Overview of Addiction: Course and Symptoms | Counseling Continuing Education

Hi and welcome to the addictions and co occurring disorders treatment overview brought to you by allce.com now for those of you who are attending today as a live class, there are going to be several poll questions that come up that you'll need to provide answers to. In order to get credit for participating in a live workshop. We have to be able to demonstrate to your board that you are here and paying attention at least part of the time. So we're going to go through these questions. The first couple questions, ask for your name and then your email address. That's for our notification and so we can tie your answers to your name and email address in case we ever have to prove to your board that you were here. Now that doesn't mean anything else. It won't go public. It doesn't go out on any other list. It's just for our own knowledge and again to provide to a board that you are here. So with all that being said, let's go ahead. The first question. What's your name? Hopefully that's an easy one. I'll let you go ahead and start typing that while I go through the objectives. And you can keep typing even after I switch off of this slide. Excuse me. Tonight we want to define addiction and co occurring disorders, examine the similarities between chemical and behavioral addictions, discuss Maslow's hierarchy and its impact on early recovery, conceptualize the progression of addiction and recovery and identify common stumbling blocks to sustain recovery and interventions. Now the next slide is going to ask you for your email address. So I'll go ahead there. Hopefully I can get this tickle out of my throat before we go any further. Okay. Now it is important that we have your email address. After the class is over, we will email you the password so you can get into the quiz. So the beginning. What is an addiction? Well, nobody really knows. But what we do know is it's a person, activity or substance. So there's a whole range of things. It can be. So something that continues to be used to escape from negative emotions, situations or pain. That's another critical point. It's used to escape. It's not just a beer on the weekends. It's not just something you do every once in a while. It has a purpose and it continues to be used despite causing problems in one or more areas of life functioning. So people say, well, how do I know if I've got an addiction or not? I drink. Well, let's take a look at it. Are you using it to escape from negative emotions? Well, yeah, I have a drink Or a few when I come home and I have a bad day. Okay, so maybe next area. Do you continue to drink despite the fact that it's causing problems? You're having marital problems, family problems, financial problems. Because of your use, you are neglecting other areas of your life in order to use. Generally people say no. And I say, well, sounds like you may have a lot of stress that you could deal with in a different way. But whether you meet the criteria for addiction right now, I'm not hearing that. But you are in an orange danger zone that you want to pay attention to. So let's go on from here and talk about co occurring disorders. Remember I said that person may have a lot of stress they need to deal with. One of the things that we see in most patients with addiction is a co occurring or several co occurring disorders. That means things that are going on with that person in one or more domains that may or may not have to do with the addiction. Mood disorders, psychotic disorders, personality disorders, medical disorders, these all fold in on each other. Psychosocial, what we used to refer to as axis 4. Problems in their relationships, problems at their workplace problems, problems with the law. We need to look at what's going on with the person and how all of these factors interact. So there are different patterns to addiction. A lot of people start out with recreational use or experimentation. Very few people wake up, go out, have a drink and are an alcoholic from there on out. Occasionally there are some drugs that are what I call one hit wonders. People have told me that crack is one of those. So it's not unheard of to go straight into an abuse situation. But most of the time when you look at somebody, they didn't just start with crack. They started with something else that was a gateway drug or a gateway addiction. So recreational use and experimentation, then the person progresses to abuse when the recreational use isn't cutting it anymore. When their life around them is getting more stressful and they know, hey, when I do this, I feel better, so I'm going to do more of it. Well, if we're talking about exercise or doing something pro social, that might be a great idea. In this case, not so much. Because as the person starts to engage in whatever activity or use of a substance they're doing, it takes over their life. They have a bad day at work, they drink. Then they get up in the morning and they're dreading going into work, so they drink and it starts to filter in and become more and more part of their daily repertoire. People who fail to fulfill major Role obligations. They call in sick to work because they'd rather gamble, drink, do whatever the addictive behavior is, that's going to be a real big red flag. Warning sign. If you call in sick once a year, not as worried about it. Calling in sick two, three, four times a year, that's starting to be a problem. One of the biggest warning signs for supervisors is if you have an employee who consistently calls in either every Monday or the day after payday. If you get paid on a Thursday and they almost always call in sick on Friday, gives you a clue that something's going on. It may not be substance abuse. It could be gambling or some other addiction. It could be a variety of things, but it's worth paying attention. If there's a pattern in somebody's absenteeism. Use when physically hazardous. Having somebody who uses despite knowing it's going to worsen their physical condition, or somebody who uses and drives, and I say uses, it's not just drinking. There are a lot of drugs that impair your ability to react as well when you're driving. I know for me, I don't even like to take Benadryl before I drive. But I'm definitely not taking any painkillers because I'm kind of a lightweight and Benadryl will put me out painkillers. I don't even know what's going on even if I take a half a dose. So it's important to know how you react to stuff. But other people may not feel the reaction as much as I do, but they're still being affected as much. They still may have the reduction in their awareness of their surroundings or the reaction time. So it's important to be aware of whether you're choosing to use and then doing something that's going to put you or others in jeopardy. Recurrent legal problems as a result of the addiction or the substance use. Whether it's financial problems, bankruptcy, criminal legal problems. And it doesn't have to be dui. It could be domestic violence, because you're a very angry person when you're under the influence. So it's important to kind of look at what these things are caused by. And if it all keeps coming back to the substance or the addiction, that's what we call a clue. And recurrent social or interpersonal problems. You have this great group of friends you've grown up with since high school. You spend a lot of time with. They're fun to be around. You go out and do things. But gradually you start changing your circle of friends to that circle of friends that wants to sit around, use, gamble, do whatever that addiction is. So you slowly move over to a group of friends that supports your addictive behaviors. The friends that didn't support your addictive behaviors have backed off a little bit. They don't want to be around that type of, that type of behavior. Or maybe they don't want to be around you when you're engaging in that type of behavior. So it's important to look at this, but it's also important just to throw something else in the mix. When we're assessing for co occurring disorders, we have to say, okay, this person has major depressive disorder. We know that there have been episodes in this person's past when they've gone through major depression. Let's look at when they're using and see if there's a correlation. Do they wake up and they've entered a major depressive episode out of the blue? And we'll talk about that later. That people need to be aware of their relapse, warning signs for their mental health as well as for their substance issues. But we'll get to that. So failure to fulfill major role obligations. They wake up and their depression is so heavy on them that they can't even dream of getting out of