Triggers and Cravings

All right, welcome, everyone. Today we're going to be discussing triggers and cravings and how to deal with them. Over the next little while. We're going to define a trigger, define a craving, explore the concept of stimulus generalization and discuss the functions of triggers. Then explore triggers in terms of mental health symptoms as well as addiction. We'll then move on to explore how cravings can lead to obsessive thinking. I mean, craving is really the thought that follows once a trigger is actually encountered. So they kind of go together like peanut butter and jelly. And we have to really remember that and not try to differentiate too much from one from the other. When we're treating one, we're kind of treating the other. Review stages of the recovery process and identify potential relapse triggers at each phase and appropriate interventions. Now, again, I want to remind you that relapse is relapse, whether it's substance abuse or mental health. So if we have someone who we're treating for major depressive disorder, they can relapse, they can go back and have another episode. And that is just as frustrating for them as somebody who has an addiction, who goes back into an addictive set of behaviors. So what is a trigger? A trigger is a physical or a cognitive stimulus. So basically, it's something in the environment, something that we see, hear, smell, touch, taste, or something that we think about. So a trigger can be just about anything that causes a physical or cognitive reaction. So if we see something and we have a positive thought, what's our first reaction? We're going to be happy, we're going to smile, we're going to do something like that. If we see something and it makes us scared, we're going to do something else. We'll have a different cognitive reaction. If you're thinking of the ABCs, we know that the thoughts and the actions kind of go hand in hand. We will have those automatic thoughts, beliefs, and then we will have an action that kind of corresponds. Now, once that trigger is encountered, we have those automatic thoughts, and then we do whatever the behavior is, and it's either going to be rewarded, which will trigger the reward system, the dopamine, you know, all that stuff, or is going to be punished. And if it's rewarded, we're probably going to do it again. If it's punished, we're probably not going to. Now, that is really overly simplistic because, you know, sometimes you have the lesser of 2e or the more rewarding of 2 rewarding options. So we'll talk about that as we go along. It's important to remember that any pleasurable activity is associated with elevated dopamine levels and elevated reward pathway activity. So whether it's eating a brownie or taking methamphetamine, you're still going to enact those chemicals. So triggers can be auditory things that you hear. If you hear a siren, a trigger for. We have two cockatiels at home, and I don't know what their malfunction is. I don't know if they think the cockatiel is talking to them or what's going on. But if they hear a siren, whether it be outside or on tv, they will start shrieking. Nothing else causes them to do this, but that is a trigger for them to shriek. And, you know, we start to think, okay, well, what's the reward for this behavior? It's got to be something internal to them. It's got to be some sort of ingrained protective mechanism, because I certainly don't reward that behavior. So that's an auditory stimulus. When a baby cries, we react. Okay, we've kind of got Animal House going on at our place, but whatever. One of our foster dogs, whenever she hears a baby crying, whether it's on TV or in real life, she starts barking. She's very upset that the baby is upset, and as soon as the baby calms down, she quits barking. Or if you can, tell her it's okay, but that is a trigger for her. Something in her past told her that when the baby cries, you need to let somebody know. There are a lot of other auditory cues when a baby cries. As a mother, you know, you tend to learn what your baby's cries mean, and it will trigger you. It will tell you this is something that you need to do. Now. Negative or triggers for negative behaviors, if you will, can also be auditory. Certain songs, if you listen to songs that glorify or romanticize drug use, there's just a whole variety of things. So I want you to remember, it can be sounds, the environment. It can be things like, I volunteered at the crisis center suicide hotline when I was an undergrad, and I always did the overnight shift, and I worked there a little too long to the point I got kind of burned out. And every time I would hear that phone ring, I would have this automatic stress reaction. Well, okay, so I took some time off, and I wasn't thinking about it too much. I was walking through the mall, and that same telephone ring was on the phones in the mall. The phone rang. I had an automatic stress reaction. That fight or flight reaction kicked right in as soon as I heard that phone, it was like, okay, jump. Jump into. Into. Into high gear. We want our clients to understand that sometimes triggers are very innocuous, and they need to be aware that if they feel something, that there was probably some sort of trigger. You may not be able to identify every single trigger, which is why we're going to talk about what to do once you experience a trigger in order to deal with the cravings, in order to deal with whatever your body's telling you to do. Because you can't possibly plan for everything all the time. Visual triggers, I mean, these are simple things, things that you see in the environment, whether it's a poster of Bob Marley or I can tell you a visual trigger for me, on the bad note, and it's also an auditory one. Those awful, awful Humane Society commercials that have Sarah McLachlan singing, if I hear her singing or if I see the beginning of those commercials is just devastating. I can't stand to see it. It drives me nuts. And that sort of throws me into high gear. So I know as soon as I see that, I need to quit watching the tv, change the channel, do something else. Olfactory smell. Smell is one of our most enduring memory triggers. So if you have someone, we'll talk about the happy ones first. I guess when you think about a happy time, maybe it was birthdays or maybe it was, you know, for me, going to my grandmother's house, it always smelled like Pine Sol at my grandma's house. So whenever I smell Pine Sol, I have a