All right, hello. My name is Dr. Alex Santoro, and I will be presenting today on cognitive behavior therapy skills for healthcare providers. My intention with this presentation is to offer some very accessible cognitive behavioral tools that can be integrated easily and seamlessly into a patient-physician dialogue during a regular follow-up. I have no disclosures for this presentation. So a few things to keep in mind. So our goal here is to develop additional cognitive behavioral therapy skills that can be easily integrated into your practice. By the end of this talk, participants will be able to describe the basic theoretical framework of cognitive behavior therapy, which I'll be referring to as CBT. You will also be able to apply five CBT techniques that can be easily integrated into patient dialogue during a routine follow-up. Additionally, participants will be able to guide patients in implementing these evidence-based tools for managing distressing thoughts, emotions, and maladaptive behaviors. These tools are meant to be ones that can be easily applied to several different situations and circumstances that an individual may face. The nice thing about CBT is that it's highly applicable to multiple conditions. Of course, we'll be focusing on patients with substance use disorders today. So let's talk a little bit about CBT and substance use treatment. It's well known across the research that CBT is considered an evidence-based practice. A few articles to note, just to highlight specifically the use of CBT with substance use treatment. For example, one study found that when examining substance use frequency and quantity, the combination of evidence-based therapies and MAT pharmacotherapy produced better outcomes than MAT in addition to usual clinical management or nonspecific therapy. So essentially, incorporating these specific interventions from a CBT lens produced better outcomes. And that's consistent across the research. CBT in conjunction with medication management is often referred to as the gold standard for creating behavioral health change. Another study through the VA found that CBT for substance use disorders training program that they were developing offered by the Veterans Administration observed statistically significant reductions in alcohol and drug use and improved quality of life for their participants over the course of treatment based on the questionnaires that they offered. One question that frequently comes up is what is CBT? CBT is a term that we often use in clinical settings, but it's true meaning and definition has certainly broadened over the years. Aaron Beck, based out of Philadelphia, is considered to be the founder of CBT. He practiced out of the University of Pennsylvania. And his daughter, Judy Beck, has largely carried forward his work through her work at the Beck Institute, which is also in Philadelphia. I'm a graduate of the Philadelphia College of Osteopathic Medicine, which is actually right across the street from the Beck Institute. So my program was very CBT focused and we were lovingly referred to as the farm team for the Beck Institute at times because our students would be involved in their trainings. And Judy Beck has developed a wonderful set of resources. The website is listed at the end of this presentation. The Beck Institute website offers several resources for practitioners and clients alike. So CBT has largely become an umbrella term at this point. It largely refers to a framework of interventions that are structured, repeatable, and applicable to multiple mental health and behavioral health conditions. The general premise of it is that we understand that our thoughts, emotions, and behaviors are all influenced by one another. And by targeting one of those three areas, we can make changes, either adaptive ones or understand maladaptive ones. Some research has also found that there is opportunities for increased flexibility with CBT to make it much more accessible across multiple modalities of communication. So for example, one such proposed style would be to be able to increase accessibility of CBT through digital access. And you might be aware that there are apps and different virtual options that individuals can access CBT tools. So at the core of this, I'd like to talk about some of the foundation upon which these CBT skills will be integrated. Motivational interviewing has certainly picked up speed over the last several years and its utility in the physician-patient dialogue. And so as I'm reviewing these CBT skills, I think it's really important for us to keep in mind essentially the spirit of motivational interviewing. So motivational interviewing at its core is very similar to a humanistic, almost Rogerian type of therapy approach, where it's very strengths-based. It's a collaborative style of communication. And at the core of it, we're looking to help our patients identify their values that underpin and enhance their motivation for behavior change. So for example, if an individual tells us that their family is the most important thing in the world to them, then that's a really important clue for us to keep in mind that when we are working in conversation to move toward behavior change, that pulling in the value of the family for this individual might be a motivating source for behavior change. So for example, if I'm willing to go to therapy to work on my addiction, how could that benefit my relationships with my family? Can I envision that addressing my substance use would allow me to be present with my children and allow me to spend time with my family in a meaningful way? We also use motivational interviewing to assess an individual's readiness and confidence related to making a change. So as we know in motivational interviewing, readiness and confidence are two very different things. And in motivational interviewing, we use a ruler or a numeric scale, typically from zero to 10, to assess a person's both readiness for making a behavior change and confidence in their ability to do so. So for example, how ready do you feel to start working toward addressing your addiction with that goal in mind of being able to be more present and actively involved with your family? Well, on a scale of zero to 10, I'd say I'm a nine out of 10. I feel very ready. And you might ask that person, great, what makes it a nine and not an eight? And that's really where that thought process, that