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Dr. Amalia Fantasia Bio

Dr. Amalia Fantasia Bio

 

Dr. Amalia Fantasia, PhD, is recognized widely as a leader in the field of health care, health care management, ambulatory health care and nutraceutical medicine. Acknowledged by chemists, bio-engineers, geneticists, physicians and health care administrators alike, Dr, Fantasia has pio- neered many of the preventive and integrative medical practices being standardized and inte- grated into traditional and primary health care today. The nutraceutical protocols and support treatments she has created in conjunction with physicians are well sought after on an international basis by patients and health care providers.

 

In 1996, she founded Cherry Hill Clinic, an ambulatory primary care practice serving the Southern New Jersey, Philadelphia and New York regions. As Clinic Director, Dr. Fantasia is not only responsible for the clinic’s founding and management, but was instrumental in developing its method of care processes and marketing, working with scientists, bio-chemists and Clinic Physi- cians in establishing entirely new health care modalities and standardizing primary and secondary health care treatment for the Clinic’s patients. As a health care management and bio-chemistry PhD, who has a particular focus in IV nutraceutical medicine as a preventive and support therapy for traditional health care, including cancer, opioid dependence, pre and post surgery, bariatrics and auto immune disorders,  Dr. Fantasia has developed a range of formulated proprietary IV nu- traceutical treatments that are becoming well known and sought after worldwide. Her clinical data from the same period has demonstrated the overwhelming success of Cherry Hill Clinic’s proto- cols and the modularization of the Clinic’s treatments and standard of care that are being sought after nationally by large-scale health care organizations and systems.

 

The author of several articles and studies in the field, Dr. Fantasia’s peer-reviewed works include: “The Value of Point of Care Testing in the Physician’s Office Setting,” in Advanced Labora- tory Medicine Magazine; “The Role of Nutraceutical Medicine in Preventing Cardiac Incident,” in Philadelphia Magazine;“The Assessment of Serum Markers as Related to Select Tumors,” published by Temple University Press; and “The Development of CPT Coding for Alternative and Preventive Medicine,” by City University of New York (CUNY) Press. Dr. Fantasia is also known widely for her many media and television appearances to discuss related health care topics, including appearances on CNBC,WBCB,WPEN and CNN, and she is also well known and respected as the host of her own weekly radio show serving Southern New Jersey and Philadelphia discussing topics related to health care with a focus on Nutraceutical and Preventive Medicine. In addition, Fantasia is invited to speak regularly by organizations on health care topics, including such well-known entities as the Pennsylva- nia Society for Clinical Laboratory Services, the Health Care Strategies Association, the Southern New Jersey Holistic Nurses Association, the American Nurses Association and the Philadelphia Busi- ness Women’s Network and Forum.

 

Prior to founding Cherry Hill Clinic, Dr. Fantasia, who has a PhD in Health Care Administra- tion from City University of New York, and a PhD in Chemistry, MBA in Health Care Finance and BS MT (AMT) in Chemistry from Temple University in Philadelphia, Pennsylvania, worked in various ca- pacities in the health care field gaining a diverse and wide range of experience in health care man- agement for medium and large scale hospital and related health care systems. From 1989 to 1996, she was Senior Consultant and Medical Laboratory Coding Specialist for Affiliated Health Manage- ment Associates in Chicago, Illinois, and from 1980 to 1985 the Outpatient Services Director for Broad Street Hospital Group in Philadelphia, where she also served as Hematology Supervisor be- ginning in 1974.  From 1969 to 1974, she was Senior Staff Technologist at Methodist Hospital in Philadelphia.

 

Dr. Fantasia is a member of several professional health care organizations including the American So- ciety for Clinical Pathology, the American Medical Technologist (AMT), the American Society for Clin- ical Lab Sciences (CLMA), the American College of Medical Practice Executives, the American College of Health Care Executives, and the American College for Advancements in Medicine. Dr. Fantasia also holds several Board certifications, including certifications from the Bupreneophine and Office-based Treatment for Opioid Dependence; the New Jersey Psychiatric Association; the International Acad- emy of Physiological Regulating Medicine; and the Association for Physiological Regulating Medicine in Pain Management and Aesthetic Medicine, among others. A native of Philadelphia, Dr. Fantasia lec- tures nationwide on subjects ranging from the semi-rapid detox of opioid dependence to the prac- tice and integration of preventive health care into existing health care systems and the successful use of IV Nutraceutical medicine to support traditional health care treatments and protocols.


Suicide, an Addictive Behavior

Suicide, an Addictive Behavior

Robert M. Lichtman, Ph.D., LMHC, CASAC, FAPA, MAC, CRS

Phone: 914-665-8622 or 914-960-9943

 

‘Daniel’ was intent on killing himself. He threatened his outpatient treating team and his family, that if he did not receive a prescription for Ativan, a highly addictive anti-anxiety drug, he was going to drink himself to death. In order to prevent this, his family took him to a psychiatric emergency room, where he was hospitalized as a danger to himself. Once again, he demanded that the ward psychiatrist give him the drug Ativan. As with most chemically dependent patients receiving efficacious treatment, the drug was not prescribed. He then persuaded his family into taking him home, promising that he would not harm himself. Unfortunately, they believed him and returned to the hospital, signing him out AMA (Against Medical Advice). Once home and out of his familys’ sight, he secured the anti-anxiety drug on the street, bought a liter of vodka, rented a room in a local motor inn and successfully committed suicide. The combination of Ativan and vodka proved to be quite lethal, and he knew it would be. Following a psychological “autopsy” and a root cause analysis, it was determined that Daniel “was going to do what he was going to do,” and the culpability was his own. I have often reflected on Daniel’s case and his drive to kill himself, thinking short of: locking him up and throwing away the key,” did we do everything clinically possible to prevent that suicide? That question haunts me to this very day. The concepts of free will and self-determination are challenging when someone takes their own life.

Running on Empty

Daniel was neither religious nor spiritual. Church and self-help programs held little value for him. The central activity in his life was to remain in the altered sense of consciousness produced by the psychoactive properties of an anti-anxiety drug. When the drug was not available, alcohol took its place, but that was not his drug of choice, Ativan was. Alcohol drove him into misery and made his hunger for Ativan worse. Daniel in an alcohol intoxicated state was literally hopeless, hapless and helpless. He was running on empty, unable to fill himself, and the alcohol was a poor second place substitute. It was the lure of Ativan that kept him going. He could not tolerate the protracted withdrawal enforced by the controlled environment of a hospital ward or a locked rehabilitation program. He had gone through countless detoxification and rehabilitation programs, both inpatient and outpatient.  His comfortable state was his addicted state and without the anti-anxiety drug in his system he was very uncomfortable. As with many substance dependent people, his tolerance increased exponentially to a point where he required four times the dosage indicated for someone with an anxiety disorder. Other medications were tried, all to no avail. They only made him tired and produced sleep. Once awake, the craving returned twofold. He could not live in his skin, the pain was too great. The addiction to the Ativan was now turning towards the drive towards death. He saw his life ending as the only way out of his misery and what was once an addition to the drug became an addiction to suicide.

 

When Ingestive Addictions Become Process Addictions

Specialists in addictive disorders usually separate behaviors that involve the administration of substances into one category and others like pathological gambling, shoplifting, exercising, the internet, and sexual compulsivity into another, hence the terms ingestive and process. They are not mutually exclusive, as people engage in both types of addictions and at times, simultaneously. I prefer to call the latter, “Addictions Without Substance,” although both have a payoff in the form of physiological, psychological and sociological reinforcement. Incidentally, I have seen a number of cases where the person’s life ended in an intentional suicide, either by design, as in Daniel’s case, or by moral deterioration, to a point where an “accident” takes the person’s life. When there is literally nothing more to live for other than seeing oneself being strangled and falling into a deeper abyss, suicide is no longer viewed as an option. The drive to die takes on all of the properties of addictive behavior, especially the obsessive and compulsive components. Suicide is not viewed as some clinicians say, “a permanent solution to an otherwise temporary problem,” it becomes the “solution” itself. The drive towards oblivion is all too powerful.

Note: The name of the case study in this article has been changed in order to maintain confidentiality.

 

Biography

 

Dr. Bob Lichtman, Ph.D., LMHC, CASAC, FAPA, MAC, CRS, is a clinical administrator at a psychiatric hospital and a professor at local colleges. He is a founding member and former president of the Addictions Division of the New York State Psychological Association and a specialist in the assessment and treatment of people who have co-occurring emotional and substance use disorders. Bob lives in the Fleetwood, a section of Mount Vernon, New York and maintains a private practice specializing in relationship counseling and addictive behaviors.

 

If you or anyone you know are in crisis, please know that you are not alone. You can reach out to the National Suicide Prevention Lifeline where skilled, trained counselors are available 24 hours a day, 7 days a week at 1-800-273-TALK (8255) or online at http://www.suicidepreventionlifeline.org/.

 


Complementary and Alternative Medicine for Older Adults with Depressive Symptoms:

Complementary and Alternative Medicine for Older Adults with Depressive Symptoms:

Analyzing Data from the 2012 National Health Interview Survey

 

Dr. Ryan Harrison, Psy.D.

 

University of the Rockies

School of Organizational Leadership

555 East Pikes Peak, Colorado Springs, CO  80903

United States

Phone: (909) 392-4392

Email: RHarrison@LivingAtHillcrest.org

 

 

 

Abstract

This study explored how older adults with symptoms of depression relate to Complementary and Alternative Medicine (CAM) therapies.  Data from the 2012 National Health Interview Survey were analyzed to reveal the frequency of distinct CAM therapies’ use among depressed older adults, as well as subjective measurements of CAM therapy helpfulness in this population. Some CAM therapies such as natural supplements, chiropractic/osteopathic treatment, massage, yoga and acupuncture are utilized more commonly than others by older adults with symptoms of depression.  Similarly, some CAM therapies are also subjectively determined to be more helpful than others in managing symptoms of depression.  The major findings of this study suggested that some CAM therapies are used with greater frequency than others by older adults experiencing symptoms of depression. In addition, some CAM therapies are also perceived to be more helpful than others in terms of depression care and management.

 

Keywords

older adult depression, complementary and alternative medicine, frequencies, National Health

 

Interview Survey

 

Although research has shown that depression is not an inevitable part of growing older, it does remain one of the most common mood disorders experienced by older adults (Centers for Disease Control and Prevention [CDC], 2012b; Geriatric Mental Health Foundation [GMHF], n.d.; National Institutes of Mental Health [NIMH], n.d.).  The literature is replete with data describing both risk factors for depression in the older adult population and the multiple adverse health effects of depression.  At the same time, diagnosing depression in the elderly population can be difficult for several reasons.  This has implications for treating this population, and research suggests that many depressed older adults go undiagnosed or under diagnosed and, therefore, untreated (Lakey et al., 2012; Wancata, Alexandrowicz, Marquart, Weiss, & Friedrich, 2006).

In general, standard treatment of depression for older adults places greater emphasis on prescription medications than on psychotherapeutic approaches (Wancata et al., 2006).  In some cases, the two are combined to significant effect (Blazer, 2003; NIMH, n.d.; Rojas-Fernandez & Mikhail, 2012).  Paradoxically, even when seemingly adequate treatment is available to depressed older adults, rates of compliance and adherence may be low.  Ivanova et al. (2011) found that physicians are more likely today than in earlier eras to prescribe antidepressants. Many older adults resist diagnosis and treatment and are willingly noncompliant with medical treatment.  Bosworth, Voils, Potter, and Steffens (2008) reported that as many as 20% to 80% of depressed older adults who are prescribed medications fail to adhere to their medication protocols one month later.  There may be additional reasons for medical noncompliance, including adverse side-effects caused by medications, the lack of a complete understanding of the benefits and risks associated with such treatment, cost concerns, alternate recommendations made by others, or preference for therapies that meet the patient’s more holistic needs (Bomar, 2013; Bosworth et al., 2008; Jin, Sklar, Oh, & Li, 2008; Tait et al., 2013).

Depression may itself predispose older adults toward poor medication compliance, including the under-use of medications or inappropriate discontinuation of the medication (Lutwak & Dill, 2012).  Problems with memory and cognition, poor vision or hearing, lack of social support, inadequate access to medication, economic burden, difficulty swallowing pills and the lack of dexterity or strength required to open drug containers or handle small pills may also predispose older adults to poor medical compliance (Jin et al., 2008).

