 Welcome back to the third part of the overview of behavioral addictions course. So let's talk about gambling. That's one we've talked about kind of throughout the course so far, but let's talk about what that means as far as diagnosis and treatment. One of the first things we've got to do is figure out what is the function of gambling for a lot of our clients? What is the function that this behavior is serving? For some people they're seeing easy money. For some people they're seeing relief from debt. Some people it's a game and part of the tension and release is figuring out how to beat the system. So the function may differ a little bit for each person and in order to help them really effectively deal with it, we do need to help them figure out what purpose this gambling is serving. Manifestations, tolerance as it gets worse or as it goes on, the amount of gambling tends to get significantly more. The amount of money spent gambling, the amount of time spent gambling. They need to have bigger wins in order to get the same rush. Withdrawal, when they are not gambling they're thinking about gambling. They're wishing they could be gambling. They're missing the tension and release, the build-up. Unsuccessful efforts to cut down, you know, pretty self-explanatory. A lot of time and energy is spent obtaining, using and or recovering. I think a lot of us by now have been around people who've played fantasy football and realized how much energy goes into researching and preparing and doing all that stuff. The same thing is true if you're betting on ponies, if you're gambling in a casino, if you are, you know, day trading stocks. And yes, day trading can be considered a form of gambling for some people. Spend a lot of time using it and then recovering both from the tension and release and just the physiological exhaustion from it, but also from the lack of sleep and any financial losses that may have occurred. Other activities are reduced or eliminated. Well, you're going to probably spend more time talking with people who share this interest, which is now starting to dominate your life and continued despite negative consequences. So I want you to think about what are some negative consequences that might be caused by gambling addiction? Some of the consequences, depression, anxiety, if you're losing a lot of money, that can be depressing. If you have lost money that you need for paying bills, paying tuition, that can cause anxiety. If your family is having difficulty with your gambling, that could cause some anxiety and social problems. If you're gambling at work, it can cause work problems. So you can see kind of how there are a lot of different things that are going to be affected by gambling. You're not just gambling by yourself. The other thing, if we want to jump back up to functions, for some people gambling starts as a social outlet. So their friends are the guys that they play poker with. But then it's not enough just to play that one poker game. They need to expand. And some people may say, well, that's where all my friends are. So we need to talk about, well, you know, would those friends be interested in doing anything besides gambling with you? Maybe try to get them to go out and go fishing or something. So what are the benefits of gambling for the person? Some of the benefits include social activity, money gain. It's a game, so there is some sort of euphoric rush if you win. An excuse to travel. Some people, my daddy, every year he and my stepmother would go to Las Vegas and they would go gambling. And, you know, that's just, it's what they did. And it was something that they looked forward to. And then what are the drawbacks to and negative consequences of gambling? I identified some on the previous slide, but I want you to think about what other ones might exist. If you're doing this with your group, it's a great group activity because you can have 8 or 10 people in group all giving their ideas. So you're going to get a lot of ideas. But if you're not doing it with the group, I'd really encourage you to spend 10 or 15 minutes trying to get into the mindset of somebody who is an addictive gambler in order to have the euphoric rush, they have to win sometimes. So experiencing some wins. And think about what the benefits and the drawbacks are and write those down on a piece of paper. That will give you a better idea if you're working with somebody who has a gambling addiction about what issues you may need to address. So food. Well, typically the function of food is nourishment. When it becomes an addiction, it's being used to cope and to soothe. Let's think about it. In our society, when we talk about conditioned stimuli, things that are going to make you feel better, when we fall, well, maybe not anymore as much. But back in the olden days, if you fell down and skinned your knee, while you were getting it bandaged up, you got a cookie. If something bad happened, you generally got a cookie. If you went to the doctor and were good, you got a sucker. If you behaved at the bank, you got a sucker. At holidays, we eat. At all celebrations, we eat. When somebody passes away, even at funerals, we eat. So pretty much everywhere you go, food is associated with comfort and feeling better. So it makes sense if somebody is feeling stressed or depressed or anxious or miserable, that food might be something that they turn to to feel better. It tastes good. It does have some natural rewarding properties to it. And it can be associated with a lot of pleasant feelings from the past, which makes it even more rewarding for most people. So let's talk about tolerance. Tolerance and withdrawal are a little bit different with food addiction. When we're talking about tolerance, we're talking about being able to eat more. When we're talking about withdrawal, now definitely there is a psychological withdrawal if people cannot access food when they're feeling stressed, anxious, depressed. They start to become very agitated. Unsuccessful