Sociological Approach to Reducing Risk and Increasing Resilience Addiction Certification Exam Review

 This episode was pre-recorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through ALLCEUs. Register at ALLCEUs.com/CounselorToolbox. I’d like to welcome you to today’s presentation on the sociological approach to reducing risk and building resilience. As I was putting together This presentation it was kind of like right in the wake of when Harvey hit. And then you know recently we’ve had the shooting in Las Vegas, and some of the counselors, especially counselors in training that can’t be practiced independently yet that are in some of my social media groups and in my professional groups have been talking about how frustrating it is and even some of us who are licensed but just can’t wake up and go help the Red Cross right now about how frustrating it is not to be able to help and how much we want to help so what I usually do because you know I I’m generally not upwardly mobile where I can just drop everything and go to a crisis what I did after 9/11 was look at what things in that situation could I positively impact and how could I do it in a way that made sense but you know for my life because I can’t you know at that point I for 9/11 I had an infant at home and you know other stuff so we’re going to look when we’re talking about addressing issues like the opiate epidemic or the major problem of depression almost I guess anxiety almost one in four people has anxiety issues and we’re gonna look at some of that and try to figure out what can be done what can we do from where we are in a way that makes sense because yes we can influence politics and advocacy but what can we do with small chunks of time that are beneficial to helping the cause as well as you know could help the clients we have currently so we’ll define the socio-ecological not model which is Broth and Brenner’s model we’re going to apply it to addiction and mental health issues and explore different variables in this model and then discuss how this framework can be used in prevention and treatment of co-occurring or independently occurring disorders so we’re going to talk about how it may sense to conceptualize not only the development of addiction but also the development of things like eating disorders and mood disorders in terms of a socio-ecological model and even some things like bipolar and schizophrenia can be a person being genetically predisposed or whatever but there could be certain environmental factors that could you know trigger that first psychotic episodes so we want to look at what might be going on and how can we help prevent or treat now prevention can take the form of three different activities if you will prevent the problem so helping people not get depressed at all ever so starting to provide those skills and tools when people are knee-high to a grasshopper hopefully preventing worsening of the problem so people don’t get severely clinically depressed where they can’t get out of bed so the early intervention services and effective you know frontline resources and preventing associated fallout okay the person gets to press gets clinically depressed well let’s see if we can help them avoid losing their job because they can’t get out of bed to go to work develop additional health problems from being depressed or developing an addiction in order to self-medicate that depression so we’ve there are three different methods or avenues we can take in prevention and you know we want to look at them all because when you’ve got somebody who’s becoming clinically depressed you know they’re depressed you know situationally whatever something happened and it started to turn into something more than just a couple of days it’s going to start having associated fallout early and you know it’s not going to be huge they’re not going to lose a job right off they’re not going to start having major family problems right off but they are going to start having little hiccups because that depression causes an imbalance in their in their environment and we know environments like to maintain homeostasis and you know the kids are gonna be like well Mom why aren’t you getting up and doing these things and what’s going on and you know things are going to start changing and the person will need to be able to deal with that so the socio-ecological model explores and explains human behavior as the interaction between the individual and environmental systems there’s a fifth one that is more of your longitudinal but we’re going to talk about the four main ones today the micro the meso the EXO and the macro systems the microsystem involves well let’s start before that the individual if you look at the model is sort of the bull’s eye here and the individual is not considered a system but it involves all of the things about the individual including biology and personal learning that make people who they are okay so this person exists within a microsystem and that micro system is their family peers School Church synagogue whatever and health services things that they probably interface with regularly work should also be on that but it’s for some reason it’s not on this diagram anyway the mesosystem is the interconnection between microsystems so how do family and peers interact I don’t know about you thankfully my family might be very accepting of most of my peers but I know other friends of mine who brought home peers who were not as well accepted by their family so there was some conflict between the the family and the peers and we know how much peer pressure and peer relationships are important in an adolescents’ lives which creates conflict and consternation how does the family interface with school how does Pierce how does your peer group interact with school and do they see it as a good thing to do they see it as worthwhile you know etc so when we’re talking about the microsystem and the mesosystem we’re talking about things that people interface with daily so I want you to think about how the mesosystem and you can feel free to chime in on the chat room if you want how does the mesosystem family peer school church you know recreational activities health services impact the development of mental health or illness now you notice I’m trying to kind of switch ears for health because we want to promote health and we can look at the opposite for mental illness but you know if you have positive family peer interactions it’s probably going to support mental health it’s probably going to support decision-making in the adolescent it’s probably going to I mean and I’m thinking adults and adolescents here but family and friends you know if you want to think about you know how do you get along with your significant others peer groups and do they interface well or is it kind of like oil and water how does the how does your family interface with your work how do they deal with how many hours you have to work whether you’re getting called in at night or getting emails or text messages at 8 p.m. or you know what are their expectations and how does that influence if there’s a conflict you know if the family doesn’t like what’s going on at work or the fact that you know your boss is emailing you at 8 p.m. then it can create conflict within the environment which can lead to increased anxiety and depression and Yabadabadoo now how does mental health or illness impact the mesosystem so again thinking about how if someone is clinically depressed how does it impact their family how does it impact their peers and if you have a family member who has you know clinical depression or generalized anxiety how does it impact how your family interfaces with everything else because you know you end up having somebody or somebody in the family who may be caretaking for the person who has depression or anxiety or whatever the mental health issue is who’s not able to do the stuff that they were able to do so the rest of the families kind of pick slack so how does that affect how they interface you know the rest of the family members interface with school and work you know maybe they end up showing it more exhausted so it’s important to look at the mesosystem the exosystem involves links in a social setting in which the individual does not have a direct active role so for example how would I impact my spouse’s work and again if I am the identified patient and I’ve got clinical depression and I’m calling my spouse to come home because I just can’t be alone or my spouse is late to work or unproductive because he’s always exhausted when he gets to work because he has so much to do since I am you know not able to do as much right now then it could negatively impact his work and so we want to look at how that impacts how the home environment impacts work and how work impacts the home environment the macro system describes the culture socioeconomic status poverty ethnicity etc so what we’re looking at in the macro system is really the larger you know not just within your city maybe or even closer to your neighborhood we’re looking at what you see in the media what you see on national TV your your statewide elections your national elections your state laws and culture and what’s being communicated if you are a religious person what your religious culture communicates because you know religion generally is not just in one little area it’s international or national so what types of things does that communicate to to the person and how does that influence the development or not development if you will of depression anxiety or addiction so again think about how the exosystem of the social setting in which the individual doesn’t have a directive or an active role think about how much people were influenced after the elections I mean yeah we had a role if you went out and voted you had a role but you don’t decide the election so once that happens how do you know the exosystem impact you know your your emotions your other community events employment etc and how those things impact the family I know you know there was a lot of consternation and concern among some of my friends who are Jewish after the last election so their families experienced a high ink or a great increase in anxiety development of mental health or mental illness how does all this stuff that’s going on in the exosystem and stuff that you don’t have direct control over how does it impact the development of mental illness you know or mental health and we’re going to talk more specifically in a couple of minutes and again likewise how does mental illness or mental health impact the exosystem if you have a healthy workforce if you have healthy people who are actively participating in work and going to community activities voting to participate then you’re probably going to have a healthier outcome than if you have people who are not able I mean they’re so depressed they’re not able to even get out and participate so we want to look at the reciprocal nature it’s not one way the community doesn’t just affect us you know it may affect us but then how we react affects the community how does the attitude of the culture impact the community if you’ve got a a culture that is accepting of certain ideologies they’re accepting of LGBTQI they’re accepting of people who are Muslim in their religion they’re accepting of people who are Christian and their religion they’re accepting of you know fill in the blank if the culture is accepting of that how does that affect the community and those people within the community who might you know otherwise not have been accepting does it kind of pressure them in or does it cause anxiety and consternation in those people how does the attitude of the culture for example about premarital sex and marriage affect the family how does it affect the development of and again we’re thinking about anxiety depression and addiction so how does it affect the development of stress which may lead to mood disorders or problems and how did the community families and individuals with mental health or mental illness impacts the culture you know so we have an impact on our culture we get together we see you know we have Generation X Generation Y but the baby boomers all had their sort of or we all have our sort of unique cultures and things that we bring to the table and things you know that was given to us we said no we don’t want to thank you very much so there is a give-and-take among the individuals within the culture and that’s good because that means we can start small you know start in our locale and create this positive mesosystem and then build from there if If you have a positive community then that’s probably going to spread think about when a company goes and dumps fertilizer for example into a waterway it doesn’t just stay there over time that fertilizer bleeds out and you start having algae blooms everywhere things don’t stay I mean in our society things don’t stay in one place for very long they tend to move they tend to migrate so positive will migrate that’s awesome negative can also migrate so we want to look at how can we enhance the positive migration and keep down the negative if you will so now let’s start talking about what can we do and how can we operationalize all of this we realize that if we affect the individual it’ll have a positive effect on the meso system which can have a positive effect on the exosystem Yabadabadoo so great we also realize that one of the only things we have a lot of control over is the individual ourselves so a lot of people come to counseling individually score so this is where we’re going to start so what things contribute I start by listing risk factors for the development of mood disorders and addictions and then we talk about capital you know what you have in order to you need to have to prevent these things and then prevention strategies so that’s kind of how we’re going to go it’s not going to stay depressing individuals with chronic pain are at higher risk of mood disorders or addiction addiction because of the pain management you know drugs that are out there and you know once they start taking payment management drugs opiates a lot of times the brain quits producing endogenous opioids the natural painkillers so when they first come off the body doesn’t automatically pick up so it takes a little while for the person’s pain tolerance to build back up which keeps some people from wanting to get off the medication among other things but chronic pain can also be debilitating it can make people lose some abilities that they used to have or crush some dreams if you will you no, I think I’ve told you before that I have a bad shoulder and carpal tunnel so I can’t garden the way I used to you know I still go out and do it but I’ve got to pay attention and only be out there for an hour too instead of spending six hours out on the farm which is frustrating to me it was only mildly frustrating but my grandfather when he started developing Parkinson’s couldn’t make his miniatures anymore and he made gorgeous miniatures and I know that’s not chronic pain but it’s kind of the same thing if you’ve got rheumatoid arthritis he couldn’t make his miniatures and he became devastated and became withdrawn so understanding that pain has multiple influences that can cause depression that may trigger a grief reaction that we need to help people address now the things I put in bold are things that we as clinicians can easily help people prevent or/or address chronic pain we can help For people with low self-esteem that’s a no-brainer if people don’t feel good about themselves and they’re looking for external validation they’re going to be at a higher risk for anxiety fear of abandonment fear of not being good enough fear of failure and depression a sense of hopelessness and helplessness substance use especially early substance use can cause changes in the prefrontal cortex leading to problems with impulse control and decision-making but it can also disrupt the balance of neurochemicals leading to symptoms of depression and/or anxiety so it’s important to understand that especially the earlier the substance use starts the greater the chance that it’s going to cause some sort of brain changes and we’ve also found that a lot of people, not the majority but there is a percentage a significant percentage of people that when they start using early they kind of quit developing coping skills after that they find something that works they’re like oh I like this I think I’ll use that from now on when we start talking about people who started drinking or smoking marijuana when they were you know 9 10 11 12 you might see more mood issues or addiction issues in those people than people who didn’t start using mood-altering drugs as early as a history of abuse can contribute to the development of PTSD but not everybody who is abused develops PTSD but there can be episodes of anxiety and depression as well as it increases the chances of the development of addiction genetic vulnerability we know that mood disorders and addictions tend to run in families and they’ve done studies that have shown that there is a genetic component doesn’t mean it’s going to happen it just means you have this gene there that could be triggered so we don’t want we want to make sure that clients know that they are not just doomed you know they can prevent triggering that but they need to be aware that they may be more vulnerable inappropriate coping responses if we are not born with coping skills so if somebody doesn’t know how to cope with life on life’s terms because either because they’ve always been shielded or because they’ve never had anybody helped them maybe they were kind of on their own from the get-go so they learned to lash out and get angry or withdraw and get depressed but they never really learned how to deal with the stuff they’re gonna be at higher risk of mood and addictive disorders we can help people develop coping responses are one of the things you want to look at when people are using seemingly unhelpful behaviors is to remember to ask what is the cause of this so we want to look at what is the root cause of what is prompting this behavior and what is the benefit of the current behaviors and I’m going to keep reminding you of that as we go through this violence and aggression you know again what’s the cause of the violence and aggression did people do this person learn that’s how you cope with distress in their family of origin is it a protective mechanism because they’ve experienced situations where that has helped them deal with conflict before what prompts this and what the benefit to it when they act out when they’re violent and aggressive what is the benefit it gives them power it pushes people away they just enjoy hurting people hopefully that’s the minority but we want to ask that because we can’t figure out an alternative until we know what the function is same thing with risk-taking and impulsivity there are certain theories that says some people need more stimulation than others they get bored easily so they tend to be higher risk-takers and maybe more impulsive than you want to ask if this person doing this you know I have a friend who is an adrenaline junkie you know skydiving rock climbing you name it he’s done it and you know more power to him I don’t see a purpose of jumping out of a perfectly good airplane but he he thrives on that and when he can’t get out and do those sorts of things he feels good so what is it about this risk-taking and what kind of risk-taking it risk-taking as in holding a balloon liquor store or is it risk-taking as in doing something like skydiving which is theoretically safe and what’s the benefit it makes gives them a rush makes they feel good helps him you know escape or whatever great that’s fine the rebellious nests you know again what is and this is a key for adolescents especially but even if you’re a supervisor working with employees if they’re being rebellious you want to look and say what’s the point what’s the benefit to being rebellious what are they holding on to and refusing to let go of that you want them to let go of or what are they refusing to do that you want them to do and what’s the benefit to it if they are being rebellious and they’re staying like think again adolescents staying out all night OK well what’s a motivating factor is it to get under their parent’s skin probably not is it to conform to peer pressure you know oftentimes that’s maybe the case but you have to look at the individual and say ok how can you do this in a way that helps you move forward rejection of pro-social values if the people who espouse the pro-social values are the people that the person rejects then they’re probably going to reject those values so we want to look at you to know if you’re rejecting those what values are you espousing and why are those important to you and why are you rejecting these over here you know not saying it’s right or wrong I’m just trying to understand where you’re coming from and you know that’s something that we’ve got to be sensitive to and different people are going to hold different values lack peer refusal skills to stay out late to get into trouble to use drugs to have early sex whatever it is those things a lot of times indicate poor communication skills and low self-esteem need to be accepted you know all that stuff that’s challenging during during teen and early adolescent years those are things we can help with being bullied you know that’s a risk factor when people are bullied they tend to get depressed and when they’re bullied they may turn to substances to try to make themselves feel better to numb the pain they make self-injure there’s a lot of different things might happen we can help people develop skills to deal with being bullied since we don’t understand a hundred percent why people bully we need to help the victims become survivors we need to help them have the tools to be able to deal with it and understand why it happens without letting it hurt them early and persistent problem behaviors that’s just so broad but again look at why the person’s child acting out an early sexual activity could be a history of sexual abuse could be a dysfunctional family of origin and the child is trying to get out I worked with a 14-year-old who once told me she was gonna get pregnant as soon as she turned 15 because that’s when she could get into housing on her own so she was intentionally going to get pregnant at 15 and there was a reason for it she was very clear about her logic a lot of times it’s peer pressure and acceptance but uh asking what is that what is the cause and is this cause going to keep the person from developing healthy coping skills and being happy is potentially going to lead to depression peer rejection you know that hurts so helping people figure out how to navigate peer rejection because you’re not going to be liked by everybody academic failure we can help with now not necessarily as clinicians but we can advocate for the person we can help them find tutors resources etc lack of information on positive health behaviors put it out there most of the time youth these days have a pretty good idea of what’s healthy and what’s not they just aren’t motivated for it they’re motivated for something else when addictive behaviors are you used to cope with stress or unpleasant feelings I said coping skills may fail to develop or when they’re used to enhance self-confidence such as drinking before going to a party then they may start to develop anxiety and self-consciousness when they don’t have a drink on board so it may start prompting the development of some mood disorders in addition to the fact that repeated use especially in a young brain can cause some neurotransmitter imbalances using addictive behaviors also to enhance other experiences ties it to those experiences making them person more likely to use those and similar situations desensitizing the brain’s pleasure centers so what am I what do I mean I mean if you typically drink when you are watching football then you’re going to be more likely to drink every time you watch football it’s just one of those things you do when you watch football if you’re one of those people who eat when they watch TV then when you watch TV you’re more likely to eat when you go to the movies because that’s a similar situation you’re more likely to want to have popcorn or eat so it’s important to understand that with addictive behaviors if you have something that produces pleasure it can be triggered you know the person can start thinking about it in a similar situations using repeatedly can cause neurochemical imbalances in genetics you know you can’t be born with a neurochemical imbalance not enough serotonin too much whatever and poor health behaviors as I’ve talked about a bunch of times not enough sleep quality poor nutrition and high stress can also cause neurochemical imbalances so we can educate people about some of the things that can cause depression and anxiety so they can prevent it we can educate parents so they can start coaching their kids from the get-go so personal recovery capital to develop what we need to be happy and healthy human beings we have to have certain things to help us along the way we need to have the things to enable us for physical health think about Maslow’s pure hierarchy bottom level is all your health and biological needs we need to have our physical health and that includes nutrition Slee and you know not being in pain all the time sometimes you’re gonna feel pain that’s being human that’s being alive but we need to have our health for the the most part we need to have financial assets to get our basic needs met you now get that food keep clothing on our back transportation roof over our heads health insurance and access to medication and there are two different things health insurance covers theoretically going to the doctor and the mental health counselor etc access to medication is not covered under a lot of insurance so remember that most pharmaceutical companies have patient assistance programs that can help clients access their medication if they can’t afford it because some medication is a really expensive safe housing conduct that’s conducive to recovery and that’s not just addictions if you’ve got somebody who is clinically depressed or highly anxious living in a radically dysfunctional household where there’s lots of yelling or arguing or other people who are similarly dysfunctional it’s probably not going to prompt those positive cognitions and mindfulness and everything that we’re trying to establish doesn’t mean they can move unfortunately a lot of people can’t so we got to talk about how can you create an area in your housing environment that’s safe people need to have adequate clothing to stay warm to be able to dress for work and you know go to their job and be dressed appropriately and transportation to get their needs met most of us don’t live in a city where we can just walk but walking I guess is a form of transportation we need to be able to access the resources that are out there whether it be food or going to work so we can pay our light bill or whatever it is values awareness people need to know what’s important to them to figure out what they need to do to be happy a sense of purpose helps people keep going and we can help people with this I mean these are easy exercises when you give them a values activity worksheet you know what are your top five values when you look at the sense of purpose what is your purpose in life and a lot of us don’t know but we know what we want it to be or we can start theorizing about what is the purpose of what I do as a job on a day-to-day basis, what is the purpose of this activity that I’m doing so they can start to see some meaning in the stuff they do we can help people develop hope and optimism and we’ve talked about that one people need to have a perception of their past present and future they need to be able to look over the past and it may suck or it may be great but they need to be able to look back over it and go yep that’s it they need to be able to look at their present and realistically assess what they’ve got and maybe what they don’t have but realistically assess what they’ve got and look at their future and go where do I want to go from here because you’re here and you don’t want to stay here forever you can’t stay here forever because times gonna move on what next people need to be able to see but understand that they’re not necessarily controlled by their past or stuck in the present that they have the ability to make choices every single moment to work toward what they want for the future education training and job skills people need to be able to make a living that’s just the way it is you need to be able to feed yourself and put a roof over your head so we can make referrals to job training agencies we can make referrals to social service agencies problem-solving skills interpersonal skills and self-esteem are all things that we are super skilled at teaching and we can teach these in chunks they don’t have to be these long groups don’t have to be big drawn-out sessions we can provide people snippets you can provide somebody with the concept of distressed tolerance and the improve acronym in a handout and have them look at that or in an email you know if you email your clients once each day or on your blog there are a lot of different ways, you can just get that information out there and in front of people so I can look at it I call I tell my clients it’s bathroom reading you know I usually give them a handout or two and I just put it on the back of the toilet and when you’re in there you know take a look at it if it’s useful great if not bottle it up and throw it in the the trashcan I’m good with that but there’s no pressure and I’m not putting extra assignments on them I’m just providing information about a skill and then if they want to pursue it further when they come back to counseling we can talk about it so what can we do we can promote positive health and wellness behaviors by educating people about why they’re important and what to do and where to find more information you know because some of these things like nutrition we can’t be prescriptive but we can point people in the direction of where to get good advice and information and we can also model this you know in our treatment plan at least in mind I try to make sure that people are putting a print emphasizing getting enough quality sleep eating well and maybe exercising at least moving around if they don’t want to call it exercise but taking care of themselves and getting some relaxation and recreation in their bonding to a pro-social culture is difficult for us to do for people or do with people we can talk about what are your hobbies what are things that you enjoy doing and encourage people to try out volunteering or get involved in meetups to engage in activities with other people but that’s something that they’re going to have to do on their participation in extracurricular activities again kind of the same thing we can point them in the right direction of volunteerism meetups things through their through their church or their synagogue or their you know whatever clubs that they’re involved in positive relationships with adults now obviously this is more important if we’re working with children or teenagers we want to help children and teenagers kind of see where adults don’t have their head that far in the ground but we also want to help adults learn how to more effectively communicate with teenagers because a lot of adults lecture at and I know this and you’ll you’ll understand when you’re older and you know lots of that kind of stuff so things that we can do to enhance relationships with adults is to educate people about you know how to effectively communicate with teenagers for example who are trying to find their way and trying to assert independence and resisting some rules how do you deal with that how do you communicate with them in a way because a lot of parents have difficulty navigating that boundary between friend and parent so we can help with that active workshops in the community workshops you can do at churches at libraries those are things you can do there you can put them on for like an an hour once a month it’s good if you’re it’s free but it’s a good promotion for your practice if you know you go out and do it and people come to learn something from you, they’re like hey that might be helpful social competence it’s another one of those things that we can do in little snippets we can provide tips and tips and tools whether infographics on an Instagram page are really useful for a lot of teenagers they want something that’s you know in a picture and fast it’s a snapshot so social competence checklists are another really good thing if you’re teaching different types of skills for communication or how you’re supposed to use different forks I know the first time I went to a formal dinner I was looking at all the silverware going I have no idea what to do with this stuff the sense of well-being and self-confidence we can help people develop this by encouraging them to focus on what they do well we want to make sure they have plans well that means goal setting and since a lot of people don’t know how to goal-set they don’t have goals, so they’re just kind of floating out there not looking at the future we want to help people look at the future and figure out how they’re going to get there so they’re like wow this is doable this is attainable this is another thing you can put work put worksheets on your website you can do short workshops to help people figure out how to look at how to define or learn how to define a rich and meaningful life and figure out how they’re going to define their goals and achieve their knowledge about risks associated with addictive behaviors now a lot of kids you know think back to the old dare programs I had a lot of clients tell me that those programs only taught me how to you safely I was like well that’s not what they were intended for but we do want to educate youth about you know still about the risks of some of those drugs and even adults not just youth educate people about how dangerous or how potentially addictive opiates for example can be after three to five days your body has already started to build up a tolerance that’s kind of scary so helping people understand that but also addictive behaviors like pornography a lot of teens don’t think about it a lot of adults don’t think about it until they’re stuck in it or online gambling you know those are some things that can kind of catch people unawares because they didn’t think about it wasn’t a substance we typically think of addictions as substances since it’s not a substance they didn’t think about the effect that the pleasure from those activities were going to have on our neurochemicals and create a a situation where they didn’t feel okay they didn’t feel normal they didn’t feel happy without having that in their life because their dopamine receptors had been blunted individual prevention strategies the big summary is we want to promote attitudes beliefs and behaviors that ultimately provide the person with healthy coping skills whether it’s through health class whether it’s through workshops I know at organizations I’ve worked at before the Jaypee would come in and do periodic workshops that’s a great way to connect with people and reduce utilization if you do psycho-educational prevention group because an ounce of prevention is worth a pound of cure we want to make sure that they’re aware of positive health behaviors and how to access those resources in Gainesville I don’t know about up here but I know in Gainesville the mall used to open at six o’clock in the morning so people could walk inside in a safe place and you know be out of the elements and yadda-yadda so just letting people know that that existed was a big step because they were like well I don’t want to join a gym and go to the mall with effective interpersonal skills we want to make sure people know how to effectively communicate set boundaries all that stuff that we talked about this can be taught it’s nice if your local news is willing to use you to do you know wellness minute I find one of the best places to do that is either right before or right after the weather because most everybody Tunes in for the weather, I may not stick around for the animal of the day or whatever well I always do but I’m always tuned in for the weather so if you get either right before or right after that you tend to get higher viewership and reach more people and a minute gives somebody a chunk of something that they can use today-specific approaches may include education and life skills training in schools you know is provided to the kids and have them share it with their parents through the media and community center or library workshops those are all great ways to get stuff out I encourage you if you want to get into providing prevention and helping to help your community helping people to prevent getting depressed or anxious or developing other problems to look at doing some of these very time-limited things because you don’t want to lose a lot of billable hours but we still want to be able to do more than we’re doing at least that’s what a lot of a lot of us tend to feel like the mesosystem so we’ve been talking about the individuals so far because that’s where we can have the greatest effect the mesosystem examines close relationships that may increase the risk of experimenting with high-risk behaviors or developing mood disorders people’s closest circle of peers partners and family members influence their behavior and contribute to their range of experience if you’ve got a child that grows up in a household where the parent or parents are clinically depressed they’re not able to model effective coping skills where they model cognitive distortions guess what jr. Is gonna pick up if you are in a household where you know you’re in college and you’ve got four other roommates and all of your your other roommates tend to be negative and naysayers you’re either probably going to move or you may that might start wearing off on you a little bit likewise if they are you know all kinds of go-getters that can wear off on you too so you know there’s going to be an impact risk factor is peer and family reinforcement of negative or unhealthy norms and expectations so if your family says you know people suck they’re always going to take advantage of you what are you going to take away from that and is that going to contribute to you probably having difficulties with trusting and maybe developing depression possibly so we want to look at what kind of messages is the peer group or family sending to the individual that may contribute to the development of mood or anxiety disorders early sexual activity among peers could communicate that well this is the norm so everybody’s doing it ties to deviant peers and gang involvement you know especially at that particular group there’s a lot of pressure to conform or there’s a negative consequences family members who don’t spend much time together and this could be because parents work a lot this could be because everybody’s you know involved in all kinds of other stuff but they found that when families are disengaged the parents tend to miss out on subtle cues when families are disengaged even if they don’t have children in the mix that there tends to be a weakening of those bonds supportive bonds so people are at higher risk for development of depression and anxiety because they don’t have that you know everybody’s behind me sort of feeling parents who have trouble keeping track of youth can indicate that the youth may be at risk for developing substance or more mood disorders lack of clear rules and consequences you think about even just being at work when there’s a lack of clear rules and consequences you don’t exactly know what you’re supposed to do I know for me that creates doodles of anxiety I like manuals and to date pretty much every job I’ve ever taken I’ve walked in and there hasn’t been a manual and I’ve been like okay there must be a manual written and that’s been my first thing now I’m kind of on the structured side so I don’t expect everybody is that way but most of us tend to experience a little bit of anxiety about failure about acceptance if we don’t know what’s expected so it’s important whether it’s a family or a job situation to make sure there’s clear rules and consequences you know what’s expected and what’s going to happen if you mess up or if you don’t meet this expectation there also needs to be consistent expectations and limits you know when people especially children but a lot of us tested our limits when we were kids and even as adults you know I know you know going back to working in organizations I would have staff who would test limits and see how long they could go without turning in a progress note before I’d be knocking on their door going paperwork it’s natural for people to kind of test limits especially with stuff they don’t want to do stuff that’s not rewarding family conflict and abuse can cause a high risk of depression and anxiety whether adults or children I mean if there’s a a lot of conflict and chaos it’s exhausting and it can cause a lot of dysphoric emotions and loss of employment that’s kind of self-explanatory protective factors close family relationships so as clinicians we can encourage people to identify who they consider their family it may not be their blood relatives or their family who are there for them who can they call it 2:00 in the morning and how can they nurture those relationships encourage people to develop relationships with peers that are involved in pro-social activities like hiking or volunteering in the community consistency of parenting is important in terms of producing children who are who are stronger healthier more resilient encouraging education and parents who are actively involved can help prevent future depression because they’re creating children who can join the workforce and have that individual capital to prevent depression and anxiety and cope with stress positively and this is a family protective factor and a peer for protective factor why because we learn from observation so if our peers cope with stress positively by prayer or exercise or whatever it is they do and our family has other positive ways of coping with stress and we’re going to have a greater venue of stuff to choose from supportive relationships with caring for adults beyond the immediate family is encouraged so we want children to grow up being able to interact with teachers coaches with you know Scout leaders whomever and start seeing that people outside of the nuclear family are trustworthy sharing and family responsibilities including chores and decision making and that’s true for children teenagers and even adults you know if you’re living in the same household it important that everybody feels like they have a say in what’s happening and participates in the upkeep of the family environment and family members are nurturing and support each other and this is one where I tend to stop and I do a love languages little mini class to help people remember that we don’t always experience nurturance in the same way so understanding one another’s love language is really important to be able to nurture in a way that’s meaningful to that other person peer and family interventions are designed to identify norms goals and expectations in the family foster family problem-solving skills so there’s not just one person always fixing it develop structure and consistency within the family unit promote healthy relationships and engage peers and family of choice in the recovery process so if somebody’s already depressed we need to be able to hopefully engage everybody that’s involved in this person’s immediate environment in helping them move towards recovery and you know preferably not dragging them back down so we want to engage them and make sure that people have a supportive others school and work risk factors lack of clear expectations both academic or performance-wise and behavioral lack of commitment or sense of belonging at school or at work if you just kind of go and you feel like a number you punch in punch out that may not make you feel appreciated which can contribute to depression and you know just bad feelings high numbers of students failing academically at school and work translates to high amounts of turnover if you never know who’s going to get laid off it increases stress and anxiety and parents and community members who are not actively involved in keeping kids in school and helping make sure that the workforce workforce is strong but we want to make sure that people have access to how when it’s needed we want to make sure that people have access to tutoring in school if they need it to prevent failing school they have access to transportation to get to work now those are things those are meta concepts that are more on the community level but it’s important that as a community member you know we look at different things that we may be able to participate in advocacy and say you know it’s really important to get a bus system going I live out about 30 miles east of Nashville and we must have the the train that goes from my city out to Nashville so people have access to more jobs so that was important for us to get past the City Commission protective factors school and work positive attitudes gotta find a reason why you’re doing this you know and sometimes it’s hard to find a reason for algebra but we need to help kids find a reason for that we need to help adults find a reason for why they’re going to work why are they doing what they’re doing regular attendance shows you know it is associated with higher mood less less risk of mood or addictive disorders because you’re able to get up and do it and interface with people and get that social support hopefully from your colleague’s high expectations are communicated effectively in setting and positive social development is encouraged you know whether it’s at work or at school, there are goals there are things you’ve got to accomplish there are performance objectives but we also want to encourage morale and positive social bonding whatever the setting having a positive instructional climate again whether at work or school, I know we learn things when we’re on the job we learn things and I don’t want people to feel like they’re having difficulty like they’re stupid I want people to feel like anything that we teach them as a challenge and something that may be beneficial down the road leadership and decision-making opportunities are really important again for students or employees to prevent burnout keep morale up reduce anxiety and increase a sense of personal empower and connection and active involvement for everybody is fostered and the school or organization is responsive to the student’s needs making sure that in school in the case of school they have access to tutoring resources it’s a safe environment for them to be in and the children that are going to that school have enough food in their bellies you know they can’t learn if they’re hungry all the time workplace is a little bit different but we still need to be responsive to people’s needs in terms of you know family requirements whether they need to if they’re going back to school shifting schedules a little bit we need to try to work with people instead of being completely rigid and it’s my way or the highway when possible to promote the best mental health characteristics of settings in which relationships are often associated with the development of mood disorders and addictive behaviors so we want to look at the characteristics of schools that are they safe are they positive environments are they cheering squads or are they places where people know they’re gonna go and get thrown under the bus same thing with workplaces you know when you walk into a place you get most of we get a sense and you’re either like oh this is a cool place to work or oh I can’t wait til I can get out of here you know we want to go toward the other end and neighborhoods when you go into a neighborhood – people take care of their environment do they or do they have trash strewn all over their lawn all of these things communicate how people feel about their environment and generally how they feel about themselves and whether they have the energy to take care of stuff or they just feel completely disenfranchised and don’t care more about community risk factors no sense of connection to the community neighborhood disorganization rapid changes high unemployment a lack of strong social institutions lack of monitoring of youths activities imbalanced media portrayals of safety health and appropriate behavior misleading advertising and alcohol or drugs readily available a lot of stuff we do we’re not going to be able to affect on the community level so much but we’re gonna hit them real quick we want to improve the climate process and policies within community schools and workplaces to make it safe and promote positive health behaviors prevention strategies are designed to reduce social isolation reduce and address stigma increase awareness of local recovery models you know who’s out there that has recovered and can serve as a role model improve economic and housing opportunities so people have a house a safe roof over their head and they can you know earn money and feel good about themselves increasing the accuracy and improving the positivity of media messages and increasing physical and financial ability availability of recovery so like I said I live in a little town so it’s nice that we have a community mental health center here so people don’t have to rely on going into Nashville but also making sure that services are financially available whether you have a free clinic once a month or you know make sure you’ll you take Medicaid but there are still a lot of people who have no insurance so where do they go the socio-ecological model identifies how the end the individual impacts and is impacted by not only his own characteristics but also those of family peers community and culture prevention takes the form of preventing the problem preventing the worsening of the problem and preventing associated fallout like I said as clinicians a lot of what we’re going to do is target the individual providing them with resiliency skills to deal with some of this adversity that might be around them and to help them sort through some of those media messages and go yeah that’s not even true you know if I drink this vodka I’m not suddenly going to have 14 supermodels hanging on me or whatever it is that’s being communicated so encouraging people to be informed and Wylie consumers any change in the the system will affect other parts of this system so if it’s a positive change is probably going to have positive changes negative has negative changes addressing addictive and mood disorder behaviors require a the multi-pronged approach we need to look at the individual and you know provide provide as many skills as possible there because that’s where we’re going to have a lot of our impact especially in prevention but we also need to realize that this person resides within a family you know whether they live alone which sometimes is less problematic or they live in a household with other people, we need to make sure that where they lay their heads at night where they spend their non-working hours feel safe and is conducive to recovery where they work or go to school also needs to feel safe and be conducive to recovery and that’s part of the community so we need to kind of look at these areas and if they aren’t safe or they don’t feel safe or aren’t conducive to recovery, we need to help people how to figure out how they can fix that or address it like I said they may not be able to move so what can you do to set some boundaries to create as much safety as you can how can you do this and there are a lot of different techniques that I’m sure you already have that you used to help people but it’s important again not to just focus on the individual because they don’t live in a bubble we need to look at everything right and are Are there any questions now we have or I have added a Wednesday class, so you don’t don’t have to come but if you have unlimited membership same time same station Wednesday so Tuesday Wednesday and Thursday we have a class from noon. CST 1 p.m. EST 2 for an hour all righty I will talk to y’all maybe tomorrow maybe on Thursday have a great day if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with Doctor Snipes by subscribing at all CEUs comm slash counselor toolbox this episode has been brought to you in part by all CEUs com providing 24/7 multimedia continuing education and pre certification training to counselors therapists and nurses since 2006 use coupon code consular toolbox to get a 20% discount off your order this month.As found on YouTubeI thought my anxiety disorder was for life… $49.⁰⁰ But I Discovered How Hundreds Of Former Anxiety Sufferers Melted Away Their Anxiety And Now Live Relaxed, Happy Lives – With No Trace Of Anxiety Or Depression At All! http://flywait.anxiety4.hop.clickbank.net We’ve seen so many people go anxiety-free that we have no hesitation in guaranteeing this program. 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Addressing Vulnerabilities to Prevent Anxiety, Depression and Pain

 This episode was pre-recorded As part of a live continuing   education webinar on-demand CEUs are still available for this presentation   through all CEUs registered at all CEUs.com/counselor toolbox I’d like to welcome everybody to today’s presentation we’re going to return to   talking about vulnerabilities and this is a topic We’ve covered it before, but you know I don’t seem to   be able to say enough about it so we’re going to talk some more about it we’re going to define   what vulnerabilities are and you know I expand the definition more than what occurred in   dialectical behavior therapy because I think there are a lot of other resources or vulnerabilities   out there sorry I’m trying to read two things at Once anyhow we’re going to identify some of the   most common vulnerabilities as I define them so We’re going to go beyond sleep in nutrition and we’re going to look at environmental vulnerabilities…
 
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Dr. Dawn-Elise Snipes is a Licensed Professional Counselor and Qualified Clinical Supervisor. She received her PhD in Mental Health Counseling from the University of Florida in 2002. In addition to being a practicing clinician, she has provided training to counselors, social workers, nurses, and case managers internationally since 2006 through AllCEUs.com A direct link to the CEU course is https://www.allceus.com/member/cart/i…
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Overview of Screening | Addiction Counselor Exam Review

