Hello, everyone. I'm Dr. David Stifler, and on behalf of the American Academy of Addiction Psychiatry, welcome to today's webinar, which is part of the series on Advanced Addiction Psychotherapy. This is our monthly series focused on evidence-based intensive psychotherapy training for addiction psychiatry fellows and faculty. It's hosted in partnership with the Oregon Health and Science University and New York University. We're excited you could join us today and that we can offer you these live trainings that will be held the second Wednesday of each month from 530 to 7 Eastern time. Today's presentation will focus on integrated group psychotherapy. We will not be having a presentation in December because of the annual meeting and hope to see all of you there. Please say hi to either Chris or me if you see us. We'd love to hear from you. And you can check the AAA website for updates on speakers, including the next one, which will be in January. A few housekeeping items before we get started. You can certainly ask questions any time during the presentation. You can use the chat box on your control panel, and you can submit questions to be asked at the end of the talk, and we'll reserve some time. And you can use the Q&A section for that. And then finally, after your session, you can claim credit by logging onto your AAAP account and accessing this course. And please complete the evaluation and follow the prompts provided to claim your credit. Turn it over to you, Chris. All right. Well, welcome everybody again. I'm Chris Blazes from OHSU. We're very excited to be joined by Dr. Weiss today, who is professor of psychiatry at Harvard Medical School and chief of the Division of Alcohol, Drugs, and Addiction at McLean Hospital. He's been the principal investigator on numerous NIDA and NIAAA grants and was actually a creator of what we're going to be talking about today, integrated group therapy, which is an evidence-based treatment for patients with co-occurring bipolar disorder and substance use disorder. So he has led multi-site national study of treatment of prescription opioid dependence as part of a NIDA clinical trials network, and is currently a lead investigator on multiple site retention, duration, discontinuation study, examining optimal treatments for opiate use disorder. So he's authored over 400 peer-reviewed articles and has written four books. And we are very fortunate to have Dr. Weiss speak to us today. So I will pass it over to you, Dr. Weiss. Thanks so much. I'm really pleased to be able to do this. And I'm pleased that this is part of the... It's a great series of seminars. And thank you to you, to the two of you for developing this whole thing. I think it's a great idea. So this is my disclosure. So this talk is going to focus at the beginning about reasons for the high rates of comorbidity between substance use disorders and other psychiatric disorders, then something about the general principles of co-occurring disorders, psychosocial treatment, and then specific discussion of integrated group therapy for patients with bipolar or other mood disorders. The learning objectives to learn the reasons for high rates of co-occurrence of substance use disorders and other disorders, learn general principles of co-occurring disorder treatment and the key principles underlying integrated group therapy or IGT. So just to get started to talk about the scope of the problem, the NISARC study, large study looking at comorbidity shows that the... That's not odds rations, odds ratios of substance use disorders in people with bipolar disorder. In other words, the increased likelihood that you are going to have a substance use disorder if you have bipolar disorder for alcohol use disorder, nearly six and drug use disorders, 14. So bipolar disorder carries obviously a very high risk of having a co-occurring substance use disorder. So it raises the question, why are substance use disorders so prevalent in patients with psychiatric illness? And I like to divide it into several different reasons. One is enhanced reinforcement. Basically saying that in addition to the reinforcing properties that misused substances have in general, if you have a psychiatric illness, in addition to that, some substances may have the ability to reduce unwanted psychiatric symptoms. This is what is typically described as self-medication. And I'm going to get into that a little bit later on. So if you think of self-medication, for example, as mood improvement, that's distinct from mood change, which is also a very important motivator for a lot of people with co-occurring disorders. Mood change doesn't necessarily have to be improvement, but just different. So when you hear people say with severe depression, talk about drinking or drug use, they don't necessarily say that it makes them feel better. But often what they say is, I just didn't want to feel anything. I just wanted to obliterate the way I wanted to feel, or I wanted to feel numb. So why would people use something that doesn't make them feel better? Sometimes it makes them feel worse, and it's because they just want to escape. They don't really care in They just want to escape. They don't really care in what direction, just I don't want to feel the way I'm feeling now. Why would they do that? Because they feel hopeless about feeling better. So if you feel like there's nothing that's going to make me feel better, maybe second best is to just feel nothing. And so hopelessness is a key issue in people with co-occurring disorders. And I describe, I like to think of what I call layers of hopelessness. And the first layer of hopelessness is, I feel hopeless that I can stop drinking or using drugs. The second layer of hopelessness, the second layer of hopelessness, which I think is the most important one and the biggest obstacle to treatment this population is, I feel hopeless that even if I do stop, that my life will be any better because I've dug such a deep hole for myself that nothing I do is going to improve that. Third layer of hopelessness for people, depression is the cognitive hopelessness that people with depression often experience. So that hopelessness is a huge part of the treatment of this population. And finally, there's poor judgment, impulsiveness, and the inability to appreciate the consequences of your behavior. And so for people who are manic or hypomanic, this becomes an important feature in their risk for returning to substance use. So I'm going to talk a little bit about pharmacotherapy of co-occurring substance use and bipolar disorder and then focus on psychosocial treatment. So pharmacotherapy in general, co-occurring disorders pharmacotherapy, most studies that have been done have typically focused on the treatment of the psychiatric disorder, although more recent studies have focused on treatment of the substance use disorder as well. So most studies that have been done, for example, on people with major depressive disorder plus alcohol use disorder have been antidepressant studies. The studies of bipolar disorder have typically been mood stabilizer studies. Almost, or not almost, all of them that I'm aware