Trascrizione completa di Rethinking Drinking: Dr. William R. Miller and Dr. Ricardo Muñoz on 50 Years of Alcohol Use Research

00:05:08.000 And there's some medications that doctors can prescribe now to help people cut down on the drinking as well. 00:05:08.319 --> 00:05:21.920 So it's it's become routine in healthcare just to ask about alcohol use as a health risk factor uh and to suggest that people cut their drinking down or stop, uh, depending on their situation. 00:05:22.480 --> 00:05:35.519 Um but yes, when we started this, uh it was highly controversial because either you were alcoholic and would be unable to cut down your drinking, uh, or you weren't, and what's the problem? 00:05:35.680 --> 00:05:37.120 You can drink whatever you want. 00:05:37.360 --> 00:05:39.519 We now know that uh the latter is not true. 00:05:40.000 --> 00:05:44.959 There was a funny line in the book that said, so basically this was for no one. 00:05:45.519 --> 00:05:47.040 Right, nobody did our book. 00:05:47.759 --> 00:05:50.800 Because either they couldn't do it or they didn't need to. 00:05:51.040 --> 00:05:51.360 Yeah. 00:05:51.680 --> 00:05:53.120 But people used it anyhow. 00:05:53.279 --> 00:05:58.639 So our our focus back then was to help people to learn how to do moderate drinking. 00:05:58.879 --> 00:05:59.040 Yes. 00:05:59.279 --> 00:06:00.399 Uh that was the focus. 00:06:00.560 --> 00:06:06.480 And I think uh again, this is the fifth version basically of our book uh fifty years later. 00:06:06.560 --> 00:06:18.000 And now uh with uh the knowledge that there are so many health risks that we were not as aware of back then, um one of the choices, of course, is not drinking at all. 00:06:18.319 --> 00:06:22.560 But we we totally respect and acknowledge people's rights to make a decision. 00:06:22.639 --> 00:06:24.639 You know, we all take risks with things. 00:06:24.800 --> 00:06:28.399 Every time we get in a car, we take a risk, right, that something could happen. 00:06:28.480 --> 00:06:41.120 Uh so we very much respect people's uh right to make choices, uh, but they should make choices knowing the uh most accurate information currently available. 00:06:41.519 --> 00:06:45.600 So that's the point of the current book, rethinking drinking. 00:06:46.000 --> 00:06:46.560 Yes. 00:06:47.839 --> 00:06:52.160 Ricardo made a choice long ago to to not use alcohol. 00:06:52.399 --> 00:06:58.399 Uh and I I do drink, but very moderately, uh less than a glass of wine a day. 00:06:58.639 --> 00:07:02.879 Um and so we represent two choices that that one can make. 00:07:03.360 --> 00:07:10.000 Uh and the book really is all about making those choices for yourself, and nobody else can make that choice for you. 00:07:10.560 --> 00:07:27.600 And ideally making those choices not in an emotional way, but just thinking, again, rethinking your drinking and decide whether you want to use alcohol, and if so, how to use it in a way that's least likely to create problems for yourself and other people. 00:07:27.759 --> 00:07:29.759 I mean that's that's really the point. 00:07:30.000 --> 00:07:39.120 You know,

uh Bill uh mentioned that I I decided not to drink, not out of religious or other reasons, but just it seemed like a logical choice. 00:07:39.199 --> 00:07:40.560 Back when I was in college. 00:07:41.120 --> 00:07:52.240 Uh back then in the 1970s, I was at Stanford and in the dorms, people would pass joints around, you know, marijuana joints around, like you know, every time we got together, and I would just pass them on to the next person. 00:07:52.399 --> 00:07:57.279 And one time this guy who had just given me a joint said, Yeah, you so you don't drink you don't smoke? 00:07:57.439 --> 00:07:58.240 And I said, No. 00:07:58.480 --> 00:07:59.839 And he said, Well, do you drink? 00:08:00.000 --> 00:08:01.199 And I said, Yes. 00:08:01.439 --> 00:08:07.279 Uh and he said, Well, you know, drinking is a lot more dangerous than marijuana. 00:08:07.439 --> 00:08:08.879 And if you don't believe me, look it up. 00:08:09.040 --> 00:08:14.879 So I went, I went to the library and I actually looked it up, and I found all these problems with alcohol. 00:08:14.959 --> 00:08:31.839 I mean, you know, problems with your brain affecting your brain, affecting your emotions, and all these problems like violence and sexual abuse that occurred when one or or both people were drinking, and of course, all the alcohol uh-related uh uh auto accidents and and other accidents. 00:08:32.080 --> 00:08:40.559 So there were all these problems with alcohol, and I thought the logical thing was not to drink and not to use marijuana, so I did not. 00:08:41.679 --> 00:08:45.600 And you know, uh at first I had to explain to people why I wasn't drinking. 00:08:45.759 --> 00:08:49.519 Back in the 70s, you were expected to drink when you were in a social situation. 00:08:49.759 --> 00:08:54.960 And people would actually get upset with you if you didn't, which was really something. 00:08:55.200 --> 00:08:58.879 And after a while I got used not to even, you know, mentioning it. 00:08:58.960 --> 00:09:00.399 I ch I just don't do it. 00:09:00.639 --> 00:09:07.200 And it it has uh had an impact on like on my family, you know, my my immediate family doesn't use alcohol. 00:09:07.360 --> 00:09:11.279 Um which is that's just not part of what we do. 00:09:11.759 --> 00:09:13.600 But it's not any big deal. 00:09:13.759 --> 00:09:17.200 It's not like uh you know, not big emotional thing. 00:09:17.279 --> 00:09:19.519 I I'm not asking people not to drink. 00:09:19.759 --> 00:09:22.639 If people want to drink, I think that's their their choice. 00:09:22.879 --> 00:09:28.480 Hopefully not drinking in a harmful way, which again is a main the main focus of the book. 00:09:28.799 --> 00:09:36.240 How to drink in a way that was not going to have harmful effects on you or your family or or people around you. 00:09:36.879 --> 00:09:42.799 Yeah, especially like you mentioned that almost half of people report now that they don't drink. 00:09:43.039 --> 00:09:52.240 It's a good time not to, because there doesn't feel like there's as much social pressure as maybe there was when people were expected to earlier on. 00:09:52.879 --> 00:09:58.960 You have lots of company, and and now it's normal in restaurants to have alcohol-free beverages offered. 00:09:59.039 --> 00:10:07.200 You go in the grocery store, there are shelves of alcohol-free wines and beers and things, so it's it really has changed quite a lot. 00:10:07.600 --> 00:10:12.720 My brother works in the uh rock industry, uh, heavy metal, those kinds of things. 00:10:12.960 --> 00:10:24.080 And he was telling me that uh people now have these cans of water that have names like like uh liquid death and all these kinds of things. 00:10:24.240 --> 00:10:34.159 And people are are using these instead of alcohol because they want to have something in their hand that looks like it could be alcohol, even though it's just plain water. 00:10:34.399 --> 00:10:36.879 It's interesting how things have changed in the last few years. 00:10:37.200 --> 00:10:37.440 Yeah. 00:10:37.600 --> 00:10:37.759 Yeah. 00:10:38.000 --> 00:10:44.720 I just saw this week that Coca-Cola did a rebrand to have a more evening-looking black and gold can. 00:10:46.480 --> 00:10:48.320 So everyone's following suit. 00:10:48.639 --> 00:10:56.960 In addition to some of those social pressures, what were the other reasons for drinking that people have identified in your research? 00:11:36.389 --> 00:11:41.350 We we talk about reasons that people drink because we're looking at the pros and cons. 00:11:41.589 --> 00:11:42.709 Uh yeah. 00:11:42.949 --> 00:11:47.269 And I think the the most common one probably is I I like the taste. 00:11:47.429 --> 00:11:51.990 I, you know, I just enjoy a glass of wine now and then. 00:11:52.389 --> 00:11:55.990 Um or socializing is a is a pretty common one too. 00:11:56.149 --> 00:11:59.509 When I'm with friends, out with friends, I like to have a drink. 00:11:59.669 --> 00:12:08.230 You know, that uh just maybe maybe helps me relax a little bit, but mostly it's just part of socializing for me. 00:12:08.709 --> 00:12:12.149 Then you get into I like what alcohol does to me. 00:12:13.189 --> 00:12:16.870 Uh and it helps me relax is an example of that. 00:12:17.350 --> 00:12:26.149 Um and and there you're talking about a uh partly a chemical effect of drinking and partly a psychological effect. 00:12:26.469 --> 00:12:38.309 Because we've known for a long time that if people believe they're drinking alcohol, their behavior changes uh in the same kinds of ways that it does when people are drinking alcohol. 00:12:38.870 --> 00:12:53.429 Um one of the things we say in the book is that if if you think you've had a drink, which this has been done experimentally, you give people something that they think has alcohol in it, they kind of relax and they start having a good time. 00:12:54.309 --> 00:12:56.870 And their mood just kind of lifts for a while. 00:12:57.110 --> 00:12:59.589 And Ricardo knows a lot about mood