 This episode was pre-recorded as part of a live continuing education webinar on demand. Ceus are still available for this presentation through ALLCEUs Register at ALLCEUs com, CounselorToolbox, Hi everybody, and welcome to your review of the Process of Screening. In this presentation, we’re going to review key skills for engagement, discuss factors impacting engagement, define screening explore how to do a screening, and identify types of screening instruments. Now screening is one of those steps that a lot of people will do, especially as a job. An entry-level job in mental health, if you’re working towards your hours for certification or licensure as an addiction counselor, you’re, probably going to be in a position at some point where you’re doing a fair amount of screening. So let’s learn how to do that. The first step in screening and assessment and even counseling is developing engagement and engagement means that you need to develop verbal and nonverbal skills to establish rapport and promote engagement. So how do you establish rapport? How do you connect with somebody when they walk into the office? Do you sit down with a clipboard and start writing right away? No, you want to be able to be open to being warm to make eye contact to respond to them in a culturally appropriate and culturally sensitive way. So you know you got to be aware of the people that you’re working with, whether you know how much eye contact is enough, how much is too much, etc. You want to be able to talk to people, and you know a lot of people when they’re coming in for a screening. You know, may not know what’s going on. You want to be able to put them at ease. So hopefully you know those are the skills that you already have, which is one of the reasons that you’re getting involved in this field. But screening means you know, first and foremost developing that relationship because the quality of the relationship with you is going to determine in many cases whether somebody goes on for the assessment and treatment if needed, you want to discuss with the clients the rationale, purpose, and procedures associated with screening an assessment so sit them down and say you know we’re going to do a screening for substance use, so we’re going to do a screening for depression. This is why we do it. You know because we know that whatever percentage of people in this area struggle with depression and that early intervention is a whole lot more effective than late intervention, so the earlier we can help people arrest the problem, then the better off they’re going to be, And this is what screening is going to, be you know, so they know if they’re going to get there, not going to get their blood drawn. They know you’re just going to sit there. You’re going to. Ask them five or six questions, and they’re going to be done because they may be thinking that you know they need to lay on the couch and tell you their deepest darkest secrets and they’re not ready to do that. Well, of course not they just met you, so let them know this is what screening is assess. Client’s immediate needs, including detoxification. If you’re meeting with somebody – and you know you notice that they’re under the influence of substances, then they may need detoxification. If you’re assessing them for substance, use or substance use disorders, and they admit that they have been using consistently or they’re under the influence, they may need detox, administer evidence-based screening and assessment instruments to determine clients, strengths, and needs, and we’re going to talk about some of those evidence-based instruments later, but you know you can use the cage you can use the Sassi. You can use a variety of different instruments, and obtain a relevant history to establish eligibility and appropriateness of services. Wherever you are, you know you probably accept some insurance. Don’t accept others. You may have private pay, or you may not. We want to make sure that once we scream we can get the person into services that they may need. You know. So we need to determine: where can they go? You know if they’ve got Medicaid if their private pay if they’ve got private insurance. You know where could where’s the best referral place for them, and to do that, we need to get that relevant history. Other things that affect eligibility appropriateness for certain treatment programs, some treatment programs will work with people who are on benzodiazepines, while others won’t. Some treatment programs will work with people who have co-occurring mental health disorders. There won’t. So this history is important to figure out. Does this person need a specialized program? Are they dealing with specialized issues like LGBTQ issues? Are they if they’re an adolescent? They’re going to need an adolescent program, so we need to get all of this stuff. You know when we’re doing the screening we’re, going to get a little demographic data there and we’re going to do. The screening screen for physical needs, medical conditions, and co-occurring mental health issues. So, while a screening for substance use may be five questions, a full screening is probably going to take 20 or 30 minutes. So we’re going to ask them a variety of questions. We’re, not going to get super in-depth, but we are going to get sort of an overview of how this person is doing. That way. We can look at it and say you know: maybe they’ve got medical conditions that are contributing. If we’re screening for depression, maybe they’ve got medical conditions that are contributing to their depression. If they have a substance, use disorder, you know: are their medical conditions being made worse by their substance use? And if so, what do we need to do so? We want to you, know, the screen we want to screen for co-occurring mental health issues. It does not matter if the person had depression or anxiety or bipolar before they started using or they develop depression or anxiety after they started using right now they’re. If they have depression or anxiety, it needs to be addressed, because you can’t, have somebody sober up and still feel miserable and expect to stay sober for long. Likewise, you know you can’t just treat their mental health issue and expect substance use. Just to go, oh so, if they, if you’re screening for one is really important to screen for the other substance, use will monkey with the neurotransmitters that can contribute to depression and anxiety. So you know they’ve got substance. Use we want to screen for that mental health issues. Sometimes people will self-medicate to try to numb the pain of mental health issues so again always screen for both of them because the likelihood is if one exists, the other exists at some level as well as interpret the results of the screening and assessment and integrate information to Formulate a diagnostic impression and determine the appropriate course of action, so you’re not doing a full diagnosis, but you’re going to go through and you’re going to look at the screening results and say yep. You know, technically, this person meets the criteria for substance use disorder, so we need to send them on for an assessment to see what may need to be done and what our options are to help them deal with it. If you’re screening for depression, the same things going to be true. This person meets the criteria. You know, we suspect that they may have a major depressive disorder. So let’s refer them for an assessment. So we can figure out what’s causing the depression and what options we have for helping the person deal with it. We want to develop a written integrated summary to support our diagnostic impressions and you’re going to do more of that with assessment, but in the screening, you know the Assessors going to want to know. Why did you send this person, you’re going to present a summary of the information that you gathered. That told you that this person may need to be assessed for substance, abuse, or mental health issues. You know it. Doesn’t have to be a dissertation, it can be a paragraph, but you do want to kind of put it all together in a nice little package. So the Assessor doesn’t have to go back and read through everything and try to figure out what you saw establish, rapport and an effective working alliance in which the client feels heard and understood you know to be respectful, and make eye contact and smile. You know don’t go directly to your paperwork and make them feel like a number, be punctual that’s important non judgmental if they’re talking about their substance, use don’t act shocked like oh, my gosh. I can’t believe that you drank while you were pregnant or oh, my gosh. I can’t believe that you’re using that much of that substance, or you did that to get your drugs, no, they did what they did to survive. They did what they did to survive, and given the tools that they had then we weren’t in their shoes. You know they’re by, but the grace of God goes so we want to remember that people did what they had to do and it got them here and it helped them survive until now, and we want to be attentive if we see that the Person starts moving around in their seat a little bit. You know, ask them, you know, are you uncomfortable? Is there something I can do to make you comfortable? They may be uncomfortable about what you’re talking about. They may be, you may be running late, and you know you’ve been in the session for 30 minutes and they need to go or they may need to go to the bathroom or they may be thirsty or cold. You know if you see them starting to become a little bit fidgety and not necessarily even agitated ask them. You know it seems, like you’re, becoming a little bit anxious or something I’m wondering if there’s, something you need something I can do to help that will go a long way to helping them feel like you care about them, motivate and Engage the client and identified service needs, so if you determine that they need an assessment, you’re going to have to motivate them to go so help them see how going to an assessment could be beneficial to them. How it help could help them meet their life goals. Engagement puts the clinician in the best position to negotiate with the client about what to do and how to do it. So assessment is usually done at whatever treatment center that you’re, hoping the person is going to be enrolled in. So we want to talk with them during the screening about what is it. What type of Center do you want to go to? Is there a place that you have in mind? Are there particular characteristics of treatment that you’re, hoping to experience, or likewise not experiencing some people, who don’t want to be in a hospital-type environment or whatever so start talking with them about what their options are and negotiate with them. You know if you think they need an assessment and you’re likely going to need to go to residential. You know you might want to start moving them toward the four or five options that offer that service and encourage them to go, and if they don’t think they have a problem, they may not be willing to go yet if they think they’ve Got a problem make sure that the handoff goes well to that agency. If it’s not within your same agency, make sure that that referral goes really well and that they are received equally warmly by the Assessor at that agency. Help them feel comfortable going to do this. If you give them a referral and just say here, go to this place and they’ll take care of you. The person may be like I don’t know where it is. I don’t know who this person is if you hand them this and say you know, go down to this place and do you know how to get there? So let me draw you a map and that help them know how to get there and then you’re going to meet with Jane at this facility and she’s. Going to do your assessment. I’ve worked with Jane for years. She’s, really awesome. You know she’ll take her time listening to what you have to say and what your want. Is she not going to force you into anything you don’t want? That goes a whole further to motivating the client to go because they’re not apprehensive about what in the world am i walking into engaged clients are more likely to participate, willingly, be treated, be compliant, and complete treatment. Now, engagement doesn’t stop when they leave the screening that’s just the beginning, but you are the face of the mental health system so to speak because you’re the first person that they interface with so you kind of set the tone for Their experience most of the time create a welcoming environment that’s pleasant and sensitive to age. If you’re working with kids, don’t have a sterile environment with only big people chairs, you know, have little people chairs and have you know books that are appropriate if it’s, have it be sensitive to gender? You know men, aren’t 39, t going to be wanting to sit in an office where everything is pink and frilly and whatever likewise adults, aren’t going to want to sit in a playroom to do counseling. So you know make sure you’ve got age. Appropriate stuff in the room that you’re working with, makes it sensitive to disobeying ability. If people have hearing disabilities, you know make sure that you can talk loudly enough, that they can hear you make sure you minimize extraneous noise that may keep them from hearing you make sure the area is compliant with the Americans with Disabilities Act. So people who are physically disabled can get through doorways and things like that. The physical environment should be sensitive to sexual orientation, so have little clues around that you are accepting of the LGBTQ lifestyle, so a rainbow flag on your desk or something doesn’t have to be huge, you know just little things in the environment that say hey. You know I’m cool with whoever you are cuz. You’re an awesome person same thing with religion. You know try to make sure the assessment environment is friendly and not necessarily oppressively religious. You know, if you have you know across here or prayer there or something you know that’s, fine, that’s, your expression of who you are, but we want to make sure that people who are of a different religion or who are atheist. Don’t feel oppressed in that environment. Likewise, people who’ve been traumatized potentially through their church in some way or another may be off-putting if they see that so be cognizant of the things that seem benign to you and what they may mean to the people who are coming in for Screenings and make sure your environment is sensitive to socioeconomic status, and what I mean by that is, you know, have a pleasant environment for everybody, but people who are from a higher socioeconomic status, for example, are probably going to affect. Expect a plusher environment and a much different experience more concierge-type services than somebody who is of a middle class or lower socioeconomic status. Now, does that mean you can just throw folding chairs out for other people? No, we want to make sure everybody is comfortable and they feel kind of like it,’s their living room. You know we don’t want them to feel like it,’s, a stair-scary environment, but you do need to pay attention to it. What is this person, or what are the people in my community expecting when they come in factors impacting engagement, can include stigma about the diagnosis or even about help seeking not everybody is cool with counseling some cultures say you know, counseling disgraces the family. Some of you know older people like my grandmother,’s, age back then, and in the 1940s and 50s you didn’t tell other people your stuff, so be conscious of the fact that just being there may be overwhelming for people’s, expectations about The effectiveness of treatment can impact their engagement if they’ve been in treatment before or they’ve known. Somebody who’s been in treatment before and it just never seems to work. Then they may be there because they have to be for some reason, but they don’t expect you to be able to help them, so their engagement going to be low. One of the things you can do with those people is to make sure you have some tools in your toolbox that are brief interventions that can help them start feeling better. Today, you know tomorrow, something like that. So talk with them, sleep is one of the first and easiest things to start addressing. You know talk with them about their sleep hygiene patterns. You know, because people’s, inability to relax, can contribute to depression and anxiety and a whole bunch of other stuff, so learn about sleep hygiene and how to create a good sleep routine and encourage them to start doing that or encourage them to make a List of the people and things that are important to them, so they can figure out where they’re going from here, and they can figure out why they’re doing all this so find a couple of tools that you can give people, so they can Focus on the fact that yeah, this might help me and it might help me move towards my goals and, oh by the way I’m, starting to figure out what my goals are. People may have expectations about their role or power in the treatment process, so we want to make sure that clients understand that they are in charge. They are in charge of their treatment, make them. You know unless I have to do an involuntary commitment, but that’s something a therapist or is going to do or psychiatrist, but 99 99 of the time you want to work with the client and they’re going to be the ones to tell you what 39, s worked in the past. What hasn’t worked in the past? What’s working right now even a little bit, and you’re going to talk about ways to enhance that. You know we’re not going to force them to do things that they don’t want to do, and they may have certain expectations about the treatment itself. So we want to dispel any myths about what treatment is like. We want to help them know what our facility or the facility we’re, referring to can provide in terms of treatment, and we also want to just help them understand what to expect so. They’re not apprehensive, and you’re likable nests. I hate to say it, but you are likable enough sand. They’re likable near in pact engagement. If somebody comes into your office and you’re doing a screening and they are just, they have no social skills, they’re not attentive. They’re not attractive, they’re, not happy, they’re just mean and cantankerous it’s, going to be hard to engage them and it’s going to take an extra effort on your part to try to hear where they’re. Coming from and hearing what’s important to them and forming a bond, the client’s social skills will impact engagement. If they don’t have great social skills. You know you got to work with it and you know if they’re. I had one client that bless his heart. He was in college and he would still pick his nose and eat it, and you know I had a hard time focusing when he was doing that. So you know I got to the point where he would do it and as soon as he pick his nose, I pick up a tissue and hand it to him and go here. You go looks like you need that, but those are things that you can run into when you are working with clients and you need to keep that from causing a barrier in your ability to engage with them if they’re, not attentive. Ask them why you know or try to look for reasons why they’re, not attentive. You know you seem to be kind of distracted. Is there something I can do to make you more comfortable? And you know it’s just human nature that we tend to be more engaged with attractive people. Not everybody’s attractive. So you know focus on what the person has to say and what their heart has to say to engage, and you know likewise, you may not be written off the pages of Vogue either, but try to present yourself well, try to you know, dress appropriately Don’t show up all disheveled and smelly clothes like looking like you haven’t bathed in a week that that’s not helpful so make sure that you’re presenting your best face and you’re dealing with whatever face the client brings And still trying to build that engagement remember the way a client presents. This tells us a lot about what’s contributing to their presenting issues: poor social skills, and ADHD pain. You know there are a variety of things that can contribute to depression, anxiety, and substance use. So try to look at it from that way, even if it’s not your ideal client understand what’s causing this person to be negative and just argumentative and frustrating try to get under there and figure it out. Why is this person so unhappy? What’s motivating is that first impressions impact engagement, so your professional presentation is promptly courteous and smooth handling paperwork. If you walk in there with 15 sheets of paper – and you’re shuffling them around and it seems like you, don’t know what you’re doing. You’re like just a second. I know I had that form around here somewhere, they’re not going to feel very confident in anything. You have to say so and put on a good first impression. Put it together and make sure your paperwork is put together ahead of time. If you have an electronic medical record, make sure you know how to use it because it’s disturbing to people, even though it happens when you’re, using an electronic medical health record to do a screening and you get stuck and you’ve got To call somebody else in to help you figure out how to get on the next screen make sure the environment is calm, clean and comfortable, not too formal or informal like we talked about it, avoids interruptions and provides the appropriate level of privacy. You don’t want clients sitting in the waiting room being able to hear other clients that are in the therapy, rooms or screening rooms. If you’re doing screenings, you may not even be in an office, you may be out at a festival or something so make sure that you’ve got. You know little pull-around screens or something, if appropriate, to give people privacy other people, shouldn’t be hearing their responses to what you are asking them, even if it’s, you know like I said, even if it’s at a Workplace festival or something other people should not hear their answers. So how can you give them privacy if there’s, no way to do that where they can have auditory privacy put as much as possible on check sheets and forms that they can fill out? And then you can point to something and go so help me understand your answer to this right here. Most of the time you want to try to do a screening in a private room. In the initial interview you’re, developing trust and rapport so be empathetic. They’re nervous, probably or they don’t want to be there or maybe they do want to be there and they’re, just hoping that you can help paraphrase that to them whatever vibe you’re getting off of them, paraphrase that and work With it convey warmth and respect and explores the clients, strengths, and skills, you know you’ve been dealing with this depression or this addiction for a long time. I’m wondering how you’ve survived until now. What has helped you deal with it? And keep on keeping on facilitating the clients, understanding the rationale, purpose, and procedures of the screening and assessment exploring the clients, problems, and expectations regarding treatment and recovery, and determining whether a further assessment is needed. That’s your screening. So the definition of screening is the process by which the counselor, client, and significant others, when possible, review the current situation, symptoms, and collateral information to determine the probability of a problem. So we’re going to sit down and we’re going to go okay. What brings you here today? What makes you think you got a problem, you know, and then we’re going to start asking questions or using instruments to try to determine whether we think that there’s a probability that that problem exists screaming is used by all types of Human Service Personnel to determine eligibility and appropriateness of services and needed referrals, so it may be used by a physician by a nurse by a counselor by a caseworker to determine how can we best help this person achieve their goals and their maximum quality of life? It’s not unusual for caseworkers at the Department of Children and Families. If people are coming in to get their food stamps or EBT that month, or they’re enrolling in the process to do a screening to determine how can we best help this person? You know be able to start earning more money, you know, maybe they just need a better job, or maybe they’re not able to maintain employment because their depression is so oppressive. So you can see where screening may be used in a lot of different systems and situations to help people figure out how to help their customers. Screening determines the immediacy of the need. You know you could be doing a screening with somebody who’s like on the fence, or they don’t think they’ve got a problem and it you know there or their problem is minor, so the immediacy may not be great or you could Be screening somebody who is you know heavily intoxicated was just kicked out of his house is facing three DUIs. You know they have a much more immediate need for their safety as well as, hopefully, they’re. More motivated screening needs to be a trance process. We don’t want to sit there with a clipboard and be asking questions and scribbling things down and going uh huh. Well, I think you need to go for an assessment that’s not transparent. The clients like, where did you come up with that I usually use screening instruments, and I talk with people when I’m writing things down. I tell them at the end. If you want to see anything I wrote down, I would encourage you to know I don’t write well, and I’ve got poor penmanship, but I encourage you to read what I wrote and we’re going to talk about these instruments after you Take them so you know you know why were we asking these particular questions? What does it mean to me as a therapist doing your screening, so they understand how you’re arriving at your conclusions? Screening does require informed consent. You know it. Doesn’t have to be a big thing, but it does have to happen before you start screening somebody you need to go. You know I’d like to screen you for depression or anxiety, or this is a wellness screening that your agency is offered, but have them ideally have them sign a sheet acknowledging that they know that they’re being screened for whatever and screening identifies Early warning signs and helps provide early intervention, services and resources, so you know think about high blood pressure or diabetes or any of those physical things doctor screens for that regularly, and if they see that there might be a problem creeping in, they can do something right. Then, to keep it from becoming a full-blown problem. Mental health screening is the same. We notice people are under a lot of stress. We know that that’s probably going to wear them out after a while, and it might lead to depression. So we can start helping them, develop stress management skills, for example. They may not need to go to treatment, maybe they need to go to psychoeducation and learn about stress management, or maybe you’ve got a book. You can let them read or something. But screening is a method of determining what the person needs. Screening is the first opportunity to engage the client in the therapeutic relationship and treatment process, sometimes based on observations or other circumstances. People may be referred directly for assessment, for example, if people come into the detoxification unit we kind of bypass screening. We know there’s a problem and jump straight into assessment, so screening doesn’t always happen, but a lot of times. It does because of that referral source – you know if you’re an Assessor that person came from somewhere. You know their lawyer could have screened them. Their doctor could have screened them whatever, but somebody along the way, probably screen them to determine yeah. You probably need to go over to this facility and talk to an Assessor of the clients. Internal motivation is the primary reason for engaging in treatment. So if they’re there because their wife told them they had to be or their boss or the courts that got them there, but to get them actually engaged in treatment and not just going through the motions they have to have internal motivation. There has to be something in it for them, and that’s, what we want to work on developing throughout the whole process, help them see how this benefits them, what’s in it for them, how can it help them accomplish and get closer to their goals for their life, internal motivation may be fleeting, so rapid engagement is vital. If you see a spark of interest or a spark of willingness, we kind of need to pounce on that spark and go alright. It seems like you know you want to get on with this because you’re sick and tired of being sick and tired. So let’s get you enrolled. Now, if you have to make an appointment for an assessment that’s six weeks out, you may lose the person. You know that engagement doesn’t last for long. The engagement lasts while they’re in your office, and then you know you got to have somebody else, pick it up and keep that momentum going. Screening should be brief. You know twenty-thirty minutes you don’t want to have somebody in there for three hours, that’s the assessment conducted in a variety of settings by a range of professionals on persons deemed to be at risk. Some things we do Universal screenings for like domestic violence, other things you may do selected screenings for – and it also depends on your setting and all that kind of thing. But the take-home point is that screenings are conducted in a variety of settings, whether it be a Health Fair at an employer,’s, a doctor,’s office, sometimes churches will even set up wellness days and do screenings screening represents the first part of a Collaboration among the multidisciplinary team because the screener is going to say, okay, I think I’ve identified that this person probably has an issue with this and needs to be referred to assessment over here, but they also need help with housing and food and affording their Prescriptions, so the screener will kind of link them to other team members in the multidisciplinary team. Screening needs to be sensitive to racial, cultural, socio, economic, and gender-related concerns, so make sure that you’re, culturally responsive and it needs to be developed from information gathered from multiple sources when possible. When you’re doing a screening a lot of times, the only person you’ve got to do. The screening is the person sitting right in front of you, but if you’ve got other information. When I do screenings on people in the criminal justice system, I want to see their criminal records. You know that gives me some objective. Information on you know how many times have they been caught? Dui, whether or not they’ve been convicted? How many times have they been caught DUI, that gives me a little bit more information than just what that person is telling me if they’ve been involved with the Department of Children and Families. I want them to bring their case report, especially if they’ve got an open case going on. Screening assesses signs and symptoms of intoxication and withdrawal. Three key elements: we want to verify that the behavior deviates from the norm and rule out all non-drug related causes. So if somebody is having difficulty focusing or they’re agitated, we want to rule out ADHD and schizophrenia and some other things that might cause that, to rule in, if you will stimulant abuse, for example, you want to verify that there. This is not how they normally behave. You know some people are agitated and a little bit more bouncy or fidgety or whatever you want to say most of the time. If that’s how they are, then you know that’s how they are and it’s not a drug, wants to rule out the drug-related causes, including physical causes. You know if they’re in chronic pain if you know etc. There are a lot of reasons somebody could be excessively sleepy have difficulty concentrating be overly agitated. There are a lot of things that use diagnostic procedures to determine the types of drugs being used. So in screening, we’re going to ask them what they’ve been using. But ideally, you can also do an on-site drug screening. You know having a pee in a cup and the on-site. Screenings are not super reliable, but it gives you something to look at. You know most cases, it’s anywhere between 60 and 70 percent reliability, which is why, if it comes up positive and the person says, I didn’t use that it needs to be sent off to a lab for mass spectrometry. To determine what happened, because you can get false positives and you can get false negatives, they may have used something and it doesn’t show up on the test. So you don’t want to just trust the on sites as being a hundred percent, but it is a good tool to identify whether the person is telling you the truth about how much or what their current, whether they’re currently using or not assess Clients, mental health and trauma history. You’re not going to get deep into the weeds here, just ask them if they have a history of depression, anxiety, or abuse of any sort and move on to their safety or environmental needs. Do they have a safe place to sleep? You know if they have an address, you know, do they feel safe in their home? Do they eat well, how’s their nutrition? Do they have any physical health needs that are not getting met? Do they have any other wraparound needs? If they’ve got kids, do they have access to childcare? Are they having problems with transportation? Are they able to afford the medications that they’re already prescribed, etc? So we want to ask them about some basic things like that, and then we’re going to assess the danger to themselves and others. Are they talking about harming themselves or someone else? And we also want to ask if they’re thinking about hurting themselves or someone else. Screening methods include interviewing the clients and significant others using screening instruments and lab tests like urinalysis that we talked about signs of substance, use disorders or mental health issues. We want to look for number one, the circumstances of contact. If the person was referred by the court, then that’s a pretty good sign that there may be a substance use disorder going on if they’re referred because of a DUI. For example, if they’re referred because of a fight they got into, but they weren’t using at the time their blood alcohol was zero. We want to look maybe for mental health issues and things like intermittent explosive disorder. You want to look at the clients, demeanor, and behavior. Are they acting like they’re under the influence when they come in for the screening? Are they showing signs of acute intoxication or withdrawal? Are there any physical signs of drug use or self-injury? Needle injection marks, if they have a get frequent bloody noses, you know if they get bloody noses, while they’re in your office or if they have signs that they’ve been picking. Those can be all physical signs of drug use. Emaciation and malnutrition are also signed some drugs will cause the pupils to be dilated. Other drugs will cause the pupils to be pinpointed. So you want to know what the signs of different drugs are for drugs of intoxication and different signs that people have been using, especially injection, but, like I said, sometimes, drugs will cause people to pick or itch, and that will show indicate to you that there might Be an underlying issue and information spontaneously offered by the client or significant others can give you information about whether there’s a substance, use or mental health issue, and sometimes the significant other. Let me just kind of back up: there may be the significance the spouse brought the person in and when you go out to meet them you, the person, the person being interviewed. Doesn’t want their spouse in there. They want. They want to go back by themselves, okay, that’s cool, you go out and meet the person and then, if you can, with permission, bring the spouse back after the screening to give them both the results, and at that point the significant other the spouse may Spontaneously say: oh well, why didn’t you tell them about? You know the DUI you had three years ago or whatever. So sometimes spouses will just kind of blurt things out because they suspect that the significant other didn’t already say it during the interview. So if you can get that person in a private place where they have an opportunity to say something wonderful but remember you know you do have to have the client’s permission. Screening instruments can be developed by the agency or use standardized instruments. The cage is a common one and you ask a person: have they tried to cut down unsuccessfully, do they feel annoyed when people talk to them about their substance use, do they feel guilty about the substances about using their substances and do they sometimes have to Use first thing: in the morning to kind of wake up we call it an eye opener if they say yes to one or more of those, there’s a chance that they may have a problem. The gain is another tool that you can use, as is the Michigan alcohol screening test or the Sasi. So all of those are standardized instruments, and some of them cost money. Others, like Kay, don’t, so it may depend on your agency and what kind of budget you’ve got. What instruments you’re using any instruments you do use must detail what action should be taken based on received scores. So if a person takes the cage – and they say yes to one but not any of the others, does that mean they should be sent for a referral if they say yes to two, when at what point should they be sent for a full assessment? You want to screen when screening for mental health you want to screen for acute symptoms such as hallucinations, delusions or depression or anxiety, suicidal thoughts and behaviors, and other mood and thought disturbances. So you’re going to ask them about time, place, purpose, and person. Do you know what time it is? Do you know where you are? Do you know why you’re here and do you know who I am you’re going to ask them about short and long-term memory if they can tell you about something from their childhood great, but you’re also going to ask them If they can tell you about what they had for lunch, another thing you want to assess or another way to assess short term memory is to tell them. I’m going to tell you four words and I want I’m going to. Ask you in a few minutes to recall those four words for me and then tell them four words: make them easy words like dog cat, bird, and fish. You know not something hard to remember and then in five or ten minutes. Ask them what were the four words I told you and see if they can remember you’re going to ask them about prior involvement in mental health treatment. What worked and what didn’t if they have been in treatment? What prescription medications do they use, and this includes all prescriptions because physical health prescriptions can have mental health side effects? Ask them about recent traumas again, don’t get into it, but ask them if they’ve been victimized or experienced any sort of abuse and a family history of mental illness. If they have a family history of mental illness, the chances of them developing mental illness are a little bit greater. When screening for mental health, you’re going to use the modified mini screen, the Mental Status exam, the mini Mental Status exam. The brief symptom inventory, a brief psychiatric rating scale, or the symptom checklist 9 t r. So those are the ones that you’re, typically going to use a lot of times. They’re already in your electronic medical record, so you’re not going to have to figure out what to use in terms of you know, knowing what the instruments are for certification and testing purposes. These are the six that you want to be aware of. So you can google each one of them and find out more about what each screening test can provide. Your screening is the initial contact to decide if a person may need a more in-depth assessment. Screening is brief but requires the person to be engaged in the process to get an accurate result. How well the person is engaged in the screening process is a direct predictor of whether he or she will continue in the process. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube, you can attend and participate in our live webinars with doctor Snipes by subscribing at all CEUs comm slash counselor toolbox. This episode has been brought to you in part by all CEUs com providing 24 7 multimedia, continuing education, and pre-certification; training to counselors therapists, and nurses, since 2006 use coupon code consular toolbox to get a 20 discount off your order. This month,As found on YouTubeThis solution reverses kidney disease! Guaranteed to be effective or your money back: Beat kidney disease. Just by following a simple treatment plan, you can reverse kidney disease. No matter how old you are! Just listen to what people who have tried this solution have to say. “Thank God I came across your solution by accident! 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Common Co Occurring Issues in Addiction | Addiction Counselor Exam Review