of have not been comparative effectiveness studies. It's been drug versus placebo studies. So there's never been a study of two different antidepressants against each other or two different mood stabilizers against each other to see which one would be better for people with co-occurring alcohol or drug use disorders. Rather, the choice of psychotropic medication used for this population is typically based on the usual considerations that would make you prescribe one antidepressant or one mood stabilizer over another. Their side effect profile, family history of medication response, patient choice, likelihood of medication adherence. So the single most effect, single study that has shown the best effect for patients with co-occurring alcohol use disorder and bipolar disorder was a study done nearly 20 years ago now by Isan Saloon at the University of Pittsburgh. He's not there anymore. He's in Texas, but it was a 24-week trial of valproate versus placebo in 59 patients on lithium. So sometimes people misinterpret this as a valproate versus lithium study. It was not. It was valproate plus lithium versus lithium alone. And the people who got valproate had fewer heavy drinking days, less drinking on their heavy drinking days, but there were no differences in manic or depressive symptoms. So one of the key issues in pharmacotherapy of people with bipolar disorder and substance use disorder is medication adherence, which tends to be relatively poor in this population. So in the study of integrated group therapy that I'm going to be describing in a few minutes, we were interested in the patterns of medication adherence or non-adherence in this population of people with co-occurring bipolar disorder and substance use disorder. So we gave people a list of a variety of psychotropic medications, and we asked them over your lifetime, which of these medications have you taken? And to what extent did you take these medications as prescribed? Ranging from never to 100% of the time. At the time, this study is kind of old right now, but at the time, lithium and valproate were the two key mood stabilizers in the treatment of bipolar disorder. And we found that people were much more likely to take valproate as prescribed all of the time than lithium. What we were more interested in actually was reasons for non-adherence. So if you look at why people didn't adhere to lithium, most common reason was physical side effects or they saw no need for medications. A third one that was, I think, important was they wanted to use alcohol or drugs and they didn't want to mix drugs with medications. So unfortunately, they chose alcohol or drugs and didn't take their medication when they did that. So it's important. You also see that in 15% of the valproate patients. So I think it's important to recognize that and to try to cut that off at the pass to tell people, even if you decide to drink or use drugs, it's important to continue to take your medication. So non-adherence of medication does not necessarily mean that I took less than prescribed or I didn't take any. Sometimes it means I took more. So if you go down to the bottom of this slide, benzodiazepines, unsurprisingly, 29% took more to get high. Another 29% also took more, but they gave a different reason for it, which is I was impatient waiting for the medication to work, so I took more. It's not just substances that can be misused commonly like benzodiazepines that people will sometimes take more, but neuroleptics, 26% of the people who didn't adhere to neuroleptics took more either because they were impatient waiting for it to work, modify effects of substance use or to get high. Some people like the anticholinergic or sedating effects of neuroleptics. Early in my career, one of the antipsychotics that was a first-generation antipsychotic, Melaril, it was a pretty dreadful medication. It had very severe sedation and anticholinergic side effects, but the patients on our treatment unit called it Melaril because they liked those two side effects. If you look at tricyclics, the most common reason for non-adherence was taking more. Someone would say, yeah, I'm supposed to take 50 milligrams of desipramine, but I'm really depressed today. I'm going to take 200 milligrams. So these are the same folks who will sometimes take 6-tylenol when they have a headache. So the lesson for me from this study was and is, before I did this study, I asked patients, are you taking your medication? And if they said yes, I would then ask, how is it working? Are you having side effects, et cetera? Now, the first question I ask after they say yes is how much are you taking? And it's very common that people are taking more or less than what I prescribed. And I do believe that if I hadn't asked that specific question, they wouldn't tell me because they didn't think it was that important. So people say, well, yeah, my depression got worse, so I doubled the dose. Or I started to feel better, so I cut the dose in half. Or I started taking it every other day. So sometimes these decisions make sense, but sometimes they're pretty risky. So it's just important to know what folks are doing. So psychosocial treatment of co-occurring bipolar and substance use disorders. If you look at models of co-occurring disorder treatment, there are really three major models that get discussed. Sequential treatment is you treat the more acute disorder first. And then when that one is stable, you deal with the other disorder. So that's the sort of thing you might see with somebody who's hospitalized, for example, with acute mania or DTs, where if somebody's manic, you're not going to be talking about their substance use until their mania is better. If somebody is delirious, you're not going to be talking about their bipolar disorder. The problem with sequential treatment is that oftentimes the second disorder never does get addressed after the person is out of the hospital. Parallel treatment is a relatively common outpatient model. So you go to your alcohol clinic on Monday and your mental health clinic on Thursday. And both on Monday and Thursday, you get very knowledgeable treatment about the disorder that you are there for. But when there's an overlap between the two disorders, for example, you get depressed four weeks after you gave up drinking, you might have a different interpretation of that on Monday and Thursday, and it can be confusing. So integrated treatment means that that a person or a team treat both disorders at the same time. Integrated treatment, there is no gold standard definition of what integrated treatment is other than that. So if you asked 20 different program directors, do you do integrated treatment? Probably 18 of them would say yes. And if you ask them, how do you integrate it? You probably get 15 different answers about how they do it because there's no roadmap that says this is how you do it. Very often integrated treatment means it's integrated at the program level. So you have a, for example, an intensive outpatient program at 10 in the morning, you have a group on relapse prevention to addiction. At 11 o'clock in the morning, you have a group on