resers. 00:13:00.069 --> 00:13:08.469 Um and then if it but if you are drinking, then the alcohol begins to kick in, and the actual effect of alcohol is depressant. 00:13:10.230 --> 00:13:13.029 And so literally you may get a happy hour. 00:13:14.309 --> 00:13:20.709 Uh and and after that it's pretty much downhill from there on from the chemical effects of alcohol. 00:13:21.110 --> 00:13:23.990 Um but but people look for those effects. 00:13:24.149 --> 00:13:28.709 It's I feel stronger, I feel more courageous, I feel less anxious. 00:13:29.589 --> 00:13:36.870 So if you're using alcohol to change the way you feel, now you're getting into more risky use of alcohol. 00:13:37.110 --> 00:13:44.389 And people who report those reasons for drinking tend to drink more and to tend to get in trouble more. 00:13:45.110 --> 00:13:52.389 Um and at the top end of the spectrum uh is drinking in order to drive away the effects of withdrawal. 00:13:52.629 --> 00:13:56.149 So you become addicted to alcohol, which you literally can. 00:13:56.789 --> 00:14:03.909 Uh, and when you drink alcohol, then that discomfort goes away, just like other drug addictions. 00:14:04.069 --> 00:14:09.669 And of course, that one is the most associated with alcohol problems and and the most drinking. 00:14:09.829 --> 00:14:12.309 So why you drink matters. 00:14:12.549 --> 00:14:14.469 And that's one of the things that we look at in this book. 00:14:14.870 --> 00:14:18.230 Yeah, so the first parts of the book, you know, focus on on those things. 00:14:18.389 --> 00:14:27.750 Uh uh drinking, the reasons for drinking, uh reasons for not drinking, uh, and uh the effect of alcohol on on your body. 00:14:27.829 --> 00:14:30.149 I mean, uh BAC levels and so on, you know. 00:14:30.230 --> 00:14:32.309 Then we get into a great detail. 00:14:32.549 --> 00:14:35.509 Uh I mean, alcohol is is a drug, right? 00:14:35.669 --> 00:14:43.029 It's a drug, and it's important to know how the drug works on your body in order to make a rational decision as to how much to use. 00:14:43.269 --> 00:14:49.429 Um that that's the first part of the book, the first uh three parts of the book focus on on all these things. 00:14:49.669 --> 00:15:05.110 And then part four of the book focuses on alternative ways of achieving some of the things that alcohol does for a lot of people, like uh Bill was mentioning, dealing with low mood or anxiety or getting to sleep and so on. 00:15:05.269 --> 00:15:16.629 And um unfortunately, even though it does help some, it actually has a number of negative consequences for all of these anxiety, depression, uh sleep. 00:15:16.870 --> 00:15:24.789 Um and so we talk about those things in part four of the book and we provide alternative ways of achieving those uh goals. 00:15:25.189 --> 00:15:37.110 I've heard I heard even this week the first drink is the most fun, and then I spend the rest of the night trying to capture how good that first drink felt, and it never comes back. 00:15:37.669 --> 00:15:38.629 Literally true. 00:15:38.870 --> 00:15:40.069 That's the happy hour. 00:15:40.149 --> 00:15:40.230 Yeah. 00:15:40.629 --> 00:15:41.829 Yeah, I love that. 00:15:42.149 --> 00:15:42.629 Uh-huh. 00:15:42.789 --> 00:15:43.269 Uh-huh. 00:15:43.990 --> 00:15:47.029 Well, we really have have a couple of audiences for this book. 00:15:47.189 --> 00:16:01.110 Originally we wrote it for people who kind of know they're drinking too much, who are drinking above what would be regarded to be reasonable limits, uh, and we were trying to work with them just to get their alcohol down. 00:16:01.669 --> 00:16:12.069 My first experience with alcoholism was actually in an inpatient treatment ward at the Veterans Hospital, seeing people whose lives had basically been destroyed by alcohol. 00:16:12.389 --> 00:16:21.669 And what that convinced me was I wanted to go upstream and try to keep people from falling into the stream before they got down to those waterfalls that I had seen. 00:16:21.829 --> 00:16:27.189 Uh, and so we were trying to work with those folks who were already drinking too much to cut it down. 00:16:27.509 --> 00:16:32.069 Now the book is also for people who are saying, Do I want to drink at all? 00:16:32.230 --> 00:16:37.350 I mean, why why am I why am I drinking and and you know, how can I decide? 00:16:37.509 --> 00:16:50.870 And so we look at the pros and cons for people that don't have a problem necessarily with alcohol, but are just thinking about this is a drug and I want to make a good decision about how I'm gonna use it. 00:16:52.469 --> 00:17:03.669 And we mentioned uh you know the impact that uh alcohol has, 178,000 deaths due to alcohol a year in the US, like that's 480 some a day. 00:17:03.909 --> 00:17:14.470 I mean, you know, I think many of us are not aware of how much uh impact uh alcohol has, a negative impact on on our lives. 00:17:15.269 --> 00:17:18.069 Uh so and then there are again other ways. 00:17:18.150 --> 00:17:27.029 Uh uh Bill's point about trying to prevent people from getting into the severe alcohol problems that he was working with in the inpatient units. 00:17:27.190 --> 00:17:31.350 That was the the main goal of of our first uh version of the book. 00:17:31.750 --> 00:17:42.550 Uh but now we're we're talking about uh ways of preventing not just alcohol problems, but things like depression, anxiety, and things like that. 00:17:42.710 --> 00:17:46.790 We talk about those things in the book and in part four of the book. 00:17:47.110 --> 00:17:49.509 Uh so we're both very interested in prevention. 00:17:49.830 --> 00:18:05.670 Yeah, I think that piece is interesting too, because uh some people would identify that they are, to your point, drinking more so they can sleep better, or because they've been having a hard time or feeling a little bit depressed. 00:18:05.910 --> 00:18:11.590 But you're noting that those things actually increase and get worse with alcohol use. 00:18:11.750 -->

00:18:14.230 They don't they don't actually improve, especially in the long term. 00:18:14.790 --> 00:18:21.430 Also built into the book this time sort of a self-checkup uh for people who wonder. 00:18:21.670 --> 00:18:23.509 I wonder if I'm drinking too much. 00:18:24.470 --> 00:18:29.910 Uh and that was a group that in my own research I I was interested in helping too. 00:18:30.070 --> 00:18:36.070 And we offered free checkups in the newspaper for people who just wonder whether they're drinking too much. 00:18:36.230 --> 00:18:38.870 Uh you won't be labeled, it's not a treatment program. 00:18:38.950 --> 00:18:45.750 Just come on in, we'll do some some measurement with you, some assessment, we'll give you feedback, and that's it. 00:18:46.070 --> 00:18:48.150 Called it the drinker's checkup. 00:18:48.390 --> 00:18:52.310 Um people came to that who had never been near a treatment center. 00:18:53.509 --> 00:19:00.950 Uh and yet almost everybody who came in wondering whether they were drinking too much uh was. 00:19:02.390 --> 00:19:05.750 They were drinking at a level that was doing some harm to them. 00:19:05.990 --> 00:19:14.470 Uh so part of them knew already, uh, but they didn't want the label of I have a problem or I'm an alcoholic or whatever. 