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 all
CEUs.com/counselor toolbox I’d like to welcome everybody to today’s
presentation we’re going to return to talking about vulnerabilities and this is a topic
We’ve covered it before, but you know I don’t seem to be able to say enough about it so we’re going to
talk some more about it we’re going to define what vulnerabilities are and you know I expand
the definition more than what occurred in dialectical behavior therapy because I think there
are a lot of other resources or vulnerabilities out there sorry I’m trying to read two things at
Once anyhow we’re going to identify some of the most common vulnerabilities as I define them so
We’re going to go beyond sleep in nutrition and we’re going to look at environmental vulnerabilities…
Dr. Dawn-Elise Snipes is a Licensed Professional Counselor and Qualified Clinical Supervisor. She received her PhD in Mental Health Counseling from the University of Florida in 2002. In addition to being a practicing clinician, she has provided training to counselors, social workers, nurses, and case managers internationally since 2006 through AllCEUs.com A direct link to the CEU course is https://www.allceus.com/member/cart/i…
Nurses, addiction and #mentalhealth#counselors, #socialworkers, and marriage and family therapists can earn #CEUs for this and other presentations at AllCEUs.com #AllCEUs courses are accepted in most states because we are approved as an education provider for NAADAC, the States of Florida and Texas Boards of Social Work and Mental Health/Professional Counseling, the California Consortium for Addiction Professionals and Professions.
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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 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 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.
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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
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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.
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CEUs are available at AllCEUs.com this episode was pre-recorded
as part of a live continuing education webinar on-demand, CEUs are still available for this presentation at AllCEUs.com/counselortoolbox I’d like to welcome everybody to today’s
presentation of dialectical behavior therapy techniques emotion regulation we are going to
start by reviewing the basic premises of DBT and the reason we’re doing that we’re only
going to do it in this one because emotion regulation we’re starting kind of at
the beginning but we want to go over what is the theory underlying a lot of what we’re going
to talk about we’ll learn about the HPA axis and this isn’t something that Linehan talks about
in DBT but it is important for understanding our physiological stress reactions will define
emotion regulation identify why emotion regulation is important and how it can help clients ourselves
staff yay and we will finally explore some emotion regulation techniques there are things
besides just preventing vulnerabilities that we can provide to clients to help them regulate
their emotions before moving into that distress tolerance realm of skills and activities so basic
DBT premises everything is interconnected when you get up in the morning if you’re having a bad
the day you know you didn’t sleep well your back hurts you’re cranky you got a lot of stuff to do
it’s raining outside you know yay you’re noticing all the negatives your thoughts
maybe more negative you may be more likely to notice the negative you may be more likely to have
what we call commonly call a bad attitude if you start to have a better attitude what happens to
what you observe and we’ll talk about that in a little while the reality is not static what is true
right now in the present may not be true which is you know was the future from what
the present was half a second ago so reality changes when we look at a situation when we look
at an event, we’re looking at how am i reacting and what is my feeling about the situation right now
you know we can learn to change where we’re at but with the information, I have right now what’s
going on and a constantly evolving truth can be found by synthesizing different points of view
because most of the time as humans it’s just kind of part and parcel of being humans we don’t have
the whole picture and I did the best I could with these little graphics here think back if you will
to some of PJ’s experiments when he was trying to demonstrate egocentrism when we’re looking at
this yin and yang sort of model the girl’s stick figure what does she see if you ask her what
color is this orb she would probably say black because we’re assuming she sees the black side
if we ask this little thick figure model over here what color is the orb she’s seeing the white
side so he’d say white now if we asked a little confused guy who is standing kind of on the third
side or the south side he sees both of them so he hears the stick figure girl say it’s black he
sees a stick figure boy say it’s white and he’s going well it’s kind of both you can synthesize
both perspectives and figure out that this is an orb that has multiple colors even though she
can’t necessarily see those colors and he can’t necessarily see those colors so BBT says let’s try
to take a look and see if there are blind spots see if there are things we’re not seeing or things
we didn’t observe the basic assumptions of DBT and well people do their best if we didn’t think
that we probably wouldn’t be in this profession so people are doing their best with the tools they
have and the knowledge they have at any given time and I added that extra part people
want to get better and be happy most people don’t want to be miserable if it seems like they don’t
want to get better then we need to ask ourselves what is the benefit to staying miserable why is
it is scarier more threatening more awful to look at getting better or being happy and that’s one of
those motivational things we’re not going to go there today but in general people are going to
choose the most rewarding option when prevents presented with multiple options okay now this
one area in that I kind of diverge from the official statement is clients need to work harder and be
more motivated to make changes in their lives I’ve had a lot of clients who have been working their
butt off but they may not have the right tools it’s like trying to unscrew something that is
Phillips head with a butter knife they’re working hard but it’s not going anywhere because
they can’t get any traction so I crossed out the work harder and I tend to replace it with work
smarter clients need to work smarter they need to have more tools they need to have more effective
tools and some of the tools they have may be awesome if we just tuned them up a little
bit sharpen their oil and grease them whatever you need to do and be more motivated to make changes
in their life and you’re saying well they’re in therapy they’re coming here for whatever reason
there why aren’t they motivated to make changes well again let’s look back at motivation and what’s
the most rewarding choice is if they tried to make changes before and it hasn’t worked out and
they’ve been told that it was their fault they were being resistant or you know they were blamed
in some way or they just felt disempowered what’s going to make them motivated to try to do that
again please let me run the gauntlet most people don’t want to do that so we need to help
clients work smarter and understand that they are working hard and they need to continue to do so
and we’re going to help them get more effective tools and we need to help them get more motivated
we need to help them see that this time it’s going to be different maybe a little bit different
but this time we’re trying something new it may be different even if people didn’t create their
problems they still must solve yep you know if you grew up in a dysfunctional household you
didn’t create that problem but it is negatively impacting you today so you’re going to have to fix
it if you want to be happy which is the whole goal of the lives of suicidal or addicted
people are unbearable and when we’re talking about DBT we’re generally talking about people
who are highly emotionally reactive and suicidal self-harm those behaviors are away at this point
that they’re trying to figure out how to tolerate what seems like an unbearable situation in their
head addiction is much the same way it provides some relief from something they feel they have no
control over people need to learn how to skillful live skillfully in all areas of their life well
yeah because every area is interconnected if you’re stressed out at work do you just
leave work go home and you have not stressed out anymore no that’s not the way it works it would
be great if it did but it’s just not even if you don’t take all your stresses of work home with you
it has taken a toll on your energy level so when you get home you’re more vulnerable to emotional
upset or just fallen asleep on the couch at 6:00 p.m.
Whatever it is so we need to help people
learn how to live skillfully in each area so the exhaustion or negativity or whatever it is
from one area doesn’t bleed over into the other area so we need to learn how to juggle stresses
in all of our areas to prevent vulnerabilities and people cannot fail in treatment when someone
relapses when someone you know backslides whatever word you want to use I look at it as a learning
the opportunity I say okay you made a different choice than we wanted you to make a different choice than
you were hoping you would make so let’s learn from and figure out why that was the most rewarding
choice than what was on your treatment plan the goal that you’re working toward why what
happened what were you more vulnerable so you didn’t choose the newer behaviors because they
weren’t as readily available let’s use this as a learning opportunity to figure out what’s going
on it’s not a failure it’s a learning moment or a teachable moment so what is emotion regulation
emotional dysregulation will start there results from a combination of high emotional
vulnerability so you’ve got somebody who is kind of reactive and extended time needed to return to
baseline so that when they get upset it takes them longer to de-escalate and get back to baseline
and an inability to regulate or modulate one’s own emotions so I want you to think about some
the time that you’ve been driving on the interstate and you’re just driving along cruising along and
heaven forbid if this has happened I hope not but if it did you’re probably just late a semi comes
along and runs you off the road onto the shoulder and oh my gosh you get onto the shoulder your legs
just to go in like this you can’t even press the gas pedal because you are so stressed out you’re
gripping your knuckles are white from gripping the steering wheel so tight your heart racing you’re
breathing fast you’re in full-out fight-or-flight mode so you went from a1 on the stress meter
you know kind of cruising along aware of the fact that you need to be cognizant of dangers to
a5 of oh crap that could have been bad alright so you take a couple of deep breaths you
your breathing goes down a little bit you get to the point where you can press the gas
pedal and you pull back out onto the highway now are you returning to baseline and just like
la-dee-da cutting around like you were before most likely not you’re a little bit more
on edge and you’re checking your bat rearview mirror more often you’re looking back making
sure nothing’s in your blood spot more awesome so you’re not returning to that same level of less
stress Tunis if you will you stay a little bit elevated because your brain is gone you know I
thought it was kind of a safe situation but I’m realizing now that not so much so I’m going to
keep you on higher alert and it’s going to take longer for you to return to baseline because
you’re looking for those threats now you’re much more aware that it could happen to people who
come from invalidating environment people who are regularly chronically stressed they’re constantly
looking around for anything else that is going to threaten them anything else that’s going to stress
them out so they’re not going from a 1 to a 5 back down to a 1 again they’re going from a 1 to a 5
back down to a 2 and then back up to a 5 and then now we’re only going down to a 3 it’s that
stress is ramping up so we need to figure out how to help people deescalate get back down to that
one and realize okay I got this that was an unpleasant situation but I got this now emotional
vulnerability refers to the situation in which an individual is more emotionally sensitive or
reactive than others or then they normally would be you know some people this is kind of and when
we’re talking about personality disorders this is pervasive when we’re talking about someone who
has been under a bunch of stress for six months this may be a situational sort of thing that we
need to help them figure out how to get out of but it may not be something that is completely
and utterly pervasive in any event when you are stressed you know you’re already kind of on edge
and something happens do you react the normal way that you normally would if you were just like
sitting there and going off oh well okay let’s figure out how to handle this or does it throw
you up sort of into the stratosphere and for a lot of people with emotional dysregulation when
they’re their relaxation is on the brink of chaos so they’re standing there teetering
and they’re going okay I cannot take one more wind or it’s going to push me over and then they
call them damp they get upset and they’re kind of on freefall for a while they get their balance
again but then they’re still right there on that precipice they never come down so what
we want to look at is what’s going on with these people that’s making them more reactive that’s
making them more alert and more hyper-vigilant to stresses and stressors some of these may be
because of differences in the HPA axis which play a role in making people more vulnerable or
reactive and we’re going to talk about the HPA axis in a minute environment of people who are
more emotionally reactive or often invalidating and what does that mean well pick Jane Jane
has had a heck of two years you know there’s just been death after death a job loss
she lost her home she’s living in an apartment right now but she’s not happy and you know yeah
you can just pile stuff on okay so James struggling right now she’s holding on and really
trying to do the next right thing she’s trying to make ends meet trying to do what’s right
by our kids just feeling stressed out and then something happens something that most of us
would react with it to you know it’s annoying but it wouldn’t throw us into utter chaos well James
on that precipice Jane’s already at a four maybe a four and a half depending on the day so when
this happened just that too puts her on a scale of one to five puts her at a
six-and-a-half which is in freefall but people may not understand that they may not understand
what’s going on in Jane’s life and they’re like this is not that big of a deal why are you just
overreacting which makes Jane feel guilty Phil is self-conscious and feels misunderstood so
then she feels isolated and rejected and we’ve talked about basic fears being rejection isolation
failure loss of control and the unknown well James kind of experiencing all of those right now and
the people around her instead of being validating and going okay you were already stressed out I
can see how this was just the straw that broke the camel’s back they’re going what is your
the problem so she doesn’t feel like she’s got social support she’s out there on an island unto
herself so we want to help Jane with emotional regulation because we know she’s up here and we
know she doesn’t like going into that freefall but how do we help her emotional regulation is the
ability to control or influence which emotions you have when you have them and how you experience or
express them and that’s a quote straight out of Linda hands book so emotion regulation prevents
unwanted emotions by reducing vulnerabilities so you can go through life you can go through
the day you can experience stress but instead of feeling overwhelmed or enraged you might feel
mildly irritated for a second and then choose to move on emotion regulation helps people learn how
to change painful emotions once they start so you don’t get stuck nurturing that emotion or feeding
into it and being angry with yourself because you got angry about something you have no control over
it teaches that emotions in and of themselves are not good or bad they just are it’s your brains
hardwired way of responding based on waiting for it the information that it has at this particular
point in time spiders if you’re afraid of spiders that is your brain’s way you see a spider and you
feel fear it’s your brain’s way of going threat spiders can be a poisonous big threat so you want
to get away from it that’s your body’s way your brain’s way of going let’s survive we want to do
this now you can figure out you can learn more about spiders so in the future when you encounter
then you realize that they’re not you know 99% of them are not threatening to humans but right now
at this moment your brain is saying warning getaway you probably want to do that so it teaches
that emotions internet themselves are just prompting us to do something they are survival
responses and suppressing them makes things worse telling yourself I shouldn’t feel afraid does that
do any good if your kid comes to you and tells you that you know I’m having a crappy day or I
hate this does it usually do any good to tell them well you shouldn’t feel that way feel better you
know just be happy does that work I’ve never had an experience where that worked now it may work
for some people but so we want to help people identify their emotions and not get consumed
by the emotions are effective when acting on the emotion is in your best interest so sometimes
it’s in your best interest expressing your emotion gets you closer to your ultimate goals sometimes
expressing your emotion gets you closer to your short-term goals like making the pain stop
and true pain is unpleasant however in the big scheme of things 15 minutes from now 3 hours
from now is that getting you closer to the goals that you want to achieve or was it just a
stopgap expressing your emotions will influence others in ways that will help you so if you want
to influence others in ways that are positive and will help you then emotions can be very kinder
that can be very helpful emotions are sending you an important message and we already talked about
that so I’m thinking the devil’s advocate amigos well I can think of a client that goes you rage
is a great emotion to express is it in my best interest yeah gets people to leave me the heck
alone does it get me closer to my ultimate goals yeah it reduces my stress by getting people to
leave me the heck alone will it influence others in ways that will help you, yeah it make them
go away and are these emotions sending you an important message yet rage is telling me that
these people like everybody are a threat to me so in the short term when you look at it that
way it can be tricky to see but we want to help people get outside of this immediate threat and
say where you want to be what happiness looks like to you or however you want to define
that ultimate goal and then once you get into distress tolerance was your Thursday talk about
how do you endure unpleasant emotions so you don’t take the stopgap route now on to our favorite
HPA axis the hypothalamic-pituitary-adrenal axis is our central stress response system and doesn’t
get too caught up and all the psychobiology of this I think it’s good to be cognizant of but
we’re not prescribing hypothalamus place in the brain release is a compound
called corticotropin-releasing factor or CRF which triggers the release of adrenocorticotropic
hormone from the pituitary gland which triggers the adrenal glands to release stress hormones
particularly cortisol and adrenaline now your adrenal glands are actually on your
kidneys and why is that important what I want you to see or understand is there are a lot of systems
involved there are a lot of hormones involved there’s a lot of stuff involved it’s not just box
you know you’re releasing a bunch of chemicals in your body that are altering the neurochemicals
and the other hormones to prepare you for spiders the adrenals control chemical reactions over large
parts of your body including the fight-or-flight response and produce even more hormones than
the pituitary gland so you’ve got these adrenals this is kind of your stress area if you will it
produces steroid hormones like cortisol which is a gluteal corticoid which means it makes your
body release glucose what we know is that glucose is blood sugar energy all right so it increases the
availability of glucose and fats for the long-term fight-or-flight reaction it also produces sex
hormones like DHEA and estrogen okay why is that important because we know that when estrogen
goes up serotonin availability goes up so if there are the adrenals are busy doing something
else it may cause other hormonal imbalances and it also produces stress hormones like adrenaline
that is going to ramp you up they’re going to increase your respiration increase your heart rate
all that kind of stuff so once you have that whole reaction we talked about and the perceived threat
passes cortisol levels return to normal great this is what happens in the ideal situation but what if
the threat never passes what if we’re working with a client who is constantly fearing rejection
and isolation they need external validation because they don’t feel good enough as they are
they don’t have social support because their emotional reactivity kind of pushes everybody
away so they’re constantly feeling this threat of rejection isolation failures loss of control
and the unknown they’re holding on just like you were holding on to the steering wheel after you
ran off the road and you got back on you know you kept chugging because you wanted to get to
your destination but you were scared witless okay so you’re chugging along what’s going
on what’s going on in that body the amygdala and the hippocampus are intertwined with the
stress response the amygdala modulates anger fear or fighter flight and the hippocampus helps
to develop and store memories when you’re under stress and think about a time when you are under
a lot of stress were you effective at learning and paying attention to the good things and the bad
things or were you just trying to make the pain stop and make the threat go away from the brain of the
child or adolescent is particularly vulnerable because of its high state of plasticity which is
why do we see people who tend to have personality disorders much of their trauma and stuff really
started early in their development and which is why it’s pervasive in every area or many areas
of their life, bad things are learned emotional upset prevent learning new positive things to
counterbalance it if you’re in a bad mood if you’re scared if you’re threatened you know if
you’re hungry homeless put whatever stuff is there are you paying attention to the
bluebirds that are flying around and singing pretty songs or are you paying attention
to the fact that you got an a on a test maybe not so, we need to understand this person who lives
in a chronically stressful environment may also have an overactive HPA axis so they’re already
they’ve already got some adrenaline and cortisol going on they live kind of in this state
of hyper-vigilance and then something happens and they’re just like through the roof kind of like
when you scare a cat what happens to the brain one is a chronic threat to its safety and a constant
the underlay of anxiety is constant undercurrent as it learns your brain forces synaptic connections
from experience and pruned away connections that aren’t utilized by people who feel a lack of control
over their environment are particularly vulnerable to excessive stimulation of the stress response
now it’s not just children abuse and neglected children pop right up there but abuse and
neglected adults think about a client you’ve worked with who’s been in an abusive relationship
for years does she have all the happy connections or is she pretty much terrified exhausted and
stressed out most of the time adults with anxiety or depressive disorders it doesn’t even
have to be an abusive or neglectful situation if you have someone that forever whatever reason has
clinical anxiety or depressive symptoms they are in this state of constant threat and constant of
people if you will so they’re not seeing they’re not able to learn and take in as much of the
good stuff so there’s more bad stuff coming in they’re paying attention to more of the bad stuff
or unpleasant stuff the synaptic connections that form the foundation of people’s schema of
