cheap ceus – Effects of Anxiety

Anxiety Disorders in the DSM 5 TR | Symptoms and Diagnosis

Hey there, everybody, and welcome to this presentation on diagnosing anxiety and panic in the DSM 5tr. I’m your host Dr. Donnelly Snipes in this presentation.Very briefly, we’re going to review the diagnostic criteria for anxiety disorders or at least most of them in the DSM 5 tr.So let’s talk a little bit about anxiety disorders in general, when we’re talking about anxiety disorders, we need to remember that fear and anxiety may be expressed as fighting agitation, tantrums fleeing freezing fawning clinging, or withdrawal, or what I call the final f, Which is um politely forget about it, because people, just don’t have any more energy left, so they kind of withdraw anxiety.Disorders differ from each other regarding the types of objects or situations that cause fear, anxiety, or avoidance behaviors and the associated beliefs.Anxiety disorders represent a response that is not developmentally culturally or, I also add, contextually normative in terms of intensity or duration.So when we’re looking at what somebody is anxious about, we want to examine, obviously culture and development, something that a five-year-old is afraid of is not necessarily going to be the same thing that a 25-year-old is afraid of.We also want to look at context, though, something that uh, you’re, afraid of in one context, you may not be afraid of in another like for children being around strangers may not be stressful for them when they are at home or when they’re.At school, somebody comes in to do a presentation versus when they are alone and they don’t have a caregiver around.Interestingly, from August 2020, through December 2020, the percentage of adults reporting symptoms of an anxiety disorder rose from 31 4 to 36 9.Now, when you go through the DSM and you start adding up the prevalence of these anxiety disorders, it is really hard to get to a number anywhere close to 36 9. So the numbers in the DSM and the numbers in the uh national health survey, don’t seem to jive very well.We also have to remember that during 2020 we were at the beginning of the pandemic, so there was more anxiety.You would expect that, but even the 31 percent that it was before 2020 seems to be higher than what is identified in the DSM.So I think that’s interesting the anxiety chapter in the DSM 5tr, just like in the DSM 5, is arranged in order of diagnosis which appears in children first, so separation, anxiety, and disorder appear first, and generalized anxiety.The disorder is down a little way, whereas you might expect some of the quote more common disorders to be first, but that’s not how the DSM is arranged.However, in this presentation, I did put generalized anxiety first, when we talk about generalized anxiety, we’re talking about excessive anxiety most days for six or more months, and the anxiety is about a variety of things.It’s not just about one particular thing like health or an individual or a phobia.It is about a variety of things.The worry, in addition to being excessive for the person’s developmental age, culture, and context.The worry is difficult to control the anxiety or the feeling of anxiety is associated with three or more symptoms in adults or one or more symptoms in children, feeling restless or feeling keyed up or on edge, easily fatigued difficulty concentrating, or mind going blank, irritability muscle, tension Or sleep disturbance, I want you to think about it. Anxiety is part of the fight or flight response, so we would expect somebody to experience anxiety.Would it be experiencing symptoms of hpa, axis activation, or activation of the threat, threat, response, or stress response? Whatever you want to call it, so we would expect all of these symptoms or any of these symptoms. When the fight or flight system is engaged, the body is not focused on higher order, processing, memory, or concentration it’s focused on self-preservation protection the person becomes more vigilant because they are trying to protect themselves from threats.They’re not able to relax enough to get good quality sleep because guess what they are keyed up.They’re scanning for those threats, muscle tension and I’ve mentioned in other videos.When I used to play tennis, my coach always used to say don’t stand flat-footed on the baseline, because it takes more time and it’s harder for you to run and spring into action to where that ball is going to be.Now.That is not a threat per se, but the same thing is true for people with anxiety disorders, when you are when you’ve got that muscle tension, it’s kind of like standing on your toes on the baseline.In tennis, you are primed and ready to go and it makes it easier to theoretically fight or flee.These symptoms have to cause clinically significant distress.People can have subclinical anxiety disorder where they have a lot of worry about a variety of things, but it is either not excessive for what they’re worried about, or it doesn’t cause them clinically significant distress. Overall, they report a decent quality of life.It doesn’t interfere with functioning in major areas of their life and generalized anxiety disorder, as well as all of the disorders, are not better explained by a medical, mental, or substance use disorder, and we’re going to talk in the end about differential diagnosis Of the anxiety disorders in general because there’s a lot of overlap between the symptoms, as well as the differential, diagnosis, and comorbidities for anxiety disorders.Remember the difference is often what the person experiences anxiety about and the cognitions associated with the diagnostic features of generalized anxiety disorder.Well, this section, as with most of the sections in the anxiety chapter, pretty much just recapitulated the diagnostic criteria and it elaborated a little bit.One interesting feature is that for generalized anxiety disorder, they noted that adults tend to worry about general life, things like paying bills and getting a promotion, or what’s going to happen with this or that or what’s going on in the world. Kids tend to worry about their competence like performing at school or their ability to be competent in relationships.Sometimes they worry about disaster now, with the coming of the pandemic.We can probably add that too, but other disasters like hurricanes and fires and floods and those sorts of things can prompt a lot of worry in children and punctuality.Interestingly enough, some children become very concerned about being punctual, and so it’s interesting to note that there is a difference in what they worry about, which makes sense, because adults have different responsibilities than kids do, and you notice that, except for disaster, a lot of these worries revolve around the primary life areas or functions of the person.You know: kids, are, n’t worried about paying bills or or maintaining or parenting, or some of the things that that adults worry about associated symptoms.Well, let me talk about disaster. Quick, I’m trying not to go too far off the rails today, because we’ve got a lot to cover, but it’s important to recognize that children have a difficult time, understanding, the prevalence and likelihood of things.So when there is a disaster such as you know, we’ve had several in middle Tennessee over the past two years and a child watching the news or hearing about the news may not understand how close or far away that disaster was or the likelihood of It recurring adults are better able to understand.You know it’s a 100-year flood or there’s the chance of it happening again.Do you know whatever? The probability is depending on what you’re talking about children don’t understand that they see it on the news it feels like, since it’s on the news, it’s kind of in their house.So it feels like it’s right in their space and it’s hard to know when it’s going to end or when it’s going to happen again, which can prompt them to have a lot more worries about disasters.Parents can help by explaining some of the things to them and explaining to children the probability of another disaster occurring, and you know how they’re safe right now and the steps that they can take.It won’t do everything, but it is important again to recognize children’s different cognitive abilities compared to adults, associated symptoms with generalized anxiety, disorder, and other somatic symptoms that are not as intense as those seen in panic disorder.So we will also see potentially heart racing clammy, skin, rapid breathing other things, and an upset stomach that isn’t specifically indicated in diagnostic criteria, but we know it happens when that fight or flight response is kicked off the prevalence.Remember I said if you start adding up the prevalence of all these anxiety disorders.You’re going to be hard-pressed to get anywhere close to 31 percent and according to the DSM 5 tr between one percent of adolescents and three percent of adults in the? U s experience generalized anxiety disorder according to the National Center on Health Statistics in 2019. Now that was before the pandemic.15 6 of adults experienced symptoms of generalized anxiety disorder in the prior two weeks.The development, and course the mean onset, is rarely before adolescence, and is I’m? Sorry, the mean onset is 35 and rarely before adolescence.So this is one of the disorders that has a much later onset than other disorders, which I did find to be somewhat interesting.Now we’ll move on to separation.Anxiety, separation.Anxiety is the first disorder in the chapter because it tends to be the one that presents earliest and it can be diagnosed as early as preschool separation.Anxiety is characterized by developmentally inappropriate, excessive, recurrent anxiety about separation from major attachment figures.To be diagnosed, the person has to have three or more symptoms.It can be diagnosed in childhood. It can be diagnosed in adulthood if it’s diagnosed in adulthood.You do not have to have a childhood onset of separation anxiety.It actually can have an adult onset, so that is something to remember: symptoms, three or more distress due to or in anticipation of separation from home or from major attachment figures, anxiety about losing a major attachment figure, or possible harm to them.Anxiety about something bad happening to the person, the patient, which would cause them to be separated from an anxiety from an attachment figure.So they have fears about something happening to the attachment figure, causing separation, and fears about them, something bad happening to themselves, causing separation, a reluctance, a refusal to go out or away from home because of fear of separation.Now, generally, this is leaving home and separating from that attachment figure, but in some cases, it can include even being reluctant to leave the house to be cut with the attachment figure because they’re afraid that when they’re out there, they may get separated.Now think how this might occur if there was a child who happened to be at a carnival and got separated from their caregiver that might prompt future fears of separation when in public places, fear of or reluctance to be alone, or without major attachment figures.Refusal to go to sleep without being near a major attachment figure, nightmares about separation, or physical complaints in reaction to or in anticipation of separation.So they have those physiological symptoms of anxiety now note here they keep talking about major attachment figures because remember this can be diagnosed in adulthood.We’re not talking about the primary attachment from infancy. We’re talking about the person’s current major attachment figure, whether that be their significant other, their parent, or whomever that happens to be the fear, anxiety, or avoidance, is persistent, lasting at least four weeks in children and adolescents, and typically six months or more In adults – and you’ll find that’s a common theme where a lot of these situations or conditions have to last six months or more and be causing clinically significant distress for six months or more to rank a diagnosis.Although the symptoms often develop in childhood, they can be expressed throughout adulthood.It can be diagnosed in adults in the absence of a history of childhood separation, anxiety, or disorder, and, as I said, it causes clinically significant distress or impairment in one or more areas of functioning.The diagnostic features section repeats the diagnostic criteria with some elaboration and examples.It’s a pretty straightforward diagnosis in terms of development and, and course the onset of separation.Anxiety can be any time from preschool through adulthood, but generally before the age of 30.So you can have diagnoses of separation anxiety up through the 20s, there may be periods of exacerbation and remission, although most child onset cases do not experience ongoing, clinically significant impairment.I thought that was kind of an interesting associated feature.Now these are not diagnostic criteria.These are features that are associated with separation anxiety but didn’t rank in the diagnostic criteria, sadness or apathy. Well, if somebody is perpetually anxious that hpa axis is going to down-regulate some which may contribute to apathy, if they are perpetually anxious, they may also start feeling hopeless and hopeless, which is associated with feelings of sadness and depression.They may have difficulty concentrating well.The mind is not focused on concentration.If it’s in a perpetual state of fight or flee, there may be social withdrawal just stepping away from everything, because they don’t have the energy to engage with others.Because the anxiety is so pervasive in older children you may see homesickness or pining when they are away at camp or or something like that.Now.A lot of children who don’t have separation, anxiety, or disorder, experience homesickness when they’re away at camp.For the first time, however, this is also associated with separation, anxiety, the child migs or the person may exhibit anger or aggression towards separators.So anybody who’s causing a separation between the patient and their major attachment figures may provoke anxiety, anger, and perceptual disturbances.Now these are not hallucinations. These are when a person is alone, for example at night, and they feel like somebody’s watching them, or they think they see something moving in the shadows.It’s not there and by turning on the light.So there are no more shadows.You know that goes away.It’s, not a persistent uh hallucination that the person is experiencing, but perceptual disturbances are more common in children than they are in adults, and we want to make sure we don’t mislabel that as something related to a psychotic disorder, children with separation, Anxiety tends to be described as demanding intrusive and in need of constant attention.According to the DSM now, I would argue when we get down a little further that this may be true of all people with separation, and anxiety, adults may appear dependent and are likely to contact their major attachment figures throughout the day and track their whereabouts.They are also often overprotective as parents and pet owners.Interestingly enough, the DSM did mention pets where the person with separation anxiety may be excessively concerned about knowing where their pet is at all times.The prevalence of separation.Anxiety in children is approximately four percent, and in adolescents and adults, it ranges from one to two percent. In the culture section, the DSM talked about the importance of differentiating separation, and anxiety disorder from the high value, some cultural communities place on strong interdependence among family members.Specific phobias is the next in the line of disorders we’re going to talk about and a specific phobia is pretty straightforward.There’s a marked, fear or anxiety about an object or a situation about 75 percent of people that have one phobia have more than one phobia, and I think, if you think about it, even if it doesn’t rise to the level of being a Diagnosable phobia you can think about.If you have one what we’ll call irrational fear, you probably have a couple of others when I started to think about it.I’m, like yeah, i have i have a couple in there.The stimulus almost always produces an immediate fear response and is actively avoided.The fear is disproportionate to the threat that persists for guess what six months or more and causes clinically significant distress – and I have this bold and italicized because it’s important to remember that.Having a fear – and I’ve talked in other videos about my fear of bridges, I also have a fear of enclosed spaces.I hate you know those little water, tubes and tunnels and things that make me feel closed in.Does it cause me clinically significant distress or cause me to have to alter my life to get around it? No, so it doesn’t rise to the level of a specific phobia. A lot of people have fears that may not have a um basis or the fear may be disproportionate to the threat.In reality, we recognize it, but it doesn’t cause us clinically significant distress, so it would not be diagnosable as a specific phobia and the specific phobia is not better explained by another mental disorder and I’m thinking here more obsessive, compulsive disorder.But in the differential diagnosis list on the anxiety disorders, there were a lot, so we’re just going to go through all of those.In the end, the diagnostic features again for specific phobias were pretty much a restatement of the diagnostic criteria-associated features.Interestingly enough, some people are arousal.Well, that makes sense when the HPA axis kicks off.A lot of people have a um increased heart rate, sort of a panic sort of feeling about them, not to the level of a panic attack necessarily, but they have that aroused state in preparation for fight or flee.Other people may have what they call a vasovagal response in which their heart rate decelerates their blood pressure drops, and they may faint my grandmother used to do this.Oh my gosh, and it wasn’t necessarily hers.Wasn’t phobia-related, but when she would get startled she would fall out and for the longest time the doctors, couldn’t figure out exactly what was going on. But ultimately my guess would be.It re had something to do with with anxiety or generalized anxiety.The prevalence of phobias is between eight and twelve percent, it peaks in adolescence at sixteen percent.So sixty percent of adolescents have specific phobias.The development, in course usually develops before age, 10 or after a trauma, and the presence of phobias is a risk factor for neurocognitive disorders in older adults.Why is this? We’ve again, we’ve talked in other videos about how hyperactivation of that stress response system keeps levels of glutamate and norepinephrine and stuff high in the brain which causes neurodegeneration, which can lead to neurocognitive disorders additionally, because of social withdrawal and avoidance and restructuring Of their daily lives, to avoid the phobic stimulus, there tends to be less stimulation for the person with specific phobias, which may also lead to a decline in what they call cognitive reserve and social anxiety disorder in social anxiety disorder.There’s a marked fear of social situations when in which one might be judged.So you’ve got generalized anxiety, which is anxiety about a lot of things over at least six months.We have a specific phobia, which is something specific.Like enclosed spaces or spiders, or snakes, um separation, anxiety, which is anxiety or fear of being separated from an attachment figure, and then social anxiety, which is fear from being in situations in which one might be judged by children. The symptoms have to be present not only in relationships with adults but in relationships with their peers.It’s natural for children to be somewhat anxious if they’re interacting with adults if they’re having the same anxiety when they’re interacting with their peers, then that’s really what we’re going to look for for a trigger The person has an excessive fear of being embarrassed, rejected or offensive, and the offensive seems to be increasing in popularity or not popularity in commonality, um very quickly, with Twitter and Facebook and tick tock, and all these other things and trying to be politically correct.A lot of people have developed a level of social anxiety, maybe not to the level of being a disorder, but, a level of social anxiety, because they fear not saying the right thing because they fear being canceled.Social situations almost always trigger anxiety and social anxiety disorder.Social situations are actively avoided or endured with intense fear, and the level of fear is disproportionate to the potential consequences.People may have a high level of fear and anxiety uh before going out and giving a performance in front of 10,000 people the level of anxiety for that would probably be different than giving a speech in front of six classmates.You know you see the difference here, but a person with social anxiety disorder.They would have that same level of fear in front of six people.They knew as opposed to ten thousand, that they didn’t persist again for six months or more causing clinically significant distress and is not due to another medical, mental, health, or substance-related condition.There is a note that social anxiety disorder can be performance only and you do want to specify that if it only has to do with giving speeches performing sports music, or anything like that, the diagnostic criteria features section, gave further examples of the symptoms that were identified in The diagnostic criteria associated features with social anxiety. The person may be passive or shy.They may want to kind of blend into the wall.They may be somewhat withdrawn because they don’t want to be out there in the limelight.They don’t want to be in this position where they fear being judged.On the other end of the spectrum, though, there’s a proportion of people with a social anxiety disorder who are highly controlling of situations, and they may try to control the conversation and control other people in the situation to avoid feeling out of control.Use of substances, substance, use, misuse or abuse is often associated with people with social anxiety disorder, and I have parenthetically heard liquid courage is what we used to call it back in the day I don’t know if it’s what they still call it but using substances to help temporarily allay anxiety.Interestingly, as alcohol leaves, the body people tend to have an enhanced anxiety response.So using alcohol before a social situation may end up causing more problems for some people, but that’s that’s up to them.Additionally, you may see a worsening of physical illness symptoms such as tachycardia or increased tremor in people with social anxiety disorder, so if they already have something that causes a tremor or a tick that may get worse, if they already have something that causes tachycardia, that may Get worse in situations in which they fear being judged.Now I have here increased pain, a question mark that’s not identified in the DSM 5t. However, we know that hyperactivation of the hpa axis contributes to ultimately development of systemic inflammation and the worsening of autoimmune disorders.So I would be interested to see what the actual numbers are for that and no, I could not find any research that compared the rates of increased pain with social anxiety, specifically prevalence.Seven percent of people in the United States experience social anxiety, disorder now brace yourself.This is not a typo.2 3 percent of people in Europe can be diagnosed with social anxiety disorder.So what is that? A third? What’s different in the United States? That is contributing to significantly higher rates of social anxiety fear of being judged and fear of offending people.Just saying additionally, social anxiety disorder does tend to be highest in non-Hispanic whites.So what is unique about nonhispanic? Whites in us I’ll leave you to talk about that and panic disorder, people with panic, disorder, experience, recurrent unexpected surges of intense fear or discomfort that peak within minutes and has a and accompanying four-plus symptoms.Now I have bolded and italicized unexpected here there are expected panic attacks when you’re in a situation in which you’ve had a panic attack before when there is a known trigger for the panic attack that’s an expected panic attack that doesn’t count towards our diagnosis here, which I don’t know seems a little strange, but okay, the panic attacks have to be unexpected.That is, they come from out of the clear blue and the panic attacks need to be characterized by four or more of the following symptoms palpitations, which is when it feels like your heart, is like fluttering, pounding, heart or tachycardia, which is racing heart, sweating, trembling or Shaking a feeling of shortness of breath or smothering you just can’t don’t feel like you can breathe, feeling like you’re, choking chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady lightheaded or faint chills or heat, sensations, numbness or tingling. Derealization, in which things just don’t feel real.You feel like you’re kind of a dream or depersonalization.You don’t feel, like you, ‘re part of your own body, anymore, with fear of losing control or going crazy and fear of dying.Now I’ll mention it, even though it’s pretty obvious.Many of these symptoms are also symptoms of a heart attack.It is important if you are a clinician not to assume that somebody who is experiencing a panic attack it’s, it’s, just a panic attack and to dismiss it.It’s important to take every panic attack seriously when somebody’s experiencing it and work with their medical provider to help them differentiate between what’s a panic attack.How do I know when I’m having another panic attack versus how do I know when I need to go to the ER and their doctor will work with them on that culture? Specific symptoms of panic may include tinnitus or ringing in the ear and neck.Soreness headache, uncontrollable, screaming, or crying.Interestingly, even though these are culture-specific symptoms, the DSM said those don’t count toward the required four plus symptoms. Additionally, at least one of the attacks – unexpected attacks has been followed by one month or more of both of the following persistent concern or worry about additional panic attacks or their consequences and a significant maladaptive change in behavior related to the attack avoidance of situations where You think they might happen again or ritualized, or superstitious behavior or extreme behavior, like changing your diet completely or doing something extreme to try to prevent the attack, so the unexpected attack happens and then for the next month or more.Both of those persistent concerns about it happening again and significant maladaptive changes in behavior are occurring, it has to cause clinically significant distress and it’s not due to another mental medical or substance use disorder.Interestingly, for panic attacks, there were no specifiers, but in the diagnostic features, it did note that panic attacks can be full meaning four or more symptoms or limited symptoms, so it doesn’t meet all of them.Doesn’t meet four symptoms or more, but the person’s having a panic response.If the person has never had a full-blown panic attack, uh, four or more symptoms, then you would not diagnose panic.Disorder frequency can be relatively regular like one per week or it can come in bursts where they, where they have multiple, really close together, then they go weeks months, or even years without having them, and then they have another burst of panic attacks, and there could also Be instances where they just have a panic attack, and then they may go for a couple of years or more before they have another one.It still qualifies as panic disorder.There is no code for remission of panic disorder and the expectation is unfortunately that if somebody has had a panic disorder at some point, they probably will have another panic attack at another point.Remember that expected panic attacks occur with known triggers, and there are many culture-related diagnostic issues due to expected triggers.So if you read through the culture-related diagnostic issues, a section of the DSM 5tr, you will find they talk about a lot of culture-bound triggers that can cause a panic attack in people’s associated features. People who have panic attacks.Panic disorder may also cause intermittent anxiety about health or mental health.They tend to be more somatically sensitive.That means they’re more aware of what’s going on in their body.Well, that makes sense if you’ve already had your body kind of go haywire on you once makes sense that you would be a little bit more hypersensitive to it happening again.They may have increased anxiety about their ability to tolerate daily stress there.A lot of times this may stem from the fear that if they experience too much stress it, ‘ll trigger another panic attack and they may have more extreme behaviors to control panic.The prevalence of panic disorder is about the same two and two percent to three percent in both the: u s in europe and Europe, the only disorder that had a marked difference between the; u s and other countries.Interestingly enough was social anxiety, disorder.The development of panic disorder, the median age – is 20 to 24 in us and 32 worldwide. So that is a little bit divergent.You know the prevalence, and the number of people that experience it worldwide are pretty comparable, but the median age for panic disorder is much younger in us than in other countries.Additionally, they speculate that older adults may attribute symptoms to medical conditions, so they may be underrepresented in the prevalence rates because when they’re having these panic symptoms, they’re, attributing them to medication, side effects, or other health conditions that they already have.So let’s talk about some of the risk and prognostic factors for anxiety disorders in general.Anxiety disorders often develop afterlife stress.This could be a death, a severe illness, a disaster, a big move becoming a parent adverse childhood experiences, or aces that’s just to name a few that those aren’t all of the causes, but I think it’s interesting that becoming A parent was in there as a life stress that often triggers the development of anxiety disorders.I mean I’m a parent myself.I can see how that could happen, but it’s not something that I had considered in the past as a risk factor for the development of anxiety disorders.People who’ve been bullied have an increased risk of developing anxiety disorders.The heritability of anxiety disorders ranges between 30 and 75 percent. I found that interesting, but they didn’t explain in any of the diagnoses whether they were looking at twins that were raised in the same household or twins that were raised in different households.If they’re raised in different households, it gives more credence to a genetic component.If they’re raised in the same household, then they experience the same psychosocial, and environmental stressors.Both of them are so.I don’t know what the actual data is on that person with negative affectivity.They tend to be more brooding, more depressed, more irritable people who are more self-conscious.People who ruminate more also all of these kinds are combined often referred to as neuroticism.They are at higher risk for the development of anxiety disorders.Attentional bias to threat was noted in generalized anxiety disorder as being an associated feature, but research shows that people with any anxiety disorder tend to have a stronger attentional bias to threat, which means they tend to be more hyper-vigilant.They tend to be more aware when there are, threats in the environment, and anxiety disorders by and large – tend to be much more frequent in women than in men. Interesting, not sure.Why again, my assumption is this is people who are biologically female and it seems to be consistent across cultures.Therefore, I am wondering what the genetic predisposition might be that may cause this.It seems like it’s, less about environment and shaping and behavioral training and more about a physiological response.But additionally – and these last two were not in the DSM.However, I did a PubMed search for risk factors for anxiety disorders and those who have a more external locus of control.That means they believe that things happen in the world by fate.By chance, there’s not a they.Don’t have a whole lot of control or ability to change what’s going on destiny is preordained, etc.People with that outlook who have a more external locus of control, tend to have much higher rates of anxiety and depressive disorders, and again not in the DSM, but in the PubMed. In the literature.People who have a lack of emotional support also tend to be at greater risk for developing anxiety disorders seems pretty self-explanatory in terms of suicidal thoughts.Anxiety itself increases the risk of suicidal thoughts.All of your anxiety disorders carry with them an increased risk of suicidal thoughts.People with separation anxiety have that generalized anxiety, related to increased risk, but people with specific phobias, interestingly enough, have an increased transition from ideation to attempt in a study that was cited in the DS well mentioned in the DSM, but they didn’t say what the study Was they looked at adults and they found that up to 30 percent of people who had their first suicide attempt? It was related.They also had a specific phobia or it was related to that specific phobia so that’s 30 percent is a big number uh.When we’re, especially when we’re talking about suicide attempts and suicidal ideation, if you have somebody with a specific phobia, we often downplay that because we think it’s just a fear of this or a fear of that.But that fear can feel very, limiting and oppressive to a lot of people, and again 30 percent of them.Uh, 30 percent of people who have attempted suicide also had specific phobia functional consequences.Now I could go on a diatribe about the functional consequences of anxiety disorders. The DSM didn’t have much to say about it, so let’s talk about some of these limited independent activities.This is especially true in agoraphobia and separation, anxiety, people who are afraid of leaving the house for fear of being separated from their significant other or for fear of being separated from their safe place, and people who have social anxiety, who fear being in social situations, may Have a lot of restrictions on their life activities and limited activities that they feel safe or comfortable doing by themselves, not in the DSM 5 tr, but in the literature, also the functional consequences of impaired relationships.People with anxiety disorders may be because of their restrictions on life activities and their um potential need to know where people are and their separation, anxiety, etc.A lot of times, people with anxiety disorders struggle in their relationships, because it can feel overwhelming to the partners.As I mentioned earlier, people with anger, and anxiety disorders, have higher rates of autoimmune issues.Continuous or excessive levels of stress hormones contribute to systemic inflammation, which will trigger depression or is associated with triggering depression and associated with worsening of autoimmune conditions and obesity.I thought this one was interesting, but it makes sense when you look at it.People with anxiety disorders, who often are restricted in their life activities, may feel worn down and exhausted.From being stressed out, all the time may not have a lot of energy to do.Other stuff tends to be more prone to develop obesity so that’s an interesting functional consequence now differential diagnosis, I told you there was a laundry list of them. Generalized anxiety, a disorder in gad.Excessive anxiety is about a variety of things for at least six months.Separation, anxiety, the worry or the anxiety is about separation from the attachment figure.Okay, that’s pretty clear, agoraphobia.The fear is about being trapped or helpless in situations in which escape is difficult.The fear surrounds being away from their safe place, not being away from a person they want to be in a place where they feel safe, and it needs to be not specific to one setting so being trapped or helpless in a situation.I give the example of an MRI that closed MRIs.Oh my gosh, I can’t stand them.I’m terrified of them, but that is specific to one setting and I’m not afraid to leave the house for fear of being trapped or helpless in a situation, social anxiety, anxiety is about being judged negatively, and illness anxiety and this illness anxiety.Falls under somatic disorders but illness anxiety. The worry is about the illness, not separation, judgment, or being away from your safe place, so that’s a differential diagnosis of your basic anxiety disorders in terms of other disorders because there’s that criteria not better explained by another mental health or medical disorder.In psychotic disorders, people who have hallucinations and delusions may also have anxiety, but their worry or fear surrounds hallucinations or delusions and is not reversed by context or the presence of an attachment figure.So a person with psychotic disorders, if their major attachment figure shows up does. n’t help them feel more comfortable if they turn on the light to eliminate the shadows that don’t make them feel more comfortable, and the hallucinations are not due to psychotic disorders.The hallucinations are not due to something present in eating disorders avoidance behavior is only related to food and food-related cues.According to the DSM, however, one of the main criteria for your eating disorders is an excessive fear about weight, shape, and size, and it’s important to recognize that, because people with eating disorders may avoid mirrors and scales and food, obviously certain foods, and that could All be related to their eating disorder, body, dysmorphic disorder.The fears are only related to people being offended by a particular perceived flaw in obsessive-compulsive disorder.The fear is an object or situation as a result of obsessions.So if they start thinking about germs on their hands – and they keep thinking about it, then they start developing a fear of getting germs on their hands, so the fear becomes the object of their obsessions.Their obsessions turn to cause what they’re.Thinking about becoming a fear in the autism spectrum, the person lacks sufficient age, appropriate relationships, and social communication capacity in anxiety disorders. The person often has sufficient age-appropriate relationships and can communicate socially, and socially understand others, just fine.What we’re, looking at in anxiety, is fear of being judged conduct.Disorder.School avoidance is a very common symptom of conduct disorder, but school avoidance is not due to worry or fear in conduct, disorder, school avoidance, and conduct disorder are due to not wanting to be told what to do.Thank you very much in oppositional defiant disorder, the oppositional behaviors occur in response to multiple situations, not just separation or situational anxiety, not just in response to an anxiety-provoking threat.So if somebody has separation anxiety, they may become oppositional about leaving their major attachment figure.If somebody has a social phobia, they may become oppositional about engaging in situations that would prompt that anxiety, or if they have a specific phobia, maybe they’re afraid of snakes.They may become oppositional about doing something like going hiking because they are actively avoiding that phobic stimulus if they are actively avoiding a phobic stimulus or an anxiety-provoking stimulus.It’s, probably not oppositional defiant.Now you can have both you can have them. Co occurs, but you do want to differentiate.What is the cause of the behavior? Prolonged grief is characterized by intense longing and yearning for the deceased, not fear of separation from them.Now you can have prolonged grief and separation.Anxiety, co occur, but you can’t.Have somebody who develops a fear of separation from others after a particularly particularly traumatic loss? That can happen, but you do want to differentiate and diagnose appropriately and in depression and bipolar.A lot of people who are in a major depressive episode may have reluctance to leave home, but this is due to a lack of motivation and energy to engage and apathy.It’s not due to fear of something out there.They just don’t care or they don’t have an energy personality.A person with a dependent personality relies too much on others.It’s not that they fear uh their safety or loss of attachment figures and avoidant personality disorder, broader avoidance patterns, and a pervasive negative self-concept, differentiate, avoidant, personality disorder from anxiety, and related disorders, not in the DSM I’m. Bringing up for differential diagnosis.Anxiety is related to apprehension and vigilance of physiological sensations and may have an onset after a concussion pots is a postural orthostatic tachycardia and when people have it, when they stand up, their heart rate will jump 30 or more beats just from when they move from sitting To standing and that can feel very scary, they can also get light headed they can.Faint hypoglycemia can also produce symptoms of anxiety sweating and agitation in people, so we want to differentially diagnose.I believe I read a study that more than 25 of Americans are pre-diabetic and don’t know it.Co-morbidity and anxiety disorders are comorbid with each other.So if you have one, you probably have some of its buddies.It’s also comorbid with depression.Bipolar PTSD, prolonged grief, obsessive-compulsive disorder, obsessive-compulsive personality disorder, somatic symptom, related disorders, so any of your physical symptom disorders, anti-social personality, specifically social anxiety, common commonly may co, occur with anti-social, oppositional, defiant disorder and substance use disorders.Physically autoimmune diseases may increase the risk of psychiatric disorders partially due to thyroid dysfunction when that hpa axis goes offline.It also affects the functioning of the thyroid cardiovascular issues like supraventricular tachycardia can also be misdiagnosed and is often misdiagnosed for panic disorder. Hormone level fluctuations, especially extreme hormone fluctuations, can contribute to anxiety, related symptoms, high levels of estrogen or testosterone, nutrient deficiencies, or toxicities.So too, much or too little of certain vitamins and minerals can also cause anxiety-like symptoms.Environmentally poverty is a high risk factor for the development of anxiety disorders, for obvious reasons and socially adverse childhood experiences that include abuse, neglect, abandonment, or mental illness in the household.Are all risk factors for the development of anxiety disorders later in life? Anxiety disorders represent an anxiety response that is developmentally culturally and contextually excessive it’s persistent or recurrent, and causes clinically significant distress, so that differentiates it from people’s run-of-the-mill anxiety.If you will multiple anxiety disorders are common.This presentation covered some of the more common anxiety disorders but did not cover selective mutism substance-induced anxiety or other specified and unspecified anxiety disorders.Finally, it is important to rule out or diagnose comorbidly any physiological causes of anxiety.Symptoms include cardiovascular issues, pots, or diabetes.100 Hot BooksComputers LaptopsExplaindio Agency Edition FREE Training How to Create Explainer Videos & SELL or RENT them! Join this FREE webinar | Work Less & Earn More With Explaindio AGENCY EDITION

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Cognitive Behavioral Therapy (CBT) Skills and Counseling Techniques with Dr. Dawn-Elise “Doc” Snipes

