Pros and Cons

Pros and Cons is a basic skill that’s taught early on in CBT and is part of DBT’s distress tolerance module.  The tool has a broad application;  it can be used to examine decision making across a variety of issues (lack of motivation for treatment, high risk behaviors in addiction, parenting, distress tolerance, etc..). It’s also a nice bridge to other tools in CBT as it gets a person accustomed to what the work is going to look like moving forward.

Although most folks feel like they already know how to apply Pros and Cons,  much of what the skill has to offer isn’t fully utilized.

The purpose of this post is to demonstrate the benefits of using the Pros and Cons skill in a manner consistent with CBT.

Pros and Cons allows us to examine a situation, potential action or decision away from emotional intensity and logical rigidity and yes, it is important that you write it out. Writing it out gives you a kind of perspective that may not be possible when doing the math in your head simply because of what else may going on up there.

The other benefit to the tool is that it can act to increase motivation around adaptive behaviors and call your attention to the consequences of maladaptive behaviors.

The example below may relate to a person whose symptoms of depression or anxiety affects their ability to maintain an orderly household. The first thing you may notice about the tool is that it breaks the decision down between two potential actions and four possible sets of outcomes.


The tool pushes your thinking around outcomes related to action and inaction and this distinction matters.  The benefits of looking at it both ways allows you to determine consistent themes in the decision making and increases the likelihood that you’ll consider other factors that may not have come up for you if you went with a traditional approach.

The other benefit to the Pros and Cons tool that I tend to emphasize is that, although the action considered may not be effective if implemented, you may be able to tease out needs that could be met by simply using a different strategy.  In this example, Tom considers whether he should tell Joe (a coworker) off for taking his donut.


So creating a spectacle over a donut appears to be a no-go but, by examining what was written closely Tom may able to tease out some goals in developing a new strategy in his communication with Joe.  Using Tom’s sheet and what he highlighted as an example, a different strategy could center around the following priorities:

-Letting Joe know that Tom is aware of the issue.

-Communicating the issue in a way that seeks to effectively influence change in Joe’s donut stealing ways.

-Communicating in a way that does not endanger Tom’s employment.

-Communicating in a way that avoids embarrassing Joe and is consistent with Tom’s moral understanding of how people ought to be treated.

I was debating whether to post the tool because really….you should be able to draw a bunch of rectangles that vary in size on your own.   However, being the generous and compassionate soul that I am, I decided to post it anyway.


I’m also humble.

Pros and Cons Tool (pdf)

Why Cues Count.

One of the first skills I go over and practice with clients is mindfulness and anyone who knows me probably finds this laughable.

You don’t have to play baseball well to coach it, so get off my back.

An early application of mindfulness in my work with most clients has to do with becoming aware of cues in relation to distress; whether the distress is related to anger, anxiety, depression, urges to relapse….whatever.  Being aware of our cues can serve us in different ways and today we are going to focus on using them as part of an early warning system for maladaptive behaviors (outbursts, isolation, panic attacks, relapse, self-harm etc..). Being aware of our cues can help us identify when we are escalating to our “tipping point”.  The tipping point is where you become highly vulnerable to feeling like you’ve lost control.  It’s where you still feel sort of okay in backing out of a situation but you’re not quite sure you will.

At the bottom of this post is a distress matrix I developed for clients I work with.

“Unfortunately, no one can be told what the Matrix is. You have to see it for yourself.”

Actually, Morpheus is wrong. I’m going to go over what each of the items on the matrix are, how to complete the matrix and how to apply it.

It may be helpful to print the sheet out so you can refer to it while reading this post.

Explanation of Categories

Triggers- Triggers are people, places, things, thoughts (including memories) and emotions that create or amplify the distress.  This may require some thought as what we believe created the distress may not really be the trigger; when filling this portion of the matrix out be aware of the chain of events regardless of how minor they may seem that led up to the event you identified as the trigger.  After completing this analysis write the trigger you feel is most connected to your distress in this area.

Intensity- Examine the intensity of your distress (how bad or strong it feels) and try to place a value on  it using a scale of 1 (lowest) to 10 (the worst it’s ever felt). When starting out don’t worry so much about getting it right; you probably have not examined your distress to this degree. It may be hard to come up with a rating because you have little to compare it to.  As you use the matrix more, you’ll be more comfortable in assigning a number to your intensity. For now compare your current distress to other times that come to mind and try to take an educated guess.