themselves in the world become skewed towards the traumatic event at the expense of a synaptic
Network-based on positive experiences and healthy relationships so we had this client here and these
are her negative experiences she has a lot of them and she’s got these going through her head a lot
and it’s not they don’t just go away whenever she meets somebody and she’s like well they’re going
to leave me whenever something happened she feels isolated and alone she may fear so she’s got
really strong connections to those memories and past experiences and when you’re in the midst
of all this, there’s not a lot of happy stuff and even when she appears happy a lot of times she’s
faking it she’s not seeing and remembering all the happy stuff she just wants to avoid the pain
another example I could give you is thinking about a city planner now a city planner only has a
the certain budget just like we only have a certain amount of energy the city planner looks and says
what roads and what connections between cities get the most traffic and let’s devote our resources
and strengthen those connections because we know we’ve got all kinds of traffic going over there
and those roads that don’t travel those back roads we don’t need to pay much attention to
them right now because we need to make sure that those roads that are used the most are strong
but that’s the best analogy I can give without putting out strings and everything else but so
the hyper-vigilant state active IDEs activated by the stress response that disrupts our ability
to focus and learn you know we’re just trying to not die we’re trying to not be consumed by pain
it impairs the ability to form new memories and recall information due to the physiologic changes
in the hippocampus, it’s not time to learn and process and do all that kind of stuff have you
ever tried to study for a test when you had 16 other things going on that you are stressed about
how well did you remember this stuff over here sometimes people relate things to prior experience
well most of the time so maybe they’ve had a lot of dysfunctional relationships and they start to
get in a relationship which side is going to be triggered the negative memories are the positive
memories and then you have somebody who may be attached to some positive relationships they start to
get into a relationship and they remember some of the positives because there have been some really
good relationships but you know they may remember the negative too but most likely they’re going
to remember more strongly the positive so what’s their reaction going to be if we’re trying to help
our clients develop a healthy support system we need to help them address some of those highways
that are going towards the negative memories emotion regulation is transdiagnostic or useful
with many disorders it helps people increase their present focused emotion awareness it says right
now right here right now what are your feelings what are your physical sensations what are your
thoughts and what are your urges it helps people increase cognitive flexibility because it helps
the kind of step back and take a look and say okay what are my options let me step back from
being intertwined with this feeling and go okay I feel angry got it what are my options here what
do I usually do what I want to do when I’m on autopilot what are some other options I could
do that might help me move toward where I want to go identifying and preventing patterns of emotion
avoidance and emotion-driven behaviors we don’t want to get into the situation of constantly trying
to avoid unpleasant emotions by lashing out by hurting ourselves or by doing things reactively
when I feel this way I must smoke a cigarette I must cut myself I must fill in the blank we want
to help people find alternate ways and be able to step back and say that is an option is it the
option I want to choose today increasing awareness and tolerance of emotion-related physical
sensations sometimes these physical sensations are just so powerful and so overwhelming and
sometimes the rush of adrenaline and that foggy wibbly-wobbly feeling you get in your head when
you have just adrenaline coursing through your veins is so overwhelming that people don’t know
what to do with it and are afraid it won’t stop so let’s help them increase their awareness and
tolerance of this helped them understand that it passes and use emotion-focused exposure procedures
when they get upset help them think about things in the group sessions that get them a little bit
revved up you know we don’t want to precipitate a full-scale crisis or talk about something that
happened last week that got them upset and let’s apply these procedures emotional behavior is
functional to change the behavior it’s necessary to identify the functions and reinforcers of the
behavior so when they did it you know let’s talk about cutting because you know that is one of
those behaviors that we see are self-injury it’s what is the function of that behavior cutting
or self-injury is a way of inflicting physical pain where the person has control and they focus
on that and they feel a sense of mastery when the stuff going on in their head feels completely
uncontrollable and intolerable it diverts their attention and it also is something that they
they can control how much pain they’re in so that’s how it’s functioning now is the best
the response we want no but we can see why somebody might engage in that behavior and what reinforces that
behavior well when they do that not only do they get a reprieve from this emotional turmoil that
they don’t feel like they can touch or control or do anything with but their body also releases
endorphins release natural painkillers to kill that physical pain which makes them feel a little
a bit better so they’ve got kind of a double whammy on reinforcers there so we understand that
now we need to find something else that they can do and help them figure out how to tolerate
the turmoil emotions function to communicate to others and influence and control their behaviors
and serve as an alert or an alarm to motivate one’s behaviors so let’s talk about the first
one communicate to others so I’m communicating to a rat around me the people around me through my
emotions what’s going on if I’m angry I’m lashing out I’m going to influence people’s behavior and
they’re probably going to back off if I am sad or crying or scared that might bring them closer
and in a more supportive sort of thing you know again you’ve got to look at some of the behavior
self-injury can elicit a caretaking response but these emotions before somebody start
acting out the behaviors the emotions serve as a cue that okay Sally is getting ready to go in
free fall so they can start reacting sooner and it serves as an alert or an alarm to the person to
motivate their behaviors if they know you’re on the precipice if you know you’re right on the
edge of being vulnerable cranky being irritable that day can motivate your own
behaviors to figure out how to reduce some of your vulnerabilities and identify obstacles to
changing emotions now we can’t just say be happy and all of a sudden somebody’s like oh I
don’t know why I didn’t think of that I’m just going to go ahead and be happy that’s just not
how it works we want to look at organic factors do they have an organic long-standing chemical
imbalance of some sort and it may not be neurochemical it may be hormonal they may have too
much estrogen too much testosterone too little estrogen too little testosterone whatever let’s
figure out you know have them go see their doctor and figure out if there is something fibroids
or moans whatever that might be affecting their mood okay once we identify anything that we can
tweak there we can’t measure neurotransmitters we’re out of luck there because they’re found
in so many places in the body that there’s no way to isolate how much serotonin is actually
in the brain can’t do it yes we want to look at other factors that are biological imbalances
neurochemical imbalances that are caused by chronic stress that cause addiction to sleep
deprivation and nutritional problems so what sort of chemical imbalances are we precipitating
by keeping the stress going and keeping the adrenaline going keeping your body revved up
all the time we want to look at obstacles well let me stay with biological factors here real
quick the organic things if we can refer to the physician and we can figure out ways to address
those that give the person one step forward so they’re not feeling as depressed or they’re not
feeling as reactive people with hyperthyroid you know when their thyroid is overactive may have
some anxiety issues or some other mood issues that can be addressed with medication then we
Looking at situationally caused things is the ways we can help them reduce their chronic stress
sometimes there are some easy right-now sort of solutions other times but chronic stress comes
from issues that are so long-standing it’s going to take a while it’s not that we can’t do it but
it’s going to be a process so we move on and we say okay addiction we know that when people use
stimulants rev them up and then they crash and it makes them more than emotional yo-yo caused
by the substances or the addictive behaviors also makes them more vulnerable to emotional
reactivity sleep deprivation is all kinds of hormones out of whack and tends to make people more
irritable that’s one almost everybody can look at addressing right now and nutritional problems
if they’re not eating well not eating at all encourage them to see a nutritionist to
make sure they’re getting something balanced that they will adhere to not something that
they look at and go yeah that looks great but no way I’m eating nuts skill factors what can we help
they with we can identify cognitive responses that are obstacles which as I can’t do that
I won’t do that resistance in some way my response to that obstacle is set to look at it and weigh
the positives and the negatives do a decisional balance exercise to address the cognitive
responses and figure out why is the dysfunctional or unhelpful reaction more rewarding why is it
more rewarding to be angry or scared than to look at doing things and thinking of things that will
help you feel happier what’s the disconnect generally, it comes back to prior failures and fear of
failure because they’ve been down that road before and it’s such a letdown when they’re feeling
good for like three weeks and then they crash behavioral responses that are obstacles to
changing emotions if somebody lashes out when they get upset they lash out and throw things
and then they feel guilty so this behavioral response may lead to having more difficulty
changing emotions because we’ve got to help them figure out how to pause before the behavioral
the response so they don’t compound the situation with more negative emotions and environmental factors
people places and things being in environments where you’re surrounded by people who either agon
negativity or who bring out you know they’re there with you they’re talking about conspiracy theories
they’re just negative about everything or they’re critical of you or remind you of situations where
you’ve been criticized before so first, we want to help people identify and label emotions a lot
of our clients are relatively Alex Simon you know they have a small repertoire if any of
noting their emotions they just generally go from situation to reaction and label what they
felt is kind of a mystery so we want to help them and doing it retrospectively is fine at first
because that’s probably all you’re going to be able to get the event profiting the emotion what
were your thoughts your physical sensations and your urges help me describe this in enough detail
that if we were going to give it to an actor or an actress they could recreate the situation what
expressive behaviors were associated with that emotion you know did you cry did you throw
things did you hit the wall what were your interpretations of that event at the moment not
retrospectively but at the moment what were your interpretations of what was going on
what history before the event increases your vulnerability to emotional dysregulation lots
of big words what happened before that that already stressed you out or had you on edge
and you know we go through a whole bunch of different things and this is you know behavior
chaining we’re looking at kind of what led up to the event what made you more vulnerable and what
were you feeling at that time and then what were the after-effects of the emotion or the reaction
on your other types of functioning so after this event and you went into freefall and you got angry
and you lashed out and you screamed and you threw things how did that affect your work how did that
affect your relationships with your family how did that affect your mood and just generally your
sense of being in yourself for the rest of the day changing unwanted emotions okay so we started
labeling them we figure out what we’re feeling we figure out that yeah when we feel that way
we act in ways that you know make us feel worse afterward what do we do about it let’s change
All alright we already talked about the obstacles and we’re trying to address those but in a moment
check for facts ask yourself what are the facts for and against your belief if you believe that
someone did something to be antagonistic towards you okay what was their motivation what is the
facts for and against that also ask yourself is this emotional or factual reasoning am I making
a decision based on how I felt I felt attacked therefore I must have been being attacked or
facts you know I felt attacked yes but that was because this person said ABCDE and all of those
were very attacking and I felt like I needed to defend myself so those are to check the facts sort
of steps or you can go with problem-solving so let’s change the situation that’s called cause
any unpleasant emotion like I said with spiders at the moment you may not have enough information
to not feel scared but maybe your spouse loves hiking and camping and you want to go but
you’re afraid of those aren’t spiders so how can you change the situation so spiders don’t
trigger that same reaction increase knowledge increase exposure there are a lot of different
ways but problem-solving says ok what can I do so my reaction my correct reaction is not one of
threat or anger but it is one of at least mild acceptance prevent vulnerabilities which helps
reduce reactivity if you are a hundred percent you know you get up and you’re like this is going
to be a good day to day things that come your way are probably going to roll more like water off a
duck’s back then smack you upside the face like a mud pie so we want to prevent vulnerabilities from the turn
down the stress response because when you’re not when you’re not up here already then you know
you can fluctuate a little bit more and they help the person be aware of and able to learn and
remember positive experiences so if you turn down that vulnerability and somebody’s in a good place
or a better place than they were at least they’re going to be able to notice and we’re going to
want to encourage them to notice the positive experiences you know instead of thinking that all
people are threatening all people are going to hurt me all people are going to leave they might
notice that you know there’s Sally over here who’s worked here for 15 years with me and you know
she’s there she sometimes calls in sick but then she comes back she’s generally in a good mood
you know she’s not such a bad person and you start noticing some of the things that are
not self-fulfilling processes building mastery through activities that build self-efficacy
self-control and competence smuggle we don’t want to say you don’t want to set a goal
where somebody needs to go an entire week without having an emotionally reactive response let’s
say go for hours or maybe even a whole day that would be wonderful but first, we’ve got to talk
about how to reduce those vulnerabilities so we set the person up for success what things can you
do and well and we’re going to get down here in a minute what can you do if you wake up and you’re
feeling vulnerable you know the creepy crowds are going around they cancel school
for the entire week for school the county school system kids are off for an entire week
because of illness right now but you wake up in the morning and you’ve got a fever and a sore
the throat you’re like I don’t want to go to work and get out of bed today what can you do
to prevent being grumpy and overly reactive throughout the day’s mental rehearsal and this can
go for if you’re getting ready to do something scary or threatening seeing yourself do that and
do it successfully and this can even be during the day just envisioning yourself getting up and eating
your breakfast driving to work going through your day seeing that one person at the office that
always has some sort of snarky comment to say or whatever irritates you laughing at it or dealing
with it just fine going through everything in your day as you would like to see it happen envision it
see see what you can do rehearse it rehearse how to handle negativity you know if you know you’re
going to have to go in for your annual evaluation with your boss okay so mentally rehearse how it’s
going to go how are you going to react what’s going to happen so you’re prepared for it you have
your responses and it takes some of the unknown out of the situation physical body mind care pain
and illness treatment and the acronym for this is please I changed one of them to laughter
it used to be physical illness and that was both PNL but I like laughter anyway we’ll get there
when you’re in pain or when you’re sick you’re vulnerable to being a little bit cranky you know
that’s just because your body is already saying you are weak you know back in the day when you had to
defend yourself against predators the sick ones and the ones that were in pain were the ones
that usually got taken out first as a part of our brain that still remembers that for whatever
the reason so when we’re in pain or when we’re sick our body keeps that cortisol keeps our cortisol
levels higher and the stress response a little bit higher so we want to deal with those things but
know if we wake up and we’re in that situation moment that was a little bit more vulnerable
so we need to handle it with care and laughter you can’t be miserable and happy at the same time laughter
releases endorphins laughter helps people feel a little bit better and find something to laugh at
and have on my phone I keep comedy skits every once in a while I’ll just pop one in even if
I’m not having a bad day pop it in because I like to laugh eat two-sport mental and physical
health avoid addictive or mood-altering drugs or behaviors that are going to put you on that
the up-and-down roller coaster that goes up and it goes even further down than you were when you
started to get adequate quality sleep and exercise also helps increase serotonin and release
endorphins which help people be in a better mood mindfulness is a judgemental observation and
description of the current emotions we’re not going to go deep into this right now
another class on mindfulness and you can also google it remembering that primary emotions
are often adaptive and appropriate I know I said that like six times much emotional distress
is a result of your secondary responses shame over having it I shouldn’t feel this way anxiety
about being wrong you know maybe this is the wrong way to respond or you know what if
I’m wrong about this or rage doing due to feeling judged for feeling that way I feel this way
and you’re telling me I shouldn’t how dare you so mindfulness is kind of an exposure technique
because it helps people identify that yes I feel that way but it helps them learn to step back and
figure out how to not judge that and just go okay I feel that way better or worse whatever that’s how I
feel exposure to intense emotions without negative consequences that non-judgmental acceptance just
going all right is what extinguishes the secondary emotional responses of feeling guilty
about it or feeling ashamed or angry at yourself for being angry so think of it this way if you
can’t see this one’s the best Bruce Lee picture I could come up with scenario one is an unpleasant
experience the person has an unpleasant emotion and then feels guilt shame or anger for feeling that
an emotion so instead of having to deal with one emotion one-on-one now you’re having to fight for
different unpleasant emotions and you start acting to try to stop the avalanche of negativity in the
absence of adequate skills now Bruce Lee he was able to take out four or five at a time but most
of us you know we would be beaten because all of these adversaries would be coming at us and
we would be building on them in scenario two and this is where we want people to get they have an
unpleasant experience which is part of life they identify unpleasant emotions again part of
life is sucky but part but they can deal with one emotion they’re like okay I’m
angry what do I do about it instead of I’m angry what do I do about it and I’m guilty and you
see how you know she’s got this she can take that one emotion so what we’re helping people do is
uncomplicated this regulation is common to many disorders people with dysregulated emotions
have a stronger and longer-lasting response to stimuli yes they’re already kind of stressed
out they’re already hyper-vigilant if you want to say they’re already wound up a little bit and
then something happens and it amps for months now we have a scale of 1 to 5 if they’re already on
a 4 and it amps them up 2 points they’ve fallen off the scale they’re in freefall so we need to
understand that what we perceive as an excessive emotional reaction they may not have been starting
from the same place that we were, we’re starting from a 1 if they’re starting from a 4 you know
then their reaction to the same thing you seemed pretty reasonable emotional dysregulation is often
punished or invalidated and increases hopelessness and isolation emotional regulation means we help
people use mindfulness to be aware of and reduce their vulnerabilities so we help them take it so
they’re not at a 4 there may be a 2 you know they’re in therapy for a reason we’re going to
help them work on the other stuff and get them down to a 1 but right now let’s help them figure
out ways, they can take down their stress response take down their just underlying anxiety, and stuff
identify the function and reinforcers for current emotions when they happen was understand where
they came from because they’re functional do that chaining worksheet check for facts ok now that
I know how I feel I know what my reactions are I know what my thoughts are I know what my urges
are let’s check the facts in the situation for and against that forces people to kind of step
back which lets the urge sail out some and then problem-solves what can I do right now to improve
the situation and what can I do in the future so I don’t necessarily experience this exact
the same situation again how can I break that mold okay so emotion regulation doesn’t provide us
with a whole lot of distress tolerance skills, emotion regulation is really about preventing
vulnerabilities and helping people figure out okay here’s where I’m at how do I pause so then
I can choose from my disgust distress tolerance problem-solving or interpersonal effectiveness
skills but it’s a big step how awesome would it be if you could eliminate some of your
vulnerabilities and think about it just for a minute or two what vulnerabilities you’ve
got going on in you right now and how many of those you know could you potentially over
the next week or two kinds of address sleeping and eating maybe you have 16 things going on
and you could pare it down to eight there are a lot of different things that you might
be able to kind of pull out of the rabbit hat if you will and what kind of a difference
would it make if you’re talking to your staff and looked around at your organizational environment
what vulnerabilities are there environmental vulnerabilities physical vulnerabilities my best
friend’s working somewhere right now where pretty much everybody is required to work doubles because
they are so short-staffed they’re going to start getting vulnerable pretty soon so look around
what can you do to moderate that so they can model effective emotional regulation but they
can also not be emotionally dysregulated by a client who has emotional dysregulation issues all
right so that concludes our discussion today if you have any questions I would love to hear them
if you want to discuss that’s awesome if you want to get on to your next client you know I totally
understand that I want to wish everybody a happy Valentine’s Day for me I don’t particularly pay
a lot of attention to Valentine’s Day but it is the eve before half-price chocolates
and that is my kind of my kind a day you you you you if you enjoyed 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.