efforts to cut down. One of the reasons for this is because food is one of those things that abstinence is just not possible. So it causes a little bit of a hiccup here. So what do people do? Well, most of the time, and we're going to talk about this more in the treatment section, but most of the time when we're talking about a food addiction, there are certain types of foods that someone is more likely to binge on. Highly processed, prepared, easily accessible foods. Because remember earlier we talked about the name of the game in addictions is immediate gratification. So if they have to boil rice or if they have to bake the bread, by the time they get around to doing that and it is ready, the feeling may have passed. Encourage people in early recovery especially to keep all of those easily accessible, highly processed, highly rewarding foods out of the house. Does it mean that they have to stay out forever? No, not necessarily, but at least until the new coping skills are stronger. Does it mean they have to not have those foods anymore? Depends on your therapeutic approach, my philosophy is no, they can still have them, but they need to have them in a controlled setting. Instead of having a one pound bag of M&Ms and thinking you're just going to have a handful, get a little snack size packet of M&Ms and only eat that one packet, keep the other packet somewhere where you can't go back and get a second and a third and a fourth. So that's one way you can do it. You can also, if you wanted to share a bag of M&Ms with somebody or get one out of the vending machine at the office, once you get one you've got to find the change to get the next one. Other activities are reduced or eliminated? Well, if you're feeling overwhelmed and you just want to go home and eat an entire gallon of Haagen-Dazs, you may forego going out with friends in the evening in order to do that. Excessive time energy is spent obtaining, thinking about, using and recovering from. People who are addicted to food have binge eating disorder, bulimia and even to a certain extent anorexia. People with anorexia actually do think about food a lot. Spend a lot of time planning what they're going to eat, how it's going to be prepared, what it's going to taste like, how they're going to get the food, how long it's going to take to prepare it, yada, yada, yada, yada. Then they spend the time using which a binge can go anywhere from 15 minutes to four hours and then recovering from. If you've eaten 15,000 calories, you're probably not going to feel so good. So if they've binged, if they've eaten an entire pizza, if they've eaten a gallon of ice cream, there's going to be a recovery time and if they purge, there's going to be a recovery time from that too because their electrolytes are going to get out of whack and they could rupture their esophagus and all kinds of other stuff. But I digress, regardless of what happens, if you eat that much food, there is going to be a recovery period. Other activities are reduced or eliminated, partly because you don't feel so good after you eat 15,000 calories even if you do purge and I'm not advocating for purging. I'm just saying, you know, if somebody binges, then purges, they're not going to have the energy or the desire to go out and hang out with other people. There's an enema that happens after purging. It's exhausting. Their throat hurts. Their electrolytes are out of whack. They're just not going to feel so hot. And it's continued. This use of food is continued despite negative consequences. One of the biggest ones is uncontrolled weight gain or physiological repercussions from purging behaviors. Physically, you can have a lot of repercussions from food. Socially, a lot of people who are addicted to food, who use food to cope, also start not wanting to eat in front of other people because they feel like they're being judged. So they don't want to go out to dinner with anybody. They don't want to go out to lunch with anybody. They don't want to have anybody in where there's a chance somebody might see them eating. Well, it's a legal way of self soothing. Is it healthy? No. Most of the time not. If you're doing anything to that much excess, it's probably not healthy. It provides comfort foods. That's true. There aren't a whole lot of other benefits to it. What are the drawbacks to and negative consequences of binge eating? I named a couple on the last slide. So again, if you work with people who do binge eat and even not to a addiction definition or a dependency definition, I would I'll go out on a limb and say the majority of Americans out there binge eat as a way of coping. You know, maybe not a 15,000 calorie binge, but I have a lot of friends who, when they get upset, when they get stressed will, you know, put down an entire pizza or eat an entire bag container or whatever it's called of Oreos. So it's not an unusual behavior at all. Which means they are having difficulty coping with life on life's terms and it could become an addiction. So when we're evaluating people even if they're not meeting the clinical definition if they seem to be using to excess or if it's causing them any of those um concerns that are identified on the cage then you want to start talking about alternate coping skills. Pornography and this is another one that has, you know, volumes written on it. The function of pornography well, it helps people engage that dopamine system. It gives people a chance to focus on one or, you know, 150 images and temporarily feel better. The tolerance at a certain point your run of the mill porn from Pornhub or the free stuff that's out there is not going to actually cut it. So the person needs to increase the intensity or the shock value or the egregiousness however you want to say it of the addiction. They need to change what they're looking at. Withdrawal they think about it all the time they miss it when they don't have it. It's kind of like being without your best friend. It starts to cut down pretty