Behavior Modification Tools for Obsessions, Cravings and Addictive or Compulsive Behavior

Hey there, everybody. Welcome to today's show. We're going to be discussing behavior modification for addictive and compulsive behaviors. I'm your host, Dr. Donnellice Snipes. In this presentation, we're going to review basic behavior modification interventions and their utility with addictive and compulsive behaviors. Pretty straightforward, right? So the first thing we want to do when we are trying to modify a behavior is to figure out what we're working with. And we do this by starting to gather what we call baseline data. So to understand a behavior, you first need to understand the frequency, how often it happens. It can be how many times per hour, per day, per week. You know, you get the point, the intensity of it. And is it a little bit, Is it a medium amount, or is it a whole lot? Depending on what behavior you're measuring, there can be variations in intensity. Like, if you're talking about how much you eat, the intensity would be the number of calories. So, you know, zero to 500 calories, 600 to a thousand calories. You see what I mean? Duration is how long the behavior lasts. So if somebody is getting upset or if they are engaging in compulsive behaviors, is it lasting three hours or is it lasting 30 minutes? Big difference there. You also want to start understanding vulnerabilities. And these are things that make people more likely to be triggered into their addictive or compulsive behaviors. And we're going to talk about those more in a minute. And then we're going to also talk about PACER proximal triggers. And what PACER stands for, remember is physical, affective or emotional, cognitive, environmental, and relationship triggers for the addictive or compulsive behaviors. Now, a little side note here. Compliance with keeping baseline data is often enhanced with checklists or simple fill in the blank worksheets. If you leave it to somebody to have to remember everything they need to write down, then they're probably going to forget stuff. And that's just human nature. So what are we talking about here? Obsessions or cravings are thoughts that we have that can. We can feel like we're stuck on them. We can feel like we can't get them out of our head. Sometimes we call this ruminating. Compulsions or addictive behaviors are things that we do in order to try to get rid of that thought. So in obsessive compulsive disorder, somebody may have the obsessive thought that they are in danger, that they're not safe because they left the oven on or they forgot to lock the doors or something like that. So their compulsion would be to get up and check those things. When they do that, it makes them feel better for a minute. But a lot of times it's not very long before they start feeling anxious again and they start wondering, well, did I actually check all the doors? And then they start obsessing about it again. And in order to make those obsessions go away, in order to stop those thoughts, they have to get up and check again. Now it becomes a problem, according to the dsm, when these obsessions or compulsive behaviors take more than an hour per day or cause clinically significant distress. So if it is something that is taking, you know, even 15 or 30 minutes a day and it's causing the person significant distress in their life, then, you know, they may meet the criteria for obsessive compulsive disorder. They certainly need to be screened for it. In obsessive compulsive disorder, people have thoughts about. And we can fill in the blank here. There are a lot of different obsessions about, you know, whether they're safe, whether there's going to be a fire, whether they turned off the stove, whether they lock the doors, whether they're going to get sick, whether they're, you know, there are a lot of different things that people can obsess about. And those obsessions that generally revolve around some fear, some perceived threat, and they're trying to keep themselves safe, they want to stay safe. And in order to make those fears go away, in order to keep that anxiety at bay, they may engage in a variety of different behaviors that are usually make sense with whatever it is. So if you're afraid, you left the stove on, checking the stove. But some people also just have particular rituals to keep something bad from happening to them. They have to do these 15 rituals correctly in the same order each day before they leave. And if they make a mistake, they've got to start all over again. And I've worked with people who have had situations where it would take them literally hours. And sometimes they couldn't even get out the door because they kept making a mistake and having to start all over again. Some people also have obsessive or persistent thoughts when things are not the way they want them. And this can move over to obsessive compulsive personality disorder. But really what we're talking about are these persistent thoughts, such as, there are dishes in the sink. I can't go to sleep with dishes in the sink. There are dishes in the sink. And the person may feel like, they've got to get up, and every time a dish is in the sink, they've got to get up and clean it. They can't let a dish sit in the sink. So we're going to talk about things that might make somebody more vulnerable to that. Now, as with any mental health issue, generally, one approach is not going to be sufficient to ameliorate the problem completely. All we're talking about here are behavior modification techniques that can be used in addition to other things in order to help somebody cope with obsessions, ruminations, compulsions, and addictive behaviors. Body dysmorphic disorder was moved into that category with compulsions. And people with BDD often have thoughts about some part of them that they perceive to be disfigured. And they spend an inordinate amount of time trying to cover it up, disguise it, fix themselves so nobody sees it, and then checking themselves to make sure that it's still hidden. In addictions, people will have cravings, which are thoughts about using. Thoughts about using whatever their, their addiction of choice is, whether it's alcohol, drugs, food, porn, sex. The list goes on. Now, there are other behaviors. Not all behaviors are bad. Go figure. Recovery behaviors are also something that you can work with with behavior modification because, and I had a great teacher when I was in