happy feeling. I'm like, oh, this reminds me of Grandma. Now, there can also be negative associations. If you smell something for someone who was abused, for someone who was attacked, for someone who was, you know, there are a variety of negative associations. And if there's a smell associated with that, especially a unique smell, cigar smoke, a certain type of pipe tobacco. There can be damp, sort of mildewy. You know, what old houses smell like, anything like that. Patients need to identify if there are certain things that will trigger them. Does it mean they can avoid them all the time? No. But it does mean if they encounter that trigger in the environment and they start feeling wonky, for lack of a better term, then you know what they can do. They can say, I am here, I am now, I am in the present. And they can work on mindfulness, reminding themselves that they're not back in that unpleasant situation from the past. Tactile triggers. And this can be just being touched. This can be, you know, anything that involves touch. People being too Close. People hugging you a certain way. You know, tactile triggers are kind of, you know, different, but they do exist sometimes. Then cognitive triggers, these are those automatic beliefs. These are those thoughts we have that tell us it's going to be a bad day or something bad is happening. And cognitive triggers can happen because of transference issues or a variety of. A combination of other triggers can combine to trigger a negative cognition. So that's triggers kind of in a nutshell. My name's not Aw. My name's Jeffrey. This is one of my favorite memes. I don't know why. Well, yes, I do know why. It's got a cute little kitty on it. But when you first see this, your first reaction is, aw, that's a trigger. Cute little kitty makes us go, aw. I have a. On the screensaver of my phone, I have a picture of a hamster in a sweater, because who can be upset when they see a hamster in a sweater? It's a visual stimulus. It triggers sort of a happy thought or a happy reaction in people. So where do triggers come from? The important thing to remember is that triggers can be innate. Like with my cockatiels, it's something in bread. They hear that sound. It reminds them of a danger sign, and they do what they need to do. My chickens are the same way. When they hear certain birds call, they will scatter. When they hear one another talk in certain ways, those are innate triggers. They don't have to be conditioned. When the animal or organism is born, it's there when we're born. Put your hand on a hot stove. Guess what? That's going to be a trigger to say, ouch, and pull your hand away. We don't have to be taught that, you know, you put your hand there, it's going to hurt. Learned triggers can come from experience. If I do this, I'm going to get in trouble, or there's going to be a punishment. I remember my son when he was little, would test things out. He was always a little scientist. And actually, this foster dog that I have right now is kind of the same way. He'll grab something and he'll run up to me and with it in his mouth. And if I say, brewster, that's not yours, he'll drop it. But if I tell him it's okay, then he'll go play with it. And he figures out through trial and error what he's allowed to play with if he gets bored with his other toys. But we learn through experience. We learn through observation. If we see someone else do Something and get punished for it. Maybe they lose their life savings, maybe they go to jail, maybe their relationships break up. There's they get sick, they get hiv. There's a whole host of different ways someone can experience punishment. But if we see someone else do it, then, you know, it might lessen the chance that we will do it again. The same is true for reinforcement though. If we see someone get away with something or if we see someone benefit, like from playing the lottery, intellectually, we know that playing the lottery, it's like a 1 in 10 million chance or something. But we watch and we see people win the lottery. So we go, oh, maybe I could win the lottery if I played. You know, it's that connection that we make. Education, you know, you might just educate someone. The DARE Program HIV PREVENTION A lot of our prevention programs are geared to letting people know what the consequences are or the punishments are of certain activities. So unconditioned triggers generally serve a survival purpose. For example, sight, bright sun, something headed to your face. You're going to block your eyes. That's your first reaction is to either squint, block your eyes, duck, do something like that. You're not taught to do that. You don't have to look up at the sun one time and have your eyes burned and then go, oh, maybe I should cover my eyes. It's just a natural knee jerk reaction. Sound, loud noises. We cover our ears because it's loud. It hurts, we want it to stop. On the upside, you know, I try to give some positive examples for each one. A heartbeat. When children are in the nicu, when I have foster animals that are orphaned, they have little things that make a simulate a heartbeat sound and that's calming to infants, whether it's, you know, four legged critters or two legged critters. The heartbeat is one of those unconditioned stimuli because the both, you know, kittens, dogs and humans kind of grew up in their mother's womb hearing the heartbeat smell. Pleasant smells are going to make you inhale deeper. Noxious smells are going to make you go, oh no, cover your nose and get out of there. Touch. If something causes pain, you're probably not going to do it again. If something is pleasant, then you may do it again. You know, think about when you have a stiff neck, putting a heating pad on your back or your neck may help loosen that up. So that's a rewarding thing. And taste pleasant or noxious most of the time. I mean, there are some things that you can say you have an acquired taste for but most of the time, our taste buds, you know, they know from the get go what to eat and what not to eat. This is why a lot of animals in the wild, they're exposed to poisonous stuff everywhere. But you know what, they have this innate ability to either taste it or smell it and say, yeah, that's not. Oh, that's not something I'm going to eat. Because their body knows that it's poisonous, which I think is kind of cool. Condition triggers also can be a survival thing. Generally provide rewards, avoid punishment and survival. So