bed. They're just like, I can't face the world, I can't move. It hurts to breathe. So they finally get the energy to get up because it hurts so much to breathe. They want to make it stop. And they use. Okay, well are they using the substance to escape from a negative situation? Oh yeah, yeah, they are. However, that negative situation correlates with an episode of their mood disorder. So what does that tell us? Well, first thing, we want to figure out how to get this mood disorder under control. Because if we don't, this person's going to have a real hard time getting clean and staying sober. Use when physically hazardous. Again, somebody with major depressive disorder, and I'm just using that as an example. There's a lot of co occurring stuff, but that one's real easy to pick on. You wake up, you're depressed, you're borderline suicidal, you don't really care if you die or not. Yeah, I've seen people wake up or at the end of the day just kind of decide, I don't really give a crap whether I live or die. So I'm going to just start taking whatever's in the medicine cabinet or I'm just going to start drinking or whatever the case may be. So again, would this person have used as Much Would this addiction be progressing as much if this mood disorder were under control? Now, it doesn't mean that if we take the mood disorder away, the addiction is going to spontaneously remit. It's important to understand that. Likewise, if we take the addiction away, it doesn't mean the mood disorder is just going to poof, be all better. Both of these have longstanding issues, long standing behaviors and long standing triggers that we're going to need to address and that person is going to need to focus on really working on for the rest of their life. Is it fair? No. However, if they're in your office and they're willing to work on it, this is where we can start. Start. We want to look at all the factors. Think about a house. If a house is built on a foundation and all of a sudden the doors aren't closing anymore, you might say, hmm, the foundation's cracking. Well, the foundation hopefully doesn't just crack out of the clear blue. Unfortunately, it means there's probably multiple things going on. The foundation was poor, the ground wasn't level. I don't know enough about this metaphor to really go much further than that. But I do know from looking at houses that you need to know that the house is level, the house is sitting on a good strong foundation, it was poured to the right thickness, etc. Same thing. When we're talking about addictions and co occurring disorders. We need to look at all the factors and how they are feeding into the current issues, the current presenting issues. And just like when you've got a house thing going on, you've got people who are going to go, well, I don't really care about balancing out the floor. If things slide a little bit, that's okay. I just need to be able to open and close the doors. Okay, I'll meet you where you're at. Let's get these doors opening and closing. And then when they get stuck again, we'll come back and talk about maybe dealing with the larger issue. See, I'd be a great contractor. Moving on. Dependence is when somebody evidences three or more of the following tolerance, they need more of the substance to get the same high, or they need to use different substances in combination withdrawal. Their body has gotten used to having that substance in, so they feel physically uncomfortable and sometimes psychologically uncomfortable when they don't have that substance. Now obviously when we're talking about behavioral addictions, we're talking more about psychological discomfort, having all that anxiety and everything creep up because you're not distracting yourself with gambling and whatever cards you have in your hand or however, whatever horse is doing using larger amounts over a longer period of time than intended. So if you intend to go out to the bar and have a couple of drinks with friends and before you know it, you can't stand up, oops, you're also probably going to be spending a lot more time recovering from not only the physical impacts of that extended use, but also the financial impacts. And, and most of the time, if you've gotten to that point where you can barely walk, there's a lot of things you're going to wake up the next morning and go, oh, please don't tell me I did that. Yeah, if you're laughing right now, you've been there. So these are all things that we need to pay attention to because everything that happens now has the potential to live on indefinitely on YouTube, which means it can negatively impact your social media life, your relationships, your work life. Fill in the blank. We are now on camera permanently, forever. I think unsuccessful efforts to cut down. If you say, well, I'm only going to drink on Friday evenings after work before I go home, and then it turns out Friday evenings after work, then when you get home you have a couple of more and then, oh, while the game's on on Sunday, we're going to have a few more. That's not what you said you were going to do. Again, go back to the definition. Is it causing you problems in one or more areas of your life or functioning? If not, you're still in that danger zone area, but you might not qualify as having an addiction. We also need to make sure that people with co occurring disorders understand the impact that their addiction, whatever it is, is having on their mental health disorder. One of the clients I worked with recently is a professional gambler. That's all he's ever done, that's all he's ever known. And one of the things that we needed to look at was, was when he was gambling, how did that impact his mental health? Well, you know, he was okay with it, he felt confident at it. All right, we'll leave that alone. When he was gambling, he felt like he needed to use amphetamines in order to be up and stay on top of everything and be able to keep track of everything all the time. So then we looked at, okay, well how's that affecting your co occurring anxiety issues? And he said, well, that's not helping so much. But when I don't use the amphetamines because of state dependent learning, I don't feel like I can Keep track of as much. And I certainly don't do as well gambling, which means I can't pay the bills, which increases my anxiety. So you see how all this kind of folds in on itself. So he said, okay, well we need to figure out what your end goal is and continued use despite adverse consequences. So this particular patient was in that position where he was going, well, if I gamble, then I'm going to use because the two go together. If I don't gamble, I can't pay the bills. But if I do gamble, then I'm using the drugs. And that's having all kinds of other negative repercussions. So I'm caught between a rock and a hard place. So we had to choose where we were going to start, the rock or the hard place. There are a variety of different addictions and I've hit on a bunch of those so far. Illicit drugs, well, those are pretty easy to see. If somebody's using illicit drugs, there's a good chance they're going to have some sort of legal problems at some point. Because by using the drugs they're breaking the law. Okay, alcohol, some people can use it, not have any problems, other people can't. Prescription drugs, some people don't have any problem with some of the more mood altering prescription drugs. Some people do. Behavioral gambling, sex, food. Now, something we don't talk about a lot is interpersonal addictions. Relationships that are domestically violent, dependent, fatal Attraction sort of things. I always want to say hand that rocks the cradle and that's not it. It's Fatal Attraction. That's why I put it there because I forget the name of the movie all the time and high risk behaviors. I have known a lot of people, especially cops, who have this addiction to adrenaline. They have to get that rush and if they're not at work getting it, they they're bungee jumping or doing something else. Flying in helicopters without perfectly good doors. That's for my husband there. There are a lot of different things that people can be addicted to because it gives them that dopamine rush, it gives them that feel good, it gives them that escape when life is kind of not pleasant for one reason or another. And it can get addicting. Now some of the behavioral addictions is really easy and the legal chemicals, it's easy for people to justify. Well, it's legal. I'm not hurting anybody else, relatively speaking. It's not in the dsm so it can't be a problem. How many people. I didn't put Internet on here and just think how Many people you know who have had marriages or relationships break up because of computer games or Internet porn. Okay, it's not