this episode was pre-recorded as part of a live continuing   education webinar on-demand CEUs are still available for this presentation   through all CEUs registered at all CEUs comm slash counselor toolbox I’d like to welcome everybody to today’s presentation on common co-occurring issues   exploring the interaction between mental health physical health and addiction so we’re kind of   putting together the stuff that we’ve been talking about for a couple of sessions now   we’re going to start by talking about some questions and then reviewing what a healthy   person needs and then going through and talking about how different addictions may cause or be   caused by mood disorders and physical health issues and we’re going to talk about things   that you may see in private practice or the a facility that you’re working in just real quickly   for those of you who are here how many people if you would just type in the chat window if you’re   a mental health counselor type mhm if you are a addictions counselor type SI or whatever so just   kind of so and know who I’m talking to you okay so mostly mental health ok cool so what we’re going to look at is what you may see in private practice or a mental health   setting because these clients a lot of clients that have substance abuse or addiction issues   and I use the term addiction because we’re talking about behavioral addictions too many   times they don’t meet the criteria for admission for substance abuse because they don’t meet that   threshold of a substance use disorder tolerance withdrawal yay yay so substance abuse agencies   can’t get funding to provide the treatment so they end up in a mental health facility or a   mental health counselor’s office and they may be dealing with some of these addiction issues   and wanting to address them or they may not be but those issues are out there and exist so   we want to know how they interact so told you we’re gonna have a couple of questions to think   about and I’m just asking you to ponder these for right now and you can add throughout the class if   you want but we’re gonna talk about it more at the end how can we and why is it important   to address chronic illness and disabilities that result from or that cause mood disorders   or addictions so thinking about you know like HIV or hepatitis are two of the big one’s cirrhosis of the liver chronic obstructive pulmonary disease from smoking so these are   things that can result from addiction why or how is it important for us as clinicians mental health   clinicians mainly to think about addressing these how can we address depression and/or anxiety kind   of our mood disorder genre and hopelessness that results from or causes depression and anxiety so   we know that thinking back affects acceptance and commitment therapy there’s clean discomfort   which is what he calls your initial emotion when you feel something if you feel depressed   if you feel anxious that’s how you feel and it’s uncomfortable but it’s clean it is it is   what it is and then he calls dirty discomfort the feelings that we have about those feelings   so we can get angry that we are depressed we can get depressed that we’re still depressed and he   calls that dirty discomfort because we’re kind of layering on and piling in think about just kind of   throwing somebody into a hole and piling more dirt on top of them so we want to think about   how can we address these issues that result from depression or anxiety or sleeping eating or energy   changes so if you’ve got somebody who is dealing with a chronic illness or something else has   happened or they’re they’ve got some sort of an addiction and they are not eating well not   sleeping well it could trigger depression or anxiety so we’re going to talk about that how   can we address sleeping eating and energy changes seems like we’re getting repetitive we’re looking   at how each one interface and how can we address these things that are caused by or cause mood   disorders or addictions because we know when we look at the diagnostic criteria for depression   for example sleeping eating and energy changes primary in there and how can we address guilt   and regret which may accompany addiction recovery or the diagnosis of the disease as the result of   addiction such as lung cancer or HIV or cirrhosis of the liver and people who have liver disorders   cirrhosis of the liver and hepatitis are at a greater risk of liver cancer so that can they   can have some additional anxiety that is related to that so they may look back and go I wish I   hadn’t well you have so how can we help you deal with that and come to some level of acceptance so   my little editorialized soapbox when we’re talking about addictions I mean sometimes we don’t want to   think that they exist we want to pretend that our clients are coming in their mental health clients   otherwise their perfectly healthy things are going great well that may not be the trick the   case a lot of people begin to use and I mean think about ourselves when we’re when we were   in high school and college or you know even later some people use it for recreation you know they want   to go out have a few beers do whatever cool you know that’s fine some people drink or use it for   relaxation my son has a love of we will use that word videogames and he will get on his videogames   and we’ll kind of get lost in it it helps him escape from you know life as we know it for a   little bit of time some people use because of peer pressure you know it’s everybody’s   doing it or you know you’re at a football party or something and everybody’s having a beer and   somebody offers you one and you don’t want to be rude things like that can happen and some people   begin to use straight up for self-medication they’re like I feel crappy I need something to   help me feel better or numb the pain so there’s a lot of reasons people begin to use so then you   might say well why don’t they just say no because it’s easy to say no well it’s not some   people start to use it because they’re bored and they want something to bring some excitement some   euphoria to their life and we’re talking about everything from sex addiction to internet addiction to cocaine use I mean we’re running the gamut here they may lack the awareness of the dangers or how   quickly you can become addicted I know when I was working in the facility in Florida there was the   sort of knowledge if you will and knowledge is not the right word rule I guess that with crack   cocaine for some people, it was a one-hit wonder you did it once and you were hooked and several drugs can be highly addicting quickly especially if they’re taken either   through injection or inhalation but we’ve talked before about the fact that our bodies can start   developing tolerance to opiates within 3 to 5 days so you know people may not a lot of people   don’t realize when they go in and their doctor writes him a script for two weeks of opiates and   they take it as prescribed that they’re actually becoming somewhat addicted to those opiates if   they take the whole prescription so they may not understand that some people don’t say no because   they have low self-esteem so they’re looking for comfort to help them relax to help them loosen   up so they can be more fun at the party and or to peer pressure somebody tells them why don’t use or why don’t come out and go drinking with us or whatever the case may be so to fit in   they may try to use it to fit in to feel part of a crowd and part of it can also be you   know with that peer pressure just generally the culture promoting this kind of behavior going   it’s ok I think I’ve shared with you before at At the beginning of some of the original Beverly   Hillbillies episodes they still advertised Winston cigarettes, like they are the greatest thing and cool people, have them and that’s the thing to do so if that message gets out people may start   believing it and not do their research so to speak on what the true problems or risks may be and then again self-medication some people may be struggling just to get by from day to day and   this helps them survive the best they can with the tools they have until we give them some new tools   so just saying you know I had I grown up during the era of Nancy Reagan and you know God loves her she was trying to help and for a certain small percentage she probably did but for a larger   percentage just saying no is not that easy we need to give people the tools so they can say no so   they don’t so they aren’t relying on these drugs for some reason because when people start using it for recreation and relaxation some people may not have a big big issue with it other people may   start throwing their neurotransmitters kind of out of whack depending on how much how often they use   what combinations if they’re on any medication so people may inadvertently start messing with their   neurotransmitters and creating and we’ll talk about this creating depression or anxiety   that they end up trying to self-medicate so that that is my soapbox for it is not that easy to just   say no we as a culture not just as clinicians have some work to do so what do we need to do to help people be able to just say no they need to have access to healthy nutrition   and knowledge of what that means my son and it’s still like drawing fingernails on a blackboard   to me today this week, I told his sister that you no, he didn’t understand why she was so concerned   with the nutrition he’s a guy he doesn’t need to pay attention to nutrition it’s just whatever and I   was just like oh my gosh you know everything I’ve said has fallen on deaf ears but okay we’ll back   up and figure out a way they need access to it and then they also need to eat it you know if   we have healthy foods available but people are still eating peanut butter and jelly sandwiches   for every single meal it’s not going to help so we need to make sure people understand what a healthy   diet looks like and how to do it in a way that’s not painful you know we’re not asking you to just eat   rabbit food as my daddy used to say but so what does it look like to eat a diet or nutrition that   makes you feel good that’s happy that makes you feel happily fulfilled you like it tastes good   whatever you want to say but that’s also healthy you know it’s not just pizza or just   peanut butter we need to educate people and a lot of adults that I work with have no clue about   sleep hygiene you know they know they’re supposed to try to go to sleep but they don’t know anything   about turning off the blue turning on blue light filters so the blue lights are not keeping them   up so we need to do some education here ideally in elementary schools but if we can get it out to the   community so they can pass it on to their little minions we’ll be on a good path to pain control we   need people to start having pain control but we need to also have them have alternatives to   pain control besides opiates and there are a lot of them out there again people don’t know about   so we must educate and we’re not prescribing pain control that’s not our job but   if we have a client who’s in chronic pain we can suggest that they work with their doctor that they   look into options for pain control you can google it and find a lot of different alternatives now   if they don’t want to go to the doctor but you know there are a lot of different things from   acupressure it attends units to things that are nonpharmacological that can help people manage   their pain so they can sleep which will help the rest and rebalance to deal with fatigue and   be able to deal with life kind of on life’s terms because they won’t be in this constant state of   stress people need access to regular medical care to prevent problems so you know we want to prevent   this thing on your face from becoming skin cancer we want to prevent anything else that that might   trigger problems and early intervention so like with Lyme disease, if people get early intervention   mentioned they don’t end up with the chronic problems with HIV the earlier the intervention   the better same thing with hepatitis you know the list goes on so we want to make sure that if   people have some sort of issue that’s disrupting their ability to get enough sleep process   nutrition go to work do any of these things that they have access to some method whatever method   they need to address it so sometimes it’s medical sometimes it’s mental health it’s social   services they need safe housing so we’re on to social services now and that includes a roof   over their head that they’re not worried when they go to sleep at night but also being safe   from domestic violence and things like that safety and this kind of goes with safe housing and I put   internal and external because you know the first part is external safety we want to be able to know   that our patients can relax wherever they’re at they have enough money to keep a roof over their   head in a safe place and you know typically that’s not something that we think about as mental health   counselors we think about helping them deal with their anxiety but if they can’t get enough sleep   and they never feel safe when they’re at home they’re not going to be able to rest and they’re   at best their recovery is going to be impeded at worst you know it’s going to contribute to the   issue that they’re seeing us for so safe housing is important we’re not going to get it for them   but we can point them in the right direction your local United Way which is 2-1-1 and most places   generally has a listing of different resources for accessing safe housing if you don’t work   in a facility that’s used to dealing with that and then internal safety that’s shutting up that   internal critic that’s being able to go through a day without being derogatory to yourself and that’s something that we definitely can help with we can help people shut down that   internal critic or that internal person that is always calling gloom and doom and you know   waiting for the other shoe to drop or whatever the case maybe we can help clients change their   cognitions so it’s safe inside their head and then people need love and acceptance and   this should sound pretty familiar are you know Maslow’s hierarchy here kind of in Reverse   but people need love and acceptance but in order for love to have love and acceptance in many cases   they also need to love and accept themselves so we’re gonna work on self-esteem we’re gonna help   people develop relationship skills hopefully there are some people in their life that have provided   some level of love and acceptance maybe not the unconditional positive regard we’ve hoped for but   they’re there so these are things that the healthy happy person needs and these are things in large   part we can do through education referral and direct services help people get so why do we care about   co-occurring issues as mental health counselors well 35 percent of people with anxiety disorders   have according to one of these studies abused opiates so that’s a lot if you’ve got somebody   with an anxiety disorder this isn’t just panic this isn’t just something you know severe   this is you know any of your anxiety disorders one in three roughly have abused opiates they’ve   used some sort of opiate drug to help them kind of chill out of opiate or alcohol dependent patients   20% have major depressive disorder so of that 35% you know there’s going to be a percentage   of them who may be opiate or alcohol dependent and there are a lot of our clients that we see in   mental health treatment who are not willing to be truthful about how much they really drink or how   often they drink because they might be suspecting it’s a little bit of a problem but   they’re not wanting to go there yet they’re in what we call pre-contemplation okay so let’s   just go with this in mind that there may be some underlying other stuff that they haven’t told us   about opiate or alcohol-dependent patients 20% have major depressive disorder so you know we’re   taking them and we may be seeing them in the clinic for depression and we do want to be suspect of   whether there’s either some opiate or alcohol issues there depression and opioid-dependent patients including pain management patients so those who are opiate-dependent by prescription have been associated with poorer physical health decreased quality of life increased risk-taking behaviors and suicidality am I saying that pain management clinics are bad no but what I’m saying   is those who are in pain management clinics for a variety of reasons are at a high in a higher risk   category I mean think about it if your pain is bad enough that you need to be going to a pain   management clinic think about how much that must hurt think about how much that must impair your   daily life think about the impact of the drugs that you’re taking on your mood your energy levels   and the stigma in some cases associated with it some people here suboxone and they’re like yeah   whatever my neighbor takes that other person here suboxone and they’re like ah you can’t be taking   that so there is still a lot of social stigmas that goes along with medication-assisted therapies so there are a lot of things that may contribute to depression in opioid-dependent patients   the prevalence and severity of depression tend to decline within the first few weeks after treatment   initiation so if they are trying to get off of you know ideally their detox and they’re   trying to you know remain sober the prevalence and the severity of depression tends to decline so we   need to get them off of it first and get them through that acute withdrawal from a depressant   including alcohol and I know this slide is boring but we’re gonna be through in a second withdrawal   from depressants including alcohol opioids and even stimulants invariably include potent anxiety   symptoms so it’s important to pay attention and withdrawal from stimulants can also include potent   depressive symptoms if they’ve been on a crack binge for you know five days that won’t sleep for   a while many people with substance use disorders may exhibit symptoms of depression that fade over   time and are related to acute with drawl well we talk about acute withdrawal we’re talking about   the first three months we’re not talking about the detox period which is generally three days so   encourage people who’ve gone through detox and maybe they’re seeing you on an outpatient basis   encourage people to you know be patient and work with the treatment team if they need to but the first   three months is always the hardest so chicken or the egg you know did the person start using and become   depressed or was the person depressed so they self medicated does it matter depression and anxiety   are associated with addiction because because if you have stimulant withdrawal or recovery   that period after you quit using that’s maybe a week maybe two weeks where your body is going   whew that was a run people may feel depressed fatigued have difficulty concentrating which can   impact how well they eat it’ll impact their sleep they’re gonna sleep a lot more but the   quality of sleep may be poor so they can mess up their circadian rhythms and you know they   may not have access to the social support that they wanted they may but really with stimulant   withdrawal we’re looking at nutrition and sleep so we want to educate patients if they   decide to stop taking stimulants what they need to look at stimulant use can also be associated   with depression and anxiety because many people not you know the majority but a lot of people   out there will self-medicate depression with stimulants from anything from caffeine which   you know maybe like mild dysthymia but if you abuse enough caffeine you know it starts getting   into your system you become dependent on it but if you start combining caffeine and nicotine plus oh   let’s add in some workout supplements or you know the occasional Ritalin or something not suggesting   it then it’s these things can wear the body down which can lead to additional depression but people   may use these things to try to feel better because think depression is related for some people   they may not feel like they can wake up they’re fatigued they’re lethargic all the time and   they’re feeling blue so if they take stimulants they get that dopamine rush they’re starting   to feel good and they’re awake stimulant use can cause anxiety well the so if you’ve got   somebody who already has maybe they are depressed but they’ve also got some anxiety and they start   using stimulants which may make the anxiety way worse alcohol or opiate use some people use these things   to numb or to forget and that’s just your the standard used the depressant some people will   use either one of these but especially opiates to deal with physical pain to medicate depression or   anxiety remember there are a lot of trials not several trials right now that are looking at   using opiates to treat intractable depression but a lot of people also use opiates off-label illegally to address anxiety so if you’ve got a client with depression or anxiety just kind of   be alert for how they’re behaving if they’ve got pinpoint pupils or if they’re itching and   picking all the time I mean not the occasional are winter and the heat just turned on I’ve got   dry skin itch but constantly itching and picking and you know where you’re like please just settle   down detox from opiates can all often produce depression produces a lot of flu-like symptoms   which can make people feel crappy and the flu-like symptoms I won’t get graphic impaired   nutrient absorption impaired sleep you know they’re sleeping a lot because they feel like   crap but they’re also having to get up every 10 minutes to go to the bathroom sometimes so   this first week or so during the initial if they go cold turkey so to speak can be rough   detox from alcohol as I’ve talked about before can produce anxiety symptoms so understanding   that when people are going through detox whether they are alcohol dependent and have been drinking   a whole lot which needs to be medically monitored I can’t say this enough and I’ll say it a lot more   tomorrow when we talk about where Nikki Korsakoff syndrome but people who are detoxing from alcohol   will have anxiety symptoms and a period of high blood pressure and sometimes depression and anxiety are associated with addiction just because they sober up one morning and they look at their life   and they’re like what the hell have I done so you know and you’re looking at them going yeah   I don’t blame you for feeling that way now let’s see what we can do to improve the next moment   so make sure that we understand that these things are going to go hand in hand and to be   on the lookout because like I said a lot of people aren’t forthcoming even about alcohol use which is   legal but if they’re using something illegally or using maybe their kid’s Ritalin or something   they’re pretty much almost guaranteed not to tell you so we want to be on the lookout for signs and   symptoms bipolar disorder can be triggered by drug use so we just know that we can the person could   get worn down mess with the neurotransmitters enough they’re not exactly sure how it happens   but we have seen the initial acute episode of bipolar disorder-triggered mania triggered by   drug use it is more common for people with bipolar to use stimulants when they’re depressed and just   about anything when they’re manic now if you’re working with somebody with bipolar you know   you’re probably already having these discussions about how you stay safe when you’re in a manic   episode people with ADHD may use to self-medicate and we’re talking cannabis is a big one for ADHD   to help people feel like they’ve got more focus and not feel like they’ve got so much coming in   and so much stimulation all the time which can be exhausting and after the use of any of the substances   of abuse the disruption and neurotransmitters can make people feel like they’ve got ADHD-type symptoms faculty concentrating difficulty following through with things etc so understanding   that even if things don’t meet the threshold for DSM-5 diagnosis we want to look at what symptoms   are there and how can we help people manage them so they’re getting adequate sleep nutrition pain   control social support and safety borderline and antisocial personality just kind of threw those   in there because we see those a lot when we’re working in dual diagnosis facilities more people   are more likely to use addictions to cope with a lack of sense of self and their emotional lability   if they’re borderline so I mean their world is so chaotic many people with borderline personality   disorder are likely to use to try to get some calm in the storm now I will put out my other soapbox   here with both of these personality disorders when you see somebody in active addiction or early recovery they probably have symptoms that would meet diagnosis you know their symptoms   are pervasive in multiple areas of life their symptoms would meet the diagnosis for one of these   two personality disorders during this period but it resolves as recovery becomes the norm   as the neurotransmitter stabilizes they develop interpersonal skills so you know giving people   a little bit of time before we say it’s borderline personality disorder versus borderline personality   characteristics if you will be helpful because both of these diagnoses can block people from   getting into certain treatment centers and getting some of the services they need okay so we’re going   to move on to some of our more common addictions alcoholism is associated with eating disorders   there’s a really strong Association and it usually flip-flops between bulimia and alcoholism so if   somebody’s symptomatic for bulimia they may not be drinking a lot of alcohol but they may during   periods of remission from the bulimia drink a lot more alcohol become alcohol dependent so there’s   a lot of research out there that shows there’s a strong correlation between these two things and   it’s also associated with binge eating disorder but especially bulimia nutritional deficiencies   from alcoholism can cause mood disorders so even if somebody is not and I use the term   I should have put alcohol instead of alcoholism because even the term heavy use without physical   dependence can cause nutritional deficiencies that can cause ulcers it can cause physical problems   physical exhaustion which can disrupt sleep alcohol impairs sleep quality alcohol makes   apnea worse so if you’ve got a client who has sleep apnea they’re drinking they’re probably   gonna sleep even worse than they normally do depression is the result of using well alcohol as a depressant so what do people expect well most people expect to relax they don’t think about the   rest of the stuff that’s going on in neurochemical imbalances because the alcohol exits our system a   lot faster than our brain can catch up and go okay it’s not in there anymore so I need to adjust the   temperature and in sleep disruption anxiety can also, be triggered as a result of use I’ve said   before say it again after that initial period where people feel the depressant or relaxing   effects of alcohol there is an upsurge in anxiety so a lot of people have another drink to kind of   quell that anxiety feeling but you know people with anxiety disorders are gonna feel it more   prominently and the neurochemical imbalances that alcohol use causes can worsen pre-existing   anxiety conditions or trigger anxiety conditions nicotine is another one that we see a lot even   in just straight-up mental health clinics not co-occurring so what effect does nicotine have   well anxiety and depression are 70% more likely in smokers so that’s one of those statistics we want   to look at nicotine triggers dopamine release okay so nicotine is one of the most addictive drugs on   the planet and you’re thinking I thought that was opiates well opiates are in there but nicotine   not only is nicotine legal but it’s also one of the most addictive drugs on the planet so that’s   another important point to think about people are using their trigger and dopamine release their   brain gets used to being flooded with dopamine so their receptors on the other end start sensitizing   so we’re creating an artificial environment basically when people are smoking blood vessel   changes when people smoke it causes blood vessel changes that can cause high blood pressure as well   as depression and fatigue and confusion in the blood vessels narrow and get stiffer so the oxygenated   blood has a harder time getting to where it needs to be so people start feeling blah and that can   cause them to think that they’re starting to feel depressed can also cause those cause loss of   energy people with severe and persistent mental illnesses are two to three times more likely than   the general population to use nicotine so that’s just an interesting little fact to have out there   if you work with people with SP MI and people with ADHD may smoke because it increases their   concentration and attention for about five minutes literally, for about five minutes but during that   five minutes they’re like oh my gosh it’s a relief I can like focus for half a second so we   want to look at what else is going on whether the a person has adult ADHD for example physical health   mental nicotine is linked with COPD and emphysema and lung cancer so you know all kinds of lung   and cardiopulmonary stuff well when that happens you know we have less oxygenated blood efficient   efficiently getting through the system we’re going to have increased fatigue increased confusion some   grief that may go along with that especially if people are starting to have to carry an oxygen   tank around with them or something you know we may have to help them deal with disability acceptance   and depression and stroke because smoking like I said increases blood pressure and reduces   circulation so cutting off or greatly reducing circulation to the brain they have shown that   people who smoke especially heavy smokers are at a much greater risk of stroke and addiction nicotine   is strongly correlated with other addictions a a lot of people when they’re in the bar well not   so much anymore since smoking is not allowed in public places but used to be when they were in   the bar they would also be smoking but a lot of people associate alcohol and nicotine or nicotine   and other drugs so if somebody is using other drugs likely they’re smoking now it doesn’t work   the other way around just because they’re smoking doesn’t mean they’re likely using other drugs the   reason this is more important is that people who continue to smoke after they have gone into   recovery for their drug of choice have a relapse rates as high as 68 percent higher than for people   who quit smoking so we start thinking about that and we say well why is that well because nicotine is a mood-altering substance you know we don’t think of it as such because it’s not a   woohoo it’s Marva hey okay it’s not as prominent of interaction as maybe cocaine or something   but it does change the balance and people still do use smoking to cope with life when things get   stressful they smoke well if things get stressful and you know they’re too stressed for smoking to   handle then they may start going back to what else can I take use or do that will make this   feeling go away right now we know also that was smoking and that repeated release of dopamine   they’re messing with the neurochemical balances in their brain, so it makes sense that eventually   just like tolerance to other drugs happens it may not be enough at a certain point and they may fall   back into other habits nicotine has been known to suppress appetite and but whether it keeps weight   off or not they haven’t shown alcohol and nicotine both are appetite suppressants which   is another reason people with bulimia tend to drink and one of the reasons why people quit   smoking they tend to be hungrier so helping them get through that period now whether it   helps them keep weight off the party that deals with the reason that they eat it’s not really that it’s   suppressing their or increasing their metabolism so much its nicotine suppresses the anxiety   and sometimes the desire the hunger but if people are still eating out of anxiety if they’re still   eating under stress eating then you know when they stop smoking and they don’t have a cigarette to put   in their mouth when they’re stressed they tend to go for other things and so we need to help people   figure out when they stop smoking are you eating because you’re hungry or are you eating   because you’re stressed if they’re eating because they’re hungry and they’re getting heavier   than they want to be they need to talk with their doctor about you know thyroid tests and also let   their doctor educate them on biological setpoint theory of you know not everybody’s going to be   a zero so you know that may be something we can help them deal with body acceptance issues if   you know maybe they’re programmed genetically to be you know a size X whatever that is and they’re   not happy because they want to be a zero which our culture does tell us to do as clinicians   we can help them look at you know the costs and benefits of continuing to smoke and what being   you know a size zero means for them to opiate abuse there’s a lot of physical stuff and we’re   just gonna run through it real quick because you’re not as concerned with it the physical   stuff the doctors are gonna see but we need to be aware of from a clinical point because it can keep   people from getting their basic needs met blood and injection site infections you know that’s   probably going to lay them up for a while but if they have repeated infections and are repeatedly   out of work they can lose their job they can lose their housing they can you know get some sort   of MRSA or something else which can be really expensive it can be life-threatening ya-ya   collapsed veins and this is more common obviously this is only for injection drug users but   collapsed veins just as you would expect keep the oxygenated blood from getting where it needs to be   so people are more likely to experience strokes and may have certain forms of vascular dementia   because of the strokes dementia we’re familiar with endocarditis is the inflammation around   the heart so again this is only for needle drug users but if you’ve got a client who is using   needles to inject any kind of drug be aware of that and what they get and what they inject is   rarely pure so knowing what else they’re injecting into their system if they’re you know crushing   pills from the pharmacy you’re a little bit more sure about what they’re getting as opposed to if   it’s from the corner dealer and sometimes they’re cut with really nasty things like   you know comic bathroom cleaner and stuff HIV if people get HIV from injection or some other risky   behavior they’re probably going to experience some depression and a lot of times HIV from   opiate abuse they’re gonna experience depression remorse regret all that kind of stuff anxiety   about how long they’re going to live what’s going to happen and oh those medication side   effects those the antiretroviral medications that they have to take are doozies I’ve seen people go   through the induction weeks on their medications and it is a rough time so helping people   get through it so they are medication compliance so they can continue to live we need to help them   maintain hope and self-efficacy and all that kind of stuff to maintain that forward movement to get   through the induction period liver damage from acetaminophen can set people up for you know   physical pain among other things and it decreased pain tolerance now this generally the decreased   pain tolerance goes away after the the body starts producing its endorphins and   natural painkillers again but that initial period Stevie-Wright-rare-interview if somebody quits using and maybe you know you are seeing them as a mental health client and they had an accident or had surgery or something   they started using pills they got a couple of refills then the doctor said no I’m cutting you   off and now they’re going through a detox period detox from opiates is unpleasant but it is rarely   life-threatening unless somebody becomes their electrolytes get imbalanced because of the flu   symptoms but we still may see this in private practice in mental health practice because   of the scenario I just told you people can start taking painkillers as prescribed for something   they may get addicted you know take them for a month or so then when they get off of them   not only do they feel like you know really bad but their pain is also back and it may be they   had their wisdom teeth out that pain may be gone but other aches and pains and everything you feel is probably going to be intensified until the body kicks back in so educating clients about   this is what happens you know it’s not uncommon if you think it’s too bad go see your   doctor helping them make sure they’re getting good nutrition you know it’s hard if you’ve got   flu symptoms to feel like you want to eat or hold anything down so what can you do to make   sure your body has the building blocks to make the stuff that it needs to help you feel better what   can you do to improve your sleep and a lot of our clients and you know where I used to work we   had a methadone clinic and we also had a mother baby unit and as soon as the mothers would give   birth then the doctor would start them on their detox from methadone and he didn’t believe   in the kinder gentler taper he was just like okay baby’s gone threats gone because you can’t detox   from somebody from opiates when they are pregnant because it can cause the baby to die anyway   so as soon as they would stop or as soon as they weren’t pregnant anymore he would just   D see them and they would feel really bad I mean not only did they just push an 8-pound something   out of their body but they also are experiencing a decreased pain tolerance because they’re not   on the opiates anymore and all they want to do is sleep it’s just like please so understanding that   is important in helping people get through that period even though they may want to sleep   all the time helping them understand that it’s important to maintain their circadian rhythms   if they have to take two or three ten-minute power naps throughout the day to get through   the day you know more power to them but if they can practice good sleep hygiene they’re gonna   be way better off in the long run OPD opiate abuse is also or opiate use is also associated   with the treatment of depression but it can cause depressive symptoms due to its pharmacological   properties I mean it slows everything down from you’re gastrointestinal to your heart rate to your   respiration you’re not breathing as much you’re not getting as much oxygen in you’re gonna have   more fatigue you’re gonna have more confusion you’re going to have more of those symptoms of   depression for some people they find it is and certain opiates they find it is a powerful way   to reduce anxiety it makes them feel like they’ve got a ton of energy because they’re not stressed   out anymore and this last one is one of the The main reason that I find people don’t want to give   up opiates is that they finally feel better when they’re on the eating disorders commonly a coat   co-occur with depression and anxiety which can be caused by nutritional deficiencies you know   you’re not giving your body the building blocks so it can’t make the neurotransmitters it needs   and it also probably disrupts your sleep some and depression anxiety can cause or trigger or   whatever you want to say eating disorders because people with eating disorders may fear becoming fat   have low self-esteem have a sense of lack of self-control or have body dysmorphic disorder   so we also want to be aware that there are mental health stuff that can trigger dysfunctional eating   patterns there’s about a 24% prevalence of PTSD among people with eating disorders so if you’ve   got a client with eating disorders especially bulimia be on the lookout for depression anxiety   body dysmorphic disorder alcoholism and PTSD they maybe smoking too but of the things, I just listed   that’s probably the least of their worries it’s all eating disorders are also associated with   alcoholism and smoking I said physical health issues now you’re seeing somebody with an eating   disorder it’s a mild eating disorder you’re seeing them once a week outpatient so you’re not and you   have you know you have training and working with eating disorders or maybe it’s   mild enough that you’re just getting supervision on treating this issue whatever being aware that   people with eating disorders anorexia or bulimia can have irregular heartbeats and cardiac arrest   due to potassium imbalances and electrolyte imbalances so if they’re not eating or if   they are binging and purging in some way shape or form and that includes excessive exercise which can   trigger a lot of heart problems they may have loss of bone mass and osteoporosis so they may   break bones a little bit easier going back up to the heartbeat not to belabor the point but again   heart problems mean a lack of available oxygen mean confusion fatigue potential difficulty   sleeping depressive symptoms and you know cardiac arrest in and of itself is bad kidney damage from   Doretta caboose and low potassium can also potentially drain damaged the adrenals which   are on the kidneys and so it’s important to be aware of what people are using a lot of people   with eating disorders are going to creatively use stimulants to suppress their appetite think   about any of your diet drugs your enter mean I think it’s one of them the ones they give to help   people lose weight they’re stimulants they’re intense stimulants so people who are   struggling with eating disorders are likely to go towards abusing stimulants or at least using them   which can drain the adrenals it can in some cases have been linked to the development of   Addison’s disease liver damage from not eating or binging and purging causing toxin buildup   and possibly pain we can help people deal with it as much as we can anemia which can cause symptoms   of depression in and of itself so goes back to that nutrition making sure they’re getting enough infertility which in and of itself can be devastating for young women if they can’t   have children anymore or can’t have children ever that may be a grief issue that we need to   help them deal with cathartic: and this is an important one to be aware of because you   don’t have to have somebody who uses laxatives all the time but people who regularly use or   abuse laxatives can become dependent on them so when they don’t use them they have a feeling of   bloating feeling full and abdominal pain which especially in people with eating disorders or   body morphic disorders surrounding just general body fit bad back body fat can greatly increase   anxiety depression hopelessness and in some cases of suicidality so again educating people   is the first step to helping them understand what’s going on and how dangerous laxatives can be but   also if somebody is trying to cut back on their use of laxatives or just recently stopped using   laxatives like when people stopped using opiates it takes the body a while to get back   online but for most people it eventually does people with eating disorders also have chronic   ulcers which are painful and can keep you up at night As you know gastric reflux and pancreatitis   which can flare up at a moment’s notice will is extraordinarily painful and can cause people to   lose time from school or work social activities feel bad about themselves and also   pancreatitis causes a lot of bloating which in eating disorders is a huge trigger   for anxiety and depression pathological gambling is associated with stimulant abuse especially   cocaine methamphetamine and Ritalin to stay focused disrupted sleep and rebound depression   when they quit taking that stuff they wake up and they’re like oh wow what did I just do alcoholism   is also associated with pathological gambling some people drink to calm their nerves some   people drink because it’s the culture if you go to any of the casinos you know their hand-and-out drinks, they’re trying to get you drunk so you keep gambling more and there’s as we spoke about   earlier rebound depression or anxiety smoking may help people increase their focus or make   them think they can increase their focus so if you can’t smoke in public places this is more of   an issue if you have somebody who does a lot of online gambling or they gamble at their friend’s   house or somebody’s house where there’s poker games and stuff smoking has some anti-anxiety   anti-anxiety properties and may be part of the the culture I know when my daddy used to have his   poker games everybody would smoke cigars and even the one woman who went there would be smoking a   cigar with everybody else and it was just the culture of being there so there are a lot of   different reasons that people may use substances in addition to gambling mental health issues from   gambling anxiety from the stimulant use or from the tension and release of am I going to you know   I’m down $20,000 am I going to make it back ADHD is also strongly associated with pathological   gambling bipolar disorder, especially during manic phases are associated with pathological gambling   generally you see them co-occurring it’s not like gambling causes it it’s you will see co-occur depression can occur due to losses and gambling can start because somebody’s depressed   because of their financial situation and their trying to figure out a way to you know borrow from   Peter to pay Paul and get ahead you also see pathological gambling is more strongly associated   with people who have obsessive-compulsive disorder if you’ve got clients with these   diagnoses just kind of you know be attentive to the fact that they are more likely to engage in   pathological gambling or if they start gambling it’s more likely to become a problem than for   people who don’t have these issues internet an addiction that is diagnoseable so   you know I’m not just making something up depending on your resource affects eight   point two percent to thirty-eight percent of the general population now obviously we were looking   at you know like games versus you know games plus Facebook plus shopping or something so depending   on the study you looked at their parameters were a little bit different but either way up   to 38 percent of the population has sacrificed significant personal recreational activities to engage in some sort of internet behavior Internet addiction can cause anxiety or   depression due to eyestrain and chronic headaches you know if you’re hurting all the time it can   make you feel wonky it can also interrupt your sleep can cause circadian rhythm disorder which   can trigger depression fatigue reduced stress tolerance this is a condition when your body   doesn’t know whether it’s supposed to be awake or asleep because a lot of people who engage in internet-addictive behaviors do so in the dark or you know they don’t pay attention to whether the   lights are on or not they may just sit there kind of in their cave carpal tunnel contributes to pain   and sleep disruption because carpal tunnel does wake you up at night back ache again may disrupt   your sleep and can cause chronic pain during the a day which can interrupt your daily activities poor   nutrition I know a lot of gamers that will sit there for an entire weekend and not get up to go   eat so if it’s not brought to them they don’t eat they’ll even wear adult diapers so they don’t have   to get up to go to the bathroom reduced immunity due to exhaustion from not sleeping and job or   relationship problems I know uh several people whose marriages ended over a world of warcraft’   so internet addiction is a real thing and it’s something that we need to be cognizant of because   it does cause a lot of problems and a lot of relationships and it may be one of many problems   but it’s something to look at sex addiction can cause hepatitis and a variety of different STDs   which if not treated can cause systemic problems it’s related to anxiety and depression because sex   addiction may begin in order because somebody wants to feel loved or connected maybe after   a breakup or because they never felt loved you’re connected and then they feel that rush and they’re   like oh I like that I want to do that again part of it could be engaging in that behavior which is   so thrilling you know depends on the person psychological withdrawal from sex addiction   people who have been engaging in sex addiction type behaviors and I include pornography addiction   in it for this presentation if they’re not able to access that may start feeling anxious or depressed   they can’t get to that they can’t get to the the thing that’s gonna cause the dopamine rush and   reflection on behaviors that they’ve engaged in as a part of their sex addiction can also prompt   anxiety about a spouse finding out you know am I going to develop an STD and am I you know how I feel about what I’ve been doing so as clinicians if we’re working with somebody who has compulsive   sexual behaviors even if you know anywhere about that the spectrum we need to be aware that these things may   exist and figure out or help them figure out how they feel about it and what they need to   do to make sure that they’re getting good sleep that they’re dealing with their depression and   their anxiety so that they can have a safe internal and external environment so back to that global   perspective how can we and why is it important to address chronic illness and disabilities   that result from or cause mood disorders or addictions how can we address depression anxiety   and hopelessness that results from or causes depression anxiety or physical problems how can   we address physical problems that are caused by mood or addictions and how can we address   guilt or regret which may accompany addiction recovery or the realization of a diagnosis of a   disease caused by the addiction so while you kind of ponder those there was a question that came in so question what about robbing Peter to pay Paul in association with trauma specifically childhood trauma so if you could clarify that for me a little bit I had mentioned robbing Peter   to pay Paul in terms of gambling so I’m just so mental health issues can be caused by or trigger   addictions or physical health issues addictions can cause or trigger mental health issues or   physical health issues that can be caused by addictions or mental health issues   so again chicken-or-egg we don’t necessarily know which one came first when you have any one of   these it’s probably going to or likely impact each other person or each other area common   issues are seen in all three changes in sleeping changes in nutrition fatigue and grief effective   treatment requires addressing the underlying causes as well as the ripple effects you know so yes after childhood trauma or trauma of any sort, some people may spend a lot   of time feeding the addiction as you put it or engaging in addictive behaviors to avoid some   of the PTSD symptoms to avoid thinking about it to deal with the grief to deal with the shame so   they may engage in something that makes them feel better or helps them forget to cope with the trauma that happened until they have other tools so they can come to   some sort of terms with it and you know as I say close that chapter in their book already   if there are no other questions tomorrow’s the presentation I learned a lot creating is   on alcohol-related dementia and vascular dementia and fetal alcohol spectrum disorders all three of   which are issues that are caused by substance use and specifically alcoholism and then I’ll   give you a hint about where an acute Korsakoff a a lot of clients who abuse alcohol but they’re not   alcohol dependent who decide to stop drinking can trigger where Nikki Korsakoff syndrome   and causes alcohol-related dementia-type symptoms so again in mental health, we need to be on the   lookout for it if we hear that our clients are trying to cut down on their alcohol use   alrighty everybody and so tomorrow is that presentation and then Thursday we’re going to   look at different models of new bottles of treatment 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 com VirtualBox this   episode has been brought to you in part by all CEUs calmly provide 24/7 multimedia continuing   education and pre-certification training to counselors therapists and nurses since 2006 used coupon code consular toolbox to get a 20% discount on your order this month  As found on YouTubeAnimated Video Maker – Create Amazing Explainer Videos | VidToon™ #1 Top Video Animation Software To Make Explainer, Marketing, Animated Videos Online It’s EASIER, PRODUCTIVE, FASTER Get Commercial Rights INCLUDED when you act NOW Get Vidtoon™

