Good afternoon, everyone. Again, I'm Dr. David Stifler. On behalf of the American Academy of Addiction Psychiatry and SAMHSA, I want to welcome you to today's webinar in our series on Advanced Addiction Psychotherapy, which is a monthly series focused on evidence-based intensive psychotherapy training for addiction psychiatry fellows and faculty. This is hosted in partnership with Oregon Health and Science University and New York University. We're excited you could join us today and to offer you these live trainings that will be held on the second Wednesday of each month from 5.30 to 7 p.m. Eastern Time. Today's presentation is on Advances in Cognitive Behavioral Therapy for Addictive Disorders with a focus on content and process. Our next presentation will be in March when Dr. Irina Nguyen will talk about emotion-focused therapy. Please check out the AAAP website for updates on other upcoming speakers. Thanks, everybody, for joining. Once again, I'm Chris Blazes from Oregon Health and Science University. Today, we're very grateful to be joined by Dr. Bruce Lees, who is a PhD and is a professor of family medicine, community health, and psychiatry at the University of Kansas Medical Center. Dr. Lees has taught more than 100 courses and workshops on addictions, psychotherapy, and evidence-based practice and supervised hundreds of psychotherapy trainees. Dr. Lees has more than 75 publications. He's on editorial boards of three APA journals and has co-authored three texts on addictions. His most recent text, Cognitive Behavioral Therapy of Addictive Disorders, was recently published in 2022 with a co-author of the creator of CBT, which is Dr. Aaron Beck. In addition to all these ongoing activities and publications, he also has the time and continues to see 25 patients per week. I think that a combination of research with clinical practice, with where the rubber meets the road, is a rare combination. We're grateful that you're here to teach us more about CBT and addictions. Thank you, Dr. Lees. Thank you. You can hear me well, I assume, and I can share my screen now. Please let me know if it's clear and up there and looks okay. Terrific. Well, it is a pleasure and an honor to be here. I was thrilled to be asked to be involved with your organization and really appreciate the opportunity to disseminate the things we've been working on for decades now. I think the hardest thing about doing research is that so much of it isn't disseminated, and hopefully what I present today will be of real value. So, yes, my name is Bruce Lees, and you see here where I work. If anybody wants to reach me, I'm very easy to reach, blees at kumc.edu. I do like to disclose that I have co-authored several textbooks with Dr. Aaron Beck, and they are published, and the most recent one, which was mentioned a moment ago, is the most recent, and I do receive royalties for the sale of these books. So, I'd like to begin, since the title of this presentation is Advances in Cognitive Behavioral Therapy, I definitely would like to begin where we began our journey in studying and treating and working with people with addictions back in 1993. Drs. Beck, Wright, Newman, and I were fortunate to be able to put a book together that was used in research on addictive disorders, and that was back in 1993, and I always enjoy describing what we have learned since then because there's so much. Back in 1993, I don't know if you can see me now. I look the same in this picture as I did 35 years ago. No, I don't, but that's my dear friend, Dr. Aaron Beck, and his study many, many years ago. So, back in 1993, we were in the midst of a cocaine epidemic. Crack, in particular, was the focus of everyone's attention. It was described as the greatest threat to the United States. Nobody questioned our labeling, and when I say our, I mean pervasively. People who used drugs who were in trouble for their use of drugs were called drug addicts. They were people who drank too much were called alcoholics. I don't even think we used the word stigma back then, but it was clearly stigmatizing. The stereotypes back in 1993 were ubiquitous. People were viewing people with addictions as having every problem in the book, financial, social, interpersonal. People's problems were attributed to all the wrong things like race and religion and you name it, social class. If somebody looked like they were a mess, they might be drug addicts. It was unfortunate, to say the least. We were at that time using DSM-IV, where diagnoses were abuse and dependence, and probably more importantly, you either did or did not have a diagnosis of addiction back then, and again, it was called abuse and dependence. Back in 93, each addiction was considered unique and different, and each was stereotyped, so if you were a cocaine addict or a heroin addict, that was much worse than being, and again, I'm using this terminology because that's what was being used in 93. Back then, boy, you were the worst of the worst, smoking what we then freely called marijuana, now cannabis. If you were smoking weed, that wasn't so good, but not nearly as terrible as if you were a heroin addict or a cocaine addict. Alcohol and nicotine, pervasive, ubiquitous, if you got in trouble with those things, it wasn't quite as bad. At least that was the idea back then. The sole aim of treatment back in 93 was abstinence, and we were focused predominantly on relapse prevention, which you could also think of as just trying to get people to avoid an acute relapse, so we were totally focused on the drugs. There were also real problematic misconceptions of cognitive behavioral therapy back in 93, so besides misconceptions of addictions and people with addictions, misconceptions about CBT, that it was superficial and mechanistic, that it focused only on symptoms, it ignored personality, we weren't concerned about early life experiences or interpersonal factors or the therapeutic relationship in treatment, we ignored motivational issues, and when I say we, it was a misconception that was spread widely, including in academics, and so a lot of people were pulled to cognitive behavioral therapy because they understood it to be a panacea, one size fit all people, all problems. If you were depressed or anxious or had any kind of problem, CBT was going to be the cure. Again, those are misconceptions. You'll notice in the bottom, usually the left-hand corner, I include references, so my friend and colleague back then, Vicky Guhosky, wrote a good article in 94 in the journal Psychotherapy on Misconceptions in Cognitive Therapy, but let's race to the current day. Today, we understand through the many changes and advances that we've gotten to observe that, well, unfortunately, we are in the midst of what some people are still describing as an epidemic, and when I say it tentatively, it's because people vary in whether or not they're viewing the current problem with opioids as an epidemic, but clearly, the use and misuse of opioids is problematic today versus cocaine back when we started. What's interesting is that alcohol and nicotine are still, I believe, among the most dangerous of substances that are used, and clearly, they contribute to the greatest morbidity and mortality. Today, when I do the work I do, because yes, I still see 25 patients a week and have for over 40 years, people mostly come in to talk, when they do come in to talk about addictions, it's generally to alcohol or to tobacco or to nicotine products, so again, the high morbidity and mortality rates with alcohol and nicotine, I would say, make them among the most dangerous. Of great interest to all of us should be that cannabis accessibility is introducing a whole new set of problems that we, as experts in addiction, need to pay attention to. Today, we're more aware of stigmatizing behavior and language. We have extensive data to refute the stereotypes that were pervasive back in the day. Everyone, obviously, in this meeting today is aware of the changes from DSM-IV to DSM-V. It's hard to believe that craving wasn't one of the diagnostic criteria, but in DSM-V, thankfully, craving was added. Thankfully, legal problems were removed because they only affected a minority of people who were having problems with addictions and generally marginalized groups of people, so craving added, legal problems removed. Of great interest to me, and I hope to all of you, is that behavioral addictions were recognized, of course, with attention paid to gambling and to internet or online gaming, in particular, with it being in Section 3 of DSM-V, and something that is controversial. I'll reveal my prejudice. I think it's great that now diagnoses