Utilizing Cognitive Behavioral Therapy

David Condos: Hello and welcome to this episode of Recovery Unscripted, a podcast powered by Foundations Recovery Network. I’m David Condos, and my guest today is Lori Ryland, CEO of Skywood Recovery, a residential program for co-occurring addiction and mental health disorders in Michigan. She joined me at the Innovations in Recovery Conference in San Diego to demystify the components of Cognitive Behavioral Therapy and to explain how our experiences, our perceptions, and our biochemistry all interact and change the way we see ourselves and the world.

She also shares how she works with the governor of Michigan to raise awareness about human trafficking, and to improve the way we heal the unique trauma and addiction issues that affect the victims. Now, here’s Lori.

I’m here with Lori Ryland. Thank you so much for being with us.

Lori Ryland: Well, thank you for inviting me.

David: Yes, of course. Let’s start off by having you tell us a bit about your own personal story and the journey you took to start serving in the world of recovery.

Lori: I completed my PhD in clinical psychology in 2000. I’ve been very fortunate to have had some of the amazing experiences in my career. My dissertation research was Examining Anger Management Protocols Within Inmate Populations. I also had experience in the VA system, working with combat and sexual trauma PTSD in the military.

David: Wow, some really interesting patient populations.

Lori: Yes, exactly. I am certified as an Advanced Alcohol and Drug Counselor. Also, I’m board certified as a behavior analyst, and I’ve had expertise in treating autism as well.

David: Really? What does a behavior analyst do exactly?

Lori: Behavior analysis is a modality that looks at specific behavior and how to impact behavior change. You’re either trying to increase behaviors that you want to see more of or decrease behaviors you want to less of.

David: Yes. Then, how did you get into more specifically like this road with addiction treatment?

Lori: I started out in more community mental health settings, and worked a lot in a rural population. In rural community mental health, you tend to treat everybody because you tend to be the only game in town. Being one of the few PhD licensed psychologists in the county, I was involved in a lot of the evaluations for crisis and then emergency departments and working with the jails, trying to figure out how to reduce violent behaviors or self-injury.

David: What part of the country was this in?

Lori: In Michigan. I’ve worked in Michigan in my entire career.

David: Then eventually you started working at Skywood, could you tell us a little more about how you got connected with Skywood specifically and what you started doing there?

Lori: It was fascinating, David, because I wasn’t even looking for a job. I was really enjoying my work. One day, I was contacted through LinkedIn, through Foundations Recovery Network and wanted to talk more about what foundations was doing. I had those conversations and was just blown away by the integrity of the organization, the attention to implementing evidence-based treatment, as well as the commitment to research and education in the field prediction.

David: This was maybe a couple of years ago, and so Skywood is not that old. It was kind of Skywood was starting?

Lori: That’s exactly right. I was actually hired to be the clinical director and to build the program. Then a year later, became the CEO.

David: Could you tell us a little bit more about what that entails, like a day to day basis. I’m sure a bit of everything.

Lori: It does, and I’m very, still very involved in the program itself. We work very diligently to make sure that the patients get that treatment that they need. That treatment needs to consider not only the addiction issue and how to help them navigate the addiction issue and get into recovery, but also any co-occurring mental health issues that may be there, as well as physical health. It’s not uncommon for an individual to come to our facility who has physical health issues that either they have not been treating well, or that they didn’t even know they had.

We do an integrated treatment approach that’s individualized to what that patient needs. We want to make sure that by the time that person discharges from Skywood, they’re in the best condition they possibly can be and to be successful.

David: You have been appointed by the governor of Michigan to the Human Trafficking Health Advisory Board, and that’s something you’re currently still doing, right?

Lori: That is, and this is my third governor appointment. I’m the psychologist appointment on the board. Our role is to not only review legislation and provide consultation, but to ensure that there is a plan in Michigan for addressing human trafficking. Human trafficking in Michigan is a significant issue in comparison to other states.

David: Really?