00:19:14.710 --> 00:19:19.190 They just wanted to make a decision about about their drinking and how alcohol is affecting them. 00:19:19.670 --> 00:19:21.910 And so the book is really for folks like that too. 00:19:22.230 --> 00:19:22.390 Yeah. 00:19:22.870 --> 00:19:28.310 Could you give an example of the type of question that would be found on the checkup? 00:19:28.710 --> 00:19:28.950 Sure. 00:19:29.029 --> 00:19:37.509 I mean, we we certainly ask questions about the amount that the person's drinking, because that's that's directly related to the amount of harm. 00:19:37.670 --> 00:19:39.830 Uh and most people haven't thought about it. 00:19:40.070 --> 00:19:44.790 In the treatment programs that it that I ran, we had people actually keep little cards. 00:19:45.029 --> 00:19:53.269 And every time they had a drink before they had a drink, they would write down the time and the day and and what they were having. 00:19:53.509 --> 00:19:56.630 And people found with that actually they were surprised. 00:19:56.710 --> 00:20:00.150 I never really thought about how much I was drinking. 00:20:00.390 --> 00:20:06.310 Uh and the at the first week we said you don't have to make any changes in your drinking, just write it down. 00:20:06.550 --> 00:20:10.150 But in that first week, drinking went down by about a third. 00:20:10.310 --> 00:20:14.470 Uh, and people said, you know, I went to write it down, and I thought, do I really need this one? 00:20:14.630 --> 00:20:19.269 You know, so so just that awareness of how much is a is a piece of it. 00:20:19.509 --> 00:20:25.670 Uh we have questions about the kinds of life problems that people can run into and whether those are happening. 00:20:25.910 --> 00:20:30.150

And uh you can compare yourself with the scores of uh other people. 00:20:30.950 --> 00:20:45.190 Uh we actually did, and we can't do this in the book, but we did some neuropsych testing uh of brain functions that are very sensitive to alcohol and that get changed early, and you may not notice them even. 00:20:45.750 --> 00:20:52.310 Um but so we tested those things to look for early effects of drinking, and we give people feedback about that. 00:20:53.029 --> 00:20:58.230 Uh we uh took a blood sample and we looked at liver function. 00:20:58.470 --> 00:21:04.710 And most of the people coming in to our programs or for the checkup weren't in trouble at that level. 00:21:04.870 --> 00:21:12.790 Some of them had elevated liver functions, but most of them hadn't done that much damage yet, which is perfect because we're looking for prevention, you know. 00:21:12.950 --> 00:21:17.190 So just a variety of things like that that we've built into the checkup. 00:21:17.430 --> 00:21:20.070 Um trouble that you can have with it. 00:21:20.230 --> 00:21:31.509 Dependence is also uh to what extent is alcohol beginning to be built into your life as something that you're just used to, and in fact a little uncomfortable without it. 00:21:32.390 --> 00:21:36.870 And so you can get yourself a score on the extent to which that's happening. 00:21:37.110 --> 00:21:44.070 Um so we just look at a whole variety of things in the uh in the checkup, most of which we could do in book form. 00:21:44.630 --> 00:21:48.550 We couldn't do the neuropsych testing or the blood testing, of course. 00:21:48.790 --> 00:21:53.350 Um but otherwise uh we could build into the book the kinds of things that we were looking at. 00:21:53.750 --> 00:22:07.509 One of the things we talk about uh uh at the beginning of part four, chapter twelve, is this idea of the healthy management of reality, by which we mean that most of us learn from the time we're infants how to deal with our world, right? 00:22:07.590 --> 00:22:12.710 I mean we learn the language that our parents speak, we learn how to behave, etc. 00:22:13.029 --> 00:22:13.350 Right? 00:22:13.590 --> 00:22:21.590 And um sometimes the things that we use to manage our day to day lives are very helpful. 00:22:21.830 --> 00:22:23.190 Most of the time they are. 00:22:23.430 --> 00:22:27.110 But from time to time we learn something that may not be very helpful. 00:22:27.350 --> 00:22:31.590 For example, a lot of drinking begins in adolescence. 00:22:32.390 --> 00:22:37.590 When you know when young people are trying to figure out how to become sociable, how to deal. 00:22:38.150 --> 00:22:40.310 With emotions, all those things. 00:22:40.550 --> 00:22:53.910 And so they begin to learn to manage their emotions and their social interactions with alcohol because alcohol is so available, even though it's illegal, you know, to drink under age, but still it's so available. 00:22:54.070 --> 00:22:56.070 People are are beginning really early. 00:22:57.029 --> 00:23:06.950 And so once you've learned to use alcohol for these things, it's very hard to give it up and learn an alternative way of doing it. 00:23:07.269 --> 00:23:09.990 One of the things we talk about is the idea of freedom. 00:23:10.230 --> 00:23:18.790 You know, if you have three choices to do something, and somebody else has ten choices, the person who has ten choices has more freedom, right? 00:23:18.950 --> 00:23:24.550 If somebody only knows how to deal with depression by using alcohol, they really don't have any choice. 00:23:24.710 --> 00:23:29.029 But if they can learn other ways of doing it, then they have choices. 00:23:29.190 --> 00:23:29.910 They have freedom. 00:23:29.990 --> 00:23:32.550 And that's what we're trying to encourage. 00:23:32.630 --> 00:23:35.750 Uh it's having increasing people's freedom. 00:23:35.910 --> 00:23:37.590 That's the point of the book. 00:23:38.070 --> 00:23:38.630 Yes. 00:23:39.670 --> 00:23:41.269 Yeah, that's a neat way of saying that. 00:23:41.509 --> 00:23:44.950 I thought this was an interesting fact uh that you shared, Ricardo. 00:23:45.110 --> 00:23:49.110 Your senior thesis advisor was Albert uh Bandura. 00:23:49.509 --> 00:23:49.750 Yes. 00:23:49.990 --> 00:23:57.590 And so you mentioned that in chapter twelve, some of those ideas are based on his self-efficacy research. 00:23:58.070 --> 00:23:58.470 Exactly. 00:23:58.630 --> 00:23:58.950 Yes. 00:23:59.190 --> 00:24:04.550 I mean, one of the problems, you know, with depression, for example, is a feeling of helplessness and hopelessness, right? 00:24:04.630 --> 00:24:08.470 And the feeling that you cannot deal with whatever is going on in your life. 00:24:08.710 --> 00:24:11.190 And sometimes people use alcohol to deal with that, right? 00:24:11.269 --> 00:24:12.470 I mean, you hear this all the time. 00:24:12.870 --> 00:24:17.350 I need a drink at the end of the day because of all the stress you're dealing with, right? 00:24:17.750 --> 00:24:32.070 And so I um I I did my my uh senior thesis with Albert Bandura at uh in Palo Alto, working with adults in Palo Alto, and then I did my dissertation with Peter Lewinson at Oregon, again, working with adults there. 00:24:32.150 --> 00:24:42.150 And both in Palo Alto and Oregon, the people I was working with were almost entirely white people with good education and good uh uh salaries and so on. 00:24:42.310 --> 00:24:44.950 And then I came to San Francisco General Hospital. 00:24:45.029 --> 00:24:47.350 Uh I had grown up in the mission district in the back. 00:24:47.670 --> 00:25:02.390 I immigrated from Peru when I was 10 to the to the mission district in San Francisco, and I was very lucky to get a job as a professor at a medical school at UC San Francisco, based at San Francisco General Hospital, which works with very low-income people. 00:25:02.630 --> 00:25:12.390 And their reality, their day-to-day reality, was totally different from people in Palo Alto or Eugene, Oregon, which is, you

