press play!
[00:00:00] Sonia: Welcome to Sisters in Sobriety. Today we have the pleasure of having our guest here for the [00:01:00] second time. Erin Gilmore is an incredible psychotherapist and founder of Rose Psychotherapy. And in our last episode, we talked about IFS or parts therapy, and we didn't even get to all our questions.
[00:01:14] Erin: a
[00:01:15] Kathleen: so we definitely had to have Erin back. Erin has extensive experience working with individuals struggling with substance use disorders and co occurring mental health conditions. Her approach is deeply rooted in empathy and evidence based practices and she aims to guide her clients towards healing and long term recovery.
[00:01:33] Sonia: So in today's conversation, we'll be diving into the complexities of co occurring disorders, how they manifest, the challenges they present, and the best practices for treating them. Erin's insights will help us understand the intricate relationship between mental health and substance use, and how we can better support those on their journey to recovery.
[00:01:55] Sonia: So Erin, can you tell us a little bit about your background and what led [00:02:00] you to specialize in treating co occurring disorders?
[00:02:04] Erin: First of all, thank you for having me back. It was such a blast the first time, and I'm just so, so grateful. Happy and honored and privileged to be invited back. Um, I think it's great work you guys do and happy to participate in any way that I can. So co occurring disorders, essentially means kind of a substance use disorder alongside or diagnosed alongside with a mental health issue.
[00:02:28] Erin: And it's the question is how did you Get into treating that or specialize in that. And the answer is truly out of necessity. Right? So it's, it's not anything that I sought, uh, specifically in my education and training. It is now definitely a part of all education and training for substance use, counselors and registered psychotherapists.
[00:02:49] Erin: And the reason is because it is so common, and it is. Difficult to find someone who has a substance use disorder that doesn't have a co occurring mental health issue [00:03:00] as well. So, the 1st kind of experience that I had was working in the field is working in a residential or a live in treatment center for women and.
[00:03:11] Erin: The co occurring issues of anxiety, depression, post traumatic stress disorder. Neurodivergence ADHD, et cetera. We're in the majority of our clients, right? So the treatment became, it became very necessary to, to train and to practice treating co occurring disorders, because it's, it's difficult, especially in the treatment setting to find someone with a kind of just a substance use disorder without co occurring disorder.
[00:03:39] Erin: So what we find in a lot of the population, especially treatment seeking population is that they will be dealing with the complexity of a mental health issue alongside. Substance use disorder.
[00:03:49] Sonia: That's interesting. So how do you identify and diagnose co occurring disorders in your practice? [00:04:00] That's
[00:04:01] Erin: lot of history taking a lot of listening to the client, listening to their experience. specifically in terms of so, if a client comes and says, I'd like to work on my, my substance use disorder. There is a lot of context to that. They don't develop out of nowhere.
[00:04:19] Erin: They don't fall out of the sky. And in very rare cases, is it. kind of recreational use that turns into a severe substance use disorder. There is usually a deeper context of using substances to cope with pre existing difficulties, whether it be anxiety or a traumatic experience, symptoms of depression.
[00:04:42] Erin: So we'll often find that. So when I work with clients, it's doing a lot of history taking of why did the substance You start, when did it become problematic? What was going on for you before that? And really trying to identify [00:05:00] symptoms of what may have been occurring before. And also once the substance you started, what new symptoms arose then?
[00:05:08] Erin: Because as we know, it's bi directional. So sometimes the. The mental health issue, anxiety or depression comes first and substances are there to cope with those symptoms. And sometimes the substance use starts and creates some of the, the symptoms of anxiety or depression or another mental health issue.
[00:05:25] Erin: So it's really taking that in depth history, listening to the client. They know their experience. They know how they felt before, during and after using substances. And mostly they know why. So, I would say the majority of my clients say, I have this pain, whatever kind of symptom is showing up and creating pain, grief, loss, symptoms of depression.
[00:05:48] Erin: I have this pain and these substances help me cope with that pain. it's also important to try as best as possible. It can get complex sometimes [00:06:00] to see what's there when the substance use isn't there. so if there has been a period of abstinence or a period of sobriety. Is in a little while, because the 1st, couple of weeks are are difficult after, stopping using or changing use after a little while is anxiety increased or is it better.
[00:06:20] Erin: Are symptoms of depression, more prevalent when you're not using. Or are they relieved and that kind of helps tease out a little bit of what might be contributing. in terms of diagnosis, I, as a psychotherapist, I don't diagnose, but we would go through some of the screeners, we would talk at length about what's your experience like, and most of my clients will show up with a, with a diagnosis already given, what, by a family doctor or a psychiatrist, so they'll know, like, yes, I have co occurring mental health issues.
[00:06:50] Kathleen: So you've named some of the challenges already, like in a sense of, of treating a client that has substance use disorder and a co occurring condition. But what [00:07:00] are some of the challenges for you when you're, when you're treating those
[00:07:05] Erin: Yeah. Yeah, it's, it's more complex, right? there's some different layers and I don't want to pathologize it because truly, I mean, if you look at the research, I think the research says it's very hard to figure out instead, but I think the research says anywhere between 20 and 80 percent or kind of ballpark it more about a third of people will have concurrent disorders.
[00:07:29] Erin: So, it's, it's quite frequent, right? And in my own experience. anecdotally, almost everybody that I've worked with with the substance use issue has a concurrent mental health issue. So, I don't want to pathologize it. It's not, it doesn't mean recovery can't happen. It doesn't mean that it's a long and arduous journey anymore.
[00:07:53] Erin: So, then a kind of recovery just from substance use would be, but it is more complex, right? So, a [00:08:00] person navigating triggers, navigating a recovery plan, navigating urges, cravings and desires to engage in substance use. Uh, that's hard enough, but navigating that within a context of a major depressive episode or panic attacks or, traumatic flashbacks.