underlying thought process can really be brought to the surface to understand what exactly it is that's motivating them so much in this moment to rate their readiness so high. And then following up with that, we might ask about their level of confidence in making this change. How confident do you feel at this point, a scale of zero to 10, that you can make this change in your life? And perhaps we get a different rating. Maybe they say, it's more like a four out of 10. Okay, what makes it a four out of 10? What makes it a four and not a three? Well, it makes it a four out of 10, because I've tried to do this before, and it hasn't worked for me. And I rate it as a four and not a three, because there's part of me that does believe that there might be some hope for me to make a lasting change this time if I can do it differently. So that's really where that change talk starts to become brought to the surface that we can help someone enhance their motivation for these changes. This presentation today isn't going to go very in depth with motivational interviewing necessarily, but I think it's important to highlight these basic premises of MI, because they do fit in really nicely with these cognitive behavioral skills. And MI is one of those areas that might be considered to be under the CBT umbrella as well. So there are four guiding processes across motivational interviewing. So keeping in mind that motivational interviewing is collaborative and patient-centered. And so we want to make sure that we're keeping in mind these four guiding principles. We're working to engage with the person in front of us, essentially approaching it in a collaborative way of, can we work on this together? We also want to stay focused on what our goal is and really be able to identify exactly what that shared goal is. If the provider's goal is different from the patient's goal, it's going to be difficult to engage in change talk. The next principle is evoke. So really eliciting information from our patient to understand what and why, what is most important to them and why is it important for them to make this behavior change. And then formulating a solid plan, a really concrete set of behaviors that both the physician and the patient agree upon that would move in the direction toward achieving this goal. We tend to take ownership of behavior changes that we come up with ourselves. It is much more meaningful for our patients to generate goals and sources of motivation in their own words, as opposed to in ours. Most people don't like being told what to do, but if it's something that we can formulate ourselves using our own words, it oftentimes will come from a much more genuine place and really feel as though it's something that we can essentially hang our hat on that feels genuine and real to us. So anytime we can guide our patient there, as opposed to telling them what to do, sometimes we get more buy-in for that. Now with that in mind, my work as a psychologist, I'm typically sitting with someone for 45 minutes to an hour and sometimes more. And a lot of times in a follow-up with their physician, we don't have the luxury of that time. So again, that's the reason why I'd like to share with you some CBT interventions that can be very quickly integrated into the conversation that you're already having. And it starts with the style of dialogue. Again, this is rooted in MI. So we want to consider the distinction between open versus closed-ended questions. Open-ended questions invite more dialogue, whereas closed-ended questions elicit brief and concrete responses. And both are needed, right? We know that if we're seeking more information from a person, it's better to present them with an open-ended question so that we can take in as much data as possible. But if our time is limited or we are staying focused on a very clear structure of where the follow-up is going, then closed-ended questions are useful in keeping us on track. So for example, an open-ended question might be, you know, so how do you see your relationships changing when you get sober? What do you think is the interaction between your substance use and your mental health? These types of questions are going to elicit a self-reflection. Whereas a closed-ended question, do you feel ready to stop using? It's a yes or no. Affirmations. So it's important for us to highlight areas of our patient's strengths. So this really underpins the strengths-based approach of MI and using these strengths to support areas that are in need of growth or change. You know, it's not uncommon for me to sit with someone who is dealing with low self-worth and low self-esteem. So if we're targeting the areas of weakness and someone already has within their mind that they have low capability to make these behavior changes, then sometimes taking this strengths-based perspective allows us to say, yes, but look at the skills that you do have and let's see if we can apply them in a way to lift you up in the areas where you're struggling. MI also relies upon reflections. So a simple reflection would be repeating or rephrasing back a key component of what our patient has said. Something like, okay, so you had three months of sobriety prior to your most recent relapse. It's essentially there to clarify and make sure that we're getting the information that we need. And it's also making sure that our patients feel heard and understood. A complex reflection can look like a lot of different ways, but its goal is to amplify what the patient has said, sometimes for the effect of them to get to a point where they say, okay, well, not that extreme. And this is where we start getting into some of the CBT aspects of this, of modifying language that we use to talk to ourselves and how that impacts our emotions and behaviors. So if my reflection to a patient is, so it sounds like you feel like you're never going to be able to stop using, and they say, well, okay, well, not quite. I mean, it's not that I don't think I'll never be able to stop using, it's just that I'm seeing barriers up against me right now. Great. So that's a much more balanced reflection and a balanced thought that takes out that extreme language. And so sometimes when we reflect back in a way that's almost more extreme than what our patient is describing, then their reflection will balance back that down to come up with a more balanced and realistic thought. And that's really the goal