Hold Hands, Instead of Shaking Them
Episode Guest:
Saurabh Bhardwaj, M.D.
Dr. Saurabh Bhardwaj, a University of Mississippi Medical Center board-certified addiction psychiatrist, joined co-hosts Meagen Rosenthal, Ph.D, and Alexis Lee for The Mayo Lab’s third episode of Season 2. Together, they discussed the stigma and science around alcoholism.
Dr. Bhardwaj shared how the fear of failure for patients in overcoming alcoholism can keep them from reaching out for the help that they need. “That’s an important part of treatment, to be honest,” he said. “When we look at how we approach the issue of substance use treatment with patients, the patient’s motivation to get help is very important…You want to approach the patient, give them the full autonomy to be able to make a decision and collaborate with them to get to the goal that they want to achieve.”
Alcoholism, or severe alcohol use disorder, is a chronic illness, Dr. Bhardwaj explained, just like diabetes or hypertension—though that perspective is not shared by our overall culture.
“I think education does play a huge role in how we change minds and how we show that there are treatments that actually work—and they are effective in helping reduce the risk of relapsing or maintaining the sobriety long-term. And once we are able to communicate that on a bigger basis, using tools we have—be it advertising, be it something that we do in primary care clinics—this way it’ll become normal for people to get help and be able to help other people get help.”
— Dr. Saurabh Bhardwaj
Dr. Bhardwaj spoke of abstaining from alcohol as a disease process. Much in the same way that one must keep a broken bone from moving in order for it to heal, those dealing with alcohol issues must maintain sobriety long enough that their brains are able to recalibrate their neural pathways. “Some of these changes may not reverse back ever, and that’s why it’s a chronic disease,” he said.
On the topic of advancing conversations about problematic stigmas, Dr. Bhardwaj said, “I think the less we use pejorative terms and the more we see this as a chronic disease and be able to have some empathy for those people who are suffering and struggling, I think will help us find the right path for those people and not just look at it from a law enforcement perspective or from, ‘They're just not good enough people.’ These are just people out in the community who are normal folks who've fallen into this trap. And over time, it's not just about choosing to use a substance, it's more about the disease driving this repeatedly and we need to help those folks.”
For those dealing with a family member who is struggling with alcohol, Dr. Bhardwaj suggests entering a conversation by asking if they’re struggling with something and how they can help. That discussion can help gauge whether the family member is ready to change. If they aren’t, continue supporting them while not enabling them.
“You should have your ears open if they want to say something, even if it's bad, just listen and see how you can provide that support that they need. Being authoritative or telling them what to do may not work all the time, but maybe that's an approach. Sometimes it might be necessary to show them the right direction, and you might want to suggest treatment if you see that the patient's declining. Ultimately, the choice is the patient's, but certainly being invested in their recovery and keeping the communication channels open can go a long way,” Dr. Bhardwaj said.
To hear more from Episode 3 of Season 2, scroll down to listen to the episode or read the transcript.
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Meagan Rosenthal:
I am Meagan Rosenthal.
Alexis Lee:
And I'm Alexis Lee, and this is the Mayo Lab Podcast. Hello everyone and welcome back to the Mayo Lab Podcast and for those of you watching, yes, this is a new environment. We are in Jackson, Mississippi at the University of Mississippi Medical Center and have just a great day ahead of us and this is one of two episodes that will be brought to you from this UMMC campus. We're excited to change it up a little bit this year, but we are joined today with Dr. Bhardwaj, or we will call him Dr. B from now on, and he's going to talk to us a little bit about being alcoholic, alcoholism, and the stigma around that, so we are very excited. Thank you for joining us today. Welcome to the podcast.
Dr. Bhardwaj:
Thank you very much. My pleasure.
Alexis Lee:
If you could just give us a little overview of your background, your current work in the center, the CID, or CIDA. CIDA. Go into that a little bit here because that's a new center, too.
Dr. Bhardwaj:
Yeah, thank you. Again, as I said, pleasure to be here. I've been at the University of Mississippi Medical Center for about five years now. I came here in 2018. I am a psychiatrist by training and did an additional one year of addiction fellowship, so I'm a board-certified addiction psychiatrist. I am on faculty here at UMMC in the Department of Psychiatry. I'm an associate professor and also the medical director for the CIDA, which is a new center, as you mentioned. It stands for Center for Innovation and Discovery in Addictions. This is a fairly new center.