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

This episode was pre-recorded as part of a live continuing education webinar on demand. Ceus are still available for this presentation through all CEUs registered at allies com, counselor toolbox, hi everybody, and welcome to today’s presentation on emotional eating and making peace with food during the next hour.So we’re going to define emotional eating and differentiate it really from eating when to celebrate and when it’s a problem and also differentiate, differentiating it from eating disorders will explore emotional eating in terms of its, beneficial functions and rewards and discuss.Why restrictive diets, don’t resolve emotional eating a lot of times? People will say you know, I have been on this diet forever and it doesn’t seem to be working or I can’t seem to stick to any diet that I try and we’re going to look at different reasons why this might Be what is emotional eating and it’s exactly what it sounds like it:’s eating in response to emotions and feelings other than hunger.So if you’re eating, because you’re bored, if you’re eating at someone and sometimes especially if you are angry at someone or disappointed in someone, you may eat and sort of be eating and thinking you made me do this so eating At someone eating to forget or distract yourself eating, to feel better because when you eat, regardless of what you’re eating, but especially if you eat high sugar high-fat foods, you’re going to release serotonin and dopamine eating out of boredom.You know hand to mouth bang, eating out of habit and, as I said a few minutes ago, not all emotional eaters have an eating disorder um and we want to differentiate that.Does it mean that their eating is not problematic to them? No, not at all.OIP-28If they’re telling you it’s a problem, then it’s a problem.They may not meet the criteria for binge eating disorder or bulimia, but it’s important to address it because they understand that they’re eating for a reason.Other than hunger, they want to stop because they want to eat, for hunger, but not otherwise, and for us as clinicians.The first thing we need to do is understand: why is it that they’re eating? Is it boredom? Is it a habit, so they need to keep a food log or a food journal for over a week or two weeks, and sometimes when people come in for an assessment, especially if that’s one of their main presenting issues? I’ll start by just doing a retrospective of the last three days to get an idea of what may be triggering some of their eating episodes.And then we can look at some of the habits or bad habits, maybe that they’ve gotten into, and start talking about ways to address those remembering that Rome wasn’t built in a day this isn’t going to go away overnight.But a lot of times, if you give people some tips, tricks, and tools to think about implementing when they walk out of your office after the assessment before the first official session, it provides them some hope and gets the momentum going and again you don’t Have to binge to be an emotional eater, some people graze all day long.Some people will eat and it’s not what would be considered technically a binge, but it’s more than they had anticipated.Maybe they go back for second helpings or third helpings when they weren’t hungry, but it was good.So why is eating so soothing? There are a lot of reasons.Now there’s obvious it’s, tastes good, so that’s.You know the big obvious bonus, but thinking about the function eating serves, we have to eat to survive.When you were an infant, it eating involved a closeness with your parental unit, which could release oxytocin, and I say, parental unit because even if it was dad feeding the baby a bottle there was that connection.There was that contact that caused the infant and the parent to release oxytocin. This is our bonding chemical, so eating was associated early on with bonding food may also have been associated with sleep.If the infant or child was given a bottle every night to go to sleep, then they may start thinking or they may be in the habit of eating to wind down or calm down, and we need to help them figure out different ways to do That as a toddler, what eating mean think about when you went from well, we probably don’t, remember that, but think about when your kids went from eating.You know food out of a jar to even their first Cheerios.That was a huge figure out.How to pick up that little cheerio and get it in their mouth and it involved exploration and mastery.They were discovering all different types of textures and tastes and figuring out what smell went with what taste, and it was a cool and exciting time for kids, and I mean think about it.They’re like a year old, so it doesn’t take much to amuse them, but this was the rewarding reward.Equals dopamine equals let’s do that again.It involved power and control of the child.At this point was starting to be able to feed himself or herself and was starting to be able to be somewhat independent of the parent when it came to the basic physiological function of eating. So eating itself had its rewards and it was self-esteem building because the child started learning.You know how to feed yourself and how to ask for what he or she wanted, at least in terms of food.There are formations of memories around foods, even as early as toddlerhood.You know we have celebrations, we have birthdays, we have different things and most children have certain foods that they like, and it could be because the first time that ate that food was a really happy experience or it could be just that’s, their favorite Food and that’s all they want to eat, but they remember that food and they remember when they ate it, they felt good.They felt happy so as an adult there,’s a part of their brain going chicken nuggets.Make me happy now that’s, how the toddler thought as an adult.We can understand that chicken nuggets themselves, aren’t making you happy, but you see the connections that we’re making.Here there’s been an association between happiness and chicken nuggets unhealthy foods, especially for children when, as adults, we’re still able to control what they eat.Your sugary foods and your unhealthy foods are usually reserved for treats or rewards.So when you’re feeling like you need to be rewarded when you’re feeling like you want to feel good, sometimes you’ll resort to those things. When you were a kid that made, you feel good like chocolate, chip, cookies, Haagen Dazs, or whatever it was for you.We’ve talked in the past, about associations and conditioning, and this is all coming back kind of full circle now because we need to understand that our brain has associated pleasure and reward with food for a lot of different reasons.Not just because of nourishment looking at the reasons why your patient eats is going to help you understand what underlying issues you may need to address in treatment.Culturally, we associate eating with caring and celebration and think about birthdays and holidays.What do we get together? We have buffets, we have pot Luck,’s.When someone passes away.What do you bring food over when somebody’s sick? What do you bring food over to in our culture? There is a lot of emphasis put on eating and nourishing, and that’s, true of a lot of different cultures.Low blood sugar can cause feelings of depression and anxiety which are quelled by food.So if somebody typically doesn’t eat well during the day, you know they go long periods without eating or if they have blood sugar issues, to begin with, and then they eat they feel better.So when they start feeling not so good, what do you think their first reaction is, let me eat and see if that helps evolution, predisposes the human body to crave high sugar, high fat, high-calorie foods for quick energy and to prepare for a famine. Our bodies are cool and frustrating at the same time because you know your body takes in this these foods and it says we’re going to secrete, the most amount of dopamine and the most amount of reward for these high-calorie foods because We want to make sure we’re prepared in case there’s a famine back.You know in the day many many many years ago, hundreds of years ago we couldn’t guarantee.We would have a meal every day, let alone three meals every day.So the body prepared – and it said alright – we need to get whatever we can when we can.So we’re going to make this higher fat higher calorie food more rewarding.Now I said it:’s also can be a blessing and a curse.Today, there’s still a little part of our primordial brain.That says, if it thinks there’s a famine, it will slow down your base metabolic rate, which causes people to gain weight.We see this a lot in people with eating disorders, who tend to not take in very many calories, or if they take them in they purge them.So the body goes well. I can’t guarantee I’m gon to get enough food.I’m going to get enough energy to survive.So I’m just going to turn down the thermostat a little bit and turn down the base metabolic rate, which compounds the problem for the person with the eating disorder.So it’s important to understand that the brain is somewhat active in what’s going on.So I keep saying we need to figure out what’s behind or underlying the craving.First, we need to rule out physical causes for some people.It’s as simple as this.If they’ve got low blood sugar because they’re not eating too often and obviously as counselors, we’re not going to diagnose this their doctor or their nutritionist will, but we can start exploring and go.It sounds like you might need to look at having your blood sugar checked or talk to your doctor about how frequently you need to eat because some people – and I know I’m – are very guilty of it.If I get into it into a groove doing something I’ll eat breakfast and then I’ll get into a groove and before I know it, it’s 3 00 in the afternoon and I haven’t eaten for like a whole bunch of Hours I’m not doing math today and my blood Sugar’s low and I’m starting to get foggy, headed and irritable and tired. So it’s a real, simple fix there in our society we are so driven and we are so.We get so caught up in things because that’s such a fast pace that it’s easy to forget to eat or is easy to avoid eating so that’s.The first thing we want to rule out.Are you eating in response to low blood sugar, which is making eating, seem more rewarding when you eat in response to low blood sugar a lot of times, people who do that end up eating more than they normally would because they start eating fast.It’s like I’m going to shovel, in as much as I can.Your brain doesn’t register you’re eating for 20 minutes or so so, before their brain, even registers.What’s gone on and gets the blood sugar back up? They’ve already eaten a whole ton of food.Why is this under-emotional eating? Well because generally, when they go in to just start eating, yes, they’re hungry, but they’re, also cranky and irritable, and most of the time they’re.Not thinking about I’m eating for the nourishment it’s, I’m eating, feel better lack of sleep, and this is so true for shift workers as well.As you know, new parents and college students, and anybody who’s not getting enough sleep. If we are surviving on sugar and stimulants, we’re going Peak and Lower Valley, Peak, and Lower Valley, and you just keep going up and down until you just crash, because every time you crash you crash a little bit lower.So if somebody’s on that roller coaster, they’re going to feel worse between you know: eating episodes they’re going to feel tired.They’re going to feel a flood of sluggish irritable fatigued and, to a certain extent, maybe depression, and they may be missing attribute those feeling, those emotional feelings to emotions versus physical causes, and likewise we also want to make sure that you know we’re addressing The emotional causes because there’s probably stuff there too, but if they’re not getting enough sleep and they’re living on sugar and stimulants their body is kind of in a state of hyper-vigilance, a lot of times it’s exhausted.So they’re going to be tired and cranky.So those are a couple of things that we want to look at.Those are relatively easy fixes or at least relatively easy things to point out and go let’s think about this.One of the things that I suggest for a lot of my clients is just to take a week and mindfully and it is difficult but try to eat healthfully.You know try to eat a few times a day.You know try to eat like three meals a day and get enough water and try to get enough sleep and try not to overdo it.On the stimulants at the, beginning I, 39, am not going to say cut out anything because that 39, is not, realistic and it’s not fair, and they 39, are probably already struggling if they’re coming in to see me, so if I go hey Let’s just turn your world upside down and guess what you’re not going to drink any caffeine anymore. It’s not going to create a happy person, so I asked them to try to make some small changes and see if that starts, to help dehydration causes fogginess and symptoms of depressionWe want to make sure that they rule that out and too many stimulantsAlso causes dehydration, so you know we’re looking at some of the physical causes of irritability and fatigue and cravings because again we’re going back to when I felt this way before not looking at it.Why I felt this way.But when I felt irritable depressed cranky, what made me feel better and generally food, and generally it’s, not good food.For me, it’s M Ms.I love my M Ms, especially the ones with almonds, but I digress.Nutritional causes of cravings, high carbohydrate, and high starch foods caused a greater release of serotonin and endorphins.So if you’ve got somebody who’s depressed for whatever reason that they may crave these kinds of foods to increase their serotonin level or increase the endorphins, their energy levels, chocolate people who crave chocolate may be low in magnesium.It also um the level of magnesium affects how much serotonin is available again. Just I keep saying this just for legal reasons.We want to make sure their doctor or nutritionist goes in and makes this diagnosis, but if there are particular foods that they do crave, they need to bring that up with their medical provider if they’re craving fatty foods.Now again, fatty foods are just good.I love fried foods, but it also could mean that they’re not getting enough Omega threes, Americans, typically don’t and interestingly, if they crave soda, they may be calcium deficient, who knew so?These are things to take a look at to ask people.You know if they’re craving soda, maybe cutting back on their soda a little bit and seeing what happens and or getting blood work done.R-1Once we’ve ruled out the obvious physical causes.They’ve gone to the doctor.Gotten blood work done everything I’m coming back happy.They’re getting enough sleep, but they’re still eating when they’re, not hungry, we need to rule out habits. Is there a particular time or activity that makes you crave this food? When I was growing up, I would go to the grocery store with my mother, and on the way back home from the grocery store.She would always we would always get junk food and she would get a bag of chips and put them in the front seat.It was like a 20-minute drive from the grocery store to our house and by the time we would get back to the house.We would have put a good dent in those potato chips.That being said, I got into the habit of whenever I went to the grocery store.I would get something out of the bag and put it in the front seat and eat on the way home.Now am I paying attention to what I’m eating? No likely am I eating, because I was hungry, probably not so.We want to look at habits.A lot of people will eat when they are watching TV.It’s a huge one. So we want to not do that or if you’re going to eat when you’re watching TV make sure you sit at the table.At least that makes you a little bit more mindful so think about whether are there particular times or activities that you eat and you’re just not hungry.Are there particular times that you mindlessly eat, like, like, I said when you’re driving or when you’re watching television? Those are both habits and can be mindless because you’re not paying attention to how much is going in your mouth.You’re not probably paying attention to the taste and you’re not paying attention to whether you’re full or not.So if you’re mindlessly eating, then there’s going to be a lot more calorie consumption.In addition to the fact that you’re not eating because you’re hungry, you’re just eating to eat, are you going too long between meals than needing a sugar boost which leads to a sugar crash? So again that’s a physical cause? But we want to rule it out.These are bad habits that we can tend to get into other things that can be construed as bad habits are eating without putting food on a plate.If you eat straight out of the bag, you’re going to eat.More than if you put it on a plate, so put it on a plate, sit down, try not to watch TV, all the things that your grandmother would have told you.So what do we do about it? Emotional eating interventions? I talked earlier about the food diary. Do a retrospective during the assessment if they want to get a jumpstart on things, but have them keep a food diary, preferably for the duration of treatment, but at least for a week.What time did they eat? Were they craving just any old food or something salty, something that was sweet, something that was sour? This will give you a general idea and can give their medical provider a general idea if there are any nutritional imbalances or if there are particular associations.What emotion or state were you in, I say state because being exhausted is not necessarily really an emotion.Were you happy sad, mad glad exhausted drained whatever state feels like it would work, and then, because of why were you feeling this way it doesn’t have to be a dissertation? It can be short and sweet, but I encourage clients to write down everything.They eat before they eat it during the first week, or you know, like I said, preferably throughout the entire course of treatment why, before they eat it because it’s a stop, remember we’ve talked before about how we have an urge.We have a craving, we have an urge and then we engage in the behavior oftentimes without stopping mindfully.Think is this what we want to do this provides that stop.It says: okay, I’ve got it to write down the time, and then I’ve got to think about why I’m eating, and honestly a lot of clients notice, a reduction and their habit of eating when they have to do this, just because they don’t want to record-keeping that up for a month or two months helps break some of the habits, eating that they might do like.I said before when they’re eating, I encourage them to use a plate.Sit down. Don’t walk around don’t stand at the counter, eliminate distractions as much as possible and focus on the food you’re eating that goes with mindfully eating.What does it taste like? Is it good to take small bites when my son was young, I think I’ve shared this before he had gastric reflux and we would sit down at the table and I would shovel in food as fast as I could get it in my mouth because He couldn’t be put down for too long before he would start to get fussy, at least until we figured out that he had gastric reflux and Zantac was just a lifesaver.I developed that habit when he was little and I kept it up for a while.It took a while to learn for me to learn to go back to take.You know reasonable bites and tasting my food, and even today, if I’m not paying attention too much, I’ll eat my dinner fast and then I’ll sit there and I’ll be like well.Yes, I’ll taste that a little bit later, because I didn’t taste it when I ate it encourage clients to be aware of their eating habits, and try to avoid setting up a binge by restricting certain foods.Now.Does that mean you have to have cakes and candy and whatever your trigger foods are in your house all the time and in your face? No, I would encourage people not to do that, but to say you know, I said for me M Ms, is one of my favorite reward foods.If you will, I don’t keep them in the house, but I will allow myself occasionally to buy a small snack-size pack of M Ms, when I’m out or I will get a regular-size pack and I’ll share it with my daughter, so I’m not restricting it.I’m not saying I can never M. Ms again, I’m just not making it available to myself when I might have some unrestricted time, try to avoid buying a bunch of comfort foods and keeping them around the house, and when you’ve got kids when you’ve got family, it’s not entirely possible, usually to not have some of that stuff around but try to avoid having the things that you particularly used for comfort, because if it’s not readily available, then you’ve got to focus on guess what dealing with the emotions.Instead of stuffing them with food, try not to go too long without eating.Like I said earlier, if you go too long, then by the time you get to the food, your blood, Sugar,’s low and you’re just shoveling it as fast as you can initially distract.If you know that you’re getting you’re eating and you’re, like I’m – really not hungry, but I want to eat, take a bath, take a walk, call a friend, heaven forbid get on Facebook.Whatever it is, you can do to distract yourself for 10 or 15 minutes if, after 10 or 15 minutes, you’re still going, I want whatever it is, then you can decide what to do about it.Then, most of the time when people stop and go, I’m not hungry.Let me distract myself.They get caught up in that distraction and before they know it, they’ve forgotten about the craving, and identify the emotions.If you know that you’re not hungry, but you want to eat, then say: okay, what’s going on what’s going on with me? It doesn’t mean that the person is never going to eat when, when they’re upset, because a lot of people do, and is it the end of the world, probably not necessary if they can start reducing the frequency of times that they eat.In response to emotional distress that’s, what we want, we want to progress, not perfect if it’s, depression, what’s causing them to feel hopeless or helpless right now, if it’s, stress, anxiety, or anger, remember our big kind of lump together stuff. What are they stressing out about? Do they feel like they’re overwhelmed? Are they afraid of failure, rejection, and loss of control of the unknown? We’ve gone through those things.We want them to identify what’s going on with them, and then they can make better choices about how to deal with it.So general coping helps them develop, alternate ways of coping with distress.Distract we’ve, already kind of gone over that one.I encourage people – and you know it’s – one of those DBT things – that a lot of therapists encourage their clients to keep a list of things.They can do to distract themselves because it’s not always practical to get up and go on a walk.If you’re at work or it’s, you know two in the morning.So what else can you do to distract yourself? Talk it out with a friend with yourself with your dog? Sometimes you just got to get it out.People who are more auditory will prefer talking it out as opposed to journaling it now.If they talk it out with themselves, they can record it if they want to, or sometimes it’s just better to have a dialogue with themself. If it worked for Freud, it can work for other people journaling.If your clients are inclined to journal, encourage them to write it down.Sometimes just getting stuff out of your head and onto paper will help the feelings dissipate a little bit.So you’re not mulling them over and obsessing over them and getting stuck in those thoughts and feelings.Additionally, while you’re distracted talking it out or journaling, this is also your break.Your stop between the urge and the behavior make a pro and con list of the de-stress, not the eating whatever it is, that’s stressing you out and how can you fix it or what are the pros of this situation and what are the downsides To this situation, encourage them to focus on the positive.You know.If something stressing you out at work, you know you’ve got a big meeting coming up or something you don’t want to do or what it is.You can get stuck on focusing on that or you can focus on the positive that you do have a job.That meeting only comes around once a month. You can it’s time you don’t have to be doing paperwork whatever the pros are for that person encourage them to focus on the positive.If you’re distressed because of some kind of a failure or perceived failure, figure out what you learned from it, whether it was a relationship failure, or maybe you learned what not to do in a relationship anymore. Maybe you learned things that you may have ignored.Maybe you learned what you should have done instead, but how can it be a learning opportunity, instead of somewhere to stay stuck and finally, if something’s making you upset if something’s causing anxiety, depression, hopelessness, helplessness, whatever the negative feeling figure out.If it’s worth your energy to get stuck here, is it worth the turmoil? Is it worth you know having to pacify yourself with food or whatever? It is a lot of times people say you know what now it’s, just it’s, not even worth my effort.It’s not worth moving me away from my goals, because my goal is to stop emotional eating.My goal is to eat for hunger, so I can go to dinner with people and feel comfortable.I can be at a party where there’s a buffet and not feel stressed out that I’m going to go and eat half the stuff on the buffet that’s my goal so is holding on to whatever this de-stress is getting me Closer to being able to do those things and generally the answer:’s no develop alternate ways of coping with the stress the ABCs, the a is the activating event.What is stressing you out and what’s causing the de-stress C is the emotional reaction.Angry depressed stressed, whatever be: are your behaviors? What behaviors or B are your beliefs? Sorry, what are the beliefs that are in there that may need to be addressed? What kind of things are you telling yourself, and, and how can you counter them? Cognitively eliminate your vulnerabilities.You knew we couldn’t get through a presentation without talking about vulnerabilities. If someone is well-rested.Well, the fed has a good social support network, not stretch timewise.Then it will be easier to deal with stress or stressors when they come your way.You’ll have more energy to deal with it, so there won’t be this overwhelming feeling of I just want to bury my head in a jar of peanut butter, be compassionate with yourself.Some days, you know you’re, just going to feel anxious.You’re going to feel depressed.You’re going to get angry.You can beat yourself up over it and you know a lot of people do.Is that the best use of your energy or can you be compassionate? Can you learn from it? Can you give yourself a break and go? You know what I’m having a bad day today and that’s okay, I’m not going to unpack and stay here, but I’m not going to fight.It either helps clients learn how to urge surf help. They understand that, just like a panic attack just like a wave just like a lot of other things in life, it will come, it will crest and it will go out again, so they can sort of identify where they are on the energy of that Urge other tools people can use close the kitchen once I have the kitchen cleaned and you know all the dishes are done and it looks pretty.I hate going in there and finding dishes in the sink again now I’ve got teenagers, so we always have dishes in the sink.But before I had children, you know at seven o’clock.I finished all the dishes and closed the kitchen, and that would be enough motivation for me to not go in there and at least not use plates and stuff to eat.So if we’re saying that we’re going to only eat using utensils plates and sitting and all that stuff that we already talked about, then once you close the kitchen, you’re not going back in, there turn off the light.That also helps so you’re not being attracted to the pretty lights, and you know all the goodies that are in the kitchen to brush your teeth.This is something my grandmother used to do and it works.There’s some research behind it.Minty flavors reduce our appetite.So if you brush your teeth, you get all the other flavors out of your mouth and it reduces your urges to eat because it again it’s clean and fresh. And do you really want to brush your teeth again, and meditate, sometimes just getting in a space where you’re, not obsessing about anything, can help people get past that urge to self-soothe by eating a CT for emotional eating.What am I feeling or thinking about what’s going on with me right now? What is important to me? So if I am thinking I want to eat, I want to you know just dive into this jar of peanut butter, and then I think about what’s important to me.Is it important to me to get control of this? Is it important to me to you know, be able to fit into my clothes in six months or not? So what is it in? What way is controlling my eating habits and eliminating emotional eating important to me, and how does that get me closer to other things that are important to me, and what other things could I do? That would get me closer to my goals.So if the goal is to have improved relationships, be able to feel more comfortable around food reduce the stress around going out to eat, and just around food in general, what else can you do when you are stressed out? Somebody also suggested that adding a blue light in the refrigerator decreases the appeal of foods, which is interesting because yellow red and orange, and browns, I think Pizza Hut – are all foods that increase people’s, hunger and desire to eat.But blue is just a completely different primary color, and adding a blue hue seems like that would be effective, so cool thanks for that.Little tidbit there holiday help, and you know we’re coming into the holidays.So I’ve got to bring that up at every single glass and choose lower-calorie foods.If you tend to get stressed out or caught up or mindlessly eat when you are at family gatherings.Okay, you know cut yourself a break, know that that’s, probably going to happen, and fill up on the lower-calorie foods.The carrot sticks the broccoli, the white meat, turkey, anything that’s available, that’s, not like sweet potato pie or brownies, keep water or low-calorie beverage. In your hand, if you’ve got your hand full, you can’t eat at the same time.So you know if you walk around with a cup in your hand, it helps talk to people.Hopefully, you don’t talk with your mouth open or talk with food in your mouth.So if you’re talking to people, you’re not going to be as inclined to go and get something to eat because you’re wanting to stay engaged in that conversation.Stay away from the buffet, especially if you know that it could get stressful, or maybe you know for me, I turn into a pumpkin at like 7 30 at night.I get up at 4 00, but I turn into a pumpkin at 7, 30 and a lot of times holiday parties and those sorts of things are at eight, nine, o’clock at night, and you know I’ve already turned into a pumpkin.So I know that if I go to those I’m going to be more likely to eat just to kind of stay away because I’m tired and it’s a bad habit.It’s not because I’m hungry.So I know I need to stay away from the buffet during those times we rehearse refusal skills.If somebody says. Oh, you, I’ve got to try it by two.This figure out how you’re going to address that ahead of time, because there’s generally probably a lot of really good foods, and you may really want to taste some, but sometimes people who emotionally eat know if they start eating.If they start eating high-fat high calorie foods, they’re going to want to eat everything.So if I start with one bite of a brownie, I’m going to want to eat every suit that’s on the table.If they know that, then they may want to choose to not even go down that road at that juncture, encourage people to stay mindful of their distress meter before they go back for another helping and ask themselves, am I hungry? Am I just wanting to taste what’s here and how do I feel about that? Or am I eating just because I don’t want to be here and I’m bored and I want to fill the time? Have people keep an index card with their coping mantra and two reasons they don’t want to emotionally eat, so I need to be here.I can do this whatever the mantra is that’s going to get them through the night, whatever they’re.Telling themselves that it’s going to help them plow through and make the right choices, but also two reasons that they don’t want to eat, or they’re going to get around it.Maybe they’ve got something at home that they can eat when they get home eating before they go to.The party may also help prevent some grazing holidays, bringing out a lot of emotions in people.Some people struggle with depression, anxiety, jealousy, grief, and anger. You know the whole gamut during this time and during this time there’s food everywhere I mean starting at Halloween when your kids bring home the Halloween candy, which usually lasts about a week in our house baby.Oh, Halloween candy followed by getting ready for Thanksgiving, followed by doing all the baking or whatever you do, and the holiday parties coming up on the December holiday season.There’s just food everywhere, so it’s really easy to cope.If you will, with stress being overwhelmed with being tired by not eating enough healthy food by binging on unhealthy and soothing food if you will so it’s, encouraged it’s important to encourage people to stay.Mindful of why they’re eating what they’re eating, when constantly bombarded with high-fat high carbohydrate foods, people are tempted to eat to feel calm yeah.I challenge anybody to say that they’ve never eaten and go okay.You know I’m.Just focused on this right now I’m not thinking about everything out here and it feels good um.I’m good now, good, probably not the word I should use, but it does help people distract themselves sometimes when they eat, especially those high-intensity foods.You feel happier serotonins are released. Dopamine is released.You’re, like oh, that’s good.I want to do that again or you just feel numb.You can get into a zone where you’re just eating and not caring about it’s.Not that you’re feeling calm, you’re just not feeling anything, and a lot of times when people get into that zone.They’re not tasting the food either.They’re just kind of on autopilot for emotional eating, like most other escape behaviors.Never addresses the underlying emotions and their causes, so we need to look at them.Are you feeling anxious? Are you feeling jittery? Are you feeling depressed because your blood Sugar’s low, because you’re nutritionally deficient because you’re not getting enough sleep or because there’s something cognitive going on, or all of the above emotional eating, often results in physical issues like weight gain Poor sleep and reduced energy weight gain, are you know in and of itself a few pounds here and they’re not a big deal, but some people can start emotionally eating to feel better.They gained a lot of weight. Then they start feeling less energetic.It starts being harder to move around.They get to the point where they are clinically obese.Then they’re going.I’m never going to take all this weight off.They feel hopeless and helpless.You see where this is going, so they eat some more.Can cause poor sleep apnea, it’s hard to get it’s also hard to get comfortable.Sometimes, if you’ve eaten a whole bunch of food right before you go to bed, you know your bellies are all full, and little you wake up.The next morning and your belly are still awful, which means you probably didn’t, sleep very well the night before and emotional eating often results in reduced energy because the foods we binge on the foods we eat for self-soothing often end up causing a sugar Crash some people try to undo emotional eating by restricting other calories which can lead to nutritional deficits and more cravings. I had a girlfriend when I was in high school and you know think back to I don’t know if they still do it, but when we were in high school there was always some kind of candy sale going on and she would always forgo all Other food, so she could have two chocolate bars each day and you know we’re not going to get into the all the other issues surrounding only eating two chocolate bars.But the point I’m making it right now is the fact she wasn’t getting protein.She wasn’t getting it.You know most of her vitamins and minerals and stuff that her body needed to make the neurotransmitter.So she could feel happy and she was contributing to a sugar crash, but I also know that it’s common around the holidays for people to do this.They’ll let go all day without eating because they know they’re going to a party tonight and there’s going to be a lot of really good food doing that once in a while.Not a big deal doing that 10 or 15 times in a month could start to have problems.Emotional eaters need to first find a way to stop before they eat, so, whether it’s writing in a journal or adding.There are a lot of apps on your phone that you can put your food in, even if you’re, not writing about your emotions and your cravings and all that kind of stuff.Sometimes it’s enough to make people stop before they reach. For the food – or you know, kind of an extreme way to go is to not keep pre-processed or prepackaged foods in the house.So anything that you’re going to eat you’ve got to make second identify the underlying reason for your eating figure out.Do I generally eat in response to and then address the thoughts and emotions leading to the urges?So if you figure out the underlying emotions for your eating or your depression, then what thoughts are maintaining that depression? And how can you address it once you address the underlying issues, some of the emotional eating will go away, but some of its habits?We’re going to have to break that habit and, throughout you know, the past couple of decades of working with people.My experience has been the majority of the time people don’t want to hear.Well, once you deal with your emotional issues, the emotional eating will go away now.They’re there because they want to stop that behavior right now.So, yes, we need to work on all the underlying issues but give them a tip or a trick or a tool whatever you want to call it to use before they walk out of your office after every single session.That way, they have something else they can put in their toolbox and feel more empowered to have control over what’s going on with them. And what’s coming their way, having the knowledge of what and why is 80 of helping them get to the recovery point now, if there’s co-occurring or if the eating issues are more than just emotional eating, if there’s, the person meets The criteria for binge eating disorder, bulimia or anorexia.There are a lot of other underlying issues they’re going to have to be dealt with.So I don’t want to trivialize that, but I do want people to feel like they’ve got some hope over what’s going on.Are there any questions? If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube, you can attend and participate in our live webinars with doctor Snipes by subscribing at all CEUs comm slash counselor toolbox.This episode has been brought to you in part by all CEUs com providing 24 7 multimedia, continuing education, and pre-certification; training to counselors therapists, and nurses, since 2006 use coupon code consular toolbox to get a 20 discount off your order.This month,As found on YouTubeAnimated Video Maker – Create Amazing Explainer Videos | VidToon™ #1 Top Video Animation Software To Make Explainer, Marketing, Animated Videos Online It’s EASIER, PRODUCTIVE, FASTER Get Commercial Rights INCLUDED when you act NOW Get Vidtoon™

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

this episode was pre-recorded as part of a live continuing   education webinar on-demand CEUs are still available for this presentation   through all CEUs register at allceus.com/counselortoolbox hi everybody and welcome to today’s presentation on emotional eating making peace with food during   the next hour so we’re going to define emotional eating and differentiate it really from eating   when to celebrate and when it’s a problem and also differentiate differentiating it from   eating disorders will explore emotional eating in terms of its beneficial functions and rewards and   discuss why restrictive diets don’t resolve emotional eating a lot of times people will   say you know I have been on this diet forever and it doesn’t seem to be working or I can’t seem   to stick to any diet that I try and we’re going to look at different reasons why this might be   what is emotional eating and it’s exactly what it sounds like it’s eating in response to emotions   and feelings other than hunger so if you’re eating because you’re bored if you’re eating at someone   and sometimes, especially if you are angry at someone or disappointed in someone you may   eat and sort of be eating and thinking you made I do this so eating at someone eating to forget   or distract myself from eating to feel better because when you eat regardless of what you’re eating but   especially if you eat high-sugar high-fat foods you’re going to release serotonin and dopamine   eating out of boredom you know hand-to-mouth bang eating out of habit and like I said a few minutes   ago not all emotional eaters have an eating disorder um and we want to differentiate that it means that their eating is not problematic to them no not at all if they’re telling you   it’s a problem then it’s a problem they may not meet the criteria for binge eating disorder or   bulimia but it’s important to address it because they understand that they’re eating for a reason   other than hunger and they want to stop because they want to eat for hunger but not otherwise and   for us as clinicians the first thing we need to do is understand why is it that they’re eating is   it boredom is it a habit so they need to keep a food log or a food journal over a week or   two weeks and sometimes when people come in for an assessment especially if that’s one of their main   presenting issues I’ll start just doing a retrospective of the last three days to get   an idea of what may be triggering some of their eating episodes and then we can look at some of   the habits or bad habits may be that they’ve gotten into and start talking about ways to address those remember that Rome wasn’t built in a day this isn’t going to go away overnight but a lot   of times if you give people some tips tricks and tools to think about implementing when they walk   out of your office after the assessment before the first official session it provides them some hope   and gets the momentum going and again you don’t have to binge to be an emotional eater some people   graze all day long some people will eat and it’s not what would be considered technically a binge   but it’s more than they had anticipated maybe they go back for second helpings or third helpings when   they weren’t hungry but it was good so why is eating so soothing there are a lot of reasons   now there’s obvious it tastes good so that’s you know the big obvious bonus but thinking about   the function the eating serves we have to eat in order to survive when you were an infant it eating   involved a closeness with your parental unit which could release oxytocin I say parental   unit because even if it was dad feeding the baby a bottle there was that connection there was that   contact which caused the infant and the parent to release oxytocin this is our bonding chemical so   eating was associated early on with bonding food may also have been associated with sleep if the   infant or child was given a bottle every night to go to sleep then they may start thinking or they   may be in the habit of eating to wind down or calm down and we need to help them figure   out different ways to do that as a toddler what an eating means to think about when you went from well we   probably don’t remember that but think about when your kids went from eating you know food   out of a jar to even their first Cheerios that was huge figuring out how to pick up that little   cheerio and get it in their mouth and it involved exploration and mastery they were discovering   all different types of textures and tastes and figuring out what smell went with what taste and   it was a cool and exciting time for kids and I mean think about it they’re like a year old   so it doesn’t take much to amuse them but this was the rewarding reward equals dopamine equals let’s do   that again it involved power and control of the child at this point was starting to be able to feed him   or herself was starting to be able to be somewhat independent from the parent when it came to the basic physiological function of eating so eating itself had its rewards and it was self-esteem   building because the child started learning you know how to feed himself and how to ask for what   he or she wanted at least in terms of food there are formations of memories around foods even as   early as toddlerhood you know we have celebrations we have birthdays we have different things and most   children have certain foods that they really like and it could be because the first time   that ate that food was a really happy experience or it could be just that’s their favorite food   and that’s all they want to eat but they remember that food and they remember when they ate it they   felt good they felt happy so as an adult there’s a part of their brain going chicken nuggets make me happy now that’s how the toddler thought as an adult we can understand that chicken   nuggets themselves aren’t making you happy but you see the connections that we’re making here there’s   been an association between happiness and chicken nuggets unhealthy foods especially for children   when as adults we’re still able to control what they eat your sugary foods your unhealthy foods   are usually reserved for treats or rewards so when you’re feeling like you need to be rewarded   when you’re feeling like you want to feel good sometimes you’ll resort to those things when you   were a kid that made you feel good like chocolate chip cookies or Haagen-Dazs or whatever it was for   you we’ve talked in the past about associations and conditioning and this is all coming back kind   of full circle now because we need to understand that our brain has associated pleasure and reward   with food for a lot of different reasons not just because of nourishment looking at the reasons why   your patient eats is going to help you understand what underlying issues you may need to address in treatment culturally we associate eating with caring and celebrating think about birthdays and holidays what do we do we get together we have buffets we have pot Luck’s when someone passes   away what do you do you bring food over when somebody’s sick what do you bring food   over so in our culture there is a lot of emphases put on eating and nourishing and that’s true of a   lot of different cultures with low blood sugar can cause feelings of depression and anxiety which   are quelled by food so if somebody typically doesn’t eat well during the day you know they   go long periods without eating or if they have blood sugar issues to begin with and then they   eat they feel better so when they start feeling not so good what do you think their first reaction   is let me eat and see if that helps evolution predisposes the human body to crave high sugar high-fat high calorie foods for quick energy and to prepare for a famine our bodies are cool   and frustrated at the same time because you know your body takes in these foods and   it says we’re gonna secrete the most amount of dopamine and the most amount of reward for these high-calorie foods because we want to make sure we’re prepared in case there’s a famine back   you know in the day many many many years ago hundreds of years ago we couldn’t guarantee we   would have a meal every day let alone three meals every day so the body prepared and it   said alright we need to get whatever we can when we can so we’re going to make this a higher fat   higher calorie food more rewarding now I said it’s also can be a blessing and a curse today   there’s still a little part of our primordial a brain that says if it thinks there’s a famine   it will slow down your base metabolic rate which causes people to gain weight we see this a lot   in people with eating disorders who tend to not take in very many calories or if they take them   in they purge them so the body goes well I can’t guarantee I’m gonna get enough food I’m gonna get   enough energy to survive so I’m just gonna turn down the thermostat a little bit to turn down the   base metabolic rate which compounds the problem for the person with an eating disorder so it’s   important to understand that the brain is somewhat active to what’s going on so I keep saying we   need to figure out what’s behind or underlying the craving first we need to rule out physical   causes for some people it’s as simple as this if they’ve got low blood sugar because they’re not   eating too often and obviously as counselors we’re not going to diagnose this their doctor or their   nutritionist will but we can start exploring and go it sounds like you might need to look at having   your blood sugar checked or talk to your doctor about how frequently you need to eat because some   people and I know I’m very guilty of it if I get into it into a groove doing something I’ll   eat breakfast and then I’ll get into a groove and before I know it it’s 3:00 in the afternoon and I   haven’t eaten for like a whole bunch of hours I’m not doing math today and my blood Sugar’s low and   I’m starting to get foggy-headed and irritable and tired so it’s a real simple fix there in   our society we are so driven and we are so we get so caught up in things because that’s such a fast   pace that it’s easy to forget to eat or easy to avoid eating so that’s the first thing we want to   rule out are you eating in response to low blood sugar which is making eating seem more rewarding   and when you eat in response to low blood sugar a lot of times people who do that end up eating   more than they normally would because they start eating fast it’s like I’m gonna shovel in   as much as I can your brain doesn’t register you’re eating for 20 minutes or so so before your brain even registers what’s gone on and gets the blood sugar back up they’ve already eaten a   whole ton of food why is this under emotional eating well because generally when they go in   to just start eating yes they’re hungry but they’re also cranky and irritable and most   of the time they’re not thinking about what I’m eating for the nourishment it’s I’m eating feel better after lack   of sleep and this is so true for shift workers as well as you know new parents and college students   and anybody who’s not getting enough sleep if we are surviving on sugar and stimulants we’re going   Peak and Lower Valley Peak and Lower Valley and you just keep going up and down until you just   crash because every time you crash you crash a a little bit lower so if somebody’s on that roller   coaster they’re going to feel worse between you know eating episodes they’re going to feel tired   they’re going to feel a flood of sluggish irritable fatigued and to a certain extent maybe depressed   and they may be missing attributing those feeling those emotional feelings to emotions versus   physical causes and likewise we also want to make sure that you know we’re addressing the emotional   causes because there’s probably stuff there too but if they’re not getting enough sleep   and they’re living on sugar and stimulants their the body is kind of in a state of hyper-vigilance a   lot of times it’s exhausted so they’re going to be tired and cranky so those are a couple of things that we want to look at those are relatively easy fixes or at least relatively easy   things to point out and go let’s think about this one of the things that I suggest for a lot of my   clients is just to take a week and mindfully and it is difficult but try to eat healthfully you know   try to eat a few times a day you know try to eat like three meals a day and getting enough water and trying to get enough sleep and try not to overdo it on the stimulants at the beginning I’m not   going to say cut out anything because that’s not realistic and it’s not fair and they’re probably   already struggling if they’re coming in to see me so if I go hey let’s just turn your world upside   down and guess what you’re not going to drink any caffeine anymore it’s not going to create a happy   person so I asked them to try to make some small changes and see if that starts to help dehydration   causes fogginess and symptoms of depression we want to make sure that they rule that out and   too many stimulants also causes dehydration so you know we’re looking at some of the physical causes   of irritability and fatigue and cravings because again we’re going back to when I felt this way   before not looking at why I felt this way but when I felt irritable depressed cranky what has made me   feel better and generally food and generally it’s not good food for me it’s M&Ms I love my M&Ms, especially the ones with almonds but I digress nutritional causes of cravings high carbohydrate   and high starch foods caused a greater release of serotonin and endorphins so if you’ve got   somebody who’s depressed for whatever reason that they may crave these kinds of foods to increase their serotonin level or increase the endorphins in their energy levels chocolate people   who crave chocolate may be low in magnesium it also um the level of magnesium affects how   much serotonin is available again just keep saying this just for legal reasons we want to   make sure their doctor or nutritionist goes in and makes this diagnosis but if there are particular   foods that they do crave it’s important for them to bring that up with their medical provider if   they’re craving fatty foods now again fatty foods are just good I love fried foods but it also could   mean that they’re not getting enough Omega threes Americans typically don’t and interestingly if   they crave soda they may be calcium deficient who knew so these are things to take a look   at to ask people you know if they’re craving soda maybe cutting back on their soda a little bit and   see what happens and or getting blood work done once we’ve ruled out the obvious physical causes   they’ve gone to the doctor gotten blood work done everything I’m comes back happy they’re getting   enough sleep but they’re still eating when they’re not hungry we need to rule out habits is there a   particular time or activity that makes you crave this food when I was growing up I would go to the   grocery store with my mother and on the way back home from the grocery store she would always we   would always get junk food and she would get a bag of chips and put them in the front seat it   was like a 20-minute drive from the grocery store to our house and by the time we would get back to   the house we would have put a good dent in those potato chips that being said I got into the habit   of whenever I went to the grocery store I would get something out of the bag and put it in the   front seat and eat on the way home now am I paying attention to what I’m eating no likely am I eating   because I was hungry probably not so we want to look at habits a lot of people will eat when   they are watching TV it’s a huge one so we want to not do that or if you’re going to eat when   you’re watching TV make sure you sit at the table at least that makes you a little bit more mindful so think about their particular times or activities that you eat and you’re just not   hungry are their particular times that you mindlessly eat like like I said when you’re   driving or when you’re watching television those are both habits and can be mindless because you’re   not paying attention to how much is going on in your the mouth you’re not probably paying attention to the   taste and you’re not paying attention to whether you’re full or not so if you’re mindlessly eating   then there’s going to be a lot more calorie consumption in addition to the fact that you’re   not eating because you’re hungry you’re just eating to eat are you going too long between   meals than needing a sugar boost which leads to a sugar crash so again that’s a physical cause but   we want to rule out these bad habits that we can tend to get into other things that can   be construed as bad habits are eating without putting food on a plate if you eat straight   out of the bag you’re gonna eat more than if you put it on a plate so put it on a plate sit   down try not to watch TV all the things that your grandmother would have told you so what do we do   about it emotional eating interventions I talked earlier about the food diary do a retrospective   during the assessment if they want to get a jumpstart on things but have them keep a food   diary preferably for the duration of treatment but at least for a week what time did they eat   were they craving just any old food or something that was salty sweet sour this will give you a general idea and can give their medical provider a general   idea if there are any nutritional imbalances or if there are particular associations with what emotion or   state were you in and I say state because being exhausted is not necessarily really an emotion where you are happy sad mad glad exhausted drained whatever state feels like it would work and   then because of why were you feeling this way it doesn’t have to be a dissertation it can be short and sweet but I encourage clients to write down everything they eat before they   eat it during the first week or you know like I said preferably throughout the entire course of   treatment why before they eat it because it’s a stop remembering we’ve talked before about how we   have an urge we have a craving we have an urge and then we engage in the behavior oftentimes without   stopping to mindfully think is this what we want to do this provides that stop it says okay I’ve   got it to write down the time and then I’ve got to think about why I’m eating and honestly, a lot of   clients notice a reduction and their habit of eating when they have to do this just because they don’t   want to record-keeping that up for the period of a a month or two months helps break some of the habits eating that they might do like I said before when they’re eating I encourage them to use a plate sit   down don’t walk around don’t stand at the counter eliminate distractions as much as possible and   focus on the food you’re eating that goes with mindfully eating what does it taste like is it   good take small bites when my son was young and I think I’ve shared this before he had gastric   reflux and we would sit down at the table and I would shovel in food as fast as I could get   it in my mouth because he couldn’t be put down for too long before he would start to get fussy   at least until we figured out that he had gastric reflux and Zantac was just a lifesaver I developed   that habit when he was little and I kept it up for a while, it took a while to learn for me to   learn to go back to take you to know reasonable bites and tasting my food and even today if I’m   not paying attention too much I’ll eat my dinner rest and then I’ll sit there and I’ll be   like well yes I’ll taste that a little bit later because I didn’t taste it when I ate it encouraging   clients to be aware of their eating habits and try to avoid setting up a binge by restricting certain   foods now does that mean you have to have cakes and candy and whatever your trigger foods are   in your house all the time and in your face no I would encourage people not to do that but to say   you know I said for me M&Ms is one of my favorites reward foods if you will I don’t keep them in the   house but I will allow myself occasionally to buy a small snack-size pack of M&Ms when I’m out or   I will get a regular-size pack and I’ll share it with my daughter so I’m not restricting it   I’m not saying I can never M&Ms again I’m just not making it available to myself when I might   have some unrestricted time to try to avoid buying a bunch of comfort foods and keeping them around   the house and when you’ve got kids when you’ve got family, it’s not entirely possible usually to not   have some of that stuff around but try to avoid having the things that you particularly used for   comfort because if it’s not readily available then you’ve got to focus on guess what dealing   with the emotions instead of stuffing them with food try not to go too long without eating as I said earlier if you go too long then by the the time you get to the food your blood Sugar’s low   and you’re just shoveling it as fast as you can initially distract if you know that you’re   getting you’re eating and you’re like I’m really not hungry but I want to eat take a bath take a   walk call a friend heaven forbid get on Facebook whatever it is you can do to distract yourself   for 10 or 15 minutes if after 10 or 15 minutes you’re still going I rant whatever it is   then you can decide what to do about it then most of the time when people stop and go I’m not hungry let me distract myself they get caught up in that distraction and before they know   it they’ve forgotten about the craving to identify the emotions if you know that you’re not hungry   but you want to eat then say okay what’s going on what’s going on with me it doesn’t mean that   the person is never going to eat when they’re upset because a lot of people do and is it the end   of the world probably not necessary if they can start reducing the frequency of times that they   eat in response to emotional distress that’s what we want to progress, not perfect if it’s   depression that’s causing them to feel hopeless or helpless right now if it’s stress anxiety   or anger remember our big kind of lump together stuff what are they stressing out about do they   feel like they’re overwhelmed are they afraid of failure rejection loss of control of the unknown   we’ve gone through those things we want them to identify what’s going on with them and then they   can make better choices about how to deal with it so general coping helps them develop alternate ways   of coping with distress distract we’ve already kind of go over that one I encourage people   and you know it’s one of those DBT things that a lot of therapists encourage their clients to   keep a list of things they can do to distract themselves because it’s not always practical to   get up and go on a walk if you’re at work or it’s you know two in the morning so what else can you   do to distract yourself talk it out with a friend with yourself with your dog sometimes you just got   to get it out people who are more auditory will prefer talking it out as opposed to journaling   it now if they talk it out with themselves they can record it if they want to or sometimes it’s   just better to have a dialogue with themself if it worked for Freud it can work for other people journaling if your clients are inclined to journal encourage them to write it down sometimes just   getting stuff out of their head and onto paper will help the feelings dissipate a little bit   so you’re not mulling them over and obsessing on them and getting stuck in those thoughts and   feelings additionally while you’re distracting talking it out or journaling is also your   break stop between the urge and the behavior make a pro and con list of the de-stress, not the   eating whatever it is that’s stressing you out and how can you fix it or what are the pros of   this situation and what are the downsides to this situation encourages them to focus on the   positive you know if something stressing you out at work you know you’ve got a big meeting   coming up or something you don’t want to do or what it is you can get stuck on focusing   on that or you can focus on the positive that you do have a job that meeting only comes around once   a month you can it’s time you don’t have to be doing paperwork whatever the pros are for that   person encourage them to focus on the positive if you’re distressed because of some kind of a   failure or perceived failure figure out what you learned from it whether it was a relationship   failure maybe you learned what not to do in a relationship anymore maybe you learned things   that you may have ignored maybe you learned what you should have done instead but how can it be a   learning opportunity instead of somewhere to stay stuck and finally if something’s making you upset if something’s causing anxiety depression hopelessness helplessness whatever the negative   feeling figure out if it’s worth your energy to get stuck here is it worth the turmoil is   it worth you know having to pacify yourself with food whatever it is a lot of times people say you   know what now it’s just it’s not even worth my effort is not worth moving me away from   my goals because my goal is to stop emotional eating my goal is to eat for hunger so I can   go to dinner with people and feel comfortable I can be at a party where there’s a buffet and   not feel stressed out that I’m gonna go and eat half the stuff on the buffet that’s my goal so is   holding on to whatever this de-stress is getting me closer to being able to do those things and   generally, the answer’s no develop alternate ways of coping with the stress the ABCs the a is the   activating event that is stressing you out what’s causing the de-stress C is the emotional reaction   angry depressed stressed whatever we are your behaviors what behaviors or B are your beliefs   sorry what are the beliefs that are in there that may need to be addressed what kind of things are   you telling yourself and how can you counter them cognitively eliminate your vulnerabilities   you knew we couldn’t get through a presentation without talking about vulnerabilities if someone   is well-rested well-fed has a good social support the network does not overstretch timewise then it will be   easier to deal with stress or stressors when they come your way you’ll have more energy to deal with   it so there won’t be this overwhelming feeling of I just want to bury my head in a jar of peanut   butter be compassionate with yourself some days are you know you’re just gonna feel anxious you’re   gonna feel depressed you’re gonna get angry you can beat yourself up over it and you know a lot   of people do is that the best use of your energy or can you be compassionate can you learn from it   can you give yourself a break and go you know what I’m having a bad day today and that’s okay I’m not   gonna unpack and stay here but I’m not gonna fight it either help clients learn how to urge   surf helps them understand that just like a panic the attack is just like a wave just like a lot of other   things in life it will come it will crest and it will go out again so they can sort of identify   where they are on the energy of that urge Panic-loop-3 other tools people can use close the kitchen once   I have the kitchen cleaned and you know all the dishes are done and it looks pretty I hate going   in there and finding dishes in the sink again now I’ve got teenagers so we always have dishes in   the sink but before I had children you know at seven o’clock I finished all the dishes and closed   the kitchen and that would be enough motivation for me to not go in there and at least not use   plates and stuff to eat so if we’re saying that we’re going to only eat using utensils plates and   sitting and all that stuff that we already talked about then once you close the kitchen you’re not   going back in there turn off the light that also helps so you’re not being attracted to the pretty lights and you know all the goodies that are in the kitchen brush   your teeth this is something my grandmother used to do and it works there’s some research   behind it minty flavors reduce our appetite so if you brush your teeth you get all the other   flavors out of your mouth and it reduces your urges to eat because it again it’s clean and   fresh and do you want to brush your teeth again meditate sometimes just getting in a space   where you’re not obsessing about anything can help people get past that urge to self-soothe   with eating a CT for emotional eating what am I feeling or thinking about what’s going on with me right   now and what is important to me so if I am thinking I want to eat I want to you know just dive into   this jar of peanut butter and then I think about what’s important to me is it important to me to   get control of this is it important to me to you know to be able to fit in my clothes in six months or   not so what is in what way is controlling my eating habits and eliminating emotional   eating important to me and how does that get me closer to other things that are important to   me and what other things could I do that would get me closer to my goals so if the goal is to   have improved relationships and be able to feel more Being comfortable around food reduces the stress around   going out to eat and just around food in general what else can you do when you are stressed out somebody also suggested adding a blue light in the refrigerator decreases the appeal of foods   which is interesting because yellow red and orange and browns I think Pizza Hut are all foods   that increase people’s hunger and desire to eat but blue is just a completely different   primary color and adding a blue hue seems like that would be effective so cool   thanks for that little tidbit their holiday help and you know we’re coming into the holidays so   I’ve got to bring that up at every single glass choose lower-calorie foods if you tend to get   stressed out or caught up or mindlessly eat when you are at family gatherings, okay you know cut   yourself a break know that that’s probably gonna happen to fill up on the lower calorie foods the   carrot sticks broccoli the white meat turkey anything available that’s not like sweet   potato pie or brownies keeps water or low calorie beverage in your hand if you’ve got your hand full   you can’t eat at the same time so you know if you walk around with a cup in your hand it helps   talk to people hopefully you don’t talk with your mouth open or talk with food in your mouth so if   you’re talking to people you’re not going to be as inclined to go get something to eat because you’re   wanting to stay engaged in that conversation stay away from the buffet especially if you know that   it could get stressful or maybe you know for me I turn into a pumpkin at like 7:30 at night I get up   at 4:00 but I turn into a pumpkin at 7:30 and a a lot of times holiday parties and those sorts of   things are at eight nine o’clock at night and you know I’ve already turned into a pumpkin so   I know that if I go to those I’m gonna be more likely to eat just to kind of stay away because   I’m tired and it’s a bad habit it’s not because I’m hungry so I know I need to stay away from   the buffet during those times we rehearse refusal skills if somebody says oh you’ve got to try it by   two this figure out how you’re going to address that ahead of time because there’s generally   probably a lot of really good foods and you may want to taste some but sometimes people who   emotionally eat know if they start eating if they start eating high-fat high calorie foods they’re   gonna want to eat everything so if I start with one bite of a brownie I’m gonna want to eat every   suite that’s on the table if they know that then they may want to choose to not even go down that   road at that juncture and encourage people to stay mindful of their distress meter before they go   back for another helping and ask themselves am i hungry am I just wanting to taste what’s here   and how do I feel about that or am I eating just because I don’t want to be here and I’m   bored and I want to fill the time have people keep an index card with their coping mantra   and two reasons they don’t want to emotionally eat so I need to be here I can do this whatever   the mantra is that’s gonna get them through the night whatever they’re telling themselves that   it’s gonna help them plow through and make the right choices but also two reasons that they   don’t want to eat or they’re going to get around maybe they’ve got something at home that they   can eat when they get home eating before they go to the party may also help prevent some grazing   holidays bring out a lot of emotions in people some people struggle with depression anxiety   jealousy grief anger you know the whole gamut during this time and during this time there’s   food everywhere I mean starting at Halloween when your kids bring home the Halloween candy which   usually lasts about a week in our house baby Oh Halloween candy followed by getting ready   for Thanksgiving followed by doing all the baking or whatever you do and the holiday parties coming   up on the December holiday season there’s just food everywhere so it’s really easy to cope if you   will with stress being overwhelmed by being tired by not eating enough healthy food by binging   on unhealthy and soothing food if you will so it’s encouraged it’s important to encourage people to   stay mindful of why they’re eating what they’re eating when constantly bombarded with high-fat high carbohydrate foods people are tempted to eat to feel calm yeah I challenge anybody to say that   they’ve never eaten and go okay you know I’m just focused on this right now I’m not thinking about   everything out here and it feels good um I’m good now goods are probably not the word I should use but   it does help people distract themselves sometimes when you eat especially those high-intensity foods   you feel happier serotonins release dopamine is released you’re like oh that’s good   I want to do that again or you just feel numb you can get into a zone where you’re just eating and   not caring it’s not that you’re feeling calm you’re just not feeling anything and a lot   of times when people get into that zone they’re not tasting the food either they’re just kind of on an autopilot emotional eating like most other escape behaviors never address the underlying   emotions and their causes so we need to look at it are you feeling anxious are you feeling   jittery are you feeling depressed because your blood Sugar’s low because you’re nutritionally   deficient because you’re not getting enough sleep or because there’s something cognitive going on or   all of the above emotional eating often results in physical issues like weight gain poor sleep   and reduced energy weight gain is you know in and of itself, a few pounds here and they’re not a big   deal but some people can start emotionally eating to feel better they gained a lot of weight then   they start feeling less energetic it starts being harder to move around they get to the point where   they are clinically obese then they’re going I’m never going to take all this weight off they feel   hopeless and helpless you see where this is going so they eat some more can cause poor sleep apnea it’s hard to get it’s also hard to get comfortable sometimes if you’ve eaten a whole   bunch of food right before you go to bed you know your bellies all full and little you wake up the   next morning and your belly still awful which means you probably didn’t sleep very well the   night before and emotional eating often results in reduced energy because the foods we binge on   the foods we eat for self-soothing often end up causing a sugar crash some people try to undo   emotional eating by restricting other calories which can lead to nutritional deficits and more   cravings I had a girlfriend when I was in high school and you know think back to I don’t know if   they still do it but when we were in high school there was always some kind of candy sale going on   and she would always forgo all other food so she could have two chocolate bars each day and you   know we’re not going to get into the all the other issues surrounding only eating two chocolate bars   but the point I’m making it right now is the fact she wasn’t getting protein she wasn’t getting you to know most of her vitamins and minerals and stuff that her body needed to make the neurotransmitter   so she could feel happy and she was contributing to a sugar crash but I also know that it’s common   around the holidays for people to do this they’ll let go all day without eating because they know   they’re going to a party tonight and there’s going to be a lot of really good food doing that once in   a while is not a big deal doing that 10 or 15 times in a month could start to have problems emotional   eaters need to first find a way to stop before they eat so whether it’s writing in a journal   or adding there are a lot of apps on your phone that you can put your food in even if you’re   not writing about your emotions and your cravings and all that kind of stuff sometimes it’s enough   to make people stop before they each for the food or you know kind of an extreme way   to go is to not keep pre-processed or prepackaged foods in the house so anything that you’re going   to eat you’ve got to make a second identity the underlying reason for your eating figure   out do I generally eat in response to and then address the thoughts and emotions leading to the   urges so if you figure out that the underlying emotions for your eating or your depression then   what thoughts are maintaining that depression and how can you address it once you address the   underlying issues of some of the emotional eating will go away some of its habits we’re going to   have to break that habits and over the course of you know past couple of decades of working with   people my experience has been the majority of the time people don’t want to hear well once you deal   with your emotional issues the emotional eating will go away now they’re there because they want   to stop that behavior right now so yes we need to work on all the underlying issues but give them   a tip or a trick or a tool whatever you want to call it to use before they walk out of your office   after every single session that way they have something else they can put in their toolbox and   feel more empowered to have control over what’s going on with them and what’s coming their way knowing what and why is 80% of helping them get to the recovery   point now if there’s co-occurring or if the eating issues are more than just emotional   eating if there’s the person meets the criteria for binge eating disorder bulimia   or anorexia there are a lot of other underlying issues they’re gonna   have to be dealt with so I don’t want to trivialize that but I do want people   to feel like they’ve got some hope over what’s going on are there any questions if you enjoy this podcast please like and subscribe either in your podcast player or   on YouTube you can attend and participate in our live webinars with doctor Snipes by   subscribing at all CEUs comm slash counselor toolbox this episode has   been brought to you in part by all CEUs com providing 24/7 multimedia continuing   education and pre-certification training to counselors therapists and nurses since 2006 used coupon code consular toolbox to get a 20% discount on your order this monthAs found on YouTubeHuman Synthesys Studio It’s Never Been Easier To Create Human Spokesperson Videos. 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Documentation Review Addiction Counselor Exam