of CBT. In MI, we also offer summaries. And so when we're offering a summary, sometimes it's that we are collecting information. So we're bringing multiple points of data together for the patient. Sometimes we're offering summaries to link information. So we might be tying in new data and linking it back to a patient's previous point to help them make connections between their thoughts. And sometimes we use summaries for a transitional effect. So when we are keeping our goal in mind of where the follow-up is going, we can use a summarizing statement to essentially validate and close up the current topic and then lead into the next step, such as making a plan. So what keeps us stuck from making behavior changes? From a CBT lens, a lot of this, when we think about those three areas that influence each other based on the theoretical underpinnings of CBT, which are our thoughts, emotions, and behaviors all influence one another. So if we're stuck in a maladaptive behavior pattern, we want to look at the other two areas of that triad. Okay, so what's happening in our thoughts? What's happening in our emotions? So something that keeps us stuck is rigid thought patterns. So we might hear our patients say, or perhaps imply, that no matter what I do, I will never get better. Or this always happens to me. Or simply, I can't do this. And you can hear the rigidity in those statements. If you were to rate these statements on a scale of 0 to 100, of how much these statements really sit with a hard line, these are worded as 100% kind of statements, or 0% statements if you want to look at it that way. Really what we're looking to get to in CBT is the shades of gray, where there's balance in our thinking, where it's instead of, I can't do this, it might be just validating the emotion in the beginning to say, I'm scared I won't be able to do this. The other piece that often keeps us stuck are these self-defeating behavior patterns with a self-fulfilling quality of, see, I told you so. So a lot of times, we will do things that line up with the things that we already believe about ourselves. So if I believe that I can't do this, and then I engage in a self-defeating behavior pattern, then I've essentially proved myself right to be able to say, see, I told you so. I told you I wouldn't be able to do this, and look at what happened. And as uncomfortable as that is, sometimes it can feel familiar to us. If that's what we walk around believing about ourselves, then when our behavior matches, we at least feel that there's this quality of predictability to it, that we know what's going to happen. Whereas sometimes, making a behavior change can be really scary for people, especially when that behavior pattern of adaptive and healthy change essentially disproves their beliefs about themselves. It creates, at times, cognitive dissonance for people, this kind of internal sense of discomfort where their beliefs about themselves don't match with what they're observing. There are a couple of key areas that can keep us in this self-fulfilling, self-defeating behavior pattern. So behaviors like avoidance, isolation, and of course, self-sabotage can keep us stuck in these self-defeating behavior patterns, and we certainly see that commonly with addiction. So skill one, conceptualizing core beliefs through the cognitive triangle. I'm going to show you a map of what the thoughts, emotions, and behaviors look like to better illustrate this for you. So keeping in mind that our thoughts in a CBT conceptualization don't come out of thin air. They come from our underlying core beliefs, and beliefs inform the way we make sense of situations, relationships, and ourselves. And by understanding or at least having an inkling of what our patients might believe about themselves at their core, it can allow us to start listening for statements that seem to fit with that maladaptive core belief. A core belief isn't something that a patient might outwardly express or perhaps even have the language to pinpoint, but we might hear of it more in terms of the themes of their thoughts. So at their core, if our patient believes, I'm a failure, then they might not come out and say to us, I am a failure, but their reflections and their interpretations of how they're doing will likely reflect that to us. Or I can't trust anyone. They might come out and say that to us. They might not, but it might be more readily observable in their reflections or even in their behaviors towards us and others. This is the CBT triangle. So essentially what this is demonstrating is that we start with the core belief, and that core belief is going to inform the thoughts we have on a regular basis. And those thoughts, emotions, and behaviors are all going to influence one another. So if I believe that I'm worthless and I think about myself in that way, then that's going to shape the thoughts that I have on a regular basis. It's going to shape my interpretations of events. So if I believe that I am worthless and I go to a meeting, I might be very acutely aware about little nuances in my interactions with others, and that will likely shape my interpretation of whether or not I'm feeling valued and accepted. And so if I conclude that the people in this room are judging me or they don't feel that I have anything valuable to contribute, then that's certainly going to affect the way I feel about myself. And it's certainly going to affect my emotions and likely bring up some distressing ones. And as a result, I'm likely going to engage in behaviors that align with this. Even if my interpretations of the situation might not be accurate, I'm likely to isolate, I'm likely to become socially withdrawn during the meeting, and I'm also likely to leave without engaging with anyone afterwards. Let's look at an example of this. So let's say your patient's core belief is I'm broken, and they show up at your office, and they're saying to you, there's no point in trying to get to my appointments, I'm going to fail anyway. What emotions are likely coming up for your patient? They're likely experiencing shame, perhaps frustration. And this is just an example, you might have to ask them directly. And as a result of thinking and feeling this way, we might notice that they're starting to miss appointments, or they're engaging in other pre relapse behaviors. The idea here is keeping this structure in mind of this connection between thoughts, emotions