[00:08:17] Erin: It's more complex, there's more tools that are needed. There's more safety and stabilization as a forefront of the therapeutic process and really building up those skills and tools. I find. Psycho education goes a really long way. Right, so often, and I'm sure you guys have experienced this, with clients is they come in and say, I have all these problems and it's because something is wrong with me.
[00:08:40] Erin: But that psychoeducation piece of, actually these are, you have substance use disorder and that's what this looks like. And you also, sounds like you have anxiety or panic disorder and that's what that looks like. And it's not because something is, uh, fundamentally flawed with you, they're just two different disorders at the same time.
[00:08:58] Erin: And it, it does make it. [00:09:00] Harder on some days for some people, I think another challenge as a psychotherapist is being able to identify if there's different treatment needed for the different things. So, the research shows that concurrent treatment works best for concurrent disorders, right? but there are times where 1 does take precedence.
[00:09:21] Kathleen: you give an example of that?
[00:09:24] Erin: Sure, so yeah, if there's a person who is struggling with a mood disorder and is using a substance every day to the point of intoxication, it's really hard to, to make headway in navigating that mood disorder or stabilizing mood and learning coping skills and strategies if the person's intoxicated every day, or if they're in and out of, I don't know if they're in the emergency room because of, overuse, or if they're, I don't work with many of these people in my private practice, but I certainly did prior to [00:10:00] this, if they're unhoused or in unsafe situations, certain things take priority, for a time.
[00:10:06] Erin: Yeah,
[00:10:09] Kathleen: doing my practicum, I did it at a hospice and it was, there was various types of clients that I used to see from all different walks of life and grief obviously was there, um, cause I was seeing a lot of people who had lost loved ones and if there was a substance use disorder, sometimes I would have clients come in, intoxicated and there's definitely an ethical piece around that, but we would, I wouldn't.
[00:10:35] Kathleen: I couldn't do any sort of treatment, but I would hold space, right? Hold space, make sure the person was safe. Like they're sometimes priorities just shift. Like I'm not going to be dealing with grief in that moment. in a sense, like treating it specifically, but holding space.
[00:10:51] Erin: yeah, exactly. And you, you, work with what's in front of you. I can have all the treatment plans and research and evidence based tools at my ready, [00:11:00] but the person who's in front of me in session is dictates what we do based on what they need in that moment and sometimes it is the holding space.
[00:11:07] Erin: I think some of the complexity too is for people who have, I'm thinking in this case primarily because this is the population I work most with, but women who. things are very functional in their lives. Mothers, people who are women who are working really on the outside, things look functional.
[00:11:27] Erin: But the experience of anxiety, a truly kind of clinical level anxiety disorder has been with them for so many years. It becomes a part of how they think. They are who they think they are part of their personality and that alcohol or the whatever substance fill in the blank becomes such an important part of coping and functioning.
[00:11:51] Erin: That's complex too, right? Like sometimes a functional life can be built around something that is harmful or becomes harmful [00:12:00] over time, like a substance use disorder. And that's the only coping skill that's been developed over time to deal with some mental health issue that's been there for a very long time.
[00:12:08] Erin: SoSometimes it's a longer process and it's relearning and, and, and developing new ways of existing while also managing the symptoms of a mental health issue.
[00:12:21] Kathleen: Mm hmm.
[00:12:22] Sonia: so interesting, Aaron. When I started researching this episode, in my mind, co occurring disorders were like, A porn addiction, like you have an alcohol problem and a porn addiction. You have, this issue and like, yeah, eating disorder. And when you, start to work on the substance use, the other one kind of has room to proliferate.
[00:12:44] Sonia: So I didn't associate, um, anxiety, depression, which I have both as, as co occurring disorders. So, it's really, now I realize I have co occurring disorders. so I, yeah, so I have [00:13:00] anxiety and so how does that manifest in somebody who's struggling with substance use and is it different if I hadn't struggled with substance use disorder?
[00:13:12] Erin: right? Yeah. Yeah. So, great question. anxiety disorders are kind of the most. Prevalent mental health issue. and in fact, I would say, like, so common that most of the population, or at least the people I see and talk to and hear about, uh, have some sort of some form of anxiety disorder and the experience of having an anxiety disorder is a, an experience of constant. Activation and feeling of threat or unsafety within the body and within the mind, right? Cognitive processes. And so, for me, in my experience, and just my viewpoint, it makes absolute perfect sense that a person constantly feels activated or that a threat is coming would find comfort and some [00:14:00] sort of relief in a substance that dampens or numbs some of that intense discomfort, right?
[00:14:07] Erin: So we, it makes perfect sense to me that alcohol or another substance would come in as a bit of a savior in the beginning with, for someone who has an anxiety disorder. The problem with that is that substances never continue performing as they initially do, and they eventually start, Creating their own issues.
[00:14:29] Erin: The other problem in the framework of anxiety is that so safety behaviors, things that kind of steer us away from confronting or working through the anxiety and make us feel better in the moment, unfortunately, paradoxically, do increase anxiety over time. So, What initially serves as a solution so a couple glasses of wine at night or whatever that looks like to Bring the system down a little bit in terms of activation will eventually lead to higher [00:15:00] levels of anxiety in the long run not to mention like the Anxiety that comes like after the day after it and so it's it's It's a bit of a lie that it tells us is that using these substances is helping my anxiety when in the long term, it's actually increasing it and decreasing our capacity and space to develop other coping strategies.