Welcome to the Addiction Counselor Exam Review. This presentation is part of the Addiction Counselor certification training. Go to http://www.ALLCEUs.com/certificate-tracks to learn more about our specialty certificates starting at 149 dollars Hi everybody and welcome to this presentation of Documentation Principles and what you're supposed to do in documentation. Over the course of the next hour or a little bit more yeah buckle in guys it's going to be a while we're going to discuss the elements of good documentation we're going to talk about different types of documentation that you need to know how to do this is not a instructional manual or presentation on how to write good treatment plans or good progress notes this is really hitting the highlights so if you hit or you get to a place where you hear about a type of documentation you don't feel comfortable with especially treatment planning from what I've been told on the current certification exams treatment planning plays a big role so you want to make sure that you know how to identify effective interventions but that's a different class today we're just going to hit the highlights of what you need to know about documentation so documenting the treatment process the client record is the most important tool to ensure continuity of care that's going to help every person on the treatment team collaborate and coordinate that's going to help you track progress remember what you did last week and what you're doing in the future you know what your goals are it's going to help the client visualize what's going to happen so documentation is really important and remember if it doesn't get documented it didn't happen and that's true in terms of billable services you know don't not document something because you make a mistake because that'll still come back to bite you but in terms of reimbursement and you know showing that you did what any good therapist would do in order to prevent liability document document document it's your best friend there are ways to shorten documentation there are a lot of times that you can use check sheets and things create check sheets in private practice to make it a little bit easier for yourself but it is important to have that documentation documentation contributes to service delivery by reducing the replication of services so if I look and I see that jimbob's already been referred to a psychiatrist well then I don't need to make a referral for Jim Bob to a psychiatrist if I look and I see that he's already interacting with workforce development services then I don't need to refer him there because it's already been done so it saves some effort on everybody's part it presents a cohesive longitudinal record of clinically meaningful information which is gibberish for saying you can see the clients progress you can see what's worked you can see what hasn't worked you can see incremental changes and more importantly sometimes the client can see incremental changes so they can look back you know six weeks and at what you were talking about back then and how they were presenting and how they were feeling and then look at today and you can compare and contrast so they can see that yeah everything may not be coming up roses but there has been a significant improvement documentation helps ensure reimbursement for services you don't ever want to say is going to ensure because the people who are reimbursing have the right to not reimburse you know they can deny claims so but you know you're not going to get paid if you don't document so you have to document in order to have any hope of reimbursement and good documentation will reduce the number of denials that you get and it assists in guarding against malpractice because you're documenting what was done by whom and if they were adequately credentialed you know if you're referring somebody for a nutritional assessment to a dietitian a registered dietitian you're going to note that in the record if you are providing nutritional assessment and information yourself you're probably not a registered dietitian which means you're not adequately credentialed so you know you could see the difference but you're showing that you're referring to other professionals and you're taking adequate precautions in the event that somebody's in crisis or you know needs some other sorts of assistance clinical documentation records professional services you do an intake we all know what intakes are differential diagnosis it shows how you arrived at your conclusion that this person has substance induced depression or or whatever you're going to show how you ruled out some of the medical conditions you're going to show how you ruled out underlying mental health pathology placement criteria are used in decision making so you have the a Sam generally sometimes it's the locus and you can use that to show you know the powers-that-be if anybody ever comes and look at looks at the record why you made the recommendation for residential or outpatient or or whatever recommendation you made you can show your clinical justification by the patient placement criteria which is really awesome now sometimes the client is gonna say no you know you're recommending residential but I'm not willing to do that and you're gonna document that in the chart what your recommendation is and what the client chooses to do because they do have the ability to choose but again you know you're showing that you made a good honest effort to put them in what appears to be the best placement it documents treatment and other services provided so we can see what's going on if I'm looking at a record and of somebody and I'm hearing that they're on medications but I have no record of any sort of a doctor and you know I've read assessments before and it just drives me batty where they talk about a client being on antidepressants for example but then the client never gets any sort of mental health diagnosis and I'm like well what are they on the meds for if the doc is prescribing meds the doc clearly thinks that they have some sort of mental health issue so you want to identify what's going on what services you're providing what refer you're making the response to any interventions think about it this way you know if that client comes back for another episode of care and we know in recovery oriented systems of care that treatment is episodic and you may not be there the next time JimBob comes back but the next therapist can go back and review the record and figure out what's worked what didn't where the kind of where you left off and build upon that instead of having to recreate the wheel which saves a lot of frustration a lot of time and it enhances client engagement if they feel like they can go in and kind of hit the ground running instead of having to you know start back at square one it identifies referral services and the outcome not all referrals are going to go swimmingly but generally they do and you want a document that you're attending to the clients biopsychosocial needs if they need housing you're referring to the appropriate agency that can help them get housing if they need you know food stamps you're referring to the appropriate agency where they can get that there's a little bit of case management sort of stuff going on here because a lot of times you don't have a case manager but it's important because a client who is homeless hungry in pain and sick is not going to do really well on dealing with their depression or their self-esteem because they're not getting their basic needs met so you want to show that you're you know taking everything into account it shows the clinical course the record can help you identify and look back retrospectively and see you know what things may trigger an episode what things may trigger a relapse what things tend to mitigate it and help it you know not become so severe what sorts of interventions worked and looking at the course you can see when it started and whether it's continuing to get worse or whether it's starting to get a little bit better and instead of having long relapse periods you have shorter episodes maybe of lapses and it shows reassessment and treatment plan reviews people change you know as they get better that's awesome they're changing and the treatment plan will need to be updated to reflect their current needs and wants we want to do reassessments at least every 90 days but preferably every 30 days a lot of insurance companies and if you look at the level of care guidelines it's really important because they can deny payment if you're not doing a treatment plan review every single week for people who are in intensive outpatient partial hospitalization or residential that's not true of every insurance provider but it is true of a lot of them so you need to know how frequently you need to do these things in order to prevent denial of payment records compliance with state accreditation and payer requirements so you know clinical documentation helps you you know document exactly what's going on in Florida for example the state tells you certain services that have to be provided at the IOP level and at the residential level and you need to be able to document that if you're getting state funding you need to be able to document certain things if you're accredited by Jayco are you're gonna have to be able to show in the record that your treatment is you know in line with their guidelines you know they're going to look around at what's going on now but they also want to look at the charts to see you know how you actually follow through an entire course of care and it helps you maintain payer compliance I can't state this enough and we are in it to help people don't get me wrong and I hate to harp on dumb reimbursement however if you don't get reimbursed you don't keep your doors open so it's important to know what each payor requires in terms of you know how quickly does the intake need to be done how quickly does the treatment plan need to be done some payers say three days some payers say a week how frequently does the treatment plan need to be updated does the person have to see a psychiatrist within a certain period of time for your high levels of care the answer is yes so all this stuff is in what's called the level of care guidelines and each independent insurance provider has their own level of care guidelines so my recommendation and what I do in my practice is identify all of the providers that I accept and then I take the most stringent requirements for everything from all the different providers so I'm going above and beyond for some but I'm at least meaning every single providers minimum requirements and it takes a little while to do the crosswalk but it is well worth it because it helps you have a clinical record that applies whether it's Blue Cross and Blue Shield or Aetna or United or you know whomever documentation eases the transition to other programs and to referral sources if you call up a referral source and say you know maybe you're working with a client who has trauma issues and you're referring to an EMDR therapist and you call them up and say hey I got this person coming over and who's gonna need EMDR services sending them your way well that doesn't give them anything to work on so instead of again having them rip open that wound and go through you know a bunch of stuff that they've already talked about with you that was painful and distressing the clinical record can help ease that transition so the receiving therapist the EMDR therapist can review it and kind of know what they're dealing with and then start a little bit ahead of the game and it prevents duplication of information gathering when possible you know everybody seems to have to get demographic information well if there's a centralized clinical record that has the demographic information then everybody can add to that instead of having to get the same demographic information from clients every single time it facilitates quality assurance it documents the appropriateness clinical necessity and effectiveness of treatment when you are writing your integrated summary you are going to identify things in the intake that you did that support your diagnosis and support your intervention so you're gonna identify I'm doing this because in order to meet this need we're going to use this intervention so it identifies the clinical necessity you'll talk about appropriateness and that's in terms of diagnosis that's in terms of treatment setting and that's also in terms of age and culture so you're gonna if you use different interventions maybe use cognitive behavioral for some things and you use experiential for something else or maybe you refer to IOP for one thing for one client and you refer another client to outpatient or residential the appropriateness can be defended with your integrated summary and your patient placement criteria and then the effectiveness of treatment is going to be seen in your progress notes and your reassessments so you're going to be identifying okay we accomplish this goal accomplished that goal accomplished the next goal and you're gonna hopefully be marking them off and if you're not marking them off you're you're going to have addendums where you did you know an adjustment to the treatment plan in order to help the client start making progress towards that sometimes you're gonna scrap a goal because something else comes up that's more important I worked with one client who was just an amazing woman but she found out when she was in treatment with us that she had breast cancer well you know getting housing and getting a job those kind of goals kind of went out the door when that came up and the one of the main focuses of treatment for awhile became remaining clean and sober managing her anxiety and managing her feelings and you know recovery from the breast cancer and she went into significant chemotherapy and we were blessed enough to be able to keep her on our unit while she was going through chemo because she didn't have any family but you can see how sometimes you know there's a great treatment plan but then life happens and you got a drop back in punt and the treatment plan is going to show and the reassessment is going to show why you changed gears or changed directions so nobody goes well what in the world happened there you know I thought she was gonna discharge and then three months later she's still on the unit what's going on well you know we can we were able to justify why that was important it substantiates the need for further assessment and testing if you have a client who comes in who may have fetal alcohol spectrum issues you know because we know that alcoholism runs in families it's not uncommon for clients to have a mother who was an alcoholic now you know I'm not saying that every mother's an alcoholic and every person who has an addiction has a parent a mother who's an alcoholic but I'm saying the likelihood is higher if you're working with somebody with an addiction that their mother and for fetal alcohol spectrum disorders this has to be the mother because it's taint damage to the fetus that's done in utero so you know dad doesn't have anything to do with that so if you think the person has FASD or an F ASD you can refer because you need to get neurocognitive testing and all kinds of other things done but that will help them get set up for higher level services and reimbursement on multiple levels through SSI potentially if they have significant impairment its documentation supports termination or transfer of services if they've reached maximal gains at this level of care it's going to show or and kind of along the same thing if something happens and they can't participate in this level of care right now they need to be transferred to a crisis stabilization unit documentation will show why they were discharged from one place and sent to another it identifies problems with service delivery by providing data to support corrective actions when I worked at the facility I worked out we had multiple programs we had case management and outpatient residential and detox and crisis stabilization and yada yada yada and sometimes there would be too cooks in the kitchen so referrals wouldn't go off as planned or one person would think they were running the master treatment plan while another program would think they were running the master treatment plan and then reimbursement would get messed up so we were better able to figure out who was the single point of contact for this client and what the treatment plan was adding two methods to improve and assure quality of care so if we figure out that yeah this is working really well but you know we have this great intensive outpatient program but our aftercare program is really non-existent and it's it's imperative to have an aftercare program let's look at how we can do this in order to help people stay clean and sober it provides information that's used in policy development program planning and research another example that we used during the time that I was working at the at that clinic we realized that there was a need for a mother baby unit there wasn't one in our 13 County region so we wrote a grant and we created a unit that reached out to mothers who were still pregnant ideally didn't have to be but ideally still pregnant we helped them stay clean and sober until they delivered and then they stayed with us for another six months so we identified a gap in services you know because pregnant and postpartum women were really not getting a lot of services and we met that need and documentation provides data for use in planning professional development activities it helps you see what might be a need if you've suddenly got a lot of people coming in who have trauma issues then staff maybe need to be trained on trauma focused cognitive behavioral or cognitive processing therapy in order to better serve that particular population or you may have an influx of clients from a different culture you know right now in Florida there are a lot of people that have come into Florida from Puerto Rico after the hurricane so there's a need for services that are truly sensitive to people from Puerto Rico so it helps you identify who's coming through our doors what are their needs and what kind of training would benefit our staff so they can serve them more effectively and it fosters communication and collaboration between multidisciplinary team members a lot of times I would never see the doctor or the psychiatrist when they would come to see the clients that were on residential but I knew that they were reading my notes and they knew I was reading their notes because we had to initial so it made sure that all of the people in the team are at least communicating via the chart if not a team meeting unfortunately when you get into documentation you also get into big sticky issues with confidentiality and with substance abuse you need to be really aware of the Code of Federal Regulations 42 part 2 or CFR 42 part 2 and this handles the confidentiality of alcohol and drug abuse page patient records 42 CFR part 2 applies to all records relating to the identity diagnosis prognosis or treatment of any patient in a substance abuse program in the u.s.


So this is in addition to HIPAA and hi-tech and all of those substance abuse clients have additional protections there's a prohibition data that would identify a patient as suffering from a substance use disorder or as undergoing substance use disorder treatment you can't identify that information unless you have a specific release of information so if you're seeing somebody for mental health issues but they've also got you know a substance use disorder you can't divulge that that's separate information and their record is extra protected 42 CFR part 2 allows for disclosure where the state mandates child abuse and neglect recording sometimes the child abuse and neglect is directly related to the substance use or you're the only provider and you're in a substance abuse treatment program and you have to make a mandated report yeah it's allowed it allows for disclosure when cause of death is being reported so if you have a client in your program who dies and you have to report the cause of death you can disclose at that point or if the client passes away when they're on your on your facility and unfortunately it happens sometimes then you know obviously people are going to know where that person died because the everybody's going to come pick them up and do the investigation and you can disclose when there's an existence of a valid court order sometimes the courts will say this is important to know and that's varies by jurisdiction so in order to release information you have to have a written release and a written consent requires 10 elements and this is so important because so often I see releases of information that don't contain all ten elements number one do not ever have a client sign a blank release of information you know saying you know just in case we need it just sign it so I haven't know that's a big big big big no-no so anyway the release of information to be valid and if it's not valid then technically you can't release the information so it has to have all ten of these elements the names of the program's making the disclosure the name of the individual or organization that will receive the disclosure the name of the patient who is the subject of the disclosure you know that's all pretty standard the specific purpose or need for disclosure that gets a little bit you know why are you making this disclosure because the client requested it because of a court order in order to coordinate care what's the need a description of how much and what kind of information will be disclosed generally it's not everything you need a special release of information according to HIPAA in order to release progress notes as opposed to release other information so you know on ours we have we'll check boxes so you can identify whether its assessment attendance drug trip drug testing results etc you have to have a patient's right to revoke the consent in writing and the exceptions so there has to be a paragraph somewhere that lets the patient know that they have the right to revoke consent in writing you know at any time unless and there are a few exceptions but there they're few and far between and your legal department will handle that some agencies say clients can revoke consent verbally however the requirement is only that it has to be done in writing so if a client wants to revoke consent they need to write it down and give it to you showing that they want the consent revoked and then you know if they're there you cross through the the consent form you write void you date it you put your initials on it and they put their initials on it that's the ideal situation they can mail in a letter revoking consent as well you have to have the date or condition when the consent expires if not previously revoked now my program we always did a standard one year or 90 days depending on the program unless the client revoked consent however your program may be different or the client may choose the wind' the timeframe the signature of the patient and/or other authorized persons so if the patient is a minor or is not able to sign for themselves and they have an authorized representative you know you need those signatures your signature and the date on which the consent is signed so generally you have a witness there and you have the date that the witness and the person signed it so it has to have all ten of these things when used in the criminal justice setting expiration of the consent may be conditioned upon the completion or termination from a program so when Jim Bob gets released from jail this consent expires is can happen information can be shared within an agency on a need-to-know basis only with people on the treatment team only so it need to know you know if you're not on the treatment team then you don't need to know so we used to have this big medical records room and you would walk into it and there were literally thousands of files could I have pulled a file off the off-the-rack and looked at it and read it yeah I could have but that's not okay that is a violation of HIPAA as well as a bunch of others because I have no need to know about any random patient that is being seen so it's important to make sure that you've got good control over who can access records information sharing can be done with the release it can be done to the client you don't have to have a release to give the information to the client or under specific circumstances and that goes into confidentiality we'll talk about a little bit later agencies generally have policies for who is allowed to release information so the lady at the front desk probably can't release information it probably has to come from the therapist or from the risk manager clients have the right to review and amend their records if they request to view or amend the record is denied then we must provide a written explanation to the client so you know generally write your notes and write your everything assuming the client is going to read it use objective information don't be you know derogatory in any sort of way explain your findings and you know keep the client involved if they request to amend the record and and the agency denies it for some reason it says no you can't see your record or no you can't amend it there has to be a really really good reason we had some circumstances where the client wanted to amend the record and our executives decided that the amendment they were going to make was not didn't seem to really have a good grounding in reality the client was allowed to submit their amend in their handwriting and it was added to the case file and noted that this was a client amendment to the case file so your agency may handle it multiple ways but unless you provide them really good reason they have the right to review and amend the record now that doesn't mean take out something that you put in there because once something's in the record it's in the record henceforth and forevermore but they can add an addendum and so can you all right HIPAA and hi-tech these protect insurance coverage of workers when they're when they change or lose their job this is the idea what it was supposed to be for its safeguards the privacy of their information so if you're changing jobs or whatever you know nobody can really access your information to find out anything about you before they hire you etc it combats waste in healthcare delivery because it insures or hope hopefully ensures that we're communicating and the portability part of HIPAA means clients can take their record from one place to the other so you don't have to duplicate the intake and all a bunch of the other stuff necessarily and it simplifies administration of health insurance those were the that was the hope of HIPAA it kind of ballooned out of that so what do we need to know about HIPAA medical records are legal documents all states have policies regarding record retention medical records of adults are retained for seven years medical records of minors may be retained for longer so you need to know what your state requirements are agencies and solo practitioners should have policies identifying retention and storage policies so how long do you store it how do you store it how do you keep it safe who has access to it yada yada yada back to CFR 42 all records must remove patient identifying information and sanitize software printer ribbons FAQs hard drives and printer hard drives when you're talking about disposing of files you need to dispose of them in a way that removes patient identifying information and if you use hard copy still if you have software and this includes the hard drive in your copier a lot of people forget that one that has to be wiped and printer ribbons have to be destroyed fax hard drives have to be destroyed and printer hard drives have to be wiped and I guess wiping is really what we're calling it you don't have to actually physically destroy it but it has to be completely wiped don't just delete the file if you delete the file it goes in bits and pieces into your computer's never-never-land so to speak but people can put those pieces back together that's actually what my husband does for his you know career is find those pieces that have had been lost or somebody tried to delete something and he gets it back all client records and identifying information must be kept out of sight of unauthorized personnel well we know that so we keep our records behind to close to closed and locked doors okay that's great we have passwords in order to get into computer systems that's great but there are other things like lists and rosters you know sign-in sheets technically are supposed to be kept out of sight and people aren't supposed to be identifying information attendance records you don't want have want to have clients coming up and signing their own attendance record where they can see who and their groups been there for the past five days and who hasn't appointment schedules you don't want to be a client a client to be able to see what your schedule is for the week and who's coming in to see you computerized information must be on an encrypted hard drive full encryption of the whole hard drive not just that one folder client records need to be kept you know secure and phone messages you don't want to have the secretary sitting there with 17 phone messages across her desk while other people are coming in and checking in and then looking and going oh I didn't know Bob Jones was the client here so you need to make sure that phone messages are kept you know if they have the little message sheets keep them in a like a cigar box or a pencil box and then disseminate them to the therapists as appropriate therapists do the same thing don't have receipt books or phone messages just out where any client can see them if you discontinue your program you decide to close your practice or your practice gets bought by somebody else it must you must remove patient identifying information from your records or destroy your records including sanitizing any associated hard copies or electronic media to render the patient identifying information non retrievable in a manner consistent with the policies and procedures established under CFR 42 part 2 unless the patient gives written consent to transfer the records to the acquiring program so if somebody buys your program your your practice you have to keep those files for that 7 year period or whatever but and you're not going to transfer those unless you have written release from the client or if there's a legal requirement that records be kept for a period specified by law which doesn't expire until after the discontinuation or acquisition of the program so again if you haven't met your 7-year requirement that's generally a legal requirement you still have to hold on to those records but you're not going to pass them on and definitely not pass them on with patient identifying information to the new program unless you have a written release records which are paper must be sealed in envelopes or other containers and labeled as follows records of insert name of program required to be maintained under insert the statute or regulation until a date no later than insert the appropriate date so basically it says I have to hold on everything in this box or in this envelope that is sealed until XYZ date and time at which time it will be destroyed all hardcopy media from which the paper records were produced also need to be sanitized in order to render the data non retrievable records which are electronic must be transferred to a portable electronic device with implemented encryption so a hard drive that has that is encrypted so there's a low probability of assigning meaning without the use of confidential processes or key so you know what's on that hard drive it's encrypted so nobody else can access it even if you know they were to put it into a computer but you still have the client information there the electronic records must be transferred along with a backup copy to separate electronic media so that both records and the backup have implemented encryption so you don't want to just have one hard drive because hard drives can fail you need to have backups in order to say you're securely sir securely saving the data within one year of the discontinuation or acquisition of the program all electronic media on which the patient records or patient identifying information resided prior to being transferred must be sanitized so again you want to check with your legal department to see where the seven year rule falls but if it's outside of that seven year rule then definitely within a year after that the information needs to be destroyed portable electronic vise device or the original backup electronic media must be sealed in a container along with any equipment needed to read or access the information this is important because technology moves quickly and you know back when I started working on computers we had those you know five and a quarter floppy disks you can't find a computer now that can read those most computers don't even have CD drives in them anymore everything has to be on a thumb drive so you need to make sure that not only is the information there but it will be readable in the future and then there's a special thing records of this program required to be maintained under this legal authority until a date not later than duh so you want to label everything so you know what it is when it's to be destroyed okay so many agencies govern the content scope and quality of documentation the single state authority or SSA in your state has state service and licensing rules so it's important to communicate with your SSA and that's generally also the agency that does your licensing so when you get licensed as an independent provider you'll know what the regulations are the SSA may set forth time frames for documentation completion and who needs to sign and credential the documents so if you're a registered intern or you're not certified yet who has to co-sign on your documentation accreditation bodies also put their two cents in about documentation and they addressed quality from an organizational leadership and client care perspective so generally accreditation bodies are looking at quality of care and quality of documentation so good quality documentation will hopefully show good quality care many agencies govern the content scope and quality of documentation including third-party payers who set the guidelines through their level of care guidelines and other provider agencies so if you are when I worked with the Department of Corrections for example they had certain very specific requirements for the documentation of my clients so what types of documentation are there there's lots screening is the first type of documentation and good screening identifies the referral source the presenting problems background biopsychosocial information and this isn't going to be an in-depth everything but it's going to get a general idea about what's going on so we can rule out or rule in physical issues social relationship interpersonal issues as well as psychological issues is going to note the person's emotional and mental status at that time it will note their strengths and preferences for treatment for recovery for interventions and it will make a recommendation for assessment or other referral as needed so sometimes screenings just happen like it workplace affairs the screening happens and it's like yep you seem to be fine no further action needed by the bank and that chart is closed for others you may determine that the person may need a physical to rule out you know things like hyperthyroid that may be causing symptoms that look like hypomanic symptoms or look like stimulant intoxication you may need to refer to detox you may there are a lot of referrals that may need to be made but a screening is not a diagnostic interview it's when you identify whether there's a likelihood that the person may have a problem that needs further assessment intervention documentation so intervention is like your entry level services intervention documentation includes client identifying information the source of the referral client placement information you know why were they put into your program when were they put in how long are they going to be there the screening information that got them to that point informed consent for services including any drug testing that may be required and drug testing has its own form that needs to be signed dated credentialed by the client and counselor and witnessed and if you've done drug tests you know all this but it's important to get that informed consent for intervention services there's a release of information that has all the ten necessary components as needed so if you need to talk to a referral source get a release of information signed the intervention plan which is a lot broader or whatever you want to say than a treatment plan is signed dated and credentialed by the client and counselor and witness so you know you know this with your documentation you've probably done this already you know with intakes and everything else the client signs it you sign it you both date it and you have to make sure your credentials are on it if you're not already certified or licensed then you have to have somebody who is certified or licensed cosign on it most of the time intervention documentation also includes copies of correspondence or reports with referral sources and a transfer or discharge summary at the end of the intervention service administrative documentation in general this is going to be the stuff that's used for billing it's not the clinical it needs to be accurate concise include recommendations referrals case consultations legal reports family sessions and discharge summaries what you're like well that's kind of clinical isn't it a little bit but in order to get reimbursed the administrative side of things we have to have good documentation in all of those areas administrative documentation is conducted at admission and specified intervals throughout care so your administrative documentation is going to be a reassessment it's going to be your treatment plan updates it's going to be all of those things so types of administrative documentation your client identifying and demographic information referral source name and address financial information assigned client rights document assigned informed consent for treatment document any releases of information that you need assigned orientation to the program indicating that the client did receive orientation outcome measures that help identify whether your program is being successful and when you know when JimBob meets these criteria he or she is going to be ready for discharge and client placement information that goes back to your a sam or your locus medical documentation which is often in another section of the file includes the medical history the nursing assessment the physical exam the lab tests which almost always have to include a TB and pre-admission physical records of medical prescriptions and changes in medications that occurred you know what prescriptions were the person on when they got there and what what did they take while they were in your program even if you're not residential you need to know what meds they're on and any changes that their doc may make or your doc and what are they discharged with your medication administration records so if you're in residential then the client is probably going to or may receive medication while he or she is there so the medication administration records need to become part of the chart to show you know when Jim Bob took his medication who administered it and yadda-yadda and nursing notes so any notes that your staff nurse makes regarding the client's progress now clinical documentation is the stuff that we enjoy doing screening assessment treatment planning progress notes and your discharge summary so we're going to get into those in the in a few minutes I do want to mention electronic health records really quickly because you know you have all this administrative medical and clinical documentation a lot of times now it's going into an electronic health record health information technology is the secure management of health information on computerized systems it helps track data over time track progress of those who leave treatment and monitor quality care within practice just like documentation does but when it's on a computer it's a whole lot easier to run a program and get pretty little charts spit out behavioral health lags in adoption of these electronic health records because of cost technical limitations you know there's a lot of different players who want different things so creating a standardized electronic health record for behavioral health has been really difficult lack of standardization of data elements lack of interoperability of systems between you know doctors and therapists and whatever you know you have to have if your doctor has a system made by X Y Z and you have a system made by Acme they still have to be able to talk it's kind of like getting an apple or a Mac computer and a Windows computer to talk doesn't always happen so we need to make sure that the different electronic health records out there can communicate with one another attitudinal constraints we don't like change an organizational lack of expertise in health information technology management most programs don't have a technology director especially smaller programs so integrating this is really overwhelming and it can be really costly if everybody has to have a computer in order to put in there their client information general elements of clinical documentation whether it's administrative clinical or medical must be clear concise accurate written in ink time stamped or dated so you have to have all that information in there if you write I've had some staff members their handwriting was atrocious you could not read their notes or their assessments to save their life that is not good clinical documentation because it doesn't help anybody documentation is an ongoing responsibility for all professionals and should be completed as soon as possible after the contact don't wait until Friday to do all your notes for the week ethically you need to do it as soon as possible and I'll give you a little hint when I do groups oftentimes I will have a sheet that I pass out at the end of group has the client identify three things they got out of group and then you know a couple other questions about you know how they're feeling if they feel like they need a treatment plan reassessment and just a few other things to give me information then I have something in the clients handwriting to put in the chart but I also have the brunt of the progress note kind of done already and if you use soap notes or DAP notes you can kind of put that on there and have the client fill out what they think they would put for their notes that's helpful in group for individual individual sessions are generally supposed to be 45 to 50 minutes so I end right about 45 minutes maybe a little longer tend to run late and the client and I create the progress note together that way they review what we talked about they review the progress they've made they review what they're supposed to be doing in the upcoming week and they know what's going in the chart so it's not mystical and magical you know they are an active participant and I have the note done before the end of the hour so it's kind of a win-win-win all around okay documentation of sure's accountability the responsibility for accurately representing the client situation rests with the counselor and the clinical record not the client so like I'm saying we can get all of this input from the client but making sure that it's accurate when we put it in there and you know pulling it all together is incumbent upon us good clinical documentation spares the client from repeating painful details so we're not going to have them you know if you're talking with a client about a trauma situation you're gonna put enough in your clinical record that you don't have to have them remind you you know remind me again about what happened when your house burned down or what no that's rude um so you want to have enough documentation that gives you an overview or the next counselor sort of an overview of what happened and then if they need to delve into details later they can language language must be objective but descriptive so if you're saying that the client is decompensating well that doesn't tell me anything in what way as evidenced by you know the client is I diagnosed with the client with depression because they have these symptoms as evidenced by that is your best friend phrase as evidenced by documentation must identify persons places direct quotations and sources of information so if the client says you know I'm really feeling off my game you can put that in there so we know kind of where the clients coming from we want to use direct quotes from collateral sources that we get and identify who gave us this information clinical documentation is a legal record and the clinicians signature and credentialing indicates the truthfulness of it so if you sign it then it happened the treatment plan good treatment plans are hard to come by they're really easy to write if you don't overthink it but I find that most people overthink it so there's a hole that's actually a couple of classes on treatment planning because it is so important not only to guide treatment but to help clients learn how to set goals and achieve them treatment plans are a contract between the client counselor and treatment team each being responsible for its development and implementation the clinician needs to recognize that treatment occurs in different settings over time so you know treatment may be happening but you know counseling is only part of what going on there also in maybe case management or vocational rehabilitation or you know so treatment occurs medical in different settings and we need to be able to integrate all that into the treatment plan much of the recovery process occurs outside of or immediately following formal treatment when people do their homework assignments and they have their aha moments when they generalize their progress when they create that support system on the outside treatment is often divided into phases engagement stabilization primary treatment and continuing care treatment planning plots out a roadmap for the treatment process treatment plans are completed once a diagnosis is made a level of care is determined and the client is admitted to the program now after the initial assessment there's usually an initial treatment plan done but the real treatment plan generally needs to be completed within three to five days after admission once the clinician has finished the assessment paperwork and everything level of care is determined based on diagnosis and the clients strengths and assets so if you're familiar with the a Sam for example recovery environment is one of those dimensions that we look at and if they've got a really strong recovery environment then the option may be or decision may be made to refer the person to eiope instead of residential whereas if they have a really poor recovery environment then we may opt to refer the person to residential so they have a better chance in the first 30 to 60 days of you know getting a handle on things treatment plans address all biopsychosocial needs not just mental health they establish what changes are expected through achievable goals clarifies what interventions and counseling methods will be used to help the patient achieve those goals sets the measures that will be used to gauge success and that's where we go with as evidenced by again so if the client says you know instead of saying I'm going to quit using drugs they may say I'm going to develop a healthier life so how do we know when the client has developed what he or she defines as a healthier lifestyle well as evidenced by I'm going to develop a healthier lifestyle as evidenced by getting eight to nine hours of sleep a night eating a relatively nutritious diet as decided upon but between myself and the dietitian developing healthy support systems yada yada you see what I'm getting at so you're going to be able to go through and anybody would be able to go through and Mark off and say either yes or no achieved it achieved it achieved it achieve the goal so it's kind of a yes or no thing treatment planning incorporates the clients strengths needs abilities and preferences and I'm big on this you all probably know that if you took our addiction counselor certification training course temperament is huge extroverts and introverts have different needs judgers and perceivers have different needs auditory and visual learners have different needs and people in general based on their culture and just their cognitive aptitudes are going to have different strengths and needs so we want to form the treatment plan around the clients strengths and build off what's already there what already works referrals are made to other agencies as needed when referrals are made collaboration is essential to keep clients from falling through the cracks so treatment planning is going to identify you know client will get enrolled for Medicaid well you're probably not going to do that so you're going to identify who the client is going to see at whatever office they've got to go to in order to get enrolled in Medicaid but that's going to be part of the treatment plan treatment planning information even within the agency is restricted to need-to-know and treatment plans may have to be co-signed by a clinician who is already certified or licensed the function of the treatment plan well treatment planning is an action-oriented process that lays out logical goal directed strategies for making positive changes just like if you're going to make lasagna from scratch and you're gonna follow a recipe same sort of thing here and based on your preferences you know when I make my marinara sauce I use roma tomatoes that is my preference I know other people who use different kinds of tomatoes so different preferences I know that I want to do it in a shorter period of time so I'm not going to make the the noodles from scratch that's a need that I have because I don't have the time to make noodles from scratch so my recipe is going to be slightly different than my stepfather's recipe but that's okay and treatment planning is the same way just think of it very very simplistically like a recipe don't get too overwhelmed and tried trying to make it too complex because clients aren't going to be able to make complex treatment plans and treatment planning establishes a collaboration between you and the client so you can mutually prioritize agreeable goals you figure out what do you want I've worked with clients who were involuntary and you know they didn't really want to quit using however they were on probation and they wanted to get off probation well I wanted them to get off probation but I wanted him to quit using in order to get off probation they had to be clean during the time they were in treatment so that became our goal because that was mutually agreeable you know it's like well your goal is to get off probation in order to do that you got to stay clean so let's work together to make that happen during the next 16 weeks and generally it worked that way achievable goals are selected by assessing and prioritizing client needs and taking into account their level of impairment if you've got a client who is significantly impaired they've got major clinical depression they're detoxing from five years of stimulant abuse they're not going to be going out and getting a job next week that's you know well down the road so the goals we're looking at now are more like stabilization and engagement you want to take into account motivation what does the client want to achieve because they're not going to be real motivated to achieve what you want to achieve unless they want to get out they want to get discharged from the program successfully and in order to do that they've got to meet your goals but ideally help them identify goals that are meaningful to them and you're going to look at the real world influences on needs so if they're going to be discharged in 30 days even though they may not be quite ready to start looking for housing if they need to have housing when they get out in 30 days then that's probably going to be a high priority treatment plan goal because you don't want them being discharged to the street treatment plants consider client needs readiness preferences and prior treatment history looking at what did and didn't work because there's no sense repeating something that you've done four times that hasn't worked yet we're going to look at their personal goals and then we'll look at obstacles like transportation and childcare and those sorts of things that might preclude someone from going into residential or make it difficult for them to get the evening IOP for example treatment plans have SMART goals specific measurable achievable realistic and time limited these goals are broken down into smaller objectives so you know think about it like you want to climb a staircase well that's great that's your goal you want to climb a staircase in the next 45 days wonderful you're gonna be taking a little while at each step but each step is an objective so your end goal is the top of the staircase what is the first thing you need to do to start moving towards the top of that staircase what's your first step all right once you get that done what's the next thing you got to do again think of the recipe first thing you've got to do is find the recipe then you've got to figure out what you've got on hand then you've got to figure out you know what you need from the store then you've got to go shopping you know one step at a time don't make it too complex treatment plans anticipate the type duration and frequency of services so you know a lot of times we may say if they're in IOP there's going to be three hours a day five days week for the first month and then once they accomplish certain goals then they can step down to three hours a day three days a week etc treatment plans identify who's responsible for what so if the client has to go do something it's going to be clearly indicated that the client needs to make the appointment with social services to get enrolled in programming versus the counselor will make the appointment for the client to go to Social Services you know whoever supposed to do it it needs to be noted and there has to be a timetable you know this needs to be accomplished by X date if it doesn't get accomplished by X date it's not the end of the world however you need to do a reassessment and go okay why didn't this happen what do we need to adjust it incorporates client input and participation in development it helps the client prioritize presenting issues so I mean they come in and generally there's a whole litany of stuff that they need to work on and it can feel really overwhelming but I liken it to a woven blanket for clients that woven blanket is over your head right now you can't breathe you can't see it's miserable it's hot any string you pull on is gonna start making air holes in that blanket and making it lighter and eventually you will unravel the whole blanket so let's figure out you know of the issues that you've got going on right now which are most you think are most important to work on and which are you most motivated to work on what string are you willing to pull first you get input from client on their goals and objectives so what is there as evidenced by look like you know if I am happier as opposed to being depressed what is that going to look like if I am healthier as opposed to unhealthy what is that going to look like how am I going to know when I'm living a healthier lifestyle and both the counselor and client sign the plan the clinician may also facilitate and manage referrals because oftentimes we don't have case management that we can rely on at minimum the plan is a flexible document that uses a stage match process to address identified substance use disorders so stage match process if you think back to the stages of readiness for change pre contemplation contemplation preparation action and maintenance each stage requires different interventions so that's tip 35 from Samsa if you need to refresh it looks at the recovery support environment it addresses potential potential mental health conditions you know based on readiness for change for that issue you know somebody may be in the action stage of readiness for change on their substance use but not you know ready to do a lot about their anxiety it's usually the opposite but whatever so you need to make sure that you stage match by issue because the person is not just going to be globally in the action stage of change there are going to be some things that they're not really that ready to work on yet you want to identify potential medical issues employment education spiritual issues social needs and legal needs and there are other things like childcare and other wraparound services that can go into this too but these are the big ones initial treatment plans are done an admission or within 24 hours based on information from the assessment and screening and serves as the initial roadmap they include presenting problems preliminary goals type frequency and duration of service and the signature and date of the client and counselor with counselor credentials so again this is the initial treatment plan as you get into treatment and start to know the client a little bit better you're going to formulate a more in-depth treatment plan this one has to be done either at admission or within 24 hours an individualized treatment plan has the problem and a problem description that answers the question why are you here that's the problem not the goal I'm here because I have a substance use disorder what's my goal to not have a substance use disorder it identifies the clients strengths you know we are going to build on strengths so client will build on his to stay clean and sober yada yada it has concrete measurable goals concrete means you can observe them you can see them you can either say yes it was done or no it wasn't not yeah it was probably accomplished it's yes or not the objectives are there so that big goal is broken down into those smaller steps it has strategies for achieving those smaller steps so you know if the first step is to start building a recovery support network well that's wonderful how are you going to do that strategies answer how you start going to a a meetings you know start going back to church call up your five closest friends that are healthy supports whatever the treatment plan includes the diagnosis usually that's up at the top the signature of the client and counselor and the signature of the clinical supervisor if required ongoing assessment and collaboration is used to regularly regularly review the treatment plan and make necessary modifications many IOP and residential programs have to review the treatment plan once a week with the client and get the client to sign off sometimes you get a 30-day reprieve but you need to know what your payers and your state requires review should be completed at minimum at major or key points in the client's treatment course including admission obviously you're going to develop it readmission you know maybe they discharged and they were out for three months and then they relapsed and they're back well you may be able to look at their treatment plan and see where they're supposed to be because they were in an IO P program and work with that but you're gonna need to reassess it at readmission at transfer at discharge if there's a major change in their condition such as you know they'd have a manic episode or they're admitted to the crisis stabilization unit for suicidal ideation you're gonna do a reassessment and after 12 months regardless of what's going on after 12 months progress notes document the clients progress in relationship treatment plan goals and objectives each progress note should have the problem name and number because most clients will have like three treatment plan problems and then multiple like say eight objectives underneath it so maybe substance abuse recovery is the first treatment plan problem okay so that's problem number one and goal number a if you will the first goal is to start developing a recovery support system so in the treatment plan if I talk with the client about developing that recovery support system then I'm going to identify that we talked about problem 1a and what we what we addressed the progress note identifies what the client says and does generally I mean you're not going to do it verbatim it puts in counselor observations and assessments if the client seems to be doing really well as evidenced by and the clients observations and assessments I always put those in there too how do they think they're doing and what's their evidence as evidenced by and continued plans to address the presenting problem you also may need to document any new information if they get into a new relationship get a new job breakup whatever that will go in the progress notes the format for most people is the soap format the first part is the specific objective information and the last part is the assessment the interpretations and the plan for how to proceed you want to document the clients progress progress notes are based on what the client says and it does what the clinician observes the clients attitude demeanor nonverbals you know how compliant they are with treatment the counselors knowledge and experience so counselors are going to be able to differentiate between a lapse and a relapse for example they're going to be able to differentially diagnose if the client starts presenting with some symptoms of depression for example the clinician is going to rule out the use of depressant substances they're going to rule out detoxification from stimulants they're going to rule out hopefully medical conditions and they may rule in mood disorders or something so differential diagnosis is important to look at the physical and other potential causes for symptoms and danger to self or others I encourage my staff at every single treatment meeting to identify whether the client had any suicidal or homicidal ideation espoused I mean if they said I'm suicidal or I wish I could end it all that needs to be documented and to identify if the client had future plans was oriented to place and time you know just a general Mini Mental Status exam at every contact is really good to protect you and even in group I mean you're looking at people and are they bright and are they oriented and are they talking about future things or they withdrawn and sad and tearful and talk about how you know there doesn't seem any point in being there well you know if you hear that you probably need to pull them aside and talk to them more in depth so you know get a some documentation that you had good contact with the client and you have a good kind of idea about the pulse of things progress notes are not a verbatim transcript but a cohesive summary so one page you know don't write a dissertation the discharge summary discharge planning begins at admission discharge planning begins at admission okay I know I said it twice because it's that important you see client Jim Bob and you know your things are going well but then client Jim Bob goes out and relapses and never comes back well he's discharged at that point you don't know when the client is going to discharge necessarily so if you begin discharge planning at admission which actually is required by most insurance companies then you have a plan and you and Jim Bob have made a plan for this is how you're going to progress these are the options and resources available to you so Jim Bob has something to work off of in case he never returns you want to summarize in your discharge summary the service is delivered you know the discharge summary is done when Jim Bob is actually discharging discharge planning begins at admission so the discharge summary summarizes any services you did deliver how well the client accomplished goals and objectives and any discharge recommendations including referrals continuing care etc the elements of the discharge plan include the referral source you know because this is going to go back to the referral source saying Jim Bob discharged this is the summary of what happened presenting problems and the reason for services treatment goals methods and outcomes outcomes generally pertain to the person's ability to attain recovery build resistance and work learn live and fully participate in the community of choice so discharge summary is basically a big summary of the entire treatment episode it's going to indicate the condition of the client at discharge your prognosis and you know that's a little subjective but we got to make it follow up recommendations including continuing care and the aftercare plan and the counselors signature date and credentials you want to include the reasons for discharge on the discharge summary but reasons for discharge can be varied treatment completion that's the idea they may lead leave AMA or against medical advice that's not so ideal but it happens treatment non-compliance they're just not getting with the program or they're showing up and they're under the influence or you know a variety of reasons that it's therapeutically indicated to discharge them or treatment was just incomplete you know again they left before treatment finished they just it wasn't some what treatment incomplete is a lot like AMA but those are the four main reasons for discharge identified for the review exam organization of documentation is gonna vary a little bit between each agency but each page has to have the clients name and some sort of identifying number all entries must be signed if you make an error in documentation you line through it once you don't scratch it out you line through it once initial it date it and write error above it notes of any sort should never be removed from a file if you have late entries or Corrections they're put in as a separate document and noted as an addendum to you know progress note from to one of 18 or whatever so clinical document character at documentation characteristics need to be written knowing that others will read it it needs to be objective you know stay away from vague terms like client is doing well if you use a vague term then explain it as evidenced by uses descriptive behavioral terms client is oriented to person place and time not client seems to be with it today you know you want to use descriptive behavioral kind of clinical terms it avoids jargon so you don't want to overuse clinical clinical terms and it keep it simple again remember the client may read this it's concise and it's positive you know these are the steps the client is making this is the progress the client is making yes the client has had a setback but hey he returned for treatment and you know we're picking up and figuring out what we did wrong you don't want to be doomsaying and talking about how the client is non-compliant and resistant and just doesn't seem to want to be here and you want to keep it as positive as possible focusing on the strengths and the progress and making lemonade whenever you your client gives you lemons all right well that was a lot that we covered and I know documentation is not the most interesting thing but that kind of hits the highlights of what you need to know for your addiction counselor certification exam if you need more training we have lots of training at all CEUs calm and we have a full addiction counselor certification track that is a little over 400 hours and of multimedia information and that's for one hundred and forty nine dollars alright thanks for participating today or listening today and I will talk to you again soon