and behaviors so we can start exploring this with them in our dialogue. So this might help us to pinpoint in conversation, you know, I've noticed that you've missed some appointments. And you had mentioned that you don't feel like there's any point in trying to get there. It seems like there might be this part of you that maybe believes that you wouldn't be able to get sober, or you're too far into your addiction process to get better. Is that accurate? And it's okay for us to take a gentle guess at some of these things just to open up that dialogue. Again, it becomes an open ended question for them then to engage in some reflection and help us to start engaging our patients in problem solving. Let's look at another skill, identifying cognitive distortions. This is one to quickly grab onto in the course of an appointment because we can listen for some key words that our patients might be using that would let us know that they're engaging in distorted thinking. Once we know that our patients are engaging in distorted thinking, that's our clue to offer some quick dialogue based interventions. So here are some words to look for. Cognitive distortions have a few key qualities. They're rigid. They're often all or none type of thinking. And sometimes they contain what I like to refer to as these red flag words. So just things to pick up on. Always, never, every time, nobody, everyone, should, must, and have to. These types of wording that we might use in conversation are ones that should at least start to send up this little red flag for us that our patient might be engaging in some distorted thinking that will ultimately have a negative impact on their emotions and behaviors. Sometimes our patients will directly state these types of words and sometimes they're implied. So we want to listen if there might be what I like to refer to as like a hidden should. They maybe didn't use the word should in their sentence, but it certainly implied that there is this internal expectation being placed on themselves. So when we hear this, how do we respond? So our goal here is to help our patients develop some cognitive flexibility. What we understand about CBT is that cognitive flexibility is one of the most important skills to develop overall through the use of several of these interventions to help us move toward behavior change and manage mental health in an effective manner. So moving, for example, from rigid thinking to more flexible thinking is really where we see progress happen. This is certainly true for mental health conditions like anxiety and depression, where rigid thinking is really at the core of the way we think about ourselves when we're experiencing these symptoms. So the goal here is for us to help our patients reframe these distorted thoughts into something that's still genuine for them, but is also more helpful and more adaptive. And there's a few quick strategies that we can apply that I'm going to go over, such as rating the validity of thoughts, using an ABC technique, and examining evidence. Sometimes just catching the cognitive distortion is enough. If you think about your MI skills, just repeating back a statement like that in a summary to a patient is sometimes enough for them to hear it themselves when it's said by someone else of where that distortion might be. Sometimes just as we're using our own language, we might not catch ourselves in it until it's reflected back to us. So skill number three, identifying balanced cognitions through a validity rating scale. This is one of my favorites to use because I find it to be one that's really easy to integrate into conversation. And what I believe you'll notice is that there are similarities between a validity rating scale and a confidence and readiness ruler with motivational interviewing. So basically the way we use validity rating is when you catch your patient engaging in a distorted cognition. So if they say, I'm never going to get better, you might ask them on a scale of zero to 10, how accurate is that statement? And let's say that zero is, it's totally inaccurate. It's totally false to say that about yourself. And let's say that 10 is completely true. So on a scale of zero to 10, how would you rate that statement? You just made that you're never going to get better. And maybe your patient says, I'd say it's about an eight. And you're going to ask what makes it an eight? And they're likely going to tell you their rationale for that. And they'll give you probably reasons as to why they don't believe they're going to get better. They might cite likely past experiences that they've had or past failures that have come up in their perception, or it might even be things that others have said to them. My mom always said that she didn't believe I would be able to get through this. She always said that she didn't think I'd get sober, or I've tried to get sober before and I've relapsed so many times. That's why I rated it an eight out of 10. The next question we want to ask them then is, and this is where the confidence ruler comes in, why do you think you're going to get better? This is where the confidence ruler comes in. Why didn't you rate it higher? What makes it an eight and not a nine or even a 10? And that space in between their response and a 10 out of 10 is where a healthy thought is hiding underneath. And this question is designed to help our patient access that adaptive thought. Let's take a look at an example of this and what it looks like in dialogue. So let's say that you're talking to your patient and you ask them about their support system and your patient says, I don't have anyone in my support system. So there's a couple of clues here that there might potentially be some distortion going on. Don't is the first word. I do not. So there's that potentially rigid quality there. And anyone, again, potentially rigid. We don't want to invalidate that this is how our patient feels. We can stick with that about how that feels emotionally. And we don't want to deny them of their own reality of this, if that's their perception. But we do want to take a gentle and a cure and curious approach to breaking down that statement a little further. I'm a big fan of asking permission in these kinds of dialogues. You know, especially if we want to look at this through a trauma sensitive lens. A lot of times at the core of trauma is that control has been taken from someone. So anytime