Okay, good afternoon, everyone. I'm Dr. David Siffler. On behalf of the American Academy of Addiction Psychiatry, welcome to today's webinar. This is the first, or actually the second in a monthly series focused on evidence-based intensive psychotherapy training for addiction practitioners. This is hosted in partnership with the Oregon Health and Science University and University of California at San Diego. We're excited to offer these trainings and that you can join us today. The live trainings will be held on the second Wednesday of each month from 5.30 to 7 p.m. Eastern Time, and the archived recordings will also be available. Today's talk is about CBT, and I'm sure everybody here is acutely aware of how important it is to have CBT skills in treating patients with addiction. Our next presentation will be October 12th on narcissism with Dr. Ramani Durvasala. Please check the AAAP website for updates on upcoming speakers. Before we begin, we have a few housekeeping items. Please feel free to ask questions by clicking the questions tab in the lower portion of your control panel and typing in your question. You can also submit questions anytime during the presentation. We will reserve 10 to 15 minutes at the end of the presentation for Q&A. Following this session, you will receive an email with information on how CME or Certificates of Participation can be obtained without charge. To claim credit for this event, please log on to your AAAP account and access the course. Complete the course evaluation and follow the prompts provided to claim credit. Additional courses are being added, so remember to click the new course titles to register and get your calendar invite with your Zoom link emailed to you. So now, once again, were you done, David? Yes. So I'm Chris Blazes. I'm also the other course director, and I'm very excited to introduce Dr. Donna Sudak. She is the Professor and Vice Chair for Education in the Department of Psychiatry at Drexel University and the Director of the Residency and Psychotherapy Training at Tower Health Phoenixville Hospital. She's a master educator. She's a clinician educator with a wealth of experience in teaching and patient care. She's made a number of significant contributions to the literature and CBT education and has played a major role in developing suggested curricula for guidelines for supervision and resident competency in cognitive behavioral therapy. She has multiple publications, multiple books regarding combining treatment with medication and CBT. In her most recent book, The Handbook of Psychiatric Education, was written with a group of noted experts, and it provides multiple resources for educators. In addition to her teaching responsibilities at Drexel and Tower Health, Dr. Sudak is adjunct faculty member at the Beck Institute. Rest in peace, Tim Beck. He recently just died, as many people know. She's the past president of the Academy of Cognitive Therapy and former editor of the PIPE examination. She has served on the board of regents of the American College of Psychiatrists. She's a member of the review committee for psychiatry in ACGME and has held multiple leadership roles in the American Association of Directors of Psychiatric Residency Training, including the president. So besides that, she's just a remarkable teacher, and we're lucky to have her. And thank you, Donna, for Dr. Sudak, for agreeing to do this. Hey, it's my pleasure. And thanks so much, Chris and David, for asking me and for that gracious introduction. And without further ado, I'm going to do what everybody does on these and get my slides up there. You'll notice that I'm not much in the way of patterns or colors, but what I do want you to notice is my email. I'm pretty committed as a person to trying to get people to learn about this mode of treatment so that if something piques your interest and I don't explain it fully or you have another question about it, please don't hesitate to email me in the future. And although I'm not going to speak about CBT for other disorders and just for substance use disorders itself, but I am going to try to give you some basic principles because unlike most good educational places to start, you usually start with your learners and you usually know what they know. And since this is a webinar, I don't know. So I'm going to, if it turns out that you know a lot about the basics of CBT, you can use that time to text your friends or find out if I'm doing it right. And Chris mentioned that I write books. These books do have something to do with this topic, but I'm not going to reference them in any way. One big underlying principle to know is that there are lots of different CBT protocols for substance use disorder. You have one person, Smart Recovery coming up, which is going to, I'm going to actually speak to some of their protocols for how we put together this very powerful set of tools in trying to help folks with substance use disorder. But as with many of the other kinds of treatment, it's a lot easier to produce change than to maintain it. And so just like with other types of treatment for this problem, engagement and relapse prevention is really an important set of skills that you're going to need to have in order to navigate this. It's also important to know that I'm not going to speak very much about data that support the use of CBT because this was really going to be the practical kind of nuts and bolts of what you could do differently if you wanted to use this form of treatment. We know that with Project MATCH that CBT certainly does seem to work, but we don't know exactly for which patient. We know it's more variable in its use for drug use disorders than for alcohol use disorder. We also know that contingency management, which is a behavioral way of managing individuals who have substance use disorders, is a very powerful tool, although it's very hard to convince people about the utility of it or spending money on it because we're Calvinists as a group of people generally, politically. And so the management of people with contingency management is also a little complicated, and so it's not as well disseminated as some of the other CBT interventions. And this is what we're going to try to get accomplished this evening. So in an overarching way, there are really four basic strategies that we're thinking about when we're employing this form of treatment. And the idea is that we would adapt the strategies of CBT to help minimize the harm involved in using substances. And many individuals who use CBT for this often moderate their substance use rather than become totally abstinent. So one of the things about CBT protocols for substance use is that many of them are espoused harm reduction and meeting the patient where they are in terms of how much or what they want to do in terms of their use, even though we'll give people information potentially about the particular difficulty that they might have in trying that. We adopt sort of a collaborative style as we approach patients around this. And so we're going to actually amplify on these particular strategies as we think about the different treatment arms and protocol that we might employ with patients. And one of the things that we want to think through before we delve into how we would plan treatment is how do we understand this as a model and in terms of the CBT model. And if we were thinking about basic behaviorism, part of what we would be thinking about is the concept of reinforcement and that using substances often provide very powerful positive reinforcement in the initial use of the substance itself and the induction of euphoria or relaxation. And it also can provide powerful negative reinforcement. Many people make the mistake of thinking that negative reinforcement is actual punishment, is applying something bad, where negative reinforcement is actually taking away something bad. So if when I have a drink, my spouse is less annoying, I've just been negatively reinforced. And so it's going to mean that I do that behavior more frequently. So we know that substance use can provide powerful ways of both positively and negatively reinforcing the person behaviorally and also powerful reinforcement by stimulating the reward centers of the brain. And