self-explanatory. Excessive time or energy used obtaining, using or recovering from. Now with pornography this is one of those interesting ones obtaining, figuring out where to get it and if you're getting it illegally figuring out how to cover your tracks again, not advocating for it just saying it happens using it and then recovering from it not only physiologically is not meant to experience that many dopamine rushes over that short of a period of time you can actually get over sexed. So letting the brain recover from the use but also going around and trying to clean up your computer afterwards to make sure that your significant others don't find out about it. So a lot of time is spent around this ritual. Other activities are reduced or eliminated and you continue to use despite negative consequences. I've heard of people using pornography viewing pornography at work on the train to and from work in the bathroom at the office at their desk at the office so it's not it starts invading or getting through into every aspect of a person's life. So what are the benefits? One of the benefits I've been told is that it's the ability to view and fantasize about something basically without any other work. It gives some people a chance to just escape into a different reality where they can envision themselves with whatever person or situation is going on. Thinking about some other benefits sometimes it makes people feel not as alone because they do have an imaginary relationship kind of going on for 5, 10 minutes, 2 hours whatever it is. What are the drawbacks to and negative consequences of pornography? Well it can cause relationship problems. It can cause work problems if you're doing it at work. It can cause depression if you over tax your pleasure centers at a certain point you may not be able to get an erection with a human partner anymore. So there are a lot of cascade effects that take into account as a result of viewing pornography. It can also be expensive and illegal. So those can also be drawbacks. So let's go from pornography which can be a little bit depressing to shopping. What function does shopping serve? Well it occupies your mind so you're thinking about what you're buying. Some people buy things to make themselves feel better. They'll get themselves a new outfit to reward themselves to feel better for something. For a lot of people who are compulsive shoppers their entire self-esteem is built around having the best, the most, and being able to show people tangibly with purchased items their personal value. Their value is completely defined by their possessions. Manifestations, the tolerance at a certain point shopping and just getting occasional little things are not enough especially if they're defining themselves by it. They need to have the best and they need to make sure everybody knows it. So it's not something they can keep in the house it's more like having the biggest house on the block. Withdrawal, thinking about it all the time unsuccessful efforts to cut down either on spending, you know, setting a limit of $100 instead of spending $2,000, or on the amount of shopping you do or the amount of recreational shopping you do. And again, shopping is not something you can really abstain from because we all have to go grocery shopping. We all occasionally have to go to Walmart or Target or somewhere to get something. So we're going to have to help people figure out how to not turn those activities back into their addiction. Using a list is one of them going with the buddy is another. Those are the two big ones that I tell people to start with. Excessive time and energy is spent obtaining whatever it is or figuring out how you're going to pay for it, getting it, flaunting it, and then recovering from the financial drain of buying it. Other activities are reduced or eliminated. It becomes about having the most, having the best and being able to flaunt what you've got. People who have shopping addiction tend to be very, very empty on the inside and have very fragile, brittle self-esteem because it's all built on exterior stuff. They don't like themselves. They like the clothes they wear. They don't like themselves. They love their house. They don't like themselves, but they can show you the Oakley sunglasses they bought. And it's continued despite negative consequences. Shopping addiction actually causes a lot more than just financial harm. Many, many marriages break up over it. Many people get in trouble at work because they're online shopping when they're supposed to be doing their job. There are a lot of things that can go by the wayside. So what are the benefits of shopping? We talked earlier about the fact that like all other behavioral addictions it gives a person something else to focus on. If you've had a really bad day and you just need to distract yourself shopping is an option for some people. Window shopping is definitely an option for some people. With behavioral addictions not every behavioral addiction is going to work for every person. I hate to part with my money. So shopping addiction is not something I'm probably ever going to be at fault for. But we do need to consider what the benefits are for this person. Like I said before one of the hugest, one of the most marked benefits of shopping addiction that I've seen in the patients that I've worked with is they define themselves by their stoff. So it gives them an identity. And if you take away their stoff you take away their identity. Think about that for a second. Try to get into the mind of someone whose entire identity is wrapped around what they can show others. The outside wrapper. And now you can start to see where we need to work. What are the drawbacks and negative consequences of shopping? Well, we kind of talked about those relationship problems, financial drain those sorts of things all start to build up. Even with something as seemingly mundane as shopping. And it doesn't matter if you're shopping at Cartier or if you're shopping at