CEUs are available for this presentation at AllCEUs.com/CBT-CEU Hi everybody and welcome to today’s presentation on cognitive behavioral therapy skills. Like the other The presentation we did on assert not assertive community treatment acceptance and commitment therapy, which is also based on providing information about skills that can be used not providing an evidence-based practice We couldn’t cover that in a full hour or just an hour so over the next hour we’re going to define cognitive behavioral therapy and its basic principles a lot of us are familiar with this but it’s going to be a good review and it also may highlight some nuances that you didn’t know about will identify factors impacting people’s choice of behaviors explore causes and impact of thinking errors and identify common thinking errors and their relationships to cognitive distortions so why do we care well as therapists we want to help people figure out the best way to live a happy healthy meaningful goals-driven life for some people that’s going to mean using some cognitive behavioral interventions that can be in addition to mindfulness that can be in addition to a lot of other things but it’s important to help people understand that the way we believe things to be the way we interpret things is going to affect our reactions so for example think about a situation you know you’ve walked into and maybe you walked into it with a small child and it was a different situation it was a new situation but you know it was no big deal you walked in it was not a threatening situation to you because you were like hey I got this the little kid walks in and goes oh wow there are a lot of people walking around here, this is really scary same situation as two different perceptions you probably didn’t have much of a stress reaction going on whereas the little child probably had this fight-or-flight thing going on grabbing onto your hand like please don’t let go Atlanta Airport is a perfect example if you’ve ever taken a little kid through Atlanta Airport it gives you an idea about how People can perceive things differently and when you enact that fight-or-flight reaction you’re going to have all those stress hormones you’re going to have all either anxiety or anger or whatever that goes with it it may serve to exhaust the person and leave them feeling hopeless and helpless so what we want to do is help people see that but we also want to help them see that when They’re depressed when they’re tired when they’re sick things are going to seem a lot worse a lot of times because they don’t have the energy to perceive it differently I mean when you’re sick it’s overwhelming to think of going through Atlanta Airport so this is what we want to help people start understanding is it’s two sides of the same coin they interact if one is you know kind of going wonky is going to affect the other one the good thing is If one’s going really well the other one’s going to go well if you’re Having positive thoughts you’re probably going to feel pretty good there’s an activity and I think we’re going to talk about it later it’s called the coin flip activity and I asked client clients to flip a coin in the morning and in the morning if it turns heads then they have to be the most positive Pollyanna all day long look for the silver lining and everything smile walk with their head up hold those nonverbals up and see how they feel at the end of the day besides a little sore because there are muscles they’re using they haven’t been used in a while if it lands on tails they can just be their normal selves which generally if they’re seeing me means that they are depressed anxious stressed out angry about something in the negative realm then we Talk about how things seemed different on the days when you were feeling better when you were walking taller when you were smiling even our nonverbals it doesn’t even have to be sickness it can be our nonverbals that can make us feel or make our body feel heavy and tired and make it seem like it’s a whole lot harder to deal with life as a person who perceives the world generally good and believe they can deal with challenges as they arise that good old self-efficacy will be able to allow their stress response system to function normally so if they’re like you know what I can deal with whatever life throws at me I’ve got it and maybe I need help with it maybe I’ll need to ask for support but I’ve got it it’s not going to completely overwhelm me with people who see the world as hostile unsafe and unpredictable You know for a variety of reasons whatever happened to make their scheme as such that they don’t believe that people or the world is trustworthy are predictable They are always on guard they’re always kind of like a hamster in a cage that has Have you ever had a hamster hamsters doesn’t recognize you and goes Hey that’s my own Or human contact score hamsters go run under their little house And you just kind of open the cage and stick your hand in there and flip over their house and you’re like come here and give me cuddles and you’re like you know 200 times bigger than they are so the little hamster is like freaking out this is what it’s like for people and obviously, I’m exaggerating but this is what it’s like for people who have a negative perspective a negative view or a hostile view of the world so kind of keep that little hamster in your mind cognitive behavioral therapy we have core beliefs those things that are in our hearts when I talk with my clients about honesty step one and that’s what they’ve got to do to start recovery is get honest with themselves first and then other people we talk about head heart and gut honesty do you think it’s right does it seem like the right thing to do does it feel right in your heart you know does it make you happy it doesn’t make you feel good and then the Spidey senses is your gut saying and or Is your gut fine if one of those is saying this might not be the right choice and we need to think about what’s going on so we have those core beliefs and I put them in the heart just because that’s the middle of the head heart and gut but you have core beliefs about yourself whether you’re good with You’re bad whether you’re effective at certain things yadda You have core beliefs about other people same thing good bad effective predictable and you have core beliefs about the future and a lot of that goes with locus of control but also your past experiences if the world in the past is seemed unfriendly and uncontrollable and you’ve perceived it that way then you’re going to expect the future to be uncontrollable so what we want to do is help people look at their schemas and their core beliefs about themselves others in the future and figure out kind of what they want it to look like these schemas are going to affect your behavior your thoughts and your feelings and you know you can pick wherever you want to start it doesn’t matter because all three interfaces with one another so if you haven’t let’s Start with negative thoughts If you have negative thoughts then you might feel anxious angry stressed dysphoric which will affect the behavior you’re going to do different things than if you have positive thoughts about something you feel excited and energized you’re going to have different behavior the best thing example I can give you is if you’ve ever done public speaking or had to present something Some people detest public speaking it’s just terrifying for them to get up in front of a group of people so their thoughts are I’m going to trip up I’m going to forget what I’m going to say I’m going to make a fool of myself I’m going to you know it can go on forever that when you get on a roll you can get on a negative roll and go on forever or positive hopefully get on that roll with those thoughts you start holding onto Those thoughts remember as we talked about in a CT the other day when you hold those thoughts and you kind of mush them around in your mind and you come to believe them that you’re going to make a fool of yourself and it’s going to be awful you’re going to start feeling terrified which is going to likely affect your behavior if you go out on the stage and you’re terrified You’re going to probably stutter you’re probably going to get foggy-headed You’re going to have that fight-or-flight reaction so there’s an adrenaline rush and you start sweating and you can’t focus and you can’t concentrate you want to away as opposed to somebody like me who loves public speaking and I’m just like cool I get to go out there and try to engage however many people are in the audience it’s a game for me because when I can see your faces I enjoy trying to figure out and make eye contact with people and figure out what it is that they’re there for what is it that’s going to make them tick what resonates with them so my behavior as You can kind of see right now when I go out there I’m excited and I want to engage people and it’s a fun experience for me again just like the airport the same experience for two different people and two very different interpretations and reactions to it so what effects I don’t like the term rational but when We’re talking about CBT irrationally comes up a lot I like to replace it with helpful because every behavior in its weird sort of way is or probably was rational at one time that being said we’re going to get back to that stress affects our behavioral choices if we’re under stress we can have negative emotions negative emotions will affect our thoughts if we’re feeling sad we’re probably going to look at the dark side if we feel sad we’re going to look at the bottom falling out if we’re happy we’re probably going to look for that silver lining physical factors if you’re in pain sick sleep-deprived poorly nourished so your body can’t produce the neurotransmitters it needs to or heaven forbid intoxicated you’re probably not going to make the same decisions as you would if you were comfortable healthy well-rested nourished and not Intoxicated any of those things can impact how you perceive a situation or how you react in a situation, especially the intoxication whereas in your intoxicated State in your sober state, you may think that you want to do something but then you’ve got that filter that does not not a good idea in an intoxicated State or even in a manic state if you’re you know if you have somebody with bipolar that filter kind of goes away so the behaviors that someone may normally not do because they have a rational filter That goes you know punching this guy out is probably not the best idea right Now the filter goes away when you’re sleep-deprived you’re less generally People are less patient generally people don’t have as much of a filter thing about watching your children if you have children or your grandchildren or even yourself I know myself when I’m sleepy I am giddy as all get-out and things I wouldn’t normally say because they’re you know stupid I’ll just come out and say anyway and my kids just roll their eyes or the mom you’re overtired could go to bed, uh but that’s okay You know I’m okay with that In that situation now if I acted that way at work it would be a worse thing environmentally if you’re introduced to a new or unique situation and you perceive it as stressful because the unknown we know can be stressful then you may not make as rational of a choice or as helpful of a choice because you Maybe trying to escape the same thing as exposure to UNPROFOR bellowing for a word here but UNPROFOR ball is the best I could come up with we all prefer certain situations some people like I said would rather do just about anything then get up in front of a lecture hall of a hundred and fifty people and talk but if they have to do it then they’re going to be under stress which may affect how they do things so we want people to understand that their perception and their feelings are affected by a lot of other things not Just you know an emotion here or a particular memory there’s a lot that goes into it and social if peers your family convey irrational thoughts as necessary very standards for social acceptance people may tend to cling more to it to those unhelpful thoughts and unhelpful behaviors you know in CBT they say irrational because quote nobody wants to associate with those people you know who are those people and why can’t we associate with them there are a lot of things if you think back think high School you know high school is pretty rough if we’re going to talk about having irrational thoughts and cognitions if you have to be part of this particular group to be accepted you have to do this you have to do that but do you do you do those kinds of all-or-nothing statements are cognitive distortions and while they may have served a purpose in some way shape or form in the past we need to encourage our clients to take a look at them now and go are they still helpful ways of thinking is it still helpful for me to think that I am only successful if I live in a million-dollar house in a gated community and do this that and the other or can I be can I define success as a different way or do I define success differently and lack supportive peers to buffer stress so we had those peers who caused stress by talking about the half dues and categorizing and lots of attributions but then there’s Also not having somebody to go you know does this make any sense because sometimes we are our own worst enemies and if we go to a friend and we go you know this is what I’m thinking and I think I have to do this in order to be acceptable to be loved or you know whatever the case may be Most people are not going to use those exact phrases A good friend is probably going to listen and go yeah you’re right or no that’s way off so supportive peers are essential to reminding us to consciously regularly check in with our cognitions to make sure that they are hopeful and rational so a note about irrationality and this is mine this is not from CBT the origins of most beliefs for rational and helpful given the information the person had at the time and their cognitive development their ability to process that information so concepts schemas and core beliefs that people formed when they were five are probably going to be very egocentric you know the person is going to feel like everybody sees it my way because this is how I see it you know just like A five-year-old does A five-year-old doesn’t think Well you know let me take Johnny’s perspective is no he assumes that Johnny sees it the same way so it’s going to be egocentric It’s probably going to be focused on only one aspect of the situation because small children can’t focus on multiple aspects and it’s probably going to be dichotomous it’s all-or-nothing Mommy loves me mommy hates me and it could be personalized you know Everything a lot of kids think that everything has to do with them so if something happens something bad happens many times Children will take it personally or be afraid it’s going to happen to them Again you know if Hurricane Katrina hurricane Andrew those sorts of things you know we saw a lot of trauma in children and they developed very real fears about thunderstorms and hurricane season And if you’ve watched Florida hasn’t had a notable hurricane in years now but There’s a lot of stuff that goes into that but young people During some of those really bad hurricane seasons perceive those situations differently okay so we need to help people understand that if we especially if we use the term irrational those thoughts you form when you are knee-high to a grasshopper and they made perfect sense to you back then but now that you’re an adult you’ve got more experience and you’re able to take different perspectives your brain is more developed Let’s take a look at it and see if you can look at different perspectives and Come up with something a little more helpful maybe a different way of perceiving this situation the irrational irrationality or unhelpful Nosov Fox comes when those beliefs are perpetuated without examination so something a the belief that you formed when you’re five you’re still holding when you’re 35 and you’ve never questioned it you’ve never gone you know does this make sense is This is helpful to getting me toward where I want to be Most of us don’t know We form these attitudes and beliefs when we’re you know growing up when we’re in elementary school middle school high school from watching TV to being around our peers from being around our family in our community and we get all This input of the way things should be and a lot of times people don’t stop to question and go and go Well does this make me happy Is this really what I want and they can be irrational if they continue to be held despite causing harm to the person so the person continues to hold this belief even though it is causing them general emotional cognitive harm is making them miserable we need to look at what’s motivating them to hold on to that belief why is that belief so important and how can we make it so they can live a happy values-driven life with an emphasis on the harness and how can we make it less harmful sometimes it’s more productive for clients to think of these thoughts as unhelpful or helpful instead of irrational sometimes when I say irrational to clients and you know I’m the same way if somebody says you’re being irrational I’m like oh I’m not it elicits this instantaneous defensive reaction it’s like when you tell them they’re being resistant they’re like I am NOT resistant so helpful or unhelpful and then we talk about why it is unhelpful in getting them toward their goals basic principles of cognitive behavioral therapy we teach or help clients learn to distinguish between thoughts and feelings I can think something is scary I’ll probably feel it but if I have an automatic you know feeling I walk into Atlanta Airport and I see yeah I went to an airport in New York I can’t even remember which one it was because my plane was diverted and I got off and I walked out there and I have never seen so many people packed in his place like sardines before in my life I was just completely overwhelmed that was kind of an automatic feeling now that was a feeling based on you know who knows it was overwhelming to be surrounded by that many people so then I had to separate the thoughts and go Okay what am I thinking that’s making me feel so overwhelmed and at that point you know I didn’t know how to get to my gate and all that other sort of stuff with traveling I don’t travel well but encouraging clients to stop and go okay why am I feeling this way what are my What thoughts am I having that are contributing to these dysphoric feelings CBT helps people become aware of how thoughts can influence feelings in ways that are sometimes not helpful We have hecklers in our gallery the automatic tapes that we plaything memories that we have whatever you want to call them when you try something When you are just going through daily life you hear these voices in the back of your head and not real voices but that is saying you’re never going to make this or if you would have just blah blah blah then you’d be a better person helping clients become aware of those thoughts and how they’re Negatively influencing their feelings and keeping them kind of stuck is a huge part of CBT we help them learn about thoughts that seem to occur automatically without even realizing how they may affect emotions again those thoughts from the they’re saying you’re not good enough You’re not smart enough and nobody’s going to like you Where did that come from and do you believe it you know maybe it came from somebody When you were in high school so was that a valid was that a valid source Maybe it came from somebody yesterday on Facebook was that a valid source taking in those thoughts and then figuring out is something I’m going to hold because it makes me happy or is this something that I’ve got to deal with because I’m having a negative reaction constructively evaluate whether these automatic thoughts and assumptions are accurate or perhaps biased the other thing to remember is a lot of our clients not all of them but a lot of them hold themselves to a standard there’s like up here and they hold everybody else to a standard that’s down here so they are a failure if they don’t achieve this but Everybody else is successful as long as they achieve this so encouraging them to take a look at how accurate and biased or unbiased are the thoughts and like I said they may be their thoughts they may be telling themselves these things evaluate whether the current reactions are helpful and a good use of energy or unhelpful and a waste of energy that could be used to move toward those people and things important not impotent important to the person road-rage you’re In the car you’re driving somebody cuts you off Okay natural reaction fight or flight reaction you’re just like slam on the brakes and do whatever you got to do aversive maneuvers you’re good so you could let it go at that point ago got Lucky on that one and keep driving most people not all but most found that 80% of drivers have reported incidences of road rage which is a high number but most people will start getting all fired up and irritated and grumpy and we and just rageful and so my question would be I hear that and I hear that it made you angry In retrospect did screaming at the person as you pass them at sixty miles An hour in your car with the windows rolled up does any good Did it Did any good at all what else could you have done with that energy if you wouldn’t have expended it all yesterday we had to wait for the vet to come by and my daughter just completely wore herself out worrying about when the vet was going to get there what he was going to say about her donkeys and was beside herself so by the time it got to evening and it was time for her to go to her martial arts class she didn’t have the energy to go she’s like um wiped out I just want to go to bed in retrospect we’re looking back and saying okay now Tell me what it was that you were so stressed out about and let’s talk about whether that was a realistic and helpful line of thought to perseverate on all day long and what could you have done differently because she didn’t bother to mention any of that to me yesterday and then developed the skills to notice interrupt and correct these biased thoughts independently causes of these thinking errors information processing shortcuts when we form schemas and we encounter a situation that reminds us of something in the past like when I go to my grandmother’s house I have a schema I have a belief system I have you know stuff that I know about my grandmother’s house so when I go to my grandmother’s house it’s kind of a shortcut to knowing what to expect when I walk in and how to behave how to do different things and it helps me plan and predict if you’re Using outdated or dichotomous all-or-nothing schemas may cause thinking errors because you may be now incorrectly processing current events mental noise some of us have it a lot of us have it Not everybody thinks about trying to focus and study for a final exam in the middle of a really busy sports bar okay this is a cause of thinking or you’re going to miss important things you’re not going to be able to focus you’re not going to necessarily attend to the correct things because there’s just so much else going on your attention is drawn in 17 different directions and or the brain’s limited information processing capacity due to age we talked about that before young kids think all or nothing they think dichotomously egocentric ly middle school-aged kids and older start developing the ability for abstract thinking, by the time we get older, you know as adults theoretically We’re able to you know think pretty well and think pretty clinically about different events but if we’re in crisis when someone is in crisis it could be like what we think of clinically as a crisis or it could be they’re just completely overwhelmed and burned out and have been burning the candle at both ends for three months they’re not going to process information quite as well They’re not going to take in all this stuff because they’re just like shell-shocked have you ever seen teachers in the hallway of like an elementary school Oh at the end of the second nine weeks they just kind of stand there with this blank look on their face they’re not processing as much as they were the first day of school and you know God loved them they have a lot to deal with but we need to help our clients understand that there are some times that they are going to have to really stop and focus write things down so they can remember or they can make decisions A little more my guess is most of us have times in our lives when we’ve been able to think through complex problems but then there are other times where you just can’t keep it all in your head and you’ve got to put it on a Whiteboard maybe that’s just me but we want clients to understand that they are not broken they’re not faulty they’re doing the best they can with the tools they have and the knowledge they have and our job is to help them see where some of this might have gone a little awry other causes of thinking errors and emotional motivations I feel bad therefore whatever I’m thinking must be bad if I’m scared that means whatever it’s coming on the other end of the phone is bad news moral motivations I did it because it was the right thing to do and that can be an excuse for doing wrong behaviors as well it can also be you know you can argue on The moral one social influence well everyone else is doing it so it must not be bad set that again a lot of times and this is where the frames approaching the Motivational interviewing is helpful It stands for feedback about the reality of what’s going on is everybody doing it let’s look at statistics you know not subjective information let’s look at objective information so the impact of these thinking errors makes people want to fight or flee when they get upset and we use upset as a kind of this all-encompassing garbage term emotionally they get depressed or anxious we don’t want to feel that way Anxiety and anger are flee or fight fight or flee it’s our body saying there’s a threat you got to do something depression is your body going I give up I just don’t I don’t even have the energy to do it anymore behaviorally some people withdraw because they Shut down We all know people get frustrated when they get overwhelmed When they start feeling hopeless or helpless they just kind of withdraw from Everything and everyone’s addictions numb that out so they don’t have to feel the dysphoria sleeping problem and changes when we start being on that constant fight-or-flight hyper-vigilant sort of thing going on in the body is always sort of turned on which means you’re not going to sleep as well then The circadian rhythms get messed up which starts causing exhaustion and lethargy and then everything seems harder because you’re sleep-deprived and then you start thinking more negatively and more hopelessly you see where this is going it’s a downward spiral and eating changes some people eat a lot more because they’re eating comfort foods some people eat a lot less because Their stomach is so torn up from the stress they can’t even think about holding anything down physical stress-related illnesses fibromyalgia gastrointestinal problems headaches neck aches backaches you know the whole the gamut of it when you start feeling bad when you start hurting generally it gets frustrating after a while and that frustration makes it kind of raises the bar brings you up a little bit so you’re That thatch closer to kind of just kind of being overwhelmed as you do You have as much of a cushion as you would if you were happy healthy well nourished not in pain and socially a lot of times we will get irritable or impatient with other people or withdrawal when we’re having these negative cognitions these thinking errors that are keeping us in a dysphoric state these effects of thinking errors contribute to fatigue a sense of hopelessness and helplessness which intensifies thinking errors This is an important concept that I want my clients to understand and I want to drive home in this presentation so thinking errors what are they emotional reasoning feelings are not facts and we want to help people learn to identify feelings and separate them from facts so if somebody says I’m terrified okay that is a feeling what are the facts supporting that feeling why are you are terrified what is the evidence that you are in some sort of danger Right now you know that danger may not be the right word for your client at that a particular point in time but what’s the evidence that there’s a threat in what ways is this similar to other situations maybe it’s triggering something from the past that was scary or you know you were too little to be able to handle it but you can handle it now and how if you dealt with similar situations Like in the past, we wanted people to just step back and get some distance between their feelings and their thoughts and try to figure out you know which thoughts are helpful and productive and even if a sought makes people anxious or angry it can be helpful it may be telling them hey dude you need to get your butt up and get out of there if it’s helpful it means it’s moving them toward where they want to be happy healthy safe and values-driven life so happy and helpful developed a stress tolerance skills when people use emotional reasoning they feel emotions which then they start attributing finding the facts to support those emotions instead of looking at all the facts we want to help them learn to tolerate their distress so they can kind of let that subside for a second they can accept their feeling they can name them They say I’m scared I’m stressed I’m angry and whatever but they don’t have to act on it right then they can tolerate the distress for a minute without having to try to make it go away and emotional regulation skills they can feel a feeling without having to make it go from zero to 120 You know if they feel sad they go I feel kind of sad instead of grabbing onto it and going I wonder what I feel sad about I must feel sad about all these sad things now I’m going to be sad and devastated so we want to help people learn how to regulate their emotions identify them accept them Whatever word you want to use tolerate them because feelings are there for a reason they’re there to tell you your brain thinks something’s going now thankfully we have that higher-order cognition stuff going on so We can contradict our brain and we can go you know maybe that’s not true in this situation cognitive bias negativity mental filter whatever you want to call it people who focus on the negative they walk in they get up in the morning and They look outside and it’s partly cloudy They get to work and they say instead of saying there was it was very light traffic they said there was a fair amount of traffic everything is always the flip side of what somebody who’s optimistic would say so asking them what’s the benefit to focusing on the negative in what ways is this helpful to you know some people say Well it keeps me from getting disappointed because I know It’s going to end up negative anyway so we can trap challenges that know that whatever it is they think they know and see if there have been exceptions when It hasn’t turned out that way What are the positives to this situation I give the example a lot of you know I wash my car or it rains and maybe I wanted to go out on a run that day but I can perceive it I can look at the positives you know the rain washed my car for me so I don’t have to do it now score it watered my garden all the better it knocked down some of the pollen out of there even better I can find and I can encourage people to find positives in a situation yes there are negatives there are negatives to every situation if you want to find them you’re going to find them but if you want to find the positives you can too which takes us down to what are all the facts there’s the positive and the negative and the neutral I told you Earlier about the coin toss activity having people toss a coin on the heads days they act like it is just the greatest day to be alive and see how Things are different when they do their journal because you know I have my clients do I’m sort of a mindfulness check-in in the morning and in the evening and preferably at lunchtime how are they feeling what’s their emotional state what’s their energy level on the happy days a lot of times it can be less and sometimes they need a little coaching throughout because some of those old patterns kick in but I want them to start challenging some of their automatic thoughts that we’re going to talk about in a minute disqualifying or minimizing the positive most of us can probably say we’ve had a bunch of clients that do this they are more than happy to tell you about all the things that they mess up but then when they do something right they minimize it encouraging people to hold themselves to the same standard they would hold everyone else to and I know I talked about that earlier ask them things like would it minimum would you minimize this.

If it was your best friend’s experience your best friend came to you and said I just got into such-and-such college would you say awesome or would you say anybody can get in there how would that go ask them what is scary about accepting these positive things that you might have had an accomplishment for some people it means that it might mean other people expect more of them for other people they just don’t know how to accept the positive They don’t know how to accept compliments they don’t know how to be the center of attention and they don’t like it and then we want to look at why that is sometimes we disqualify the positive because it fails to meet someone else’s standards so as people might that be true here you know I know When I was growing up and going through college and going through school and everything got my doctorate but I will always not being not a real doctor because a Ph.D. is not an MD and I’m like really So is it somebody else’s standards or can I feel good about having a Ph.D. egocentrism My perspective is the only perspective I’ll being egocentric but it doesn’t work most of the time so encouraging people to take alternate perspectives Maybe you’re texting with someone and they say something that is not what you interpret as not the nicest thing and this happens in text messages a lot and they get upset now an egocentric thinking error would say that purse is just grumpy today Someone who’s taking other perspectives would stop and go back and read the text and go I wonder if maybe this could have been taken some other another you know obvious reaction is not what I intended So egocentrism if you hold on to that I don’t understand anybody else because You know I don’t see a problem with anything personalizing and mind-reading This is when you assume that everybody’s frowning because of something you did your boss walks down the hallway and looks at you and grimaces and continues to walk on oh I must have done something wrong No maybe he just got out of his senior management meeting that was five hours long and he’s got to go to the bathroom you know there could be a hundred different explanations for why that happened so encourage clients to ask themselves what some alternate explanations for this event that are doesn’t involve me you know why this might have happened if they hold on to that, I must have done something wrong but as soon as their boss calls them up and goes hey can you come to my office for a second you know where their thoughts are going to go I’m getting fired I’m going to get laid off I don’t know what it was that I did wrong but he walked by me two weeks ago in the hallway and grimaced and I’m just I’m the worst person in the whole world But where did that come from so encouraging people to not necessarily assume they know what’s going on in someone else’s mind and not automatically attributing every person’s negative behavior to something they did How often and then ask them how often has it been about you now think about the last 10 times you’ve taken something personally how many of Those 10 times has it been about something you did versus something with the other person then the availability heuristic remembering what’s most prominent in your mind so asking clients what the facts ah the most obvious One that we talk about is plane crashes You know it is very dangerous to fly on a plane because you hear about all those plane crashes well yeah you hear about the airlines crashes but don’t hear about the 20,000 every day that land safely so you remember it and it seems more dangerous because that’s what is in your mind that’s what is available to you that’s what you’ve based your thought processes on because maybe you didn’t know that 20,000 planes or more fly and land just perfectly every day this can also be true with people remembering what’s most prominent in your mind sometimes and this can be very very true in domestically violent relationships if somebody falls in love with someone and that person is just the greatest person since sliced bread for the first four months and then the cycle starts and there’s this little tiny a sliver of the honeymoon period after the battering cycle and the person’s like That’s the person I fell in love with that’s what I remember and they try to focus on that that’s most prominent in their mind and they ignore the rest of the stuff so we need to encourage people to look objectively at the facts magnifying high and low probability outcomes what are the chances that this is going to happen how Many clients have worked with have gone to the doctor and gotten into a physical or get a test run and then the doctor had to call them back and This could be true for you too and the doctor had to call them back two or Three days later when the tests came back from the lab and that whole three days they were just in a panic because they were afraid they were going to get some terminal diagnosis so thinking about high and low probability outcomes another instance or example of magnification is somebody that thinks this is the end of the world whatever it I think I’ve told you before my little story about um tripping when I was walking down the hall at work and falling and yeah it was embarrassing my folders went everywhere and yeah but in that big scheme of things will it matter That much from now you know are people going to think Oh she is such a clutch she must be a ditz too no I mean they may have thought that at that time I don’t know but you know in six months nobody’s going to remember and then ask them in the past when something like this has happened when you’ve had to get a test done and you’ve had to wait on results or if you’ve done something that was embarrassing and you didn’t think you thought everybody was going to remember it forever how did you tolerate it how did you learn to deal with it building on those strengths that they already have all-or-nothing thinking errors These are things like love versus hate I love them or I hate them it’s all or Nothing she does this all the time or she never does it if I’m going to do it I’m going to do it perfectly or I’m not going to do it at all thank you all good intentions or all bad intentions you know sometimes we do things with good intentions that have some bad repercussions so did we do it with all Bad intentions are all good intentions and the answer is neither most of the time life is kind of in that middle-ground gray area encouraging clients to Look and find examples where something hasn’t been one of the polls when have they done something that they’re proud of that wasn’t perfect or when again When has somebody else done something that they were proud of that wasn’t perfect remembering that with availability heuristic remembering how often something happens and how long it’s been since you’ve seen that behavior and remember that sometimes good times are amazing but how frequent are they compared with the bad times another thinking error is a belief in a just world or a fallacy of fairness I just asked clients to identify for good people you know who’ve had bad things happen and in in reality we all have bad things happen good people do bad people do in between people do attributional errors and this is a pet of mine you know labeling yourself is not a behavior so global versus specific and I am stupid versus I’m stupid at math I don’t have good math skills it’s not about me it’s about the skills I can change skills stable I am and I always will be versus it’s something I can change it’s something I can learn internally It’s about me as a person versus it’s about a skill deficit or something I could learn or change and there’s you know lots of information on attributions out there on the internet if you need a refresher on it but we find that a lot of people who have dysphoria have negative global stable internal attributions so questions for clients remember the beliefs equal thoughts and facts plus personal interpretation another way of saying it is reality is 10% perception is 10% reality and 90% interpretation so what are the facts for and against my belief is the belief based on facts or Feelings Does the belief focus on one aspect or the whole situation Does the belief seem to use any thinking errors what are alternate explanations what Would you tell your child or best friend if they had this belief how would you want someone to tell what would you want someone to tell you about this belief so If you’re telling somebody about this what are you hoping they’re going to say in return and finally, how is this belief moving you toward what and who is important to you or moving you away from what or who is important to you now they can do a worksheet and have all of these or you can pick one or two of these questions that are most salient for your clients but they can have kind of at their fingertips so as they’re going through the day and something happens They can ask themselves ok what’s an alternate explanation Or you know Whatever it is this salient for that client’s irrational thoughts how do these thoughts impact the client’s emotions health relationships and perceptions of the world you know this is what we want to ask them How is this thought impacting you globally how may this thought have been helpful in the past Where did it come from How does it make sense from when you formed it in the past when you’re dealing with it ask the person if the thought is bringing you closer to those that are important Are there any examples of this thought or belief not being true and how can the statement be made less global less all-encompassing so it’s about a specific incident a specific situation less stable which means you can change it and less internal which means it’s not about who you are as a person but maybe something that you do or a skill that you have so we’re going to go through some of these thoughts real Quickly here mistakes are never acceptable and if I make one it means that I’m incompetent well never is kind of stable and I am incompetent is kind of global, that’s also that extreme all-or-nothing thinking so you can see where these cognitive distortions end up leading to unhelpful beliefs When somebody disagrees with me it’s a personal attack Well there’s Personalization If I ever heard it before maybe it’s not about you may be They’re having a bad day and you just happen to be the unlucky target or maybe they’re disagreeing with you because they have a different point of view and It’s not a personal attack it’s just their point of view If someone criticizes or rejects me there must be something wrong with me personalization all-or-nothing thinking global stable and internal something wrong with me as a person to feel good about myself others must approve of me Now this is one we’ve talked about external validation before and we can’t control other people to feel good about yourself how can you do that Besides necessarily requiring other people to approve of you to be content in life I must be liked by all people Wow I’ve never met anybody who’s liked by all people I’ve never even met anybody who’s been hated by all people but it’s important to help clients see how this is dramatic to say all people and for them to be content everybody has to like them I mean I like to be liked but if everybody doesn’t like me you know That’s pretty understandable My true value as an individual depends on what others think of me I would challenge this one this is all you know Also very personally I would challenge people to look at and say it so your child’s value as an individual depends on what other people think of Most people would say no but the perspective thing nothing ever turns out the way you want it to okay all-or-nothing thinking and probably availability heuristic if something bad just happened then they may be focusing on that which causes them to focus on all the other bad things in the past that have happened not to focus on that is okay you know bad thing happen but look at all these good things I won’t try anything new unless I will be good at it this fear of failure fear of rejection It just really paralyzes a lot of people when they get stuck with that thinking the area that they have to be perfect I am in total control of anything bad that happens is my fault well that’s egocentric and personal if They think they’re in total control that’s their perception of how the world Do they think if they’ve got everybody on marionette strings anything bad in the world that happens is their fault how powerful are they I feel happy about uh if I feel happy about life something will go wrong It happens sometimes but let’s look at times when you’ve been happy that something hasn’t gone wrong you know let’s get rid of that all-or-nothing thinking it’s not my fault my life didn’t go the way I wanted could be true but it seems like that’s making you unhappy so what do we do about that if I’m not in an intimate relationship I’m alone No, again that’s pretty extreme I’m either in an intimate relationship or I am alone and a loner and you know it’s just me and my 17 cats which follows with there’s no gray area so encouraging people to look at what these beliefs are saying important thoughts impact behaviors and emotional and Physical reactions emotional and physical reactions impact thoughts and interpretations of events so if you do something and it’s pleasurable and you have a great physical reaction you know let’s take bungee jumping or Skydiving if you go out there and it’s scary but you do it and you’re just like Whoa what a rush Your interpretation of that is probably going to be good which means you’ll probably do it again if you go out there and it’s just the most horrible experience you’ve ever had you’re probably not going to do it again and your interpretation of it is going to be not good which is going to make it hard to understand why other people would do it irrational thinking patterns are often caused by cognitive distortions so let’s just look back at some of those because there are a lot fewer cognitive distortions or general ways of thinking about the world then there are thinking errors because There are lots and lots of thinking errors Cognitive distortions are often schemas which were formed based on faulty inaccurate or immature knowledge or understanding and by identifying the thoughts of the hecklers you know the automatic tapes that maintain our unhappiness the person can choose whether to accept those thoughts or change them.As found on YouTube Natural Synergy $47.⁰⁰ New Non-Invasive Alternative. 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Best Practices for Anxiety Treatment | Cognitive Behavioral Therapy

This episode was pre-recorded As part of a live continuing education webinar on-demand CEUs are still available for this presentation AllCEUs.com/Anxiety-CEU I’d like to welcome everybody to today’s presentation on best practices for the treatment of anxiety I am your host, Dr. Dawn Elise Snipes now not too long ago we did a presentation on strengths-based biopsychosocial approaches to addressing anxiety while Those are wonderful you know I thought maybe we ought to look at you know what’s some of the current research so I went into PubMed which is I don’t know it’s a playground for me it’s where You find a lot of journal articles and you can sort I sorted by articles that were done and meta-analyses that were done within the past five years so that gives us an idea About current research I mean there’s a lot of stuff that is still the same like some of The medications that were known to work ten years ago are still known to be you know good first-line treatments but there are also some newcomers that we’ll talk about and there are also some changes that we’re going to talk about so we’re going to explore some common causes for anxiety symptoms in order to treat it, we really need to and of course, this does play into the biopsychosocial aspect we really need to understand kind of what causes it because anxiety that’s caused by for example somebody having a racing heart may be different than anxiety that’s caused for somebody who has abandonment issues so we’re…

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…It can be incorporated in a lot of various places again where they’re not applying it or ingesting it in any way all they’re doing is smelling it they’ve used it in defusing aromatherapy in hospital emergency rooms and they found that it reduces stress and irritability the people in emergency rooms and I’ve been to enough emergency rooms over the course of the years to know that People who are in emergency rooms typically are not in the best mood so if it can help those people then It’s probably going to have some sort of an effect so psychologically helping clients realize that their body thinks there’s a threat for some reason that’s why it triggered the threat response system which is what they call anxiety, so they need to figure out why is there really a threat You know sometimes it’s like the fire alarm going off in my house it just means that the windows are open and there’s a strong breeze there is no fire there is no problem there’s just a malfunction It’s a false alarm A lot of times clients get this threat reaction they get this stress reaction and it’s not a big deal right now so they can start modifying what their brain responds to and again, those basic fears that a lot of people worry about failure rejection loss of control the unknown and death and loss distress tolerance is one of those cognitive interventions that has taken center stage in anxiety research and it isn’t about controlling your anxiety you know helping people recognize their anxiety acknowledge it and say okay I’m anxious it is what it is How can I improve the next moment instead of saying I’m anxious I shouldn’t be anxious I hate being anxious and slang with that anxiety let it go just accept it is what it is have the client learn to start saying I am feeling anxious okay so distracted don’t react because I explain to them The whole notion of feelings comes in crest and go out in about 20 minutes It’s like a wave so once they acknowledge their feeling if they can distract themselves for twenty or thirty minutes you know Obviously, they figured out there’s no real threat if they can distract themselves for twenty or thirty minutes those emotions can go down and then they can deal with it in their wise mind and encourage them to use distancing techniques instead of saying I am anxious, or I am terrified or whatever Have them say I am having the thought that this is the worst thing in the world I am having the thought that I could not handle this because thoughts come and go and that comes from acceptance and commitment therapy functional analysis makes it possible to specify where and when with what frequency with what intensity and under what circumstances the anxious response is triggered so it’s important that we help clients develop the ability to do functional analyses on their own so when they start feeling anxious, they can stop and say okay where am I what’s going on how intense Is it what are the circumstances, and they start really trying to figure out what causes this for them so they can identify any common themes from their psychoeducation about cognitive distortions and techniques to prevent those circumstances or mitigate them can be provided so if the client knows that they get anxious before they go into a meeting with their boss and it’s usually a high intensity of anxiety okay so we can educate them and help them identify what fears that may be related to techniques to slow their breathing calm their stress reaction and help them figure out times in the past when they’ve handled going in and talking to their boss and it really wasn’t the end of the world you know there’s lots of different things we can do there for them there but the first key and it gives them a lot of a huge sense of empowerment to start becoming detectives in their own life and going okay now under what situations does this happen positive Writing this was another really cool study each day for 30 days the experimental group and this was high school-aged youth in China but you know the experimental group engaged in 20 minutes of writing about positive emotions they felt that day so they’re writing about anything positive that make them happy that made them enthusiastic give them hope whatever long-term expressive writing positive emotions so after 30 days it appeared to help reduce test anxiety by helping them develop insight and use positive emotion words so it got them out of the habit of using the destruction and doom words and encouraged them to get in the habit of looking at the positive things and being more optimistic it’s a really cool activity that clients can try it’s…

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Best Practices for Anxiety Treatment | Cognitive Behavioral Therapy