you all probably know way more about that than the average people that I'm speaking to about this. So I'm not going to spend any time on that. One thing that we do believe in this form of treatment is that cognitions exert a powerful effect on our responses to wanting a substance. So either cognitions about the way that we regard craving, like if I feel like this and I'm craving this so much, I'm going to lose my mind, I'll become psychotic, I won't be able to stand it. And so that would induce a powerful desire to use that is over and above the craving itself. And or cognitions can exert a positive effect on our use of the substance in terms of permission giving kinds of cognitions. For example, the most common cognition that I can think of is it's Friday. And I've had a hard week and I deserve to go have a good time. And so we develop these sets of rules around use that become inducers for the use. And so as we work in CBT, we have to think about these particular paradigms as potentially the things that begin to set up the regular use that eventually stimulates the brain's reward centers. So before we get to the whole shebang about using this in substance use disorder, it might be useful to think about some basic things about this form of treatment. This is a very active, highly collaborative problem and solution oriented form of therapy that's based on two things. One is the cognitive behavioral model, and we'll get to that in a second. And the second is the need to learn new things. We believe that therapy works because people learn something new. And sometimes that learning is experiential and sometimes that learning is highly cognitive, but they learn something new about themselves and their ability to navigate the world in a different way. And we want them to learn what we know about the problems that they have and how to fix it. And we think that is what is responsible for the durability of this particular form of treatment. There's a significant amount of empirical data about CBT. It's adaptable to a number of different conditions. And as I said, it's a very collaborative form of treatment. You and the patient are a team that are working to help the patient both feel, think, and function better. And one thing that CBT isn't is a way of looking up some disorder in a cookbook and going through step-by-step, like a recipe, how to fix somebody. In fact, we really try to look at the person. We want to know how did they develop this particular way of doing things, of thinking about things, what skills do they have available that we can count on, or what skills do we need to teach them in order to help them to not be in the position that they're in right now. We're looking at learning how they learn to think about the world or their current situation. And this accounts for not just their developmental history, but also their interpersonal interactions. And we especially want to think about this with respect to substance use, because we know that social and interpersonal triggers are big drivers for the use of substances. And so if you think about that, it may well be that those are things that figure into the case conceptualization that we have to work on with the patient so they can navigate their relationships a little differently. There are also intrapersonal triggers that we want to look for. A patient might feel calmer when they use, feel more confident, have less negative thinking. And we need to find some other ways for those things to happen in order to have their recovery be more durable. Now, the kinds of things we do in CBT are pretty variable. And we were having a conversation actually beforehand of what makes a person a cognitive behavioral therapist is not what they do so much. It's how they think about the way problems develop. But there are very specific things that are really the nuts and bolts and tools that we use commonly as we're working with folks. And one very fundamental thing is education. We really want people to understand how we think problems come about, how we think their particular brand of this problem came about, and how we plan to tackle it, what kinds of things we think might be helpful and why. Obviously, cognitive restructuring is very important. And what that means essentially is not telling people how to think differently. It's applying the scientific method to somebody's thinking. We know that all humans fall prey to biases in the way they think about things and that that colors their perceptions of the world and the things that happen to them, information they take in. And so that if we're able to shine a light on the things they're not considering and have them take a fuller look at what's happening and perhaps have a more logical way of thinking about what's going on, they generally can feel and function much better. We use both behavioral activation and exposure. And what that means in behavioral activation is really exposure to activity. When someone has a response to emotion that, in this case, feeling sad generally, where they withdraw and want to do much less, we gradually expose them to activities that are pleasurable or important to them. And that usually helps their mood to get much better. And we expose people to things that really have negative emotion-producing properties. Or sometimes we expose people to situations where they get into behavioral difficulty. This is an important piece of sometimes what we do with substance use disorder. So if someone, for example, has cravings to use when they're interpersonally rejected, we may have them practice the sensation of that. We may have them get into situations where they don't get rejected in quite the same way as they might if they break up with somebody, but they practice smaller levels of asking for things and not getting what they want, or smaller levels of being exposed to social mishaps so that they can tolerate those and do that without engaging in substance use. So we might use exposure-based treatment there. Contingency management, I already mentioned, where one would reward the things that they want and not reward the things they don't want. So that's a pretty easy thing to do potentially in terms of more controlled environments in specific. Stimulus control is something we use early on in most behavioral disturbances, including in substance use disorder. And what most of you probably know it as, and certainly I did before I knew about CBT, is people, places, and things. When we talk about that in 12-step, what we're really talking about is staying away from things that are associated with the use of a particular substance. And it's useful in the very beginning of working with this kind of problem, but it generally speaking by itself is insufficient. But it helps in the very beginning to help people get their urges and use under control. And finally, I have had multiple experiences when I've treated people with substance use problems where they had big holes in their skills, especially with people who begin to use it as young people. They don't engage in some of the developmental tasks that they need. And so they might be deficient in things like emotion regulation or assertiveness or time management. There are very basic psychological skills that people need to get through the world in a particularly easy way. And there are things that we have to ask ourselves when we're looking at skills. One of two things is usually the case. We can look at somebody's developmental history to try to suss this out. It's either that they don't have the skill, in which case we have to help them get it, or they have the skill and there's a reason they're not using it. There's a motivational reason they're not using it. So for example, somebody might be reasonably assertive, but if they're assertive with their family, their family screams and yells and it's highly unpleasant. And they might not use a skill that they've got because they don't want to be in the midst of all that conflict. So we have to understand whether or not there's a reason motivationally people don't use their skills. Now, we mentioned that learning theory was a piece of this. And one of the things about that is that you probably know about CBT a little bit in terms of knowing