The idea behind the center is to bring the clinical research and education arms all below one umbrella and we're trying to have more collaborations, interdepartmental collaborations, obviously different types of people ranging from physicians to researchers, educators, everyone under the same umbrella. That's the idea behind CIDA. As part of the CIDA, I'm also directing the outpatient clinic, which is the Addiction Clinic, which is the clinical arm of CIDA, and the clinic is located in the Psychiatry Clinic in Flowood. That's our main location. So that's the work that I do at UMMC. Outside of here, I'm also a medical director for rehab in Brandon, which is a Defining Wellness, and I do that part-time, providing inpatient rehab services over there. So just trying to provide as many services we can.
Alexis Lee:
I love it and I'm so excited because I know your breadth of knowledge is going to be so just educational, I know for me. And I'm particularly excited in a strange way about this episode. Alcoholism runs in my family, and so I have just really dug into this and really gotten to know a lot and just with the help of people like Meagan giving me insight and background. So, if you will, tell us the actual definition of what being an alcoholic is or alcoholism in the actual formal sense.
Dr. Bhardwaj:
Sure. It's much broader at this point when we talk about alcoholism. We've come a long way from semantic to now having scientific ideas about what this stands for. We don't even like to use the term, and we're talking about stigma here and probably a lot moving forward. That term itself can sometimes be pejorative. So what we know now is alcoholism, overall, can be classified as a severe alcohol use disorder, which is more a DSM diagnoses, which is the Diagnostic and Statistical Manual of Psychiatric Disorders. That's our main diagnostic book.
And what that basically entails is struggling with alcohol, and even similar to other substance use disorders, with having difficulty quitting, stopping, having a functional impairment, unable to perform your responsibilities, having some form of consequences from the alcohol you use, and potentially also developing physiological symptoms of tolerance and withdrawal. So it encompasses a lot of these symptoms that we know from the four domains in the DSM criteria. So that's pretty much what alcohol is. The formal definition would be the severe alcohol use disorder.
Alcoholism, per se, can be more abstract to understand. It might have a different meaning for different people. For some it might be just not being able to stop drinking and for others it might be just going through the hardships associated with the alcohol use, getting a DUI or struggling with family situations or just having a medical issue from long-term alcohol use. So it might mean different for different people. That's why it's important to understand we're going into more scientific terms to be able to focus on what's severe, what's less severe, and how do we get more people into treatment.
Alexis Lee:
I know a lot of people don't understand that range of spectrum and I know I haven't, until recently, understood the severities of different parts of it. I grew up knowing an alcoholic, or functional alcoholic, and how these things, just the stigma around it that unfortunately I still had up until recently and just being able to understand. How would you suggest people start digging into this topic in this specific use disorder, because it is so broad?
Dr. Bhardwaj:
Well, that's a great question. Stigma has long been an issue in addiction, and it's not just the stigma from outside, it's stigma from inside, too. A lot of people themselves are either ashamed or scared to get help. And when you look at the data out there, if you have 100% of the people who are having a substance use disorder, only 11% out of those actually get any treatment or help. That shows that there's such a huge discrepancy in what people understand about their own substance issues, especially alcohol use, which can come with a huge amount of stigma, but also that we need people from outside to be able to understand the family members, to understand what that entails and be able to help provide the support that the patient needs.
A good place to start would be to have a simple conversation with your close ones, with your family members, with your doctor, that you have a problem. And it might be as simple as just communicating what's going through your day-to-day struggles with alcohol, and being able to get help, the right help, can go a long way.
Meagan Rosenthal:
I want to circle back for just a second on your reference to the DSM-5 and the clinical definition and understanding that that has been an evolution over time. Substance use disorder, as we understand it clinically right now, hasn't always had that same level of understanding even within the clinical world, let alone in the public, in the general sphere. So would you be able to talk us through how this has evolved over time? Because I think that it also leads us to some other kinds of stigma that we'll dig into in a minute as it relates to providers and conversations with our healthcare providers, and does that feel safe to somebody who might be struggling with alcohol use?
Dr. Bhardwaj:
Yeah, absolutely. That's a great question, too. We've learned about alcohol use disorder over the last 10, 20 years. As you might remember, DSM-4 had two different diagnoses, alcohol abuse and alcohol dependence, and those two were now merged as alcohol use disorder in DSM-5. There are a couple of reasons why that was done. Obviously, to remove stigma, because those terms can be quite stigmatizing, but also to make it more easy for providers to make a diagnosis and be able to catch people who are at risk of developing severe disorders over time. When you look at the criterias, there are 11 different criterias in DSM-5 and you only need two to make a diagnosis of alcohol use disorder.
