Tag: online training

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. No Learning Curve, So Easy To Use

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



As found on YouTube

Human Synthesys Studio It’s Never Been Easier To Create Human Spokesperson Videos. No Learning Curve, So Easy To Use

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. No Learning Curve, So Easy To Use

Best Practices for Anxiety Treatment | Cognitive Behavioral Therapy

this episode was pre-recorded as part of a live continuing   education webinar on-demand CEUs are still available for this presentation   AllCEUs.com/Anxiety-CEU I’d like to welcome everybody to today’s presentation on best practices for the   treatment of anxiety I am your host, Dr. Dawn Elise Snipes now not too long ago we did a presentation on strengths-based biopsychosocial   approaches to addressing anxiety while those are wonderful you know I thought maybe   we ought to look at you know what’re some of the current research so I went into PubMed which is   I don’t know it’s a playground for me it’s where you find a lot of journal articles and you   can sort I sorted by articles that were done and meta-analyses that were done within   the past five years so that gives us an idea about current research I mean there’s a lot   of stuff that is still the same like some of the medications that were known to work ten   years ago are still known to be you know good first-line treatments but there are also some   newcomers that we’ll talk about and there are also, some changes that we’re going to talk about so we’re going to explore some common causes for anxiety symptoms to treat, we need to and of course, this does play into the biopsychosocial aspect we need to   understand kind of what causes it because anxiety that’s caused by for example somebody having a   racing heart may be different than anxiety that’s caused for somebody who has abandonment issues so   we’re gonna treat the two things differently so we want to look at some of the common causes we’re   gonna look at some common triggers for anxiety Do you know what are some of these common themes that   we see in practice I will ask you to share some of the themes that you see that underline   or underlie a lot of your client’s anxiety and identify current best practices for anxiety   management including counseling interventions medications physical interventions and supportive   treatments so we care because anxiety can be debilitating and a lot of our clients   have anxiety a lot of our clients have anxiety comorbid with depression and they’re looking at   us going how can I feel anxious and stressed out and like I can’t sit still and be depressed at the   same time you know when you’re depressed you’re supposed to want to sleep well a lot of times   people who have both issues want to sleep but they can’t so I want to help clients   understand that also sometimes anxiety when people are anxious for long enough the body   starts kind of holding on to the cortisol the body recognizes at a certain point this is a   losing battle I’m not going to put energy into this anymore so it starts withdrawing some of   its excitatory neurotransmitters so to speak and people will start to feel depressed the   brain has already said this is hopeless this is you’re helpless to change the situation so   then people start feeling hopeless and helpless which is sort of the definition if you will of   depression low-grade chronic stress and anxiety arose energy and people’s ability to concentrate   so if we’re going to help them become their uber selves we need to help them figure out how to   address anxiety not just generalized overwhelming debilitating anxiety but also panic social anxiety   and those minor anxiety triggers that come along that may not meet the threshold for diagnosis   anxiety is a major trigger for addiction relapse if you have a client who is self-medicated before   or had an addiction for some reason anxiety is a major trigger increased physical pain when anxiety   goes up people tend to tense their muscles when they tense their muscles they tend to feel more   pain I mean think about when you’re stressed you tend to have more pain like in your neck your   back and things that already hurt may hurt more why because serotonin which is one of our major   anti-anxiety neurotransmitters is also one of our major pain modulators so when serotonin levels are   too low because anxiety is high then our pain perception is going to be more acute and people   can have sleep problems if they’re stressed out your body thinks there’s a threat you’re not   going to be able to get into that deep restful sleep you may have you may sleep a lot but it’s probably not quality sleep which means your neurotransmitters may get out of whack   your hormones make it out of whack and your body is going to start perceiving yourself in a   persistent state of stress when you’re exhausted the body knows that we may be the weakest link   in the herd so it continues to secrete cortisol to keep you on alert a little bit so you   may again you may be resting kind of like when you have a new baby at home those first couple   of months that my children were home from the the hospital I slept but I didn’t sleep well I mean   the slightest little noise and I was awake and I was looking around and you know I felt it I felt   exhausted and a lot of new parents do so triggers for anxiety abandonment and rejection and we’re   going to talk about ways we might want to deal with these things but some of the underlying   themes that I’ve seen in a lot of clients and when I do the research and a lot of what themes that   come out include low self-esteem if someone has low self-esteem they’re looking to be externally   validated oftentimes they’re looking for somebody else to tell them you’re lovable you’re okay so   that can lead to anxiety about not having people to tell them you’re okay which makes   their relationships tenuous and can make them dysfunctional irrational thoughts and cognitive   distortions may lead people to believe that if I’m not perfect for example I am not lovable so we’re   going to look at some irrational thoughts and cognitive distortions unhealthy social supports   and relationships when you’re in a relationship it takes two to tango and even if your client is   relatively mentally and physically healthy if they are in a dysfunctional relationship they can fear   abandonment and rejection if that other person is always saying if you don’t do X I’m going   to leave you or if that other person is always cheating on them or whatever so relationships   can trigger abandonment anxiety and ineffective interpersonal skills can lead to relationship   turmoil and social exile if our clients are in relationships even if they’re not completely   dysfunctional if our clients are not able to ask for what they need and set appropriate boundaries   and manage conflict effectively because conflict happens in every relationship then they may start   to argue more which may lead to fearing may lead to relationships ending in the past and them going   well every relationship I get into ends which means I must not be lovable so they start fearing   abandonment and rejection these are four areas that we can look at one more assessing clients   another issue is the unknown and loss of control a lot of times negative self-talk and cognitive   distortions can contribute to that if I don’t have control of everything then it’s all going to be a   disaster negative others when clients hang out or when people hang out with negative people it   kind of wears on you after a while you notice that people who tend to be more negative   pessimistic conspiracy-minded tend to hang out with people who are also negatively pessimistic and   conspiracy-minded so if you’re hanging out with somebody who tends to be anxious then the anxiety   can be palpable and it can kind of permeate physical complaints can lead people to be   anxious because they don’t know what’s causing it like I said earlier sometimes if your heart starts   to race if you don’t know what’s causing it for you can start thinking I’m having a heart attack or   I’m gonna die when people have panic attacks for the example they truly think they’re having a heart   attack and it’s I’ve had them they are very very unpleasant experiences but when people   start having physical complaints and it can be you know they have a weird rash that they can’t get to   go away or whatever but when they don’t know what it is and they can’t control it they can’t   make it go away they start thinking about all the worst-case scenarios and going online and   getting on WebMD which usually gives you all the worst-case scenarios um so physical complaints   are important we need to normalize the fact that nobody’s pain-free all the time and you know the   fact that you may have an ache or a pain or a lump or a bump or you know a cough most likely you know   when we look at probability the probability of it being something significant is pretty small now   do you want to get it checked out probably but you know the probability that is anything to be   worried about is relatively small and a sense of powerlessness can trigger fear of the unknown   and loss of control for somebody who doesn’t feel like they have any agency in their life   if they have an external locus of control or if they felt victimized all of their life then   they may fear not being in control they may be holding on and saying okay this is the one area   of my life I can control when I grew up you know I grew up in a very chaotic environment I had no   control I was bounced around in the foster system yadda yadda yadda now that I’m an adult you know I   can control these things and I am going to hold on with white knuckles and if I can’t control   everything then that terrifies me to death and loss are other triggers for anxiety and it can   be people or pets and pets are important I don’t want to minimize pets because you know they are   little parts of a lot of our families so making sure we check that my daughter’s dog for example   is it’s getting old she’s getting older she’s 14 now I think and you know she’s in decent health   we took her to the vet and the vet said yeah she’s got a little heart murmur but that’s expected for   a 14-year-old dog and but when she goes out if she doesn’t come back when I call her I have this rush   of anxiety for a second oh my gosh I hope this wasn’t the day so anxious around losing people   and you know if she when she