Chemical and Behavioral Addiction Overview Part 2 | Addiction Counselor and NCMHCE Test Prep

Welcome back to part two of the Introduction to Chemical and Behavioral Addictions. I'm your host, Dr. Donnelly Snipes. In this segment, we're going to examine some of the most common behavioral addictions and discuss similarities and differences in treatment between chemical and behavioral addictions. Again, I'm going to say it because I know that's one of the first things that I'm going to see in the YouTube comments, that there's really no such thing as behavioral addictions. The DSM has really resisted adding that diagnostic category or label for a lot of these things. What we're really talking about is engaging in the use of a person, relationship, substance or activity in order to escape from distress and continuing to engage in that behavior despite negative consequences that are caused directly or even indirectly by that behavior. Once something starts causing problems and you continue to do it anyway, that's when we start saying, hey, there might be something going on here. So what are some similarities between behavioral and chemical addictions or addictive behaviors? They both cause chemical reactions in the brain. They both produce pleasure. They trigger the dopamine system. They trigger the release of norepinephrine, they trigger the release of endocannabinoids. You know, it provides a sense of relief, a sense of a break from whatever the pain is, whether it's physical or emotional. They are a tool to escape or avoid distress. Some people will continue to use because they don't want to feel the withdrawal symptoms and they don't want to sober up, if you will, and have to address what's going on around them. They often produce a tolerance. And we see this with everything in the body, which is really kind of cool because it's the body's way of protecting itself. But when the body is regularly exposed to excess levels, as it above normative levels for a chemical, the receptors often become less sensitive to it. So the dopamine may be knocking on the door and the receptors are going, nah, not interested right now. You know, that's another analogy that you can use. But our bodies do this with insulin. They do it with dopamine. It does it with cortisol. You know, whenever the balance of chemicals and neurochemicals in the body starts to go wonky, lack of a clinical term, the body automatically tries to adjust in order to balance it out again. So it's kind of like a. If you're running a bath, you know, I have this problem at my house. I don't know if you do. Running a bath. I like mine really hot, so I'll be running the bath water. And about halfway through filling up the tub, the hot water runs out. All of a sudden it's really, really cold. And, you know, in that case, I don't have any other hot water. I've got to wait for it to warm up again. But you want to maintain that lukewarm bath water. Your brain wants to maintain a certain balance of hormones and neurochemicals. And when you do something that suddenly increases it, the brain goes, whoa, okay, well, I guess I don't need to produce any more dopamine for a while or send out any more dopamine for a while, because we got more than enough now. So tolerance is something that is physiological. And people develop tolerance with behavioral addictions too. Because when you engage in behavioral addictions, you're causing that fluoride of dopamine and other neurochemicals depending on what you're doing. There are psychological withdrawal symptoms when dopamine, norepinephrine, serotonin, even cortisol and estrogen and testosterone. When those get out of balance, we don't feel good. We feel unhappy, we feel bored, we feel anxious, we feel dysphoric. And the body says, hey, I know how to help you feel better. You're deficient on dopamine. So guess what? If you start doing that behavior again, you'll get an extra hit and we can, you know, get back up and running again. So psychological withdrawal symptoms are often a sign that the body is saying, hey, our balance is out of whack and we need an extra surge of xyz. Chemical dopamine is usually the one that we use as the example. But whenever dopamine increases, lots of other things increase. So it's not just dopamine, but either way. And both behavioral and chemical addictions can have devastating biopsychosocial consequences, including disease. And you may be thinking, well, how can gambling lead to disease? Well, when people are not getting enough sleep, when they are not eating healthfully enough, when their immune system starts to go to crap, guess what? They are more susceptible to disease. They are more susceptible to colds, to flus, and even stress related diseases, neurotoxicity. And that's when you start having changes in the brain because it is revved up for too long. It's under too much stress for too long. Mental illness, trauma, and general losses in life. So biopsychosocial, physical, psychological, and interpersonal consequences. Now, in terms of behavioral and chemical addictions, I've wracked my brain and I have yet to come up with a Chemical addiction that would have a significantly negative impact on somebody's life if they quit doing it. Now, there may be one out there, but