Meagan Rosenthal:
Interesting.
Dr. Bhardwaj:
That allows a provider to make a quick diagnosis and be able to refer patients to treatment. That's the philosophy of SBIRT that is taught, screening, brief intervention and referral to treatment. It goes a long way in identifying more people and being able to provide treatment, so it certainly has helped reduce the stigma associated with even making a diagnosis. And there was also an issue with those two terms, abuse and dependence. There were thought to be two distinct entities where abuse was not as big of an issue, though it was kind of seen as something that was not appropriate. But at the same time, dependence was thought to be the main problem and, until you met the criteria for dependence, you really didn't need treatment, per se. So again, we're moving away from that dichotomy to have just one scientific definition under which we can make a diagnosis.
Meagan Rosenthal:
Right, right. I think that's really interesting and shows the evolution of our knowledge and understanding over time. Until I entered into this world and began learning more from experts like you and other experts in this field, from the outside looking in, it kind of seems simplistic. Either you have a problem or you don't have a problem or you're this or this. But the reality is that these things evolve and our understanding and our knowledge evolve over time. And so it feels like a little bit of a moving target from the outside looking in if you're not in that space up to your eyeballs and it all day long.
And so the other thing I thought about as you were speaking, the idea of self-stigmatization or self-questioning about whether or not this is actually maybe a problem or if I am suffering in this. What are some of the more common explanations or stigmas that individuals feel about themselves when they're working towards the idea of getting into treatment and then ultimately, hopefully, recovery?
Dr. Bhardwaj:
Right. Well, again, that's another good question because a lot of times there is fear of failure that drives the shame and lack of self-esteem that could be huge in patients who are struggling with alcohol use, or any substance use disorder for that matter. And that fear of failure, not being able to make it on the other side, drives this understanding that what's the point of getting help? And that is the kind of stigma that the patients feel themselves. And also there's this understanding that when you try to get help, more people in the healthcare will know, and with the electronic medical records, there's this fear that, once that diagnosis pops up on your system system, it's going to last forever.
So, that's another fear, if there's somebody who has a lot of stakes in maintaining the sobriety. But also not letting other people around them know that they're actually struggling with alcohol use disorder. So again, coming from the old times to new times, there are newer reasons why the stigmas have changed over time, but the main reasons still are the society, the peers looking at them in a different way, having that family dynamic that changes if they share about their alcohol use, how they're perceived, lack of self-esteem, just this idea that they themselves are unable to quit successfully by themselves, and needing that external help to do it can actually take people down significantly.
Meagan Rosenthal:
And I think that's a really important observation that folks may not have a great appreciation for, this idea. Because I think, and please correct me if I'm misinterpreting this, but where you're talking about this idea of willpower, like if I want to quit, I should be able to quit and that, if I don't have the capacity to do that, suddenly I run into this idea that, "Well, I'm not good enough or I'm not worthy enough," or all of those kinds of things. And so I wonder if you could talk a little bit more about that idea of the reality of willpower and its potential or capacity to actually do the thing that we think it's supposed to do, right?
Dr. Bhardwaj:
Right. Yeah, that's an important part of treatment, to be honest. And when we look at how we approach the issue of substance use treatment with patients, the patient's motivation to get help is very important. We see this a lot. Patients show up in the clinic and some people do not have an idea why they're there, and that can be very challenging because we're not trying to twist people's minds or trick them into getting help. What we're trying to do is actually see if the patient is at a stage or a place where they're ready to make the change. And that's part of the motivational interviewing spectrum. You want to approach the patient, give them the full autonomy to be able to make a decision and collaborate with them to get to the goal that they want to achieve. For that, you have to make sure the patient is willing and ready to do that.
So, that part of the willpower that we talk about, that can be in different shapes or forms. It could be just the patient has something that is driving the change, they have things at stake. Maybe it's the family, maybe it's the job, maybe it's just their own self-esteem that's driving the change, so that is important, but not the only thing needed for treatment, but it's a good place to start. And when we look at patients, when we try to talk to them, we see if they're anywhere there on that spectrum from pre-contemplation to making that action stage where they're ready to make the change. So yes, I would say having willpower is important, but that helps drive treatment over long-term, for sure.