know, it's a college town, basically. 00:25:12.630 --> 00:25:18.390 And so I had to change the way I was thinking about cognitive behavioral approaches. 00:25:19.350 --> 00:25:25.670 Just telling people think differently or increase your personactivity today didn't seem like that was really sufficient. 00:25:25.910 --> 00:25:34.070 So I came up with this idea that you needed to shape or manage your day-to-day reality using cognitive behavioral methods. 00:25:34.150 --> 00:25:44.630 You know, and we would teach people about how their thoughts affected their mood, how what they did affected their mood, but the point was to shape or mold their day-to-day realities. 00:25:44.790 --> 00:25:45.509 That's the point. 00:25:45.670 --> 00:25:59.269 And so that's what part four of the book uh deals with, different ways of using your thoughts and your behaviors to change your day-to-day reality, whether that be depression, anxiety, sleeping, etc. 00:25:59.750 --> 00:26:06.150 There's an advertising message in America also that you you shouldn't have to feel uncomfortable. 00:26:06.470 --> 00:26:08.790 And and if you do take something. 00:26:34.070 --> 00:26:35.830 Uh is a real problem. 00:26:36.470 --> 00:26:40.390 Because mostly what you take isn't particularly helpful. 00:26:40.630 --> 00:26:43.110 Uh sometimes it is, but mostly it isn't. 00:26:43.350 --> 00:26:58.550 And so part four of the book, again, is about things that you can actually do that don't involve taking something, uh, to uh to have a better life, to enjoy your life and uh and to feel comfortable without taking something. 00:26:59.269 --> 00:27:20.710 Yeah, I think about that cognitive distortion a lot in my practice, that it seems like pain is bad or avoid pain can lead to a lot of these difficulties, but other ones too, if if it feels like we're not supposed to feel difficulty or any pain is avoidable. 00:27:21.190 --> 00:27:21.910 Yes, right. 00:27:22.230 --> 00:27:23.029 That's a very good point. 00:27:23.269 --> 00:27:29.110 One of the things we talk about is that depression, like physical pain, is actually a good thing. 00:27:29.509 --> 00:27:36.150 I mean, we we need to be able to feel depression or physical pain in order to protect our body or our emotional health. 00:27:36.390 --> 00:27:43.670 The problem is when depression, for example, becomes very intense, lasts a long time, or is very frequent. 00:27:43.910 --> 00:27:45.110 So that's what you want to do. 00:27:45.190 --> 00:27:53.029 You want to reduce the intensity, the frequency, and the duration of severe depression, just like you want to do the same thing with physical pain. 00:27:53.350 --> 00:27:57.350 Also, Ricardo's research shows that depression is preventable. 00:27:57.590 --> 00:28:05.350 Use using the same methods, uh particularly postpartum depression, women who are uh have delivered. 00:28:05.590 --> 00:28:20.390 It's it's uh not uncommon to uh to develop depression after delivering a baby, uh, and that is preventable, using the same kinds of things that Ricardo has been talking about that are used to treat depression when it does occur. 00:28:21.029 --> 00:28:29.509 I think both of us were very much influenced by the uh in the 1970s by the focus on self-control approaches, right? 00:28:29.670 --> 00:28:32.870 That people had there there was a book called Power to the Person. 00:28:33.190 --> 00:28:39.430 I remember, you know, Albert Bandura was one of the people who you know, the whole idea of self-efficacy is the idea of self-control. 00:28:40.630 --> 00:29:00.950 And we are very much focused on this idea that human beings have the potential to control their lives, their emotions, their behavior, and so on, in ways that uh you know, the radical behaviorist, for example, you know, uh Skinner talked about how we were totally determined by our past history and so on. 00:29:01.110 --> 00:29:08.870 And psychoanalysis also talked about how all these subconscious things affected us and we were not even aware of what they did. 00:29:09.110 --> 00:29:29.190 But Albert Mandura and other people who were doing work on cognitive behavioral therapy focused on how the idea of reciprocal determinism, the idea that the environment obviously affected our behavior, but we could also affect the environment in order to change our behavior, right? 00:29:29.269 --> 00:29:32.630 I mean, I that was a very freeing idea for me. 00:29:32.790 --> 00:29:34.710 Uh I just I just love that idea. 00:29:34.870 --> 00:29:37.990 And then you know I've been using that ever since then. 00:29:38.230 --> 00:29:46.230 And uh and I think Bill and I both are uh are focused on how to give people more of a sense of control over their lives. 00:29:46.550 --> 00:29:55.029 Another piece of this that that got some attention recently is is how much better people feel when they let go of drinking too much. 00:29:55.269 --> 00:30:05.670 There was a book called Sober Curious a few years ago, uh written by a woman who said, I just wondered what life would be like for me without alcohol. 00:30:05.990 --> 00:30:07.269 And it sold well. 00:30:07.350 --> 00:30:09.110 I mean, it sold a lot of copies. 00:30:09.350 --> 00:30:12.950 And people were just it was an idea that caught on. 00:30:13.350 --> 00:30:20.630 Uh and the reason I've stayed 50 years in the addiction treatment field is the outcomes are so good. 00:30:21.750 --> 00:30:28.470 Most people get better, and most people get like way better in a way that you don't need subtle instruments to measure it. 00:30:29.110 --> 00:30:32.230 So what a wonderful field to work in for me. 00:30:32.390 --> 00:30:33.750 I've really enjoyed it. 00:30:33.990 --> 00:30:44.710 Uh, and so you can make a very positive difference in your life by by reducing the amount of uh alcohol that you're using as well, uh, or letting it go completely. 00:30:44.870 --> 00:30:47.670 And that's one of the messages in a book as well. 00:30:48.550 --> 00:30:52.150 Yeah, Bill mentioned

my work on uh preventing depression. 00:30:52.310 --> 00:31:06.870 You know, back in the 1980s, NIMH had a document called uh Depression What We Know, and in it, one of the things it said was, in general, the onset of major depressive episodes cannot be prevented. 00:31:07.029 --> 00:31:10.390 I was very upset by seeing that because there was no evidence either way. 00:31:10.550 --> 00:31:20.790 And I actually, uh with my colleagues, uh ran the first randomized controlled trial specifically to test whether the onset of depressive episodes could be prevented. 00:31:20.950 --> 00:31:30.470 And uh now, 40-some years later, there's a lot of evidence that we can, in fact, prevent the onset of new cases of major depression. 00:31:30.710 --> 00:31:36.950 My own work has focused more on uh preventing postpartum depression or depression during pregnancy. 00:31:37.110 --> 00:31:38.870 And uh now the U.S. 00:31:38.950 --> 00:32:05.990 Preventive Services Task Force just a few years ago came out with recommendations in in GAMA and the Journal of the American Medical Association that we should be providing uh preventive interventions, and they specifically uh listed uh the the intervention we had developed called the Mothers and Baby Scores as something that could prevent 53% of new episodes of perinatal depression, which is amazing when you think about it, right? 00:32:06.710 --> 00:32:14.390 So going from it can't be prevented to we can probably prevent 50% of new episodes is is just amazing to me. 00:32:14.630 --> 00:32:26.870 And some of those ideas are in part four of the book, you know, the kinds of things that we've we've used, which are basically the same cognitive behavioral methods that we've learned in terms of treating depression. 00:32:27.110 --> 00:32:29.670 They can be used to manage people's mood. 00:32:29.830 --> 00:32:40.870 The idea being that with stress we eventually develop depression and we cross a threshold into a clinical depression, and then treatment can help with that, of course. 00:32:41.110 --> 00:32:48.790 But if we could begin using those mood management methods before we cross threshold, then we could prevent the episode from occurring. 00:32:49.029 --> 00:32:56.870 And we know that once somebody has one episode of major depression, the likelihood of having another goes way up, something like to 50%. 00:32:57.190 --> 00:32:59.670 And if you have two, it goes up to 70% and so on. 00:32:59.910 --> 00:33:05.670 So if we could prevent the first one, we might be able to prevent chronic depression throughout somebody's lives. 00:33:05.910 --> 00:33:10.230 And even if we can prevent it after the first or second, we're still doing something. 00:33:10.470 --> 00:33:14.630 So those ideas are uh in part four of the book. 00:33:15.110 --> 00:33:18.870 Um and uh and we hope they'll be useful too to people. 00:33:19.670 --> 00:33:32.390 And it's more generally a hope with our book, I think, that the information there can help people to not