are on a continuous scale, mild, moderate, and severe, because we can work with people who say, do I have an addiction? And we can warn them, kind of like pre-diabetes, we can say, you know, you are really at risk. What you have now would be considered a mild addiction. Again, what I'm doing here is talking about advances by way of talking about changes that have happened to the world, in the world, of substance use and also behavioral addictions. So today, we realize there's more to treatment than preventing relapse, and it's understood that patients should determine their own goals. Back in the day, we understood that we knew what was best for patients, and that they should do what we want them to do, which is to stop using, and they'd be better off, and their lives would be much greater. MI has contributed to emphasis on collaborative therapy process, and again, the other part of the title of the talk today is that process is very, very important in the treatment of people with addictions, and I was raised, I went to the same program that Dr. Carl Rogers cut his teeth in at Columbia University Teachers College. I was really relieved when motivational interviewing was introduced, and we started talking again about really patient-focused or client-focused treatment. So that was kind of a quick discussion of what it was, what it is in regards to addiction. In 2022, we came out with this book, a book that I'm very excited about and proud of, and it's being now used in many, many psychology programs and treatment centers, the Cognitive Behavioral Therapy of Addictive Disorders. It reflects what I hope we are doing today, which is, and anyone who identifies as a cognitive behavioral therapist, I hope is being in their work, being flexible and prepared to hear profoundly complex problems, profoundly complex problems. As they say in various circles, if you've seen one person with addiction, you've seen one person with addiction. So besides focusing on addiction, it's important for us, those of us who care for people with addictions, to pay exquisitely close attention to coexisting mental health problems, personality, context, culture, and much more, and I'll talk about that throughout this 90-minute presentation. It's important for us to conduct and share with our patients careful, thorough case conceptualizations and to include early life and cultural experiences, and treatment should be based on the case conceptualization, and I'll talk again in detail about that. It's important to us, following up on that word, CC, case conceptualization, it's important to conceptualize when we're helping people with addictions and address interpersonal processes, extremely important because people, the people we see and care for with addictions have ruptured so many relationships with people in their lives that helping them to look at those relationships and addressing interpersonal relationships is vital. Attending to the therapeutic relationship, I would call that number one concern, and then emphasizing this centrality of motivation. What makes you want to use, and what are the emotions, the feelings that you may not even know about as long as you're using? So in thinking about that transition and how we got there, I was the head of the arm of the NIDA collaborative study of cocaine addiction, and from that study on, we learned so much about what people were doing wrong when delivering cognitive behavioral therapy. In addition to the misconceptions I talked about earlier, the functional analysis, which again I'll talk about a little bit more in a little while, the functional analysis is a careful consideration of what happens before, during, and after you use, not just to say, oh, you use, let's get some strategies for you to stop, I know you must crave, we have to help you figure out how to serve those urges and cravings, but in more detail, what happens? By the way, you see asterisks in this slide. That's because these are right out of a study by Kim Holland and Altagene that in the journal Psychotherapy back in 2016, these were actually found to be the most common CBT errors. So, the first errors I show you are from that article, clearly things we saw in both supervising and treating and researching cognitive behavioral therapy, people not asking enough questions about the experience of using, leaving the patient behind, wanting to teach cognitive behavioral therapy before the patient is ready, over-focusing on cognitions or behaviors, let's talk about what you're thinking, let's talk about what you're thinking, let's talk about what you're thinking, excessive focus on that, and even excessive focus on feelings without regard to the thoughts or the behaviors or the origins of some of the thoughts and the behaviors. So, a good cognitive behavioral therapist is well-rounded and knows the importance of paying attention to the whole person, not just their thoughts or their behaviors. Over-reliance on the alliance. We discovered that we actually had to release people from studies, therapists from studies, who believe that all they needed to do was to form a good relationship with a patient and develop trust and nurturing and be real positive, and if a therapy session felt good, then the therapy session must have been helpful to the patient. That's over-reliance on the alliance. The rest are some that are not in the article, definitely in the book, that have to do with just observations from teaching and supervising cognitive behavioral therapists, over-relying on one's preferred techniques, advantages, disadvantages, analyses, for example, or urge-surfing, just picking a technique and overdoing it, and often that's based on a person's home theory. There's also, most addiction psychologists, psychiatrists I know also treat people with depression, anxiety, bipolar illness, etc., etc., thought disorders, thinking that we're not seeing people with addictions right there in the room with us, when maybe we are treating depression, anxiety, and there are addictive behaviors that are contributing to them. Missing vital opportunities to focus on process. In 40-plus years of providing treatment, I crave those aha moments where the patient says, wow, I never thought of that, and oftentimes it's when we pay attention to something that's happening in the session between the patient and I. A profound problem. If you have an addiction, it's highly likely that it's difficult to focus on your goals, your dreams, your hopes, your aspirations. It's easy to jump around and not really know what's important because the substance or the behavior you've been engaging in becomes so important that wandering is a real problem. A great therapist is able to redirect people who are in their care and do that wandering, and there's a real reluctance of a lot of therapists to violate social convention, and they're fearful that, oh, I don't want to interrupt the patient, but our patients can go on and on about things because of experiential avoidance, not wanting to suffer or feel pain. You can spend a 50-minute therapy hour and have very little real substance occur if you don't redirect, and yes, interrupting is an uncomfortable part of the exchange, but inevitable. So that's just an overview of what a good cognitive behavioral therapist will will be thinking, but for this to be a meaningful presentation, it's important for me to talk about what CBT is. CBT is an umbrella term that includes all of these other so-called other therapies. I use the term so-called because they aren't other therapies. They're all cognitive behavioral therapies. They all focused on thoughts. Now, Dr. Beck, Aaron, or as his friends knew him, Tim Beck and I were having dinner one night, and he said to me, I said, where do you think cognitive behavioral therapy will be in 10 years? This was 30 years ago, and he said, I hope cognitive therapy, actually, we were talking about cognitive therapy because that was the brand name back then for us. He said, I hope it doesn't exist anymore, and I said, Tim, what do you mean you hope it doesn't exist? And he said, all good therapy looks alike. This is a phrase that I have never dropped. There's never a presentation I make where I don't emphasize it. All good therapies look the same. We just published a study on supportive expressive therapy combined with cognitive behavioral therapy and experiential therapy, a study we published treating veterans with very severe depression with suicide and alcohol problems. When you put all the therapies together and acknowledge that they all have value and integrate them well, you're doing good therapy. These are all cognitive behavioral therapies. But