Meagan Rosenthal:
Right, and I think what I hear you saying there is that willpower, it's an important component, but not the only component, right?
Dr. Bhardwaj:
Correct.
Meagan Rosenthal:
It's a place to begin, but that there are other interventions and supports that folks need oftentimes to be successful in that space. One of the other things, broadening out from that individual sphere, is talking through what are the stigmas or what are the concerns that patients have as it relates to their family sphere, is that that gets out. Because our audience for this podcast are parents and families of students in different walks in their lives, and obviously they have larger communities around them. What are some of the things that you have seen in your practice directly or heard from your patients related to the feelings of inadequacy and shamefulness related to alcohol use from family members or close peers?
Dr. Bhardwaj:
Sure. There is a lot of research out there and one of the reviews that I read recently were looking at how people perceive alcohol use disorder versus other mental illnesses. Now we know any substance use disorder, even alcohol use disorder, is a chronic disease, so we want to perceive it or see it as a chronic disease model. However, that's not the case for a lot of people. And when they looked at data from different countries, this was a multi-site, multi-country research, and they saw how people perceived schizophrenia versus substance use and that they think both are part of the mental illness spectrum. The majority of the people were able to identify schizophrenia as a huge mental illness, but only less than 30% or close to 40% identified alcohol use as anything to do with a mental illness.
So, as you can imagine, there is certainly a lack of understanding of how these processes work, and I don't blame family members for that. I mean, it's something we are still learning as we're going, but at the same time, I think more education, helping work with the families together as part of the treatment plan and not just only seeing the patient as the person who needs to be worked on can go a long way in helping develop a successful treatment plan.
Again, there are multiple avenues that can be done, as you all know about Alcohol Anonymous, there's A-Anon, similar to that, that provides information for family members to learn how to deal with family members who have alcohol use issues. And there are other alliances like NAMI that can help provide more support into understanding how to handle patients who have mental illness, from a family perspective. So a lot of resources are out there to understand some of these issues.
Meagan Rosenthal:
Would you be able to, because I think one of the understandings, if I think back to when I was younger that I didn't necessarily have a good appreciation of at that time, is that substance use disorder is a chronic illness, just like diabetes, just like hypertension. If you were to going to be explaining, because one of the ideas for the season of the podcast is really to get into the weeds on things so that we can explain the mechanism of action and how things function to people in a way that they can understand and appreciate. So if we're going to talk about alcohol or substance use disorder as a disease, a chronic disease, what is a good way to explain that to folks that are listening so that they have an appreciation for this is a chronic disease like any other chronic disease that we maybe have more exposure to?
Dr. Bhardwaj:
Right. That's a great question and what I'm going to start with is, over the last, I guess, couple of decades, we now know what's happening in the brain. Certainly we talked about willpower being the main issue. At some point it was thought to be the only problem with the person, but now we know that it's not just that. There's actually changes in the brain that are happening over time. So when you start using a substance or alcohol, gradually your reward system is working overtime, and because of the overtime that it's doing, there's actually changes happening in the brain which are very neuroplastic, so they're happening over time and what that leads to is that areas of the brain start to get different.
They start to get modified and the circuits are starting to form where you're not even thinking before actually using, you're just kind of having that compulsive nature of use. And now we know that there are actually three stages of development of addiction over time. One is obviously experimenting state and a second one is a withdrawal phase, and the other one is a compulsive phase where the person is using it more compulsively. And all of these stages are driven by underlying neuronal changes and neuroplastic changes that are happening in the brain. So it's all a disease process. It's not just something that person just wants to do it. At some point it becomes a pathological process, which is driving the whole issue.
Meagan Rosenthal:
Which I think is fascinating. So you're actually changing the physical structures in your brain when you're going through each of those three phases that you talked about. Because we think about disease processes as it relates to breaking your arm, so you have a bone that is not where it should be anymore, it's cracked, it's done, whatever, we put a cast on it to mend it, to put it back into the place that it should be. I think, similarly to when we're talking about alcohol use disorder or substance use disorders more broadly, is that you are needing to rework the wiring in your brain to get it back to a place where it's functioning as it should.
You have to have a cast on for 6, 8, 12 weeks depending on how bad the break is. These things take a lot of time to recalibrate. So thinking on that kind of pathway, going forward, how long, because again, we're getting in the weeds here, how long does it take for somebody's neural pathways to rewire in that kind of way and then working backward, once they're done, how do we undo them?