remember, we're not talking about something that a person is using Order to help them function. And they're using it, but they're only using it, and it's not causing them negative consequences. Okay? Remember, you have to have the negative consequences out there. So people may use certain substances, Psychotropic medications, for example. You know, most of them you're not going to get a buzz off of, you're not going to get high off of, but you will, over time develop a tolerance and have to increase your dosage. That's not an addiction, number one, because it really doesn't produce a high, but mainly because you're continuing to use it, but it's not causing negative psychosocial consequences. So, you know, that that consequence issue Is really integral to the definition of what we in. In the lay community call addictions. So abstinence is not ideal for some behavioral addictions. Most people are not interested from abstaining from sex for the rest of their life. People can't abstain from food for the rest of their life and have any quality of life shopping. Now, yes. Could you abstain from shopping and have somebody else do it for you? Possibly, but not everybody has that luxury either. And exercise, exercise in moderation is good for you. So, you know, that's another one of those examples of something that you probably don't want to completely abstain from. So treatment of behavioral addictions can be very different because the person is. Not. Not going to abstain. And you can get into the whole debate about whether chemical addictions can be the same way. The important thing to remember with chemical addictions Is the amount of physiological changes that happen when somebody uses a substance Is often significantly greater than the amount of physiological changes. The amount of dopamine, the amount of glutamate, the amount of everything that is pumped out when somebody engages in behavioral addictions. So chemical addictions can be more toxic and more damaging in shorter order. Many treatment centers ignore the substitution Of a behavioral addiction for a chemical addiction. And this is a soapbox point for me, because people who replace a chemical addiction with behavioral addictions Are not finding full recovery. What they're doing is just numbing in a different way, Continuing to take the edge off. So what are some examples of behavioral addictions? Now? Just about anything that produces pleasure. Can be used to help someone escape from unpleasant feelings, okay, Physical or emotional. So there's obviously, I can't list them all here but some of the big food, sex, pornography, gambling, shopping, exercise, Internet gaming, relationships, and even chaos and drama. And we'll talk about that one a little bit more in a minute. Once an addiction starts, once the person has gotten to the point where their body has started to develop a need for that behavior in order to maintain the accurate balance of neurochemicals, it becomes so encompassing that psychosocial development slows or stops, Especially regarding coping skills and relationships. The person is so focused on trying to feel okay that they quit giving energy to those other things. The longer someone is engaged in addictive behaviors, the more damage it does to the body, to their memories and the way they interpret the world, which we call schema, to their thinking patterns, which often become more negative, hopeless, pessimistic, and their relationships. Think about behaviors that people engage in when they're deprived of their addiction of choice. What behavioral substitutions appear? So if someone is deprived of their addiction of choice, what do they do instead? One of the ones that's been studied a lot in the research, interestingly enough, is the correlation between alcoholism and eating disorders. And when a person can't engage in the eating disorder, oftentimes we see a turn to using substances. When they can't access the substances, they may revert to the eating disorder behavior. But there are a lot of substitutions out there. That just happens to be one that went through a period about 15 years ago where people were really studying the correlation. We want to look and see what is the trigger for and function of those behaviors. When I worked in community behavioral health, we would, you know, obviously people were coming for chemical addictions. And when they were deprived of not able to access their chemical addiction of choice, we saw a lot of these other behaviors emerge. So the question is, why behavior is communication? What was that behavior saying? And to me, that behavior was saying, I don't feel well. I need some relief. And the skills and tools you're giving me ain't cutting it right now, and I'm scared. So it's important to examine the function of those behaviors. A lot of times we would see them increase in people as we started to get to sensitive areas in their treatment. Now, for some people, from the time they got out of detox and they started actually coming out of their fog and looking around at the devastation that was the beginning of the overwhelmed response. So they switched into default protection. Early on. It's important to remember as a provider or even as a sponsor or something, or when you're working with