Schneider I subscribing at all CEUs comm slash counselor
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As found on YouTubeHi, 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…
Welcome to happiness isn’t brain surgery
with Dr. Snipes. This podcast was created to provide you
the information and tools Doc Snipes gives her clients so that you too can
start living happier. Our website DocSnipes.com has even more resources
videos and handouts and even interactive sessions with Doc Snipes to help you
apply what you learn. Go to DocSnipes.com to learn more. Hey everybody and
Welcome to happiness isn’t brain surgery with Doc Snipes: Practical tools to
improve your mood and quality of life. Tonight we’re talking about 10 ways to
deal with social anxiety a lot of people have social anxiety and that’s basically
having unreasonable fears that you know are kind of excessive when it comes to
being in any kind of social situation some people have only social anxiety
when they’ve got to do things like perform or public speaking or something
like that other people have social anxiety when they have to go to work
when they have to be in crowds they don’t like going to the shopping center
or the mall where there are a lot of people around so depending on your level
of social anxiety, some of these things may be helpful to help you work through
and deal with your social anxiety the first is to minimize stimulants
stimulants Reb you up anxiety Rebs you up when you take stimulants if
you drink too much coffee you may feel anxious so if you’re drinking stimulants
before you go into an anxiety-provoking situation you may miss attributing your
anxiety about the social situation when in actuality it was the caffeine or the
nicotine the other thing that you want to do is pay attention when you’re at
some of these events that you’re minimizing your stimulants the other
thing and I’ll you know this is not stimulant alcohol is technically a
depressant but when alcohol starts to wear off about it 30 minutes after you
drink your drink it starts to wear off and there’s an anxiety rebound with
alcohol so if you have high anxiety if you have social anxiety drinking to
quell that anxiety is probably not your best
bet because in the end it’s gonna kind of backfire and bite you in the ass know
your temperament not everybody likes being around big groups of people
I draw energy from being around people so I love being around
groups but my daughter on the other hand is much more of an introvert and she
would prefer to be around you know two or three people at a time she gets
exhausted when she has to be in big groups of people it doesn’t mean
she’s got social anxiety so know what your preference is for being around
people so when you’re developing your self-confidence when you’re developing
your skills when you’re working through social anxiety you’re not putting
yourself in situations that would stress you out anyway so know your temperament
if you’re an introvert when you’re making your exposure hierarchy which
we’re going to talk about it in a minute you’re gonna start with something like
going out for coffee with a friend to Starbucks or maybe even having a friend
over for coffee in your house depending on how bad your social anxiety is and
then you’re gonna work up from there but if you are an introvert you’re never
gonna be relaxed in a group of a large group of people so I just
understanding the difference between being anxious and feeling like
you’re gonna crawl out of your skin and be uncomfortable or have it be very
draining to be in a large group of people who understand your temperament
that’s part of it so you can say you know this is normal I am not the type of
a person who likes to be in a large group of people so it’s going to take some
preparation and it’s going to take a lot of energy but I can do it knowing your
triggers different things trigger anxiety for different people some people
have anxiety when they feel like they’re going to be evaluated so if they’re
doing a presentation for their colleagues or their peers they’re more
likely to be more anxious than if they’re say hanging out with five other parents at a
kid’s play date or something some people have one of their triggers is
authority figures I know whenever I had to present in front of the CEO or in
front of my department chair or whoever gave me more anxiety than
presenting even in front of a class of a hundred and fifty students so it’s kind
of all about what your particular triggers are if the other trigger you
might want to consider the situation you know if you feel like you are on
stage if you feel like you are the center and everybody’s looking at you
that’s probably going to be a lot more anxiety-provoking than if you are mixing
and mingling with other people at a party so know what triggers your anxiety
so thinking about how your social anxiety impacts your life what kinds of
things can you not do or what kinds of things do you find are just terrifying
to keep a list of all of those things starting with the things that only make
you a little bit nervous about things that you would rather you know pull your
eyebrows out then do and start at the beginning start with the things that
only cause you a little bit of anxiety imagine them rehearsing and doing them
in your mind see yourself going through them successfully for example a job
interview or a first date imagine what it’s going to be like what the other
a person is going to say how you’re going to respond and how it’s all going to go
well just keep imagining that until you can imagine it or think about it and you
don’t feel stressed than when you go in to do it it’s going to be a lot easier
once you get past that first thing move on to the next thing that causes a
little bit more anxiety all right start at the beginning again imagine doing it
see yourself going all the way through maybe it’s doing a public speech see
yourself getting dressed for it getting ready for walking out on stage and
delivering the speech and seeing it go well you’re not going to see yourself
tripping and falling you’re not going to see yourself stuttering and stammering
or dropping all your note cards or anything those are the things the cat
strophic thoughts that you have that are likely not going to happen I want you to
imagine it going perfectly rehearse it in your mind until you can do it
literally with your eyes closed then when you go out to do it, it’s going to
be that much easier because you’ve already done it 20 times in your own
head and been successful at it so just do it like you practiced keep a rational
outlook a lot of times social anxiety is caused by catastrophic self-statements
things that you tell yourself people are judging me they’re laughing at me
people are gonna think I’m an idiot um whatever your thoughts are so keep a
list what those thoughts are and write counter thoughts to the people
are judging me well they may be but do you care so if people are judging me
that’s on them if people are laughing at me well at least they’re laughing but in
reality what other reasons could the people have had to be laughing what are
three other explanations for why they might be laughing besides laughing at
you so look at your catastrophic self
statements like I told you before imagining that you’re going to go
out on stage and you’re gonna walk out there you’re gonna trip over your own
two feet and you’re gonna wipe out on the way to do this presentation and
humiliate yourself well that’s pretty darn catastrophic so think about exactly
what is going to happen what are you going to do and how rational how
realistic how likely is it that all these things are gonna happen and you
know if that is one of your fears watch the movie Miss Congeniality because she
is going at as Miss America I think is who she’s trying to portray and she
falls flat on her face and she just picks herself right back up and walks on
and nobody thinks anything of it after that it’s not like a week later or 20
minutes later in the movie, people are still talking about her falling she
did she over it and you know move past it when
you make a big deal out of it when people start to think about it a little
bit more practice breathing when we get stressed we tend to breathe more
shallowly and more rapidly when you breathe slowly and deeply you’re
triggering the relaxation response in your body it doesn’t mean you have to
take those big giant deep breaths as you do at the doctor’s office or
anything that’s overly dramas is it but focus on your breathing if you start
feeling yourself getting an anxious breath in for a count of three hold for a count
of three and breathe out for a count of three and you know again it doesn’t have
to be noticeable that you’re doing it you can do it in a meeting and nobody
will even know but if you can slow your breathing you’ll slow your heart rate
and you’ll trigger the relaxation response to help you deal with your
anxiety sometimes we’ve just got to suck it up and go through things that create
a lot of anxiety for us I remember one place I worked once a month we would
have to get up in front of all of our colleagues and all of the executives and
give a report on how our department was doing I hated doing that I hated being
up there giving this report not because of the content of the report I just
hated being up there in front of everybody and it was no big deal
but it would cause me a little bit of anxiety if I had to do it
so distress tolerance techniques were always useful because it was an
eight-hour meeting so it might be four hours of me sitting there anticipating
going up and having to give my speech so what would I do during the four hours
while I was waiting I would do activities I would listen to what other
people were saying I would make notes I would sometimes go through clinical
charts and sign off on documentation and not pay attention but you know I digress
contributing so if you’re at a party you can’t do it in a meeting but if
you’re at a party for example and used feeling anxious get up maybe help the
hostess out or the host out in the kitchen go around pick up glasses pick
up trash throw things away do something to be helpful to contribute so you’re
not feeling like you’re having to sit there and be on the spot comparisons can
help too you can just kind of blend back into the wall a little bit and compare
how you’re doing to how other people are doing or how you’re doing to how you’ve
done in the past because you’re probably doing better now than you did then
trigger opposite emotions is another way of dealing with distress if you’re
feeling anxious you know bring out the opposite tell a joke find something
funny find a video or something that makes you laugh and share it with other
people because that’ll make you start laughing and feel more relaxed and
release endorphins you can also just push away some of those thoughts that
keep coming into your head I’m gonna make a mistake I’m gonna say something
stupid they’re judging me it’s gonna be awful just push those thoughts away and
Do you know what no I can do this and I’m going to push through the final
the thing you can do in this particular set of distress tolerance techniques is
sensations focus on sensations some people have a rubber band that they snap
on their wrists to kind of help them focus on something else
some people wring their hands I don’t recommend that because you know that
just kind of shows you’re anxious and keeps your anxiety going listening to
loud music you can go into the bathroom and splash cold water on your face
unless it’ll make your mascara run there are a variety of things you can do that you
can also find go and find some coffee because coffee is hot and that focus on
how the coffee feels in your hands when you’re holding the cup focus on the
taste of the coffee that hot sensation will kind of distract you from other
things that are going on so focus and we’re going to talk about one thing at a
time in a minute another set of distress tolerance techniques that can help our
imagery and we’ve talked about rehearsing it before you go to the party
imagine what you’re going to do before you go to the mixer or your in-laws
or wherever it is you’re going that’s potentially going to cause you anxiety
imagine going through it and doing it successfully to find meaning in what you’re
doing so sometimes you know maybe you’re going to your spouse’s holiday Christmas
party and it’s like the last thing you want to do because you don’t like big
crowds like that you don’t know anybody but find meaning in it why are you doing
this is because it’s helpful to your spouse you’re providing support and you know
maybe you can find somebody that has similar hobbies or something before you
go if you’re going to your spouse’s Christmas party for example try to find
out who might be at the party that shares similar hobbies and stuff I know
my husband works with people who do organic gardening and who are kind of
health-conscious I won’t say fanatical but health-conscious like I am and we
like to use a lot of lentils and beans and cook in health healthy ways so
identifying those people I can’t talk about what they do at work because
that’s just way out of my wheelhouse and over my head but I can talk with them
about these other things so I’m not just standing there looking around and feeling
like I’m out of place so find meaning in what you’re doing and try to find
connections and commonalities with other people before you go and then you know I
can have I would have my spouse introduce me to one of the people that
does organic gardening for example and then we could start talking once you get
more comfortable then you’re going to feel more at ease walking up to people
and going hey you know and striking up a conversation and finding out
commonalities if you’ve got children a lot of other people have children so
you can talk about your kids or if you’ve got pets you can talk about your
pets your dog’s people love their dog’s prayer can help sometimes you
just got to take a breath and say a prayer before you walk into that
situation to kind of get you through and get you going
practice relaxation if you’re feeling stressed just again don’t
have to get out of your chair you don’t have to go anywhere but practice tensing
and releasing your muscles clenching your fists and releasing your hands and feel
the difference between tense and released and then tense kind of your
whole upper body and you don’t have to do it like this because that’s obvious
but you can kind of tense up a little bit and relax and feel the difference
between stressed and relaxed and then when you do it one more time you tense
and when you relaxed you feel all the stress just draining out of your body
out of your fingertips so that’s a kind of guided relaxation to help you when
you’re kind of on the spot one thing at a time when you’re in a
the social situation there is a lot of input there is a lot of stimulus going around
a lot of people focus on one thing at a time if you start getting overwhelmed if
you’re at a party maybe you can go over and get something to eat and focus on
talking to one person at a time or focusing on what you’re eating or you know find
something that you can focus on so you’re not trying to keep up with
everything that’s going on takes a mental vacation or a physical vacation
sometimes you just got to excuse yourself and go to the bathroom and hide
out for five minutes and that’s okay you know sometimes you need to go somewhere
where you know nobody’s watching and you can take those good deep breaths and go
you know I got this it’s gonna be okay I’m doing fine give yourself a pep talk
look realistically over how the night’s gone and the majority of it has gone
okay yeah they’re probably going to be some hiccups and Pho paws here and there
and if there are that’s okay it happens to everybody nobody is perfect at their
social interactions all the time and that’s okay
but look over it realistically to realize that tonight is going
okay it may not be going the way you had hoped it would but it’s going okay
there’s nothing catastrophic ly wrong and remember that we are a lot more
important in our minds than we are in anybody else’s mind so when we make a
the mistake we will remember it for six months but other people probably forget
it’s about sixty minutes later it’s just you know even if it’s something like you
walked out of the bathroom and you had your dress tucked in the back your
panties did that before trusting me not something I want to repeat
but I would bet if I asked any of my staff now yes I did it at work about
that incident they’d look at me and go no I don’t remember that I remember it
because it was mortifying but nobody else cared they were passed it by
the next day nobody thought anything about it so remember that a lot
of stuff that seems huge and glaring to you is only because it happened to you
and other people are so involved in their own life they probably didn’t
notice or won’t remember that fear is an acronym standing for false
evidence appearing real so always examine the evidence if
something happens and you think it is the absolute worst thing in the world
and you’re just gonna die how likely is it that that’s true is it the worst
the thing in the world is people judging you so look at the evidence how do you
know this is going on for certain and what are other explanations for what
might be going on mentally rehearsing those stressful social situations get
ready for it the job interview the first date and for some people even going to
the doctor can be a stressful social situation because they get kind of a
white coat syndrome where they don’t they’re afraid to speak up to their
doctor, I found that if there is a certain set of things that you need to
say like if you’re going in to talk to your boss or you’re going in to talk to
your doctor sometimes it’s helpful to write down a list of the points that you
want to cover with them or the symptoms that you’re having
so you can go over it and make sure you get everything said and you don’t end up
kind of getting shut down when I used to go have supervision with my boss you
know I only got supervision for one hour once a week and that was if I was lucky
so I would go in with a whole laundry list of things and it could be the stuff
that I was upset about or having difficulty with and I could have a
laundry list and just go through it and mark it off so I would make sure that I
got everything said and I covered and we were on the same page by the end of the
the meeting finally practice mindfulness and focus on your surroundings to know how you
feel if you start feeling anxious a step back and ask yourself why am I anxious
what do I need right now to feel calmer try to do this periodically
so you don’t wait until your anxiety is off-the-charts focus on your
surroundings look around to find places and little niches that you might feel
comfortable maybe there’s somebody else sitting over in the corner and you can
go sit down with them and chat maybe there’s an empty seat somewhere that you
can just go sit down and take a breath or go out on if it’s a patio or a party
maybe you can go out on the patio for a few minutes oftentimes there’s somebody
sitting out on the patio trying to get a little peace so you
can find a situation that’s less anxiety-provoking two little bonus things I’m
going to tell you with social anxiety a lot of times people are afraid that
they’re going to offend someone and these days it is so easy to offend
people so what I tell my clients and my kids and what I try to remember myself
is before I speak or when I’m talking to people if what I’m saying is true
helpful important necessary and kind then you know
there’s probably a good chance I won’t offend them look on your social media
look at the comments people leave on other people’s posts and stuff and see
if they meet these criteria true helpful important necessary and kind 90% of the
time the answer is no well I won’t say that much about 50% of the time the
the answer is no there are a lot of times people will just say nasty stuff that
didn’t need to be said and that can be offensive but if you practice and
focus on making sure what you say is true helpful important necessary and
kind and if you’re following me that spells out think then the chances that you’re going to
offend somebody are greatly reduced if the person still gets offended it’s
probably more about them because you aren’t trying to offend them you weren’t
trying to be hurtful you are trying to be helpful and kind therefore it may be
more about their stuff whether they have an issue with you or they have an issue
with something else that’s going on and you just happen to be kind of in the way
it’s more about them you can’t control how they react to things it’s their
responsibility if you’re being nice and they take it the wrong way and they get
offended that’s their perception and they need to work on that the other
bonus that I’ll tell you to take away is something I got from dr.