have trouble with alcohol in the first place, to never be harmed by it or to never develop a problem with it. 00:33:32.550 --> 00:33:32.710 Trevor Burrus, Jr. 00:33:32.790 --> 00:33:38.310 You had mentioned a a little bit ago adolescence and how early those problems can start. 00:33:38.390 --> 00:33:41.269 And I think in the book you also mentioned older adults. 00:33:41.590 --> 00:33:49.110 Can you speak to the challenges that alcohol use or alcohol overuse can have on older adults? 00:33:50.470 --> 00:34:00.550 Well, the the rate of alcohol problems goes way down with older adults, uh, of course, in part because uh people who use a lot of alcohol don't live that long. 00:34:00.870 --> 00:34:03.990 Um but I live in a retirement community. 00:34:04.230 --> 00:34:12.389 Uh and also when you retire, you may be losing the main source of meaning that you had in life. 00:34:12.630 --> 00:34:17.269 Uh and also if you're changing the place you live, so much is shifting around you. 00:34:17.429 --> 00:34:31.349 And if you're isolated, which is a real risk factor for depression and and for uh alcohol problems, if you also get isolated, it's just too easy to drink and uh and watch television. 00:34:31.429 --> 00:34:44.710 Uh and and so there are some things in the normal aging process that can put you at higher risk of then developing uh habits of drinking too much and some of the consequences of it. 00:34:45.029 --> 00:34:48.789 It it's not nearly so common as it is with adolescents. 00:34:49.269 --> 00:34:59.509 Uh in the uh teen years and early twenties, those are the peak years of uh of having difficulty with alcohol, indeed of dying from alcohol-related causes. 00:34:59.989 --> 00:35:09.670 Um both of those, the kind of the young years and the older years, uh alcohol problems can occur anywhere in in the lifespan. 00:35:09.989 --> 00:35:18.230 I guess in our treatment programs, it was people in their forties were about the average age coming in, um, having developed problems already. 00:35:31.909 --> 00:35:32.230 Yeah. 00:35:32.549 --> 00:35:34.789 Yeah, it is, it sneaks up on you. 00:35:35.029 --> 00:35:36.869 It it is a gradual thing. 00:35:37.109 --> 00:35:48.069 Uh and so even if people don't drink like they did in in high school or college, nonetheless they develop a habit of just having alcohol there. 00:35:48.549 --> 00:35:52.389 Uh and over time the effects build up in the brain. 00:35:52.549 --> 00:36:07.670 Uh and and so it can take a while to catch up with you, uh, or it can affect employment, lose a job, or you lose a marriage, a relationship, uh, and problems like that begin to hit in the 30s and 40s. 00:36:07.829 --> 00:36:15.029 Uh, and that's uh the kind of the average time when people come into a specialist treatment program. 00:36:15.750 --> 00:36:19.190 But we're interested in helping people way before that time. 00:36:19.909 --> 00:36:30.469 The drinker's checkup was an example of that to try to help people take a look at their alcohol use and decide if they want to make changes before they're really in serious trouble with it. 00:36:31.109 --> 00:36:40.230 Uh Ricardo, you mentioned part four of the book, and it sounds like there's some great CBT ways of thinking about thoughts and evaluating. 00:36:40.389 --> 00:36:44.069 Are there other substitutes or in part four? 00:36:44.549 --> 00:36:46.549 We also have a section on mindfulness. 00:36:46.629 --> 00:36:56.389 Uh, you know, my uh so the cognitive behavioral approaches to depression focus on recognizing what thoughts are harmful and helpful uh in terms of mood. 00:36:56.549 --> 00:36:57.829 So they're very active. 00:36:57.989 --> 00:37:04.309 Uh and mindfulness uh is uh another approach, right, in which you're not actually trying to change anything. 00:37:04.549 --> 00:37:09.190 You're trying to increase awareness and equanimity, right? 00:37:09.349 --> 00:37:21.029 Trying to be aware of your thoughts, feelings, uh, your behaviors as well, uh, but not necessarily reacting to them or judging them at all, just becoming aware of them. 00:37:21.190 --> 00:37:40.389 So the the whole idea of drinking, for example, is to consider your drinking, but not necessarily having an emotional reaction to whether you should drink or not, but just being aware that you're drinking, how much are you drinking, what is the impact of drinking on you, and and so on. 00:37:40.629 --> 00:37:43.670 Just being aware of it without necessarily reacting to it. 00:37:43.829 --> 00:38:06.869 We talk about things like uh the stream of consciousness, for example, you know that we have a stream of consciousness throughout our days, and how that stream of consciousness can lead to feeling negative feelings, depression, anxiety, and so on, and how you can actually redirect that stream of consciousness by recognizing which thoughts you're having and what the impact of those thoughts are. 00:38:07.029 --> 00:38:11.509 One of the things that Bill has written a lot about is the consequences of thoughts. 00:38:11.750 --> 00:38:18.469 It's not whether the thoughts are necessarily accurate or not, but what are the consequences of thoughts. 00:38:18.629 --> 00:38:21.029 Um, and so we we we talk about those things. 00:38:21.109 --> 00:38:24.549 We talk about how thoughts have a tremendous impact on our body. 00:38:24.789 --> 00:38:28.710 The example that we mentioned, for example, is nightmares, right? 00:38:29.109 --> 00:38:33.190 Nightmares can produce tremendous emotional impact on them. 00:38:33.429 --> 00:38:36.629 You can wake up sweating from fear and so on. 00:38:36.869 --> 00:38:38.230 Nothing is happening. 00:38:38.549 --> 00:38:42.789 You're just having a thought that your your brain has created. 00:38:43.029 --> 00:38:47.029 And we talk about how you can also have daymares, like nightmares, right? 00:38:47.190 --> 00:38:55.109 In which while you're awake, you begin thinking, or your brain comes up with ideas that really scare you or make you very

depressed. 00:38:55.429 --> 00:39:04.230 Um and how you can you can change those those uh thoughts in ways that will be less harmful to you. 00:39:04.549 --> 00:39:11.190 We talk about how harmful thoughts are like the kinds of things we talk about thoughts as sentences you tell yourself. 00:39:11.429 --> 00:39:21.909 And harmful thoughts are the kinds of sentences that somebody who doesn't like you would tell you, somebody who wants to hurt you would tell you, like you're a loser, you'll never account to anything, etc. 00:39:22.309 --> 00:39:22.710 Right? 00:39:22.869 --> 00:39:29.349 And helpful thoughts are sentences you tell yourself as you would talk to somebody you care about. 00:39:29.829 --> 00:39:32.389 You know, supportive kinds of things that you would say. 00:39:32.549 --> 00:39:41.509 And again, becoming aware of how these sentences you tell yourself and how the things you do each day have an impact. 00:39:41.750 --> 00:39:44.949 We talk about how at every moment we have three choices. 00:39:45.509 --> 00:39:52.309 We can think or do something that will improve our mood and our health, leave it as is, or make it worse. 00:39:52.469 --> 00:40:02.149 And we're making these choices every moment throughout our day, and the more choices we make that are helpful, the better our mood and our health is at the end of the day. 00:40:02.389 --> 00:40:08.230 And if we make choices that are not helpful, harmful, you know, the worse our mood and health will be. 00:40:08.389 --> 00:40:14.149 So we talk about all these ideas that I've I mean I've been working on these things for 50 years now. 00:40:14.230 --> 00:40:22.949 Uh my dissertation was actually done with Pete Lewinson, who was one of the pioneers in behavioral activation, and we talked about self-control methods for depression. 