someone who is not engaging in their addictive behavior of choice, but they're engaging in addictive behavior. They are struggling and until they have something to replace that behavior with, they are going to be at risk. So it's important to remember that people are doing the best they can with the tools they have. Okay, so Jim Bob did not leave treatment and go back out and use the substance of choice. Again, that's a win. In my column, Jim Bob is engaging in this new behavior. You know, we'll say gambling. Okay, that's not ideal. However, he didn't go out and use. So we've made a baby step forward. So let's, you know, examine what else we can help Jim Bob do, what other behaviors we can help Jim Bob develop. So gambling isn't, you know, needed either. Speak of the devil. Gambling and gaming, and I put these both on the same slide, they are not the same. But the DSM actually has started to recognize compulsive gambling and Internet gaming disorder as problems. So these are kind of recognized in the DSM 5. The function, same function of every addictive behavior, help the person cope with distress. Now, for gambling, it's a little bit different because some people start gambling when they are experiencing financial difficulties and they're trying to make ends meet and then it starts spiraling from there. Other people do it, begin doing it as a way to relax. So there are different again, always different reasons for why something begins. But ultimately when it crosses over into being a problem, it is often being used because use is less painful than non use. So we need to understand what, what is so painful when you sober up? What is so painful when you're not using and how can we help you address it? We see tolerance in these things. Gambling people have to gamble longer or with more money or in riskier games. In gaming, we see them engage in higher risk games or games that don't really have an end to them. Withdrawal. When people are not engaging in them, they feel antsy, they feel distressed, they may feel flat. Well, that's because those neurotransmitters are out of whack. Unsuccessful efforts to cut down. Well, the body wants to rebalance itself. So eventually, unless you find a new way to help it balance itself, it's going to revert. Excessive time and energy spent obtaining. So thinking about, you know, what game am I going to play? How can I access that game? Or what am I going to gamble on? Who should I put my money on? Used to be people would read the sports pages and things. I don't know how it goes now, but there's also lots of online gambling and online gambling options. So thinking about all of those options and, and figuring out okay, now how am I going to do this so nobody finds out. And that may mean moving money around. There's a lot of stuff that goes into getting ready to use, use itself. So the gambling itself or the gaming itself, and then recovering from use, whether it's lack of sleep, financial losses you experience, people who do a lot of gaming also start to develop physical problem, physical pain, some overuse injuries, those sorts of things. However, again, they continue to use, other activities are reduced or eliminated. We see people spending more time gambling, less time doing other things. They feel compelled to do it. So instead of studying for their final exams, instead of, you know, cutting the lawn, you know, obviously neither one of those things people really usually look forward to doing. But instead of going out with friends, they choose to engage in their behavior. Why? Because it produces a more potent rush of those neurochemicals. At this point, once somebody's fully into addiction, you know, going out with friends, it's maybe fun and all, but it just doesn't have the same intoxicating nature as their addictive behavior. And again, they continue to use despite negative consequences. So you want to go through that list of physical consequences, emotional consequences, cognitive thinking consequences, environmental financial consequences, and relationship consequences. Almost everybody who engages in addictive behaviors ends up having some level of relationship consequences. Now I said almost. But it is important to recognize that that is often one of the early tragedies when people are developing addictions. The Internet. Now this is different than Internet gaming. What I'm talking about is social media surfing the Internet. And this is not in the dsm. But I want you to think about it. How can it serve as an addictive function? How can it serve a self medicating or numbing function tolerance? You don't see that as much, but you do see people surfing the web and you know, being on the Internet more and having more difficulty putting down the tablet, turning off the Internet withdrawal. Often, you know, you have some neurochemical changes. But we also have, with the Internet we have this whole fear of missing out. If I'm not constantly refreshing this page, if I'm not constantly scrolling, then I might miss out on something and that causes me distress, that causes me anxiety, I need to have that. Unsuccessful efforts to cut down. A lot of people have a lot of difficulty putting down the device. They have difficulty logging off. They may be, you know, logging