graduate school who provided all of my education on applied behavior modification. And he pointed out that you can't just eliminate behaviors. If you eliminate behaviors and eliminate behaviors, then the person or organism is left with no behavioral responses. So if I can't do this when I get stressed, what can I do? So it's really important to replace, to add positive behaviors that help solve the same problem that can replace the targeted or less preferable behaviors. So recovery behaviors are things that we want to enhance, we want to reward, we want to increase. They can include sleep, exercise, nutrition, pain management, biofeedback, that, that is paying attention to slow your breathing, slow your heart rate, reduce your stress response, happiness promoting behaviors, and positive or empowered thought processes. So here are a couple of charts that are very, very basic, but they can be helpful for gathering that baseline data that you're looking for. This first chart is designed for behavior reduction. So whatever the undesirable behavior is that you are wanting to eliminate or reduce, this is a kind of worksheet that people could use. So they would put their name and they would put their date at the top of the page. And then there would be multiple iterations of this if the behavior generally occurs more than once a day. But what is the behavior that they are writing about what are they doing. Because a lot of people have multiple kind of related behaviors. Not everybody, but we want to make sure that we note what behavior we're talking about. What was the intensity of the behavior? And, you know, I mentioned there are a lot of different ways to measure intensity. And down here in the corner I have where it says on a scale of one to four, one is a minimal intensity, zero to 10% effort, zero to 10% in intensity. Two is moderate, so that would be 11 to 35%. Three is a lot. So that would be more than a third, all the way up to two thirds. And then four, four would be over 85%. So that would be pretty extreme. So if you're thinking about in the gym, giving effort, minimal effort, less than 10%, moderate effort, up to 35%, that's a, you know, decent workout, a lot of effort, a hard workout, up to 60% of the person's full effort. And then just an extreme workout would be full out, full open, the whole time, 85% effort or more the whole time. So that's really what we're looking at in intensity. So what are we talking about? How can we chart intensity for cravings? Well, somebody can rate the intensity of their craving. How bad is it on a scale of 1 to 10, is it. I'm kind of having that thought to 4, which is extreme. And they're feeling like, I have to act on this. I'm having this thought, and I have to act on this. Right now it feels almost unbearable. So, you know, that's. That's the range that we're talking about there. Same thing for obsessions. When people are having obsessions, are they thinking about it? You know, it's a fleeting thought that would be a one, or is it this persistent thought that is just almost screaming in their head, and they feel like they've got to get up and do something to make that obsession stop. So that would be extreme. And then you've got in between gambling. Gambling is a little easier because you can measure money. How much money did you spend when you were gambling? Was it, you know, penny slots for $10? Or was it you spent more than 85% of what you had allotted? Or however you want to. However you want to measure that smoking intensity. That would be how many cigarettes did you smoke per sitting, for example? So my mother used to be a chain smoker, and after dinner, she could easily smoke three or four cigarettes before even leaving the table. So that would be intensity, reducing the intensity. How much? How much she smoked in one period of time with checking or disguising, with behaviors that somebody's engaging in. What is the intensity again? One minimal. Is it fleeting? They just kind of looked in the mirror or they, you know, kind of fluff their hairs or a little different or something, or extreme, you know, How. How much. How intense were they engaging in this behavior? Duration? Well, that's easy. How long were you doing it? How long were you having these cravings, these obsessions? How long did you spend gambling? How much time were you smoking? How much time did you spend checking or disguising? The reason we gather this data, the frequency, intensity, and duration is so we can see progress because people are not going to go from, you know, extreme intensity, long duration and multiple times a day to, you know, all of those dimensions being better. So we want to see changes. Maybe the first, the frequency gets less, but the intensity and the duration stay at first. All right, well, that's fine. So then let's start working on reducing the intensity, and then let's start working on reducing the duration. But seeing this, you can see incremental changes, and that is really important. So this gives us an idea. When we're getting this baseline data, just like it sounds, we're getting an idea of where are we starting? What are we starting with? So then we can start setting goals for reducing the frequency, intensity, or duration. Other information that we're gathering is related to triggers and vulnerabilities, but typically triggers. What were you feeling physically when this happened? So if somebody's heart was racing or they weren't feeling well or they were tired or something, and that triggered them, that triggered their cravings for some reason. That's good to know. For example, people who have high levels of anxiety, people who tend to have more obsessions, may find that when they drink a lot of caffeine, that ramps them up, that amps up their. Their stress response system, which triggers their obsessions and compulsions, their behavior. Their brain says, hey, I'm feeling really anxious. I wonder what I'm anxious about. And then it finds something to. To think about. And it. People get involved in what we call emotional reasoning. But what's important is to recognize that when you feel a certain way or if you feel a certain way, that you are more likely to engage in the undesired behavior. For gambling, some people, when they're feeling physically, when they're feeling tired, when they're worn out after a long day, when they're burnt out, and that's kind of emotional as well as physical, that May trigger