[00:15:21] Erin: so a short summary answer is that using substances actually can increase. how anxiety shows up for a person to make it more difficult and solidify some of those anxiety patterns cognitively, to make it even more intractable or, or difficult to cope with and
[00:15:43] Kathleen: definitely felt that in my experience, Sonia. I think you did too. Like, anxiety would be, my, my substance of choice was not alcohol necessarily, but I could, my anxiety went way up whenever I drank. Um, and you too, right, Sonia?
[00:15:58] Sonia: [00:16:00] Yeah, it's a weird idea, right, because I was self medicating the anxiety with alcohol. And so the only part I would say that was harder when I quit drinking was that sort of getting used to feeling that initial like 10, 20 minutes of anxiety without running to a drink. And then once I could get through that, all of a sudden it was better.
[00:16:50] Sonia: Oh, let me think clearly on how to deal with this instead of I would drink and then either forget about it or come up with this fantastical solution to my anxiety.[00:17:00]
[00:17:00] Erin: Yeah.
[00:17:01] Sonia: They're like, wait, I think the issue is and I would come up with some bizarre solution. So, the self medicating it's so temporary and that's what I noticed when I quit drinking.
[00:17:15] Erin: Yeah. Yeah. It is. And it, it's, it's. Like digging a hole, like every time we think, okay, I'm going to have the drinks, or I'm going to do the thing, or I'm going to engage in the behavior. Same is very true of eating disorders, which weirdly I didn't mention because that's my other area of focus in my practice, but, um, it's like the behavior is going to make me feel better right now, but it actually just kind of digs the hole a little bit deeper.
[00:17:38] Erin: Um, and then to your earlier point with the question of a person without a substance use disorder, anxiety is. It's also incredibly difficult and painful for, for that person. And they may experience, the same kind of difficulties of what anxiety shows up as and the discomfort of that. They may have more opportunities to develop [00:18:00] other coping skills or healthier coping skills to cope with those panic attacks or moments of anxiety if they're not using a substance.
[00:18:09] Kathleen: So how do you address the relationship between anxiety and substance use in therapy? Are you, is it a lot of psychoeducation? Is it like pulling it apart for the, how do you do that?
[00:18:19] Erin: Yeah, you know what it is a lot of psychoeducation at the outset and to collaboratively with the client pick apart, what's this? What's that? What was there? 1st? How does it I'm a big fan of kind of mapping out cycles.
[00:18:34] Kathleen: Mm hmm. Mm
[00:18:36] Erin: and where it goes and how it ends and often we'll see the different.
[00:18:41] Erin: Okay, when you do this, the panic happens when the panic happens. So, it's a lot of, technically mapping it out, getting to know, both of those parts if we use an IFS lens, how they work, what their purpose [00:19:00] is, and how they would interact with each other, and doing it, I'm exploring clients learning, it's a very collaborative exploratory process of just what's going on here, right?
[00:19:10] Erin: I often, So I can't diagnose or prescribe, but I often will support the client in bringing in a medical professional, their family doctor. Sometimes they're interested in seeing a psychiatrist because when we are dealing with, let's say, specifically mood and anxiety disorders, medication can sometimes play a very important role.
[00:19:30] Erin: Same with recovery from certain substances, right? So we'll often discuss a support plan that involves other professionals. And then we do. a plan for symptom reduction, symptom management on the surface level, while also doing kind of the deeper work of IFS and, andexploring what's underneath all of this.
[00:19:53] Sonia: What is that symptom plan and symptom management?
[00:19:57] Erin: It's different for everybody, but just [00:20:00] in let's say in the case of someone with an eating disorder We'd be looking at what is happening most often and why? the Exploration and identification of again like that trigger and the cycle and trying to interrupt that cycle so in that way, especially with Let's say behavioral addictions.
[00:20:23] Erin: I'm a big fan of dbt skills, wedge those in there somewhere in the cycle. because sometimes it really is
[00:20:30] Kathleen: DBT is, just for our listeners who don't know the acronym,
[00:20:33] Erin: Sorry. Yes. Dialectical behavior
[00:20:37] Kathleen: Thank
[00:20:37] Erin: Yes, and I'm, I, I'm trained in dbt. It's not my primary modality, but I cannot like, sing the praises enough of some of those distress tolerance skills because. Thank you. When you are engaging in a repetitive, compulsive behavior, addictive behavior, whether it be using substances or, eating disorders or [00:21:00] any other sort of harmful or unhealthy coping strategy. And you stop doing that, or you even think about stop doing that there is distress. So, the DBT skills assist with coping with some of that distress. And allowing some space to make a new choice. So that's how we would kind of deal with symptom interruption in terms of the addiction. And then with the concurrent mental health issue, we do that alongside, sometimes it's the same strategies for symptom interruption, and symptom coping, and sometimes it's different strategies.
[00:21:37] Erin: So with anxiety, I do, do lots of kind of skills around acceptance and commitment therapy, sometimes cognitive behavior therapy, if they seem that they fit. And that's what's in our plan, kind of surface level plan, and we would practice using those things for the person in the moment. and kind of in my sessions, they would be framed deeper and where, where did this come from?
[00:21:59] Erin: What's the [00:22:00] underlying emotional and cognitive processes? And usually that is through IFS. Mm
[00:22:05] Kathleen: Would you approach it the same way if anxiety is manifesting into panic attacks? Like I'm assuming that panic attacks and, and, and substance cravings can intersect at times. So if there's cravings happen, then the anxiety ramps up. And would you treat that in the same way?
[00:22:23] Erin: So, in that situation, it would depend on kind of the client story and what their experience was. But as you framed it in that way, and what I'm imagining, I think the panic attack would take precedence, right? Because the anxiety, the craving can probably create a panic attack. Kind of the kindling for that, that panic response, but the panic response is very physiological, right?