Physical Cues- Try not to confuse this category with behaviors; these are not willful actions on your part, this is more about what your body does as an automatic response to the trigger.  Sweating, headaches, other pain, heart rate, shaking and heavy breathing are all automatic reactions of the body and are appropriate for this category.  When completing this category scan your body up and down and notice what it’s doing; jot down anything that feels different or unusual.

Behavioral Cues- These are actions that you take in response to the trigger, things like pacing, making a fist, sighing, rolling your eyes, hitting are all appropriate for this category.

Emotional Cues-These are the emotions or feelings that are prompted by the trigger; avoid writing down secondary emotions such as anger and dig to the primary feelings – fear, humiliation, jealousy.  Some folks have a difficult time identifying emotions, if you’re one of them use this list to help you out.

Cognitive Cues-This is the stuff that your brain is spitting out, the thoughts that automatically pop up in response to the trigger; “I can’t stand this.”, “I hate her.”, “I won’t let them get away with this.”, “This is going to ruin everything.”. Try not to regulate it, just be aware – watch it like your watching a movie and take notes.

How to complete the Matrix

When you’re starting out don’t worry about organizing events in order of intensity; just use it to collect data about yourself.  It’s important to remember that low levels of distress are very important to track for several reasons.

1. You probably already know what the higher numbers sort of look like.

2. Catching distress at the bottom gives you the best opportunity to understand how it escalates.

3. Recognizing low levels of distress can create better opportunities to cope prior to further escalation.

So if something triggers you to an intensity of 1 or 2 complete a row on the matrix.  Complete the matrix during the event; step back and examine what’s going on with you across these categories in the heat of the moment. This not only provides you with the best shot at good data but can also work to mitigate some of the distress that you’re feeling.  Really, that’s what the initial phase is all about, just collecting data about your distress while giving you an opportunity to delay reaction with a task. Speedometer display dial

Once you feel you have enough data (maybe a solid week or two of daily sheets) you can begin to organize it all.  Try to identify trends and develop a master sheet of triggers and cues and organize them according to the level of distress they are associated with.  For example gather all your 3’s and create one row containing all the associated triggers and cues.

How to apply the Matrix

There are a million things that’s done with this thing in therapy, for our purposes here we are going to keep it to just this tool.  Begin by looking at the data and seek to understand how cues change as your distress escalates.  Identify the tipping point and pick a point one or two notches before that; this will be your action point.  The action point is where you begin to use coping skills to actively de-escalate; this can mean stepping away from the situation and revisiting it later.

So if your tipping point is a 7 your action point could be a 5.  A 5 could look like this:

Trigger- When someone goes after the last piece of bacon after I called it. When I get cut off on the parkway, When I have to watch “Ever After”………..again.

Physical – Breathing becomes slightly more rapid

Emotions –  anxiety, irritation

Behavioral – hands tense up, my voice begins to rise,

Cognitive – “I’m not going to let this happen”, “This is dead wrong”, “Here we go again”, “I am so tired of this shit”, “Can’t Drew Barrymore just not win this one time?”

So the next time I’m confronted with these horrors, I’ll try to be really aware of the cues associated with a 5 so if they start happening I can engage in whatever plan I’ve developed to de-escalate.

The matrix is a working document; feel free to add or change it as needed. Overtime becoming aware of your cues and reacting to them adaptively and ahead of the impulse will probably become more natural to you; even for triggers you haven’t identified or curve balls that come your way.  Thanks for checking in.

Distress Matrix (pdf)

Why should I have to change?

Claudio Lerici Part of my job involves educating family members and loved ones about mental health issues.  This is an important part of what I do because family involvement and support can be keys to sustainable recovery.  Managed care companies and intensive treatment settings tend to push family involvement in higher levels of care (IOP, Partial Care, Inpatient treatment) because research consistently demonstrates strong relationships between family involvement and improved treatment outcomes.

Clients themselves typically desire family involvement and believe it could be helpful.