depression. So you deal with both substance use and psychiatric illness, but not necessarily at the same time. So what I want to talk about is integrated treatment at the patient level. You've got a patient or a group of patients with co-occurring disorders in front of you. How do you integrate the treatment while they're in front of you? So I just said this. So integrated group therapy or IGT has a number of core principles. So let me tell you how it got developed. So back in the 1980s and 90s, the National Institute on Drug Abuse or NIDA conducted many, many studies of pharmacotherapy of cocaine use disorder, none of which developed an FDA approved pharmacotherapy. One reason that none of those studies led to an effective medication was not that none of these medications worked, that nobody got better. The problem was lots of people got better. The patients who got placebo did really well. One of the ways that these studies kept people in treatment was by giving them behavioral therapy that might keep them in treatment. NIDA at some point said, a lot of these people are getting better with behavioral treatment. Maybe we should focus on the development of new behavioral treatments in the same way that we focus on the treatment of new medications. New medications have phase 1 studies, phase 2, phase 3. They did the same thing with behavioral treatments. They just called it stage 1, stage 2, stage 3 to distinguish it from medications, where stage 1 was develop an idea for a new treatment or an old treatment for a new population. Try it out. See if it looks promising. If it does, then you can do a controlled study against an active treatment. That's when I submitted a grant application to develop IGT, a treatment for people with co-occurring bipolar disorder and substance use disorders, because there was no psychosocial treatment that was focused on this population. McLean Hospital, where I work, has done a lot of research, mostly medication research with people with bipolar disorder. Those studies always exclude people with substance use disorders. There were lots of people around that I could study because lots of those people had substance use disorders. IGT is a cognitive behavioral model, cognitive behavioral, quote, light, that focuses. It's got several core principles. One is that there are parallels between the disorders in the recovery and relapse thoughts and behaviors. In other words, the same kinds of thoughts and behaviors that will facilitate your recovery from one disorder will facilitate your recovery from the other disorder. Same kinds of thoughts and behaviors that will get you into trouble with one disorder will get you into trouble with the other disorder. That's the first key principle. The second one is to focus on the interaction between the disorders, to basically tell patients, playing around with your medication for bipolar disorder is bad for your addiction. Using drugs and alcohol is bad for your bipolar disorder. You focus not just on the negative consequences of the addiction itself, but its effect on the other disorder. The third one is what we call the single disorder paradigm. We tell patients, don't think of yourself as having two distinct disorders, bipolar disorder and substance use disorder. Think of yourself as having one disorder that we call bipolar substance use disorder. The definition for bipolar substance use disorder is stay away from drugs, stay away from alcohol, take your medication as prescribed, get a good night's sleep, hang around with the right people, monitor your moods, monitor your drug urges. In other words, with this single disorder, that helps with the recovery for a package deal recovery. Then finally, we have what we call the central recovery rule, which central recovery rule says no matter what, don't drink, don't use drugs, and take your medication as prescribed no matter what. A great deal of the group focuses around that particular rule. The structure of IGT, it begins with a check-in in which we ask people about their substance use, their mood, and medication adherence. We said, did you use any drugs and alcohol this week? If yes, on how many days? How was your overall mood for the week? Did you take your medication as prescribed? Then we review the previous week's group. We review the skill practice, which is essentially a homework assignment that is assigned at the end of each group. Things like write down three things you might say if someone asks you if you want to drink. Then we have a topic, and there's a didactic and a handout that we give people on the topic. The topic is seen as relevant to both disorders. For example, dealing with depression without using alcohol and drugs, and there's discussion. What makes IGT integrated? First, the check-in focuses equally on mood, substance use, and medication adherence. This is not an addiction group that just mentions bipolar disorder, and it's not a bipolar disorder group that just mentions your alcohol and drug use. Everything is woven together. We talk about the effects of substance use on your mood, on your mood on your substance use, constantly going back and forth. The topics that we talk about are relevant to both disorders. The single disorder paradigm is indicative of the integration. We talk about the relationship and the similarities between the disorders and the recovery process. These are some sample topics. Dealing with depression without using alcohol or drugs, denial, ambivalence, and acceptance, how that plays out in each disorder. Taking medication, which focuses more on bipolar disorder, but also on substance use disorder medications. Mutual help groups, both for substance use disorder and bipolar disorder. Identifying and fighting triggers of both disorders. One of the things that we point out is that a trigger for depression or mania can be substance use. A trigger for substance use can be mania or depression. Getting a good night's sleep, et cetera. Those are just sample topics, things that are important for both disorders. This is the central recovery rule. We put that on the bulletin board, blackboard, whatever it is that we've got in the room. A lot of patients don't like this rule. They'll say something like, it's too simple. You don't understand. I'm self-medicating, which becomes a huge part of the discussion. Huge part of the discussion, which is drugs and alcohol are not good medicines. They will make things worse, not better. Some patients really embrace it. There are people who have discussed wanting to put, no matter what, as a bumper sticker on their car. How people respond to this hopefully does evolve over time. Studies of IGT research. There were three studies funded by the National Center on Drug Abuse compared IGT initially to either treatment as usual or standard manualized group drug counseling. All three studies showed significantly greater likelihood of abstinence in the IGT patients. There were fewer differences in mood outcomes. A review article on psychosocial treatments of co-occurring bipolar and substance use disorder said, at present, IGT is the most well-validated and efficacious approach of substance