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Anxiety Disorders in the DSM 5 TR | Symptoms and Diagnosis

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

 Unlimited CEUs for $59 are available at AllCEUs.com/Trauma-CEU this episode was pre-recorded as part of a live continuing education webinar. CEUs are still available at AllCEUs.com/Trauma-CEU welcome to today’s presentation on the neurobiological impact of psychological trauma   on the HPA axis we’re going to define and explain the HPA axis which we’ve talked about before is a response system so it’s not anything to get to you know overly concerned about   that it’s going to be super dry well identify the impact of trauma on this axis and on basically   your whole nervous system in your brain identify the impact of chronic stress and cumulative trauma   on the HPA axis because a lot of times when we talk about PTSD we think only about some   particular acute event and that’s not necessarily true there are a lot of people with PTSD who have   basically what I call cumulative trauma and they were exposed to extensive child neglect they were   in domestically violent relationships they were in a situation where they were exposed to trauma   over and above what a normal person would think lawfully think of law enforcement military personnel think first responders I mean they see stuff that no human should have to see   and they see it not only once but you know once a week or once a month depending on kind of where   you are so it’s important to understand well one thing may not be so traumatic to create   post-traumatic stress we’re going to look at some of the reasons that PTSD symptoms may develop as   a cumulative sort of thing which I found this to be interesting anyway we’ll identify   symptoms of dysfunction and we’ll talk about some interventions that are useful for this population   now my guess is none of you are prescribing physicians so when we’re going through this you’re   going to be going yeah that’s all well and good what’s the exact point of thinking about   exactly what this information is telling me on each slide show used to be the hat to help my   clients who have been annoyed by trauma and have not yet developed any sort of PTSD symptoms   or who have PTSD symptoms and how can I use this information to better tailor my treatment plan to   help them become more effective in managing their symptoms this is kind of a unique presentation   because it was based on only one article this was a meta-analysis so it’s a long article   and it’s a really good article that I would strongly suggest looking at it in your resources   section in the class it lays out the many changes and/or conditions that are seamed in the brain and   nervous system of people with PTSD so they really looked at a lot of research longitudinally to see   what we know and what we don’t know as clinicians awareness that these changes can help us educate   patients about their symptoms why do you feel this way and find ways of adapting to improve quality   of life so neurobiological abnormalities in PTSD overlap with features found in traumatic brain   injury so that started making a lot of researchers go hmm you know traumatic brain injury there is   something or again of course hurting part of the brain so why are the symptoms similar in   PTSD you’re going to find out pretty soon is that PTSD does cause damage   actual physical damage in the brain the response of an individual to trauma depends not only on   the stressor characteristics but also on factors specific to the individual so somebody can see a   trauma and not be as traumatized if you will as someone else and part of these factors and   there was a study done by Pi Newson Nader back I believe the early 80s looked at triage   factors for PTSD and some of the factors that they found why certain traumas may be more   traumatic than certain people versus others have to do with this particular trauma, you’re experiencing   it close to one of your safe zones where you live where you work somewhere where you’re not   where you’re supposed to be feel safe and if so then it’s probably going to be perceived as   more traumatic now again think about the survival capacity or the survival function of this behavior   when your brain says this is supposed to be a safe zone and it’s not so I need to respond in kind   you’re trying to protect yourself make sense the similarity to the victim if it could happen to her   if it could happen to him they’re like me it could happen to me that makes me feel scared because we   like to categorize the world in terms of using them bad things happen to those people not to us people   but if you’re looking at a victim who’s liked you and you say well I am and us people then you’re   going to have more difficulty separating it and feeling safe and going well that couldn’t happen   to me and the degree of helplessness you know if you saw something and you were just like there   was nothing I could do there’s a greater sense of helplessness and horror then if you didn’t have   that necessarily that same experience so those are a couple of things as far as the prestress or   perception that we want to consider when we’re talking to our patients even if you’re not a   therapist that works with the trauma specifically some people refer out for that some people are   working with an EMDR therapist and you know cool but as important to understand and if you happen   to go down this road with your clients help them understand why they perceived that particular   stressor so intensely versus some other stressor that they think may have good English there   oh well sorry they think should have stretched them out more so their perception of the stressor   prior traumatic experiences and we’re going to learn that prior traumas do cause changes   in the brain to prepare you basically Therese bond more quickly when there’s a threat   so prior traumatic experiences can send you from zero to 100 a lot faster which means it’s going   to be or could be more traumatic the amount of stress in the preceding months if you’re already   worn down and your body has already said I can’t fight anymore it’s not doing any good then when   it encounters PTSD and when it encounters a trauma the body might be going I just can’t   take another thing please just I can’t do it which is why we see in people with PTSD chronic stress   burnout and chronic fatigue this inability to tolerate stress because the body’s just already   waived them that white flag going I can’t do it current mental health or addiction issues again   that’s your body’s way of saying something in the neurotransmitter something in the system   is a little bit wonky and that means I’m not going to be able to respond a hundred percent   healthy and functionally to whatever’s going on and the availability of social support now   a lot of the research especially with emergency service personnel points to the availability of   social support within 24 hours of the trauma so when there’s an officer-involved shooting   when there’s something that they encounter on the duty that’s trauma the ability to have social   support within that first 24 hours preferably first two-hour period to at least touch base with a   social positive social support is vital to helping somebody process the memories instead of   just kind of them disappearing into never-never land and getting solidified in an unhelpful way for the vast majority of the population though psychological trauma is limited to an acute   transient disturbance you see something that’s traumatic you’re like oh my gosh Wow it is   devastating and yeah is going to affect you for a little while but in a week or two you’re kind   of feeling like you got your land legs again so there’s this subpopulation of the population   there’s a small group that ends up developing PTSD the signs and symptoms of PTSD reflect   a persistent adaptation of the neurobiological symptoms to witnessed trauma and I crossed out   abnormal in the article it says abnormal and I look at it as a perfectly normal adaptation   because the body is either going with the reserves I have right now I can’t deal or you know whatever   it’s doing it’s trying to protect itself now it may not be helpful but from a survival   perspective it generally makes sense so I try when I’m working with clients to help   them see the functional nature of their symptoms given the knowledge they had or the state they   were in at the time so now to the HPA axis the The hypothalamic-pituitary-adrenal axis aka your   threat response system controls reactions to stress and regulates many body processes   including digestion the immune system mood and emotions sexuality energy storage and expenditure   so let’s think about this real quick when you’re under stress, your body feels threatened I needs to survive so it sends out excitatory neurotransmitters that get you wired up which   kind of makes your digestion speed up it can cause some cramping in the abdominal area   your immune system is not really important right now threat we’re not worried   about the flu mood and emotions you tend to be hyper-vigilant and more easily startled threat   means fight or flee which means anger or anxiety so you’ve got some stress emotions and I don’t   want to say dysfunctional because they’re very functional your body perceives a threat and it’s   saying you need to do something sexually well if there’s a threat this is no time to procreate so   your body says let’s turn off those sex hormones right now, because we need to use us for fighting   and fleeing not procreating which is all well and good but when we have reduced sex hormones   it also reduces our serotonin availability which serotonin is one of those calming chemicals   which help us calm down the excitatory neurons so without them, you stay revved up which brings   us to energy storage and expenditure you’re revved up you’re on high alert you’re staying   up here and your body says you know what if I’m going to survive this fight or flight I   need fuel which means you need to eat preferably high-fat high-sugar foods that give us instant   energy and sustained energy we want calorie defense stuff now thinking about it from that perspective   you can see how when you’re under chronic stress or a big stressor you know some of your symptoms   make sense why do you want to go eat chocolate or do whatever you do that’s my go-to pizza and   chocolate when I’m stressed is generally what I crave not what I need but what I crave so we want   to help people understand that there’s a reason it makes sense now we just have to figure out   how to deal with it differently the ultimate result of HPA axis activation is to increase   levels of cortisol in the blood during times of stress now cortisol is the hormone that goes out   and sets off kind of this whole well there are a couple before it but it sets off this whole   event cortisol is your stress hormone cortisol is the one who says no sex hormones right now   you know and it monkeys with all your different hormones to make sure and your energy storage to   make sure that you’re ready for this fight or flee its main role is to release glucose into   the bloodstream in order to facilitate the fight or flight now glucose is sugar is raising your   blood sugar so you’ve got energy now we’re going to talk regularly about glucocorticoids which are glucose hormones that make your body release glucose which is mainly cortisol and that   term is going to become important later I’m just kind of throwing it out there right now cortisol   also suppresses and modulates the immune system digestive system and reproductive system so again   cortisol is saying we’ve got this energy we’ve got this threat let me figure out how to sort of dole   out our resources right now for survival in the now it’s cortisol is very present focused   it’s not looking at you know the long-term and going well this will pass cortisol is very right   now HPA axis dysfunction the body reduces HPA axis activation when it appears further fight-or-flight   may not be beneficial and they call this hypo cortisol ism so basically a threat response system   is you know warning the alarm in my dorm when I was in college used to have these   really annoying blinking lights I because why I do this all the time sorry the hypercritical ism is   your body’s response to going if I keep fighting I am just throwing good energy after bad there is no   sense in surrendering so it turns down the system and it stops producing as much cortisol that way   it has cortisol your stress hormone for when there is a bigger more threatening threat well what does   that mean well we need cortisol is what helps us get up in the morning our cortisol goes   up and down throughout the day which helps us have the energy to get up go to work do those   sorts of things it’s a normal hormone when it’s in the right balance hypo cortical cortisol ISM   seen in stress-related disorders such as chronic fatigue syndrome burnout and PTSD is actually a   protective mechanism designed to conserve energy during threats that are beyond the organism with   us ability to cope so dysfunction in the axis causes abnormal immune system activation so   you have increased inflammation and allergic reactions cortisol is also related to   cortisone your body does not release its natural antihistamines when you are pardon me   under stress which is why your allergies seem to bother you more which when your allergies bother   you more you’re probably not sleeping as well at night and we know that not sleeping as well at night keeps your HPA axis activated so you’re fighting this battle you’re trying to squeeze   blood out of a turnip basically because your body said we’re not releasing any more cortisol I don’t   care what you say but everything else you’re not sleeping as well you’re still kind of revved up   you’re fatigued and your body is going but there’s a threat and back in your brain they’re going yep   but it’s not a big enough threat yet so you can see where this cascade you’re fighting inside your   own body and all your systems are kind of arguing irritable bowel syndrome such as constipation and   diarrhea because cortisol speeds things up and if you don’t have enough cortisol you know what might   happen reduce tolerance to physical and mental stresses including pain remember I said that sex   hormones go down which means that the availability of serotonin goes down we know that serotonin is not   only involved somehow in mood it’s involved with some level of anxiety reduction but we   also know it’s involved in pain perception so when serotonin goes down we perceive pain   more acutely and altered levels of sex hormones so fatigue and you’re like where did that   come from well the HPA axis is activated see how many times I can say that without tripping on my   tongue when it’s activated it sends out these you know excitatory neurotransmitters when   you’re excited for too long you get fatigued well interesting little caveat or thing here   fatigue is actually an emotion generated in the brain you know we’ve learned to label it which   prevents damage to the body when the brain perceives that further exertion could be harmful sounds   similar to hypo cortisol ISM it is so what do we know from athletes we know that fatigue and   sports is largely independent of the state of the muscles themselves so fatigued you know your   muscles usually only work up to about 60% of their ability to work and then fatigue starts to   set in so there was still a big margin that you could work before your muscles finally gave out   and said hold no more I’ve got jelly legs but your muscles quit you start feeling tired you   start feeling exhausted so this is a protective mechanism the body’s gone we need to conserve a   little bit of energy because you have to get home and shower and you know prepare to run in case   the tiger chases you but what factors is your body paying attention to but tells it OK whoa we need   to stop so we’ve got enough reserve in the event of a problem core temperature, you’re working out   your core temperature goes up at a certain point it goes that’s high enough your glycogen your   blood sugar levels your oxygen levels in the brain how thirsty you are whether you’re sleep-deprived, to begin with, it’s going to mean that you fatigue a lot easier and the level of muscle soreness and   fatigue going into that