this episode was pre-recorded as part of a live continuing education webinar on-demand CEUs are still available for this presentation AllCEUs.com/Anxiety-CEU I’d like to welcome everybody to today’s presentation on best practices for the treatment of anxiety I am your host, Dr. Dawn Elise Snipes now not too long ago we did a presentation on strengths-based biopsychosocial approaches to addressing anxiety while those are wonderful you know I thought maybe we ought to look at you know what’s some of the current research so I went into PubMed which is I don’t know it’s a playground for me it’s where you find a lot of journal articles and you can sort I sorted by articles that were done and meta-analyses that were done within the past five years so that gives us an idea about current research I mean there’s a lot of stuff that is still the same like some of the medications that were known to work ten years ago are still known to be you know good first-line treatments but there are also some newcomers that we’ll talk about and there are also some changes that we’re going to talk about so we’re going to explore some common causes for anxiety symptoms to treat, we need to and of course, this does play into the biopsychosocial aspect we need to understand kind of what causes it because anxiety that’s caused by for example somebody having a racing heart may be different than anxiety that’s caused for somebody who has abandonment issues so we’re gonna treat the two things differently so we want to look at some of the common causes we’re gonna look at some common triggers for anxiety Do you know what are some of these common themes that we see in practice I will ask you to share some of the themes that you see that underline or underlie a lot of your client’s anxiety and identify current best practices for anxiety management including counseling interventions medications physical interventions and supportive treatments so we care because anxiety can be debilitating and a lot of our clients have anxiety a lot of our clients have anxiety comorbid with depression and they’re looking at us going how can I feel anxious and stressed out and like I can’t sit still and be depressed at the same time you know when you’re depressed you’re supposed to want to sleep well a lot of times people who have both issues want to sleep but they can’t so I want to help clients understand that also sometimes anxiety when people are anxious for long enough the body starts kind of holding on to the cortisol the body recognizes at a certain point this is a losing battle I’m not going to put energy into this anymore so it starts withdrawing some of its excitatory neurotransmitters so to speak and people will start to feel depressed the brain has already said this is hopeless this is you’re helpless to change the situation so then people start feeling hopeless and helpless which is sort of the definition if you will of depression low-grade chronic stress and anxiety arose energy and people’s ability to concentrate so if we’re going to help them become their uber selves we need to help them figure out how to address anxiety not just generalized overwhelming debilitating anxiety but also panic social anxiety and those minor anxiety triggers that come along that may not meet the threshold for diagnosis anxiety is a major trigger for addiction relapse if you have a client who is self-medicated before or had an addiction for some reason anxiety is a major trigger increased physical pain when anxiety goes up people tend to tense their muscles when they tense their muscles they tend to feel more pain I mean think about when you’re stressed you tend to have more pain like in your neck your back and things that already hurt may hurt more why because serotonin which is one of our major anti-anxiety neurotransmitters is also one of our major pain modulators so when serotonin levels are too low because anxiety is high then our pain perception is going to be more acute and people can have sleep problems if they’re stressed out your body thinks there’s a threat you’re not going to be able to get into that deep restful sleep you may have you may sleep you may sleep a lot but it’s probably not quality sleep which means your neurotransmitters may get out of whack your hormones make it out of whack and your body is going to start perceiving yourself in a persistent state of stress when you’re exhausted the body knows that we may be the weakest link in the herd so it continues to secrete cortisol to keep you on alert a little bit so you may again you may be resting kind of like when you have a new baby at home those first couple of months that my children were home from the hospital I slept but I didn’t sleep well I mean the slightest little noise and I was awake and I was looking around and you know I felt it I felt exhausted and a lot of new parents do so triggers for anxiety abandonment and rejection and we’re going to talk about ways we might want to deal with these things but some of the underlying themes that I’ve seen in a lot of clients and when I do the research and a lot of what themes that come out include low self-esteem if someone has low self-esteem they’re looking to be externally validated oftentimes they’re looking for somebody else to tell them you’re lovable you’re okay so that can lead to anxiety about not having people to tell them you’re okay which makes their relationships tenuous and can make them dysfunctional irrational thoughts and cognitive distortions may lead people to believe that if I’m not perfect for example I am not lovable so we’re going to look at some irrational thoughts and cognitive distortions unhealthy social supports and relationships when you’re in a relationship it takes two to tango and even if your client is relatively mentally and physically healthy if they are in a dysfunctional relationship they can fear abandonment and rejection if that other person is always saying if you don’t do X I’m going to leave you or if that other person is always cheating on them or whatever so relationships can trigger abandonment anxiety and ineffective interpersonal skills can lead to relationship turmoil and social exile if our clients are in relationships even if they’re not completely dysfunctional if our clients are not able to ask for what they need and set appropriate boundaries and manage conflict effectively because conflict happens in every relationship then they may start to argue more which may lead to fearing may lead to relationships ending in the past and them going well every relationship I get into ends which means I must not be lovable so they start fearing abandonment and rejection these are four areas that we can look at one more assessing clients another issue is the unknown and loss of control a lot of times negative self-talk and cognitive distortions can contribute to that if I don’t have control of everything then it’s all going to be a disaster negative others when clients hang out or when people hang out with negative people it kind of wears on you after a while you notice that people who tend to be more negative pessimistic conspiracy-minded tend to hang out with people who are also negatively pessimistic and conspiracy-minded so if you’re hanging out with somebody who tends to be anxious then the anxiety can be palpable and it can kind of permeate physical complaints can lead people to be anxious because they don’t know what’s causing it like I said earlier sometimes if your heart starts to race if you don’t know what’s causing it you can start thinking I’m having a heart attack or I’m gonna die when people have panic attacks for the example they truly think they’re having a heart attack and it’s I’ve had them they are very very unpleasant experiences but when people start having physical complaints and it can be you know they have a weird rash that they can’t get to go away or whatever but when they don’t know what it is and they can’t control it they can’t make it go away they start thinking about all the worst-case scenarios and going online and getting on WebMD which usually gives you all the worst-case scenarios um so physical complaints are important we need to normalize the fact that nobody’s pain-free all the time and you know the fact that you may have an ache or a pain or a lump or a bump or you know a cough most likely you know when we look at probability the probability of it being something significant is pretty small now do you want to get it checked out probably but you know the probability that is anything to be worried about is relatively small and a sense of powerlessness can trigger fear of the unknown and loss of control for somebody who doesn’t feel like they have any agency in their life if they have an external locus of control or if they felt victimized all of their life then they may fear not being in control they may be holding on and saying okay this is the one area of my life I can control when I grew up you know I grew up in a very chaotic environment I had no control I was bounced around in the foster system yadda yadda yadda now that I’m an adult you know I can control these things and I am going to hold on with white knuckles and if I can’t control everything then that terrifies me to death and loss are other triggers for anxiety and it can be people or pets and pets are important I don’t want to minimize pets because you know they are little parts of a lot of our families so making sure we check that my daughter’s dog for example is it’s getting old she’s getting older she’s 14 now I think and you know she’s in decent health we took her to the vet and the vet said yeah she’s got a little heart murmur but that’s expected for a 14-year-old dog and but when she goes out if she doesn’t come back when I call her I have this rush of anxiety for a second oh my gosh I hope this wasn’t the day so anxious around losing people and you know if she when she crosses the bridge she will and you know I’m okay with that I’m I have a harder time dealing with my daughter’s emotional turmoil when that happens and because she’s grown up with this dog so you know those are the types of things that we want to talk about with our clients what things are weighing on you that you may not even be thinking about because I know in the back of my mind there’s always that worry about one of our donkeys and her dog jobs and promotions can trigger anxiety if people are afraid they’re gonna lose their job if they’re always afraid that you know they’re gonna walk in and get a pink slip or get fired you know we want to help them look at how realistic they are you doing what you need to do to achieve and keep your job and sometimes it’s not easy to answer I mean the first thought that a lot of us have is well you know if you’re doing the right thing so just do it but there are those bosses out there and I’ve had some amazing bosses a lot of them and I’ve had two horrendous bosses and those two bosses I could never I never felt like I was able to do anything right and so going to those jobs there was always this anxiety about what I’m what am I going to get in trouble for today so you want to talk with people about does your job cause anxiety what can you do to moderate that anxiety the same thing with promotions people may get anxious about whether they’re going to get promoted to safety and security you know when you lose safety and security you can feel anxious so if there’s a break-in at the house next door or shooting down the road or you start watching the news you can feel very unsafe and insecure quickly so we want to help people figure out how safe and secure are you really and a lot of it goes back to really looking at facts when people lose their dreams and hopes or fear that they’re going to lose their dreams and hopes they can start to get anxious you know they have this dream that they’re going to be a doctor or I just finished the presentation on helping high school students transition to college and a lot of high school students for example start college with these wide eyes and hopes to save the world and they want to be doctors and engineers and this and that and they get into it and they realize that it’s a lot harder then they thought or they realize that you know what I don’t like this but I’ve already committed to it so what do I do I want to help people but I can’t I can’t cut it doing this you know for me I figured out in my second year that I wasn’t going to medical school because I wasn’t going to pass calculus and that caused a lot of anxiety it was like okay what am I gonna do now Do you know what career should I choose to help people figure out do they have dreams that have maybe kind of crashed and burned and you have to find new ones you know okay that one we’ve got to accept it figure out that it’s not going to be and what can you do now people may also have dreams about relationships, they get into relationships and see themselves with this person forever and then this relationship ends and or starts to get rocky and they’re like but that’s my dream what happens if that’s got to happen because it’s my dream I don’t know how to function if that goes away we want to help people be able to rewrite their narrative and then sickness spiders and other phobias kind of go in with death a lot of times when people get sick they start getting anxious that oh my gosh what if this is terminal oh my gosh what if this is you know incurable if I get bit by a spider it’s gonna kill me and which is rare you know there are very few spiders that is that poisonous same thing with snakes going over bridges I’ve shared with you all that is not one of my irrational fears you know I am just terrified that you know something’s going to happen and I’m going to get pushed off the side of the bridge which is completely irrational but we need to help people look at those and identify the thoughts that they’re telling themself about those phobias and dealing with that anxiety failure is another trigger for anxiety especially in this culture our culture American culture is in large part puts a high premium on success and perfectionism so when people realize that they’re not perfect they may start to get anxious because they feel like if I’m not perfect then I’m a failure you know those cognitive distortions of all-or-nothing thinking and they start with that negative self-talk you know you can’t do anything right so those are some of the issues that you know we often see in counseling sessions so what do we do you know somebody comes in and is like I can’t live this way doc anxiety depression and substance disorders as well as a range of physical disorders are often comorbid so this is the first the thing we need to realize is that we’re very rarely dealing with a very simple diagnosis you know when somebody comes in we need to figure out you know if they come in and they’re presenting with depression all right let’s talk about that and then we start realizing that there depression started to occur after a long period of being anxious okay so we need to deal with that but we also need to help them with their sense of hopelessness and helplessness we need to develop that sense of empowerment and then substance disorders we know that substance use is often a way of self-medicating but we also know that it monkeys with the neurochemicals in the brain and can contribute to anxiety and depression the same thing to physical issues pain from physical disorders anxiety about having physical disorders medications you’re taking for physical disorders can all contribute to anxiety so we need to look at the person as a whole and go what are all the things that are contributing to the anxiety and what are all the things that the anxiety is contributing to so we have started having this big list of stuff that needs to be addressed and then we can start figuring out okay where we start so knowing that these things are comorbid helps researchers explore pathways to mental disorders so they can start figuring out you know what little string can we pull to unravel this blanket of anxiety so it doesn’t suffocate somebody and for us as clinicians it provides us key opportunities to intervene in you know sometimes clients will come in and start talking about their anxiety and their physical issues you know maybe their anxieties about you know heart palpitations and because that’s a common one we may want to encourage them to go see the doctor to get that ruled out you know rule out anything that has to do with hormone imbalances or you know heart conditions or anything else that might be contributing to it which can help them address it and if they do have physical disorders let’s go with hormone imbalances that are contributing to the heart palpitations then they can start to treat that if they don’t start to treat that then no amount of talk therapy we do is going to get them to the quality of life that they’re looking for because they’re still gonna feel those so we want to make sure that we’re addressing them holistically anxiety disorders should be treated with psychological therapy pharmacy therapy or a combination of both and what they found and this is no surprise this is kind of old news is that counseling Plus pharmacotherapy tends to have the best outcomes but separating the two have similar outcomes in many cases but that’s just looking at and I hate to call it simple anxiety but we’re just looking at anxiety symptoms here we’re not looking at the full quality of life and we want to make sure that we’re also including any medical issues behavioral therapy is regarded as the psychotherapy with the highest level of evidence, there are a variety of cognitive behavioral approaches ranging from acceptance and commitment therapy to dialectical behavior therapy to CBT to debt you know any of those that deal with the thoughts and the cognitions that fall in that realm and it is effective in the current conceptualization of the etiology of anxiety disorders includes an interaction of psychosocial factors such as childhood adversity or stressful events and a genetic vulnerability so the psychosocial factors and these are other things when we do our assessment we want to pay attention to because our approach to treatment is going to be different for people for example who have trauma-related brain changes maybe then for somebody who doesn’t so, we want to look at childhood adversity and stressful events that it may have caused basically what I tell clients is like rewiring of the brain there are trauma-related brain changes in soldiers and especially in children or in people who’ve been exposed to extreme trauma that is designed to protect them but it also can cause complications kind of later on in dealing with anxiety coping skills that were learned that are ineffective you know sometimes people grow up in a household or an environment or a situation where they don’t learn effective coping skills so we need to kind of help them unlearn those and learn new ones build on their strengths and trauma issues that may still need to be dealt with such as domestic violence you know if they grew up a lot around a lot of domestic violence they may think you know I’m out of that situation it’s over I don’t want to think about it it’s not bothering me anymore or a parental absence and I put absence because it can be death it can be a parent that just packed up and left it could be a child that got put up for adoption whatever put the child in a position of feeling like they were rejected by a parent can be very traumatic and bullying among other things but there are a lot of trauma issues that people once they’re out of that situation often say you know I’m out of it it’s not a big deal I dealt with it let’s move on and they don’t realize the full ramifications and how that’s contributing to their current anxiety and their current self-talk and cognitions of current stressors if somebody has a lot of current stressors that’s also going to impact whether they develop generalized anxiety you know we’re kind of stacking the deck here and the current availability of social support if they don’t have effective current social support then they’re gonna have difficulty bearing the weight of everything on their shoulders so we want to look at all these psychosocial factors when we do our assessment now going back to the trauma issues if you’ve taken the trauma courses at all CEUs you know that some people are not ready to acknowledge that the trauma is still bothering them or work on the trauma and that’s okay we can educate them that it might be an issue and then let them choose how to address it but we want to bear in mind the fact that you know this could be sort of an underlying force motivating some of the current cognitions and genetic vulnerability so you take any three people and you put them or 300 people and you put them through roughly the same psychosocial situations they’re all probably going to react a little bit differently based on their prior experiences but also because of their genetic makeup there are certain permutations and they found four we’ll talk about later that make the brain more or less responsive to stress and more or less responsive to serotonin which is your calming chemical so brains that are less responsive to serotonin isn’t going to you know send out as much or send out serotonin as easily so people can stay kind of tensed and wired that’s an oversimplified explanation but that’s all you need for right now so genetic vulnerability impacts people’s susceptibility to the effects and development of dependence on certain substances which can increase anxiety when people are detoxing from alcohol when they’re detoxing from benzos when they’re detoxing from opiates they can feel high levels of anxiety when they take opiates some people find that opiates have wonderful anti-anxiety properties not that I am advocating for the use of opiates I’m just client experiences have shown that that can be true so some people are going to be more susceptible to the anti-anxiety effects of certain substances and some people are going to be Cerrone to become dependent on substances where others may not and that part of that is genetic vulnerability and they estimate about 30% the predictability of the development of anxiety disorders is genetic and genetics also impact which medications are effective if you have genetic makeup then SSRIs might be helpful then atypical antipsychotics may be more effective and SSRIs might not do anything which is why a lot of our clients get so frustrated because they know there’s no way to figure out exactly what I guess there is now that there’s genetic testing out there but up until then it was harder to figure out which medications to start with and most physicians matter of fact I don’t know of a single physician that starts by saying well let’s do a genetic profile to see what med to start you out with most we’ll start with events as with an SSRI or some other anti-anxiety medication some sort of Benzo that’s been my experience so we may want to encourage clients to consider genetic testing if they’re having difficulty finding a medication regime that works for them and they are feeling like they have to have medication genetic vulnerability also affects what’s going to make somebody more vulnerable now than all of you in class today you know thinking about sleep you know sleep may not be a big deal for some of you I know people who can go days or weeks with four or five hours of sleep and they feel fine it’s not a big deal, not me I need eight or nine hours of sleep so genetically for whatever reason I am programmed to need a lot of sleep so when I don’t get that much sleep I tend to be it tends to be harder for me to deal with life on life’s terms and I know that that makes me more vulnerable to being irritable so genetic vulnerability affects who can become addicted and affects what medications work best and affects what situations are going to tend to make somebody more vulnerable to anxiety so our medications and I know the type on here is small but we’re going to go through the first-line drugs are the SSRIs selective serotonin reuptake inhibitors and SNRs is selective norepinephrine reuptake inhibitors now the names are a little bit deceptive because selective norepinephrine reuptake inhibitors also increase available serotonin but the mechanism of action is different the mechanism of action for each SSRI is a little bit different as well which is why you can put somebody on Prozac and they have an awful experience and you can put them on Zoloft and they have a much better experience like I said earlier a lot of the research pre five years ago had been done on medications and Zoloft paxil luvox lexapro celexa and their generics have all been found to be effective at treating anxiety in certain people no one medication works for everybody in the last five years effexor has come on the radar and it has been found effective according to the Hamilton rating scale for anxiety so that’s another one to consider if clients are not successful or getting the treatment effect that they need for on some of the other medications obviously, none of us probably are prescribers but we do need to educate clients about why the first drug or even the third drug that the doc tries may not work so they don’t start feeling helpless and hopeless like I said earlier there are at least four different genetic variations which are correlated with the development of generalized anxiety disorder and different medications are more or less effective depending on the genetic makeup of the person there’s a high mortality rate moving on to two benzos the recommendation has switched to back off from the use of benzos now for some doctors will prescribe an SSRI and for the first, four weeks while the SSRI is building up in the system they will also prescribe a Benzo to be taken as needed to moderate the anxiety and you know you could argue on either side of that, if somebody has a history of substance use or substance dependence benzos are really a bad idea because they do have a high rate of dependence but the other reasons that they are now cautioning against the use of benzodiazepines is that there’s a higher mortality rate among benzo users compared with non-users there’s an increased risk for dependence with use for more than six months and that’s a long time to be using Benzo and when we’re talking about dependence and six months we’re talking about somebody who uses it like every four hours or every eight hours depending on your Benzo every single day, not a PRN user if somebody’s using it at night to help them go to sleep or you know three or four times a week when the anxiety gets high the risk of dependence is relatively low but a lot of people with anxiety because if they find the right Benzo makes them feel so much better they may not want to be off of it and for a lot of people when that benzo reaches its half-life and starts getting out of the system even more their anxiety spikes you know they have rebound anxiety which they want to medicate with more benzos that’s gonna be an issue for them to discuss with their doctor there’s also an increased risk of dementia identified in long-term benzodiazepine users again this is for the people who use you know throughout the day every day for six months or relatively every day for six months or more and it doesn’t matter if it’s you know we’re talking about somebody who’s 65 or somebody who’s 35 who’s been using Benzos for you know six months a year two years the risk of later life dementia is greatly increased according to the research benzodiazepines also don’t treat depression okay so if you’ve got somebody who has concurrent anxiety and depression there’s a much higher suicide risk if they’re on benzodiazepines so being aware and generally that suicide risk comes from overdosing on benzodiazepines but not always other treatment options you know if the benzos aren’t something that people want to touch you know they scare the living daylights out of I SSRIs and SNRIs don’t seem to be working then tricyclic antidepressants can be tried on those your older generation antidepressant seroquel is used a lot and there are some there’s some research that shows it can be effective with anxiety like some of the antidepressants and depending on the person the benzos seroquel can make people very very very sleepy so you know it may not be the side effects of the Seroquel the weight gain and the fatigue and you know sleepiness may be an unacceptable side effect for some clients and boosts perón is the third option boost Barone works more like an anti-depressive serotonin reuptake inhibitor and that it takes you know four weeks or so to kind of build up in the system studies have shown that there’s really no long-term benefit to taking it but after six months to eighteen months of use it has been shown to be effective in talking with clients a lot of clients report that boost bar when they take it doesn’t necessarily help them stop being anxious like a benzodiazepine does but it helps them not go from zero to 200 in 2.3 seconds it kind of you know keeps them from having this gush of a freak out reaction every time something goes wrong which a lot of clients report helps because they feel more stable throughout the day after remission medication should be continued for six to twelve months and during that last six months first six months keep it as is last six months you know they say that tapering is best it’s best not to stop somebody cold turkey on any of these but it’s important for people once they’re in remission to not just suddenly go okay I feel better I don’t need any of this anymore they need to work into it and make sure they’ve developed the skills and tools that they need to deal with some of the anxiety that is going to happen in life so physical signs and symptoms of anxiety may include fatigue irritability muscle tension or muscle aches try laying feeling twitchy being easily startled trouble sleeping nausea diarrhea irritable bowel syndrome headaches so the first thing we want to do with clients when we’re talking to them well second thing first thing is say get a physical let’s rule out physiological causes of this but we can also help clients look at you know what might be causing these things that you can do to mitigate it what might be contributing to your fatigue what might be contributing to your irritability and your muscle tension or your muscle aches I mean let’s look at economics did you recently get a new bed or do you need to get a new bed what about your desk chair I know you know I get more muscle tension and muscle achy when I do a lot of mousing because I have deplorable posture being becoming aware of that helps and then I’m like okay well I know it caused unfortunately, it’s unpleasant but it’s not a big deal trembling or feeling twitchy you know that can be caused by low blood sugar that can be caused anxiety that can also be caused by early onset Parkinson’s symptoms you know there’s you know it can be worst case scenario or it can be something benign so we want to have people figure out you know when you start trembling or feeling twitchy is there something that it’s related to you know I know when my son gets excited he’s he just sits there and you can see him almost shake because he’s so excited about something so we want to have people prevent misidentification we don’t want them to jump to that worst-case scenario we don’t want them to go onto WebMD and go oh my gosh I’ve got cancer I’ve got this debilitating disease and I’m going to die in six months probabilistic Lee speaking it’s not gonna happen yes get a doctor’s opinion I’m certainly not going to tell them it’s all in your head I want them to get an evaluation but I do want to in the meantime help them think about how likely is this and other things for headaches and this is one another one of those that can be frustrating as we get older our eyesight starts to go and you know there was a period there I did fine and then after I hit 45 my eyesight just started to like steadily and kind of rapidly in my mind decline so I have to get my eyeglass prescription changed every couple of years and that can cause headaches so instead of starting to worry about oh my gosh I’ve got a headache all the time maybe I’ve got a brain tumor you know I know that it’s probably my glasses or I’m grinding my teeth so other biological interventions that have been evaluated there’s something called the floatation rest system that reduced environmental stimulation therapy reduces sensory input into the nervous system through the act of floating supine which is on your back in a pool of water saturated with Epsom salt you know I’m looking at this going sounds good and you can’t quite get the same experience in a bathtub because you’re not floating you’ve got pressure points and you’re still hearing stuff clients can sort of simulate it with you know earplugs or whatever but it’s if they can access this it’s been shown to be effective the float experience is calibrated so that sensory signals from visual auditory olfactory gustatory thermal tactile or tactile vestibular gravitational and preceptive channels are minimized which means you don’t see here taste touch smell feel anything as is most movement and speech so you want people to lay just like completely motionless and not talk which can be hard for some people with anxiety in the study the study I looked at fifty participants reported significant reductions in stress muscle tension pain depression and negative effects and it was accompanied by significant improvement in mood characterized by increases in relaxation happiness and well-being I read the study I’m like where can I sign up you know it sounds in looking at some of the research this was more effective for addressing anxiety than something like a massage Tai Chi also produced significant reductions in anxiety there was approximately a 20% treatment effect 25% treatment effect in patients with anxiety and fibromyalgia who practiced twice a week for a year now you know we want to look at the confounding things here is it the Tai Chi itself or is it learning to control the muscles and becoming more in tune with your body and learning to control your breathing helps people reduce their anxiety either way you know Tai Chi helps people do that and it was shown that after a year after the first six months, there was a significant treatment effect but after a year you know it kept growing and after a year it was about 25% so Tai Chi can be effective acupuncture at the HT 7 median Meridian can attenuate anxiety-like behavior induced by withdrawal from chronic morphine treatment through the meditation of the GABA receptor system what does that mean that means if you if the acupuncture is done in very certain places the anxiety behavior the GABA a receptor system GABA is your main calming relaxation neurochemical that is triggered and causes your body to sort of flood that receptor system and this research was done on people who were detoxing from morphine treatment but we can look at generalizing the results and I would be interested to see further studies on it pain other things we need to do to help people with anxiety when people are in chronic pain they often have anxiety that oh my gosh this is getting worse or It’s never gonna get better or I just can’t take this pain anymore or they may get anxious that they’re going to be rejected because they can’t do some of the things they used to do because they’re in so much pain so there’s a lot of guilt and anxiety that can kind of revolve around pain what can we do to help clients guided imagery is generally very helpful if we can help them imagine you know if that pain in their shoulder imagine the pain is like the color red flowing out of their arm or other focus mindfulness so you know when you think about something you know when you get a shot if I don’t think about it it doesn’t hurt near as much as if the nurse says okay now one two three and you know she’s counting down and I’m getting prepared and I’m focused on it I had another nurse one time who she was just talking to me and you know put the alcohol on my arm and just kept on talking and didn’t tell me she was getting ready to give me a shot and before I knew it she had given me a shot and she was like okay we’re done I’m like you didn’t give me a shot yet she said yes I did it’s like oh so not focusing on it and next time you have an itch for example if you’ve ever been driving on the interstate and you can reach on your foot I get those on the bottom of my foot sometimes and I’m like okay I’m not going to pull over to each my foot if you focus on something besides the itch eventually, it goes away I’m not saying the pain is gonna completely go away but the more people focus on it the more it hurts physical therapy can help so encourage them to get a referral and encourage them to do a self-evaluation if nothing else of ergonomics in their car at work where they watch TV and spend most of their time at home and they’re sleeping so those are the four places that they spend most of their time what do their ergonomics look like and that can help a lot of people mitigate a lot of pain hormones are another thing that we need to look at imbalances of estrogen and testosterone can contribute to anxiety symptoms heart palpitations fatigue irritability having people get a physical we can’t as clinicians do anything about it but doctors can rapid heart weight rate sweating palpitations are not uncommon in women in perimenopause or menopause so a lot of women start feeling like they’re developing generalized anxiety and/or something’s going wrong when they start reaching that mid-40s to mid-50s area and they start having some of these symptoms again we’re not going to diagnose it but we do want them to recognize that it may not be anything you know is catastrophic this is something that a a lot of women experience and help them figure out how to deal with that supportive care biologically now you know this isn’t gonna treat anything but we can help them minimize their vulnerabilities help them create a sleep routine so their brain and body can rebalance this can help repair any adrenal issues that may be going on and improve energy levels people with anxiety don’t sleep well so helping them figure out how to get some quality sleep is important nutrition minimizing caffeine and other stimulants are going to be a big help because those make people feel anxious and encourage them to work with a nutritionist to try to prevent spikes and drops in blood sugar which can trigger the stress response when your blood sugar goes way up or way down you can start getting kind of shaky and feel weird and that can cause people anxiety because they might think oh my gosh I’m having a stroke or a heart attack or you know I don’t know what these tremors are so it’s important that they don’t miss identify symptoms and encourage them to drink enough water dehydration can lead to toxic Ardea which is increased heart rate sunlight vitamin D deficiency is implicated in both depression and anxiety mood issues vitamin D has been found in those main areas where serotonin receptors are found vitamin D receptors are found so we know the serotonin and vitamin D have something going on sunlight prompts the skin to tell the brain to produce neurotransmitters and set circadian rhythms which impact the release of serotonin your calming neurochemical melatonin which is made from breaking down serotonin and helps you sleep and gaba so sunlight actually helps increase the release of GABA when it’s time to start calming down and going to sleep exercise studies have shown that exercise can have a relaxing effect and encourage clients to start slowly there’s not a whole lot of new research on exercise and anxiety aromatherapy has been used a lot, especially in other countries in the treatment of people with anxiety people with hospital anxiety people women who are giving birth and they have some birth anxiety there they’ve been found to be effective in a lot of those studies essential oils for anxiety include lavender rose Bedevere ylang ylang bergamot chamomile frankincense and Clary sage encourage clients to just go to a health food store and you know sniff some of these and see if it makes them feel happy and calm and content the aromatherapy molecules enter the nasal membranes and they will start triggering neurochemical reactions and so you don’t need to apply it you don’t need to ingest it all you need to do is so encourage clients if they’re open to it to think about this because aromatherapy can be integrated into their bedroom for example with an atomizer or a Mr. It can be incorporated in a lot of different places again where they’re not applying it or ingesting it in any way all they’re doing is smelling it they’ve used it in defusing aromatherapy in hospital emergency rooms and they found that it reduces stress and irritability the people in emergency rooms and I’ve been to enough emergency rooms over the years to know that people who are in ers typically are not in the best mood so if it can help those people then it’s probably going to have some sort of an effect so psychologically helping clients realize that their body thinks there’s a threat for some reason that’s why it triggered the threat response system which is what they call anxiety so they need to figure out why is there a threat you know sometimes it’s like the fire alarm going off in my house it just means that the windows are open and there’s a strong breeze there is no fire there is no problem there’s just a malfunction it’s a false alarm a lot of times clients get this threat reaction they get this stress reaction and it’s not a big deal right now so they can start modifying what their brain responds to and again those basic fears that a lot of people worry about failure rejection loss of control the unknown and death and loss distress tolerance is one of those cognitive interventions that have taken center stage in anxiety research and it isn’t about controlling your anxiety you know helping people recognize their anxiety acknowledge it and say okay I’m anxious it is what it is how can I improve the next moment instead of saying I’m anxious I shouldn’t be anxious I hate being anxious and slang with that anxiety let it go just accept it is what it is have the client learn to start saying I am feeling anxious okay so distracted don’t react because I explain to them the whole notion of feelings comes in the crest and goes out in about 20 minutes it’s like a wave so once they acknowledge their feeling if they can distract themselves for twenty or thirty minutes you know they figured out there was no real threat if they can distract themselves for twenty or thirty minutes those emotions can go down and then they can deal with it in their wise mind and encourage them to use distancing techniques instead of saying I am anxious or I am terrified or whatever have them say I am having the thought that this is the worst thing in the world I am having the thought that I cannot handle this because thoughts come and go and that comes from acceptance and commitment therapy functional analysis makes it possible to specify where and when with what frequency with what intensity and under what circumstances the anxious response is triggered so it’s important that we help clients develop the ability to do functional analyses on their own so when they start feeling anxious they can stop and say okay where am I what’s going on how intense is it what are the circumstances and they start trying to figure out what causes this for them so they can identify any common themes from their psychoeducation about cognitive distortions and techniques to prevent those circumstances or mitigate them can be provided so if the client knows that they get anxious before they go into a meeting with their boss and it’s usually a high the intensity of anxiety okay so we can educate them and help them identify what fears that may be related to techniques to slow their breathing and calm their stress reaction and help them figure out times in the past when they’ve handled going in and talking to their boss and it wasn’t the end of the world you know there’s lots of different things we can do there for them there but the first key and it gives them a lot of a huge sense of empowerment to start becoming detectives in their own life and going okay now under what situations does this happen positive writing this was another cool study each day for 30 days the experimental group and this was high school-aged youth in China but you know the experimental group engaged in 20 minutes of writing about positive emotions they felt that day so they’re writing about anything positive that make them happy that made them enthusiastic gave them hope whatever long-term expressive writing positive emotions so after 30 days it appeared to help reduce test anxiety by helping them develop insight and use positive emotion words so it got them out of the habit of using the destruction and doom words and encouraged them to get in the habit of looking at the positive things and being more optimistic it’s a cool activity that clients can try it’s not gonna hurt anything if you have them journal each day for 30 days mindfulness also came up in the research and was shown to be effective in a meta-analysis of six articles about mindfulness based stress reduction four about mindfulness-based cognitive therapy and three about fear of negative appraisal and emotion regulation were reviewed all of these showed that mindfulness was an effective strategy for the treatment of mood and anxiety disorders and is an effective in therapy protocols with different structures including virtual modalities so you know if you’re doing it via teleconference mindfulness can still be helpful mindfulness helps people start learning how to observe what’s going on and become aware of what’s going on more aware of those circumstances which will help them complete their functional analysis but it also helps them become aware of vulnerabilities and head off things in the past and if they’re taking better care of themselves that they’re living more mindfully then they may not experience as many situations that trigger their anxiety mindfulness also encourages clients to learn acceptance that radical acceptance of it is what it is I’m not gonna fight it I’m angry right now I am anxious right now however I’m feeling right now is how I feel and that’s okay it’s hard for clients to get to that but once they get a hold of that and they truly believe it and they can say all right it’s fine I’m not gonna feel this way forever I’m gonna do something else until the feeling passes it helps and that’s where the labeling and letting go comes in mindfulness can also help them identify trigger thoughts what thought were you having right before you started feeling anxious if people are mindful or let’s start back when people are not mindful they often notice or don’t notice that they’re getting anxious until they’re like super anxious when people are mindful they become more aware of subtle cues address unhelpful thoughts when they say or believe it’s a dire necessity for adults to be loved by significant others for almost everything they do always running gonna happen why is it a necessity what we can encourage them to do is concentrate on their self-respect on winning approval for practical purposes you know for promotions or whatever but it’s not about me being lovable it’s about me getting a promotion and making more money and focusing on loving rather than being loved because when we give love we generally get love back with unhelpful thought number two people feel they aren’t able to stand it if things are not the way they want them to be or are not in their control so encourage clients to focus on the parts that are in their control and other things in life which are going well and to which they’re committed number three misery is invariably externally caused and is forced on us by outside people and events just by reading that makes me feel disempowered so encouraging clients to focus on the fact that reactions such as misery or happiness are largely caused by the view that people take of the conditions so if you see it as a tragedy and devastating then it’s probably going to produce misery if you see it as an opportunity and a challenge it’s probably going to produce a different emotional reaction if something is or may be dangerous or fearsome people should be upset and endlessly upset about obsessing about it a lot of people with anxiety get stuck on this you know if I feel like it’s fearsome I need to worry about it getting on a plane for example if I fear that that’s dangerous that I need to think about it and worry about it that’s not going to do any good so encourage clients to figure out how to face it and render it harmless if possible and when that’s not possible accept the inevitable so looking at airplanes you know facing it means researching to figure out how dangerous is it really and realizing that it’s not that dangerous so that helps render it a little bit harmless in their mind it proves to them that it’s not as dangerous as it could be and when it’s not possible accepting the inevitable you know you got a fly so getting on there figuring out how you’re gonna get through it hurricanes are the same way people especially in places like Texas Louisiana Florida may obsess as soon as it starts coming to hurricane season or if a hurricane is spotted out in the Atlantic somewhere they start checking the weather every hour or more wondering what the path is going to be and you know what there’s you can’t change the path of the hurricane so all you can do is board up your house evacuate if necessary and deal with the fallout child driving is just another example I’ll give you know my children are learning how to drive and that’s kind of scary and fearsome you know what’s gonna happen when they’re out there you know you see crashes all the time well render it harmless by making sure they’ve got good training on how to drive make sure they’re good drivers and then accepting that some things are just not within my control it’s easier to avoid than face life difficulties and responsibilities Well running from fear is usually much harder in the long run so encourage clients to look back at times when they’ve avoided difficulties and responsibilities and the eventual outcome you know what happened there people believe they should be thoroughly competent in achieving in all possible respects or they will be isolated rejected and failures we need to encourage clients to accept themselves as imperfect with human limitations and flaws and focus on what makes them loveable human being what qualities like courage and intelligence and creativity and those things that can’t be taken away what inherent qualities do they have that make them awesome people because something once strongly affected people’s lives they should indefinitely fear it if you got lost you know when little kids get lost it’s terrifying when you’re grown up if you get lost you turn on the GPS and you figure out your way but some people still, you know freaked out about getting lost if they got lost once so we want to help people look back at past episodes that may be contributing to the current anxiety and compare the situation’s you know are you the same person or is this not a big deal now that you’re older wiser stronger encourage them to learn from past experiences but not be overly attached to or prejudiced by them yeah you could have maybe got lost in the past and it was a horrible experience well you were six I can see where that would be terrifying and a horrible experience but it doesn’t have to continue to impact you that way now when you’re you know 26 getting lost you know could be an opportunity to try a new restaurant or something people must have complete control over things well this doesn’t happen so encourage clients to remember that the past and the future are uncontrollable we can’t change the past it is what it is we can learn from it so it doesn’t repeat but we can’t change it and the future is largely uncontrollable I mean there are a lot of things I can do to stay moving toward a rich and meaningful life but life is going to throw me curveballs sometimes and there’s nothing I can do to plan for or control that we can control our actions in the present to stay on our preferred path and general develop general skills to deal with adversity should it arise so we want to help clients develop those general problem-solving skills and the general support system so when they are thrown a curveball you know it doesn’t knock them upside the head people have virtually no control over their emotions and cannot help feeling disturbed by things well encourage them to think about the fact that they have real control over destructive emotions if they choose to work at improving the next moment and changing inaccurate thoughts then they’re not going to experience the destructive emotions as intensely or as frequently when you feel an emotion you feel how you feel but again you don’t have to wrestle with it fight it and nurture it you can say this is how I feel how do I improve the next moment when it comes to cognitive distortions encourage them to find alternatives when they start to personalize things if somebody laughs when you walk out of the room then the and the person starts getting anxious thinking oh they were making fun of me I wonder what they thought I wonder if I had something stuck to the back of my dress and they start getting all panicked about it that doesn’t do any good encouraging them to think you know what our three alternate explanations that hadn’t but had nothing to do with you for why they laughed magnification of the worst thing you know taking something and saying if this happens then it’s going to be a catastrophe and minimization going along with that a lot of times when people magnify and see a catastrophe they minimize not only their strengths and resources but all the other stuff that they’ve got going for them all they’re seeing is this catastrophe so encouraging them to focus on the facts of what is actually happening and what is the high probability event and encourage them to get information and look at the broader picture you know yes you got into a car crash and your car is totaled and that is unfortunate you know it sucks but you know that is not going to cause you to lose your job and then become homeless and penniless and yadda-yadda it might cause your insurance to go up but okay so you don’t have a car but what are the resources that you have who can Who do you work with that might be able to give you a ride to work you know let’s look at the resources you have and work around so problem-solving helps with magnification and also focusing on you know let’s be grateful for what didn’t happen you know you could have been killed but you weren’t the car was totaled it’s replaceable all or nothing thinking again have them think about what else could have been happening like Brittney suggested finding the exceptions instead of saying she always does this look for exceptions when has she not done that what else has she done instead of this selective abstraction and filtering is when people look for the good the bad and the ugly a selective abstraction means you kind of see what you expect to see so if you expect something to be devastating you see only the devastating aspects of it which kind of goes with the magnification and minimization you filter out the stuff a lot of times when people are in a bad mood or are anxious they see the negative because that’s the state of mind they’re in so encouraging people to complete the picture alright there’s all this bad stuff now what’s the good stuff you know to encourage them to look at the good the bad and the ugly so they get a wide view of exactly what’s going on and encourage them to remember that hindsight is twenty-twenty when people have something embarrassing happens or they get anxious about something that happened they look back and they go I should have or I could have or Oh I wish I wouldn’t have when you were in that situation you did what you did and you know maybe you may have had a reason for it or you know you may have not had other options or it may have just been a bonehead thing to do but okay so you made one mistake hindsight is 2020 that’s gonna that mistake is gonna stand out just like the great big letter on the eye chart because you’re thinking back and you’re looking at it and that’s all you see but encouraging clients to remember that other people are too busy worrying about themselves to remember what they did jumping to conclusions encourages clients to remember to get all the data if your significant other male significant other comes home and is smelling like perfume don’t just jump to the conclusion that he was cheating on you maybe he went to the mall to get a new tie and walked through the perfume area and got spritzed or bought you some perfume or who knows maybe the person sitting next to him at work sprayed her perfume on the desk and some of it filtered on there are all different reasons that that might happen so encourage people to get all the data mind reading we can’t do it you know you can’t read somebody’s mind you don’t know what they’re thinking so ask them what you think about this don’t assume anything and emotional reasoning encourages people to step back from a situation and ask themselves am I feeling anxious about this because I’m feeling anxious and I’m looking for reasons that it should be scary or am I feeling anxious about this because it’s really scary for some reason there are facts support my anxiety a lot of times when we go into new situations we may feel anxious because it’s a new situation but when we step back we say you know what there’s nothing to be worried about here you know no big deal I got this and move on so instead of rolling with it and trying to figure out okay I feel anxious so there must be a reason not necessarily very likely a false alarm other psychological interventions relaxation skills encourage people to learn how to relax not only physically but mentally diaphragmatic breathing helps encourage them to breathe through their stomach and put their hand on their belly and feel their belly expand and contract slows breathing down which triggers the rest and digestion reaction in the brain which is calming meditation can be helpful for some people some people find trying to quiet their minds too frustrating because they’ve got too much monkey mind going on that can be later or maybe never for some people we don’t want to increase their anxiety with interventions cute progressive muscular relaxation also has a lot of research support and remembers with cute progressive muscular relaxation we’re Sakura getting them to attach a cue AK you word like relax or breathe with the relaxation response so they tense their muscles and then relax their muscles and as they relax their muscles they say their “querk”-word like relaxed and they work from head to toe or from toe to head tensing and relaxing different muscle groups so they become more aware of what a tense muscle feels like versus a reactive relaxed muscle there are great scripts that are online that people have already recorded that can walk people walk clients through CPM are I highly encourage it because once they get used to it then they can just think that cue they can think relax and as they exhale they will start to feel their entire body kind of relaxing because it’s trained when it hears that just like when you hear the word pop quiz when you were in high school you had a stress reaction well we want to use it in reverse and train the body so that when it hears a cue word relaxes helps them develop self-esteem because fear of failure and rejection a lot of times come from needing other people’s approval to help them develop a rational idea of their real self develops compassion self-talk instead of saying I’m an idiot or I’m stupid or I’ll never measure up to anything encourage them to talk to themself like they would talk to their child or hopefully their best friend and encourage them to spotlight strengths whenever they feel like they’ve got an imperfection to identify these three strengths that they have so they’re you know balancing out the imperfections and the strengths of cognitive restructuring reframes challenges in terms of current strengths, not past weaknesses so if you’re going to give a presentation in front of 60 people and you hate public speaking instead of thinking about you know this is terrifying because the last time I went up in front of people I forgot everything I was going to say and drop my note cards well that’s a past weakness what is your current strength you’re prepared you know the material you Jabba-dada so encourages people to look at all the strengths and resources they currently have them develop an attitude of gratitude and optimism because like I said with that the positive writing exercise when people are in a grateful optimistic frame of mind they tend to see more of the good stuff they see the bad stuff too but they can also see more of the good stuff and some of the bad stuff they see opportunistically instead of as a devastation acceptance and commitment therapy says that some of the reasons that we’re miserable are fear we get fused with our thoughts we think I am terrified well if I am terrified then I can’t I mean if I am I can’t get rid of anything I am if I’m having the thought that I’m terrified well I can get rid of a thought I can forget things easily encourage people to evaluate their experience and empower them to look at things as challenges and opportunities instead of hardships encourage them not to avoid their experiences so things that are scary gradual exposure and finding exceptions like for me bridges you know I love public speaking so that’s not a thing but when I go to a bridge you know when I Drive to the bridge you know when I’m on the bridge somebody else is driving I get used to doing that when I Drive over a bridge than when I Drive over one of those bridges that opens up I hate those bridges um I know y’all are just like oh my gosh yeah it’s an irrational fear I realize that but instead of going straight for the bridge that opens up going for the little bridges first and then thinking back over times that I’ve gone over bridges and there’s been no problem you know there are exceptions nothing happened it wasn’t a big deal Sometimes I didn’t even notice it until somebody pointed out hey look down there at that pretty water and I’m like oh we’re on a bridge so encourage people to not avoid their experiences get used to them embrace them and learn that they have the power to deal with them and stop reason giving for behavior you know use the challenging questions if something is fearsome let’s look for at the evidence for and against it instead of you know making excuses for social interventions improve their relationship with their self which goes with self-esteem improvement people are going to feel less anxious about getting their needs and wants to be met if they know what their needs and wants are so part of that is becoming mindful cuz a lot of our clients don’t know what they need and want they just want to feel better but they don’t know how they don’t know what they need to feel better so helping them identify their needs and wants to encourage them to be their own best friend you know when they get a promotion take themselves out to dinner pat themselves on the back whatever it is don’t rely onother people to do it because other people it’s not that they don’t care but other people are often very involved in thinking about their stuff and they may not notice encourage them to develop a method of internal validation so they can feel like they are all that ‘no bag of chips and they realize why they are lovable human beings and they accept the the fact that everybody is not going to like them and nobody is gonna like them all the time and that’s okay you know my kids don’t like me all the time my husband doesn’t like me all the time I’m okay with that I know I can be challenging but you know most of the time you know they like me and that’s okay and there are some people you know who don’t like me at all and okay there’s nothing I can do about that helping our clients develop an okayness with that helps relieve a lot of anxiety because a lot of people feel like they have to be liked by everybody and if somebody doesn’t like them it’s like what did I do wrong oh my gosh encourage them to develop healthy supportive relationships with good boundaries develop assertiveness skills so they can ask for help when they need it anxiety a lot of times you know that’s the body saying there’s a threat well if there’s a threat maybe you need some help you know dealing with it so people need to be willing and able to ask for help and not feel like that’s going to lead them to be rejected and allow them a certify this will allow them to say no to requests again without feeling like that’s going to result in them being fully rejected describe the ideal healthy supportive relationship and encourage them to separate the ideals from the reals you know let’s look at if you had the best relationship what would it look like okay you know Warden June Cleaver we got that now how realistic is that you know let’s look at you know rephrasing this a little bit so it’s less extreme you know warden June Cleaver never fought their kids were perfect you know all those extreme words let’s look at what’s real what happens in real relationships encourages people to identify who would be a good partner in supportive relationships I’m not meaning necessarily romantic I’m meaning friends and where they can be found you know where would you find people that you could be friends with and encourage them to play through what it means when gaming cuz a lot of times again this goes with my reading you know what it means when your friend doesn’t return your text right away what does it mean when your friend cancels dinner on Friday night what does it mean when you see where I’m going with this and a lot of times clients with anxiety and rejection issues and low self-esteem will go to the worst-case scenario so encourage them to go back to finding the exceptions what else could have been happening what else could it be that caused this and it’s not about you so anxiety is a natural emotion that serves a survival function excessive anxiety can develop from lack of sleep nutritional problems neurochemical imbalances failure to develop adequate coping skills cognitive distortions low self-esteem and a variety of other stuff recovery Ambala involves improving health behaviors making sure your body’s functioning and making the neurotransmitters it needs and you know release them as needed to identify and build on current coping strategies address cognitive distortions and develop a healthy supportive relationship with self and others if you enjoy this podcast please like and subscribe either in your podcast player or on youtube, you can attend and participate in our live webinars with Dr.

Snipes by subscribing at all CEUs comm slash counselor toolbox, this episode has been brought to you in part by all CEUs calmly provide 24/7 multimedia continuing education and pre-certification training to counselors therapists and nurses since 2006 have used coupon code consular toolbox to get a 20% discount on your order this month.As found on YouTube Brain Booster | Blue Heron Health News ⇝ I was losing my memory, focus – and mind! And then… I got it all back again. Case study:

Brian Thompson There’s nothing more terrifying than watching your brain health fail. You can feel it… but you can’t stop it. Over and over I asked myself, where is this going to end? What am I going to end up like? And nobody could tell me. Doesn’t matter now. I’m over it. Completely well. This is how I did it!