00:40:23.109 --> 00:40:28.789 And I'm still using those things that uh I worked on with my dissertation even now. 00:40:29.349 --> 00:40:40.309 So, and I sent I sent you a link to some of our manuals, which are available at NoCharts to anybody who wants to use them on preventing and treating depression. 00:40:40.469 --> 00:40:43.589 Uh and they're available in English and Spanish, almost all of them. 00:40:43.829 --> 00:40:44.149 Yeah. 00:40:44.389 --> 00:40:48.469 And some of them are available in Chinese, Japanese, Korean, Greek, Persian. 00:40:48.710 --> 00:40:49.589 It's just amazing. 00:40:49.670 --> 00:40:49.829 Yeah. 00:40:49.989 --> 00:40:53.269 But they're all available for free in that website that I sent you. 00:40:53.429 --> 00:40:56.069 So yeah, I'll link them all in my show notes. 00:40:56.149 --> 00:40:59.509 I couldn't believe how much information is there. 00:40:59.589 --> 00:41:04.949 As even you have uh manuals for group facilitators and for participants. 00:41:05.269 --> 00:41:05.429 Yes. 00:41:05.670 --> 00:41:08.869 All smoking cessation, you have so much there. 00:41:09.029 --> 00:41:16.710 I mean, it's like I said, I I've gotten more information in the week leading up to this chat than ever before from the both of you. 00:41:16.869 --> 00:41:23.109 I it's just so neat to see uh 50 years of research from two people come together. 00:41:23.429 --> 00:41:25.909 You know, when I immigrated from Purdue when I was 10. 00:41:25.989 --> 00:41:39.029 And before I did, my mother sat me down and said to me, um, your father finished primary school, I finished high school, but we want our kids to go to university, but we don't have the money to send you. 00:41:39.509 --> 00:41:44.069 So your father has decided to immigrate to the US, where there are a lot of educational opportunities. 00:41:44.230 --> 00:41:48.549 And when you finish your education, we want you to share what you've learned with people here. 00:41:49.589 --> 00:41:55.029 So that's the mission I came to the mission district in San Francisco. 00:41:55.269 --> 00:41:57.750 And uh I this still is what drives me. 00:41:57.829 --> 00:42:00.389 You know, I'm trying to share what I've learned. 00:42:00.549 --> 00:42:06.230 Uh, in addition to the stuff I've done uh in person, you know, with prevention and treatment interventions. 00:42:06.389 --> 00:42:15.670 I've also done work on internet interventions, worldwide interventions to help people stop smoking using, again, uh mood management approaches and so on. 00:42:15.829 --> 00:42:21.029 And so I've been able to reach thousands of people in Peru and throughout the world. 00:42:21.190 --> 00:42:24.069 So I'm doing what my mom suggested I do. 00:42:24.549 --> 00:42:26.230 Yeah, you made good on your commitment. 00:42:26.629 --> 00:42:26.869 Yes. 00:42:27.109 --> 00:42:31.109 Sharing what I've learned with as many people as I can. 00:42:33.029 --> 00:42:37.509 We were both affected by an article in our graduate training called Giving Psychology Away. 00:42:37.670 --> 00:42:38.069 Yes. 00:42:38.230 --> 00:42:41.269 Uh actually psychology for the promotion of human welfare. 00:42:41.509 --> 00:42:50.230 But the the central idea was uh we have a responsibility to share with the public what we have learned that helps people. 00:42:50.710 --> 00:42:54.710 Uh and that's kind of driven both of us in the kinds of research that we do. 00:42:55.109 --> 00:43:01.349 And we are very aware that these methods are not going to help everybody, but they help a lot of people. 00:43:01.670 --> 00:43:01.829 Yeah. 00:43:01.989 --> 00:43:02.149 Right? 00:43:02.309 --> 00:43:06.469 And many are people who don't have access to professional counseling. 00:43:07.109 --> 00:43:07.349 Right. 00:43:07.589 --> 00:43:11.269 And so that's why we try to make it available in books and other forms. 00:43:11.670 --> 00:43:17.589 I'm passionate about that too, with the availability to access all kinds of information. 00:43:17.750 --> 00:43:26.710 It feels really important to me that people can access evidence-based and accurate information along with any other information they might be receiving. 00:43:26.869 -->

00:43:29.190 So I think it's it's it's neat. 00:43:29.269 --> 00:43:32.789 I can feel that uh goal from both of you. 00:43:33.509 --> 00:43:38.149 How did you come together on that first book in 1976? 00:43:40.469 --> 00:43:42.710 We we shared a quonset hut. 00:43:43.989 --> 00:43:54.710 We were both in graduate school, and uh the the University of Oregon had these little rickety buildings uh that I think were left over from the World War. 00:43:55.029 --> 00:43:59.109 And uh we we were assigned to one of those as an office. 00:43:59.429 --> 00:44:17.109 Uh and so we found ourselves in the same space and and became friends through school and through spending time together as well, and uh just got interested in this topic uh and um decided to write a book about it, and that's where it started. 00:44:17.269 --> 00:44:19.589 So it was it was my very first book. 00:44:19.909 --> 00:44:21.750 Bill and I were in graduate school together. 00:44:21.829 --> 00:44:31.589 He was a year ahead of me, and um uh when he began his dissertation, he he decided to prepare this this book uh and invited me to join him. 00:44:31.750 --> 00:44:37.670 And uh again, we've been working together for 50 years, and of course, Bill became famous for his work on. 00:44:38.069 --> 00:44:39.109 Motivational interviewing. 00:44:39.190 --> 00:44:42.549 I mean, that's probably what he's best known for all over the world. 00:44:42.710 --> 00:44:43.589 It's just amazing. 00:44:43.750 --> 00:44:47.750 It's being used not only in psychology but in medicine, in other areas. 00:44:47.829 --> 00:44:50.949 It's just amazing how how far it has gotten. 00:44:51.190 --> 00:44:58.230 So anyway, I was very fortunate that I shared that little uh concert hot office with him right back then. 00:44:58.389 --> 00:44:59.429 And we're still friends. 00:44:59.589 --> 00:45:03.190 We get together about every month to chat about life. 00:45:03.750 --> 00:45:04.789 Oh, that's great. 00:45:04.949 --> 00:45:10.789 And I I was really moved to see the the decades of collaboration just as you've updated this book. 00:45:10.869 --> 00:45:19.509 It seems like such a service to come back, review the literature, and observe that things change in the process of writing these books. 00:45:19.829 --> 00:45:20.149 Indeed. 00:45:20.789 --> 00:45:23.429 We want our work to be uh current. 00:45:23.989 --> 00:45:24.149 Yeah. 00:45:24.549 --> 00:45:25.829 As current as we can, yes. 00:45:25.909 --> 00:45:29.589 And things have changed, and so we've we've changed with those things, yes. 00:45:29.989 --> 00:45:30.309 Yeah. 00:45:30.629 --> 00:45:33.670 Bill, can you talk a little bit about motivational interviewing? 00:45:33.750 --> 00:45:41.349 And I don't think you mention it explicitly in this book, but I can feel elements that guide your work, of course. 00:45:42.469 --> 00:45:42.869 Yeah. 00:45:43.269 --> 00:45:47.109 Well, again, I developed that in the early 1980s. 00:45:47.429 --> 00:45:55.190 And at the time, the addiction field, the addiction treatment field, was very moralistic and authoritarian. 00:45:55.589 --> 00:46:04.549 Uh and a therapist might literally say to a person coming in with alcohol problems, sit down, shut up, you don't know anything. 00:46:04.710 --> 00:46:07.750 I'm going to tell you what's wrong with you and what you have to do. 00:46:08.710 --> 00:46:16.949 And it was based on the mistaken idea that alcohol and drug problems come with a personality disorder. 00:46:17.190 --> 00:46:22.949 And the personality disorder involves extreme defenses and denial and so forth. 00:46:23.429 --> 00:46:29.029 And that that was thoroughly believed in professional aspects of this field. 00:46:29.269 --> 00:46:33.269 It turns out that was a result of the way in which we were treating people. 00:46:33.670 --> 00:46:38.949 And if if you treat people with disrespect as if they don't know anything and you're the expert, guess what? 00:46:39.029 --> 00:46:40.069 They get defensive. 00:46:41.909 --> 00:46:49.029 And so there never was a personality pattern like that, unique to people with alcohol problems. 