we're working on collaborating with a patient, if we can ask for their permission, that will sometimes open the door to helping our patient feel as though they are truly collaborating with us rather than being told what to do. So anytime we can ask for permission is usually, I shouldn't even say usually, it can be a helpful way to open the door to this type of dialogue. So let's say we say to them, can we look at that a little closer? On a scale of zero to 10, with zero being totally false and 10 being totally true, how accurate is it to say that you don't have anyone in your support system, that you truly, and you might even exaggerate it a little bit as we saw in the MI reflections, we might offer it as a complex reflection. And not even by changing the words necessarily that they use, but perhaps it's the emphasis that we put on our own words. How accurate is it to say that you do not have anyone in your support system? And let's say our patient says, it's pretty accurate. I'd say it's probably a nine out of 10. And instead of invalidating that or trying to dispute it with them, we're just going to stay curious. What makes it a nine? And this is going to open up our patients to give us an explanation for their response. Well, here's why I rated it a nine. I feel alone. My partner just left and my family won't let me live with them because they say that they still don't trust me even though I agreed to come here today. So the example of a response I gave is just an example, of course. There's a lot of opportunities in this patient's response for us to validate how they're feeling because we know, regardless of the statements that they're giving us, that the emotions are valid. You know, very similarly, we'll say, you know, feelings aren't facts, right? Feelings aren't facts, but feelings are valid. So we might validate that and say, yeah, I can understand why you'd feel really alone right now and really frustrated probably too, that you feel like you're putting in this work and yet the trust still isn't built yet and that must be really frustrating. And along with that, we might say something to them like, that makes sense why you would rate it that high. And then this is the part where we'd get curious, why didn't you rate it higher? Why isn't it a 10 out of 10? And again, this space in between our patient's rating of nine and the highest rating of a 10 is where that change talk can happen. So our patient reflects to us, I guess a 10 would have been too extreme. I had some contacts and contacts from the rooms, but I've been out of touch with them for a while. So this should start jogging our own planning process of where we can go with this. She is essentially letting us know that at some point she did have additional members in her support system within the recovery community. So with her permission, we might want to look at a goal of increasing supports for her right now, especially knowing what's going on in her personal life. Let's say that just as an alternative, let's say that she rated it a 10 out of 10 though. Let's say that she said it's totally accurate. It's absolutely accurate to say 10 out of 10. I don't have anyone. I'm not exaggerating when I say that. We still want to go through the same process of, we're just not asking why she didn't rate it higher necessarily. Instead, we're still going to validate the emotion and still engage in problem solving with her. Let's take a look at where there might be some opportunities for us to increase your support. Because if you think of this from the perspective of that cognitive triangle, thoughts, emotions, and behaviors, we can make changes in a positive direction on any of those areas by targeting one of the corners. So in this case, okay, the thoughts, the thoughts are very distressing for her, and she's saying that they're valid. And as a result, the emotions are high. So what do we have access to? Let's look at the behaviors. If we can make some of those behavior changes, even if it's just giving her the opportunity to engage with some others in the recovery community who might become supports for her, we could start giving her additional data points to then speak back to those thoughts and say, you know what? Yeah, my support system is really limited right now. And I'm not going to be able to do that. Let's look at another skill, reframing using the ABC worksheet. So ABC in cognitive behavior therapy stands for activating event, belief, and consequences. This is considered a core CBT skill. This is one that several modalities that would fall under that CBT umbrella really start with. And this is a worksheet that might not necessarily be realistic for you to use in an abbreviated follow-up, but it's important, I believe, for practitioners to be familiar with this worksheet because if your patient is working with a CBT therapist in conjunction to their medical appointments, it is likely that at some point or another, they have used an ABC worksheet or are at least engaging in dialogue that reflects the ABC worksheet. So again, you can choose to use the worksheet if you have time, but you can also integrate it into your dialogue. So an ABC worksheet looks like this. We have an activating event. So we have an event that prompts the activation of a core belief. So something happens. And as a result of that thing happening, we go to that core belief that gets kicked up for us and causes us distressing thoughts and emotions as a result. So something happens, and we make meaning of that event and interpret its outcomes through the lens of our core beliefs. So essentially, we tell ourselves something. And we tend to avoid any cognitive dissonance. So what I mean by that is the things we tell ourselves are going to match up with our core belief. We're going to try to make it fit. So for example, if the activating event is my partner leaves and my core belief is everyone will leave me, then that's probably similar to what I'm going to be telling myself about the meaning of this event. I might be saying to myself, it was only a matter of time before he left because I'm not good enough. And we tend to avoid making statements to ourselves that would suggest that our core belief isn't accurate, because it's not how we make sense of the world. So if I believe that people will always leave me, my first thought is probably not, you know, this was probably more about him and what he needed