by Wayne Munchel, LCSW   1 Comment

In order for youth and young adults to obtain support and treatment they usually must be diagnosed with a severe mental illness. Many of these young people have already been labelled with a litany of childhood diagnoses such as oppositional/defiant disorder, conduct disorder and ADHD. As they come of age and seek help from the adult systems of care, they must be re-diagnosed with adult psychiatric disorders to remain eligible for services.

What are the potential impacts on youth being diagnosed?

Some youth may describe their diagnosis as having a beneficial impact, while others may find it to be deeply troubling and detrimental to their emerging identity and forward progress. Here are some of the more common reactions:

  • Many young people express a sense of relief for having their problems identified and named.
  • Some youth and their families discuss how their diagnosis reduced or removed much of the shame, blame and confusion in trying to understand their struggles.
  • A percentage of youth may draw considerable comfort in not feeling alone and being able to access support groups where they can share their struggles and coping strategies with others who’ve had similar experiences.

  • Others report an experience of being stigmatized and “othered” for being different.
  • Still other youth may react negatively to being labelled for what’s wrong with them, rather than being seen and understood for what’s happened to them.
  • Many young people may report feeling a heightened sense of hopelessness and foreclosing of their futures upon hearing they have a chronic, life-long brain disease.

Of course, young people may experience a mixture of all the above and they may change over time.

Here are a few recommendations to consider when diagnosing youth:

  1. Devote ample time and repeated opportunities for youth to question, challenge and explore what their given diagnosis means to them, their families and friends. (Note that due to wide power differentials and perceived authority, this is a difficult conversation for most youth to initiate.)
  2. Ensure that diagnosed youth understand that their “diagnosis is not destiny” and does not describe who they are, nor define who they wish to become. Not for a minute.
  3. Emphasize that they are the authors of their unfolding story and that their self-understanding is far more important than any label.
  4. Ultimately, it is the young adult’s prerogative to accept or reject any diagnosis and seek second opinions.

What do you see as the potential helps and harms of diagnoses? Leave a comment below.

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by Wayne Munchel, LCSW   2 Comments

“We treat people’s solutions as problems.” Vincent Felitti MD, eminent author of the original ACE’s (Adverse Childhood Experiences) study, often makes this point when discussing how we focus on eliminating people’s desperate means of coping, without recognizing their adaptive functions. When addressing substance abuse (the most common method of tolerating overwhelming fear and pain) do we commit the same error of attempting to control the “solution” while largely ignoring the underlying core problems associated with traumatic exposures? For many people struggling with addictions, substance abuse represents their survival.

The linkage between ACE’s and trauma and substance abuse disorders (SUD’s) is compelling. In his paper, Origins of Addiction, Felitti reports that people who experience 4 or more ACE’s are 500% more likely to abuse alcohol. People who report five ACE’s or more are 7 to 10 times more likely to report illicit drug abuse. A jaw-dropping data point indicates that individuals who survive 6 or more ACE’s are 46 times more likely to be IV drug abusers than people who report no ACE’s. Trauma truly is the “gateway drug” to addictions.

Kanwarpal Dhaliwal and the youth at RYSE (Richmond Youth Services) have amplified the ACE’s pyramid to include the toxic impacts of social conditions and local contexts such as poverty, racism and historical trauma. This expanded view helps us recognize that it’s not just what has happened to you, but what environmental stressors and social conditions you are born and raised in. As attention has turned to the “opioid crisis,” it would seem to be no coincidence that the communities most affected are beset by high rates of unemployment, poverty, and social isolation. In contrast to the reductive medical model, the ACE’s trauma-informed approach encompasses neighborhoods as much as neurons, and it relates to zip codes more than just genetic codes.

Some substance abuse programs and mental health agencies have begun integrating the ACE’s questionnaire into their initial assessments. What might be the potential impacts of incorporating enhanced ACE’s informed perspectives into treatment?

  • Asking about childhood maltreatment, listening and offering empathy represents a significant intervention in itself. Simple, straightforward human compassion for “what has happened” to people, acknowledging human suffering and distress can be healing.
  • Inviting people who abuse substances to be “compassionately curious” about themselves and to connect the dots between their unseen wounds and their attempts to cope with overwhelming distress can provide relief and self-understanding. (“I use substances for understandable reasons, I’m not just crazy or stupid.”) This is often a long-term, life-time process.
  • Instilling hope for a better future is an essential ingredient for recovery. “What can be hurt can be healed” seems to illuminate this pathway much more than “you have an incurable, life-long brain disease.”
  • Empowering people to take responsibility for owning their own stories and writing (and rewriting) new chapters. Talk of genetic predispositions and chemical imbalances can engender passivity and resignation.
  • Supporting meaning making and setting the stage for post-traumatic growth.
  • Emphasizing the central need for social supports and human connection. In his enlightening TED talk, Johann Hari asks this challenging question: “What if the opposite of addiction is not sobriety, but the opposite of addiction is connection?” A key aspect of reducing substance abuse is how well we can help people develop their social networks and resilience.
  • This reminds us all that unless we also vigorously address issues such as social justice, poverty and racism, our progress will be limited.

Utilizing this broader, trauma-informed lens often seems at odds with the dominant medical model approach to addiction as a disease. Framing problems such as addiction as solely problems within an individual’s disordered neural circuitry are favored. We prefer our solutions to be fast-acting, cheap and to avoid discomforting questions about social conditions. In his book “In the Realm of Hungry Ghosts,” Gabor Mate makes the following observation: “We keep trying to change people’s behaviors without a full understanding of how and why those behaviors arise.” A trauma informed approach to substance abuse and dependence brings the potential of deep healing, not just for individuals but our communities as well.


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