their desire to gamble, partly so they can get an escape, but partly because gambling may give them hope that they can win enough money that they can quit this job they hate and, you know, fill in the blank. What were you feeling emotionally when this happened? Now, emotions are typically, typically dysphoric or unpleasant when people are experiencing cravings, obsessions, or being triggered to engage in addictive behaviors. That's not always the case. Some people feel more comfortable feeling depressed because that's what they know. And when they start feeling happy, they start waiting for that other shoe to drop, and that makes them anxious. So they start becoming hypervigilant and looking for, okay, what's going to go wrong? And that can cause them to engage in more checking behaviors. So it's important for every person to know what their triggers are. What were you thinking when this happened, when you engaged in this behavior? Typically, people who have obsessional thoughts, and we'll just stick with checking, they may have laid down in their bed, and they had the thought that, I hope I turned off the stove, because if I didn't, it might cause a fire. And then the house would catch on fire, and, you know, that would be really bad. So that was their thought that triggered the obsession of, did you turn off the stove? Did you remember to turn off the stove? Or did you turn off. Did you unplug the iron, whatever it is? And then until they can get up and verify that, until they can address that thought, they may keep repeating that. So generally, the obsession is not where it starts. There's a thought that kicks it off that says, there might be a problem, you might be in danger. And when that happens, then the person starts ruminating or obsessing about what that potential danger might be. What helped you stop this behavior? People can get into that loop where they have the obsessions, and then they engage in the compulsion, the behavior that stops it. Then, you know, before long, they're thinking about it again, and they've got to check again. So what stops this cycle for people, even if it's only for an hour or, you know, so they can go to sleep that night? What happened? What was different that helped you feel confident that, yes, I've checked all the doors, and some people have things. One. One person I worked with who did tend to check a lot. She'd get back to her bed, and she'd lay down, and she's like, I wonder if I remember to check everything. So what she started doing was taking little sticky notes, you know, little. The little tiny ones. And every Time she would check a door or a window, she would place a sticky note on it, place a little sticker on it, so she knew that she had checked everything that went, reduced it. So instead of checking five, six, seven times, she ended up getting to the point where she would check twice. And for her that was significant relief because she'd lay down, she start having the obsessions, she'd get up, she'd check everything and put the stickies on it. And if she laid back down, started wondering, did I remember to check everything? She would get up and check everything again. I had another person who had a similar checking issue. It wasn't as much with doors and windows, but checking to make sure that they got everything done. So we created a checklist that they would go through and check off so they knew they had everything done that was important. So they would check the iron, they would check the stove, they would check the locks, they would check to make sure that all the kids were in bed. They would check to make sure the dog was in, all of those things that they would worry about when they would lay down to go to sleep. So again, those thoughts can be problematic. And I've already gotten into some of the interventions, but this is why we're trying to identify what triggers it, so we can figure out how can we help you feel safer? Because remember, a lot of these things, whether it's addictive behaviors or compulsions, often come from a place of feeling unsafe or disempowered, which can lead to high levels of anxiety, depression, etc. So what helped you stop this behavior? Anything that they've done? Because then we can build off that and then what are the consequences of this behavior? And that helps the person see or remember regularly the reasons why they want to stop. Like the consequence. I had to get up six times, and the fourth time I did, I accidentally woke the baby up. Or I didn't get near as much sleep as I needed because I was up checking until one in the morning, or I didn't get near as much sleep as I needed. And I feel awful this morning because I'm hungover. I drank too much last night. So these are things that we want to look at. And each day people will keep track of their behaviors. And then I have a sheet that helps people process how the week went for behavior enhancement. Remember I said, you don't want to just eliminate a behavior, you want to add a behavior too, or, you know, two or three behaviors, ideally. So again, if they're not going to do this, what are they going to do instead. So another sheet, name, date, time they did it. And these would be, we'll call them, recovery behaviors. Reading. Sometimes distracting themselves with reading can be helpful. Going to support group meetings, either in real life or online. Calling their sponsor, their coach, their friend. Going to sleep, practicing biofeedback. There's a whole list of things, but whatever behavior that they used that was helpful is what they're going to put here. Frequency, you know, how. How many times did they do it? Intensity, how intensely did they do it? Did they, you know, meditate once for 20 seconds or did they try meditating once for 15 minutes? What motivated you physically to try this behavior? You know, how did you think it would make you feel better physically? What did you think the benefits were going to be? What motivated you emotionally to try this behavior? What did you think the benefits were going to be to how you felt emotionally? What thoughts motivated you to engage in this behavior? You know, how did you talk yourself into doing it? And ultimately, what were the benefits of this behavior? How did it work for you? This helps us analyze different things that people do to find the interventions that are most helpful for them. And then you've got a. And I have daily, weekly review, name