[00:22:44] Erin: It's maintained by what's going on in the mind, but it's a very physical experience. So I probably work primarily on how to manage and ride the wave of that panic attack and kind of [00:23:00] openings for other ways of. of coping with that aside from just using the substance. So I think that would be like a two in one situation where we talk about both kind of strategies and yeah.
[00:23:14] Kathleen: And so what about, social anxiety? Does that, like, how does that specifically affect recovery from substance use disorders? I'm imagining in my mind, like someone wanting to go to a 12 step program, um, and they have, social anxiety, disorder. What do you do in that case?
[00:23:35] Sonia: Girl, that happened to me two weeks ago.
[00:23:38] Erin: yeah, it's so hard.
[00:23:40] Sonia: yeah, I went to an AA meeting and I was just like, Uh, what if people look at me and what if this? And my social anxiety was kicked up.
[00:23:49] Erin: Yeah. Yeah. Yeah. It's social anxiety is so, oh. I've experienced it, I've lived it, it comes up still sometimes. It's it's brutal, right? It's [00:24:00] because the solution often or part of kind of the wellness and recovery plan is really connection with others and, and getting out there and having a support network and then social anxiety just says, Nope, you're not doing that, which can create, like, we're stuck at home alone with our thoughts and a bunch of fear and what makes sense, like substance use.
[00:24:21] Erin: Right? So it's, That cycle really feeds into each other, uh, with social anxiety. I'm a big fan of okay. So again, this is the psychoeducation piece, the really understanding how anxiety works and what might be going on there. And I find that it gives people a lot of power. They're like, oh, it's actually just this experience.
[00:24:39] Erin: I'm having again,what the parts the parts work. It's like, oh, this is 1 experience that I'm having. And there's also a part that has been through this so many times and knows I'm going to be okay and is willing and able to face that fear. Um, and I would never say, okay, go to like, The scariest place you can think of and speak, for an hour, like, [00:25:00] we will approach it in that, in that pyramid kind of like, so, okay, maybe your goal is to get to that a meeting and shake a couple hands and that feels like a level 10 scary, but what's like a level 1 scary and let's start there. Right. So maybe it's an online meeting and you just build that resilience. Anxiety is, the more we do the scary thing and see that, hey, I'm okay. I did it. The smaller anxiety gets the more we listen to anxiety and say, yeah, you're right. That is terrifying. I'm not going to do it. You know, eventually we get kind of stuck in
[00:25:34] Kathleen: it gets.
[00:25:35] Erin: Yeah.
[00:25:36] Kathleen: Yeah, someone very, very close to me was just diagnosed with social anxiety disorder. And you know, There was that discussion of, unfortunately, it's not like you have to have repeated exposure to that anxiety and to build it up. And it's not about hiding away, especially with social anxiety disorder.
[00:25:57] Kathleen: It's not about hiding away. It's about becoming [00:26:00] familiar and doing it repetitively again and again for it to lessen.
[00:26:05] Sonia: so for me,you go to your first day meeting and you're like, this would be so much easier if we could have a drink, and so it's hard when you've used that as your coping mechanism for social anxiety,for me, for as long as I can remember.
[00:26:19] Erin: it it is and that's where the complexity of a concurrent disorder comes in. Right? So someone with just social anxiety, we might be able to say, okay, here's your exposure pyramid plan and some strategies and coping skills. And then you. who had it in someone who has learned to cope through substance use And it does become a little bit more complex, right, and so it's about trigger management support plan and figuring out how to cope with cravings at the same time as coping with that anxiety.
[00:26:50] Sonia: Yay!
[00:26:52] Kathleen: to acceptance and commitment therapy book this morning because that's a modality I practice. And I was, they [00:27:00] were talking about how having those coping strategies through cravings and your anxiety is going to heighten. It's going to be more at the beginning but the so short term it's going to feel harder.
[00:27:11] Kathleen: But the long term is, Is what you want, right? Like is what you want to get to. And it's almost like that piece once you're aware. So if you can say to your client or if someone knows, okay, my anxiety might feel worse in this moment, but it's going to get better. Even just knowing that is so helpful.
[00:27:29] Erin: helpful. yeah, exactly. And I often will will kind of in session kind of laugh and just be like, oh, my gosh about the paradox of working with. Anxiety, or, other mental health issues too, is sometimes you just have to sit in the.
[00:27:45] Erin: It's going to get really loud in the beginning. It's going to get really loud. And if you can ride that wave, practice that urge surfing and that distress tolerance and just what you can do in that moment, what the wave is really high. And to Sonia's point [00:28:00] earlier, get to the other side of that.
[00:28:01] Kathleen: And it usually doesn't last as long as it, we think it will. That's where resilience is. That is where healing is. It's if it hurts, you're doing the work for the most part. Yeah.
[00:28:12] Erin: In the right context. In the right context. If it's uncomfortable, and you're, you're doing the thing, the next right thing, and it's uncomfortable, getting through it is a new, a new level of being.
[00:28:26] Erin: It's a new level of resilience.
[00:28:28] Kathleen: Yeah. Yeah, for sure, for sure. I think we're going to switch gears a little bit to depression. Another hot topic.
[00:28:34] Sonia: I got that too!
[00:28:35] Erin: huh. Yeah.
[00:28:38] Kathleen: I do not, actually. Luckily, I don't. but how do you differentiate between symptoms of depression and those of substance use disorder when they co occur? I almost, I often think as Is it chicken or egg? Which one is the one that comes first? Is it the depression that causes the substance use?
[00:28:56] Kathleen: Is the substance use the cause of depression?[00:29:00]
[00:29:00] Erin: Yeah, it's, to be honest, there's no, even in the literature and the research, like, no 1 really knows and what we know our best guess and what we've seen, um. In various kind of areas of psychology is that everything is kind of multifactorial and will be a mix of a bidirectional kind of activities in anecdotal experience.