Seuss and I
love something he says about the judgment of those whose minds don’t matter and those
who matter don’t mind so the people who matter in your life they’re going to be
people judge you all the time that’s just the way humans are but those who
mind what you do those who get offended those who judge you all the time they
don’t matter the people who matter to you don’t mind if you make a mistake
don’t mind if you’re not perfect they probably embrace all of your
imperfections so before you approach a social situation remember not
everybody’s gonna like you that’s just it’s not possible to have everybody like
you so remember the wise words of dr. Seuss those whose minds don’t matter and
those who matter don’t mind if you like this podcast subscribe to your favorite
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As found on YouTubeHi, 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…
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 all
CEUs comm slash counselor toolbox I’d like to welcome everybody to today’s
presentation on a strengths-based biopsychosocial approach to recovery from bipolar disorder
so we’re going to talk a little bit about what bipolar is what causes it and how to
mitigate it by helping people understand their own bipolar because what triggers it for John
may not trigger it for James help them identify their warning signs because bipolar episodes
just like depressive episodes and manic episodes often don’t come from completely out of the
blue if we look backward we can see where the person was beginning to resume some unhealthy
lifestyle habits that were making them more vulnerable well look at the symptoms
of depression and mania and real quickly review bipolar one versus two and look at some
co-occurring disorders and interventions another thing I added to this presentation was a little
a short piece on differential diagnosis because I often see people who are diagnosed either only
with bipolar when there’s also attention deficit disorder present or they’re diagnosed with anxiety
when it’s bipolar disorder so we’re going to talk about how people might mistakenly diagnose
one for the other and how to kind of try to ferret that out a little bit one way is using the online
assessment measures there’s another measure we’re going to talk about in here too so we care
because uncontrolled bipolar puts people at risk for suicide addiction and addiction relapse you
know even if somebody doesn’t have an addiction when they are in a manic episode they can be more
likely to engage in potentially self-injurious behaviors, not for self-injury but
just because they’re looking for even more of a rush and when they’re in a depressive episode
they can also be at risk for addictions because they’re looking to feel better in some sort
of the way so a lot of it we’re talking about well with we’re talking about self-medication with
mania we’re just talking about what they perceive as something exciting and people are often in manic
episodes engage in extreme risk-taking behavior we don’t want our clients to go down any of these
paths so we want to be aware of what might trigger it and I don’t think I talk about it anywhere
else in the presentation, it’s important to be aware that for suicide when somebody is coming
out of a depressive episode who somebody who’s bipolar well or unipolar depression but when
they’re coming out of the depressive episode and they start having more energy is actually
when they’re at greater risk of suicide than when they’re at their absolute bottom not saying
they’re safe at their absolute bottom but we don’t want to get complacent when somebody starts
feeling better and assume that they’re out of the woods with poorly controlled bipolar disorder
can leave people feeling hopeless and helpless if they have bipolar one and they have at least
a full-blown manic episode but maybe more they may not mind that they may because it disrupts
their life the depressive episodes tend to be when patients usually present when they’ve got
bipolar disorder so we want to look at what’s going on with them and help them see how the
bipolar disorder disrupts their life because that can go a fair way to encouraging medication
and treatment compliance well controlled bipolar like well-controlled addiction helps a person feel
happy optimistic motivated and energized the key is helping them manage their vulnerabilities you
now take care of their body so they have enough energy to do things but also make sure
that they get their medications right some of the mood stabilizers can be flattened and make
people feel more exhausted and it’s important it’s vital that they openly communicate with their
psychiatrist or physician about the medications if they are if the side effects are so significant
is impairing their quality of life which means they’re likely to be medication non-compliance so
we want to make sure that if they’re feeling too flat that they talk it over with their medication
provider bipolar disorder is a brain disorder you know sometimes with like depression we can look
for situational causes for anxiety we can look for some situational causes we can look for some
cognitive stuff we know in bipolar disorder something is going on in the brain that causes
unusual shifts in mood energy activity levels and the ability to carry out day-to-day tasks many
very successful let me go back to that so just to be clear and generalized anxiety panic disorder
depression they also can have a brain organic component to them but not always sometimes you
can have those from a situational cause whereas in bipolar disorder we know that there’s something
that’s not quite right with the balance of the neurotransmitters for most people with bipolar
okay so who has bipolar lots of people you’d be surprised Mel Gibson demi Lovato Axl Rose, Britney
Spears Jean-Claude Van Damme Marc Vonnegut and Amy Winehouse to name just a few that I came
across you know doing some internet research Lee Lee Thompson young and Robin Williams were
also, both are quite successful and revered in their fields despite if you want to call it losing
their battle with bipolar so why do I bring that up because a lot of times people when they
are given a diagnosis of bipolar disorder feel very isolated feel very unique and I want them to
realize that there are a lot of really successful awesome people who have bipolar disorder you
know it once it’s managed then people can live a stereotypical life I work hard to
avoid the word normal because what’s normal for one person may not be for another but we want
to look at they can have a very high-quality active life bipolar disorder is caused by imbalances and
neurochemicals especially dopamine serotonin and norepinephrine the imbalances could be genetic or
triggered by sex hormone changes or stress hormone changes so they may be at you know steady state
but when there’s a particular stressor some sort of change or you know other thing and it depends
on the person, it can throw those neurotransmitters out of balance enough that it causes either a
manic episode hypomanic episode or a depressive episode more than one in 50 adults are classified
as having bipolar disorder in any 12 months so I encourage people when they’re walking around
the store when they’re walking around the grocery store when they’re at church when they are sitting
in a meeting at work with you know 50 other people at least one person in that group has bipolar
disorder and or will be diagnosed with it in the year I want them to recognize how common
it is I want them to start looking around and thinking when they’re driving down the road on
rush-hour traffic you know every 50th car they pass somebody in those 50 cars probably had
bipolar disorder to help them realize again it’s not us weird diagnosis is pretty
doggone common among patients seen in primary care settings for depressive and/or anxiety
symptoms twenty to thirty percent are estimated to have bipolar disorder a lot of times primary
care physicians misdiagnosed bipolar disorder as either generalized anxiety or unipolar depression
so it’s you know eighty percent of the time seventy eighty percent of the time they’re right
but the other twenty to thirty percent you’ve got this person who is going to continue to struggle
and get frustrated because the treatments for generalized anxiety and depression are
generally, SSRIs and SSRIs can trigger mania so it can make the mood lability worse bipolar
the disorder is still under-recognized primarily due to misdiagnosis as unipolar depression and
that’s not just in primary care that’s also in you know our field because if we see somebody who
has unipolar depression you know they may not have had a manic episode yet likely they have but they
may not have had a manic episode yet or they may not report it or if it’s a hypomanic episode they
may not note that as something problematic and yes diagnosis of mental health conditions
is out of the scope for a lot of GPS and a lot of them will tell you that a lot of them will say
If you’ve been diagnosed before I can help you continue your medication but there are so many
nuances to psychological diagnosis I want you to get an evaluation from a psychiatrist in
order to better make sure that we’re getting you started on the right path because nothing is
more frustrating to somebody who is struggling and again generally they present in a depressive
episode nobody is nothing is more troubling for somebody who’s presenting and struggling then
getting on medication and not feeling like it’s working is one of the things they see and I’m jumping
ahead of me is when somebody who has bipolar disorder is started on an SSRI one effect could be
to set off a manic episode another effect could be to have rapid improvement and you know it
takes four to six weeks for the SSRIs to get in there but they tend to have rapid
improvement in days unfortunately that improvement doesn’t last and then they tend to go back into
a depressive episode and they start to feel even more defeated I want clients to understand us
if they start talking about that pattern where they’ve been on antidepressants and it works
for a little while but then it doesn’t anymore you know that may just be the wrong medication
for them, their case is not hopeless so we know the symptoms of depression apathy feeling down
empty hopeless low energy decreased activity sleep changes worrying difficulty concentrating
forgetting things a lot of changes in eating habits and feeling tired or slowed down how is this
different than Low Energy I’ve had clients ask me this before and what I try to the way I try to
differentiate is energy is your desire to get up and do things and feel like you can when people
are feeling tired or slowed down it almost feels like they’ve got a 50-pound rucksack on their back
or their arms and legs feel like they’re just lead and it is exhausting to even get up and walk
across the room go to the kitchen go outside so there’s a difference there’s energy to do things
and then there’s just feeling like you’re filled with cement mania people feel very up high or
elated now after people come out of a depressive episode even unipolar depression there’s a period
of mild very very mild euphoria and we don’t want to mistake that for hypomania or mania they’re
just feeling good they’re like oh my gosh I see the Sun again I see colors how awesome is this and
then you know it kind of levels out but you don’t have a crash it’s just kind of a good and
then a-ok contentment people in a manic episode have a lot of energy and increased activity levels
they often feel jumpy or wired you know like they can’t settle down they want to sometimes but they
can’t they’re wide awake and they’re just looking for something to do they have trouble sleeping
may talk fast about a lot of different things so they’re jumping around and when we talk
about ADHD in a minute, we’re going to talk more about these symptoms they may agitate irritably
or touchy not everybody who’s manic is in a good mood so they can be manic but agitated
they feel like their thoughts are going fast and think they can do a lot of things at
once people especially in a hypomanic episode often find themselves taking on three four five
six projects and not being able to complete them you know when they come out of their hypomanic
In the episode, they’re like oh my gosh what did I get myself into but there’s no sense of time in a
manic or hypomanic episode and they can especially in a manic episode engage in risky and reckless
behavior so mixed bipolar includes symptoms of both manic and depressive symptoms at the same
time which can be confusing to clients they’re up they feel like they’re wired but they
have no their flat they have apathy and just that lack of pleasure and anything they may feel
very sad empty and hopeless and energized bipolar one now that big difference is bipolar one has at
At least one full-blown manic episode if there hasn’t been one full-blown manic episode then we’re going
to look for bipolar 2 where you have hypomania and major depressive disorder bipolar one can have
either major depressive disorder or persistent depressive disorder so the big difference is if
there’s a manic episode there they’re number one bipolar one patients experienced depressive
symptoms more than three times as frequently as manic or hypomanic symptoms so yeah when they
hit a manic or hypomanic period it’s not a wonder they feel pretty good and they don’t want it to
go away if they experienced it three times more often bipolar 2 patients experience depressive
symptoms approximately hold your horses 39 that’s not a mistake 39 times more often than
hypomanic symptoms so people with bipolar 2 can have 39 depressives before a manic episode now
unfortunately, the body is not that consistent where we can go okay 38 39 you’re due for a manic
episode but we do know that both types of bipolar depression are experienced a lot more frequently
than mania or hypomania so a common misdiagnosis is generalized anxiety disorder how do you
differentiate because some people when they get anxious get revved up and they feel
like they’re wired and they can’t sleep the goal-directed activity and generalized anxiety
the disorder is often related to an anxiety theme like if they think that there’s a problem with
their finances or if they’re you know whatever they’re worried about their activities and their
thoughts generally race in that direction they’re not all over the place they’re pretty directed in
more or less and their mood is often irritable and energetic versus elated now again just because
somebody is irritable doesn’t mean it’s the anxiety we want to look specifically at what is causing
the sleep disruption and what are the themes of the thoughts that the person is having the racing
thoughts because if you know something’s going bad at work you hear there’s going to be layoffs
somebody can get anxious and go well if I get laid off then I’m going to lose my job if
If I lose my job then I’m not going to be able to pay the house payment and I’m dead a debt a debt
it and go in this rapid cycle of catastrophe and get themselves all worked up and then not sleep
then they start trying to figure out okay what I need to do to make sure I can pay
the house payment what do I need to do to make sure I can do this so anxiety disorder pretty
focused ADHD approximately 60 to 70 percent of people with bipolar disorder also have ADHD and
20% of people with ADHD have bipolar disorder so you can draw your own Venn diagram if you
want the take-home message is we don’t want to assume that they’re mutually exclusive because if
you’ve got somebody with bipolar disorder you can get that controlled but they’ve still got the ADHD
symptoms going on over here they’re going to feel often feel frustrated now what’s the difference
people with ADHD often have a hyper focus that’s one of the hallmarks this may happen on a deadline
pressure or when wrapped up in a compelling book project or video game and so you can you can
see where there’s a trigger for it hyper focus may cause a decreased need for sleep and look like
increased goal-directed activity but is often short-lived in people with ADHD who
feel exhausted when the hyper-focus fades so we want to look for number one was there something
that triggered this hyper-focus could be a video game could be an awesome book or even
a Netflix marathon whatever it is and once that hyper-focus faded did they feel exhausted
if so we’re probably looking more towards ADHD than bipolar a manic episode is independent of
external circumstances you know it’s not where somebody gets a project and it sends them into
In a manic episode, there’s a lot less control and predictability in people with bipolar disorder
and people with bipolar often want to go to sleep or relax but describe the feeling as if they can’t
wind down which can go on for a week or more so we’re looking at duration we’re looking at what
triggers it if they report let’s go back to here sometimes having manic episodes that there was
no trigger and they lasted a long time but they also report manic goal-directed activity under
deadline pressure or you know they can have all these symptoms which means you’re looking at ADHD
and mania or bipolar disorder together potentially in ADHD people often interrupt or talk too much
without noticing because they miss social cues or because they lose focus on the threads of
a conversation because their minds going six ways till Sunday I had a friend of mine one time
who had ADHD she was in graduate school with me and she gave a presentation on it one time and we
were talking and she was presenting and as she was presenting somebody started flicking the lights on
and off and all of us were looking around at each other going this is annoying and then a little
while later you know 30 seconds or a minute later somebody turned on the radio not loud but
low in the background and we’re all looking at each other and then she started doing something
else after that oh she turned on a fan so the fan was oscillating and blowing in our faces and and
finally, she’s like is this annoying and we were like yeah that’s annoying it’s hard
to concentrate and she said this is what life is like for somebody with ADHD many times because
we have difficulty filtering out what’s important to pay attention to and what’s not so we’re paying
attention to everything so that made it a lot more understandable to me which was helpful later when
my son was diagnosed with ADHD because you know it helped me tailor his learning environment