Dr. Bhardwaj:
That's a struggle. We're still trying to understand. Wish we could give a timeline, but what we do know is some of these changes are chronic. Some of these changes may not reverse back ever, and that's why it's a chronic disease. Simple things like the reward pathway might start to not work over time after a given period of abstinence, but some of the downstream changes that have already taken place might take six months to one year to even get reversed.
When we talk about keeping the sobriety long enough so that you start to not have those negative patterns of behaviors, that is very important. The longer you stay sober, the better the chance that you'll keep maintaining that sobriety. But there is no number that I can give you that, "This is what you need," or to wait until before your brain is reversed completely.
Meagan Rosenthal:
Yeah, yeah. Right. Well, and I think you did answer the question, that it is a longer process and that it is going to take time. Because I think oftentimes in the experiences and exposures I've had to folks who are working through this process, oftentimes families are like, "Well, just stop and then get better." But more thinking about this in terms of changes in our neural pathways, it took time to get there and it's going to take time to get back out of those again. And often, because of our physiological structure, sometimes we can't fix all of those things, but we can get back to a good place and have tools to move forward from there.
Alexis Lee:
On the family note, I have a question, and I don't know if we have answers to this, but are genetics at play when it comes to substance use disorder or alcohol in general? Is someone more susceptible? Can they be passed down? Is there a factor in that?
Dr. Bhardwaj:
Oh, absolutely. We already know that there's a lot of genetic susceptibility and if you have a family history, you're at a higher risk of developing a substance use disorder, so it does get passed down. At the same time, that's not the only piece. It's just one piece of the puzzle. The environment does play a huge role. That could be how you were raised, what you saw growing up, what your mental health looks like, how your coping mechanisms are, access to alcohol, how you've grown up looking at it, approaching at it, so a lot of factors go into that. History of trauma can change things. So it's not just the genetics, but also things that come along with it, the environment and things that can actually move the needle one way or the other.
Voiceover:
You're listening to the Mayo Lab Podcast. For more information and resources, visit the mayolab.com. Now, back to the episode.
Meagan Rosenthal:
I appreciate this conversation because we're dispelling maybe some common myths that we have as a society and a community around alcohol use disorder or substance use disorder more broadly. And coming back to the topic of conversation around, we've talked about stigmas from an individual perspective. We've talked about the potential stigmas that family members bring to the table as part of their interactions with the person who may be suffering from this condition.
What are some stigmas or stereotypes or negative imagery that you have seen as part of being a member of our larger community that, as someone with your expertise and working with the community of patients that you work with, that you want to call out and say, "Look, these are really problematic and we need to be thinking about these, whatever they are, in a different kind of way as we advance this conversation"?
Dr. Bhardwaj:
Unfortunately, there's a lot of stigma associated with just being an addict and there's a lot more pejorative terms that people use and it's not just with alcohol, with any substance use disorder. And, to be fair, what does happen is the substance use does come with a lot of negative consequences, too. People who are using substances do end up making mistakes or doing certain behaviors that might place them in the negative bucket of how people view people in the community. So that can become challenging. Maybe getting DUIs, maybe making poor judgments can lend you into situations that may not be looked at favorably in the community. So there's always a challenge.
At the same time, I think the less we use pejorative terms and the more we see this as a chronic disease and be able to have some empathy for those people who are suffering and struggling, I think will help us find the right path for those people and not just look at it from a law enforcement perspective or from, "They're just not good enough people." These are just people out in the community who are normal folks who've fallen into this trap. And over time, it's not just about choosing to use a substance, it's more about the disease driving this repeatedly and we need to help those folks.
So again, I think education does play a huge role in how we change minds and how we show that there are treatments that actually work and they are effective in helping reduce the risk of relapsing or maintaining the sobriety long-term. And once we are able to communicate that on a bigger basis, using tools we have, be it advertising, be it something that we do in primary care clinics, this way it'll become normal for people to get help and be able to help other people get help.
Meagan Rosenthal:
And I wonder if you might walk through thinking of, because one of the things we want to leave our listeners with this season is practical things you can do right away, and so I would be curious to know if you're working with a patient and their family, what are some of the practical things that you are working with, either the patient or their family member, to educate them around what you're talking about here? How do you dispel those longstanding myths that we have? How do you practice empathy in this space? Because I think that's a term that gets used an awful lot, but it's not really well understood or well applied oftentimes. So how do we do some of those things in our engagement with a person who might be struggling with something like this?