and date at the top. Of course, I'm assuming this is something that, you know, a counselor is working with client, the behavior that was targeted. So maybe we're targeting checking behaviors or gambling behaviors. All right, so that's the behavior. What was the frequency that you did that this week? So they're going to go back through their daily sheets and they're going to add up the frequency that they engaged in that behavior. Was it once a day? Six times a day. So that would be six times. Seven is four, 42 times. How many times did you do it this week? How many times did you do it each day? Now, why do I ask both of those? It seems kind of redundant, but it's not because we can see changes. You know, a person may go from having four days a week where they do it five times a day, then three days a week where they only do it once a day. So that would be four times. Five is 20 plus three. So that'd be 23 times. They could also have, you know, for that week, maybe their Average week is 20, 24 times or something. But normally what they were seeing, and I know I'm getting down into the math weeds here, but normally what they were seeing is four times a day. So they were seeing an average of 28, but they were seeing four times a day. But then something started to change and they were seeing that Mondays, Tuesdays and Wednesdays seemed to be a lot lower, but Thursday, Friday, Saturday and Sunday all of a sudden actually increased. So that's something that you want to look at and say, okay, what's different on those days? What was the average intensity? So going back over every time that you engaged in the behavior, what was the average intensity? Was it a three? You know, add them all up and then divide by the total number and that gives you an idea of where you are for that week. And when you're reducing intensity, especially when you're using a four point scale, use decimals. Be aware that you're not necessarily going to go from a three to a two. From one week to another. You may go from a three to a 2.75, and that's okay. We want to look at were there common triggers? Going back over the daily and weekly review, we want to examine whether the physical, the affective, the cognitive things that may have motivated them to engage in that behavior were the same, or if there were different triggers. We want to examine what motivated them physically, what motivated them emotionally, what thoughts motivated them, and what were the benefits to the behavior. And I know that's weird because you're thinking, well, this is a behavior we're trying to get rid of. Why would we want to look at the benefits? Because we keep doing things that have a benefit. So as long as that behavior still has a significant benefit, it's going to be harder to extinguish. So what we're looking at is trying to figure out what function is it still serving, and are there any other ways we can meet that need? Working toward change. Generally, you want to try to structure rewards and punishments in terms of what would happen naturally. Now, this isn't always possible, but you take what would happen naturally and then you want to try to intensify it some. So let's talk about rewards. Rewards or reinforcements are things that increase the likelihood of a behavior. If you do this behavior and you experience this consequence, your brain says, let's do that again. We want to look at positive reinforcement and negative reinforcement. And it just drives me crazy when the media gets these mixed up. Okay, so positive reinforcement means adding something positive, like a paycheck or. Well, a paycheck is a good example. You get something. Or for a little kid, if you eat your vegetables, then you can have dessert. That is positive reinforcement because we're giving them something as a reward for the behavior. So think about what positive consequences exist if you Change your behavior. What are the things that are encouraging you, that are motivating you to change your behavior? That's positive reinforcement. What will you get that you want physically, you know, how will it make you feel better? Physically, how will it make you feel better affectively or emotionally, how will it make you feel better cognitively, that is less negative, less pessimistic, clear headed, easier to solve problems, how will it improve your environment and you know, the stress that's in your environment and other things, maybe even make your housing more stable and your job more stable and how will it improve your relationships? So those are all positive reinforcements. Negative reinforcement is still reinforcement. It's still something that's going to increase the likelihood of a behavior. So negative reinforcement means taking away, subtracting something unpleasant. So think about what unpleasant things will be removed if you change your behavior. For example, if you stop drinking, one of the unpleasant things that may be removed is hangovers. You know, another unpleasant thing that may be removed if you quit engaging in that in addictive behaviors may be relationship problems. So you want to look at the benefits. You know, what are the bad things that will go away and what are the positive things that I'll get? So in terms of recovery behaviors, a lot of these things that a lot of these behaviors are the things we want to reward because they will help the person be less vulnerable and be less triggered. So we're going to look at behaviors like sleep, nutrition, exercise, relaxation, doing things that actually make them happy. Go figure. There's nothing to feel guilty about. When you do something that makes you happy, that gives you a dose of your natural relaxation happy chemicals, which reduces anxiety, reduces stress, reduces inflammation, improves sleep, happiness is a good thing. Distress tolerance skills, coping skills, calling a friend or going to counseling or group therapy or a support group, all of those are behaviors that can be used to either prevent or mitigate or stop unpleasant or the undesired behavior. In terms of punishment, we want to decrease the likelihood of a behavior, so we are going to. Positive punishment means adding something unpleasant. So think about what unpleasant or bad things will you get if you fail to change your behavior. And this could be discomfort. When people think about when they start having obsessive thoughts, one of the things that they can do is something like push ups or put