exercise session the brain kind of takes all these factors into   effect and goes okay I can unless you work out this much and then I’m going to shut you down I’m   wrong it’s off what they have found though is we can override this so when clients come into   our office, they’re fatigued they are they’re off they’re just like I’m exhausted I’m agitated I’m   irritable I’m not sleeping well I just uh okay so with athletes, we know that psychological factors   can be used to reduce fatigue such as their emotional state if they go in in a positive   emotional state or a hyped up energized emotional state if they’re listening to really energizing   music it can help them push past that fatigue point a little bit if they know the endpoint   maybe they know they’re doing three sets of ten reps they’re going to push through faster or more   effectively than if they’re working with the coach and they have no idea how many sets they’ve got or   how many reps they’ve got to do they’re just like are you going to make a stop to other competitors that   service motivation they’re looking around they’re seeing other people doing it they’re going okay   I got this and in the case of athletes visual feedback you know they’re seeing growth in their   muscles they’re seeing positive changes so they can push through that fatigue a little bit more   they’re like okay this is worth it so fatigue is one sign that the body is getting ready to down-regulate that HPA axis and go conservation in practice and counseling practice how can we   help reduce mental fatigue and help clients restore their age PA access functioning and   one of the things I would challenge you to think about is how can we increase their self-efficacy and their high ductless if you will in their the emotional state that a can-do attitude increases their hardiness and resilience you know we talk about those, a lot man make sure they know their   endpoint where are they going what does their what do their symptoms look like what is it   going to look like in three weeks in three months and what can we reasonably think will change you   know let’s give them some tangible goals that they can look at other competitors or motivational group therapy can be very helpful in dealing with some of this stuff obviously, you’re not going   to do a lot of trauma work in the group most of the time but having other people around knowing that   there are other people who are dealing with PTSD and having support groups can be really   helpful because they can cheer each other on and go come on John you got this you just need to push   I know this is a really tough week for you and that can help people push through that fatigue and feedback now in the case of psychological issues we’re not talking about visual feedback but   we’re talking about looking at that treatment plan or looking at their symptoms and being able   to say you know what I have made progress I’m not having nightmares as much as I actually slept through   the night last night who knew and finding those things that they can latch on to and go things   are getting better you know they’re not going to get exponentially better overnight likely but they are   getting better and I can see this incremental progress and in doing that we can help people   get a sense increase that those dopamine levels increase that learning and go okay I can do this   we want to make sure that we are considering their fatigue level though and not putting too   much on them at once let’s look at really small steps and then solidifying those steps not   taking one step after another but taking one step and then taking a breather for some of our clients   helping them identify how they’re feeling and be aware of their own fatigue level low cortisol   has been found to relate to more severe PTSD hyperarousal symptoms and you’re like yeah it   took me quite a while to wrap my head around this whole concept but it makes sense now so when you   have low cortisol your body is conserving all its energy can in case it needs to respond   to an extreme threat the sensitized negative feedback loop in veterans diagnosed with PTSD   have they’ve shown that they’ve got greater ludic corticoid responsiveness now remember I talked   about cortisol being a glue to co-corticoids and there’s just no nice way to talk about   this without using really obnoxiously clinical terms anyhow which means that the body is holding   on and it’s going you’re not going to have cortisol to just get irritable or happy or excited about   just anything but if there’s a threat I’ll let you have it unfortunately in patients with cortisol   ISM when there’s a threat they have an exaggerated response thank hyper-vigilance and I call it the   flatter the Furious so their mood is either kind of flat and they’re not really responsive too much   but when there is something that startles them or their body perceives as a threat all of a sudden   their body dumps cortisol and dumps glucose into the system which floods the system and if you’ve   ever flooded your engine you know what happens doesn’t respond quite as well but there are even   more problems with this so evidence says that the role of trauma experienced in sensitizing the HPA   axis regulation is independent of PTSD development okay so what does that mean that means even if   somebody doesn’t develop PTSD clinical diagnosis if they’ve had trauma HPA access is going to   sensitize them a little bit and hold them back a little bit more cortisol and be a little bit more reactive   when there is trauma which means successive traumas could produce success successively   significant reactions in those with prior trauma maybe more at risk of PTSD for later traumas   so again as a clinician what does this mean for me this means that if I’m working with a client   who comes from a troubled childhood there were adverse childhood events or you know whatever   you want to label it they had chronic stress they had trauma in their childhood even in the prenatal   period they found I wanted to educate them about the the fact that they are at a greater risk of developing   PTSD if they’re exposed to more trauma so they can learn how to keep their stress levels under control because it’s more important for them according to this research because of some   persistent brain changes that we’re going to see core endocrine factors of PTSD include abnormal   regulation of cortisol and thyroid hormones okay so we’ve already talked about cortisol our stress   hormone and you’re probably familiar with thyroid hormones being sort of your metabolism hormone but   what happens when cortisol goes down in the body starting to rein in the energy thyroid hormones   also go down hypo cortisol ism and PTSD occurs due to increased negative feedback sensitivity   of the HPA axis okay studies suggest that low cortisol levels at the time of exposure to trauma   may predict the development of PTSD so if their cortisol levels were already low they were already   suffering if you will from hypercortisolism and remember we’ve seen hypercortisolism in burnout   and you know regular old burnout chronic fatigue syndrome as well as PTSD so we’re not just talking   about veterans here if the cortisol levels are already abnormally low and the body’s already   started conserving cortisol when they’re exposed to a trauma we can with more certainty   predict which people are going to develop PTSD symptoms back to those gluteal corticoids they   interfere with the retrieval of traumatic memories an effect that may independently prevent or reduce   symptoms of PTSD so when cortisol is in the system and it’s causing all the blood   sugar to develop we’re not forming lots of memories right now we’re just surviving which they   hypothesize could prevent or reduce the symptoms if those memories aren’t consolidated and they   go away, or it could contribute to difficulty in treating PTSD why well let’s think about   it if people who’ve been exposed to trauma you know hypercortisolism they respond to threats by   increasing the amount of cortisol and political corticoids exponentially have an exaggerated   response than when they’re in our off and we’re talking to them about their trauma, and they   start to get upset they start to get excited there the body’s going to start dumping all these gluten coke   or turquoise and guess what it’s going to make it more difficult for them to retrieve those memories   potentially so it’s kind of an interesting thing to look at because a lot of clients that I   worked with PTSD have been like I can’t remember why can I not remember and my very   general response because they don’t want to know about all this stuff generally is it’s your brain’s way of protecting you it’s your brain’s way of saying there’s a threat right now and you need   to protect yourself from the threat we don’t need to be worrying about all those memories back there   so we do some you know relaxation activities and those sorts of things to help them you know get   back down to baseline so we’re not continuing to fight against those gluten Co corticoids and thus   cortisol because when you fight with that what happens the client generally gets progressively   frustrated progressively upset and progressively unable to think clearly and access those memories   neurochemical factors corner or chemical factors of PTSD include abnormal regulation   of catecholamines serotonin amino acid peptide and opioid neurotransmitters each of which is found in   brain circuits that regulate and integrate the stress and fear response now again if you’re   thinking I’m never going to remember this for the quiz don’t get too stressed out about it because   I want you to take home the overarching concepts I’m not going to ask you really nitpicky questions   about stuff that you have absolutely no control over or at least that’s what I tried to do that   being said I want I think it’s important that you know that all of these neurochemicals including opioids are involved in the regulation and integration of stress and fear responses it’s not   just serotonin or two dopamine the catecholamine family including dopamine and norepinephrine are   derived from the amino acid tyrosine now it’s not really all that important but an interesting   little aside is that norepinephrine is made from the breakdown of dopamine so your focus and get   up and go chemical is made from your pleasure chemical interesting little concept there when   a stressor is perceived the HPA axis releases corticotropin-releasing hormone which interacts   with norepinephrine to increase fear conditioning and encoding of emotional memories enhance arousal   and vigilant vigilance and increase endocrine and autonomic responses to stress so when the   threat response system is turned on it releases cortisol which interacts with norepinephrine the stress hormone and they get up and go hormone say there’s some really bad mojo brewing here   which increases fear conditioning because the heart rates go in and everything and the response   is stress there’s an abundance of evidence that norepinephrine accounts for certain classic   aspects of PTSD including hyperarousal heightened startle and increased encoding of fear memories so   what about serotonin you know that’s supposed to be one of our calming chemicals it where   did it go poor serotonin transmission and PTSD maybe may cause impulsivity hostility aggression   depression and suicidality remember you’ve got the downregulation of the sex hormones so less   availability of serotonin and there are other things that cause the serotonin to not be as   available but they found that serotonin binding to 5h t1a receptors and this is just a little   soapbox I’m going to go on don’t differ between patients with PTSD and controls so what does that tell us that’s the only way we can really To figure out what’s going on in the brain in a live   subject look at PET scans what we have figured out or they’ve hypothesized is the fact that the   serotonin may not transmit as effectively as it may be a really weak connection it’s connecting but   it’s you know it’s kind of like having a rabbit ears you got to twist it to get the signal to   come in correctly all right this is another one just a concept I want you to think about all   they’re looking at in the research is the 5-hit 1a receptor there are a ton of 5-ht serotonin   5-ht receptors and each one of these receptors is involved in some aspect of addiction anxiety mood   sexual behavior mood sleep so when we’re talking about why SSRIs don’t work well SSRIs only bind   to certain receptors and if we’re not picking the right receptor if it is the serotonin at   all then we’re probably barking up the wrong tree I educate my patients about this if they decide   they need to go on antidepressants just so they don’t get frustrated as easily I mean it’s still   frustrating but so they don’t feel hopeless if the first medication they start taking doesn’t   seem to work or makes it worse we talked about why that might be because there are so many different   receptors for each one of the neurotransmitters there is a really cool table if you’re into this   stuff it’s actually on Wikipedia and it talks also about not only what these receptors do   but also what chemicals and medicines act on these receptors and how Food for Thought   GABA has profound anxiolytic effects in part by inhibiting the cortisol norepinephrine   circuits so it turns down the excitatory circuits patients with PTSD exhibit decreased peripheral   benzodiazepine binding sites well we know that when the body secretes a neurotransmitter goes   to the other end and it binds like a lock-and-key if you will or it knocks on the door and the door   gets opened and it goes through however you want to think about it basically what they found is   in patients with PTSD the Kem GABA goes through and the GABA levels are okay but then it knocks   on the door to get let in or it tries to put its key in the lock and there’s something wrong at   the binding sites or the binding sites you know somebody’s super glued them shut and they’re just   not there which is why patients with PTSD tend to have a harder time de-escalating when their   anxiety and stuff gets up because the GABA is there but it’s got no doors to go through no   locks to bind with however you want to whatever metaphor you want to use this may indicate the   usefulness of emotion regulation and distress tolerance skills due to the potential emotional   dysregulation of these clients so remember we talked about them having a more exaggerated   get-up-and-go response to a perceived threat and they also have a harder time calming down which is   basically one of your primary tenants of emotional dysregulation so one thing clinicians can   do is help patients learn that okay their body responds differently to stress than other people   at least for right now so it’s important for them to understand what emotional dysregulation   is emotional regulation strategies as well as distress tolerance skills to help them until they   can calm down to baseline because it sometimes takes them longer than other people as clinicians   we also can help reduce excitotoxin in order to reduce stress improve stress tolerance and enable   the acquisition of new skills when the brain gets really going when the cortisol is out there and   the glucocorticoids are in there it’s actually toxic and starts causing neurons to disappear which we’re going to talk about in a second it’s kind of scary NMDA receptors have been implicated in synaptic plasticity.Which means the brain’s ability to adjust and adapt as well as learning   and memory so these are good receptors I like them glutamate binds with these receptors and high   levels of glutamate are secreted during high levels of stress glutamate remember is what   GABA is made from but high levels of glutamate it’s an excitatory neural net in the brain and   overexposure of neurons to this glutamate can be excited toxic and may contribute to the loss of   neurons in the hippocampus of patients with PTSD so we’re actually seeing brain volume decrease as   a result of exposure to certain chemicals elevated gluten core glucocorticoid and yeah glucocorticoids   increases the sensitivity of these receptors so you’ve got a bunch of glutamate being dumped and   you’ve got a bunch of glucocorticoid you’ve got cortisol in there making these receptors more   sensitive so it’s got they’re