on in the middle of the night just to Catch up. Excessive time and energy is used, doing it, recovering from it, and again recovering. We want to include all of those effects. So they may spend a lot of time on the Internet. Fear of missing out, all of that stuff. And then when they finally do put down the mobile device, they realize that they haven't done the laundry, they haven't for weeks. They haven't finished a project that they needed to finish. They need to spend a lot of extra time trying to repair the relationships because they forgot and they stood up their best friend for lunch. Other activities are reduced or eliminated. Again, same thing that we saw with a lot of the other addictions and continues despite negative consequences. For a lot of people, the Internet is almost a different world that they can transport themselves in. It may not be going on news sites, it may be going on Instagram, it may be going to various different websites to learn more about interior decorating or whatever. But whatever it is, they're sort of putting themselves in this world where, you know, bills and dogs that need to go out and whatever else that doesn't exist. They immerse themselves in this never ending world wide web. And it provides an escape because they're so focused on what they're looking at that they are not thinking about what they're avoiding. Food. Now food provides us with our basic nutrients for our body, our basic building blocks for our body to repair, to grow, to make neurotransmitters, to make hormones. It's necessary. We need food. But food, because of that, our body has been constructed so that when we eat it also increases levels of happy chemicals. And some foods do it more than others, like processed foods, chocolates, etc. They increase dopamine and serotonin levels. So people may engage in eating for other than hunger and eventually it can become very self soothing because it does release the dopamine and the serotonin. They are focused on on what they're eating. They're focused on the moment or they may just be focused on the behavior itself. And you know, they may not even really be tasting it. Some people when they binge, they don't really even taste the food that much. Or when they do taste tastes so good like cookies for example, that they want more. Because it's like, oh my gosh, that that's what happiness feels like. And happiness and food, I don't like to see the two equated, but I do know that or we do know that food causes the increase, an increase in happy chemicals. So again, you can see tolerance. The same types of Foods may start to not be as comforting anymore. We don't see as much tolerance when we talk about food, but we do see that when people can't access it, when they can't use it to provide them with the surge of dopamine, when they can't use it to distract their attention from the distress that they start feeling, they start thinking about it even more and start feeling very unhappy. Unsuccessful efforts to cut down excessive time and energy spent obtaining, using, eating and recovering. Now it could be, you know, going out to all the different stores. It could be thinking about what you're going to make. There are a lot of things with food that can take a lot of time. Eating doesn't necessarily take that long, but then recovering. Some people eat so much that they are uncomfortable and it takes them a while until they feel okay again. They may spend so much money on food that they have to recover. People can spend a whole lot of money on the food that they eat. And if they're on, especially if they're on a limited budget, it can be problematic. Other activities are reduced or eliminated. People may not want to go out with friends because they just want to go home and dive into, you know, a bucket of Haagen Dazs or something, and they continue to use despite negative consequences. And this again can include physical consequences like significant weight gain, hypertension, diabetes. They may continue to use anyway because that is the one thing that they can count on to help them feel something. Pornography. And the interesting thing with pornography, the function is generally to increase those happy neurochemicals. But there are a lot of other functions of pornography because some people, not everybody, but some people who engage in the use of pornography do so because they have a lot of social anxiety. And this allows them a way to have a pseudo intimate relationship with somebody who is not going to reject them. So there are a lot of reasons people may engage in viewing pornography. What we do see with pornography, and this is one where we do see tolerance again, is that over time, what people view, what they find arousing increases in intensity, severity. It changes qualitatively in order to help them get that arousal. They experience withdrawal when they're not engaged in it. And they may find that they have difficulty getting aroused in real life with their current partners if they're not engaged in some sort of extreme behavior. This often leads to unsuccessful efforts to cut down. Because at a certain point, real life intimate interactions aren't fulfilling and sometimes aren't even possible. They start developing sexual dysfunctions. So