However, non-adherence to medical care does not necessarily equate inaction on the part of older adults coping with depression.  Research suggests that a significant number turn toward CAM therapies (Astin, Pelletier, Ariane, & Haskell, 2000; Barnes, Bloom, & Nahin, 2008).  The suggested prevalence of CAM use among depressed older adults varies widely, although there is growing consensus in literature that it is steadily increasing.  In their study of CAM use in the elderly population, Astin et al. (2000) reported that 41% of a sample of older adults reported using CAM within the prior year.  Of these, 59% reported mood disorders such as depression while 80% reported improvement in their symptoms following CAM use (Astin et al., 2000).

A 2007 iteration of the NHIS, which included a CAM supplemental questionnaire, revealed growing use of CAM by older adults (Barnes et al., 2008).  Additional research utilizing the 2007 NHIS data found that older adults with chronic conditions including depression were more likely to use CAM than their healthier counterparts (Tait et al., 2013).  Certain health characteristics do contribute independently to CAM usage.  Three of these characteristics, strongly supported by research, are chronic conditions, comorbidity, and depression (Bishop & Lewith, 2008; Eisenberg et al., 1998; Keaton et al., 2009; Nahas & Sheikh, 2011; Park, 2013; Qureshi & Al-Bedah, 2013; Varteresian, Merrill, & Lavretsky, 2013).  Older adults often experience one or more of these predisposing factors suggesting there may be a significant numbers of older adults who are using CAM therapies specifically for treating depression and depressive symptoms.

Discerning precise statistics of older adult CAM usage is confounded, however, by low levels of CAM use disclosure. Numerous studies have found that as many as 38% – 60% of instances of CAM usage are not discussed with medical doctors or health care practitioners (Eisenberg et al., 1998; Nemer & McCaffrey, 2010; Willison, Williams, & Andrews, 2007).  The result is an inaccurate understanding of how many depressed older adults are using CAM therapies and how effective those CAM users find the therapies to be.  The data collected via the 2012 National Health Interview Survey (NHIS) and its CAM supplemental questionnaire can provide recent data that can be used to address these questions.

Methods

Study Data and Study Participants

The sample for this study consisted solely of participants in the 2012 NHIS Sample Adult survey and its CAM supplemental questionnaire.  Only data from respondents who indicated being 65 years of age or older were used.  The 2012 NHIS procedures were designed to collect data representative of the national population.  Accordingly, individuals aged 65 and older who were African American, Hispanic, or Asian had increased odds of being selected as the sample adult from each household (CDC, 2012a).

The NHIS is a cross-sectional household interview survey with sampling and interviewing occurring continuously throughout the year (CDC, 2012a).  According to the Centers for Disease Control and Prevention (CDC, 2012a), the NHIS sampling plan “follows a multistage area probability design” (para. 7) that is redesigned after every census.  For the 2012 NHIS, 428 primary sampling units (PSUs; consisting of counties, contiguous counties, or metropolitan areas) were drawn from all 50 states and the District of Columbia.  Within each PSU, 4 to 16 addresses were used.  For the adult sample of the 2012 NHIS, one civilian adult per family was randomly selected to self-report responses to survey questions, including those asked as part of the CAM supplement.  Because there were no identifiers associated with the NHIS data, and because the dataset was free to download and use in the public domain no official permission was required to utilize the data.

As illustrated in Table 1, of the 14,438 older adults sampled, 7,935 of those provided complete data, including gender.  Over 1,000 of the older adults indicated that they had been told by a health professional that they had depression.  Although 45% of the sample was missing gender-related data, 32% were coded as female and 22% as male.  The majority of the sample adults were Caucasian (44%), with African American being the second most prevalent reported ethnicity.  Table 1 indicates common demographics of this sample of older adults.

 

Table 1

Demographic Characteristics

 

Characteristic

N %
Gender

Female

Male

Missing

14,438

4,647

3,288

6,503

 

32.2

22.8

45.0

Age

65-84

85+

 

7,000

935

 

88.2

11.8

Ethnicity

White/Caucasian

African American/Black

Indian (American), Alaska Native

Asian Indian

Chinese

Filipino

Other Asian

Primary race not releasable

Multiple race, no primary race selected

7,935

6,374

1,078

47

29

80

112

189

17

9

 

44.1

7.5

0.3

0.2

0.6

0.8

1.3

0.1

0.1

Note. Data from 2012 National Health Interview Survey Sample Adult questionnaire and complementary and alternative medicine questionnaire.

 

Research Questions and Study Design

In this study, there were two research questions: (1) Which CAM therapies do depressed older adults use most commonly, as evidenced by a higher frequency of self-reported CAM use via the 2012 NHIS? and (2) Which CAM therapies do depressed older adults find most helpful for treating their mood disorder, as evidenced by a higher frequency of self-reported CAM therapies used for treating depression via the 2012 NHIS?

This correlational and quantitative study used frequencies of data from the 2012 NHIS to determine to which CAM therapies older adults with depressive symptoms utilized most commonly and which they found most helpful for managing their condition.  The NHIS CAM supplemental questionnaire invoked the term “CAM” to refer to 23 distinct therapies about which survey participants were asked directly.  These therapies included:  chiropractic/osteopathic medicine, massage, acupuncture, energy healing therapy, naturopathy, hypnosis, biofeedback, ayurveda, chelation therapy, craniosacral therapy, natural supplements, homeopathic treatment, meditation, mindfulness based therapy, guided imagery, progressive relaxation, yoga, tai chi, qi gong, the Feldenkrais method, the Alexander technique, Pilates, and Trager psychophysical integration.

Results

            To answer the first of these research questions, regarding which CAM therapies depressed older adults used most commonly, frequencies were generated regarding the occurrence of specific CAM therapy use by older adults whose reported depressive symptoms were greater than zero.  Out of 7,889 older adults with depressive symptoms (indicated by responding in the affirmative to one or more of a range of NHIS items coded for symptoms of depression), the highest occurrence of CAM therapy use was natural supplements with 1,390 users.  This was followed by 612 participants who used chiropractic or osteopathic manipulation, 351 who used massage therapy, 294 who used yoga and 142 who used acupuncture.  These most commonly used CAM therapies are reflected in Table 2.  This dataset represented survey respondents who answered the questions about CAM therapy use in the affirmative.

 

Table 2

CAM Therapies Used Most Commonly by Depressed Older Adults

 

Type of CAM therapy

# of users % of users
Natural supplements 1,390 17.6
Chiropractic/osteopathic   612 7.8
Massage therapy   351 4.4
Yoga   294 3.7
Acupuncture   142 1.8

 

To answer the second research question, regarding which CAM therapies depressed older adults find most helpful for treating their condition, frequencies were calculated by filtering for depressive symptoms greater than zero and CAM therapy use greater than zero, based on three NHIS items that asked respondents which CAM therapies were their top three most important for addressing their health problem.

The top five CAM therapies reported by older adults with depressive symptoms as most helpful for addressing their health condition were chiropractic/osteopathic therapy (325), supplements (133), massage (117), acupuncture (65) and mind-body therapies (48).  Of those who reported using  therapies for managing their health condition, between 78.5% and 95.8% said that the therapy helped “some” or “a great deal.”  This is illustrated in Table 3.

 

Table 3

CAM Therapies Deemed Most Helpful by Depressed Older Adult CAM Users

Type of CAM therapy # who found therapy to help “some” or “a great deal” # who listed therapy as 1 of 3 top choices % who found the therapy to help “some” or “a great deal”
Chiropractic/osteopathic 287 325 88.3%
Natural supplements 109 133 82.0%
Massage therapy   99 117 84.6%
Acupuncture   51   65 78.5%
Mind-body medicine   46   48 95.8%

 

Discussion

Both research questions, answered by descriptive statistical analysis, revealed similar findings.  More specifically, the five CAM therapies most commonly used by depressed older adults were found to be similar to those they found most helpful for treating or managing their health condition, with one exception. Mind-body therapies were felt to be more helpful than yoga and those findings may lay the groundwork for a number of additional research studies.

The first research question concerned the CAM therapies which older adults with depressive symptoms use most commonly.  As illustrated in Table 2, there were a combined 2,789 responses indicating use of one of five CAM therapies.  This number was generated by filtering the dataset to find data from older adults with depressive symptoms who also reported CAM therapy use (n = 7,889).  The most commonly used CAM therapy was found to be non-specified natural supplements, followed (in order) by chiropractic/osteopathic, massage, yoga and acupuncture.  Although additional CAM therapy usage was reported, the 142 positive responses related to acupuncture represented 1.8% of the sample; smaller results were deemed unnecessary for inclusion in the list of most common therapies.  Overall, this analysis revealed there is a general trend in the selection of CAM therapies by depressed older adults.

These findings provide current support for what previous research has uncovered.  A number of resources suggest that the five top CAM therapies resulting from an analysis of 2012 NHIS data are also among those that adults and older adults have used most commonly for many years (Astin et al., 2000; Lavretsky, 2009; National Center for Complementary and Alternative Medicine [NCCAM], 2013; Nemer & McCaffrey, 2010; Okoro, Zhao, Li, & Balluz, 2013; United States Department of Health and Human Services [USDHHS], 2011).  Indeed, research from the 2002 and 2007 iterations of the NHIS revealed similar results for the older adult population, suggesting a strong preference for natural supplements, acupuncture, chiropractic, massage and yoga (Barnes, Powell-Griner, McFann, & Nahin, 2004; NCCAM, 2013; Nemer & McCaffrey, 2010; Upchurch et al., 2007).

The answer to the second research question, regarding which CAM therapies depressed older adults found most helpful, was represented by Table 3.  The dataset suggested that the majority of CAM users found the therapies they used to be helpful either somewhat or a great deal.  This information was acquired by compiling data from older adults with depressive symptoms who used CAM and who answered a series of questions regarding their top three CAM therapies used to address their health problem.

The findings were similar to those resulting from the first research question.  The CAM therapies deemed most helpful also tended to be those that were most commonly used.  One exception was that yoga, which was a frequently utilized CAM therapy, was not one that was found to be among the most helpful.  Mind-body medicine appeared to take yoga’s place.  Further, mind-body medicine was found to have the highest degree of helpfulness, compared to other therapies, with a 95.8% response indicating helpfulness.  It should be noted, however, that this high degree of helpfulness was reported by only 48 individuals, representing fewer than 0.01% of the sample (n = 7,889).

The findings of this study were supportive of conclusions reached by earlier research.  For example, the connection between depressed individuals and the therapeutic application of mind-body practices is not new; a study by Meeks and Jeste (2007) found that depressed older adults in a geriatric psychiatric clinic reported greater use of mind-body CAM therapies than other subpopulations.  Earlier, Astin et al. (2000) conducted a survey of CAM therapy usage by 728 older adults in California, 80% reported receiving substantial benefit from the CAM therapies to which they turned.  Similarly, Cerino (2005) reported on a survey by the National Institutes of Health, which found that a majority (55%) of adults turned to CAM therapies for the perceived helpfulness of the therapies.

The present research study determined that, after mind-body therapies, chiropractic/ osteopathic (88.3%) and massage (84.6%) produced the next highest percentages indicating helpfulness, with natural supplements—the most commonly used CAM therapy—deemed helpful by 82.0% of respondents and acupuncture by 78.5%.  As mentioned earlier, however, it should be noted that this represented data provided by only 688 respondents, or 8.72% of survey respondents with depressive symptoms (n = 7,889) who used CAM over the prior 12 months.

Limitations

There were several limitations in this study.  One includes the subjectivity of the NHIS.  Although the NHIS is a respected source of public health information, it’s nature as an interview schedule produces nonstandardized responses.  Many of the questions are subjective in nature such as the degree in which a CAM therapy was experienced as helpful.  While subjectivity is useful in qualitative research for measuring perspective and point of view, in quantitative research, it can have a confounding effect, making it a variable that should be controlled if possible (Drape, 2002; Mackellar, n.d.).  It should be noted that the NHIS includes subjective questions making some of the findings of this study unreliable.

In relation to the subjectivity of the NHIS, a second limitation of the current study is the necessary weight given to individual respondents’ personal understandings, beliefs and biases toward CAM therapies.  For example, there is little within the NHIS that helps a person understand what the different CAM therapies are or how they are used in practice.  As a result, respondents’ answers to items about CAM therapies could only be made from personal experiences.  If an individual had been exposed to CAM therapies by poorly prepared practitioners, the resulting answers to CAM-related items would have been unduly skewed.  This lack of standardization of knowledge and experience with CAM therapies may also contribute to unreliable findings.