sight. When a baby sees a bottle, you know, initially a baby has no idea what a bottle is. By the time a baby's three or six months old or whatever it is, shortly after they begin using a bottle, they figure out what it is and they will calm down upon the sight of it. They will, once they get to the point where they can willfully smile, they will smile. They will reach for it. Snow. This is another one of those triggers. Either makes you happy or it makes you go, oh, I've got to shovel that driveway again. But either way, it does trigger a reaction sound. You know, music can make you happy, can make you sad, can make you melancholy, can make you reminiscent. Music is great in therapy as well as, you know, just being aware of what, what it triggers sirens, it's another one of those things. It can, it puts you on alert to things that are going on. I grew up in a family full of first responders. So I hear a siren and my response is completely different than maybe someone who has a history of being in and out of jail, in and out of the system. Smell. If you smell smoke, what are you going to do? Well, around my house, usually go check the oven, but whoops means I got distracted. But smoke triggers a certain behavior in our house that's, you know, checking to see what mommy forgot on the stove. But in a lot of other houses, it's often a trigger to get out. When you smell brownies, some people get hungry, some people have a craving, some people remember a good time in the past when they used to have brownies. Touch, touch a hot stove. It's, you know, it's gonna hurt. And you eventually learn, you know, hot we get, that's unconditioned. Stove is a little bit different because until you figure out what a stove is, you don't really know. My son's cat will be the first to tell you that he didn't know that a stove was hot until he stepped on a hot burner one time. Poor kitty wool Sweaters. When you first see a wool sweater, you're just like, okay, it's a sweater, but as soon as you put it on, you're like, okay, this is a really hot, itchy sweater. Not all wool is hot and itchy, but you know, for the majority of your wool, it is a bit scratchier. That is something you learn by experience, by exposure. Taste. You know, if you taste coffee, if you taste Reese's ice cream, it's going to trigger certain feelings, certain thoughts. You taste coffee and you like it, you're probably going to drink it again. If you taste it and you hate it, you may still drink it again, but put a lot more sugar in it. Thoughts? I love this condition. Trigger lice. You know when your kids come home from school and I'm itching right now just thinking about it, and they start talking about, you know, how there's a lice outbreak and even if your kid does not have lice, your head itches for like the next three days because you're constantly thinking about it. It's one of those triggers that as soon as you learn about it and you learn about the creepy crawlies and some of you are probably going, okay, just move past it. You get my point. Other things like holidays. Holidays mean different things to different people. So if someone starts thinking about Thanksgiving and it's a stressful time for them, it may trigger stress related feelings. My mother's current husband, his family was killed in a fire on Christmas Eve. So Christmas is not a happy time for him. When he thinks about Christmas, that's what he thinks about. He has a hard time, you know, conceptualizing everything else. Even though that was something that happened back in 1960, something. So stimuli, triggers and generalization. Okay, we know what triggers are. We kind of got that now. Why? What's the function of them? When we engage in a behavior that produces dopamine, it produces a reward in your brain, so you're likely to do it again. So this is how our body learns. You know, we learn through exploring our environment. Think about children when they're, you know, first they learn how to put cross their hands in front of their body and learn how to like move their body. But then they go through that period when they're like one and a half to three where everything goes in their mouth and they have to touch everything. They're exploring, they're learning, they're trial and error figuring out what they can touch, what they can't, what they like, what they don't like. And then the body is the Brain is rewarding the good stuff. And if they get in trouble or they get admonished about it, then they're learning from that too. Generalization occurs when a reminder for the behavior occurs in different settings. Now, let's talk about behaviors. Let's talk about eating. What sorts of settings remind us to eat? Obviously, the kitchen, the dining room. But there's also holidays. There's also going to grandma's house. There's also, you know, when I was growing up, we would go to the movies every Friday night, and my mother would always get popcorn. So when I go into a movie theater, my first thought is, gotta get popcorn. And then I see how much it is, and I'm like, okay, that'll control that craving. But generalization occurs when there are a lot of things in the environment that start to say, you need to do this. Whether it's use, whether it's be afraid, eat. You know, there's a whole host of behaviors. So let's think about triggers for eating as an infant. Birth to three months. Hunger. You know, the child wants to eat when it's hungry. There are other internal states. Sleepy, fussy, sick. That if the baby is given a bottle every time it cries, it may start saying, oh, when I feel this way, I'm supposed to eat. Not I'm supposed to go to sleep or I need to have somebody hold me because I'm fussy, or I need something else because I'm sick. As the baby matures three months to a year, you know, hunger. Still, we want it to learn that when you're hungry, you eat. But there are also certain times that the baby will start to get hungry. It learns, you know, over a period of time that this is the time of day we eat, and their body sort of gets hungry. Ours does that. You know, I know that when it comes to about 11:30, I'm looking at my watch going, I'm hungry. So our circadian rhythms. And there's a whole lot more to it than just learning, because there are neurotransmitters, your serotonin levels, your melatonin levels, all that stuff that cues your body that it's time to eat. But. So circadian rhythms are important to keep in alignment, if you will. But other things can trigger