it's a relatively structured kind of treatment. And one of the reasons for the structure is because it makes it easier and more efficient for people to learn. And so one thing that we do is we want to be efficient about our treatment, but we also want to make it easier for people to learn. And so we're doing things that educators will do. We do a lot of summarizing. We do things like get people to write down the main points of the session. We sometimes get people to record the session and listen to it outside the session, because we know that in the highly charged emotional place of therapy, a lot of times what happens is that people just forget a lot of the main things that go on. And they miss out that way. And so we want to make sure that there's a durable way for them to remember and learn the things that happen in treatment. Another thing that we want is people spend 168 hours in a week. And if they only spend an hour or 30 minutes with me, and they don't practice tools that we have talked about in the session, outside the session, they might get to be a very good patient, but that doesn't help their everyday life. And so a big piece of what happens in CBT is probably known to you is that people have the concept that we make people do homework. Well, most of my patients hate that word. And most of everybody's patients hate that word. So they've come up with a new word in CBT. Now they call it action planning, which sounds like something out of corporate speak to me. I hate that word too. And so we can find other ways of saying that, but how could you practice? How could you find out? How could you do one more thing this week that would help to use this tool outside of the session? We want to bring what happens in the room into the person's everyday life. It doesn't do anybody any good to just be a good patient. They have to be able to use these tools outside of the session. And so that's a really big piece of the learning. Now I mentioned the cognitive behavioral model, and really this is a schematic about what that is. And what it essentially says is that how you think affects how you feel and what you do. It also affects your physical response to things. That in fact, it's not events that make us feel a certain way. It's not events that generally make us act a certain way. It's how we think about those events that really, generally speaking is related to these particular aspects of our life. Now, this is a tremendously simplistic way of looking at it. We know obviously that emotions can also affect people's thinking. We know that certain behaviors can affect people's thinking and certainly affect things that happen in their life. We know that reinforcers will make behavior more likely so that this is the the CBT simple way of looking at things. But it really helps people to understand that it isn't the trigger producing the behavior. It's often the trigger that produces a thought or a trigger that produces an urge that you have a thought about that then will lead to particular emotional states or behaviors or physiological responses. And so it helps people to understand when they come in and they say, I just don't know why I did this, or I don't know why I said that to back up the truck and say, well, let's take a look at what was going on in your mind just before then. Because oftentimes that helps us to figure out just exactly what was going on at the time. Now, it's important to know, I know that many of you probably see people in briefer sessions and CBT is very adaptable to use in 20-minute, 25-minute time frames, some things in briefer time frames than that. But in order to do that, you really have to know how to do this. Not something you can just sort of paste on as an add-on. You need to have a plan that makes sense and a good alliance. But when I'm working with somebody in a briefer session, I'm thinking, what can we, we should measure one thing. I'd like to teach one skill. I'd like to practice one new idea outside of the session. And I want to make sure that the person really understands the principle. I need to get feedback about that because if the pace of interventions is too fast, it becomes just sort of an add-on that might get thrown away rather than something that the person can use over their lifetime. It's important that we have, if we're going to have briefer sessions, even if we're not, that we have written materials available to us to give to patients. And you want to, you have to decide when you can make briefer sessions what you're doing. So for example, it might be the case that in the very beginning of treatment, that you need a longer timeframe to form a solid alliance and have the person understand a little bit more about what it is that this treatment is all about. But then as they get more skilled and more attuned, you can adapt this to do in a briefer session. Okay. So that's sort of a global bird's eye view of CBT generally. I want to just give one disclaimer, which is that I don't think of myself as a particular expert in substance use treatment, although I have used CBT for substance use disorder in many, many patients along the way. And so what I'm trying to do with the rest of this is to give you a real world example, and not a real world, it's actually a fictitious example, but about how I might approach this with a patient and sort of from a clinical standpoint, let you know what this would look like. And generally CBT is a form of treatment that involves having a treatment plan. That means that I'm looking ahead from session to session, thinking ahead about what the next thing is going to be about. What's the next thing I'm going to teach? Where do I think therapy is going? And within the session itself, I'm thinking about how I'm going to spend the time. So, and it's a little like Google maps, because how I'm going to spend the time is often derailed by road conditions at hand. So, I might have a plan that just doesn't turn up to be what I do, but generally speaking, I have an overarching sense of what I'm going to be doing. And really, when I think about CBT for substance use disorder, I'm usually thinking about, is there a need for motivating the patient to become involved in treatment and in sobriety? And then some CBT for this problem, and then thinking about relapse prevention. And the mindset really for me is that recovery is a process and that what I'm really working hard to do is to help the person both improve their health, as well as reach their full potential with allowing them to begin to really recognize what it is that's happening in their life right now and set goals accordingly. And so, what I'm thinking through initially, and these are really a summary of part of what we're going to begin to elucidate, is using motivational enhancement. And I actually would use group-based support during that period of time, if the person's agreeable, either 12 steps or smart recovery groups, and whichever the person is amenable to or can access. And a piece of what we want to do very early on when the person is making that decision is to educate them a bit about both how therapies can work, but as well as how does this problem happen? And then what we're going to do is to begin to see how this problem began to happen in this person. What are the situations that are at highest risk for them to use, how they could plan to do things differently, and then looking at not just the external triggers, but the internal reactions to not using and the internal triggers that might induce use in the future. So part of what I have to do is to get a real sense of what makes this person's vulnerable to use, and making certain that I'm considering, are there any co-occurring disorders that need to be treated? Is this a person who's going to be doing better if I use combined treatment? Is it a good candidate for using pharmacological treatments that might assist them with their sobriety? And it's not one size fits all. Everybody's going to have different vulnerabilities. Everyone's going to have different consequences and reinforcement for their use and the need to change some of those so that relapse is less likely. In many ways, when I'm using CBT for substance use disorders, it's a lot like CBT for insomnia. So