in the dsm, but it doesn't mean it's not a problem. So let's talk briefly about how relationships fit into the addiction scope. Remember we were talking about how you need more of the same substance. You need more of it to get the same comfort or feeling of happiness. Spend longer doing it. Let's see. Larger amounts over a longer period of time. Needing to spend more and more time with a person in order to avoid experiencing anxiety or depression. So when you start to become sort of part of that person, when you are so and so's significant other, when you start to lose your own identity, it can start to become an addiction. Not always, but it can. Unsuccessful efforts to cut down. Trying to spend less time with a person but experiencing significant negative consequences. Obsessing about that person when you're not with them. Having to text them. And if they don't text back right away, like going on this text spamming thing because they're not answering. Being codependent on another person for a sense of self. If you need that person to feel whole. Oh, this is a long one. Time spent obtaining, recovering from or using the substance replaces social, occupational or recreational activities. Somebody was in the DSM trying to figure out how to be with the person and ignoring other activities to be with that person. Or recovering from injuries or problems caused by being with that person. So basically your entire life revolves around spending time with the significant other, doing whatever that significant other wants at the expense of your hobbies, recreations and friends. And if it's a violent relationship, maybe recovering from injuries sustained from that relationship. Continued use despite adverse consequences. So yeah, I mean, continuing to stay in the relationship despite friends saying, I can't help you anymore, you're going to have to help yourself. Or losing friends or becoming more and more isolated because of that relationship. I've known people who've lost jobs because they've snuck out of work to go be with somebody or lost jobs because their significant other kept showing up at their workplace. So relationships can be addictive. Staying with a significant other because they. And I'm assuming you mean the person needs attention. One of the things we talk about in early recovery is the difference between being lonely and being alone. You can be alone and not be lonely. You know, when I go home, I have all my little four legged critters and I am happy as a clam. When people are lonely, they can be lonely in a room full of 50 people. If you are in a room but you're relying on somebody else to tell you you're okay, somebody else to validate you. If you're afraid to be alone with yourself because what goes on in your own head is too scary, that's loneliness. So definitely being aware of the reason somebody's staying in a relationship and, and whether it's causing them multiple harm in multiple different areas. Okay, wonderful. Let's move on. So we also look at patterns of use. Continuous use is self explanatory binge use. Again, this allows people to really justify, minimize, rationalize all my favorite stinkin thinkin sort of behaviors. I only do it on the weekends. Okay, but what happens on the weekends? I know at our house on the weekends we have honey do lists that are this long. And it's not just for my husband, it's also for my children. We have stuff to do. So if the person is using all weekend long and they're ignoring their family, they're not helping around the house, they're not getting stuff done, that can be a problem. If they are only using on the weekends, but they happen to continue to get DUIs. Again, it's a problem if they only use in response to overwhelming events. Again, we want to look at the frequency of this. If it is, you know, once in a blue moon because their house was foreclosed on or somebody died or something, you know, it's probably not going to cause problems in multiple areas of their life. If every time you turn around they're having an overwhelming event, that means to me that they're probably having difficulty dealing with life on life's terms. And again, that could be because they have inefficient coping skills. It could be because there is an underlying mood disorder. It could be because there's an underlying physical disorder where they've got chronic pain and they're not getting enough sleep and they hurt all the time and they just can't deal with life. So we have to look at what is going on with each individual person. Does it mean that using is, it negates the use? No, it means that those underlying issues are going to continue to cause the person to want to use. Most likely, unless we find an alternative. Increasing in response to tolerance. This is the whole theory of gateway drugs. You start with one drug and when that loses its kick, you move on to something else. Now most of the time when you start hanging out with those friends that support use, they're going to introduce you to lots of something else's and eventually you'll find one and you're like, oh, I like that one a whole lot better. That's a lot better. Again, start using that one and then you either need more or you start combining. Not a good pattern to be in. So you're increasing in either intensity or quantity, or you're adding different drugs. So you could use something that's stronger or use lots of different drugs or use more, just increased and substitute addictions, my favorite pet topic, if you will. I've got a lot of favorites. Substitute addictions. You see this so much in residential, especially because people are kind of right there in the little petri dish. But in people in recovery, especially early recovery, they may not be smoking anymore, but instead of chain smoking, they're chain eating. A lot of patients that I've seen go through residential will not use for 30 days, but they'll put on 30 pounds in 30 days because they're using something else to fill that void, to help them distract themselves from their current pain. The other thing we see a lot of in residential, if you've worked in a residential facility, you can probably attest to this is there's a lot of sexual interaction. If they can figure out how and where they'll do it. I've seen people crawl through drop ceilings before. So where there's a will, there's a way. It's a matter of trying to help people understand that all they're doing is finding a different way to get a dopamine release. And that's not really solving their problem. We need to deal with what's causing the underlying physical, emotional, psychosocial pain. So give me examples of how you've seen patients develop substitute addictions. What substitute addictions have you seen out there? I gave you the example of food and sex. So I took the two big ones off the table. Yeah. Using food to deal with issues, our society kind of supports that, though. When somebody dies, people bring food. At a birthday, people bring food. At pretty much any event, people bring food. Exercise, that is a substitute addiction. Again, everything in moderation. Exercise can be an addiction. It produces a great endorphin rush. But if you're exercising past the point where your knees are swollen and you have shin splints and fractured legs, that's not good. Internet porn is available 24 7. So if you're struggling at, you're in intensive outpatient and you're struggling at 11 o' clock at night or 2 in the morning, Internet porn is always there for you. Just like your drug was adrenaline behavior going out and engaging in different types of risky behaviors in order to kind of get that rush from feeling like you're in control of your own destiny. And for someone who is an addict, and we know that addicts tend to be somewhat on the side of control freaks. There you go. Hello. While working in a methadone clinic, helping those addicted to opiates, they get stabilized, then turn to sweets. In particular, food is one the definitive sweet tooth. Okay, so carbohydrates have a really interesting place because not only are carbohydrates used in the manufacture of serotonin, so the body needs them, but we've also conditioned a lot of these foods. Our comfort foods over the years have been carbohydrate based foods. Cookies, candy. Back in the olden days when it was okay to give kids suckers and stuff, I remember going to the bank and if you were good in line, you got a sucker. If you went to the doctor, you got a sucker. When you fell down and skinned your knee, you got a cookie. Well, they poured all kinds of stingy stuff on it. We've conditioned that over the years for people. We have also created synthetic sort of sweets and things that you wouldn't necessarily find in nature that make your blood sugar go woo. Partying