the baby to think about eating. Seeing a bottle, even if it's not dinner time or lunchtime, seeing others eating. How many times have you been, you know, not hungry, but other people have been eating, so you've just eaten anyway? And then these internal states, if they haven't been counter conditioned are still going to trigger eating. So sleepy, fussy and sick. So now you've got a child who eats when it's hungry, but it also eats at 11:30 just because it's 11:30. And that's when you're supposed to eat lunch. And it eats when it sees a bottle, it wants to eat when it sees other, other people eating. You know, with children sometimes you'll see a baby who's been given its meal, but then it's given Cheerios to eat while the grownups eat to keep it pacified, if you will. So it's learning through experience that all these different things are times to eat, which is not necessarily accurate. As it becomes a toddler, we still have hunger, circadian rhythms, bottles, other people eating. But now the toddler has started to put smells with it. And it's like, I smell that, that's good, I know what that is, I want to eat that. Even if they're not hungry, the smell may trigger the desire to eat places again. If kids are put in the backseat and they're given a sippy cup and a snack to keep them quiet, guess what? When they get in the car, that's going to trigger them to want to eat even if they're not hungry, if they're at the store or watching television. How many kids do we know that sit on, sit on the couch, watch television or play video games and just eat mindlessly? They're not hungry necessarily. It's something to do with their hands. So these are all ways we can generalize different triggers in someone's environment to trigger a particular behavior in a way that we may not necessarily want to do this because this person has developed some very, very unhealthy eating habits. At this point, The generalization just kind of continues. As people get older, there are certain functions that you eat at, yada, yada, yada. So we need to, in treatment we need to help people become more mindful instead of mindless about their behaviors. They need to eat when they're hungry. Certainly they need to pay attention to what they're hungry for. Our body will crave certain things if it needs certain nutrients. We need to help them establish, you know, some good circadian rhythms. So there's a relatively stable time when they eat every few hours. But then all that other stuff that triggers the desire to eat even when one is not hungry, that needs to be counter conditioned. They need to be pay attention and learn to eat only when they're hungry, which is, you know, a big task. And most of us actually don't do that. But you know, we can strive toward eating to live, not living to eat. So let's talk about alcohol. You know, eating is one of those that we can't say abstinence, but alcohol, we kind of can. We want to ask what is the benefit alcohol to somebody? Well, some people think it relaxes them, some people thinks it makes them more sociable, some people think it helps them deal with stress. You know, and depending on what stage of intoxication someone's in, all of those can be true. So there is a short term benefit. So what are the associated stimuli with drinking sites? Beer commercials, football games, beer in the fridge, going to the grocery store. They sell beer and wine in the grocery store. There are a lot of different sites that say, hey, have something to drink. Sounds could be the opening of a top, it could be a coke can, but it'll trigger someone who likes to drink beer maybe to think about drinking a beer. Maybe the sound of being at their kids football game. Go through these with your clients and go, you know, what kinds of things make you think about using? And they may not have a list for everything. Have them keep a log, Just pay attention to when they have thoughts about using. Touch, taste, thought setting, you know, like I said, the kids game, maybe carrying a cooler, going fishing, you can just kind of brainstorm. This is a fun activity to do in groups sometimes so people can see how many stimuli there really are in the environment that say, hey, you want to have a beer? Okay, so let's switch gears a little bit and let's talk about mental health triggers, types of triggers for ptsd. Well, what are the benefits? Let's think about this. PTSD symptoms. Flashbacks, hypervigilance, those are some of the big ones. Emotional numbing. Okay, so let's think about that. When the person experienced this situation, it was one in which there was the threat of death or significant bodily injury. So yeah, I mean it makes sense that the body is going to go, we don't want to do that again. So let's kind of up our guard and be aware of these things so we don't ever get ourselves in that situation again. Emotional numbing, that amount of stress, that amount of threat is overwhelming to anyone. That amount of grief, if you saw somebody get killed or were in a situation where there was grief, helplessness is almost too much for some people to handle, for most people to handle. So one of the reactions in acute stress as well as PTSD is that emotional numbing. It's like I can't I need to wall this off. I cannot feel anything right now because it just hurts too much to feel anything. So when you think about the symptoms that we have, and you can do this for anxiety or depression or bipolar or borderline or any of those, it makes sense from a functional survival perspective. Now, is it over generalized? Yeah, that's when it becomes a problem. You know, I would expect someone to be hypervigilant on the battlefield. I would not expect someone to be hypervigilant in their own bathroom. You know, there's a big difference. So when you have someone who is hyper vigilant in other situations where the stimuli have been overgeneralized, they don't feel safe anywhere. Then we need to start looking at what things remind you of that event that are being translated into, you know, right now. You know, maybe at home. One of the things that people report hearing a lot is loud noises, like banging of a cabinet if they've been exposed to a car accident or gunfire or something where there was a loud banging sound. So we can say, okay, there's a similar sound in your environment. Now how can you reground yourself to remind yourself that you're safe, you're not on the battlefield anymore, or you're not in the middle of that car wreck