Dr. Beck also said to me, if therapy is going well, it is cognitive behavioral therapy. Because even as you know, many of you who know his history, he came from psychodynamic, the psychodynamic world. And he said, all good therapy looks the same and all focus on the way people think, how they feel, how they act, what their background is, how they suffer now, how they suffered then, and you understand. So this is a graphic I spent one long, long night playing with. It's the house that CBT built all under one roof. The focus of those, there were just letters there. ACT is acceptance and commitment therapy. DBT is dialectical behavior therapy. BA is behavioral activation. REBT, rational emotive behavior therapy. Cognitive therapy, exposure and response prevention, mindfulness-based cognitive therapy, and contingency management. These all focus on different aspects of how people think and how they feel and how they act. And to be good at what we do, it's important that we don't join a camp, claim it's different from cognitive behavioral therapy. Oh, I'm an ACT therapist. Oh, I do DBT. I don't do cognitive behavioral therapy. If you do any of these, you do good cognitive behavioral therapy. And guess what? If you do good cognitive behavioral therapy, you also do good emotion-focused therapy. And if you do good cognitive behavioral therapy, you also do good psychodynamic therapy, because again, all good therapy looks the same. So the problems of our patients are complex. They don't just have addictions. They come to treatment to make cognitive behavioral affective changes, to feel less sad, less worried, less angry, happier, content, fulfilled. They come for all these different reasons. Some just come because they feel so alone. Some come because they want to end the pain they associate with living. So to start out with the assumption that people come to see us to do the work that we can direct them to is, I think, a mistake. This is one of my favorite, favorite, favorite graphs, charts in all of history. In 2019, this is just to reflect the complexity of psychotherapy, of all psychotherapies. This was a study that was done many years before 2019, where you can see that cognitive behavioral therapy and interpersonal therapy did quite well in treating depression, according to the Beck Depression Inventory, over 14 sessions. Look at that nice little downward curve. Everybody changed significantly. Isn't that beautiful? Proves that people aren't complex. Therapy isn't complex. You just give them a good dose of CBT, and they're all better. Well, what Lund did that was unique and brilliant, published in the Journal for Person-Oriented Research, was to break down each of the 14 sessions, not break them down, but get the scores from every single patient, all 30, for every single session. And this is what the course of therapy really looked like. Good reflection of the complexity of therapy and the people who come to see us. Again, advances in cognitive behavioral therapy require an understanding of the complexity of all therapy and the fact that no one therapy fits all patients. Some people do benefit from changing their thoughts. Some benefit from accepting what they can't control. Some patients need to activate and commit to valued behaviors before some. And actually, most patients benefit from some combination of all of these things, rewarding themselves along the way, becoming more mindful, etc., being exposed to their triggers, being able to go to an event after work where other people are drinking and they aren't. Now, no presentation on therapy would be complete without nodding to the research on therapist effects. Again, all good therapy looks the same. Cognitive behavioral therapy is not superior to other therapies. What it does is that it provides a breakdown of what is process, what is the content, what are some techniques, when is it time to educate patients. Those are the advances in good cognitive behavioral therapy. But therapist effects, the effect of you, the human being, not you, the therapist. Therapy outcomes vary substantially across studies. In one meta-analysis, when I say psychotherapy outcomes, I mean it's not like a drug treatment study where an antibiotic has pretty much the same effect across all studies. You can do a study of two treatments in 10 different settings and get one, two, three, four, five to 10 different outcomes. A lot of that is because of differences in therapists, the actual human being themselves. One percent, it's been found in this study by Johns et al in 2019. Again, this is all important to understand, to understand cognitive behavioral therapy. In some studies, only one percent of outcome was attributable to change in patients, improvement over time. In other studies, as many as 29 percent of outcome is attributable to the individual therapist, not the treatment condition. You don't get that with antibiotics. So, it could be because of the research methods, but also therapist characteristics and their caseloads and where they work and their treatment-related variables. So, therapist characteristics, again, therapist effects are important whether you're doing psychodynamic therapy or emotion-focused therapy or interpersonal therapy. Therapist characteristics include how efficient the work feels to the therapist. This is part of this study and just a reality as I understand it. The therapist's own coping skills, the therapist's own interpersonal like facilitative skills, humility, ability to withstand practice difficulties. And here's a real clincher. In 2005, Brown and colleagues took the most effective therapists in a study and the least effective and the most effective therapists, 71 most effective based on outcome scores versus 210 where symptoms didn't change much. And the highly effective therapists in the middle column, well, yeah, it's the middle column, they had the same approximate number of cases, 25.4 versus 26.9 with approximately the same patient mean intake score. But when you separated the effective therapists, regardless of their treatment model, regardless of whether they said, I am a cognitive behavioral therapist, the mean change score was profoundly different. Well, statistically different, but also profoundly different. So, highly effective therapists at the end of treatment on average had their patients leave therapy with a depression score of 10 versus only three when you took the 210 therapists that didn't do as well. So, and people who went to therapists who are more highly effective ended up having more days in treatment, stayed in treatment more. So, now let's get to the meaty part of the presentation. Thankfully, by my watch, we still have quite a bit of time left. Good. So, cognitive behavioral content process promised in the subtitle of this talk. Content is what is being discussed for the purpose of facilitating change. And I'll explain that versus process, how change is facilitated in this session. So, you have you have, well, like I said, I'll explain it. Content and process, what versus how. So, the person's presenting problem or their symptoms provide the content. If I'm here to see you for addictive behaviors, hopefully you'll talk to me about addictive behaviors. You won't start out and persistently ask me about how I was treated as a child. You will ask that where it's relevant, but you won't start there. You won't start with depression and anxiety. At least the presenting problem should provide a context, at least for the initial conversation. So, content is driven by patient symptoms. Again, content process itself, what is of much more interest to me in all current therapy models is the components of therapy. So, the content is, again, likely to be impacted by what the patient says the patient is upset about. The process, the essential components, there are only, I smile when I say this. I don't know if you can see my face. I am smiling. The components, the process of therapy, there are five essential components. If you do therapy, you do these things. I'm going to say it again. If you do therapy, if you identify as a psychotherapist, besides the other things you do, med management, etc., you do these five things. You structure the time you have together. You don't just willy-nilly say, oh, it's a nice day. It's supposed to be a nice day Friday. Let's meet in the park. I'm not sure when I'll get there. I'm not sure how much time we're going to spend together, but let's meet at the park and we'll hang out and I'll help you. Every therapist structures sessions to some extent. Every therapist, I hope, aims to be collaborative and align with the patient. Every