The relative homogeneity of the study may represent another limitation.  Although some research suggests that depression is more common among minority groups than among white people (Dunlop, Song, Lyons, Manheim, & Chang, 2003), conflicting research suggests that the prevalence of major depressive disorder (MDD) may be higher in white people than in minority groups(Riolo, Nguyen, Greden, & King, 2005).  One common perspective, however, is that non-white, depressed older adults tend to seek treatment less readily than their white counterparts (Conner et al., 2010; USDHHS, 2011).  This may be reflected in the dataset resulting from the 2012 NHIS.  The majority of survey respondents were white (80%), suggesting that this study may not have captured significant data related to minority use of CAM therapies.

An additional limitation has to do with the design of the study.  This research project concerned depression, for which there are a number of standardized reliable and valid screens or interview schedules.  All of the data used for this study came from the NHIS.  Although the NHIS included the World Health Organization’s Composite International Diagnostic Interview Short Form (CIDI-SF) since 1999, as a survey, the NHIS is not considered a standalone depression scale (Egede, 2004; Kessler, 2007).  The items from the NHIS coded for a correlation to depression do relate to commonly known depressive symptoms (feeling sad, hopeless, worthless, etc.).  However, the data used for this study related to the incidence of depressive symptoms were subjective in nature.

The NHIS’s CAM supplemental questionnaire’s approach to the topic of natural supplements presented a confounding factor, as well.  Although it is well-known that there are many distinct natural supplements, as well as synergistic combinations of supplements that are advertised as helpful for mood stabilization (including ingredients such as St. John’s Wort, l-theanine, lemon balm, SAMe), the CAM supplemental questionnaire allowed respondents to select simply “natural supplements” as a distinct CAM therapy used within the prior year, without necessitating more specificity.  Because natural supplements, as a whole, comprise any number of vitamins, minerals, herbs, or other natural substances, its designation as a distinct CAM therapy can be considered a limitation insofar as it obfuscates more precise accounting of active compounds.  The degree of this limitation is quite clear when “natural supplements” was found to be the CAM therapy most commonly used and one of the five CAM therapies deemed most helpful by older adults with depressive symptoms. Not knowing which specific supplements were used by this population renders these particular findings somewhat negligible.

Finally, while data analysis revealed which CAM therapies depressed older adults used most commonly and which they found most helpful, these findings do not constitute a list of CAM therapies that have been rigorously tested for their utility in treating depression in older adults, and should be considered grounds for additional research.

Implications for Theory, Practice, and Future Research

            There are several implications for theory, practice and research resulting from this study.  First, the results of this study underscore what previous research has uncovered. Older adults living in the United States tend to turn toward some CAM therapies more readily than others.  Concurrently, there is some indication that the degree of scientific research into specific CAM therapies and their utility in treating depression is not a factor that drives older adults to CAM therapy use.  Barnes et al. (2008), for example, discovered that “there is no meaningful correlation between the number of published studies of a CAM therapy and its use by the American public” (p. 7).  The implication, supported by this current study, is that additional research needs to be conducted in order to discern precise reasons for the popularity of some CAM therapies over others in the older adult population.  Perhaps some reasons include the broader availability of some therapies over others, differences in cost, health insurance coverage, perceived variations in helpfulness, differences in the awareness of available CAM therapies, or internalized value judgments about specific CAM therapies.  Additional research is needed to discern whether these reasons, or others, bolster the popularity of some CAM therapies over others in this specific population.

Such research would support theories of CAM use by older adults that have already been suggested in the literature.  For example, a number of sources report a variety of reasons why older adults turn to CAM.  These include recommendations from health care providers, recommendations from friends, family, or coworkers, displeasure with conventional care approaches and the cost of conventional medicine. Other reasons include desire for general health improvement, need for pain management, desire for increased health autonomy, fear of side-effects from conventional medicine and desire for a more holistic approach to well-being (Astin et al., 2000; Bomar, 2013; Tait et al., 2013).  Thus, the results of this study support some previously reached conclusions while also giving emphasis to the need to further research the validity of proposed theories regarding the intersection of older adults’ use of CAM.

The implications of this research on potential changes in practice are modest.  In part, this is due to the nature of the study, which was not designed to elicit causal relationships.  However, given the large sample used in this study, the growing relevance of CAM therapies in the United States, and a changing perspective toward CAM therapies in the approaching older adult population (AHA, 2007; Cerino, 2005; Sioux, 2011; Varteresian et al., 2013), some suggestions can be made.  For example, although it is now common for therapists or other health care practitioners treating older adults to ask about CAM use to avoid negative treatment interactions and to produce a clear picture of overall care, professionals working with older adults with prior depression would have an additional reason for making such an inquiry.  Namely, knowing which CAM therapies depressed older adults find most helpful may be of use to practitioners who are less well-acquainted with CAM therapies in general.  Health care professionals who exhibit some expectancy that depressed older adults may be using CAM therapies may increase the likelihood within the clinical setting of CAM use disclosure, which has been difficult to determine (Eisenberg et al., 1998; Nemer & McCaffrey, 2010; Willison et al., 2007).

Further, clinicians can use the results of this study to inform their own research into the most common and helpful CAM therapies for their depressed patients.  This would have the dual benefit of familiarizing the health professionals with CAM therapies that might otherwise be considered inconsequential and also providing a research-based understanding of which sound integrative health care recommendations could be made.

Finally, should an older adult with depression ask for a recommendation of a CAM therapy, health care providers would be able to give a list of those therapies that other depressed older adults most commonly use as well as which therapies they find most helpful.  Even if the CAM therapies in question do not exert the kind of strong effects hoped for by either the practitioner or the patient, this would still represent an advance in practitioner-patient dialogue about the topic of CAM use.

As a result of this correlational study, several recommendations for further research can be made.  Studies could shed light on more precise relationships between each of the CAM therapies that depressed older adults use and find helpful and said therapies’ effectiveness.  Randomized, controlled, double-blind studies of distinct CAM therapies used for preventing recurrence of depressive symptoms or for treating depression in older adults have been conducted.  However, sample sizes tend to be small and such studies typically suffer from weaknesses in research design.  Correcting these limitations would constitute meaningful research.  Conducting a comparison analysis of the results of similarly scientifically strong studies could help determine the relative utility of some CAM therapies over others in relationship to older adult depression.

Additionally, a qualitative study regarding the reasons why depressed older adults self-select certain CAM therapies over others could yield important insights.  Such a study may reveal whether there are some CAM therapies that have correlating stigmas attached to them, discouraging their use and whether cultural familiarity with distinct CAM therapies increases the use of some therapies over others. The degree to which marketing campaigns influence CAM therapy selection and use may be a factor as well.  These findings would solidify a growing understanding of the complex relationship between CAM therapies and older adults’ health and wellness behaviors.

References

 

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Barnes, P. M., Bloom, B., & Nahin, R. L. (2008). Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Reports, 12, 1-24.

Barnes, P. M., Powell-Griner, E., McFann, K., & Nahin, R. L. (2004). Complementary and alternative medicine use among adults: United States, 2002 (Advance Data: From Vital and Health Statistics No. 343). Retrieved from National Center for Health Statistics website: http://www.cdc.gov/nchs/data/ad/ad343.pdf

Bishop, F. L., & Lewith, G. T. (2008). Who uses CAM? A narrative review of demographic characteristics and health factors associated with CAM use. eCAM, 7(1), 11-28.

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Ivanova, J. I., Bienfait-Beuzon, C., Birnbaum, H. G., Connolly, C., Emani, S., & Sheehy, M. (2011). Physicians’ decisions to prescribe antidepressant therapy in older patients with depression in a US managed care plan. Drugs & Aging, 28(1), 51-62.

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Keaton, D., Lamkin, N., Cassidy, K. A., Meyer, W. J., Ignacio, R. V., Aulakh, L., . . . Sajatovic, M. (2009). Utilization of herbal and nutritional compounds among older adults with bipolar disorder and with major depression. International Journal of Geriatric Psychiatry, 24, 1087-1093.

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Lakey, S. L., LaCroix, A. Z., Gray, S. L., Borson, S., Williams, C. D., Calhoun, D., & … Woods, N. F. (2012). Antidepressant use, depressive symptoms, and incident frailty in women aged 65 and older from the Women’s Health Initiative Observational Study. Journal of The American Geriatrics Society, 60(5), 854-861. doi:10.1111/j.1532-5415.2012.03940.x

Lavretsky, H. (2009). Complementary and alternative medicine use for treatment and prevention of late-life mood and cognitive disorders. Aging Health, 5(1), 61-78.

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Meeks, T. W., & Jeste, D. V. (2007). Complementary and alternative medicine (CAM) use in geriatric psychiatry clinics. The Journal of Alternative and Complementary Medicine, 13(7), 705-707. doi:10.1089/acm.2006.6419

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Qureshi, N. A., & Al-Bedah, A. M. (2013). Mood disorders and complementary and alternative medicine: A literature review. Neuropsychiatric Disease and Treatment, 9, 639-658.

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Rojas-Fernandez, C., & Mikhail, M. (2012). Contemporary concepts in the pharmacotherapy of depression in older people. Canadian Pharmacists Journal, 145(3), 128-135.e2.

Sioux, T. (2011, December). Boomers increasingly embracing alternative medicine. Northern Colorado Business Report, 15-16.

Tait, E. M., Ladtika, J. N., Laditka, S. B., Nies, M. A., Racine, E. F., & Tsulukidze, M. M. (2013). Reasons why older Americans use complementary and alternative medicine: Costly or ineffective conventional medicine and recommendations from health care providers, family, and friends. Educational Gerontology, 39, 684-700.
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Upchurch, D. M., Chyu, L., Greendale, G. A., Utts, J., Bair, Y. A., Zhang, G., & Gold, E. B. (2007). Complementary and alternative medicine use among American women: Findings from the National Health Interview Survey, 2002. Journal of Women’s Health, 16(1), 102-113.

Varteresian, T. C., Merrill, D. A., & Lavretsky, H. (2013). The use of natural products and supplements in late-life mood and cognitive disorders. FOCUS, 11(1), 15-21.

Wancata, J. J., Alexandrowicz, R. R., Marquart, B. B., Weiss, M. M., & Friedrich, F. F. (2006). The criterion validity of the Geriatric Depression Scale: A systematic review. Acta Psychiatrica Scandinavica, 114(6), 398-410.

Willison, K. D., Williams, P., & Andrews, G. J. (2007). Enhancing chronic disease management: A review of key issues and strategies. Complementary Therapies in Clinical Practice, 13, 232-239.

 

 Biography

Dr. Ryan Harrison, Psy.D., DAAIM, CWP, is the Director of Resident Life & Wellness at Hillcrest, a continuing care retirement community in Southern California.  After having practiced privately as a board certified health and wellness consultant for over ten years, Ryan completed his doctorate in Health & Wellness Psychology at the University of the Rockies, where he focused his research on the intersection of older adult health and well-being and Complementary and Alternative Medicine.  He currently leads a team of dedicated staff to optimize older adult health, fitness and wellness.

 


Who Has Helped Shape Your Therapeutic Style?

Who Has Helped Shape Your Therapeutic Style? 

By Erica Goodstone, Ph.D., LMHC, LMFT

A recent article in Counseling Today, an official publication of the American Counseling Association, began with the question:  “Who are the major influencers on today’s counseling professionals?”  I was fascinated by the variety of responses and the array of different professionals mentioned. Contemporary mentors were cited as well as influencers from much earlier times; these included both professional counselors and other thought leaders outside of counseling professions.  What struck me was the realization that each of us has taken our own unique path to becoming a qualified professional.  Each of us has learned different modalities and implemented the techniques in our own unique ways.  Each of us has been trained and mentored by different people.  And each of us has learned so much of what we know from people and situations outside of counseling or health professions.

When I think of who has influenced me, I begin with my junior high school English teacher who made me love the subject with her way of teaching through stories and drama and my college art teacher who took an assembly-ize audience into the heart and meaning of art history and artistic creation.  Then there was my dissertation advisor whose training in ego psychology led me to study and write about the long-term effects of mother-infant bonding upon adult love relationships.  In addition, there were all those consciousness-raising workshops I had taken in the 1970’s and 80’s and my spiritual awareness practices in yoga, meditation, and many different religious perspectives.  My own body aches from sports injuries as a fledgling professor of health and physical education, led me to receive and study many different body therapy methods, eventually learning the unique combination of talk with touch.  And my fascination with love, relationships and sexuality led me to undertake training with William Masters and Virginia Johnson in sex therapy. Finally, there were countless dedicated and skilled psychologists, social workers, counselors, coaches, psychiatrists and others who provided cutting edge training in the many different areas and aspects of counseling.