more sensitive and they’ve got more coming in which makes it a whole   lot easier to become toxic and start causing neuronal degradation what does that mean why do   we care it may take clients with PTSD more time to master new skills because of emotional reactivity   but also because some of their synaptic plasticity may be damaged so it may take them a little bit   longer to actually acquire and integrate these new skills it’s not saying they’re stupid they   can remember it just fine however when they’re an emotionally charged state and helping their   brain learn that okay this isn’t a threat that’s one of those sort of subconscious things that has to   happen that can take longer if the brain becomes excited toxic during stress inhibited learning   and memory then it becomes excited toxic during stress which inhibits learning and memory so it’s   under stress things are excited toxic neurons are starting to disappear so I’m wondering and   I’m just hypothesizing here I don’t know the answers obviously or I wouldn’t be practicing   it but what happens during the exposure therapies because that’s exactly what we’re doing is we are   flooding the brain with all of these chemicals and creating basically an excitotoxin now they   found some evidence that exposure therapies can be helpful according to the DOJ website but or   not the DOJ I can’t even think of it right now the VA website but you know I’m wondering   long-term what the impact is endogenous opioids natural painkillers act upon the same receptors   activated by exogenous opioids like morphine and heroin exerts an inhibitory influence on the   HPA axis well we know that people take opiates and it has depressant effects on them it slows   them down and calms them down alterations in our natural opioids may be involved in certain PTSD   symptoms such as numbing stress-induced analgesia and dissociation again think of any clients you’ve   had who have been abused or even taken and not like the side effects of opiates are what opiates do to   some people make them feel more relaxed stress induced and analgesia they don’t have as much   physical pain sometimes they just it’s there I don’t care pill another interesting factor   is now truck zone which is used to oppose opiate appears to be effective in treating symptoms of   dissociation flashbacks in traumatized persons so basically, they’re saying if we undo the endogenous   opioids we can treat these symptoms it highlights the risk of opiate abuse for persons with PTSD   though because if endogenous opioids produce some of these numbing symptoms and dissociative   symptoms so they can get away from the pain and the flashbacks then if they add to that you know   oral opioids it could prove to be a very tempting cocktail we do want to as clinicians figure out   how we can assist them with their physical and emotional distress tolerance so they don’t feel   the need to numb and escape and you know I can’t imagine what some people have seen have   gone through and I’m not trying to take that away from them, I’m trying to help them figure out how   they can stay present and learn to integrate it changes question marks in brain structure and one   of the questions that’s come up in the research is because there aren’t any longitudinal studies that   looked at it was the hippocampal volume as low to begin with which created a predisposition for PTSD   or did PTSD create the smaller hippocampal volume interesting hippocampus is implicated in the   control of stress responses memory and contextual aspects of fear conditioning so it helps you to find these triggers in the environment that help you become aware with your senses about when   there might be a trauma prolonged exposure to stress and high levels of glucocorticoids damage the hippocampus we’ve talked about that hippocampal volume reduction in PTSD may reflect   the accumulated toxic effects of repeated exposure to increased cortisol levels what I called earlier   the flatter the Furious having you know your body holding on to cortisol for this extreme stress   and then when it perceives stress it’s either nothing or it’s extreme there are no kind sort   of mild stressors out there that decrease hippocampal volumes might also be a pre-existing vulnerability   factor for developing PTSD the amygdala yet another brain structure is the Olympic structure   involved in the emotional process and it’s critical for the acquisition of fear responses   functional imaging of studies has revealed hyper responsiveness and PTSD during the presentation of   stressful script cues or trauma reminders but also patients show increased amygdala responses   to general emotional stimuli that are not trauma associated such as emotional faces so they show an   increased responsivity to things they see on the TV that aren’t trauma-related to people crying   to people showing anger’s going to have a stronger emotional amygdala response than people   without PTSD so clients with PTSD may be more emotionally responsive across the board leading   to more emotional dysregulation again an area that we can help provide them with tools for early adverse   experiences including prenatal stress and stress throughout childhood has profound and long-lasting   effects on the development of neurobiological symptoms the brain is developing and if is exposed   to a lot of stress and some of these excited toxic situations how does that differ in the amount of   damage caused versus a brain that’s already kind of pretty much-formed programming may change for   subsequent stress reactivity and vulnerability to develop PTSD so if these happen during   childhood or at any time the brain can basically reprogram and go that it’s a really   dangerous place out there so I need to hold on to cortisol and I need to hold on to these   stress hormones because every time I turn around it seems like there’s a threat so I am going to be hyper-vigilant and respond in an exaggerated way to protect you from the outside world adult women   with childhood trauma histories have been shown to exhibit sensitization of both neuroendocrine and Audino stress responses so basically they’re showing hypo cortisol ISM a variety of changes   take place in the brains and nervous systems of people with PTSD and we talked about a lot of   those the key take-home point is stress can actually get toxic in the brain and cause physical   changes not just thought changes in the brain preexisting issues causing hypo cortisol ism where   the brain has already downregulated whether it’s due to chronic illness or chronic psychological   stress increases the likelihood of the development of PTSD this points to the importance of   prevention and early intervention of adverse childhood experiences we really need to get   in there and help these people develop distress tolerance skills understanding of vulnerabilities   so they’re not going from flat to furious all the time and so that they can understand why   their body kind of responds and why they respond differently than others and you know as we talk   about this and of course I’m regularly bringing up DBT buzzwords if you will think about your clients   if you’ve worked with any who’ve had borderline personality disorder what kind of history do they   have did they have just a great childhood no we know that people with BPD generally had pretty   chaotic childhoods so this research is also kind of underscoring why they may react and act   the way they do that flat to furious people with hypo cortical ism may or may not have PTSD so we   don’t want to say well you’re fine if you don’t have PTSD symptoms we do know that every trauma   potentially can cause the body to down-regulate and I kind of look at it as conserving a little   bit more of the energy that it needs each time so instead of conserving 60% now it’s conserving 65   and 66 each time it encounters a stressor in order to prepare for potential ongoing threats in the   environment hypercortisolism sets the stage for the flattened the furious leading to toxic levels   of glutamate upon exposure to stressors which can cause the theorized reduction in hippocampal   volume and persistent negative brain changes now I always say the brain can you know rebalance itself   and all well that’s part of the plasticity that is the really cool thing about our brain however as   far as regenerating those neurons I haven’t found any evidence in the research that we found a way   to help people regenerate once we’ve already those neurons are gone they’ve been killed off the brain   has to find a workaround so it does take time but I do believe people can minimize some of the   impact of the trauma they may have experienced people with PTSD are more reactive to emotional   stimuli even stimuli unrelated to trauma again think about some of your clients especially   if you work in a residential situation where you’re around on 24/7, you know for 30 or 60 days, and   you may see some clients that seem to get upset over everything and you’re like ah such a drama   queen or such a drama king and to yourself not to anybody else but when you think about it from   this perspective it gives you a different perspective and you might say oh maybe their body   responds differently they’ve got more emotional dysregulation because of prior trauma they’re not   trying to overreact this is their body’s response because it’s perceived threat so many times it gives me a different approach to working with that client hypercortisolism results when the   brain perceives that continued effort is futile feelings of fatigue set in akin to reduced stress   tolerance so think about you know when you’ve had a really long stressful period you know weeks or   months maybe you’re dealing with an ailing family member or something it’s just a lot of stress and   you start getting really tired and when you’re really tired and you’re worn down and somebody   gives you one more thing it’s that one more thing normally wouldn’t bother you but right now you   just can’t take it so we can see how there’s a reduced stress tolerance when somebody’s already   at this stage reducing fatigue in our clients can be accomplished in part with psychological factors   including motivation or knowledge of other people who are dealing with similar things support groups   feedback about their and making sure they have frequent successes not once a week but I want to   have them keep a journal every day of something good that happened or something positive that   may indicate they’re moving forward in their treatment goals and knowledge of an endpoint.OIP-6Where are we going with this when is the treatment going to end I don’t want most clients don’t   want to be with us forever no matter how lovable we are do you want to feel better and be done   with us so having to help them see that there is an endpoint we’re going to accomplish this   goal this month and then we can reassess 46% of people in the US are exposed to adverse childhood   experiences so like I said this is a huge area for early intervention where we can prevent people   from developing PTSD later in life how awesome would that be instruction and skills to handle   emotional dysregulation including mindfulness vulnerability prevention and awareness emotion   regulation distress tolerance and problem-solving could be wonderful additions to health curriculums   anything any skills groups you do with children or adolescents or even adults I mean just because   they’re adults doesn’t mean that they’re safe from PTSD or that they’ve crossed any threshold   where they’re too old to learn we’re never too old to learn of those exposed to trauma education   about and normalization of their heightened emotional reactivity and susceptibility to PTSD   in the future may be helpful in increasing their motivation for their current treatment protocol   whatever it is but it also just normalizes things so they don’t feel like they’re overreacting or   they don’t feel guilty for being so tired or whatever they’re experiencing right now are there any questions I know I went through a lot of really complicated stuff but I thought   it was really interesting not only the way our brain reacts in order to protect us   but how cross-cutting a lot of this stuff was it not just PTSD we’re talking about   necessarily but a lot of this information applies to our clients with chronic fatigue burnout and chronic stress and we can see that those people also are at risk at   higher risk of PTSD should they be exposed to trauma and none of us is immune I mean   there are tornadoes there are hurricanes there are you know things that happen that   really stink so the more we can help clients be aware of things develop skills and tools to prevent as much harm as possible I think the more effective we are as clinicians depending on the client and I can do some more research on the VA website because   they’re really into medications for PTSD I know ketamine which is a horse tranquilizer   has been shown to be effective in people with PTSD and there have been some others   that have kind of given me pause ketamine is a hypnotic you know most of the drugs   they’re trying out right now are really in my opinion they’re powerful drugs but a   lot of them all of them that I know of have pretty high addictive potentials too so they   make me nervous but you know when you’re weighing the when you’re going from a harm   reduction model that’s not necessarily not necessarily such the be-all-end-all I guess that’s interesting that you use ketamine in the ER it’s definitely powerful effective stuff and like I said earlier some of the stuff that some of my clients and some people   have seen done experienced I couldn’t even imagine and you know sometimes for them to   actually survive we may need to look at some of these more intense more powerful drugs PTSD and veteran trauma is not are not my focus right now and yes marijuana is being experimented   with or looked at used whatever however you want to look at it for PTSD treatment with veterans   there’s pretty much not a drug out there they haven’t tried to throw at it to see well what   will this do I believe they were even using LSD experimentally for a little while too you the VA I mean if you’re interested in this topic let me see if I could pull that   down into here, we go to the National Center for PTSD US Department of Veterans Affairs   has a lot of information if you go for professionals, it has a ton more information   if you can get on get some of your SI CEUs on demand they do have some free CEUs for PTSD   here I’ve never taken any of them but what I’ve looked at when I’ve looked at like the   PowerPoints the presentations and stuff I’m sure they’re good so if you’re you do focus   a lot on PTSD and you can get on-demand CEUs then this might be a place to get some good free   ones aside from DBT are there any other evidence-based practices for therapy that   you’ve seen work best in combination with the medications cognitive processing therapy when   you’re working specifically with veterans and there is a free course on that too and this one I have gone through and it’s really awesome CPT dot must seed and here I’ll just put it into that education and this is a free course oops   and here’s the other one ah golly everyone and embryo does have a lot of research effectiveness   with people with PTSD too so yes I would definitely encourage people to explore   all options alrighty everybody I really appreciate you coming today and sticking   with me through this topic and I will see you on Thursday if you have any questions   please feel free to email me or you can always also send it to support that all   CEUs com either way I get it and otherwise I will see you on Tuesday thanks a bunch if you enjoy this podcast please like and subscribe either in your podcast player or   on YouTube you can attend and participate in our live webinars with Doctor Snipes by   subscribing at all CEUs comm slash counselor toolbox this episode has   been brought to you in part by all CEUs com providing 24/7 multimedia continuing   education and pre-certification training to counselors therapists and nurses since 2006 used coupon code consular toolbox to get a 20% discount on your order this monthAs found on YouTube15 Modules Of Intimate Video Training With Dr. Joe Vitale – You’re getting simple and proven steps to unlock the Awakened Millionaire Mindset: giving you a path to MORE money, …download-2k