[00:29:25] Erin: Oftentimes, What we were talking about before, if you do a solid history and go back and ask people about their experience early on before substance use existed, um, or was the main coping strategy, you'll usually find some, maybe not quite a diagnostic level, but you usually find some of those symptoms.
[00:29:47] Erin: Preexisting before substance use, or before addiction develops and. usually a worsening after the addiction starts, right? Especially. So one thing that would interest me when [00:30:00] I'm working with clients and picking apart where different things might have come from is like what substance they're using because a few of them are depressants, right?
[00:30:11] Erin: So alcohol, opiates can mimic kind of depression or symptoms of depression too. So that would be interesting to know. Whereas other ones like, Stimulants or amphetamines would not necessarily mimic symptoms of depression while using, but absolutely would in periods of withdrawal. So, it'd be interesting to know those interactions and what the history of uses, and then again, like the period of abstinence.
[00:30:36] Erin: Are those symptoms of depression worse? Are they better after a period of not using? sometimes we'll see people fall into a bit of a depression in sobriety, which is like, oh, so hard. I just, so want to have that not happen for people. it's just kind of like a kick in the kick in the butt when you're already working so hard for recovery.
[00:30:58] Kathleen: you mentioned about [00:31:00] sobriety and I, I really felt the empathy you have for clients. Like you just wish it wasn't so, like in terms of when they get sober, their like depression can happen.
[00:31:09] Kathleen: Yeah. Yeah. Do you think that untreated depression can contribute to the risk of relapse?
[00:31:16] Erin: yeah, absolutely.
[00:31:17] Kathleen: Yeah.
[00:31:19] Erin: Yeah, absolutely. I mean, untreated depression is just a really hard place to be right? Because the mind has a really hard time remembering anything good in a really easy time focusing on all the bad andAnd it's a disconnector, right? Depression is a disconnector and what we know about recovery from addiction is that we need connection. it absolutely does contribute.
[00:31:45] Sonia: I mean, I can't remember a time I wanted to drink more in my sobriety than when I was going through my divorce.
[00:31:53] Erin: Mm hmm.
[00:31:54] Sonia: I remember sitting there, just being like, I, there's no other way to deal with this, other
[00:31:59] Erin: hmm. [00:32:00] Yeah.
[00:32:01] Sonia: but it was really, really, really hard.
[00:32:03] Sonia: So, I can totally see how it contributes to relapse. and I wasn't, that wasn't even untreated depression. Girl, that was treated. Like, I am, like, medication and a therapist. And I still wanted to drink. And Kathleen. Yes. Yeah, and I still wanted to be like, I don't know, a glass of wine would be really good right now.
[00:32:28] Sonia: Okay, so what approaches do you find most effective, Erin, when you're dealing with clients with co occurring, co occurring depression and substance use?
[00:32:40] Erin: yeah, co occurring depression substance use is, um, a tricky one. Like, I have a lot of, uh, respect for people. I think with depression, it's like, oh, yeah, depression, everybody has depression, it's very much in the media, but the true experience of depression or major depression is such [00:33:00] a A deep like I just have so much empathy.
[00:33:05] Erin: It's such a challenge because you cannot see the light at the end of the tunnel Part of my role is holding space for the light at the end of the tunnel when the person can't see it. I find that psychoeducation around the process of depression saying, this isn't how, who you are, this is what depression shows up like.
[00:33:27] Erin: Maybe it's a symptom, maybe it's a part and not who you are. so the psychoeducation piece, it truly, if we're thinking practical, So notwithstanding any of the therapeutic interventions or like what would happen in our, in our sessions, which would probably be deeper parts work, et cetera, the practical stuff would be how do we connect you to someone or something? Okay, because what we know what I said before, but depression is it's an isolator. It's a hope killer. How do we connect you [00:34:00] with? The activities of daily living, some support system that can help hold you together, hold you in place, help you see a little bit of that light at the end of the tunnel while this happens.
[00:34:13] Erin: And again, like bringing in medical professionals if the depression is untreated. You know, I'm supposed
[00:34:20] Kathleen: Sonia, I want to, you can edit this out, but I wanted to just chat about something you do, cause I know you struggle with depression, Sonia. And one of the things I think you're so good at doing is I'm not, I obviously am not a proponent of a snap out of it thing. Cause that's not at all what I believe.
[00:34:36] Kathleen: But Sonia, you, when you are going through a depressive episode, you are very much. are so good at like, what is the one thing I can do today? Do I shower? Do I go for a walk? Do I work out? Even if you don't want to, you just do it. Like, you just force yourself to do that one thing. And I think that's been a really effective strategy for you.
[00:34:58] Kathleen: Right?
[00:34:59] Sonia: Yeah, [00:35:00] usually if my depression is not that bad, usually doing the one thing will lead to doing another thing, um. Not always, you know, sometimes I do the one thing and then I get back on the couch and watch Netflix, um. But most of the time, yeah, for sure, but I always think, that's taken so many years to figure out, I can't believe that took me, 30 years to figure that out.
[00:35:23] Sonia: Um, and so I really, empathize with, with people who struggle with both, because if you're not also getting, the right, therapy and your medications right, it's really hard, it's easy for me now to be like, Let's just do one thing but, um, but it wasn't always that easy.
[00:35:42] Erin: Yeah, yeah, it's. I am not so much of a depression girly. I'm more of an anxiety.
[00:35:50] Kathleen: Mm hmm.
[00:35:50] Erin: Lady, but I have had a couple experiences of short, thankfully, periods of depression definitely before, but definitely [00:36:00] since my recovery, which has been around 11 years now, and I'm so humbled by the experience of like, wow, it's hard to brush my teeth right now.