Dr. Bhardwaj:
Right. Certainly, if you have a family member who's using, I think starting a conversation, the first thing, is more important than actually telling them what to do because that never works. So the first step would be to ask if they are struggling with something and if they need help and trying to understand how much is their struggle and if they are even understanding that they themselves are going through a problem. Because if the patient is not ready to get help, we talked about that a few minutes ago, it is very hard to get people to change.
So, identifying where they are in their recovery, if they're even ready to make a change, is a good place to start. And then working with your doctor, I think that's the first step is to be very transparent about your struggles and your issues and getting the right help, be it from the doctor or from the community. If you already know a rehab or a place that you know can help with the alcohol use, that would be a great place to start.
Alexis Lee:
What would you say to those family members and communities or close support communities that they have someone that's maybe gone to treatment multiple times, has tried recovery and relapsed and this person that they're working with just doesn't seem to "want" to get help. What advice would you give to those people that are just kind of at the end of the rope of "We've tried"?
Dr. Bhardwaj:
Those are the most challenging situations, unfortunately. We certainly struggle the most with folks who are not ready to make a change or they just don't feel that they have a problem. The best thing we tell the family members is to just provide the support, make sure you're not enabling them because that can be a fine line. A lot of times you pity the person who's going through this and let them continue the behaviors they're doing. So you have to understand that you don't want to enable them, but at the same time, you want to make sure they are able to realize that they need help. So you can become a crutch for them and help them get where they need to go, but certainly not become part of the addiction and the problem itself. Understanding that is very important, and that's where the education and getting the right help is important.
Alexis Lee:
I want to dive into a little bit, circling back to the treatment aspect of this. What are some specific things that go on in treatment, maybe for those that have never been in there, have someone that is away at treatment right now, what's actually happening when they are in a rehab or doing treatment?
Dr. Bhardwaj:
Sure. Treatment can encompass a lot of different things, including how you want to stop drinking, first. And just stopping or quitting alcohol is the first step, and that can happen either with a detox or going to just a regular clinic and getting an outpatient detoxification done. The second step is to maintaining that sobriety once you've achieved that sobriety, and that can happen in the community in sober livings, you can still go to another 30-day rehabs and achieve that long-term. So it can look different for different people because people are at different places in their recoveries.
But at the same time, I think the approach should be to understanding where they are and helping them from that standpoint onwards. If they're still actively drinking, the first step obviously is to work with them to see how they can cut down or stop. Harm reduction is something we don't talk much about, especially in alcohol use, but there are times where even that can help, and that might simply look like the doctor advising the patient to keep drinking, but at lower levels and try cutting down over time.
That way it keeps the bond of the doctor-patient relationship going at the same time they're still engaged in treatment, so you're not losing that patient, but they're still in treatment, although it might take a longer time to get to the goal, but that's just one way to do it.
Meagan Rosenthal:
I think you hit on a really key phrase, this idea of harm reduction, and in certain circles, it's become a little taboo because it gets associated with things that I now understand that they're stigma. It's related to stigma, this idea that you should just be able to stop and if you have a substance use disorder or have an addiction, you are a bad person. You have failed as a human being. Those ideas get conflated in that harm reduction field.
And so how do we start to take this term that has become loaded and reorient our thinking to what you just went through, this idea that, "Okay, so we may not be ready to quit, but a reduction is still a reduction, and I still can have that conversation with my patient and have them in kind of my fold, so to speak, to get them to a better place." How do we start untangling that mess that we have created in that world?
Dr. Bhardwaj:
It's pretty much what it is, what you just mentioned, it's a mess. But I think, as physicians and as providers, it's always a struggle to override the autonomy of the patient. That's the first thing, do no harm. And that's why when you talk to a patient and you're trying to help them get to their goals, you want to make sure you understand what the patient wants, what are their goals? If they do not want to quit completely and they want to keep drinking socially, we cannot push them to become completely abstinent. So it's always a struggle as to what the patient wants to do and how we want to approach it. But at the same time, if the patient wants to quit, but they're having a struggle, just being more authoritative and telling them what to do never works, so at that point, they can easily choose not to come back.
So the best next step is to be able to keep that connection and be part of their support system and helping them see or realize that what they're doing may not be in their best interest and help guide them to that eventual goal. And that's where harm reduction comes in. The word might be loaded, but at the same time it's kind of self-explanatory. We're just reducing the harm for the patient. Is it better to keep drinking the way they're drinking and get no help versus continue to work on the patient even if it takes six months to get to that goal?