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

 CEUs are available for this presentation at AllCEUs.com/CBT-CEU Hi everybody and welcome to today’s presentation on cognitive behavioral therapy skills. Like the other The presentation we did on assert not assertive community treatment acceptance and commitment therapy, which is also based on providing information about skills that can be used not providing an evidence-based practice We couldn’t cover that in a full hour or just an hour so over the next hour we’re going to define cognitive behavioral therapy and its basic principles a lot of us are familiar with this but it’s going to be a good review and it also may highlight some nuances that you didn’t know about will identify factors impacting people’s choice of behaviors explore causes and impact of thinking errors and identify common thinking errors and their relationships to cognitive distortions so why do we care well as therapists we want to help people figure out the best way to live a happy healthy meaningful goals-driven life for some people that’s going to mean using some cognitive behavioral interventions that can be in addition to mindfulness that can be in addition to a lot of other things but it’s important to help people understand that the way we believe things to be the way we interpret things is going to affect our reactions so for example think about a situation you know you’ve walked into and maybe you walked into it with a small child and it was a different situation it was a new situation but you know it was no big deal you walked in it was not a threatening situation to you because you were like hey I got this the little kid walks in and goes oh wow there are a lot of people walking around here, this is really scary same situation as two different perceptions you probably didn’t have much of a stress reaction going on whereas the little child probably had this fight-or-flight thing going on grabbing onto your hand like please don’t let go Atlanta Airport is a perfect example if you’ve ever taken a little kid through Atlanta Airport it gives you an idea about how People can perceive things differently and when you enact that fight-or-flight reaction you’re going to have all those stress hormones you’re going to have all either anxiety or anger or whatever that goes with it it may serve to exhaust the person and leave them feeling hopeless and helpless so what we want to do is help people see that but we also want to help them see that when They’re depressed when they’re tired when they’re sick things are going to seem a lot worse a lot of times because they don’t have the energy to perceive it differently I mean when you’re sick it’s overwhelming to think of going through Atlanta Airport so this is what we want to help people start understanding is it’s two sides of the same coin they interact if one is you know kind of going wonky is going to affect the other one the good thing is If one’s going really well the other one’s going to go well if you’re Having positive thoughts you’re probably going to feel pretty good there’s an activity and I think we’re going to talk about it later it’s called the coin flip activity and I asked client clients to flip a coin in the morning and in the morning if it turns heads then they have to be the most positive Pollyanna all day long look for the silver lining and everything smile walk with their head up hold those nonverbals up and see how they feel at the end of the day besides a little sore because there are muscles they’re using they haven’t been used in a while if it lands on tails they can just be their normal selves which generally if they’re seeing me means that they are depressed anxious stressed out angry about something in the negative realm then we Talk about how things seemed different on the days when you were feeling better when you were walking taller when you were smiling even our nonverbals it doesn’t even have to be sickness it can be our nonverbals that can make us feel or make our body feel heavy and tired and make it seem like it’s a whole lot harder to deal with life as a person who perceives the world generally good and believe they can deal with challenges as they arise that good old self-efficacy will be able to allow their stress response system to function normally so if they’re like you know what I can deal with whatever life throws at me I’ve got it and maybe I need help with it maybe I’ll need to ask for support but I’ve got it it’s not going to completely overwhelm me with people who see the world as hostile unsafe and unpredictable You know for a variety of reasons whatever happened to make their scheme as such that they don’t believe that people or the world is trustworthy are predictable They are always on guard they’re always kind of like a hamster in a cage that has Have you ever had a hamster hamsters doesn’t recognize you and goes Hey that’s my own Or human contact score hamsters go run under their little house And you just kind of open the cage and stick your hand in there and flip over their house and you’re like come here and give me cuddles and you’re like you know 200 times bigger than they are so the little hamster is like freaking out this is what it’s like for people and obviously, I’m exaggerating but this is what it’s like for people who have a negative perspective a negative view or a hostile view of the world so kind of keep that little hamster in your mind cognitive behavioral therapy we have core beliefs those things that are in our hearts when I talk with my clients about honesty step one and that’s what they’ve got to do to start recovery is get honest with themselves first and then other people we talk about head heart and gut honesty do you think it’s right does it seem like the right thing to do does it feel right in your heart you know does it make you happy it doesn’t make you feel good and then the Spidey senses is your gut saying and or Is your gut fine if one of those is saying this might not be the right choice and we need to think about what’s going on so we have those core beliefs and I put them in the heart just because that’s the middle of the head heart and gut but you have core beliefs about yourself whether you’re good with You’re bad whether you’re effective at certain things yadda You have core beliefs about other people same thing good bad effective predictable and you have core beliefs about the future and a lot of that goes with locus of control but also your past experiences if the world in the past is seemed unfriendly and uncontrollable and you’ve perceived it that way then you’re going to expect the future to be uncontrollable so what we want to do is help people look at their schemas and their core beliefs about themselves others in the future and figure out kind of what they want it to look like these schemas are going to affect your behavior your thoughts and your feelings and you know you can pick wherever you want to start it doesn’t matter because all three interfaces with one another so if you haven’t let’s Start with negative thoughts If you have negative thoughts then you might feel anxious angry stressed dysphoric which will affect the behavior you’re going to do different things than if you have positive thoughts about something you feel excited and energized you’re going to have different behavior the best thing example I can give you is if you’ve ever done public speaking or had to present something Some people detest public speaking it’s just terrifying for them to get up in front of a group of people so their thoughts are I’m going to trip up I’m going to forget what I’m going to say I’m going to make a fool of myself I’m going to you know it can go on forever that when you get on a roll you can get on a negative roll and go on forever or positive hopefully get on that roll with those thoughts you start holding onto Those thoughts remember as we talked about in a CT the other day when you hold those thoughts and you kind of mush them around in your mind and you come to believe them that you’re going to make a fool of yourself and it’s going to be awful you’re going to start feeling terrified which is going to likely affect your behavior if you go out on the stage and you’re terrified You’re going to probably stutter you’re probably going to get foggy-headed You’re going to have that fight-or-flight reaction so there’s an adrenaline rush and you start sweating and you can’t focus and you can’t concentrate you want to away as opposed to somebody like me who loves public speaking and I’m just like cool I get to go out there and try to engage however many people are in the audience it’s a game for me because when I can see your faces I enjoy trying to figure out and make eye contact with people and figure out what it is that they’re there for what is it that’s going to make them tick what resonates with them so my behavior as You can kind of see right now when I go out there I’m excited and I want to engage people and it’s a fun experience for me again just like the airport the same experience for two different people and two very different interpretations and reactions to it so what effects I don’t like the term rational but when We’re talking about CBT irrationally comes up a lot I like to replace it with helpful because every behavior in its weird sort of way is or probably was rational at one time that being said we’re going to get back to that stress affects our behavioral choices if we’re under stress we can have negative emotions negative emotions will affect our thoughts if we’re feeling sad we’re probably going to look at the dark side if we feel sad we’re going to look at the bottom falling out if we’re happy we’re probably going to look for that silver lining physical factors if you’re in pain sick sleep-deprived poorly nourished so your body can’t produce the neurotransmitters it needs to or heaven forbid intoxicated you’re probably not going to make the same decisions as you would if you were comfortable healthy well-rested nourished and not Intoxicated any of those things can impact how you perceive a situation or how you react in a situation, especially the intoxication whereas in your intoxicated State in your sober state, you may think that you want to do something but then you’ve got that filter that does not not a good idea in an intoxicated State or even in a manic state if you’re you know if you have somebody with bipolar that filter kind of goes away so the behaviors that someone may normally not do because they have a rational filter That goes you know punching this guy out is probably not the best idea right Now the filter goes away when you’re sleep-deprived you’re less generally People are less patient generally people don’t have as much of a filter thing about watching your children if you have children or your grandchildren or even yourself I know myself when I’m sleepy I am giddy as all get-out and things I wouldn’t normally say because they’re you know stupid I’ll just come out and say anyway and my kids just roll their eyes or the mom you’re overtired could go to bed, uh but that’s okay You know I’m okay with that In that situation now if I acted that way at work it would be a worse thing environmentally if you’re introduced to a new or unique situation and you perceive it as stressful because the unknown we know can be stressful then you may not make as rational of a choice or as helpful of a choice because you Maybe trying to escape the same thing as exposure to UNPROFOR bellowing for a word here but UNPROFOR ball is the best I could come up with we all prefer certain situations some people like I said would rather do just about anything then get up in front of a lecture hall of a hundred and fifty people and talk but if they have to do it then they’re going to be under stress which may affect how they do things so we want people to understand that their perception and their feelings are affected by a lot of other things not Just you know an emotion here or a particular memory there’s a lot that goes into it and social if peers your family convey irrational thoughts as necessary very standards for social acceptance people may tend to cling more to it to those unhelpful thoughts and unhelpful behaviors you know in CBT they say irrational because quote nobody wants to associate with those people you know who are those people and why can’t we associate with them there are a lot of things if you think back think high School you know high school is pretty rough if we’re going to talk about having irrational thoughts and cognitions if you have to be part of this particular group to be accepted you have to do this you have to do that but do you do you do those kinds of all-or-nothing statements are cognitive distortions and while they may have served a purpose in some way shape or form in the past we need to encourage our clients to take a look at them now and go are they still helpful ways of thinking is it still helpful for me to think that I am only successful if I live in a million-dollar house in a gated community and do this that and the other or can I be can I define success as a different way or do I define success differently and lack supportive peers to buffer stress so we had those peers who caused stress by talking about the half dues and categorizing and lots of attributions but then there’s Also not having somebody to go you know does this make any sense because sometimes we are our own worst enemies and if we go to a friend and we go you know this is what I’m thinking and I think I have to do this in order to be acceptable to be loved or you know whatever the case may be Most people are not going to use those exact phrases A good friend is probably going to listen and go yeah you’re right or no that’s way off so supportive peers are essential to reminding us to consciously regularly check in with our cognitions to make sure that they are hopeful and rational so a note about irrationality and this is mine this is not from CBT the origins of most beliefs for rational and helpful given the information the person had at the time and their cognitive development their ability to process that information so concepts schemas and core beliefs that people formed when they were five are probably going to be very egocentric you know the person is going to feel like everybody sees it my way because this is how I see it you know just like A five-year-old does A five-year-old doesn’t think Well you know let me take Johnny’s perspective is no he assumes that Johnny sees it the same way so it’s going to be egocentric It’s probably going to be focused on only one aspect of the situation because small children can’t focus on multiple aspects and it’s probably going to be dichotomous it’s all-or-nothing Mommy loves me mommy hates me and it could be personalized you know Everything a lot of kids think that everything has to do with them so if something happens something bad happens many times Children will take it personally or be afraid it’s going to happen to them Again you know if Hurricane Katrina hurricane Andrew those sorts of things you know we saw a lot of trauma in children and they developed very real fears about thunderstorms and hurricane season And if you’ve watched Florida hasn’t had a notable hurricane in years now but There’s a lot of stuff that goes into that but young people During some of those really bad hurricane seasons perceive those situations differently okay so we need to help people understand that if we especially if we use the term irrational those thoughts you form when you are knee-high to a grasshopper and they made perfect sense to you back then but now that you’re an adult you’ve got more experience and you’re able to take different perspectives your brain is more developed Let’s take a look at it and see if you can look at different perspectives and Come up with something a little more helpful maybe a different way of perceiving this situation the irrational irrationality or unhelpful Nosov Fox comes when those beliefs are perpetuated without examination so something a the belief that you formed when you’re five you’re still holding when you’re 35 and you’ve never questioned it you’ve never gone you know does this make sense is This is helpful to getting me toward where I want to be Most of us don’t know We form these attitudes and beliefs when we’re you know growing up when we’re in elementary school middle school high school from watching TV to being around our peers from being around our family in our community and we get all This input of the way things should be and a lot of times people don’t stop to question and go and go Well does this make me happy Is this really what I want and they can be irrational if they continue to be held despite causing harm to the person so the person continues to hold this belief even though it is causing them general emotional cognitive harm is making them miserable we need to look at what’s motivating them to hold on to that belief why is that belief so important and how can we make it so they can live a happy values-driven life with an emphasis on the harness and how can we make it less harmful sometimes it’s more productive for clients to think of these thoughts as unhelpful or helpful instead of irrational sometimes when I say irrational to clients and you know I’m the same way if somebody says you’re being irrational I’m like oh I’m not it elicits this instantaneous defensive reaction it’s like when you tell them they’re being resistant they’re like I am NOT resistant so helpful or unhelpful and then we talk about why it is unhelpful in getting them toward their goals basic principles of cognitive behavioral therapy we teach or help clients learn to distinguish between thoughts and feelings I can think something is scary I’ll probably feel it but if I have an automatic you know feeling I walk into Atlanta Airport and I see yeah I went to an airport in New York I can’t even remember which one it was because my plane was diverted and I got off and I walked out there and I have never seen so many people packed in his place like sardines before in my life I was just completely overwhelmed that was kind of an automatic feeling now that was a feeling based on you know who knows it was overwhelming to be surrounded by that many people so then I had to separate the thoughts and go Okay what am I thinking that’s making me feel so overwhelmed and at that point you know I didn’t know how to get to my gate and all that other sort of stuff with traveling I don’t travel well but encouraging clients to stop and go okay why am I feeling this way what are my What thoughts am I having that are contributing to these dysphoric feelings CBT helps people become aware of how thoughts can influence feelings in ways that are sometimes not helpful We have hecklers in our gallery the automatic tapes that we plaything memories that we have whatever you want to call them when you try something When you are just going through daily life you hear these voices in the back of your head and not real voices but that is saying you’re never going to make this or if you would have just blah blah blah then you’d be a better person helping clients become aware of those thoughts and how they’re Negatively influencing their feelings and keeping them kind of stuck is a huge part of CBT we help them learn about thoughts that seem to occur automatically without even realizing how they may affect emotions again those thoughts from the they’re saying you’re not good enough You’re not smart enough and nobody’s going to like you Where did that come from and do you believe it you know maybe it came from somebody When you were in high school so was that a valid was that a valid source Maybe it came from somebody yesterday on Facebook was that a valid source taking in those thoughts and then figuring out is something I’m going to hold because it makes me happy or is this something that I’ve got to deal with because I’m having a negative reaction constructively evaluate whether these automatic thoughts and assumptions are accurate or perhaps biased the other thing to remember is a lot of our clients not all of them but a lot of them hold themselves to a standard there’s like up here and they hold everybody else to a standard that’s down here so they are a failure if they don’t achieve this but Everybody else is successful as long as they achieve this so encouraging them to take a look at how accurate and biased or unbiased are the thoughts and like I said they may be their thoughts they may be telling themselves these things evaluate whether the current reactions are helpful and a good use of energy or unhelpful and a waste of energy that could be used to move toward those people and things important not impotent important to the person road-rage you’re In the car you’re driving somebody cuts you off Okay natural reaction fight or flight reaction you’re just like slam on the brakes and do whatever you got to do aversive maneuvers you’re good so you could let it go at that point ago got Lucky on that one and keep driving most people not all but most found that 80% of drivers have reported incidences of road rage which is a high number but most people will start getting all fired up and irritated and grumpy and we and just rageful and so my question would be I hear that and I hear that it made you angry In retrospect did screaming at the person as you pass them at sixty miles An hour in your car with the windows rolled up does any good Did it Did any good at all what else could you have done with that energy if you wouldn’t have expended it all yesterday we had to wait for the vet to come by and my daughter just completely wore herself out worrying about when the vet was going to get there what he was going to say about her donkeys and was beside herself so by the time it got to evening and it was time for her to go to her martial arts class she didn’t have the energy to go she’s like um wiped out I just want to go to bed in retrospect we’re looking back and saying okay now Tell me what it was that you were so stressed out about and let’s talk about whether that was a realistic and helpful line of thought to perseverate on all day long and what could you have done differently because she didn’t bother to mention any of that to me yesterday and then developed the skills to notice interrupt and correct these biased thoughts independently causes of these thinking errors information processing shortcuts when we form schemas and we encounter a situation that reminds us of something in the past like when I go to my grandmother’s house I have a schema I have a belief system I have you know stuff that I know about my grandmother’s house so when I go to my grandmother’s house it’s kind of a shortcut to knowing what to expect when I walk in and how to behave how to do different things and it helps me plan and predict if you’re Using outdated or dichotomous all-or-nothing schemas may cause thinking errors because you may be now incorrectly processing current events mental noise some of us have it a lot of us have it Not everybody thinks about trying to focus and study for a final exam in the middle of a really busy sports bar okay this is a cause of thinking or you’re going to miss important things you’re not going to be able to focus you’re not going to necessarily attend to the correct things because there’s just so much else going on your attention is drawn in 17 different directions and or the brain’s limited information processing capacity due to age we talked about that before young kids think all or nothing they think dichotomously egocentric ly middle school-aged kids and older start developing the ability for abstract thinking, by the time we get older, you know as adults theoretically We’re able to you know think pretty well and think pretty clinically about different events but if we’re in crisis when someone is in crisis it could be like what we think of clinically as a