than it is about me. That's likely not going to be my first thought. So as a result of the meaning making that we create from the events that happen, we're going to see some consequences. And when we say consequences, we're not talking about any sort of punishment. What we're talking about is what are the consequences of thinking this way. So we're going to go back to that cognitive triangle. And we're going to look at what emotions and behaviors come up. So as a result of the meaning making that I'm engaging in, we're likely to feel heightened distress, and we're more likely to engage in unhealthy or self defeating behaviors. This map, if you look at it in a linear fashion, doesn't necessarily reflect the way we often experience our thoughts and emotions to occur. A lot of times, people will feel as though something happens, and I immediately feel something about that. This horrible thing happened, and right away, I was angry. From a CBT theory perspective, even though that happens so quickly, where we go from activating event to emotion, the theory here is that even if it's just a split second, we formulate some kind of meaning making that prompts us then to react in the way that we do. So the idea of a patient doing an ABC worksheet is this idea of slowing down this process so that we can reflect back on our reactions to events to say, okay, what led me to that reaction? Yes, the event was awful. And what was I telling myself that informed the way I responded? The idea here is by engaging in this form of self-reflection, we can start modifying the way we talk to ourselves and be able to start implementing more adaptive behaviors to help us stay on track when things happen. So let's look at the goals of this. So what's the goal of identifying and activating event? This is the reason I wanted to highlight this is because sometimes we feel a certain way, and we don't necessarily know where it started from. If any of you are familiar with the behavior chain analysis that's used in dialectical behavior therapy, again, which is under the CBT umbrella, we often use that to help our clients trace back to their trigger and the things that may have made them more vulnerable to reacting to that trigger. So it's the same kind of idea here. So we're tracing back our emotion or behavior to what the triggering experience was. What's the goal of identifying our beliefs? The goal is to understand the way we talk to ourselves. This is not something, and I hear people tell me this all the time, this is not something that we're taught in school. We're not taught how to self-examine our own thoughts. So we're really thinking about our own thoughts. We're using metacognition. So our goal for understanding and writing down our beliefs or internal dialogue related to an activating event is to understand the way we talk to ourselves and to identify themes in our thinking. So some folks can readily identify their core beliefs. Oh, yes. I have always believed that I was a failure, and that seems to have guided me through lots of different chapters of my life. But it might not be readily accessible to others. So sometimes by engaging in this process, it can help a person to really start identifying themes in their thinking. And once we start identifying those themes, it can help us get to that core belief. Some practitioners will start with the core belief and work upward to the automatic thoughts that we experience on a regular basis. So they might start out by working with the patient to say, okay, let's understand where your core beliefs might be. And that might be the focus. And then once those are identified, okay, let's see where those core beliefs then apply to your day-to-day thoughts. Other practitioners of CBT do the opposite. For themes and patterns and essentially boil down into the core belief. The other goal of the beliefs column is to identify thoughts that we can challenge or modify. So you'll see when we start applying the ABC worksheet, how we start integrating the other CBT skills into this. The consequences column, the goal of it is to understand the influence of our thoughts on our emotions and behaviors. So to really map out clearly, huh, as a result of thinking this way, this is how I reacted both emotionally and behaviorally. And to even entertain the possibility that had I been able to think about this more clearly, it might've changed my emotions and behaviors. I might still have been upset, but I might've been able to stay within the lane of healthy and adaptive responses, despite how I was feeling. The other goal is to work on identifying healthier responses for future circumstances. Now I have this awareness that it might be my automatic reaction to lash out or isolate or use in response to this kind of situation. And now that I know that about myself, I can start planning ahead for what I'd like to do differently if it happens again. So let's look at an example of how someone might complete this. Let's say their activating event was that they called their sponsor and they didn't answer the phone. As a result of this event, what were they telling themselves? So in the beliefs column, they've written, I'm not a priority. I'm not going to be able to stay sober, and I can't rely on anyone. And as a result of thinking that way, the consequences of those beliefs were feeling rejected, lonely, and scared. And behaviorally, this person isolated, ruminated, and they identified that they engaged in some mind reading. So assuming that they knew what their sponsor was thinking and future tripping. And they also wrote down that they engaged in binge eating. You'll notice that in the beliefs column, there are the validity rating scales that we went over earlier. So you'll see that there's a question written at the bottom where it says, number one, rate the validity of your thoughts in column B. So this is a scale that we already have gone over. On a scale of zero to 10, how accurate is this statement? So after the patient has gone through and completed each one of the columns, they've then been prompted to ask themselves, how accurate is each of those? So let's go back. I'm not a priority. I'm going to rate it a five out of 10. I'm not going to be able to stay sober. Seven out of 10. And I can't rely on anyone. Three out of 10. The next question is really important. It says, what is something more adaptive and balanced? You can tell yourself