Lori: Our proximity to Canada and the water ways makes it a significant challenge in Michigan.

David: As far as transporting people?

Lori: Exactly. We’re not just talking about sex trafficking and forced prostitution, but also labor trafficking is an issue. Making sure that we have the proper process in place to not only increase awareness so that we can identify human trafficking, but also making sure that the services are in place for someone once we’ve identified that they are a survivor of human trafficking.

David: Right, and not just to leave it up to say like, “Oh, well, law enforcement will take care of it or someone else will take care of it,” but really have an overarching plan.

Lori: Exactly.

David: What are some of the challenges that you see in that role, not only putting a stop to human trafficking and raising awareness, but also then reaching the victims? Like you said, having a place for them to go so they are not dropped off?

Lori: We’re doing a much better job with awareness. We have legislation to increase required training for different professionals like pharmacists and medical providers. Identification has resulted in an increase in the reporting of human trafficking when it’s found.

David: You are training them to identify science of someone who’s a victim?

Lori: Exactly. The challenges that I see in Michigan, and I’m sure elsewhere, include the awareness for the need for treatment for trauma because trauma is a significant part of human trafficking. Also, the lack of awareness of how addiction fits into a human trafficking case.

David: Really?

Lori: It is extremely common for a survivor of human trafficking to also be addicted. That’s one of the parts, the pieces in which the trafficker keeps them.

David: That’s what made them vulnerable to be in that position?

Lori: That’s exactly right. One type of scenario that is very tragic but happens, is you might have a teenage girl struggling at home, not feeling connected to her family, a lot of chaos in her family. Much older male connects with her, makes her feel safe, makes her promises, “Come stay with me.” And she leaves her home thinking that they have a relationship. Then before she knows it, she’s involved in a human trafficking scenario. With the instances of trauma associated with that, there’s a higher risk of addiction, and then it makes it very difficult for that human trafficking survivor to get well.

I’m not seeing a significant awareness in that connection with addiction, and I think that that really needs to be addressed.

David: Yes. Could you say a little bit about how Skywood would approach or does approach helping patients who have experienced that type of trauma and everything that goes into being a victim like that.

Lori: I mentioned earlier, we have the Seeking Safety Program.

David: What is that? What does that mean exactly, that program?

Lori: The Seeking Safety group is a weekly group. It helps an individual learn how to be present, because when any one of us experiences fear, every part of our body is telling us to escape or avoid. You might have someone who is triggered and has something happen and that trigger their fear, their anxiety, and they want to leave the room. They want to go and hide and detach and remove in themselves. That trigger could be anything. It could be a specific type of vehicle that they had associated with the trafficker or someone that they are afraid of. It could be a maintenance person locking down the hallway clinging their keys. If someone had been locked away or had chains clanging or something like that, that sound or a smell or a site or something like that can trigger a significant reaction. The Seeking Safety program helps a person learn how to be here and how to remain engaged in treatment.

David: At our conference in Nashville, Innovations in Behavioral Healthcare, you gave a presentation about using Cognitive Behavioral Therapy, or CBT, to treat the whole person. First, could you introduce us to some of the basic principles of CBT and the cognitive model?

Lori: Sure. Cognitive Behavior Therapy is actually an umbrella of therapies, such as Dialectical Behavior Therapy, Acceptance and Commitment Therapy, systematic desensitization, trauma-focused CBT. The basic principles of CBT include this issue that how we think, feel and behave all influence each other in a significant way, and that our beliefs about ourselves and our perception of situations can influence our experiences. Let’s talk about an analogy that I like to use when describing CBT. Let’s assume that you and I are waiting in line to get in on a roller coaster ride.

You’re really excited about that roller coaster. You can’t wait. You’ve been waiting all summer. I’m terrified about the ride. We get on the roller coaster, we experience this ride and our body, our physiology is actually very similar.

David: We’re both doing the same thing?