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Physiology of Addiction and Mental Health Issues

this episode was pre-recorded as part of a live continuing education webinar   on-demand CEUs are still available for this presentation through all   CEUs register at allceus.com/counselortoolbox I’d like to welcome everybody to today’s presentation of addiction and co-occurring disorders   part two the physiology of addiction and mental health issues over the next hour we’re going to   discuss somewhat generally because there’s a a lot of stuff to go over neurotransmitters which   we’ve talked about some before but then we’re also going to talk a little bit more today than we’ve   talked in the past about sex hormones thyroid hormones and stress hormones and how all of those   interact in the body to increase or decrease the availability of certain neurotransmitters we’re   going to go on from learning about the different hormones and neurotransmitters to discussing   the physics all the physiology of emotion and motivation and again we’ve kind of covered that   but we’re going to go over it real quick again we’ll talk about the physiology of sleep what   happens during sleep and what happens to those hormones or neurotransmitters when you don’t   get enough sleep what happens when you eat why is eating sometimes rewarding what happens when   people take stimulants whether it’s caffeine or methamphetamine what happens when we turn up the   system and how does that affect the availability of certain neurotransmitters and then we’ll talk   about the physiology of depressants so we’re looking in general at what these things do as   far as the physiology of addiction we’re going to talk generally about that right at the very   end so your inhibitory neurotransmitters are those brain chemicals turn down   the system so instead of being hyped up and awake and yadda-yadda your calm you are relaxed you are   maybe even sleepy too drowsy so your inhibitory neurotransmitters are the ones that kick   in or counteract the excitatory ones serotonin is your primary inhibitory neurotransmitter it’s   broken down to make melatonin and help you sleep okay so we know that it’s also responsible   for a lot of our bowel function angle and also for not it’s implicated in nausea and motion   sickness and they found that there are a lot fewer side effects to serotonin antagonists than there   are to dopamine antagonists when we’re talking about helping people who have motion sickness   and nausea so anyway just a little aside there but serotonin is 80 percent of it is actually in your   GI tract and it is implicated in bowel function so when we’re thinking about clients who may have   an imbalance in serotonin and who may have greater pain sensitivity we want to start thinking about   you know how is their GI working and is are some of their problems with you know stomach problems   pain irritable bowel that kind of stuff is that caused by a serotonin imbalance or is that causing   a serotonin imbalance or maybe serotonin is not implicated at all and it’s something completely   different serotonin is also implicated in anxiety and aggression if you don’t have enough of it you   tend to be more anxious and aggressive because you’re not having the turn down if you will low   serotonin has also been implicated in poor impulse control so we like serotonin but we   found and we’re gonna talk about that throughout this class of serotonin has often been given the   go-ahead or been implicated for a whole lot of things and we’ve said okay if this happens then   it’s low serotonin if this happens then it’s low serotonin and as it goes but no the research is finding that that’s rarely true that most of our problems whether it be GI problems   or mental health problems or addictive issues don’t necessarily involve serotonin at all there   is a subset of people for whom it does but the majority of people which is why antidepressants   are ineffective for about 70 percent of the population for them shortie of the people it’s not   serotonin so we do want to keep that in the back of our mind yes serotonin is everywhere throughout   the body 80% of it is in our gut and our gut is not necessarily going to communicate directly   with our brain we cannot measure neurotransmitter levels effectively in a live human being just not   how it works right now there are tests out there that say they can measure your neurotransmitter   levels and that’s true but it’s not telling you how much of that neurotransmitter is in your gut   or your muscles or wherever versus in your brain so those tests for our purposes as mental   health clinicians and people who come to us who may want to know well what antidepressant should   I be on they’re not all that effective okay so depression has been debunked as   being linked to serotonin in the majority of cases serotonin is implicated as one of those   neurotransmitters involved in pain control in people with lower serotonin tend to have a lower pain   threshold so it hurts more and that doesn’t mean that they’re sissies or anything like that   it just means that they are more reactive or they feel more pain because they don’t have the same   level of serotonin and maybe endogenous opioids kind of coursing through their system serotonin is   also like I said involved in sleep an interesting fact is that alcohol impairs the body’s ability   to convert tryptophan which is an amino acid to serotonin so when you have somebody who’s   an alcoholic let’s think about how this works if they are drinking and maybe they’re eating   a perfectly healthy diet and they just happen to drink a lot if their body can’t convert tryptophan   to serotonin then all of these problems up here that may be implicated by low serotonin can start   to rear their ugly head because the body can’t To make serotonin out of anything else it has to make   it from tryptophan and if it can’t make serotonin then it can’t make melatonin which is involved in   sleep and you’re gonna see how important all that is later so the take-home message with that is   that alcohol is something to be considered for moderation especially if we have a client who   is struggling with depression maybe they’re not an alcoholic but they need to consider the long-term   impact if they want to feel better is preventing their body from making using the building blocks   to make the neurotransmitters that they may need is it worth that drink remember that serotonin has been found in research to be implicated in low serotonin is implicated in   people with generalized anxiety disorders so it hasn’t been completely just been debunked   for everything but researchers and clinicians finally are starting to realize that there are   a multitude of reasons that somebody could have a mood issue that somebody could have even low   serotonin okay if the person has low serotonin alright that’s fine let’s address it but what   is causing the low serotonin we’ll look at that more in the next few slides GABA is your   other major inhibitory neurotransmitter it has sedative depressive and anti-anxiety properties   to them the really interesting thing it’s and when I say depressive I mean it slows down everything   it’s not that it makes people depressed but it’s your anti-anti-anxiety natural anti-anxiety   neurotransmitter helps improve concentration by filtering out background noise so you’re able to   focus a little bit better when you’ve got normal levels of gaba help with impulse control   think about when you’re anxious when you’re a little bit revved up when you’re stressed out   and somebody scares you maybe you’re a little bit more jumpy well think about if you have GABA at   the right levels in your system and you’re not stressed out and somebody scares you are you as   jumpy are you as impulsive a lot of our impulses are associated with wanting to make a threat or   a pain go away so if you’re not perceiving as many threats you’re probably not going to be as   impulsive another little interesting side thing is that glucose you know sugar is necessary for the   formation of GABA so people with hypoglycemia can have a reduction in GABA and an increase   in anxiety so think about if your blood sugar gets low even if you are not hypoglycemic but   you know you got to work back-to-back patients you didn’t take time for lunch yet back-to-back   patients you’re on the drive home from the office your blood Sugar’s low you are you more likely to   respond with some anxiety or irritability to things that happen versus when you are well   nourished and your blood sugar is kind of stable for most people, they’re gonna say yeah I tend to   be a little bit cranky err when my blood sugar is low and shake gear alright so those are our   two inhibitory neurotransmitters glutamate is generally acknowledged to be the most important   neurotransmitter for brain functioning and it’s excitatory it gets you up it gets you   going it gives you energy and it’s responsible for helping us learn and remember things so if   you’ve got low levels of glutamate you know you might have difficulty concentrating and learning   now the interesting thing is that glutamine which is an amino acid you eat glutamine   is converted into glutamate all right well that makes sense so you eat something it is turned   into this neurotransmitter that’s excitatory the interesting thing is gaba is made by the breakdown   of glutamate so you have if you have glutamate then you can have Gaba if you don’t have enough   glutamate then you’re not going to have enough GABA so it’s a balance like taking a warm bath   and you know this is important to remember simply because we want to know what’s rubbing   us up and what’s slowing us down norepinephrine or noradrenaline depending on where you are is what   they call a catecholamine it increases arousal and alertness promotes vigilance and focuses attention   so you’re hearing a theme here about attention and memory it enhances the formation and retrieval   of memories so in your norepinephrine that’s your motivation chemical is secreted it encourages you   to pay attention to remember and to be able to go and file things away and access them easily it can also promote restlessness and anxiety if you have too much so it’s all about moderation   when I talk about too much or too little of a neurotransmitter everything is always about all of the other neurotransmitters and hormones so we can’t just necessarily get a measurement and   go well you’ve got too much of this well we have to know what the levels of everything else are it   would be kind of like making a marinara sauce and saying you a teaspoon of garlic is how much you   need but that teaspoon would be enough if you were making maybe two quarts of marinara sauce   but if you are making 4 gallons all of the other spices and everything would be in much   larger proportions so what a teaspoon be enough so we need to know what proportions all the other   chemicals are at in order to know how much we need and since we can’t measure them we’re just kind of   left guessing dopamine is another catecholamine and it’s broken down to make norepinephrine now   normally we think of dopamine as our pleasure reward chemical which it is don’t get me wrong   it’s that’s what is there for and it tells us I want to do that again but it’s broken down to   make our focus concentration motivation chemical interesting so we need dopamine to make   norepinephrine we need norepinephrine to want to get up and go so if we are draining our dopamine   system through addictive behaviors or some other reason guess what we’re not going to be able to   make enough nor epinephrine or those receptors that usually receive the norepinephrine and the   dopamine are going to be basically unresponsive and you’re going to knock on the door and nobody’s   going to open so dopamine is broken down to make norepinephrine which is your motivation chemical   high levels of dopamine in the brain generally enhance mood and increase body movement too   much dopamine may produce nervousness irritability aggressiveness and paranoia so think about cocaine   if somebody takes a whole lot of really good cocaine this is probably what we’re going to   see because the levels of dopamine in their brain just skyrocketed and everything else didn’t catch   up there was no signal to all the other chemicals to go okay we’re gonna have a surge here so we   have all of those neurotransmitters that are responsible for helping us feel happy serotonin   helps us feel theoretically calm and content and focused gaba is an anti-anxiety medication   or not medication but a neurotransmitter and then dopamine glutamate and norepinephrine are all   of our excitatory ones they’re the ones that get us guess what excited happy excited mad excited   whatever the excited is they Rev us up and that’s what we label with our emotional feeling states   so what is this HPA axis thing that I talk about every once in a while in response to stress the   level of various hormones change and reactions to stress is associated with an enhanced secretion   of several hormones including your gluta Co corticoids which is cortisol your catecholamines   to increase mobilization of energy sources which is blah blah blah blah blah you get   stressed your body sends out the message that we need some energy we need some fuel for this   fight-or-flight response cortisol is activated and it’s a glue to co corticoid which tells your body   we need to prepare we need to get some glucose going so got energy for this fight-or-flight   thing catecholamines adrenaline and dopamine are released that’s your body going okay we have this   energy now let’s get the team revved up the other thing that happens though is jörgen a door opens   are suppressed your body goes you know we don’t really have time for sex right now so let’s not   worry about it so your sex hormones tend to be suppressed under high stress levels okay well   who cares you’re gonna find out in a little while but that’s kind of a big deal because there is a   strong relationship between the amount of and the balance of our sex hormones and the availability   of serotonin-norepinephrine and dopamine in our bodies oh well sweet this here we are androgen or   testosterone what we want to look at is what does it do it helps helps us with concentration mood   and not enough of it can result in an increase in belly fat they found that in men depending on the   research that you look at somewhere between 30 and 40 years of age they start losing somewhere   between 1% and 1.5 percent of their testosterone each year and so you’re thinking well you know   that’s not that much but you’ve also got to remember that everything’s in a balance so   they’re losing their testosterone but what else is not decreasing estrogen so some articles have kind   of termed it manopause if you will the increase in estrogen can increase irritability difficulty   concentrating and belly fat as well as Gyna mastika or the development of excess fat in   the breast area so something interesting to look at if you’re dealing with patients male patients   who are over the age of 40 who are having suddenly if you will depression or anxiety issues or are   talking about their midlife crisis that those all of those things could be precipitated by in their neurochemistry because of a drop in testosterone not necessarily but it’s one   positive or one possible reason estrogen believe it or not is a neuro stimulant estrogen revs us   up receptors for estrogen are very abundant in the emotional center of the brain called the   amygdala and the hypothalamus which is involved in what we just talked about the HPA axis which   tells us to fight flea or freeze estrogen increases serotonin receptor responsive ‘it   increases the number of serotonin receptors in the body and enhances serotonin transport   and uptake so we might hypothesize and we don’t know any of this for sure that if someone’s mood   disorder started or fluctuates in response to fluctuations in their estrogen then there might   be a serotonin component to this mood disorder because estrogen is so intimately connected with   serotonin availability high levels of estrogen are associated with anxiety one thing that they found   in American culture and industrialized nations but especially American culture is we have a   lot of chemicals and stuff that we eat that tend to and habits that we do that tend to increase   our levels of estrogen creating something called estrogen dominance but high levels of estrogen are   associated with anxiety so one thing clients may want to do especially female clients but   you know if you have a male who is feeling like estrogen may be increasing too much I have them   look at what they’re doing as far as lifestyle factors to see if there’s anything that might be   increasing their estrogen levels low levels of estrogen are associated with depression because   there’s not enough serotonin going around but also because estrogen is a neuro stimulant and if it’s   not there then there’s no stimulation so alright so now looking at first we started implicating   just neurotransmitters and going well if you don’t have enough of this or too much of this then you   might be depressed well now we’ve added to the mix and said well guess what these imbalances   over here in the neurotransmitters may be caused by something completely different such as sex   hormones progesterone is another sex hormone an imbalance in the ratio with estrogen is implicated   in mood disorders so progesterone kind of calms down estrogen they’re yin & yang if you will kind   of like GABA and glutamate it’s referred to as the relaxation hormone the interesting thing here is   synthetic progesterone which is present in a lot of birth control is associated with depression   whereas naturally occurring progesterone levels haven’t had that same associate association drawn   in the research literature so another thing to look at with our female clients is possibly to   ask them have they and if they’re presenting with depressive symptoms have they changed their birth   control regimen or have they recently gotten pregnant or had a baby or stopped nursing and   that was one I learned you know when I stopped nursing my first child was your body actually   maintains different levels of hormones and makes sense maintains different levels of hormones when   you’re nursing so you’re producing milk and stuff and then when you stop nursing there’s a whole   different hormonal cascade that happens so there are multiple different times that estrogen can   change and progesterone levels can change ganado trope ins hormones synthesized and released by   the anterior pituitary promote the production of sex hormones so remember earlier I said that when   we’re under stress our body releases cortisol and cortisol tells our body you know what we   don’t need to produce those sex hormones right now so let’s connect it all if you’re under a lot of   stress you may not be producing enough estrogen which is why a lot of women when they’re under a   lot of stress tend to have more erratic cycles but even in men when your sex hormones are not being   produced because your body’s focused on fight or flee it makes the availability of serotonin   and norepinephrine and dopamine less available so chronic stress can alter the availability   of sex hormones which alter the availability of neurotransmitters okay you wanted some good news   we got some good news oxytocin is our bonding hormone and they found that it can counteract   cortisol and vice-versa it’s not just getting a hug though so I mean hugs are great don’t get me   wrong but a lot of research has indicated that people who have companion animals and pet their   companion animal it can be a horse it can be a dog it can be a cat a bunny rabbit whatever it   is that does it for you where you feel that sensation of bonding 15 minutes of petting   that animal raises oxytocin levels and which counteracts cortisol sweet thyroid hormones   yet a whole nother category so we’re moving off of the sex hormones onto our thyroid you have   two types of thyroid hormones thyroxine and the other one that I can’t pronounce t4 and   t3 t4 is broken down to make t3 they are always in a balance they’re always in a ratio too much   thyroid hormone which typically is t3 speeds things up and too little slows things down so   think about somebody who’s hypothyroid they have symptoms of depression one of the things we want   to rule out early on with our patients who present with the pressive symptoms is thyroid problems   the patients with too much thyroid hormone may present with anxiety symptoms so again we want   to look and say is there a physiological cause to the neurotransmitter imbalance the pituitary gland   hypothermic hypothalamic-pituitary-adrenal axis so this is the middle of that stress axis here   the pituitary gland releases thyroid stimulating hormones to get the thyroid to release t4 and t3   majority of the thyroid hormones produced by the thyroid are t4 but t3 is the most usable form so   it sends out t4 which is kind of you know it’s just kind of there it’s not a real hard worker   at all but along the way it gets converted to 3 t3 which is a workhorse this conversion is the   critical element because a lot of times doctors will test thyroid secreting hormone and t4 alone   and they’ll say well you’re secreting enough and there’s plenty of t4 to be broken down to t3 so I   don’t know why you have hypothyroid symptoms but the piece that they’re missing is they may not be   we may not be adequately converting t4 to active t3 so it’s important if you think you have thyroid   issues going on to work with an endocrinologist who’s going to do more than just a superficial   test or if you go to a GP you have and they do just a TS h t4 test comes back normal but you’re   like no something’s not right there are more tests that can be done to be more specific about what’s   available because if we’ve got a client who goes to the doctor and says doc you know I feel awful I   can’t wake up I’ve got no energy they run these tests they say well there’s nothing wrong with   you that just disempowers the client the clients going well nothing’s wrong with me I don’t know   why I feel this way I have no hope for getting better because I don’t know what’s wrong so I   want to make sure that we educate them about all the possible things that they might be able to   look into I don’t dump all this on my clients at first you know when I go through the assessment I   start listening for things and then I encourage them to get a full blood panel done and then we   talk about all that when they come back and then narrow it down to other things that they   may want to look at further testing for if the general assessment didn’t come back with anything overactive thyroid produces anxiety feelings of nervousness butterflies heart racing trembling   irritability and sleep difficulties under activity depressive symptoms the other interesting thing   and I don’t know what other word to use is if it’s either overactive or underactive the   person can have mood swings and have sleeping difficulties so we don’t want to just say well   you’re having mood swings it must be hyper we don’t know so we want to look at maybe the   thyroid gland is sputtering and giving a little bit and then not enough and then a little bit   and then not enough it’s just important for them to understand what the thyroid hormone   does other cognitive issues difficulties with concentration short-term memory lapses and lack   of interest and mental alertness are also common in hypothyroid but they’re also common in a whole   bunch of other things I mean most of these sound like what the criteria for depression   so we’re trying to sort through and figure out what may be going on with that particular client hypothyroidism led to a significant decrease of responsiveness of the serotonin system so again   here’s something else if you don’t have enough estrogen or if you don’t have enough thyroid the   serotonin system may be implicated and we know that serotonin insufficiency is implicated in   generalized anxiety disorder so one of those little paths to kind of be aware of optimal   thyroid function may be necessary for optimal response to antidepressants antidepressants   mean the serotonin is still there but if estrogen and thyroid are responsible for transporting it   around and making sure it gets taken up in the right places then if those two systems   aren’t working no matter how much serotonin is in the system of it’s not getting to the   right places it’s not do the job hypothyroidism generally increases enzyme activities and GABA   levels now you may go well sweet we want more gaba but we don’t too much gaba has too much   of a depressive effect so the person may not be motivated may feel apathetic about things they   can’t get excited about anything so there is such a thing as being too chill thyroid hormone plays   a role in the output of dopamine the precursor to norepinephrine our motivation chemical not enough   thyroid hormone not enough excretion of dopamine not enough get up and go and norepinephrine has   also insufficient norepinephrine has also been implicated in depression so you know   serotonin is not even in there we’re talking about thyroid dopamine and norepinephrine stress hormones so we’ve moved on cortisol it’s released from that HPA axis cortisol   triggers a decrease in leptin and an increase in gralen which increases appetite and food intake   cortisol is telling you there is a threat we need energy we need to mobilize the sugars   because it’s a glucocorticoid but we also need to get more sugars in here so we have energy for the   fight-or-flight as long as it goes on which is why a lot of people who are chronically stressed also   feel like they’re chronically hungry they’re just like I’m famished all the time and it may not be   that their body needs all that energy all those calories right now their body may be hoarding it   because they think they’re going to have to it’s gonna have to fight or flight flee for a long   time cortisol also affects the endocrine system including thyroids insulin regulating blood sugar   and your sex hormones all right well that’s not good so when people are stressed they maintain   higher levels of cortisol when they maintain higher levels of cortisol basically every bodily   system and all the neurotransmitters are impacted adrenaline is another stress hormone you know we   think about it when somebody gets really upset or excited or whatever they have a rush of adrenaline   alright sigh Roxon is also released from the kidneys and are from the thyroid and helps you   get fatty acids which are long term long term energy fat has nine calories per gram sugar has   four calories per gram so fat is a much denser source of energy effective chronically elevated   cortisol includes impaired cognitive performance you’re not thinking as well dampen thyroid   function yep eventually the body goes there’s no point the stress is not going to go away there’s   no point in continuing to fight so I’m going to turn down the sensitivity of the symptom blood   sugar imbalances sleep disruption elevated blood pressure lowered immune function and increased   abdominal fat so if a client starts talking about how they’re stressed they’re hungry all the time   and they keep suddenly gaining all this weight in their belly we might start looking at chronic   stress and interventions that we might use for chronic stress including mindfulness meditation   exercise you know anything that we can throw their way in addition to having them get a full   physical to make sure there’s nothing else going on like you know actual hyper hypothyroid caused   by a physiological problem low levels of cortisol brain fog cloudy headedness mild depression low   thyroid function again blood sugar imbalances such as hypoglycemia and remember when you’ve   got blood sugar imbalances and not enough sugar then your body cannot produce enough gaba which   means you’re not going to have enough naturally relaxing chemicals fatigue especially morning and   mid-afternoon sleep disruption low blood pressure lowered immune function and inflammation so these   are all things that we can produce to work our clients to say cortisol it’s not public   enemy number one but it’s pretty close to it so let’s look at how your cortisol levels how you’re   sustained chronic stress might be impacting your mood your health and your sleep and think   about different ways we can reduce that because that’s more tangible and cortisol is measurable   obviously the doctor has to do that but it is measurable in general when we feel emotions a   stimulus is received by our peripheral peripheral nervous system the brain responds by triggering   the amygdala which is our emotion center and the hypothalamus assesses if you will the need   for fight or flee it goes there’s a threat or there’s no emotional memory that helps the brain   determine the types of neurochemicals to secrete and in what amounts if the hypothalamus goes   yeah no big deal then you’re going to have more inhibitory neurotransmitters then if you have your   hypothalamus going that’s a problem what we need to look at and this adds another layer is when   there is too much of a chemical or hypersensitive receptors so hypersensitive receptors are like the   person that you know that jumps when you tap them on the shoulder somebody who’s hyper vigilant when   they are activated they go from 0 to 100 and it’s just like in sensitive receptors on the   other hand when they’re activated they may not do anything at all so you may have enough chemical in   the system but if the receptors are not receptive then the chemical can’t do its job so if serotonin   is sitting outside the receptors door just kind of knocking on it going let me in and that door   never gets opened then it doesn’t matter how much serotonin is sitting in the synapse it’s not going   to do any good so as I said before all every time I talk about too much and too little it’s   always relative to the proportions of the other hormones and neurotransmitters for that person anxiety irritability and anger our fight-or-flight response can be caused by dot dot dot too little   serotonin where you have anxiety coming on because serotonin is not there to help   the person calm too little GABA again not enough calming too much norepinephrine too much estrogen   too much testosterone or too much thyroid so any of these too much is going to cause one   symptom either anxiety or irritability or anger and too little will probably produce something   more on the depressive continuum now happiness and excitements an interesting one because happiness   and excitement are excitatory neurotransmitters they’re going to get your heart rate going they’re   gonna get your blood blood flowing they’re gonna get your breathing a little bit faster think about   Christmas Christmas morning when you run down the stairs in order to see what’s under the Christmas   tree or something else that is really exciting your body is secreting dopamine norepinephrine   glutamate and maybe a little bit of serotonin in there but these are the same chemicals that   are going out during a stress response it’s how the amygdala processes everything so we still   need these excitatory neurotransmitters we can’t just shut them down and go well that’s causing too   much problem let’s turn it down well if we turn it down we’re also turning down the body’s ability to   Spahn to happy stimuli and like I said depression can be caused by serotonin insufficiency or excess   and why is it excess when you have too much serotonin or too little serotonin you can   have high levels of anxiety they found and high levels and anxiety trigger the stress response   system after a certain period of time the stress response system goes you know what I can’t stay   this hyped up for this long I’ve got to turn down my sensitivity I’ve just got a you know let it all   go which starts leading to feelings of apathy and depression it can be caused by nor norepinephrine   insufficiency dopamine insufficiency thyroid insufficiency or gain too much or too little   estrogen the good thing is I Roy dand sex hormones can be measured so we can easily   or somewhat easily help the person rule those in and/or rule those out as can cortisol so if they   have chronically elevated or chronically low levels of cortisol they’re going to have some   mood symptoms but we can figure out that that’s going on and we can help educate the patient to   why they’re having the symptoms they are it’s not all in their head the New England Journal   of Medicine on major depression said numerous studies of norepinephrine and serotonin in   plasma urine and cerebrospinal fluid as well as post mortem Studies on the brains of patients   with depression so we’re talking about humans not just rats studies have yet to identify the   purported deficiency reliably so while we’re talking about depression being caused by if   you will norepinephrine or serotonin deficiency there’s no real research that can reliably say   yes this is it 100% of the time or even 95% of the time it’s more like yeah 15 percent of the time   so yes deficiencies in norepinephrine and and or serotonin does cause depression in some people but   that is a small subset and they found that there are 20 or 30 small subsets of different causative   factors estrogen and progesterone modulates sleep and too much estrogen can cause insomnia so again   if you have too much estrogen well you may have plenty of serotonin going on you also may not be   able to sleep sleep deficiency promotes elevated cortisol and further disrupts our feeding hormones   now for cortisol is elevated we’re not going to get good restful sleep sleep deficiency is   related to a 30% reduction in thyroid hormone levels so again remember that the body finally   after chronic stress will start turning down the thyroid it’s just like there’s no need to   exert any more effort because this is a losing proposition with sleep deficiency the thyroid   hormone levels go down cortisol levels go up which is your stress chemical so everything’s   starting to get out of whack when people eat serotonin suppresses appetite and increases   with feeding so as we eat our serotonin levels go up especially for eating carbohydrate-rich foods   but anytime we’re eating so if there’s not enough serotonin people’s appetite suppression may be off   but that’s also one of the reasons that people eat for comfort is because serotonin helps them feel a   little bit better so when they’re eating serotonin goes up dopamine is associated with safety ATP   handy which is great but if you don’t have enough dopamine then you may never feel satisfied as we   talked about before cortisol increases appetite and neurons involved in the regulation of feeding   are located in the hypothalamus so when you’ve got that hypothalamus pituitary adrenal axis all   activated all the time the HPA axis you’re feeding is going to be probably way up here   because the hypothalamus is going there’s a threat we need food we need we need energy and all of   these chemicals are involved in stress response stimulants stimulants set off the stress response   system by causing the body to kind of dump if you will sigh roid hormones stress hormones and   suppress sex hormones you know that HPA axis it’s activated excitatory neurotransmitters dopamine   and norepinephrine gets secreted so if you’ve got a lot of pleasure reward focus and concentration   going on and you’re just like woohoo yeah you’re probably gonna want to do that again but when   that wears off when stimulants wear off they wear off a whole lot faster than what our normal neuro   chemicals would normally do so when they wear off there’s a sudden lack of stimulation pleasure and   reward and there’s an excess of gaba and other other neurochemicals when people drink alcohol   initially gaba goes way up when they drink the alcohol and they feel relaxed and disinhibited and   all that kind of stuff the alcohol wears off and all of a sudden in proportion to everything else   there’s way not enough gaba so anxiety goes way up so what we want to remember is when we’re taking   substances or engaging it well taking substances specifically they are going to impact and wear off   in a much different rate than what would happen from our body normally excreting or causing   those neurochemicals to be excreted depressant increase gaba and may increase serotonin so they   found that alcohol may increase serotonin it also increases gaba but again when it wears off you got   a problem what there are other depressants out there besides alcohol though so it’s important   to know what are your clients taking what are they using recreationally not to be judgmental you know   if you have a couple drinks in the evening it is what it is what other things are you taking are   you using including looking herbs like valerian Valerians are pretty powerful depressant so it’s   important to know what what they’re taking so they know what impact is having on their body   there are a variety of neurotransmitters that are implicated in moods sex stress and thyroid   hormones among others modulate the secretion and absorption that is modulate the availability of   these neurotransmitters so if there’s a lack or an insufficiency proportionally speaking of   norepinephrine what we want to ask is not how do we increase it but what’s causing it why is there   an imbalance in norepinephrine in this particular patient dysphoria is about having an imbalance not   necessarily too much or too little you may have too much X in relation to Y too much glutamate   in relation to GABA so talking with your clients if they start taking medications talk with them   about how they feel and whether it’s getting worse you’re getting better to help understand you know   are we targeting the right things here sleep deprivation directly contributes alterations   in hormone and neurotransmitter levels and excessive eating may be caused by high cortisol   levels because the brain thinks it needs to store energy for the long fight sex hormones impact the   availability of serotonin but oxytocin has been shown to inhibit cortisol so pet a dog get a hug   do something to promote bonding it will help with stress levels dysphoric moods are caused   by a neurotransmitter imbalance but what causes that imbalance in each person berries greatly   and they found it even berries greatly among people with PTSD so just like depression PTSD   does not have one simple cause a cascade effect can happen when any one of these systems goes   offline so if the thyroid system goes offline has a dysfunction for some reason it may negatively   impact all the other symptoms because it’s going to change the balance and the ratios   of all the other hormones and chemicals involved in those feedback loops so final thoughts chronic   stress impairs sleep which causes imbalances and hormones and neurotransmitters involved   in eating sleeping mood attention motivation and sex disruptions in nutrition can fail to   provide the building blocks for the hormones and neurotransmitters so it could be something as   simple as you know eating junk food every day sleep impairment is associated with decreases   in thyroid hormones and increases in cortisol and dysregulation of eating so if somebody’s hungry   all the time but they’ve got a low mood and you know they present with depressive symptoms we   may want to look at what’s going on and could it is a factor contributing to this is sleep   um but any of these things could also contribute to problems with sleep estrogen and testosterone, imbalances can cause depression or anxiety like symptoms and thyroid hormone imbalances can also   cause depression and anxiety-like symptoms so the the take-home message is this stuff is stinkin   complicated but what we know is everything is intimately interconnected so we don’t   want to just start by saying well it sounds like you’ve got this and try to pigeonhole everybody   into one particular causation we need to understand what’s going on with them and since   we can’t measure brain neurochemicals to figure out exactly which one’s out of whack that’s where   the part art comes into psychology as part art and part science okay so are there any questions you I think you’re all probably feeling like me when after I wrote this I worked on research for about   20 hours and I was all but drooling at myself by the end I was like really I tackled a pretty   deep subject for an hour and you may need to go back and look at the presentation to kind   of make all the connections and connect the dots as it applies to your clients but let’s   see thinking about autism symptoms and these issues and body functions and hormones yeah   I mean certainly autism is correlated and I’m pretty ignorant as to the neurophysiology of   autism but I would think that there’s a strong correlation with the neurotransmitters so I   would look at other systems to see if there are something that’s going offline that may be   contributing to the neuro neurotransmitter imbalance when symptoms are exacerbated which makes me think you know again I don’t know as much I don’t know   much about autism but when a client begins stemming I’m wondering if those impulsive   behaviors mean there’s high levels of anxiety at that point so I’m   wondering what’s happening with the stress response system in the GABA feedback loop I would love after you guys kind of digest this and stuff if you have any   thoughts reactions connections I would love to hear back from you I’ll put   my email and other than that have a wonderful amazing weekend and I will see you on Tuesday 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 YouTubeHuman Synthesys Studio It’s Never Been Easier To Create Human Spokesperson Videos. 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DBT Skills Emotion Regulation | Counselor Toolbox Podcast with Dr. Dawn-Elise Snipes