therapist, and by the way, I include alliance there. I've had the great honor of working with people like Paul Kritz-Christoph and actually doing research with them, Jacques Barber and others who we studied together, the difference between cognitive behavioral therapists and supportive expressive therapists to look at the collaboration and alliance. All people, and Lester Laborski, all people who do psychotherapy are concerned about the alliance, the collaboration between two humans. Case conceptualization, which I will talk about to a larger extent shortly. We all have to, to be effective, conceptualize our patients. Again, I want to remind you, I have CBT process up here because I want to live up to my, the title of my talk, which is advances. These things were not things we really focused on in 93 or even in 94 or 95 or even maybe in 2005, but much more attention to structure, collaboration, case conceptualization, psychoeducation, and standardized techniques. You notice standardized techniques is at the bottom because they are of little value without a good understanding of the case conceptualization, without some psychoeducation so that the patient understands what the techniques are for, what the purpose is, certainly without an alliance. When the questions come, I'd be interested if anybody here thinks I've excluded anything from the list of the things you do. I think this captures about everything. If you do dream interpretation, that's a standardized technique. If free association, standardized technique. If you give any reflection or restatement of what you're hearing, that has the potential to be educational to the patient. I didn't know I think that way until you pointed it out. I didn't know my dreams mattered. These are the five things us therapists all do. I want to pay the most attention, and let me reiterate, the most attention on the case conceptualization. To me, nothing, absolutely nothing is more important than the case conceptualization in any good therapy, and of course then in cognitive behavioral therapy. What is the case conceptualization? Then it's the collection and integration of clinically relevant information. The word iterative, vital, it's an iterative process. It never ends. It builds on itself. It changes. There are surprises. It's like a roller coaster. It goes up. It goes down. You get things that are really new. You may even get things that are scary. I didn't know. I didn't know that you thought about hanging yourself. I saw a patient who never admitted to suicidal thinking, ideation, or plans, and then one day he said, okay, I'm going to tell you the truth. There are times when I set a chair up in my house, and I have a pull-up bar, and I put my belt on the pull-up bar and try to decide whether to kick the chair out. That was obviously a new part of the case conceptualization that the patient had chosen not to talk about ever before to anyone in his life. The cognitive behavioral therapy case conceptualization, like the supportive expressive case conceptualization and the emotion-focused case conceptualization, it is a collection and integration of relevant materials. Yes, it identifies problems and targets, and it's ongoing and ever-evolving, but more importantly, it is hypothesis formulation and testing. Gee, Mr. Smith, you've told me a lot today. I've started to formulate a hypothesis about why you're using that I never thought of before, and I want to share it with you and see what you think. It is certainly influenced by the therapist's home theory as well as professional and life experiences, and let's emphasize life experiences. I would venture a guess that if there are 500 people participating in this webinar today, that I wouldn't venture a guess at least one to two hundred of you who are listening to my voice right now has personal life experiences that will influence how you relate to people with addictions that you must understand as a good cognitive behavioral therapist or any therapist. Realizing that your home theory is nice, but it is also influenced by who you are, the human being, back to the research I shared with you on therapist effects. It's vital to therapy. Everything depends on it, and it requires substantial effort. That's the case conceptualization. I have an extremely formal list of things to cover in the case conceptualization. Initially, they seem daunting, but it becomes so natural after a while. I would venture a guess if I'm talking to 500 to 600 to 400 to whatever number of people are in this webinar right now. I would venture to guess that at least 30 to 50 percent of you say, yeah, I pay attention to all those things in the case conceptualization. What are the presenting problems, the primary problems? What does our patient say is wrong? What is the culture they come from, not just today, but before that and before that and before that, that influences how they think and how they feel? Are they affected by STOH, social determinants of health? Is there some cultural, is there some environmental that they live with people who are suffering from addictions? Is it part of their social fabric to use? That's number two. Number three, distal antecedents. What were the neurobiological, in other words, or genetic? Do you have a family history? Is there a cultural impact? These are all extremely important and vital. That's three. Four are the, so the last one was distal, the proximal antecedents. What triggers you now? What are the cognitive processes that go on in your head relating to your addictive behavior? What are the emotional processes that you experience? And what are the behavior patterns involved in your addictive behavior? Now, I said earlier that I would talk more about the functional analysis. Four, five, six, and seven is where your functional analysis comes in. What triggers you? What do you think? What do you feel? What are you doing before? When you light up, what is the ritual you engage in that's so familiar to you that you can't imagine life without it? No treatment of people with addictions would be complete without a good conceptualization of where people are in their readiness to change. For all of you who have done hundreds, maybe thousands, of sessions with people with addictions, readiness to change can be one thing at the beginning of a session, something different at the middle, and something totally different at the end of a session. And unfortunately, it can go either way. A person can say, no, doc, I'm not in the mood to use anymore. It's just not who I am. And as they talk about something that they struggle with today, by the end of the session, they reveal maybe the next time that by the end of the session, they were having real strong urges, and they were thinking they might even go home and use. So this is all an iterative process. When you put it all together, integrate it, the implications for treatment are important. Now, as I was talking to the, before this webinar started, we were talking about just about just kind of background stuff. And it's really interesting. This talk I'm giving you now, 90 minutes, is really anywhere between a six-hour and a three-day talk. And I want to give you breadth rather than depth, because if we do depth, it'll be, you'll get five slides, and then it'll be time to leave. But these 10 different elements of a good case conceptualization are worth going over real quick. The primary problems, the environment, the background, is there a family history? Was there a history of not just substance use problems, but physical, psychological, emotional, sexual abuse that leave you with such powerful negative images that your use is all about experiential avoidance? What are the antecedents to use? How do you think? How do you feel? How do you act? and then how ready are you to change so that we can integrate it all and figure out treatment. Because it's iterative, it's not a list that you write on and then put it away. The list can be primarily in your head and just guide you as you proceed. Now, in 93, this is the model we came up with, and it really hasn't changed that much since. Upper left-hand corner, the proximal antecedent to using is either an internal or an external stimulus. Somebody says, well, nothing happened, I just smoked a cigarette. What do you mean nothing happened? Well, I woke up and reached for a pack of cigarettes, sat up on my bed and smoked the first cigarette. Well, the external trigger was, you looked at the pack of cigarettes, the internal trigger was you were tired, you were waking up, you felt maybe a little fatigued, and so the first hit off of that tobacco and the nicotine rush was something that