Seventy-eight percent (171 of 219) of the consumers wanted family members to be involved in their care, and many desired involvement through several methods. Consumers were concerned with the impact of involvement on both themselves and their family member. The consumer’s degree of perceived benefit of family involvement significantly predicted the degree of desire for family involvement after analyses controlled for service need (family conflict, family-related quality of life, and symptom severity), enabling factors (family contact and family capacity), demographic variables (age, gender, race, living with family, and marital status), and barriers perceived by the consumer. link

Not all clients need or want family involvement for a variety of reasons – many of these reasons are legitimate.  In my experience, a majority of folks in individual outpatient treatment do not require family involvement and in some cases involving the family can actually act as a distraction to the work being done.  However, if symptoms are acute, there is a consistent and/or recent history of acuity,  the family system ends up being the presenting problem or if the client is a child or adolescent; family involvement is usually indicated.

That being said, change is always difficult so here are a few things families can keep in mind or do to make the process easier.

Get an education

Understanding your loved one’s symptoms and diagnosis can help you understand whether how you’re trying to help is really helping. Trying to help a person with an addiction in exactly the same way you would help someone who struggles with depression (and vice versa) can back fire.  There can be a fine line between empathic support, control and enabling; understanding the differences as they relate to your family’s specific situation is hard work. To make things more complicated, family members usually need to shift in how present and supportive they are as their loved one moves back and forth on the recovery continuum.

One of the best ways to get information and guidance is to become involved in family sessions or medical appointments to the extent that such involvement is desired and/or needed. Putting yourself in front of the therapist or psychiatrist treating your loved one gives the provider community based options and flexibility in solving problems.  I also encourage parents of teens to read the worksheets and materials I give to their child so that they are aware of where the work is headed and are better equipped to help their child through the rough spots on their own.

Education can also help families gain insight into familial reactions to symptoms that can create problems for both the client and family.  School phobia (as an example) is often confused, at least initially, with a lack of desire to attend school because of laziness. As a result, families may push and prod a teen into attending. The goal on some level is correct; the more a person confronts what they are afraid of the more they become desensitized to it. The key to desensitization involves, among other things, increasing a person’s capacity to cope and providing the opportunity to retreat. By pushing a teen, or anyone really, into a situation that creates intense distress without doing anything to help them through it can actually have the opposite effect- resensitization. Folks usually end up feeling as if they did poorly and/or become symptomatic because they were not equipped to handle the trigger in more adaptive ways,  reinforcing the negative associations and interpretations they have about the thing they are afraid of.

One of the most important parts of family involvement in acute settings is a discussion around relapse prevention.  Family involvement can strengthen early warning systems clients are asked to use in mitigating relapse and ensure that plans clients developed for themselves in the event of a relapse are honored so that some degree of self-determination is ensured during the treatment process. Family intervention and support early on may lessen the impact of relapse on important areas of functioning – employment, social, academic, etc.

Be open to change

Families can become overwhelmed and intimidated by the investments they may be asked to make in evaluating how they work and implementing strategies therapists ask them to consider.  While this is completely understandable, it’s important to consider that these changes probably seem overwhelming because they are new and different.  Like any other skill the more practice and attention given to it the more natural and automatic it becomes over time. Over time these changes result in a net gain on time and emotional capacity because the family can work with their loved one in identifying and reacting to stressors and symptoms more effectively.

Some family members struggle with the idea of having to change the way they communicate or “work” out of principle -“why should I have to change…I’m not the one with the problem”.  

Family systems that operate from this perspective can act as barriers for clients in recovery because it communicates a lack of support and implicitly identifies them as the “weak link” within the family system.  If you’ve been following along, you know this isn’t necessarily true. In any case, could you imagine telling a person you love and live with who has diabetes, a heart condition or is pregnant the same thing?

“Hey honey, I know you have this whole pregnancy “issue” going on but that’s sort of your thing…so I’m going to keep doing my thing while you sort it out.  Who loves ya?”

Go ahead.

Try that.

Then you might want to get one of these  because winter is rapidly approaching and park benches can really mess up your back.

Ultimately, no…. you don’t have to change. Changing how you behave and communicate is a decision that will be determined by your reason- but not changing may mean repeating relationship patterns that create greater potential for relapse or conflict.  I’ve worked with clients who felt that they needed to make a decision between their recovery and relationships with family members.  That’s a pretty crappy position to be in. Usually, in these cases, family members refused to even consider coming to family sessions because it wasn’t their “problem”.  Unfortunately, as a result of their decision, the relationship they had with their loved one was cut off.  Many times these were temporary breaks and the cut off resulted in the family making a decision to reconsider their lack of involvement and attend but the fact that it took a break to motivate the family created more work in getting everyone on board.