use as targeted in an initial treatment phase. I'll show you the results of the third study that we did. We had shown that IGT was better than no group therapy and better than 20 sessions of IGT was better than 20 sessions of group drug counseling. The sessions were led by therapists who knew CBT and knew a lot about bipolar disorder. However, a lot of community treatment programs don't have counselors with experience with either one of those. Program directors told me that they often can't be paid for 20 sessions of anything, but they can be paid for 12 sessions of things. IGT as originally developed, there were problems adopting it to community treatment programs. NIDA put out a request for people to make these evidence-based treatments more community friendly. I was funded to do that with IGT. We cut the 20 sessions to 12 sessions that got the best reviews from patients. As I was developing it, I would ask patients to rate each session, which ones they thought was the most helpful, etc. We took the 12 sessions that they liked the most and added some more information about CBT and bipolar disorder in the manual. The groups were run by frontline drug counselors without formal CBT training or explicit bipolar disorder knowledge. We ran the same study comparing IGT to group drug counseling. In that study, 61 patients, half in each one. People had current bipolar disorder, and this was DSM-IV substance dependence. They had to have used substances in the last 30 days, although I think everybody used in the last 30 days. They had to be on a mood stabilizer regimen for the same one for at least two weeks. The results, what you can see here, is IGT is on the left, group drug counseling is on the right, and then the percentage of people who had a mood episode at the end of treatment, which is three months, 20% versus 30%. Mood results were slightly better in people who got IGT. If you look at abstinence, 71% versus 40% had at least one abstinent month. The likelihood of being abstinent throughout treatment was almost three times higher with IGT. Then we had an outcome measure that we called good clinical outcome. Whenever you enter treatment for anything, what you want to know is what's the likelihood that when I'm done with the treatment, I'll be better. If you've got two disorders, we thought a good clinical outcome means that you're doing better in both disorders. We defined it as that at the end of three months, in the last month, that you were abstinent with no mood episodes. What you see here is that people in IGT were more than twice as likely than people who got group drug counseling to have a good clinical outcome. It was named by NIDA as one of only five examples of promising behavioral therapies for adult patients with comorbid conditions. Now into how to conduct an IGT group. When we did it, we ran it for an hour. I will say it's been adapted in multiple different ways at multiple different places. Some people run it for 90 minutes. Some people have run it for two hours, an hour, 15-minute break, and another hour. When we did it, when we do it now, we run it for an hour. Starts out with the check-in and introductions, the review of last week's group, five minutes, review of last week's skill practice, five minutes, discussion of the session topic, about 20 minutes, reviewing the session handout and wrap-up, and then a handout and discuss the skill practice for the next week. These are the, as I mentioned, the check-in, have you used drugs or alcohol in the past week, if so, on how many days, how was your overall mood in the last week, did you take all of your medications as prescribed, if not, why not, did you face any high-risk situations or triggers, and if yes, how did you deal with them? Asking about how many days of use is very important. When people first enter the group, it's very common when you say, did you use any drugs and alcohol? Yes. How many days? I think three or four. Very important to say, well, was it three or four? Think hard. Why is that important? Because if you used four last week and three this week, you're getting better. If you used three last week and four this week, you're getting worse. If you used three or four last week and three or four this week, you don't know if you're getting better, worse, or the same. The other reason is the more people have to keep track of what they're doing, the less likely they are to do it. If every day you take a drink or five drinks or whatever, you know you've got to report that in the group, maybe you're less likely to do it. We've certainly had people say that in the group. We've had people say, I didn't drink at all this week. I really thought about it, but I didn't want to have to come into the check-in and say that I had drunk because I know that that might affect other people in the group, so I didn't drink at all this week. The key principles that I mentioned before, parallels between the disorders, the interaction, the single disorder, and the central recovery rule. I'm going to go through each of these. Parallels in the recovery and relapse process. To repeat what I said before, same kinds of thoughts and behaviors that will be helpful in your recovery from one disorder will help you in the recovery from the other. Same kinds of thoughts and behaviors that will get you into trouble with one disorder will get you into trouble with the other. Example, abstinence violation effect. This is an addiction term, an addiction term that you should know because it will probably be on your board exams. The abstinence violation effect goes like this. I've been sober for the last three months and I just took a drink, I may as well drink the whole bottle. I've blown my recovery. I wondered, is there some parallel with bipolar disorder? I thought, yeah. I've been taking my medication as prescribed religiously for the last year and I just got really depressed. These medications aren't doing anything, I may as well stop my medications. What's the same about this? What's the same is you're using the same language. I may as well drink the whole bottle, I may as well stop my medication. We talk about may as well thinking, that if you tell yourself, I may as well do something, you're probably about to make a bad decision because what you're doing is you're weighing two completely opposite behaviors and you're saying, well, they're the same anyway. Should I stop drinking or drink the whole bottle? Should I stay on my medication or stop my medication? They're the same. Why would you think the two things that are so different are the same? It's because you believe it doesn't matter what you do, you may as well just flip a coin. That comes back to what I talked about very early in this talk, which is the second layer of hopelessness. I feel hopeless that even if I stop drinking, my life will never get any better because I've dug such a big hole for myself, I'll never get out of it. That is essentially saying it doesn't matter what I do. Yeah, I can stop drinking, but it won't make any difference. That layer of hopelessness goes along with may as well think, doesn't matter what I do. May as well thinking and it doesn't matter what I do is an example of relapse thinking. The flip side of that, recovery thinking is it matters what you do. I'll get to that in a minute. How does that play out? I asked folks during one of these groups, because I led these groups early on, what's the earliest sign that you're experiencing depression, that you know you're getting depressed? One of the answers, and this was done long enough ago that people could answer something like that, is I don't return phone calls. That was when people typically actually answered their phone, listened to voicemail messages, et cetera. They'd say, I end up with 30 voicemail messages and I just can't. I can't get started doing that. And so when you have 30 voicemail messages to return, you only have two options, 29 or 31. 