crosses the bridge she will and you know I’m okay with that I’m   I have a harder time dealing with my daughter’s emotional turmoil when that happens and because   she’s grown up with this dog so you know those are the types of things that we want to talk about   with our clients what things are weighing on you that you may not even be thinking about because I   know in the back of my mind there’s always that worry about one of our donkeys and her dog jobs   and promotions can trigger anxiety if people are afraid they’re gonna lose their job if they’re   always afraid that you know they’re gonna walk in and get a pink slip or get fired you know we want   to help them look at how realistic they are you doing what you need to do to achieve   and keep your job and sometimes it’s not easy to the answer I mean the first thought that a lot of us   have is well you know if you’re doing the right a thing so just do it but there are those bosses   out there and I’ve had some amazing bosses a lot of them and I’ve had two horrendous   bosses and those two bosses I could never I never felt like I was able to do anything right   and so going to those jobs there was always this anxiety about what I’m what am I going to get in   trouble for today so you want to talk with people about does your job cause anxiety what can you   do to moderate that anxiety the same thing with promotions people may get anxious about whether   they’re going to get promoted to safety and security you know when you lose safety and security you can   feel anxious so if there’s a break-in at the house next door or shooting down the road   or you start watching the news you can feel very unsafe and insecure quickly so we want to   help people figure out how safe and secure are you really and a lot of it goes back to looking   at facts when people lose their dreams and hopes or fear that they’re going to lose their dreams   and hopes they can start to get anxious you know they have this dream that they’re going to be   a doctor or I just finished the presentation on helping high school students transition to college   and a lot of high school students for example start college with these wide eyes and hopes   to save the world and they want to be doctors and engineers and this and that and they get   into it and they realize that it’s a lot harder then they thought or they realize that you know   what I don’t like this but I’ve already committed to it so what do I do I want to help   people but I can’t I can’t cut it doing this you know for me I figured out in my second year that   I wasn’t going to medical school because I wasn’t going to pass calculus and that caused a lot of   anxiety it was like okay what am I gonna do now Do you know what career should I choose to help people figure out do they have dreams that have maybe kind of crashed and burned and you have to   find new ones you know okay that one we’ve got to accept it figure out that it’s not going to be and   what can you do now people may also have dreams about relationships they get into relationships   and see themselves with this person forever and then this relationship ends and or starts to   get rocky and they’re like but that’s my dream what happens if that’s got to happen because   it’s my dream I don’t know how to function if that goes away we want to help people be able to   rewrite their narrative and then sickness spiders and other phobias kind of go in with death a lot   of times when people get sick they start getting anxious that oh my gosh what if this is terminal   oh my gosh what if this is you know incurable if I get bit by a spider it’s gonna kill me and   which is rare you know there are very few spiders that is actually that poisonous same thing with   snakes going over bridges I’ve shared with you all that is not one of my irrational fears you know I   am just terrified that you know something’s going to happen and I’m going to get pushed off the side   of the bridge which is completely irrational but we need to help people look at those and identify   the thoughts that they’re telling themself about those phobias and dealing with that anxiety failure   is another –trigger for anxiety especially in this culture our culture American culture is large part puts a high premium on success and perfectionism so when people realize that   they’re not perfect they may start to get anxious because they feel like if I’m not perfect then I’m   a failure you know those cognitive distortions of all-or-nothing thinking and they start with that   negative self-talk you know you can’t do anything right so those are some of the issues that you   know we often see in counseling sessions so what do we do you know somebody comes in and is like   I can’t live this way doc anxiety depression and substance disorders as well as a range of physical   disorders are often comorbid so this is the first the thing we need to realize is that   we’re very rarely dealing with a very simple the diagnosis you know when somebody comes in we need   to figure out you know if they come in and they’re presenting with depression all right let’s talk   about that and then we start realizing that there depression started to occur after a long period   of being anxious okay so we need to deal with that but we also need to help them   with their sense of hopelessness and helplessness we need to develop that sense of empowerment and   then substance disorders we know that substance use is often a way of self-medicating but we also   know that it monkeys with the neurochemicals in the brain and can contribute to anxiety and   depression the same thing to physical issues pain from physical disorders anxiety about having   physical disorders medications you’re taking for physical disorders can all contribute to anxiety   so we need to look at the person as a whole and go what are all the things that are contributing to   the anxiety and what are all the things that the anxiety is contributing to so we have started having this big list of stuff that needs to be addressed and then we can start figuring out okay   where we start so knowing that these things are comorbid helps researchers explore pathways   to mental disorders so they can start figuring out you know what little string can we pull to   unravel this blanket of anxiety so it doesn’t suffocate somebody and for us, as clinicians, it   provides us key opportunities to intervene in you know sometimes clients will come in and start talking about their anxiety and their physical issues you   know maybe their anxieties about you know heart palpitations and because that’s a common one we   may want to encourage them to go see the doctor to get that ruled out you know rule out anything that   has to do with hormone imbalances or you know heart conditions or anything else that might be   contributing to it which can help them address it and if they do have physical disorders let’s   go with hormone imbalances that are contributing to the heart palpitations then they can start to   treat that if they don’t start to treat that then no amount of talk therapy we do is going to get   them to the quality of life that they’re looking for because they’re still gonna feel those so   we want to make sure that we’re addressing them holistically anxiety disorders should be treated   with psychological therapy pharmacy therapy or a combination of both and what they found and this   is no surprise this is kind of old news is that counseling Plus pharmacotherapy tends to have the   best outcomes but separating the two have similar outcomes in many cases but that’s just   looking at and I hate to call it simple anxiety but we’re just looking at anxiety symptoms here   we’re not looking at the full quality of life and we want to make sure that we’re also including any   medical issues behavioral therapy is regarded as the psychotherapy with the highest level   of evidence, there are a variety of cognitive behavioral approaches ranging from acceptance   and commitment therapy to dialectical behavior therapy to CBT to debt you know any of those that   deal with the thoughts and the cognitions that fall in that realm and it is effective in the current conceptualization of the etiology of anxiety disorders includes an interaction of   psychosocial factors such as childhood adversity or stressful events and a genetic vulnerability   so the psychosocial factors and these are other things when we do our assessment we want to pay   attention to because our approach to treatment is going to be different for people for example   who have trauma-related brain changes maybe then for somebody who doesn’t so, we want to   look at childhood adversity and stressful events that it may have caused basically what I tell clients is like rewiring of the brain there are trauma-related brain changes in soldiers and   especially in children or in people who’ve been exposed to extreme trauma that is designed to   protect them but it also can cause complications kind of later on in dealing with anxiety coping   skills that were learned that are ineffective you know sometimes people grow up in a household or an   environment or a situation where they don’t learn effective coping skills so we need to kind of help   them unlearn those and learn new ones build on their strengths and trauma issues that may still   need to be dealt with such as domestic violence you know if they grew up a lot around a lot of   domestic violence they may think you know I’m out of that situation it’s over I don’t want to   think about it it’s not bothering me anymore or a parental absence and I put absence because it can   be death it can be a parent that just packed up and left it could be a child that got put up for   adoption whatever put the child in a position of feeling like they were rejected by a parent can   be very traumatic and bullying among other things but there are a lot of trauma issues that people   once they’re out of that situation often say you know I’m out of it it’s not a big deal I dealt   with it let’s move on and they don’t realize the full ramifications and how that’s contributing to   their current anxiety and their current self-talk and cognitions of current stressors if somebody has   a lot of current stressors that are also going to impact whether they develop generalized anxiety   you know we’re kind of stacking the deck here and the current availability of social support if they   don’t have effective current social support then they’re gonna have difficulty bearing the weight   of everything on their shoulders so we