What influences a counselor or a healthcare practitioner to become skilled at their craft?  I believe there is no shortcut, no simple formula type training.  Psychotherapy and healthcare are both scientific and artistic endeavors.  We need specific knowledge and training in our niche areas of specialization.  We also need to do the inner work, to learn about the workings of our own mind, body and spirit.  And we need to practice, work with clients, continue our education to hone our skills, and integrate the many different types of learning into a cohesive approach to working with our clients.

Who and what has influenced you and shaped the way you work with your clients?
Please take a moment to think about this and share your thoughts with us.  Please feel free to email me your questions, comments, subjects you want to see covered, and topics which you, as an expert, would like to share here:  DrErica@DrEricaWellness.com.

If you are ready to collaborate and share on social media, join the Marketing Our Practices Facebook group at: https://Facebook.com/groups/MarketingOurPractices.

I look forward to working together with you to strengthen our professions in the coming months.

Warmly,

Erica Goodstone, Ph.D., LMHC, LMFT, LPC


Unexpected Surprises & Salt

Unexpected Surprises & Salt

By Tammera Karr, PhD, DAAIM, BCIH, BCHN, CGP, CNC, CNW, CNH

Originally published August 11th, 2014 in Minerals & Vitamins, Eat for Health, Bon Appetit – Just Plain Good Food.

My life does not transport me into the metropolitan world much, however, every once in a while I journey to the hustle and bustle of the city. I was recently in Portland, Oregon, my state’s largest metropolitan area, and for a change I had time to explore. A large gap in my commitment schedule for the day allowed for an unexpected surprise.

I was walking along Mississippi Street, exploring small, artisan specialty shops and restaurants when I spied “The Meadow” (www.themeadow.net) where under the sign it read—Salt – Chocolate – Drink – Flowers — and my mouth begins to salivate whenever I think, read, write or talk about salt. I have craved salt for as long as I can remember and have gone to great lengths as a ranch kid to get my salt fix. I remember hot summer days sitting in an apple tree with a salt shaker in hand, eating green apples, tasting warm rhubarb stalks and eating carrots dipped in salt. So of course, across the street I went, to see if I had found my dream shop.

As I approached, the neatly arranged flowers, planter boxes with herbs and displays in the window caused a tickle of anticipation. As I stepped through the doors, I looked around hurriedly for a napkin because I was quickly turning into Pavlov’s dog. A vast variety of commercial salts greeted me, as well as a mountain of Himalayan salt cooking blocks of every imaginable size, and 12 foot floor to ceiling walls loaded with perfect glass jars of salt from around the world. Oh, and there were other non-important stuff like flowers, chocolate and wine too.

Mark Bitterman and his family have created a wonderful shop on this once industrial street of Portland. Mark is the author of Salted, A Manifesto on the World’s Most Essential Mineral, with Recipes. I am delighted to add this book to my collection and it is a must-own for holistic nutritionists, foodies, chefs, and thyroid & adrenal fatigue clients who know life simply doesn’t work correctly without salt.

In the Pacific Northwest, we have an ever-growing “Food” movement. This movement may have started with coffee and microbrews, but man cannot live on these beverages alone and they taste soooo much better when paired with the right foods and yes, that includes salt!

Salt has the unique ability to connect the world like no other mineral, ingredient or food. Men, like animals, have a need for salt to survive. It creates energy for the heart to beat correctly and for the brain, thyroid, liver and stomach to function properly. But the salt we think of is far from what was consumed around the world – Morton and the industrialized salt manufacturing of the USA is a far cry from the salt mines in Asia, Europe, and Brittany, France.

Throughout Europe, small communities know the name of the individual or family who raised the beef, potatoes, vegetables, bread, wine, cheese and salt they are eating. They have a connection, they have a community, family and shared cultural history. With this, comes the return of local or artisan salt. Natural salt is available in a huge array of colors, flavors and crystal characteristics. Some are perfectly suited for confectionery masterpieces like Fleur de Sel Caramels. These salted caramels originated in Brittany, France, due to the availability of the artisan-made salts in the region.

In the United States, we generally have three varieties of salt, much of which are the same way. Mark Bitterman so aptly states in his book; “Some things do not belong in our food supply. Industrial salts like cheap sea salt, kosher salt, and table salt are products that few people want in their kitchens if they understand and face up to how they are made.”

Perhaps our decline in home cooking and our dependence on commercial foods has corrupted our sense of taste. While I am no expert, I know I can clearly taste the differences in salts and I do appreciate the value of real salt for our health. If we are enjoying the fresh abundance of produce from community supported agriculture and farmers markets, we already understand how much better local, fresh foods taste over limp, lifeless store versions. So why wouldn’t we want to use natural salts to make those flavors pop and zing even more?

I’m off to buy a salt block to try some of grilled steak recipes out …. now we are talking summer!

To Your Good Health, Real Foods.

 


Bio for Dr Shawn K Centers

Bio for Dr Shawn K Centers

Dr Shawn K Centers, DO, MH, FACOP, is the Medical Director of the Osteopathic Center for Children and is a Board Certified Pediatrician, specializing in Integrative Medicine and Osteopathic Pediatrics. Dr Centers is an internationally known expert in Osteopathic Pediatrics, nutrition, and herbal medicines as they apply to children. He was a student of the world famous Dr Viola Frymann, who developed cranial osteopathic treatment for children. Dr Frymann was a direct student of Dr William G. Sutherland, DO, the founder of Cranial Osteopathy. Dr Centers studied under Dr Frymann for over 25 years and has worked personally with Dr Frymann for the last 15 years.

Dr Centers is the founding President of The American Academy of Pediatric Osteopathy, A Component Society of the American Academy of Osteopathy (AAO). The AAO is the recognized authority on Osteopathic Manipulative Medicine to the federal government. Dr Centers is a Fellow of the American College of Osteopathic Pediatricians. He has been named a “Top Pediatrician” in San Diego County, California, by the International Association of Pediatricians, (IAP). He is a Distinguished Fellow of the American Pediatrics Council and a Lifetime member of the American Council of Pediatrics Specialists. He is a Master Herbalist and a founding Diplomate of the American Board of Holistic and Integrative Medicine, (ABHIM).

Dr Centers trained in pediatrics and served as a Pediatric Chief Resident at the Children’s Hospital of New Jersey, one of the largest children’s hospitals in the nation; Dr Centers was Board Certified in Pediatrics in 2000. During his residency, he continued his studies in Advanced Osteopathic Principles and was very active in developing and integrating Osteopathic Principles into the educational program for residents and medical students. In medical school, he was one of only four students from a class of 150 to be chosen as a Clinical and Teaching Fellow in Osteopathic Medicine. As a Clinical Fellow, Dr Centers gained extensive experience in the unique practice of Osteopathic Medicine, research methods, and had the opportunity to study and learn from the foremost practitioners in the field including Dr Frymann, Dr Becker, Dr Larry Jones, Dr Thomas Schooley, Dr Robert Fulford, and others.

Dr Centers’ credentials include a Certificate of Competency in Cranial Osteopathy from the Cranial Academy in 2003. He is Board Certified in Integrative Medicine, BCIM®, and a Diplomate of the College of Mind Body Medicine of the American Association of Integrative Medicine®. He is a member of the Americana Academy of Pediatric Osteopathy, the American College of Osteopathic Pediatricians, American Association of Integrative Medicine®, the American Academy of Osteopathy, The Cranial Academy, the American Herbalists Guild, and the International Association of Neurolinguistic Programming. In additional to his training in Conventional Medicine, Dr Centers is trained in Biomedical, Nutrition and Botanical Medicine. Dr Centers has exceptional skill and knowledge in applying osteopathic approaches, herbal medicine, and treatments that address the whole child and in developing a comprehensive health care plan. His pediatric practice encompasses both sick and well visits. He also performs routine physical exams, sports, and osteopathic exams for newborns, children and teenagers.

Dr Centers is most noted for his development of innovative osteopathic and integrative medical techniques in children with complex medical problems, especially children with Autism. He studied Herbal Medicine under John R Christopher of Springville, Utah. Dr Centers is additionally known for his mind-body approaches in the treatment of children. He has extensively studied the techniques of John Grinder, Richard Bandler, and Thad Everet James. Dr Centers utilizes the Time Line Therapy techniques developed by Tad James, PhD in many of his treatment approaches. Dr Centers is a Master Trainer of Neurolinguistic Programming and Time Therapy and was certified by Tad James.

He is the Chief Executive Officer of the Frymann Institute and maintains an integrative medicine and full-time pediatric practice at the Osteopathic Center for Children in San Diego, California. He is also the founding President of the American Academy of Pediatric Osteopathy, a component society of the American Academy of Osteopathy. Dr Centers is a Clinical Professor of Pediatrics and Osteopathic Medicine at a number of osteopathic medical schools in this country and abroad including Touro University, AT Still University and the Osteopathic College of Bologna, Italy (CIO).

Dr Centers has extensive experience with treating children who have rare, difficult to treat, developmental and neurological disorders including children with Epilepsy, Cerebral Palsy, learning disorders, Attention Deficit Disorder, Asthma, allergies, Autism, Traumatic Brain Injury, and rare diseases. Dr Centers has received international and national recognition for his work with autistic and Autistic Spectrum Disorder children. His use of Cranial Osteopathy combined with the use of therapeutic grade essential oils, diet and nutrition, and the therapeutic use of sound and light have greatly advanced the care of many children with autism. Dr Centers worked closely with the late Dr Bernard Rimland from the Autism Research Institute in San Diego and has been a featured speaker at the National Autism Conference. Dr Centers was one of the first physicians to be trained in the Defeat Autism Now Protocol and has been a Defeat Autism Now Doctor for over 15 years. Because of Dr Centers work with autistic children, the Osteopathic Center for Children was the recipient of a Las Patronas Grant which was used to purchase Vibroacoustitic Sound Therapy equipment representing the latest innovation in Neuroscience and Psychoacoustic Technology. This equipment which consists of a custom made treatment table and a specially designed chair allows the practitioner to send special tones and frequencies to pre-designated areas of the mind and body – as the child lays on the table or sits in the chair they actually feel sound, tones, and vibrations in their body creating profound states of comfort and relaxation. The sounds, music, and tones are specially designed to reach and heal injured areas of brain and body as well as enhance the deep osteopathic work done by Dr Centers.

In addition to his clinical work, Dr Centers is a sought after lecturer and teacher. He teaches regularly at medical schools, national specialty meetings and continuing education courses in both the United States and abroad. He has been a featured lecturer for the American Osteopathic Association, the American College of Pediatricians, the Western States Osteopathic Association, The AutismOne Conference, The National Autism Conference, The American Holistic Medical Association, Touro University, University of California, San Diego, San Diego State University, University of Minnesota, and others.

Dr Centers was the lead author of the Pediatrics of the Foundations Of Osteopathic Medicine which was published by the American Osteopathic Association and is a required text used in all 32 Colleges of Osteopathic Medicine and in over three hundred schools worldwide. Dr Centers wrote key chapters in Cutting-Edge Therapies for Autism, Updated Edition which was endorsed by the National Autism Association.


Is Emotional Maturity Required for Success?

Is Emotional Maturity Required for Success?

By Erica Goodstone, Ph.D., LMHC

With political debates, caucuses and name -calling campaigns in full swing, it seems as though emotional maturity is not only unnecessary for success, but a negative attribute.  Those candidates who quietly withstood attacks and refused to retaliate have lost their standing and several have already dropped out of the race.

What does this mean for mental health professionals, addiction specialists, holistic practitioners and spiritually focused therapists?  Are we advocating a model of mental health that does not serve us well in this society?  Do we advocate for a morally appropriate type of mental health that may actually put our loyal clients at a competitive disadvantage out in the real world?

The “Criteria of Emotional Maturity” were developed by William C. Menninger, MD (1899-1966), cofounder of Menninger © 1966. These criteria are as follows:

• The ability to deal constructively with reality
• The capacity to adapt to change
• A relative freedom from symptoms that are produced by tensions and anxieties
• The capacity to find more satisfaction in giving than receiving
• The capacity to relate to other people in a consistent manner with mutual satisfaction and helpfulness
• The capacity to sublimate, to direct one’s instinctive hostile energy into creative and constructive outlets
• The capacity to love

Has the world changed so drastically that these criteria no longer serve our clients’ best interests?  If what I am suggesting here is true, what would be an effective solution to help our clients navigate through the current competitive, oppositional and confusing world in which we live?

The first two qualities listed above seem to provide the solution.  We need to discover constructive ways to cope with reality as it is, not how we are told it should be nor how we want it to be.  Additionally, we must learn to adapt to changes since these are an inevitable part of reality. In fact, change is one of the few things in life that we can truly count on.