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Cognitive Behavioral Therapy (CBT) Skills and Counseling Techniques with Dr. Dawn-Elise “Doc” Snipes

CEUs are available for this presentation at AllCEUs.com/CBT-CEU Hi everybody and welcome to today’s presentation on cognitive behavioral therapy skills. Like the other the presentation we did on assert not assertive community treatment acceptance and commitment therapy, which is also based on just providing information about skills that can be used not providing an evidence-based practice we couldn’t cover that in a full hour or just an hour so over the next hour we’re going to define cognitive behavioral therapy and its basic principles a lot of us are familiar with this but it’s going to be a good review and it also may highlight some nuances that you didn’t know about will identify factors impacting people’s choice of behaviors explore causes and impact of thinking errors and identify common thinking errors and their relationships to cognitive distortions so why do we care well as therapists we want to help people figure out the best way to live a happy healthy meaningful goals-driven life for some people that’s going to mean using some cognitive behavioral interventions that can be in addition to mindfulness that can be in addition to a lot of other things but it’s important to help people understand that the way we believe things to be the way we interpret things is going to affect our reactions so for example think about a situation you know you’ve walked into and maybe you walked into it with a small child and it was a different situation it was a new situation but you know it was no big deal you walked in it was not a threatening situation to you because you were like hey I got this the little kid walks in and goes oh wow there are a lot of people walking around here, this is the really scary same situation as two different perceptions you probably didn’t have much of a stress reaction going on whereas the little child probably had this fight-or-flight thing going on grabbing onto your hand like please don’t let go Atlanta Airport is a perfect example if you’ve ever taken a little kid through Atlanta Airport it gives you an idea about how people can perceive things differently and when you enact that fight-or-flight reaction you’re going to have all those stress hormones you’re going to have all either anxiety or anger or whatever that goes with it it may serve to exhaust the person and leave them feeling hopeless and helpless so what we want to do is help people see that but we also want to help them see that when they’re depressed when they’re tired when they’re sick things are going to seem a lot worse a lot of times because they don’t have the energy to perceive it differently I mean when you’re sick it’s overwhelming to think of going through Atlanta Airport so this is what we want to help people start understanding is it’s two sides of the same coin they interact if one is you know kind of going wonky is going to affect the other one the good thing is if one’s going really good the other one’s going to go good if you’re having positive thoughts you’re probably going to feel pretty good there’s an activity and I think we’re going to talk about it later it’s called the coin flip activity and I asked client clients to flip a coin in the morning and in the morning if it turns heads then they have to be the most positive Pollyanna all day long look for the silver lining and everything smile walk with their head up hold those nonverbals up and see how they feel at the end of the day besides a little sore because there are muscles they’re using they haven’t been used in a while if it lands on tails they can just be their normal selves which generally if they’re seeing me means that they are depressed anxious stressed out angry about something in the negative realm then we talk about how did things seem different on the days when you were feeling better when you were walking taller when you were smiling even our nonverbals it doesn’t even have to be sickness it can be our nonverbals that can make us feel or make our body feel heavy and tired and make it seem like it’s a whole lot harder to deal with life as a person who perceives the world generally good and believes they can deal with challenges as they arise that good old self-efficacy will be able to allow their stress response system to function normally so if they’re like you know what I can deal with whatever life throws at me I’ve got it and maybe I need help with it maybe I’ll need to ask for support but I’ve got it it’s not going to completely overwhelm me with people who see the world as hostile unsafe and unpredictable you know for a variety of reasons whatever happened to make their scheme as such that they don’t believe that people or the world is trustworthy are predictable they are always on guard they’re always kind of like a hamster in a cage that has Have you ever had a hamster hamsters don’t recognize you and go hey that’s my own or human contact score hamsters go run under their little house and you just kind of open the cage and stick your hand in there and flip over their house and you’re like come here and give me cuddles and you’re like you know 200 times bigger than they are so the little hamster is like freaking out this is what it’s like for people and obviously, I’m exaggerating but this is what it’s like for people who have a negative perspective a negative view or a hostile view of the world so kind of keep that little hamster in your mind cognitive behavioral therapy we have core beliefs those things that are in our hearts when I talk with my clients about honesty step one and that’s what they’ve got to do to start recovery is get honest with themselves first and then other people we talk about head heart and gut honesty do you think it’s right does it seem like the right thing to do does it feel right in your heart you know does it make you happy it doesn’t make you feel good and then the spidey senses is your gut saying and or is your gut fine if one of those is saying this might not be the right choice and we need to think about what’s going on so we have those core beliefs and I put them in the heart just because that’s the middle of the head heart and gut but you have core beliefs about yourself whether you’re good with you’re bad whether you’re effective at certain things yada yada you have core beliefs about other people same thing good bad effective predictable and you have core beliefs about the future and a lot of that goes with the locus of control but also your past experiences if the world in the past is seemed unfriendly and uncontrollable and you’ve perceived it that way then you’re going to expect the future to be uncontrollable so what we want to do is help people look at their schemas and their core beliefs about themselves others in the future and figure out kind of what they want it to look like these schemas are going to affect your behavior and your thoughts and your feelings and you know you can pick wherever you want to start it doesn’t matter because all three inter interface with one another so if you haven’t let’s start with negative thoughts if you have negative thoughts then you might feel anxious angry stressed dysphoric which will affect the behavior you’re going to do different things than if you have positive thoughts about something you feel excited and energized you’re going to have different behavior the best thing example I can give you is if you’ve ever done public speaking or had to present something some people detest public speaking it’s just terrifying for them to get up in front of a group of people so their thoughts am I going to trip up I going to forget what I’m going to say I’m going to make a fool of myself I’m going to you know it can go on forever that when you get on a roll you can get on a negative roll and go on forever or positive hopefully get on that roll with those thoughts you start holding onto those thoughts remember as we talked about in a CT the other day when you hold those thoughts and you kind of mush them around in your mind and you come to believe them that you’re going to make a fool of yourself and it’s going to be awful you’re going to start feeling terrified likely which is going to likely affect your behavior if you go out on the stage and you’re terrified you’re going to probably stutter you’re probably going to get foggy-headed you’re going to have that fight-or-flight reaction so there’s an the adrenaline rush and you start sweating and you can’t focus and you can’t concentrate you want to away as opposed to somebody like me who loves public speaking and I’m just like cool I get to go out there and try to engage however many people are in the audience it’s a game for me because when I can see your faces I enjoy trying to figure out and make eye contact with people and figure out what it is that they’re there for what is it that’s going to make them tick what resonates with them so my behavior as you can kind of see right now when I go out there I’m excited and I want to engage people and it’s a fun experience for me again just like the airport the same experience for two different people and two very different interpretations and reactions to it so what effects I don’t like the term rational but when we’re talking about CBT irrationally comes up a lot I like to replace it with helpful because every behavior in its weird sort of way is or probably was rational at one time that being said we’re going to get back to that stress affects our behavioral choices if we’re under stress we can have negative emotions negative emotions will affect our thoughts if we’re feeling sad we’re probably going to look at the dark side if we feel sad we’re going to look at the bottom falling out if we’re happy we’re probably going to look for that silver lining physical factors if you’re in pain sick sleep-deprived poorly nourished so your body can’t produce the neurotransmitters it needs to or heaven forbid intoxicated you’re probably not going to make the same decisions as you would if you were comfortable healthy well-rested nourished and not intoxicated any of those things can go impact how you perceive a situation or how you react in a situation, especially the intoxication whereas in your non intoxicated State in your sober state, you may think that you want to do something but then you’ve got that filter that goes not not a good idea in an intoxicated State or even in a manic state if you’re you know if you have somebody with bipolar that filter kind of goes away so the behaviors that someone may normally not do because they have a rational filter that goes you know punching this guy outs probably not the best idea right now the filter goes away when you’re sleep-deprived you’re less generally people are less patient generally people don’t have as much of a filter thing about watching your children if you have children or your grandchildren or even yourself I know myself when I’m sleepy I am giddy as all get-out and things I wouldn’t normally say because they’re you know stupid I’ll just come out and say anyway and my kids just roll their eyes or the mom you’re overtired could go to bed, uh but that’s okay you know I’m okay with that in that situation now if I acted that way at work it would be a worse thing environmentally if you’re introduced to a new or unique situation and you perceive it as stressful because the unknown we know can be stressful then you may not make as rational of a choice or as helpful of a choice because you maybe trying to escape the same thing as exposure to UNPROFOR bellowing for a the word here but UNPROFOR ball is the best I could come up with we all prefer certain situations some people as I said would rather do just about anything then get up in front of a lecture hall of a hundred and fifty people and talk but if they have to do it then they’re going to be under stress which may affect how they do things so we want people to understand that their perception and their feelings are affected by a lot of other things not just you know an emotion here or a particular memory there’s a lot that goes into it and social if peers your family convey irrational thoughts as necessary very standards for social acceptance people may tend to cling more to it to those unhelpful thoughts and unhelpful behaviors you know in CBT they say irrational because quote nobody wants to associate with those people you know who are those people and why can’t we associate with them there are a lot of things if you think back think high school you know high school is pretty rough if we’re going to talk about having irrational thoughts and cognitions if you have to be part of this particular group to be accepted you have to do this you have to do that but do you do those kinds of all-or-nothing statements are cognitive distortions and while they may have served a purpose in some way shape or form in the past we need to encourage our clients to take a look at them now and go are they still helpful ways of thinking is it still helpful for me to think that I am only successful if I live in a million-dollar house in a gated community and do this that and the other or can I be can I define success a different way or do I define success differently and lack supportive peers to buffer stress so we had those peers that caused stress by talking about the half dues and categorizing and lots of attributions but then there’s also not having somebody to go you know does this make any sense because sometimes we are our own worst enemies and if we go to a friend and we go you know this is what I’m thinking and I think I have to do this in order to be acceptable to be loved or you know whatever the case may be most people are not going to use those exact phrases a good friend is probably going to listen and go yeah you’re right or no no that’s way off so supportive peers are essential to reminding us to consciously regularly check in with our cognitions to make sure that they are hopeful and rational so a note about irrationality and this is mine this is not from CBT the origins of most beliefs for rational and helpful given the information, the person had at the time and their cognitive development their ability to process that information so concepts and schemas and core beliefs that people formed when they were five are probably going to be very egocentric you know the person is going to feel like everybody sees it my way because this is how I see it you know just like a five-year-old does a five-year-old doesn’t think well you know let me take Johnny’s perspective is no he assumes that Johnny sees it the same way so it’s going to be egocentric it’s probably going to be focused on only one aspect of the situation because small children can’t focus on multiple aspects and it’s probably going to be dichotomous it’s all-or-nothing Mommy loves me mommy hates me and it could be personalized you know everything a lot of kids think that everything has to do with them so if something happens something bad happens many times children will take it personally or be afraid it’s going to happen to them again you know if hurricane katrina hurricane Andrew those sorts of things you know we saw a lot of trauma in children and they developed very real fears about thunderstorms and hurricane season and if you’ve watched Florida hasn’t had a notable hurricane in years now but there’s a lot of stuff that goes into that but young people during some of those really bad hurricane seasons perceive those situations differently okay so we need to help people understand that if we especially if we use the term irrational those thoughts you formed when you are knee-high to a grasshopper and they made perfect sense to you back then but now that you’re an adult you’ve got more experience and you’re able to take different perspectives your brain is more developed let’s take a look at it and see if you can look at different perspectives and come up with something a little more helpful maybe a different way of perceiving this situation the irrational irrationality or unhelpful Nosov Fox comes when those beliefs are perpetuated without examination so something a belief that you formed when you’re five you’re still holding when you’re 35 and you’ve never questioned it you’ve never gone you know does this make sense is this is helpful to get me to where I want to be most of us don’t know we form these attitudes and beliefs when we’re you know growing up when we’re in elementary school middle school high school from watching TV to being around our peers from being around our family in our community and we get all this input of the way things should be and a lot of times people don’t stop to question and go and go well does this make me happy is this really what I want and they can be irrational if they continue to be held despite causing harm to the person so the person continues to hold this belief even though it is causing them general emotional cognitive harm is making them miserable we need to look at why what’s motivating them to hold on to that belief why is that belief so important and how can we make it so they can live a happy values-driven life emphasis on the happy how can we make it less harmful sometimes it’s more productive for clients to think of these thoughts as unhelpful or helpful instead of irrational sometimes when I say irrational to clients and you know I’m the same way if somebody says you’re being irrational I’m like oh I’m not it elicits this instantaneous defensive reaction it’s like when you tell them they’re being resistant they’re like I am NOT rien resistant so helpful or unhelpful and then we talk about why it is unhelpful in getting them toward their goals basic principles of cognitive behavioral therapy we teach or help clients learn to distinguish between thoughts and feelings I can think something is scary I’ll probably feel it but if I have an automatic you know feeling I walk into Atlanta Airport and I see yeah I went to an airport in New York I can’t even remember which one it was because my plane was diverted and I got off and I walked out there and I have never seen so many people packed in his place like sardines before in my life I was just completely overwhelmed that was kind of an automatic feeling now that was a feeling based on you know who knows it was overwhelming to be surrounded by that many people so then I had to separate the thoughts and go okay what am I thinking that’s making me feel so overwhelmed and at that point you know I didn’t know how to get to my gate and all that other sort of stuff with traveling I don’t travel well but encouraging clients to stop and go okay why am I feeling this way what are my what thoughts am I having that are contributing to these dysphoric feelings CBT helps people become aware of how thoughts can influence feelings in ways that are sometimes not helpful we have hecklers in our gallery the automatic tapes that we plaything memories that we have whatever you want to call them that when you try something when you are just going through daily life you hear these voices in the back of your head and not real voices but that is saying you’re never going to make this or if you would have just blah blah blah then you’d be a the better person helping clients become aware of those thoughts and how they’re negatively influencing their feelings and keeping them kind of stuck is a huge part of CBT we help them learn about thoughts that seem to occur automatically without even realizing how they may affect emotions again those thoughts from they’re saying you’re not good enough you’re not smart enough and nobody’s gonna like you where did that come from and do you believe it you know maybe it came from somebody when you were in high school so was that a valid source maybe it came from somebody yesterday on Facebook was that a valid source taking in those thoughts and then figuring out is this something I’m going to hold because it makes me happy or is this something that I’ve got to deal with because I’m having a negative reaction constructively evaluate whether these automatic thoughts and assumptions are accurate or perhaps biased the other thing to remember is a lot of our clients not all of them but a lot of them hold themselves to a standard there’s like up here and they hold everybody else to a standard that’s down here so they are a failure if they don’t achieve this but everybody else is successful as long as they achieve this so encouraging them to take a look at how accurate and biased or unbiased are the thoughts and like I said they may be their thoughts they may be telling themselves these things evaluate whether the current reactions are a helpful and good use of energy or unhelpful and a waste of energy that could be used to move toward those people and things important not impotent important to the person road-rage you’re in the car you’re driving somebody cuts you off okay natural reaction fight or flight reaction you’re just like slam on the brakes and do whatever you got to do aversive maneuvers you’re good so you could let it go at that point ago got Lucky on that one and keep driving most people not all but most they found that 80% of drivers have reported incidences of road rage which is a high number but most people will start getting all fired up and irritated and grumpy and we and just rageful and so my question would be I hear that and I hear that it made you angry in retrospect did screaming at the person as you pass them at sixty miles an hour in your car with the windows rolled up does any good did it do any good at all what else could you have done with that energy if you wouldn’t have expended it all yesterday we had to wait for the vet to come by and my daughter just completely wore herself out worrying about when the vet was going to get there what he was going to say about her donkeys and was beside herself so by the time it got to evening and it was time for her to go to her martial arts class she didn’t have the energy to go she’s like um wiped out I just want to go to bed in retrospect we’re looking back and saying okay now tell me what it was that you were so stressed out about and let’s talk about whether that was a realistic and helpful line of thought to perseverate on all day long and what could you have done differently because she didn’t bother to mention any of that to me yesterday and then developed the skills to notice interrupt and correct these biased thoughts independently causes of these thinking errors information processing shortcuts when we form schemas and we encounter a situation that reminds us of something in the past like when I go to my grandmother’s house I have a schema I have a belief system I have you know stuff that I know about my grandmother’s house so when I go to my grandmother’s house it’s kind of a shortcut to knowing what to expect when I walk in and how to behave how to do different things and it helps me plan and predict if you’re using outdated or dichotomous all-or-nothing schemas it may cause thinking errors because you may be now incorrectly processing current events mental noise some of us have it a lot of us have it not everybody thinks about trying to focus and study for a final exam in the middle of a really busy sports bar okay this is a cause of thinking or you’re going to miss important things you’re not going to be able to focus you’re not going to necessarily attend to the correct things because there’s just so much else going on your attention is drawn in 17 different directions and or the brain’s limited information processing capacity due to age we talked about that before young kids think all or nothing they think dichotomously egocentric ly middle school-aged kids and older start developing the ability for abstract thinking, by the time we get older, you know as adults theoretically we’re able to you know think pretty well and think pretty clinically about different events but if we’re in crisis when someone is in crisis and it could be like what we think of clinically as a crisis or it could be they’re just completely overwhelmed and burned out and have been burning the candle at both ends for three months they’re not going to process information quite as well they’re not going to take in all this stuff because they’re just like shell-shocked have you ever seen teachers in the hallway of like an elementary school Oh at the end of the second nine weeks they just kind of stand there with this blank look on their face they’re not processing as much as they were the first day of school and you know God loved them they have a lot to deal with but we need to help our clients understand that there are some times that they are going to have to really stop and focus write things down so they can remember or they can make decisions a little more my guess is most of us have times in our life when we’ve been able to think through complex problems but then there are other times where you just can’t keep it all in your head and you’ve got to put it on a whiteboard maybe that’s just me but we want clients to understand that they are not broken they’re not faulty they’re doing the best they can with the tools they have and the knowledge they have and our job is to help them see where some of this might have gone a little awry other causes of thinking errors and emotional motivations I feel bad therefore whatever I’m thinking must be bad if I’m scared that means whatever it’s coming on the other end of the phone is bad news moral motivations I did it because it was the right thing to do and that can be an excuse for doing wrong behaviors as well it can also be you know you can argue on the moral one social influence well everyone else is doing it so it must not be bad set that again a lot of times and this is where the frames approaching the motivational interviewing is helpful f stands for feedback about the reality of what’s going on is everybody doing it let’s look at statistics you know not subjective information let’s look at objective information so the impact of these thinking errors makes people want to fight or flee when they get upset and we use upset as a kind of this all-encompassing garbage term emotionally they get depressed or anxious we don’t want to feel that way anxiety and anger are flee or fight fight or flee it’s our body saying there’s a threat you got to do something depression is your body going I give up I just don’t I don’t even have the energy to do it anymore behaviorally some people withdraw because they shut down we all know people who get frustrated when they get overwhelmed when they start feeling hopeless or helpless they just kind of withdraw from everything and everyone’s addictions numb that out so they don’t have to feel the dysphoria sleeping problem and changes when we start being on that constant fight-or-flight hyper-vigilant sort of thing going on in the body is always sort of turned on which means you’re not going to sleep as well then the circadian rhythms get messed up which starts causing exhaustion and lethargy and then everything seems harder because you’re sleep-deprived and then you start thinking more negatively and more hopelessly you see where this is going it’s a downward spiral and eating changes some people eat a lot more because they’re eating comfort foods some people eat a lot less because their stomach is so torn up from the stress they can’t even think about holding anything down physical stress-related illnesses fibromyalgia gastrointestinal problems headaches neck aches backache you know the whole the gamut of it when you start feeling bad when you start hurting generally it gets frustrating after a while and that frustration makes it kind of raises the the bar brings you up a little bit so you’re that is much closer to kind of just kind of being overwhelmed you don’t have as much of a cushion as you would if you were happy healthy well nourished not in pain and socially a lot of times we will get irritable or impatient with other people or withdrawal when we’re having these negative cognitions these thinking errors that are keeping us in a dysphoric state these effects of thinking errors contribute to fatigue and a sense of hopelessness and helplessness which intensifies thinking errors this is an important concept that I want my clients to understand and I want to drive home in this presentation so thinking errors what are they emotional reasoning feelings are not facts and we want to help people to learn to effectively identify feelings and separate them from facts so if somebody says I’m terrified okay that is a feeling what are the facts supporting that feeling why are you are terrified what is the evidence that you are in some sort of danger right now you know and danger may not be the right word for your client at that a particular point in time but what’s the evidence that there’s a threat in what ways is this similar to other situations maybe it’s triggering something from the past that was scary or you know you were too little to be able to handle it but you can handle it now and how if you dealt with similar situations like this, in the past, we want to help people just step back and get some distance between their feelings and their thoughts and try to figure out you know which thoughts are helpful and productive and even if a sought makes people anxious or angry it can be helpful it may be telling them hey dude you need to get your butt up and get out of there if it’s helpful it means it’s moving them toward where they want to be happy healthy safe and values-driven life so happy and helpful developed a stress tolerance skills when people use emotional reasoning they feel emotions which then they start attributing finding the facts to support those emotions instead of looking at all the facts we want to help them learn to tolerate their distress so they can kind of let that subside for a second they can accept their feeling they can name they can say I’m scared I’m stressed I’m angry and whatever but they don’t have to act on it right then they can tolerate the distress for a minute without having to try to make it go away and emotional regulation skills they can feel a feeling without having to make it go from zero to 120 you know if they feel sad they go I feel kind of sad instead of grabbing onto it and going I wonder what I feel sad about I must feel sad about all these sad things now I’m going to be sad and devastated so we want to help people learn how to regulate their emotions identify them accept them whatever word you want to use and tolerate them because feelings are there for a reason they’re there to tell you your brain thinks something’s going now thankfully we have that higher-order cognition stuff going on so we can contradict our brain and we can go you know maybe that’s not true in this situation cognitive bias negativity mental filter whatever you want to call it people who focus on the negative they walk in they get up in the morning and they look outside and it’s partly cloudy they get to work and they said instead of saying there was it was very light traffic they said there was a fair amount of traffic everything is always the flip side of what somebody who’s optimistic would say so asking them what’s the benefit to focusing on the negative in what ways is this helpful to you you know some people say well it keeps me from getting disappointed because I know it’s going to end up negative anyway so we can trap challenges that know that whatever it is they think they know and see if there have been exceptions when it hasn’t turned out that way what are the positives to this situation I give the example a lot of you know I wash my car or it rains and maybe I wanted to go out on a run that day but I can perceive it I can look at the positives you know the rain washed my car for me so I don’t have to do it now score it watered my garden all the better it knocked down some of the pollen out of there even better I can find and I can encourage people to find positives in a situation yes there are negatives there are negatives to every situation if you want to find them you’re going to find them but if you want to find the positives you can too which takes us down to what are all the facts there’s the positive and the negative and the neutral I told you earlier about the coin toss activity having people toss a coin on the heads days they act like it is just the greatest day to be alive and see how things are different when they do their journal because you know I have my clients do I’m sort of a mindfulness check-in in the morning and in the evening and preferably at lunchtime how are they feeling what’s their emotional state what’s their energy level on the happy days a lot of times it can be less and sometimes they need a little coaching throughout because some of those old patterns kick in but I want them to start challenging some of their automatic thoughts that we’re going to talk about in a minute disqualifying or minimizing the positive most of us can probably say we’ve had a bunch of clients that do this they are more than happy to tell you about all the things that they mess up but then when they do something right they minimize it encouraging people to hold themselves to the same standard they would hold everyone else to and I know I talked about that earlier ask them things like would it minimum would you minimize this if it was your best friend’s experience your best friend came to you and said I just got into such-and-such college would you say awesome or would you say anybody can get in there how would that go ask them what is scary about accepting these positive things that you might have had an accomplishment for some people it means that it might mean other people expect more of them for other people they just don’t know how to accept the positive they don’t know how to accept compliments they don’t know how to be the center of attention and they don’t like it and then we want to look at why that is sometimes we disqualify the positive because it fails to meet someone else’s standards so as people might that be true here you know I know when I was growing up and going through college and going through school and everything got my doctorate but I will always be ever and always being not a real doctor because a Ph.D. is not an MD and I’m like really so is it somebody else’s standards or can I feel good about having a Ph.D. egocentrism my perspective is the only perspective I’ll being egocentric but it doesn’t work most of the time so encouraging people to take alternate perspectives maybe you’re texting with someone and they say something that is not that you interpret as not the nicest thing and this happens in text messages a lot and they get upset now an egocentric thinking error would say that purse is just grumpy today someone that’s taking other perspectives would stop and go back and read the text and go I wonder if maybe this could have been taken some another way you know cuz their reaction is not what I intended so egocentrism if you hold on to that I don’t understand anybody else because you know I don’t see a problem with anything personalizing and mind-reading this is when you assume that everybody’s frowning because of something you did your boss walks down the hallway and looks at you and grimaces and continues to walk on oh I must have done something wrong no maybe he just got out of his senior management meeting that was five hours long and he’s got to go to the bathroom you know there could be a hundred different explanations for why that happened so encourage clients to ask themselves what are some alternate explanations for this event that doesn’t involve me you know why might this have happened if they hold on to that, I must have done something wrong but as soon as their boss calls them up and goes hey can you come to my office for a second you know where their thoughts are going to go I’m getting fired I’m going to get laid off I don’t know what it was that I did wrong but he walked by me two weeks ago in the hallway and grimaced and I’m just I’m the worst person in the whole world but where did that come from so encouraging people to not necessarily assume they know what’s going on in someone else’s mind and not automatically attributing every person’s negative behavior to something they did how often and then ask them how often has it been about you now think about the last 10 times you’ve taken something personally how many of those 10 times has it been about something you did versus something with the other person then the availability heuristic remembering what’s most prominent in your mind so asking clients what are the facts ah the most obvious one that we talk about is plane crashes you know it is way dangerous to fly on a plane because you hear about all those plane crashes well yeah you hear about A few planes crash but you don’t hear about the 20,000 every day that land safely so you remember it and it seems more dangerous because that’s what is in your mind that’s what is available to you that’s what you’ve based your thought processes on because maybe you didn’t know that 20,000 planes or more fly and land just perfectly every day this can also be true with people remembering what’s most prominent in your mind sometimes and this can be very very true in domestically violent relationships if somebody falls in love with someone and that person is just the greatest person since sliced bread for the first four months and then the cycle starts and there’s this little tiny a sliver of the honeymoon period after the battering cycle and the person’s like that’s the person I fell in love with that’s what I remember and they try to focus on that that’s most prominent in their mind and they ignore the rest of the stuff so we need to encourage people to look objectively at the facts magnification are you confusing high and low probability outcomes what are the chances that this is going to happen how many clients have we worked with that have gone to the doctor and gotten in a physical or get a test run and then the doctor had to call them back and this could be true for you too and the doctor had to call them back two or three days later when the tests came back from the lab and that whole three days they were just in a panic because they were afraid they were going to get some terminal diagnosis so thinking about high and low probability outcomes another instance or example of magnification is somebody that thinks this is the end of the world whatever it I think I’ve told you before my little story about um tripping when I was walking down the hall at work and falling and yeah it was embarrassing my folders went everywhere and yeah but in that big scheme of things will it matter that much from now you know are people gonna think oh she is such a clutch she must be a ditz too no I mean they may have thought that at that time I don’t know but you know in six months nobody’s going to remember and then ask them in the past when something like this has happened when you’ve had to get a test done and you’ve had to wait on results or if you’ve done something that was embarrassing and you didn’t think you thought everybody was going to remember it forever.

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How did you tolerate it how did you learn to deal with it building on those strengths that they already have all-or-nothing thinking errors these are things like love versus hate I love them or I hate them it’s all or nothing she does this all the time or she never does it if I’m going to do it I’m going to do it perfectly or I’m not going to do it at all thank you all good intentions or all bad intentions you know sometimes we do things with good intentions that have some bad repercussions so did we do it with all bad intentions are all good intentions and the answer is neither most of the time life is kind of in that middle-ground gray area encouraging clients to look and find examples where something hasn’t been one of the polls when having they do something that they’re proud of that wasn’t perfect or when again when has somebody else do something that they were proud of that wasn’t perfect remembering that with availability heuristic remembering how often something happens and how long it’s been since you’ve seen that behavior and remember that sometimes good times are amazing but how frequent are they compared with the bad times another thinking error is a belief in a just world or a fallacy of fairness I just asked clients to identify for good people you know who’ve had bad things happen and in reality we all have bad things happen good people do bad people do in between people do attributional errors and this is a pet of mine you know labeling yourself is not a behavior so global versus specific and I am stupid versus I’m stupid at math I don’t have good math skills it’s not about me it’s about the skills I can change skills stable I am and I always will be versus it’s something I can change it’s something I can learn internally it’s about me as a person versus it’s about a skill deficit or something I could learn or change and there’s you know lots of information on attributions out there on the internet if you need a refresher on it but we find that a lot of people who have dysphoria have negative global stable internal attributions so questions for clients remember the beliefs equal thoughts and facts plus personal interpretation another way of saying it is reality is 10% perception is 10% reality and 90% interpretation so what are the facts for and against my belief is the belief based on facts or feelings does the belief focus on one aspect or the whole situation does the belief seem to use any thinking errors what are alternate explanations what would you tell your child or best friend if they had this belief how would you want someone to tell what would you want someone to tell you about this belief so if you’re telling somebody about this what are you hoping they’re going to say in return and finally, how is this belief moving you toward what and who is important to you or moving you away from what or who is important to you now they can do a worksheet and have all of these or you can pick one or two of these questions that are most salient for your clients but they can have kind of at their fingertips so as they’re going through the day and something happens they can ask themselves ok what’s an alternate explanation or you know whatever it is this is salient for that client’s irrational thoughts about how to do these thoughts impact the client’s emotions health relationships and perceptions of the world you know this is what we want to ask them how is this thought impacting you globally how may this thought have been helpful in the past where did it come from how does it make sense from when you formed it in the past when you’re dealing with it ask the person if the thought is bringing you closer to those that are important are there any examples of this thought or belief not being true and how can the statement be made less global less all-encompassing so it’s about a specific incident a specific situation less stable which means you can change it and less internal which means it’s not about who you are as a person but maybe something that you do or a skill that you have so we’re going to go through some of these thoughts real quickly here mistakes are never acceptable and if I make one it means that I’m incompetent well never is kind of stable and I am incompetent is kind of global, that’s also that extreme all-or-nothing thinking so you can see where these cognitive distortions end up leading to unhelpful beliefs when somebody disagrees with me it’s a personal attack well there’s personalization if I ever heard it before maybe it’s not about you may be they’re having a bad day and you just happen to be the unlucky target or maybe they’re disagreeing with you because they have a different point of view and it’s not a personal attack it’s just their point of view if someone criticizes or rejects me there must be something wrong with me personalization all-or-nothing thinking global stable and internal something wrong with me as a person to feel good about myself others must approve of me now this is one we’ve talked about external validation before and we can’t control other people to feel good about yourself how can you do that besides necessarily requiring other people to approve of you to be content in life I must be liked by all people Wow I’ve never met anybody who’s liked by all people I’ve never even met anybody who’s been hated by all people but it’s important to help clients see how this is dramatic to say all people and for them to be content then everybody has to like them I mean I like to be liked but if everybody doesn’t like me you know that’s pretty understandable my true value as an individual depends on what others think of me I would challenge this one this is all you know also, very personally internally I would challenge people to look at and say it so your child’s value as an individual depends on what other people think of he or most people would say no but the perspective thing nothing ever turns out the way you want it to okay all-or-nothing thinking and probably availability heuristic if something bad just happened then they may be focusing on that which causes them to focus on all the other bad things in the past that have happened not to focus on that is okay you know bad thing happen but look at all these good things I won’t try anything new unless I will be good at it this fear of failure fear of rejection it just really paralyzes a lot of people when they get stuck with that thinking the area that they have to be perfect I am in total control of anything bad that happens is my fault well that’s egocentric and personal if they think they’re in total control that’s their perception of how the world are they think if they’ve got everybody on marionette strings anything bad in the world that happens is their fault how powerful are they I feel happy about uh if I feel happy about life something will go wrong it happens sometimes but let’s look at times when you’ve been happy that something hasn’t gone wrong you know let’s get rid of that all-or-nothing thinking it’s not my fault my life didn’t go the way I wanted could be true but it seems like that’s making you unhappy so what do we do about that if I’m not in an intimate relationship I’m alone no, again that’s pretty extreme I’m either in an intimate relationship, or I am alone and a loner and you know it’s just me and my 17 cats which follows with there’s no gray area so encouraging people to look at what these beliefs are saying important thoughts impact behaviors and emotional and physical reactions emotional and physical reactions impact thoughts and interpretations of events so if you do something and it’s pleasurable and you have a great physical reaction you know let’s take bungee jumping or skydiving if you go out there and it’s scary but you do it and you’re just like whoa what a rush your interpretation of that is probably going to be good which means you’ll probably do it again if you go out there and it’s just the most horrible experience you’ve ever had you’re probably not going to do it again and your interpretation of it is going to be not good which is going to make it hard to understand why other people would do it irrational thinking patterns are often caused by cognitive distortions so let’s just look back at some of those because there are a lot fewer cognitive distortions or general ways of thinking about the world then there are thinking errors because there are lots and lots of thinking errors cognitive distortions are often schemas which were formed based on faulty inaccurate or immature knowledge or understanding and by identifying the thoughts of the hecklers you know the automatic tapes that are maintaining our unhappiness the person can choose whether to accept those thoughts or change them

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Cognitive Behavioral Therapy (CBT) Skills and Counseling Techniques with Dr. Dawn-Elise “Doc” Snipes