Lori: Exactly. Our body is responding in many of the same ways, and many of the chemicals of our body may look the same. Our interpretations are going to be very, very different. You’re going to interpret your feeling as excitement. I’m going to interpret mine as terror.

David: Interesting. Yes.

Lori: Important thing to keep in mind is, we’re on the same ride. Our experience is essentially and functionally the same. The point is, is how we interpret and perceive can be very, very different based upon what we bring to the table, and life is like that. We go about our day, we have different experiences, we have different thoughts that we tell ourselves. If one has a thought, “Everybody hates me.” they’re going to behave in a different way than someone who has the thought, “I’m competent and I can handle the situation.”

We may actually look different.

Someone who has these interpretations or these thoughts, “Everybody hates me.” may not look very approachable. Everyone leaves that person alone.

David: They become self-fulfilling.

Lori: That’s right. That validates this person sees nobody is talking to me because everybody hates me when in fact that person doesn’t appear very open to being approached. CBT is this treatment that incorporates this idea that we have beliefs about ourselves, we have beliefs about the world, we have perceptions, and how you can actually impact those to improve the way you view the world and how you approach situations.

David: Yes. Could you give some examples of some specific conditions that CBT has been showed to help heal and how that works.

Lori: CBT has been shown to be effective not only with addictive disorders, but also anxiety and depression, personality disorders, eating disorders, marital issues, and also it’s been shown to be effective and utilized more and more in chronic medical conditions. Improving conditions such as irritable bowel syndrome, pain issues, migraines, insomnia. In fact, there was a study not too long ago in the United Kingdom looking at CBT helping to reduce the likelihood of a second heart attack. Just about any condition you think of, you could google CBT and that condition and you’ll find an article about it.

It’s really that utilized.

David: At Skywood, what does it look like to implement some of these CBT elements within a patient’s treatment plan there?

Lori: Many of our therapists employed at Skywood are trained on CBT. They utilize various forms in their individual therapy. For a patient attending a program at Skywood, they’ll have an individual therapist and they’ll have individual therapy a couple of times a week. They’ll also have process group with their individual therapist four times a week. Then they have evidence-based groups and also psycho-educational groups. Each individual has their individualized treatment plan, so they would come in and say, “Okay, here are the things that I’m struggling with, that I would really like your help with.”

They would develop, with their therapist, individualized goals to address those. Then one key piece of CBT is that you’re doing a lot of homework. Homework isn’t a handout. I think that some therapists overuse handouts. Homework is basically an opportunity to practice what you’ve learnt that day. I have one example of someone that I worked with many, many years ago. She came into treatment and her head relapsed. She was really struggling getting back on track, and we were doing CBT therapy with her.

In the end, I said, “What do you think your homework assignment should be?” Because CBT is very collaborative. She said, “Well, I know I need to go to a meeting. I need to go a night meeting.” I’m like, “Great. That’s awesome idea, wonderful.” I said, “How likely are you to go to a meeting, from 0 being there’s no way, to 10 being consider to me there?” She said, “I don’t know, maybe a four.” I’m like, “Uh.”

One thing about CBT though is, when someone says a four when you really wanted it to be an eight or a nine, your immediate assumption is that this is just the wrong assignment. That’s all. Because it has this re-enforcement model in it. I need to be able to have an assignment for that person that they can be successful with. I don’t want to give them something that they can’t complete. We negotiated for a few minutes and she decided that what she knew she could do was go home, get the paper on the counter and circle the meetings she might go to one day. That was like a 10. She’s like, “I know, I’ve set the paper there when I left, I can do that.” That was the end of the session as she came back and she walked in the door and she was literally beaming.

I’m like, “How did it go?” She is like, “I went to a meeting.” Of course, that’s where the therapist says, “That’s fantastic and look at you. Oh my gosh.” I said, “How did that happen? You didn’t think you could go.” She said she went home to do her assignment and when circling the meetings and had this memory, “Oh, I remember this lady, I use to go with, and I wonder if she’s still going. I think I might have her number in my phone and maybe I’ll text her and ask her if she still goes.” She connected with this woman. The woman is like, “Absolutely, I’m going tonight, I’ll pick you up.”