[00:36:07] Erin: I do not have it in me to brush my teeth right now. I would then do it anyways, which I understand some people don't have the capacity to do that, but it just gave me so much of an understanding of. There's a phrase I've heard spoken about in different therapeutic trainings, and you can't ask a fish to climb a tree, right?
[00:36:29] Erin: And so it helps me understand that when I'm working with clients who are in intense periods of depression, I'm not going to say, okay, here's your 10 point plan, or let's really go deep into your childhood right now. it really is. Sometimes just about their very practical skills of let's find an anchor to hold on to right now and do what seems like maybe a small thing to them, maybe a small thing to the rest of society.
[00:36:54] Erin: But it's actually a huge thing. Like you were saying, it's funny, it's like the one thing, [00:37:00] because that is a monumental task, right? And a couple of that with recovering from an addiction and it becomes, Very important to do that one thing and usually it would be, something for your recovery and then maybe something for your physical well being.
[00:37:16] Erin: And if that's all you do in a day, that's okay.
[00:37:18] Sonia: yeah,
[00:37:19] Erin: next right thing.
[00:37:20] Sonia: yeah, I think what's interesting too, and that, that is me medicated, right? And so that actually leads me to the next question and is how important is medication management in treating clients, with co occurring depression or depression in general.
[00:37:34] Erin: Yeah, I'm a big fan of use the tools that are available. Right? So definitely there's some people that say I don't want medication and, that's up to them and that's okay for them. There are some people that, um, I work with where it's very clear to me that, they think, it's a chemical imbalance.
[00:37:53] Erin: Like that's how that's coming across, right? Um, and they're very open to talking about that with their [00:38:00] doctor and working with their doctor and, and as the person has a good doctor that's knowledgeable and understanding huge differences, when people have their medication managed properly. I, I think it's really important.
[00:38:13] Erin: It's not for everybody, but I, like I. I'm a big fan of using the tools that are available and using what works and definitely a big proponent of a medication when it feels right for the client and when it's helpful. Yeah.
[00:38:29] Sonia: a lot of conversations about, the chemical imbalance. And so obviously like my, my family history. So that means Kathleen's ex and the children involved have, do they have a predisposition and
[00:38:41] Sonia: do you give people essentially a pass because there's a chemical imbalance?
[00:38:45] Sonia: or do you give yourself a pass? Do you say, you know what, this is a chemical imbalance, I'm gonna sit here and watch Netflix all day. Um, and so yeah, we talked about that a lot last week.
[00:38:54] Kathleen: We did, we did. I think we, I mean, there isn't going to be a right [00:39:00] answer. but our viewpoint was, I think the knowledge is power. So like knowing there is a genetic component potentially, so meaning that maybe you have extra strategies in place, maybe you are more aware of it.
[00:39:14] Kathleen: so knowing that there is that component. Um, you pay more attention to it. So you know,I can't just, like, let chance happen. Like, I really have to have those tools and strategies on a consistent basis in my life.
[00:39:30] Erin: Absolutely, and substance use is creating a chemical imbalance. But
[00:39:35] Kathleen: Right.
[00:39:36] Erin: there's that piece to, um, when we think about the concurring together and 1 will exacerbate the other or what we know about kind of epigenetics and life experiences is like that predisposition could be there and then engaging in certain behaviors or substance use or having something happen to us will like, flip those switches on. There's the addiction or there's the depression,
[00:39:58] Sonia: that's how I look at it, is [00:40:00] that it's, yeah, okay, there's a chemical imbalance that gets, it's triggered, right? it's a combination of genetics and The situation that triggers it.
[00:40:10] Erin: yeah, absolutely. And in that vein, we will see 2 people who. will use substances for long enough that. There will be a resulting
[00:40:19] Sonia: Mm
[00:40:20] Erin: chemical imbalance that remains to some degree and needs to be treated after if they do stop using substances. And there's some sensitization that happens in the brain structures and chemicals that, so in a very intense experience, example, people who use crystal meth for a very long time may have long term delusions, long term paranoia.
[00:40:47] Erin: People who use alcohol for a very long time may have brain impairment that leads to symptoms of depression or anxiety for a very long time. So it's kind of like the intense end of the spectrum, the more extreme, but
[00:40:59] Kathleen: [00:41:00] Mm hmm.
[00:41:00] Sonia: I dated this guy. I did this guy in college who did too much MDMA and he had major issues after, Iwith actually with really serious depression when he had never been depressed before.
[00:41:14] Erin: Yeah, yeah, and I will stop myself from going into like the nerd out neurochemical explanation of that, but that makes perfect sense, right? And it's humbling to recognize like sometimes the solution, the thing that feels good can,
[00:41:29] Sonia: Hmm.
[00:41:29] Kathleen: Make it way worse or cause well, yeah, I realized you didn't want to say create or cause but it's it's it's true It can really really Contribute to that contribute to that. So we wanted to shift a little bit to Another topic, which is eating disorders, and I know you have expertise in this area. This is a topic that is very near, dear to my heart, not because I treat eating disorders.
[00:41:57] Kathleen: I do not, but I myself, [00:42:00] I'm in recovery from eating disorder, uh, quite substantially when I was a teenager, with anorexia and bulimia. Uh, and then. Interestingly, it shifted to binge eating disorder in my later years, which is apparently common.
[00:42:14] Erin: It does do that.
[00:42:16] Kathleen: It does, that sneaky little sucker. It does do that.
[00:42:19] Kathleen: Yeah, yeah. So we wanted to talk about eating disorders. How common are eating disorders with substance use disorder and why is this combination challenging?