next time. It's really important to do the validity ratings first. It's difficult to come up with something more helpful and adaptive before identifying some of the distorted thinking in each one of the beliefs we wrote down. So once this person has had an opportunity to reflect and note that these beliefs are not 10 out of 10s, even though in the moment they probably felt that way, rating them back after this has happened and having an opportunity to self-reflect leads to the statement at the bottom where it says, I know my sponsor has other responsibilities, and it doesn't mean that they don't care about me or that I'm not important. I jumped to these conclusions because I'm terrified of relapsing again. Great. That's something that we can work with. So, keeping in mind that an ABC worksheet might not be realistic for the time constraints of a follow-up, let's look at how this might flow in a physician-patient dialogue. So your patient comes in, and they are experiencing, let's even say, the same example that we went over. And they are experiencing, let's even say, the same example that we went over, where they're telling you that they don't feel like they're going to be able to stay sober, and that their sponsor doesn't care about them. And they tried to call them the other day. They didn't answer the phone. They were really struggling. So you might ask them, so what triggered you? And you might just be keeping in mind at this point, the flow of the ABC worksheet, even though you're not doing it in this particular follow-up. What do you think triggered you? And your patient might say, I know it was that my sponsor didn't answer. I really needed someone at that time. And the fact that she didn't answer really upset me. And you might say, yeah, so what sort of things were you telling yourself about this? And if they're not really sure how to answer that, you might ask them alternatively, what did that mean to you that she didn't answer? How did you interpret that? And that's where you might then get to the beliefs. So your patient might say, well, it meant to me that I must not be a priority to her. And I jumped right to the fear that I'm not going to be able to stay sober. And it's hard enough for me to trust people. And so the fact that I called for help and she didn't answer, just made me feel like I can't rely on people. Now you have the beliefs from column B. And as a result of thinking that way, you might ask her then, what emotions were you struggling with at that point? How'd you feel? And she's likely going to tell you that she was feeling rejected. She was lonely. She was scared. She was frustrated. She feels like she did what she was supposed to do in a moment in which she needed support and it didn't pan out. And you might say, was there anything you did to try to deal with that feeling, even if it was healthy or unhealthy? And that's when you might be able to start engaging her in conversation of, yeah, I isolated myself. I just went home, locked the door, turned down the shades and just shut everybody out. It's not even worth it for me to try. I ruminated. And she might not use the word ruminate, perhaps maybe she will, but she might say, I was going over and over in my mind about what I must've done that could have upset my sponsor and why she wouldn't have answered the phone. And I started worrying about the future and how I was ever going to stay sober without having enough support. And then I binge ate because I was just trying to numb myself and I was really trying not to use. So I substituted one addiction for another at that point. So it's up to us in this type of dialogue to keep in mind what kind of beliefs that she gave us so that you can then ask that first question there at the bottom. So on a scale of zero to 10, looking back on it now, as we're sitting here now, we know, and you can even validate for, we know that at the time that this happened, it felt like a 10 out of 10, right? It felt like a 10 out of 10, that you were not a priority, that you were never going to be able to stay sober and that you can't rely on anyone. Again, we're using some of that exaggerated inflection in our voice to really highlight where those cognitive distortions might be in her thinking. So as you look at it now, as we sit here today, how accurate were your thoughts? Like scale of zero to 10, were those accurate? And let's say she gives you similar ratings where she's saying, huh, about a five out of 10, seven out of 10. Great. What made it a seven out of 10 and not a 10 out of 10? And that's where she, now you're back in the validity scale intervention where she's giving you a rationale for why she didn't rate it higher. And that's likely where her more adaptive belief is going to be sitting. That's essentially your answer to number two. Is there something you would have wanted to do differently? What do you think you need to remind yourself about if something like this ever happened again? And she might be able to say to you, you know, I know it's that my sponsor doesn't care about me. I know she's got other stuff going on. I absolutely jumped to the conclusion that it was something defective about me, but I know that that's not true, even though that's how I feel. And I'm just really scared right now. Okay. What can we tell ourselves in the future if this happens again? Because we know that something like that could happen again, where we reach out for help and someone's not available. And it doesn't necessarily mean that they are trying to reject us. So what now that we're sitting here, what would you think might be helpful to tell that part of yourself if this were to come up again? Last skill I'd like to show you is checking the facts by examining the evidence. This is another one that I'm going to show you as a worksheet format, but that can absolutely be integrated into dialogue. So examining the evidence. When we examine the evidence, we first identify a distorted thought and we're going to approach our patient again, gently and curiously and saying, what's your evidence for that? What makes that, what data do you have that would say that that's true? And we're going to let them explain exactly why it feels true to say that. And we can validate that. And then we're going to ask them, what evidence do you have against that? Is there anything that would suggest that that's not true? When you do this as a worksheet, some