Walmart if you're spending above your means it could be a problem. If you are buying stoff to represent yourself if you're buying stoff because you have no personal identity you need to be the one with the latest fads with whatever then it's a problem. I wonder where it comes from. Exercise. Can you abstain from exercise? Oh, I try. I'm in the fitness protection program. Sorry couldn't resist. Exercise is one of those things that people can do to avoid dealing with life. When you go into the gym or when you get out on the trails or get out on the track your mind goes to whatever you're doing. You're focused on your breathing. You're focused on pushing yourself faster or getting the longer distance or whatever it is. You're focused on that. When I exercise I listen to music and I just get completely immersed in the music and it's sort of my downtime. It's my zen time my blank mind time. That's awesome. It's just when it starts being used to excess despite causing negative consequences that it's a problem. So let's talk about tolerance. How can you have tolerance to exercise? Oh, you can. Tolerance is when what you did or what a normal person would do isn't enough anymore. You want to be the fastest runner. You want to completing a marathon isn't enough anymore. You did that once then there done that. Now you need to complete an endurance run which is 50 miles. So tolerance means in order to get the same endorphin rush and the same psychological pleasure from whatever you're doing you need to intensify whatever you're doing either by making it longer in duration or intense or switching it up and combining like cross training. Withdrawal you get to exercise. You start feeling agitated. You get cranky. Unsuccessful efforts to cut down. You decide that you're only going to work out three days a week. But those other four days of the week nobody better cross your path. Well that's not a very successful effort to cut down. That's about white knuckling again. And generally people end up going back to the gym because they just feel so lousy when they're not there. Excessive time or energy is spent planning out your workouts planning out your meal plans exercising and recovering from exercise. People who are exercise addicts will exercise through injuries. They get a pain and they're like you know if I keep working out my body will give up and I will win and I will be able to keep running or keep lifting or whatever the case may be. We're not real smart. Activities are reduced or eliminated so you can go to the gym or so you can get your workout in. Some people will arrange their entire day around their workout because they're not going to miss it. They will avoid any activities, any jobs any anything that might conflict with their workout. And this also can have devastating consequences on vacations and holidays and things like that when schedules get a little bit wonky anyway because the person has to figure out when they're going to get their exercise in which puts everybody else in a weird position and can cause a lot of strife. And it continues despite negative consequences relationship problems health problems being two of the big ones. I know exercise causing health problems who knew. Anything too excess is probably going to have some negative consequences and you can really easily get repetitive injuries if you're working out that hard all the time. So the benefits of exercise oh there's lots of them. You feel better you maintain your weight. It's a good place to clear your head. You can get things you can get your muscles balanced so you get some of the chronic pain under control. You can release some of those muscles if you store all your tension in your back. There's a lot of awesome things about exercise which is why I don't like to see people say oh I'll just abstain. No problem there. An exercise addict wouldn't say that anyway. They'd be like you're going to make me do what? Oh no, no, no, no. So the benefits of exercise are there. There are a lot of them. We have to help people figure out how they can control their exercise and not use it dysfunctionally. The main drawbacks are those overuse injuries and family problems or issues that result because the person with the exercise addiction will not budge will not skip a day, will not cut an activity short. And the internet Well when we're talking about the internet addiction we're not talking about porn necessarily. And I see this when I work with couples a lot. One couple one person in the couple will come home from work put their stuff down get something to drink, sit down on the computer and not get up from the computer until it's time to go to bed. Which leaves the other partner feeling neglected and frustrated and all that kind of stuff. So what's the function of the internet? It is a place where you can go to occupy your mind to escape. It is a place where you can go where you're not thinking about all the other stuff. Pinterest if you've ever been on Pinterest Pinterest can be a time suck. Just like Facebook, Instagram any of those places that you go where you just want to explore get away from your own reality for a few minutes. Now those can also be places where you connect with your friends and people with other interests and ideals. Remember all of these behavioral addictions can be used in a healthy way. But they can also become addictions and become used dysfunctionally. So a lot of time is spent on it and we'll also kind of throw in video games here because I don't have another slide for video games. But the person spends an entire evening doing this instead of house chores, instead of homework, instead of eating well and sometimes they may go to sleep so they can stay up and keep doing it. And you know they get on the computer at six when they get home. Next thing they know they look up and it's three a.m. and they've got to be up in two hours for work. So there's a lot of secondary consequences to internet addiction. Also depends on what the person