want to look at all these psychosocial factors when   we do our assessment now going back to the trauma issues if you’ve taken the trauma courses at   all CEUs you know that some people are not ready to acknowledge that the trauma is still bothering   them or work on the trauma and that’s okay we can educate them that it might be an issue and   then let them choose how to address it but we want to bear in mind the fact that you   know this could be sort of an underlying force motivating some of the current cognitions and genetic vulnerability so you take any three people and you put them or 300 people and you   put them through roughly the same psychosocial situations they’re all probably going to react   a little bit differently based on their prior experiences but also because of their genetic   makeup there are certain permutations and they found four we’ll talk about later that make the   brain more or less responsive to stress and more or less responsive to serotonin which   is your calming chemical so brains that are less responsive to serotonin isn’t going to you know   send out as much or send out serotonin as easily so people can stay kind of tensed and wired that’s an oversimplified explanation but that’s all you need for right now so genetic   vulnerability impacts people’s susceptibility to the effects and development of dependence   on certain substances which can increase anxiety when people are detoxing from alcohol when they’re   detoxing from benzos when they’re detoxing from opiates they can feel high levels of anxiety when   they take opiates some people find that opiates have wonderful anti-anxiety properties not that   I am advocating for the use of opiates I’m just client experiences have shown that that   can be true so some people are going to be more susceptible to the anti-anxiety effects   of certain substances and some people are going to be Cerrone to become dependent on substances   where others may not and that part of that is genetic vulnerability and they estimate about   30% the predictability of the development of anxiety disorders is genetic and genetics   also impact which medications are effective if you have genetic makeup then SSRIs might   be helpful if you have genetic makeup be then atypical antipsychotics may be more effective   and SSRIs might not do anything which is why a lot of our clients get so frustrated because they know there’s no way to figure out exactly what I guess there is now that there’s genetic testing   out there but up until then it was harder to figure out which medications to start with and   most physicians matter of fact I don’t know of a single physician that starts by   saying well let’s do a genetic profile to see what med to start you out with most we’ll start with events as with an SSRI or some other anti-anxiety medication some sort of benzo   that’s been my experience so we may want to encourage clients to consider genetic   testing if they’re having difficulty finding a medication regime that works for them and they   are feeling like they have to have medication genetic vulnerability also affects what’s going   to make somebody more vulnerable now than all of you in class today you know thinking about sleep you   know sleep may not be a big deal for some of you I know people who can go days or weeks with four   or five hours of sleep and they feel fine it’s not a big deal, not me I need eight or nine hours   of sleep so genetically for whatever reason I am programmed to need a lot of sleep so when I don’t   get that much sleep I tend to be it tends to be harder for me to deal with life on life’s terms   and I know that that makes me more vulnerable to being irritable so genetic vulnerability affects   who can become addicted and affects what medications work best and affects what situations are going   to tend to make somebody more vulnerable to anxiety so our medications and I know the type   on here is small but we’re going to go through the first-line drugs are the SSRIs selective   serotonin reuptake inhibitors and SNRs is selective norepinephrine reuptake inhibitors   now the names are a little bit deceptive because selective norepinephrine reuptake inhibitors also   increase available serotonin but the mechanism of action is different the mechanism of action   for each SSRI is a little bit different as well which is why you can put somebody on Prozac and   they have an awful experience and you can put them on Zoloft and they have a much better experience like I said earlier a lot of the research pre five years ago had been done on medications and   Zoloft Paxil luvox Lexapro Celexa and their generics have all been found to be effective   at treating anxiety in certain people no one the medication works for everybody in the last five   years Effexor has come on the radar and it has been found effective according to the hamilton   rating scale for anxiety so that’s another one to consider if clients are not successful or getting   the treatment effect that they need for on some of the other medications obviously, none of us   probably are prescribers but we do need to educate clients about why the first drug or even the third   drug that the doc tries may not work so they don’t start feeling helpless and hopeless like   I said earlier there are at least four different genetic variations which are correlated with the   development of generalized anxiety disorder and different medications are more or less effective   depending on the genetic makeup of the person there’s a high mortality rate moving on to two   benzos the recommendation has switched to back off from the use of benzos now for   some doctors will prescribe an SSRI and for the first four weeks while the SSRI is building up   in the system they will also prescribe a benzo to be taken as needed to moderate the   anxiety and you know you could argue on either side of that, if somebody has a history of substance   use or substance dependence benzos are really a bad idea because they do have a high rate of   dependence but the other reasons that they are now cautioning against the use of benzodiazepines is   that there’s a higher mortality rate among benzo users compared with non-users there’s an increased   risk for dependence with use for more than six months and that’s a long time to be using benzo   and when we’re talking about dependence and six months we’re talking about somebody who uses it   like every four hours or every eight hours depending on your benzo every single day not   a PRN user if somebody’s using it at night to help them go to sleep or you know three or four   times a week when the anxiety gets high the risk of dependence is relatively low but a   lot of people with anxiety because if they find the right benzo makes them feel so much better   they may not want to be off of it and for a lot of people when that benzo reaches its half-life and   starts getting out of the system even more their anxiety spikes you know they have rebound anxiety   which they want to medicate with more benzos that’s gonna be an issue for them to discuss   with their doctor there’s also an increased risk of dementia identified in long-term benzodiazepine   users again this is for the people who use you know throughout the day every day for six months   or relatively every day for six months or more and it doesn’t matter if it’s you know we’re   talking about somebody who’s 65 or somebody who’s 35 who’s been using benzos for you know   six months a year two years the risk of later life dementia is greatly increased according   to the research benzodiazepines also don’t treat depression okay so if you’ve got somebody who has   concurrent anxiety and depression there’s a much higher suicide risk if they’re on benzodiazepines   so being aware and generally that suicide risk comes from overdosing on benzodiazepines but   not always other treatment options you know if the benzos aren’t something that people want to touch   you know they scare the living daylights out of me and SSRIs and SNRIs don’t seem to be working   then tricyclic antidepressants can be tried on those your older generation antidepressant Seroquel   is used a lot and there are some there’s some research that shows it can be effective   with anxiety like some of the antidepressants and depending on the person the benzos Seroquel can   make people very very very sleepy so you know it may not be the side effects of the Seroquel   the weight gain and the fatigue and you know sleepiness may be an unacceptable side effect for   some clients and boosts perón is the third option boost Barone works more like an anti-depressive   serotonin reuptake inhibitor and that it takes you know four weeks or so to kind of build up in   the system studies have shown that there’s really no long-term benefit to taking it but after six months   to eighteen months of use it has been shown to be effective in talking with clients a lot of   clients report that boost bar when they take it doesn’t necessarily help them stop being anxious   like a benzodiazepine does but it helps them not go from zero to 200 in 2.3 seconds it kind of you   know keeps them from having this gush of a freak out reaction every time something goes wrong which   a lot of clients report helps because they feel more stable throughout the day after remission   medication should be continued for six to twelve months and during that last six months first six   months keep it as is last six months you know they say that tapering is best it’s best not   to stop somebody cold turkey on any of these but it’s important for people once they’re   in remission to not just suddenly go okay I feel better I don’t need any of this anymore they need   to work into it and make sure they’ve developed the skills and tools that they need to deal with some of the anxiety that is going to happen in life so physical signs and symptoms   of anxiety may include fatigue irritability muscle tension or muscle aches try laying feeling twitchy   being easily startled trouble sleeping nausea diarrhea irritable bowel syndrome headaches so the   first thing we want to do with clients when we’re talking to them well second thing first thing is to say get a physical to let’s rule out physiological causes of this but we can also help clients   look at you know what might be causing these things that you can do to mitigate it what might   be contributing to your fatigue what might be contributing to your irritability and your muscle   tension or your muscle aches I mean let’s look at economics did you recently get a new bed