Being asked to change speaks to skill not love or capacity

Sometimes family members interpret suggestions or requests for change as a judgment on how they handled things.  One common statement I hear in family sessions is “Well we did this with our other kids and they all turned out fine.” Generally we get that we have to relate to different people we come across in our jobs, social circles and even extended family in different ways.  For some reason the more proximate the relationship the more rigid we can become about our approach and positions- we become more defended because having to change may mean that we’ve failed.

In the same way a person with anxiety, depression or addiction has to re-learn their thinking and how they approach relationships you may have to relearn what having a relationship with that person looks like. This advances your interest, their interest and the interest of the relationship. Some of the guidance you receive may include taking a step back and not doing so much – that’s right you may be asked to do less work; but even then you may not like it. Change is hard and the person you’re living with or close to who is struggling with a mental illness or addiction knows this as well as anyone. Change means work. Change doesn’t mean you were a bad parent, sibling, spouse or friend.

The obvious exception here involves family systems that were abusive. On some level family involvement may actually be contraindicated unless the client is a minor and even then, depending on the sort of abuse that was perpetrated, involvement should occur after family members have worked on themselves, safety can be assured and the client feels that family work is necessary and that they are ready for it. In these circumstances therapy will seek to work on these issues directly which will probably involve an expectation on the part of the client that family members take ownership over the event(s) that happened.

I know that what I wrote here gives the impression that family involvement in treatment is laborious and intense. Depending on the issue it can be. Keep in mind that I had folks with higher level of needs or presenting problems related to their family system in mind when writing this.  Not all family involvement in treatment requires the sort of change the article speaks to – sometimes involvement is a one or two session deal. This may be enough to increase awareness and can act as the catalyst for small but substantial change that can help your loved one in their recovery.

Reducing the Social Cost of Recovery

photo_22580_20121013 One of the biggest struggles people have when it comes to recovery from addiction is the social sacrifices that are usually required in order to make recovery successful.   As someone gets deeper into their addiction, their social network gets defined by the addiction – most of the people they hang out with use.

There are obvious reasons for this – it’s more acceptable to use, increased access to substances, higher tolerance within the group for bad behavior and diminished healthy supports as a result of the bad behavior. While these relationships primarily revolve around use and manipulation there are also significant and meaningful shared experiences (losses involving mutual friends due to addiction as an example). Although difficult, ending these friendships are necessary but the lack of support one may experience need not be permanent – there are steps folks in recovery can take to overcome their losses.

1. 12 Step it

I try to make AA or NA a condition of treatment for folks in early recovery for many reasons; the first being that it measures up well to other forms of professional treatment;

Nevertheless, the results of one well-designed investigation called Project Match, published in 1997, suggest that AA can facilitate the transition to sobriety for many alcoholics. In this study, a group of prominent alcoholism researchers randomly assigned more than 900 problem drinkers to receive one of three treatments over 12 weeks. One was an AA-based treatment called 12-step facilitation therapy that includes contact with a professional who helps patients work the first few of the 12 steps and encourages them to attend AA meetings. The other treatments were cognitive-behavioral therapy, which teaches skills for coping better with situations that commonly trigger relapse, and motivational enhancement therapy, which is designed to boost motivation to cease problem drinking.

The AA-based approach seemed to work and compared favorably with the other therapies. In all three groups, participants were abstinent on roughly 20 percent of days, on average, before treatment began, and the fraction of alcohol-free days rose to about 80 percent a year after treatment ended. What is more, 19 percent of these subjects were teetotalers during the entire 12-month follow-up. Because the study lacked a group of people who received no treatment, however, it does not reveal whether any of the methods are superior to leaving people to try to stop drinking on their own.  link

The relationships formed in 12 step programs are far more sustainable than those developed in professionally led groups or in individual treatment.  In more intense acute settings, clients are generally discouraged from communicating with peers outside of group (for good reason) but AA encourages contact among members.  Folks in early recovery will find others who have been where they have been and are able to relate to at least some part of their experience. I can’t think of a more effective way for folks to rebuild their social networks than becoming active in AA or another 12 step program. Finding the right meeting is important so I encourage clients to go to as many different meetings as they can until they find one they are most comfortable with.