David: Yes, it just opened the door enough.

Lori: That’s right. It opened the door enough and then you draw on that experience for weeks or months. Look, you can do hard things. You thought you couldn’t yet you did and you build up on some of those examples. You also want to make sure that that person is practicing the skills in there and where they live. You want the practice to occur there. You don’t want the work to all be done in the session.

David: That’s the real context that they’ll be in.

Lori: Exactly. How you know you’ve been successful is when behavior change occurs down the road. When that person is faced with an opportunity to use or not and they choose not to because of some skills that they have acquired from a treatment.

David: What are some other challenges that you face and that your patients face as you approach engaging in CBT?

Lori: Like with any treatment in addiction, one of the predominant challenges we face includes how to keep a patient in treatment itself. It’s very, very common for someone to go under treatment and to have a moment or two or three or seven or ten where they think, “I can’t do this anymore. I don’t want to do it anymore. I’m not going to make it.” This is especially an issue when someone has already been in recovery before and they relapsed, because then they have a lot of thoughts around, “Sure, you were hopeful once, right?”

You were hopeful that that was the time and I failed and I’ll probably going to fail again. They have a lot of these thoughts that can trip them up. They may also have family members who are saying, “Sure, I’ve heard all this before.”

David: They’ve been legitimately heard.

Lori: Exactly. There’s this tension around whether the person can make it. In my experience in working with co-occurring disorders and addiction, you can be ready and still be hopeless, and still think, “Yes, I’m ready to make a change in my life yet I don’t really believe that it can happen for me.” They’re ready, they’re doing the work. They’re really focused, they’re engaged. Then they have a moment of hopelessness that trips them up. One thing that we incorporate in treatment is, we try to use some strategies like inoculation and education.

If you’re a patient coming in, I’m likely to tell you, “Hey, you’re going to have a moment when you’re going to think this is too hard.”

David: Just get that right out of the way?

Lori: Yes. It’s probably going to happen and they’re like, “No, no, no. I know I’m here. I have a baby at home or whatever.” I’m really like, “Seriously, you are probably going to have that moment when you think you can’t do it anymore.” We tell the family, “Hey, it’s not uncommon or unusual that you may get a call that this person is going to say, “I don’t like it here, I want to come home, I need a plane ticket. I can’t take it anymore” and you need to hear that and you need to tell the person, “You’re doing the right thing. It’s going to be okay. Don’t give up.”

We use this inoculation strategies to prepare that person so when it happens, it’s not so frightening.

David: To have lasting recovery, to maintain recovery, you’ve got to have ways to cope with cravings, you’ve got to have ways to prevent relapse. What are some ways that CBT can help with that as well?

Lori: You brought up coping with cravings, that’s a good example. One of the strategies we utilize with coping with cravings is, first, helping someone understand what a craving is. When you look at the changes in the body when a craving happens, you see an increase in activation, and then there is this fear that it’s just going to keep building, when in reality, when you look at the psychological changes with the craving, you could do nothing and it’s going to go away. Helping them understand that yes, it’s really difficult. Yes, it’s not comfortable. It will go away on it’s own even if you do nothing. Then also making sure they have strategies to face cravings. Some of those strategies may be distraction. Maybe go for a walk, maybe you call your sponsor. When you overuse distraction, because then you’re not growing. You use a balance of distraction and mindfulness where you’re being present, and you’re experiencing as it is and not clinging to some of the concerns and fears around what it might be, and seeing it dissipate. Overtime, those cravings become less intense and less frequent and they learn more strategies on how to deal with them.

David: What about relapse prevention as well?

Lori: With relapse prevention, one of the strategies we utilize for that includes this process of behavior chance. When an individual relapses, we’ll sit down and chain that behavior from the first recollection through the use. We chain it so that we can help them see what happened in a very objective way, and also to identify strategies that may have helped along the way that may reduce the risk next time.