or do you   need to get a new bed what about your desk chair I know you know I get more muscle tension and muscle   achy when I do a lot of mousing because I have deplorable posture being becoming aware of that   helps and then I’m like okay well I know it caused unfortunately, it’s unpleasant but it’s not a   big deal trembling or feeling twitchy you know that can be caused by low blood sugar that can   be caused anxiety that can also be caused by early onset Parkinson’s symptoms you know   there’s you know it can be worst case scenario or it can be something benign so we want   to have people figure out you know when you start trembling or feeling twitchy is there something   that it’s related to you know I know when my son gets excited he’s he just sits there   and you can see him almost shake because he’s so excited about something so we want to have people prevent misidentification we don’t want them to jump to that worst-case scenario we don’t   want them to go onto WebMD and go oh my gosh I’ve got cancer I’ve got this debilitating disease and   I’m going to die in six months probabilistic Lee speaking it’s not gonna happen yes get a doctor’s   opinion I’m certainly not going to tell them it’s all in your head I want them to get an   evaluation but I do want to in the meantime help them think about how likely is   this and other things for headaches and this is one another one of those that can be frustrating   as we get older our eyesight starts to go and you know there was a period there I did fine   and then after I hit 45 my eyesight just started to like steadily and kind of rapidly in my mind   decline so I have to get my eyeglass prescription changed every couple of years and that can cause   headaches so instead of starting to worry about oh my gosh I’ve got a headache all the time   maybe I’ve got a brain tumor you know I know that it’s probably my glasses or I’m grinding my   teeth so other biological interventions that have been evaluated there’s something called   the floatation rest system that reduced environmental stimulation therapy reduces sensory input into   the nervous system through the act of floating supine which is on your back in a pool of water   saturated with Epsom salt you know I’m looking at this going sounds good and you can’t   quite get the same experience in a bathtub because you’re not floating you’ve got pressure points and   you’re still hearing stuff clients can sort of simulate it with you know earplugs or whatever   but it’s if they can access this it’s been shown to be effective the float experience is   calibrated so that sensory signals from visual auditory olfactory gustatory thermal tactile or   tactile vestibular gravitational and preceptive channels are minimized which means you don’t see   here taste touch smell feel nothing as is most movement and speech so you want people to lay just   like completely motionless and not talk which can be hard for some people with anxiety in the study   the study I looked at fifty participants reported significant reductions in stress muscle   tension pain depression and negative effects and it was accompanied by significant improvement in mood   characterized by increases in relaxation happiness and well-being I read the study I’m like where can   I sign up you know it sounds in looking at some of the research this was more effective for   addressing anxiety than something like a massage Tai Chi also produced significant reductions in   anxiety there was approximately a 20% treatment effect 25% treatment effect in patients with   anxiety and fibromyalgia who practiced twice a week for a year now you know we want to look at   the confounding things here is it the Tai Chi itself or is it learning to control the muscles   and becoming more in tune with your body and learning to control your breathing helps   people reduce their anxiety either way you know Tai Chi helps people do that and it was shown that   after a year after the first six months, there was a significant treatment effect but after a year   you know it kept growing and after a year it was about 25% so Tai Chi can be effective acupuncture at the HT 7 median Meridian can attenuate anxiety-like behavior induced by   withdrawal from chronic morphine treatment through the meditation of the GABA receptor system   what does that mean that means if you if the acupuncture is done in very certain places the anxiety behavior the GABA a receptor system GABA is your main calming relaxation   neurochemical that is triggered and causes your body to sort of flood that receptor system and   this research was done on people who were detoxing from morphine treatment but we can look at   generalizing the results and I would be interested to see further studies on it pain other things we   need to do to help people with anxiety when people are in chronic pain they often have anxiety that   oh my gosh this is getting worse or it’s never gonna get better or I just can’t take this pain   anymore or they may get anxious that they’re going to be rejected because they can’t do some of the   things they used to do because they’re in so much pain so there’s a lot of guilt and anxiety that   can kind of revolve around pain what can we do to help clients guided imagery is generally very   helpful if we can help them imagine you know if that pain in their shoulder imagine the pain is   like the color red flowing out of their arm or other focus mindfulness so you know when you   think about something you know when you get a shot if I don’t think about it it doesn’t hurt near as   much as if the nurse says okay now one two three and you know she’s counting down and I’m getting   prepared and I’m focused on it I had another nurse one time who she was just talking   to me and you know put the alcohol on my arm and just kept on talking and didn’t tell me she was   getting ready to give me a shot and before I knew it she had given me a shot and she was like okay   we’re done I’m like you didn’t give me a shot yet she said yes I did it’s like oh so not focusing   on it and next time you have an itch for example if you’ve ever been driving on the interstate and   you can reach on your foot I get those on the bottom of my foot sometimes and I’m like okay   I’m not going to pull over to each my foot if you focus on something besides the itch eventually it   goes away I’m not saying the pain is gonna completely go away but the more people focus on it the more   it hurts physical therapy can help so encourage them to get a referral and encourage them to do a   self-evaluation if nothing else of ergonomics in their car at work where they watch TV and spend   most of their time at home and they’re sleeping so those are the four places that they spend most   of their time what do their ergonomics look like and that can help a lot of people mitigate   a lot of pain hormones are another thing that we need to look at imbalances of estrogen and   testosterone can contribute to anxiety symptoms heart palpitations fatigue irritability having   people get a physical we can’t as clinicians do anything about it but doctors can rapid heart   weight rate sweating palpitations are not uncommon in women in perimenopause or menopause so a lot   of women start feeling like they’re developing generalized anxiety and/or something’s going wrong   when they start reaching that mid-40s to mid-50s area and they start having some of these symptoms   again we’re not going to diagnose it but we do want them to recognize that it may not be anything   you know is catastrophic this is something that a a lot of women experience and help them figure out   how to deal with that supportive care biologically now you know this isn’t gonna treat anything but   we can help them minimize their vulnerabilities help them create a sleep routine so their brain   and body can rebalance this can help repair any adrenal issues that may be going on and improve   energy levels people with anxiety don’t sleep well so helping them figure out how to get some quality   sleep is important nutrition minimizing caffeine and other stimulants are going to be a big help   because those make people feel anxious and encourage them to work with a nutritionist to try to prevent   spikes and drops in blood sugar which can trigger the stress response when your blood sugar goes way   up or way down you can start getting kind of shaky and feel weird and that can cause people anxiety   because they might think oh my gosh I’m having a stroke or a heart attack or you know I don’t know   what these tremors are so it’s important that they don’t miss identify symptoms and encourage   them to drink enough water dehydration can lead to toxic Ardea which is increased heart rate   sunlight vitamin D deficiency is implicated in both depression and anxiety mood issues   vitamin D has been found in those main areas where serotonin receptors are found vitamin D receptors   are found so we know the serotonin and vitamin D have something going on sunlight prompts the skin   to tell the brain to produce neurotransmitters and set circadian rhythms which impact the release of   serotonin your calming neurochemical melatonin which is made from breaking down serotonin and helps you sleep and GABA so sunlight actually helps increase the release of GABA when it’s   time to start calming down and going to sleep exercise studies have shown that exercise can   have a relaxing effect and encourage clients to start slowly there’s not a whole lot of new research   on exercise and anxiety aromatherapy has been used a lot, especially in other countries in   the treatment of people with anxiety people with hospital anxiety people women who are giving birth   and they have some birth anxiety there they’ve been found to be effective in a lot of   those studies essential oils for anxiety include lavender rose Bedevere ylang ylang bergamot   chamomile frankincense and Clary sage encourage clients to just go to a health food store and   you know sniff some of these and see if it makes them feel happy and calm and content the aromatherapy   molecules enter the nasal membranes and they will start triggering neurochemical reactions   and so you don’t need to apply it you don’t need to ingest it all you need to do is so encourage   clients if they’re open to it to think about this because aromatherapy can be integrated into their bedroom for example with an atomizer or a Mr.It can be incorporated in a lot of different places   again where they’re not applying it or ingesting it in any way all they’re doing is smelling it   they’ve