their hands in an ice bath and that's uncomfortable. Or when they start having cravings to go online and gamble or look at pornography, they can put their hands in an ice bath and the intensity of that sensation is uncomfortable enough that it generally untriggers it forces their brain to focus on something else. So the obsessions, the cravings generally die down because they're so focused on, okay, this is really not good. And then in the future, when they think, start thinking about those behaviors, they start thinking about, oh, if I keep going here, then I'm going to have to put my hands in cold water, I'm going to have to do 50 push ups and I really don't want to do that. That is really unpleasant. So they can start pairing the craving or the obsession with something that they don't like so it becomes less rewarding. Negative punishment means taking away something pleasant. And parents used to do this when they would ground their children. They would say, you can't have the car. Well, that's negative punishment because they're taking away something the kid likes. So think about what positive things will be removed if you fail to change your behavior with cravings and obsessions. Well, even an addictive behaviors, they take a lot of time. So people lose time, which is precious. You can't get time back. Sometimes they'll lose money. Not at, not all of these behaviors involve money, but some of them do and some of them also involve health and relationships. So you want to look at, if you keep doing this, what are you, what, what things that are important to you, are you going to lose? And that can help increase motivation. Now, I mentioned vulnerabilities earlier, but we're going to talk about them a little bit more in depth here. Vulnerabilities are conditions that exist that make you more likely to be triggered. So for example, on a day when I get up, I had plenty of rest, I'm feeling great, and you know, I'm bebopping through my morning. Getting cut off in traffic may not trigger my anger. You know, I may just be like, whatever, you know, I, no big deal. But on a day that I get up and I'm tired and I'm sick and I'm in pain and I really don't want to be going to work. So I'm in an irritable mood already and somebody cuts me off in traffic. That will often trigger my anger. Okay, so you see how vulnerabilities can make you more likely to be triggered. People who use substances, for example, may be able to drive past that billboard drive, you know, their normal route to work, past the liquor store on most days and have no problems. You know, it's just, it's there. They kind of know it's there. They don't really notice it. But on a day when they are feeling hungry, angry, lonely, tired. And they drive past that, you know, alcohol billboard and that liquor store. That may be really triggering that day because they're already feeling anxious. And those triggers, those stimuli in the environment just kind of jump out and say, hey, pay attention. So think about for you, what conditions make you more vulnerable to being triggered? Are you, what about when you're hungry, when you're tired, when you're sick, when you're in pain? Those are the big ones. But there are others that people can put up there affectively. So emotionally, a lot of people are more likely to be triggered when they're experiencing distress, anxiety, anger, grief, guilt, jealousy, depression, you know, all of those unpleasant feelings. But as I mentioned earlier, some people are triggered when they feel happy because they worry. It's like, ah, crap, I'm afraid to feel happy because every time I felt happy before the bottom's fallen out. So they start getting anxious because they feel happy recognizing that. And there are techniques that you can do with baselining and with, you know, journaling, like for example, keeping a log of how many times, how many days were you happy that nothing bad happened. How many days or how many? Well, that's a good example. So I'll just stop there. Cognitively, some days we get up and we are creative, we are clear headed, we are optimistic, we are ready to take on the world. And other days we may get up and we are negative or pessimistic. You know, we're foggy headed because we didn't sleep well. So cognitively, are there differences in how likely you are to be triggered based on your attitude and your ability to process information environmentally? And let me just go back up to cognitively real quick. When people are foggy headed, when they're, you know, having difficulty thinking clearly because they're not getting enough sleep, a lot of times this triggers anxiety and obsessive thoughts because people start, they recognize that they are not on their A game and so they start worrying that they forgot something. They worry that they missed something. So being tired or foggy headed can contribute to triggering obsessive thoughts. For some people, environmental, just stressful environments can be a vulnerability. You may be having a great day and you walk into this environment and you know, people are maybe it's a all call staff meeting. So there's like 50 people in there and 80% of them are in an awful mood. And the CEO gets up and just reams you out from one end to the other. And so it's a negative stressful environment. And that type of situation makes people feel often anxious. And that anxiety often triggers cravings, obsessions, compulsions, and addictive behaviors. So recognizing that your environment, if you don't feel safe, if you don't feel relaxed, can make you more susceptible. Because when you feel unsafe, when you feel tense, your body, your HPA axis, that threat response system tends to be more active. So you tend to be more hyper vigilant, you tend to notice more things and be more hyper aware. And that can contribute to the behaviors that we're talking about. And relationally, if you're feeling lonely, and I know that's a feeling, but it has to do with relationships, or for some people, if they're feeling like they're in love, if they're feeling vulnerable because they're starting to care about somebody, both of those, either of those can trigger obsessions, worries, and repetitive thoughts, or can trigger cravings for substances. Because the anxiety, the fear of abandonment, or the depression that's associated with the loneliness can be so intense that the person wants to escape. So remember, vulnerabilities make you more likely to be