29 means you're getting better. 31 means you're getting worse. But it matters. Everything you do either gets you closer to getting better or getting worse. So there's no such thing as it doesn't matter what you do. So a good example of this, we had a patient who said, I need some help because I was in bed for three days last week, and I just couldn't get out of bed. I was so depressed. So she asked the group, do you have any suggestions of what I can do to get out when that happens? So one of the patients said, oh, yeah, I've been there lots of times. The thing that I find most helpful when I'm like that is I brush my teeth. When I brush my teeth, then I can take a shower. After I take a shower, I have to get dressed. If I get dressed, I can sit down and eat something, and then I can get out of the house. And as she was talking, I look around the room and everybody's nodding like, whoa, good idea. Brush your teeth. Perfect. These were not fancy cognitive behavioral interventions. This was going from 30 voicemails to 29. When you're 100 miles from where you want to go, you either walk in the right direction and you'll get there eventually, or you walk in the wrong direction and you'll never get there. So that ends up being a very important part of this group because there's a lot of very hopeless people. People who enter this group, it's all about depression. Almost no talk about mania. Why do we use the term bipolar substance use disorder? It's because, why tell people they've got a single disorder? It's because having two lifetime disorders that take that much work for most people is just intolerable. They just won't do it. So I learned that going around the room going around the room when I was running the group, asking the people, each person, scale of 0 to 10, how much are you worried about your substance use and how much are you worried about your bipolar disorder? How serious a problem do you think it is? So most people, almost everybody scored one better, higher than the other. Typically, bipolar disorder, higher than their substance use. So this one guy said, well, bipolar disorder, I give that a 10. I've been hospitalized nearly 20 times. I take my medication religiously. People have been telling me that I drink too much. I really don't think I give that like a 2. I really don't think it's a problem, even though as it turns out, it was a very serious problem. That's where I give it. So in my mind, I thought, well, we got to really focus with this guy on getting him to accept that he's got a drinking problem. So a few weeks later, I went around the room and asked the same question of everybody. And he said, drinking, I'm going to give that a 10. And for a brief moment, I thought, oh, good. We're doing better here. And he said, bipolar disorder, actually, I've been really thinking hard about this. And I realized, I've never really dealt with my bipolar disorder when I was sober before. So I'm going to do it right this time. So I've stopped my medication, dot, dot, dot. So that's when it became clear that people just find it too hard to give both of them a 10. They almost always think of one of them as their, quote, real disorder, and the other one is the disorder that people tell them they've got. And yeah, maybe a little bit, but no, it's not so serious. And so you just can't get around that. If you get them to accept the other one, then they'll think of that as their real disorder. But everybody always thinks of one as their real disorder, and the other one is a consequence or symptom of their other disorder. So when we talk about this bipolar substance use disorder, patients jumped on that. They said, yeah, that's me. So they like that. And then things like the interaction, drinking is bad for your mood, playing around with your medication is bad for your addiction. General guidelines for IGT. So focus on both successes and failures. So if someone said, I drank three days, what did you do on the four days that you were sober that you didn't do on the three days that you drank? So you're not being either, quote, hard on them or easy on them. Let them compare themselves with themselves, their own successes versus their own failures. Like, learn from what you already know. Those four days, you did something right. So maybe next week you can make that five days or six days. Therapics characteristics for IGT. Familiarity with substance use disorder and bipolar disorder, ideal. It can be successfully run by frontline substance use disorder counselors. Some knowledge of relapse prevention or CBT is very helpful. Being empathic, warm, friendly, non-confrontational. Who should be in an IGT class? Who should be in an IGT group? Willingness to enter a group that addresses both problems. You don't have to come in saying, I want to stop drinking completely, et cetera. But don't come into the group saying, I don't know what I'm doing here. I don't have bipolar disorder. The group can't work with people who don't understand what the group's about. It deals with both disorders. You can't be acutely manic in any group. We tell people they can't come intoxicated. We define that. If you have used any mind-altering substance in that calendar day, don't come to the group. That got a lot of people to not use on that day when they might otherwise have done it. IGT is designed to be delivered with pharmacotherapy. This is not a substitute for pharmacotherapy and other psychosocial treatment is also encouraged. IGT can be adapted to other settings. The length of the sessions can be changed. The check-in items, people in different settings add or subtract things. You can add, did you get any exercise? Did you go to any self-help meetings? Did you eat healthily? Were you honest with your treaters? People add all sorts of things that they wanna do it. Some places like mood disorder programs have added a preparation group to get people to the point where they're willing to be in a group that deals with both disorders. You can broaden the population. So you can do this with people who have psychotic disorder. Hillary Connery, one of my colleagues, adapted the manual to add a little bit to it to deal with psychosis. You don't have to add much, just sort of add psychosis to everything else we talk about. You can broaden the population. So we use this, for example, at McLean Hospital in our outpatient program, in