used it in defusing aromatherapy in hospital emergency rooms and they found that it   reduces stress and irritability the people in emergency rooms and I’ve been to enough emergency   rooms over the years to know that people who are in ers typically are not in the   best mood so if it can help those people then it’s probably going to have some sort of an   effect so psychologically helping clients realize that their body thinks there’s a threat for some   reason that’s why it triggered the threat response a system which is what they call anxiety so they   need to figure out why is there a threat you know sometimes it’s like the fire alarm going   off in my house it just means that the windows are open and there’s a strong breeze there is no fire   there is no problem there’s just a malfunction it’s a false alarm a lot of times clients get this threat reaction they get this stress reaction and it’s not a big deal right now so they   can start modifying what their brain responds to and again those basic fears that a lot of people   worry about failure rejection loss of control the unknown and death and loss distress tolerance is   one of those cognitive interventions that have taken center stage in anxiety research and   it isn’t about controlling your anxiety you know helping people recognize their anxiety acknowledge   it and say okay I’m anxious it is what it is how can I improve the next moment instead of   saying I’m anxious I shouldn’t be anxious I hate being anxious and slang with that anxiety let it   go just accept it is what it is have the client learn to start saying I am feeling anxious okay so   distract don’t react because I explain to them the whole notion of feelings comes in the crest and goes out   in about 20 minutes it’s like a wave so once they acknowledge their feeling if they can distract   themselves for twenty or thirty minutes you know they figured out there was no real threat if they can distract themselves for twenty or thirty minutes those emotions can go down and then   they can deal with it in their wise mind and encourage them to use distancing techniques instead of   saying I am anxious or I am terrified or whatever have them say I am having the thought that this   is the worst thing in the world I am having the thought that I cannot handle this because thoughts   come and go and that comes from acceptance and commitment therapy functional analysis makes it   possible to specify where and when with what frequency with what intensity and under what circumstances   the anxious response is triggered so it’s important that we help clients develop the   ability to do functional analyses on their own so when they start feeling anxious they can stop and   say okay where am I what’s going on how intense is it what are the circumstances and they start trying to figure out what causes this for them so they can identify any common themes from   their psychoeducation about cognitive distortions and techniques to prevent those circumstances or   mitigate them can be provided so if the client knows that they get anxious before they go into   a meeting with their boss and it’s usually a high the intensity of anxiety okay so we can educate them and help them identify what fears may be related to techniques to slow their breathing and calm   their stress reaction and help them figure out times in the past when they’ve handled going in   and talking to their boss and it wasn’t the end of the world you know there’s lots of   different things we can do there for them there but the first key and it gives them a lot of   a huge sense of empowerment to start becoming detectives in their own life and going okay now   under what situations does this happen positive writing this was another cool study each   day for 30 days the experimental group and this was high school-aged youth in China but you know   the experimental group engaged in 20 minutes of writing about positive emotions they felt that   day so they’re writing about anything positive that make them happy that made them enthusiastic gave them hope whatever long-term expressive writing positive emotions so after 30 days it   appeared to help reduce test anxiety by helping they develop insight and use positive emotional words so it got them out of the habit of using the destruction and doom words and encouraged them   to get in the habit of looking at the positive things and being more optimistic it’s a cool activity that clients can try it’s not gonna hurt anything if you have them journal each day   for 30 days mindfulness also came up in the research and was shown to be effective in   a meta-analysis of six articles about mindfulness based stress reduction four about mindfulness-based cognitive therapy and three about fear of negative appraisal and emotion regulation was reviewed all of these showed that mindfulness was an effective strategy for the treatment of   mood and anxiety disorders and is an effective in therapy protocols with different structures   including virtual modalities so you know if you’re doing it via teleconference mindfulness can still   be helpful mindfulness helps people start learning how to observe what’s going on and become aware of   what’s going on more aware of those circumstances which will help them complete their functional   analysis but it also helps them become aware of vulnerabilities and head off things in the past   and if they’re taking better care of themselves that they’re living more mindfully then they may   not experience as many situations that trigger their anxiety mindfulness also encourages clients   to learn acceptance that radical acceptance of it is what it is I’m not gonna fight it I’m angry   right now I am anxious right now however I’m feeling right now is how I feel and that’s okay it’s hard for clients to get to that but once they get a hold of that and they truly believe it   and they can say all right it’s fine I’m not gonna feel this way forever I’m gonna do something else   until the feeling passes it helps and that’s where the labeling and letting go comes in mindfulness   can also help them identify trigger thoughts what thought were you having right before you   started feeling anxious if people are mindful or let’s start back when people are not mindful they   often notice or don’t notice that they’re getting anxious until they’re like super anxious   when people are mindful they become more aware of subtle cues address unhelpful thoughts when they   say or believe it’s a dire necessity for adults to be loved by significant others for almost   everything they do always running gonna happen why is it a necessity what we can encourage them   to do is concentrate on their self-respect on winning approval for practical purposes you   know for promotions or whatever but it’s not about me being lovable it’s about me getting a promotion   and making more money and focusing on loving rather than being loved because when we give   love we generally get love back with unhelpful thought number two people feel they aren’t able to stand   it if things are not the way they want them to be or are not in their control so encourage clients   to focus on the parts that are in their control and other things in life which are going well and   to which they’re committed number three misery is invariably externally caused and is forced   on us by outside people and events just by reading that makes me feel disempowered so encouraging   clients to focus on the fact that reactions such as misery or happiness are largely caused by the   view that people take of the conditions so if you see it as a tragedy and devastating then   it’s probably going to produce misery if you see it as an opportunity and a challenge it’s   probably going to produce a different emotional reaction, if something is or may be dangerous or fearsome people, should be upset and endlessly upset about obsessing about it a lot of   people with anxiety get stuck on this you know if I feel like it’s fearsome I need to worry about   it getting on a plane for example if I fear that that’s dangerous that I need to think about it   and worry about it that’s not going to do any good so encourage clients to figure out how to   face it and render it harmless if possible and when that’s not possible accept the inevitable   so looking at airplanes you know facing it means researching to figure out how dangerous   is it really and realizing that it’s not that dangerous so that helps render it a little   bit harmless in their mind it proves to them that it’s not as dangerous as it could be and when   it’s not possible accepting the inevitable you know you got a fly so getting on there figuring   out how you’re gonna get through it hurricanes are the same way people especially in places   like Texas Louisiana Florida may obsess as soon as it starts coming to hurricane season or if a   hurricane is spotted out in the Atlantic somewhere they start checking the weather every hour or more   wondering what the path is going to be and you know what there’s you can’t change the path of the   hurricane so all you can do is board up your house evacuate if necessary and deal with the fallout child driving is just another example I’ll give you know my children are learning how to drive and   that’s kind of scary and fearsome you know what’s gonna happen when they’re out there you know you   see crashes all the time well render it harmless by making sure they’ve got good training on how   to drive make sure they’re good drivers and then accepting that some things are just not within   my control it’s easier to avoid than face life difficulties and responsibilities well running   from fear is usually much harder in the long run so encourage clients to look back at times when they’ve avoided difficulties and responsibilities and the eventual outcome you know what happened   there people believe they should be thoroughly competent in achieving in all possible respects   or they will be isolated rejected and failures we need to encourage clients to accept themselves as   imperfect with human limitations and flaws and focus on what makes them loveable human being   what qualities like courage and intelligence and creativity and those things that can’t be taken   away what inherent qualities do they have that make them awesome people because something once   strongly affected people’s lives they should indefinitely fear it if you got lost you know   when little kids get lost it’s terrifying when you’re grown up if you get lost you turn on the   GPS and you figure out your way but