this is a whole set of treatment possibilities. And what it turns out to be for the individual depends on their own personal and developmental history and the drivers for their use of the substance and their current interpersonal feel. And so that helps me to plan treatment. So in the very beginning, part of the discussion for me is often about reducing use versus abstinence. And in this conversation, I generally let people know that for most people, abstinence is a lot easier. And that particularly with anything except alcohol use, it's generally much, much more successful. And I've already done the education about how all of this works. And if the person is really allergic to abstinence, I might say that one of the things that they could consider is that it's an experiment. They've already tried the experiment of using and seeing how that works. Maybe they could try the experiment if not and see how that would be. But sometimes that is just not what the person is interested in doing. And so I think that one of the things that's important is that there might not need to be a perfect way of figuring this out with someone, might sort of navigate a potential goal that they have. And particularly with alcohol, I will say, well, if abstinence isn't what your goal is, what is your drinking goal? What is it that you'd like to have happen? And I'm assuming that many people have done this with people who want to decrease their alcohol use. I'm gonna have them measure all their drinks. Often that is an eye-opener by itself. I'm gonna have them alternate drinks with alcohol and drinks without alcohol. And I find this is particularly important with women, at least in my experience. And I treat a lot of women, more women than men, frankly, and that women often drink very fast and they're drunk before they know it. And so they wind up, their judgment is really impaired. So sometimes slowing them down is a very good way of helping them to reduce their drinking. And I tell them that going to bars is inadvisable because they don't give you those salty snacks because they think you're hungry. That the idea would be that that's a place where they're really working to try to get you to drink more. And then I might reevaluate this and see how it went. So that's one of the earlier discussions I might have with people when they're ambivalent. And part of what I want to think through is how this might work with a person. And so I'm gonna actually talk about this fictitious person, Ms. A, who's 47. She's divorced, she has kids. She's a manager as a tech company. She's pretty socially isolated and has symptoms of major depression. And she's had two other episodes like this. She has a family history of alcohol use disorder in her father and her brother. Her sister is a successful star. And you find out really and begin to uncover that she's drinking a fair amount. Usually after her kids go to bed, she's occasionally had blackouts. She started to miss work. And she's been episodically drinking pretty heavily since she was in college. And it stopped when she was pregnant. And it's a very important fact about this. And she's very ashamed of her drinking but really can't imagine being without it. Now, a piece of what I'm starting to ask myself in conceptualizing this person is what gets better for her when she loses? And what are the things that sets off use for her? And what and when are there negative consequences? And so as I start to conceptualize this patient, what I come to find out is that she started doing this in order to treat herself at the end of a long day when she really didn't have many opportunities for recreation. And she also had a lot of beliefs about sleep that she had to get to sleep exactly when she wanted to and she could go to sleep immediately. And when her kids weren't at home because she was a relatively isolated person, she started to look forward to drinking and that she really wanted to be in treatment because she didn't want to feel sad, didn't consider the alcohol as being a problem. So the most important thing to begin with for me is to think about making an alliance with this person that's going to stick. Because if I don't have a good alliance, none of what I'm going to do as elegantly as I may do it, it's going to go anywhere. So that part of that alliance is being hopeful and optimistic, being curious about how things work and really giving the person an explanation for how it is that I think this treatment will help them and what kinds of things we're going to be doing. And so a piece of this is really spending a reasonable amount of time helping the person to understand how this problem came about. And so in the very beginning, I might discuss with Ms. A both the formulation, how I understand this all came about, how the drinking functioned for her in her life. And that I also felt that she had a depression. And because of that, I would recommend that she stopped drinking because I thought it would make the depression worse as well as have some other potential health consequences. And that she started an antidepressant. And I'm going to give her some reasons to be optimistic that she could stop. One is that she's done it before for the benefit of the health of her children. And so a piece of this is to potentially enlist her to do this to benefit her own health. And we can do lots of things. And I'm sure that you all know about how to do this in terms of motivational enhancement. Helping the person to recognize how much they're drinking and what really that constitutes, how significant it is. Particularly if they don't recognize that. And a piece of this is really helping them to understand what the negative consequences are for their use. And one of the things that I find is really typical is that very often what happens is that I see people telling the person what the negative consequences are. And this does not work very well. What does work is helping the person come up with their list of consequences. What brings her in, not what I think is a negative consequence. And how is this interfering with the values that this person has? And not just now, but also in the future. So pros and cons of using for now, of not using for now. And pros and cons of using in continuing to use versus not continuing to use. So if we were looking at Ms. A, this might be what we come up with as a decisional matrix. Now, the decisional matrix are the pros and cons of doing something and the pros and cons of not doing something. And we do it that way because often it comes up with different items. And these are the things that she came up with. And because we really need to help the person to come up with enough reasons so that the benefits of not doing this look like they outweigh the costs. And so one of the things we have to teach people is that using has a lot of short-term payoffs. And because it has short-term payoffs, it generally is gonna be a very strong desire to use. And that the longer-term aspects of not using are sometimes elusive in the face of that short-term payoff. And so that we're gonna need to do a lot of things to help them, to fortify them when the short-term payoff is what's in front of their mind, right? So that's a piece of what we work with and as we begin looking at the decision to not do this. So part of this is looking potentially at somebody's values, look at what isn't working in their life and what their priorities are in terms of domains of their life that are being interfered with by use, right? So maybe considering benefits that they're not seeing like benefits to their physical health or benefits to their self-regard, et cetera. And so that we're looking a little bit also down the road at benefits to them that they might not be considering. And so part of this is sometimes stepping back to look at the patient's values and what step that they could take to get closer to the things that are valuable. Because the list of things that people value often doesn't include substance use. Often includes things about recreation, about their spiritual life, about their family life, about things that are important to them, but doesn't include substance use, even though that might be a great deal of how they're spending their