anymore. What can you do to get back into the here and now and be mindful of where you are? One of the things I have a lot of my clients do is stop, take a breath because their heart rate's gone up. We need to get that heart rate down. We do something called combat breathing. They breathe in, hold it for three, and then slowly exhale for three. And they do that once or twice. You know, they do it too many times, they start getting dizzy. But when the respiration slows, the heart rate slows, and it sends a signal to the brain going, there's not a threat. So that's the first thing. But while they're doing that, I want them to look around and be aware of where they are. Notice, you know, if they're in the bathroom, notice the sink, notice the mirror and maybe the spots on the mirror. And focus on things to get outside of their own head and into the current present moment. Generalized anxiety. When somebody is anxious a lot, they're fearful. That tells me that there was a time in their life where they didn't feel safe. So their anxiety is there to protect them from feeling unsafe again. First thing, establish safety. Seems like a very basic concept. All right, let's find a place where you feel safe. When you're at work. How can you create an environment or a situation where you feel safe when you're at home, when you're in the car, you know, you want to hit those big places where people usually are. You can't hit everywhere, but there are generally some common places where people hang out and you can say, okay, how can you make that place feel safe to you? For some people, it may be not having people walking behind them. You know, coming from a family of first responders, I don't think anybody in my family will sit unless they can see the door and have their back to the wall. I just kind of grew up knowing that I was always going to have my back to the door because everybody else needed to see the door. That's how they feel safer. That's kind of ingrained in their personality. What else can they do to make it feel safe when you're home? Lock the doors, lock the windows. I was home the other day and I heard, you know, a weird bump upstairs. And I took my big foster dog. He's a big bulldog. And I'm like, brewster, come on, let's go clear the house. That made me feel safe. We walked around the house, and I knew if anybody saw him, they'd pee their pants before they do anything to me. So, you know, it was good. People need to know how to feel safe in their own environment. They also need to take a realistic look at all of these places and go, is it realistic or what things about this could be unsafe? You know, obviously when you're driving, there are certain situations that could be unsafe. How can you make those safer? When you're at the office, hopefully you're in a situation where that's not an unsafe place to be. So let's counter those cognitive distortions and say, you know, this really isn't all that dangerous. You know, Sally over in Payroll may have her moments where she, you know, gets a little crazy, but it's all good because nobody's dangerous here. So we need to challenge cognitive distortions, create a sense of safety and help the person figure out where eventually, where that initial fear came from and maybe address that issue. Depression, now this is the one that people are like. It doesn't make a survival sense, but it does it so. So does when people are depressed. You know, especially if they become depressed. It's not something, you know, they've been depressed since they were knee high to a grasshopper, or there was a traumatic brain injury and there's some depression, or there was a. Well, even if there's an incident where they're maybe in a car accident and they come out of a coma and realize that they're paralyzed. You know, let's just take this, put 100 on 10. As my daughter would say, yeah, you're going to be depressed, but what is the survival benefit of this? What is the function of this depression? Depression slows you down. Depression, you know, it's a sense of hopelessness and helplessness. Your body's telling you we need to change the way we're thinking about things a little bit. Sometimes depression is your body's way of saying, I'm out of gas. I can't do this by myself. I need help. So when we look at depression and we look at people's symptoms, we need to ask ourselves, what's the function of each symptom? If they are having difficulty sleeping, you know, they're sleeping too much, Their circadian rhythms are getting out of whack. The neurochemicals that, you know, tell them when it's time to sleep and when it's time to be awake are out of whack. So their body is. Doesn't know when it's time to be awake, when it's time to be asleep. That's easy. Easy peasy. We have people get started on a schedule. And I tell my clients who have depression, because a lot of times depression is just so hard to do anything. I tell them, try 15. That that's sort of our slogan. Try 15. I want you to get up at a reasonable time and whatever that is for that person. For some people, at 6am for some people, it's 8:30 or 9. But I want you to get up at a reasonable time and I want you to get dressed and I want you to sit by. Either go outside or sit by an open window. You know, a window with the blinds open so you can get some natural light in. And try staying up and out of bed for 15 minutes. I mean, ideally you'd stay up and out of bed until it's bedtime. But let's try 15, because for a lot of my clients, the thought of getting up and staying out of bed all day long and, and not being allowed to go back is just too overwhelming. Try 15. If you still can't stand it after 15 minutes, let's talk about what are some other options that you can do. Most of the time after 15 minutes, if somebody's gotten up and gotten their blood moving, they realize it's not so bad. Now after two or three hours, they may be tired again. You know, their body is telling them, I've got something going on. I've been burning this, burning the candle at both ends for too long, and there needs to be some changes. I'm burnt out. I'm overwhelmed. I am exhausted. I am physically getting sick. You know, it takes a lot of energy to stay healthy. So when people experience a depressive episode, we want to identify their symptoms, look at what those symptoms are doing for them. We want to look at what triggers their depression. There are certain sights, sound, smells that they can eliminate, but there are also