crisis or it could be they’re just completely overwhelmed and burned out and have been burning the candle at both ends for three months they’re not going to process information quite as well They’re not going to take in all this stuff because they’re just like shell-shocked have you ever seen teachers in the hallway of like an elementary school Oh at the end of the second nine weeks they just kind of stand there with this blank look on their face they’re not processing as much as they were the first day of school and you know God loved them they have a lot to deal with but we need to help our clients understand that there are some times that they are going to have to really stop and focus write things down so they can remember or they can make decisions A little more my guess is most of us have times in our lives when we’ve been able to think through complex problems but then there are other times where you just can’t keep it all in your head and you’ve got to put it on a Whiteboard maybe that’s just me but we want clients to understand that they are not broken they’re not faulty they’re doing the best they can with the tools they have and the knowledge they have and our job is to help them see where some of this might have gone a little awry other causes of thinking errors and emotional motivations I feel bad therefore whatever I’m thinking must be bad if I’m scared that means whatever it’s coming on the other end of the phone is bad news moral motivations I did it because it was the right thing to do and that can be an excuse for doing wrong behaviors as well it can also be you know you can argue on The moral one social influence well everyone else is doing it so it must not be bad set that again a lot of times and this is where the frames approaching the Motivational interviewing is helpful It stands for feedback about the reality of what’s going on is everybody doing it let’s look at statistics you know not subjective information let’s look at objective information so the impact of these thinking errors makes people want to fight or flee when they get upset and we use upset as a kind of this all-encompassing garbage term emotionally they get depressed or anxious we don’t want to feel that way Anxiety and anger are flee or fight fight or flee it’s our body saying there’s a threat you got to do something depression is your body going I give up I just don’t I don’t even have the energy to do it anymore behaviorally some people withdraw because they Shut down We all know people get frustrated when they get overwhelmed When they start feeling hopeless or helpless they just kind of withdraw from Everything and everyone’s addictions numb that out so they don’t have to feel the dysphoria sleeping problem and changes when we start being on that constant fight-or-flight hyper-vigilant sort of thing going on in the body is always sort of turned on which means you’re not going to sleep as well then The circadian rhythms get messed up which starts causing exhaustion and lethargy and then everything seems harder because you’re sleep-deprived and then you start thinking more negatively and more hopelessly you see where this is going it’s a downward spiral and eating changes some people eat a lot more because they’re eating comfort foods some people eat a lot less because Their stomach is so torn up from the stress they can’t even think about holding anything down physical stress-related illnesses fibromyalgia gastrointestinal problems headaches neck aches backaches you know the whole the gamut of it when you start feeling bad when you start hurting generally it gets frustrating after a while and that frustration makes it kind of raises the bar brings you up a little bit so you’re That thatch closer to kind of just kind of being overwhelmed as you do You have as much of a cushion as you would if you were happy healthy well nourished not in pain and socially a lot of times we will get irritable or impatient with other people or withdrawal when we’re having these negative cognitions these thinking errors that are keeping us in a dysphoric state these effects of thinking errors contribute to fatigue a sense of hopelessness and helplessness which intensifies thinking errors This is an important concept that I want my clients to understand and I want to drive home in this presentation so thinking errors what are they emotional reasoning feelings are not facts and we want to help people learn to identify feelings and separate them from facts so if somebody says I’m terrified okay that is a feeling what are the facts supporting that feeling why are you are terrified what is the evidence that you are in some sort of danger Right now you know that danger may not be the right word for your client at that a particular point in time but what’s the evidence that there’s a threat in what ways is this similar to other situations maybe it’s triggering something from the past that was scary or you know you were too little to be able to handle it but you can handle it now and how if you dealt with similar situations Like in the past, we wanted people to just step back and get some distance between their feelings and their thoughts and try to figure out you know which thoughts are helpful and productive and even if a sought makes people anxious or angry it can be helpful it may be telling them hey dude you need to get your butt up and get out of there if it’s helpful it means it’s moving them toward where they want to be happy healthy safe and values-driven life so happy and helpful developed a stress tolerance skills when people use emotional reasoning they feel emotions which then they start attributing finding the facts to support those emotions instead of looking at all the facts we want to help them learn to tolerate their distress so they can kind of let that subside for a second they can accept their feeling they can name them They say I’m scared I’m stressed I’m angry and whatever but they don’t have to act on it right then they can tolerate the distress for a minute without having to try to make it go away and emotional regulation skills they can feel a feeling without having to make it go from zero to 120 You know if they feel sad they go I feel kind of sad instead of grabbing onto it and going I wonder what I feel sad about I must feel sad about all these sad things now I’m going to be sad and devastated so we want to help people learn how to regulate their emotions identify them accept them Whatever word you want to use tolerate them because feelings are there for a reason they’re there to tell you your brain thinks something’s going now thankfully we have that higher-order cognition stuff going on so We can contradict our brain and we can go you know maybe that’s not true in this situation cognitive bias negativity mental filter whatever you want to call it people who focus on the negative they walk in they get up in the morning and They look outside and it’s partly cloudy They get to work and they say instead of saying there was it was very light traffic they said there was a fair amount of traffic everything is always the flip side of what somebody who’s optimistic would say so asking them what’s the benefit to focusing on the negative in what ways is this helpful to you know some people say Well it keeps me from getting disappointed because I know It’s going to end up negative anyway so we can trap challenges that know that whatever it is they think they know and see if there have been exceptions when It hasn’t turned out that way What are the positives to this situation I give the example a lot of you know I wash my car or it rains and maybe I wanted to go out on a run that day but I can perceive it I can look at the positives you know the rain washed my car for me so I don’t have to do it now score it watered my garden all the better it knocked down some of the pollen out of there even better I can find and I can encourage people to find positives in a situation yes there are negatives there are negatives to every situation if you want to find them you’re going to find them but if you want to find the positives you can too which takes us down to what are all the facts there’s the positive and the negative and the neutral I told you Earlier about the coin toss activity having people toss a coin on the heads days they act like it is just the greatest day to be alive and see how Things are different when they do their journal because you know I have my clients do I’m sort of a mindfulness check-in in the morning and in the evening and preferably at lunchtime how are they feeling what’s their emotional state what’s their energy level on the happy days a lot of times it can be less and sometimes they need a little coaching throughout because some of those old patterns kick in but I want them to start challenging some of their automatic thoughts that we’re going to talk about in a minute disqualifying or minimizing the positive most of us can probably say we’ve had a bunch of clients that do this they are more than happy to tell you about all the things that they mess up but then when they do something right they minimize it encouraging people to hold themselves to the same standard they would hold everyone else to and I know I talked about that earlier ask them things like would it minimum would you minimize this.If it was your best friend’s experience your best friend came to you and said I just got into such-and-such college would you say awesome or would you say anybody can get in there how would that go ask them what is scary about accepting these positive things that you might have had an accomplishment for some people it means that it might mean other people expect more of them for other people they just don’t know how to accept the positive They don’t know how to accept compliments they don’t know how to be the center of attention and they don’t like it and then we want to look at why that is sometimes we disqualify the positive because it fails to meet someone else’s standards so as people might that be true here you know I know When I was growing up and going through college and going through school and everything got my doctorate but I will always not being not a real doctor because a Ph.D. is not an MD and I’m like really So is it somebody else’s standards or can I feel good about having a Ph.D. egocentrism My perspective is the only perspective I’ll being egocentric but it doesn’t work most of the time so encouraging people to take alternate perspectives Maybe you’re texting with someone and they say something that is not what you interpret as not the nicest thing and this happens in text messages a lot and they get upset now an egocentric thinking error would say that purse is just grumpy today Someone who’s taking other perspectives would stop and go back and read the text and go I wonder if maybe this could have been taken some other another you know obvious reaction is not what I intended So egocentrism if you hold on to that I don’t understand anybody else because You know I don’t see a problem with anything personalizing and mind-reading This is when you assume that everybody’s frowning because of something you did your boss walks down the hallway and looks at you and grimaces and continues to walk on oh I must have done something wrong No maybe he just got out of his senior management meeting that was five hours long and he’s got to go to the bathroom you know there could be a hundred different explanations for why that happened so encourage clients to ask themselves what some alternate explanations for this event that are doesn’t involve me you know why this might have happened if they hold on to that, I must have done something wrong but as soon as their boss calls them up and goes hey can you come to my office for a second you know where their thoughts are going to go I’m getting fired I’m going to get laid off I don’t know what it was that I did wrong but he walked by me two weeks ago in the hallway and grimaced and I’m just I’m the worst person in the whole world But where did that come from so encouraging people to not necessarily assume they know what’s going on in someone else’s mind and not automatically attributing every person’s negative behavior to something they did How often and then ask them how often has it been about you now think about the last 10 times you’ve taken something personally how many of Those 10 times has it been about something you did versus something with the other person then the availability heuristic remembering what’s most prominent in your mind so asking clients what the facts ah the most obvious One that we talk about is plane crashes You know it is very dangerous to fly on a plane because you hear about all those plane crashes well yeah you hear about the airlines crashes but don’t hear about the 20,000 every day that land safely so you remember it and it seems more dangerous because that’s what is in your mind that’s what is available to you that’s what you’ve based your thought processes on because maybe you didn’t know that 20,000 planes or more fly and land just perfectly every day this can also be true with people remembering what’s most prominent in your mind sometimes and this can be very very true in domestically violent relationships if somebody falls in love with someone and that person is just the greatest person since sliced bread for the first four months and then the cycle starts and there’s this little tiny a sliver of the honeymoon period after the battering cycle and the person’s like That’s the person I fell in love with that’s what I remember and they try to focus on that that’s most prominent in their mind and they ignore the rest of the stuff so we need to encourage people to look objectively at the facts magnifying high and low probability outcomes what are the chances that this is going to happen how Many clients have worked with have gone to the doctor and gotten into a physical or get a test run and then the doctor had to call them back and This could be true for you too and the doctor had to call them back two or Three days later when the tests came back from the lab and that whole three days they were just in a panic because they were afraid they were going to get some terminal diagnosis so thinking about high and low probability outcomes another instance or example of magnification is somebody that thinks this is the end of the world whatever it I think I’ve told you before my little story about um tripping when I was walking down the hall at work and falling and yeah it was embarrassing my folders went everywhere and yeah but in that big scheme of things will it matter That much from now you know are people going to think Oh she is such a clutch she must be a ditz too no I mean they may have thought that at that time I don’t know but you know in six months nobody’s going to remember and then ask them in the past when something like this has happened when you’ve had to get a test done and you’ve had to wait on results or if you’ve done something that was embarrassing and you didn’t think you thought everybody was going to remember it forever how did you tolerate it how did you learn to deal with it building on those strengths that they already have all-or-nothing thinking errors These are things like love versus hate I love them or I hate them it’s all or Nothing she does this all the time or she never does it if I’m going to do it I’m going to do it perfectly or I’m not going to do it at all thank you all good intentions or all bad intentions you know sometimes we do things with good intentions that have some bad repercussions so did we do it with all Bad intentions are all good intentions and the answer is neither most of the time life is kind of in that middle-ground gray area encouraging clients to Look and find examples where something hasn’t been one of the polls when have they done something that they’re proud of that wasn’t perfect or when again When has somebody else done something that they were proud of that wasn’t perfect remembering that with availability heuristic remembering how often something happens and how long it’s been since you’ve seen that behavior and remember that sometimes good times are amazing but how frequent are they compared with the bad times another thinking error is a belief in a just world or a fallacy of fairness I just asked clients to identify for good people you know who’ve had bad things happen and in in reality we all have bad things happen good people do bad people do in between people do attributional errors and this is a pet of mine you know labeling yourself is not a behavior so global versus specific and I am stupid versus I’m stupid at math I don’t have good math skills it’s not about me it’s about the skills I can change skills stable I am and I always will be versus it’s something I can change it’s something I can learn internally It’s about me as a person versus it’s about a skill deficit or something I could learn or change and there’s you know lots of information on attributions out there on the internet if you need a refresher on it but we find that a lot of people who have dysphoria have negative global stable internal attributions so questions for clients remember the beliefs equal thoughts and facts plus personal interpretation another way of saying it is reality is 10% perception is 10% reality and 90% interpretation so what are the facts for and against my belief is the belief based on facts or Feelings Does the belief focus on one aspect or the whole situation Does the belief seem to use any thinking errors what are alternate explanations what Would you tell your child or best friend if they had this belief how would you want someone to tell what would you want someone to tell you about this belief so If you’re telling somebody about this what are you hoping they’re going to say in return and finally, how is this belief moving you toward what and who is important to you or moving you away from what or who is important to you now they can do a worksheet and have all of these or you can pick one or two of these questions that are most salient for your clients but they can have kind of at their fingertips so as they’re going through the day and something happens They can ask themselves ok what’s an alternate explanation Or you know Whatever it is this salient for that client’s irrational thoughts how do these thoughts impact the client’s emotions health relationships and perceptions of the world you know this is what we want to ask them How is this thought impacting you globally how may this thought have been helpful in the past Where did it come from How does it make sense from when you formed it in the past when you’re dealing with it ask the person if the thought is bringing you closer to those that are important Are there any examples of this thought or belief not being true and how can the statement be made less global less all-encompassing so it’s about a specific incident a specific situation less stable which means you can change it and less internal which means it’s not about who you are as a person but maybe something that you do or a skill that you have so we’re going to go through some of these thoughts real Quickly here mistakes are never acceptable and if I make one it means that I’m incompetent well never is kind of stable and I am incompetent is kind of global, that’s also that extreme all-or-nothing thinking so you can see where these cognitive distortions end up leading to unhelpful beliefs When somebody disagrees with me it’s a personal attack Well there’s Personalization If I ever heard it before maybe it’s not about you may be They’re having a bad day and you just happen to be the unlucky target or maybe they’re disagreeing with you because they have a different point of view and It’s not a personal attack it’s just their point of view If someone criticizes or rejects me there must be something wrong with me personalization all-or-nothing thinking global stable and internal something wrong with me as a person to feel good about myself others must approve of me Now this is one we’ve talked about external validation before and we can’t control other people to feel good about yourself how can you do that Besides necessarily requiring other people to approve of you to be content in life I must be liked by all people Wow I’ve never met anybody who’s liked by all people I’ve never even met anybody who’s been hated by all people but it’s important to help clients see how this is dramatic to say all people and for them to be content everybody has to like them I mean I like to be liked but if everybody doesn’t like me you know That’s pretty understandable My true value as an individual depends on what others think of me I would challenge this one this is all you know Also very personally I would challenge people to look at and say it so your child’s value as an individual depends on what other people think of Most people would say no but the perspective thing nothing ever turns out the way you want it to okay all-or-nothing thinking and probably availability heuristic if something bad just happened then they may be focusing on that which causes them to focus on all the other bad things in the past that have happened not to focus on that is okay you know bad thing happen but look at all these good things I won’t try anything new unless I will be good at it this fear of failure fear of rejection It just really paralyzes a lot of people when they get stuck with that thinking the area that they have to be perfect I am in total control of anything bad that happens is my fault well that’s egocentric and personal if They think they’re in total control that’s their perception of how the world Do they think if they’ve got everybody on marionette strings anything bad in the world that happens is their fault how powerful are they I feel happy about uh if I feel happy about life something will go wrong It happens sometimes but let’s look at times when you’ve been happy that something hasn’t gone wrong you know let’s get rid of that all-or-nothing thinking it’s not my fault my life didn’t go the way I wanted could be true but it seems like that’s making you unhappy so what do we do about that if I’m not in an intimate relationship I’m alone No, again that’s pretty extreme I’m either in an intimate relationship or I am alone and a loner and you know it’s just me and my 17 cats which follows with there’s no gray area so encouraging people to look at what these beliefs are saying important thoughts impact behaviors and emotional and Physical reactions emotional and physical reactions impact thoughts and interpretations of events so if you do something and it’s pleasurable and you have a great physical reaction you know let’s take bungee jumping or Skydiving if you go out there and it’s scary but you do it and you’re just like Whoa what a rush Your interpretation of that is probably going to be good which means you’ll probably do it again if you go out there and it’s just the most horrible experience you’ve ever had you’re probably not going to do it again and your interpretation of it is going to be not good which is going to make it hard to understand why other people would do it irrational thinking patterns are often caused by cognitive distortions so let’s just look back at some of those because there are a lot fewer cognitive distortions or general ways of thinking about the world then there are thinking errors because There are lots and lots of thinking errors Cognitive distortions are often schemas which were formed based on faulty inaccurate or immature knowledge or understanding and by identifying the thoughts of the hecklers you know the automatic tapes that maintain our unhappiness the person can choose whether to accept those thoughts or change them.As found on YouTubeNatural Synergy $47.⁰⁰ 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Cognitive Behavioral Therapy (CBT) Skills and Counseling Techniques with Dr. Dawn-Elise “Doc” Snipes