constantly, going out. Anything to occupy themselves. Getting into trouble in the process because they can't be alone. Okay, so you've got several things here. Partying constantly. So you're around other people and you're sucking their energy. And if everybody else is having a good time, you can forget about how crappy your life is. All right, we got that. Anything to occupy themselves. I need to forget about whatever it is that's bothering me. So if it means turning around in circles and singing the ABCs, maybe that's what I'll do. Getting into trouble again. There's an adrenaline component there and can't be alone. Needing other people to validate their existence and say, you're okay, you've made some bad choices, but I like you. That validates them and gives them a sense of belonging. Going to meetings, becoming an AANA Big book guru. Okay, this is another one that has multiple parts to it. Great, great parts. And there goes the train. Going to meetings. Yes, meetings are great. Meetings are. Well, if you are a 12 step person and you enjoy meetings and you find good meetings, that's great. But if you live at meetings in order to avoid the outside world, that's a problem. Same thing can be said for church. If you go to church in order to escape from Negative emotions. And to avoid dealing with life on life's terms can be a problem. Exercise, we've talked about not staying at home. Now again, part of that can be healthy because if you're alone and you know that that's a trigger, maybe getting out is a good relapse prevention technique. But if you can't ever be at home alone, then you may need to look at what's going on there. And working multiple jobs some people have to do leads to you being hungry, angry, lonely and tired. Halt. But sometimes it needs to be done. So it's a matter of figuring out how to work that into a relapse prevention plan so you can keep a roof over your head and food in your belly without driving yourself into a relapse. Working multiple jobs can also be. Or working the same job and just working 80, 90, 120 hours a week. Are that many hours in a week? Okay, never mind. Math was never my strong suit. If you're staying at work so you can feel needed, so you can feel important, so you can forget about everything else that's out there, again, it's a problem. We need to look at the motivations, what the activity does for you, if it's beneficial or if it's causing a cascade of problems outside of whatever the activity is. Awesome. Excellent answers. Reasons for use to feel like you belong, to feel part of something, to not feel lonely. Boredom. Self explanatory habit. Self explanatory. We'd have clients who would go into work phase and as soon as they start getting a paycheck, I swear that check had acid in it and it would burn a hole in their pocket. They would want to use because that was their trigger. They were conditioned, they got money, they went and bought. It can also be a habit when we talk about food, sex, those sorts of things. I've said in other presentations before floor that I'm very, very guilty of habit eating. I come home, I set my stuff down at the front door, hopefully not to open it again, and then I go straight into the kitchen and look for something to eat because I'm hungry. I don't know, I don't pay attention. It's just, I'm home, it's time to eat. Now that doesn't really work very well for self awareness and mindfulness and recovery and all that other stuff that we talk about. So we want to help our clients understand that they need to pay attention to their habits. My mother was a smoker for the longest time and she had certain times of day and I've heard this from a lot of people who smoke. They have certain times of day where they just automatically light up when they hit those key points of day. It's time they've got to do something with their hands. So habit habits are a little bit easier to break because you find an alternate behavior and there's very little underlying psychological stuff going on. But it's not all habit. Habit's only like the tip of the iceberg. Numbing emotional or physical pain. Self explanatory. We do it. All of us will occasionally take ibuprofen if we've got a backache or something to numb physical pain. People will occasionally drink if they've had a bad day at work to numb emotional pain. That doesn't mean they're addicts. But if it gets to be your go to every time you have emotional or physical pain, you need to think about what's it doing? Is it helping at all or is it just making it go away for a few minutes in my mind, but out here it's festering. Psychiatric self medication. If you have that co occurring disorder, especially a mood disorder and you are using in order to deal with the anxiety or the depression or the mania, well, there you go. If we can get that under control, then there will be less desire. I'm not saying it goes away. There's going to be less desire to use the challenge with co occurring and we find out, okay, is psychiatric self medication fine, so we'll put the person on antidepressants, fine. It may not work as quickly as what they were using, it may not work as well as what they were using and it may have side effects that are less acceptable than what they were using. So these are all things we've got to look at as far as medication compliance and relapse prevention. A lot of the antidepressants out there, not all of them will make libido go through the floor and that's an unacceptable side effect for a lot of people. So you need to talk with your clients and say, okay, let's look at the reasons you used, let's look at the alternative ways to solve those problems and let's look at any drawbacks to those. Prepare them so they can figure out how to navigate and they're not just caught unaware. I had one client talk to me early on in my career who had a co occurring mood disorder but had also been using cocaine for 20 some odd years. And he said, you know, I'm clean, I've been clean for two months. But Just like I was clean in the past at a certain point, I just can't live with everything being gray all the time. There's no highs, there's no lows, there's no color. It's just blah. And I said, okay, I understand that he was doing all the right things, but his brain chemistry still hadn't gotten back into sync with not having those drugs in his system in that particular case, and I'm not saying this is for every case, but in that particular case, the psychiatrist ended up putting him on a short course of antidepressants. And it did wonders, did wonders to help him feel like recovery was worth it. And people use for relaxation again to numb the feelings out. The I don't give a crap pills or drink or whatever it is. So the Gyllenic curve, and I know this is really small. You can Google it, you can find it online. It's a great general understanding of the slide down into addiction and then back up into recovery. So you start out with occasional relief, and then you start moving to the feelings of guilt, the minimization, rationalization, the stinking thinking. Then you start losing a bunch of stuff, which makes you want to use more. And eventually you get down to all your alibis are exhausted, all your sober or sane social supports are gone, you're pretty much flapping out there in the breeze, and you've hit whatever your bottom is. And that's different for different people. And I'll say that again, that's different for different people. So don't assume just because somebody hasn't lost everything that they haven't hit their proverbial bottom at that point in time. So as recovery progresses, they stop using. Well, hey, there's a concept. But just stopping using. What happens if you've got a problem? Let's say you've got some kind of chronic pain and you're taking painkillers and you decide for whatever reason you're going to stop taking painkillers. Well, okay, you're not taking painkillers anymore. So if you're abusing them, that's great. But guess what? That pain is still there. And probably it's going to be a lot worse because your body's quit producing the natural endorphins and natural pain killers going on. So for a short period of time, short to medium period of time, people are going to feel a lot worse unless you give them reasonable alternatives to solve the same function. So with pain, we've got progressive muscular relaxation, we've got massage, we've got hydrotherapy we've got electric transcutaneous electronic nerve stimulation, TENS units. There are a lot of different non chemical things, non chemical ways to help people deal with pain. There are also other medications that can help people deal with pain that are not mood altering. They're not your opiates, they're not your heavy duty good stuff. So we need to work