time. So I've mentioned education a fair amount and certainly we need to help people to understand the reinforcing effects of substances. And I have found that explaining a little something about the neurobiology at whatever level is appropriate has been helpful too. And that substance often has other effects as well. And how primates work, even with some of these long-term downsides, that all of us, because we are primates, are subject to the lure of immediate gratification. That immediate gratification will have big influences on our behavior. And so we need to know when we're gonna work with someone and they need to know that there's gonna be the need to tolerate and accept some discomfort here to make a change. That in order to make a change, tolerating discomfort is gonna be necessary. Now, this is true of most change in therapy. I happen to be a person who likes physical activity a lot. So I use a lot of analogies from that. And so I'll often talk to people about how would you get to be stronger if you were a weightlifter? Would you have to lift an easy weight over, just all the time, the same one all the time? Or how would you get stronger? And most people will say, well, you have to increase the weight. And that's true. And when you first lift this more difficult weight, is that, does that incur any discomfort? Then yes, of course it does. And so that's how you get stronger. And that's true for most of the skills that I teach people. If you're gonna get to be less afraid of doing something, generally speaking, you have to accept some short-term discomfort in terms of exposure in order to help make a change. And one of the things that I will often say is that one of the fortunate things about being in therapy is that my job is really helping people to tolerate that discomfort and be able to do things to help them to get into contact with some of this more difficult stuff to do. And that we're gonna be in this together so that I can help them to be able to not be so influenced by that immediate gratification. It's also the case that there might be issues like I'm more assertive when I use, that the person doesn't know that the substance is helping, that we uncover later that we need to remedy. So back to Ms. A, she agrees to the plan to take SSRIs. And she says she wants to abstain entirely from using alcohol. Okay, great. And to make this simpler, I didn't add that she was gonna take a medication for that as well, but you could certainly combine treatment here. But one of the things that I would do is to ask her to just keep a record of any use in the next week or an urge to use and what happened just before so that we can begin to identify triggers. She might know some of them and we're gonna ask her to write those down as well, but we're gonna wanna do that observationally too. And we're also gonna ask her early on to keep the list of reasons to not use in the front of her mind. And the way that's gonna work is I'm gonna ask her to keep looking at the list and adding to it every single day, coming up with other reasons to not use that she might not be thinking about. So we're gonna keep that in the front of her mind. So part of the looking at triggers is really identifying high-risk situations. And this sometimes will be obvious and sometimes subtle. Sometimes it will take some time. And in order to identify high-risk situations, you might have to teach someone about what an urge is. And so what I might talk to Ms. A about is the idea that an urge is like having an itch or having to pee. And that it's sort of this sense of, I really need to do this. And that part of what we wanna do is to identify when the urge to use is like that, what's going on around her and what she might be thinking about and what she might think once that urge starts. So all of those are gonna be important for us to identify. And at first, we're looking at particular things that are external as well as internal. Any cue that triggers that urge, any cue that triggers that drives this particular engine. And some of these will become very predictable to the person as we begin to examine this. And we need to distinguish that an urge doesn't mean that it's a reason to use. It's just an internal sense of wanting something very badly. And so we can figure it out by looking at the person's internal senses. We can figure it out by looking at what's happening around them interpersonally. Sometimes it's what's available, what's around them, what cues exist. There are endless things within the environment. Sometimes it's just the time of day. And I had an interesting experience about urge like that. I spent part of the pandemic in Alaska and in the winter. And as I was in Alaska and it was winter, I come from the East Coast and it's three in the afternoon and the sun goes down and I'm thinking it's time for dinner. Just the darkness that happened induced that particular urge even though it wasn't a particular time for that to happen. And I found myself thinking, substance use disorders are pretty high in Alaska. And that a piece of that might also be not just because it's dark, it's because people associate getting dark with, okay, now it's time. And so you can see how that setup could happen. Sometimes high risk is alleviating something. So the urge to use when I'm anxious, when I'm angry, when I'm frustrated, when I'm bored, it alleviates feeling states. And so we have to begin to figure this out. And once we figure out particular external triggers or relational triggers, like when I'm with certain friends, we wanna avoid those. And we wanna think about developing other kinds of social supports, for example, that are not using friends. And often depending on how long this has gone on for substance use disorders are a lot like anxiety disorders. They build a house around themselves, right? So the person has divested themselves of non-using friends and divested themselves of people that are less associated with the use. And so we need to bolster and help them to find different kinds of relationships. And we wanna try as much as possible to avoid triggers that are possible to avoid until the person has more success in managing urges, until we know what their thoughts are in the situation where they're in the presence of a trigger and we can do something about the thinking that they're doing at that time. I've done all kinds of things to help people picture that. I look at red light, yellow light, green light, what kinds of social situations are easy ones to manage versus cautionary ones, versus stay away from that for right now. And you can find ways of navigating that early in treatment that help. So often one of the useful things to do is to put together a diary card. And a diary card is really, it's actually used in something called dialectical behavior therapy, but what it is is a recording device that has the person begin to record what time, what happened that was the trigger for the urge and the strength of the urge. Now, depending on how much the person's ready to do, I'm gonna have them record other information once they get good at this. How long did it take from the urge to the time when they used? What did they use? How much did they use? And was there a trigger that occurred once the use had started? Because particularly over time, one of the things that we find out is that a lot of times people will have a slip and then the trigger for use once they've started is a cognition like I've screwed up or I deserve this, or I just need to do something to cope so that we're starting to find out what thoughts are that continue use once the use has started. And so we begin to get people to just observe and use diary cards. And that helps us to put together a picture of the kinds of things that are the high risk situations with this person and the kind of thinking that they do in the presence of use. Here's some more diary cards of Min Zay. And so as we assemble these, what we wanna do is to begin to look at triggers and consequences. And so the triggers might be a certain event that's occurring interpersonally. Kids are getting ready to go to bed. What's my internal reaction? An internal reaction could be emotional states, could be thoughts that the person's having. Here I