some people still, you know freaked out about getting lost if   they got lost once so we want to help people look back at past episodes that may be contributing to   the current anxiety and compare the situation’s you know are you the same person or is this not   a big deal now that you’re older wiser stronger encourage them to learn from past experiences   but not be overly attached to or prejudiced by them yeah you could have maybe got lost in the   past and it was a horrible experience well you were six I can see where that would be terrifying   and a horrible experience but it doesn’t have to continue to impact you that way now when you’re   you know 26 getting lost you know could be an opportunity to try a new restaurant or something   people must have complete control over things well this doesn’t happen so encourage clients   to remember that the past and the future are uncontrollable we can’t change the past it is what   it is we can learn from it so it doesn’t repeat but we can’t change it and the future is largely   uncontrollable I mean there are a lot of things I can do to stay moving toward a rich and meaningful   life but life is going to throw me curveballs sometimes and there’s nothing I can do to plan for   or control that we can control our actions in the present to stay on our preferred path and general   develop general skills to deal with adversity should it arise so we want to help clients   develop those general problem-solving skills and the general support system so when they are thrown   a curveball you know it doesn’t knock them upside the head people have virtually no control over   their emotions and cannot help feeling disturbed by things well encourage them to think about the   fact that they have real control over destructive emotions if they choose to work at improving the   next moment and changing inaccurate thoughts then they’re not going to experience the destructive   emotions as intensely or as frequently when you feel an emotion you feel how you feel but again   you don’t have to wrestle with it fight it and nurture it you can say this is how I feel how   do I improve the next moment when it comes to cognitive distortions encourage them to find   alternatives when they start to personalize things if somebody laughs when you walk out of the room   then the and the person starts getting anxious thinking oh they were making fun of me I wonder   what they thought I wonder if I had something stuck to the back of my dress and they start   getting all panicked about it that doesn’t do any good encouraging them to think you know what   our three alternate explanations that hadn’t but had nothing to do with you for why they laughed   magnification of the worst thing you know taking something and saying if this happens then it’s   going to be a catastrophe and minimization going along with that a lot of times when people magnify   and see a catastrophe they minimize not only their strengths and resources but all the   other stuff that they’ve got going for them all they’re seeing is this catastrophe so encouraging   them to focus on the facts of what is actually happening and what is the high probability   event and encourage them to get information and look at the broader picture you know yes you   got into a car crash and your car is totaled and that is unfortunate you know it sucks but   you know that is not going to cause you to lose your job and then become homeless and penniless   and yadda-yadda it might cause your insurance to go up but okay so you don’t have a car but what   are the resources that you have who can who do you work with that might be able to give you a   ride to work you know let’s look at the resources you have and work around so problem-solving helps   with magnification and also focusing on you know let’s be grateful for what didn’t happen you know   you could have been killed but you weren’t the car was totaled it’s replaceable all or nothing   thinking again have them think about what else could have been happening like Brittney suggested   finding the exceptions instead of saying she always does this look for exceptions when has   she not done that what else has she done instead of this selective abstraction and filtering is   when people look for the good the bad and the ugly a selective abstraction means you kind of   see what you expect to see so if you expect something to be devastating you see only the   devastating aspects of it which kind of goes with the magnification and minimization you filter out   the stuff a lot of times when people are in a bad mood or are anxious they see the negative because   that’s the state of mind they’re in so encouraging people to complete the picture alright there’s   all this bad stuff now what’s the good stuff you know to encourage them to look at the good the bad   and the ugly so they get a wide view of exactly what’s going on and encourage them to remember   that hindsight is twenty-twenty when people have something embarrassing happens or they get anxious   about something that happened they look back and they go I should have or I could have or oh I   wish I wouldn’t have when you were in that the situation you did what you did and you know   maybe you may have had a reason for it or you know you may have not had other options or it may have   just been a bonehead thing to do but okay so you made one mistake hindsight is 2020 that’s gonna   that mistake is gonna stand out just like the great big letter on the eye chart because you’re   thinking back and you’re looking at it and that’s all you see but encouraging clients to remember   that other people are too busy worrying about themselves to remember what they did jumping   to conclusions encourages clients to remember to get all the data if your significant other male   significant other comes home and is smelling like perfume don’t just jump to the conclusion that he   was cheating on you maybe he went to the mall to get a new tie and walked through the   perfume area and got spritzed or bought you some perfume or who knows maybe the person sitting next   to him at work sprayed her perfume on the desk and some of it filtered on there are all different   reasons that that might happen so encourage people to get all the data mind reading we can’t do it   you know you can’t read somebody’s mind you don’t know what they’re thinking so ask them what you think about this don’t assume anything and emotional reasoning encourages people to step back   from a situation and ask themselves am I feeling anxious about this because I’m feeling anxious and   I’m looking for reasons that it should be scary or am I feeling anxious about this because it’s   really scary for some reason there are facts support my anxiety a lot of times when we go into   new situations we may feel anxious because it’s a new situation but when we step back we say you   know what there’s nothing to be worried about here you know no big deal I got this and   move on so instead of rolling with it and trying to figure out okay I feel anxious so there must   be a reason not necessarily very likely a false alarm other psychological interventions relaxation   skills encourage people to learn how to relax not only physically but mentally diaphragmatic   breathing helps encourage them to breathe through their stomach and put their hand on their   belly and feel their belly expand and contract slows breathing down which triggers the rest and digestion reaction in the brain which is calming meditation can be helpful for some people some   people find trying to quiet their minds too frustrating because they’ve got too much   monkey mind going on that can be later or maybe never for some people, we don’t want to increase   their anxiety with interventions cute progressive muscular relaxation also has a lot of research   support and remembers with cute progressive muscular relaxation we’re Sakura get them   to attach a cue AK you word like relax or breathe with the relaxation response so they tense their   muscles and then relax their muscles and as they relax their muscles they say their “quack”-word   like relaxed and they work from head to toe or from toe to head tensing and relaxing different   muscle groups so they become more aware of what a tense muscle feels like versus a reactive relaxed   muscle there are great scripts that are online that people have already recorded that can walk   people walk clients through CPM are I highly encourage it because once they get used to it   then they can just think that cue they can think relax and as they exhale they will start to feel   their entire body kind of relaxing because it’s trained when it hears that just like when you hear   the word pop quiz when you were in high school you had a stress reaction well we want to use   it in reverse and train the body so that when it hears a cue word relaxes helps them develop   self-esteem because fear of failure and rejection a lot of times come from needing other people’s   approval to help them develop a rational idea of their real self develops compassion self-talk   instead of saying I’m an idiot or I’m stupid or I’ll never measure up to anything encourage them   to talk to themself like they would talk to their child or hopefully their best friend and encourage   them to spotlight strengths whenever they feel like they’ve got an imperfection to identify these   three strengths that they have so they’re you know balancing out the imperfections and the strengths of cognitive restructuring reframes challenges in terms of current strengths, not past weaknesses   so if you’re going to give a presentation in front of 60 people and you hate public speaking instead   of thinking about you know this is terrifying because the last time I went up in front of people   I forgot everything I was going to say and drop my note cards well that’s a past weakness what   is your current strength you’re prepared to know the material you ‘yoyo’ so encourage people   to look at all the strengths and resources they currently, have them develop an attitude of   gratitude and optimism because as I said with that the positive writing exercise when people   are in a grateful optimistic frame of mind they tend to see more of the good stuff they see the   bad stuff too but they can also see more of the good stuff and some of the bad stuff they see   opportunistically instead of as a devastation acceptance and commitment therapy says that some of the reasons that we’re miserable are fear we get fused with our thoughts we think I   am terrified well if I am