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

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

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

 Unlimited CEUs for 59 at AllCEUs com welcome everybody. Today,’s, presentation is on dialectical, behavior therapy skills. This presentation is based in part on dialectical, behavior therapy a practical guide by Kelly Koerner. This is one of those books that, if you want to do dialectical therapy as a practice, not just look at some of its tools is a must-read. Then it’s also based in part on dialectical, behavior therapy skills, workbook DBT made simple and DBT for substance abusers, which is an article that was published by Marsha Linehan. So the links to those are in your class, but just give you an idea about sort of the breadth of what we’re going to be looking at today. In the short time that we have together, what we’re going to do is take a look at why DDT was created, we’ll look at understanding emotional regulation, dis-regulation and regulation will identify DBT assumptions about both clients and therapists, and we’ll Explore skills to help clients learn to stress tolerance, emotional regulation, and interpersonal effectiveness. As an aside, we’re taking – or I’ve taken the information from this course and combined it with a bunch of other information to make a six-hour on-demand course. That will be available by the end of the week, but for now, we’re just going to hit the highlights in the 1-hour introduction. So why do we care? Why do we want to learn about DBT skills and DBT tools? Many of our clients, experience emotional dysregulation, or the inability to change or regulate their emotional cues experiences, and responses. Think for a minute about any of your clients, if they’re depressed, if they’re anxious, they’ve got anger management issues, something is going on with their emotional states, or they’re not able to either get unstuck or control their behavioral responses. So they may be engaging in self-injurious, behavior risky, behavior, or addictive behaviors. They’ve tried to change and failed, leaving them helpless and hopeless. In a lot of our clients. We try to fit them in not that we should, but we do try to fit them into this box. If you’re depressed, then we’re going to look at these things, and one thing I hope you get from these webinars is the fact that every single client is different and there is no box that we can put them in and you’re, Like well, then, how can you do group therapy? Group therapy is awesome because you can tailor and that’s, part of the challenge of doing psycho. Educational group therapy is tailoring the tools and helping people tailor the tools to meet their individualized needs, but they can get feedback and they can see how different tools can be modified just a little bit to fit different individual needs and untenable emotional experiences that lead to Self-preservation behaviors such as addiction, you know to kind of numb the pain to give them a distraction, nonsuicidal self-injury. We’re talking about cutting, we’re talking about those sorts of things, and then even those suicidal behaviors. At a certain point, the pain has got to stop, so some people may end up going as far as trying to stop the pain by stopping their existence instead of hurting anyone else. People with emotional dysregulation have high sensitivity, so these people tend to be highly hyper-vigilant. They’re aware of a lot of things that go on now. This was created and I want you to really kind of think about it. It was created as a tool or a protocol to use with people with borderline personality disorder. What do we know about people with BPD? They grew up in really ineffectual environments, so they had to be hyper-vigilant about everything that was going on for their safety and security. So you have someone who, either by nature or by nurture, is hyper-vigilant. These situations have been over-generalized. The dangerous situations have been over-generalized, so the world tends to seem more and dangerous, and out of control, people with emotional dysregulation are easily thrown off kilter because they often have a lot of vulnerabilities. They’re not eating. Well, they’re depressed which is contributing to them not being able to sleep. Well, they can’t focus yadda, we’ve talked about vulnerabilities. One thing that dr Turner talks about is no emotional skin and she likens it to someone who has third-degree burns and every single thing, even the air when it touches it, is just excruciating there’s no middle ground. There’s. No, oh! That’s kind of uncomfortable it’s either not hurting or it’s. Excruciating. People with emotional dysregulation are also highly reactive, so they’re hyper-vigilant. They’re aware of everything that’s going on and then every time something happens that sort of triggers their awareness they jump into this immediate fight or flight reaction. Then they’re slow to de-escalate. So we’re talking about situations in which someone is hyper-vigilant. They’re on edge, maybe because of situations in the past or not. They have this sort of persistent fight or flight or frequent fight or flight reaction. And again, I’ll refer back to our dream fatigue class that talked about how the body can only stand to be all hands on deck for so long before it’s just like dude I give up, and then the sense of depression and helplessness and Apathy starts to set in people who are who have emotional dysregulation, really they’re either like flat and none nonexistent in their emotions. They just can’t even deal with it when they should, or they’re, overly reactive and then the person isn’t in a validating environment. What would be a to some of us on a scale of 1 to 10? As far as how distressing something is it’s, probably like an 8 to somebody with emotional dysregulation, think about a time when you were stressed out or you had a lot of vulnerabilities going on. Maybe you had a new baby at home, so you were, ‘t sleeping and your other kids were acting out. There were just all kinds of stuff going on and you reacted to something with an 8 that everybody else was like that. Doesn’t deserve that. Much of a reaction is that’s it what’s wrong with you, people with emotional dysregulation that’s their environment, all the time, everybody’s looking at them and going what’s wrong with you there? This is not that upsetting. So we need to help people understand that their experience is their experience and it’s not for me to say whether it’s a 2 or an 8. For me, it’s a 2, but let’s look at why it’s an 8 for you. So the emotional reaction – and this is I didn’t – get red eye reduction when I took this picture of bruit but bless his heart. When I got him, he was a rescue and he had such terrible terrible abandonment issues and is so hyper-vigilant. Even to this day, I’ve only had him like four months, but he’s hyper-aware of stimuli and people can be hyper. Aware of stimuli so anytime somebody moves, he’s up, he’s. Looking he’s like. Are you going to leave me alone again when he perceived that something is changing when there was a threat, he goes into all hands on deck and turned into a survival sort of thing and starts acting out? He goes and finds toys and brings them to me. Heaven forbid. We should have to put him out in the garage because we have visitors or something and it’s. You know climate controlled, it’s not like it’s horrible, but he will sit out there and how, until I let him in or go out and tell him it’s going to be okay, now see as a person I’m going. That is not a valid reaction. He’s like totally overreacting to having to spend ten minutes in the garage, whereas from his perspective he’s not overreacting, because in the past when he’s been put in the garage he left out there for days weeks months. Who knows I don’t know his story too. Well, now I use that to kind of highlight the fact that people with emotional dysregulation don’t know what their experience was. What they’re doing is trying to survive. Now they may be trying to survive a situation in their past. You know when there were six and we’re going back to the abandonment discussion that we had the other day, but it’s important to understand that all these things play in together. Something happens and the body’s response system takes in these stimuli and it says it’s dangerous it’s, not dangerous. What do we do with it? The brain decides to fight or flee, and then they go into the survival response with treatment. What we want to do is help people be able to feel that feeling and not have to act on it right away until they can de-escalate some and use a combination of assessing their cognitions and deciding whether their perceptions are based. On the present. The present moment or the past moment so primary invalidation caregivers dismiss emotional reactions as invalid. We just talked about that. The child or person could be mocked or shamed for their emotional response. We have all probably met parents or worked with parents who have children that are highly emotionally reactive, and who tend to get frustrated and overwhelmed by the constant drama that seems to be presented by this child all the time. So the child is often not taught how to self-soothe or de-escalate the parents just like really let it go and go away, which is not helpful because the child doesn’t learn how to deal with it. The child is not taught mindfulness to figure out okay, what’s causing this, and the child is not taught effective cognitive processing in most situations in validating environments, if the child gets upset, even if it seems to be disproportional to whatever the event was, the caregiver Will take the child in and say? Okay, I hear you’re upset right now, let’s talk about it and we’ll walk the child through, maybe not thinking about it, but just being a good parent walks. The child, through this de-escalation process and the cognitive processing of secondary trauma or invalidation, is, and I’m putting this in here. Coping skills can be overwhelmed by trauma or intense stress, leading to this high alert raw status. Think about the people who were survivors of Hurricane Katrina or Hurricane Andrew. I come from Florida, so I think hurricanes, but any big event that is ongoing enduring, and distressful at a certain point. You’re on your last nerve, so anything could precipitate sort of a crisis. Many people don’t receive the necessary support during these times and may be shamed for being weak or needy. Sometimes nobody can cope and everybody’s kind of decompensating. At once, which is a lot of what we saw with Katrina but other times there may be people that are functioning just fine and they don’t understand why some other people are 39, t coping just fine, and they see that as abnormal and want to distance themselves from it, it’s important for us to communicate to people because we already noticed that crisis is a normal response to an abnormal event. What was abnormal, though, is it this particular incident? Maybe, or is it the fact that this particular incident kind of was the straw that broke the camel’s back on a whole chain of incidents leading up to it that was abnormal? What caused this person? Excessive stress I was talking to a woman the other day who, in the past six years, has had half a dozen significant losses and I’m just like wow. You know that that’s pretty intense to have all those and she’s, also starting her practice and everything else. Right now – and I’m – just like oh my gosh – I can’t imagine the amount of stress this woman is – going through most humans, aren’t inherently prepared to deal with the crisis alone. We’re kind of group sort of people. We rely on other people, so if we have this reaction and it’s judged to be disproportionate and people kind of distance themselves from us, because they see us as abnormal or dysfunctional, then we lose any social support that might have been able to serve as A buffer which just kind of in turn, feeds back and exacerbates the sense of hopelessness, helplessness, and isolation. What precipitates a crisis may vary between people based on pre, existing stress or mental health issues, and it also may vary with the same person longitudinally across time. What may be overwhelming today – maybe not may not be overwhelming six months from now, because all of those prior stressors that I’m dealing with right now may have had time to kind of work themselves out. So we must help people understand that their reaction is their reaction and let’s just go from there. Let’s not say it’s bad or is disproportionate or it’s whatever it just is so the result of this sort of unpredictable reactivity results in frantic efforts to numb withdraw or protect. I need to numb the feelings because I can’t take this kind of pain. If you’ve ever had a burn that’s had to be cleaned or even an open wound that’s had to be cleaned out. You know that’s pretty excruciating so thinking in terms of that, you can see why people would want to kind of get a little novocaine withdrawal if this support system is invalidating, that has extra pain and that’s excruciating to be rejected. On top of everything else, so a lot of times, people withdraw which eliminates any opportunity for social support, and it also exacerbates this sense of rejection, and they do this to protect themselves. People learn who they are in invalidating environments. They learn who they are and how they are resulting in rejection, so they avoid threats. They avoid putting themselves out there. They avoid making relationships because they’re afraid of rejection and they avoid thoughts and feelings and sensations that may lead to invalidation. I don’t want to feel these things because then if I do and I communicate them, you may tell me I’m wrong. Okay, we’ve laid the groundwork. Now we see where this is a problem. So what do we do about it? Well, the first thing we want to do is look at some of the DBT assumptions about clients. Clients are doing the best they can given the tools they have at this present point in time, and I truly believe that clients want to improve themselves. Wouldn’t be in your office if they didn’t want to improve for one reason or another. It may be an involuntary referral and they want there’s a means to end there. They are in your office because they have hope that something can change and it will benefit them. They cannot fail at DBT if they go through dialectical behavior therapy, the protocol and it fails, then the protocol failed them or we as clinicians, fail to implement it correctly. Now, today, again, we’re talking just about tools that are present in DBT, not how to do dialectical, behavioral therapy. The evidence-based practice wants to make that very clear clients are existing in what is for them an unbearable state. This pain has got to stop. They need to learn new behaviors in all contexts, not just at work, not just in their relationships, but they need to learn how to function and deal with life on life’s terms in all contexts, so they can go to the grocery store they can get In a traffic jam, they can be in a crowded Airport and not feel like the walls are closing in on them. Clients are not responsible for all of their problems. We know this some things they had no control over are causing problems for them, but they are responsible for all of their solutions, and we’re going to talk about the four options for problem-solving in a few minutes, but they are responsible. They choose to do something and clients need to be motivated to change motivation, choosing the more rewarding option out of the available options. Well, yeah that whatever they’re doing right now is the most rewarding option they have available in their toolbox. So we’re going to give them new tools, but then we need to teach them how to make those tools effective. If you just hand me a jigsaw and say, okay go about woodworking and whatever I’m, not a woodworker, but I’m not going to know what to do with that. So I may go back to using my circular saw or whatever the case may be, which may be very clunky. We need to help clients learn how to use these new tools, so it’s more rewarding to use those than those old behaviors. They just numbed out the pain or distracted them assumptions about therapists, clarity, precision, and compassion are of the utmost importance. We need to be clear with our clients about what’s going on. Let’s not speak in generalities. We want to try to avoid some of the Socratic questions that we would normally do. We want to be clear about what we’re getting at and what we want them to look at. We need to be precise. Do we need to not say well what is it last week that caused all the problems in your relationships? Well, if they had four different fights that’s four different things we need to look at, we need to be precise to identify all of the things that trigger and we’re going to talk about behavior chains in a few minutes. So we need to be precise. We also need to be compassionate, even if we don’t agree, or we think that the reaction was disproportionate, putting ourselves in their mind in their place in their raw state. We need to be compassionate and go okay, you survived it, you did the best, you could let’s take a look at what might have caused that. Why you made the choices you did and what you might choose better next time. The therapeutic relationship is between equals, DBT or therapists can fail to achieve the desired outcome, but the client can’t fail and therapists who treat patients with pervasive emotional dysregulation needs support we need to remember that patients who are always in crisis by their very nature, it’s, exhausting because they’re always in crisis, which means we are responding in a crisis manner, not that we need to get all upset and worked up because that’s just modeling the wrong thing. But there is a lot of energy that it takes for us to use the DBT tools for us to model the DBT tools and for us to help work. The client is out of their emotional state into one where they can use their wise mind. So the first step is core mindfulness. Until they figure out what’s going on, they can’t fix it, so we want to help them integrate their rational mind they’re cognitive. This is what happened factual mind with their emotional mind. This is what it felt like in the wise mind, so you can take the facts. You can take your feelings and you can say with what I know and what I felt. What would be the best interpretation of this or the correct one for me? Interpretation of this event at this point, and what can I do about it? One of the things DBT talks about is the fact that truth is sort of subjective. What is true for one person may not be the truth for the other person, because we’ve all had different experiences, but we need to help people not underreact and stay. In that cognitive mind, if you’re a star, trek fan, think data um. He was the AI that was kind of human-robot sort of thing or, and we also don’t – want people to act in their emotional mind, acting solely based on feelings and trying to make feelings facts because feelings aren’t facts. They’re feelings, so we want to help them integrate these two things, and that is more difficult and it sounds like it takes time. Mindfulness is using effective, nonjudgmental observation and description of experiences, those thoughts, and feelings, and identifying what’s the objective evidence for and against what’s going on right here, how I’m feeling what is all the evidence. Let’s look at the big picture, not just one little aspect of it, and what are my feelings about this event? Getting in touch with what’s going on inside their mind and inside their body is going to be one of the first steps. So I talked about those four options: when there’s a problem, you have four options. You can tolerate it, grit your teeth, and Barratt there. Sometimes you just can’t do anything about it. Traffic jams probably can’t do much of anything about it. Change your beliefs about the event. Instead of seeing a traffic jam as a waste of time and just a complete pain in your butt, you can see it is a time to check voicemail and maybe return. Some phone calls are productive, make it billable, and you can solve the problem or change the situation, while you’re in a traffic jam and stopped, of course, looking at Google Maps to figure out where the next exit is so that you can get off. So you can change that situation or you can choose to just stay miserable and choosing to stay miserable is a valid choice. When clients make these decisions, we need to look at them. Why was that? Whatever their option was? Why was that option more rewarding than all the others? Why is it more rewarding sometimes to stay miserable for some people that’s what they know and they’re afraid if they feel happy, then they may get disappointed and end up feeling sadder than they already do now? Some people tolerate the problem because it’s what they know and change is hard and they would rather just tolerate it and deal with it and suck it up than have to muster up the energy to try to change whatever’s going on. So again we want to look and ask them or ask ourselves, maybe because they may not know right away the choice that you made. Why was it more rewarding? Why did you choose that over the other three options, distress, and tolerance we’re going to talk about a lot of acronyms here acronyms are really important in DBT because it helps clients have sort of a drop back and punt. There are some worksheets. There are lots of worksheets online for DBT but the acronyms we’re going to hit here are going to be some of the highlights that are going to be important for you to remember tip temperature. So you’re tipping your physiological balance now temperature. I’m not necessarily advocating for this. You don’t want to do it. If you’ve got a heart condition. You don’t want to suggest it to clients that have a history of child abuse, especially anything that involved drowning. So this one’s a little tricky one of the things I suggest to some of my clients instead of this is holding on to ice cubes. But the suggestion in the book holds your breath. Dunk your face in for as long as you can hold your breath into a sink full of ice water, then come up. Exhale, inhale and dunk, again repeat as many times as you need until you feel calmer. Well, guess what we’ve talked about combat breathing. If you are slowing your breathing, which you do, if you’re holding your breath, your heart rate is naturally going to slow. When your heart rate slows down your brain says: oh the threats going away, yippee yay, I can call off the dogs. There are other ways to slow down your breathing. Besides necessarily dunking your dunking, your head holding ice cubes is one of the reasons that that can be helpful. Instead of cutting the person’s focus, it’s a distracting technique. The person focuses on the pain because it is painful to hold on to ice cubes for a long time, instead of cutting themselves, but it also gives their body something to focus on to go. Oh, my heart rate is up because there’s a pain when the pain goes away. I can make my heart rate go down, so we’re redirecting the brain to go. Oh, this is why the heart rates are up it’s, not because there’s emotional distress, it’s because of extreme physical pain. Intense exercise increases body temperature, but it also increases the heart rate when you’re sitting still and your heart rate is 120 beats a minute because you are in a panic attack or a state of panic. It’s very, very uncomfortable and your mind is going. I don’t understand you, ‘re not moving. Why is the heart racing when you start exercising, which is why walking and getting those big muscles moving often helps? Then the body gets less confused. It’s, like Oh heart rates, beating fast, because the body is moving score, got it so when the person stops moving, the heart rate starts to go down, and this is true, even if you’re walking around. If you take a client out to walk when they’re upset – and you are talking about whatever the distressing thing is – I have found without exception.When they come back inside, they can start to calm down a little bit more and their heart rate naturally starts to go down when they