Contributing writer Gloria Dickerson interviews SAMHSA's Steven Samra on motivational interviewing and applying those techniques in recovery support.
Steven Samra is deputy director of SAMHSA’s Bringing Recovery Supports to Scale Technical Assistance Center Strategy (BRSS TACS) and works on SAMHSA projects, including Projects for Assistance in Transition from Homelessness (PATH) and Services in Supportive Housing (SSH) consumer involvement initiatives. He lives in Nashville, Tennessee, with his family, and entered into recovery in 2000 from substance use and mental illness. Steven has devoted his career to assisting and advocating for marginalized, disenfranchised populations.
Today, Mr. Samra speaks about living through a crisis while in long-term recovery. Mr. Samra and Ms. Dickerson both work at the Center for Social Innovation (C4) as recovery specialists. They often share perspectives and model peer support as a foundation for their work to promote the recovery of all peers and the integration of peer-providers into services to people who are homeless. As peer providers, their combined knowledge and expertise from the lived experience of recovery informs the translation of research into practice at C4.
Dickerson: Steven, what has been your experience of recovery?
Samra: I have two things that are part of my behavioral health background - addiction and a mental health condition that has never been clearly identified. At age 7 or 8, I was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and medicated with Dexedrine.
Dickerson: Did you experience yourself as really having ADHD or were you misdiagnosed?
Samra: I was extremely anxious, over-energized, and couldn’t function well in school... so yes, I believe the diagnosis was accurate.
Later, when I was 14 or 15, whenever I took the medication, my symptoms would worsen. The professionals said my body chemistry had changed so the medication was speeding me up instead of calming me down. They determined that I had “aged out” of treatment. Today, professionals know ADHD is not cured with age. But, back then, I was discharged from treatment with no medication and in full-blown mania. My anxiety was overwhelming and this led me to self-medicate.
I used marijuana daily to calm myself. But marijuana is a short-acting drug and I searched for something that would last longer. Through experimentation, I discovered opiate painkillers. Opiates gave me longer periods of relief. I could get through the day. And I really liked the guy I became under the influence of opiates. I was more thoughtful, calmer, and not so emotional. I was able to keep a job and function in a community. I was likeable. The supercharged emotional outbursts were gone.
I had all kinds of schemes to get opiate prescriptions from my doctors. But in the late ’80s, there was a crackdown on prescribing opiates. They were hard to get. When I didn’t have the drugs, I would lose my job because of showing up sick or not at all. It was also very difficult for people close to me to co-exist with me as a result of the cycles of wellness and “dopesickness.”
Dickerson: Steven, excuse me. Can you explain the difference between opioids and opiates?
Samra: First, opioids and opiates function within the body exactly the same. “Opioids” are synthetic. “Opiates” are direct from the poppy plant. Basically, they all are considered “opioids.” They all have the same kind of effect; they are calming and there is some euphoria. If you manage your doses and don’t indulge in them, they can be somewhat therapeutic, especially for people who are in full-blown mania.
After the crackdown on prescription opiates in the ’80s, I started to use heroin. Fast-forwarding to the ’90s, I found myself a full-blown heroin addict. Heroin was cheap and easy to get. I wasn’t scared of needles because I am a trained paramedic. I understood the need to use clean needles and I had no fear of injections.
By age forty, I was a functioning heroin addict. Then I was arrested and sent to prison for a drug crime. My feeling at the time was that, with a felony drug crime, my life as I knew it was over! After release from prison, I had to find work and make a life for myself. But I had a felony, and finding a job was much harder. Additionally, my anxiety, impulsiveness, and drug habit were all still overwhelming.
Dickerson: Steven, how did you enter into a commitment to recovery?
Samra: In 1996, I became contemplative about recovery. I had previously been court ordered into counseling as a result of my drug use, and the first two counselors betrayed my trust. Then, I met a counselor who was welcoming and trustworthy, and was also a person in recovery from addiction issues. It was his approach that made the difference. Looking back, I know now he used early motivational interviewing techniques.
My commitment to recovery did not begin with a "light switch moment" or sudden realization. I’m not even sure I had reached the “bottom” point of my life; it was all bad and worsening by the day. It was after two years of using on and off while in therapy with my counselor that I was able to tell him that, for the first time in twenty years. I could finally choose to use or not. Up to that point, I had never had that ability before. Also, I met the love of my life in 1999, who, after discovering my drug addiction, said, “You can have me, or you can have your drugs, but you cannot have both.” Because I had cut down my heroin use at this point, but was still suffering from mental health and post addiction symptoms, I decided to explore a medication-assisted treatment center. Participation in methadone maintenance over the next 15 years gave me the opportunity to work, learn about the principles of recovery, and develop social networks and solid coping skills. I began to deal with the residual effects of having used drugs most of my adult life.
I now live with a solid foundation in the four domains of recovery: health, home, community, and purpose.
Because that foundation was so strong, I made a decision to withdraw from methadone after 15 years in a medication-assisted treatment program. Withdrawal from methadone brought a crisis of having to go through two withdrawals. Methadone withdrawal involves an acute and a post-acute phase. The acute phase involves physical and mental symptoms directly associated with the detoxification of the drug from my system. The post-acute withdrawal syndrome (PAWS) involves longer-term mental health symptoms, along with some minor but irritating and stressful physical symptoms. I am in the post-acute phase. Coupled with PAWS is the reemergence of what have now been diagnosed as bipolar symptoms, which are significant at times. I move from very low energy states, to severe anxiety, to hypomania. Sometimes I am too tired and/or overwhelmed with even the relatively simple task of fixing lunch. Other times, my low self-confidence evokes strong anxiety. Still other times, I have so much energy, I can’t sleep or stop working. But, when I remember that I am in crisis mode and that I have an anxiety disorder, the awareness makes coping easier. Today, I will ask for help, something I never did previously and simply self-medicated the symptoms away. I can be patient and gentle with myself, and I understand that I already have successful coping skills. I ask friends, family, and work supports to help me manage this crisis.
Dickerson: Steven, this has been a very informative interview. What recommendations can you make for people who are trying to help others who are experiencing this type of crisis while in long-term recovery?
Samra: Providers can use motivational interviewing techniques to assist clients who are in the contemplation phase of change. Help clients become curious about their experience and possible solutions. Remind clients of past successful strategies and their history of recovery. Use the stance of a partner or ally for recovery. Help clients remember to ask for help and use peer supports and feedback from valued family, friends, and co-workers. Avoid pointing out client deficits and using shame to promote change. Invite and encourage clients to make positive change.
A big barrier that comes with long-term recovery is the fear of getting sick, relapsing, and then letting others down. The terror of withdrawal can become a barrier to asking for help. Also, too much self-disclosure can become a huge burden, due to the stigma that is often associated with addiction. Self-care and professional help can be part of one’s lifeline. Above all, tell your clients, “You are not alone!”
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