certain sights, sound, smells, you know, go on. That they can add to their environment to make it a happier place. And the same thing is true with PTSD and with anxiety. We don't want to just eliminate the negative. We need to add the positive. One of the things that my professor, when I first took behavior modification first semester, I remember him saying, if all you ever do is punish a behavior, then you're left with an organism that doesn't behave. It just sits there catatonic. You have to provide alternatives. The same thing is true with stimuli in the environment or triggers. We want to trigger people to be happy. So what makes them happy and what can remind them to do that? Maybe it's the sound of children laughing. Maybe it's certain YouTube videos. Maybe it's their pets. Maybe, you know, brainstorm what things make you happy and what kind of reminders. Instead of using the word triggers, use the word reminders. What kind of reminders can you put in your environment? Okay, borderline. And you see, I'm just randomly. Not randomly, but I'm going through each different type, if you will, of mental health and addictive issues. So you can see where triggers are there for everything. Frantic efforts to avoid abandonment. And they vacillate between valuation, you know, thinking you're all that in a bag of chips to devaluation. You are the devil incarnate. And there is no middle ground. When you're working with someone who has borderline personality tendencies, and you see a lot of these same tendencies in people with addictions. So I do want to, you know, point out that we want to look at the symptoms more than focus on the labels, because the labels don't mean a whole lot. What is the survival benefit of this reaction? Well, if they're trying to avoid abandonment, that tells me they've guess what? Been abandoned. If they go between valuation and devaluation, maybe they haven't learned to look at the gray areas. So there's lots of different treatment issues that are there but we want to say what things trigger this fear? Because when they go from valuation, thinking you're all that, to thinking you're, you know, not, what's the function that pushes the person away, that gives the person with the borderline tendencies more power. If I'm saying that you are lower than me, you're beneath me, you're worse than me, then I feel better about myself. So both of these come back to abandonment and fear, loss of control. So what things in the environment, in their own head might trigger this fear of abandonment or loss of control? A lot of times it's stuff from their past, but stuff in the present reminds them of stuff from their past, which then becomes a thought in the present. What sites, what smells, sounds. If there are things, if they came from a very dysfunctional household and there are things that remind them of their family of origin, guess what? Those sorts of triggers are probably going to be going to trigger some of your more borderline esque behaviors. When people are under a lot of stress, they may tend to be more polar in their reactions and more extreme in their reactions and become more fearful of abandonment, needing, fearing that they can't be alone, they can't handle life on their own. So taste is not probably one that's going to be here. But sight, sound, smell, touch and thoughts are definitely present when we're talking about people with borderline personality disorder or borderline tendencies. What is it that makes this person feel like a scared child that is going to be dumped? And what is it that makes this person feel inadequate, so much so that they need to put others down to feel okay again? On the positive side, help them put things in their environment to remind them and to build their self esteem. Remind them of how awesome they are. Remind them to look at the grays. Look for the exceptions. It's rare that someone does something all the time. Always. There are usually exceptions to things I've said before. Math is not my strong suit, but I didn't always fail at math. You know, there were some things I got. There were just some things once they started putting in Greek letters that made my head spin. So have them look for exceptions and identify what is good about this person. And maybe examine their behavior in terms of whatever they did to make you mad or whatever they did that makes you want to push them away. Is this a situational thing or does this more represent them as a person? Did they make a bad choice or do you feel like they are a bad person and have them start looking at their relationships in that sort of, you know, gray area, respect. But they also need to look at themselves that way because they do the same thing with themselves. If they do something right, they're all that in a bag of chips. If they do something wrong, they're the scum of the earth. And so we want to help them address those cognitive distortions. What things do they see? What things do they experience? What, you know, things do they hear that make them question whether or not they're good enough? Gratitude journals, self esteem journals. Having them really work on their relationships and develop some relationship skills. Those are all things that they can sort of include in their repertoire. And look at putting some triggers in the environment to remind them to reach out to people. So what are the takeaways? It is impossible to address every trigger. Triggers represent a desire for a reward to avoid punishment or survive. These are things in the environment that go, you gotta do something. And you know, sometimes it's not survival, sometimes it's like, oh, I want that, or ooh, I want that. But the triggers are those things that can be good or can be bad. The cool thing is you can also have competing triggers. So when you have somebody getting ready to go into a situation, you know, a job interview, for example, they've got competing triggers going on. They are probably stressed about the job interview, they're anxious, they're afraid they're going to say the wrong thing, yada, yada, yada. But they're also, there's a desire for the reward, desire to have that job. So there's this push and pull of which is going to win the anxiety of going into the interview or the reward of getting the job. What kind of visualizations can you have people do before they go into a job interview that can serve as positive triggers for them? Triggers always serve a function. And once we break it down