so people with ADHD kind of get lost and they’re paying attention so much that they
can miss the social cues people experiencing manic bipolar episodes are often very aware that they’re
changing topics quickly and sometimes randomly but they feel powerless to stop or understand they’re
quickly moving thoughts so they’re just trying to keep you in the loop in everything and they
may notice that you’re getting uncomfortable or irritated or impatient but they don’t feel like
they can stop racing thoughts you know all these kind of go together but kind of not people with
ADHD report racing thoughts that they can grasp and appreciate but can’t necessarily express
or record quickly enough think about the time you got excited about something and you just
had all these ideas whenever we get a new grant that comes in I’m in charge of or I used to be in
charge of writing the grant so I get the grant and I’d read through and I start identifying all the
different things that we could do to you know get this grant and it would be hard for me to
keep my pencil going fast enough to keep up with my ideas and you know I don’t have an and you
know that was perfectly normal but I was excited and so my mind was racing people with ADHD can do
this a lot you know not just because of a grant coming in people with mania the racing thoughts
flash by like a flock of birds overtaking them so fast that their color and type are impossible to
discern I loved this explanation because it’s just like you have this whole massive bird coming
in and then going out and you didn’t have a chance to even notice what they were people with with
mania often feels that way they don’t can’t grab any of those thoughts and hook on to them they’re
just in and out so helping people differentiate to make sure that if they’ve got anxiety and bipolar
if they’ve got anxiety and ADHD and bipolar bless their hearts that were attending to all of their
presenting symptoms and issues so what do they do to treat bipolar well we’re going to get down into
that in a minute sorry got ahead of myself things that can trigger a bipolar episode medications
antidepressants as I said can propel a patient into mania captopril which is an ACE inhibitor
something that’s used for high blood pressure can also trigger a bipolar episode corticosteroids
certain immunosuppressant medications levodopa which increases dopamine you may see patients
with schizophrenia or Parkinson’s taking web dopa and methylphenidate or dexmethylphenidate
which are ADHD medications all of these different categories of medications can potentially trigger
a bipolar so do they trigger it in every single person no so that makes it even more difficult
but it is important to be aware if somebody has bipolar when they start taking medications
that they need to be conscious and cognizant of their symptoms so they can you know identify
early onset of a depressive or a manic episode circadian rhythm desynchronization can trigger
or look like bipolar disorder hyperthyroidism can look like a manic episode that means too much
thyroid you know a lot of times we talk about hypothyroidism and depression hyperthyroidism
gets people to revved in children mania can be misdiagnosed or look like oppositional defiant
disorder and substance use both intoxication and withdrawal but more specifically intoxication can
also, look like mania or depression depending on whether they’re taking stimulants or depressants
so it’s important to make sure that the person when they’re being assessed is substance-free
Do you know what medications they’re on they’ve had a physical to rule out any hormone causes
the thyroid is a hormone and looks at their circadian rhythms if they happen to be visually impaired
that can cause problems in circadian rhythm if they are shift workers that can cause problems
with circadian rhythm so let’s make sure we don’t label something as bipolar and start treating
as such before we’ve ruled out everything else bipolar distinguishing factors and let’s see
let me see if I can get that open for me right now well anyway spontaneous hypomania premorbid
affective temperament particularly hyper thymic or cyclothymic so before somebody had an episode
that they presented with do they have a history of remembering dysthymic is feeling blue
low unhappy hyper thymic is more elated and cyclothymic is rapidly switching Moodle ability
increased mental or physical energy even during depressions family you know you know
we talked about the mixed episode if there’s a family history of bipolar disorder or a good
response to lithium for unipolar depression or bipolar that’s a risk factor or a hallmark
that you might be dealing with bipolar in this client if they have treatment-emergent hypomania
mania or mixed States so as soon as they start medication treatment generally SSRIs they have
an uncharacteristically rapid response followed by a crash again and or they have more than two
failures on antidepressants now we want to look at what that means because antidepressants work
differently for different people, somebody can be on and I’m going to use the trade names here just
because I don’t have all of the generics memorized I’m not promoting any particular trade name but
people could be on Lexapro or Paxil and feel like they can’t wake up people can be on Prozac and
feel like they’ve got more energy some people are on Zoloft and don’t feel any energy change some
people feel lousy but with antidepressants, we want to look at what failure means did it fail to
improve the mood or were the side effects so bad that the person had to switch if this if it was
the side effects that are not classified as a failure because the person wasn’t able to
stay on it long enough for that antidepressant to get in their system now I do want
you to see the mood disorders questionnaire, haha and that’s in this article here but there
are three all of these questions that you can have people just complete at assessment and
it helps you identify if they’ve had a manic or hypomanic episode so have there ever been
a period of time when you are not your usual self and you felt so good or hyper that people
thought you are not the normal self you were so irritable that you shouted at people or started
fights you felt much more self-confident than usual you got less sleep than usual and found
you didn’t miss it you were much more interested in sex than usual spending money got
you or your family in trouble you know you can go through all the rest of the questions and they
identify yes or no to each of these once they do that if they did check yes to more than one of the
above have they ever happened during the same period if yes then again we’re probably looking
at one of the bipolar and finally how much of a problem did any of these cause for you and if it’s
a minor problem then we may want to look for other things this does not diagnose bipolar but it is an
excellent screening instrument to give you an idea about whether you need to look in that direction
have clients keep a life chart ideally for three to six months where they chart their sleep their
dietary habits their exercise their life stressors hormones for women and any bipolar symptoms that
they’re having now when I have clients chart this much I create a really simple fill in the blank
a chart like for sleep number of hours did you feel rested yes or no dietary habits I have them
keep on their mobile device for exercise did you exercise yes or no if so how much for how long you
know really simple things so they can complete the chart in under five minutes otherwise, they’re
not going to do it for the bipolar symptoms I have check blocks you know did you feel depressed
did you have difficulty sleeping yada-yada so it’s easy it’s very very simple for them to fill
out and it’s also simple for me to evaluate when I go through it encourages people to understand
their bipolar because everybody’s presentation is going to be a little bit different have them
identify you know their cognitive patterns and negative thinking patterns that contribute to
their depression and if so how do they handle those in the past when they felt depressed how did
they change their thinking or what they do to help themself be a little bit more optimistic and
also looking cognitively what if they got going for them are they intelligent are they creative
are they you know build on those if somebody is creative you know I’m not so I it’s wonderful
to see creative people but for somebody who’s creating one of the greatest things they can do
to work with their depression is art therapy you know it’s very therapeutic for a lot of people
so find their strengths and use those to help them resolve their current presenting symptoms
physically encourage them to get adequate sleep to avoid opiate and sedative medications alcohol and
any sort of over-the-counter herbs including Jen Singh Sant Sami 5htp without talking to their
the doctor first encourages them to eat a good diet they may already be doing some of this so how much
they change at one time it is gonna vary between the person and what they’re motivated to change
remind them not to change too much at once let’s just do one or two things right now and then you
can work on two more things once you have those under underway situationally have them do
a coping skills inventory to figure out how they cope when things get stressful and have them
identify triggers for their bipolar that what types of situations make you feel depressed what
types of situations have you noticed might seem to trigger a manic episode some people when they
get stressed about something there’s that anxiety it can the stress of that and having the
HPA axis activated can trigger a manic episode for them so encourage them to you know in their chart
they’re going to be keeping track of what might be contributing to triggering and mitigating bipolar
symptoms so if they’re getting good sleep and eating a decent diet their life stressors are pretty
low and they’re not having any symptoms well we know what they can do interpersonally have them
identify supportive friends to help them learn about interpersonal behaviors that trigger them and ways
to deal with those interpersonal behaviors so if when somebody tends to be in a manic episode or
even in a depressive episode if they tend to be irritable think about having them look at what
behaviors trigger their irritability trigger their anger and figure out a plan to deal with
it to minimize the impact that being on one end of the spectrum or the other mood wise
might have on their relationships angers normal irritability is normal don’t get me wrong but when
somebody is in a depressive episode or a manic episode that irritability can be intensified
tenfold and people may be taken aback by it environmentally encourage clients to look around
their environments and look at what they can do to make their environment cheerful calm and safe you
know what that looks like for that particular person those are things that they can do because
it’s you know when you felt calm and safe before what was different or what was the same what helps
you feel cheerful we just recently had the inside of the house repainted because it was time but
I’ve always felt more cheerful, especially during the winter and when there’s less sunlight when I
have like a light yellow color on the walls like straw not bright yellow and that helps me feel
a little bit more cheerful which is in contrast to all the black that I put in there but whatever it
works for me and that’s how I feel comfortable in my environment to encourage clients especially
you know when they’re feeling like they’re heading toward a depressive or manic episode
to eliminate negativity from social media and television media you know if it stresses them out
to watch the news do they have to watch the news you know what will happen if they go for a month
without watching the news and in their real-life environment encourage them to try to eliminate
as much negativity as possible and that can be altering how they deal with interpersonal
relationships that can be looking around and finding things that stress them out and addressing
there are a lot of different things but we want to look at it as biopsychosocial II Romania
we still want to build on strengths and encourage them to become aware of any medications they’re
taking and how those medications affect them this can include stimulants thyroid medications, Sammy
and 5htp encourage them to avoid stimulants when possible and don’t combine them with caffeine
if they put ephedra for example in combination with caffeine that used to be a common
combination in pre-workout supplements that can get somebody revved up and so we want
to make sure that they’re aware of the effect not only on their body but the likelihood
that could also trigger a mood episode have them identify warning signs and
interventions sometimes like I said that for people with bipolar disorder the
depression and/or manic episode may seem like it comes out of the blue and sometimes
it may but 99% of the time when I’ve traced it back with clients they weren’t taking good
care of themselves they were either taking on too much at work or they weren’t getting
enough sleep or they weren’t eating well or you know there had been something that had
changed from when they were doing well and they felt good too when they started feeling
like they were heading down towards an episode some patients may try to identify triggers for
manic episodes to increase those we want to encourage them not to do that because
that’s like driving your car with the RPMs up at five indefinitely that’s not good for your
the car eventually something Bad’s gonna happen so we don’t want them to read themselves up that
much we need to help them find that happy medium where they’re content there are three or four
on a scale of 1 to 5 and they’re feeling good for some clients when they start feeling depressed
they notice thinking changes and have difficulty concentrating this is a warning sign you know they
may not feel completely depressed yet but they may be waking up in the morning going yeah not so sure
I want to get out of it they may have low energy changes in sleeping or eating irritability
sadness negativity resentment withdrawal and environmentally they may notice that they’re in
the area becomes more disorganized or they may just not be caring as much about personal hygiene as these
are all things that they can identify early on and say huh you know it looks like maybe I need to
take a little bit better care of myself and it’s hard for clients it’s hard for a lot of us to
listen to our body and go okay I wanted to do XYZ but my body is telling me that maybe I
need to rest for mania warning signs can include racing thoughts heightened creativity that’s
one that for people to be aware of especially if you’re dealing with somebody who’s naturally
creative they may thrive during this period of heightened creativity and get upset when
you start suggesting that they may need to temper that to stabilize their mood they’re
gonna have to cut the top off the highs and raise the bottom on the lows physically they may have
difficulty sleeping or sitting still maybe may feel elated excited irritable or thrill-seeking
you may have some anger outbursts frustration with others and environmentally what I’ve seen
with patients especially with full-blown mania, it varies on what they do sometimes they are
cleaning like crazy and other times it looks like a whirlwind absolutely hit the room but so it’s
usually extreme so treatment compliance we want to encourage clients to do a decisional balance
back exercise and I broke it down so it’s shorter what are the benefits of eliminating depressive
episodes if the person was no longer depressed how would they feel emotionally mentally physically
and how would it impact their family and friends a lot of times that this one’s easy to fill out
the drawbacks to eliminating depression are this can be harder to fill out because they’re like well
I’ll see any drawbacks okay we can leave that for now sometimes patients come to the awareness
that if they’re no longer depressed they may not get as much attention and people may expect more
of them which is anxiety provoking but this area usually doesn’t have a whole bunch of stuff
in it and then we want to ask them what are the benefits of eliminating the mania emotionally
mentally physically and socially this one’s a little harder not as hard as the drawbacks to
eliminating depression a lot of times clients can see the benefits of eliminating the manic
episodes because they don’t have the periods I mean they have the highs and those are awesome
but they don’t have the periods where they have the lows and they don’t feel like they can do as
much they don’t have the loss of time they don’t kind of come out of it and realize that they’re
completely overwhelmed because when they were in the manic episode they took on 17 things so there
are a lot of things that clients may identify as benefits to eliminating the mania but we also
want to talk about the drawbacks to eliminating it because like I said for some people that’s
when they’re their most creative and if they’re a writer or an artist or a musician this may be
the time when they are feeling like they’re uber selves so they don’t want to get rid of it and
it’s terrifying to them to think that they might not be able to tap into what we can talk about
ways to tap into their creativity when they’re not manic and you know there are techniques that
they can use it to get that focus that they so desire but it depends on the person exactly
what you’re going to use if we don’t address all of these concerns about eliminating their
mania treatment compliance is going to be lower because people will just they’ll miss it they’ll
miss it a lot and they’ll want to feel that high again so general techniques in clot ask
clients how do you deal with it up until now when you felt depressed what have you done this helped
you feel better even for 10 minutes or an hour or half a day you know maybe it didn’t work the whole
time but or it helped you feel instead of feeling just devastated you felt sad you know it helps
you feel a little bit less intensely depressed build on that ask them what they’re willing to do
some clients are gonna look at you and go no I’m not gonna do that keep your
journal no not gonna do that okay so what are you willing to do I tell my clients a lot of times I’m