have them both depicted. What does the person do? And what's the positive and negative consequence of use once they do it? So that we're beginning to build a framework for this person and for ourselves about what kinds of things we have to work on to help the person to be more motivated to stop using or to be more successful to get rid of the maintenance factors for their use once they do stop. So we develop a hierarchy. Again, easier things to avoid to the hardest things to avoid in terms of triggers. And then we wanna develop a written plan with the person about how to manage the most common ones, right? And we need plans for each one that you identify. So we sometimes can identify distractions that the person can use or coping statements or avoidance for right now. We can have them behave differently in the presence of the trigger. If the person's also in 12-step treatment, we can have them call their sponsors. We can have them picture the future if they are continuing to use or if they stop using. We can have them remember past negative consequences. But one of the things we have to be able to help them to understand is that it is possible to not give in to an urge. That it is possible to accept the desire to do something without doing it. Because coping with the desire is what actually distinguishes using and not using. So remember, these were her triggers. And if we came up with some very common ones, what we might do is to come up with some other things that she could do that would help her to avoid use. So it might be that she would stay with her kids in the evening instead of being by herself in the kitchen while her kids went upstairs. We might find some other activities that she could engage in after the kids go to bed that she likes a lot. We might help her to cope with her sleep fears. That not falling asleep immediately is actually normal. And to use particular tools to help her with that. We might help her to plan some activities for the weekend when she's gonna be alone, not with the kids that are away from going to the liquor store that delay or find other pleasures that she might engage in. Or that are incompatible with drinking. Those are the best kind. If I can find things that the person really likes to do that really don't work very well if they're drinking, then that sometimes is a real bonus. And we wanna have the person keep in the mind, in the front of their mind, the reason that they want to stop using. Now, we mentioned that coping with urges is really important and so that we need to help the person recognize what the urge is, how it feels to them, and really practice not doing it. Delaying, urge surfing. And we have to really understand what they believe might happen if they don't follow the urge. And because we might need to have them actually test out whether that's really true. The range of things is that I just won't be able to stand it to, I might just lose my mind. I'll be so anxious. I won't be able to be rational any longer. And so we need to help people understand that their ideas about urges could be realistic, but also could be unrealistic. And that humans have unrealistic ways of thinking about things that sometimes makes that things more difficult for them. So for example, we might talk about other kinds of urges that they might have, and I use scratching or if you have bad poison ivy and you know that scratching is going to make it much worse, how would you deal with that? And look at other examples of that in order for them to help marshal strengths that they might have to navigate this. With Ms. A, I might talk about how did she manage the desire to use when she was pregnant and what distinguished that time from now. And so this leads to the beginning of looking at not just external but internal triggers for the urge to use. That sometimes it isn't just actual physical situations or being in the presence of certain actual cues. The cues are our internal thoughts or emotions or physiology. Sometimes the cue to use the urge is a withdrawal symptom. You know, obviously we have ways of navigating that pharmacologically. And sometimes there are particular emotions the person has that stimulate the urge to use. And so that leads us to a treatment plan about that. And sometimes there are particular problematic thoughts the person has. And sometimes they're in categories that are typical. One typical problematic automatic thought that we have to navigate is what the person might expect about a situation when they're not using. So if I go to this Super Bowl party and I don't have a drink, I won't have any fun. Everyone else will be having fun and I won't have any fun. Or if I go out socially with my friends and I don't have a drink, I won't be able to say anything. I'll just be so anxious that it will be terrible for me. So that's one category that we might have to look at. Another is permission giving beliefs. You know, I really deserve this. It's been a terrible day. I screwed up, so that's the overreaction to slips is the third one is I screwed up so that I might as well just keep doing it. That's another cognition. And sometimes beliefs about the self that are negative it's another set of triggers, you know not just that I screwed up, but I'm a terrible person and I don't deserve to be treating myself well and I might as well just drink. So that those are problematic automatic thoughts. So we have to teach people that triggers are normal and that triggers for urges are normal in this particular problem. And that what we have to do is to do things to manage the urge and the trigger whether it's internal or external. And part of that is evaluating the thoughts that you might have. So we have some good plans for Ms. A and her triggers. And some of them are not just external events but they might be criticism. They might be thoughts that the person has about other people. And so we're very carefully coming up with other things that can happen that is not about giving into the urge. We also need to look at what happens in terms of positive or removal of negative consequences once the person uses and then work to remove these. So, and many times it's looking at thoughts that lead to use. So how do we do that? We do that with a standard way of looking at thoughts called a thought record. And the thought record is really just a device that we use to help the person to identify thoughts that occur just before a particular problematic behavior or before a very, or just after a very strong emotion or urge. And then what we wanna do is to look at the thoughts in terms of how logical they are. So one thing we can do is just remind ourselves of the consequences of use. But it also may be the case that looking at evidence about the thinking might be helpful. And what we wanna do after we come up with evidence about thinking is to come up with a more logical response to the thoughts. And once we have a more logical response to thoughts, particularly because we tend to think in patterns and our automatic thoughts tend to be fairly similar in problematic situations, we wanna practice those new ways of thinking when we're having a difficult time so that when we are having a difficult time, we have some of those new thoughts available. So here is a thought record. So what's on a thought record, and we have to teach people how to use these and how to do that is beyond the scope of this evening, but it's very available in any standard CBT kind of book, is we teach the person really to, at the time of a strong emotion or the time of a strong urge to ask themselves, what was just going through my mind? And so, and we teach them to record the thought that they have at that moment, as well as what was going on that led to that thought. So sometimes the situation is having a thought. So here's Ms. A, she's thinking about her boss criticizing her in the car on the way home and feels this very strong urge and very strong anger at the time. And when she asked herself, what was she thinking? She says, I'm fed up. I deserve to relax. Life is just too hard. I need a drink. It's the final common pathway here. And so part of what we want to do is to take a look at how accurate all these thoughts are or how functional they are by thinking