CEUs are available for this presentation at AllCEUs.com/CBT-CEU Hi everybody and welcome to today’s presentation on cognitive behavioral therapy skills. Like the other the presentation we did on assert not assertive community treatment acceptance and commitment therapy, which is also based on just providing information about skills that can be used not providing an evidence-based practice we couldn’t cover that in a full hour or just an hour so over the next hour we’re going to define cognitive behavioral therapy and its basic principles a lot of us are familiar with this but it’s going to be a good review and it also may highlight some nuances that you didn’t know about will identify factors impacting people’s choice of behaviors explore causes and impact of thinking errors and identify common thinking errors and their relationships to cognitive distortions so why do we care well as therapists we want to help people figure out the best way to live a happy healthy meaningful goals-driven life for some people that’s going to mean using some cognitive behavioral interventions that can be in addition to mindfulness that can be in addition to a lot of other things but it’s important to help people understand that the way we believe things to be the way we interpret things is going to affect our reactions so for example think about a situation you know you’ve walked into and maybe you walked into it with a small child and it was a different situation it was a new situation but you know it was no big deal you walked in it was not a threatening situation to you because you were like hey I got this the little kid walks in and goes oh wow there are a lot of people walking around here, this is the really scary same situation as two different perceptions you probably didn’t have much of a stress reaction going on whereas the little child probably had this fight-or-flight thing going on grabbing onto your hand like please don’t let go Atlanta Airport is a perfect example if you’ve ever taken a little kid through Atlanta Airport gives you an idea about how people can perceive things differently and when you enact that fight-or-flight the reaction you’re going to have all those stress hormones you’re going to have all either anxiety or anger or whatever that goes with it it may serve to exhaust the person and leave them feeling hopeless and helpless so what we want to do is help people see that but we also want to help them see that when they’re depressed when they’re tired when they’re sick things are going to seem a lot worse a lot of times because they don’t have the energy to perceive it differently I mean when you’re sick it’s overwhelming to think of going through Atlanta Airport so this is what we want to help people start understanding is it’s two sides of the same coin they interact if one is you know kind of going wonky is going to affect the other one the good thing is if one’s going well the other one’s going to go well if you’re having positive thoughts you’re probably going to feel pretty good there’s an activity and I think we’re going to talk about it later it’s called the coin flip activity and I asked client clients to flip a coin in the morning and in the morning if it turns heads then they have to be the most positive Pollyanna all day long look for the silver lining and everything smile walk with their head up hold those nonverbals up and see how they feel at the end of the day besides a little sore because there are muscles they’re using they haven’t used in a while if it lands on tails they can just be their normal selves which generally if they’re seeing me means that they are depressed anxious stressed out angry about something in the negative realm then we talk about how did things seem different on the days when you were feeling better when you were walking taller when you were smiling even our nonverbals it doesn’t even have to be sickness it can be our nonverbals that can make us feel or make our body feel heavy and tired and make it seem like it’s a whole lot harder to deal with life as a person who perceives the world generally good and believes they can deal with challenges as they arise that good old self-efficacy will be able to allow their stress response system to function normally so if they’re like you know what I can deal with whatever life throws at me I’ve got it and maybe I need help with it maybe I’ll need to ask for support but I’ve got it it’s not going to completely overwhelm me with people who see the world as hostile unsafe and unpredictable you know for a variety of reasons whatever happened to make their scheme as such that they don’t believe that people or the world is trustworthy are predictable they are always on guard they’re always kind of like a hamster in a cage that has Have you ever had hamster hamsters don’t recognize you and go hey that’s my own or human contact score hamsters go run under their little house and you just kind of open the cage and stick your hand in there and flip over their house and you’re like come here and give me cuddles and you’re like you know 200 times bigger than they are so the little hamster is like freaking out this is what it’s like for people and obviously, I’m exaggerating but this is what it’s like for people who have a negative perspective a negative view or a hostile view of the world so kind of keep that little hamster in your mind cognitive behavioral therapy we have core beliefs those things that are in our hearts when I talk with my clients about honesty step one and that’s what they’ve got to do to start recovery is get honest with themselves first and then other people we talk about head heart and gut honesty do you think it’s right does it seem like the right thing to do does it feel right in your heart you know does it make you happy it doesn’t make you feel good and then the spidey senses is your gut saying and or is your gut fine if one of those is saying this might not be the right choice and we need to think about what’s going on so we have those core beliefs and I put them in the heart just because that’s the middle of the head heart and gut but you have core beliefs about yourself whether you’re good with you’re bad whether you’re effective at certain things ya ya you have core beliefs about other people same thing good bad effective predictable and you have core beliefs about the future and a lot of that goes with the locus of control but also your past experiences if the world in the past is seemed unfriendly and uncontrollable and you’ve perceived it that way then you’re going to expect the future to be uncontrollable so what we want to do is help people look at their schemas and their core beliefs about themselves others in the future and figure out kind of what they want it to look like these schemas are going to affect your behavior and your thoughts and your feelings and you know you can pick wherever you want to start it doesn’t matter because all three inter interface with one another so if you haven’t let’s start with negative thoughts if you have negative thoughts then you might feel anxious angry stressed dysphoric which will affect the behavior you’re going to do different things than if you have positive thoughts about something you feel excited and energized you’re going to have different behavior the best thing example I can give you is if you’ve ever done public speaking or had to present something some people detest public speaking it’s just terrifying for them to get up in front of a group of people so their thoughts am I going to trip up I going to forget what I’m going to say I’m going to make a fool of myself I’m going to you know it can go on forever that when you get on a roll you can get on a negative roll and go on forever or positive hopefully get on that roll with those thoughts you start holding onto those thoughts remember as we talked about in a CT the other day when you hold those thoughts and you kind of mush them around in your mind and you come to believe them that you’re going to make a fool of yourself and it’s going to be awful you’re going to start feeling terrified likely which is going to likely affect your behavior if you go out on the stage and you’re terrified you’re going to probably stutter you’re probably going to get foggy-headed you’re going to have that fight-or-flight reaction so there’s an the adrenaline rush and you start sweating and you can’t focus and you can’t concentrate you want to away as opposed to somebody like me who loves public speaking and I’m just like cool I get to go out there and try to engage however many people are in the audience it’s a game for me because when I can see your faces I enjoy trying to figure out and make eye contact with people and figure out what it is that they’re there for what is it that’s going to make them tick what resonates with them so my behavior as you can kind of see right now when I go out there I’m excited and I want to engage people and it’s a fun experience for me again just like the airport the same experience for two different people and two very different interpretations and reactions to it so what effects I don’t like the term rational but when we’re talking about CBT irrationally comes up a lot I like to replace it with helpful because every behavior in its weird sort of way is or probably was rational at one time that being said we’re going to get back to that stress affects our behavioral choices if we’re under stress we can have negative emotions negative emotions will affect our thoughts if we’re feeling sad we’re probably going to look at the dark side if we feel sad we’re going to look at the bottom falling out if we’re happy we’re probably going to look for that silver lining physical factors if you’re in pain sick sleep-deprived poorly nourished so your body can’t produce the neurotransmitters it needs to or heaven forbid intoxicated you’re probably not going to make the same decisions as you would if you were comfortable healthy well-rested nourished and not intoxicated any of those things can go impact how you perceive a situation or how you react in a situation, especially the intoxication whereas in your non intoxicated State in your sober state, you may think that you want to do something but then you’ve got that filter that goes not not a good idea in an intoxicated State or even in a manic state if you’re you know if you have somebody with bipolar that filter kind of goes away so the behaviors that someone may normally not do because they have a rational filter that goes you know punching this guy outs probably not the best idea right now the filter goes away when you’re sleep-deprived you’re less generally people are less patient generally people don’t have as much of a filter thing about watching your children if you have children or your grandchildren or even yourself I know myself when I’m sleepy I am giddy as all get-out and things I wouldn’t normally say because they’re you know stupid I’ll just come out and say anyway and my kids just roll their eyes or mom you’re overtired could go to bed, uh but that’s okay you know I’m okay with that in that situation now if I acted that way at work it would be a worse thing environmentally if you’re introduced to a new or unique situation and you perceive it as stressful because the unknown we know can be stressful then you may not make as rational of a choice or as helpful of a choice because you maybe trying to escape the same thing as exposure to UNPROFOR bellowing for a the word here but UNPROFOR ball is the best I could come up with we all prefer certain situations some people as I said would rather do just about anything then get up in front of a lecture hall of a hundred and fifty people and talk but if they have to do it then they’re going to be under stress which may affect how they do things so we want people to understand that their perception and their feelings are affected by a lot of other things not just you know an emotion here or a particular memory there’s a lot that goes into it and social if peers your family convey irrational thoughts as necessary very standards for social acceptance people may tend to cling more to it to those unhelpful thoughts and unhelpful behaviors you know in CBT they say irrational because quote nobody wants to associate with those people you know who are those people and why can’t we associate with them there are a lot of things if you think back think high the school you know high school is pretty rough if we’re going to talk about having irrational thoughts and cognitions if you have to be part of this particular group to be accepted you have to do this you have to do that but do you really so those kinds of all-or-nothing statements are cognitive distortions and while they may have served a purpose in some way shape or form in the past we need to encourage our clients to take a look at them now and go are they still helpful ways of thinking is it still helpful for me to think that I am only successful if I live in a million-dollar house in a gated community and do this that and the other or can I be can I define success a different way or do I define success differently and lack supportive peers to buffer stress so we had those peers that caused stress by talking about the half dues and categorizing and lots of attributions but then there’s also not having somebody to go you know does this make any sense because sometimes we are our own worst enemies and if we go to a friend and we go you know this is what I’m thinking and I think I have to do this in order to be acceptable to be loved or you know whatever the case may be most people are not going to use those exact phrases a good friend is probably going to listen and go yeah you’re right or no no that’s way off so supportive peers are essential to reminding us to consciously regularly check in with our cognitions to make sure that they are hopeful and rational so a note about irrationality and this is mine this is not from CBT the origins of most beliefs for rational and helpful given the information the person had at the time and their cognitive development their ability to process that information so concepts and schemas and core beliefs that people formed when they were five are probably going to be very egocentric you know the person is going to feel like everybody sees it my way because this is how I see it you know just like a five-year-old does a five-year-old doesn’t think well you know let me take Johnny’s perspective is no he assumes that Johnny sees it the same way so it’s going to be egocentric it’s probably going to be focused on only one aspect of the situation because small children can’t focus on multiple aspects and it’s probably going to be dichotomous it’s all-or-nothing mommy loves me mommy hates me and it could be personalized you know everything a lot of kids think that everything has to do with them so if something happens something bad happens many times children will take it personally or be afraid it’s going to happen to them again you know if hurricane Katrina hurricane Andrew those sorts of things you know we saw a lot of trauma in children and they developed very real fears about thunderstorms and hurricane season and if you’ve watched Florida hasn’t had a notable hurricane in years now but there’s a lot of stuff that goes into that but young people during some of those really bad hurricane seasons perceive those situations differently okay so we need to help people understand that if we especially if we use the term irrational those thoughts you formed when you are knee-high to a grasshopper and they made perfect sense to you back then but now that you’re an adult you’ve got more experience and you’re able to take different perspectives your brain is more developed let’s take a look at it and see if you can look at different perspectives and come up with something a little more helpful maybe a different way of perceiving this situation the irrational irrationality or unhelpful Nosov Fox comes when those beliefs are perpetuated without an examination so something a the belief that you formed when you’re five you’re still holding when you’re 35 and you’ve never questioned it you’ve never gone you know does this make sense is this is helpful to get me to where I want to be most of us don’t know we form these attitudes and beliefs when we’re you know growing up when we’re in elementary school middle school high school from watching TV to being around our peers from being around our family in our community and we get all this input of the way things should be and a lot of times people don’t stop to question and go and go well does this make me happy is this really what I want and they can be irrational if they continue to be held despite causing harm to the person so the person continues to hold this belief even though it is causing them general emotional cognitive harm is making them miserable we need to look at why what’s motivating them to hold on to that belief why is that belief so important and how can we make it so they can live a happy values-driven life emphasis on the happy how can we make it less harmful sometimes it’s more productive for clients to think of these thoughts as unhelpful or helpful instead of irrational sometimes when I say irrational to clients and you know I’m the same way if somebody says you’re being irrational I’m like oh I’m not it elicits this instantaneous defensive the reaction’s like when you tell them they’re being resistant they’re like I am NOT being resistant so helpful or unhelpful and then we talk about why it is unhelpful in getting them toward their goals basic principles of cognitive behavioral therapy we teach or help clients learn to distinguish between thoughts and feelings I can think something is scary I’ll probably feel it but if I have an automatic you know feeling I walk into Atlanta Airport and I see yeah I went to an airport in New York I can’t even remember which one it was because my plane was diverted and I got off and I walked out there and I have never seen so many people packed in his place like sardines before in my life I was just completely overwhelmed that was kind of an automatic feeling now that was a feeling based on you know who knows it was overwhelming to be surrounded by that many people so then I had to separate the thoughts and go okay what am I thinking that’s making me feel so overwhelmed and at that point you know I didn’t know how to get to my gate and all that other sort of stuff with traveling I don’t travel well but encouraging clients to stop and go okay why am I feeling this way what are my what thoughts am I having that are contributing to these dysphoric feelings CBT helps people become aware of how thoughts can influence feelings in ways that are sometimes not helpful we have hecklers in our gallery the automatic tapes that we plaything memories that we have whatever you want to call them that when you try something when you are just going through daily life you hear these voices in the back of your head and not real voices but that is saying you’re never going to make this or if you would have just blah blah blah then you’d be a the better person helping clients become aware of those thoughts and how they’re negatively influencing their feelings and keeping them kind of stuck is a huge part of CBT we help them learn about thoughts that seem to occur automatically without even realizing how they may affect emotions again those thoughts from they’re saying you’re not good enough you’re not smart enough and nobody’s gonna like you where did that come from and do you believe it you know maybe it came from somebody when you were in high school so was that a valid source maybe it came from somebody yesterday on Facebook was that a valid source taking in those thoughts and then figuring out is this something I’m going to hold because it makes me happy or is this something that I’ve got to deal with because I’m having a negative reaction constructively evaluate whether these automatic thoughts and assumptions are accurate or perhaps biased the other thing to remember is a lot of our clients not all of them but a lot of them hold themselves to a standard there’s like up here and they hold everybody else to a standard that’s down here so they are a failure if they don’t achieve this but everybody else is successful as long as they achieve this so encouraging them to take a look at how accurate and biased or unbiased are the thoughts and like I said they may be their thoughts they may be telling themselves these things evaluate whether the current reactions are a helpful and good use of energy or unhelpful and a waste of energy that could be used to move toward those people and things important not impotent important to the person road-rage you’re in the car, you’re driving somebody cuts you off okay natural reaction fight or flight reaction you’re just like slam on the brakes and do whatever you got to do aversive maneuvers you’re good so you could let it go at that point ago got lucky on that one and keep driving most people not all but most they found that 80% of drivers have reported incidences of road rage which is a high number but most people will start getting all fired up and irritated and grumpy and we and just rageful and so my question would be I hear that and I hear that it made you angry in retrospect did screaming at the person as you pass them at sixty miles an hour in your car with the windows rolled up does any good did it do any good at all what else could you have done with that energy if you wouldn’t have expended it all yesterday we had to wait for the vet to come by and my daughter just completely wore herself out worrying about when the vet was going to get there what he was going to say about her donkeys and was beside herself so by the time it got to evening and it was time for her to go to her martial arts class she didn’t have the energy to go she’s like um wiped out I just want to go to bed in retrospect we’re looking back and saying okay now tell me what it was that you were so stressed out about and let’s talk about whether that was a realistic and helpful line of thought to perseverate on all day long and what could you have done differently because she didn’t bother to mention any of that to me yesterday and then developed the skills to notice interrupt and correct these biased thoughts independently causes of these thinking errors information processing shortcuts when we form schemas and we encounter a situation that reminds us of something in the past like when I go to my grandmother’s house I have a schema I have a belief system I have you know stuff that I know about my grandmother’s house so when I go to my grandmother’s house it’s kind of a shortcut to knowing what to expect when I walk in and how to behave how to do different things and it helps me plan and predict if you’re using outdated or dichotomous all-or-nothing schemas it may cause thinking errors because you may be now incorrectly processing current events mental noise some of us have it a lot of us have it not everybody thinks about trying to focus and study for a final exam in the middle of a really busy sports bar, okay this is a cause of thinking or you’re going to miss important things you’re not going to be able to focus you’re not going to necessarily attend to the correct things because there’s just so much else going on your attention is drawn in 17 different directions and or the brain’s limited information processing capacity due to age we talked about that before young kids think all or nothing they think dichotomously egocentric ly middle school-aged kids and older start developing the ability for abstract thinking by the time we get older, you know as adults theoretically we’re able to you know think pretty well and think pretty clinically about different events but if we’re in crisis when someone is in crisis and it could be like what we think of clinically as a crisis or it could be they’re just completely overwhelmed and burned out and have been burning the candle at both ends for three months they’re not going to process information quite as well they’re not going to take in all this stuff because they’re just like shell-shocked have you ever seen teachers in the hallway of like an elementary school Oh at the end of the second nine weeks they just kind of stand there with this blank look on their face they’re not processing as much as they were the first day of school and you know God loved them they have a lot to deal with but we need to help our clients understand that there are some times that they are going to have to really stop and focus write things down so they can remember or they can make decisions a little more my guess is most of us have times in our life when we’ve been able to think through complex problems but then there are other times where you just can’t keep it all in your head and you’ve got to put it on a whiteboard maybe that’s just me but we want clients to understand that they are not broken they’re not faulty they’re doing the best they can with the tools they have and the knowledge they have and our job is to help them see where some of this might have gone a little awry other causes of thinking errors and emotional motivations I feel bad therefore whatever I’m thinking must be bad if I’m scared that means whatever it’s coming on the other end of the phone is bad news moral motivations I did it because it was the right thing to do and that can be an excuse for doing wrong behaviors as well it can also be you know you can argue on the moral one social influence well everyone else is doing it so it must not be bad set that again a lot of times and this is where the frames approaching the motivational interviewing is helpful f stands for feedback about the reality of what’s going on is everybody doing it let’s look at statistics you know not subjective information let’s look at objective information so the impact of these thinking errors makes people want to fight or flee when they get upset and we use upset as a kind of this all-encompassing garbage term emotionally they get depressed or anxious we don’t want to feel that way anxiety and anger are flee or fight fight or flee it’s our body saying there’s a threat you got to do something depression is your body going I give up I just don’t I don’t even have the energy to do it anymore behaviorally some people withdraw they shut down we all know people who get frustrated when they get overwhelmed when they start feeling hopeless or helpless they just kind of withdraw from everything and everyone’s addictions numb that out so they don’t have to feel the dysphoria sleeping problem and changes when we start being on that constant fight-or-flight hyper-vigilant sort of thing going on in the body is always sort of turned on which means you’re not going to sleep as well then the circadian rhythms get messed up which starts causing exhaustion and lethargy and then everything seems harder because you’re sleep-deprived and then you start thinking more negatively and more hopelessly you see where this is going it’s a downward spiral and eating changes some people eat a lot more because they’re eating comfort foods some people eat a lot less because their stomach is so torn up from the stress they can’t even think about holding anything down physical stress-related illnesses fibromyalgia gastrointestinal problems headaches neck aches backaches you know the whole the gamut of it when you start feeling bad when you start hurting generally it gets frustrating after a while and that frustration makes it kind of raises the the bar brings you up a little bit so you’re that is much closer to kind of just kind of being overwhelmed you don’t have as much of a cushion as you would if you were happy healthy well nourished not in pain and socially a lot of times we will get irritable or impatient with other people or withdrawal when we’re having these negative cognitions these thinking errors that are keeping us in a dysphoric state these effects of thinking errors contribute to fatigue and a sense of hopelessness and helplessness which intensifies thinking errors this is an important concept that I want my clients to understand and I want to drive home in this presentation so thinking errors what are they emotional reasoning feelings are not facts and we want to help people to learn to effectively identify feelings and separate them from facts so if somebody says I’m terrified okay that is a feeling what are the facts supporting that feeling why are you are terrified what is the evidence that you are in some sort of danger right now you know and danger may not be the right word for your client at that a particular point in time but what’s the evidence that there’s a threat in what ways are this similar to other situations maybe it’s triggering something from the scary past or you know you were too little to be able to handle it but you can handle it now and how if you dealt with similar situations like this, in the past, we want to help people just step back and get some distance between their feelings and their thoughts and try to figure out you know which thoughts are helpful and productive and even if a sought makes people anxious or angry it can be helpful it may be telling them hey dude you need to get your butt up and get out of there if it’s helpful it means it’s moving them toward where they want to be happy healthy safe and values-driven life so happy and helpful developed a stress tolerance skills when people use emotional reasoning they feel emotions which then they start attributing finding the facts to support those emotions instead of looking at all the facts we want to help them learn to tolerate their distress so they can kind of let that subside for a second they can accept their feeling they can name they can say I’m scared I’m stressed I’m angry and whatever but they don’t have to act on it right then they can tolerate the distress for a minute without having to try to make it go away and emotional regulation skills they can feel a feeling without having to make it go from zero to 120 you know if they feel sad they go I feel kind of sad instead of grabbing onto it and going I wonder what I feel sad about I must feel sad about all these sad things now I’m going to be sad and devastated so we want to help people learn how to regulate their emotions identify them accept them whatever word you want to use and tolerate them because feelings are there for a reason, they’re to tell you your brain thinks something’s going now thankfully we have that higher-order cognition stuff going on so we can contradict our brain and we can go you know maybe that’s not true in this situation cognitive bias negativity mental filter whatever you want to call it people who focus on the negative they walk in they get up in the morning and they look outside and it’s partly cloudy they get to work and they said instead of saying there was it was very light traffic they said there was a fair amount of traffic everything is always the flip side of what somebody who’s optimistic would say so asking them what’s the benefit to focusing on the negative in what ways is this helpful to you you know some people say well it keeps me from getting disappointed because I know it’s going to end up negative anyway so we can trap challenges that know that whatever it is they think they know and see if there have been exceptions when it hasn’t turned out that way what are the positives to this situation I give the example a lot of you know I wash my car or it rains and maybe I wanted to go out on a run that day but I can perceive it I can look at the positives you know the rain washed my car for me so I don’t have to do it now score it watered my garden all the better it knocked down some of the pollen out of there even better I can find and I can encourage people to find positives in a situation yes there are negatives to every situation if you want to find them you’re going to find them but if you want to find the positives you can too which takes us down to what are all the facts there’s the positive and the negative and the neutral I told you earlier about the coin toss activity having people toss a coin on the heads days they act like it is just the greatest day to be alive and see how things are different when they do their journal because you know I have my clients do I’m sort of a mindfulness check-in in the morning and in the evening and preferably at lunchtime how are they feeling what’s their emotional state what’s their energy level on the happy days a lot of times it can be less and sometimes they need a little coaching throughout because some of those old patterns kick in but I want them to start challenging some of their automatic thoughts that we’re going to talk about in a minute disqualifying or minimizing the positive most of us can probably say we’ve had a bunch of clients that do this they are more than happy to tell you about all the things that they mess up but then when they do something right they minimize it encouraging people to hold themselves to the same standard they would hold everyone else to and I know I talked about that earlier ask them things like would it minimum would you minimize this if it was your best friend’s experience your best friend came to you and said I just got into such-and-such college would you say awesome or would you say anybody can get in there how would that go ask them what is scary about accepting these positive things that you might have had an accomplishment for some people it means that it might mean other people expect more of them for other people they just don’t know how to accept the positive they don’t know how to accept compliments they don’t know how to be the center of attention and they don’t like it and then we want to look at why that is sometimes we disqualify the positive because it fails to meet someone else’s standards so as people might that be true here you know I know when I was growing up and going through college and going through school and everything got my doctorate but I will always be ever and always being not a real doctor because a Ph.D. is not an MD and I’m like really so is it somebody else’s standards or can I feel good about having a Ph.D. egocentrism my perspective is the only perspective I’ll being egocentric but it doesn’t work most of the time so encouraging people to take alternate perspectives maybe you’re texting with someone and they say something that is not that you interpret as not the nicest thing and this happens in a text messages a lot and they get upset now an egocentric thinking error would say that purse is just grumpy today someone that’s taking other perspectives would stop and go back and read the text and go I wonder if maybe this could have been taken some another way you know cuz their reaction is not what I intended so egocentrism if you hold on to that I don’t understand anybody else because you know I don’t see a problem with anything personalizing and mind-reading this is when you assume that everybody’s frowning because of something you did your boss walks down the hallway and looks at you and grimaces and continues to walk on oh I must have done something wrong no maybe he just got out of his senior management meeting that was five hours long and he’s got to go to the bathroom you know there could be a hundred different explanations for why that happened so encourage clients to ask themselves what are some alternate explanations for this event that doesn’t involve me you know why might this have happened if they hold on to that, I must have done something wrong but as soon as their boss calls them up and goes hey can you come to my office for a second you know where their thoughts are going to go I’m getting fired I’m going to get laid off I don’t know what it was that I did wrong but he walked by me two weeks ago in the hallway and grimaced and I’m just I’m the worst person in the whole world but where did that come from so encouraging people to not necessarily assume they know what’s going on in someone else’s mind and not automatically attributing every person’s negative behavior to something they did how often and then ask them how often has it been about you now think about the last 10 times you’ve taken something personally how many of those 10 times has it been about something you did versus something with the other person then the availability heuristic remembering what’s most prominent in your mind so asking clients what are the facts ah the most obvious one that we talk about is plane crashes you know it is way dangerous to fly on a plane because you hear about all those plane crashes well yeah you hear about A few planes crash but you don’t hear about the 20,000 every day that land safely so you remember it and it seems more dangerous because that’s what is in your mind that’s what is available to you that’s what you’ve based your thought processes on because maybe you didn’t know that 20,000 planes or more fly and land just perfectly every day this can also be true with people remembering what’s most prominent in your mind sometimes and this can be very very true in domestically violent relationships if somebody falls in love with someone and that person is just the greatest person since sliced bread for the first four months and then the cycle starts and there’s this little tiny a sliver of the honeymoon period after the battering cycle and the person’s like that’s the person I fell in love with that’s what I remember and they try to focus on what’s most prominent in their mind and they ignore the rest of the stuff so we need to encourage people to look objectively at the facts magnification are you confusing high and low probability outcomes what are the chances that this is going to happen how many clients have we worked with that have gone to the doctor and gotten in a physical or get a test run and then the doctor had to call them back and this could be true for you too and the doctor had to call them back two or three days later when the tests came back from the lab and that whole three days they were just in a panic because they were afraid they were going to get some terminal diagnosis so thinking about high and low probability outcomes another instance or example of magnification is somebody that thinks this is the end of the world whatever it I think I’ve told you before my little story about um tripping when I was walking down the hall at work and falling and yeah it was embarrassing my folders went everywhere and yeah but in that big scheme of things will it matter that much from now you know are people gonna think oh she is such a clutch she must be a ditz too no I mean they may have thought that at that time I don’t know but you know in six months nobody’s going to remember and then ask them in the past when something like this has happened when you’ve had to get a test done and you’ve had to wait on results or if you’ve done something that was embarrassing and you didn’t think you thought everybody was going to remember it forever how did you tolerate it how did you learn to deal with it building on those strengths that they already have all-or-nothing thinking errors these are things like love versus hate I love them or I hate them it’s all or nothing she does this all the time or she never does it if I’m going to do it I’m going to do it perfectly or I’m not going to do it at all thank you all good intentions or all bad intentions you know sometimes we do things with good intentions that have some bad repercussions so did we do it with all bad intentions are all good intentions and the answer is neither most of the time life is kind of in that middle-ground gray area encouraging clients to look and find examples where something hasn’t been one of the polls when having they do something that they’re proud of that wasn’t perfect or when again when has somebody else done something that they were proud of that wasn’t perfect remembering that with availability heuristic remembering how often something really happens and how long it’s been since you’ve seen that behavior and remember that sometimes good times are amazing but how frequent are they compared with the bad times another thinking error is a belief in a just world or a fallacy of fairness I just asked clients to identify for good people you know who’ve had bad things happen and in reality we all have bad things happen good people do bad people do in between people do attributional errors and this is a pet of mine you know labeling yourself is not a behavior so global versus specific and I am stupid versus I’m stupid at math I don’t have good math skills it’s not about me it’s about the skills I can change skills stable I am and I always will be versus it’s something I can change it’s something I can learn internally it’s about me as a person versus it’s about a skill deficit or something I could learn or change and there’s you know lots of information on attributions out there on the internet if you need a refresher on it but we find that a lot of people who have dysphoria have negative global stable internal attributions so questions for clients remember the beliefs equal thoughts and facts plus personal interpretation another way of saying it is reality is 10% perception is 10% reality and 90% interpretation so what are the facts for and against my belief is the belief based on facts or feelings do the belief focus on one aspect or the whole situation does the belief seem to use any thinking errors what are alternate explanations what would you tell your child or best friend if they had this belief how would you want someone to tell what would you want someone to tell you about this belief so if you’re telling somebody about this what are you hoping they’re going to say in return and finally, how is this belief moving you toward what and who is important to you or moving you away from what or who is important to you now they can do a worksheet and have all of these or you can pick one or two of these questions that are most salient for your clients but they can have kind of at their fingertips so as they’re going through the day and something happens they can ask themselves ok what’s an alternate explanation or you know whatever it is this is salient for that client’s irrational thoughts about how to do these thoughts impact the client’s emotions health relationships and perceptions of the world you know this is what we want to ask them how is this thought impacting you globally how may this thought has been helpful in the past where did it come from how does it make sense from when you formed it in the past when you’re dealing with it ask the person if the thought is bringing you closer to those that are important are there any examples of this thought or belief not being true and how can the statement be made less global less all-encompassing so it’s about a specific incident a specific situation less stable which means you can change it and less internal which means it’s not about who you are as a person but maybe something that you do or a skill that you have so we’re going to go through some of these thoughts real quickly here mistakes are never acceptable and if I make one it means that I’m incompetent well never is kind of stable and I am incompetent is kind of global that’s also that extreme all-or-nothing thinking so you can see where these cognitive distortions end up leading to unhelpful beliefs when somebody disagrees with me it’s a personal attack well there’s personalization if I ever heard it before maybe it’s not about you may be they’re having a bad day and you just happen to be the unlucky target or maybe they’re disagreeing with you because they have a different point of view and it’s not a personal attack it’s just their point of view if someone criticizes or rejects me there must be something wrong with me personalization all-or-nothing thinking global stable and internal something wrong with me as a person to feel good about myself others must approve of me now this is one we’ve talked about external validation before and we can’t control other people to feel good about yourself how can you do that besides necessarily requiring other people to approve of you to be content in the life I must be liked by all people Wow I’ve never met anybody who’s liked by all people I’ve never even met anybody who’s been hated by all people but it’s important to help clients see how this is dramatic to say all people and for them to be content then everybody has to like them I mean I like to be liked but if everybody doesn’t like me you know that’s pretty understandable my true value as an individual depends on what others think of me I would challenge this one this is all you know also, very personal internal I would challenge people to look at and say it so your child’s value as an individual depends on what other people think of he or most people would say no but the perspective thing nothing ever turns out the way, you want it to okay all-or-nothing thinking and probably the availability heuristic if something bad just happened then they may be focusing on that which causes them to focus on all the other bad things in the past that have happened not to focus on that is okay you know bad thing happen but look at all these good things I won’t try anything new unless I will be good at it this fear of failure fear of rejection it just really paralyzes a lot of people when they get stuck with that thinking the area that they have to be perfect I am in total control of anything bad that happens is my fault well that’s egocentric and personal if they think they’re in total control that’s their perception of how the world are they think if they’ve got everybody on marionette strings anything bad in the world that happens is their fault how powerful are they I feel happy about uh if I feel happy about life something will go wrong it happens sometimes but let’s look at times when you’ve been happy that something hasn’t gone wrong you know let’s get rid of that all-or-nothing thinking it’s not my fault my life didn’t go the way I wanted could be true but it seems like that’s making you unhappy so what do we do about that if I’m not in an intimate relationship I’m alone no, again that’s pretty extreme I’m either in an intimate relationship, or I am alone and a loner and you know it’s just me and my 17 cats which follows with there’s no gray area so encouraging people to look at what these beliefs are saying important thoughts impacts behaviors and emotional and physical reactions emotional and physical reactions impact thoughts and interpretations of events so if you do something and it’s pleasurable and you have a great physical reaction you know let’s take bungee jumping or skydiving if you go out there and it’s scary but you do it and you’re just like whoa what a rush your interpretation of that is probably going to be good which means you’ll probably do it again if you go out there and it’s just the most horrible experience you’ve ever had you’re probably not going to do it again and your interpretation of it is going to be not good which is going to make it hard to understand why other people would do it irrational thinking patterns are often caused by cognitive distortions so let’s just look back at some of those because there are a lot fewer cognitive distortions or general ways of thinking about the world then there are thinking errors because there are lots and lots of thinking errors cognitive distortions are often schemas which were formed based on faulty inaccurate or immature knowledge or understanding and by identifying the thoughts of the hecklers you know the automatic tapes that are maintaining our unhappiness the person can choose whether to accept those thoughts or change them

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Emotional Eating Signs and 7 Tips Cope | Making Peace with Food | Counseling Techniques

This episode was pre-recorded as part of a live continuing education webinar on demand. Ceus are still available for this presentation through all CEUs registered at allies com, counselor toolbox, hi everybody, and welcome to today’s presentation on emotional eating and making peace with food during the next hour.So we’re going to define emotional eating and differentiate it really from eating when to celebrate and when it’s a problem and also differentiate, differentiating it from eating disorders will explore emotional eating in terms of its, beneficial functions and rewards and discuss.Why restrictive diets, don’t resolve emotional eating a lot of times? People will say you know, I have been on this diet forever and it doesn’t seem to be working or I can’t seem to stick to any diet that I try and we’re going to look at different reasons why this might Be what is emotional eating and it’s exactly what it sounds like it:’s eating in response to emotions and feelings other than hunger.So if you’re eating, because you’re bored, if you’re eating at someone and sometimes especially if you are angry at someone or disappointed in someone, you may eat and sort of be eating and thinking you made me do this so eating At someone eating to forget or distract yourself eating, to feel better because when you eat, regardless of what you’re eating, but especially if you eat high sugar high-fat foods, you’re going to release serotonin and dopamine eating out of boredom.You know hand to mouth bang, eating out of habit and, as I said a few minutes ago, not all emotional eaters have an eating disorder um and we want to differentiate that.Does it mean that their eating is not problematic to them? No, not at all.

If they’re telling you it’s a problem, then it’s a problem.They may not meet the criteria for binge eating disorder or bulimia, but it’s important to address it because they understand that they’re eating for a reason.Other than hunger, they want to stop because they want to eat, for hunger, but not otherwise, and for us as clinicians.The first thing we need to do is understand: why is it that they’re eating? Is it boredom? Is it a habit, so they need to keep a food log or a food journal for over a week or two weeks, and sometimes when people come in for an assessment, especially if that’s one of their main presenting issues? I’ll start by just doing a retrospective of the last three days to get an idea of what may be triggering some of their eating episodes.And then we can look at some of the habits or bad habits, maybe that they’ve gotten into, and start talking about ways to address those remembering that Rome wasn’t built in a day this isn’t going to go away overnight.But a lot of times, if you give people some tips, tricks, and tools to think about implementing when they walk out of your office after the assessment before the first official session, it provides them some hope and gets the momentum going and again you don’t Have to binge to be an emotional eater, some people graze all day long.Some people will eat and it’s not what would be considered technically a binge, but it’s more than they had anticipated.Maybe they go back for second helpings or third helpings when they weren’t hungry, but it was good.So why is eating so soothing? There are a lot of reasons.Now there’s obvious it’s, tastes good, so that’s.You know the big obvious bonus, but thinking about the function eating serves, we have to eat to survive.When you were an infant, it eating involved a closeness with your parental unit, which could release oxytocin, and I say, parental unit because even if it was dad feeding the baby a bottle there was that connection.There was that contact that caused the infant and the parent to release oxytocin. This is our bonding chemical, so eating was associated early on with bonding food may also have been associated with sleep.If the infant or child was given a bottle every night to go to sleep, then they may start thinking or they may be in the habit of eating to wind down or calm down, and we need to help them figure out different ways to do That as a toddler, what eating mean think about when you went from well, we probably don’t, remember that, but think about when your kids went from eating.You know food out of a jar to even their first Cheerios.That was a huge figure out.How to pick up that little cheerio and get it in their mouth and it involved exploration and mastery.They were discovering all different types of textures and tastes and figuring out what smell went with what taste, and it was a cool and exciting time for kids, and I mean think about it.They’re like a year old, so it doesn’t take much to amuse them, but this was the rewarding reward.Equals dopamine equals let’s do that again.It involved power and control of the child.At this point was starting to be able to feed himself or herself and was starting to be able to be somewhat independent of the parent when it came to the basic physiological function of eating. So eating itself had its rewards and it was self-esteem building because the child started learning.You know how to feed yourself and how to ask for what he or she wanted, at least in terms of food.There are formations of memories around foods, even as early as toddlerhood.You know we have celebrations, we have birthdays, we have different things and most children have certain foods that they like, and it could be because the first time that ate that food was a really happy experience or it could be just that’s, their favorite Food and that’s all they want to eat, but they remember that food and they remember when they ate it, they felt good.They felt happy so as an adult there,’s a part of their brain going chicken nuggets.Make me happy now that’s, how the toddler thought as an adult.We can understand that chicken nuggets themselves, aren’t making you happy, but you see the connections that we’re making.Here there’s been an association between happiness and chicken nuggets unhealthy foods, especially for children when, as adults, we’re still able to control what they eat.Your sugary foods and your unhealthy foods are usually reserved for treats or rewards.So when you’re feeling like you need to be rewarded when you’re feeling like you want to feel good, sometimes you’ll resort to those things. When you were a kid that made, you feel good like chocolate, chip, cookies, Haagen Dazs, or whatever it was for you.We’ve talked in the past, about associations and conditioning, and this is all coming back kind of full circle now because we need to understand that our brain has associated pleasure and reward with food for a lot of different reasons.Not just because of nourishment looking at the reasons why your patient eats is going to help you understand what underlying issues you may need to address in treatment.Culturally, we associate eating with caring and celebration and think about birthdays and holidays.What do we get together? We have buffets, we have pot Luck,’s.When someone passes away.What do you bring food over when somebody’s sick? What do you bring food over to in our culture? There is a lot of emphasis put on eating and nourishing, and that’s, true of a lot of different cultures.Low blood sugar can cause feelings of depression and anxiety which are quelled by food.So if somebody typically doesn’t eat well during the day, you know they go long periods without eating or if they have blood sugar issues, to begin with, and then they eat they feel better.So when they start feeling not so good, what do you think their first reaction is, let me eat and see if that helps evolution, predisposes the human body to crave high sugar, high fat, high-calorie foods for quick energy and to prepare for a famine. Our bodies are cool and frustrating at the same time because you know your body takes in this these foods and it says we’re going to secrete, the most amount of dopamine and the most amount of reward for these high-calorie foods because We want to make sure we’re prepared in case there’s a famine back.You know in the day many many many years ago, hundreds of years ago we couldn’t guarantee.We would have a meal every day, let alone three meals every day.So the body prepared – and it said alright – we need to get whatever we can when we can.So we’re going to make this higher fat higher calorie food more rewarding.Now I said it:’s also can be a blessing and a curse.Today, there’s still a little part of our primordial brain.That says, if it thinks there’s a famine, it will slow down your base metabolic rate, which causes people to gain weight.We see this a lot in people with eating disorders, who tend to not take in very many calories, or if they take them in they purge them.So the body goes well. I can’t guarantee I’m gon to get enough food.I’m going to get enough energy to survive.So I’m just going to turn down the thermostat a little bit and turn down the base metabolic rate, which compounds the problem for the person with the eating disorder.So it’s important to understand that the brain is somewhat active in what’s going on.So I keep saying we need to figure out what’s behind or underlying the craving.First, we need to rule out physical causes for some people.It’s as simple as this.If they’ve got low blood sugar because they’re not eating too often and obviously as counselors, we’re not going to diagnose this their doctor or their nutritionist will, but we can start exploring and go.It sounds like you might need to look at having your blood sugar checked or talk to your doctor about how frequently you need to eat because some people – and I know I’m – are very guilty of it.If I get into it into a groove doing something I’ll eat breakfast and then I’ll get into a groove and before I know it, it’s 3 00 in the afternoon and I haven’t eaten for like a whole bunch of Hours I’m not doing math today and my blood Sugar’s low and I’m starting to get foggy, headed and irritable and tired. So it’s a real, simple fix there in our society we are so driven and we are so.We get so caught up in things because that’s such a fast pace that it’s easy to forget to eat or is easy to avoid eating so that’s.The first thing we want to rule out.Are you eating in response to low blood sugar, which is making eating, seem more rewarding when you eat in response to low blood sugar a lot of times, people who do that end up eating more than they normally would because they start eating fast.It’s like I’m going to shovel, in as much as I can.Your brain doesn’t register you’re eating for 20 minutes or so so, before their brain, even registers.What’s gone on and gets the blood sugar back up? They’ve already eaten a whole ton of food.Why is this under-emotional eating? Well because generally, when they go in to just start eating, yes, they’re hungry, but they’re, also cranky and irritable, and most of the time they’re.Not thinking about I’m eating for the nourishment it’s, I’m eating, feel better lack of sleep, and this is so true for shift workers as well.As you know, new parents and college students, and anybody who’s not getting enough sleep. If we are surviving on sugar and stimulants, we’re going Peak and Lower Valley, Peak, and Lower Valley, and you just keep going up and down until you just crash, because every time you crash you crash a little bit lower.So if somebody’s on that roller coaster, they’re going to feel worse between you know: eating episodes they’re going to feel tired.They’re going to feel a flood of sluggish irritable fatigued and, to a certain extent, maybe depression, and they may be missing attribute those feeling, those emotional feelings to emotions versus physical causes, and likewise we also want to make sure that you know we’re addressing The emotional causes because there’s probably stuff there too, but if they’re not getting enough sleep and they’re living on sugar and stimulants their body is kind of in a state of hyper-vigilance, a lot of times it’s exhausted.So they’re going to be tired and cranky.So those are a couple of things that we want to look at.Those are relatively easy fixes or at least relatively easy things to point out and go let’s think about this.One of the things that I suggest for a lot of my clients is just to take a week and mindfully and it is difficult but try to eat healthfully.You know try to eat a few times a day.You know try to eat like three meals a day and get enough water and try to get enough sleep and try not to overdo it.On the stimulants at the, beginning I, 39, am not going to say cut out anything because that 39, is not, realistic and it’s not fair, and they 39, are probably already struggling if they’re coming in to see me, so if I go hey Let’s just turn your world upside down and guess what you’re not going to drink any caffeine anymore. It’s not going to create a happy person, so I asked them to try to make some small changes and see if that starts, to help dehydration causes fogginess and symptoms of depressionWe want to make sure that they rule that out and too many stimulantsAlso causes dehydration, so you know we’re looking at some of the physical causes of irritability and fatigue and cravings because again we’re going back to when I felt this way before not looking at it.Why I felt this way.But when I felt irritable depressed cranky, what made me feel better and generally food, and generally it’s, not good food.For me, it’s M Ms.I love my M Ms, especially the ones with almonds, but I digress.Nutritional causes of cravings, high carbohydrate, and high starch foods caused a greater release of serotonin and endorphins.So if you’ve got somebody who’s depressed for whatever reason that they may crave these kinds of foods to increase their serotonin level or increase the endorphins, their energy levels, chocolate people who crave chocolate may be low in magnesium.It also um the level of magnesium affects how much serotonin is available again. Just I keep saying this just for legal reasons.We want to make sure their doctor or nutritionist goes in and makes this diagnosis, but if there are particular foods that they do crave, they need to bring that up with their medical provider if they’re craving fatty foods.Now again, fatty foods are just good.I love fried foods, but it also could mean that they’re not getting enough Omega threes, Americans, typically don’t and interestingly, if they crave soda, they may be calcium deficient, who knew so?These are things to take a look at to ask people.You know if they’re craving soda, maybe cutting back on their soda a little bit and seeing what happens and or getting blood work done.

Once we’ve ruled out the obvious physical causes.They’ve gone to the doctor.Gotten blood work done everything I’m coming back happy.They’re getting enough sleep, but they’re still eating when they’re, not hungry, we need to rule out habits. Is there a particular time or activity that makes you crave this food? When I was growing up, I would go to the grocery store with my mother, and on the way back home from the grocery store.She would always we would always get junk food and she would get a bag of chips and put them in the front seat.It was like a 20-minute drive from the grocery store to our house and by the time we would get back to the house.We would have put a good dent in those potato chips.That being said, I got into the habit of whenever I went to the grocery store.I would get something out of the bag and put it in the front seat and eat on the way home.Now am I paying attention to what I’m eating? No likely am I eating, because I was hungry, probably not so.We want to look at habits.A lot of people will eat when they are watching TV.It’s a huge one. So we want to not do that or if you’re going to eat when you’re watching TV make sure you sit at the table.At least that makes you a little bit more mindful so think about whether are there particular times or activities that you eat and you’re just not hungry.Are there particular times that you mindlessly eat, like, like, I said when you’re driving or when you’re watching television? Those are both habits and can be mindless because you’re not paying attention to how much is going in your mouth.You’re not probably paying attention to the taste and you’re not paying attention to whether you’re full or not.So if you’re mindlessly eating, then there’s going to be a lot more calorie consumption.In addition to the fact that you’re not eating because you’re hungry, you’re just eating to eat, are you going too long between meals than needing a sugar boost which leads to a sugar crash? So again that’s a physical cause? But we want to rule it out.These are bad habits that we can tend to get into other things that can be construed as bad habits are eating without putting food on a plate.If you eat straight out of the bag, you’re going to eat.More than if you put it on a plate, so put it on a plate, sit down, try not to watch TV, all the things that your grandmother would have told you.So what do we do about it? Emotional eating interventions? I talked earlier about the food diary. Do a retrospective during the assessment if they want to get a jumpstart on things, but have them keep a food diary, preferably for the duration of treatment, but at least for a week.What time did they eat? Were they craving just any old food or something salty, something that was sweet, something that was sour? This will give you a general idea and can give their medical provider a general idea if there are any nutritional imbalances or if there are particular associations.What emotion or state were you in, I say state because being exhausted is not necessarily really an emotion.Were you happy sad, mad glad exhausted drained whatever state feels like it would work, and then, because of why were you feeling this way it doesn’t have to be a dissertation? It can be short and sweet, but I encourage clients to write down everything.They eat before they eat it during the first week, or you know, like I said, preferably throughout the entire course of treatment why, before they eat it because it’s a stop, remember we’ve talked before about how we have an urge.We have a craving, we have an urge and then we engage in the behavior oftentimes without stopping mindfully.Think is this what we want to do this provides that stop.It says: okay, I’ve got it to write down the time, and then I’ve got to think about why I’m eating, and honestly a lot of clients notice, a reduction and their habit of eating when they have to do this, just because they don’t want to record-keeping that up for a month or two months helps break some of the habits, eating that they might do like.I said before when they’re eating, I encourage them to use a plate.Sit down. Don’t walk around don’t stand at the counter, eliminate distractions as much as possible and focus on the food you’re eating that goes with mindfully eating.What does it taste like? Is it good to take small bites when my son was young, I think I’ve shared this before he had gastric reflux and we would sit down at the table and I would shovel in food as fast as I could get it in my mouth because He couldn’t be put down for too long before he would start to get fussy, at least until we figured out that he had gastric reflux and Zantac was just a lifesaver.I developed that habit when he was little and I kept it up for a while.It took a while to learn for me to learn to go back to take.You know reasonable bites and tasting my food, and even today, if I’m not paying attention too much, I’ll eat my dinner fast and then I’ll sit there and I’ll be like well.Yes, I’ll taste that a little bit later, because I didn’t taste it when I ate it encourage clients to be aware of their eating habits, and try to avoid setting up a binge by restricting certain foods.Now.Does that mean you have to have cakes and candy and whatever your trigger foods are in your house all the time and in your face? No, I would encourage people not to do that, but to say you know, I said for me M Ms, is one of my favorite reward foods.