[00:42:31] Erin: Yeah, so, like with the concurrent disorders in general, it's hard to pin down specifically what the number is. I have my own experience kind of anecdotally, but I would say, like, the ballpark is anywhere between, 20 and 50 percent for eating disorders and. Anecdotally, it's so common, especially, we find.
[00:42:51] Erin: Lots of, of men are being diagnosed with eating disorders now for a very long time, it was kind of women, uh, [00:43:00] primarily. But I'm just thinking back to my time working in the inpatient treatment unit and so many of those clients, I would say probably a third of them had concurrent eating disorder issues.
[00:43:11] Erin: And the process that I would typically see is sometimes both addiction and eating disorders would be very active at the same time. But what we typically see. Is while the substance use is active, the eating disorder is less active, and then once recovery happened from the substance use, the eating disorder pop back up really strongly again, which was my experience, right?
[00:43:32] Kathleen: So, while I was actively using substances, I wasMm
[00:43:36] Erin: in the corner waiting. and then when I put down all the drugs and alcohol, the eating disorders, like, here I, here I am. Right, so I see that quite often, it's very common.
[00:43:48] Sonia: So, how do you approach the treatment of a client who has both an eating disorder and a substance use disorder? And from what you're saying, when you treat one, the other one kind of has space to [00:44:00] grow.
[00:44:01] Erin: Yeah, so, in my approach, we do a lot of kind of what I spoke about before, identification, like what are the different processes at play here, I'm trained in CBT E, it's not my, Main modality, because I, I tend to not be very good at sticking in the box of CBT and it would do a lot of IFS and eating disorder treatment too, but the 1 thing that's helpful about CBT E, which is CBT for eating disorders, is this idea of maintaining factors.
[00:44:31] Erin: Right? So that every eating disorder will have factors that maintain it. And I find that to be true of addictions too. So we do a lot of work at the forefront of therapy, like what is showing up to maintain these behaviors? What are the core beliefs underneath them? What's going on? I view eating disorders and addictions as symptoms, or our best attempt to cope with a pain that is within us.
[00:44:54] Erin: So what is, what is that pain? What purpose are these two things [00:45:00] serving? and IFS is super helpful for that because you get into the different, like, parts of why. Usually it's a protector in some way. So a lot of work around that in the forefront. Sometimes eating disorder work can't happen unless the substance use has slowed down a little bit.
[00:45:21] Erin: So I'm never a person who says, you need abstinence, unless that's the client's goal. But sometimes regular intoxication to the point of not really being able to show up in therapy and get into that deeper level will prevent eating disorder treatment from happening. And sometimes you have to deal with the symptoms that are the most harmful first.
[00:45:42] Erin: So sometimes that's eating disorder symptoms. Sometimes that's substance use symptoms.
[00:45:47] Kathleen: How, how do body image issues and self esteem challenges affect the recovery process from, well, substance use and eating disorders,Oh, that's a big one. [00:46:00] Body image challenges are so deeply ingrained as a Sense a source of toxic shame and self hatred for people that it's, it's really stuck in there. Right? For a lot of people and I don't know if you guys have had this experience, but we're like a. A bad body day or feeling a sense of shame or or unhappiness with the body can truly impact your mood for the rest of the day.
[00:46:30] Kathleen: Yeah, yeah.
[00:46:31] Erin: that's big. That's big for the clients that I work with. And again, sometimes it's that stress tolerance. It's like, how do we. that? We can't always run from it. we want it to be different. And that takes time. But sometimes it's like, okay, you're having like a really big shame flare up because of this body image experience that you're having.
[00:46:50] Erin: And how do we cope with that without engaging in harmful behaviors? Right. I, when I do eating disorder work, do a lot of. [00:47:00] psychoeducation and diet culture, and just like the big lie that we're all being sold.and I love to see my clients get like, a little bit angry about that.
[00:47:09] Kathleen: Mm
[00:47:10] Erin: go a little bit angry about that, uh, that lie that we're being sold it and the idea that our bodies are equal our worth.
[00:47:17] Erin: So there's a lot of a lot of that work and opening the lens and challenging the paradigm a little bit. Um, but. Yeah, I feel like I'm going on, so I'm going to stop now.
[00:47:28] Sonia: No, that's really enjoyed that. Um, so also, so there's this idea that like eating disorders are about control. And so how does that play into this kind of co occurring disorder idea with substance use and an eating disorder?
[00:47:50] Erin: The frameworks I sometimes use are just like an image with my clients is like this idea of a tree, right? So the roots are things. They're the roots [00:48:00] and and maybe the, the wound, the trauma, the pain, whatever might be going on. That's the roots and then it'll grow into these different branches. Right?
[00:48:07] Erin: And there are different manifestations of kind of the same. Um, and I don't know if there's any like research backing that, but it's just what makes sense to me. And it seems to fit well with my clients. And some of those branches can be, substance use. So addiction and eating sort, and we can trace it back to the same place and realize that both of those behaviors as well as other ones that show up are serving a very similar purpose.
[00:48:33] Erin: Thanks. Right, so the coping and in your kind of to your point control, I find, like, some eating disorder presentations are about control. And I think some are are.
[00:48:48] Kathleen: Not.
[00:48:48] Erin: losing control about breaking free about having being messy for once in their life. And then, especially kind of bulimia and binge eating disorder.
[00:48:58] Erin: If we break that into kind of like a [00:49:00] parts lens, which I love to do, like, the part that wants to eat or binge is like the. The effort part, I'm going to do what I want for once in my day. I'm going to do what I want because I'm always so strict and I'm always so perfect. And the pressure of perfection is like, so intense and pressure of restriction.