happened. The thoughts, the beliefs were activated that I am a smoker, I smoke, here's my cigarettes, I will smoke this. The urge and craving is there, the opportunity to abstain is there. What does that mean? It means, you know what? When you first go into recovery, you learn that every urge and every craving doesn't have to be an opportunity to use, it can be an opportunity to abstain. However, if you give yourself permission to engage in the addictive behavior, and you start, the lapse turns into a relapse, which is the next trigger. So, true to form, if you're not worth much as any kind of therapist, if you're not interested in the development of a person's psychological, mental health, psychiatric problem, early life experiences are vital. Distal antecedents, as I called them earlier, psychosocial, environmental, neurobiological risk factors are vital because they create the vulnerability, the cognitive behavioral affective vulnerability, wherein if you are exposed to an addictive behavior or substance, and you continue using it, you're gonna develop this pattern. Put it all together, and here's what you get. There's always an opportunity to lead this vicious cycle. My experience and the experience of the people I've trained and taught and worked with is that the insights that are gained from understanding the distal antecedents and what it means to have a family history, and what a genetic loading might look like, you're different from other people. You have a genetic loading from having 14 family members who have had addictions and five that have died by suicide. Understanding this is a big part of that case conceptualization. I gave you a list of five components of all therapies that are effective. All effective therapies have five components. The five components, again, are structure, collaboration, case conceptualization, psychoeducation, and techniques. And I said techniques are about the least important, but the collaborative relationship, it's necessary but not sufficient. And the structure, the first thing I list there, the structure is gonna depend, and so is your collaborative relationship gonna depend on your case, if you conceptualize that this is a person whose life is in such disarray that imposing upon them too much structure would be threatening. I mean, I believe you form a quality therapeutic relationship not by being sweet and kind and thoughtful and gazing into the patient's eyes and saying, I care about you. Those warm behaviors are essential to good therapy, but really getting the person, making them feel understood vis-a-vis the conceptualization. So when you listen well and hear what they're saying and you can put together the map in your head and share it with them, then you can start to really structure therapy in a way that's beneficial. Because without structure, it's just a chat. As linear as this slide makes the structure look, it's not a linear process. What do you want to work on today? The agenda. Well, you know, I came here for addictions and I'm still smoking and I'm still drinking and nothing we've done has really helped. Okay, do you wanna put that on the agenda? Yeah, that's why I mentioned it to you. Well, I suspect there's more to put on the agenda then because you sound like, this is number two, mood, you sound like you're feeling some despair when you tell me that. How do you feel right now? I, you know, I feel discouraged. Let's talk about your mood. How's your mood today? How's it generally? What do you do when you don't feel good? How do you, how do you treat it? Like, what do you, what's available to you to feel better? And after you've done that and you say, before we go into the agenda, what, let's just review what we did last time and the time before and the time for that to make sure we don't lose continuity in the therapy. Here's what I know about you. And I'm curious about what you've been getting out of therapy since you sound discouraged and it hasn't been that helpful. And let's prioritize ourselves today so that we're really focusing what's important. Maybe today we shouldn't talk about urges and craving. Today we need to be flexible because I am conceptualizing you to be struggling with anxiety and depression now. Maybe we need to focus on that. And I will guide you now to discover through motivational interviewing and functional analysis. I'm gonna help you discover, you know, how your moods and your depression may interact with your addiction to really exacerbate it. And then maybe we'll have time for developing some skills, self-management skills, emotion regulation skills. I hope we have time for that, but 60 minutes goes by really quickly. I want, but throughout, I wanna know what you're getting out of this. And certainly at the end, I wanna know what you're learning here. And I just read a study on homework. Homework is the number one process. It has the most impact in all psychotherapies, just saying what will you do between now and next time it's gonna help. So since the way you structure it, this is content, but it's the content of a session, which ultimately means it is the process that goes on in the session. And for those of you who are interested in groups, Dr. Beck and colleagues and I also did a book on CBT for groups. And group structure is important also. We emphasize that within 90 minutes or more time if needed, and five to eight is optimal, but not, sometimes you get a lot more. And with open enrollment, it has to be compatible with other approaches and it has to be understood that members' goals are variable but we still, it's kind of like, what do you all wanna work on today? And how are you all feeling? And let's just reflect a little bit on what we have been doing as a group. And that way, when there's open enrollment, you can always bring people up to speed who may have just entered the group. So structure is the process, how you organize the session. Now, I will be surprised if there are many of you who don't remember the importance or are familiar with the importance of the work of Yalom. Since we're talking about process, the work of people like Irvin Yalom is vitally important. Like I said, all good therapy looks alike. If you're doing good therapy, good group therapy and even good individual therapy, people will be instilled with some hope. I'm not alone, Dr. Jones. It sounds like I'm not the first person you've seen with an addiction or in a group. Boy, am I relieved to hear that I'm not a freak and you guys all have been so nice today and you have the same addiction as me. I find myself now feeling a lot better already. So these processes you see in front of you, altruism is my favorite because altruism in a group is where a group member gets to help and nurture and be kind to other group members. And they say, wow, that really helped me. So that's altruism. And the corrective recapitulation of family of origin issues. My trainers, none of them were cognitive behavioral therapists back in the day, that was just a baby theory. But my group therapy trainer, Dr. Walter J. Lifton, did a series of, then we had movies, we didn't have videos. He did a series of movies on the group as family and how a good group gives people what they didn't get when they were growing up in an extremely corrosive family, is people being kind and listening and thoughtful. So these are all factors, processes that are just as important in individual therapy, except for the group cohesiveness, of course, but that is really the relationship between therapist and patient. Now, just I wanna add a little more to the rules because it's part of the process. I do two groups a week. One of them has as many as 30 people and it's free and it's in the library in my community. And we also are on video for people all over the country. We reliably, it's supposed to be tonight, but I have a co-facilitator who's running it tonight. So we do groups for people with addictions and the rules really matter, confidentiality. And these are processes. No click formations or outside meetings. Now, if you're in an inpatient setting, that's a silly idea, or in a prison, there are gonna be clicks. But for the most part, in a practice, we really encourage people to not form clicks because people feel like outsiders. Don't give people advice. Nobody really wants advice in a group. Personalize everything with I statements rather than you statements. No threatening or disrupt. It's amazing. We had a guy who screamed at us and we've only had, we've been doing this group for six years, seven years. And we've only had two people, three people storm out. And we just had a guy storm out last month. And it was because