with the patient and work with their physician and have the physician work with your psychiatrist. Get that whole multidisciplinary team going on to make sure that this person has stop gaps. And one of the things that one of the analogies I make is it's kind of like rock climbing. If you're rock climbing, you're not going to climb all the way up an 80 foot cliff and not put some footholds in somewhere along the way. With recovery, it's the same way you want to make sure that they've got some good footholds along the way. So if they slip, they don't go all the way back to the bottom. Mood is the same way. They need footholds. If they've got some sort of mood disorder, organic, situational, I don't care, major depression, generalized anxiety, whatever, they need to learn where their footholds are. Because sometimes we say if you've got these things going on, you need to deal with your stress and get plenty of rest and exercise and yada, yada, yada. And all of a sudden this person's going along in a nice steady state and we'll say female and they get pregnant. Oh boy. Didn't plan for that. It's going to throw a kink in it. So we need a foothold because guess what? When that child comes along, you're not going to sleep again for six months. At least that's been my experience. But I digress. So there are things that life is going to throw at our clients that they need to be prepared to deal with so they can kind of maintain. They may not progress anymore for a while, they may just have to tread water. But we need to provide them those tools with their addiction and their mood disorder. Okay, now on to the fun part. Maslow's hierarchy. If you have someone who is sick, hungry, exhausted and homeless, they're not going to give a crap about working on their self esteem. That is the least of their worries at this point. So when we're working with people in early recovery, a lot of times I start down there with I need to find something to refer to it as besides what we used to call Axis 4. But the psychosocial issues? Can they get sleep? If not, why is their sleep environment not conducive? Do they have chronic pain? Are they on medications that have a side effect that make it difficult to sleep? Do they have restless leg syndrome? Go through the list. Make sure your patients have had a physical recently with a full lab workup. Check for thyroid issues, hormone issues. Those can all impact mood, impact sleep, and impact pain. Do they have access to food now in early recovery, I'm not really going to preach the food pyramid and all that stuff. I would like them to try to eat healthfully. I would like them to try to get at least eight glasses, eight eight ounce glasses of non caffeinated fluid every day. Notice I didn't say water because as soon as I say water, people look at me like I've lost my mind. If we can get them to start getting hydrated again, if we can get them to start eating something that slightly resembles a healthy diet, and if we can get any medical conditions that are going on, hepatitis, any list of medical conditions from the flu to something more chronic, get those under control so the person can focus on life, then we move to safety. Safety is not just not being attacked from somebody outside. Actually, those external threats to safety in most cases are actually the least of your worries or the least of the patient's worries. What tends to be more damaging to them and more threatening to them are those tapes that they've got playing in the back of their head that tell them that they are stupid, that they're going to fail, that they are useless, that they're worthless. All those negative tapes, it's a whipping block inside their head. And every regret they ever have, they're still beating themselves up for. This is where we start. Cognitive behavioral therapy goes a long way here because they can't change the past. And this is where step one and honesty comes in. Accept the things you cannot change. So we look at what you can't change. You can't change the past. Okay, well what do we do with that? They have this here and they haven't done anything with it. It's just kind of been stuck away in a corner in the back of their head somewhere. Safety. Most of the first 30 days or 28 days in a residential program, this is what we focus on. Safety and physiological needs. Getting people out of the fog, able to be attentive and present, increasing their motivation and helping them identify what tools they already have that have worked in the past and strengthening those. All of that starts to go to a sense of love and Belonging. Once they stop all that negative self talk and all those horrendous things and they start dealing with maybe the nightmares and the traumas that they still have going on in their head, they start to feel like they're not alone. It's like, oh, that's one of the reasons I love group therapy. Because they start to realize that it's not just them, other people have been there. Maybe not exactly the same way. One of my pet peeves is when somebody says, I understand how you feel. I don't care who you are. You don't understand how I feel. Because you haven't had every single one of my experiences up till today. I would like to understand how you feel. Or I would like to hear more about that, or I can relate. Those are different. But I understand sets a lot of people off, me included. So just bear that in mind. Especially if you've got a client in crisis, they're processing something, be with them. I hear how much this is hurting you right now. That's okay. Try to stay away from. I understand. Love and belonging. We start to work on relationship skills in early recovery. We encourage them to find a 12 step group and a home group and a sponsor, at least a temporary sponsor. This kind of starts nudging us into love and belonging again. Where they don't feel like they're the only person who has this problem or they're the only person who's made these mistakes. Self esteem, it comes, you get there, but it's different for every person. Just like working the 12 steps is. It bugs me, but I try to again meet the person where they are. When somebody goes through a 28 day program and proudly announces their last day in treatment that they've completed the 12 steps, really, I feel like, have you ever seen a German shepherd? When they cock their head almost sideways and that one ear flops down? They may have gone through it, but it was kind of like running over hot coals. They just went as fast as they could so they didn't get burned. And I know when you run over hot coals, that's not the way to do it. But stick with the metaphor. Health, food, sleep and safety. This is where we need to focus for addiction as well as for mental health. Think about the last time you were sick. Were you the most pleasant person to be around? I know I'm not. If you come between me and my television when I'm not feeling well, there is going to be something to pay. I just don't have the energy to deal with drama So I like to be left alone. Part of my introverted self. Not all people are like that. Some people aren't affected as badly when they're sick, but when we're sick, our body says, okay, I need this energy here to enhance the immune system. So you're going to have to give it up from somewhere. Your concentration, your mood, your fill in the blank. Where are you going to give it to me? So we need to help people have good health so they're not feeling run down all the time because their body is just sucking every last bit of energy they have, which takes us to sleep. People need to rest, recharge and recover good quality sleep. Now for some people that's six hours. For some people that's 10 hours. People also need to be aware that their sleep patterns are not necessarily going to be the same all the time. There are some days I get up after six hours, I feel great. And there are other days I get up after 10 hours and I want to go back to bed. Generally that's right before I get sick. If I force myself to get up, my body's telling me, whoa, I need some energy here, just chill out for today. But do I listen? No. I tell my children and my patients, do what I say, not as I, I do. And food. Like I said early on, I try to get people to start doing something resembling a healthy diet. If they leave treatment after 28 days and they remember nothing else about proper nutrition, it's drink plenty of non caffeinated fluids and eat colorfully. Aim set a goal to have three different colors of food on your plate at every meal and different colors of or shades of white and brown. Don't cut it. In order to do that you have to have fruits and vegetables and grains and meats. Mix it up a little bit, okay? Common characteristics of addicts Poor nutrition. Food and