to its barest components, then we can figure out alternate ways to meet that need. Eating is one of those things that we've generalized and overgeneralized in a lot of different ways. When we look at our triggers for eating, we have to ask ourselves, what is the function of this behavior? What is the function of mindlessly eating while you're watching tv? Well, for me, I can't sit still. And you know, if you've been watching the video part of this, I talk with my hands. My hands are constantly moving. What could I do alternatively? Well, in my living room I have my iPad, so I can either surf on the Internet or play Words with Friends or something that occupies my fingers, or I can crochet or there's always a dog on my lap too. So there's always something to do with my hands. Opposed to eating. But you want to ask, you know, smoking is the same way for a lot of people. They don't know what to do with their hands if they're not smoking. So we have to say, what is it? You know, in a social situation, Some people, it's not that they're stressed about the social situation, they just don't know what to do with their hands when they're talking to somebody. So have them say, figure out what they could do differently with their hands when they're talking to someone. I'm one of those people that's terribly guilty of it. Don't give me a business card and then stand there and talk to me for 15 minutes because I will have folded the business card into like sixteenths, that fidgety thing. And that is, you know, I'm not saying that's a good thing, but I know that's one thing I do just because I have to have something to do with my hands. Many triggers are wrongly conditioned. You know, we don't want the sound of a bell to make you hungry. You know, we want the sound of a bell to be the sound of a bell. Remember when you were in high school and the sound of the bell meant put your books in your bag, get up and go to your next class. So now when you hear that bell. For most of us, even when I went to visit my kids when they were in public school, when I would hear that bell, my automatic reaction was up, time to get up and you know, get moving. We need to make sure that the triggers in our, in our clients environment are triggering the positive behaviors when they get triggered. Mindfulness and riding the wave are two crucial skills that clients need to deal with. The triggers and cravings, if they want to drink, if they want to self injure, if they want to run away, if they want to, you know, fill in the blank, whatever it is. Or you know, with ptsd, if they start feeling really, really anxious, mindfulness will help bring them back into the present moment. And riding the wave reminds them that urges and cravings crest and then fall just like a wave coming in and out. So after about 10 minutes, and the same thing's true with a panic attack, after about 10 minutes it's going to start to subside. So you have to get through that 10 minutes. What can you do? Stay focused on the present. Have an emergency plan written down. When people are craving, when they're Having urges, they're not thinking, okay, what was it that we talked about in therapy? They're in crisis. They need to have a written plan that they can pull out, go, okay, what am I supposed to do right now? So cravings are a desire for something and can become obsessive. You know, when I was pregnant in the evening, there was always this commercial for something from Hardee's. And I don't even remember what it was now, but I wasn't hungry. But it was one of those like super ultra processed fried, you know, a bazillion calories per bite sort of sandwiches. And I would see that and I was like, oh, I need it, I want it. Thankfully, I was too lazy to get up and go get it. But commercials, part of what their job is, is to basically trigger people to go out and purchase a service or a product. People need to ask themselves, what is it that I'm craving? What is it that I'm wanting and why do I crave it and want it? And that's really getting down to the nitty gritty. Am I craving the sandwich or am I just, you know, I need to go to sleep. And that looked really, really good. Is this, whatever this is, healthy and beneficial? Is it getting me towards my final goal? If it isn't, how else could I meet this need or deal with this craving? You know, in the case of the sandwich at 9:30 at night when I wasn't even hungry, go to sleep. You know, when I'm sleeping, I'm not eating, so go to sleep and the craving goes away. When we're talking about drugs, when we're talking about alcohol, when we're talking about, you know, other things people need to recognize, whether they're bored, they're scared, they're angry, they're stressed, all those cognitive emotional things, or if there is something that their body is telling them they need, like sleep, and then figure out what the next step is from there. Our body's main goal is to protect us. And it will do that kind of at all costs. And it's not necessarily the smartest thing in the world. So we've got to pay attention to what those cravings are telling us and then use our higher order thinking processes to figure out whether that's accurate or not. When we do something that aids in our survival, the limbic system rewards us by releasing dopamine. The more rewarding the behavior, the more dopamine and other pleasure chemicals that are released. Prolonged engagement in an addiction can lead the brain to stop producing as much dopamine as it naturally does eventually, because your brain, brain wants homeostasis. It says, I'm only supposed to have 2 ounces of dopamine a day, and you're giving me 6 ounces. And those are completely the wrong numbers. But I'm just giving you an example. So if you're giving it way too much, it's going to start shutting down some of the receptors because it's like only 2 ounces can go through. You can't keep, you know, overwhelming me with this. So then it slows down the dopamine secretion or production, which means the person is going to need more to feel normal. So stages of recovery, and I'm going to whiz through the last part of this because I'm going a little long, but withdrawal the first one to two weeks. Now, you know, this is early recovery when we're talking about depression or anxiety. The first one to two weeks, the brain is still kind of restabilizing from whatever neurochemical imbalances were going on. Anxiety, ptsd, depression, alcoholism, methamphetamine, whatever