is looking at. If it is video games that has its own issue because there's a whole culture surrounding a lot of video games. If it's news, if it is Facebook, chat rooms, whatever the case may be it's going to be a little bit different in the way that it actually helps the person cope or escape with whatever's going on in their life. So what are the benefits of compulsive internet use? Just like food used properly is necessary. In our society the internet used properly is probably necessary unfortunately. But we want to look and say what are the benefits of using the internet? Well if you're using it to kind of escape and wind down and just block everything out for an hour that can be healthy. If you're using it to get your news information that can be healthy. If you're using it to find recipes or do something productive that can be healthy. Unless or until it starts causing you to ignore all the other areas of your life. So quick little look at treatment. Unlike chemical addictions where we know that abstinence is possible and it's actually preferable. With behavioral addictions you have to ask yourself and the other person is abstinence possible? If you have somebody who is a gambling addict and you say is abstinence possible? Most people are going to automatically go well yeah you don't need to gamble. But what if the person sitting in your office that has a gambling addiction is also a day trader or somebody who does trading and stock stuff for a life for a living. They're actually kind of gambling all day at work. And that's part of their job. So is abstinence possible? Not for them. They're going to need to figure out how to deal with it in a healthy way and not carry it outside of the walls of work. And not take it into work where they start trying to make riskier deals in order to get their needs met while they're at the office. So we have people identify whether abstinence is even possible for them for this addiction at this point in time. And we have to go with whatever their response is because they're going to do whatever they want to do. Then we do a decisional balance exercise. What are the benefits to you of this behavior? And what are alternate ways you can meet those needs? It provides excitement. Okay great. So how else can you get excitement? I don't know. Well that's your assignment for the next week is to look around and figure out other things that might be exciting. Do you want to learn to skydive? See I go to those adrenaline things automatically. There are other things that can produce pleasurable feelings. So what other ways could you find excitement or happiness? What are some of the other pros? And what are some alternate ways you can meet those needs? What are the drawbacks to your current behavior? What are the benefits to recovery? Most people will say they'll have more time their relationships will improve their mood will improve their health will improve. That pretty much goes for every addiction. But what are the other pros of stopping? The person needs to really think about this and figure out why is it that they want to stop? What is motivating them? It's not because they're going to change for their spouse or their children or whatever. What are the benefits of change for them? What are the drawbacks to recovery? Yep there are some and we're going to talk about them. We're not going to sweep them under the rug and go recovery is great. No. Sometimes recovery really sucks and you know, I'm sorry that's just the way it is. Sometimes life sucks and if you are dealing with life on life's terms you're going to have to deal with the lemons and figure out how to make lemonade. So if you're in recovery you're going to hit some bumps in the road but the benefits are you're going to get to feel the good times. You're not going to constantly be hiding out, you're not going to constantly be obsessing about whatever that addiction is. You're going to actually get to live in the moment and feel happiness when it happens and that's really cool. So we need to help people start identifying what their triggers are because they're like well I always think about this I can't not use. It's just constantly going through my mind. Okay so let's look at triggers. Initially people are going to list the obvious ones. The triggers are having it accessible maybe being stressed. We need to think about the media. Not only billboards and advertisements and radio media but also what people are watching on TV. Is it triggering them? There's a lot on TV that can trigger sex addicts. A little bit as far as gambling goes not near as much. Shopping? Oh my gosh I mean there are entire channels dedicated to shopping. So yeah there are some things in the media. Then they need to look at their surroundings at home, in the office and when they're out. What things trigger them to want to use. What things remind them of using. Obviously you're not going to tell somebody who has a shopping addiction to go walk around at the mall in order to deal with stress. We need to make sure their surroundings are safe. Sight, sound and smell the three S's if they see something that reminds them of it then they're going to start thinking about it which is going to increase the craving which may lead to use unless they have a way to stop that craving. So when they start craving what do they do? In the first section we talked about exceptions. What are you doing times when you're not using. Go on a drive, go out on a walk go to the gym write in your journal whatever it is that person does they need to do that as soon as they start to think about craving. Sounds if when we're talking about drugs for example the sounds from the same songs that we're playing at the club where you used to use the sounds of a game going on behind you or a football game or a hockey game or any kind of sports event that you used to bet on may trigger you. The smell now there's the smell of the club there's you know smells of certain perfumes there's also smells