In some cases, children who have been neglected, abused, suppressed or abandoned may have developed greater resources for coping with a changing world than those who have been loved and protected, pampered and supported.  If a child always views the world as loving and supportive, how does that person cope with bullies and abusers, people who view loving behaviors as weak and spineless?

One quality that seems to be missing from this list is the ability to stand up for what you believe is right and having the courage to take on your adversaries. The ability to fight back with the strength of your convictions is a powerful and positive characteristic. Another missing quality is the ability to align and influence others, to be a bridge between ideas, attitudes, projects and actions.

Anyone who is able to stand up for what they believe in and influence others for the larger and more inclusive benefit of all, will naturally gravitate toward having the other qualities as well.  When you stand up for yourself and others you will naturally have fewer stress-related ailments, be happier to give than to receive, more easily create mutual satisfaction in your relationships, be able to express your creative energy with less need for hostility and your life will be a triumph of love.

Take a moment to evaluate your own criteria for mental health and make sure you include standing up for yourself as well as developing the capacity to guide and influence others for the greater benefit of all concerned.

Please feel free to send me your questions, comments, subjects you want to see covered and topics which you, as an expert, would like to share here.  If you are ready to collaborate and share on social media, join the Marketing Our Practices Facebook group https://Facebook.com/groups/MarketingOurPractices

I look forward to working together with you to strengthen our professions in the coming months.

Erica Goodstone, Ph.D., LMHC, LMFT, LPC

 


Integrative Treatment Pilot Study: An Extended Care Holistic Treatment Facility for Women with Co-occurring Disorders

Integrative Treatment Pilot Study:
An Extended Care Holistic Treatment Facility for Women with Co-occurring Disorders

Tricia Chandler, PhD, LPC, BCPC
Consulting Clinical Director and Researcher

Key Words: Integrated care, co-occurring disorders, addiction, mental illness, complementary therapies

Learning Objectives

1. Discuss the differences in needs of women from men in treating addiction issues and underlying co-occurring disorders.

2. Describe integrative treatment modalities.

3. Explain the role and significance of personal relationships in women’s lives.

4. Compare the relevance and presence of various caregiver roles that women assume throughout their lives.

5. Discuss the unique medical issues facing women with co-occurring disorders.

6. Explain positive psychology and the movement toward wellness and its implications for treatment modalities.

7. Describe therapeutic modalities that have demonstrated efficacy in treating mood disorders and addiction issues.

Abstract

A longitudinal pilot study conducted in 2011/2012 researched the efficacy of an integrated protocol that provided treatment to women with co-occurring disorders in an extended-care group home environment. Eight women who had been referred from in-patient thirty-day substance abuse facilities participated in the study while receiving holistic care that included: recovery groups, somatic experiencing, dialectic behavioral therapy, individual psychotherapy, mindfulness groups, yoga, acupuncture, Reiki, massage, art therapy, vocational assistance, nutrition and exercise, along with daily AA/NA meetings. Assessment measurements included the Beck Depression Inventory, Purpose in Life Questionnaire, URICA inventory on stages of change, and an Anxiety Scale. These were administered at intake, discharge, three-months after discharge and at the twelve-month interval to examine long-term efficacy of the model. Results demonstrated positive change from baseline to discharge. Gains were maintained at the three-month interview and continued to show improvement at the twelve-month interview for those women that participated.

Historical Context for Protocol

Over the past twenty years research has begun examining the differences in regards to how and why men and women develop addictions. This research has concluded that women have special needs within substance abuse treatment. This research has produced a great deal of information into the differences in physiology, interpersonal issues and risk factors relating to women with these issues (Becker, 2011; Gudrais, 2011; Kauffman et al, 1997). The Substance Abuse and Mental Health Services Administration (SAMHSA, 2011) has noted specific “risk factors associated with substance abuse” in women include:

• Sensation-seeking
• Anxiety
• Depression
• Eating disorders
• Posttraumatic stress

Further research suggests these additional risks are due to histories of trauma and childhood sexual abuse, as well as interpersonal abuse and socioeconomic issues all relating to the issues of regulating affect (Bloom and Covington, 1998; Chandler, 2010; Manhal-Baugus, 1998; Najavits, 2002; Nelson-Zlupko et al, 1995; US Dept of Health and Human Services, 2000, 2003; SAMHSA, 2011).

Two different research studies by Engstom et al (2002/2008) at the University of Chicago Center for Health and Social Sciences, found that in over 400 women being treated for opiate addiction in a methadone clinic, 58% had experienced childhood sexual abuse, 90% had experienced intimate partner violence and 29% met the criteria for posttraumatic stress disorder. Similar findings have been substantiated by Robert Jamison (2011), a clinical psychologist at Harvard Brigham and Women’s Hospital, who discovered correlations between women who abuse pain medications having sexual and/or physical abuse histories, as well as psychological distress as motivating factors for their drug misuse. These findings further substantiate the complicated relationship between trauma and substance abuse for women that were included in the research conducted by this writer in relation to determining resiliency in women with childhood sexual abuse histories (Chandler, 2010).

Based upon years of research into the special needs females in substance abuse treatment, SAMHSA has identified core principles for gender responsive treatment. These core principles include:

• Recognizing the role and significance of personal relationships in women’s lives
• Addressing the unique health concerns of women
• Acknowledging the role and importance of different socioeconomic issues among women
• Promoting cultural competency that is specific to women
• Endorsing a developmental perspective
• Attending to the relevance and presence of various caregiver roles that women assume throughout their lives (SAMHSA, 2011/PIT 51)

Although the reasons behind substance abuse have been acknowledged as being different for women than for men (Kauffman et al, 1997), treatment protocols have been slow to acknowledge this difference and to change in accordance with the need for integrative treatment protocols specific to women’s needs. Traditionally substance abuse treatment has offered a specialized treatment protocol that has been provided for both women and men in the same facility.

While primary residential facilities state that women and men are treated separately, in actuality most of these facilities intermingle groups, resulting in findings that women have greater risk for relapse after completing treatment in these environments (Gudrais, 2011). And, although men and women are housed in different wings of the same facility although they have access to one another in group interactions and within a social context.

The normal length of stay to address the substance abuse issue for both genders is usually thirty days. Primary treatment has traditionally included cognitive therapy and recovery based protocols with a strong element of 12-step indoctrination aimed solely at the substance abuse issue, while deferring additional issues that the individual may have.

Programs that do attempt to incorporate an integrative approach are extremely expensive and are not accessible to individuals without significant financial resources. Funding grants from SAMHSA for substance abuse treatment is less than it was seven years ago, when considering inflation, per Harold Pollack, faculty chair at the Center for Health Administrative Studies. This adds to the difficulty in accessing appropriate substance abuse treatment (SAMHSA, 2011).

While the need for gender specific treatment has been identified, few protocols have been identified to treat the whole person relating to the issues that women have in substance abuse treatment. One 12-week pilot study of substance abuse treatment done by Shelly Greenfield, in connection with Harvard Medical School, found that women’s self-efficacy improved with a combined woman-centered approach and group dynamics in treatment (Gudrais, 2011). This writer’s research in what methods assist in reclaiming resiliency in women with childhood sexual abuse histories uncovered a variety of modalities that work to treat all issues simultaneously and this became the basis of a truly integrative approach to healing. This preliminary research provided the data used in a structured protocol that was utilized within a longitudinal pilot study for an extended care residential facility for women with co-occurring disorders in 2011.

Pilot Study: Extended Care Program

Client Demographics

Over the course of seven months, eight women with co-occurring disorders of substance abuse and psychological disorders moved through a suggested ninety-day treatment facility that provided holistic integrative treatment modalities designed to treat the whole woman. Each of these women had been referred for extended treatment from a primary residential facility after completing a thirty-day program to regain sobriety.

Demographics concluded that all of these women were Caucasian from middle to upper-middle class socioeconomic status. The average age of the women was 39 years, with a range from 21 to 58 years of age. Most of the women had college educations, although only two of the women had careers that were not adversely affected by their co-occurring disorders. All of the women had some family support, but it was tenuous at best.

Each of the women had been treated for a variety of substance addictions that included alcohol, opioids, methamphetamine, and in a few women, poly-substance abuse. In addition, each of the women had co-occurring diagnoses of major depression and anxiety, and three of the women had an eating disorder diagnosis. Physical problems included chronic pain, fibromyalgia, reoccurring benign tumors, and one woman was aware she carried the gene for a life-threatening genetic disorder.

Additional, all of the women had severe interpersonal problems, six of them had experienced trauma in the form of physical, emotional, spousal or sexual abuse, and all of them were facing legal issues related to substance abuse. When admitted, four of the women were dealing with marriage issues and the potential loss of their custodial rights to their children.

The treatment protocol included a thorough assessment, including having the women complete a psych-social-medical history at intake. The Beck Depression Scale, the Purpose in Life Inventory, the URICA Inventory on stages of change, and an Anxiety Scale were completed at intake, discharge, and after discharge at three months and twelve months. The assessments led to the development of individualized treatment plans based upon clients’ specific issues.

Treatment Milieu

The women lived in a house within a middle-class community and were provided some form of round-the-clock supervision and holistic services that addressed all areas of functioning. The house was run like a home, with the women specifying their food preferences, planning menus, and helping with shopping. They were responsible for cooking as a community and for maintaining the cleanliness of the house. Once per week a professional chef came and the women helped him prepare a family meal with their children and spouses, or other family members who were welcome to share in the meal. Sundays were allocated for family visits and the women could go off site for those visits. Family and couple counseling was provided during the week and community outings occurred on Friday nights.

Clinical Services

Clinical and healing services included:

• Three 60-minute individual sessions per week
• Three 90-minute recovery groups that included: Somatic Experiencing, Dialectic Behavioral Therapy, and Addiction Recovery themes
• Three to five 90-minute psychotherapy groups on mindfulness, guided visualization, identifying and developing personal spiritual values and practices, positive cognitive therapy, vocational/educational planning, and budgeting skills
• Two 90-minute acupuncture sessions that included National Acupuncture Detoxification Association (NADA) protocols, Emotional Freedom Therapy (EFT) and/or Psy K
• Two 120-minute expressive art therapy sessions
• One 60-minute massage (and/or Reiki) weekly
• An initial nutritional assessment and follow up as needed.
• One 90-minute yoga session weekly
• Daily AA/NA meetings

In addition, a gym membership was made available to the clients that included yoga, a pool, weights and a climbing wall. As women progressed through the program, if they had careers or jobs, they were allowed to pursue those vocations and eliminate some parts of the program. If they needed vocational counseling or resumes updated they were assisted with those endeavors and/or volunteering at some community projects was made available one to two times per week. Transportation was provided until they had moved into the status of using their own forms of transportation.

Rationale for the Modalities of Treatment

Protocols were based upon a holistic or transpersonal model of care with the idea that treating the whole person simultaneously is the most efficient and efficacious way to help people heal from the multiple problems that lead to substance abuse. Positive psychology has developed a ‘wellness’ philosophy over the past few decades that build upon clients’ strengths as opposed to just focusing on pathology (Seligman, Stein, Parks, & Peterson, 2005).

Research in regards to which attributes support having good life outcomes for people who have experienced serious adversity in life, strongly endorses resilience as a key factor (Bogar & Hulse-Killacky, 2006; Valentine & Feinauer, 1993; Chandler, 2010). Resilience has been associated with stable characteristics such as wellbeing, optimism, faith, wisdom, creativity, self-control, morality, gratitude, forgiveness, and hope (Liem et al, 1997; Werner & Smith, 2001). Thus the treatment modalities used in the pilot study were meant to provide clients with positive psychotherapy and recovery modalities, mindfulness training within both a cognitive and spiritual framework, outlets for creativity, somatic therapies to help with balancing and integrating both hemispheres of the brain, energetic healing modalities to assist with activating the client’s own immune systems, and practical skills to develop self-control, self-efficacy, and to build self-esteem.

Literature Review

Cognitive Based Mindfulness Therapies

Mindfulness-based cognitive approaches are a departure from traditional, cognitive-behavioral treatment. Cognitive-behavioral therapy includes a clear goal of changing negative behaviors and irrational thinking patterns, while mindfulness practice suggests that clients observe their thoughts as impermanent and refrain from judging them. Mindfulness-based stress reduction, and dialectical behavior therapy (DBT) have shown promise as therapies that support women with trauma histories and co-occurring disorders to focus on strategies that support improved health.