Meagan Rosenthal:
Right. I think, for folks that have been listening to this episode so far, you talked initially about this idea of motivational interviewing, and that's really what you're walking us through is the process of going through and motivational interviewing. And so for those who are listening who may not have heard of that term before, do you have a more formal definition that you can provide so that folks are connecting all those dots, because you walked through the steps very beautifully, but maybe we don't have that definition to land our feet on yet?
Dr. Bhardwaj:
Well, I'm not sure I can tell the official definition because, again, this is more an approach than anything else. We've been using this in the substance use field for a long time now, and the main four steps we use are being able to have that open conversation with the patient, providing patient the autonomy to make decisions, having that collaborative approach with the patient and be able to elicit information without being judgmental. That's the main approach for motivational interviewing. And this is not just for substance use disorders. This approach can be used in any chronic disease model. And that's where this whole idea comes in that addiction is not just an issue of willpower, it's just like any other chronic diseases.
Meagan Rosenthal:
Right, right. Yeah. The first time I ever got exposed to the idea of motivational intervening was actually in the diabetes self-management support field, is walking people through making changes related to diet and exercise and all of those things that we know we need to deal with if we have a diagnosis of diabetes or pre-diabetes or what have you. And on the outside looking in, four steps don't seem super complicated, but one of the things that you talked about is eliciting information in a nonjudgmental way, which I think also gets back to your comments earlier around those conversations that families start with each other if you're recognizing that maybe somebody in your circle is struggling.
And so how do you, as a provider, work through the process of knowing, somebody comes to your door, you know they have something going on. They're maybe not ready yet to have that conversation or make any of those changes, but to not shake them and be like, "What is wrong with you? This is a bad thing." How do you quell that knee-jerk reaction of trying to solve the problem for them so that you can have that ongoing conversation?
Dr. Bhardwaj:
Right. Well, that's a great question, and I'll go back to the word autonomy. Folks who are struggling have gone through so many stages where their autonomy was taken away, and that is one of the main ways to give patients the self-esteem that they need and deserve, and being able to recognize that they make their own choices and decisions, even if that means they might continue drinking for a little bit. But what we, as providers, and especially in addiction arena, recognize, is that we need to hold hands and not shake them. We need to walk with them in their path of recovery.
So when a patient comes in and they do not feel that they have a problem, we're not rejecting the idea that they came in for a wrong reason. We say that we are actually their support system. We're always here. They may not recognize that they need help right now, but at some point, if they do need the help, we will be here. Not to say that we definitely provide some psycho-education, we definitely let them know about outcomes and how, if they keep drinking, it may not be in their best interest.
At the same time, we're always there for them and they can always seek help between the provider and the patient. So just that doctor-patient connection, making sure they're engaged in treatment, using non-judgmental terminology, not being very authoritative with the patient can go a long way in having that self-esteem back for the patient and being able to feel that, yes, they can make their own decisions.
Alexis Lee:
For those family members and other people that are listening that maybe want to start having these conversations with people in their life that they know are struggling, what do you recommend on ways for them asking and working with that patient to not guard or protect themselves but not emotionally take on? Because, as providers, you guys have skills and trained to do this, but maybe us lay people, we don't have those. So what do you recommend on how to be supportive but also not take on that emotional load?
Dr. Bhardwaj:
That is challenging, and not having that training to even know what to say can be very difficult. I think when we started this conversation a few minutes ago, I mentioned about the struggles the family members can have because of lack of education or even understanding what substance use disorder means. So I think the best place to start, and we tell this to the family members all the time, is to continue to explore and keep the communication channels open. You want to be on the side all the time for the patient and be a support system.
You should have your ears open if they want to say something, even if it's bad, just listen and see how you can provide that support that they need. Being authoritative or telling them what to do may not work all the time, but maybe that's an approach. Sometimes it might be necessary to show them the right direction, and you might want to suggest treatment if you see that the patient's declining. Ultimately, the choice is the patient's, but certainly being invested in their recovery and keeping the communication channels open can go a long way.
Alexis Lee:
And I think, moving out one more sphere to the communities of how can we move forward with our communities and equip them and us as holding hands, like you said, how do we start doing that, practically?