gonna suggest things that you may not think fit for you or work for you or you’re not going to do
well I’d rather you tell me number one that you’re not going to do it and what I’m more
concerned about is what you’re gonna do instead if you don’t want to keep the journal okay how are
we going to be able to notice changes and find connections between your eating your sleeping your
stress levels and your mood episodes you know help me let’s figure out a way that we can we can
do this and they may come up with something you know I state what it is that I want to
do or accomplish and why it’s important and I say is there another way we can accomplish this
when I work with clients and recovery sometimes they don’t want to go to 12-step meetings okay
if you’re not going to go then what are you gonna do instead because you need to have some social
support you need to have something to do besides sitting alone in your apartment from the time you get
off work until the time you go to work the next day because that’s a dangerous period encourage
clients emotionally to practice mindfulness because it does prevent episodes from sneaking up
if they start feeling run down or tired or off you know sometimes I hear that word I just feel off
okay that’s when you need to stop and check in with yourself and go what’s going on how do I feel
what do I need and mindfulness also encourages behaviors that prevent vulnerabilities when people
check in with themselves they may say you know what I’m really tired today I need to rest and
that’s a good thing because it keeps them from becoming vulnerable and potentially triggering
an episode of stress reduction encourages clients to identify and eliminate or mitigate stressors
so what stressors do you have and they can write them down on the list they can a lot of times if
I’m doing an individual I’ll have somebody write down on our big whiteboard all of their stressors
and then we go through on one by one and say okay can this one be eliminated if so how and the
the client will start making a plan for how they’re going to start eliminating stressors if there’s a
a stressor that can’t be eliminated maybe they don’t get along with their in-laws and periodically
the in-laws come to visit or whatever okay well you can’t eliminate that so how are you going
to mitigate that stressor before your in-laws come what can you do or may it be less stressful
if you go to their house instead of them coming to yours so we talk about different things we talk
about time management because in those manic and hypomanic episodes people can take on too much and
then they feel a little overwhelmed when they’re steady-state and they feel overwhelmed
if they’re in a depressive episode I do want to point out and I think most of us know this person
don’t usually cycle from a manic to a depressive to a manic like that they can have a depressive
episode and then be asymptomatic for anything for months and then have another depressive episode
or a manic episode so it’s important to recognize that most people who are bipolar don’t rapidly
cycle and there are periods of remission or symptomatology in between cognitive processing
therapy can also help people mitigate stressors when they start feeling overwhelmed encouraging
them to identify what thoughts they’re having that are contributing to them feeling stressed
or overwhelmed and then looking for the facts for and against that thought if they’re feeling
like they’ve got too much to do what are the facts for it what are the facts against it if
they do have too much to do then they need to figure out how to address it but this helps keep
people from getting stuck in emotional reasoning where every time they feel stressed or they feel
depressed or they feel anxious they think there’s something to be dysphoric about encourage people
to identify their anger management triggers they differ for everyone they need to develop a plan
for de-escalation and begin addressing their anger triggers to maintain control of their energy
they need to identify if driving in heavy traffic stresses you out and makes you irritable and angry
well ok how can you address those triggers maybe driving a different way or maybe putting on your
favorite music loud in the car or whatever it is that you can do to mitigate that anger anger
takes a lot of energy everybody everybody’s energy is precious but people with bipolar disorder
stress and excess energy drain can potentially trigger an episode so we want to help them
conserve their energy so yeah they’re gonna get angry about some stuff but help them identify
what’s worth getting angry about and using their anger energy for and how to deal with the
rest of it so they have more energy to enjoy the life we’ve been talking about the negatives but let’s
look at the positive they need to infuse happiness have them make a list of what makes them happy and
do more of it or be around it more encourage them to schedule a belly laugh every day and there are
Reddit forums there are YouTube videos there are places they can go to get a good old belly laugh
but it helps release endorphins and release some of the calming neurotransmitters that have them keep
a good things silver lining or gratitude journal and it doesn’t have to be prose you can have them
identify at the end of the day three things three good things that happen that day or three things
they’re grateful for or when things go bad they say I got demoted at my job today alright well
what’s the silver lining to that you didn’t get fired and maybe have less responsibility now I
don’t know but there are different ways you can approach it but encouraging people to be cognizant
and try to embrace the dialectics there’s going to be bad in life but help them focus on the good to
reduce dysphoria mentally address cognitive errors all Arnon thinking focusing on only the positive
or negative using feelings as facts and focusing only on a small piece when something happens maybe
you turned in a group project and your boss sent it back and said uh no try again some people will
take it very personally and focus only on the fact that the boss sent it back with feedback instead
okay it wasn’t just me participating in this project so you know all of us need to contribute
to it again and you know yes it was given back to us but we get a second opportunity so it’s looking
at a bigger piece of the puzzle encourage clients to develop their self-esteem and view failures
as lessons applaud courage and creativity and nurture their inner child I have an inner
the child my inner child comes out a lot more than some people would like to admit or really
like to see but that’s okay you know on Saturday morning it is not uncommon for me to be watching
cartoons in the living room my kids are teenagers I can’t say I’m watching it with them anymore I
like Yogi Bear I’m sorry I’m weird that way but you know sometimes at the end of a long week of
being serious and everything I just kind of need to regress for you know half an hour two hours no
encourage people to nurture their inner child and don’t be afraid to be silly don’t be afraid to
laugh or do something goofy physically increase clients to exercise class to increase exercise
it increases serotonin levels reduces stress helps balance hormones and neurochemicals and
may combat some medication side effects exercise is anything that moves the body gardening cleaning
going to the gym of course walking the dog playing soccer with the kid anything like that so what
is it that they like to do or at least they’re willing to do nutrition provides the building
blocks for the neurochemicals so people need to have quality proteins and a nutritionist
A friend of mine suggested always try to have three colors on your plate at every meal and use
a salad plate that is smaller instead of a dinner plate because it tricks your brain into thinking
that you’re getting more food as Americans we tend to eat way more than we need and try
to avoid mindless or comfort eating when people start comfort eating a lot of times they’re not
being mindful they’re eating to deal with stress instead of acknowledging the stress and dealing
with it so yeah they’re infusing themselves with carbohydrates and fats and getting the serotonin
and dopamine flowing but when all that goes away whatever was causing the stress is probably
still there so they’re either gonna have to stress eat again or deal with it so encouraging
people to be mindful of their eating sleep helps the body repair and rebalance and sleep
deprivation is known to trigger both manic and depressive episodes too much sleep or sleeping
at the wrong times can also mess up circadian rhythms so keeping naps to a minimum of 45 minutes
one time a day, if the person has to take a nap, is important so they don’t get into that deep
sleep and preferably try to avoid naps for most of a 15-minute power nap where you’re
closing your eyes and you don’t ever completely drift off has been shown to increase focus in
the afternoon but naps where you’re laying down and getting under the covers tend to mess
up circadian rhythms, if people are on medication for their bipolar which they probably will be
have them work with their doctor to adjust the dosages and dosage times to fit their schedule so
if they have a medication that makes them feel sleepy maybe they take it right before
dinner so it’s worn off completely by the time they get up in the morning and it’ll be up to the
person to work with their doctor I had one client who took Seroquel and she ended up having to take
it at 2:00 in the afternoon for it to be out of her system enough where she felt alert
when she woke up at 6 o’clock the next morning so it’s gonna differ for different clients again
encourage them to discuss any negative medication side effects with their doctor and not to expect
a pill to do everything you know the pill can help stabilize the moods but if you’re taking this pill
but then you’re still you know pulling the rug out from under it by not sleeping and using cocaine or
or whatever it’s likely the pill is just not going to be able to do it all interpersonally support
groups are really helpful to chat rooms if the person is either in a rural area working shift work can’t
get to an appropriate support group not all communities have support groups that are embracing
of all different types of people so it’s important to recognize that even though there may be a support
group the person that you’re working with may not feel comfortable with the people that are in that
the particular group so chat rooms can be helpful in the know family and friends and I say in the know
these are people who have to understand or have to know that the person has bipolar disorder and be
aware of their warning signs trigger their symptoms which helps so they can be supportive
and facilitative environmental clients can explore things that improve their environment
different pictures a temperature can also be a big thing if you’re too cold or too hot it can
make people irritable certain essential oils can help increase energy such as peppermint rosemary
or lemon calming essential oils if somebody tends to have some anxiety going on lavender chamomile
valerian Valerians kind of they say woody some people think it stinks to high heaven some people
love it catnip is the same way yes stuff you use for your cats you can get it in essential oil
and it’s a sedative type essential oil for humans bergamot it’s a pretty mild smell
rose is helpful rose geranium is a little bit less expensive and frankincense is all supposed
to help with calming so he’s hypomanic having difficulty winding down anxious whatever some of
these may help memory triggering include ginger cloves cinnamon orange and jasmine which works for
one person is not necessarily going to work for another I mean there are studies out there that
show certain essential oils have effectiveness at anxiety reduction and depression improvement but
it’s going to be up to that person and I found that when a person smells something if it
smells noxious to them then it’s probably not something that they need if they smell valerian
and they’re like oh my gosh that stinks okay that’s not triggering what their brain needs their
the brain knows what it needs I do the same thing with my rescue animals you know I let them take a
a good whiff of it and if they like it they’ll stick around and they’ll sniff it some more if
it’s not what they need then they’ll go somewhere else I tried fur for our donkeys when we first
got them into rescue I tried lavender because I thought you know that’ll help them calm down they
hated it they liked valerian so I learned that for them they preferred that particular
essential oil for whatever way it works in the brain and encourage clients to visit a store that
sells essential oils because they have testers and they can sniff them to see which ones work for
they and essential oils also smell different from different manufacturers so it’s important
again for them to figure out places that they can get their essential oils and try to stick with
the same company once they find one that works organization can help another thing that’s
important for people with Bipolar is to manage impulse items when they go into a manic or
hypomanic episode especially and they’re prone to engage in risk-taking behavior or less restrained
behavior car keys need to be somewhere where maybe they can’t access them if they’re known to go out
and drag race or you know drive 100 miles an hour just to see how it feels credit cards that’s a
big one credit cards need to be somewhere some of my clients will freeze their credit cards in
a block of ice so they can’t get to them and they can’t see the numbers to read them and
put them in on the phone this can help prevent unrestrained spending, especially at 2:00 a.m.
or something when the infomercials are on porn sites if the client happens to have an attraction
to porn sites having those blocked because it’s really easy to get sucked into that same thing
with video games and alcohol and other drugs alcohol a lot of people have in their house so
if this is a dangerous impulse item for somebody make sure they have it locked up somewhere so if
they do and have a hypomanic or manic episode they can’t drink the same thing with certain medications
especially the benzos and the opiates if you can keep it locked up somewhere all the better and
during the day keep it light and bright try not to be in an office where it’s dark
some people can’t help it I mean if you’re a nurse and you’re working in the neonatal intensive
care unit it’s going to be dark most of the time and there’s nothing you can do about that
but if you can help it keep the lights on if you don’t like fluorescent lights get lots of stand up
lights that you can put around to keep it bright so your brain knows that it’s time to be awake
co-occurring disorders depression can co-occur with bipolar I mean you can have part
of bipolar is depression so when somebody is in depressive episode suicidality high-risk and
addictive behaviors and self-medication we want to shout for it just like we would for unipolar
depression with mania we want to help the person become aware and look out for explosive anger
which can get them into legal trouble relationship issues etc heightened libido which also can get
them into legal trouble and relationship issues etc and any other risk-taking that they do because
when they’re in a manic episode is like they’re this is a bad idea filter is completely turned off
or it’s switched on the other way and as the let’s try this filter so helping them understand that
when they’re in that manic state it’s important to have safeguards so that when they come out of it they
haven’t done something that they’re going to end up regretting or have to undo so bipolar is caused
by neurochemical imbalances especially among serotonin dopamine and norepinephrine the symptoms
and presentation varies widely depending on the person it’s more important to address each symptom
then to address bipolar as a whole you know we want to look at what symptoms this person
presenting with and how can we help them manage those the medication provider is going to be
managing kind of the bipolar as a whole and trying to stabilize the mood but we want to help them
start addressing their symptoms so they can feel as healthy happy healthy and productive as
possible help them address each symptom identify warning signs and eliminate or mitigate
triggers and vulnerabilities remember that treatment compliance is a huge issue because the mood
stabilizers tend to flatten those highs and people miss the most dangerous times for suicidal
ideation and people with bipolar disorder are when they’re coming out of a depressive episode
or and I didn’t mention this before or during a mixed episode remember mixed they can be depressed
and have high energy both at the same time ensure people with bipolar disorder have a crisis plan
and people who interact with them daily who are aware of their warning signs and symptoms because
sometimes they’re not being mindful and most of us are guilty of not being mindful all the time
sometimes these symptoms can creep up so if they have people they interact with daily
who are in the know and can say you know John it seems like you’re starting to destabilize a
little bit then John can take a look at it people with co-occurring addictions also need to be aware
that a bipolar episode can trigger an addiction relapse and vice versa so they need to be aware
and have an extra-special relapse addiction relapse prevention plan for when their mood
symptoms arise if you haven’t already signed up please remember that addiction and mental health
counseling and Social Work continuing education credits are available for this presentation and
are accepted in most US states Canadian provinces Great Britain Australia and South Africa go to all
CEUs com counselor toolbox and click on the link counselor toolbox CEU spreadsheet to easily
locate the course based on this presentation okay are there any questions now remember we’re not having class
tomorrow but we’re having class on Thursday and that is just chock-full of
stuff that I’ve never actually presented before so there is no repeat possible there
oh and then next Tuesday we’re going to be talking about enhancing social justice
and why that’s important for recovery you
As found on YouTubeAlzheimer’s Dementia Brain Health ➫➬ ꆛシ➫ I was losing my memory, focus – and my 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.