they turn more to the pornography, because that is there, that's not going to reject them. Excessive time and energy is used viewing pornography, recovering from pornography use. And for some people, their viewing crosses over the line into illegal activity in which they also may start losing their job and going to jail and other things which they've got to recover from. In terms of shopping, there's online shopping which can be really detrimental because it's so easy to just put something in the cart. It was easy enough when you still had to go to the store. But with online shopping, shopping addiction has become really problematic for a lot of people because it helps them escape, but it also sometimes helps them feel okay because there's so much emphasis put on appearance and what you have versus what you don't have in our culture. And that sometimes people use shopping in order to bolster their self esteem. They often experience withdrawal feelings when they're not, when they're not online shopping, when they're not on top of having the newest thing and making sure that they're engaged in it. But a lot of what we see is an excessive time and energy sense spent online shopping, recovering often financially from their shopping expeditions. Reduction of other activities. Unfortunately, with the development of mobile devices, sometimes you'll see people with addictions that can be accessed online, like gambling, gaming, shopping. They still do things like they go out with friends or they go to their kids soccer game, but they're not mentally there. They are steady typing away on their mobile device and engaging in their addiction. So they're physically there, but they're not engaged in terms of exercise. Now exercise is good. Exercise increases dopamine and serotonin. But when again when you do it to the extent that it starts causing physiological harm like shin splints and stress fractures and those sorts of things, then it starts becoming a problem when you start doing it where you are causing yourself other problems like you have to work out for X number of minutes or hours in the morning before you can do anything else. Yet your job wants you to come in at, you know, early one day and you just tell them, no, I'm not coming in because I've got to do my exercise. That can start causing problems in your job. Your relationships can take a hit if you spend an inordinate amount of time exercising every day. Your studies, if you're in school, can take a hit if you're prioritizing exercise over going to class or doing your homework. Those sorts of things. Relationships can be addictive in their own way. When you are in a relationship, you know, a Lot of times when we're in a new relationship, there's that new relationship energy and it feels wonderful. But when you are not with that person, you miss them. Okay, that's pretty run of the mill stuff. However, for people who start developing addictive relationships or compulsive relationship behaviors, the discomfort they feel when they're separated from that person is overwhelming. So they start spending more and more time with that person, a lot of energy with that person, and it starts causing problems at work. You know, they may, instead of, you know, leaving that person's house in the morning, going to work and then coming home and then they have dinner together, there's also, you know, rampant texting and phone messaging and whatever else throughout the day. So they're not getting their work done. And it can be tempting, especially in that, you know, new relationship phase, to want to do that. But people who don't have a problem with it are able to say, no, I need to get my work done, and then I will do this. People who have more of an addictive type relationship, they are often put that communication, put that behavior above all else. So work starts taking a hit, exercise starts taking a hit and etc. Just like we've seen with all the other behavioral addictions and finally chaos. And this is one that a lot of people don't talk about, but I've seen it, and I think it's important to recognize that chaos serves a function. Sometimes people who grew up in chaotic environments, that's how they feel. Okay? They don't feel okay if there's not chaos going around. It's stressful to them when they're not in the midst of chaos. Chaos causes our HPA axis, our threat response system, to ramp up. That ramping up and can trigger the release of cortisol, dopamine, norepinephrine, all kinds of feel good chemicals, sort of stimulant type chemicals. So when somebody has habitually been in a chaotic environment and then they're not again, there's a neurotransmitter imbalance because then their threat response system goes down, their dopamine levels go down, and their body goes, hey, what the heck just happened? But chaos also serves another function a lot of the time because it distracts. So if somebody is feeling fearful or feeling vulnerable in some way, sometimes they will use chaos in order to get people to look elsewhere. So chaos, often chaos creating chaos is detrimental. Whether it is an addictive behavior or not really depends on the person. But some people really do find that when they're not in the midst of chaos, they don't feel right, they experience