Dialectical behavior therapy (DBT) is one example of a cognitive approach that embraces humanistic principles toward personal growth (Baer, 2003; Hayes & Shenk, 2004). DBT is a multifaceted approach that was initially conceptualized as a treatment for individuals diagnosed with borderline personality disorder but has been expanded to use with addictive behaviors (Baer, 2003; Hayes, et al., 2004). Clients in the study learned mindfulness practices including nonjudgmental observation of thoughts, emotions, sensations, environmental stimuli, acceptance of personal histories and current situations while working to change behaviors and environments that support building better lives.

Mindfulness-based stress reduction has demonstrated its effectiveness for treating anxiety and panic (Kabat-Zinn et al., 1992; Miller et al., 1995). A meta-analysis of 20 empirical studies suggested that mindfulness-based stress reduction help individuals cope with depression, anxiety, pain, cancer, and heart disease (Grossman et al., 2004). By integrating cognitive behavioral approaches with humanistic, transpersonal theories, and mindfulness practices, creative healing strategies are promoting wellness.

These treatment modalities show promise as therapies that support women with trauma histories by helping them to integrate their past abuse experiences with their current substance abuse issues and encouraging them to focus on strategies that support improved health.

Consciousness and Developing Spiritual Practices

Consciousness has been linked with awareness, attention, and memory (Farthing, 1992) and has been highly correlated with resiliency (Liem et al., 1997; Werner & Smith, 2001). Jungian theory suggests that the unconscious mind retains information not readily available to the ego. While the personal unconscious holds repressed memories, the collective unconscious contains dreams, visions, religious experiences, and the myths of all cultures throughout the ages.

Murphy (1963) wrote that the unconscious mind possesses infinite wisdom that is available to the conscious mind when it is open and receptive. Thus human consciousness can be viewed from a multidimensional perspective that includes both a psychological and a spiritual context (Chandler, 2010). While we have access to our everyday consciousness to assist us in dealing with daily activities, we can be adversely impacted by what lies in the repository of our personal unconsciousness, of which we may be totally unaware (Chandler, 2010). Traumatic events narrow the focus of consciousness, and “the mind at large has to be funneled through the reducing valve of the brain and nervous system” (Huxley, 1954, p. 23). Meditation and other mindfulness techniques have been shown to lessen the hypervigilance, restlessness, anxiety, and fear associated with severe trauma (Miller, 1993).

In researching what practices and therapies helped abused women regain resiliency, personal spiritual practices were endorsed as providing meaning, hope, increased self-esteem and a sense of belonging (Chandler, 2010). Additionally, research is integrating spiritual practices with science such is seen with power of prayer (Bensen, 2006; Byrd, 1988; Krucoff & Crater, 2001) and other nonlocal healing techniques to assist in healing a variety of medical issues (Achterberg, et al., 2005; Chandler, 2010; Shealy, 1999; Shealy & Myss, 1988).

While organized religions have been found to be detrimental for certain trauma survivors (Chandler, 2010), the development of a spiritual practice can significantly aid in one’s search for meaning and purpose (Ryan, 1998), which echoes Frankl’s (1962) position that the way a person deals with suffering is a key to adding deeper meaning to life. Jaffe (1985) further asserted that adversity might become the cornerstone of a new identity, as a person discovers meaning in life’s struggles. It is, therefore, important for counselors to assess clients’ spiritual functioning and assist them in addressing spiritual concepts while searching for meaning in traumatic life experiences (Ganje-Fling & McCarthy, 1996).

Creativity and Expressive Arts

Sikes (2001) suggests that creativity plays a central role in the healing process. Creativity has been cited as one of the factors that assisted in the maintenance of resiliency (Seligman et al., 2005). Creativity embodies our natural impulse for change, without which stagnation would occur (Sikes, 2001). Throughout human history, people have used creativity to adapt and recover from stress, loss, trauma and pain. Seeking meaning (Frankl, 1962) is vital to the healing process, and humans have always found a structure in which to contain difficult experiences such as through rituals, ceremonies, storytelling, and songwriting (Sikes, 2001). Creating art has an established history of being a helpful adjunct therapy for working with psychological and physiological disorders, as well as for its cathartic properties (Chandler, 2010; Lusebrink, 1990/2004; McNiff, 1992).

Body Psychotherapy

Bessel van der Kolk, the medical director of the Trauma Center in Boston, found evidence that trauma affects the entire person and that treatment is most effective when it integrates psychotherapy with somatic, body-memory treatment such as EMDR, art therapy, and massage (Collinge et al., 2005, van der Kolk, 1994/1996). Van der Kolk’s findings concurred with Burgess, Watkinson, Elliot, MacDermott, and Epstein’s (2003) similar research.

Field (2000) demonstrated that massage benefits the musculoskeletal, circulatory, lymphatic, and nervous systems, and mental disorders associated with sexual abuse (Field, 2000). In studies of PTSD, depression, and anxiety, massage was shown to decrease symptoms and to improve mood and behavior.  A chronic fatigue study concluded that massage decreased depression, anxiety and pain, and improved immune function (Field, 2009).

Although research on the treatment of trauma with alternative medicine is limited, studies on the neurobiological findings of trauma support the need for an integration of both somatic and cognitive therapies to treat the layers of problems that affect victims with trauma histories and subsequent co-occurring disorders (Chandler, 2010).

Somatic experiencing, a mind/body modality developed initially by Peter Levine (1997), is a modality in the mental health field that goes beyond talk therapy. It teaches ways of recognizing, reducing, and discharging stressful energy from the nervous system. It helps the client understand exactly how the body is managing overwhelming, stressful, or traumatic events. In a gentle, yet powerful way, somatic experiencing helps people to let go of accumulated trauma in the body and allows the body to regain its innate ability to self-regulate and be resilient.

Three studies were found on the use of somatic experiencing method by social workers who had worked to help victims of both Hurricane Katrina and Rita. According to the authors of the study, the treatment group showed statistically significant gains in resiliency indicators and decreases in symptoms of PTSD. Although psychological symptoms had increased in both groups at the three to four month follow-up, the treatment group’s psychological symptoms were statistically lower than those of the comparison group (Leitch, Vanslyke, & Allen, 2009). The limbic center of the brain is where the pain and pleasure center is located that is affected by trauma and substance abuse and it appears to be another powerful technique for helping individuals with both disorders.

Acupuncture and Energy Medicine

The National Acupuncture Detoxification Association (NADA) was developed in the 1970s when it was discovered that a five-needle ear protocol was effective in reducing tremors, shakes, and both physical and mental agitation in heroin addicts while in detoxification units (Huff, 2007). Although the results of clinical studies have been mixed on demonstrated effectiveness for addiction treatment using the NADA protocol, more than 1,500 clinical sites around the world currently use these protocols.

The NADA protocols began to be used with traumatized populations in New York after the September 11, 2001 attacks. The group Acupuncturists Without Borders has been going to natural disaster sites since then to provide trauma relief using the NADA protocols (Huff, 2007). A pilot study by Hollifield, Sinclair-Lian, Warner, and Hammerschlag (2007) at the University of Louisville School of Medicine in Kentucky examined the effects of acupuncture on depression and anxiety in 73 individuals diagnosed with PTSD. During a 12-week period, participants were assigned to acupuncture, cognitive-behavioral, or wait-list groups. Both acupuncture and cognitive-behavioral groups had similarly improved symptoms that were superior to those of the wait-list control group and maintained the effects for three months after the end of treatment (Hollifield, Sinclair-Lian, Warner, and Hammerschlag, 2007).

Charles Engel, MD at the U.S. Army Walter Reed Medical Center, has been conducting an on-going randomized, wait list controlled trial from 2006 through 2008 to evaluate the efficacy of acupuncture for PTSD based upon the reported results on the study by Hollifield, Sinclair-Lian, Warner, and Hammerschlag (2007) stating that acupuncture improved wellbeing, stress, anxiety, sleep, digestion, and pain conditions, and that it held promise as a treatment option for PTSD.

Reiki, which means universal energy in Japanese, is a nonintrusive, hands-on and distance healing technique, which originated in Japan by Dr. Mikao Usui (1865-1926) at the beginning of the 20th century. Research on Reiki healing shows it to be effective in treating emotional trauma, releasing toxins, reducing side effects of drugs after surgery or chemotherapy, improving immune system function, increasing vitality, creating deep relaxation, and releasing stress and tension (Chandler, 2010).

Quantum physicists have acknowledged that the human body generates an electromagnetic field and that negative emotions that occur in response to trauma, influence the physical tissue in the body (Oschman, 2000; Smith, 1988, 1994; Tiller, 1997). Acceptance of Reiki in the medical world has been limited by a lack of empirical investigations, but professional nurses have recently led the way in exploring Reiki’s healing benefits (Oschman, 2000; Vitale, 2007).

Two Reiki studies of surgical patients showed less use of pain medications and quicker recovery with Reiki treatments (Alandydy & Alandydy, 1999; Motz, 1998). A study at St. Vincent’s Medical Center in New York demonstrated that Reiki lowered anxiety in 30 heart patients (Rand, 2009). Three cancer studies found Reiki to be useful for palliative care and pain management (Bullock, 1997; Burden, 2005; Olson & Hanson, 1997). The Department of Veterans Affairs uses Reiki in their Hepatitis C treatment program, and most recipients report a peaceful sense of relaxation and reduction in pain, anxiety, fear, and anger.

Further findings have suggested that Reiki fits easily within a harm-reduction model and can be used successfully as self-treatment by people with HIV, in conjunction with appropriate medical and/or psychiatric care (Miles & True, 2003). Reiki was found to be a helpful treatment modality for women with childhood sexual abuse histories in the Burgess Watkinson, Elliot, MacDermott, & Epstein (2003) study. Additional research into the efficacy of this treatment modality specific to treating women with co-occurring disorders is indicated.

Based upon the collective research being done to validate the efficacy of all these healing and mindfulness modalities with a variety of psychological, physiological, and substance abuse issues, they were all included in the extended care facility’s regimen. Each woman had an individualized treatment plan that included access to consistent use of treatment modalities that fell within the body-mind-spirit continuum to fully explore the core principles of integrated treatment as stated by the SAMHSA findings (SAMHSA/PIT 51).

Results of Longitudinal Research

While this was a small sampling of women with co-occurring disorders in an extended care facility, the results were encouraging that a holistic, integrated treatment model is an effective strategy. Using the self-administered Beck Depression Scale, an Anxiety Scale, the Purpose in Life Inventory, and the URICA Inventory of Stages of Change to quantify baseline, discharge, three months after discharge, and twelve months after discharge provides some statistical data to substantiate findings.

 

Beck Depression Scale – 20% is considered significantly depressed.

Baseline                       Discharge                    3-Months                     12-Months

AVG.    20.38                             8.38                              3.3                                .75

At intake the average depression rating for the women was 20.38%, which is considered significantly depressed. The average depression scaled diminished over the ninety-day stay to 8.38%, which indicates minimal if any clinical depression, and the average percentage continued to decrease among the women.

Anxiety Scale – Five-point scale with 5 being the worst.

Baseline          Discharge              3-Months                     12-Months

4.75                  2.63                             .5                                  >.25

All of the women indicated high anxiety upon intake, with the average point distribution being 4.75%. This scale related to how effective acupuncture was in addressing anxiety symptoms. After three months of weekly acupuncture sessions, the average anxiety scale for the women was 2.63% and anxiety levels continued to decrease after discharge from the program.

Purpose in Life Inventory – Below 90 = No Purpose; Over 112 = Definite Purpose

Baseline         Discharge                 3-Months                  12-Months

88.25                103                              114                               119

The Purpose in Life Inventory rates sense of purpose, which is tied to resiliency and hope for recovery. The survey’s instructions state that a score below 90% indicates the individual feels she/he has no purpose in life. At intake the baseline average of the women who participated in the treatment protocol was 88.25%. At discharge average scores were 103%, which is in the contemplation or more hopeful stage, and this score continued to increase on average to the women feeling they had renewed purpose in life.

URICA Inventory

Precontemplative                    Contemplative             Action             Maintenance

Baseline                                        Discharge               3-Months             12-Months

AVG. P/C                                           C/A                        A/M                          M

The URICA inventory suggests where the individual sees herself in relation to recovery from substance abuse. At intake the women were pre-contemplative or contemplative about their ability to recover from substance abuse/dependence. At discharge all of the women had developed action plans to maintain the sobriety they had developed through treatment. By the twelve-month follow up, those that were willing to be interviewed had maintained sobriety and were actively pursuing lifestyles that supported their continued sobriety.

The findings at baseline were that even after a thirty-day primary inpatient program the majority of the women were still depressed, extremely anxious, had a low score on purpose in life inventory, and ranged in the pre-contemplative to contemplative range on wanting to maintain recovery from substance abuse. All of the women came into the extended program with a sense of being overwhelmed with their lives and some sense of hopelessness that they could not improve the quality of their lives and build their self-esteem. The average length of stay for the eight women was 2.75 months. Only five of the original eight women could be reached at the twelve-month mark, but those that were contacted had maintained the gains made and, in some measures, continued to improve.