our residential program, on our inpatient unit. So when you've got, for example, an inpatient unit where people are there for just five days or so, you have to change the check-in. We don't even do a check-in because you're asking somebody, have you used drugs or alcohol? Well, hopefully not since you've been on the inpatient unit. Are you taking your medication as prescribed? Well, the nurses are giving you your medication. So a lot of these things are just irrelevant. The, we have changed IGT to be mood disorders and just adding depression. Even if you don't have major depressive disorder, everybody's got, everybody that comes to addiction treatment has experienced depression. Some people recite the central recovery rule at the end of the group. People have asked me, can you use IGT principles in individual therapy? Yes. I used it in individual therapy and that's how I developed IGT was things that I did in individual therapy. I then said, well, let's do that in a group. Current status, as I mentioned, it's been about this adaptations. It's currently in use in multiple clinical research and correctional settings in the US, Canada, Paris, Geneva, Nepal, maybe other places. There's a book published in 2011. That's the book. And that's it. So I'll stop sharing. So we're gonna open it up for questions and feel free to raise your hand and we can call on you or you can type the questions into either the chat box or the Q&A area. It looks like there was one. The timing, I'm not sure exactly if it was clarified, but there was a question just again, to go over the difference between parallel versus the integrated approaches. Okay. Parallel patients receive their, it's an outpatient model and patients receive their treatment in two different settings at different times. So they go to an alcohol clinic one day and a mental health clinic on a different day, but they don't, so it's not integrated. Whereas integrated treatment, they just go to one place and both disorders are dealt with in an integrated fashion, but this could be in many different forms, as I mentioned. Not necessarily, I mean, this is not the only model for integrated treatment, but it's just one. So I have a question. So it seems like the spirit of this has a lot to do with its efficacy in terms of, I don't know. I guess my question is, is there some sort of cheat sheet or do you have to go through the complete manual? Is this something that requires a lot of expertise in order to do effectively, or is it something that a therapist can pick up quite easily and integrate it into their practice right away? The latter, the latter. You can pick it up quite easily. You know, the manual is pretty simple. It's divided up into different, 12 different session modules. Each one, there's a handout that you give the patients and then how to run the session. Do this, do that. These are the themes. And you don't need, it's something you can read and pick up very quickly. It's pretty, it's simple stuff. And people really like it. People really like running it. Can you kind of like, is it best to follow the sequence of- Oh, great question, great question. There are 12 sessions. They are, they do not have to be done in order. Each one is meant to stand on its own. So there are a few sessions that are sort of like on our inpatient unit, people rotate through. I mean, patients rotate through every five, six days or something. There are certain sessions that are really more, more central and sort of to the point and popular than others. Probably the most, the one that talks about may as well thinking and then dealing with depression without using alcohol and drugs. Those are probably the two most popular ones. But there's ones about the effects on your family, triggers. And then when people are running the group, they choose each week based on how patients are doing, which session would probably be the best one for them this time. And it seems like it's something that would be amenable to even an ongoing group beyond 12 weeks, just for- Oh, absolutely. Right. I mean, in our outpatient setting where we're, there are people who've been in it for two years. We have a few people with raised hands. I can go ahead and go down the line and allow some of them to ask their questions. Go ahead. Should have access now. So Dr. Leong. And can you say where you're from? That would be great. Hi, I'm Jennifer Leong. I'm currently in Portland, Oregon. Hi. I've worked as an inpatient psychiatrist most of my career and most years in Philadelphia. And since I've come back to the West Coast, it seems almost like a luxury to find people with this type of double trouble where they can actually, where they can even mentally participate in the psychoeducation of their mood disorder because we have so much methamphetamine on the West Coast. Yeah. And I'm, so that's one of my questions. Like, what's your reaction to that? I also want to thank you for conceptualizing this double trouble thing because, you know, it makes me feel sort of like less bad about maybe over-diagnosing bipolar disorder in these folks, because from the inpatient point of view, sometimes I feel like I'm over-diagnosing it. And the third part of my question, if you want to react to it, is in your outpatient higher functioning folks, have you done anything with ADHD, which is not a condition that's very easy to use medications for in adults and especially for adults with, you know, addictions? That's all my questions. Okay. I'm not sure I'm going to remember all three of them, but let me get to the question of the folks using methamphetamine. So methamphetamine has not really captured the East Coast the way it has captured the West Coast. People who use stimulants here typically use cocaine. So we've, and that's back on the rise here. When I developed this treatment, did it at McLean Hospital. And I would say that the patients are higher functioning in general than the average population with bipolar disorder and addiction. And I wondered how this would play with people who were more impaired, lower functioning. And I got invited, a colleague of mine was doing a study in Washington, DC with people with bipolar disorder and psychosis and addiction and wanted to run IGT there. So he was doing this study and he said, he invited me to go down and see how it was going and to sit in on a group. So I sat in on a group of people. It was six patients. They were all psychotic craft users, mostly homeless. And they loved this group. Five of them were abstinent, one had used a little bit. They were the ones that came up with the idea of reciting the central recovery rule at the end of the session. They would hold hands and recite it. And when they got to the second, no matter what, they shouted it out at the top of their lungs. So I was really just delighted. That's just really touching to hear that image. So there is something about, and I talked to the group leader, the central recovery rule is not exactly a paragon of motivational interviewing. It's more or less dictatorial. And the group leader said, that's exactly what these patients wanted and needed. They're so disorganized that