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 I’d like to welcome everybody to today’s
presentation on trauma-focused cognitive behavioral therapy part 1 treating trauma and
traumatic grief in children and adolescents in this first part we’re going to define
trauma-focused CBT and talk about what we’re dealing with here because trauma-focused
CBT is a best practice and it is a manualized best practice so you’re going to learn about it
today but you’re not going to have enough skills where you can say you are certified in TF
CBT however I will provide your resources should you want to go out and pursue those so we are
going to talk about TF CBT as a best practice and implementing fidelity but I’m going to
also take a few detours and as I always do and talk about how this might be able be
useful with adults who have a history of trauma in childhood we’ll explore the components
of trauma-focused CBT and their intended functions, we’re not going to get through all of
those today but we’re going to start and we’re going to explore ways to use TF CBT with adult
clients so TF CBT works for children who have experienced any trauma including multiple traumas
so what we’re talking about is children who come to your office who are presenting with
trauma-related issues it’s effective with children from diverse backgrounds and works
in as few as 12 treatment sessions so a lot can be accomplished in 12 sessions they’re not
necessarily weekly sessions they can be spaced out a little bit part of it depends on the age
level of the child how long ago the trauma was any concurrent developmental or mental health
issues that might be present yada yada yada so it may be a little bit longer it may be a little
a bit shorter in terms of calendar time but you can also extend the number of sessions because
some of these things for example when they start talking about cognitive coping differentiating
between thoughts and feelings, some children take a while to get the hang of the
the nuance between the difference between thoughts and feelings so you might have to do two or
three sessions helped them to identify feelings and use the feelings thermometer this
has been used successfully in clinics schools homes foster care residential treatment facilities
and inpatient settings so there’s not an environment in which it can’t be used provided
that there is a supportive caregiver that can be of assistance obviously if you’re working with
a 10 or 11-year-old or a little bit younger or an older adolescent but you know any child who may
need some support outside of session we don’t want to be creating a crisis and then leaving them
kind of defend for themselves between sessions without some sort of emotional and cognitive
support so there must be a relationship that there is a bond if you will a
the rapport between the clinician and the caregiver who may not be the biological parent or the caregiver
and the child it does work even if there is no parent or caregiver to participate in treatment
however again we need to be selective about how we’re using that so if you have a child and
you’re going to use this particular approach and there’s no parent or caregiver to participate
it may be safer to use it in a residential setting or an inpatient setting where there is a
clinician somewhere where they can get emotional support because as you’ll see when we get into
the trauma narrative gets intense TF CBT is intended for children with a trauma history
whose primary symptoms or behavioral reactions are related to the trauma so if you’ve got someone
who has an unfortunate childhood but you think their behaviors may be more related to the peer group
maybe more related to conducting disorder or FASD or something else that may not be appropriate
because what we’re going to look at with TF CBT is reducing the PTSD symptoms the hyper-vigilance
avoidance behaviors etc as well as improving social skills and helping the person identify and
communicate their feelings and needs traumatic stress reactions can be more than simply symptoms
of PTSD and also present as difficulties with affect regulation we’ve talked before about how
people who are experienced who have experienced trauma may develop a situation where they are more
likely to experience emotional dysregulation the HPA axis kind of tightens up and holds on to the
stress hormones hold on to the stress reaction but then when it does perceive a stressor it goes
from 0 to 250 there’s no I’m going to get a little bit upset it is either nothing or it is a huge
mountain there’s no mole hills there so there may be problems with affect regulation there may
be problems in relationships because of difficulty trusting other people because of difficulties with
their self-perception and systems of meaning which you know we’re getting to in a few minutes but
the way they conceptualize the world because all of a sudden their world was turned upside down
somatization feelings coming out as physical symptoms so headaches body aches more illnesses
more days where they just don’t feel well and you know sometimes they just really don’t feel well
however, is it because of a bacteria or a virus or is it because of a stress reaction that is
kicking off all kinds of imbalances in hormones and neurotransmitters so we want to look at what
the effect are these traumas having on this youth or person and if we address this trauma and if we
help help them come to some sort of resolution or acceptance of the trauma and integration into
their world view of why this trauma happened and making meaning from it will help improve
these areas will help them reduce their hyper-vigilance etc and for many clients the answer is
yes and I talked earlier about the fact that this may be useful now it was designed for children
and adolescents but many of the adults I’ve worked with are very Alex thymic they are very unable
to identify their emotions their very unable to express their feelings sometimes they don’t even
know where their fear is coming from they’re just sort of paralyzed with fear and don’t trust the
world and they’re angry at everybody and if it comes from a traumatic experience then helping
them explore how that trauma is impacting them in the present can be useful in their
recovery process so these issues that TF CBT may help improve aren’t just limited to children and
adolescents they can present in adults who were traumatized as children and who didn’t develop
the skill to effectively deal with the trauma components of CBT TF CBT psychoeducation we’re
going to start by teaching them what they need to know about the trauma we’re going to talk about in
depth about these so I’m not going to detail them very much here parenting skills and if you’re
dealing with an adult oftentimes I will provide what I call reap Aron ting skills if your parent
were here or if your parent would have responded how you would have wanted how would they have
responded how can you do that for yourself now because sometimes you don’t have a significant
other or a caregiver with an adult client either but we want to help them figure out how to self
nurture if needed relaxation and stress management skills because some of the stuff we’re fixing to
talk about is going to be extremely distressful so you have some wiggle room if you will in terms of
what skills do you teach here they prescribe some but as far as relaxation and stress management affect
expression and modulation DBT skills seem to fit well into this framework for helping
people tolerate the distress not act on their impulses understand where the emotions are coming
from and preventing vulnerabilities and all that other stuff that can help them function outside of
session and when they’re not doing their homework help them feel like they’re able to focus on
something besides the trauma because we’re just kind of ripping the band-aid off that wound
at a certain point and they may have difficulty focusing on anything else likewise some children
and adolescents will come to you when that trauma is still relatively present and all they can think
about is that trauma or it regularly comes up for them and so we can help them learn skills so
they can start living more of what they might consider a meaningful life that’s not dominated
by memories of this trauma while we’re working through the process we want to give them a little hope
that there’s relief in sight cognitive coping and processing are provided next and enhanced by
illustrating the relationships among thoughts feelings and behaviors so initially cognitive
coping skills are taught and then all of this is going to be applied later as soon as we
get into the trauma narration helping the youth work through narrating the trauma and cope
with the feelings and thoughts that come up in vivo mastery of trauma reminders so any of those
triggers that are triggering flashbacks that are kicking off hyper-vigilant situations we’re going
to address as they come up in the trauma narration we’re going to help the person identify what it
is about certain situations that bring up this particular memory and how we master how to do
we deal with it and then finally conjoint Parent Child sessions and these don’t come till the end
all along the parents or the caregivers are participating in the process assuming there is a
parent or caregiver and understand learning a little bit more about what’s going on but we’ll
talk about what the clinician does in the parent sessions as well as what the clinician does in
the child sessions as we go through each stage effects of TF CBT reduction in intrusive and
upsetting memory so that’s awesome and you know if you think about what’s the function of these
intrusive memories a lot of times it is because either they haven’t been integrated into the
person’s schema of the world and well-being and or they still feel unsafe they have some cognitions
that is telling them they need to be alert they need to be aware they’re not safe so helping them
identify any cognitions and triggers that may be causing intrusive and upsetting memories
and addressing those again in the in vivo desensitization avoidance helping people reduce
their avoidance of certain situations and certain activities so they don’t feel like they are
confined basically to their prison it helps reduce the emotional numbing of a lot of people when they
go through trauma it’s so overwhelming and they’re so afraid if they feel they won’t be able to stop
feeling so they numb emotionally it’s protective it makes sense and as they develop the skills to
handle this and as they learn they can tolerate the distress of the memories of the trauma it
empowers a lot of clients there’s a reduction in hyperarousal depression and anxiety behavior
problems when you’re dealing with adolescents or children, especially ones who don’t have the
ability to articulate their feelings and their thoughts that are underlying these
feelings and how they relate to the trauma I don’t know many adults that can do that so
children typically act out physically to either protect themselves or try to get some
sort of protection comfort attention so they feel more secure so it’ll help reduce some of
that as we empower the child to identify what’s going on and articulate their needs more effectively
communicate with their parent and also deal with some of the stuff that’s making them still feel
threatened or afraid reductions in sexualized behaviors trauma-related shame interpersonal
distrust and again social skills deficits if a youth has been dealing with this trauma issue
for a while, they may have avoided other people because they don’t trust other people they’re
afraid of other people haven’t made sense of it so they may not have developed the social skills
that other youth have developed because they have been avoidant situations that might trigger
the trauma memories so who is is inappropriate for if the primary issue is defiant or conduct
disordered it if you don’t believe from a clinical standpoint that this is coming from a
the root of trauma history and addressing trauma is probably not going to do it now do these
children who are oppositional defiant conduct disordered have traumas in their history sure
probably they do but are those traumas causing the behavior or are those traumas sort of
irrelevant and one thing that you’ll find is a lot of we’ll talk about it more in a minute
a lot of people have multiple traumas but they may have resolved certain ones and be okay with
they but others are still open wounds don’t use it if the child is suicidal homicidal or severely
depressed if a child is in that particular state we don’t want to start poking the bear
especially in an outpatient setting but even in residential and even residential with adults I
was always extraordinarily cautious and hesitant to do any sort of trauma work in the first 30 to
60 days I had a client in residential substance abuse treatment I mean the first 30 days they’re
still kind of sobering up there are a lot of impulse issues and in the next 30 days there’s usually a
a lot of mood issues so I want them to feel like they’ve got a handle on things before we start
ripping band-aids off open wounds if possible and if you’re obviously if you’re dealing with a
a child the safety and ethics would just tell you when this might not be appropriate additionally
when children remain in high-risk situations with a continuing possibility of harm such as in
many cases of physical abuse or exposure to domestic violence some aspects of TF CBT may
not be appropriate for example attempting to desensitize to trauma memories is contraindicated
when real danger is present I took that verbatim from the TF CBT training or one of them
that is cited in your booklet or your class it is important to understand that not all of
these children are coming or existing living in an environment that is healthy and you may
have a parent who is court-ordered or ordered by child welfare to bring the youth to counseling
to address trauma issues but that child is going back to a chaotic situation so again it’s going to
be an ethical decision on your part once you have all of the training and you’ve become
certified and TF CBT it would be an ethical decision at that point whether or not to implement
the program to fidelity and you know we want to make sure that the child is cognizant
of any real and present dangerous challenges, they always come up, especially when you’re dealing with
families if the carrot parent or caregiver does not agree that the trauma occurred and we’ve all
dealt with this whether you deal with adults who were traumatized as children and they say nobody
believed me when I was a child and I tried to get somebody to here or whether you’re dealing
with a child right now who is with a caregiver or removed from a caregiver it doesn’t matter
but the caregiver was present at the time and the caregiver doesn’t believe the trauma occurred
it can be a huge barrier because that caregiver is not going to be able to be as supportive if the
The caregiver agrees the trauma occurred but believes that it is not affecting the child significantly
or thinks that addressing it will make matters worse then we can do some education here we can
identify symptoms that are coming out that are present which may be caused by the trauma and we
can show the research of TF CBT as well as other methods if you choose not to use TF CBT but you
can show the caregiver how addressing this trauma can mediate or mitigate some of those symptoms if
the parent is overwhelmed or highly distressed by his or her emotional reactions and is not
able to attend to the child’s experience so if the parent feels guilty for what happened or you
know such as in the cases of domestic violence the parent is dealing with their trauma
because they are surviving domestic violence they may not be able to attend to the issues of the
child at that point and it’s not a judgment it’s just how much energy you have and if you’re
trying to survive yourself you’re probably not going to be able to devote your full attention to
jr.
Over here so we need to look at timing if the parent is suspicious distrustful or doesn’t
believe in the value of therapy again we can do some education here rapport building and go
slow if the client and I my experience has been this occurs when the client is court-ordered or
ordered by child welfare the parent does not trust the system and by the fact the system
referred them to you you’re part of the system so start low go slow try to be as compassionate
open and honest as possible I try with all of my clients but especially with my clients who are
involuntary I am very open about what’s in my records and what I write down because that could
go to the court which could you know potentially reflect upon them you know we talked about what’s
going in into the chart I don’t use subjective judgment everything’s objective unless we talk
about something and they say yeah I’ve made progress here or I feel like I’m backsliding here
and then we talk about how to how that’s going to be put in the notes I don’t lie I don’t cover-up
but I do want to make them feel more comfortable with what’s being written in that magic file that
gets stored away that nobody can see if the parent is facing many concrete problems such as housing
but consume a great deal of energy again if it’s a domestic violence issue and they’ve moved out
and they’re living in a homeless shelter or a domestic violence shelter the parents may be
exhausted and just not able to fully attend to the increased emotional and psychological demands
of the child during this therapy you know they’re going to be doing good to help junior through
the present crisis let alone anything else or if the parent is not willing or prepared to
change parenting practices even though this may be important for treatment to succeed and
there are few and far between situations where this may happen one of the situations would be
if you have a parent who is the biological parent and you have a boyfriend or girlfriend
who is abusing the child and you know that comes out and there needs to be some change in the
the way that children are introduced to new people or there may need to be some change in another
situation and how to indiscipline there are a lot of variations that may come up but ultimately
we need the parent’s full buy-in we need them to be willing to work with children on emotions
identification and cognitive coping and all this other stuff which ultimately ends up helping them
most of the time anyway because I don’t believe any of these skills can be harmful to a person at
At least the initial skills of the trauma narrative if it’s done inappropriately or incorrectly can be
very very harmful but we’ll get there specific strategies that can be undertaken through perseverance
in establishing the therapeutic alliance reach out to contact and try not to serve as the all-knowing
omniscient person but asking them what they need asking them what changed with jr.
Asking them for
feedback and suggestions about what helps when jr. gets like this and so you can brainstorm put
the parent in the expert role of being the parent imagines that explore past negative interactions
with social service agencies or therapy not that we can undo that but we can make sure not to
repeat it and if they start acting disengaged we can evaluate the situation and come back and
say is this reminding you of that prior situation or you know are you feeling disempowered again or
whatever the case may be being fully aware that n TF CBT you have two very distinct clients plus a
the third one is the family so you’ve got a lot of different things to juggle if you want to explore
the parent’s concerns that may make them feel as if they’re not being understood or accepted
the lead listens to or is respected and that gets a little dicey sometimes especially when we start
talking about cultural sensitivity about belief about why the trauma occurred or a
variety of other things that we’ll talk about it’s important to be able to hear the parent and
come from a culturally sensitive and culturally informed perspective it’s also important if
the parent feels guilty for some reason you know and sometimes they will be cognizant of
any nonverbals or any statements that you make that might make them feel that way and if it comes
out or if there’s no other way to say it you know talk about any feelings they may have that about
being not believed or not respected and how can you best facilitate making them feel respected
and accepted and all that stuff explore and help them to come overcome barriers to participating
in treatment, if it’s transportation if it’s a job if it’s something else there may be some
brainstorming that’s required and a little bit of case management and I recognize that most of us
when we work in private practice or agency work don’t get any credit for billable hours for
case management but it has to be done in the best interest of the client and emphasize the centrality
of the caregiver’s role in the child’s recovery making sure that they understand that this can’t
succeed without their help by using parent sessions to reduce parent caregiver distress and guide them
through structured activities that empower them in interactions with the child so you’re going to
bring them in each week and you’re going to talk to the parent independently about what’s going on
what you’re covering how juniors behaving how you can help them help jr.
Etc sometimes you need to
delay joint sessions until the parent or caregiver can offer the child support and sometimes that
means not even starting treatment really until the parent and caregiver parent or caregiver
can be on board now you can get started with psychoeducation emotions identification feelings
identification and stress management and coping skills you know there were not really
poking a bunch of bears so you can probably safely get started on that if it’s sometimes it’s
court-ordered and they have to start treatment by April 1st or something so there are things you can
do but you may need to delay the actual beginning of the trauma narrative until the parent is
able to be available to educate everybody on how therapy works and instill in everyone not just
the parent optima optimist that well optimism about the child’s potential for recovery you
know sometimes they’ve been dealing with this child’s acting out behaviors for so long they’re
just like you know we’ve already been to three other therapists I don’t know what’s going to
fix it or I’ve done everything I know how to do good luck so we can talk about you know a
different approach or we can talk about what they’ve done that’s worked for a short period
of time and build on those strengths to instill optimism and hope and empowerment so
initially, when we talk about psycho-education it’s important to provide accurate information
about the trauma when children are traumatized they can be confused and not completely understand
what happened they may blame themselves and they may hold on to myths because they’ve been misled
and/or deliberately given incorrect information so one of the best ways we can help is to correct
that information provides information about how often this happens and whether you know it’s okay
to do this that or the other psychoeducation clarifies inappropriate information children may
have obtained directly from the perpetrator or on their own so the perpetrator may have told them
that this is how I express love or this is how you need to be disciplined because you don’t learn
this is how I was disciplined whatever it is or they could have gotten it on their own they could
have gotten it from school from the internet or just come up with it in their little heads trying
to make sense of what happened psychoeducation also helps them identify safety issues the
difference between safe situations and dangerous situations and as we get through this I really
want you to get away from the notion that TF CBT and childhood trauma are only physical and sexual
abuse there are so many other traumas as evidenced by the adverse childhood experiences survey that
I want you to wrap your head around that and there are things they didn’t cover in the aces such as
bullying and natural disasters so we want to help children whatever the trauma is the trauma made
they feel unsafe so we want to identify safety issues if the trauma was a hurricane then we want
to talk about what hurricanes are how often they hit what to safety plan etc so every time a
the thunderstorm comes they don’t freak out and we want to use psychoeducation to provide another
way to target faulty or maladaptive beliefs by helping to normalize thoughts and feelings about
the traumatic experience you know it makes sense that that was scary and makes sense that
you’re angry it makes sense that you feel this way and we can talk about why that makes
sense and why it makes you feel that way through cycle education you’re getting the child to start
talking about the specific trauma that he or she experienced in a less anxiety-provoking way by
talking in Jen wrong about the type of trauma so you’re talking about natural disasters you’re
talking about plane crashes you’re talking about domestic violence so they start learning about
it and then eventually you’re going to move down to their experience with it so like I said there
are a ton of different traumas and the ACE study even acknowledges that these are just the ten most
common ones that they heard however there are many many many different traumas and types of trauma
some of the biggest ones are physical and sexual abuse physical neglect emotional abuse
and neglect and the Aces identified mother treated violently I would say anyone in the household
treated violently it’s not just the mother’s substance misuse within the household and that
can be by the parents or by siblings household mental illness parental separation or divorce and
an incarcerated household member so those were aces but then like I said there’s also bullying
the death of a parent or sibling is extremely traumatic hurricane tornado natural disaster and
then I put the fire out separately because sometimes fire can be man-made sometimes it can be a wiring
problem but sometimes it can be Jr was playing with matches now even if jr.