honeymoon is the first four weeks. After that, you know, the initial stages of ickiness are gone, and you're starting to feel kind of okay. 12 to 16 weeks is that reorganization period where the brain is really normalizing, the body's normalizing. If somebody started on antidepressants, they're really kicking in now. Then the readjustment phase is when they're learning the new cognitions, the new behaviors, all that stuff. So the first part is dedicated to getting them feeling a little bit better and getting the energy and focus to do what they need to do for recovery. And then we work in the readjustment phase. We start really focusing on turning the new coping skills and things into regular behaviors. In the early phase, depression, we want to address low energy, remind people they don't have to do everything. They need to delegate. They need to do what has to be done and leave the rest for later. You know, there's a lot of things that I may want to do that they don't have to do. Watch those circadian rhythms. Get them on some sort of good sleep hygiene schedule for them, and it's going to be different for each person. Changes in appetite often represent, you know, either anxiety, wanting to eat because you're not engaging in other things, or your body saying, I need some healthy building blocks. You know, Cheetos and Pizza are not quite cutting it, and then difficulty concentrating. As the neurochemicals balance out a lot of People report they have difficulty concentrating. And this is true with depression, anxiety, PTSD and addiction recovery. You know, people go through this initial period where sometimes it's just hard to get out of the fog, dealing with anxiety and irritability. Have clients identify how they've dealt with that in the past and then build upon it. Don't reinvent the wheel. Level the playing field. Next week we're going to talk about vulnerabilities. These are situations that make it more difficult to remain optimistic, enthusiastic, and do the next right thing. So take care of themselves. Remember Maslow's hierarchy. Proper nutrition, enough sleep, preferably some exercise. Taking care of themselves will go a huge long way to helping them feel better and being able to focus on doing the cognitive work. This feeling, you know, that things are getting better, this pink cloud lasts about four weeks until the newness wears off. People who are coming out of their depression are like, oh, this feels pretty good. They may feel like they're cured, they're starting to feel better. But family members often see this as the beginning of a relapse because they start getting complacent in doing what they need to do in order to feel better. It's like, okay, you know, I went to therapy for three weeks, I'm feeling better, I'm cured, I'm done. I can quit taking the meds and go back to my old way of life. And that's not it. Some people need to be on meds for a while, if not, you know, for an enduring period. But the behaviors are things that generally need to change and the cognitions generally are things that need to change in perpetuity, if you will. So family members are often right when they see a person thinking, you know, I, I got a little taste of what it feels like to feel better. I got it. Moving on. So the wall lasts about 12 to 16 weeks. It's the hardest stage of recovery because this is when people are learning the new skills, they feel okay. So there's not this big jump into, oh, I feel wonderful now, that already happened. So maintaining motivation in this stage is really challenging. People can experience depression, irritability, low energy, loss of enthusiasm. If we're talking about drug addiction recovery, obviously we're still talking about physical recovery as well, as this is the period where people start working on their stuff, you know, whatever that stuff is, which can trigger depression, irritability, low energy, and loss of enthusiasm. Prepare people, remind them that therapy is not a picnic. It's hard work. This is a 40 hour job. Even if you're only in therapy, one hour a week. You know, you're doing stuff, you're doing activities outside of therapy and you're working on changing the way you approach life, you know, the whole time you're awake. So this is a full time job and you need to be good to yourself. People can get easily overwhelmed while they're dealing with their stuff. I mean, they're emotionally exhausted, they are learning new skills, which is also exhausting. Remind them to give themselves a break. Relapse issues, people, places, things, times, activities, feelings and lack of self care. If you fall back into those old behaviors, or hanging with that old crowd, or hanging out at those places that remind you of when you were depressed, when your wife left you, when you, you know, whatever, you're risking relapse. So let's figure out what your relapse triggers are. What could trigger you to want to go back to those old behaviors, trigger your depression again and write out a plan to deal with them. So trigger prompt a response. Cravings are the thoughts that come after a trigger happens. It's that desire to achieve whatever it is. Triggers and cravings can be good or bad. You know, most people with addiction and or mental health issues have multiple triggers that need to be reconditioned. Football games should not necessarily represent a negative trigger. You know, football games can be fun, clean, sober activities. Addiction does cause changes in the brain, so the brain needs time to recover. Using produces feelings of escape or euphoria which become associated with people, places and things. So if I'm used to feeling good or every time I hang out with Jim Bob, we would get high. Then whenever I'm around Jim Bob, I'm going to want to get high in order to feel good again. So exposure to these people, places and things can cause cravings. When faced with unpleasant emotions or situations, people may also have cravings they want to escape. So we need to help them figure out how to escape healthfully. So recovery involves becoming aware of triggers in their function, eliminating or minimizing vulnerabilities, creating new positive triggers or associations, developing new ways to feel good and deal with stress. And you can put these all on a piece of paper and have your clients write out little essays about how they figure out how they think they could do these things and share them in group. 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