having this and people, I've got these different things, like I've got something called the three A's, like when you're faced with a trigger, you remember your three A's, you avoid it if you can, you avoid dealing with alone. And if you can't avoid it, distract yourself with activities. And a couple of the patients said, I was walking down the street, I ran into my drug dealer and I just, I just thought, use the three A's, use the three A's. And that's how I got through it. So, so it, it can work in a variety of different populations. What about the ADHD people that are so prominent these days? It's a tough group. I know that there are people who are developing more, you know, in addition to the pharmacotherapy, more behavioral treatments for them. That, and I should remember the guy's name because he's local, but Hallowell, Ned Hallowell has written a more of a behavioral approach in addition to pharmacotherapy. So, and I really, so integrated approaches, there are somewhat different integrated approaches for different disorders. And I think ADHD has got its own, you know, very specific sorts of things that, that an integrated approach that uses those behavioral features is a good idea. Yeah. Thank you. And then we have another one from Dr. Mignola. Go ahead and allow that. Hi, thank you so much. That was a great presentation. My question is about the abstinence based nature of this program. So this seems to be pretty, you know, abstinence based. So my question is, could it be adapted for use in individuals who are maybe, you know, considering different goals like using in moderation, or maybe they use multiple substances and one of them they want to be completely sober from, but the other one's not so much. So what are, what are your thoughts on that or your experience? So, it's a great question. But I came at this with the belief, you know, this isn't just any random population of people with substance use disorders. They've got bipolar disorder too. And I think that for people with bipolar disorder, the kinds of substance use that many people may find not particularly problematic can be very destabilizing. So that's why we stress abstinence in it. That doesn't mean everybody's going to do it. But I think that, I think that substance use in people, these are people with a substance use disorder where, you know, we're not talking about, if I have bipolar disorder, can I have a drink? And there's some people that would say no to that. You know, that any amount of drinking or drug use in people with, with bipolar disorder may be risky. I'm not going that far. But if you come in with a substance use disorder and bipolar disorder, I think that your safest bet is abstinence. What I tell people is like, and this is where the central recovery rule comes from. And I say this very explicitly, you know, you have bipolar disorder. That's not a good thing. You didn't ask for that. Bipolar disorder is not something that you did anything to get. And the course of bipolar disorder is to some extent out of your control. But there are two things you can do to either make the course of your bipolar disorder smoother or rockier. Alcohol and drug use, and taking medication as prescribed. If you take medication prescribed and abstain, that will make the course as smooth as it can be. If you do either or the other, it'll make it rockier. Why would you do that? That's kind of the, that's my thing. So that sort of leads into my second question, which was, what about conditions that are not maybe as serious, for lack of a better word, as, you know, true bipolar disorder? Like maybe a mild, milder depression, or is something that you suspect strongly that is a substance use, substance induced mood disorder, for example, and maybe even something that might not require medication. So that, you know, that, that pillar of strictly adhering to medication might not be necessary. Right. Yeah, I mean, yeah, once you're the difference between bipolar disorder, and mild depression is a big difference. Best. Yeah, right, right, right. So I wouldn't, this isn't a, like a one size fit all fits all that this should be integrated treatment for any co-occurring condition. Yeah, yeah, anything. Yeah, it was really designed for bipolar disorder. And as the population changes, then things change. I mean, there are other people, there are people who've adapted it. I talked to a guy who ran this in Paris. And he said, when he mentioned the central recovery rule, people just sort of looked at him like he had two heads. And he said, it's just a guideline. He said, if you try to make that a rule, everybody would walk out, out the door. So, so you have to be flexible. Yeah, you have to be flexible. But, you know, what I'm saying is that the effects of this were pretty dramatic with this population, and with that population I mentioned in DC. So, you know, if you, it's one of those things where if you start pulling one thread out of the sweater, you're just, it could it might all crumble apart. Yeah, yeah. Thank you. Thanks so much. I think Carla had a comment. I find starting with review of medications, especially what they are taking versus what they are supposed to be taking at the beginning of every session to be enormously helpful for structuring the visit and making the time much more efficient. Thank you for providing a structured evidence-based rationale for this approach. Thank you, Carla. And I think at one point, somebody else had a hand up earlier. Maybe it was accidental. I don't know. I don't see another hand up. So maybe that's it for. I think it was Dr. Paulson. Hello, I'm Hillary, Addiction Psych Fellow over at OHSU. Really appreciating your talk and the discussion with the questions leading off of that. I, funnily enough, I have kind of the opposite approach to Dr. Leong, where I tend to have this hesitancy to put myself in the shoes of a bipolar disorder when there is significant methamphetamine use involved and it's clouding the diagnostic picture. But I noticed in your talk that if we're moving this group over to a population with more depressive disorders, that there is benefit to including, say, someone with dysthymia or maybe substance-induced depression, something milder that doesn't quite meet criteria for MDD. And I'm curious in your experience, you know, after a certain point, like how much does it matter to tease out whether this is true bipolar type 1 versus something induced by a stimulant or other substances with the potential risk of overprescribing maybe medications that don't need to prescribe or adding a pretty serious label that maybe doesn't totally apply, knowing that people get a significant benefit with this IGT model of how to navigate the ups and downs of their moods and their substance use? That's a really good question. So when we're doing the research studies, we were very careful about diagnosis. And so then when it is when we have adapted it to a broader population, so for example, if you're in an inpatient setting or a residential setting, you've got people with all sorts of disorders, including people with no psychiatric disorders, you know, in there. And so