triggered by triggers. And in behavior modification, we call triggers discriminative stimuli. So discriminative stimuli are those triggers or motivators that trigger behavior both the desired and undesired. So what you're going to want to do is minimize or eliminate as many of the triggers for the undesired behavior and replace them with triggers for the desired behavior. For example, let's take alcohol. One of the triggers for drinking may be having alcohol in the house. So getting the alcohol out of the house and putting in its place a notepad that either your journal or a notepad with the phone number of your sponsor on it, you know, that is a very obvious alteration. But those are things that you're going to want to do. Because when you're stressed, when you're having those obsessive thoughts or those cravings, you're in a fight or flight stage, you're in a stress response state, which means you're not going to be thinking as clearly. So it's not the time to expect yourself to, to think, oh yeah, I've got six other things I could do. You know, you just want it to stop. You want the thoughts to stop, you want the pain to stop, you want whatever. So it's important to put positive triggers, reminders in your environment that say, hey, these are the behaviors that you want to do. So you can go, oh yeah, okay, that I can do that. So physical triggers for behaviors can be hunger, pain, low energy, Level, poor sleep quality, those sorts of things. So figuring out how can you minimize those? Some people who have issues with eating may find that when they're hungry, that's a trigger to start eating, and then they have difficulty stopping. So hunger may be their trigger. Hunger can also be a vulnerability. But you know you're getting down in the weeds if you worry too much about which is which. What you want to do is say, okay, if I start feeling really hungry, regardless of whether it's a vulnerability or a trigger, that's not good for me. And I need to figure out how to prevent myself from, from getting over hungry pain. I need to figure out how to prevent myself from getting to that point where I'm in so much pain, I can't stand it, or I'm in so much pain, I start worrying about what's going on. Some people who have chronic pain tend to have health anxiety when they start having pain elsewhere or their pain starts to get worse. They start worrying that their condition is spiraling out of control or they've got something else wrong with them. So with pain, you know, figuring out, how can I deal with it when I have it? You can't always avoid pain. It's gonna happen. You're gonna get a kink in your neck. You're going to have some stress that triggers an autoimmune flare up. Whatever causes your pain, occasionally, it's going to happen. So when you start having it, what can you do to deal with it in order to prevent or stop your obsessional thoughts about it, to address that anxiety? Energy level. Some people, when they've got really low energy level, they start having cravings for, guess what? Stimulants. So figuring out, what can I do to moderate my energy level? What can I do to improve my sleep quality? If you know that when you're tired, that tends to trigger you, you tend to be, you know, more vulnerable to getting triggered in the first place. But again, some people will crave stimulants when they are. When they're overtired. Affective. What moods trigger these behaviors? If you're feeling X, you know, guilty, angry, anxious, just keep filling in the blanks. Does that trigger obsessive thoughts, cravings, or addictive behaviors? If it does, then that's a trigger. So you want to figure out, okay, what causes this mood? What can I do? What other things can I do to address it in order to try to prevent it from getting to the point where it triggers me? Now, it's important to remember that feelings are important. We don't want to get rid of anger and anxiety because those are two feelings that we have that our brain's trying to tell us. Just like a smoke alarm, hey, there might be a problem. Doesn't mean there is. Means there might be. So using that feeling, our body dumps a bunch of adrenaline and blood sugar to give us the energy to examine whether there is a problem. That's all. It doesn't tell us we need to ruminate on it because there must be a problem somewhere. It says, hey, I think there might be a problem. Get up and check it out. Cognitive thoughts about the behavior or yourself or problem solving difficulties. So looking at if you're having negative thoughts about the behavior or negative thoughts about yourself, does that trigger the problem? Environmentally, environmental triggers are huge. Sights, smells, sounds, even temperatures sometimes. But places, certain places may trigger obsessions. Certain environments, certain paint colors, time of day, Certain sounds or smells may trigger people. When people are trying to quit smoking, for example, and somebody who does smoke walks by them and they smell the nicotine, that can be quite triggering for them. So it's important to notice what's going on in terms of recovery behaviors. One environmental intervention that you can do is set up push notifications. That's something you see and sometimes hear that may remind you to do things like a mindfulness body scan or meditate or, or take your medication or whatever it is. And relationally, what people or types of interactions are triggering for the problem behavior and what people or types of interactions are triggering for the recovery behaviors. Because there's going to be different people in each group. Ultimately, you want to enhance stimuli. You want to add stimuli in each area, Physical, affective, cognitive, environmental, and relationship that motivate your desired behaviors. You're also going to want to add stimuli in each of those areas that mitigate, because sometimes they can't be prevented or eliminate stimuli that trigger unwanted behavior. So again, like pain, that's a trigger. We can't necessarily completely eliminate it, but we can learn how to mitigate it so it doesn't end up triggering a desire to use or escape. A functional analysis explores the vulnerabilities and triggers for and the functions of the behavior. So a functional analysis takes all this information you've gathered and it synthesizes it, and it says, okay, what need is this behavior filling? And in terms of obsessive compulsive disorder, we've got to look at the need