 CEUs are available at AllCEUs.com this episode was pre-recorded as part of a live continuing  education webinar on-demand, CEUs are still available for this presentation   at AllCEUs.com/counselortoolbox I’d like to welcome everybody to today’s presentation of dialectical behavior therapy   techniques emotion regulation we are going to start by reviewing the basic premises of   DBT and the reason we’re doing that we’re only going to do it in this one because emotion regulation we’re starting kind of at the beginning but we want to go over what is   the theory underlying a lot of what we’re going to talk about we’ll learn about the HPA axis and   this isn’t something that Linehan talks about in DBT but it is important for understanding   our physiological stress reactions will define emotion regulation identify why emotion regulation   is important and how it can help clients ourselves staff yay and we will finally explore some   emotion regulation techniques there are things besides just preventing vulnerabilities that   we can provide to clients to help them regulate their emotions before moving into that distress   tolerance realm of skills and activities so basic DBT premises everything is interconnected when you   get up in the morning if you’re having a bad the day you know you didn’t sleep well your back   hurts you’re cranky you got a lot of stuff to do it’s raining outside you know yay   you’re noticing all the negatives your thoughts maybe more negative you may be more likely to   notice the negative you may be more likely to have what we call commonly call a bad attitude if you   start to have a better attitude what happens to what you observe and we’ll talk about that in a   little while the reality is not static what is true right now in the present may not be true which is you know was the future from what the present was half a second ago so reality   changes when we look at a situation when we look at an event, we’re looking at how am i reacting and   what is my feeling about the situation right now you know we can learn to change where we’re at but   with the information, I have right now what’s going on and a constantly evolving truth can   be found by synthesizing different points of view because most of the time as humans it’s just kind   of part and parcel of being humans we don’t have the whole picture and I did the best I could with   these little graphics here think back if you will to some of PJ’s experiments when he was trying to   demonstrate egocentrism when we’re looking at this yin and yang sort of model the girl’s stick   figure what does she see if you ask her what color is this orb she would probably say black   because we’re assuming she sees the black side if we ask this little thick figure model over   here what color is the orb she’s seeing the white side so he’d say white now if we asked a little   confused guy who is standing kind of on the third side or the south side he sees both of them so he   hears the stick figure girl say it’s black he sees a stick figure boy say it’s white and he’s   going well it’s kind of both you can synthesize both perspectives and figure out that this is   an orb that has multiple colors even though she can’t necessarily see those colors and he can’t   necessarily see those colors so BBT says let’s try to take a look and see if there are blind spots   see if there are things we’re not seeing or things we didn’t observe the basic assumptions of DBT   and well people do their best if we didn’t think that we probably wouldn’t be in this profession so   people are doing their best with the tools they have and the knowledge they have at any given   time and I added that extra part people want to get better and be happy most people don’t   want to be miserable if it seems like they don’t want to get better then we need to ask ourselves   what is the benefit to staying miserable why is it is scarier more threatening more awful to look at   getting better or being happy and that’s one of those motivational things we’re not going to go   there today but in general people are going to choose the most rewarding option when prevents   presented with multiple options okay now this one area in that I kind of diverge from the official   statement is clients need to work harder and be more motivated to make changes in their lives I’ve   had a lot of clients who have been working their butt off but they may not have the right tools   it’s like trying to unscrew something that is Phillips head with a butter knife they’re working hard but it’s not going anywhere because they can’t get any traction so I crossed out the   work harder and I tend to replace it with work smarter clients need to work smarter they need to   have more tools they need to have more effective tools and some of the tools they have may be awesome if we just tuned them up a little bit sharpen their oil and grease them whatever you   need to do and be more motivated to make changes in their life and you’re saying well they’re in   therapy they’re coming here for whatever reason there why aren’t they motivated to make changes   well again let’s look back at motivation and what’s the most rewarding choice is if they tried to make   changes before and it hasn’t worked out and they’ve been told that it was their fault they   were being resistant or you know they were blamed in some way or they just felt disempowered what’s   going to make them motivated to try to do that again please let me run the gauntlet most   people don’t want to do that so we need to help clients work smarter and understand that they are   working hard and they need to continue to do so and we’re going to help them get more effective   tools and we need to help them get more motivated we need to help them see that this time it’s going   to be different maybe a little bit different but this time we’re trying something new it may   be different even if people didn’t create their problems they still must solve yep you know   if you grew up in a dysfunctional household you didn’t create that problem but it is negatively   impacting you today so you’re going to have to fix it if you want to be happy which is the   whole goal of the lives of suicidal or addicted people are unbearable and when we’re talking   about DBT we’re generally talking about people who are highly emotionally reactive and suicidal self-harm those behaviors are away at this point that they’re trying to figure out how to tolerate   what seems like an unbearable situation in their head addiction is much the same way it provides   some relief from something they feel they have no control over people need to learn how to skillful   live skillfully in all areas of their life well yeah because every area is interconnected if   you’re stressed out at work do you just leave work go home and you have not stressed out   anymore no that’s not the way it works it would be great if it did but it’s just not even if you   don’t take all your stresses of work home with you it has taken a toll on your energy level so when   you get home you’re more vulnerable to emotional upset or just fallen asleep on the couch at 6:00   p.m. Whatever it is so we need to help people learn how to live skillfully in each area so   the exhaustion or negativity or whatever it is from one area doesn’t bleed over into the other   area so we need to learn how to juggle stresses in all of our areas to prevent vulnerabilities   and people cannot fail in treatment when someone relapses when someone you know backslides whatever   word you want to use I look at it as a learning the opportunity I say okay you made a different choice   than we wanted you to make a different choice than you were hoping you would make so let’s learn from   and figure out why that was the most rewarding choice than what was on your treatment plan   the goal that you’re working toward why what happened what were you more vulnerable so you   didn’t choose the newer behaviors because they weren’t as readily available let’s use this as   a learning opportunity to figure out what’s going on it’s not a failure it’s a learning moment or a   teachable moment so what is emotion regulation emotional dysregulation will start there   results from a combination of high emotional vulnerability so you’ve got somebody who is   kind of reactive and extended time needed to return to baseline so that when they get upset it takes them   longer to de-escalate and get back to baseline and an inability to regulate or modulate one’s   own emotions so I want you to think about some the time that you’ve been driving on the interstate   and you’re just driving along cruising along and heaven forbid if this has happened I hope not   but if it did you’re probably just late a semi comes along and runs you off the road onto the shoulder   and oh my gosh you get onto the shoulder your legs just to go in like this you can’t even press the   gas pedal because you are so stressed out you’re gripping your knuckles are white from gripping the   steering wheel so tight your heart racing you’re breathing fast you’re in full-out fight-or-flight   mode so you went from a1 on the stress meter you know kind of cruising along aware of the   fact that you need to be cognizant of dangers to a5 of oh crap that could have been bad alright so you take a couple of deep breaths you your breathing goes down a little bit you get to   the point where you can press the gas pedal and you pull back out onto the highway now   are you returning to baseline and just like la-dee-da cutting around like you were before most   likely not you’re a little bit more on edge and you’re checking your bat rearview   mirror more often you’re looking back making sure nothing’s in your blood spot more awesome   so you’re not returning to that same level of less stress Tunis if you will you stay a little bit   elevated because your brain is gone you know I thought it was kind of a safe situation but I’m   realizing now that not so much so I’m going to keep you on higher alert and it’s going to take   longer for you to return to baseline because you’re looking for those threats now you’re   much more aware that it could happen to people who come from invalidating environment people who are   regularly chronically stressed they’re constantly looking around for anything else that is going to   threaten them anything else that’s going to stress them out so they’re not going from a 1 to a 5 back   down to a 1 again they’re going from a 1 to a 5 back down to a 2 and then back up to a 5 and then   now we’re only going down to a 3 it’s that stress is ramping up so we need to figure out how   to help people deescalate get back down to that one and realize okay I got this that was an unpleasant situation but I got this now emotional vulnerability refers to the situation in which   an individual is more emotionally sensitive or reactive than others or then they normally would   be you know some people this is kind of and when we’re talking about personality disorders this is   pervasive when we’re talking about someone who has been under a bunch of stress for six months   this may be a situational sort of thing that we need to help them figure out how to get out of   but it may not be something that is completely and utterly pervasive in any event when you are   stressed you know you’re already kind of on edge and something happens do you react the normal way   that you normally would if you were just like sitting there and going off oh well okay let’s   figure out how to handle this or does it throw you up sort of into the stratosphere and for a   lot of people with emotional dysregulation when they’re their relaxation is on the brink   of chaos so they’re standing there teetering and they’re going okay I cannot take one more   wind or it’s going to push me over and then they call them damp they get upset and they’re kind   of on freefall for a while they get their balance again but then they’re still right there on that   precipice they never come down so what we want to look at is what’s going on with these   people that’s making them more reactive that’s making them more alert and more hyper-vigilant to stresses and stressors some of these may be because of differences in the HPA axis which   play a role in making people more vulnerable or reactive and we’re going to talk about the HPA   axis in a minute environment of people who are more emotionally reactive or often invalidating   and what does that mean well pick Jane Jane has had a heck of two years you know   there’s just been death after death a job loss she lost her home she’s living in an apartment   right now but she’s not happy and you know yeah you can just pile stuff on okay so James struggling right now she’s holding on and really trying to do the next right thing she’s trying   to make ends meet trying to do what’s right by our kids just feeling stressed out and   then something happens something that most of us would react with it to you know it’s annoying but   it wouldn’t throw us into utter chaos well James on that precipice Jane’s already at a four maybe   a four and a half depending on the day so when this happened just that too puts her on a scale of one to five puts her at a six-and-a-half which is in freefall but people   may not understand that they may not understand what’s going on in Jane’s life and they’re like   this is not that big of a deal why are you just overreacting which makes Jane feel guilty   Phil is self-conscious and feels misunderstood so then she feels isolated and rejected and we’ve   talked about basic fears being rejection isolation failure loss of control and the unknown well James   kind of experiencing all of those right now and the people around her instead of being validating   and going okay you were already stressed out I can see how this was just the straw that broke   the camel’s back they’re going what is your the problem so she doesn’t feel like she’s got   social support she’s out there on an island unto herself so we want to help Jane with emotional   regulation because we know she’s up here and we know she doesn’t like going into that freefall   but how do we help her emotional regulation is the ability to control or influence which emotions you   have when you have them and how you experience or express them and that’s a quote straight out of   Linda hands book so emotion regulation prevents unwanted emotions by reducing vulnerabilities   so you can go through life you can go through the day you can experience stress but instead   of feeling overwhelmed or enraged you might feel mildly irritated for a second and then choose to   move on emotion regulation helps people learn how to change painful emotions once they start so you   don’t get stuck nurturing that emotion or feeding into it and being angry with yourself because you   got angry about something you have no control over it teaches that emotions in and of themselves are   not good or bad they just are it’s your brains hardwired way of responding based on waiting for   it the information that it has at this particular point in time spiders if you’re afraid of spiders that is your brain’s way you see a spider and you feel fear it’s your brain’s way of going threat   spiders can be a poisonous big threat so you want to get away from it that’s your body’s way your brain’s way of going let’s survive we want to do this now you can figure out you can learn more   about spiders so in the future when you encounter then you realize that they’re not you know 99% of   them are not threatening to humans but right now at this moment your brain is saying warning getaway you probably want to do that so it teaches that emotions internet themselves are just   prompting us to do something they are survival responses and suppressing them makes things worse   telling yourself I shouldn’t feel afraid does that do any good if your kid comes to you and tells you   that you know I’m having a crappy day or I hate this does it usually do any good to tell them   well you shouldn’t feel that way feel better you know just be happy does that work I’ve never had   an experience where that worked now it may work for some people but so we want to help people   identify their emotions and not get consumed by the emotions are effective when acting on   the emotion is in your best interest so sometimes it’s in your best interest expressing your emotion   gets you closer to your ultimate goals sometimes expressing your emotion gets you closer to your   short-term goals like making the pain stop and true pain is unpleasant however in the   big scheme of things 15 minutes from now 3 hours from now is that getting you closer to the goals   that you want to achieve or was it just a stopgap expressing your emotions will influence   others in ways that will help you so if you want to influence others in ways that are positive and   will help you then emotions can be very kinder that can be very helpful emotions are sending you   an important message and we already talked about that so I’m thinking the devil’s advocate amigos   well I can think of a client that goes you rage is a great emotion to express is it in my best   interest yeah gets people to leave me the heck alone does it get me closer to my ultimate goals   yeah it reduces my stress by getting people to leave me the heck alone will it influence others   in ways that will help you, yeah it make them go away and are these emotions sending you an   important message yet rage is telling me that these people like everybody are a threat to me   so in the short term when you look at it that way it can be tricky to see but we want to help   people get outside of this immediate threat and say where you want to be what happiness looks like to you or however you want to define that ultimate goal and then once you get into   distress tolerance was your Thursday talk about how do you endure unpleasant emotions so you don’t   take the stopgap route now on to our favorite HPA axis the hypothalamic-pituitary-adrenal axis   is our central stress response system and doesn’t get too caught up and all the psychobiology of   this I think it’s good to be cognizant of but we’re not prescribing hypothalamus   place in the brain release is a compound called corticotropin-releasing factor or CRF   which triggers the release of adrenocorticotropic hormone from the pituitary gland which triggers   the adrenal glands to release stress hormones particularly cortisol and adrenaline now your adrenal glands are actually on your kidneys and why is that important what I want you   to see or understand is there are a lot of systems involved there are a lot of hormones involved   there’s a lot of stuff involved it’s not just box you know you’re releasing a bunch of chemicals in   your body that are altering the neurochemicals and the other hormones to prepare you for spiders   the adrenals control chemical reactions over large parts of your body including the fight-or-flight   response and produce even more hormones than the pituitary gland so you’ve got these adrenals   this is kind of your stress area if you will it produces steroid hormones like cortisol which   is a gluteal corticoid which means it makes your body release glucose what we know is that glucose is blood sugar energy all right so it increases the availability of glucose and fats for the long-term   fight-or-flight reaction it also produces sex hormones like DHEA and estrogen okay why is that   important because we know that when estrogen goes up serotonin availability goes up so if there are the adrenals are busy doing something else it may cause other hormonal imbalances and   it also produces stress hormones like adrenaline that is going to ramp you up they’re going to   increase your respiration increase your heart rate all that kind of stuff so once you have that whole   reaction we talked about and the perceived threat passes cortisol levels return to normal great this   is what happens in the ideal situation but what if the threat never passes what if we’re working with   a client who is constantly fearing rejection and isolation they need external validation   because they don’t feel good enough as they are they don’t have social support because their   emotional reactivity kind of pushes everybody away so they’re constantly feeling this threat   of rejection isolation failures loss of control and the unknown they’re holding on just like you   were holding on to the steering wheel after you ran off the road and you got back on you know   you kept chugging because you wanted to get to your destination but you were scared witless okay so you’re chugging along what’s going on what’s going on in that body the amygdala   and the hippocampus are intertwined with the stress response the amygdala modulates anger   fear or fighter flight and the hippocampus helps to develop and store memories when you’re under   stress and think about a time when you are under a lot of stress were you effective at learning and   paying attention to the good things and the bad things or were you just trying to make the pain   stop and make the threat go away from the brain of the child or adolescent is particularly vulnerable   because of its high state of plasticity which is why do we see people who tend to have personality   disorders much of their trauma and stuff really started early in their development and which is   why it’s pervasive in every area or many areas of their life, bad things are learned emotional   upset prevent learning new positive things to counterbalance it if you’re in a bad mood if   you’re scared if you’re threatened you know if you’re hungry homeless put whatever stuff is   there are you paying attention to the bluebirds that are flying around and singing   pretty songs or are you paying attention to the fact that you got an a on a test maybe   not so, we need to understand this person who lives in a chronically stressful environment may also   have an overactive HPA axis so they’re already they’ve already got some adrenaline and   cortisol going on they live kind of in this state of hyper-vigilance and then something happens and   they’re just like through the roof kind of like when you scare a cat what happens to the brain   one is a chronic threat to its safety and a constant the underlay of anxiety is constant undercurrent as   it learns your brain forces synaptic connections from experience and pruned away connections that   aren’t utilized by people who feel a lack of control over their environment are particularly vulnerable   to excessive stimulation of the stress response now it’s not just children abuse and neglected   children pop right up there but abuse and neglected adults think about a client you’ve   worked with who’s been in an abusive relationship for years does she have all the happy connections   or is she pretty much terrified exhausted and stressed out most of the time adults with   anxiety or depressive disorders it doesn’t even have to be an abusive or neglectful situation if   you have someone that forever whatever reason has clinical anxiety or depressive symptoms they are   in this state of constant threat and constant of people if you will so they’re not seeing they’re   not able to learn and take in as much of the good stuff so there’s more bad stuff coming in   they’re paying attention to more of the bad stuff or unpleasant stuff the synaptic connections   that form the foundation of people’s schema of themselves in the world become skewed towards   the traumatic event at the expense of a synaptic Network-based on positive experiences and healthy   relationships so we had this client here and these are her negative experiences she has a lot of them   and she’s got these going through her head a lot and it’s not they don’t just go away whenever she   meets somebody and she’s like well they’re going to leave me whenever something happened she feels   isolated and alone she may fear so she’s got really strong connections to those memories   and past experiences and when you’re in the midst of all this, there’s not a lot of happy stuff and   even when she appears happy a lot of times she’s faking it she’s not seeing and remembering all   the happy stuff she just wants to avoid the pain another example I could give you is thinking about   a city planner now a city planner only has a the certain budget just like we only have a certain   amount of energy the city planner looks and says what roads and what connections between cities get   the most traffic and let’s devote our resources and strengthen those connections because we know   we’ve got all kinds of traffic going over there and those roads that don’t travel those   back roads we don’t need to pay much attention to them right now because we need to make sure that   those roads that are used the most are strong but that’s the best analogy I can give without   putting out strings and everything else but so the hyper-vigilant state active IDEs activated   by the stress response that disrupts our ability to focus and learn you know we’re just trying to   not die we’re trying to not be consumed by pain it impairs the ability to form new memories and   recall information due to the physiologic changes in the hippocampus, it’s not time to learn and   process and do all that kind of stuff have you ever tried to study for a test when you had 16   other things going on that you are stressed about how well did you remember this stuff over here sometimes people relate things to prior experience well most of the time so maybe they’ve had a lot   of dysfunctional relationships and they start to get in a relationship which side is going to be   triggered the negative memories are the positive memories and then you have somebody who may be   attached to some positive relationships they start to get into a relationship and they remember some of   the positives because there have been some really good relationships but you know they may remember   the negative too but most likely they’re going to remember more strongly the positive so what’s   their reaction going to be if we’re trying to help our clients develop a healthy support system we   need to help them address some of those highways that are going towards the negative memories emotion regulation is transdiagnostic or useful with many disorders it helps people increase their   present focused emotion awareness it says right now right here right now what are your feelings   what are your physical sensations what are your thoughts and what are your urges it helps people   increase cognitive flexibility because it helps the kind of step back and take a look and say   okay what are my options let me step back from being intertwined with this feeling and go okay   I feel angry got it what are my options here what do I usually do what I want to do when I’m on   autopilot what are some other options I could do that might help me move toward where I want to   go identifying and preventing patterns of emotion avoidance and emotion-driven behaviors we don’t   want to get into the situation of constantly trying to avoid unpleasant emotions by lashing out by   hurting ourselves or by doing things reactively when I feel this way I must smoke a cigarette I   must cut myself I must fill in the blank we want to help people find alternate ways and be able   to step back and say that is an option is it the option I want to choose today increasing awareness   and tolerance of emotion-related physical sensations sometimes these physical sensations   are just so powerful and so overwhelming and sometimes the rush of adrenaline and that foggy wibbly-wobbly feeling you get in your head when you have just adrenaline coursing through your   veins is so overwhelming that people don’t know what to do with it and are afraid it won’t stop   so let’s help them increase their awareness and tolerance of this helped them understand that it   passes and use emotion-focused exposure procedures when they get upset help them think about things   in the group sessions that get them a little bit revved up you know we don’t want to precipitate   a full-scale crisis or talk about something that happened last week that got them upset and let’s   apply these procedures emotional behavior is functional to change the behavior it’s necessary   to identify the functions and reinforcers of the behavior so when they did it you know let’s talk   about cutting because you know that is one of those behaviors that we see are self-injury it’s what is the function of that behavior cutting or self-injury is a way of inflicting physical   pain where the person has control and they focus on that and they feel a sense of mastery when the   stuff going on in their head feels completely uncontrollable and intolerable it diverts their   attention and it also is something that they they can control how much pain they’re in so   that’s how it’s functioning now is the best the response we want no but we can see why somebody   might engage in that behavior and what reinforces that behavior well when they do that not only do they   get a reprieve from this emotional turmoil that they don’t feel like they can touch or control   or do anything with but their body also releases endorphins release natural painkillers to kill   that physical pain which makes them feel a little a bit better so they’ve got kind of a double whammy   on reinforcers there so we understand that now we need to find something else that they   can do and help them figure out how to tolerate the turmoil emotions function to communicate to   others and influence and control their behaviors and serve as an alert or an alarm to motivate   one’s behaviors so let’s talk about the first one communicate to others so I’m communicating to   a rat around me the people around me through my emotions what’s going on if I’m angry I’m lashing   out I’m going to influence people’s behavior and they’re probably going to back off if I am sad   or crying or scared that might bring them closer and in a more supportive sort of thing you know   again you’ve got to look at some of the behavior self-injury can elicit a caretaking response but   these emotions before somebody start acting out the behaviors the emotions serve as   a cue that okay Sally is getting ready to go in free fall so they can start reacting sooner and   it serves as an alert or an alarm to the person to motivate their behaviors if they know you’re   on the precipice if you know you’re right on the edge of being vulnerable cranky being irritable that day can motivate your own behaviors to figure out how to reduce some   of your vulnerabilities and identify obstacles to changing emotions now we can’t just say be   happy and all of a sudden somebody’s like oh I don’t know why I didn’t think of that I’m just   going to go ahead and be happy that’s just not how it works we want to look at organic factors   do they have an organic long-standing chemical imbalance of some sort and it may not be neurochemical it may be hormonal they may have too much estrogen too much testosterone too little   estrogen too little testosterone whatever let’s figure out you know have them go see their doctor   and figure out if there is something fibroids or moans whatever that might be affecting their   mood okay once we identify anything that we can tweak there we can’t measure neurotransmitters   we’re out of luck there because they’re found in so many places in the body that there’s no   way to isolate how much serotonin is actually in the brain can’t do it yes we want to look at   other factors that are biological imbalances neurochemical imbalances that are caused by   chronic stress that cause addiction to sleep deprivation and nutritional problems so what sort   of chemical imbalances are we precipitating by keeping the stress going and keeping the   adrenaline going keeping your body revved up all the time we want to look at obstacles well   let me stay with biological factors here real quick the organic things if we can refer to the   physician and we can figure out ways to address those that give the person one step forward so   they’re not feeling as depressed or they’re not feeling as reactive people with hyperthyroid you   know when their thyroid is overactive may have some anxiety issues or some other mood issues   that can be addressed with medication then we Looking at situationally caused things is the ways we can help them reduce their chronic stress sometimes there are some easy right-now sort of   solutions other times but chronic stress comes from issues that are so long-standing it’s going   to take a while it’s not that we can’t do it but it’s going to be a process so we move on and we   say okay addiction we know that when people use stimulants rev them up and then they crash and   it makes them more than emotional yo-yo caused by the substances or the addictive behaviors   also makes them more vulnerable to emotional reactivity sleep deprivation is all kinds of   hormones out of whack and tends to make people more irritable that’s one almost everybody can look at   addressing right now and nutritional problems if they’re not eating well not eating at all encourage them to see a nutritionist to make sure they’re getting something balanced that   they will adhere to not something that they look at and go yeah that looks great but no   way I’m eating nuts skill factors what can we help they with we can identify cognitive responses that   are obstacles which as I can’t do that I won’t do that resistance in some way my response   to that obstacle is set to look at it and weigh the positives and the negatives do a decisional   balance exercise to address the cognitive responses and figure out why is the dysfunctional   or unhelpful reaction more rewarding why is it more rewarding to be angry or scared than to look   at doing things and thinking of things that will help you feel happier what’s the disconnect generally, it comes back to prior failures and fear of failure because they’ve been down that road before   and it’s such a letdown when they’re feeling good for like three weeks and then they   crash behavioral responses that are obstacles to changing emotions if somebody lashes out when they   get upset they lash out and throw things and then they feel guilty so this behavioral   response may lead to having more difficulty changing emotions because we’ve got to help   them figure out how to pause before the behavioral the response so they don’t compound the situation with   more negative emotions and environmental factors people places and things being in environments   where you’re surrounded by people who either agon negativity or who bring out you know they’re there   with you they’re talking about conspiracy theories they’re just negative about everything or they’re   critical of you or remind you of situations where you’ve been criticized before so first, we want to   help people identify and label emotions a lot of our clients are relatively Alex Simon you   know they have a small repertoire if any of noting their emotions they just generally go   from situation to reaction and label what they felt is kind of a mystery so we want to help them   and doing it retrospectively is fine at first because that’s probably all you’re going to be   able to get the event profiting the emotion what were your thoughts your physical sensations and   your urges help me describe this in enough detail that if we were going to give it to an actor or an   actress they could recreate the situation what expressive behaviors were associated with that   emotion you know did you cry did you throw things did you hit the wall what were your   interpretations of that event at the moment not retrospectively but at the moment what   were your interpretations of what was going on what history before the event increases your   vulnerability to emotional dysregulation lots of big words what happened before that that   already stressed you out or had you on edge and you know we go through a whole bunch of   different things and this is you know behavior chaining we’re looking at kind of what led up to   the event what made you more vulnerable and what were you feeling at that time and then what were   the after-effects of the emotion or the reaction on your other types of functioning so after this   event and you went into freefall and you got angry and you lashed out and you screamed and you threw   things how did that affect your work how did that affect your relationships with your family how   did that affect your mood and just generally your sense of being in yourself for the rest of the day changing unwanted emotions okay so we started labeling them we figure out what we’re feeling   we figure out that yeah when we feel that way we act in ways that you know make us feel worse afterward what do we do about it let’s change All alright we already talked about the obstacles   and we’re trying to address those but in a moment check for facts ask yourself what are the facts   for and against your belief if you believe that someone did something to be antagonistic towards   you okay what was their motivation what is the facts for and against that also ask yourself is   this emotional or factual reasoning am I making a decision based on how I felt I felt attacked   therefore I must have been being attacked or facts you know I felt attacked yes but that was   because this person said ABCDE and all of those were very attacking and I felt like I needed to   defend myself so those are to check the facts sort of steps or you can go with problem-solving so   let’s change the situation that’s called cause any unpleasant emotion like I said with spiders at the moment you may not have enough information to not feel scared but maybe your spouse loves hiking and camping and you want to go but you’re afraid of those aren’t spiders so how   can you change the situation so spiders don’t trigger that same reaction increase knowledge   increase exposure there are a lot of different ways but problem-solving says ok what can I do   so my reaction my correct reaction is not one of threat or anger but it is one of at least mild   acceptance prevent vulnerabilities which helps reduce reactivity if you are a hundred percent   you know you get up and you’re like this is going to be a good day to day things that come your way   are probably going to roll more like water off a duck’s back then smack you upside the face like a   mud pie so we want to prevent vulnerabilities from the turn down the stress response because when you’re not   when you’re not up here already then you know you can fluctuate a little bit more and they   help the person be aware of and able to learn and remember positive experiences so if you turn down   that vulnerability and somebody’s in a good place or a better place than they were at least they’re   going to be able to notice and we’re going to want to encourage them to notice the positive   experiences you know instead of thinking that all people are threatening all people are going to   hurt me all people are going to leave they might notice that you know there’s Sally over here who’s   worked here for 15 years with me and you know she’s there she sometimes calls in sick but then   she comes back she’s generally in a good mood you know she’s not such a bad person and   you start noticing some of the things that are not self-fulfilling processes building mastery   through activities that build self-efficacy self-control and competence smuggle we don’t   want to say you don’t want to set a goal where somebody needs to go an entire week without   having an emotionally reactive response let’s say go for hours or maybe even a whole day that   would be wonderful but first, we’ve got to talk about how to reduce those vulnerabilities so we   set the person up for success what things can you do and well and we’re going to get down here in a   minute what can you do if you wake up and you’re feeling vulnerable you know the creepy crowds   are going around they cancel school for the entire week for school the county   school system kids are off for an entire week because of illness right now but you wake up in   the morning and you’ve got a fever and a sore the throat you’re like I don’t want to go   to work and get out of bed today what can you do to prevent being grumpy and overly reactive   throughout the day’s mental rehearsal and this can go for if you’re getting ready to do something   scary or threatening seeing yourself do that and do it successfully and this can even be during the   day just envisioning yourself getting up and eating your breakfast driving to work going through your   day seeing that one person at the office that always has some sort of snarky comment to say or   whatever irritates you laughing at it or dealing with it just fine going through everything in your   day as you would like to see it happen envision it see see what you can do rehearse it rehearse how   to handle negativity you know if you know you’re going to have to go in for your annual evaluation   with your boss okay so mentally rehearse how it’s going to go how are you going to react what’s   going to happen so you’re prepared for it you have your responses and it takes some of the unknown   out of the situation physical body mind care pain and illness treatment and the acronym for this is   please I changed one of them to laughter it used to be physical illness and that was both   PNL but I like laughter anyway we’ll get there when you’re in pain or when you’re sick you’re   vulnerable to being a little bit cranky you know that’s just because your body is already saying you are   weak you know back in the day when you had to defend yourself against predators the sick ones   and the ones that were in pain were the ones that usually got taken out first as a part of   our brain that still remembers that for whatever the reason so when we’re in pain or when we’re sick   our body keeps that cortisol keeps our cortisol levels higher and the stress response a little bit   higher so we want to deal with those things but know if we wake up and we’re in that situation  moment that was a little bit more vulnerable so we need to handle it with care and laughter you can’t   be miserable and happy at the same time laughter releases endorphins laughter helps people feel   a little bit better and find something to laugh at and have on my phone I keep comedy skits every   once in a while I’ll just pop one in even if I’m not having a bad day pop it in because I   like to laugh eat two-sport mental and physical health avoid addictive or mood-altering drugs   or behaviors that are going to put you on that the up-and-down roller coaster that goes up and it   goes even further down than you were when you started to get adequate quality sleep and exercise also helps increase serotonin and release endorphins which help people be in a better mood mindfulness is a judgemental observation and description of the current emotions we’re not   going to go deep into this right now another class on mindfulness and you can also   google it remembering that primary emotions are often adaptive and appropriate I know I   said that like six times much emotional distress is a result of your secondary responses shame over   having it I shouldn’t feel this way anxiety about being wrong you know maybe this   is the wrong way to respond or you know what if I’m wrong about this or rage doing due to feeling   judged for feeling that way I feel this way and you’re telling me I shouldn’t how dare you   so mindfulness is kind of an exposure technique because it helps people identify that yes I feel   that way but it helps them learn to step back and figure out how to not judge that and just go okay   I feel that way better or worse whatever that’s how I feel exposure to intense emotions without negative   consequences that non-judgmental acceptance just going all right is what extinguishes the   secondary emotional responses of feeling guilty about it or feeling ashamed or angry at yourself   for being angry so think of it this way if you can’t see this one’s the best Bruce Lee picture I   could come up with scenario one is an unpleasant experience the person has an unpleasant emotion and then feels guilt shame or anger for feeling that an emotion so instead of having to deal with one   emotion one-on-one now you’re having to fight for different unpleasant emotions and you start acting   to try to stop the avalanche of negativity in the absence of adequate skills now Bruce Lee he was   able to take out four or five at a time but most of us you know we would be beaten because all of   these adversaries would be coming at us and we would be building on them in scenario two and   this is where we want people to get they have an unpleasant experience which is part of life they   identify unpleasant emotions again part of life is sucky but part but they can deal with one emotion they’re like okay I’m angry what do I do about it instead of I’m angry   what do I do about it and I’m guilty and you see how you know she’s got this she can take that   one emotion so what we’re helping people do is uncomplicated this regulation is common to many   disorders people with dysregulated emotions have a stronger and longer-lasting response   to stimuli yes they’re already kind of stressed out they’re already hyper-vigilant if you want   to say they’re already wound up a little bit and then something happens and it amps for months now   we have a scale of 1 to 5 if they’re already on a 4 and it amps them up 2 points they’ve fallen   off the scale they’re in freefall so we need to understand that what we perceive as an excessive   emotional reaction they may not have been starting from the same place that we were, we’re starting   from a 1 if they’re starting from a 4 you know then their reaction to the same thing you seemed   pretty reasonable emotional dysregulation is often punished or invalidated and increases hopelessness   and isolation emotional regulation means we help people use mindfulness to be aware of and reduce   their vulnerabilities so we help them take it so they’re not at a 4 there may be a 2 you know   they’re in therapy for a reason we’re going to help them work on the other stuff and get them   down to a 1 but right now let’s help them figure out ways, they can take down their stress response   take down their just underlying anxiety, and stuff identify the function and reinforcers for current   emotions when they happen was understand where they came from because they’re functional do that   chaining worksheet check for facts ok now that I know how I feel I know what my reactions are   I know what my thoughts are I know what my urges are let’s check the facts in the situation for   and against that forces people to kind of step back which lets the urge sail out some and then problem-solves what can I do right now to improve the situation and what can I do in the future   so I don’t necessarily experience this exact the same situation again how can I break that mold okay so emotion regulation doesn’t provide us with a whole lot of distress tolerance skills, emotion regulation is really about preventing vulnerabilities and helping people figure out   okay here’s where I’m at how do I pause so then I can choose from my disgust distress tolerance   problem-solving or interpersonal effectiveness skills but it’s a big step how awesome would   it be if you could eliminate some of your vulnerabilities and think about it just for   a minute or two what vulnerabilities you’ve got going on in you right now and how many   of those you know could you potentially over the next week or two kinds of address sleeping and eating maybe you have 16 things going on and you could pare it down to eight there   are a lot of different things that you might be able to kind of pull out of the rabbit hat   if you will and what kind of a difference would it make if you’re talking to your staff and looked around at your organizational environment what vulnerabilities are there environmental   vulnerabilities physical vulnerabilities my best friend’s working somewhere right now where pretty   much everybody is required to work doubles because they are so short-staffed they’re going to start   getting vulnerable pretty soon so look around what can you do to moderate that so they can   model effective emotional regulation but they can also not be emotionally dysregulated by a   client who has emotional dysregulation issues all right so that concludes our discussion today if   you have any questions I would love to hear them if you want to discuss that’s awesome if you want   to get on to your next client you know I totally understand that I want to wish everybody a happy   Valentine’s Day for me I don’t particularly pay a lot of attention to Valentine’s Day but it is   the eve before half-price chocolates and that is my kind of my kind a day you you you you if you enjoyed this podcast please like and subscribe either in your podcast player or   on YouTube you can attend and participate in our live webinars with dr. Schneider I   subscribing at all CEUs comm slash counselor toolbox this episode has been brought to you   in part by all CEUs calm providing 24/7 multimedia continuing education and pre-certification training for counselors therapists and nurses since 2006 have used coupon code consular toolbox to get a 20% discount on your order this month.As found on 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…