During the stay in the extended care house, three of the four married women resolved that divorce was inevitable and began that process. They felt empowered to take the necessary steps to provide for joint-custody of their children, and they were able to advocate appropriately for themselves with their ex-husbands. The one woman that remained married continued in outpatient therapy and marriage counseling, and determined after several months of both, that enough growth in the relationship had occurred to warrant staying in the marriage.

The women that had careers resumed those careers and were among the ones that responded at the twelve-month mark. Three of the women began to explore how to re-vitalize their careers and two of the women began to explore returning to college. The women who had struggled with dysmorphic body image issues and eating disorders were able to develop healthy eating strategies through proper nutrition, regular exercise programs, and somatic/mindfulness therapies such as yoga and meditation.

Of the group, the two women under 30-years-old had the hardest time committing and staying committed to their sobriety. They each committed to stepping down in treatment to sober living facilities and extensive outpatient programs to continue their therapeutic work. In addition, several of the women developed a real bond with one another and maintained that connection, even at the twelve-month mark.

Limitations

As a small pilot study, there were not sufficient participants for the results of the study to be considered quantifiably significant. In addition, the integrative techniques were offered collectively along with traditional therapeutic approaches, which do not expressly demonstrate how any of these therapies offered exclusively would or would not be beneficial in additional studies. Thus, from a scientific method perspective, validity or reliability cannot be established for retest possibility. The premise of this study was to provide a variety of holistic services in a clinical setting and to monitor the progress of clients from a longitudinal perspective to determine efficacy of the whole program to affect positive change in clients.

As a clinical treatment protocol, a major issue with this program was cost and the lack of insurance carriers that would pay for the program. Insurance carriers that were approached would not consider the whole program, and would only consider paying piecemeal to practitioners that were on their specific insurance panel, and in this, effectively managed to discount the program.

While considering the nature of the program received, as well as room and board, the cost was $7500 per month, which is about half the cost of a month in a primary treatment facility in the same geographical area. However the reality is that the majority of families with this need cannot afford even one month of this cost, much less three months. This dilemma suggests that a comprehensive, integrative program would need to be funded through federal grants to continue research into its efficacy, and developed as a teaching model to take into the non-profit sector.

In this way the efficacy of therapies could be further tested with individuals that currently do not have access to alternative therapies and may be of diverse cultures and economic statuses. The pilot study may provide opportunities to develop research protocols to further elucidate efficacy of therapies in other settings such as in community mental health settings and in traditional residential treatment facilities for the treatment of substance abuse. While providing therapies piecemeal has been the way co-occurring disorders have been traditionally treated, this might be an appropriate way to begin incorporating some of the other therapies into mainstream treatment facilities.

Conclusions

The outcomes for the eight women in the three-month pilot study into integrative holistic treatment for co-occurring disorders was a reduction in depression and anxiety, a renewed sense of purpose, raised self-esteem, and the ability to face interpersonal and legal problems with increased self-efficacy. Of the five women that responded to repeating the assessment measurements a year after treatment, all of them maintained and increased gains of treatment, which provides encouragement for potentials of integrative treatment.

Additionally the interpersonal, vocational, legal, medical, and Axis I issues of each individual were addressed in a comprehensive and holistic program, which encouraged more research into integrative care. Even with the inherent problems of developing funding for a change in rationale from piecemeal treatment protocols to an integrative model, the encouraging trend noted in this pilot study suggests that the overall problems of recidivism for substance abuse and the underlying gestalt of co-occurring issues in women being treated simultaneously with a holistic model may produce more lasting and effective changes.

Further research is needed in integrative and alternative therapies for the treatment of mental illness and co-occurring substance abuse disorders. There may be ways to do additional research within community mental health and substance abuse treatment facilities to elucidate efficacy of treatment modalities. Specific treatment modalities could be provided in set participant groups to determine treatment efficacy for those modalities. From the clinical perspective of holistic care, it is not one or two therapies that provided the treatment outcomes, but the therapeutic perspective of a holistic and fully integrated treatment program that treated the whole person that made the difference.

Providing specific care to women with co-occurring disorders from the holistic perspective suggests a need to consider the relational issues that may be causal to women becoming dependent upon substances, along with co-occurring disorders, and the core principles noted in SAMHSA for gender differences to develop protocols that lead to healing.

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About The Author

Dr. Tricia Chandler, PhD, LPC, BCPC, has been working in the field of psychology for the past nineteen years as a Licensed Professional Counselor and Art Therapist with children, youth, and adults in a variety of milieus. This has created the opportunity to research and develop holistic therapeutic practices for individuals with considerable trauma histories and co-occurring disorders. Dr. Chandler has trained in transpersonal psychology, energy medicine, personal spiritual/mindfulness practices, and somatic therapies she researched resiliency in healing from childhood sexual abuse for her dissertation in 2010 and developed a holistic model to treat women with co-occurring disorders after noting that therapeutic techniques for women lack an understanding of the multiple problems that face women seeking treatment for addiction issues. In addition to completing the longitudinal research presented in this paper, Dr. Chandler has a private practice and teaches graduate counseling and psychology students in online format for three universities where she teaches diagnostic psychopathology, family systems, biological basis of behavior, introduction to addiction counseling, counseling theories, advanced research, and professional ethics.


The Compassionate Mind: A New Approach to Life’s Challenges

The Compassionate Mind:
A New Approach to Life’s Challenges

Written By: Paul Gilbert, PhD
Publisher: New Harbinger Publications Inc., 513 pages
Reviewed By: Dr. Susan Stuntzner PhD, LPC, CRC, NCC, DCC, FAPA
Assistant Professor
University of Texas Rio Grande Valley
School of Rehabilitation Services and Counseling

College of Health Affairs

Compassion and self-compassion have gained momentum as topics of interest to psychologists, counselors and allied helping professionals in the past decade. During this time, there has been an expansion and application of these skills and constructs to professions. This includes education and the teaching of children in the public school system, rehabilitation counseling and its application to the coping and adaptation needs and concerns of persons with disabilities (i.e.,  see Stuntzner, 2014a, 2014b; Stuntzner& Dalton, 2014; Stuntzner& Hartley, 2015), medicine as it may relate to patient care or self-care of the medical professional, as well as discussion and momentum towards how to integrate compassion and self-compassion into a societal paradigm and way of life.

Additionally, there has been an increase in the number of books written and published about these skills and approaches. These generally focus on specific parts of life such as weight loss and dieting (i.e., The Self-compassion Diet: A Step-by-Step Program to Lose Weight with Loving Kindness), self-esteem  (i.e., Self-Compassion – I Don’t Have To Feel Better Than Others To Feel Good About Myself: Learn How To See Self Esteem Through The Lens Of Self-Love and Mindfulness and Cultivate The Courage To Be You) and self-compassion and mindfulness practices as part of psychotherapy (i.e., Self-Compassion in Psychotherapy: Mindfulness-Based Practices for Healing and Transformation).

Such a burgeon in awareness and application of compassion and self-compassion suggests that there is a need within our own culture to understand, study, and cultivate self-acceptance and kindness. Some of this need is evident as we live in a culture, while advanced in many ways, has not historically given people permission to be kind and compassionate towards themselves and more recently, towards others. Evidence of this is everywhere in our daily lives as there is increased pressure to perform, work harder and longer hours (sometimes without financial compensation), juggle multiple demands in an ever-changing society, survive and flourish in what may appear to be borderline-hostile work environments, and so forth.

The point being that we live in era where there is heavy competition for jobs and many people feel the need to out-do the next person. Similarly, some feel it is hard to relax or give themselves permission to go on a vacation and ‘unplug’ from the computer or electronic devices (i.e., i-phones) out of concern they will miss an important memo. Related to this notion is the fact that much of our culture is very ‘production-oriented’ and is based on work and the perceived value it holds.

While employment and work are definitely important and a necessary component of life, so is the need to learn about, understand, value, and practice life-affirming skills such as compassion and self-compassion. Gilbert’s book, “The Compassionate Mind: A New Approach to Life’s Challenges” helps bring to light the struggle society (and the world as a collective) has in relation to understanding the ways of being, living and approaching life from an evolutionary standpoint and how those same ways of living, currently, can hinder and hurt us.

For example, thousands of years ago, people and tribes had to be on guard for threats and danger on a regular basis. Survival was based on their ability to ward off possible threats; thus, their brains were hard-wired for anxiety, concern, and self-protection which were all essential. Gilbert (2009) also sheds understanding that the “primitive” and old ways of living were functional, at the time, and necessary but that they may not be so presently. Related to the evolutionary skills of man-kind is the notion that people are a by-product and influence of history, their biological-inherited genes, and of their upbringing. Gilbert (2009) repeatedly reinforces throughout the book that much of how we are today (as human beings) is evolutionary, in our genes and for those reasons is not our fault.

The concept of something (i.e., a personal trait or characteristic) not being our fault is an interesting one to consider, especially in an era where much of societal behavior focuses on “who is at fault” for something. According to Gilbert (2009), however, much of our undesirable traits can be viewed as a product of the past. These were useful and invaluable for survival when life was much harder and not as ‘comfortable’ as it is today. Much of the human-condition is explained as that which is biological, inherited, and conditioned or learned, and therefore, not our fault, is an interesting perspective for many reasons.

First is the fact that much of what has been written about compassion and/or self-compassion has been derived from Buddhist psychology or spiritual practices. In this book, although these concepts are mentioned, they are not the focus of it. Rather, much of the context and the first half of the book explain the rationale for people being who and how they are from an evolutionary and a brain-functioning perspective.

Second is that if our brain is ‘hard-wired’ to be a certain way to help promote survival at in the past, there is no need to ‘beat one’s self up’ for not being more compassionate or self-compassionate. Third is the connection between how people are raised and their ability to be compassionate and self-compassionate. Throughout the book, Gilbert shares that people who experience difficult or traumatic experiences (i.e., abandonment, lack of parental comforting or emotional soothing, abuse), torture, and earlier developmental life challenges are likely to have some kind of alteration in relation to brain development and maturation. As a result, people’s brains are affected or hindered in their ability to identify and practice self-calming and compassionate approaches as a natural way of life.

Fourth is the notion that peoples’ brains evolve and change throughout life and the lifespan. More specifically, as people go through life and have experiences, they are also afforded opportunities to interpret situations and to change their focus, intention and their brains for the better. Understanding this concept is important because it points out the fact that regardless of a person’s genetic disposition or life events, s/he can change one’s brain, its wiring, functioning and capabilities.

An example of this is a quote Gilbert (2009) shares extensively throughout, “Neurons that fire together, wire together……” The fundamental take away from this quote is the idea that people can choose to change their focus (i.e., focus on compassion and the cultivation of self-compassion versus operating according to threat, loss, safety, and survival). If they train their brain to be more kind, loving, tolerant, and self-compassionate, it will follow-suit and begin to function accordingly. Similarly, if people behave and react according to the ‘old brain’ patterns (i.e., anxiety, angst, threat/safety), so will their brain.

Fifth is the idea that change is possible and that there is a solution for better living. As the reader, it was helpful to fully consider the past and the way people’s brains have functioned and evolved over time, but it was also invaluable to understand how our “old brains” or ways of keeping ourselves safe were simply trying to help us survive until we could get to a better, more kind and loving place. Chapter 6 helped set the stage for exploring the connection between a person’s thoughts, feeling, and brain functioning.

Gilbert (2009) references that change is not easy but it is possible. He also begins to set the stage to assert that people can cultivate self-compassion and self-soothing as viable and healthier alternatives to self-criticism and judgment. He further explains that compassion and self-compassion can be used as a new “mind pattern” or generator for our brains and that as people learn to cultivate compassion within themselves, they may also experience changes in motivations and personal competencies (p. 192). All of these changes translate into an improved sense of well-being.

The second half of the book focuses extensively on information, skills, and exercises the reader can use to build and cultivate self-compassion and to create a more compassionate mind-set. Collectively speaking, it is the reader’s experience that the chapters are presented along a developmental continuum. For instance, Chapter 7 introduces the concept of deep breathing, followed by mindful breathing, mindfulness, mindful relaxing, exercises and suggestions for applying relaxation techniques to a person’s everyday life.