that the obsession, the thoughts fill and the need that the compulsion fills. Generally, the thoughts are designed to help protect the person from something so we need to help them figure out how they can feel safer in their environment and they don't feel as triggered. The compulsions are designed to stop the obsessions. The compulsions are designed to help them feel safer and less anxious. So when we address the underlying issues that are causing them to feel unsafe, and we give them other tools to, to help them feel safe and empowered, we're addressing that issue. So we need to identify alternate ways to meet the need. In addictions, the need is often escape. Escape from pain, physical, emotional, whatever. And we need to explore triggers for motivating the person to continue positive behaviors. What do we need to have them add to their environment, to remind them to journal, to get adequate sleep, to eat, a good diet, to go to meetings, to whatever it is that's on their treatment plan? A functional analysis also helps us identify what's maintaining the current behavior. And as I've mentioned multiple times, in many cases, it's anxiety reduction. What are the vulnerabilities and triggers for that person, for anxiety in general, and how could those things be addressed to prevent anxiety? So, for example, if someone was a survivor of a home invasion, then one of their triggers for obsessional thoughts and checking may be when they lay down, they're trying to go to sleep, they feel vulnerable. And that sense of vulnerability, that sense of fear or threat keeps them in this loop. So what else could they do? And you know, an alarm system can be helpful. Being able to see the doors can be helpful. There are a lot of different things they can do, but we want to help them figure out what needs to change. So when you lay your head down on that bed, you, you feel safe, you feel empowered, and you can relax. What other behaviors can be used to reduce anxiety when it does happen? Because there are going to be times things happen. You hear a bump in the house in the middle of the night, you have a bad day at work, and you're afraid you're going to get fired. Whatever the case may be, what other behaviors do? Can the person add to their toolbox so they can address the anxiety before it starts to spiral? Behavioral alternatives. Three to one is a good ratio. I love this ratio. When you remove a behavior, replace it with a menu of two or three others. So when you're feeling like you want to use, you can call your sponsor, you can go to a meeting, you can take a bath. For some people, just getting to a place where they are, you know, unable to access their addictive behavior helps them urge surf, as we call it. So identify at least Three alternate ways to address the need. Competing responses and you know, to figure out competing responses. Look for exceptions when you're not engaging in that behavior, when you're not having the obsessions, engaging in the compulsions or the addictive behaviors. What are you doing? Are you taking a bath? Are you sleeping? Are you reading some of the ones? Just examples that I have up here. Chew gum while cooking. Some people tend to taste and snack and eat while they cook. And that can be a problem for somebody who does a lot of non hungry eating. So if they chew gum, then they're not likely going to be eating at the same time. Crochet while watching television. This can help people keep their hands busy. So instead of smoking, they are doing something else with their hands. Journaling instead of checking. It's really hard to write in a journal and walk around the house and check at the same time. So writing down your feelings, writing down what's going on instead of getting up and checking. Playing with your kids instead of smoking. That was what one of my clients did one time because he wouldn't smoke around his kids and he loved spending time with them. So that was one of the exceptions. I asked him, when you're not smoking, what are you doing? He's like, I'm usually hanging out with my kids. Okay, well do that more. Sing. When you go over a bridge, that's mine. I have phobias of going over bridges. So my anxiety ramps up. I start having obsessional thoughts when I go over a bridge. And you know, I've been able to get that under control over the years. But going over exceedingly long bridges or through tunnels, that's another one of my things. In order to keep myself from spiraling and having the obsessive thoughts, I do something else. I either sing or say my rosary. It works for me because I am focused on something else. I'm not focused on the fear inducing situation because I recognize objectively that it is not threatening. I recognize that the bridge is very safe. The tunnel is very safe. I know this. So it's a matter of basically distracting my mind. Call a friend or a sponsor when you feel triggered. And this can be for checking behaviors, this can be for ritual behaviors, this can be for addictive behaviors. It's not a friend or a sponsor. Doesn't just have to be addictions. Sometimes just calling that person. You're less likely to engage in the behavior if you're talking to them. You can calm your anxiety by talking to them instead of having to get up and do it for People who smoke nicotine gum is a competing response because you can't smoke and use nicotine gum or nicotine patches at the same time. It's just dangerous. Aversion is something some people use and for drinking they have Antabuse, which is a medication you can take that makes you pretty sick if you drink while you're taking it. For non hunger eating only, keep low preference foods available. So the things that you really like to eat, like you know, peanut butter or chocolate or cookies or whatever, don't keep those in the house or, you know, don't keep those where they're easily accessible. Instead, keep prepared celery sticks, plain rice cakes, those sorts of things available. So you look at them and you go, no, I'm not hungry enough to eat that. Compulsive behaviors. We talked about this earlier. Do something that is unpleasant. So it starts getting paired. Every time you start having those thoughts it's like, nah, I don't want to have to do that. Push ups, squats, holding ice cubes. Some people find having a rubber band on their wrist and snapping it is sufficient. I've never found that to be overly effective. You can also put pictures up to remove