Group Counseling Modules 1 & 2 Based on SAMHSA TIP 41

 This episode was pre-recorded as part of a live continuing education webinar on demand. Ceus are still available for this presentation through all CEUs registered at all, CEUs comm slash counselor toolbox. I’d like to welcome everybody to group therapy, which is a product of treatment improvement. Protocol 41. Today we’re going to be going over chapters 1 and 2 tips 41. They did make it into an in-service, which is what I loosely based. The next set of presentations on and we’re, going to talk about some of the different ways you can use group and make it beneficial and hopefully easier than some other ways of approaching treatment. So, in the first part of today’s presentation, the goal is to provide an overview of group therapy which is used in substance, abuse, and mental health treatment, and, as I said, I’m, loosely basing it on it, but a lot of times the groups That we’re doing in substance abuse are the same ones. We’re doing in mental health. We’re going to discuss the uses of group therapy in treatment, define five therapy models, explain the advantages of group therapy and modify group therapy to treat and address substance abuse issues. So group therapy is awesome because it supports members in times of pain and trouble. It’s something that we can make available to the community mental health center that I worked at before and if you’ve worked in community mental health or even private mental health. Maybe a lot of times. There are waiting lists to get into IOP to get into PHP to get into residential to get into detox. So one of the things that we started instituting was an intervention-level psycho-educational group, so we were able to sort of keep a tab on people who are on our waiting list. They got on the waiting list and they started coming to these groups that provided them with tools provided them skills. We weren’t treating any particular issue. We were focusing more on life skills, distress, tolerance, emotion, regulation, and all that other DPP kind of stuff. Helping them get through, was also enabling us to provide them with some hope and keep their motivation going. Group therapy can enrich members with insight and guidance. I found, and one of the reasons I love doing group so much is because you can ask a question to a group of 10 people and get 8 or 10 different answers to it, and the cool thing about that is that each person has their blind spots, so what they might not have thought about before might still be germane to them, and somebody else puts it out there. So when you start putting asking questions and putting the answers on the board or using the flip chart papers and having stations around the room that people go and contribute to the group process, you start getting a lot more feedback from individuals and they’re going To come up with ideas and suggestions and thoughts that not only each other had never had so they’re going to enrich each other’s lives, but they teach me something every single time. So I loved doing and still do love doing group and it’s. A natural ally with addiction, treatment or treatment in general group therapy enables us to provide a basic framework of information to people in a cost, effective manner. You know there are a lot of things like emotion, regulation, distress, tolerance, self, esteem, skills, effective interpersonal communication relationship skills, and self-esteem. I may have already said that we give to all of our clients whether it’s substance, abuse or mental health, and everybody who’s coming through the program. Has this curriculum? If you will go through now, it’s going to apply a little bit differently to each one and they’re going to take the stuff they get from those groups and they’re going to be able to take it back to their Therapists and say this is what I learned in group. If it is just a group process, then they’re going to be able to talk among each other and come up with their ideas, but IOP, PHP, and residential all have individual accounts. One component, if you’re doing an intervention level group 0 05 on the ACM. If you will, you may not have that individual therapy component. So you want to make sure that when you provide members with information – and you help them start gaining insight you tie it up in a nice little bow at the end and help them apply it. So what did you get out of today?’s group that could have been helpful last week and how could you have used it then go back around the room and say from whatever you got from today:’s group or what’s a morsel you got from today,’s, group that You’re going to use next week, and how do you expect to do that? So I encourage them to take one or two morsels and figure out how they can use that in their particular life. A little bit of a slide track here. In support groups, if somebody is going to celebrate recovery or 12 step group, or even a depression or anxiety management group, I encourage them when they walk out of the group to be able to answer the question. What was in that group for me? What can I take away from that now? It may be, I know what I don’t want to do, or it may be. That was a great idea that so and so had, but I want them to answer that question every time, not just walk out of a group and go well. That was a good group. Why? Why was it a good group? What did you get out of it? Group therapy, as opposed to self-help groups and support groups, if you will have trained leaders, so you do have a lot more ability to facilitate what’s going on and kind of point people in directions that you want them to go. Where support groups may have facilitators, but they don’t have the training that clinicians do and group therapy produces healing and recovery from substance abuse and mental health issues. You see a lot of people gain. Hope you see a lot of people gain optimism. You see a lot of people learn tools from one another and nobody can comic con. If you will – and I had to figure out a way to say that a little bit nicer than the way I usually do. But when people are in recovery and you can even think about it with your teenagers, if you’ve been around known more if you have them, teenagers hear what their parents say and they’re like yeah, okay, whatever old, fuddy-duddy, but when their Parents or when their peers say it, it carries a lot more weight, so sometimes the hope and faith and tools and stuff that they hear from their cohort has more impact than what we say. If we’ve created a good supportive, healthy, nurturing environment, group therapy has a lot of power to it because it’s basically like having a bunch of code therapists and the ability to control it a little bit more than in group therapy. You can address factors associated with addiction or these factors by themselves, such as depression, anxiety, anger, shame, temporary cognitive impairment, character, pathology, ie, personality disorders, medication management, and pain management. So let’s go through these a little bit. Depression groups are wonderful. Now we’re going to talk about different types of groups and there’s everything from the traditional therapy group where people are sitting in a circle and or however, usually in a circle and sharing what’s going on in their particular situation. To psycho-educational and skills groups, where we’re, providing them the tools to understand what’s going on and the tools to deal with what they’re experiencing, and you know with depression. One of the groups I’m, going to do is depression. Well, any of these is to talk about what is it. What causes it? Where did it come from? How is it impacting you to have people start figuring out what that means to them, then we’re going to start talking, probably in the next group, about what are some ways we can start addressing this and what has worked for you. What what has worked in the past and what things might you want to do? Try? Temporary cognitive impairment can be addressed in the group in the sense that we can provide some life skills coaching. We can provide for early recovery and substance abuse. For example, a lot of people come to our groups, or at least where I used to work. They would get out of detox and they weren’t fully detoxed. Yet they had two days under them and the drug was out of their system. For the most part, you know, except for like marijuana or benzos, but they were still not on their game so getting them to just get there on time, be prepared, pay attention, and process what’s going on was huge. We didn’t expect to make huge therapeutic gains, but what I wanted was somebody to be able to dress up and show up. If you will character, pathology can be addressed in groups, one of the basic reasons that Marsha Linehan created dialectically. Behavior therapy was to address borderline personality disorder and DBT is very strong in skills groups. Now it has individual components and coaching components as well, but she uses the skills groups to help people with character, pathologies, and borderline personality disorder, among other things, start learning about what are these symptoms. What do they mean? What does it look like and how can I deal with them and then they personalize it in their sessions? Medication management is huge for me, whether it’s, somebody who’s on antidepressants or somebody who’s on methadone. I don’t care, but I think it’s really important for people when they start taking medication, especially psychotropic medication, whether it’s, addiction or mental depression, or anxiety to be able to go into a group and talk with others who’ve Been on similar medications understand the side effects understand that gets better understand what they’ve done, that helped them deal with the side effects. For example, a lot of my clients used to be on Seroquel and Seroquel is extremely sedating, so a lot of them found that they needed to take it at night. But I had a small group of people who, when they took it at night, you know they would go to sleep at like 11, 00 get up at 6 30 and they were still groggy. As I’ll get out from the Seroquel and among themselves, they started talking about okay, so I need to take it at 7, 00 every night for it to be out of my system. So I can function the next morning they worked it out by talking about how long before it starts sedating you and how long the sedating effects last, but it helped clients stay more compliant with their medication because a lot of times and not knock Psychiatrists or doctors, but the ones that I’ve had experience with. For the most part, I’ve had a couple of awesome: attendings they don’t have the patients they don’t have time in their schedule to hear all of the issues and help the client brainstorm, and a lot of times they don’t think to share with the patient. These are the most common side effects that people tell me they experience. Yes, they get the handout from the pharmacist. There are like six pages, long and in eight-point font of all the potential side effects. But what do people feel like when they start taking it? This Zoloft is another one. You know that’s, what one is commonly prescribed and a lot of patients feel kind of like they’ve got the flu. They feel dizzy for the first two-to-three days and then that wears off, if they understand that, if they have a place where they can go and talk about the side effects and talk about how to deal with some of the side effects, it helps. And this is also a place where they can talk about things like weight, gain and fatigue, and lethargy. And how do you deal with this when you’re on this Giller medication, it doesn’t have to be facilitated by a nurse or a doctor. That’s more helpful if it’s facilitated by a clinician. What we want to do is encourage patients to become aware of what their potential obstacles are to be maintained to remain med, compliant, and identify some ways to address them. Some intervention that might be effective and then go talk to their doctor, so they are armed with knowledge when they go see their psychiatrist and say I’m having these problems, it also gives them a chance to talk to other people and understand what it looks like if the medication is working for them and gives them hope if they have to change two three four times to find the right medication, so medication management obviously, is a group that I think is important. If you’ve got clients that are medicated on pain, management,’s, pain can cause depression and anxiety. Your body perceives pain as a stressor, so anybody who has pain may experience negative affect, especially if it goes on for a while, so helping them figure out ways to deal with the pain and ways to deal with breakthrough pain. If you’re dealing with somebody who’s in recovery, then you’re also dealing with the issue of pain management without narcotics, so pain management groups can help teach stress management skills, progressive muscular relaxation, and sharing nonpharmacological interventions that they can discuss with their doctor, such as massage physical therapy, acupuncture yay, it also is a place that people get hope again. This is going to keep coming up with group therapy hope because they hear other people’s stories and yeah. I hear that after John’s accident, he was in agony for six months and he was able to get through it, so they can share and support one another. Another group provides positive peer support for abstinence from substances or addictive behaviors. Remember we want to check our clients, and assess our clients to make sure they’re, not engaging in addictive behaviors like internet gaming, pornography, gambling, food-ish food, and eating addiction. Anything like that, but it also provides positive peer support for positive action in any direction. So if it’s growth goals, if it’s depression goals, the group is there to cheer you on. They’re also there to notice when you’re starting to lose your motivation and point it out and help you increase that motivation groups reduce isolation. So if you’re dealing with someone who’s got empty nest syndrome, someone who’s got depression, someone who’s got it up an addiction. It helps them understand that they’re, not the only one dealing with that and they can share and support, enabling the members to witness the recovery or transformation of their fellow group members and see how other people deal with similar problems, because we all I mean There’s what twelve people in class today. So if I throw out any problem, I’m probably going to get at least eight or nine different suggestions for how to deal with it and that’s cool, but that’s. The awesome part about group two because they can share. What do you do when you can’t get to sleep at night? What do you do when the anxiety is so oppressive that you feel like you can’t breathe, rich, and provide information to clients who are new to the recovery process? So they know what to expect they’re not going to be giddy as all get out. Twenty-four hours, seven days a week, 365 days a year, probably ever that’s not reality, but it helps them learn what the recovery trajectory looks like helps. They accept the fact that they’re going to be bad days and it helps them see how they can be empowered in the process. It provides feedback on group members, values, and abilities. They’re going to hone in on their values, and you know I encourage them in my groups and obviously from a multicultural perspective. I think it’s vital that we encourage members to explore their values and accept or reject them as they are and do not meet them. For me to say whether your values are right or wrong, I want you to know what your values are and make sure that they’re. Yours, not something that came from the media or something that just kind of popped into your head. You don’t know where it came from that you, don’t agree with, and sometimes that will come up, especially as it pertains to medication, use or controlled drinking, or anything like that. But it also provides feedback on their abilities, and this is where I focus more than values. What is it that you have done already? What are your strengths if you went three hours yesterday without being depressed and crying that is awesome? What did you do? How did you do it? How are you able to do that, I want to highlight that ability, so we can build on it. We want to highlight the exceptions to the problems and offer the sort of family-like experience where people get a sense of belonging and support when groups are run well, even if their skills are psycho-educational groups when a group member leaves drops out relapses, whatever happens, They just if they suddenly leave. It affects the entire group. When you’ve got a well-run group and a group member graduates or completes treatment, there’s still a whole process and sort of a grieving process, as that person leaves the family and launches out of the nest. Whatever you want to say, we the way I’ve always run groups and what the way I was taught was. We always celebrate that at the end of somebody,’s treatment, or experience after the last group that that person attends we have a little bit of a little pizza party or something to celebrate. Let people say their goodbyes and have a good sense of closure. A lot of our clients did not have good family experiences, so we want them to have the experience of being supported, being able to have different opinions and disagree with others, but being respected and being able to care about groups encouraged coach support and reinforce What they’re doing? Well, we don’t have to focus on what they’re doing wrong. You know, we can talk about that. An individual – or you know it may become germane to the group, but what we want to do is reinforce what they’re doing. Right from a management perspective groups allows a single treatment professional to help several clients. At the same time, as I said, there are a core set of groups – educational modules, if you will that, I think all clients need to be exposed to so group is a great way to do it instead of saying the same thing six times a day to Each one of your clients having a group available with the advent of media and Internet, just like we’re doing right now. Web chat web groups. You can do some skills-based groups, you know if they’re, not treatment. You don’t have as many issues with confidentiality, but you can also have videos online that you have them watch, learn from complete a worksheet and then come and participate in a one-hour group, instead of maybe having to sit through the whole lesson, which is An hour or so and then participate in the group, so there are a lot of different things that you can do using group techniques to reach a bunch of people in with one treatment provider. In the same hour. Groups add needed structure and discipline because, generally the group leader has a certain goal for the group or has a certain style of managing the group, so it can help sort of add a rhythm. If you will to the group process. Now we’re talking about traditional therapy groups. You’re going to be sort of like the parent that controls the rhythm of the family. If you’re talking skills or psycho, read groups, you’re going to be setting more of a tone like a teacher and creating a learning experience, but it adds structure, so people feel safe. They know what they can share, what they’re. What’s too much sharing or what’s inappropriate sharing and it helps people also learn to bite their tongue, wait their turn all those other things that can be helpful in life. They instill hope in a sense that, if that person can make it so can I so they see people doing a little bit better yeah. They also see some people doing a little bit worse, sometimes, but that’s an opportunity for them to be able to reach out and provide support, and that helps the person providing support as much as it helps the person receiving it. I truly believe that most people get a sense of contentment if you will, by being able and being able to reach out and help someone that they are concerned about, it provides support and encouragement to one another outside the group setting now this gets a little dicey Depending on your groups and your agency philosophy in reality, in substance abuse groups, the people that are in your group are probably going to be going to the same support group meetings so telling them not to ever contact each other outside of the group is unrealistic. They’re going to see each other in the community, so it’s important to help them understand how to set boundaries and what’s? Okay, behavior, and what’s? Not okay, behavior between group members, other groups, other facilities are less stringent on that and encourage the clients to reach out to one another outside of the group setting. So, depending on the group, the issue, your agency, all that kind of stuff there’s going to be more or less sharing. What I want to see, especially, is, if you have, for example, in IOPS three hours here and have three groups with breaks. I want to see people talking outside a group. I want to see people sharing, not just all sitting in there going when do we get out of here? I want them to develop relationships and learn how to effectively communicate so group therapy is not individual therapy done with an audience. It is not a mutual support group. It’s designed to help people develop and practice knowledge and skills in a microcosm. You’re, creating a mini family or a mini-community. It aids patients in learning how to develop healthy, supportive relationships and also how to terminate relationships, because sometimes when people graduate they move on it, which doesn’t necessarily mean that they’re going to continue to interact with the clients in the group. Alright. So the second half of this class, we’re, going to look at the group therapy models used in treatment, explain the stages of change, and discuss three specialized group therapy modules that may be used for the stages of change. I’ve gone over this before for new people. I’ll go over it again, real quick think about getting into a pool in the summer. It’s hot it’s like 90 degrees. You are sweating bullets, pre-contemplation, and you’re still laying on the lawn chair going. I ain’t hot. Yet no, I’m not anywhere near hot enough to go near that pool contemplation you’re starting to get hot and sweaty, and you’re looking at the pool going. You know that might be a nice change in preparation. You move to the side of the pool and you’re dangling your feet in the water trying to figure out. If you’re ready to take the plunge because it’s cold, I mean compared to the 90 92 5 degrees C is outside and you know your 98 6 body temperature water is cold, so you’re preparing action is when you jump in you. ‘re, like I, can’t take it anymore. I’m too hot to jump in the pool. Now, if that pool is too cold, if it’s too painful to stay in there because you’re just like a ho ho, you may jump back out again and back into preparation or further back. If you get in there and get moving – and you know, get your body temperature back up that’s – sort of basically like treatment – and you’re getting the swing of things, then you just want to maintain. So you don’t get cold again and recurrence is when you get out you get hot again and go through this process again so pre-contemplation, I ain’t got a problem. Contemplation yeah, I’m a little uncomfortable, but I’m not ready to do anything yet preparation. I’m starting to get ready to make a change because this is uncomfortable, but I’m not very it action I’m on it, and maintenance is keeping your gains and maintaining a steady state, so variable factors for groups, the group leader group or Leader of focus, so if you’re focusing on a part of it, is your training. You know if you are more Rogerian client-centered in your training versus cognitive, behavioral versus DBT versus AC T, whatever your theoretical underpinnings are and what you choose to focus on. In that particular group, there’s a lot of stuff. We can focus on whether it’s cognitive, physical, or emotional. We want to another thing that affects it is the specificity of the group agenda. If you’re going to have a group and it’s on self-esteem, well that’s not specific, so we could go sixteen different ways till Sunday if you’re looking at self-esteem and disarming the internal critic. Now that’s much more specific for that group, so that’s going to affect what that group looks like for that session or that says sessions how similar or different your group members are. If they have a lot of different experiences, you’re going to have a different experience as a group leader. Then, if you have a lot of people who have the same experiences, open, ended or determinant duration of treatment, if you’ve got a group that somebody can join and if they want to stay for 104 weeks, they can stay for 104 weeks. That’s up to them versus a group that is 16 weeks long that’s also going to affect how your group goes. What do you cover, how connected do group members become? I use 104 weeks just to sort of overemphasize. I hope nobody stays in the group for 104 weeks, but the level of leader activity is. I have seen groups where its leaders will throw out a discussion and are like okay topic for today is what do you think about it, and let the group facilitator with a little bit of nudging here and there versus other groups where the leader is very involved In goes around goes okay, Sam.What do you think about this sally? What do you think about it and that affect how people react and what they expect it? Doesn’t necessarily affect what they get out of it, but these are variables that could affect how someone meshes with the group. Not everybody is going to like a real open, ended, a loosey-goosey group I don’t. You know I’m structured. So I prefer to be in groups where I know what the agenda is, and what we’re going to do. In my groups, start with a review from the last group that’s the first five minutes, and check in with everybody. Next, in five minutes we do a 15 to 20-minute psycho, ed piece, and then the last. You know 30 minutes of group. I spend going around the room and having people tell me, what is it that you got out of this? What do you think you could use this next week etc and apply it to what they know that’s how my groups go, so they’re, really very structured. You’ve got to be able to drop back and punt. If a client is in crisis or something strikes a nerve with them, you know you might have to change up a little bit. But overall you’re sort of setting the tone for what’s going to happen in the group, the duration of treatment, and the length of each session. You’re going to cover a lot more in a 3 hour of IOP session. That and treatment is five days. A week for 12 weeks, then you’re going to cover in a treatment program that’s one hour a week for eight weeks, just knowing what you’re going to try to cover will affect the depth or the breadth of what you go through. The arrangement of the room also affects how the people interact. If you have them set up in theatre, style, or classroom style. People interact differently than if they’re all sitting around in a circle, and if you ever want to experiment with that, it is interesting to notice how much differently people interact and how much more they seem to participate when they’re sitting sort of in A circle versus when they’re in theater style and I feel like they can hide and the characteristics of the individuals. Sometimes you’re, going to have people who are enthusiastic and chatting. Sometimes you’re going to have people who are not, and it could be for a whole host of reasons. It could be a bad fit, it could be their involuntary, or it could be they just got out of detox. It could be that they’re. All are just at that level of clinical depression that they’re having a hard time staying with the group and it’s up to us to adjust to try to meet the needs of as many people in a group as possible. Now, while I’m saying this, they didn’t say to size of the group. Here, the recommended size of the group is 8 to 12 people. If you’re dealing with adolescents or people with severe and assistant Mental Illness, it’s more along the lines of 812. For your average group 15 for psycho-educational and skills groups any more than 15. You’re doing a class and not a group. Psycho-egg groups assist individuals in every stage of change, pre-contemplation contemplation, yay. It helps clients, learn about their disorders, their treatment or intervention options, and other resources that might be available to them, such as assistance with prescriptions or physical therapy, or whatever other wraparound services. We often call it might be available. They can also be used to provide family members with an understanding of the person in recovery, so family egg groups can be awesome because then you get to understand and hear what the family thinks is going on and expects is going to happen in treatment and What they’re seeing and hearing, and you can normalize for them what’s going on with the client, so somebody recovering from clinical depression or somebody with bipolar disorder. You know this is what recovery looks like this is what living with the disorder looks like. This is what being on this medication looks like, I, ‘ve had a lot of patients because I deal with mainly co-occurring. I’ve had a lot of patients who have bipolar disorder, and you know some sort of substance abuse issue. They start taking. Seroquel, because that seemed to be the drug of choice for our prescribing at that particular time and they would start acting all groggy and family would freak out going you’re using again, and so Family Education groups were a great time for us to educate. Not only about the disorder but also about treatment, medication, side effects, and how to interact with the loved one to be as most supportive as possible. So ad groups educate about a disorder or teach a skill or tool and work to engage the clients in the discussion. I don’t want to stand up there in the lecture. I want them to be able to throw out ideas. So if I say you know what is it that you do when you’re struggling with somebody, because they just great on your every last nerve, what are some things you do to solve that problem or to deal with it? I don’t want to just tell them everything I want to do something more Socratic and encourage them to tell me how they work with it, and if they come up with something that’s, not quite on point. As far as being the most effective or healthiest approach, then we’ll talk about it and we’ll say well. I’m sure that’s worked for you. I’m wondering you know if there’s a kinder gentler way to do it, or you know you kind of massage it a little bit to morph it into something useful. We want to prompt clients to relate what they learn to their issues, including their disorders. You know how you, how this relates to your depression, but also your goals, your challenges, and your successes? Psycho-ed groups are highly structured and follow a manual or curriculum, and it doesn’t have to be a manualized curriculum that you buy from somewhere. You can create your curriculum, but you teach the same thing and it’s sequential and it follows a teach, apply practice method. So you teach a skill, you have them talk about how they would apply it, how that might apply to them, and then you have them practice it in role plays or imagine how they might use it. Next week, basic teaching skills are required for psycho-ed groups, though, which requires that you understand the basic components of learning, and I call these the three C’s capture, which is how you get the knowledge I mean you got to get it into your brain. Somehow I am a visual kinesthetic learner. I learned virtually nothing from sitting in lecture classes. I’m off in la la land in about 30 seconds. I know this about myself, so I need to have material that I and see, which is why I do powerpoints here some of y’all may not might not even be looking at the screen. You may be often doing something else and listening to me more power to you. However, you get the information in your brain is great. Global and sequential. Some people are global. They need the big picture when they’re doing a puzzle. They want to see the box first to do the frame and then fit all the pieces in sequential people. Don’t want the box that’s cheating they look for pieces and put them together and then try to figure out how all the pieces go together to make a hole and then their wall out as a whole. To appeal to both of those at the beginning of the group give an overview of what you’re going to cover in the group, and if you can sort of a written agenda it’s, not always practical. I always tried to put it up on the whiteboard. We always had issues with how many copies we were allowed to make and stuff. So in the interest of saving trees, try to give them some sort of an agenda, so they know what the progress is or what they can expect from group talk about it, so people can hear it and apply it through role plays having them apply it to themselves. Make them manipulate that information in their mind and provide visual representations like bullet points of what you’re going over. If you can’t, if copies again are an issue, have them bring a notebook and write on a whiteboard, so they can see it. So you’re presenting information in as many ways as possible. Conceptualization is relating the information to building blocks. So if you’re teaching a unit on cognitive distortions, then you’re going to talk about maybe using extreme words or nothing talk. So I might say tell me about a time that you’ve said something like you always do this and then what we’re going to talk about, how to change that and how you know. Thinking about things that way might be contributing to some of their distress and then caring. This is the biggest one which is again why I have clients when they leave a group, ask themselves: what could I get out of that? Why was that important to me if they’re not motivated to remember it, they’re not going to think back to high school biology or college humanities archaeology? 101. For me, I learned what I needed to learn for as long as I need to learn. It’s to pass the test, and then I forgot it all because I didn’t care about it, so we want them to care or they’re not going to remember so get it in their heads and help them relate it to something they know and make Them care about it, make them figure out why it’s important to them, foster an environment, to support participation, encourage participants to take responsibility for their learning, use a variety of learning methods that require sensory experiences, which means talking about it. You know talking about it listening to it and maybe drawing art therapy try to incorporate as many senses as possible. I always find that role plays are a big hit. You can also break up concepts and have to break up your group into smaller groups and have each of the smaller groups reteach a concept to make sure that they understand it and be mindful of cognitive impairments. So if you’ve got someone who is impaired in some way, make sure that you have some sort of method to ensure that that person is keeping up with the rest of the group. If it’s a diverse group skills development cultivates the necessary skills to prevent a relapse, depression, anxiety, and addiction and achieve an acceptable quality of life. Part of the skills groups assumes that the clients lack needed skills such as coping skills, interpersonal skills, and communication skills, hence the term skills group. So we want to allow clients to practice skills in groups. Psycho-ed groups provide the knowledge and, if you remember basic treatment, planning, and knowledge skills and abilities, so you know it, you learn how to use the skill and then the ability is a put those skills into practice. So we want them to be able to practice. These skills in a safe microcosm, you want to focus on skills, directly related to recovery and those to thrive in general. Think about Maslow’s hierarchy. They need to get those biological needs met, they need food, shelter, medication, pain management, health, safety and safety from themselves and love and belonging. So we want to help them make sure they’re getting those not just focusing specifically on depression or anxiety skills development groups have a limited number of sessions and a limited number of participants. So everybody can practice. We don’t want a big auditorium. We want that 8 to 15 number ideally, and there used to strengthen behavioral and cognitive resources. Skills groups focus on developing an information base on which decisions can be made and actions can be taken. So when they’re thinking when they practice the pause and they’re trying to decide okay, what is the best reaction to this current situation that’s when skills kick in and they’ve got a menu of skills to choose from cognitive, behavioral Groups, conceptualize dependence on substances as a learned, behavior that subjects to modifications through various interventions, which is a bunch of garbage garbled a for CBT groups, really look at using as a triggered behavior in response to pain. You want the pain to go away and your drug of choice does that. The same is true for self-injury or a variety of other symptoms that we see in our patients. So we want to look at what’s triggering those and how can we. What are they trying to meet? What need are they trying to meet with that behavior and how can we help them meet that? Otherwise, sorry, my nose is itchy today, work to change, my learned, behavior by changing my thinking, patterns, beliefs, and perceptions and include psychological elements like thoughts, beliefs, decisions, opinions, and assumptions. Cbt groups develop social networks that support abstinence, so the person with dependence becomes aware of behaviors that may lead to relapse and develop strategies to continue in recovery. Now that’s for addictions, groups for anxiety and depression, the same is true. We want them to have social networks with other people who experience the same diagnosis. If you will so, they can become aware of relapse. Warning signs when are starting to become impatient. They’re not sleeping as much, whatever their relapse warning signs are for their condition, disorder, whatever you want to call it, so they can develop. Strategies to stay, happy and healthy educational devices are used in CBT groups including worksheets role plays, and videos that encompass a variety of proof, and approaches that focus on changing the way we think and the behavior that flows from it. I cannot stand feeling this way can be changed too. I don’t like feeling this way, but I know it will change. In the next moment. Cbt techniques teach group members about self-destructive, behavior and thinking that lead to maladaptive behavior. We look at those unhelpful, cognitions and their effects of them. How does that impact you in your relationships? The way you perceive the world and your general sense of empowerment and happiness? They focus on problem-solving and short and long-term goal-setting which a lot of people don’t know how to do. Imagine how much better people and more empowered people feel when they figure out hey. I know how to do that. I know how to see a problem, develop a plan and solve the problem and they help clients, monitor feelings and behavior, particularly those associated with their diagnosis. Support groups are useful for apprehensive clients who are looking for a safe environment and they boast remembers efforts to develop and strengthen their ability to manage thinking and emotions and interpersonal skills support groups. Don’t have a trained facilitator necessarily, so they’re. Not necessarily. How do I want to say this? They’re only as effective as the effectiveness of the group leader and the health of the group leader, support groups, address pragmatic concerns, and generally improve members, self-esteem and self-confidence they’re. Often open-ended with changing members, encourage discussion about members, current situations, and recent problems. So we’re less focused on education and skill building and more focused on what’s going on with you today, and they provide peer feedback and require members are accountable to one. Other support groups vary with group goals and member needs and include facilitating desilting discussion among members while maintaining appropriate group boundaries, which can be a little difficult, especially with untrained if there are no trained facilitators there. These groups can help the group the whole group work through obstacles and conflicts. So if you’ve got people that are arguing within the group remember, this is a microcosm. This is a little family, whether it’s a support group or any other kind of group. These people meet every week and there are going to be conflicts, so we want to help people work through these and develop acceptance and regard for one another support groups ensure that interpersonal struggles among group members do not hinder group development. So if you’ve got a relationship budding between two people, not unheard of, or if you’ve, got a huge conflict, getting ready to happen between two people. You want to make sure that doesn’t interfere with the group process, so you may need to handle that outside of the group, or you know, figure out how to address it. Interpersonal process groups recognized conflicting forces in the mind, some of which may be outside of one’s. Awareness determines a person’s behavior, whether it’s helpful or unhelpful. So interpersonal process groups help people identify the developmental influences and other things that have gotten them to where they are, that influence, how they act and react the way they do currently, and bring a lot of stuff into awareness. Oh, that makes sense that I react that way because that’s how my mom used to react or when I did that when I was a kid I got in trouble for it whatever the case may be interpersonal process groups delve into major developmental issues. Searching for patterns that contribute to the problem or interfere with recovery abandonment issues is one that comes up a lot looking at the family of origin and their coping skills. We want to learn. What did you learn when you were growing up that is? You are using now and how effective is that for you, these groups use psycho dynamics or the way people function psychologically to promote change and healing and rely on the here-and-now interactions of members. So we’re focusing on all this stuff. That made you who you are and gave you the tools that you have right now, how’s that working for you? So there are multiple types of groups that are available to assist clients in achieving their goals. We view current coping skills as creative adaptations to what they’ve learned and ways to get their needs met. They may not be the healthiest coping skills, but they are serving a purpose. So we want to look at the way. Clients are coping acting interacting. Just look at their behaviors and ask ourselves what’s the benefit to that? What’s motivating is that, because we always choose the behavior. That seems – and I emphasize the word seems to have the most reward to it, based on reward and effort groups, help strengthen the healthy skills, but they also help point out some of the unhealthy ones, and again a lot of times it has more to it. If it comes from a peer, as opposed to, if it comes from a therapist skills required to facilitate groups, overlap significantly a lot of my psycho, groups are also kind of skills groups. I kind of do a psycho, ed skills blend when I do groups that are, my style though, and the group facilitator needs to figure out his or her style because you’re going to set the tone for your group. Not everybody is going to thrive in your group. Just like not everybody is going to mesh with you as an individual therapist, knowing your style and being confident is one of the first steps to having a really strong group experience. Types of groups include psychoeducational, which provides your knowledge, and classroom-type format. Skills development provides takes the information that knowledge and helps people translate it into skills. Okay. Now I know what an unhelpful thought or a cognitive distortion is. What do I do about it? Skills group is the: what do I do about it and let’s practice it. So when I have this thought, what can I do? Cognitive behavioral groups kind of integrate those but focus strongly on what’s going on with the individual and the thoughts if you think, of the ABCs, the automatic beliefs that may be perpetuating or maintaining the unpleasant consequences and support groups are those groups that Are not facilitated by a trained facilitator or by a clinical facilitator. In some groups like smart recovery, the facilitators are trained, but they’re, not necessarily clinicians and group members are accountable to one another more so than accountable to a group leader who starts the group by telling people what they’re going to learn and do and why it’s useful to them make them care, give them that global perspective of what’s going to happen and then go through the information step by step or sequentially. So all of your learners are getting as much as possible provide an overview of what you’re talking about have written material like I said, if copies are a big issue where you come from it’s, not unheard of, or if you just don’t like making lots of Xerox copies, write it on a whiteboard and encourage clients to bring a notebook and write it down. Clients will remember things better if they have to write them down because they’re going. To paraphrase it, which is a form of kinesthetic learning before they write it down most likely because they want to write down as little as possible, discuss the material and apply it ask for their input. How do you deal with this? What do you think about this option? How could you use this? How could you have used this last week and what do you think you might? How do you think you might use it next week and give me an example of what that would look like for you? Can also have them roleplay, maybe they’re having somebody in the group having a particular issue with a supervisor or roommate. You may choose to roleplay that in a group and have them apply a skill that you’re talking about. Have each group member close by identifying one thing they got at a group and how they are going to use it in their recovery plan. Again, it brings it back to caring, has the kind of tie it up into a neat bow, and is able to walk out with one tool. Yep give them two too many tools in one group and they’re going to walk out, and none of them are going to get used. You give them one tool and they walk out. They may try to use it throughout the week and then next week in the group, you can ask them how’d it go. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube, you can attend and participate in our life. Webinars with doctor Snipes by subscribing at all CEUs comm, slash counselor toolbox. This episode has been brought to you in part by all CEUs com providing 24 7 multimedia, continuing education, and pre-certification; training to counselors therapists, and nurses, since 2006 use the coupon code consular toolbox to get a 20 discount off your order. This month,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…