Patrick McElwaine, PsyD, is a Licensed Clinical Psychologist, Licensed Professional Counselor (LPC), and a Beck Institute CBT Certified Clinician. Dr. McElwaine is an Associate Professor and the program director of the Graduate Counseling Psychology Program at Holy Family University and is a faculty member at Beck Institute. Dr. McElwaine has taught 33 workshops at Beck Institute.
Dr. McElwaine has been working in the psychology field for more than 25 years. His expertise lies in suicide prevention, depression, anxiety, trauma, grief, and substance use disorder (SUD). He has seen all sides of SUD – from working in residential, outpatient, inpatient, and primary care with people with SUD, to struggling with substance use himself. He has been in continued recovery for 13 years.
We had the pleasure of interviewing Dr. McElwaine about his work surrounding trauma and substance use disorder.
Photo ©2018 Dan Z. Johnson www.danzphoto.net
Talk about the trajectory of your career. Why did you eventually specialize in substance use disorders?
I’m in recovery. I celebrated 13 years of continued recovery from drugs and alcohol on February 12th of this year. June 23rd of 2006 is when I started my recovery journey, and I didn’t get it right until February 12th, 2009.
I never wanted to specialize in addiction because early on, I knew I had a problem. I knew I was good at connecting with people, relating to people, and helping people, but substance use was one area that I really, really struggled in. In 2010, I went to Philadelphia College of Osteopathic Medicine (PCOM) to pursue a doctorate. I started to really embrace and understand CBT. The person who helped me out in my own therapy used CBT, among other things, and that’s where the trajectory of my life related to treating substance use changed. I saw first-hand how friends, family, and I, myself can be positively impacted by CBT. Going to see somebody whom I could connect with, but who also practices as a cognitive behavioral therapist, was amazing.
I want people to know that going to therapy and being in recovery are amazing things that don’t have to be a reaction to trauma or a problem. It could just be a benefit to your quality of life. One of the big things Beck Institute does, and I’m proud to be part of, is trying to change the narrative of the way mental health is looked at.
How has your own recovery journey, as well as working in community settings, influenced the way you teach?
My evaluations for my Beck Institute workshops are pretty nice. I love it when I see a statement like “I’ve been in this field for like 30 years and this is the best workshop I’ve ever been part of.” It’s so nice to hear because these are 8-hour long workshops, so it can be intense. Right from the very beginning, I let people know that I’m in recovery. I have so much clinical experience in the field working with really intense and tough cases, and so I bring that into workshops and supervision, along with my personal experience with recovery. When I give a talk on substance use disorder or suicide prevention, I want students to say: “Hey, Doctor Mac, I’m struggling with this client right now who’s attempted suicide five different times and they’re doing xyz.” It enables me to pull in my experiences and give them practical techniques for intervening.
One of the techniques I use in all my workshops is the value card sorting activity. I’ve continued to do it with all my patients, and I did it when I worked as an inpatient practitioner. I was the lead clinical psychologist at an inpatient psychiatric facility, which I loved. When I bring up certain techniques I used in inpatient that were successful, I’ll get emails from people who attended my workshops that say, “I tried it, and I can’t believe this is working!” I love seeing evidence that students were actively engaged in the workshop and took things from it and applied it to their clients.
In what ways can trauma impact people who have substance use disorders?
I think trauma is one of the biggest factors for someone who develops a substance use disorder. It’s not always a significant problem related to Post-Traumatic Stress Disorder (PTSD). There’s another diagnosis like PTSD that I think will eventually be in the newest DSM, called Developmental Trauma Disorder. It hits on trauma moments that might not fit the criteria of PTSD. An example of a trauma moment would be being bullied. It’s something that might not fit PTSD, but it’s impacting somebody’s life and they might start to use alcohol as a way of coping or feeling connected. I know they say marijuana is the gateway drug, but I think of trauma as the gateway drug to substance use disorder. Negative experiences can build up and lead someone to develop a negative way to cope.
What’s tough about drugs and alcohol is that they work. I felt better when I used drugs and alcohol, and I didn’t feel alone. When I talk about my personal story, I talk about the gifts of alcohol and drugs. With alcohol and drugs, I was able to talk to girls and defend myself. I felt like I was able to make more friends. I attributed these gifts to drugs and alcohol and not me as a person. I now talk about the gifts of recovery. I think a lot of people whom I work with who struggle with addiction can’t see the gifts of recovery. They’re thinking, “I’m always going to be miserable. I’m always going to feel broken. I’m always going to relapse.” A lot of these thoughts we address in workshops when we cover cognitive errors. We, as therapists, want clients to get to a place where they start to believe they’re resilient, strong, empowered, and a good person.