stop their physical exercise and then progressive relaxation. You’re going to move from head to toe or toe to head. Whatever you prefer but head to toes, usually how we do it focusing on muscles focusing on breathing slowing, breathing relaxing muscles forcing the body to relax. So this addresses physiological arousal, so the temperature, intense exercise, and progressive relaxation. All of these serve as an ability serve the function of distracting the person from whatever cognitively or inter psychically wants to say, is going on, and all of these either explain to the brain why the heart rate is going so fast or Help reduce the heart rate, so you know there’s something to be said for them. The important thing is for you to brainstorm with your clients when you get physiologically aroused when you get upset, and you are just your hands – are shaking your palms are sweating. You’re breathing fast, and your heart rate going fast. How do you calm yourself down what works for you and we’re back to bruit again? Another acronym is accepted to distract when there’s emotional turmoil, so you can kind of let that adrenaline surge go because you have that initial fight or flight reaction and then the body kind of goes. Alright, let’s reassess and see if there’s still a threat, get involved in activities that will help you distract yourself from whatever’s going on when kids get upset. You know if they’re getting stressed out because they’re sitting in the lobby and the doctor’s office, and they know they’re going to get a chhoti. We give them something to do. We read a book, we talk we play because then they’re not focusing on the fact that they’re going to get a shot, contributing to the welfare of others. Do something nice for someone to volunteer. Do something productive that gets. If you are focused on someone else, compare yourself to others who are doing less well, that doesn’t work for everybody. You can also compare yourself in the present to your old self and focus on how much better you’re doing now compared to what you were doing six months ago, this doesn’t always work. You know these are options. Not everyone is going to work for every person, emotions do the opposite. If you’re feeling really sad get a comedian, get it to go to YouTube, and Google a comedian and watch a skit or two or ten, so you’re doing something that makes you laugh. That makes you happy to sing. Silly songs, dude silly dances go out and there’s very little. I find it more amusing than just listening to a baby laugh. If I’m having a really bad day, I will find those stupid videos of babies laughing at paper tearing if you can’t help, but laugh with them pushing away build an imaginary wall between yourself in the situation. Imagine yourself pushing away the situation with all your might or blocking the situation in your mind, and each time it comes up, tell yourself to tell it to go away. So if you start thinking about something that is particularly hurtful as soon as it comes into your mind and it comes into your awareness go no, I am NOT going to think about that right now. Thoughts counting some people count to ten, a hundred whatever it takes to get through that initial rush. Some people sing for me. I think I’ve shared before I have this irrational fear of bridges, but so, whenever I Drive over a bridge I sing, and usually, it’s, not songs on the radio. Usually, it’s songs. I used to sing to my kids. I’ll sing the ABCs something that doesn’t require a whole lot of cognitive interaction because I’m doing pretty good just to get over the bridge. And yes, I know I should be over it, but I’m not and that’s just the way it is the 10 game. I like this one think of 10 things that you like the smell of think of 10 green things. Think of 10 things you see where we’re going with this, and you can incorporate all the different senses with it. If you go through multiple iterations of it 10 things that you smelled yesterday, 10 things that you see right now, 10 things that you hear when you’re on your way to work. This helps people focus on something other than what’s going on. Here the 5 4 3 2 1 game is sort of similar to the 10 things game, identify 5 things. You see, 4 things you smell, 3, things that you can touch and follow down. Sensations like I talked about on the last slide. Sensations can help distract you from what’s going on until you have a chance to kind of get through that initial adrenaline rush, cold, holding ice, cubes, rubber band – and I don’t like this one. But some people do they put a rubber band on their arm and every time they start to perseverate on a negative thought. They snap its smells and find some good smells. Some smells bring back good memories, smells that you like. Maybe it’s roses: maybe it’s a purse-specific perfume. Maybe you just go to Walmart and start smelling all the air fresheners. Whatever makes you happy, I do suggest avoiding taste, because if you start using taste as distress tolerance, then you start moving toward emotional eating. I’ve seen it happen, so I would avoid that for most people, but if they just desperately want to go there, then you know we’re going to go there because they are choosing how to distract from their cognitive or intrapsychic. Sensations improve at the moment. Imagery goes to your happy place. Whatever your happy place is meaning find an alternate, meaning for what’s going on now. This can be Linehan refers to it as making lemonade. We all know how to do that. We don’t we’re, not necessarily the best at it, but try to make lemons. I try to look for the optimistic meaning in whatever it is prayer. Now, even if someone is not religious, they can be using radical acceptance. Accepting it is what it is and not trying to change it, just putting it out there for the universe, relaxation is always good to relax one thing at a time and this isn’t focusing on one problem at a time. This is focusing on something we’re talking about distress, tolerance, and improving the moment so focus on one thing, like your breathing: get your breath and calm down once your breathing calmed down. If you need to focus on something else, then move to. Maybe the tension in your neck. Maybe you need to lower your shoulders and release the tension in your neck, focusing on physiological things and focusing on other senses. Besides, that abstract stuff that’s in your head and your emotions can help people tolerate the distress until they can think more clearly vacation takes a timeout. Sometimes you just need to get away from it. For a few minutes, we’ve had time at work. I’m sure we all have where you’ve just been like. You know what I’m done and you lock your computer screen. You get up, you walk out of the building, and none of its clients are in there, but you walk out of the building and do a couple of laps around the campus and then you’re like okay. I can deal with this again just clear your head before you try to tackle whatever it is, an encouragement providing yourself, because you can’t necessarily rely on anyone else. Positive and calming self-talk now back to those stupid, memes and videos that I love to death there’s, one has a kitten on a laundry wire and it says: hang in there, I love having those things on screensavers. It’s, juvenile, maybe but whatever it makes me happy, and it reminds me you know even when I’m, not in a state of emotional distress. It reminds me all right keep on hanging in there. You got it and it’s got an all-factor too. So I always like anything with an all factor: the goals of emotional regulation. So once you’ve tolerated this distress, you’ve gotten through that initial surge. That initial, I cannot take this pain or upset. Then we need to move into emotional regulation, help people identify labels, understand their emotions and the functions of those emotions, decrease unwanted emotional responses and decrease emotional vulnerabilities. So what they’re going to do is identify and label emotions and their functions. I’m scared. Okay, you 39. Re scared. Tell me why what’s the function of you being scared? What do you want to do, and what do you think is causing this scared? 39. No self-awareness through questioning, like that through talking it out, people will start to understand where their emotional reactions are coming from and they can choose whether or not to follow up with it a behavior. What I guess I didn’t put in a behavior train analysis is the way you can go about helping people work through that and that’s a couple more slides cop. We want to police our thoughts and check the facts. Look at doing opposite actions. If you want to hurt yourself, look at being kind to yourself, if you want to run, maybe you need to look at staying and then look at the problem. Solving reduced vulnerability through the ABC p accumulate. The positives, remember, vulnerabilities, are those situations that happen leading up to whatever the distress is. Those are the things that make you more likely to be irritable, overwhelmed angrily depressed get sad about anything. Instead of not so, we want to eliminate those vulnerabilities or reduce them. As much as possible, so we’re going to accumulate positive gratitude, journals pictures if well, everybody has things in their life that they care about. Have those on your phone in you know little picture galleries that have them as your screen. Savers have reminders around about it. Why you get up in the morning builds mastery, so you have mastery of the skills you need to deal with emotional distress and upset cope ahead of time plan for distressing situations. If you’re getting ready to go in for an annual evaluation and those things stress you out to no end rehearse, it ahead of time plan on coping ahead of time, and figure out how you’re going to react. If it goes bad figure out how you’re going to react, if it goes good figure out how you’re going to cope and physical vulnerability prevention, maintain your health, chronic pain, chemical, chemical imbalances, hormonal imbalances, those can all cause vulnerabilities or set you up. Make you predisposed to feeling like something’s at eight when it’s only two get plenty of sleep when we’re sleep deprived, is a whole lot harder to deal with life on life 39. S terms and exercise. Exercise is a great way of releasing or using up some of that stress energy that you release during the day. Behavior chain analysis. The first thing you do and a strict behaviorist will have slightly different explanations for how to do this, but just bear with me here: name the behavior reaction. What happened now, if you’re thinking back to the ABCs, this is going to be your C. Your consequence, what happened identifying the prompting event ABC is, that would be the what was the activating event now. This is where it differs a little bit. Then we want to look at the behavioral links, so you had the activating event, and then there was this reaction and in between, there were um automatic beliefs, and we have that there. We have thoughts, but there were also sensations events, and feelings between what happened and your reaction. What sensations did you feel? Did you get flushed? Did you feel nervous? Did you feel scared? Did you feel sad? Did you have a twinge of something? What feelings were there and what events happened? Did you act out in a certain way? Did you scream? Did you yell about what happened? Because these are all things that are going to go into what ultimately ended up being the behavioral reaction, then I want to look at the short-term positive and negative effects of what you did. The behavior of the reaction. If you started screaming and throwing things okay, you did what was the short-term positive effect of that? What was the benefit of that? Because that was what you chose, which means it was likely the most beneficial response you could come up with in your highly emotionally charged mind then. So what were the benefits and what? With immediate short-term negatives and then looking at the positive and negative long-term effects in the long term, if you react to this upset by screaming and throwing things what’s the impact going to be, are there any positive impacts? Are there any potential positive effects of this and a lot of times it’s? No, but we want to ask the question just in case there are because some people will have a positive and we need to address that this is sort of. If you go back to motivational interviewing what we think about when we’re talking about decisional balance, exercises address the problematic links with skills. If some sensations or actions exacerbated the distress, then we need to look at distress and tolerance. If all of a sudden you had this immediate panic reaction and you couldn’t breathe, we need to work on distress, and tolerance skills, so you don’t go to that point where you are just for lack of a better phrase in a tizzy thoughts and Feelings if your thoughts get negative and start racing and your feelings are negative and anxious and worried and all those negative words we want to look at emotional regulation. You know if you can get through it, where you get through that initial rush and you’re still having these getting stuck in the negativity. Then we want to look at emotional regulation most of the time we’re going to look at both of them and then the third component, once we’ve learned how to get through the initial flood, the initial all-hands-on-deck call, and then people Have learned to regulate their emotions and identify helpful responses, and instead of talking about good and bad, we want to talk about helpful and less helpful responses. Then we need to look at interpersonal effectiveness and how to interact with other people to make that validating environment exist. So we want to start with interpersonal and intrapersonal if you will be effective with yourself and then move to others describe what’s going on assess how you’re feeling what your reactions are, and what the best next step is asserting. Your choice reinforces the good things. Be mindful appear confident and willing to negotiate, and yes sometimes we have to negotiate with ourselves because there’s something that we want to do right now – and this is very true – with people with addictions a lot of times – they want to use. They know the long-term consequences of use are not where they want to be, so they have to negotiate with themselves to say alright. I want to do this right now, but I’m going to choose a different option in their relationship with others. We want to encourage them to give me gently instead of critically, and harshly, which a lot of times is what they’ve gotten all of their life, being gentle with other people, accepting them where they are modeling how they want to be treated, be interested in What other people have to offer, what other people have to say and what’s going on with them? A lot of people with emotional dysregulation can’t handle their own life on life’s terms. They can’t even begin to handle anybody else.’s stuff, so a lot of times they appear disinterested, validate other people and their experiences, and have an easy manner. You know sometimes we get too intense and if everything in your world is either a zero or a ten, it’s easy to be intense. About everything, as they develop emotional regulation, things will be different. You know they’ll have fours and fives in there, but practicing that not being intense and over the top about everything, and then in their relationship with the self, be fast, be fair with themselves, not judgmental just fair, avoid apologies, stick to values and be truthful. 12-step recovery step, one starts with honesty, being honest with yourself step two. We start talking about hope and faith, which is sticking with values and being fair to oneself. Being compassionate comes couple more steps down that’s not hard or not harmful. For any of our clients to teach them to be fair, to be kind to themselves, and to be honest with themselves and others. So how does treatment progress when we’re talking about dialectical, behavior therapy as an evidence-based practice stage? One is safety. We want people to move from behavioral disk control to behavioral control. We don’t want people getting a phone call, maybe a significant other has to back out on a weekend trip which was someone with behavioral disk control could send them into a state where they are self-injuring. So we want to make sure that they have the skills to not self-harm, and you know you can’t just say. Well, you can’t cut the person’s like okay, so finish, what am I going to do? Instead? If I can’t cut, if I knew how to do something else, I’d be doing it right now. We need to help them increase their self-care behaviors instead of cutting. What can you do, I’ve talked before about some of the interventions I’ve used with some of my clients that have self-harmed. It’s not ideal. It’s not where you want to end up, but moving from self-harm, too, like I said, holding ice cubes or using a ballpoint pen to draw on yourself is preferable to cutting yourself. So we want to look at small steps, not going from. You know five or six self-harm episodes a week to nothing. You’re setting yourself and your client up for failure. We want to reduce the intensity of the self-harm, so they’re not breaking the skin, so they’re not damaging themselves decrease therapy interfering behaviors what we typically call resistance and that can be showing up late that can be always coming in and trying to derail therapy sessions, it can be being bossy, it can be being reserved whatever it is that’s interfering with the therapeutic process. It’s important to understand that therapy-interfering behaviors can be exhibited on the part of the counselor too. If the client is experiencing a lot of emotional discount role, sometimes counselors will start being late to sessions and will start forgetting to review the chart before they go in and remember what homework was assigned will start forgetting to do things. So we need to make sure that both the counselor and the client are engaging in motivating therapy participatory behaviors. We want to increase the quality of life, and behaviors and decrease the quality of life-interfering behaviors. So if they’re engaging in addictions, if they’re, not sleeping if they’re, changed smoking if they are and again these are things when we look at the priority list, my main focus at first is going to be on self-harm. You know I don’t want them to be engaging in those behaviors, and then we’re going to start looking at the other things that create vulnerabilities that make them more likely to be unhappy or to be reactive in situations that would make them unhappy. We’re going to increase behavioral skills, core mindfulness, and accurate awareness, encouraging clients, not just when they’re upset, but to engage in mindfulness scans body scans, four or five times a day. So they know where they are and they know if they are starting to feel vulnerable. If they’re, it feeling exhausted all of a sudden. If they’re feeling foggy, then they know to be kind to themselves: distress, and tolerance. We talked about those skills, interpersonal effectiveness talked about those skills, emotional regulation, and active problem-solving. So these are all going to be introduced in stage one, but they’re introduced. The client has been using their old behaviors for a lot longer than stage 1 is ever going to last. So we need to remember that we have to help clients strengthen these behaviors, remember to use them if they use them at first, one out of every five times as one more time than they were using them. Last week let’s focus on the positive forward movement and not on what we think they should have done. We don’t want to set goals that are going to set them up for failure in stage two. We want to help clients, moderate emotions from excruciating and uncontrollable to modulated and emotional um. We want to feel feelings. Well, I mean, theoretically, we do so. We don’t want people to completely numb out and become robots, but we also don’t want every single emotional experience to be like debriding. For a third-degree wound, we want something in between. We need to help them decrease intrusive symptoms, like flashbacks memories, and hecklers, the things that created the situation where they feel unlovable and unacceptable for who they are. We want to decrease avoidance of emotions, and I know that sounds kind of counterintuitive to increasing emotional awareness. Again, we don’t want them to be numb. We want them to feel because if they feel, then they can choose how to act and how to react. Decreased withdrawal increases exposure to live a lot of times, clients with emotional dysregulation have withdrawn because they don’t want to be rejected so they don’t go out with friends. They don’t experience life on life’s terms. They just sit in front of the television watching Netflix. We want to decrease self-invalidation and help them understand that their experiences are their experiences and they’re not right or wrong. Their choices may be helpful or less helpful, but at any point in time that is their best as well as they can see their best options for survival. So let’s not be critical. I’m just happy you’re still here and we want to reduce mood dependency of behaviors part of this process. We’re going to teach people how to create SMART goals that are specific, measurable, achievable, realistic, and time-limited SMART goals and make sure they’re successful by validating and teaching them to self-validate, encouraging them to imagine the possibilities when you’re successful When you accomplish this goal, what’s going to be different? How awesome will it be to encourage them to take small steps, not all or nothing? You know we want to get get rid of the dichotomy’s small steps towards recovery and applaud themselves for even trying to encourage them to lighten their load and get rid of stuff that they don’t need to be stressing over right now. You know maybe now’s not the time to start remodeling the house and then sweeten the pot and encourage clients to provide themselves with rewards for the successful completion of a goal, maybe getting through an entire week or for some clients even an entire day without self-injury. I encourage you to practice these skills yourself because you’ll see how much we don’t do and how helpful these skills can be, but it also gives you more insight into two ways to help explain thanks to clients and help them apply. These tools to themselves think about which skills you’ve used that were helpful or skills you could have used. That would have been helpful in the past week for you because you’re going to ask the clients to do this. So let’s do it for ourselves, so we can put ourselves in their position and think about which skills might have been helpful for a client that you’ve worked with in the past week. Many disorders involve some amount of emotional dysregulation. That dysregulation can be caused by high sensitivity and reactivity due to innate characteristics and poor environmental fit or external traumas and lack of support, or both DBT seeks, first to help the person replace self-defeating behaviors with self-care behaviors, and then moves toward emotional regulation and Interpersonal effectiveness to help people develop the support system and learn how to feel feelings, including the good ones. A variety of tools are imparted to clients to help them set SMART goals, identify and understand, emotions and their functions, decrease, unwanted, emotional and behavioral responses, and develop a more effective, compassionate, and supportive relationship with themselves and others. Finally, remember that not every tool is going to work for every person it takes some experimentation, so prepare your clients for that. Otherwise, if they try something and it doesn’t work, they’re going to feel rejected and validated and like failures. Again, it’s a process to work together to help them figure out how they can start interfacing with life and integrate the two dichotomies of thought and emotion to make wise choices to help them live happier and healthier. .As found on 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…