Accidentally started
the fire does that make it any less traumatic no it probably makes it more traumatic because then
there’s a whole sense of guilt and responsibility but it’s still a trauma that has to be dealt
with so I put a link to the adverse childhood experiences website if you want to go look more
about that but we’re going to move on psycho-education involves specific information about
the traumatic events the child has experienced not the child’s event we’re not going to go
into police records or something, we’re just going to talk about specific information about
domestic violence or whatever body awareness and sex education in cases of physical or sexual
maltreatment and there are caveats for getting parental consent and permission and all that other
stuff and Risk Reduction skills to decrease the risk of future traumatization now going back to
those other things it’s not just about physical or sexual abuse so we want to look at what was the
the risk created by you know how can you reduce your risk of being bullied how can you reduce your
risk of being traumatized in a tornado you know you can’t stop the tornado from coming
and they’re everywhere so what do you do and talk about a safety plan the same thing with fire
information needs to be tailored to fit a child’s particularly particular experiences and level
of knowledge obviously, you’re going to provide different information to a seven-year-old than
you are to a 17-year-old provide caregivers with handout materials to reinforce the information
discussed in session so this may help educate the parents about some of it but it lets them
know what you talked about and it gets us all on the literal same page you’re providing them a
handout of everything you went over with Junior and we want to encourage caregivers to discuss
this information at home reinforces accurate information about how safe or unsafe they
are and obviously, we’re going towards safe and reinforced accurate information and develop
a safety plan so they feel confident that at home they’re going to be taken care of when you
start psychoeducation you do want to get a sense of what the child already knows and you can use
a question-and-answer game format in which the child gets points for answering questions which I
love this suggestion so you can ask them if you know what is a hurricane or is a tornado and see
if they know and see if they know how much time and much-advanced warning we have for a tornado
versus a hurricane or you know whatever situation you’re talking about you see I did a lot of posts
Hurricane Katrina counseling in northern Florida so that’s one of those things that comes up for
I am talking with children about how likely is it that a category 5 hurricane is going to hit
again but encouraging them to give your aunt’s give answers and if they give the wrong answer you
know it’s great to try now you know try to coach them into a correct answer or provide them the correct
one but give them credit for at least making an effort sample questions might include what is
you know and put in the type of trauma what is bullying how often do you think bullying happens
and why does bullying happen you know those are some questions you can ask to just open a dialogue
about bullying, if this child has been a victim of bullying and is and is traumatized so cultural
considerations meet the child and family where they are by presenting information in a way which
they can relate it to their belief system and you may need to consult with their spiritual
guidance guides leaders whether it be a pastor or you know whatever to get some guidance
on how to handle certain aspects of whether it was the will of God and in the case of sexual abuse
how to handle the concept of virginity and how to handle the concept of bad things happening to bad
people and whatever else they think is coming from or their parents are instilling in them in a
belief system we want to make sure that we’re not necessarily contradicting it and going oh mom dad
and the church is wrong but we also want to help them try to integrate this in a way that can help
they have strong self-esteem so reaching out to those spiritual leaders and the family asking what
their belief system about certain things can be very helpful assess the general beliefs about
the trauma if something happened or when something happens ask the parent or the family that’s there
not necessarily the child but you want to get a sense of what the family stance is on why this
happened what it means how it’s going to impact life hence foreign henceforth and forever more
focus on the events they perceive as traumatic to the family but most especially the child if the
child’s going back to the Aces you know maybe the parents got divorced but the child doesn’t
see that as traumatic because there was domestic violence ahead of time the domestic violence was
traumatic the divorce was a relief so wherever the child is with each trauma we want to
be respectful of what they perceive is traumatic and tailor the information so the family can be
more receptive to it as supportive as possible and sometimes you need to make sure that the language
you know make sure the language is not jargony about general views of mental health and mental health
treatment should also be assessed and addressed in the psychoeducation piece not only with the child
but also with the family, if they are suspicious of it don’t understand it think that you’re just
going to magically fix Junior we want to demystify the process and talk about what is the purpose of
the assessment what is the purpose of each one of these activities and why am I doing this or why
are we doing this as a team and how can it help and then we also want to provide information to
D stigmatize and normalize mental health issues and seeking treatment some cultures are still
resistant to seeking treatment and I use the term cultures broadly because there’s
a stigma associated with it so normalizing for them how many people go to treatment how common
PTSD is or whatever the situation you’re dealing with it doesn’t mean they have to like it but at
At least it will give them a little bit of a nugget to understand that they’re not the only ones if
they are from a cultural group a minority cultural group of some sort you might want to provide
information about how common this particular issue is in their group I’ve done a lot of work
with law enforcement and emergency responders and they’re kind of their little group so
we talk about how common depression is among law enforcement and emergent emergency responders
specifically, because they face so much so many different stressors than you know Joe Schmo over
here so it D stigmatizes and normalizes a little bit now they still may not talk about it and
go well hey you know 37% of us have clinical depression no that’s probably not going to happen
but at least in the back of their mind, they can go you know what I’m looking around this room and
I can bet that at least one other person’s on antidepressants or something and feel a little
less unique and isolated in parent sessions you want to provide a rationale and overview of the
treatment model educates parents about the trauma and talks about the child’s trauma-related symptoms
so we’re going to go over what is hyper-vigilance what is the function it why people become
hypervigilant after trauma and what might it look like in a child because it presents very
differently for different children so we might want to give some ideas and say does this sound
like Johnny or does this sound like Johnny and help them understand why these behaviors may
be coming out we want to talk about how early treatment helps prevent long-term problems okay
maybe the trauma happened three years ago but still, it’s better than waiting ten more years and
you know Johnny’s still not having any Ellucian will want to talk about the importance of talking
directly about the trauma to help the children cope with their experiences and not hedging and
this will be on a case-by-case basis but the manual walks you through handling this discussion with
the parents about exactly how much detail do I go into if Johnny brings it up at home reassure
parents that children will first be taught skills to help them cope with their discomfort
and that talking about the trauma will be done slowly with a great deal of support so we’re not
just going to plop them down and go okay and tell me about the day that all this happened which
is what the child has experienced already if it was reported to law enforcement and/or the child
welfare they’ve probably had somebody sit down and say get right to the nitty-gritty at least
once or twice and it’s completely dehumanizing so we want to reassure parents that we’re not
going to do that to the child again will help the caregiver understand their role in the child’s
treatment since this modified since this model emphasizes working together as a team so I’m not
just going to be educating you it’s not going to be a parallel thing where I go in and I work with
Johnny and then I tell you what I did and then I work with Johnny I’m going to work with Johnny
and then we’re going to discuss what Johnny and I did in session and I’m going to get input from
you and we’re going to talk about how you feel about it and then I’m going to provide you with tools
so you can help Johnny outside of the session because you’re going to be with them for six-and-a-half
other days that I’m not and this can’t work if it’s just one hour once a week and we want to
elicit parent input questions and suggestions as much as possible because they’ve been living with
their kid for you know however many years so they probably have an idea about what works and what
doesn’t so we’ll start with both parents and children in their respective sessions helping
them understand what control breathing is and how it helps slow the heart rate and trigger the
wrist and digest sort of reaction in your body when your breathing slows your heart naturally
slows because the stress reaction tells your brain you’ve got to breathe fast and the heart
rates got to go fast well when you override that then you’re kind of overriding the whole system
and we’ll also talk about thought stopping and this is especially helpful if the trauma is recent
or and/or ever-present in the mind of the youth so they can say I am NOT going to talk about that right
now I’m not going to think about that right talk about distraction techniques go back to
your DBT stuff talks about improving the moment and accepts to help the child develop skills to
handle and work through when those thoughts pop up replace unthawed unwanted thoughts with
a pleasant one so talk about it in session when thoughts like that come up what would you
prefer to think about and then really get into the Nitty Gritty the five senses what do you see
smell hear taste you know help me get into that situation or that thought this teaches that
thoughts even unexpected and intrusive ones can be controlled so that gives them hope and again we’re
not exacerbating the thoughts right now we’re not bringing up their particular trauma and
having them get into detail we are just helping them deal with what’s happening normally on a
day-to-day basis so they feel like they have more control for the older kids you can have them
people log about when this technique is used what they were thinking about and how effective the
thought stopping was and then review it and help them tune it up if it’s not really effective and
give them praise for when they use it effectively relaxation training persons of Asian or Hispanic
origin tend to express stress in more somatic or physical terms so just be aware of that but that
doesn’t mean that Caucasians don’t relaxation training is good for anyone and the medical
school of South Carolina training recommended that relaxation is stress-free and
workbook by Davis Schulman and McKay so and it is still in publication when deciding how to
present relaxation techniques are creative have the child help you to integrate the elements
into the technique that makes it more relevant to them so, what are you thinking about when you
relax you know I know I like to go to the woods but maybe this kid likes to think about a video
game or play with their dog whatever it is but helps them make it relevant to them and then have
they identify other things they do to relax like drawing listening to music walking and making a
list of those things so they can refer to it when you’re teaching relaxation training especially if
you’re doing something like progressive muscular relaxation be sensitive to the child’s wishes if
they don’t wish to close their eyes or lie down which could trigger memories of the trauma we’re
not going there yet so if they feel vulnerable lying down or taking orders like that because
you can imagine how being told to lie down and close their eyes might be a trigger for certain
abuse survivors you know be cognizant of that and say you know get into a comfortable position
or how where would you like to sit while we talk about this like I said parents can often
benefit from the relaxation training as well so because they’re dealing with their issues
about the trauma but they’re also dealing with trying to figure out how to help Johnny and any
of them deal with any of Johnny’s misbehaviors or problematic behaviors then they move on to
feelings identification so it helps the therapist judge the child’s ability to articulate feelings
if you can tell me what makes you happy that’s great but if you can’t then you know we need to
work on figuring out what makes you happy you also want to help the child rate the intensity
of the emotion don’t let them stick with happy mad sad glad and afraid you know let’s talk about
different emotions and use the emotion chart with little faces on it or you can use the emotion
thermometer so is it a hot emotion or is it a cool emotion and helps the child
learn how to express feelings appropriately in different situations I mean sometimes they’re
going to be angry but it might not be appropriate to you know get up and stomp out of the room or
whatever however they communicate it so help them figure out how to articulate that so they can be
heard and supported some children have difficulty discussing or identifying their feelings so
you might try stepping back and discussing the feelings of other children or characters from
books or stories so you know think about Puff the Magic Dragon if they’ve read that you know
that dates me a little bit there but you know how did the little boy feel and talking about things
different characters and different stories where there are elements of anger and shame and loss and
all of that stuff helps children identify how they experience emotions if they seem detached
from the experience because sometimes they just they’ve shut it off it was just too overwhelming
so we want to talk about you know when you’re happy what does that feel like or when you’re
angry what happens what does your body feel like when you’re angry and they might be able
to tell you they hear their heartbeat in their ears or everything gets all fuzzy or whatever
but help them start tuning in to how they react and connecting that with an emotional word and then
after all, that’s done they can identify feelings they can identify feeling intensity now we want to
differentiate between thoughts and feelings many children describe thoughts when they’ve been
asked about a feeling so if you ask them how they feel they may say I want to run away so
you want to say okay well I hear that you want to run away so I’m wondering if you are bored and you
you’re bored and want to get away from it or if you’re scared can you tell me a little bit more
about what it means to you to want to run away during feelings identification the parent
sessions normalize what is going on with their child and help the parent understand that some
children may be seemingly in constant distress or detached from the trauma and that’s okay
we all react differently to traumas so again we’re going to share with the parents what we’re
Do let them know any specific difficulties if any juniors have encouraged the parent to praise
the child for appropriate management of difficult motions and I put in parenthesis successive
approximations because they’re not going to get it a hundred percent right every time so if they
try to effectively manage their emotions even a little bit let’s give them praise for that and
then help them figure out how to do it a little bit better the next time so instead of having a
complete meltdown maybe they got up and stomped out of the room well that’s an improvement so
then we want to talk about how to shape that behavior so it’s a more appropriate communication
if parents have difficulty identifying their own emotions provide them with examples so
continually ask them questions about how you feel when it’s a rainy day outside and how to do you
feel when somebody’s supposed to call you and they don’t how do you feel when and have about 15 or 20
examples and you can have them on a piece of paper and even give it to the parent to take home for
their homework if parents are overcome with their own emotions about the trauma validate
their feelings and explain how children need to see that their parents can handle talking
about the trauma so there the children need to see the strength and the parents which is what you’re
going to work on in parent sessions to make sure that the parents have the resolve and the skills
handle talking about this topic with junior TFC BT can be an effective intervention
for children or adolescents whose primary presenting issue is trauma-related emotional or
behavioral dysregulation TF CBT is not appropriate for clients who are actively suicidal and severely
depressed or currently abusing substances we want to make sure they’re clean
and sober as much as possible TF CBT starts with psychoeducation and then teaches stress
management and coping skills to aid in the management of distressing feelings psycho IDI
helps to clarify the inappropriate information children may have and start getting them a little
a bit more comfortable talking about the topic in general before we start going deeper and
feelings identification helps participants start effectively labeling and communicating their
feelings so they can receive the support and nurturance they need from their caregivers
and their support system if you enjoy this podcast please like and subscribe either in your
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Schema therapy is a cognitive behavioral approach to addressing anxiety, depression and even borderline personality disorder.
What are Schema
~ Schema are mental or cognitive representations or beliefs about a particular person or event that we repeat(and hopefully adjust) throughout our lives
~ Schema about ourselves and our goodness
~ Schema about going to the doctor
~ Schema about job interviews
~ Schema about news media
~ Schema about flu season that cause anxiety and depression
~ Schema about the stock market that cause anxiety and depression
~ Schema about coronavirus
~ Schema about the safety or dangerousness of other people
~ Schema are a type of metacognition
General Categories of Schema
~ Security/ Abandonment
~ Trust & Safety / Abuse
~ Emotional Support / Emotional Deprivation & Invalidation
~ Self Determination / Vulnerability To Emotional or Physical Harm
~ Positivity & Optimism / Negativity & Pessimism
~ Acceptance And Contentment / Hypercriticalness
~ Competence / Defectiveness
~ Independence / Dependence
~ Self Concept & Esteem /Enmeshment
~ Success & Empowerment / Failure
~ Self Control / Lack of Self Control & Subjugation
~ Belongingness, Connectedness vs. Alientation
How are they formed
~ Schema are formed based on the interpretation and memories of experiences or cognitions
~ They are a short-cut the brain creates to help us better anticipate future situations and guide out behavioral responses
~ Interpretation is impacted by
~ The person’s age and prior similar experiences
~ The person’s cognitive development and metacognition
~ Children tend to personalize, dichotomize and overgeneralize
~ People with trauma histories may notice and remember more threats in the environment (Hypervigilant thinking)
~ If you have had a bad experience with something, then you likely expect another bad experience (waiting in a doctor’s office; shots; the flu; thunderstorms)
How Schema Become Outdated
~ What was dangerous to you as a child may no longer be dangerous (staying home alone)
~ What was dangerous to you in the past (abusive significant other, emotional dysregulation) may not apply in the present (current SO, emotional regulation)
~ The expectations that applied to something 20 years ago may not apply now (stock market, cancer, HIV)
Why Schema May Be Inaccurate
~ Emotional Valence
~ We tend to notice threats when we are in a dysphoric mood
~ Lack of Knowledge
~ Fear mongering headlines
~ Conflicting or inaccurate information
Forming Healthy Schema
Cognitive Behavioral Approaches teach us that our thoughts, feelings and behaviors are connected. TO form healthy schema we need healthy thoughts.
~ Basic needs include:
~ Consistency and Predictability
~ Responsiveness
~ Acceptance and Attention
~ Validation
~ Empathy and Encouragement
~ Safety and Support in Solution Generation
Adjusting Schema
~ Identify and evaluate current schema that cause distress
~ Evaluate the facts
~ Address cognitive distortions (overgeneralization)
~ Explore schema related to old situations with “fresh eyes”
~ Abandonment
~ Safety
~ Emotional dysregulation
Also check out our other podcasts, Happiness Isn’t Brain Surgery and Addiction Counselor Exam Review
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