withdrawal, they are craving some excitement and they may cause create chaos, create drama. Excessive time or energy is used thinking about, well, how can I, you know, make this happen? You know, what can I do? And sometimes it's not thought of as, you know, how can I be malicious to somebody, but you know, thinking about what might cause a little bit of drama and then recovering from it. And there's once chaos is created, then a lot of times the person who created the chaos may rush in to be the one who tries to solve the chaos too. So there can be a lot of dynamics here, but it is important to recognize and I've again I've seen it especially when I was in working on the residential units when people weren't able to access other addictive behaviors. Sometimes chaos, creating chaos was a way for them to again feel something, to get that adrenaline surge that they were so missing. Basic treatment principles. When faced with two choices, the tendency for a person is to choose the more rewarding option. To increase motivation for change, the less rewarding choice, that is sobriety must become more rewarding. We need to figure out how can we make sobriety more rewarding than engaging in those behaviors. The alternate behaviors need to be equally ish as rewarding as the addiction. Now, you are not going to replace a healthy lifestyle or replace cocaine addiction, for example, with a healthy lifestyle in terms of its immediate rewards. Cocaine is obviously and other things can produce a much stronger dopamine pleasure response. However, the long term consequences are often much more distressful. So what we want to do is look at the helping people choose a more moderate feeling of happiness or pleasure that is enduring versus a short term surge followed by significant distress. How do you do it? Well, this is called a decisional balance exercise. So you have the behavior that they're engaged in and then in this case, sobriety is the option. So you want to go through the benefits. What are the physical benefits to you of this addictive behavior? How does it help you relax? How does it help you numb pain? And what alternatives could do that? So what else might help you relax? Maybe not to the same degree, maybe not quite as intensely, but what else could help you affectively? How does this make you feel emotionally feel better? And what else could you do that might help you feel better? What have you done in the past that's helped you feel okay cognitively? In what ways does this behavior help you cognitively? And it's hard to find cognitive benefits, but sometimes people can come up with them environmentally, how does this behavior help you in your environment, in your finances? And what alternatives are there to help you relationally? How does this behavior help you? And a lot of people develop a support system of others who also engage in addictive behaviors. So in their mind, as long as they're using, they keep those friends. Now, they may have lost other friends, but they keep those friends. And then spiritually, in what ways does this behavior benefit you in terms of your hope, your faith, your integrity, your courage? All those things we went through? And what are alternate ways for you to bolster those things besides your addiction? So we need to look at the benefits of the addiction and say, okay, your addiction is serving a purpose. What are some other, maybe healthier or less harmful ways that you could meet those same needs? What are the drawbacks to the addiction? You know, what are the reasons that you want to change? What are the physical, emotional, cognitive, environmental, relationship, and spiritual drawbacks to this behavior? And those are the reasons that, you know, describe your bottom, so to speak, and then you move over to sobriety. What do you see the benefits of sobriety being? Why is this worth the effort? And we want to help people enhance that. So sobriety starts looking kind of attractive. And then the final quadrant is the drawbacks to sobriety. There are reasons people relapse. So we want to look at the drawbacks. What are you afraid of, or what challenges have you faced in the past when you have sobered up? And what can we do to minimize that distress Physically, emotionally, cognitively, environmentally, relationally, and spiritually? We want to help people identify their relapse triggers. And here I've listed a lot of the what we call negative triggers or triggers for relapse, not recovery. And we want to help them add in triggers for recovery. So pain, fatigue, poor nutrition, all of those are things that could trigger a relapse for people. And we need to examine it and go, okay, how can we help you address these things besides use post acute withdrawal symptom? Post acute withdrawal syndrome encompasses the physiological distress and psychological distress that people experience while their brain and body is recovering, recovering from use. Neurochemical and hormonal changes are also something that can trigger the desire to use. When they suddenly have an increase in adrenaline, for example, because they get stressed out, that may trigger them to want to use to calm down. Okay, well, what can you do instead? Emotional distress, anxiety, grief, guilt, you know, all