through the drink, reminding yourself of consequences, looking at the evidence and beginning to come up with other ways of thinking in this situation. And so the person does some information gathering and evaluates this thought. He's able to say, well, life is really challenging and I do deserve a break, but there's no evidence that drinking will give me that. And then what's a different way to think in that situation? Well, if I think in that situation, when I'm thinking about the boss criticizing me, I can say, I can go home. I can do some other things that make me feel good until the urge gets better. And if I try that, I might feel better about myself and I might feel less of an urge by doing this. Another set of thoughts might come about when the person violates the behavioral contract they have with themselves. So she has two drinks at a bar and feels mad and sad and ashamed. And the thoughts that she might have and you wanna take these on one at a time, right? I'm a complete screw up. I'll never quit. There's no use. It's not fair that I can't drink like other people. And that's often a big driver. Other people can do this and I can't do it. It's just not fair. And the answer to that is, well, yeah, that's true, but it doesn't make it any better if you use. So again, looking at the information, I've messed up my plan today. That's a fact. There are other things I've not screwed up. So I'm not a complete screw up. I've been sober for four days this week. And yes, it's true. It's not fair. It might not be fair, but that doesn't make it any less a problem. And I need to go home. And you can see that there's a difference in the degree to which that she feels something and it might curtail from going from a lapse to a relapse. We also can use behavioral experiments, that people tend to overestimate how much fun being intoxicated is. I used to have such a good time when I was drinking. And so you might help them to observe that in other people. You might also have them begin to start to look at what makes them feel joy and pleasure when they're not intoxicated and begin to rate their degree of enjoyment because they might need to tune in to more pleasurable sensations that they're developing in developing new behaviors for pleasure. And it's also important that we help people to understand that what's normal in when you have had difficulties with substance use, it's normal that your sense of enjoyment might be tuned down because that's just how the chemistry works. And so that over time, the longer you're without the substance, your capacity for joy, your capacity for pleasure is likely to change. Finally, part of what we need to think through are emotion-focused triggers. Often, these are individuals who have limits to their ability to express emotion. Often they have not developed good distress-tolerant skills or frustration-tolerant skills. And we need to teach them those if they're absent. And I will refer you to the skills training manual that Marsha Linehan has put together for borderline personality disorder. This is not to say that these are folks with personality disorders, but one of the things that Marsha's done in putting that skills training manual together is to put together a wonderful manual of the psychological skills that everybody needs. And people get some of them and not some of the others. And so if we need to teach the person to regulate their emotion and tolerate distress, there are some wonderful exercises within those books to do this. We need to help people to overlearn to say no. And this is right out of smart recovery, frankly. Because frequently, and particularly if somebody is not very assertive and they have friends who are accustomed to them going out to have a drink, for example, the thing that will often happen is that their friends will say, oh, come on, it's Friday, let's go to the bar. And the person will say, I shouldn't. And that's not the same saying no. Because once you say I shouldn't, the friend says, oh, come on, you can just have one and it'll be just fine. And that's quite different than being able to say no in an assertive kind of way. And often what I will do is role play this in session so that we can come up with the thoughts or the emotions that the person might be having during the time that they're refusing. Often it has to do with other people, what they might think about them if they say no. And so we have to go through that exercise and get the person to practice. I've already mentioned this. It's the idea of navigating skill deficits. And what we need to do is to look at what skills the person finds that using replaces. And from the conceptualization of their development, we need to figure out whether some of those need to be trained. Now, often assertiveness is one of those. And assertiveness, particularly with family members can often be an issue. And so the person who uses sometimes avoids a skill with use. And so here's a situation with Ms. A, she's not very good at saying no, particularly with her family. We know her family does a lot of drinking. And so part of what we would do is to really role play ways for her to say no. And relational aspects are really important. Figuring out how to have more balance, more interest as a part of our treatment planning, cultivating new activities, finding other supports and places where you can be in people who are not using. One thing that we know is that the more we can use contingency management, that can be effective, particularly with opioids and cocaine, particularly on a variable reinforcement schedule. It's complicated to do that, but in treatment programs, it can be really useful. We know that it works very, very well. In the UK, they actually pay people with grocery cards for clean urines and that works real nicely. But again, they're hard to administer. And finally, last but not least is preventing relapses. We need to overlearn with the person risks and have a plan of action. What are you gonna do? What are the warning signs that you might be getting into trouble? What's a lapse? And what would you do if you had a lapse? And how can you stop it there versus continuing to use? And so one of the things about this is overlearning calling for help. If use occurs again, frustration, anger, and interpersonal issues are often way high risk situations for relapse. And so we would write out warning signs as we got to the end of treatment and what coping strategies would occur as we had those warning signs. And those kinds of environmental cues are the things that we begin to look at when relapses occur, when lapses occur so that we can really go back and learn something new every single time that happens. I've given you a couple of pictures of references and these are both really wonderful handbooks that the smart recovery handbook is like $12 and you can get it on Amazon. So these principles are very clearly outlined in both of these books and neither one of which I've written but I've certainly enjoyed both of them and they've both been very helpful to me. And these are probably things that you've seen before and I don't need to promulgate but I've found that all of these websites are really very helpful and the Rethinking Drinking pamphlet has been very helpful to a number of my patients as well. So with my thanks, I will stop there and unshare and I'd be very happy to take questions. Okay, well, thanks so much, Dr. Sudhak. That was a great talk, very informative. I think a lot of that can be kind of readily applied to our clinical work as addiction psychiatrists which is one of the main goals. I'll start with just kind of letting you know one of the comments from Dr. Marienfeld who I work with here at UCSD. Just appreciating you clarifying positive versus negative enforcement and she was saying it's worth repeating endlessly that the negative means removing something bad even though we often think that it is something bad. And I'll just kind of comment in my work with patients. I don't really use, try to get caught up in positive negative reinforcement because I think it just makes it more complicated for them. But I find that describing that concept to people when they hear it, something kind of clicks and they actually feel like I kind