he was so angry at the results of the election. And he was saying, everybody is under threat now. All of you, you don't know how much threat there is. And he went on and on. And I tried to use my best skills to help him feel a whole lot more peace of mind. Nothing was working. And he himself stood up and he said, well, I can tell I'm not welcome here. And he ran out. And his behaviors were threatening to people and certainly disrupted. Again, in seven years, three people have left the group dramatically. So again, the cognitive behavioral therapy, just like every other therapy, structure, collaboration, case conceptualization, psychoeducation, and techniques. I thought it useful to talk about techniques. Look at all these babies. These are all techniques. You notice in the left-hand corner, again, I referenced where you can find this stuff. All the last six or seven slides were references to our book because this stuff is all in the book. But these are all what you can do. You can do a functional analysis. You hopefully will be doing motivational interviewing much of the time. You can help people manage their environment, the stimuli in their world. People places things. You can help them learn to delay and distract. But these techniques don't work until people feel safe and secure and trusting in the therapy environment. So techniques like the automatic thought record where people, I'm going to be talking here shortly about the processes, cognitive processes, like attention and other cognitive processes. And most people don't even distinguish between their thoughts and feelings. You will never, ever, ever have people talking about themselves in the course of, every day you will hear somebody say, I feel that he shouldn't have done that. I feel like it was unfair. I feel like they were the nicest people. I feel like that was the most kind thing anyone's, those helping people understand and separate emotions and thoughts is a really valuable process. And a technique like the automatic thought record can help with that. And then the most obvious for addictions, particularly when people are starting to try to change is the advantages, disadvantages analysis. What were the advantages of using? Because when you stop, it's not going to be comfortable. There'll be real disadvantages. And that's why you've been using for 37 years. What are the advantages of quitting? Well, those are advantages, but if they were predominant, you would have quit a long time ago. They aren't predominant, predominant, like an advantage. The advantages are why I keep using. I get relief from discomfort. I have a sense of control. I can avoid problems that may just work themselves out. If I have a fight with the neighbor and I go drink, the neighbor will calm down eventually. When you stop, an advantage is feeling better. And that's why people come to treatment. They may reduce or eliminate the problems. So those are advantages. But the disadvantages of both stopping and continuing are also important. So I encourage not just cost benefits analysis, but advantages and disadvantages of engaging versus not engaging. And again, I told you there's good research that meta-analyses and reviews of meta-analyses that show that if you're willing to give homework, and it doesn't have to be called homework. I simply say, what are you planning to do between now and next time that will make you feel like you've accomplished something? So all therapy requires homework. Whether it's psychodynamic, emotion focused. I've never met a therapist who would say, it's that 50 minute hour that really makes all the difference. Whatever they do when they leave, doesn't matter. That 50 minutes with me is so powerful. So the assignment should be determined collaboratively. What do you wanna do between now and next time? In a group, sometimes other people. I just had a group this past week and some woman said, very understandably, I have got to lose weight. And somebody said, well, how much are you trying to lose? And she said, I'm gonna be gone for two weeks. If I could lose six pounds when you see me in three weeks is I'll be gone for two. I will be thrilled. Two pounds a week seems reasonable. And another group member said, do you mind if I join you and have the same goal? It's not competitive, but I'd like to try to lose that much also. So that's homework now that they both have that they came up with individually, but they shared it in a group which gave it even more potency. So the homework can be related to painful emotions, problematic behavior, but often it's just coping skills. When they come back, if you said, what are you gonna do between now and next time? It's really important to say, would you like to talk about whether you did the thing you said you're gonna do or not? And also it's important for them to know this is not school anymore. Nobody's gonna give you a big red grade. The therapist isn't gonna break out the big red marker and put an F at the top of the page. If you didn't do the homework, that's really valuable for me to know. Maybe I didn't do a good job of assigning it. Now, transition, warp speed. It's 5.34 in Kansas, 6.34 in New York, and all kinds of other times all around the world from what I saw in the chat. We are talking about advances in cognitive behavioral therapy and we're talking about processing content. I would be remiss, is that the expression? If I didn't talk about cognitive science constructs relative to CBT. Where, how we attend to things is so basic and so important. And every single psychotherapy, cognitive behavioral therapy, evident support of expressive therapy session, we're hoping the attention is to what's important. And both, now this is important here, both the therapist and the patient need to attend to what's important and use their best executive functions. The work is effortful. It's not easy. It causes strain. And we function at two levels. The science on this is fascinating. And I refer you to the book by the Daniel Kahneman, who is renowned for his work in this area. The dual processes of system one and system two that we'll talk about, heuristics and biases, intuition and expertise. These are all relevant to the patient and maybe even more importantly to the therapist. By the way, Kahneman won a Nobel Prize for his work in thinking fast and slow. And that's the name of his famous book from I think 2012 is the year approximately. It's one of the slides coming up. So how you attend to your patient, how your patient attends to you, the way you use your executive functions that we'll talk about, the way the patient use executive functions, how hard you're working cognitively to do good work versus just a nice, gentle, pleasant conversation where there's no strain by the therapist, no strain by the patient. You know, there's a big difference between working hard and not working hard in therapy. I'm not saying that a session can't be delightful and a joy, but hopefully it's because so much good work has been done that the reward is that learning has taken place both by the therapist and patient. But let's go on. What are the executive functions that are important? Not only for you, the therapist, in the process of cognitive behavioral therapy, psychodynamic therapy, supportive expressive therapy, emotion-focused therapy, interpersonal therapy. What are the executive functions? They are mental processes necessary for planning, regulating, organizing, self-managing, and making changes or helping other people to make changes. When you use them well, there is effort involved, and we're gonna talk about three core functions. And look at these functions, inhibitory control, cognitive flexibility, working memory. Let me just see something. The reason why I am so interested and excited about cognitive science is because I do have a general practice. This is not for just for people who suffer with addictions. This is for anyone you see people continue to do the same thing over and over expecting different results because of habit and habit is a powerful thing and inhibiting old habits, including The therapist's old habits may be of not interrupting when an interruption is the only way to focus but inhibitory control being able to stop from doing something that is not good for you or stop avoiding something is important cognitive flexibility is vital to learning and working memory is why it all works, but let's look at them more closely self-control is about inhibitory control. Again, these are processes versus content in cognitive behavioral therapy and all therapies inhibitory control maintains attention to what's going on. The behaviors are consistent