If you will, I don’t keep them in the house, but I will allow myself occasionally to buy a small snack-size pack of M Ms, when I’m out or I will get a regular-size pack and I’ll share it with my daughter, so I’m not restricting it.I’m not saying I can never M. Ms again, I’m just not making it available to myself when I might have some unrestricted time, try to avoid buying a bunch of comfort foods and keeping them around the house, and when you’ve got kids when you’ve got family, it’s not entirely possible, usually to not have some of that stuff around but try to avoid having the things that you particularly used for comfort, because if it’s not readily available, then you’ve got to focus on guess what dealing with the emotions.Instead of stuffing them with food, try not to go too long without eating.Like I said earlier, if you go too long, then by the time you get to the food, your blood, Sugar,’s low and you’re just shoveling it as fast as you can initially distract.If you know that you’re getting you’re eating and you’re, like I’m – really not hungry, but I want to eat, take a bath, take a walk, call a friend, heaven forbid get on Facebook.Whatever it is, you can do to distract yourself for 10 or 15 minutes if, after 10 or 15 minutes, you’re still going, I want whatever it is, then you can decide what to do about it.Then, most of the time when people stop and go, I’m not hungry.Let me distract myself.They get caught up in that distraction and before they know it, they’ve forgotten about the craving, and identify the emotions.If you know that you’re not hungry, but you want to eat, then say: okay, what’s going on what’s going on with me? It doesn’t mean that the person is never going to eat when, when they’re upset, because a lot of people do, and is it the end of the world, probably not necessary if they can start reducing the frequency of times that they eat.In response to emotional distress that’s, what we want, we want to progress, not perfect if it’s, depression, what’s causing them to feel hopeless or helpless right now, if it’s, stress, anxiety, or anger, remember our big kind of lump together stuff. What are they stressing out about? Do they feel like they’re overwhelmed? Are they afraid of failure, rejection, and loss of control of the unknown? We’ve gone through those things.We want them to identify what’s going on with them, and then they can make better choices about how to deal with it.So general coping helps them develop, alternate ways of coping with distress.Distract we’ve, already kind of gone over that one.I encourage people – and you know it’s – one of those DBT things – that a lot of therapists encourage their clients to keep a list of things.They can do to distract themselves because it’s not always practical to get up and go on a walk.If you’re at work or it’s, you know two in the morning.So what else can you do to distract yourself? Talk it out with a friend with yourself with your dog? Sometimes you just got to get it out.People who are more auditory will prefer talking it out as opposed to journaling it now.If they talk it out with themselves, they can record it if they want to, or sometimes it’s just better to have a dialogue with themself. If it worked for Freud, it can work for other people journaling.If your clients are inclined to journal, encourage them to write it down.Sometimes just getting stuff out of your head and onto paper will help the feelings dissipate a little bit.So you’re not mulling them over and obsessing over them and getting stuck in those thoughts and feelings.Additionally, while you’re distracted talking it out or journaling, this is also your break.Your stop between the urge and the behavior make a pro and con list of the de-stress, not the eating whatever it is, that’s stressing you out and how can you fix it or what are the pros of this situation and what are the downsides To this situation, encourage them to focus on the positive.You know.If something stressing you out at work, you know you’ve got a big meeting coming up or something you don’t want to do or what it is.You can get stuck on focusing on that or you can focus on the positive that you do have a job.That meeting only comes around once a month. You can it’s time you don’t have to be doing paperwork whatever the pros are for that person encourage them to focus on the positive.If you’re distressed because of some kind of a failure or perceived failure, figure out what you learned from it, whether it was a relationship failure, or maybe you learned what not to do in a relationship anymore. Maybe you learned things that you may have ignored.Maybe you learned what you should have done instead, but how can it be a learning opportunity, instead of somewhere to stay stuck and finally, if something’s making you upset if something’s causing anxiety, depression, hopelessness, helplessness, whatever the negative feeling figure out.If it’s worth your energy to get stuck here, is it worth the turmoil? Is it worth you know having to pacify yourself with food or whatever? It is a lot of times people say you know what now it’s, just it’s, not even worth my effort.It’s not worth moving me away from my goals, because my goal is to stop emotional eating.My goal is to eat for hunger, so I can go to dinner with people and feel comfortable.I can be at a party where there’s a buffet and not feel stressed out that I’m going to go and eat half the stuff on the buffet that’s my goal so is holding on to whatever this de-stress is getting me Closer to being able to do those things and generally the answer:’s no develop alternate ways of coping with the stress the ABCs, the a is the activating event.What is stressing you out and what’s causing the de-stress C is the emotional reaction.Angry depressed stressed, whatever be: are your behaviors? What behaviors or B are your beliefs? Sorry, what are the beliefs that are in there that may need to be addressed? What kind of things are you telling yourself, and, and how can you counter them? Cognitively eliminate your vulnerabilities.You knew we couldn’t get through a presentation without talking about vulnerabilities. If someone is well-rested.Well, the fed has a good social support network, not stretch timewise.Then it will be easier to deal with stress or stressors when they come your way.You’ll have more energy to deal with it, so there won’t be this overwhelming feeling of I just want to bury my head in a jar of peanut butter, be compassionate with yourself.Some days, you know you’re, just going to feel anxious.You’re going to feel depressed.You’re going to get angry.You can beat yourself up over it and you know a lot of people do.Is that the best use of your energy or can you be compassionate? Can you learn from it? Can you give yourself a break and go? You know what I’m having a bad day today and that’s okay, I’m not going to unpack and stay here, but I’m not going to fight.It either helps clients learn how to urge surf help. They understand that, just like a panic attack just like a wave just like a lot of other things in life, it will come, it will crest and it will go out again, so they can sort of identify where they are on the energy of that Urge other tools people can use close the kitchen once I have the kitchen cleaned and you know all the dishes are done and it looks pretty.I hate going in there and finding dishes in the sink again now I’ve got teenagers, so we always have dishes in the sink.But before I had children, you know at seven o’clock.I finished all the dishes and closed the kitchen, and that would be enough motivation for me to not go in there and at least not use plates and stuff to eat.So if we’re saying that we’re going to only eat using utensils plates and sitting and all that stuff that we already talked about, then once you close the kitchen, you’re not going back in, there turn off the light.That also helps so you’re not being attracted to the pretty lights, and you know all the goodies that are in the kitchen to brush your teeth.This is something my grandmother used to do and it works.There’s some research behind it.Minty flavors reduce our appetite.So if you brush your teeth, you get all the other flavors out of your mouth and it reduces your urges to eat because it again it’s clean and fresh. And do you really want to brush your teeth again, and meditate, sometimes just getting in a space where you’re, not obsessing about anything, can help people get past that urge to self-soothe by eating a CT for emotional eating.What am I feeling or thinking about what’s going on with me right now? What is important to me? So if I am thinking I want to eat, I want to you know just dive into this jar of peanut butter, and then I think about what’s important to me.Is it important to me to get control of this? Is it important to me to you know, be able to fit into my clothes in six months or not? So what is it in? What way is controlling my eating habits and eliminating emotional eating important to me, and how does that get me closer to other things that are important to me, and what other things could I do? That would get me closer to my goals.So if the goal is to have improved relationships, be able to feel more comfortable around food reduce the stress around going out to eat, and just around food in general, what else can you do when you are stressed out? Somebody also suggested that adding a blue light in the refrigerator decreases the appeal of foods, which is interesting because yellow red and orange, and browns, I think Pizza Hut – are all foods that increase people’s, hunger and desire to eat.But blue is just a completely different primary color, and adding a blue hue seems like that would be effective, so cool thanks for that.Little tidbit there holiday help, and you know we’re coming into the holidays.So I’ve got to bring that up at every single glass and choose lower-calorie foods.If you tend to get stressed out or caught up or mindlessly eat when you are at family gatherings.Okay, you know cut yourself a break, know that that’s, probably going to happen, and fill up on the lower-calorie foods.The carrot sticks the broccoli, the white meat, turkey, anything that’s available, that’s, not like sweet potato pie or brownies, keep water or low-calorie beverage. In your hand, if you’ve got your hand full, you can’t eat at the same time.So you know if you walk around with a cup in your hand, it helps talk to people.Hopefully, you don’t talk with your mouth open or talk with food in your mouth.So if you’re talking to people, you’re not going to be as inclined to go and get something to eat because you’re wanting to stay engaged in that conversation.Stay away from the buffet, especially if you know that it could get stressful, or maybe you know for me, I turn into a pumpkin at like 7 30 at night.I get up at 4 00, but I turn into a pumpkin at 7, 30 and a lot of times holiday parties and those sorts of things are at eight, nine, o’clock at night, and you know I’ve already turned into a pumpkin.So I know that if I go to those I’m going to be more likely to eat just to kind of stay away because I’m tired and it’s a bad habit.It’s not because I’m hungry.So I know I need to stay away from the buffet during those times we rehearse refusal skills.If somebody says. Oh, you, I’ve got to try it by two.This figure out how you’re going to address that ahead of time, because there’s generally probably a lot of really good foods, and you may really want to taste some, but sometimes people who emotionally eat know if they start eating.If they start eating high-fat high calorie foods, they’re going to want to eat everything.So if I start with one bite of a brownie, I’m going to want to eat every suit that’s on the table.If they know that, then they may want to choose to not even go down that road at that juncture, encourage people to stay mindful of their distress meter before they go back for another helping and ask themselves, am I hungry? Am I just wanting to taste what’s here and how do I feel about that? Or am I eating just because I don’t want to be here and I’m bored and I want to fill the time? Have people keep an index card with their coping mantra and two reasons they don’t want to emotionally eat, so I need to be here.I can do this whatever the mantra is that’s going to get them through the night, whatever they’re.Telling themselves that it’s going to help them plow through and make the right choices, but also two reasons that they don’t want to eat, or they’re going to get around it.Maybe they’ve got something at home that they can eat when they get home eating before they go to.The party may also help prevent some grazing holidays, bringing out a lot of emotions in people.Some people struggle with depression, anxiety, jealousy, grief, and anger. You know the whole gamut during this time and during this time there’s food everywhere I mean starting at Halloween when your kids bring home the Halloween candy, which usually lasts about a week in our house baby.Oh, Halloween candy followed by getting ready for Thanksgiving, followed by doing all the baking or whatever you do, and the holiday parties coming up on the December holiday season.There’s just food everywhere, so it’s really easy to cope.If you will, with stress being overwhelmed with being tired by not eating enough healthy food by binging on unhealthy and soothing food if you will so it’s, encouraged it’s important to encourage people to stay.Mindful of why they’re eating what they’re eating, when constantly bombarded with high-fat high carbohydrate foods, people are tempted to eat to feel calm yeah.I challenge anybody to say that they’ve never eaten and go okay.You know I’m.Just focused on this right now I’m not thinking about everything out here and it feels good um.I’m good now, good, probably not the word I should use, but it does help people distract themselves sometimes when they eat, especially those high-intensity foods.You feel happier serotonins are released. Dopamine is released.You’re, like oh, that’s good.I want to do that again or you just feel numb.You can get into a zone where you’re just eating and not caring about it’s.Not that you’re feeling calm, you’re just not feeling anything, and a lot of times when people get into that zone.They’re not tasting the food either.They’re just kind of on autopilot for emotional eating, like most other escape behaviors.Never addresses the underlying emotions and their causes, so we need to look at them.Are you feeling anxious? Are you feeling jittery? Are you feeling depressed because your blood Sugar’s low, because you’re nutritionally deficient because you’re not getting enough sleep or because there’s something cognitive going on, or all of the above emotional eating, often results in physical issues like weight gain Poor sleep and reduced energy weight gain, are you know in and of itself a few pounds here and they’re not a big deal, but some people can start emotionally eating to feel better.They gained a lot of weight. Then they start feeling less energetic.It starts being harder to move around.They get to the point where they are clinically obese.Then they’re going.I’m never going to take all this weight off.They feel hopeless and helpless.You see where this is going, so they eat some more.Can cause poor sleep apnea, it’s hard to get it’s also hard to get comfortable.Sometimes, if you’ve eaten a whole bunch of food right before you go to bed, you know your bellies are all full, and little you wake up.The next morning and your belly are still awful, which means you probably didn’t, sleep very well the night before and emotional eating often results in reduced energy because the foods we binge on the foods we eat for self-soothing often end up causing a sugar Crash some people try to undo emotional eating by restricting other calories which can lead to nutritional deficits and more cravings. I had a girlfriend when I was in high school and you know think back to I don’t know if they still do it, but when we were in high school there was always some kind of candy sale going on and she would always forgo all Other food, so she could have two chocolate bars each day and you know we’re not going to get into the all the other issues surrounding only eating two chocolate bars.But the point I’m making it right now is the fact she wasn’t getting protein.She wasn’t getting it.You know most of her vitamins and minerals and stuff that her body needed to make the neurotransmitter.So she could feel happy and she was contributing to a sugar crash, but I also know that it’s common around the holidays for people to do this.They’ll let go all day without eating because they know they’re going to a party tonight and there’s going to be a lot of really good food doing that once in a while.Not a big deal doing that 10 or 15 times in a month could start to have problems.Emotional eaters need to first find a way to stop before they eat, so, whether it’s writing in a journal or adding.There are a lot of apps on your phone that you can put your food in, even if you’re, not writing about your emotions and your cravings and all that kind of stuff.Sometimes it’s enough to make people stop before they reach. For the food – or you know, kind of an extreme way to go is to not keep pre-processed or prepackaged foods in the house.So anything that you’re going to eat you’ve got to make second identify the underlying reason for your eating figure out.Do I generally eat in response to and then address the thoughts and emotions leading to the urges?So if you figure out the underlying emotions for your eating or your depression, then what thoughts are maintaining that depression? And how can you address it once you address the underlying issues, some of the emotional eating will go away, but some of its habits?We’re going to have to break that habit and, throughout you know, the past couple of decades of working with people.My experience has been the majority of the time people don’t want to hear.Well, once you deal with your emotional issues, the emotional eating will go away now.They’re there because they want to stop that behavior right now.So, yes, we need to work on all the underlying issues but give them a tip or a trick or a tool whatever you want to call it to use before they walk out of your office after every single session.That way, they have something else they can put in their toolbox and feel more empowered to have control over what’s going on with them. And what’s coming their way, having the knowledge of what and why is 80 of helping them get to the recovery point now, if there’s co-occurring or if the eating issues are more than just emotional eating, if there’s, the person meets The criteria for binge eating disorder, bulimia or anorexia.There are a lot of other underlying issues they’re going to have to be dealt with.So I don’t want to trivialize that, but I do want people to feel like they’ve got some hope over what’s going on.Are there any questions? If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube, you can attend and participate in our live webinars with doctor Snipes by subscribing at all CEUs comm slash counselor toolbox.This episode has been brought to you in part by all CEUs com providing 24 7 multimedia, continuing education, and pre-certification; training to counselors therapists, and nurses, since 2006 use coupon code consular toolbox to get a 20 discount off your order.This month,As found on YouTube Animated Video Maker – Create Amazing Explainer Videos | VidToon™ #1 Top Video Animation Software To Make Explainer, Marketing, Animated Videos Online It’s EASIER, PRODUCTIVE, FASTER Get Commercial Rights INCLUDED when you act NOW Get Vidtoon™

Emotional Eating Signs and 7 Tips Cope | Making Peace with Food | Counseling Techniques

this episode was pre-recorded as part of a live continuing education webinar on-demand CEUs are still available for this presentation through all CEUs register at allceus.com/counselortoolbox hi everybody and welcome to today’s presentation on emotional eating making peace with food during the next hour so we’re going to define emotional eating and differentiate it really from eating when to celebrate and when it’s a problem and also differentiate differentiating it from eating disorders will explore emotional eating in terms of its beneficial functions and rewards and discuss why restrictive diets don’t resolve emotional eating a lot of times people will say you know I have been on this diet forever and it doesn’t seem to be working or I can’t seem to stick to any diet that I try and we’re going to look at different reasons why this might be what is emotional eating and it’s exactly what it sounds like it’s eating in response to emotions and feelings other than hunger so if you’re eating because you’re bored if you’re eating at someone and sometimes, especially if you are angry at someone or disappointed in someone you may eat and sort of be eating and thinking you made I do this so eating at someone eating to forget or distract myself from eating to feel better because when you eat regardless of what you’re eating but especially if you eat high-sugar high-fat foods you’re going to release serotonin and dopamine eating out of boredom you know hand-to-mouth bang eating out of habit and like I said a few minutes ago not all emotional eaters have an eating disorder um and we want to differentiate that it means that their eating is not problematic to them no not at all if they’re telling you it’s a problem then it’s a problem they may not meet the criteria for binge eating disorder or bulimia but it’s important to address it because they understand that they’re eating for a reason other than hunger and they want to stop because they want to eat for hunger but not otherwise and for us as clinicians the first thing we need to do is understand why is it that they’re eating is it boredom is it a habit so they need to keep a food log or a food journal over a week or two weeks and sometimes when people come in for an assessment especially if that’s one of their main presenting issues I’ll start just doing a retrospective of the last three days to get an idea of what may be triggering some of their eating episodes and then we can look at some of the habits or bad habits may be that they’ve gotten into and start talking about ways to address those remember that Rome wasn’t built in a day this isn’t going to go away overnight but a lot of times if you give people some tips tricks and tools to think about implementing when they walk out of your office after the assessment before the first official session it provides them some hope and gets the momentum going and again you don’t have to binge to be an emotional eater some people graze all day long some people will eat and it’s not what would be considered technically a binge but it’s more than they had anticipated maybe they go back for second helpings or third helpings when they weren’t hungry but it was good so why is eating so soothing there are a lot of reasons now there’s obvious it tastes good so that’s you know the big obvious bonus but thinking about the function the eating serves we have to eat in order to survive when you were an infant it eating involved a closeness with your parental unit which could release oxytocin I say parental unit because even if it was dad feeding the baby a bottle there was that connection there was that contact which caused the infant and the parent to release oxytocin this is our bonding chemical so eating was associated early on with bonding food may also have been associated with sleep if the infant or child was given a bottle every night to go to sleep then they may start thinking or they may be in the habit of eating to wind down or calm down and we need to help them figure out different ways to do that as a toddler what an eating means to think about when you went from well we probably don’t remember that but think about when your kids went from eating you know food out of a jar to even their first Cheerios that was huge figuring out how to pick up that little cheerio and get it in their mouth and it involved exploration and mastery they were discovering all different types of textures and tastes and figuring out what smell went with what taste and it was a cool and exciting time for kids and I mean think about it they’re like a year old so it doesn’t take much to amuse them but this was the rewarding reward equals dopamine equals let’s do that again it involved power and control of the child at this point was starting to be able to feed him or herself was starting to be able to be somewhat independent from the parent when it came to the basic physiological function of eating so eating itself had its rewards and it was self-esteem building because the child started learning you know how to feed himself and how to ask for what he or she wanted at least in terms of food there are formations of memories around foods even as early as toddlerhood you know we have celebrations we have birthdays we have different things and most children have certain foods that they really like and it could be because the first time that ate that food was a really happy experience or it could be just that’s their favorite food and that’s all they want to eat but they remember that food and they remember when they ate it they felt good they felt happy so as an adult there’s a part of their brain going chicken nuggets make me happy now that’s how the toddler thought as an adult we can understand that chicken nuggets themselves aren’t making you happy but you see the connections that we’re making here there’s been an association between happiness and chicken nuggets unhealthy foods especially for children when as adults we’re still able to control what they eat your sugary foods your unhealthy foods are usually reserved for treats or rewards so when you’re feeling like you need to be rewarded when you’re feeling like you want to feel good sometimes you’ll resort to those things when you were a kid that made you feel good like chocolate chip cookies or Haagen-Dazs or whatever it was for you we’ve talked in the past about associations and conditioning and this is all coming back kind of full circle now because we need to understand that our brain has associated pleasure and reward with food for a lot of different reasons not just because of nourishment looking at the reasons why your patient eats is going to help you understand what underlying issues you may need to address in treatment culturally we associate eating with caring and celebrating think about birthdays and holidays what do we do we get together we have buffets we have pot Luck’s when someone passes away what do you do you bring food over when somebody’s sick what do you bring food over so in our culture there is a lot of emphases put on eating and nourishing and that’s true of a lot of different cultures with low blood sugar can cause feelings of depression and anxiety which are quelled by food so if somebody typically doesn’t eat well during the day you know they go long periods without eating or if they have blood sugar issues to begin with and then they eat they feel better so when they start feeling not so good what do you think their first reaction is let me eat and see if that helps evolution predisposes the human body to crave high sugar high-fat high calorie foods for quick energy and to prepare for a famine our bodies are cool and frustrated at the same time because you know your body takes in these foods and it says we’re gonna secrete the most amount of dopamine and the most amount of reward for these high-calorie foods because we want to make sure we’re prepared in case there’s a famine back you know in the day many many many years ago hundreds of years ago we couldn’t guarantee we would have a meal every day let alone three meals every day so the body prepared and it said alright we need to get whatever we can when we can so we’re going to make this a higher fat higher calorie food more rewarding now I said it’s also can be a blessing and a curse today there’s still a little part of our primordial a brain that says if it thinks there’s a famine it will slow down your base metabolic rate which causes people to gain weight we see this a lot in people with eating disorders who tend to not take in very many calories or if they take them in they purge them so the body goes well I can’t guarantee I’m gonna get enough food I’m gonna get enough energy to survive so I’m just gonna turn down the thermostat a little bit to turn down the base metabolic rate which compounds the problem for the person with an eating disorder so it’s important to understand that the brain is somewhat active to what’s going on so I keep saying we need to figure out what’s behind or underlying the craving first we need to rule out physical causes for some people it’s as simple as this if they’ve got low blood sugar because they’re not eating too often and obviously as counselors we’re not going to diagnose this their doctor or their nutritionist will but we can start exploring and go it sounds like you might need to look at having your blood sugar checked or talk to your doctor about how frequently you need to eat because some people and I know I’m very guilty of it if I get into it into a groove doing something I’ll eat breakfast and then I’ll get into a groove and before I know it it’s 3:00 in the afternoon and I haven’t eaten for like a whole bunch of hours I’m not doing math today and my blood Sugar’s low and I’m starting to get foggy-headed and irritable and tired so it’s a real simple fix there in our society we are so driven and we are so we get so caught up in things because that’s such a fast pace that it’s easy to forget to eat or easy to avoid eating so that’s the first thing we want to rule out are you eating in response to low blood sugar which is making eating seem more rewarding and when you eat in response to low blood sugar a lot of times people who do that end up eating more than they normally would because they start eating fast it’s like I’m gonna shovel in as much as I can your brain doesn’t register you’re eating for 20 minutes or so so before your brain even registers what’s gone on and gets the blood sugar back up they’ve already eaten a whole ton of food why is this under emotional eating well because generally when they go in to just start eating yes they’re hungry but they’re also cranky and irritable and most of the time they’re not thinking about what I’m eating for the nourishment it’s I’m eating feel better after lack of sleep and this is so true for shift workers as well as you know new parents and college students and anybody who’s not getting enough sleep if we are surviving on sugar and stimulants we’re going Peak and Lower Valley Peak and Lower Valley and you just keep going up and down until you just crash because every time you crash you crash a a little bit lower so if somebody’s on that roller coaster they’re going to feel worse between you know eating episodes they’re going to feel tired they’re going to feel a flood of sluggish irritable fatigued and to a certain extent maybe depressed and they may be missing attributing those feeling those emotional feelings to emotions versus physical causes and likewise we also want to make sure that you know we’re addressing the emotional causes because there’s probably stuff there too but if they’re not getting enough sleep and they’re living on sugar and stimulants their the body is kind of in a state of hyper-vigilance a lot of times it’s exhausted so they’re going to be tired and cranky so those are a couple of things that we want to look at those are relatively easy fixes or at least relatively easy things to point out and go let’s think about this one of the things that I suggest for a lot of my clients is just to take a week and mindfully and it is difficult but try to eat healthfully you know try to eat a few times a day you know try to eat like three meals a day and getting enough water and trying to get enough sleep and try not to overdo it on the stimulants at the beginning I’m not going to say cut out anything because that’s not realistic and it’s not fair and they’re probably already struggling if they’re coming in to see me so if I go hey let’s just turn your world upside down and guess what you’re not going to drink any caffeine anymore it’s not going to create a happy person so I asked them to try to make some small changes and see if that starts to help dehydration causes fogginess and symptoms of depression we want to make sure that they rule that out and too many stimulants also causes dehydration so you know we’re looking at some of the physical causes of irritability and fatigue and cravings because again we’re going back to when I felt this way before not looking at why I felt this way but when I felt irritable depressed cranky what has made me feel better and generally food and generally it’s not good food for me it’s M&Ms I love my M&Ms, especially the ones with almonds but I digress nutritional causes of cravings high carbohydrate and high starch foods caused a greater release of serotonin and endorphins so if you’ve got somebody who’s depressed for whatever reason that they may crave these kinds of foods to increase their serotonin level or increase the endorphins in their energy levels chocolate people who crave chocolate may be low in magnesium it also um the level of magnesium affects how much serotonin is available again just keep saying this just for legal reasons we want to make sure their doctor or nutritionist goes in and makes this diagnosis but if there are particular foods that they do crave it’s important for them to bring that up with their medical provider if they’re craving fatty foods now again fatty foods are just good I love fried foods but it also could mean that they’re not getting enough Omega threes Americans typically don’t and interestingly if they crave soda they may be calcium deficient who knew so these are things to take a look at to ask people you know if they’re craving soda maybe cutting back on their soda a little bit and see what happens and or getting blood work done once we’ve ruled out the obvious physical causes they’ve gone to the doctor gotten blood work done everything I’m comes back happy they’re getting enough sleep but they’re still eating when they’re not hungry we need to rule out habits is there a particular time or activity that makes you crave this food when I was growing up I would go to the grocery store with my mother and on the way back home from the grocery store she would always we would always get junk food and she would get a bag of chips and put them in the front seat it was like a 20-minute drive from the grocery store to our house and by the time we would get back to the house we would have put a good dent in those potato chips that being said I got into the habit of whenever I went to the grocery store I would get something out of the bag and put it in the front seat and eat on the way home now am I paying attention to what I’m eating no likely am I eating because I was hungry probably not so we want to look at habits a lot of people will eat when they are watching TV it’s a huge one so we want to not do that or if you’re going to eat when you’re watching TV make sure you sit at the table at least that makes you a little bit more mindful so think about their particular times or activities that you eat and you’re just not hungry are their particular times that you mindlessly eat like like I said when you’re driving or when you’re watching television those are both habits and can be mindless because you’re not paying attention to how much is going on in your the mouth you’re not probably paying attention to the taste and you’re not paying attention to whether you’re full or not so if you’re mindlessly eating then there’s going to be a lot more calorie consumption in addition to the fact that you’re not eating because you’re hungry you’re just eating to eat are you going too long between meals than needing a sugar boost which leads to a sugar crash so again that’s a physical cause but we want to rule out these bad habits that we can tend to get into other things that can be construed as bad habits are eating without putting food on a plate if you eat straight out of the bag you’re gonna eat more than if you put it on a plate so put it on a plate sit down try not to watch TV all the things that your grandmother would have told you so what do we do about it emotional eating interventions I talked earlier about the food diary do a retrospective during the assessment if they want to get a jumpstart on things but have them keep a food diary preferably for the duration of treatment but at least for a week what time did they eat were they craving just any old food or something that was salty sweet sour this will give you a general idea and can give their medical provider a general idea if there are any nutritional imbalances or if there are particular associations with what emotion or state were you in and I say state because being exhausted is not necessarily really an emotion where you are happy sad mad glad exhausted drained whatever state feels like it would work and then because of why were you feeling this way it doesn’t have to be a dissertation it can be short and sweet but I encourage clients to write down everything they eat before they eat it during the first week or you know like I said preferably throughout the entire course of treatment why before they eat it because it’s a stop remembering we’ve talked before about how we have an urge we have a craving we have an urge and then we engage in the behavior oftentimes without stopping to mindfully think is this what we want to do this provides that stop it says okay I’ve got it to write down the time and then I’ve got to think about why I’m eating and honestly, a lot of clients notice a reduction and their habit of eating when they have to do this just because they don’t want to record-keeping that up for the period of a a month or two months helps break some of the habits eating that they might do like I said before when they’re eating I encourage them to use a plate sit down don’t walk around don’t stand at the counter eliminate distractions as much as possible and focus on the food you’re eating that goes with mindfully eating what does it taste like is it good take small bites when my son was young and I think I’ve shared this before he had gastric reflux and we would sit down at the table and I would shovel in food as fast as I could get it in my mouth because he couldn’t be put down for too long before he would start to get fussy at least until we figured out that he had gastric reflux and Zantac was just a lifesaver I developed that habit when he was little and I kept it up for a while, it took a while to learn for me to learn to go back to take you to know reasonable bites and tasting my food and even today if I’m not paying attention too much I’ll eat my dinner rest and then I’ll sit there and I’ll be like well yes I’ll taste that a little bit later because I didn’t taste it when I ate it encouraging clients to be aware of their eating habits and try to avoid setting up a binge by restricting certain foods now does that mean you have to have cakes and candy and whatever your trigger foods are in your house all the time and in your face no I would encourage people not to do that but to say you know I said for me M&Ms is one of my favorites reward foods if you will I don’t keep them in the house but I will allow myself occasionally to buy a small snack-size pack of M&Ms when I’m out or I will get a regular-size pack and I’ll share it with my daughter so I’m not restricting it I’m not saying I can never M&Ms again I’m just not making it available to myself when I might have some unrestricted time to try to avoid buying a bunch of comfort foods and keeping them around the house and when you’ve got kids when you’ve got family, it’s not entirely possible usually to not have some of that stuff around but try to avoid having the things that you particularly used for comfort because if it’s not readily available then you’ve got to focus on guess what dealing with the emotions instead of stuffing them with food try not to go too long without eating as I said earlier if you go too long then by the the time you get to the food your blood Sugar’s low and you’re just shoveling it as fast as you can initially distract if you know that you’re getting you’re eating and you’re like I’m really not hungry but I want to eat take a bath take a walk call a friend heaven forbid get on Facebook whatever it is you can do to distract yourself for 10 or 15 minutes if after 10 or 15 minutes you’re still going I rant whatever it is then you can decide what to do about it then most of the time when people stop and go I’m not hungry let me distract myself they get caught up in that distraction and before they know it they’ve forgotten about the craving to identify the emotions if you know that you’re not hungry but you want to eat then say okay what’s going on what’s going on with me it doesn’t mean that the person is never going to eat when they’re upset because a lot of people do and is it the end of the world probably not necessary if they can start reducing the frequency of times that they eat in response to emotional distress that’s what we want to progress, not perfect if it’s depression that’s causing them to feel hopeless or helpless right now if it’s stress anxiety or anger remember our big kind of lump together stuff what are they stressing out about do they feel like they’re overwhelmed are they afraid of failure rejection loss of control of the unknown we’ve gone through those things we want them to identify what’s going on with them and then they can make better choices about how to deal with it so general coping helps them develop alternate ways of coping with distress distract we’ve already kind of go over that one I encourage people and you know it’s one of those DBT things that a lot of therapists encourage their clients to keep a list of things they can do to distract themselves because it’s not always practical to get up and go on a walk if you’re at work or it’s you know two in the morning so what else can you do to distract yourself talk it out with a friend with yourself with your dog sometimes you just got to get it out people who are more auditory will prefer talking it out as opposed to journaling it now if they talk it out with themselves they can record it if they want to or sometimes it’s just better to have a dialogue with themself if it worked for Freud it can work for other people journaling if your clients are inclined to journal encourage them to write it down sometimes just getting stuff out of their head and onto paper will help the feelings dissipate a little bit so you’re not mulling them over and obsessing on them and getting stuck in those thoughts and feelings additionally while you’re distracting talking it out or journaling is also your break stop between the urge and the behavior make a pro and con list of the de-stress, not the eating whatever it is that’s stressing you out and how can you fix it or what are the pros of this situation and what are the downsides to this situation encourages them to focus on the positive you know if something stressing you out at work you know you’ve got a big meeting coming up or something you don’t want to do or what it is you can get stuck on focusing on that or you can focus on the positive that you do have a job that meeting only comes around once a month you can it’s time you don’t have to be doing paperwork whatever the pros are for that person encourage them to focus on the positive if you’re distressed because of some kind of a failure or perceived failure figure out what you learned from it whether it was a relationship failure maybe you learned what not to do in a relationship anymore maybe you learned things that you may have ignored maybe you learned what you should have done instead but how can it be a learning opportunity instead of somewhere to stay stuck and finally if something’s making you upset if something’s causing anxiety depression hopelessness helplessness whatever the negative feeling figure out if it’s worth your energy to get stuck here is it worth the turmoil is it worth you know having to pacify yourself with food whatever it is a lot of times people say you know what now it’s just it’s not even worth my effort is not worth moving me away from my goals because my goal is to stop emotional eating my goal is to eat for hunger so I can go to dinner with people and feel comfortable I can be at a party where there’s a buffet and not feel stressed out that I’m gonna go and eat half the stuff on the buffet that’s my goal so is holding on to whatever this de-stress is getting me closer to being able to do those things and generally, the answer’s no develop alternate ways of coping with the stress the ABCs the a is the activating event that is stressing you out what’s causing the de-stress C is the emotional reaction angry depressed stressed whatever we are your behaviors what behaviors or B are your beliefs sorry what are the beliefs that are in there that may need to be addressed what kind of things are you telling yourself and how can you counter them cognitively eliminate your vulnerabilities you knew we couldn’t get through a presentation without talking about vulnerabilities if someone is well-rested well-fed has a good social support the network does not overstretch timewise then it will be easier to deal with stress or stressors when they come your way you’ll have more energy to deal with it so there won’t be this overwhelming feeling of I just want to bury my head in a jar of peanut butter be compassionate with yourself some days are you know you’re just gonna feel anxious you’re gonna feel depressed you’re gonna get angry you can beat yourself up over it and you know a lot of people do is that the best use of your energy or can you be compassionate can you learn from it can you give yourself a break and go you know what I’m having a bad day today and that’s okay I’m not gonna unpack and stay here but I’m not gonna fight it either help clients learn how to urge surf helps them understand that just like a panic the attack is just like a wave just like a lot of other things in life it will come it will crest and it will go out again so they can sort of identify where they are on the energy of that urge

other tools people can use close the kitchen once I have the kitchen cleaned and you know all the dishes are done and it looks pretty I hate going in there and finding dishes in the sink again now I’ve got teenagers so we always have dishes in the sink but before I had children you know at seven o’clock I finished all the dishes and closed the kitchen and that would be enough motivation for me to not go in there and at least not use plates and stuff to eat so if we’re saying that we’re going to only eat using utensils plates and sitting and all that stuff that we already talked about then once you close the kitchen you’re not going back in there turn off the light that also helps so you’re not being attracted to the pretty lights and you know all the goodies that are in the kitchen brush your teeth this is something my grandmother used to do and it works there’s some research behind it minty flavors reduce our appetite so if you brush your teeth you get all the other flavors out of your mouth and it reduces your urges to eat because it again it’s clean and fresh and do you want to brush your teeth again meditate sometimes just getting in a space where you’re not obsessing about anything can help people get past that urge to self-soothe with eating a CT for emotional eating what am I feeling or thinking about what’s going on with me right now and what is important to me so if I am thinking I want to eat I want to you know just dive into this jar of peanut butter and then I think about what’s important to me is it important to me to get control of this is it important to me to you know to be able to fit in my clothes in six months or not so what is in what way is controlling my eating habits and eliminating emotional eating important to me and how does that get me closer to other things that are important to me and what other things could I do that would get me closer to my goals so if the goal is to have improved relationships and be able to feel more Being comfortable around food reduces the stress around going out to eat and just around food in general what else can you do when you are stressed out somebody also suggested adding a blue light in the refrigerator decreases the appeal of foods which is interesting because yellow red and orange and browns I think Pizza Hut are all foods that increase people’s hunger and desire to eat but blue is just a completely different primary color and adding a blue hue seems like that would be effective so cool thanks for that little tidbit their holiday help and you know we’re coming into the holidays so I’ve got to bring that up at every single glass choose lower-calorie foods if you tend to get stressed out or caught up or mindlessly eat when you are at family gatherings, okay you know cut yourself a break know that that’s probably gonna happen to fill up on the lower calorie foods the carrot sticks broccoli the white meat turkey anything available that’s not like sweet potato pie or brownies keeps water or low calorie beverage in your hand if you’ve got your hand full you can’t eat at the same time so you know if you walk around with a cup in your hand it helps talk to people hopefully you don’t talk with your mouth open or talk with food in your mouth so if you’re talking to people you’re not going to be as inclined to go get something to eat because you’re wanting to stay engaged in that conversation stay away from the buffet especially if you know that it could get stressful or maybe you know for me I turn into a pumpkin at like 7:30 at night I get up at 4:00 but I turn into a pumpkin at 7:30 and a a lot of times holiday parties and those sorts of things are at eight nine o’clock at night and you know I’ve already turned into a pumpkin so I know that if I go to those I’m gonna be more likely to eat just to kind of stay away because I’m tired and it’s a bad habit it’s not because I’m hungry so I know I need to stay away from the buffet during those times we rehearse refusal skills if somebody says oh you’ve got to try it by two this figure out how you’re going to address that ahead of time because there’s generally probably a lot of really good foods and you may want to taste some but sometimes people who emotionally eat know if they start eating if they start eating high-fat high calorie foods they’re gonna want to eat everything so if I start with one bite of a brownie I’m gonna want to eat every suite that’s on the table if they know that then they may want to choose to not even go down that road at that juncture and encourage people to stay mindful of their distress meter before they go back for another helping and ask themselves am i hungry am I just wanting to taste what’s here and how do I feel about that or am I eating just because I don’t want to be here and I’m bored and I want to fill the time have people keep an index card with their coping mantra and two reasons they don’t want to emotionally eat so I need to be here I can do this whatever the mantra is that’s gonna get them through the night whatever they’re telling themselves that it’s gonna help them plow through and make the right choices but also two reasons that they don’t want to eat or they’re going to get around maybe they’ve got something at home that they can eat when they get home eating before they go to the party may also help prevent some grazing holidays bring out a lot of emotions in people some people struggle with depression anxiety jealousy grief anger you know the whole gamut during this time and during this time there’s food everywhere I mean starting at Halloween when your kids bring home the Halloween candy which usually lasts about a week in our house baby Oh Halloween candy followed by getting ready for Thanksgiving followed by doing all the baking or whatever you do and the holiday parties coming up on the December holiday season there’s just food everywhere so it’s really easy to cope if you will with stress being overwhelmed by being tired by not eating enough healthy food by binging on unhealthy and soothing food if you will so it’s encouraged it’s important to encourage people to stay mindful of why they’re eating what they’re eating when constantly bombarded with high-fat high carbohydrate foods people are tempted to eat to feel calm yeah I challenge anybody to say that they’ve never eaten and go okay you know I’m just focused on this right now I’m not thinking about everything out here and it feels good um I’m good now goods are probably not the word I should use but it does help people distract themselves sometimes when you eat especially those high-intensity foods you feel happier serotonins release dopamine is released you’re like oh that’s good I want to do that again or you just feel numb you can get into a zone where you’re just eating and not caring it’s not that you’re feeling calm you’re just not feeling anything and a lot of times when people get into that zone they’re not tasting the food either they’re just kind of on an autopilot emotional eating like most other escape behaviors never address the underlying emotions and their causes so we need to look at it are you feeling anxious are you feeling jittery are you feeling depressed because your blood Sugar’s low because you’re nutritionally deficient because you’re not getting enough sleep or because there’s something cognitive going on or all of the above emotional eating often results in physical issues like weight gain poor sleep and reduced energy weight gain is you know in and of itself, a few pounds here and they’re not a big deal but some people can start emotionally eating to feel better they gained a lot of weight then they start feeling less energetic it starts being harder to move around they get to the point where they are clinically obese then they’re going I’m never going to take all this weight off they feel hopeless and helpless you see where this is going so they eat some more can cause poor sleep apnea it’s hard to get it’s also hard to get comfortable sometimes if you’ve eaten a whole bunch of food right before you go to bed you know your bellies all full and little you wake up the next morning and your belly still awful which means you probably didn’t sleep very well the night before and emotional eating often results in reduced energy because the foods we binge on the foods we eat for self-soothing often end up causing a sugar crash some people try to undo emotional eating by restricting other calories which can lead to nutritional deficits and more cravings I had a girlfriend when I was in high school and you know think back to I don’t know if they still do it but when we were in high school there was always some kind of candy sale going on and she would always forgo all other food so she could have two chocolate bars each day and you know we’re not going to get into the all the other issues surrounding only eating two chocolate bars but the point I’m making it right now is the fact she wasn’t getting protein she wasn’t getting you to know most of her vitamins and minerals and stuff that her body needed to make the neurotransmitter so she could feel happy and she was contributing to a sugar crash but I also know that it’s common around the holidays for people to do this they’ll let go all day without eating because they know they’re going to a party tonight and there’s going to be a lot of really good food doing that once in a while is not a big deal doing that 10 or 15 times in a month could start to have problems emotional eaters need to first find a way to stop before they eat so whether it’s writing in a journal or adding there are a lot of apps on your phone that you can put your food in even if you’re not writing about your emotions and your cravings and all that kind of stuff sometimes it’s enough to make people stop before they each for the food or you know kind of an extreme way to go is to not keep pre-processed or prepackaged foods in the house so anything that you’re going to eat you’ve got to make a second identity the underlying reason for your eating figure out do I generally eat in response to and then address the thoughts and emotions leading to the urges so if you figure out that the underlying emotions for your eating or your depression then what thoughts are maintaining that depression and how can you address it once you address the underlying issues of some of the emotional eating will go away some of its habits we’re going to have to break that habits and over the course of you know past couple of decades of working with people my experience has been the majority of the time people don’t want to hear well once you deal with your emotional issues the emotional eating will go away now they’re there because they want to stop that behavior right now so yes we need to work on all the underlying issues but give them a tip or a trick or a tool whatever you want to call it to use before they walk out of your office after every single session that way they have something else they can put in their toolbox and feel more empowered to have control over what’s going on with them and what’s coming their way knowing what and why is 80% of helping them get to the recovery point now if there’s co-occurring or if the eating issues are more than just emotional eating if there’s the person meets the criteria for binge eating disorder bulimia or anorexia there are a lot of other underlying issues they’re gonna have to be dealt with so I don’t want to trivialize that but I do want people to feel like they’ve got some hope over what’s going on are there any questions if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with doctor Snipes by subscribing at all CEUs comm slash counselor toolbox this episode has been brought to you in part by all CEUs com providing 24/7 multimedia continuing education and pre-certification training to 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Best Practices for Anxiety Treatment | Cognitive Behavioral Therapy