those unpleasant emotional feelings can trigger the desire to use. So we want to say, all right, well, distress is a part of life. So what strategies might be helpful to help you cope with that? Besides using boredom and lack of pleasure are also relapse triggers. So we want to help people figure out what do they need to do to avoid idle hands. Basically, what do they need to do to add pleasure into their life. It's not enough just to remove the unpleasant. If you just remove the unpleasant, you're left with nothing. Let's add some pleasant in there. What might help you feel happy, content, okay, you know, I'm not asking for elated. You know, I just want somebody to feel okay in that early stage and then hopefully have some really good times as they move through recovery. Cognitively, people who are distress intolerant, that is, they tell themselves, I can't tolerate this, I can't stand it, are more likely to relapse. As opposed to somebody who says, this really sucks. However, I know I can do it. I've got the courage, I've got the support, I've got the whatever to get through this. So developing distress tolerant thoughts is really important. People who ruminate, they have those thoughts and they just tumble them over, especially the negative thoughts that can serve as a relapse trigger if they have difficulty quieting their mind. So developing skills for thought stopping and problem solving can be helpful. Pessimism is a common impact of addiction because when your world is kind of falling apart, it's hard to see the sun rays when it feels like everything is clouds. Developing cognitive restructuring strategies to help recognize the pessimism, but also see hope. And this is something that we call tragic optimism. Recognizing the pain of the moment, but also having optimism that things can get better. Addressing cognitive distortions and outdated schema are also really important because using personalization, mind reading, all or nothing language that can set people up to experience distress when it's really not that distressful. When they step back and they go, okay, you know, maybe it really wasn't that bad. But cognitive distortions tend to be very extreme and intensify the distress people experience. An outdated schema are basically shortcuts that your brain uses to help you anticipate what's going to happen and, and what you can and cannot handle. But what you could or could not handle at 8 is different than what you can and cannot handle at 28. So it's important to address some of those schema and update them environmentally. Addressing sensory triggers, sights, sounds and smells that trigger distress or craving. Replacing them with sights, sounds and smells that trigger happiness, confidence and a desire for recovery. In terms of relationships, low self Esteem can be a huge trigger. It can trigger abandonment fears, it can trigger social anxiety, it can trigger a lot of stuff. So self esteem work is really important. So when somebody looks in the mirror and it is a trigger for optimism and recovery, not a trigger for anxiety and use Addressing the inner critic. People's inner critic can be very loud sometimes, and it's really important to help them address that because that inner critic is often telling them, you can't do this. Why did you think you could get sober? Or you're not good enough? Until that inner critic is put in its place, the person is at risk for feeling disempowered, for feeling hopeless. And that can trigger the desire to use people, doubters, people who don't think you can do it, people who are similarly addicted who don't want to see you get better, or people who are enmeshed. And that is their world functions based on you having an addiction. So if you start recovering, that upsets their apple cart. So they're kind of invested in pulling you back into the fray. Figuring out how to deal with those people in your recovery is going to be important as well as add adding people who are confident in your ability, who are encouraging, who are supportive of your ability to recover. Conflict can be a huge trigger for relapse because a lot of people with addictions, one of their go to responses when they've experienced conflict, when they've experienced that distress has been to numb it out or to avoid it and sometimes. So conflict resolution skills will be really important in early recovery and henceforth in the recovery process and addressing abandonment fears. There are a lot of things that can trigger abandonment fears. And people who've developed addictive behaviors have often experienced multiple instances of what they perceive as abandonment because people backed away from them when they were immersed in their addictive selves. So it's going to be important to help them identify and address their abandonment fears, whether it stemmed from childhood or adult relationships or both. Other interventions include rule out and address physical triggers like pain, behavior modification, helping people learn how to stop and choose alternate behaviors instead of defaulting to the old behavior, cognitive restructuring to handle some of those that pessimism, and stinking thinking. Chaining helps people see the connection between their environment and their behaviors and stuff