Let’s talk about an example. Let’s say that someone, they tend to be triggered around the day they get their paycheck. They know that on payday, their cravings are going to be greater and they tend to go to the ATM, get out money, drive down a specific highway, get off a specific ramp, go to a dealer’s house, buy drugs, bring them back home and use them. That looks like the chain of relapse for them. You could develop some strategies on the front end and say, “Okay. You know you’re going to likely be triggered on payday. What can you do?” Make sure you’re with a supportive friend on payday, maybe give your ATM card to a friend. You start to implement these strategies.

I had one person I worked with that she had a posted note on her steering wheel that had my number on it. If she did end up in her car getting ready to drive down the street that there was one more queue, she’d say, “Okay. Hold on. I don’t know how I got in this car, right?” [chuckles]. I ignored all of those other parts of the chain and I’m sitting in my car looking at this posted note that I’m supposed to call Lori. What could one do in all of those different instances in developing a plan to address relapse prevention at each point of the chain.

David: All right. We’ll wrap up with this last question. You’ve given a lot of yourself your time to this world over the last couple of decades really. Could we wrap up by having you say a little bit about why helping people find recovery is so important to you?

Lori: What I enjoy most about working in the field of addiction is how real people are. Not that you don’t have real people and authenticity in other areas of treatment as well. There seems to be this emphasis on learning how to be who you’re, and looking at individuals who have gone through just tremendous amounts of adversity. They’ve been victims of trauma and maybe they have been through the criminal justice system because of some behavioral issues they’ve had in the past. They’ve seen some dark days, and despite this, there is this profound sense of optimism, and strength and tenacity around the patient who has addiction issues, and the families. These families have been through a lot, and to be able to participate and watch individuals change their lives.

Sometimes it’s that person that you just know deep down that they’re going to make it this time that they’re on their way, or the person who you’re not sure about and they make it anyway. There isn’t a time that I’m working with a patient that I don’t think about their families, especially if they have children at home and there is hope that that person is going to be on a path of recovery. It drives us all. I can’t even begin to describe how wonderful it is to work with such an amazing team and to work with an amazing organization in doing this kind of work together. There is a lot of passion around what we do.

David: Yes. All right. Well, Lori, thank you so much for your time and for being with us today.

Lori: Thanks.

David: Thanks again to Lori for joining us. Now, I’m happy to welcome Will Hart from the Life Challenge Team. He joins us each month to give us an update from their community, which is the aftercare support network for those who’ve gone through foundations treatment programs, and anyone else of accepting the challenge of living life in recovery.

Last month’s challenge was to take care of some spring cleaning. Now Will’s back to share the new challenge for this month. Welcome Will.

Will: Thanks for having me.

David: Yes, absolutely. How are you doing on this fine day?

Will: Good. I’m glad the weather is finally turning around and really placing to the challenge we got for this month.

David: Yes. All right. Go right into it. Tell us about it.

Will: All right. Well, simple one, just spend some time outside. Go for a hike, sit on your back pouch, read a book, play catch. Outside is a big place, there is a lot of options out there.

David: A lot of options. Well yes, it’s good to get fresh air.

Will: Yes. It’s been a long winter. I’m sure everybody has been a bit down with it and I figured the sunshine, get that vitamin D in you.

David: Yes, man. Absolutely. We all need that. Like always, they can share what they’re doing. Yes, lots of options. Lots of things they can take photos of and share in your website, right?

Will: Yes, on lcaccepted.com. We always love to see all the photos and stories from the people.

David: All right. Well, thank you again, Will. We’ll see you in a month.

Will: Thank you very much.

David: This has been the Recovery Unscripted podcast. Today we’ve heard from Lori Ryland of Skywood Recovery. If you’d like to talk with an admissions coordinator about the treatment options at Skywood and other foundations programs, please call anytime at 855-823-2141. See you next time.