2. Explore hobbies that are “dry” and make sure some of them are social in nature

Another key to success in recovery are enjoyable activities – we need things to do as a way of avoiding boredom (usually a big trigger) and to help us cope in ways that are different. Folks in early recovery sometimes feel guilty about enjoying themselves- sometimes accountability is confused with punishment. It can be hard telling a friend or family member you depend on for support that you are going to spend time and money on leisure – but understand that depriving yourself of healthy leisure creates barriers to moving up the recovery ladder and robs you of tools you can use in managing abstinence. Deprivation pushes us to get needs met in impulsive and unhealthy ways.

It can also be hard to put yourself in social situations with people who may not be in recovery which is why a good first step may be to make this type of exposure activity based. Not all of our social relationship need to be deep and not everyone that we are friendly with needs to know our story – sometimes its good to have acquaintances that we spend time with in a specific context. Joining a gym is a great way to develop these types of relationships while engaging in a coping skill (exercise).

“Who can afford a gym?”

I’m sure you were blowing a lot more cash on your addiction and there are very affordable options. The YMCA offers classes and facilities for a little over $50/month (on average). Some YMCA’s provide scholarships for folks who are short on cash.

3. Volunteer

A systematic review and meta-analysis led by researchers at the University of Exeter Medical School in England found that volunteers reported lower levels of depression, increased life satisfaction and enhanced well-being.

Comparing data from several experimental trials and longitudinal cohort studies, the researchers also found evidence of an approximately 20 percent reduction in mortality among volunteers compared to non-volunteers. Researchers note the findings have yet to be confirmed in trials.  link

Volunteering kills time, can be enjoyable, gives you something to put on a résumé when you’re ready to get a job and provides you with purpose. Getting into a “work-like” environment may seem daunting but many organizations are flexible. If the whole “interacting with humans” thing feels overwhelming, consider volunteering at a no-kill animal shelter. The United Way is a great place to learn about volunteering and getting involved – much of the funding they provide to agencies and organizations is tied to the number of volunteers that are utilized.

4. If you believe in God then visit Him once in a while.

If you identify with a religion then get involved with services and go as often as you need to. Reconnecting with your faith not only gives you the ability to do something with others it can complement the work you’re doing in a 12 Step program. Church attendance and religiosity have also demonstrated positive effects on mood and physical health depending on one’s perception of God.

A study conducted in North Carolina found that frequent churchgoers had larger social networks, with more contact with, more affection for, and more kinds of social support from those people than their unchurched counterparts. And we know that social support is directly tied to better health. link

I’m not pushing religion, just saying that if you’re connected to it, then get your ass on a pew…or whatever they call it where you decide to go.

5. Get a pet

Yes I’m serious and it doesn’t have to involve a giraffe or a mountain lion (although that would be cool). Fish and hamsters will also work. Pets provide us with companionship and responsibility; they can even help us through triggers that may lead to relapse. There is a ton of research out there that demonstrates a connection between pet ownership and good mental health.

Until now, most research into the benefits of pets has been correlational, meaning it looked at the relationship between two variables but didn’t show that one caused the other. For example, prior research showed that elderly Medicare patients with pets had fewer doctor visits than similar patients without pets, or that HIV-positive men with pets were less depressed than those without.
In this study, 217 people (79 percent women, mean age 31, mean annual family income $77,000) answered surveys aimed at determining whether pet owners in the group differed from people who didn’t have pets in the areas of well-being, personality type and attachment style. Several differences between the groups emerged, and in all cases, pet owners were happier, healthier and better adjusted than were non-owners.

A second experiment, involving 56 dog owners (91 percent of whom were women, with a mean age of 42 and average annual family income of $65,000), examined whether pet owners benefit more when their pet is perceived to fulfill their social needs better. This study found greater well-being among owners whose dogs increased their feelings of belonging, self-esteem and meaningful existence.

The last study, comprising 97 undergraduates with an average age of 19, found that pets can make people feel better after experiencing rejection. Subjects were asked to write about a time when they felt excluded. Then they were asked to write about their favorite pet, or to write about their favorite friend, or to draw a map of their campus. The researchers found that writing about pets was just as effective as writing about a friend when it came to staving off feelings of rejection. link

Recovery from addiction does not mean being alone. Giving up old relationships that centered on use is necessary and although it may feel like betrayal you may want to consider the basis of the relationship and what you’re really walking away from. When you’re ready there are people, organizations, mountain lions and giraffes waiting to bring you in and help you along the way – all the way.