good nutrition is generally the last thing people are thinking about by the time they get into dependence. Low immunity. They're using all their energy to stay up all night gambling, to stay up all night using to do anything but rest, which takes us to low immunity. They're also encountering other people who are doing the same thing, which around my house we refer to mutant bugabuggas. When people have a heavy germ load because they're sick all the time and they're coughing and you're sharing their air, so your immunity starts getting bombarded all the time. Lack of rest doesn't help because then your body never has time where it can say okay, I don't need the energy for anything else but breathing, heart beating and immunity. Physical pain. It's amazing how many aches and pains you get if you're not taking care of yourself. Physical pain leads to poor sleep quality, leads to low immunity, leads to sickness. You see where I'm going with this? So start pulling at whatever thread your patient's willing to work on. And this is true again of mood disorders. When somebody is really, really depressed, they're either going to overeat on comfort foods or not eat enough. They're just going to be like, I don't care. Low immunity. We know that people who have, who are experiencing an episode of a mood disorder tend to be more likely to get sick. It's not a direct correlation, it's an anecdote. Lack of rest. If you have generalized anxiety disorder, it's hard to sleep. If you're depressed, you either may find it hard to sleep or you may sleep too much. So then you're not getting quality sleep safety. So let's go back up to this again. Pull on that thread. What are they willing to work on? What's causing them the most problems right now? What would, if they started feeling an improvement, what would that look like? What would be the first sign? If they say, I would start not feeling exhausted all the time, you can say, okay, let's look at times when you weren't exhausted all the time. What was different? What did you do differently? Did you have a different pillow? Were you sleeping on a different schedule? Were you exercising? What was going on? This is not going to be the cure all miracle question, but it gives you a place to start. Where they know they've done things in the past that have worked for them. Build upon those, educate them about what helps with rest and what hinders rest. Circadian rhythms, exercise, quiet. The list goes on and on. Sleep hygiene, wonderful. There was a book that I read when my son was little. It was called, I believe, solving your child's sleep problems. But he talked about, and I really hadn't thought about it until I read it, how we condition our bodies, or we condition our children's bodies, as the case may be, where they get up and, you know, at clockwork, my son would lay down at noon and thankfully, like clockwork, he would sleep for three and a half hours. But then he'd get up and we'd go through the day. The rest of the evening, he'd eat, he'd take a bath, we'd read a story and he went down about the same time every night. And when I Talked to other parents, you know, they could tell me what time their kids went to bed. Little Tommy goes to bed at 8:00 every night or 7:30 every night. And that didn't strike me as odd until I started reading this book. And I'm like, oh, because the body learns, hey, it's the sun's going down or not. We've eaten dinner and that kicks off the cascade. I'm taking a bath. Oh, yeah, I know what's coming next. It's story time. And after story time, I know I'm supposed to be asleep. So the brain will start secreting serotonin and getting the body ready for sleep. As adults, most of us don't do that. Most of us just kind of go until we're like drooling on ourselves and we pass out. Not the best for sleep hygiene. So try to get into some sort of a routine as best as possible. I know we just moved to Tennessee not too long ago, and in Florida, even in the winter it doesn't get dark at 4:30 in the evening. So it's been quite an adjustment for me to get used to the fact that at 4:45 it's pitch dark out some nights if it was cloudy and by five o', clock, pretty much any night. Now let clients know that that might also affect their mood, which is why we have seasonal affective disorder. Pay attention to these things. There are easy interventions, but you need to be aware of what's causing the problems. Safety. If somebody is homeless, that's obviously potentially going to be a problem. Now, I will put in the caveat here that I've worked with a lot of homeless people and there are a proportion of them, and I don't know whether it's a major or a minor proportion, but there is a portion that choose to be homeless. They don't want to pay taxes. They don't want to answer to the government. They just want to be left alone and they're okay. They have their friends, they have their stops along their route. And it's sort of a culture, so taking that away from them is not really culturally sensitive. But then there's this other portion that is not wanting to be homeless, but they are, for one reason or another. So we need to help them figure out, how can you be safe? We need to help people who have a home, but it's in an unsafe area. One of my clients lived in a, what a lot of people would call the projects. And I went over to do a home visit one day and she had boards over two of her windows. And I asked her about it and she said, oh yeah, the windows got busted out about two months ago and her brother had just come over last week to put boards over them because the landlord wouldn't come fix it. Well, okay, so there's a whole advocacy issue there, but there's also the issue of she and her three children were living in this house, house with two broken windows for a month and a half and engaging in high risk behaviors. They may have a perfectly safe place to live, but they may go out trolling the bars or engaging in other high risk behaviors. So these are things we need to figure out. What's the function, why are you doing this and how can we intervene so you don't have these issues going on? What have you done in the past when these issues haven't been happening? Sometimes it's a matter of providing education. They just. What does good nutrition mean? Nobody ever taught me what does it mean to get good sleep? There's nothing I ever learned about until I was in college. So education, planning, building on their strengths and their resources instead of reinventing the wheel. So what are some basic interventions you can use with your clients in early recovery to address physiological and basic needs so that lowest level when we're talking health, food, sleep, make sure to drink enough water, crystal light, Kool aid, non caffeinated beverages, you know, I'll take it if we're getting the person hydrated again. And educate them about the effects of dehydration leading to feelings of lethargy, confusion, a lot of the same symptoms that somebody who's depressed may have if they are taking certain medications. It's also important to make sure that they understand that their medications may affect them differently, especially antipsychotics if they start to become dehydrated. In the summer, we would see a rapid spike in admissions to our crisis stabilization unit from patients who had a psychotic disorder because especially homeless patients with a psychotic disorder because they become dehydrated and the medication wouldn't be in the right balance. Okay, limit caffeine after 1pm Caffeine has a 12 hour life in your body. So if you drink caffeine at 1pm it's still having some effects at 12:30 in the morning. So try to limit it. And that coffee, soda, chocolate, everything. Don't go cold turkey necessarily, but, but just be aware of how it impacts you get at least eight hours of sleep. If you can't get eight hours, get good quality sleep. Eat nutrition, rich healthy foods. If you're going to snack. Try to grab some fruit instead of a candy bar. Make simple substitutions here and there. Drink enough water. Healthy foods. Exercise. Exercise. At least take a walk. Did you know that most people yawn not because they're tired, but because they're not getting enough oxygen? But we attribute it to being tired. Get your blood moving. Get your blood flowing. It helps a lot with a whole myriad of things. Take your dog on a walk. You don't have to go on a power walk. Just move. Do something. Preferably outside. Eat five small meals. Keep your metabolism up so your blood sugar's not going like this all day long. Using the person centered approach. Finding out where they are and what they'd like to work on. So identify what they want to work on in regards to their recovery and educate them about how there's some