of cigars and cigarettes which could remind you of poker games. Each person has to figure out what their triggers are because they're going to differ to a certain extent for each person but they need to be aware that although it only may be a little tiny trigger little tiny triggers start little tiny thoughts that snowball into huge cravings so they need to know how to stop it as soon as they start thinking about oh I'd like to fill in the blank. Temporal triggers times of day I'm bad about coming home putting down my bag walking into the kitchen and getting something to eat I'm not hungry most of the time but that's just what I do I come home I put down my bag and I get something to eat that's a temporal trigger just what I do at the end of the day we need to encourage people to be less mindless and more mindful of what they're doing so a time of day doesn't trigger them to want to use most of the time they'll have to kind of change up their routine or change up their habit in order to break that temporal cue holidays holidays can be or anniversaries can also be a cue for relapse the one year anniversary of when you stopped using the one year anniversary of a death or a loss Christmas Thanksgiving Easter there are a lot of different reasons that people use there are a lot of different times of year that can trigger use another thing to consider is seasonal affective disorder if you have a lot of gray days where you are places like Oregon where it rains a lot or if you're in one of those climates that there are certain times where you just don't see much sunlight people may start to get depressed and they may start coping with their depression through behavioral addictions or behavioral means that become behavioral addictions help people be aware of this how do you prevent getting seasonal affective disorder so encourage them to get the special daylight spectrum lights encourage them to try to get outside if it is sunny at all or at least try to sit by a window that way their body knows when it's time to be awake when it's time to sleep and the circadian rhythms can kind of help the circadian rhythms I've mentioned them a lot are responsible not only for your sleep cycle but also for your eat cycle and a lot of hormone regulation goes on based on your circadian rhythms so it's important to try to keep those puppies in balance emotional triggers any of those distress emotions happy not happy mad sad people scared anxious any of those things that somebody would want to escape from could be a trigger for a behavioral or chemical response and social triggers being around people who are consistently negative certain people that you used with before certain social situations where people are using for example football games when you tend to hang out with a group of people at the football game and you guys always get there four hours early in pre-party then that social situation is going to be a trigger for use help people identify and remind them that they need to keep an ongoing list of triggers they're not going to come up with a comprehensive list in one sitting or even two things will come out and probably surprise them when I was working in residential there was a client that came up to me one day and said Ms. Dawn can we do something about getting rid of these sugar packets and I was like why not fully grasping everything that was about to happen and he said well you know we need sugar for the coffee and for everything but every time somebody shakes down a sugar packet it reminds me of shaking down a baggie of cocaine and it triggers me and I said oh well golly nobody's ever brought that up before so yeah sure we will get rid of the sugar packets and from there on out we had a little pourable sugars in order to minimize the triggering effect of the sugar packets on clients who used to use cocaine so remember there are certain situations that or stimuli or events that will seem to come out of nowhere and you'll be like why did that make me think of using and when you think back about it there's something about it a smell, a sight, a sound something that reminded you the follow on is you're going to have triggers we need to help our clients figure out how to avoid relapsing when they're triggered they're going to be triggered and how they deal with it is completely individualized to them so again remember when they leave your office after that first assessment you want to have them identify at least three times in the past week that they haven't been using those are your exceptions those are times when you're not using so when they get triggered when they start to feel a craving they need to go do one of those things for at least 30 minutes generally that's time for the body to sort of ride the wave and the craving the craving is kind of like a wave and the craving will have dissipated and then they can move on with life the other thing we need to encourage them to do is ask them when they've been stressed before who have they been able to talk to or how have they dealt with stress, anxiety and depression in the past that has worked ideally you want them to walk out of your office knowing three exceptions so three things they can do when they feel craving and having two or three people identified that they can call to just chat with not even chat about the problem necessarily to just be with because if they're with that person they're not going to use so your interventions support groups people in addictions treatment need support now it can be a support group at church it can be a 12 step support group it can be a smart recovery support group but people need support because people with addictions will manipulate themselves and will justify rationalize and minimize their behaviors as long as the day so you need to have somebody in your support group that not only has other tools that they can share that can remind you of your tools and that can call you out on your crap so support groups are important coping skills