00:46:49.829 --> 00:46:54.469 And motivational impinging was almost the exact opposite of that approach. 00:46:55.109 --> 00:47:01.269 Lots of listening to people interested in their own perspectives, trying to find their own motivations for change. 00:47:01.509 --> 00:47:11.670 So rather than trying to install something that's missing, rather to find in people that which they already have that helps them move in the right direction. 00:47:12.309 --> 00:47:16.789 A simple idea from it is that ambivalence about change is normal. 00:47:17.269 --> 00:47:26.309 That whenever we're facing the possibility of making a change, of course, some of us says, you know, I I can see that. 00:47:26.389 --> 00:47:29.029 And some of us says, no, I don't think so. 00:47:29.190 --> 00:47:31.589 I like the way I'm living my life. 00:47:31.829 --> 00:47:37.909 If you counsel in a way that takes all the good lines, you have a problem, here's what you have to do. 00:47:38.149 --> 00:47:40.469 The normal response is, no, I don't. 00:47:40.549 --> 00:47:42.469 Yeah, I don't really have a problem. 00:47:42.549 --> 00:47:45.269 It's not that much of a I don't I don't really want to do that. 00:47:45.509 --> 00:47:50.309 And it's literally caused by the way the counselor is working with the person. 00:47:51.269 --> 00:47:53.829 Motivationally being takes it the other way around. 00:47:53.989 --> 00:48:06.309 And I want to hear the person's own perspective, their own reasons for change, and to have them literally talk themselves into changing, rather than me trying to talk them into changing. 00:48:07.190 --> 00:48:12.309 And that that was really different from the way addiction was being handled at the time. 00:48:12.710 --> 00:48:17.349 Uh I think the treatment field has moved a lot in that direction now. 00:48:17.989 --> 00:48:25.109 And it turns out the the reason this crosses

professions and nations so much is that ambivalence is just us. 00:48:25.670 --> 00:48:27.589 That's human nature, you know. 00:48:27.989 --> 00:48:45.509 Uh and in healthcare, if you're diagnosed with diabetes as I was 20 years ago, uh I was sent to a diabetes educator who said, sit down, I'm going to tell you what you have and what you need to do, and give me about 12 behaviors I needed to change. 00:48:46.230 --> 00:48:51.989 And I did change them, but I also sat there thinking, I may know a better way to do this. 00:48:53.109 --> 00:48:59.589 Uh and in in medicine, just telling people what they have to do doesn't work particularly well. 00:49:00.469 --> 00:49:07.750 But motivational interviewing, inviting people to talk about their own motivations for change actually does. 00:49:09.589 --> 00:49:14.389 So it's being used in dentistry just to get people to floss their teeth and brush their teeth? 00:49:14.710 --> 00:49:17.190 Just even simple stuff like that. 00:49:18.549 --> 00:49:32.469 Yeah, I mean I I hear talks about that in the medical school here, you know, both at uh at UC San Francisco and at Stanford, I uh uh presentations on using motivational interviewing with people with schizophrenia recently, for example. 00:49:32.710 --> 00:49:44.309 It's just amazing how much that approach to providing healthcare has has just permeated all sorts of fields, not just in the US, but internationally. 00:49:44.389 --> 00:49:45.190 It's just amazing. 00:49:45.349 --> 00:49:45.509 Yeah. 00:49:45.909 --> 00:49:46.230 Yeah. 00:49:46.469 --> 00:50:02.549 I saw on an intake at a doctor's office earlier in the year I I was to check as a a patient, uh, whether I was contemplative or pre-contemplative in my commitment to a new doctor. 00:50:02.789 --> 00:50:12.629 So it's it is it's neat to see, like you're saying, because it is woven throughout just how we think about things now for a lot of people who've been trained. 00:50:13.109 --> 00:50:23.109 I think Bill and I, uh, although we're primarily focused on cognitive behavioral methods, also we're very much uh influenced by Roverian interviewing methods. 00:50:23.349 --> 00:50:43.349 Um our our mentors uh in grad school uh in the first year of you know clinical training taught us how to use Roverian interviewing to begin to develop uh a bonding with with our clients that then helped to move along into the moral cognitive behavioral stuff. 00:50:43.509 --> 00:50:47.589 And uh I think that's been really important in in both of our development. 00:50:47.829 --> 00:50:56.549 When I came to work at San Francisco General Hospital, one of the things I found is that a lot of the people who were coming were being treated in a very disrespectful way by everybody. 00:50:56.710 --> 00:51:05.589 I mean, you know, most of them were were not white, uh they were all of them were poor, uh usually sick, many didn't speak English and so on. 00:51:05.670 --> 00:51:18.309 And so they were treated really badly by people around

them, and just giving them a sense of respect was you know the most important thing you could do before you you began any kind of treatment or prevention intervention. 00:51:18.469 --> 00:51:20.469 So that's really being important. 00:51:20.629 --> 00:51:20.949 Yeah. 00:51:21.589 --> 00:51:24.869 Bergen was a very like uber behavioral program. 00:51:25.029 --> 00:51:30.469 So when you graduated from there, you were gonna be a behavior therapist and use these techniques. 00:51:30.629 --> 00:51:42.389 But the faculty had the wisdom to say, but before you start learning and doing behavior therapy, we want you to spend a year learning how to listen and learning how to talk to clients. 00:51:42.789 --> 00:51:48.230 And and hired a person who was an academic grandchild of Carl Rogers to teach us that. 00:51:48.469 --> 00:51:53.190 And it it became the way I did behavior therapy my whole career. 00:51:53.429 --> 00:52:09.829 Uh and behavior therapy works just a whole lot better when you respect people and you listen to them and you know notice what they do well and affirm that, and you're a real genuine person, not a distant masked expert of some sort. 00:52:10.789 --> 00:52:13.750 Uh it it just works better at doing it in that way. 00:52:13.829 --> 00:52:19.989 And I'm so grateful that we had a year of that before we laid hands on techniques. 00:52:20.469 --> 00:52:21.109 Yeah. 00:52:21.429 --> 00:52:24.549 I see that I I think that is so important. 00:52:24.710 --> 00:52:31.509 When I work with an intern or an associate-level person, that is the most important thing. 00:52:31.589 --> 00:52:37.029 And some of these folks coming through now uh were at home for high school during COVID. 00:52:37.109 --> 00:52:39.989 You know, some of the students getting into grad school now. 00:52:40.149 --> 00:52:46.869 And so some of those just sitting with a person elements seem to be so integral. 00:52:46.949 --> 00:52:50.389 It's really neat to hear how that was woven for an entire year. 00:52:50.710 --> 00:53:00.389 So, for the clinicians listening, what are some of the things that they could take away or apply through that lens, like just working with a client? 00:53:01.429 --> 00:53:06.069 I wrote a book, published it a few years ago called Effective Psychotherapists. 00:53:06.230 --> 00:53:07.750 Uh and with Dr. 00:53:07.829 --> 00:53:16.789 Moyers and I just got interested in why is it that therapists allegedly doing the same treatment get such different outcomes? 00:53:17.269 --> 00:53:30.789 That e uh even in the same clinic and the same agency, everybody using the same treatment manual, even, uh one of the big predictors of how clients are going to do is the therapist who treated them. 00:53:31.349 --> 00:53:32.949 What is it about that? 00:53:33.190 --> 00:53:38.869 And so we went back through 70 years of psychotherapy research to ask that question. 00:53:39.349 --> 00:53:42.469 What is it about therapists whose clients get better? 00:53:42.629 --> 00:53:47.589 Uh, and how are they different from therapists whose clients don't do so well or even get worse? 00:53:48.629 --> 00:53:57.670 And we came up with eight characteristics of those therapists, which are not personality characteristics, but are skills or ways of working with people. 00:53:57.989 --> 00:54:03.509 And number one on the list, because it has the biggest effect, is empathic listening. 