terrified then I can’t I mean if I am I can’t get rid of anything I am   if I’m having the thought that I’m terrified well I can get rid of a thought I can forget   things easily encourage people to evaluate their experience and empower them to look at things as   challenges and opportunities instead of hardships encourage them not to avoid their experiences so   things that are scary gradual exposure and finding exceptions like for me bridges you   know I love public speaking so that’s not a thing but when I go to a bridge you know when   I Drive to the bridge you know when I’m on the bridge somebody else is driving I get used to   doing that when I Drive over a bridge than when I Drive over one of those bridges that open up   I hate those bridges um I know y’all are just like oh my gosh yeah it’s an irrational fear I realize   that but instead of going straight for the bridge that opens up going for the little bridges first   and then thinking back over times that I’ve gone over bridges and there’s been no problem you know there are exceptions nothing happened it wasn’t a big deal sometimes I didn’t even notice it until   somebody pointed out hey look down there at that pretty water and I’m like oh we’re on a bridge so   encourage people to not avoid their experiences get used to them embrace them and learn that they   have the power to deal with them and stop reason giving for the behavior you know use the challenging   questions if something is fearsome let’s look for at the evidence for and against it instead   of you know making excuses for social interventions improve their relationship with their self which   goes with self-esteem improvement people are going to feel less anxious about getting their needs and   wants to be met if they know what their needs and wants are so part of that is becoming mindful cuz a lot   of our clients don’t know what they need and want they just want to feel better but they don’t   know how they don’t know what they need to feel better so helping them identify their needs and   wants and encouraging them to be their own best friend you know when they get a promotion take themselves   out to dinner pat themselves on the back whatever it is don’t rely on other people to do it because   other people it’s not that they don’t care but other people are often very involved in thinking   about their stuff and they may not notice encourage them to develop a method of internal   validation so they can feel like they are all that ‘no bag of chips and they realize why they   are lovable human beings and they accept the the fact that everybody is not going to like them   and nobody is gonna like them all the time and that’s okay you know my kids don’t like me all   the time my husband doesn’t like me all the time I’m okay with that I know I can be challenging but   you know most of the time you know they like me and that’s okay and there are some people you   know who don’t like me at all and okay there’s nothing I can do about that helping our clients   develop an okayness with that helps relieve a lot of anxiety because a lot of people feel like they   have to be liked by everybody and if somebody doesn’t like them it’s like what did I do wrong   oh my gosh encourage them to develop healthily supportive relationships with good boundaries   develop assertiveness skills so they can ask for help when they need it anxiety a lot of times you   know that’s the body saying there’s a threat well if there’s a threat maybe you need some help you   know dealing with it so people need to be willing and able to ask for help and not feel like that’s   going to lead them to be rejected and allow them a certify this will allow them to say no to requests   again without feeling like that’s going to result in them being fully rejected describe the ideal   healthy supportive relationship and encourage them to separate the ideals from the reals you   know let’s look at if you had the best relationship what would it look like okay you know warden June   Cleaver we got that now how realistic is that you know let’s look at you know rephrasing this   a little bit so it’s less extreme you know warden June Cleaver never fought their kids were perfect   you know all those extreme words let’s look at what’s real what happens in real relationships encourages people to identify who would be a good partner in supportive relationships   I’m not meaning necessarily romantic I’m meaning friends and where they can be found you know where   would you find people that you could be friends with and encourage them to play through what it means when gaming cuz a lot of times again this goes with my reading you know what it means when your friend doesn’t return your text right away what does it mean when your friend cancels   dinner on Friday night what does it mean when you see where I’m going with this and a lot of   times clients with anxiety and rejection issues and low self-esteem will go to the worst-case   scenario so encourage them to go back to finding the exceptions what else could have been happening   what else could it be that caused this and it’s not about you so anxiety is a natural emotion that   serves a survival function excessive anxiety can develop from lack of sleep nutritional problems   neurochemical imbalances failure to develop adequate coping skills cognitive distortions low   self-esteem and a variety of another stuff recovery Ambala involves improving health behaviors making sure your body’s functioning and making the neurotransmitters it needs and you know release   them as needed to identify and build on current coping strategies address cognitive distortions   and develop a healthy supportive relationship with self and others if you enjoy this podcast please   like and subscribe either in your podcast player or on YouTube, you can attend and participate in our live webinars with dr.Snipes by subscribing at all CEUs comm slash counselor toolbox, this   episode has been brought to you in part by all CEUs calmly provide 24/7 multimedia continuing   education and pre-certification training to counselors therapists and nurses since 2006 have used coupon code consular toolbox to get a 20% discount on your order this month.As found on 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™

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

 Unlimited CEUs for 59 at AllCEUs com welcome everybody. Today,’s, presentation is on dialectical, behavior therapy skills. This presentation is based in part on dialectical, behavior therapy a practical guide by Kelly Koerner. This is one of those books that, if you want to do dialectical therapy as a practice, not just look at some of its tools is a must-read. Then it’s also based in part on dialectical, behavior therapy skills, workbook DBT made simple and DBT for substance abusers, which is an article that was published by Marsha Linehan. So the links to those are in your class, but just give you an idea about sort of the breadth of what we’re going to be looking at today. In the short time that we have together, what we’re going to do is take a look at why DDT was created, we’ll look at understanding emotional regulation, dis-regulation and regulation will identify DBT assumptions about both clients and therapists, and we’ll Explore skills to help clients learn to stress tolerance, emotional regulation, and interpersonal effectiveness. As an aside, we’re taking – or I’ve taken the information from this course and combined it with a bunch of other information to make a six-hour on-demand course. That will be available by the end of the week, but for now, we’re just going to hit the highlights in the 1-hour introduction. So why do we care? Why do we want to learn about DBT skills and DBT tools? Many of our clients, experience emotional dysregulation, or the inability to change or regulate their emotional cues experiences, and responses. Think for a minute about any of your clients, if they’re depressed, if they’re anxious, they’ve got anger management issues, something is going on with their emotional states, or they’re not able to either get unstuck or control their behavioral responses. So they may be engaging in self-injurious, behavior risky, behavior, or addictive behaviors. They’ve tried to change and failed, leaving them helpless and hopeless. In a lot of our clients. We try to fit them in not that we should, but we do try to fit them into this box. If you’re depressed, then we’re going to look at these things, and one thing I hope you get from these webinars is the fact that every single client is different and there is no box that we can put them in and you’re, Like well, then, how can you do group therapy? Group therapy is awesome because you can tailor and that’s, part of the challenge of doing psycho. Educational group therapy is tailoring the tools and helping people tailor the tools to meet their individualized needs, but they can get feedback and they can see how different tools can be modified just a little bit to fit different individual needs and untenable emotional experiences that lead to Self-preservation behaviors such as addiction, you know to kind of numb the pain to give them a distraction, nonsuicidal self-injury. We’re talking about cutting, we’re talking about those sorts of things, and then even those suicidal behaviors. At a certain point, the pain has got to stop, so some people may end up going as far as trying to stop the pain by stopping their existence instead of hurting anyone else. People with emotional dysregulation have high sensitivity, so these people tend to be highly hyper-vigilant. They’re aware of a lot of things that go on now. This was created and I want you to really kind of think about it. It was created as a tool or a protocol to use with people with borderline personality disorder. What do we know about people with BPD? They grew up in really ineffectual environments, so they had to be hyper-vigilant about everything that was going on for their safety and security. So you have someone who, either by nature or by nurture, is hyper-vigilant. These situations have been over-generalized. The dangerous situations have been over-generalized, so the world tends to seem more and dangerous, and out of control, people with emotional dysregulation are easily thrown off kilter because they often have a lot of vulnerabilities. They’re not eating. Well, they’re depressed which is contributing to them not being able to sleep. Well, they can’t focus yadda, we’ve talked about vulnerabilities. One thing that dr Turner talks about is no emotional