training start with their strengths what do they do now to cope with stress and let's build on that let's not reinvent the wheel now some people you might try adding a couple new techniques and see if it works but I don't want to try to force them to do something that doesn't feel comfortable for them they need to write these coping skills and their social supports on an index card or on a notepad document in their phone so they can access it when they start craving because when they're craving they're not thinking they're not thinking big term they're not thinking what are my resources they're thinking I want it and I want it now I want it and I want it now and that's just kind of repetitive in their head they're trying to figure out how to get their addiction how to get their substance or engage in the activity have them identify stressors and triggers and alternate ways they cope have them bring that to group every week they can talk about what worked and what didn't and figure out how to strengthen those skills so they work more often have them identify any underlying neurochemical or physical imbalances physical causes of distress physical or mental health psychological pain I mentioned that earlier get them to go to the doctor so they can have their thyroid tested their hormones tested make sure that there's not some source of chronic pain like fibromyalgia or herniated disc or something that is causing them undue and preventable distress some people are just going to have chronic pain and there's lots of resources on how to deal with that but if there's anything that you can take care of relatively easily by all means let's get rid of those stressors so the person can have more energy to focus on the things that are more difficult to deal with so chemical and behavioral addictions often occur together when you take away the primary or the preferred addiction a behavioral addiction may kind of take its place as a stop gap chemical and behavioral addictions both co-occur with other mental health stuff so if somebody's presenting for depression expect that there may be a history somewhere of either behavioral or chemical addiction or there may be a propensity to develop one chemical and behavioral addictions represent the best the person could do the skills that they had until now and you as the therapist are the until now you have the ability to help them develop new skills and tools because they're in your office because they don't want to do it anymore they don't want to live this way anymore so they're motivated and we need to strike while the iron is hot abstinence is not always possible with behavioral addictions now some clients may try to challenge you they've got concurrent chemical addictions and go well if I don't have to abstain completely from food why do I have to abstain completely from alcohol I can do both of them with controlled use be prepared to address that there are a lot of things we can do and what I tell my clients is there are a lot of things we can do but they set us up for unnecessary risk and we can't live without food we don't have to figure out how to deal with that but why put yourself in a position where you could be at risk if you don't need to by doing control drinking that's my response when they start talking about wanting to do social drinking or control drinking ultimately I know they're going to do whatever they've decided they're going to do so it's up to me to help them develop the strongest tools they can to stay happy, healthy and relatively sober and the causes of distress must be addressed we can't just take away the addiction oh, it makes my head spin when I hear of people go in for eating disorders treatment or for any kind of treatment and the first thing the doctor says is okay we can't do that anymore no more binging, no more exercise addiction no more gambling, no more cocaine whatever the case may be and like it's that simple we just take that away and then we can start dealing with the other stuff you take that away and the person doesn't have any coping skills so you have to take that away but provide something else instead I mean ideally you take it away initially there's a detox period and you're providing those skills during that period I don't want people or I don't like for people to feel like failures if they relapse early in treatment if they haven't strengthened their coping skills enough to deal with life on life's terms and that behavior creeps back in until we fully identified and dealt with the sources of distress in their coping skills there's going to be a risk of relapse remember that's a survival mechanism everything you've given them right now is not working for some reason and that's something you need to talk about with your patient okay you had these six coping skills or whatever that we had talked about did you try them if so what happened if you didn't try them why not just the point where you just were ready to say screw it and go back to your addiction I tend to be pretty blunt with my clients because they can handle it they're not fragile by any means for the most part but your style may be a little bit different the key is to figure out what led up to the relapse and why they chose the addictive behavior instead of what you're working on in therapy because that tells me it's not resistance it tells me we have failed to provide them something that's as effective so we need to tweak it a little bit to make it work for them if you've watched and participated in this program for CEUs log into the classroom at allceuse.com and take the quiz if you've watched and participated in this program and now want CEUs but have not yet registered access to the quiz and certificate at at allceuse.com slash live hyphen interactive hyphen webinars this presentation was recorded as part of a live interactive webinar if you are watching it on replay please remember you can contact Dr. Snipes on her personal chat page at purchat.me purchat.me slash u-e-t-v-x