the thoughts. They're all focused on desired goals and not on something else. Like what time is my appointment? My last appointment of the day because I have to go get the kids from whatever daycare school, etc. That's the therapist obviously and if excessive attention in your patients is focused on I need a cig I can't wait to for the break because I need a cigarette. The attention needs to be redirected and and the thought I need a cigarette to keep to keep going today needs to be inhibited and a good discussion between therapist and patient is warranted about these processes the ability to suppress interference that gets in the way extraneous mental images overriding impulses suspending preconceived thoughts. This is all inhibitory control and cognitive flexibility is the ability for you. The therapist as you do in your conceptualization and getting new news or something. You're not familiar with you as the therapist flat being cognitively flexible while teaching patients that. Recovery is all about the possibility of being so flexible that you kind of a new person. Who is in a hundred hundred percent preoccupied with your next fix addiction wise. So it's a shifting attention from one task for another to another and empathy empathy is the ultimate in cognitive flexibility. It's when you can take their perspective, but they can take the perspective of other people. That's the second executive function working memory is the third. You know, I'm using what I am right now talking to all of you. I am using working memory to try to keep all of this in my brain to remember what I've said and at what point in the talk. I've said it and what seems like it needs elaboration and what seems like it doesn't and how do I keep from tell you about things extraneous because I only have so much time that's all in working memory and it's not the same as short-term memory. It uses the dorsal lateral prefrontal cortex. It it's it's a process of appraising and reappraising ideas to make decisions and plans. So you the therapist have to do it and what you're doing is actually teaching the patient to do it and all this takes effort. Substantial effort. Effort to depends on the load you place on it. If you have only one script for your therapy and you're trying to make everything simple and straightforward and put little load on people therapy might be easy. The question is is it effective? I think good work and requires complex functions and sometimes a heavy load and understanding that might be a strain. I will make no secret about the fact that I take naps. Why do I take naps because I can run I can run for miles and and for long periods of time and not really feel tired shortly after that. But if I'm working working on something like this talk to talk to you and really trying to think of who you are and how I'm going to frame things and how I'm going to make the slides relevant to your lives and how I'm going to pace myself. That's there's going to be some effort there real hard work and people minimize that they think snap judgments are enough. So here is Kahneman's core idea. There are two kinds of systems for the way we think and this is so universally adopted that I oh, it's 2011 in system one, which is what we operate in most often. We are fat. We make fast decisions like where we turn our car to get to work or whether we brush our teeth with a hairbrush or a toothbrush whether we use the bottom spout of the the the tub to take a shower or the top sprayer. Most of the things we do 80 plus percent of our day is done. It's possible because of fast effortless involuntary intuitive behaviors. We we face a lot in the course of a day wake up clean up eat something get in the car drive the car make the turns figure out what we're going to do for a second all this becomes automatic and that's why we can we can use simple answers or heuristics to solve like some pretty complex problems. If you're just a kid the reason why a kid can't go to work and do psychotherapy at seven years old is because they don't have the heuristics yet and they won't for many many years. So when system one thoughts are reinforced, they become our core beliefs versus system to system to is required for doing good therapy for doing good conference presentations for doing good change in yourself. It's effortful deliberate intentional reflective slow. These are the processes of all good therapies particularly since I am identify as a cognitive behavioral therapist. I will say in this talk is about cognitive behavioral therapy that my work needs to be effortful and deliberate and intentional and it needs to get activated when my system one isn't working when what do you want to work on today is responded to by a patient with I don't know. I can't think of anything then. I got to pull up system to and say, oh, what am I going to do system to searches memory? It's involved. It requires attention and concentration and agency and choice. It asks questions answers questions. It's not it's not intelligence. It's rationality. So most people assume their system to is in charge system to is pretty lazy. It only comes out when it's called upon. So again, heuristics are system one shortcuts. We draw upon what's first our first thoughts what's available. We put things in categories. Oh, this is a patient with bipolar illness plus addiction without these heuristics. We'd be very slow thinkers and we wouldn't be able to do much of anything complex. How things are framed if I come to you and the first thing I tell you is I want to quit smoking. I have a great life and I don't want to die young. It's like, oh, well, this will be this this was I'm not going to see a lot of tears in this visit. And then as you go along you find out the way the problem was framed is not the way it really is. The worst of the worst is affect. The affect heuristic is just because you feel good about something doesn't mean it's going. Well boy had a great session with Joe, you know, he liked everything I posed and he says he's going to go home and do all these things. Well, that's because Joe is ready to quit therapy and he's wants to tell you he doesn't, you know, he doesn't want to come back. So you the therapist feels good and the affect heuristic tells a person just take a drag on the cigarette. You'll feel better. Just do it. Just do a one line of cocaine and you'll have enough energy to finish this project and anchoring the first the information first presented. So biases are a function of heuristics. They're inevitable again availability. What you see is all there is categories can be chose erroneously framing overemphasize or under emphasizes things. So what what gives us our superpowers also is our kryptonite for those who aren't Superman fans. Yeah, we wouldn't be very good at much of anything if we didn't have heuristics. But then again the mistake a lot of the mistakes we make when we're trying to solve a problem because we're too quick to go to fast thinking when you ask health providers the biased health providers around you as as Walfish didn't and a classic study in 2012 on average. How do you compare to all the people in this meeting? Women it's divided up pretty equally between women and psychiatrists and psychologists, etc. The bias in therapists is that the modal rating of how good you are compared to the people in the room. The modal rating was 75th percentile. Nobody thought they were under 50%. What does that reflect? Bias that I'm pretty good or I'm overconfident. And overconfidence occurs in system one. We don't know what we don't know. We don't want to be seen. We fabricate and revise history in our egos to conserve what we don't what we like about ourselves and get rid of anything that might conflict with that. And this is all part of the process. I had a student who came to me today who was cursed out by the co-therapist of a group who said what is wrong with you? How could you have done that to that poor patient? And the therapist said to me boy, this was really aggressive person. I don't know why and I explored like what was going on that made them react so strongly and they talked about an interaction between that patient the the patient and the the the therapist and there was pure countertransference where the therapist had gotten upset because the patient was too dependent on their father and the therapist was too dependent on his father and he had gotten angry thinking damn it patient you got to change but he was totally blind to that. And when we talked about it, he said, oh my God, I got to go back to my co-therapist and apologize profusely. So we're overconfident. The research shows were overconfident. We