folks, when they start practicing it, feel as though they have to have the same number of data points on either side in their evidence for column and in their evidence against column. But that's not true. The columns don't need to be even or counterbalanced in order for this to be effective. Really, all we need is one piece of data against this statement to be able to rephrase it in a way that's more balanced. Once your patient has been able to identify evidence for their distorted thought and a piece of evidence against it or more, and you might be able to help them with this too, depending on how well you know them. If you are aware of a data point that goes against what they're saying, we'd want to ask them, based on all this information, when you look at all this together, because there's facts on both sides of this, is it still accurate to say this to yourself? What might be more accurate and more helpful? So let's look at a worksheet example of this. So let's say the distorted thought is, I'm going to fail. And we say to our patient, what's your evidence that you're going to fail? And she says, I've relapsed so many times. I don't even have a car to get to my appointments. My family is always telling me that they don't believe I'll stay sober. And I've failed at lots of things before. I've failed at sobriety before. I failed at school. I lost my job. And then you ask her, okay, yeah, all those things are true. We can't dispute that. Yes, those things happened. But is there anything that you haven't failed at? Is maybe a way to word it. Sometimes, again, we have to use that, almost that kind of exaggerated language to parrot back so that our patient can hear where the distortion might be. And maybe you help her come up with that she can't predict the future. And this might happen in dialogue. Yeah, that happened before. But who's to say that that has to happen again? Okay, I can't predict the future. That's true. And well, you did get here today, though. So how'd you get here today? Well, I did find transportation to get here. I was able to have a friend drive me. Or I found that the bus route was pretty easy for me to get to today. Or maybe it was really difficult to get to. But I was motivated enough to come that I made it work. And you might even want to remind her, yeah, okay, so you've relapsed. But that would also suggest that you've had some sober time before, right? Yeah, I've had sober time in the past. And you might need to remind her, didn't you tell me you got your GED? Weren't you just telling me that you just got a new job? It's oftentimes hard for us. And this goes for anyone, not just our patients. It's hard for us to identify the evidence against our own thoughts. Because we tend to filter our experiences through the things that we believe about ourselves. So if we believe at our core, that we're a failure, and we're telling ourselves, I'm going to fail, then evidence that doesn't fit with that, or experiences that don't validate that aren't ones that are often in the forefront of our minds. So having someone who can remind us can be really important in order to get some evidence on the against side. I counterbalance these just to show you what dialogue can look like. But again, you only need to come up with one thing. So even if all you know, is that your patient had some sober time in the past, we're good, we can we can use this as a tool. So what's this look like in dialogue? Let's say your patient says to you, I'm a failure. And you say, again, the permission granting, can we look at that a little closer? What evidence do you have that you're going to fail? What are the facts? And she says, I've relapsed several times already, it's hard for me to get transportation and meetings and appointments. I failed at school sobriety. And you say, well, what about the other side of that? Do you have any facts that would suggest that you don't fail all the time at everything? And that exaggeration might prompt some dialogue and some reflection. Well, no, I haven't failed at everything. I've been sober before. I had my own place and a job. I've sponsored some people. And you say, yeah, you're right. Living sober, sponsoring people and having your own place and a job that doesn't really fit with your belief of being a failure. So again, it's that kind of curious mentality where now we're reflecting back to her. Well, all these things that you just mentioned really don't add up with the way you're talking to yourself. So how do we make sense of this? And what she's responding with is a genuine reflection of the uncomfortable emotion. It's just that I'm so ashamed of the things that are happening in my life right now. We can work with that. We can validate that it's real. So we might be thinking to ourselves, okay, that's a more realistic statement. There's places we can go with that from here. We can validate, offer support and encouragement. We might be able to explore her values and sources of motivation to help her make some healthy changes right now. Something small and achievable, of course. So those are your five skills to integrate into appointments as you see fit. We went over a few things. We went over the cognitive triangle and understanding the relationship between thoughts, emotions, and behaviors, understanding that we can target any one of those three corners to positively influence the other tail. We went over recognizing cognitive distortions and the language that we can listen for for opportunities to apply CBT skills. We went over using a validity rating scale to challenge distorted thoughts and find underlying adaptive beliefs. We also reviewed an ABC worksheet as a way to guide dialogue on distressing thoughts and emotions and behaviors, identify triggering events, and start to engage our patients in problem solving and adaptive planning. And lastly, we also looked at examining the evidence to support our patients in reframing distorted thinking. Here are some resources. As I mentioned in the beginning, the Beck Institute has some great resources for students, professionals, and individuals. Their website is listed here at the bottom. Thank you so much for your time.

cognitive behavior therapy

CBT skills

healthcare providers

patient-physician dialogues

mental health conditions

substance use treatment

medication management

motivational interviewing

cognitive distortions

collaborative communication