of get them and that they're using the experience makes sense to me and it's actually kind of enlightening. So I think not only for us to know to understand that principle but for patients as well. I don't know if you have anything else to add on that point. Yeah, I actually use the annoying noise on the seatbelt as a good illustration of negative reinforcement. So if you don't put your seatbelt on and it goes ding, ding, ding, ding, ding and then you put your seatbelt on you've just been negatively reinforced. I like it, okay. Chris looks like another long question came in. You want to take that one? You can take that one and then I'll go next. Okay, so super helpful. Do you think that especially in substance use disorders there is an opposition between patients and providers in how we or they view the thought, emotion, behavior connection? It seems that patients with substance use disorders often view thoughts and feelings as the outcome slash result of the behavior, example, substance use and thus see their thoughts as less of a manipulable operant and more of a response to the behavior. That was the first part of the question. Right, so I actually think that there are two sets of thoughts and emotions that are worth navigating and that those are the ones that the person has after they use and the ones that they had before. And that sometimes we don't get to the ones they had before right away. It's more about what happens after. The other thing I think that we have to remember is that we often start out with the mindset that the substance use is the problem. And for the patient, the substance use is the solution. And what we need to figure out is what was that solving and how could that be solved differently? I mean, and so in a lot of ways, that's a lot about what I do in general. So for example, if somebody has got an anxiety disorder and they avoid things, the avoidance for them is the solution, right? Even though it's continuing to make the problem worse. And this is a very similar paradigm. I don't know if that answers your question. That's sort of what I would say about it. I think so. Give me a moment. There's kind of an additional, this is a long question. So I kind of broke it down. Let me just see if I think that added. Is that if so, how do you bridge that paradigm gap or convince the patient of the contrary? And does this need to be done before moving forward with thought logs and identifying particularly problematic thought processes? So from my point of view that before we get to thought logs, it's really important to get the person to look at the advantages and the disadvantages of their use. And sometimes those will be thoughts that the person has about using or not using. But I may not take those on until I get the person more motivated to that this is something they wanna change. So one of the questions that I had is that motivational interviewing is such a prominent technique that's used in addictions. And how does that jive with CBT? Are they mutually compatible? Can the spirit of MI be used in CBT sessions? It's completely compatible. In fact, there are several books written about doing them concurrently. And I think that there's a little bit of a difference in terms of, and there's often debate in CBT circles around this about the patient setting the goal when in fact something is happening where it's really clearly deleterious to the person. How responsible are we as therapists by not saying, listen, this is really bad for you. But I think that part of artful motivational interviewing is guiding the person to see the bigger picture, what kinds of things they value and what they're missing out on as a result of this. But I think motivational interviewing is something that I do. And in many of my patients with OCD, with eating disorders, with lots of other problems, because clearly the investment in continuing to do what they're doing is pretty high. And we have to look at the cost that it has because the treatment itself looks daunting and painful. One other question is you may not be dealing with this as much in Pennsylvania as we are in Oregon and California, but how cannabis has affected things in terms of your practice of psychotherapy and CBT. Well, we don't legally have it in Pennsylvania, but it is as prevalent. And this is a very big social experiment that we're doing here. And I have my own opinions about this, and we don't have another hour, but I do think that it's affected people tremendously because of the social experiment, people see this as a benign thing. You know, with some frequency, we'll get patients who say, well, I'm using, how's my medical marijuana card use gonna affect my antidepressant levels? And well, you know, it's a natural substance. It can't possibly be harmful to me. And so there are lots of beliefs about it that are fairly significant. And frankly, I think we've done a bad job educating people about that. If we had had the chance before cigarettes were manufactured to tell people what the health effects were before they became something that was out in the public, wouldn't we have wanted to do that? I mean, we've done an extensive after the fact campaign, which has worked about tobacco use. But we have done a very poor job of educating people about the mental health effects of cannabis. And I'll leave it at that. Otherwise I'm just gonna get hot and bothered. Well, but again, I think what you're alluding to is that I would suspect that the efficacy of psychotherapeutic modalities would be decreased when there's heavy cannabis use. Is that consistent with your experience? Yes. Well, anything that provides, anything that allows for avoidance, right? I mean, that's really part of, if I could like tattoo things on the backs of people's eyelids, it would be avoid-avoiding because most of the time that's what's causing the problem. And it's in one form or another. And I think there's one more thing is that if possible, could the name of the skills training manual book be put in the chat? Sure. I can do that, but I can't do that and talk at the same time. But it is the skills training manual for borderline personality disorder by Marsha Linehan. And so, and there's lots of great stuff online about that. And there are YouTubes with different psychological skills that you can find that are quality ones. So that you can use to help educate folks about it. Okay. Well, I, oh, there is another one down here. How do we educate, how do we educate our colleagues psychiatrists while also promoting medical marijuana? Sorry, let me, let me. Well, there's one above that. We have one above that, sorry. How do you address the convulsive or habitual aspect of substance use through a CBT framework? Do you sometimes have to be more strictly behavioral in your approach if someone goes offline and finds themselves using before they even think about it? So sometimes it involves getting in a time machine because nobody uses without thinking about it. It's just, it happens so quickly, right? And so they don't catch the thought, but often what you're doing in that circumstance is having people avoid particular triggers until they get a better handle on what their thoughts are about that or planning for particular triggers. Some of the particular behavioral approach as we look at this, and if you looked at the planning for triggers that we had done with Ms. A, some of those were how to act differently in the face of the urge rather than what would you think about here? It's really, so some of those things are within the behavioral paradigms. And for many people, it involves lengthy periods of staying away from the possibilities for use. Well, thank you so much, Dr. Sudhak, for this really informative lecture and passing on a lot of your wisdom. We're grateful that you took the time to help us out. And these lectures will be recorded and archived so that others can watch them in the future. And for everybody, we look forward to you joining us next month, where we'll be talking about narcissism, which is a very prominent personality characteristic in patients with addictions. So thank you again, Dr. Sudhak, and we'll see you guys next month. Thanks for having me.

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