really simple things they can start doing right now. Not everybody is going to want to eat a colorful diet. I will tell you that. Especially here in the south. We love our fried foods, but figure out what one or two things they're willing to commit to trying. Basic sleep patterns. Help them find community resources to meet their needs. Excellent housing issues. There are a lot of community resources. Social issues. If they don't have a lot of friends or a lot of social support. There are a lot of recovery groups, but there are also other social activities. Call your local United Way. Call the local churches. Find out what the networks are to help people meet their needs. Food, shelter, medicine, etc. Nutrition. Drink enough water. Okay, I think I covered everything. So again, there are a lot of different things that you can do. And one of the most important is probably the last one I talked about. Whoever said using the person centered approach. I can tell people all day long what they should do, but if they're not motivated to do it, they're not going to do it because they don't care what I say. My goal is to say, okay, here are your options. You say you want to get from here, point A, which is where you are now, and this is where you want to go, point B. So in order to get there, what needs to change in your mind and what's the first thing you're willing to work on. And if they can't come up with anything, then you can educate them about different possibilities and how those behaviors or activities may help them. Finding out what they can physically do. Walking. Ask them to list what their eating habits are like and referrals within the local community service boards, food banks, churches and hygiene. So when you do your assessment, you should be doing a pain assessment as well as a full biopsychosocial assessment and understanding what their physical and cognitive limitations are. Adopting an animal Unconditional love I can't say no to adopting an animal. However, it's not for everybody. If the person is unable to care for that animal financially, it could add an extra burden. I've seen people who worry more about their dog getting food than they worry about themselves getting food. So making sure that that person has the resources to handle that. On that same note, a lot of the Meals on Wheels programs in our area are now also doing pet Meals on Wheels. So when they go and deliver the food to the person, they're also bringing food for the animal in order to help people who do have that unconditional love from a wonderful animal but are struggling to provide. What both of them do need comes from adopted from donated food. Also, if your pet ever gets and this is my little public service announcement, if your pet ever gets a food that he doesn't like and you take the open bag back to the place where you bought it, a lot of times they will donate that to a rescue in order to feed homeless animals. Love and belonging if your only friend is your addiction, then if you give up your addiction, what the heck do you have left? So if we're ripping that away, what are you going to give them in place? Why is their only friend their addiction? Well, probably because that's the only thing that hasn't let them down yet. So we need to figure out what to give them and its stead relationship based on what can you do for me, these are unhealthy relationships. Relationships should be 50, 50, 60, 40 and they should go like a seesaw. When one person's in crisis, the other person can help out and vice versa. It shouldn't be all or nothing helping people understand that they're worthy of of healthy friendships and they don't have to just be there to do something. People like them for them, not what they can do for them if they're isolated from caring supports. And that doesn't necessarily mean family. Sometimes it does help them figure out where to reach out to find caring supports again. 12 step meetings recovery oriented meetings Church volunteer activities There's a plethora of different options that they can explore and a need for external validation. If they don't know why they're good enough to breathe the air and they need other people to tell them why they're good enough to breathe the air, that's going to cause a recurring problem. So this Is something, when you get up to that love and belonging stage, really working on helping the person understand that they're good enough and they're smart enough and, and gosh darn it, people should like them going along with this. Adults with adhd, I mean mood disorders you can kind of understand, but adults with adhd? I found a lot of patients who've come through my program who've had difficulty in relationships because of their impulsivity, inability to wait their turn, interrupting all the time. And when we look at it, we say, well, you've got all the classic symptoms of adult ADHD that hasn't been diagnosed. No wonder it's hard for you to interact with other people. Get that under control, it's a whole new person again. The pill doesn't solve everything. Now they need to learn how to interact socially, but it helps with the impulsivity. Look at the reason behind the behavior, what's causing it, and what alternatives there are out there. Lack of self esteem, not understanding why you're okay, what's good about you. Lost hope and motivation to achieve their ideal self. People in recovery, well, addicts and alcoholics often hold themselves up here to this standard and they hold everybody else to this standard here. They have to be perfect, nobody else does. What does holding that perfection do? Well, sets them up for failure, gives them excuse to use, gives them an excuse to beat themselves up and lets them keep replaying those tapes in their head that tell them they're not good enough. Yeah, none of those need to stay. One of my favorite interventions is to when I'm working with people is say, well, you're holding yourself to this standard. You're saying you have to do this 20 years from now, if your child were in your place, do they have to do that too? Most of the time it's like, no, that's ridiculous. So why are you holding yourself up here? Let's look at the motivation. Are you trying to prove that you're worthy or are you trying to give yourself an excuse to use two different motivations, two different interventions, And a lot of my patients don't remember who they are they've been using since they were knee high to a grasshopper. So they may not even have really known who they are they started using at the age of 9 or 10. One of the articles I was reading the other day said the average age that someone who is really strongly addicted to Internet porn. A lot of these youth are starting to look at Internet porn at 11. And I'm thinking about my 13 year old going, oh Lord, I need to turn off the electricity. But. But anyhow. That's the wonderful thing about firewalls. Stinkin thinkin' people who are overly pessimistic. Everything is always a catastrophe. One activity you can have them do is flip a coin. If it lands on heads, they have to act like the glass is half full all day long. If it lands on tails, they can be as negative as they want to be. They can be themselves. Have them do that for a week and compare and contrast how the day went. They need to control everything. Well, what happens if you don't? Because you know there are some things you can't control. Using cognitive behavioral therapy to look at those things that you're trying to control that are impossible to control and what good it's doing you. Playing the victim, Blaming others for feelings and situations is a whole lot easier to blame other people. Not my fault. It's your fault because it keeps people from looking at you. It makes them. Makes the person who's blaming other people try to feel better inside. Need for immediate gratification. Well, we all like it, but it doesn't always happen. And whether you need it or not are two different things. If you are gushing blood from an artery, you probably need immediate help. If you're not, then a lot of other things can wait. And it's a matter of figuring out why you need that immediate gratification most of the time. So you have something else to focus on besides life and a feeling of entitlement. Well, my life sucked, so I deserve whatever I want when I want it, thank you very much. No, it doesn't happen. So that feeling of entitlement. We want a lot of things, but you've got to weigh it in context of everything else. So last two slides, we're going to talk about different motivations and recovery concepts. Keep coming back. It works if you work it. You got to keep trying to do it over and over again. It works if you work it. That means if you give it 100%, it's probably going to give 