00:54:03.829 --> 00:54:09.190 Uh is if you if you listen well to your clients, they're more likely to get better. 00:54:09.349 --> 00:54:13.029 What across theories, whatever manual you're using. 00:54:14.389 --> 00:54:27.269 Um Affirmation of noticing what your clients are doing well and what's good about them, what's strong about them, and being sure to comment on and affirm those things. 00:54:28.149 --> 00:54:30.549 Acceptance of people as they are. 00:54:31.269 --> 00:54:32.949 There's a lovely paradox. 00:54:34.069 --> 00:54:35.589 And and it's Carl Rogers. 00:54:35.829 --> 00:54:45.349 He said, I if I feel unacceptable, I'm ashamed, I'm like I'm a bad person, I'm not okay, it's very hard to change. 00:54:45.670 --> 00:54:51.190 And when I experience acceptance as I am, it becomes possible to change. 00:54:52.869 --> 00:54:54.149 Why are we wired that way? 00:54:54.309 --> 00:54:56.789 I don't know, but it it seems to really be true. 00:54:58.309 --> 00:55:01.909 Pragmatically, just having very clear goals for therapy. 00:55:02.149 --> 00:55:05.989 That you and the client both know where you're trying to go when you agree about that. 00:55:07.349 --> 00:55:10.629 That's that's an important piece uh as well. 00:55:11.349 --> 00:55:17.269 Uh yes, giving information and advice also, but it's how you do it. 00:55:17.589 --> 00:55:22.629 You can do it in a way that the the walls of defense go up and the person can't hear it. 00:55:22.869 --> 00:55:29.429 You can do it in a way that is respectful of the person and they can listen to you and and do what they need to do. 00:55:29.670 --> 00:55:40.149 So it's it's the how of doing these other techniques, whether they're medical interventions uh or cognitive behavioral psychological interventions or whatever they are. 00:55:40.469 --> 00:55:45.190 Besides the what uh of what you're doing, there's a how of what you're doing it. 00:55:45.429 --> 00:55:52.789 And it accounts in psychology for at least as much outcome as the particular techniques that are being used. 00:55:55.589 --> 00:55:58.549 Bill's mentioning the thing of accepting somebody the way they are. 00:55:58.710 --> 00:56:10.069 We have a quote in the book uh from Suzuki uh that says, you are perfect the way you are, and you could use a little improvement. 00:56:12.549 --> 00:56:15.589 That's the b that's the balance about ourselves too. 00:56:17.909 --> 00:56:21.829 Yeah, the dialect they'd say acceptance and change. 00:56:22.230 --> 00:56:22.949 Yes, yes. 00:56:23.269 --> 00:56:24.549 They're not inconsistent. 00:56:24.789 -->

00:56:25.429 Yes, yes. 00:56:25.989 --> 00:56:31.429 That people have value, that they're valuable, they're worthwhile, just as they are. 00:56:31.670 --> 00:56:32.149 Yes. 00:56:32.469 --> 00:56:38.230 But there are things that they're happening in their lives that are causing them problems, and that those things can be changed, you know? 00:56:38.949 --> 00:56:45.109 Again, the idea of self-efficacy, we can actually make those changes that which I call the healthy management of reality. 00:56:45.349 --> 00:56:56.869 We can shape our lives, we can shape ourselves in ways that we choose to do, that are not forced upon us, or that somebody doesn't tell us, you know, you're a bad person, you gotta do this. 00:56:57.269 --> 00:57:04.469 But something that we can choose by being aware of what we're doing and being aware of where we want to go. 00:57:04.789 --> 00:57:05.029 Yeah. 00:57:05.269 --> 00:57:09.829 I don't think I could manufacture a better closing thought if I tried. 00:57:10.629 --> 00:57:17.109 Um that being said, is there anything else that feels important to capture um from our conversation today? 00:57:17.269 --> 00:57:30.230 I know people are gonna be curious to check out the book uh because it could be helpful for the clinicians listening to help guide clients and also for the clinicians listening who may need this support themselves. 00:57:30.629 --> 00:57:40.389 We we did find in my dissertation that when we gave people this book at the end of treatment, we and we randomly decided whether people would get the book or not. 00:57:41.190 --> 00:57:49.349 Um those who were given the book continued to decrease their drinking, and those who didn't receive the book just stayed where they were at the end of treatment. 00:57:49.589 --> 00:57:55.670 So they were able to continue making changes uh over time with a little bit of guidance. 00:57:55.909 --> 00:58:00.309 And that was how what Gutta started thinking about well, what if you just gave people the book? 00:58:00.869 --> 00:58:03.589 And it turns out they could do it too. 00:58:04.309 --> 00:58:04.549 Yeah. 00:58:04.949 --> 00:58:05.190 Yeah. 00:58:05.429 --> 00:58:06.309 So interesting. 00:58:06.469 --> 00:58:15.269 I uh did notice in one of the articles that when therapy alongside the book was effective, it was because of empathy, right? 00:58:15.670 --> 00:58:16.389 Well, yes. 00:58:16.469 --> 00:58:19.269 I mean that's almost my other book, but yeah, yeah. 00:58:19.509 --> 00:58:19.670 Yes. 00:58:19.989 --> 00:58:23.269 But but we did find big differences among the therapists. 00:58:23.509 --> 00:58:32.309 Uh and those the most empathic therapists, 100% of her clients were successful in making changes. 00:58:32.469 --> 00:58:39.109 And the least empathic of the nine therapists had a 25% success rate using the same manual. 00:58:40.069 --> 00:58:41.670 How did you track that? 00:58:41.829 --> 00:58:46.389 How could you uh track those differences in empathy in that way? 00:58:47.190 --> 00:58:50.149 We couldn't even afford video recording at the time. 00:58:50.389 --> 00:59:01.909 Uh so we were watching through a one-way mirror and had three different supervisors, all of whom were rating the therapists on empathic listening using a scale that Carl Rogers' students had developed. 00:59:02.069 --> 00:59:06.710 And we just rank ordered the therapists and with high level of agreement. 00:59:06.949 --> 00:59:09.989 Boy, this one was absolutely the best listener. 00:59:10.469 --> 00:59:15.269 And at the other end, two of us rated that person as nine and the other eight out of nine. 00:59:15.589 --> 00:59:25.989 Um, and so just that rank ordering had a big effect on uh likelihood the clients were gonna be changing, even though all the therapists were following the same manual. 00:59:26.389 --> 00:59:27.509 Oh, how cool is that. 00:59:27.750 --> 00:59:29.829 Any closing thoughts, Ricardo? 00:59:29.989 --> 00:59:31.989 Anything else to note? 00:59:32.710 --> 00:59:39.750 Well, just uh to reinforce that we hope people will be able to make their own choices. 00:59:39.989 --> 00:59:56.949 At the end of the book we say alcohol like tobacco is a dangerous drug with potential to cause serious harm and snare people in compulsive use, but it has also been around for a very long time, and many people have learned to use it without causing problems for themselves or others. 00:59:57.190 --> 01:00:02.710 We note that recent information about risks has led many people to rethink drinking. 01:00:03.029 --> 01:00:12.069 Making your own rational choice about drinking is far preferable to waiting for some major life event to occur that forces you to change. 01:00:12.230 --> 01:00:15.909 It may even prevent such an event from ever happening. 01:00:16.149 --> 01:00:20.309 We wish you all the best in choosing your own way. 01:00:21.829 --> 01:00:27.589 Thank you both so much for your time for t sharing with us what you've been working on. 01:00:28.149 --> 01:00:31.269 Thank you for listening to the Self-Cherapist Therapist. 01:00:31.429 --> 01:00:37.670 I hope today's conversation gave you insight, clarity, or a tool you can take straight into your clinical work. 01:00:37.909 --> 01:00:45.429 If you found this episode helpful, be sure to subscribe to the show on YouTube and leave a review on Apple Podcasts or Spotify. 01:00:45.589 --> 01:00:49.909 It helps other therapists find the show and keeps these conversations going. 01:00:50.230 --> 01:00:54.949 Until next time, keep learning, stay curious, and take care of yourself too.