478 How Schema Affect Anxiety & Depression | Cognitive Behavioral Interventions

Sponsored by TherapyNotes.com Manage your practice securely and efficiently. Two free months of TherapyNotes with coupon code “CEU”CEUs are available for this presentation at https://www.allceus.com/member/cart/index/product/id/1273/c/Want to listen to it as a podcast instead? Subscribe to Counselor Toolbox Podcast https://pod.link/1120947649Schema 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. AlientationHow 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 informationForming 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 GenerationAdjusting 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 dysregulationAlso check out our other podcasts, Happiness Isn’t Brain Surgery and Addiction Counselor Exam ReviewAllCEUs provides multimedia #counseloreducation and CEUs for LPCs, LMHCs, LMFTs and LCSWs as well as #addiction counselor precertification training and continuing education. Live, Interactive Webinars ($5) Unlimited Counseling CEs for $59 Specialty Certificates starting at $89 including #AddictionCounselor #RecoveryCoach #PeerSupportSpecialist #TraumaInformedCare #BHT #Etherapy#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, the Australian Counselling Association, National Counsel for Therapeutic Recreation Certification NCTRC, CRCC, PA Certification Board, Canadian Counselling and Psychotherapy Association and more. and more…#DrDawnEliseSnipes provides training through #allceus that are helpful for #LPCCEUs #LMHCCEUs #LCPCCEUs #LSWCEUs #LCSWCEUs #LMFTCEUs #CRCCEUs #LADCCEUs #CADCCEUs #MACCEUs #CAPCEUs #NCCCEUS #LCDCCEUs #CPRSCEUs #CTRSCEUs and more. adacb #mentalhealth #anxiety #psych #cbt #dbt #depression #mentalhealthceus #counselingceus #socialworkceus

Pharmacology: Designer Drugs

Unlimited Counseling CEUs for $59 https://www.allceus.com/ Specialty Certificate tracks starting at $89 https://www.allceus.com/certificate-tracks/ Live Webinars $5/hour https://www.allceus.com/live-interactive-webinars/ Patreon: https://www.patreon.com/CounselorToolbox Help us keep the videos free for everyone to learn by becoming a patron. Pinterest: drsnipesNurses, addiction and mental health counselors, social workers and marriage and family therapists can earn continuing education credits (CEs) for this and other course at: https://www.allceus.com/member/cart?c=17View the New Harbinger Catalog and get your 25% discount on their products by entering coupon code: 1168SNIPES at check outAllCEUs is also 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. Our courses are accepted in most states through those approvals.Review the pharmacology of alcohol  Define designer drugs  Review the effects of some of the most common designer drugs  Identify which “designer drugs” may still be legal  Discuss ways of handling “legal” drug use in your programs 3.  Alcohol indirectly activates the dompamine and opioid system producing rewarding sensations  Alcohol antagonizes GABA which causes the agitation/stimulation as the depressant effects wear off (addressed in detox with benzos)  NIH Article on the pharmacology of Alcohol 4.  “Designer drugs” refers to drugs that are created in a laboratory  DEA booklet on Drugs of Abuse  NIH Drugs of Abuse “Chart” 5.  Synthetic cathinones, “bath salts,” are drugs that contain one or more synthetic chemicals related to cathinone.  Cathinone is a stimulant found in the khat plant.  Synthetic cathinones are cheap substitutes for other stimulants such as methamphetamine and cocaine  Products sold as Molly (MDMA) often contain synthetic cathinones instead.  People typically swallow, snort, smoke, or inject synthetic cathinones.  Not at all related to actual substances put in the bath (Epsom salt based products) 6.  Synthetic cathinones can cause: Nosebleeds Dilated pupils Paranoia Increased sociability Increased sex drive Hallucinations Panic attacks Increased heart rate and blood pressure, heart attack Violent behavior Kidney failure, liver failure, suicide Increased tolerance for pain hyperthermia causing people to tear off their clothing to cool off. 7.  Depression or suicidal behavior can last even after the stimulatory effects of the drugs have worn off  Synthetic cathinones…

Pharmacology: Stimulants, Depressants and Hallucinogens

Unlimited Counseling CEUs for $59 https://www.allceus.com/ Specialty Certificate tracks starting at $89 https://www.allceus.com/certificate-tracks/ Live Webinars $5/hour https://www.allceus.com/live-interactive-webinars/ Patreon: https://www.patreon.com/CounselorToolbox Help us keep the videos free for everyone to learn by becoming a patron. Pinterest: drsnipesNurses, addiction and mental health counselors, social workers and marriage and family therapists can earn continuing education credits (CEs) for this and other course at: https://www.allceus.com/member/cart?c=17View the New Harbinger Catalog and get your 25% discount on their products by entering coupon code: 1168SNIPES at check outAllCEUs is also 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. Our courses are accepted in most states through those approvals.Define stimulants, depressants and hallucinogens  Discuss their ◦ Mechanism of action ◦ Symptoms of intoxication ◦ Symptoms of withdrawal ◦ Short and long term effects ◦ Common street names  Differential diagnosis 3.  Method of administration greatly effects the intensity and duration of onset for various drugs ◦ Oral (slowest) ◦ Inhalation/Snorting ◦ Inhalation/Smoking ◦ Injection ◦ Rectal suppository ◦ Skin patches AllCEUs.com Unlimited Online CEUs $59 | Interactive Webinars $5 4.  Drugas affect everyone differently, based on: ◦ Size, weight and health ◦ Whether the person is used to taking it ◦ Whether other drugs are taken concurrently ◦ The amount taken ◦ The strength of the drug (varies from batch to batch with illegally produced drugs) 5.  Stimulants are substances that act to excite the central nervous system ◦ Caffeine ◦ Amphetmines ◦ Cocaine 6.  Stimulants increase alertness, attention, and energy, as well as elevate blood pressure, heart rate, and respiration.  Used to treat asthma and other respiratory problems, obesity, neurological disorders, ADHD, narcolepsy, and occasionally depression 7.  Stimulants enhance norepinephrine and dopamine.  Increase in dopamine can induce a feeling of euphoria when stimulants are taken nonmedically.  Norepinepherine also increases blood pressure and heart rate, constricts blood vessels, increases blood glucose, and opens up breathing passages.

Cognitive Behavioral Therapy Skills: Counselor Toolbox

Cognitive Behavioral Therapy helps people identify unhelpful thoughts and get unstuck from negative thinking, anxiety, depression and anger. CEs can be earned for this presentation at: https://www.allceus.com/member/cart/index/product/id/520/c/AllCEUs provides counseling education and CEs for LPCs, LMHCs, LMFTs and LCSWs as well as addiction counselor precertification training and continuing education. Live, Interactive Webinars ($5): https://www.allceus.com/live-interactive-webinars/ Unlimited Counseling CEs for $59 https://www.allceus.com/ Specialty Certificate tracks starting at $89 https://www.allceus.com/certificate-tracks/ Live Webinars $5/hour https://www.allceus.com/live-interactive-webinars/ Pinterest: drsnipes Podcast: https://www.allceus.com/counselortoolbox/Nurses, addiction and mental health counselors, social workers and marriage and family therapists can earn CEs for this and other presentations at AllCEUs.comAllCEUs is also 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. Our courses are accepted in most states through those approvals.addiction counseling counseling continuing education ADACB addiction and mental health training addiction and recovery professionals addiction assessment training addiction certification training addiction ceu addiction continuing education addiction counseling addiction counselling addiction counsellor addiction counselor addiction counselor certification board addiction counselor training addiction specialist training Addiction studies addiction training addiction treatment continuing education addiction treatment counselor training addiction worker training addictions counselling alberta alcohol and drug counselor american counseling association continuing education army substance abuse Australia belfast cadc calgary California Board Behavioral sciences canadian addiction counselors certification federation cap ccapp ccdc ce certified addiction counselor certified counselor certified substance abuse counselor ceu ceu for addiction professionals chemical addiction counselor chemical dependency ce chemical dependency counselor christian counseling continuing education clinical social worker connecticut certification board continuing education continuing education for nurses in addiction continuing education mental health counseling continuing education units for addiction counselors co-occurring disorders counsel certificate counsel certification counsel webinar counseling ce counseling ceu counseling ceu webinar counseling continuing education counseling continuing education credits counseling continuing education online counseling continuing education units counseling continuing education Webinars counseling training counseling webinars free counselor ce counselor continuing education distance learning drug abuse counselor training drug addiction counselor drug and alcohol counselor continuing education Dublin education european addiction training institute FCB florida addiction counselor training Florida Board Florida Certification board georgia addiction georgia professional counselor continuing education glasgow grief counseling continuing education institute Ireland laban addiction specific training ladac ladc lcdc licensed chemical dependency counselor training licensed professional counselor continuing education lmhc london lpc lpc ce lpc ceu manchester maryland addiction counselor certification board mental health mental health continuing education mental health counseling mental health counselor naadac ce naadac training national addiction training programme national certified counselor continuing education nbcc approved continuing education online nbcc ce nbcc continuing education nbcc continuing education courses nbcc continuing education credits nbcc continuing education online nbcc-approved continuing education provider NCC ce online addiction continuing education online ce credits for counselors online ceu counselors online ceu courses for counselors online chemical dependency certificate programs online continuing education addiction counselors online continuing education counselors online training programme recovery coach scotland south africa substance abuse awareness training army substance abuse counselor programs online substance abuse counselor training substance abuse training online tennessee Texas Board of Examiners therapist continuing education toronto trauma certification UK vancouver Virginia webinar counseling training winnepeg