Introducing mindfulness and self-compassion appears to be fairly common among teachers and trainers due to the fact that these skills can help people learn to quiet their mind, listen to their breathing, and tune into their inner body experiences. Similarly, for those who are not used to practicing or integrating self-compassion and mindfulness techniques, learning to quiet one’s mind and experience one’s bodily sensations and feelings can be challenging until they become more accustomed to their regular practice. For this reason, such approaches are sound beginning steps.

Chapter 8 covers a number of exercises pertaining to compassion cultivation and mental imagery. Of importance is the idea that compassion-cultivation does not mean people will not experience hard or different times: challenges, hurt, and pain are a part of life. But, what can happen through the development of self-compassion is an alternative way to face, cope with, and address the pains we encounter (p. 242). Because some people have difficulty embracing and allowing themselves to be self-compassionate, the author suggests that people try to recall someone they know “who was caring, kind,  and warm towards them” at an earlier time in life as part of this process (p. 246).

The reader is encouraged to remember an event that was too difficult, so as prevent one from dwelling on the pain and to focus on the experience and the feeling of what it was like for another person to be kind them during this trying time. Readers are then directed to reflect on an experience where compassion was ‘flowing’ out of them towards another who was in distress. From this exercise, later in the chapter, readers are given an opportunity to imagine and create in their ‘mind’s eye’ an image of a ‘compassionate other’. More specifically, readers are asked to consider what the compassionate image looks and feels like. How does it sound? Further, the compassionate image is someone or something that “understands what it is like to be human and to go through difficult events” and has the ability to “endure and tolerate” difficulties, perhaps provide strength if needed. Also of relevance is the importance of this image being non-judgmental, critical, or condemning (pp. 256-257).

Chapter 9 is about compassionate thinking. Of relevance to helping professionals and to the people they serve is that learning to and cultivating compassion and self-compassion is a process and one in which our minds and feelings may not cooperate as desired. When this happens, when our minds wander, or when people find their old critical self and feelings resurface, readers are encouraged to be gentle and compassionate with themselves as they acknowledge (i.e., notice) what is taking place and gently redirect themselves back towards compassion/self-compassion or the practice of it should they be in the middle of an exercise. Related is the notion that our thoughts and feelings are related and when “people change their thinking they change their minds…..” (p. 274).

One part of this chapter the reader appreciated was the exploration and explanation of how compassion and self-compassion may fit into various counseling and therapeutic approaches. Some of those mentioned include Cognitive Behavioral Therapy (CBT), Rational Emotive Therapy (RET), Dialectical Behavior Therapy (DBT) and Acceptance Commitment Therapy (ACT). Although the explanation of how compassion and self-compassion were related to these approaches was not detailed, it provided another perspective for the reader to consider. This is especially interesting as these constructs have typically referenced in relation to Buddhist psychology but not towards a counseling approach. Professionals striving to understand how compassion cultivation and self-compassion fit into the therapeutic or helping relationship may find such reference of help within their own professional work with clients.

Many points of interest and self-compassion building exercises are covered in Chapters 10 to 13. Gilbert (2009) discusses the connection between shame and self-criticism, shame and disappointment, the power  and sources of self-criticism, self-esteem versus self-criticism as well as various exercises to enable the reader to get in touch with negative thoughts and feelings (i.e., conflicted feelings, self-criticism). Of importance is the mention of forgiveness, whether it is towards one’s self or others.

Forgiveness, self-compassion, and compassion tend to go hand-in-hand. For instance, it can be difficult to consider or even try to cultivate self-compassion and compassion if people are not willing to forgive. When people hold onto their negative thoughts, feelings, and/or resentments they are not able to feel or generate compassion toward one’s self or others; thus, at some point, it is likely the exploration of forgiveness may enter the therapeutic and healing process.

The book also points out that people may experience negative emotions in their pursuit of compassion cultivation. Understanding this is essential because people often assume that just because they are working towards being more compassionate and self-compassionate that this will not occur. Then when they feel negative emotions they may become discouraged. However, people can remind themselves that our brains are “hard-wired” by history, genetics, and upbringing to survive and to pay attention to perceived threats which can take the form of anger, anxiety, threat and so forth.

It is also important to know that the surfacing of negative thoughts and feelings does not mean compassion cultivation is not working; our minds and feelings wander. However, the more regular and consistent people become in their practice, the easier and more fluid compassion and self-compassion become. In essence, these skills become a way of life and a way of dealing with difficult and trying events, thoughts, and feelings. Gilbert also provides a “step-work” plan to aid the reader in coping with anxiety and anger. People who are particularly challenged by these emotions may find this information of use (see pp. 367-387).

Professionals wanting to learn more about compassion and self-compassion can learn a lot from this book. One of the ways this book differs from others on the topic is that it draws a clear connection between the brain ‘hard-wiring’, history, genetics and upbringing. This point is mentioned throughout the book but it is worthy of mention again, because it explains from a scientific/biological perspective, not just a spiritual practices approach, reasons many people may have difficulty being kind, self-compassionate, tolerant, and forgiving. Ideally both approaches are important, but the scientific/biological view is not one many scholars write about and it may be particularly helpful to those (i.e., clients) who have difficulty embracing spiritual or religious approaches as a part of the healing process.

The information presented by this book offers the reader another point-of-view about compassion and self-compassion that they might not have previously considered. Additionally, professionals are given a number of exercises which they may use or adapt as a part of the therapeutic and healing relationship. Professionals wanting to consider another view point about the challenges people may face while working towards compassion and self-compassion cultivation are encouraged to read this book.

References

Fain, J.  (2011). The self-compassion diet: A step-by-step program to lose weight with loving kindness. Boulder, CO: SoundsTrue, Inc.

Lindstrom, S. (2014).Self-compassion – I don’t have to feel better than others to feel good about myself: Learn how to see self-esteem through the lens of self-love and mindfulness and cultivate the courage to be you.CreateSpace Independent Publishing Platform

Stuntzner, S. (2014a).Compassion and self-compassion: Exploration of utility as essential components of the rehabilitation counseling profession. Journal of Applied Rehabilitation Counseling, 45(1), 37-44.

Stuntzner, S. (2014b). Self-Compassion and sexuality: A new model for women with disabilities. ACA’s VISTAs, Summer Issue.

Stuntzner, S., & Dalton, J. (2014). Living with a disability: A gateway to practicing forgiveness and compassion. American Association of Integrative Medicine®, October Issue.

Stuntzner, S.,& Hartley, M. (2015). Balancing self-compassion with self-Advocacy: A new approach for persons with disabilities. Annals of Psychotherapy and Integrative Health®, February Issue.

Tutu, D., & Davidson, R. (2015).Self-compassion in psychotherapy: Mindfulness-based practices for healing and transformation.W. W. Norton and Company.

About The Author

Dr. Susan Stuntzner PhD, LPC, LMHP, CRC, NCC, DCC, BCPC, DAPA, FAPA, is an Assistant Professor  in the School of Rehabilitation Services and Counseling at the University of Texas  Rio Grande Valley. She currently trains students to become rehabilitation and rehabilitation counseling professionals and to work directly with individuals with disabilities in numerous employment settings. Her research interests include: adaptation and coping with disability, resiliency, self-compassion and compassion, forgiveness and spirituality, development of intervention techniques and strategies, and mentorship of professionals with disabilities. She has written three books pertaining to coping and adaptation and/or resilience-based skills. Her works are entitled, Living with a Disability: Finding Peace Amidst the Storm, Reflections from the Past: Life Lessons for Better Living, and Resiliency and Coping: The Family After.  These books are available on Amazon.com or those interested may contact her directly at susan.stuntzner@utrgv.edu if they are interested in hard-bound copies. Dr. Stuntzner has researched and written articles on self-compassion, forgiveness, and resilience and their potential relationship to the needs of individuals with disabilities. She has also developed two interventions (i.e., resilience, forgiveness) for persons with disabilities to assist them in their coping process. These works are entitled, “Stuntzner and Hartley’s Life Enhancement Intervention: Developing Resiliency Skills Following Disability” and “Stuntzner’s Forgiveness Intervention: Learning to Forgive Yourself and Others”. Dr. Stuntzner has also written previous book reviews on the topic of compassion and self-compassion as well as given a number of professional presentations on forgiveness, resilience, compassion, and coping with disability. Additional information can be found on her website: www.therapeutic-healing-disability.com


Allergy Season – You know it is bad when….

Allergy Season – You know it is bad when….

Published April 16th, 2014 in Allergies

Every year we look forward to spring, the longer days, warmer temperatures, flowers and outdoor activities. What many of us don’t look forward to, are seasonal allergies, sinus headaches, itchy eyes and skin. This year we knew allergy season was going to be a bad one when our Sadie girl dog had to go visit Dr. Blair, DVM for uncontrollable scratching. After several sleepless nights for her and us it was time to call in the big guns for help.

sadieWhat I found interesting is whatever is contributing to her environmental allergy seems to be giving me the special treatment too. I know I don’t have flees…. And after visiting Dr. Blair with Sadie, I broke down and purchased my first box of Benadryl™ for myself, to curb the itching skin, sinus pressure, and so forth.  Now I’m not an over the counter or behind the counter visitor – it is funny it took my vet to remind me about the need for allergy medication sometimes.

I’m glad to report the Sadie and I are both scratching far less now, and this week reminded me of how many clients suffer from allergies and what they can do to minimize their over the counter drug use. Some due to high blood pressure have to be especially cautious of any medications they take. Antihistamines are notorious for elevating blood pressure, causing dry eye and mouth, throat irritation, drowsiness, brain fog, irritability…. Just to name a few of the side effects.

Over the years we have found several nutritional supplements to be useful, elimination of dairy foods and eggs that increase mucus production, Netty pots for nasal irrigation, homeopathic eye drops and herbs to improve lung function. And during especially bad times we break out peppermint oil along with essential oils to put in the diffuser for relief.

Don’t overlook Mold.

Mold, black mold in particular is most active when the weather turns warmer and is damp. Mold sickness and related illnesses from mold exposure are real. Mold has been linked to lung damage, brain damage, cancer and even death.

If mold spores are inhaled or ingested you can become seriously ill. As mold continues to grow inside your body it produces poisons called “Mycotoxins”, these poisons leach into your body day after day.

Different species of mold produce different toxins and people will suffer a wide range of symptoms.

The most commonly reported symptoms of short term mold exposure:

  • Sneezing
  • Itching Skin
  • Redness and skin irritation
  • Watery Eyes
  • Itching Eyes
  • Headache

Here are a few other suggestions:

Bee Pollen: Bee pollen has been used for centuries in China for seasonal allergies. It dries up the nasal cavity and slows or stops that annoying post nasal drip that leads to nagging coughing, sore throat and drippy nose. Clinically, I have found the pollen does not have to come from local sources to work. The two brands used most by our office are Nature’s Way® and Glory Bee®. Make sure it is straight bee pollen, not one with ginseng added.

Chinese Herbs: For years now I have managed the bulk of my allergy symptoms with Chinese herb tea’s blended by a local provider for me. Now, I won’t lie to you and say the stuff tastes great – it doesn’t- but it works and I only have to do between 4 – 8 oz daily to keep my lungs happy and my head clear.

Bioflavonoid Complex from Vitamin Research Products is natures “singular,” the combined benefits of this nutrient product benefit blood pressure, circulation, heart health and the combination of bioflavonoids work as a mast cell inhibitor.

OPC or grape seed extract: All of the antioxidants including Vitamin C and E play a major role in the reduction of inflammation. As we have seen allergies are a form of inflammation and they respond well to antioxidants. OPC stands for “Oligomeric Proanthocyanidin” a very powerful antioxidant found in grape seed and a truck load of other foods.  As with all natural health options synergistic combinations require lower doses and provide more bang for your dollar.

Mullen from HerbPharma™ is my daily go to. This herb has been used since the Middle Ages in Europe for colds, lung ailments, allergies, and ear congestion. It is one of the few herbals I use that doesn’t taste like it came out of some dirty sweat sock….always a good point when taking twice daily. hahahaha

What Therapy Options Work?

Acupuncture: Extensive research supports the use of Acupuncture for a host of conditions, especially those involving inflammation. Over the last ten years research has proven acupuncture is effective in the reduction of sensitivities resulting from allergies.

Chiropractic care is also very useful in reducing the inflammation response within the body; these practitioners as a whole have not only adjustments but Nutraceuticals available to help clients this time of year.

Buy a good air filter for your bedroom, living room, or office areas. This investment helps keep the cost of supplements, medications, and doctor’s visits down. It is especially important in the bedroom where you are lying down and congestion increases. Make sure it is a HEPA filtration system and spend the money for the ultra-quiet ones.  I know Costco has some nice ones on sale generally this time of year, and as a rule are better priced than through other retailers.

To pleasant spring days without Kleenex