[00:49:16] Erin: It's so intense that that eating part comes in. It's kind of a really beautiful energy, not a beautiful manifestation, but of saying, like, no, you're going to do what you want for once. Right? So it's, it is about control. And then it's also about that backlash against control as well.
[00:49:34] Erin: What about food addiction? Is that the same thing as an eating disorder? Or is that a substance use? Like, how would you, would you categorize that? How do you know the difference? That's tricky.
[00:49:47] Erin: I don't know how much I believe that food can be an addiction. Like, I
[00:49:55] Kathleen: Mmhmm.
[00:49:56] Erin: addiction is, it can, it can [00:50:00] mimic and it can meet a lot of the diagnostic criteria of addiction. And if I guess if we look at it, on a biochemical level, it does activate the same parts in the brain. But that's, that's one where I'll say I don't 100 percent know. The treatment center that I worked in had a food addiction pilot program. And so at that time I was really like, yes, food addiction, it made a lot of sense to me. Um, but the more training and work I've done in trauma and eating disorders and the manifestation of that, I wonder if food addiction isn't also just a form of disordered eating that is kind of deeper than the chemical process of dependence on Substances, so that's a tricky one.
[00:50:43] Erin: Some people find the concept of food addiction really helpful and will engage in supports based on the idea of food addiction. And if that works for them, I love that for them. Right?
[00:50:55] Kathleen: I also am not sure, Erin. I'm, I'm, I'm undecided on that. [00:51:00] I go back and forth depending on what research I'm reading. And, um, I think it is a tricky one because you can have that biochemical reaction, like the dopamine from eating sugar or like high carbohydrate foods, that, but, it's a tricky thing.
[00:51:17] Kathleen: is it an addiction? Or is it an eating disorder? And, but does it matter in a sense of what it is? if you can treat it in a similar way, I guess. I don't know. Like maybe it doesn't matter what the category is.
[00:51:33] Erin: I think it matters like some people have a very strong foundation in 12 step recovery or a specific kind of addiction focused recovery that works really well for them. So, slotting any kind of disordered eating or like a concept of food addiction into that 12 step mold is exactly what they need and exactly what
[00:51:53] Kathleen: Mm hmm. Mm
[00:51:54] Erin: I'm never gonna. Find problem with that. I think if I'm going to sit back and say what [00:52:00] my concern with, food addiction would be, is that the solution is. In, in some circles would be some form of restriction and, saying, okay, this, this is a trigger food. So don't have the trigger food and that a little bit a lot goes against kind of my general framework for understanding that, restriction contributes to the maintenance of disordered eating and also restriction is not that place of body.
[00:52:30] Erin: love and trust that we want to get to. So it's, I think personally, that's where it deviates from my framework, but I think it works well for a lot of people. So whatever works.
[00:52:41] Kathleen: hmm. And so, okay. You talked a little bit about if someone has. And eating disorder, and then they're also addressing their substance use. You're looking at, okay, which do you need to address first? So if someone has a substance use disorder and an eating disorder, are you even looking at their relationship with food at that point?
[00:52:59] Kathleen: And how to have a [00:53:00] healthy relationship with food, or are you just focusing on the substance use? Okay.
[00:53:05] Erin: depends on what is, it depends on the client. It depends on what their most distressing concern is. All right, so some people will there's a primary and a secondary. They are concurrent. Sometimes they're like this, but usually there's 1 that's more active than the other and that the client knows. But that is, if there is someone who is at a extremely low weight and physically.
[00:53:31] Erin: Or at an extreme end of the spectrum to the point that their physical well being and their safety is at risk. That would then probably for me take some sort of precedence. That being said, if a client is just in row psychotherapy practice, if a client is in medical emergency, I would not, I would support them in finding.
[00:53:52] Erin: Other supports that are more intensive than what I can offer. But that would be The eating disorder showing up first. If there's like we said, like I [00:54:00] said before, the intoxication is very prevalent, then then that would show up first. Um, but it really is what's distressing the client the most and finding out the interplay.
[00:54:10] Erin: Okay. So maybe you drink instead of eating. How can we. How can we deal with both of those things right at the same time? Like, what's a plan around that? Um. Yeah, it can be challenging and then sometimes if the addiction is more precedent, we just think. How do we keep your, like, body as healthy as possible right now while we cope with the addiction, while we
[00:54:33] Kathleen: mm
[00:54:34] Erin: Integrated treatment and concurrent treatment has the best outcome. So we try as best as possible to work with both sets of symptoms and disorder, I don't like that word, um, challenges at the same time.
[00:54:51] Kathleen: hmm, mm hmm, mm hmm. Well thank you so much Erin, like you've been such a wealth of information and I'm so happy that you agreed to come on [00:55:00] a second time. Do you have any final advice that you can give our listeners who may be struggling with co occurring disorders or even supporting someone who is?
[00:55:10] Erin: yeah, I think so much. Compassion and empathy. Or for themselves, right? so it can feel pretty daunting probably, even listening to some of the things that we've spoken about, or, or some of the things that are on other sources of media to feel like, oh, my gosh, I have 2 or 3 things that I have to recover from that feels really daunting.
[00:55:34] Erin: And it feels really like I can't do it. But just the relationship between substance use issues and mental health issues can work together to make things harder. The recovery can work together to make things easier and and it's possible like recovery is possible and the interactions can go in the positive direction to right and I think [00:56:00] to have compassion for where you are on the journey and know that support is available and if someone is struggling, in their lives and wanting to support that person again, compassion, empathy, but always self care for the caregiver as well.
[00:56:15] Erin: Yeah.
[00:56:16] Kathleen: That's an important point, self care for the caregiver. Yeah. Yeah.
[00:56:21] Kathleen: thank you so much for listening to Sisters in Sobriety and we will see you next week. [00:57:00]