100% back. But part of working it means taking general concepts because this is not a one size fits all thing, and tailoring it to you. Not every intervention is going to work for every person, so you need to take that inventory and go, yeah, that was a little bumpy. Maybe I need to try this next time. It works if you work it. Being mindful of what works for you. Sit down, shut up and listen. We spend too much time talking and not enough time listening. And it's really easy to throw blame and throw focus and not take our own inventory if we're yapping. Listen, sometimes you hear things you don't want to hear, which is why a lot of people don't want to do this. It's scary as crap. Sit down, shut up and listen. First things first. Recovery is a journey. One foot in front of the other down a path from point A to X marks the spot. If you start taking detours along the way to go sightseeing, you may get lost. You gotta figure out how to get one foot in front of the other every single day and keep it simple. This is not brain surgery. This is what I tell my clients a lot. I am not any magic person. I don't have any magic solution. You know, you. Because you've lived in your own skin for 30 years, you're living in your own skin now. So you can tell me what feels like it's working and what doesn't, and then we can talk about that. But don't make it into something super complicated. It's always easier to take somebody else's inventory. Well, duh. I would much rather take someone else's inventory than look at my own stuff. But if I don't look at my own stuff, then I'm going to lose touch with what's going on inside of me. And before I know it, boom. That relapse comes from out of the blue. Good, orderly direction. That map, when Google gives you directions, it doesn't give you choices. It says, go here, drive 500ft, turn right, drive 17 miles, turn left. It's not multiple choice. Good, orderly direction. If you want to get from here to here in a certain time frame, you need to follow directions. Again, as control freaks, we don't like to follow directions because it's scary not to be in control. Halt, Hungry, angry, lonely and tired. Big relapse triggers. If you're letting yourself get any of these and not keeping it in check, you're going to get hungry occasionally. So eat. You're going to get angry occasionally, so do something about it, yada, yada, yada. But if you're letting it get out of control, that means you are not being mindful. You're not checking in with yourself to keep tabs on things. Which means before long, a relapse is going to hit you out of the blue. It doesn't happen out of the blue. Things started gradually getting out of control a long time ago. You have to give it away in order to keep it. Talk to other people. One of the things that I learned early on in my teaching career was how little I knew until I got up there and started trying to teach something. Then I'm like, oh, wait a minute. It's kind of like my metaphors. Sometimes I use a metaphor and I'm like, ah, well, didn't think that all the way through. In recovery, as we help people walk through steps, it forces us to look at our own behaviors and our own actions. You have to give it away in order to keep it. If you're helping people walk through it and you're looking at it yourself, then hey, you're working it. Fake it till you make it. Try to do the next right thing. It doesn't always feel the best. And that's what fake it till you make it means. It doesn't mean put on a happy face and tell everybody you're fine, which in the interest of not having bleeps, we're not going to talk about what fine means. But you can look it up on the 12 step website, I'm sure Fake it till you make it means do the next right thing. Even when it's not feeling like it's your favorite fear. False expectations appearing real. When we aren't in control of everything all the time, we get very anxious and fearful. Because if you start letting your mind go, of course it's going to go to the worst possible scenario. Ego edging, God out, pushing out the fact that you may not have control over everything and pretending that you have control over the universe. You don't. So get over yourself. Go to meetings when you want to and go to meetings when you don't want to. Now this can be 12 step meetings. This can be smart recovery meetings. This can be whatever recovery oriented, sober, sane meetings you want. Want to go to pro social. But go be around people who can help support you in doing the next right thing. We have a living problem, not a drinking problem. Drinking is what you did to deal with all these other mistakes you were making and the drinking just happened to make it worse. So you need to find a different way to deal with life on life's terms, which takes us to that thinking problem, rationalizing, minimizing, justifying, etc. And happiness is not getting what you want, it's wanting what you have. I like this one. You can think on that for a little while, being appreciative of what you have because you can always want for other things. I mean even Bill Gates with his multi bazillion dollars and his huge house and pretty much anything he could probably ever materially want doesn't mean he has everything he necessarily wants in love and happiness. And you know, he wants aids to be cured and the world to be educated. Well, it's not going to happen exactly that way. So we need to look at appreciating what we have and what we can give instead of always wanting more. In summary, addiction can happen to anybody. It can start when you're seven, it can start when you're 67. And yes, I did have a man who got addicted to crack when he was 67. His 54 year old wife introduced him to it. So by the time I saw him, he was in his early 80s and he was on felony drug probation. But he was very proud about the fact that he had never used drugs until he met her. So it can happen to anybody at any time. Just be conscious. It develops over time. In most cases, like I told you earlier, every once in a while you'll have somebody who finds a drug that's like a one shot wonder and they're like, oh, I got to get me more that. And it's downhill from there. But that's rare. That's the exception to the rule. Addiction erodes health and happiness in most areas of life, as does your co occurring mental health problems or physical health problems. If you've got chronic pain, then your mood, your productivity, your hopes, dreams, desires, whatever, probably going to gradually erode if you're always hurting. Likewise if you're depressed all the time, if you're anxious all the time, this starts to erode and it starts to wear on the people around you. So they're less supportive. Not because they don't want to be, but at a certain point they've got to set boundaries. So again, be aware that we're talking, when we talk about relapse, when we talk about recovery, we're talking about the whole person, not just the addiction, which is a little part. Addiction can be chemical, behavioral or interpersonal. The addiction becomes the addict's best friend. And in some cases the addict feels like they've become the addiction which when you look at it from a philosophical standpoint, if I am an addict and I quit the addiction, then what am I? An addict in recovery. Okay, but sometimes people have to have a label so they can develop a new identity. Ideally, I like to have them use their name, but whatever it takes, recovery is not just getting clean. Getting clean means not having the drugs in your system, not engaging with that one person, or not using some substitute addiction to numb your pain. You know, being Sober means doing the next right thing to deal with those issues. It's a different way of life. It's that whole serenity prayer, accepting the things you cannot change, the courage to change the things you can, and the wisdom to know the difference. In order to know the difference, you have to, you know, stop, shut up and listen. So it's a whole different approach to life. Not everybody's willing to do everything right away. Ask your clients, what is it that you think will help you the most right now? If we work on it, and what do you think will help you in that area? What's helped you in the past? Question them sort of Socratically because they've tried to fix it on their own. They've gone through those stages of readiness, and if they hadn't, you can kind of prompt them through it. Ask them what they're ready to work on and help increase their motivation. Help them feel success and help them experience and reap the rewards of their efforts. All right, that's it. Thank you for joining me this evening, and I hope to see you again not next Wednesday, because that's Thanksgiving week, but the Wednesday after that. Take care of.