this episode was pre-recorded as part of a live continuing education webinar on-demand CEUs are still available for this presentation AllCEUs.com/Anxiety-CEU I’d like to welcome everybody to today’s presentation on best practices for the treatment of anxiety I am your host, Dr. Dawn Elise Snipes now not too long ago we did a presentation on strengths-based biopsychosocial approaches to addressing anxiety while those are wonderful you know I thought maybe we ought to look at you know what’re some of the current research so I went into PubMed which is I don’t know it’s a playground for me it’s where you find a lot of journal articles and you can sort I sorted by articles that were done and meta-analyses that were done within the past five years so that gives us an idea about current research I mean there’s a lot of stuff that is still the same like some of the medications that were known to work ten years ago are still known to be you know good first-line treatments but there are also some newcomers that we’ll talk about and there are also, some changes that we’re going to talk about so we’re going to explore some common causes for anxiety symptoms to treat, we need to and of course, this does play into the biopsychosocial aspect we need to understand kind of what causes it because anxiety that’s caused by for example somebody having a racing heart may be different than anxiety that’s caused for somebody who has abandonment issues so we’re gonna treat the two things differently so we want to look at some of the common causes we’re gonna look at some common triggers for anxiety Do you know what are some of these common themes that we see in practice I will ask you to share some of the themes that you see that underline or underlie a lot of your client’s anxiety and identify current best practices for anxiety management including counseling interventions medications physical interventions and supportive treatments so we care because anxiety can be debilitating and a lot of our clients have anxiety a lot of our clients have anxiety comorbid with depression and they’re looking at us going how can I feel anxious and stressed out and like I can’t sit still and be depressed at the same time you know when you’re depressed you’re supposed to want to sleep well a lot of times people who have both issues want to sleep but they can’t so I want to help clients understand that also sometimes anxiety when people are anxious for long enough the body starts kind of holding on to the cortisol the body recognizes at a certain point this is a losing battle I’m not going to put energy into this anymore so it starts withdrawing some of its excitatory neurotransmitters so to speak and people will start to feel depressed the brain has already said this is hopeless this is you’re helpless to change the situation so then people start feeling hopeless and helpless which is sort of the definition if you will of depression low-grade chronic stress and anxiety arose energy and people’s ability to concentrate so if we’re going to help them become their uber selves we need to help them figure out how to address anxiety not just generalized overwhelming debilitating anxiety but also panic social anxiety and those minor anxiety triggers that come along that may not meet the threshold for diagnosis anxiety is a major trigger for addiction relapse if you have a client who is self-medicated before or had an addiction for some reason anxiety is a major trigger increased physical pain when anxiety goes up people tend to tense their muscles when they tense their muscles they tend to feel more pain I mean think about when you’re stressed you tend to have more pain like in your neck your back and things that already hurt may hurt more why because serotonin which is one of our major anti-anxiety neurotransmitters is also one of our major pain modulators so when serotonin levels are too low because anxiety is high then our pain perception is going to be more acute and people can have sleep problems if they’re stressed out your body thinks there’s a threat you’re not going to be able to get into that deep restful sleep you may have you may sleep a lot but it’s probably not quality sleep which means your neurotransmitters may get out of whack your hormones make it out of whack and your body is going to start perceiving yourself in a persistent state of stress when you’re exhausted the body knows that we may be the weakest link in the herd so it continues to secrete cortisol to keep you on alert a little bit so you may again you may be resting kind of like when you have a new baby at home those first couple of months that my children were home from the the hospital I slept but I didn’t sleep well I mean the slightest little noise and I was awake and I was looking around and you know I felt it I felt exhausted and a lot of new parents do so triggers for anxiety abandonment and rejection and we’re going to talk about ways we might want to deal with these things but some of the underlying themes that I’ve seen in a lot of clients and when I do the research and a lot of what themes that come out include low self-esteem if someone has low self-esteem they’re looking to be externally validated oftentimes they’re looking for somebody else to tell them you’re lovable you’re okay so that can lead to anxiety about not having people to tell them you’re okay which makes their relationships tenuous and can make them dysfunctional irrational thoughts and cognitive distortions may lead people to believe that if I’m not perfect for example I am not lovable so we’re going to look at some irrational thoughts and cognitive distortions unhealthy social supports and relationships when you’re in a relationship it takes two to tango and even if your client is relatively mentally and physically healthy if they are in a dysfunctional relationship they can fear abandonment and rejection if that other person is always saying if you don’t do X I’m going to leave you or if that other person is always cheating on them or whatever so relationships can trigger abandonment anxiety and ineffective interpersonal skills can lead to relationship turmoil and social exile if our clients are in relationships even if they’re not completely dysfunctional if our clients are not able to ask for what they need and set appropriate boundaries and manage conflict effectively because conflict happens in every relationship then they may start to argue more which may lead to fearing may lead to relationships ending in the past and them going well every relationship I get into ends which means I must not be lovable so they start fearing abandonment and rejection these are four areas that we can look at one more assessing clients another issue is the unknown and loss of control a lot of times negative self-talk and cognitive distortions can contribute to that if I don’t have control of everything then it’s all going to be a disaster negative others when clients hang out or when people hang out with negative people it kind of wears on you after a while you notice that people who tend to be more negative pessimistic conspiracy-minded tend to hang out with people who are also negatively pessimistic and conspiracy-minded so if you’re hanging out with somebody who tends to be anxious then the anxiety can be palpable and it can kind of permeate physical complaints can lead people to be anxious because they don’t know what’s causing it like I said earlier sometimes if your heart starts to race if you don’t know what’s causing it for you can start thinking I’m having a heart attack or I’m gonna die when people have panic attacks for the example they truly think they’re having a heart attack and it’s I’ve had them they are very very unpleasant experiences but when people start having physical complaints and it can be you know they have a weird rash that they can’t get to go away or whatever but when they don’t know what it is and they can’t control it they can’t make it go away they start thinking about all the worst-case scenarios and going online and getting on WebMD which usually gives you all the worst-case scenarios um so physical complaints are important we need to normalize the fact that nobody’s pain-free all the time and you know the fact that you may have an ache or a pain or a lump or a bump or you know a cough most likely you know when we look at probability the probability of it being something significant is pretty small now do you want to get it checked out probably but you know the probability that is anything to be worried about is relatively small and a sense of powerlessness can trigger fear of the unknown and loss of control for somebody who doesn’t feel like they have any agency in their life if they have an external locus of control or if they felt victimized all of their life then they may fear not being in control they may be holding on and saying okay this is the one area of my life I can control when I grew up you know I grew up in a very chaotic environment I had no control I was bounced around in the foster system yadda yadda yadda now that I’m an adult you know I can control these things and I am going to hold on with white knuckles and if I can’t control everything then that terrifies me to death and loss are other triggers for anxiety and it can be people or pets and pets are important I don’t want to minimize pets because you know they are little parts of a lot of our families so making sure we check that my daughter’s dog for example is it’s getting old she’s getting older she’s 14 now I think and you know she’s in decent health we took her to the vet and the vet said yeah she’s got a little heart murmur but that’s expected for a 14-year-old dog and but when she goes out if she doesn’t come back when I call her I have this rush of anxiety for a second oh my gosh I hope this wasn’t the day so anxious around losing people and you know if she when she crosses the bridge she will and you know I’m okay with that I’m I have a harder time dealing with my daughter’s emotional turmoil when that happens and because she’s grown up with this dog so you know those are the types of things that we want to talk about with our clients what things are weighing on you that you may not even be thinking about because I know in the back of my mind there’s always that worry about one of our donkeys and her dog jobs and promotions can trigger anxiety if people are afraid they’re gonna lose their job if they’re always afraid that you know they’re gonna walk in and get a pink slip or get fired you know we want to help them look at how realistic they are you doing what you need to do to achieve and keep your job and sometimes it’s not easy to the answer I mean the first thought that a lot of us have is well you know if you’re doing the right a thing so just do it but there are those bosses out there and I’ve had some amazing bosses a lot of them and I’ve had two horrendous bosses and those two bosses I could never I never felt like I was able to do anything right and so going to those jobs there was always this anxiety about what I’m what am I going to get in trouble for today so you want to talk with people about does your job cause anxiety what can you do to moderate that anxiety the same thing with promotions people may get anxious about whether they’re going to get promoted to safety and security you know when you lose safety and security you can feel anxious so if there’s a break-in at the house next door or shooting down the road or you start watching the news you can feel very unsafe and insecure quickly so we want to help people figure out how safe and secure are you really and a lot of it goes back to looking at facts when people lose their dreams and hopes or fear that they’re going to lose their dreams and hopes they can start to get anxious you know they have this dream that they’re going to be a doctor or I just finished the presentation on helping high school students transition to college and a lot of high school students for example start college with these wide eyes and hopes to save the world and they want to be doctors and engineers and this and that and they get into it and they realize that it’s a lot harder then they thought or they realize that you know what I don’t like this but I’ve already committed to it so what do I do I want to help people but I can’t I can’t cut it doing this you know for me I figured out in my second year that I wasn’t going to medical school because I wasn’t going to pass calculus and that caused a lot of anxiety it was like okay what am I gonna do now Do you know what career should I choose to help people figure out do they have dreams that have maybe kind of crashed and burned and you have to find new ones you know okay that one we’ve got to accept it figure out that it’s not going to be and what can you do now people may also have dreams about relationships they get into relationships and see themselves with this person forever and then this relationship ends and or starts to get rocky and they’re like but that’s my dream what happens if that’s got to happen because it’s my dream I don’t know how to function if that goes away we want to help people be able to rewrite their narrative and then sickness spiders and other phobias kind of go in with death a lot of times when people get sick they start getting anxious that oh my gosh what if this is terminal oh my gosh what if this is you know incurable if I get bit by a spider it’s gonna kill me and which is rare you know there are very few spiders that is actually that poisonous same thing with snakes going over bridges I’ve shared with you all that is not one of my irrational fears you know I am just terrified that you know something’s going to happen and I’m going to get pushed off the side of the bridge which is completely irrational but we need to help people look at those and identify the thoughts that they’re telling themself about those phobias and dealing with that anxiety failure is another –trigger for anxiety especially in this culture our culture American culture is large part puts a high premium on success and perfectionism so when people realize that they’re not perfect they may start to get anxious because they feel like if I’m not perfect then I’m a failure you know those cognitive distortions of all-or-nothing thinking and they start with that negative self-talk you know you can’t do anything right so those are some of the issues that you know we often see in counseling sessions so what do we do you know somebody comes in and is like I can’t live this way doc anxiety depression and substance disorders as well as a range of physical disorders are often comorbid so this is the first the thing we need to realize is that we’re very rarely dealing with a very simple the diagnosis you know when somebody comes in we need to figure out you know if they come in and they’re presenting with depression all right let’s talk about that and then we start realizing that there depression started to occur after a long period of being anxious okay so we need to deal with that but we also need to help them with their sense of hopelessness and helplessness we need to develop that sense of empowerment and then substance disorders we know that substance use is often a way of self-medicating but we also know that it monkeys with the neurochemicals in the brain and can contribute to anxiety and depression the same thing to physical issues pain from physical disorders anxiety about having physical disorders medications you’re taking for physical disorders can all contribute to anxiety so we need to look at the person as a whole and go what are all the things that are contributing to the anxiety and what are all the things that the anxiety is contributing to so we have started having this big list of stuff that needs to be addressed and then we can start figuring out okay where we start so knowing that these things are comorbid helps researchers explore pathways to mental disorders so they can start figuring out you know what little string can we pull to unravel this blanket of anxiety so it doesn’t suffocate somebody and for us, as clinicians, it provides us key opportunities to intervene in you know sometimes clients will come in and start talking about their anxiety and their physical issues you know maybe their anxieties about you know heart palpitations and because that’s a common one we may want to encourage them to go see the doctor to get that ruled out you know rule out anything that has to do with hormone imbalances or you know heart conditions or anything else that might be contributing to it which can help them address it and if they do have physical disorders let’s go with hormone imbalances that are contributing to the heart palpitations then they can start to treat that if they don’t start to treat that then no amount of talk therapy we do is going to get them to the quality of life that they’re looking for because they’re still gonna feel those so we want to make sure that we’re addressing them holistically anxiety disorders should be treated with psychological therapy pharmacy therapy or a combination of both and what they found and this is no surprise this is kind of old news is that counseling Plus pharmacotherapy tends to have the best outcomes but separating the two have similar outcomes in many cases but that’s just looking at and I hate to call it simple anxiety but we’re just looking at anxiety symptoms here we’re not looking at the full quality of life and we want to make sure that we’re also including any medical issues behavioral therapy is regarded as the psychotherapy with the highest level of evidence, there are a variety of cognitive behavioral approaches ranging from acceptance and commitment therapy to dialectical behavior therapy to CBT to debt you know any of those that deal with the thoughts and the cognitions that fall in that realm and it is effective in the current conceptualization of the etiology of anxiety disorders includes an interaction of psychosocial factors such as childhood adversity or stressful events and a genetic vulnerability so the psychosocial factors and these are other things when we do our assessment we want to pay attention to because our approach to treatment is going to be different for people for example who have trauma-related brain changes maybe then for somebody who doesn’t so, we want to look at childhood adversity and stressful events that it may have caused basically what I tell clients is like rewiring of the brain there are trauma-related brain changes in soldiers and especially in children or in people who’ve been exposed to extreme trauma that is designed to protect them but it also can cause complications kind of later on in dealing with anxiety coping skills that were learned that are ineffective you know sometimes people grow up in a household or an environment or a situation where they don’t learn effective coping skills so we need to kind of help them unlearn those and learn new ones build on their strengths and trauma issues that may still need to be dealt with such as domestic violence you know if they grew up a lot around a lot of domestic violence they may think you know I’m out of that situation it’s over I don’t want to think about it it’s not bothering me anymore or a parental absence and I put absence because it can be death it can be a parent that just packed up and left it could be a child that got put up for adoption whatever put the child in a position of feeling like they were rejected by a parent can be very traumatic and bullying among other things but there are a lot of trauma issues that people once they’re out of that situation often say you know I’m out of it it’s not a big deal I dealt with it let’s move on and they don’t realize the full ramifications and how that’s contributing to their current anxiety and their current self-talk and cognitions of current stressors if somebody has a lot of current stressors that are also going to impact whether they develop generalized anxiety you know we’re kind of stacking the deck here and the current availability of social support if they don’t have effective current social support then they’re gonna have difficulty bearing the weight of everything on their shoulders so we want to look at all these psychosocial factors when we do our assessment now going back to the trauma issues if you’ve taken the trauma courses at all CEUs you know that some people are not ready to acknowledge that the trauma is still bothering them or work on the trauma and that’s okay we can educate them that it might be an issue and then let them choose how to address it but we want to bear in mind the fact that you know this could be sort of an underlying force motivating some of the current cognitions and genetic vulnerability so you take any three people and you put them or 300 people and you put them through roughly the same psychosocial situations they’re all probably going to react a little bit differently based on their prior experiences but also because of their genetic makeup there are certain permutations and they found four we’ll talk about later that make the brain more or less responsive to stress and more or less responsive to serotonin which is your calming chemical so brains that are less responsive to serotonin isn’t going to you know send out as much or send out serotonin as easily so people can stay kind of tensed and wired that’s an oversimplified explanation but that’s all you need for right now so genetic vulnerability impacts people’s susceptibility to the effects and development of dependence on certain substances which can increase anxiety when people are detoxing from alcohol when they’re detoxing from benzos when they’re detoxing from opiates they can feel high levels of anxiety when they take opiates some people find that opiates have wonderful anti-anxiety properties not that I am advocating for the use of opiates I’m just client experiences have shown that that can be true so some people are going to be more susceptible to the anti-anxiety effects of certain substances and some people are going to be Cerrone to become dependent on substances where others may not and that part of that is genetic vulnerability and they estimate about 30% the predictability of the development of anxiety disorders is genetic and genetics also impact which medications are effective if you have genetic makeup then SSRIs might be helpful if you have genetic makeup be then atypical antipsychotics may be more effective and SSRIs might not do anything which is why a lot of our clients get so frustrated because they know there’s no way to figure out exactly what I guess there is now that there’s genetic testing out there but up until then it was harder to figure out which medications to start with and most physicians matter of fact I don’t know of a single physician that starts by saying well let’s do a genetic profile to see what med to start you out with most we’ll start with events as with an SSRI or some other anti-anxiety medication some sort of benzo that’s been my experience so we may want to encourage clients to consider genetic testing if they’re having difficulty finding a medication regime that works for them and they are feeling like they have to have medication genetic vulnerability also affects what’s going to make somebody more vulnerable now than all of you in class today you know thinking about sleep you know sleep may not be a big deal for some of you I know people who can go days or weeks with four or five hours of sleep and they feel fine it’s not a big deal, not me I need eight or nine hours of sleep so genetically for whatever reason I am programmed to need a lot of sleep so when I don’t get that much sleep I tend to be it tends to be harder for me to deal with life on life’s terms and I know that that makes me more vulnerable to being irritable so genetic vulnerability affects who can become addicted and affects what medications work best and affects what situations are going to tend to make somebody more vulnerable to anxiety so our medications and I know the type on here is small but we’re going to go through the first-line drugs are the SSRIs selective serotonin reuptake inhibitors and SNRs is selective norepinephrine reuptake inhibitors now the names are a little bit deceptive because selective norepinephrine reuptake inhibitors also increase available serotonin but the mechanism of action is different the mechanism of action for each SSRI is a little bit different as well which is why you can put somebody on Prozac and they have an awful experience and you can put them on Zoloft and they have a much better experience like I said earlier a lot of the research pre five years ago had been done on medications and Zoloft Paxil luvox Lexapro Celexa and their generics have all been found to be effective at treating anxiety in certain people no one the medication works for everybody in the last five years Effexor has come on the radar and it has been found effective according to the hamilton rating scale for anxiety so that’s another one to consider if clients are not successful or getting the treatment effect that they need for on some of the other medications obviously, none of us probably are prescribers but we do need to educate clients about why the first drug or even the third drug that the doc tries may not work so they don’t start feeling helpless and hopeless like I said earlier there are at least four different genetic variations which are correlated with the development of generalized anxiety disorder and different medications are more or less effective depending on the genetic makeup of the person there’s a high mortality rate moving on to two benzos the recommendation has switched to back off from the use of benzos now for some doctors will prescribe an SSRI and for the first four weeks while the SSRI is building up in the system they will also prescribe a benzo to be taken as needed to moderate the anxiety and you know you could argue on either side of that, if somebody has a history of substance use or substance dependence benzos are really a bad idea because they do have a high rate of dependence but the other reasons that they are now cautioning against the use of benzodiazepines is that there’s a higher mortality rate among benzo users compared with non-users there’s an increased risk for dependence with use for more than six months and that’s a long time to be using benzo and when we’re talking about dependence and six months we’re talking about somebody who uses it like every four hours or every eight hours depending on your benzo every single day not a PRN user if somebody’s using it at night to help them go to sleep or you know three or four times a week when the anxiety gets high the risk of dependence is relatively low but a lot of people with anxiety because if they find the right benzo makes them feel so much better they may not want to be off of it and for a lot of people when that benzo reaches its half-life and starts getting out of the system even more their anxiety spikes you know they have rebound anxiety which they want to medicate with more benzos that’s gonna be an issue for them to discuss with their doctor there’s also an increased risk of dementia identified in long-term benzodiazepine users again this is for the people who use you know throughout the day every day for six months or relatively every day for six months or more and it doesn’t matter if it’s you know we’re talking about somebody who’s 65 or somebody who’s 35 who’s been using benzos for you know six months a year two years the risk of later life dementia is greatly increased according to the research benzodiazepines also don’t treat depression okay so if you’ve got somebody who has concurrent anxiety and depression there’s a much higher suicide risk if they’re on benzodiazepines so being aware and generally that suicide risk comes from overdosing on benzodiazepines but not always other treatment options you know if the benzos aren’t something that people want to touch you know they scare the living daylights out of me and SSRIs and SNRIs don’t seem to be working then tricyclic antidepressants can be tried on those your older generation antidepressant Seroquel is used a lot and there are some there’s some research that shows it can be effective with anxiety like some of the antidepressants and depending on the person the benzos Seroquel can make people very very very sleepy so you know it may not be the side effects of the Seroquel the weight gain and the fatigue and you know sleepiness may be an unacceptable side effect for some clients and boosts perón is the third option boost Barone works more like an anti-depressive serotonin reuptake inhibitor and that it takes you know four weeks or so to kind of build up in the system studies have shown that there’s really no long-term benefit to taking it but after six months to eighteen months of use it has been shown to be effective in talking with clients a lot of clients report that boost bar when they take it doesn’t necessarily help them stop being anxious like a benzodiazepine does but it helps them not go from zero to 200 in 2.3 seconds it kind of you know keeps them from having this gush of a freak out reaction every time something goes wrong which a lot of clients report helps because they feel more stable throughout the day after remission medication should be continued for six to twelve months and during that last six months first six months keep it as is last six months you know they say that tapering is best it’s best not to stop somebody cold turkey on any of these but it’s important for people once they’re in remission to not just suddenly go okay I feel better I don’t need any of this anymore they need to work into it and make sure they’ve developed the skills and tools that they need to deal with some of the anxiety that is going to happen in life so physical signs and symptoms of anxiety may include fatigue irritability muscle tension or muscle aches try laying feeling twitchy being easily startled trouble sleeping nausea diarrhea irritable bowel syndrome headaches so the first thing we want to do with clients when we’re talking to them well second thing first thing is to say get a physical to let’s rule out physiological causes of this but we can also help clients look at you know what might be causing these things that you can do to mitigate it what might be contributing to your fatigue what might be contributing to your irritability and your muscle tension or your muscle aches I mean let’s look at economics did you recently get a new bed or do you need to get a new bed what about your desk chair I know you know I get more muscle tension and muscle achy when I do a lot of mousing because I have deplorable posture being becoming aware of that helps and then I’m like okay well I know it caused unfortunately, it’s unpleasant but it’s not a big deal trembling or feeling twitchy you know that can be caused by low blood sugar that can be caused anxiety that can also be caused by early onset Parkinson’s symptoms you know there’s you know it can be worst case scenario or it can be something benign so we want to have people figure out you know when you start trembling or feeling twitchy is there something that it’s related to you know I know when my son gets excited he’s he just sits there and you can see him almost shake because he’s so excited about something so we want to have people prevent misidentification we don’t want them to jump to that worst-case scenario we don’t want them to go onto WebMD and go oh my gosh I’ve got cancer I’ve got this debilitating disease and I’m going to die in six months probabilistic Lee speaking it’s not gonna happen yes get a doctor’s opinion I’m certainly not going to tell them it’s all in your head I want them to get an evaluation but I do want to in the meantime help them think about how likely is this and other things for headaches and this is one another one of those that can be frustrating as we get older our eyesight starts to go and you know there was a period there I did fine and then after I hit 45 my eyesight just started to like steadily and kind of rapidly in my mind decline so I have to get my eyeglass prescription changed every couple of years and that can cause headaches so instead of starting to worry about oh my gosh I’ve got a headache all the time maybe I’ve got a brain tumor you know I know that it’s probably my glasses or I’m grinding my teeth so other biological interventions that have been evaluated there’s something called the floatation rest system that reduced environmental stimulation therapy reduces sensory input into the nervous system through the act of floating supine which is on your back in a pool of water saturated with Epsom salt you know I’m looking at this going sounds good and you can’t quite get the same experience in a bathtub because you’re not floating you’ve got pressure points and you’re still hearing stuff clients can sort of simulate it with you know earplugs or whatever but it’s if they can access this it’s been shown to be effective the float experience is calibrated so that sensory signals from visual auditory olfactory gustatory thermal tactile or tactile vestibular gravitational and preceptive channels are minimized which means you don’t see here taste touch smell feel nothing as is most movement and speech so you want people to lay just like completely motionless and not talk which can be hard for some people with anxiety in the study the study I looked at fifty participants reported significant reductions in stress muscle tension pain depression and negative effects and it was accompanied by significant improvement in mood characterized by increases in relaxation happiness and well-being I read the study I’m like where can I sign up you know it sounds in looking at some of the research this was more effective for addressing anxiety than something like a massage Tai Chi also produced significant reductions in anxiety there was approximately a 20% treatment effect 25% treatment effect in patients with anxiety and fibromyalgia who practiced twice a week for a year now you know we want to look at the confounding things here is it the Tai Chi itself or is it learning to control the muscles and becoming more in tune with your body and learning to control your breathing helps people reduce their anxiety either way you know Tai Chi helps people do that and it was shown that after a year after the first six months, there was a significant treatment effect but after a year you know it kept growing and after a year it was about 25% so Tai Chi can be effective acupuncture at the HT 7 median Meridian can attenuate anxiety-like behavior induced by withdrawal from chronic morphine treatment through the meditation of the GABA receptor system what does that mean that means if you if the acupuncture is done in very certain places the anxiety behavior the GABA a receptor system GABA is your main calming relaxation neurochemical that is triggered and causes your body to sort of flood that receptor system and this research was done on people who were detoxing from morphine treatment but we can look at generalizing the results and I would be interested to see further studies on it pain other things we need to do to help people with anxiety when people are in chronic pain they often have anxiety that oh my gosh this is getting worse or it’s never gonna get better or I just can’t take this pain anymore or they may get anxious that they’re going to be rejected because they can’t do some of the things they used to do because they’re in so much pain so there’s a lot of guilt and anxiety that can kind of revolve around pain what can we do to help clients guided imagery is generally very helpful if we can help them imagine you know if that pain in their shoulder imagine the pain is like the color red flowing out of their arm or other focus mindfulness so you know when you think about something you know when you get a shot if I don’t think about it it doesn’t hurt near as much as if the nurse says okay now one two three and you know she’s counting down and I’m getting prepared and I’m focused on it I had another nurse one time who she was just talking to me and you know put the alcohol on my arm and just kept on talking and didn’t tell me she was getting ready to give me a shot and before I knew it she had given me a shot and she was like okay we’re done I’m like you didn’t give me a shot yet she said yes I did it’s like oh so not focusing on it and next time you have an itch for example if you’ve ever been driving on the interstate and you can reach on your foot I get those on the bottom of my foot sometimes and I’m like okay I’m not going to pull over to each my foot if you focus on something besides the itch eventually it goes away I’m not saying the pain is gonna completely go away but the more people focus on it the more it hurts physical therapy can help so encourage them to get a referral and encourage them to do a self-evaluation if nothing else of ergonomics in their car at work where they watch TV and spend most of their time at home and they’re sleeping so those are the four places that they spend most of their time what do their ergonomics look like and that can help a lot of people mitigate a lot of pain hormones are another thing that we need to look at imbalances of estrogen and testosterone can contribute to anxiety symptoms heart palpitations fatigue irritability having people get a physical we can’t as clinicians do anything about it but doctors can rapid heart weight rate sweating palpitations are not uncommon in women in perimenopause or menopause so a lot of women start feeling like they’re developing generalized anxiety and/or something’s going wrong when they start reaching that mid-40s to mid-50s area and they start having some of these symptoms again we’re not going to diagnose it but we do want them to recognize that it may not be anything you know is catastrophic this is something that a a lot of women experience and help them figure out how to deal with that supportive care biologically now you know this isn’t gonna treat anything but we can help them minimize their vulnerabilities help them create a sleep routine so their brain and body can rebalance this can help repair any adrenal issues that may be going on and improve energy levels people with anxiety don’t sleep well so helping them figure out how to get some quality sleep is important nutrition minimizing caffeine and other stimulants are going to be a big help because those make people feel anxious and encourage them to work with a nutritionist to try to prevent spikes and drops in blood sugar which can trigger the stress response when your blood sugar goes way up or way down you can start getting kind of shaky and feel weird and that can cause people anxiety because they might think oh my gosh I’m having a stroke or a heart attack or you know I don’t know what these tremors are so it’s important that they don’t miss identify symptoms and encourage them to drink enough water dehydration can lead to toxic Ardea which is increased heart rate sunlight vitamin D deficiency is implicated in both depression and anxiety mood issues vitamin D has been found in those main areas where serotonin receptors are found vitamin D receptors are found so we know the serotonin and vitamin D have something going on sunlight prompts the skin to tell the brain to produce neurotransmitters and set circadian rhythms which impact the release of serotonin your calming neurochemical melatonin which is made from breaking down serotonin and helps you sleep and GABA so sunlight actually helps increase the release of GABA when it’s time to start calming down and going to sleep exercise studies have shown that exercise can have a relaxing effect and encourage clients to start slowly there’s not a whole lot of new research on exercise and anxiety aromatherapy has been used a lot, especially in other countries in the treatment of people with anxiety people with hospital anxiety people women who are giving birth and they have some birth anxiety there they’ve been found to be effective in a lot of those studies essential oils for anxiety include lavender rose Bedevere ylang ylang bergamot chamomile frankincense and Clary sage encourage clients to just go to a health food store and you know sniff some of these and see if it makes them feel happy and calm and content the aromatherapy molecules enter the nasal membranes and they will start triggering neurochemical reactions and so you don’t need to apply it you don’t need to ingest it all you need to do is so encourage clients if they’re open to it to think about this because aromatherapy can be integrated into their bedroom for example with an atomizer or a Mr.It can be incorporated in a lot of different places again where they’re not applying it or ingesting it in any way all they’re doing is smelling it they’ve used it in defusing aromatherapy in hospital emergency rooms and they found that it reduces stress and irritability the people in emergency rooms and I’ve been to enough emergency rooms over the years to know that people who are in ers typically are not in the best mood so if it can help those people then it’s probably going to have some sort of an effect so psychologically helping clients realize that their body thinks there’s a threat for some reason that’s why it triggered the threat response a system which is what they call anxiety so they need to figure out why is there a threat you know sometimes it’s like the fire alarm going off in my house it just means that the windows are open and there’s a strong breeze there is no fire there is no problem there’s just a malfunction it’s a false alarm a lot of times clients get this threat reaction they get this stress reaction and it’s not a big deal right now so they can start modifying what their brain responds to and again those basic fears that a lot of people worry about failure rejection loss of control the unknown and death and loss distress tolerance is one of those cognitive interventions that have taken center stage in anxiety research and it isn’t about controlling your anxiety you know helping people recognize their anxiety acknowledge it and say okay I’m anxious it is what it is how can I improve the next moment instead of saying I’m anxious I shouldn’t be anxious I hate being anxious and slang with that anxiety let it go just accept it is what it is have the client learn to start saying I am feeling anxious okay so distract don’t react because I explain to them the whole notion of feelings comes in the crest and goes out in about 20 minutes it’s like a wave so once they acknowledge their feeling if they can distract themselves for twenty or thirty minutes you know they figured out there was no real threat if they can distract themselves for twenty or thirty minutes those emotions can go down and then they can deal with it in their wise mind and encourage them to use distancing techniques instead of saying I am anxious or I am terrified or whatever have them say I am having the thought that this is the worst thing in the world I am having the thought that I cannot handle this because thoughts come and go and that comes from acceptance and commitment therapy functional analysis makes it possible to specify where and when with what frequency with what intensity and under what circumstances the anxious response is triggered so it’s important that we help clients develop the ability to do functional analyses on their own so when they start feeling anxious they can stop and say okay where am I what’s going on how intense is it what are the circumstances and they start trying to figure out what causes this for them so they can identify any common themes from their psychoeducation about cognitive distortions and techniques to prevent those circumstances or mitigate them can be provided so if the client knows that they get anxious before they go into a meeting with their boss and it’s usually a high the intensity of anxiety okay so we can educate them and help them identify what fears may be related to techniques to slow their breathing and calm their stress reaction and help them figure out times in the past when they’ve handled going in and talking to their boss and it wasn’t the end of the world you know there’s lots of different things we can do there for them there but the first key and it gives them a lot of a huge sense of empowerment to start becoming detectives in their own life and going okay now under what situations does this happen positive writing this was another cool study each day for 30 days the experimental group and this was high school-aged youth in China but you know the experimental group engaged in 20 minutes of writing about positive emotions they felt that day so they’re writing about anything positive that make them happy that made them enthusiastic gave them hope whatever long-term expressive writing positive emotions so after 30 days it appeared to help reduce test anxiety by helping they develop insight and use positive emotional words so it got them out of the habit of using the destruction and doom words and encouraged them to get in the habit of looking at the positive things and being more optimistic it’s a cool activity that clients can try it’s not gonna hurt anything if you have them journal each day for 30 days mindfulness also came up in the research and was shown to be effective in a meta-analysis of six articles about mindfulness based stress reduction four about mindfulness-based cognitive therapy and three about fear of negative appraisal and emotion regulation was reviewed all of these showed that mindfulness was an effective strategy for the treatment of mood and anxiety disorders and is an effective in therapy protocols with different structures including virtual modalities so you know if you’re doing it via teleconference mindfulness can still be helpful mindfulness helps people start learning how to observe what’s going on and become aware of what’s going on more aware of those circumstances which will help them complete their functional analysis but it also helps them become aware of vulnerabilities and head off things in the past and if they’re taking better care of themselves that they’re living more mindfully then they may not experience as many situations that trigger their anxiety mindfulness also encourages clients to learn acceptance that radical acceptance of it is what it is I’m not gonna fight it I’m angry right now I am anxious right now however I’m feeling right now is how I feel and that’s okay it’s hard for clients to get to that but once they get a hold of that and they truly believe it and they can say all right it’s fine I’m not gonna feel this way forever I’m gonna do something else until the feeling passes it helps and that’s where the labeling and letting go comes in mindfulness can also help them identify trigger thoughts what thought were you having right before you started feeling anxious if people are mindful or let’s start back when people are not mindful they often notice or don’t notice that they’re getting anxious until they’re like super anxious when people are mindful they become more aware of subtle cues address unhelpful thoughts when they say or believe it’s a dire necessity for adults to be loved by significant others for almost everything they do always running gonna happen why is it a necessity what we can encourage them to do is concentrate on their self-respect on winning approval for practical purposes you know for promotions or whatever but it’s not about me being lovable it’s about me getting a promotion and making more money and focusing on loving rather than being loved because when we give love we generally get love back with unhelpful thought number two people feel they aren’t able to stand it if things are not the way they want them to be or are not in their control so encourage clients to focus on the parts that are in their control and other things in life which are going well and to which they’re committed number three misery is invariably externally caused and is forced on us by outside people and events just by reading that makes me feel disempowered so encouraging clients to focus on the fact that reactions such as misery or happiness are largely caused by the view that people take of the conditions so if you see it as a tragedy and devastating then it’s probably going to produce misery if you see it as an opportunity and a challenge it’s probably going to produce a different emotional reaction, if something is or may be dangerous or fearsome people, should be upset and endlessly upset about obsessing about it a lot of people with anxiety get stuck on this you know if I feel like it’s fearsome I need to worry about it getting on a plane for example if I fear that that’s dangerous that I need to think about it and worry about it that’s not going to do any good so encourage clients to figure out how to face it and render it harmless if possible and when that’s not possible accept the inevitable so looking at airplanes you know facing it means researching to figure out how dangerous is it really and realizing that it’s not that dangerous so that helps render it a little bit harmless in their mind it proves to them that it’s not as dangerous as it could be and when it’s not possible accepting the inevitable you know you got a fly so getting on there figuring out how you’re gonna get through it hurricanes are the same way people especially in places like Texas Louisiana Florida may obsess as soon as it starts coming to hurricane season or if a hurricane is spotted out in the Atlantic somewhere they start checking the weather every hour or more wondering what the path is going to be and you know what there’s you can’t change the path of the hurricane so all you can do is board up your house evacuate if necessary and deal with the fallout child driving is just another example I’ll give you know my children are learning how to drive and that’s kind of scary and fearsome you know what’s gonna happen when they’re out there you know you see crashes all the time well render it harmless by making sure they’ve got good training on how to drive make sure they’re good drivers and then accepting that some things are just not within my control it’s easier to avoid than face life difficulties and responsibilities well running from fear is usually much harder in the long run so encourage clients to look back at times when they’ve avoided difficulties and responsibilities and the eventual outcome you know what happened there people believe they should be thoroughly competent in achieving in all possible respects or they will be isolated rejected and failures we need to encourage clients to accept themselves as imperfect with human limitations and flaws and focus on what makes them loveable human being what qualities like courage and intelligence and creativity and those things that can’t be taken away what inherent qualities do they have that make them awesome people because something once strongly affected people’s lives they should indefinitely fear it if you got lost you know when little kids get lost it’s terrifying when you’re grown up if you get lost you turn on the GPS and you figure out your way but some people still, you know freaked out about getting lost if they got lost once so we want to help people look back at past episodes that may be contributing to the current anxiety and compare the situation’s you know are you the same person or is this not a big deal now that you’re older wiser stronger encourage them to learn from past experiences but not be overly attached to or prejudiced by them yeah you could have maybe got lost in the past and it was a horrible experience well you were six I can see where that would be terrifying and a horrible experience but it doesn’t have to continue to impact you that way now when you’re you know 26 getting lost you know could be an opportunity to try a new restaurant or something people must have complete control over things well this doesn’t happen so encourage clients to remember that the past and the future are uncontrollable we can’t change the past it is what it is we can learn from it so it doesn’t repeat but we can’t change it and the future is largely uncontrollable I mean there are a lot of things I can do to stay moving toward a rich and meaningful life but life is going to throw me curveballs sometimes and there’s nothing I can do to plan for or control that we can control our actions in the present to stay on our preferred path and general develop general skills to deal with adversity should it arise so we want to help clients develop those general problem-solving skills and the general support system so when they are thrown a curveball you know it doesn’t knock them upside the head people have virtually no control over their emotions and cannot help feeling disturbed by things well encourage them to think about the fact that they have real control over destructive emotions if they choose to work at improving the next moment and changing inaccurate thoughts then they’re not going to experience the destructive emotions as intensely or as frequently when you feel an emotion you feel how you feel but again you don’t have to wrestle with it fight it and nurture it you can say this is how I feel how do I improve the next moment when it comes to cognitive distortions encourage them to find alternatives when they start to personalize things if somebody laughs when you walk out of the room then the and the person starts getting anxious thinking oh they were making fun of me I wonder what they thought I wonder if I had something stuck to the back of my dress and they start getting all panicked about it that doesn’t do any good encouraging them to think you know what our three alternate explanations that hadn’t but had nothing to do with you for why they laughed magnification of the worst thing you know taking something and saying if this happens then it’s going to be a catastrophe and minimization going along with that a lot of times when people magnify and see a catastrophe they minimize not only their strengths and resources but all the other stuff that they’ve got going for them all they’re seeing is this catastrophe so encouraging them to focus on the facts of what is actually happening and what is the high probability event and encourage them to get information and look at the broader picture you know yes you got into a car crash and your car is totaled and that is unfortunate you know it sucks but you know that is not going to cause you to lose your job and then become homeless and penniless and yadda-yadda it might cause your insurance to go up but okay so you don’t have a car but what are the resources that you have who can who do you work with that might be able to give you a ride to work you know let’s look at the resources you have and work around so problem-solving helps with magnification and also focusing on you know let’s be grateful for what didn’t happen you know you could have been killed but you weren’t the car was totaled it’s replaceable all or nothing thinking again have them think about what else could have been happening like Brittney suggested finding the exceptions instead of saying she always does this look for exceptions when has she not done that what else has she done instead of this selective abstraction and filtering is when people look for the good the bad and the ugly a selective abstraction means you kind of see what you expect to see so if you expect something to be devastating you see only the devastating aspects of it which kind of goes with the magnification and minimization you filter out the stuff a lot of times when people are in a bad mood or are anxious they see the negative because that’s the state of mind they’re in so encouraging people to complete the picture alright there’s all this bad stuff now what’s the good stuff you know to encourage them to look at the good the bad and the ugly so they get a wide view of exactly what’s going on and encourage them to remember that hindsight is twenty-twenty when people have something embarrassing happens or they get anxious about something that happened they look back and they go I should have or I could have or oh I wish I wouldn’t have when you were in that the situation you did what you did and you know maybe you may have had a reason for it or you know you may have not had other options or it may have just been a bonehead thing to do but okay so you made one mistake hindsight is 2020 that’s gonna that mistake is gonna stand out just like the great big letter on the eye chart because you’re thinking back and you’re looking at it and that’s all you see but encouraging clients to remember that other people are too busy worrying about themselves to remember what they did jumping to conclusions encourages clients to remember to get all the data if your significant other male significant other comes home and is smelling like perfume don’t just jump to the conclusion that he was cheating on you maybe he went to the mall to get a new tie and walked through the perfume area and got spritzed or bought you some perfume or who knows maybe the person sitting next to him at work sprayed her perfume on the desk and some of it filtered on there are all different reasons that that might happen so encourage people to get all the data mind reading we can’t do it you know you can’t read somebody’s mind you don’t know what they’re thinking so ask them what you think about this don’t assume anything and emotional reasoning encourages people to step back from a situation and ask themselves am I feeling anxious about this because I’m feeling anxious and I’m looking for reasons that it should be scary or am I feeling anxious about this because it’s really scary for some reason there are facts support my anxiety a lot of times when we go into new situations we may feel anxious because it’s a new situation but when we step back we say you know what there’s nothing to be worried about here you know no big deal I got this and move on so instead of rolling with it and trying to figure out okay I feel anxious so there must be a reason not necessarily very likely a false alarm other psychological interventions relaxation skills encourage people to learn how to relax not only physically but mentally diaphragmatic breathing helps encourage them to breathe through their stomach and put their hand on their belly and feel their belly expand and contract slows breathing down which triggers the rest and digestion reaction in the brain which is calming meditation can be helpful for some people some people find trying to quiet their minds too frustrating because they’ve got too much monkey mind going on that can be later or maybe never for some people, we don’t want to increase their anxiety with interventions cute progressive muscular relaxation also has a lot of research support and remembers with cute progressive muscular relaxation we’re Sakura get them to attach a cue AK you word like relax or breathe with the relaxation response so they tense their muscles and then relax their muscles and as they relax their muscles they say their “quack”-word like relaxed and they work from head to toe or from toe to head tensing and relaxing different muscle groups so they become more aware of what a tense muscle feels like versus a reactive relaxed muscle there are great scripts that are online that people have already recorded that can walk people walk clients through CPM are I highly encourage it because once they get used to it then they can just think that cue they can think relax and as they exhale they will start to feel their entire body kind of relaxing because it’s trained when it hears that just like when you hear the word pop quiz when you were in high school you had a stress reaction well we want to use it in reverse and train the body so that when it hears a cue word relaxes helps them develop self-esteem because fear of failure and rejection a lot of times come from needing other people’s approval to help them develop a rational idea of their real self develops compassion self-talk instead of saying I’m an idiot or I’m stupid or I’ll never measure up to anything encourage them to talk to themself like they would talk to their child or hopefully their best friend and encourage them to spotlight strengths whenever they feel like they’ve got an imperfection to identify these three strengths that they have so they’re you know balancing out the imperfections and the strengths of cognitive restructuring reframes challenges in terms of current strengths, not past weaknesses so if you’re going to give a presentation in front of 60 people and you hate public speaking instead of thinking about you know this is terrifying because the last time I went up in front of people I forgot everything I was going to say and drop my note cards well that’s a past weakness what is your current strength you’re prepared to know the material you ‘yoyo’ so encourage people to look at all the strengths and resources they currently, have them develop an attitude of gratitude and optimism because as I said with that the positive writing exercise when people are in a grateful optimistic frame of mind they tend to see more of the good stuff they see the bad stuff too but they can also see more of the good stuff and some of the bad stuff they see opportunistically instead of as a devastation acceptance and commitment therapy says that some of the reasons that we’re miserable are fear we get fused with our thoughts we think I am terrified well if I am terrified then I can’t I mean if I am I can’t get rid of anything I am if I’m having the thought that I’m terrified well I can get rid of a thought I can forget things easily encourage people to evaluate their experience and empower them to look at things as challenges and opportunities instead of hardships encourage them not to avoid their experiences so things that are scary gradual exposure and finding exceptions like for me bridges you know I love public speaking so that’s not a thing but when I go to a bridge you know when I Drive to the bridge you know when I’m on the bridge somebody else is driving I get used to doing that when I Drive over a bridge than when I Drive over one of those bridges that open up I hate those bridges um I know y’all are just like oh my gosh yeah it’s an irrational fear I realize that but instead of going straight for the bridge that opens up going for the little bridges first and then thinking back over times that I’ve gone over bridges and there’s been no problem you know there are exceptions nothing happened it wasn’t a big deal sometimes I didn’t even notice it until somebody pointed out hey look down there at that pretty water and I’m like oh we’re on a bridge so encourage people to not avoid their experiences get used to them embrace them and learn that they have the power to deal with them and stop reason giving for the behavior you know use the challenging questions if something is fearsome let’s look for at the evidence for and against it instead of you know making excuses for social interventions improve their relationship with their self which goes with self-esteem improvement people are going to feel less anxious about getting their needs and wants to be met if they know what their needs and wants are so part of that is becoming mindful cuz a lot of our clients don’t know what they need and want they just want to feel better but they don’t know how they don’t know what they need to feel better so helping them identify their needs and wants and encouraging them to be their own best friend you know when they get a promotion take themselves out to dinner pat themselves on the back whatever it is don’t rely on other people to do it because other people it’s not that they don’t care but other people are often very involved in thinking about their stuff and they may not notice encourage them to develop a method of internal validation so they can feel like they are all that ‘no bag of chips and they realize why they are lovable human beings and they accept the the fact that everybody is not going to like them and nobody is gonna like them all the time and that’s okay you know my kids don’t like me all the time my husband doesn’t like me all the time I’m okay with that I know I can be challenging but you know most of the time you know they like me and that’s okay and there are some people you know who don’t like me at all and okay there’s nothing I can do about that helping our clients develop an okayness with that helps relieve a lot of anxiety because a lot of people feel like they have to be liked by everybody and if somebody doesn’t like them it’s like what did I do wrong oh my gosh encourage them to develop healthily supportive relationships with good boundaries develop assertiveness skills so they can ask for help when they need it anxiety a lot of times you know that’s the body saying there’s a threat well if there’s a threat maybe you need some help you know dealing with it so people need to be willing and able to ask for help and not feel like that’s going to lead them to be rejected and allow them a certify this will allow them to say no to requests again without feeling like that’s going to result in them being fully rejected describe the ideal healthy supportive relationship and encourage them to separate the ideals from the reals you know let’s look at if you had the best relationship what would it look like okay you know warden June Cleaver we got that now how realistic is that you know let’s look at you know rephrasing this a little bit so it’s less extreme you know warden June Cleaver never fought their kids were perfect you know all those extreme words let’s look at what’s real what happens in real relationships encourages people to identify who would be a good partner in supportive relationships I’m not meaning necessarily romantic I’m meaning friends and where they can be found you know where would you find people that you could be friends with and encourage them to play through what it means when gaming cuz a lot of times again this goes with my reading you know what it means when your friend doesn’t return your text right away what does it mean when your friend cancels dinner on Friday night what does it mean when you see where I’m going with this and a lot of times clients with anxiety and rejection issues and low self-esteem will go to the worst-case scenario so encourage them to go back to finding the exceptions what else could have been happening what else could it be that caused this and it’s not about you so anxiety is a natural emotion that serves a survival function excessive anxiety can develop from lack of sleep nutritional problems neurochemical imbalances failure to develop adequate coping skills cognitive distortions low self-esteem and a variety of another stuff recovery Ambala involves improving health behaviors making sure your body’s functioning and making the neurotransmitters it needs and you know release them as needed to identify and build on current coping strategies address cognitive distortions and develop a healthy supportive relationship with self and others if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube, you can attend and participate in our live webinars with dr.