we've tended to focus more on the a lot of the things other than you should take your medication as prescribed are really focusing on things like, as I mentioned, may as well thinking these sort of cognitive behavioral principles that are similar in the two disorders. We really, in the group, since the groups aren't typically led by physicians anyway, we don't focus on which medication somebody is taking. And for the most part, within our own system, people who are in IGT are also if they're getting pharmacotherapy, it's with our own people. So there's a lot of discussion among the group leaders and the prescribers about how people are doing. So yes, I mean, first, the first thing you said, which is be cautious about making a bipolar diagnosis and people who've been misusing stimulants like methamphetamine or cocaine, I agree with you completely. So I think if it's important that people get the right prescriptions and don't get prescriptions that they shouldn't be getting, I'm not really sure how else to focus on that. We really, the key thing is don't just stop your medication on your own or take twice as much or whatever. If you're worried that you're getting the wrong prescription, here, get a consult from somebody else or something. Just, it's people who just stop or aren't taking too much. That's where they get into real trouble. That's very helpful. I appreciate the distinction between maybe the specific medications and the overall principles of here are the ways we can structure the discussion. One of the things that I very much appreciated about what you said was how you emphasized the importance of treating the layers of hopelessness. I think this is so apparent in the patients and the families of the patients. And one of the things that I heard that you said was to kind of maybe kind of put things into baby steps so that people don't think they need to do everything at once. And then that can really make a big difference. Do you have other suggestions that you can use that we could use to help treat this hopelessness? One thing that I talk about is depression. An analogy I like to use is that depression is like having dark glasses on, except you don't know you have dark glasses on. So everything you see is dark, your past, your present, and your future. And if someone tells you it's not so dark, they just don't know what they're looking at because you know it's dark. And that the darkness is realer than real. I mean, that the hopelessness that people have or the darkness is not just I know it, but I know it 100%. And people get very upset when you challenge that and say, oh, it could get better. And so the key thing is to help people to just recognize they've got dark glasses on. It doesn't make it less dark, but they can say it's dark because I've got dark glasses on. I can't make it any lighter. But they take that with a little bit of a grain of salt instead of it's no longer realer than real. And I find that that helps people sometimes. I think we have another question. Thank you for that. One other thing that I say, so there's a lot of discussion about self-medication. That central recovery rule is too simple. You don't understand I'm self-medicated. That's like very common thing. And so one of the things we talk about is the distinction between snapshot and video thinking that people have this snapshot of that first drink. I really feel better. But they don't stop after one drink. They're going to have 11 drinks, and then things are much worse. And when I teach medical students, I used to have this videotape, VHS tape, and it broke, and that was the end of that, of a study that was done at what is now NIAAA many, many years ago. And it was a study of people with alcohol use disorder who were allowed to drink all they wanted. And they were doing all sorts of tests with them. But one of the theories was they videotaped them before they drank and asked them, what do you like when you drink? Then they videotaped them during their drinking episode, and then afterwards. And the idea was if people actually saw what they were like when they were drunk, it would be so different from the way they thought they were. That would motivate them to stop drinking, which didn't turn out to be the case. But interesting videotape. So there's a videotape of this guy, and he's asked, what do you like when you drink? And he goes, oh, I'm the life of the party, and I put a lampshade on my head, and I'm funny and witty and sexy, et cetera, et cetera. Then you look at the videotape of the guy drunk. And I've never dreamed anybody could be this drunk. He could barely stand up, yelling, screaming, swearing at everybody. And then the interviewer says to him, how are you feeling right now? And he says, I hurt. I've been hurting ever since I started drinking. Drinking doesn't do anything for me. It only makes me hurt. It makes me want to die. Then right after he says that, he spills his drink and says, I need another drink, at which point I would turn off the videotape and say, why did he say he wants another drink after what he just said? So when people say they're self-medicating, they're talking about the way this guy thinks he is. But this is what he's actually like when he's drunk, that self-medication is probably what we don't have is a videotape of him after two drinks, in which case he might be exactly as described. But that's drinking. That's not 4 plus alcohol use disorder. 4 plus alcohol use disorder is this guy drunk. And so we emphasize that in the group. It's like people, they think of I have a drink and they're sitting in their rocking chair and the dog brings you your slippers and your cognac and you've got a fireplace, et cetera. That's my drink. But three hours later, you've thrown the glass into the fire, you've kicked your dog, you've burned the house down with your pipe. So we talk about snapshot and video drinking. The snapshot is that first drink. And then we'd say, and then what? What happens an hour later? What happens two hours later? How are you feeling the next day? And to a person, people say, well, I feel worse, I feel worse, I feel worse. And there's a great AA phrase that we use in this group that I think is really great when people say, I'm self-medicating and I say, there's no problem you can possibly have that you can't make worse with alcohol. And it sort of turns the self-medication idea on your head that this is self-poisoning. This is not medicine. Well, we're at the hour, Dr. Weiss. I want to thank you so much for doing this presentation for us. I feel much smarter than I was before I started in this. And next month, again, we're off. And in January, we have contingency management with Dom DeFilippis. And thank you everybody for joining this. And we appreciate you again, Dr. Weiss. Thank you. And hope to see as many of you as possibly. Thanks. Bye everyone.

integrated group therapy

IGT

co-occurring bipolar disorder

substance use disorder

cognitive-behavioral therapy

parallels between disorders

interaction between disorders

abstinence

medication adherence

central recovery rule

depression without alcohol or drugs

pharmacotherapy