What are some of the key components of treating substance use with CBT?
I use a number of techniques with substance use disorder. I like to mix motivational interviewing and Cognitive Behavior Therapy together. I think mindfulness and other interventions work well, but I think that one of the biggest problems that I hear about from individuals who are struggling with addiction is their cognitive errors. Cognitive errors are often like fortunetelling: thoughts like “I’m never going to be successful at this rehab. I’m never going to be successful with this therapist because I’ve done it before. Stigma is always going to be a part of me.” It’s this all-or-nothing thinking that disqualifies any positive thought. I use a technique with my clients called “The Rap.” When a client is dealing with a negative situation, I ask them to identify the negative thoughts they have about a situation and discern if they’re making a cognitive error. I then help them restructure their thoughts with realistic, adaptive thoughts (that are usually more positive). For example, a client’s negative thought might be something like: “Recovery is going to be too tough. I’m never going to get it.” And when we discuss this thought, we might find that a more useful perspective is “After years of drug use this is going to be hard. I just got to keep taking it one day at a time.” That kind of restructuring can really help the person move on.
Another technique for treating substance use disorder is examining core beliefs. Another one is identifying the advantages and disadvantages of going to a 12-step program meeting versus continuing to use drugs. Motivational interviewing will be important because a therapist might work with somebody who is using every defense mechanism—or maladaptive coping strategy– in the book. Validating clients’ experiences and supporting them through motivational interviewing can be very effective. Rolling with a client’s resistance and defense mechanisms can help establish trust so the client will keep coming back. Some people may struggle and relapse, but I tell my clients that that’s okay. I tell them, “It’s fine, just keep coming back.” Some of the core beliefs a person struggling with substances may have might be that they are unlovable, helpless, and worthless. Helping people draw adaptive conclusions about their experiences can help them see that they are lovable, strong, resilient, or whatever that may look like for them. Looking at co-occurring issues alongside addiction can help a therapist treat the whole person and not just the problem of substance use. Mental illnesses like PTSD, depression, and anxiety often accompany addiction.
How do the tools from 12-step programs differ from or complement CBT?
In my workshops I’ll go over 12-step meetings and CBT. There are differences and similarities between the two. 12-step programs view the person as powerless over alcohol and drugs and CBT is more about empowerment, but I think the mix of 12-steps and CBT can be really beneficial. You’re learning in CBT how to think differently about your past, future, and where you are currently, as well as developing coping skills and interventions to manage situations in a different way. 12-step programs allow you to go somewhere where you feel connected to others. One of the things that I love doing with my clients is asking them to attend a 12-step meeting and listen for cognitive errors.
I had a client who was really in a bad spot. She was addicted to fentanyl and heroin and living on the streets. This client told me: “I went to a meeting, Doctor Mac, and you’re not going to believe it, but everybody uses cognitive errors there.” When you’re struggling, cognitive errors are common. She said there was someone at the meeting that said they’re never going to be successful in treatment, because they’ve done it six times before and what’s going to be different about the seventh time? She thought about what that person said through a CBT lens: “Realistically, you’re different than who you were the last six times you tried. Things could be different on your seventh time. You’re at this meeting right now, clean and sober.” I think the 12-step program and CBT can overlap really beautifully.
What advice do you have for therapists working with people who experience substance use disorder, especially therapists who use CBT?
I think it’s really important for anybody working with substance use disorder to be well-versed in CBT and motivational interviewing. We’re taking away the only thing in clients’ lives that makes them feel better. How do we help them discover their strengths? How do we help them discover that recovery is a beautiful thing? And try not to take things personally. Having the mindset that, “I can’t do anything. They have to be ready when they’re ready,” isn’t true. Your support and ability to be present can give them an avenue to recovery. It’s hard work, but it’s amazing working how much you can help somebody who’s struggling with substance use disorder.
The numbers of substance use disorders have increased in the past decade, just like the numbers of suicides have increased. I really want therapists to try to hold on to the positive moments that they’ve had working with individuals with substance use disorder. If you get a letter or a post-it note or a thank you card from somebody who was your client, hold on to it. There may be days that you lose somebody to an overdose. There may be days when your client doesn’t come back. You want to try to hold onto the love and the passion that got you into working in mental health. Some people really lose that focus. For all therapists out there, we’re good at telling people how to practice self-care. We really need to practice self-care, too.
Learn more about Beck Institute’s trainings on substance use disorder.