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Dialectical Behavior Therapy (DBT) Skills | Mental Health CEUs for LPC and LCSW

Unlimited CEUs for 59 at AllCEUs com welcome everybody. Today,’s, presentation is on dialectical, behavior therapy skills. This presentation is based in part on dialectical, behavior therapy a practical guide by Kelly Koerner. This is one of those books that, if you want to do dialectical therapy as a practice, not just look at some of its tools is a must-read. Then it’s also based in part on dialectical, behavior therapy skills, workbook DBT made simple and DBT for substance abusers, which is an article that was published by Marsha Linehan. So the links to those are in your class, but just give you an idea about sort of the breadth of what we’re going to be looking at today. In the short time that we have together, what we’re going to do is take a look at why DDT was created, we’ll look at understanding emotional regulation, dis-regulation and regulation will identify DBT assumptions about both clients and therapists, and we’ll Explore skills to help clients learn to stress tolerance, emotional regulation, and interpersonal effectiveness. As an aside, we’re taking – or I’ve taken the information from this course and combined it with a bunch of other information to make a six-hour on-demand course. That will be available by the end of the week, but for now, we’re just going to hit the highlights in the 1-hour introduction. So why do we care? Why do we want to learn about DBT skills and DBT tools? Many of our clients, experience emotional dysregulation, or the inability to change or regulate their emotional cues experiences, and responses. Think for a minute about any of your clients, if they’re depressed, if they’re anxious, they’ve got anger management issues, something is going on with their emotional states, or they’re not able to either get unstuck or control their behavioral responses. So they may be engaging in self-injurious, behavior risky, behavior, or addictive behaviors. They’ve tried to change and failed, leaving them helpless and hopeless. In a lot of our clients. We try to fit them in not that we should, but we do try to fit them into this box. If you’re depressed, then we’re going to look at these things, and one thing I hope you get from these webinars is the fact that every single client is different and there is no box that we can put them in and you’re, Like well, then, how can you do group therapy? Group therapy is awesome because you can tailor and that’s, part of the challenge of doing psycho. Educational group therapy is tailoring the tools and helping people tailor the tools to meet their individualized needs, but they can get feedback and they can see how different tools can be modified just a little bit to fit different individual needs and untenable emotional experiences that lead to Self-preservation behaviors such as addiction, you know to kind of numb the pain to give them a distraction, nonsuicidal self-injury. We’re talking about cutting, we’re talking about those sorts of things, and then even those suicidal behaviors. At a certain point, the pain has got to stop, so some people may end up going as far as trying to stop the pain by stopping their existence instead of hurting anyone else. People with emotional dysregulation have high sensitivity, so these people tend to be highly hyper-vigilant. They’re aware of a lot of things that go on now. This was created and I want you to really kind of think about it. It was created as a tool or a protocol to use with people with borderline personality disorder. What do we know about people with BPD? They grew up in really ineffectual environments, so they had to be hyper-vigilant about everything that was going on for their safety and security. So you have someone who, either by nature or by nurture, is hyper-vigilant. These situations have been over-generalized. The dangerous situations have been over-generalized, so the world tends to seem more and dangerous, and out of control, people with emotional dysregulation are easily thrown off kilter because they often have a lot of vulnerabilities. They’re not eating. Well, they’re depressed which is contributing to them not being able to sleep. Well, they can’t focus yadda, we’ve talked about vulnerabilities. One thing that dr Turner talks about is no emotional skin and she likens it to someone who has third-degree burns and every single thing, even the air when it touches it, is just excruciating there’s no middle ground. There’s. No, oh! That’s kind of uncomfortable it’s either not hurting or it’s. Excruciating. People with emotional dysregulation are also highly reactive, so they’re hyper-vigilant. They’re aware of everything that’s going on and then every time something happens that sort of triggers their awareness they jump into this immediate fight or flight reaction. Then they’re slow to de-escalate. So we’re talking about situations in which someone is hyper-vigilant. They’re on edge, maybe because of situations in the past or not. They have this sort of persistent fight or flight or frequent fight or flight reaction. And again, I’ll refer back to our dream fatigue class that talked about how the body can only stand to be all hands on deck for so long before it’s just like dude I give up, and then the sense of depression and helplessness and Apathy starts to set in people who are who have emotional dysregulation, really they’re either like flat and none nonexistent in their emotions. They just can’t even deal with it when they should, or they’re, overly reactive and then the person isn’t in a validating environment. What would be a to some of us on a scale of 1 to 10? As far as how distressing something is it’s, probably like an 8 to somebody with emotional dysregulation, think about a time when you were stressed out or you had a lot of vulnerabilities going on. Maybe you had a new baby at home, so you were, ‘t sleeping and your other kids were acting out. There were just all kinds of stuff going on and you reacted to something with an 8 that everybody else was like that. Doesn’t deserve that. Much of a reaction is that’s it what’s wrong with you, people with emotional dysregulation that’s their environment, all the time, everybody’s looking at them and going what’s wrong with you there? This is not that upsetting. So we need to help people understand that their experience is their experience and it’s not for me to say whether it’s a 2 or an 8. For me, it’s a 2, but let’s look at why it’s an 8 for you. So the emotional reaction – and this is I didn’t – get red eye reduction when I took this picture of bruit but bless his heart. When I got him, he was a rescue and he had such terrible terrible abandonment issues and is so hyper-vigilant. Even to this day, I’ve only had him like four months, but he’s hyper-aware of stimuli and people can be hyper. Aware of stimuli so anytime somebody moves, he’s up, he’s. Looking he’s like. Are you going to leave me alone again when he perceived that something is changing when there was a threat, he goes into all hands on deck and turned into a survival sort of thing and starts acting out? He goes and finds toys and brings them to me. Heaven forbid. We should have to put him out in the garage because we have visitors or something and it’s. You know climate controlled, it’s not like it’s horrible, but he will sit out there and how, until I let him in or go out and tell him it’s going to be okay, now see as a person I’m going. That is not a valid reaction. He’s like totally overreacting to having to spend ten minutes in the garage, whereas from his perspective he’s not overreacting, because in the past when he’s been put in the garage he left out there for days weeks months. Who knows I don’t know his story too. Well, now I use that to kind of highlight the fact that people with emotional dysregulation don’t know what their experience was. What they’re doing is trying to survive. Now they may be trying to survive a situation in their past. You know when there were six and we’re going back to the abandonment discussion that we had the other day, but it’s important to understand that all these things play in together. Something happens and the body’s response system takes in these stimuli and it says it’s dangerous it’s, not dangerous. What do we do with it? The brain decides to fight or flee, and then they go into the survival response with treatment. What we want to do is help people be able to feel that feeling and not have to act on it right away until they can de-escalate some and use a combination of assessing their cognitions and deciding whether their perceptions are based. On the present. The present moment or the past moment so primary invalidation caregivers dismiss emotional reactions as invalid. We just talked about that. The child or person could be mocked or shamed for their emotional response. We have all probably met parents or worked with parents who have children that are highly emotionally reactive, and who tend to get frustrated and overwhelmed by the constant drama that seems to be presented by this child all the time. So the child is often not taught how to self-soothe or de-escalate the parents just like really let it go and go away, which is not helpful because the child doesn’t learn how to deal with it. The child is not taught mindfulness to figure out okay, what’s causing this, and the child is not taught effective cognitive processing in most situations in validating environments, if the child gets upset, even if it seems to be disproportional to whatever the event was, the caregiver Will take the child in and say? Okay, I hear you’re upset right now, let’s talk about it and we’ll walk the child through, maybe not thinking about it, but just being a good parent walks. The child, through this de-escalation process and the cognitive processing of secondary trauma or invalidation, is, and I’m putting this in here. Coping skills can be overwhelmed by trauma or intense stress, leading to this high alert raw status. Think about the people who were survivors of Hurricane Katrina or Hurricane Andrew. I come from Florida, so I think hurricanes, but any big event that is ongoing enduring, and distressful at a certain point. You’re on your last nerve, so anything could precipitate sort of a crisis. Many people don’t receive the necessary support during these times and may be shamed for being weak or needy. Sometimes nobody can cope and everybody’s kind of decompensating. At once, which is a lot of what we saw with Katrina but other times there may be people that are functioning just fine and they don’t understand why some other people are 39, t coping just fine, and they see that as abnormal and want to distance themselves from it, it’s important for us to communicate to people because we already noticed that crisis is a normal response to an abnormal event. What was abnormal, though, is it this particular incident? Maybe, or is it the fact that this particular incident kind of was the straw that broke the camel’s back on a whole chain of incidents leading up to it that was abnormal? What caused this person? Excessive stress I was talking to a woman the other day who, in the past six years, has had half a dozen significant losses and I’m just like wow. You know that that’s pretty intense to have all those and she’s, also starting her practice and everything else. Right now – and I’m – just like oh my gosh – I can’t imagine the amount of stress this woman is – going through most humans, aren’t inherently prepared to deal with the crisis alone. We’re kind of group sort of people. We rely on other people, so if we have this reaction and it’s judged to be disproportionate and people kind of distance themselves from us, because they see us as abnormal or dysfunctional, then we lose any social support that might have been able to serve as A buffer which just kind of in turn, feeds back and exacerbates the sense of hopelessness, helplessness, and isolation. What precipitates a crisis may vary between people based on pre, existing stress or mental health issues, and it also may vary with the same person longitudinally across time. What may be overwhelming today – maybe not may not be overwhelming six months from now, because all of those prior stressors that I’m dealing with right now may have had time to kind of work themselves out. So we must help people understand that their reaction is their reaction and let’s just go from there. Let’s not say it’s bad or is disproportionate or it’s whatever it just is so the result of this sort of unpredictable reactivity results in frantic efforts to numb withdraw or protect. I need to numb the feelings because I can’t take this kind of pain. If you’ve ever had a burn that’s had to be cleaned or even an open wound that’s had to be cleaned out. You know that’s pretty excruciating so thinking in terms of that, you can see why people would want to kind of get a little novocaine withdrawal if this support system is invalidating, that has extra pain and that’s excruciating to be rejected. On top of everything else, so a lot of times, people withdraw which eliminates any opportunity for social support, and it also exacerbates this sense of rejection, and they do this to protect themselves. People learn who they are in invalidating environments. They learn who they are and how they are resulting in rejection, so they avoid threats. They avoid putting themselves out there. They avoid making relationships because they’re afraid of rejection and they avoid thoughts and feelings and sensations that may lead to invalidation. I don’t want to feel these things because then if I do and I communicate them, you may tell me I’m wrong. Okay, we’ve laid the groundwork. Now we see where this is a problem. So what do we do about it? Well, the first thing we want to do is look at some of the DBT assumptions about clients. Clients are doing the best they can given the tools they have at this present point in time, and I truly believe that clients want to improve themselves. Wouldn’t be in your office if they didn’t want to improve for one reason or another. It may be an involuntary referral and they want there’s a means to end there. They are in your office because they have hope that something can change and it will benefit them. They cannot fail at DBT if they go through dialectical behavior therapy, the protocol and it fails, then the protocol failed them or we as clinicians, fail to implement it correctly. Now, today, again, we’re talking just about tools that are present in DBT, not how to do dialectical, behavioral therapy. The evidence-based practice wants to make that very clear clients are existing in what is for them an unbearable state. This pain has got to stop. They need to learn new behaviors in all contexts, not just at work, not just in their relationships, but they need to learn how to function and deal with life on life’s terms in all contexts, so they can go to the grocery store they can get In a traffic jam, they can be in a crowded Airport and not feel like the walls are closing in on them. Clients are not responsible for all of their problems. We know this some things they had no control over are causing problems for them, but they are responsible for all of their solutions, and we’re going to talk about the four options for problem-solving in a few minutes, but they are responsible. They choose to do something and clients need to be motivated to change motivation, choosing the more rewarding option out of the available options. Well, yeah that whatever they’re doing right now is the most rewarding option they have available in their toolbox. So we’re going to give them new tools, but then we need to teach them how to make those tools effective. If you just hand me a jigsaw and say, okay go about woodworking and whatever I’m, not a woodworker, but I’m not going to know what to do with that. So I may go back to using my circular saw or whatever the case may be, which may be very clunky. We need to help clients learn how to use these new tools, so it’s more rewarding to use those than those old behaviors. They just numbed out the pain or distracted them assumptions about therapists, clarity, precision, and compassion are of the utmost importance. We need to be clear with our clients about what’s going on. Let’s not speak in generalities. We want to try to avoid some of the Socratic questions that we would normally do. We want to be clear about what we’re getting at and what we want them to look at. We need to be precise. Do we need to not say well what is it last week that caused all the problems in your relationships? Well, if they had four different fights that’s four different things we need to look at, we need to be precise to identify all of the things that trigger and we’re going to talk about behavior chains in a few minutes. So we need to be precise. We also need to be compassionate, even if we don’t agree, or we think that the reaction was disproportionate, putting ourselves in their mind in their place in their raw state. We need to be compassionate and go okay, you survived it, you did the best, you could let’s take a look at what might have caused that. Why you made the choices you did and what you might choose better next time. The therapeutic relationship is between equals, DBT or therapists can fail to achieve the desired outcome, but the client can’t fail and therapists who treat patients with pervasive emotional dysregulation needs support we need to remember that patients who are always in crisis by their very nature, it’s, exhausting because they’re always in crisis, which means we are responding in a crisis manner, not that we need to get all upset and worked up because that’s just modeling the wrong thing. But there is a lot of energy that it takes for us to use the DBT tools for us to model the DBT tools and for us to help work. The client is out of their emotional state into one where they can use their wise mind. So the first step is core mindfulness. Until they figure out what’s going on, they can’t fix it, so we want to help them integrate their rational mind they’re cognitive. This is what happened factual mind with their emotional mind. This is what it felt like in the wise mind, so you can take the facts. You can take your feelings and you can say with what I know and what I felt. What would be the best interpretation of this or the correct one for me? Interpretation of this event at this point, and what can I do about it? One of the things DBT talks about is the fact that truth is sort of subjective. What is true for one person may not be the truth for the other person, because we’ve all had different experiences, but we need to help people not underreact and stay. In that cognitive mind, if you’re a star, trek fan, think data um. He was the AI that was kind of human-robot sort of thing or, and we also don’t – want people to act in their emotional mind, acting solely based on feelings and trying to make feelings facts because feelings aren’t facts. They’re feelings, so we want to help them integrate these two things, and that is more difficult and it sounds like it takes time. Mindfulness is using effective, nonjudgmental observation and description of experiences, those thoughts, and feelings, and identifying what’s the objective evidence for and against what’s going on right here, how I’m feeling what is all the evidence. Let’s look at the big picture, not just one little aspect of it, and what are my feelings about this event? Getting in touch with what’s going on inside their mind and inside their body is going to be one of the first steps. So I talked about those four options: when there’s a problem, you have four options. You can tolerate it, grit your teeth, and Barratt there. Sometimes you just can’t do anything about it. Traffic jams probably can’t do much of anything about it. Change your beliefs about the event. Instead of seeing a traffic jam as a waste of time and just a complete pain in your butt, you can see it is a time to check voicemail and maybe return. Some phone calls are productive, make it billable, and you can solve the problem or change the situation, while you’re in a traffic jam and stopped, of course, looking at Google Maps to figure out where the next exit is so that you can get off. So you can change that situation or you can choose to just stay miserable and choosing to stay miserable is a valid choice. When clients make these decisions, we need to look at them. Why was that? Whatever their option was? Why was that option more rewarding than all the others? Why is it more rewarding sometimes to stay miserable for some people that’s what they know and they’re afraid if they feel happy, then they may get disappointed and end up feeling sadder than they already do now? Some people tolerate the problem because it’s what they know and change is hard and they would rather just tolerate it and deal with it and suck it up than have to muster up the energy to try to change whatever’s going on. So again we want to look and ask them or ask ourselves, maybe because they may not know right away the choice that you made. Why was it more rewarding? Why did you choose that over the other three options, distress, and tolerance we’re going to talk about a lot of acronyms here acronyms are really important in DBT because it helps clients have sort of a drop back and punt. There are some worksheets. There are lots of worksheets online for DBT but the acronyms we’re going to hit here are going to be some of the highlights that are going to be important for you to remember tip temperature. So you’re tipping your physiological balance now temperature. I’m not necessarily advocating for this. You don’t want to do it. If you’ve got a heart condition. You don’t want to suggest it to clients that have a history of child abuse, especially anything that involved drowning. So this one’s a little tricky one of the things I suggest to some of my clients instead of this is holding on to ice cubes. But the suggestion in the book holds your breath. Dunk your face in for as long as you can hold your breath into a sink full of ice water, then come up. Exhale, inhale and dunk, again repeat as many times as you need until you feel calmer. Well, guess what we’ve talked about combat breathing. If you are slowing your breathing, which you do, if you’re holding your breath, your heart rate is naturally going to slow. When your heart rate slows down your brain says: oh the threats going away, yippee yay, I can call off the dogs. There are other ways to slow down your breathing. Besides necessarily dunking your dunking, your head holding ice cubes is one of the reasons that that can be helpful. Instead of cutting the person’s focus, it’s a distracting technique. The person focuses on the pain because it is painful to hold on to ice cubes for a long time, instead of cutting themselves, but it also gives their body something to focus on to go. Oh, my heart rate is up because there’s a pain when the pain goes away. I can make my heart rate go down, so we’re redirecting the brain to go. Oh, this is why the heart rates are up it’s, not because there’s emotional distress, it’s because of extreme physical pain. Intense exercise increases body temperature, but it also increases the heart rate when you’re sitting still and your heart rate is 120 beats a minute because you are in a panic attack or a state of panic. It’s very, very uncomfortable and your mind is going. I don’t understand you, ‘re not moving. Why is the heart racing when you start exercising, which is why walking and getting those big muscles moving often helps? Then the body gets less confused. It’s, like Oh heart rates, beating fast, because the body is moving score, got it so when the person stops moving, the heart rate starts to go down, and this is true, even if you’re walking around. If you take a client out to walk when they’re upset – and you are talking about whatever the distressing thing is – I have found without exception.

When they come back inside, they can start to calm down a little bit more and their heart rate naturally starts to go down when they stop their physical exercise and then progressive relaxation. You’re going to move from head to toe or toe to head. Whatever you prefer but head to toes, usually how we do it focusing on muscles focusing on breathing slowing, breathing relaxing muscles forcing the body to relax. So this addresses physiological arousal, so the temperature, intense exercise, and progressive relaxation. All of these serve as an ability serve the function of distracting the person from whatever cognitively or inter psychically wants to say, is going on, and all of these either explain to the brain why the heart rate is going so fast or Help reduce the heart rate, so you know there’s something to be said for them. The important thing is for you to brainstorm with your clients when you get physiologically aroused when you get upset, and you are just your hands – are shaking your palms are sweating. You’re breathing fast, and your heart rate going fast. How do you calm yourself down what works for you and we’re back to bruit again? Another acronym is accepted to distract when there’s emotional turmoil, so you can kind of let that adrenaline surge go because you have that initial fight or flight reaction and then the body kind of goes. Alright, let’s reassess and see if there’s still a threat, get involved in activities that will help you distract yourself from whatever’s going on when kids get upset. You know if they’re getting stressed out because they’re sitting in the lobby and the doctor’s office, and they know they’re going to get a chhoti. We give them something to do. We read a book, we talk we play because then they’re not focusing on the fact that they’re going to get a shot, contributing to the welfare of others. Do something nice for someone to volunteer. Do something productive that gets. If you are focused on someone else, compare yourself to others who are doing less well, that doesn’t work for everybody. You can also compare yourself in the present to your old self and focus on how much better you’re doing now compared to what you were doing six months ago, this doesn’t always work. You know these are options. Not everyone is going to work for every person, emotions do the opposite. If you’re feeling really sad get a comedian, get it to go to YouTube, and Google a comedian and watch a skit or two or ten, so you’re doing something that makes you laugh. That makes you happy to sing. Silly songs, dude silly dances go out and there’s very little. I find it more amusing than just listening to a baby laugh. If I’m having a really bad day, I will find those stupid videos of babies laughing at paper tearing if you can’t help, but laugh with them pushing away build an imaginary wall between yourself in the situation. Imagine yourself pushing away the situation with all your might or blocking the situation in your mind, and each time it comes up, tell yourself to tell it to go away. So if you start thinking about something that is particularly hurtful as soon as it comes into your mind and it comes into your awareness go no, I am NOT going to think about that right now. Thoughts counting some people count to ten, a hundred whatever it takes to get through that initial rush. Some people sing for me. I think I’ve shared before I have this irrational fear of bridges, but so, whenever I Drive over a bridge I sing, and usually, it’s, not songs on the radio. Usually, it’s songs. I used to sing to my kids. I’ll sing the ABCs something that doesn’t require a whole lot of cognitive interaction because I’m doing pretty good just to get over the bridge. And yes, I know I should be over it, but I’m not and that’s just the way it is the 10 game. I like this one think of 10 things that you like the smell of think of 10 green things. Think of 10 things you see where we’re going with this, and you can incorporate all the different senses with it. If you go through multiple iterations of it 10 things that you smelled yesterday, 10 things that you see right now, 10 things that you hear when you’re on your way to work. This helps people focus on something other than what’s going on. Here the 5 4 3 2 1 game is sort of similar to the 10 things game, identify 5 things. You see, 4 things you smell, 3, things that you can touch and follow down. Sensations like I talked about on the last slide. Sensations can help distract you from what’s going on until you have a chance to kind of get through that initial adrenaline rush, cold, holding ice, cubes, rubber band – and I don’t like this one. But some people do they put a rubber band on their arm and every time they start to perseverate on a negative thought. They snap its smells and find some good smells. Some smells bring back good memories, smells that you like. Maybe it’s roses: maybe it’s a purse-specific perfume. Maybe you just go to Walmart and start smelling all the air fresheners. Whatever makes you happy, I do suggest avoiding taste, because if you start using taste as distress tolerance, then you start moving toward emotional eating. I’ve seen it happen, so I would avoid that for most people, but if they just desperately want to go there, then you know we’re going to go there because they are choosing how to distract from their cognitive or intrapsychic. Sensations improve at the moment. Imagery goes to your happy place. Whatever your happy place is meaning find an alternate, meaning for what’s going on now. This can be Linehan refers to it as making lemonade. We all know how to do that. We don’t we’re, not necessarily the best at it, but try to make lemons. I try to look for the optimistic meaning in whatever it is prayer. Now, even if someone is not religious, they can be using radical acceptance. Accepting it is what it is and not trying to change it, just putting it out there for the universe, relaxation is always good to relax one thing at a time and this isn’t focusing on one problem at a time. This is focusing on something we’re talking about distress, tolerance, and improving the moment so focus on one thing, like your breathing: get your breath and calm down once your breathing calmed down. If you need to focus on something else, then move to. Maybe the tension in your neck. Maybe you need to lower your shoulders and release the tension in your neck, focusing on physiological things and focusing on other senses. Besides, that abstract stuff that’s in your head and your emotions can help people tolerate the distress until they can think more clearly vacation takes a timeout. Sometimes you just need to get away from it. For a few minutes, we’ve had time at work. I’m sure we all have where you’ve just been like. You know what I’m done and you lock your computer screen. You get up, you walk out of the building, and none of its clients are in there, but you walk out of the building and do a couple of laps around the campus and then you’re like okay. I can deal with this again just clear your head before you try to tackle whatever it is, an encouragement providing yourself, because you can’t necessarily rely on anyone else. Positive and calming self-talk now back to those stupid, memes and videos that I love to death there’s, one has a kitten on a laundry wire and it says: hang in there, I love having those things on screensavers. It’s, juvenile, maybe but whatever it makes me happy, and it reminds me you know even when I’m, not in a state of emotional distress. It reminds me all right keep on hanging in there. You got it and it’s got an all-factor too. So I always like anything with an all factor: the goals of emotional regulation. So once you’ve tolerated this distress, you’ve gotten through that initial surge. That initial, I cannot take this pain or upset. Then we need to move into emotional regulation, help people identify labels, understand their emotions and the functions of those emotions, decrease unwanted emotional responses and decrease emotional vulnerabilities. So what they’re going to do is identify and label emotions and their functions. I’m scared. Okay, you 39. Re scared. Tell me why what’s the function of you being scared? What do you want to do, and what do you think is causing this scared? 39. No self-awareness through questioning, like that through talking it out, people will start to understand where their emotional reactions are coming from and they can choose whether or not to follow up with it a behavior. What I guess I didn’t put in a behavior train analysis is the way you can go about helping people work through that and that’s a couple more slides cop. We want to police our thoughts and check the facts. Look at doing opposite actions. If you want to hurt yourself, look at being kind to yourself, if you want to run, maybe you need to look at staying and then look at the problem. Solving reduced vulnerability through the ABC p accumulate. The positives, remember, vulnerabilities, are those situations that happen leading up to whatever the distress is. Those are the things that make you more likely to be irritable, overwhelmed angrily depressed get sad about anything. Instead of not so, we want to eliminate those vulnerabilities or reduce them. As much as possible, so we’re going to accumulate positive gratitude, journals pictures if well, everybody has things in their life that they care about. Have those on your phone in you know little picture galleries that have them as your screen. Savers have reminders around about it. Why you get up in the morning builds mastery, so you have mastery of the skills you need to deal with emotional distress and upset cope ahead of time plan for distressing situations. If you’re getting ready to go in for an annual evaluation and those things stress you out to no end rehearse, it ahead of time plan on coping ahead of time, and figure out how you’re going to react. If it goes bad figure out how you’re going to react, if it goes good figure out how you’re going to cope and physical vulnerability prevention, maintain your health, chronic pain, chemical, chemical imbalances, hormonal imbalances, those can all cause vulnerabilities or set you up. Make you predisposed to feeling like something’s at eight when it’s only two get plenty of sleep when we’re sleep deprived, is a whole lot harder to deal with life on life 39. S terms and exercise. Exercise is a great way of releasing or using up some of that stress energy that you release during the day. Behavior chain analysis. The first thing you do and a strict behaviorist will have slightly different explanations for how to do this, but just bear with me here: name the behavior reaction. What happened now, if you’re thinking back to the ABCs, this is going to be your C. Your consequence, what happened identifying the prompting event ABC is, that would be the what was the activating event now. This is where it differs a little bit. Then we want to look at the behavioral links, so you had the activating event, and then there was this reaction and in between, there were um automatic beliefs, and we have that there. We have thoughts, but there were also sensations events, and feelings between what happened and your reaction. What sensations did you feel? Did you get flushed? Did you feel nervous? Did you feel scared? Did you feel sad? Did you have a twinge of something? What feelings were there and what events happened? Did you act out in a certain way? Did you scream? Did you yell about what happened? Because these are all things that are going to go into what ultimately ended up being the behavioral reaction, then I want to look at the short-term positive and negative effects of what you did. The behavior of the reaction. If you started screaming and throwing things okay, you did what was the short-term positive effect of that? What was the benefit of that? Because that was what you chose, which means it was likely the most beneficial response you could come up with in your highly emotionally charged mind then. So what were the benefits and what? With immediate short-term negatives and then looking at the positive and negative long-term effects in the long term, if you react to this upset by screaming and throwing things what’s the impact going to be, are there any positive impacts? Are there any potential positive effects of this and a lot of times it’s? No, but we want to ask the question just in case there are because some people will have a positive and we need to address that this is sort of. If you go back to motivational interviewing what we think about when we’re talking about decisional balance, exercises address the problematic links with skills. If some sensations or actions exacerbated the distress, then we need to look at distress and tolerance. If all of a sudden you had this immediate panic reaction and you couldn’t breathe, we need to work on distress, and tolerance skills, so you don’t go to that point where you are just for lack of a better phrase in a tizzy thoughts and Feelings if your thoughts get negative and start racing and your feelings are negative and anxious and worried and all those negative words we want to look at emotional regulation. You know if you can get through it, where you get through that initial rush and you’re still having these getting stuck in the negativity. Then we want to look at emotional regulation most of the time we’re going to look at both of them and then the third component, once we’ve learned how to get through the initial flood, the initial all-hands-on-deck call, and then people Have learned to regulate their emotions and identify helpful responses, and instead of talking about good and bad, we want to talk about helpful and less helpful responses. Then we need to look at interpersonal effectiveness and how to interact with other people to make that validating environment exist. So we want to start with interpersonal and intrapersonal if you will be effective with yourself and then move to others describe what’s going on assess how you’re feeling what your reactions are, and what the best next step is asserting. Your choice reinforces the good things. Be mindful appear confident and willing to negotiate, and yes sometimes we have to negotiate with ourselves because there’s something that we want to do right now – and this is very true – with people with addictions a lot of times – they want to use. They know the long-term consequences of use are not where they want to be, so they have to negotiate with themselves to say alright. I want to do this right now, but I’m going to choose a different option in their relationship with others. We want to encourage them to give me gently instead of critically, and harshly, which a lot of times is what they’ve gotten all of their life, being gentle with other people, accepting them where they are modeling how they want to be treated, be interested in What other people have to offer, what other people have to say and what’s going on with them? A lot of people with emotional dysregulation can’t handle their own life on life’s terms. They can’t even begin to handle anybody else.’s stuff, so a lot of times they appear disinterested, validate other people and their experiences, and have an easy manner. You know sometimes we get too intense and if everything in your world is either a zero or a ten, it’s easy to be intense. About everything, as they develop emotional regulation, things will be different. You know they’ll have fours and fives in there, but practicing that not being intense and over the top about everything, and then in their relationship with the self, be fast, be fair with themselves, not judgmental just fair, avoid apologies, stick to values and be truthful. 12-step recovery step, one starts with honesty, being honest with yourself step two. We start talking about hope and faith, which is sticking with values and being fair to oneself. Being compassionate comes couple more steps down that’s not hard or not harmful. For any of our clients to teach them to be fair, to be kind to themselves, and to be honest with themselves and others. So how does treatment progress when we’re talking about dialectical, behavior therapy as an evidence-based practice stage? One is safety. We want people to move from behavioral disk control to behavioral control. We don’t want people getting a phone call, maybe a significant other has to back out on a weekend trip which was someone with behavioral disk control could send them into a state where they are self-injuring. So we want to make sure that they have the skills to not self-harm, and you know you can’t just say. Well, you can’t cut the person’s like okay, so finish, what am I going to do? Instead? If I can’t cut, if I knew how to do something else, I’d be doing it right now. We need to help them increase their self-care behaviors instead of cutting. What can you do, I’ve talked before about some of the interventions I’ve used with some of my clients that have self-harmed. It’s not ideal. It’s not where you want to end up, but moving from self-harm, too, like I said, holding ice cubes or using a ballpoint pen to draw on yourself is preferable to cutting yourself. So we want to look at small steps, not going from. You know five or six self-harm episodes a week to nothing. You’re setting yourself and your client up for failure. We want to reduce the intensity of the self-harm, so they’re not breaking the skin, so they’re not damaging themselves decrease therapy interfering behaviors what we typically call resistance and that can be showing up late that can be always coming in and trying to derail therapy sessions, it can be being bossy, it can be being reserved whatever it is that’s interfering with the therapeutic process. It’s important to understand that therapy-interfering behaviors can be exhibited on the part of the counselor too. If the client is experiencing a lot of emotional discount role, sometimes counselors will start being late to sessions and will start forgetting to review the chart before they go in and remember what homework was assigned will start forgetting to do things. So we need to make sure that both the counselor and the client are engaging in motivating therapy participatory behaviors. We want to increase the quality of life, and behaviors and decrease the quality of life-interfering behaviors. So if they’re engaging in addictions, if they’re, not sleeping if they’re, changed smoking if they are and again these are things when we look at the priority list, my main focus at first is going to be on self-harm. You know I don’t want them to be engaging in those behaviors, and then we’re going to start looking at the other things that create vulnerabilities that make them more likely to be unhappy or to be reactive in situations that would make them unhappy. We’re going to increase behavioral skills, core mindfulness, and accurate awareness, encouraging clients, not just when they’re upset, but to engage in mindfulness scans body scans, four or five times a day. So they know where they are and they know if they are starting to feel vulnerable. If they’re, it feeling exhausted all of a sudden. If they’re feeling foggy, then they know to be kind to themselves: distress, and tolerance. We talked about those skills, interpersonal effectiveness talked about those skills, emotional regulation, and active problem-solving. So these are all going to be introduced in stage one, but they’re introduced. The client has been using their old behaviors for a lot longer than stage 1 is ever going to last. So we need to remember that we have to help clients strengthen these behaviors, remember to use them if they use them at first, one out of every five times as one more time than they were using them. Last week let’s focus on the positive forward movement and not on what we think they should have done. We don’t want to set goals that are going to set them up for failure in stage two. We want to help clients, moderate emotions from excruciating and uncontrollable to modulated and emotional um. We want to feel feelings. Well, I mean, theoretically, we do so. We don’t want people to completely numb out and become robots, but we also don’t want every single emotional experience to be like debriding. For a third-degree wound, we want something in between. We need to help them decrease intrusive symptoms, like flashbacks memories, and hecklers, the things that created the situation where they feel unlovable and unacceptable for who they are. We want to decrease avoidance of emotions, and I know that sounds kind of counterintuitive to increasing emotional awareness. Again, we don’t want them to be numb. We want them to feel because if they feel, then they can choose how to act and how to react. Decreased withdrawal increases exposure to live a lot of times, clients with emotional dysregulation have withdrawn because they don’t want to be rejected so they don’t go out with friends. They don’t experience life on life’s terms. They just sit in front of the television watching Netflix. We want to decrease self-invalidation and help them understand that their experiences are their experiences and they’re not right or wrong. Their choices may be helpful or less helpful, but at any point in time that is their best as well as they can see their best options for survival. So let’s not be critical. I’m just happy you’re still here and we want to reduce mood dependency of behaviors part of this process. We’re going to teach people how to create SMART goals that are specific, measurable, achievable, realistic, and time-limited SMART goals and make sure they’re successful by validating and teaching them to self-validate, encouraging them to imagine the possibilities when you’re successful When you accomplish this goal, what’s going to be different? How awesome will it be to encourage them to take small steps, not all or nothing? You know we want to get get rid of the dichotomy’s small steps towards recovery and applaud themselves for even trying to encourage them to lighten their load and get rid of stuff that they don’t need to be stressing over right now. You know maybe now’s not the time to start remodeling the house and then sweeten the pot and encourage clients to provide themselves with rewards for the successful completion of a goal, maybe getting through an entire week or for some clients even an entire day without self-injury. I encourage you to practice these skills yourself because you’ll see how much we don’t do and how helpful these skills can be, but it also gives you more insight into two ways to help explain thanks to clients and help them apply. These tools to themselves think about which skills you’ve used that were helpful or skills you could have used. That would have been helpful in the past week for you because you’re going to ask the clients to do this. So let’s do it for ourselves, so we can put ourselves in their position and think about which skills might have been helpful for a client that you’ve worked with in the past week. Many disorders involve some amount of emotional dysregulation. That dysregulation can be caused by high sensitivity and reactivity due to innate characteristics and poor environmental fit or external traumas and lack of support, or both DBT seeks, first to help the person replace self-defeating behaviors with self-care behaviors, and then moves toward emotional regulation and Interpersonal effectiveness to help people develop the support system and learn how to feel feelings, including the good ones. A variety of tools are imparted to clients to help them set SMART goals, identify and understand, emotions and their functions, decrease, unwanted, emotional and behavioral responses, and develop a more effective, compassionate, and supportive relationship with themselves and others. Finally, remember that not every tool is going to work for every person it takes some experimentation, so prepare your clients for that. Otherwise, if they try something and it doesn’t work, they’re going to feel rejected and validated and like failures. Again, it’s a process to work together to help them figure out how they can start interfacing with life and integrate the two dichotomies of thought and emotion to make wise choices to help them live happier and healthier. .As found on YouTube Hi, My name is James Gordon 👻🗯 I’m going to share with you the system I used to permanently cure the depression that I struggled with for over 20 years. My approach is going to teach you how to get to the root of your struggle with depression, with NO drugs and NO expensive and endless therapy sessions. If you’re ready to get on the path to finally overcome your depression, I invite you to keep reading…

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