think we know more than we do. It's important to know what we don't know the Dunning-Kruger effect is when people are blind to their own ignorance. This is all process as a therapist. It's called meta-ignorance the ignorance of ignorance the unknown unknowns and it's prevalent in everyday life. The first rule of the Dunning-Kruger Club is you don't know you're a member of the Dunning-Kruger Club. So, oh my goodness when you do an addiction treatment therapy doesn't always work. If it doesn't it might be because the processes you're losing focus. You're not sticking with the agenda that the patient produces or if they produce something in the middle. It's really more important. You're not making the shift. You might be over relying on techniques. You might be missing vital opportunities to focus on the you and me process. Failing to do a functional analysis or a good case conceptualization leaving the patient behind over focusing on triggers in context people places things over focusing on thoughts and feelings over reliance on the Alliance the things we talked about earlier. And I'm done. And delighted to take questions again. This is a three-day educational conference squished into 90 minutes because I wanted you to have it all and now what I hope you have learned is how much cognitive behavioral therapy has changed over time to focus on what's really important in therapy. It's important to all therapies and the process isn't everything but it's most everything. Well, thank you. Dr. Lee's that was certainly a presentation that was chock-full of wisdom and that came across and we all have benefited from that. I'm going to start off with a question of my own which is that oftentimes early in recovery, especially early in recovery. It's helpful to bring patients family members into sessions and whatnot. How do you think that affects the psychotherapeutic process? I am board certified in two areas in addictions and in family in family psychology. So I absolutely obviously love your question. I bring family in anytime anytime a patient says this family available that they think they benefit from so I if you come to me and say I'm afraid of flying I'll say well give me some more context and they say we're supposed to go on a trip to China. This is a real patient and I can't do the trip, you know, my spouse has gotten it and I bring people in to learn this is with patients who think it's really valuable and important and I you know, it needs to be well structured there needs to be collaboration. You get more case conceptualization when you hear from family members. There are family members who have huge misconceptions of of addictions. So let me go through the list again structure collaboration case conceptualization psychoeducation and techniques if you can get allies for your patients you can turn if somebody's willing to come to therapy because they're really really really upset with the patient for their use if you can get them to come in and understand the nature of addictions and then get them to be allies at psychoeducation help them understand addiction and even help them with the homework the techniques it's it's twice you are multiplying your effect profoundly. Dr. Blazers. Did I answer your question? Absolutely. Thank you for that. Absolutely. David you want to go next? Yeah, I'll take the next one. What do you think of the role of lived experience as a therapeutic factor while my son Oh, there's a few more sentences to this while my while my sense is that most evidence-based psychotherapies do not explicitly employ lived experience many in the addiction field and patients seek to increase the use of peers in addiction treatment. What are the advantages and disadvantages of lived experience as a component of a therapeutic intervention? And how would you think of it? Okay. I am the trainer for the peers of Douglas County, Kansas. I meet with them every other week and train them. Peers are people as the questioner asked there are people with lived experience who are there to help people with addictions and I meet with them every other week for two hours and I talked to him about their experience in helping people on the street people experiencing homelessness people who have from histories in the in the penal system people who are peers in the jail the County Jail and they have so much to offer and they are so grateful learning learning about themselves and how not just how has their lived experience influence what they think about addictions, but how does it influence how they talk to other people with addictions and and what does it mean to do something that's evidence-based and once once I make it clear that they're as smart as me. They just have a different kind of smarts. They're willing to once I'm willing to I prove that I'm willing to learn about them. They're willing to learn about what I have to offer and I'm not I'm not saying this to market anything. The county decided after we started this to buy that the textbook for every single every single peer now that gets trained in Douglas County gets a copy of cognitive behavioral therapy for addicted sores. I didn't have anything to do with it. It just showed up in boxes one day and the peers, you know, the peers really appreciate learning going beyond it extends their recovery. It's that it's the altruism part. Wait, can I say one more thing? Of course, it's group that I'm not running in the county because I'm here two peers are running one peer is running it for me tonight. There you go. All right next question in the part in the part of the presentation that I've seen I see that you did not use the word trauma. Do you call by another name? Name or is there another conceptualization and what percentage of your patients with addiction have not had trauma? Thank you so much. I I do a talk on the bi-directional influence of trauma and addiction bi-directional influence. It is a terrible vicious cycle. I am I'm actually on the board of the Institute for violence abuse and trauma in San Diego. They do two big conferences a year. I'm on the board and have a very strong interest in trauma and present on trauma regularly. It is vitally important. I am one of those kooky people who believes that we all experience trauma degree is is vast unfortunately from just the trauma of the traumas associated with childhood and adolescence that are don't have a terrible impact on everything else in our lives to the traumas that that infect us forever and are almost impossible to get over. And so, you know with the case conceptualization that is a big part the second feature the second the context is important. What were the traumas people experienced? So I I don't use a different term. I if I went back to the slide, I'd be surprised but trust that the the person asking the question is correct that I don't have it in that slide. You may have just convinced me to put trauma in the slide. I'm going to sneak a peek at that slide. But anyway, trauma is vitally important. We all experience trauma. Some people's trauma is so severe and so awful and terrible that they're that their lives are ruined by trauma. And I again, it's bi-directional you use to feel better and then the use then when it becomes addictive makes it very difficult to overcome the impact of trauma bi-directional two ways. Well, I think we're kind of at the good you have I don't think we have time for any more questions. But if you wanted to finish up this one for another minute or you feel like that one. Did you want me to? Okay. I think we're at one minute left. So we probably don't have time. So but I just wanted to thank you again for this really remarkable presentation. I certainly feel smarter for having attended and I suspect everyone in the audience feels the same and it seems like we probably could use an encore. So maybe we'll have you come back and do a whole session where we you know, can have a lot more time for questions and answers. Thank you again. And just as a reminder to the audience, all of these presentations are archived in the triple AP website so that you can watch them again. And this is a certain certainly one that is a chock full of helpful information. So it might be worth a second view and all the other old presentations are there as well. So thank you again, Dr. Lees and thanks everybody for attending. Thank you, Dr. Lees. Bye everyone.

Cognitive Behavioral Therapy

Addictive Disorders

American Academy of Addiction Psychiatry

SAMHSA

Dr. David Stifler

Dr. Bruce Lees

Therapeutic Techniques

Motivational Interviewing

Cognitive Science

Executive Functions

Therapist Characteristics

Case Conceptualization