Dr. Bhardwaj:
Right. Again, it's always challenging with the stigma associated with substance use disorders and alcohol use. I think the best approach would be to having places where patients can come and talk freely without being judged, having education camps or maybe starting at local ground level, at churches, having that conversations. And we already see that. Alcohol Anonymous meetings happen all the time in so many churches around places, and those could be grounds where these kind of conversations can start and provide a hub where people can come and get information and get help, and even family members, they can go and sit in and learn how and what to do in these circumstances.
Meagan Rosenthal:
The last question I had for you around this, because I think we've covered a lot of amazing ground today, is obviously you knew we were coming. We asked you to be part of this. You probably gave some thought to what we were going to talk about today. Is there something that you thought we were going to be talking about today that we haven't covered that you wanted to share with our listeners?
Dr. Bhardwaj:
Well, I think we had a good discussion about stigma, something that we don't talk about much. I mean, we do, but in a different sense. It's always towards the community. But I think we touched on the patient stigma, as well, and I hope that people understand that there's help available. There's treatments, scientific evidence-based treatments available, and they do work. It's a matter of just getting the right help and getting the referral to treatment that might be necessary. So again, I would like to finish with that this is a chronic medical disease. It's not just an issue of willpower and there is treatment available, and I encourage people to go out and get help, and family members to continue to work and keep the communication channels open with the patients.
Meagan Rosenthal:
Those are all amazing points. Thank you so much for making the time. If y'all didn't catch the beginning of this, Dr. B. is an incredibly busy person, and so we're really grateful that you took a few minutes out of your busy day to come and talk with us, and we hope to have you all back listening to our next episode and let us know, what did you learn from today's episode? I know I certainly learned a lot of really great tidbits. Let us know what those little tidbits are and we can start spreading that information and getting the word out into the hands of more people around our communities so that we can start taking back and chipping away at that stigma. Thank you so much, and we'll see you here next time.
Dr. Bhardwaj:
Thank you so much for the opportunity. I appreciate it.
Meagan Rosenthal:
Thank you. Thank you.
Voiceover:
Thank you for joining us on this episode of the Mayo Lab Podcast. The Mayo Lab Podcast is produced by Dr. Natasha Jeter, Dr. Meagan Rosenthal, Alexis Lee, Slade Lewis, and Hannah Finch. This podcast was recorded at Broadcast Studio in Oxford, Mississippi. The show was mixed and mastered by Clay Jones, and our original music was composed by Slade Lewis. The Mayo Lab Podcast is brought to you by the William Magee Institute for Student Wellbeing. For more information on the Mayo Lab Podcast, head over to the mayolab.com and follow us on social media @themayolab.
If you enjoyed listening to the Mayo Lab Podcast, we'd love for you to subscribe, rate, and give a review on iTunes, Spotify, or wherever you are listening to this podcast. This podcast represents the opinions of Dr. Meagan Rosenthal, Alexis Lee, and their guest on the show. This podcast is not intended to be a substitute for the medical advice of a licensed counselor or physician. The listener should consult with a mental health professional in any matters related to his or her health, or the health of a child.
Sources & Resources:
CIDA— Center for Innovation and Discovery in Addiction
Bringing clinical research and education around addiction under one umbrella.
https://www.umc.edu/Research/Centers-and-Institutes/Centers/Center-for-Innovation-and-Discovery-in-Addictions/Home.html
DSM-5: the professional diagnostic book for psychological disorders.
What is the DSM-5?
https://my.clevelandclinic.org/health/articles/24291-diagnostic-and-statistical-manual-dsm-5
DSM-5
https://repository.poltekkes-kaltim.ac.id/657/1/Diagnostic%20and%20statistical%20manual%20of%20mental%20disorders%20_%20DSM-5%20(%20PDFDrive.com%20).pdf
Alcohol Use Disorder DSM-5 Definition:
https://www.rand.org/content/dam/rand/pubs/tools/TLA900/TLA928-1/resources/step-2/AUD/RAND_TLA928-1.diagnostic-checklist_AUD.pdf
Motivational interviewing
https://motivationalinterviewing.org/understanding-motivational-interviewing
Alcoholics Anonymous:
https://www.aa.org
Al-Anon: Support for those worried about someone they know with a drinking problem.
https://al-anon.org
NAMI: National Alliance on Mental Illness
https://www.nami.org/Home
The Mayo Lab: https://themayolab.com/
Instagram: https://www.instagram.com/themayolab/
Facebook: https://www.facebook.com/themayolab
William Magee Institute: http://mageeinstitute.org