that led up to an event. And it also helps them when you forward chain. They can forecast the consequences of any behavior that they're going to choose. So chaining can be very helpful for learning what causes behaviors so they can address that as well as anticipating the consequences. So they can choose the outcome, choose the behavior that will produce the outcome that they want. Goal setting and purposeful action is really important in recovery. We talk about good, orderly direction. What does a rich and meaningful life look like to you? And then before you act, ask yourself, am I getting ready to use my energy to do something that's going to help me move toward my goals or away from my goals? Mindfulness is essential. Addiction is a state of mindlessness. A lot of times a state of numbing, a state of detachment. So mindfulness is really important to help people notice their relapse. Warning signs for helping people to act before something becomes overwhelming. And for helping people identify, well, exactly what am I feeling so they can address it more effectively. Motivational enhancement is necessary because motivation waxes and wanes. And it's important for whatever we're doing whenever we're engaging in a behavior to enhance our motivation. Even going to work, not even addictions, but even just going to work. Some days you feel it and some days you don't. And the days you don't feel it, you have to enhance your motivation to get up and get going. The same thing is true in addiction recovery. Enhancing all of the various aspects of. Of motivation to keep doing the work. Because it's hard work, it's tiring to do those things some days. Using a strengths inventory can help people identify what they've already used. That works at least somewhat. So instead of reinventing the wheel, they're building on something they already have. Stress and time management. Essential because what we call stress often builds up over time. And it impacts our ability to get quality sleep and impacts our ability to relax. It causes, can cause anxiety. It can cause us to feel worn down, burned out, overwhelmed. All of those are relapse triggers. And poor time management often contributes to high levels of stress. Environmentally. Some people may need some help from vocational rehabilitation. Finding a new job, the job accommodation network to help them find a job that meets their needs. And there is a federal bonding program for hard to place workers. So if somebody has gotten criminal charges or hasn't been employed for a really long time, or got fired from their job because of their addictive behaviors, then bonding. The federal bonding program may be able to help them get. Get started with employment again. Helping people access medical insurance and safe, stable housing through things like recovery residences can also be really important. Important to helping them recover in all aspects of their life. Targeted case management can be super effective. And a lot of times targeted case managers go out to the person's home. But there are Some iterations of targeted case management where the case manager meets people, where they congregate, whether that's at 12 step meetings or or at a treatment center. And people meet with their case manager on a daily or weekly basis in order to make sure that they are staying focused on what they need to do. The targeted case manager also helps coordinate all of the players on the multidisciplinary team, like the doctor, the psychiatrist, the social services caseworker, etc. So the person doesn't feel quite as overwhelmed. And finally, relationally, a lot of people need to work on developing more effective assertiveness and communication skills. A lot of times they need to learn about healthy relationships and how to set and maintain boundaries, how to respect other people's boundaries without fearing abandonment. Most people in recovery need to work on developing social support with healthy people. And social support in support groups can also be really helpful in support groups for people who are also in recovery. And finally, volunteering or community education classes can also be really helpful for not only increasing pro social interactions, but also for developing self esteem because people start getting out and realizing, hey, I can do this, there are things that I can do that are beneficial. And hey, this actually is kind of fun, you know, I'm not missing that other thing, whatever I was craving nearly as much. Chemical and behavioral addictions often occur together. So when assessing someone with other addictions or a family history of addiction, also look for behavioral addictions. Chemical and behavioral addictions often co occur with other mental health and physical health issues. So we want to make sure we're screening for those things as well and represent the best way the person could do could cope with life with the tools they had at that point in time. Abstinence is not always a possibility with behavioral addictions, so we do need to be sensitive to that. And for many people, behavioral addictions are a relapse warning sign for mental illness or chemical addictions. And the cause of the distress that is prompting the behavioral addictions needs to be addressed.