the desire. I had one person who engaged in a lot of pornography viewing and one of the things that he did was put pictures of his mother, his spouse and his children all around his computer. And when on his mobile devices, his lock screens were his daughter's. So you know, he would open that up and it was kind of, it helped remove the desire or at least take the edge off. Response prevention or at least response delay journaling. For people who engage in non hunger eating, one of the things they can do is write down a nutrition journal. What am I? What time is it? What am I craving? Why am I craving it? What is my feeling? And then you know, they fill in after they eat what they ate. And a lot of people, when they get to the point of they're in the kitchen, they've got the journal in their hand and they're like, it ain't worth the effort and they walk out. So making them do something between when they want it and when they can access it, sometimes that craving disappears again. Calling a friend or sponsor when there is a time delay, maybe you say, okay, I really want to do this, but I'm not going to do it for 15 minutes or 30 minutes. Okay? So putting a time delay in there to see if the urge goes away. And most urges do go away in 15 to 20 minutes. But during that period you've got to do something for distress tolerance. Take a bath. Do something, some activity that's pleasurable. Do something to distract your mind so you're not sitting there just watching the hands of the clock tick away. And I have a lot of videos on the YouTube channel on distress tolerance activities, so you can look at some of those to get some ideas. And distance, sometimes just putting physical distance between you and whatever it is. For people who do online gambling, online gaming or pornography, watching online website firewalls are really helpful because that means they can't access whatever it is from home and making it so they can't use their cell data on their digital devices, so they can't get off the network and use the cell data and go around it. So that can be helpful for those sorts of behaviors. Internet lockouts. Having the Internet shut down at a certain point in time can also be helpful. Don't keep the substance in the house. So if it is, you know, some sort of smoking cigarettes or alcohol or something like that that you would use or ingest in some way, don't keep it in the house, even if it means you're keeping it in the trunk of your car or something. If you've got to get up and get dressed to go out and get it, you're less likely to get it than if it's something that's like right there and super easy to get at 1 in the morning. Successive approximations. The goal is to stop the addictive or compulsive behavior. So you want to reduce the frequency, intensity or duration. Some people don't want to go cold turkey, okay? And with obsessions and compulsions, generally you're not going to expect yourself to go cold turkey because that's a lot of that is going on inside your own head and your own body. So, okay, so reducing the frequency of how frequently you smoke instead of when you get up in the morning on your way to work, right before you go into the office, during each one of your breaks, when you get home at dinner time, you know, so 10, 12 times a day, reduce it to maybe three times a day. And then once a day or the intensity, instead of smoking three cigarettes at a, you know, in a sitting, take it down to 1. Reduce the. Choose cigarettes that have a lower nicotine content. You know, there are a lot of different ways to reduce the intensity. Ruminating and obsessing, helping somebody. So instead of checking six times each night, they're checking two times each night can be a step in the right direction. Picking, skin picking or hair pulling. Again, Reducing the frequency. How often does somebody find that they're doing that, and what can you do to stop it? Some people pick when they're stressed. It's a sort of a fidgety habit, so maybe giving them something else to fidget with so they're not picking. I know I tend to be very fidgety, and so I find in the winter, I can't do it during the summer because I get way overheated. But. But I wear a scarf. And I'm, like, constantly fidgeting either with my necklace during the summer or a scarf. So finding things that can replace it, but recognizing that that behavior may not go completely away right away. What we want to do is set a goal to reduce it a little bit, and then set another goal to reduce it a little bit more and get closer and closer to your ultimate goal. So that's what we're calling successive approximations. Scaffolding is similar to successive approximations, but uses a support person to help you get the rest of the way to your goal. A lot of people may be able to notice that they're having these obsessions or these cravings, but they have difficulty stopping. Or they may be able to notice, and they may be able to stop themselves from immediately engaging in the behavior, but then they don't. Then they feel stuck. They're like, what do I do now? Or they may be able to notice, stop, choose an alternative, like, I need to go to a meeting. But they can't get themselves to actually go. They're like, yeah, that'd be a good idea. But, yeah, just don't have the motivation. So scaffolding involves, just like you would think for a construction worker, having something or someone that helps you the rest of the way. So in scaffolding, your sponsor, your friend, your coach, your counselor, whomever it is, meets you where you stop where you get stuck, and says, okay, let's work through the rest of this together. Behaviors can be triggered by physical things. Pain, hunger, tiredness, affect, distress of some sort, even happiness, sometimes cognitions, negative thoughts, pessimism, environmental situations, smell, sights, sounds, just stress and relationships. Vulnerabilities make people more likely to be triggered by stimuli or discriminative stimuli in the environment. Behavior modification seeks to implement new, rewarding behaviors that are desirable and either prevent vulnerabilities or aid the person in coping with distress. Additionally, behavior modification seeks to make undesirable behaviors less rewarding. Now, there are a lot of other techniques that people can engage to help them modify their behaviors, but this gives you an idea of some of the purer, if you will, behavior oriented interventions.