skin and she likens it to someone who has third-degree burns and every single thing, even the air when it touches it, is just excruciating there’s no middle ground. There’s. No, oh! That’s kind of uncomfortable it’s either not hurting or it’s. Excruciating. People with emotional dysregulation are also highly reactive, so they’re hyper-vigilant. They’re aware of everything that’s going on and then every time something happens that sort of triggers their awareness they jump into this immediate fight or flight reaction. Then they’re slow to de-escalate. So we’re talking about situations in which someone is hyper-vigilant. They’re on edge, maybe because of situations in the past or not. They have this sort of persistent fight or flight or frequent fight or flight reaction. And again, I’ll refer back to our dream fatigue class that talked about how the body can only stand to be all hands on deck for so long before it’s just like dude I give up, and then the sense of depression and helplessness and Apathy starts to set in people who are who have emotional dysregulation, really they’re either like flat and none nonexistent in their emotions. They just can’t even deal with it when they should, or they’re, overly reactive and then the person isn’t in a validating environment. What would be a to some of us on a scale of 1 to 10? As far as how distressing something is it’s, probably like an 8 to somebody with emotional dysregulation, think about a time when you were stressed out or you had a lot of vulnerabilities going on. Maybe you had a new baby at home, so you were, ‘t sleeping and your other kids were acting out. There were just all kinds of stuff going on and you reacted to something with an 8 that everybody else was like that. Doesn’t deserve that. Much of a reaction is that’s it what’s wrong with you, people with emotional dysregulation that’s their environment, all the time, everybody’s looking at them and going what’s wrong with you there? This is not that upsetting. So we need to help people understand that their experience is their experience and it’s not for me to say whether it’s a 2 or an 8. For me, it’s a 2, but let’s look at why it’s an 8 for you. So the emotional reaction – and this is I didn’t – get red eye reduction when I took this picture of bruit but bless his heart. When I got him, he was a rescue and he had such terrible terrible abandonment issues and is so hyper-vigilant. Even to this day, I’ve only had him like four months, but he’s hyper-aware of stimuli and people can be hyper. Aware of stimuli so anytime somebody moves, he’s up, he’s. Looking he’s like. Are you going to leave me alone again when he perceived that something is changing when there was a threat, he goes into all hands on deck and turned into a survival sort of thing and starts acting out? He goes and finds toys and brings them to me. Heaven forbid. We should have to put him out in the garage because we have visitors or something and it’s. You know climate controlled, it’s not like it’s horrible, but he will sit out there and how, until I let him in or go out and tell him it’s going to be okay, now see as a person I’m going. That is not a valid reaction. He’s like totally overreacting to having to spend ten minutes in the garage, whereas from his perspective he’s not overreacting, because in the past when he’s been put in the garage he left out there for days weeks months. Who knows I don’t know his story too. Well, now I use that to kind of highlight the fact that people with emotional dysregulation don’t know what their experience was. What they’re doing is trying to survive. Now they may be trying to survive a situation in their past. You know when there were six and we’re going back to the abandonment discussion that we had the other day, but it’s important to understand that all these things play in together. Something happens and the body’s response system takes in these stimuli and it says it’s dangerous it’s, not dangerous. What do we do with it? The brain decides to fight or flee, and then they go into the survival response with treatment. What we want to do is help people be able to feel that feeling and not have to act on it right away until they can de-escalate some and use a combination of assessing their cognitions and deciding whether their perceptions are based. On the present. The present moment or the past moment so primary invalidation caregivers dismiss emotional reactions as invalid. We just talked about that. The child or person could be mocked or shamed for their emotional response. We have all probably met parents or worked with parents who have children that are highly emotionally reactive, and who tend to get frustrated and overwhelmed by the constant drama that seems to be presented by this child all the time. So the child is often not taught how to self-soothe or de-escalate the parents just like really let it go and go away, which is not helpful because the child doesn’t learn how to deal with it. The child is not taught mindfulness to figure out okay, what’s causing this, and the child is not taught effective cognitive processing in most situations in validating environments, if the child gets upset, even if it seems to be disproportional to whatever the event was, the caregiver Will take the child in and say? Okay, I hear you’re upset right now, let’s talk about it and we’ll walk the child through, maybe not thinking about it, but just being a good parent walks. The child, through this de-escalation process and the cognitive processing of secondary trauma or invalidation, is, and I’m putting this in here. Coping skills can be overwhelmed by trauma or intense stress, leading to this high alert raw status. Think about the people who were survivors of Hurricane Katrina or Hurricane Andrew. I come from Florida, so I think hurricanes, but any big event that is ongoing enduring, and distressful at a certain point. You’re on your last nerve, so anything could precipitate sort of a crisis. Many people don’t receive the necessary support during these times and may be shamed for being weak or needy. Sometimes nobody can cope and everybody’s kind of decompensating. At once, which is a lot of what we saw with Katrina but other times there may be people that are functioning just fine and they don’t understand why some other people are 39, t coping just fine, and they see that as abnormal and want to distance themselves from it, it’s important for us to communicate to people because we already noticed that crisis is a normal response to an abnormal event. What was abnormal, though, is it this particular incident? Maybe, or is it the fact that this particular incident kind of was the straw that broke the camel’s back on a whole chain of incidents leading up to it that was abnormal? What caused this person? Excessive stress I was talking to a woman the other day who, in the past six years, has had half a dozen significant losses and I’m just like wow. You know that that’s pretty intense to have all those and she’s, also starting her practice and everything else. Right now – and I’m – just like oh my gosh – I can’t imagine the amount of stress this woman is – going through most humans, aren’t inherently prepared to deal with the crisis alone. We’re kind of group sort of people. We rely on other people, so if we have this reaction and it’s judged to be disproportionate and people kind of distance themselves from us, because they see us as abnormal or dysfunctional, then we lose any social support that might have been able to serve as A buffer which just kind of in turn, feeds back and exacerbates the sense of hopelessness, helplessness, and isolation. What precipitates a crisis may vary between people based on pre, existing stress or mental health issues, and it also may vary with the same person longitudinally across time. What may be overwhelming today – maybe not may not be overwhelming six months from now, because all of those prior stressors that I’m dealing with right now may have had time to kind of work themselves out. So we must help people understand that their reaction is their reaction and let’s just go from there. Let’s not say it’s bad or is disproportionate or it’s whatever it just is so the result of this sort of unpredictable reactivity results in frantic efforts to numb withdraw or protect. I need to numb the feelings because I can’t take this kind of pain. If you’ve ever had a burn that’s had to be cleaned or even an open wound that’s had to be cleaned out. You know that’s pretty excruciating so thinking in terms of that, you can see why people would want to kind of get a little novocaine withdrawal if this support system is invalidating, that has extra pain and that’s excruciating to be rejected. On top of everything else, so a lot of times, people withdraw which eliminates any opportunity for social support, and it also exacerbates this sense of rejection, and they do this to protect themselves. People learn who they are in invalidating environments. They learn who they are and how they are resulting in rejection, so they avoid threats. They avoid putting themselves out there. They avoid making relationships because they’re afraid of rejection and they avoid thoughts and feelings and sensations that may lead to invalidation. I don’t want to feel these things because then if I do and I communicate them, you may tell me I’m wrong. Okay, we’ve laid the groundwork. Now we see where this is a problem. So what do we do about it? Well, the first thing we want to do is look at some of the DBT assumptions about clients. Clients are doing the best they can given the tools they have at this present point in time, and I truly believe that clients want to improve themselves. Wouldn’t be in your office if they didn’t want to improve for one reason or another. It may be an involuntary referral and they want there’s a means to end there. They are in your office because they have hope that something can change and it will benefit them. They cannot fail at DBT if they go through dialectical behavior therapy, the protocol and it fails, then the protocol failed them or we as clinicians, fail to implement it correctly. Now, today, again, we’re talking just about tools that are present in DBT, not how to do dialectical, behavioral therapy. The evidence-based practice wants to make that very clear clients are existing in what is for them an unbearable state. This pain has got to stop. They need to learn new behaviors in all contexts, not just at work, not just in their relationships, but they need to learn how to function and deal with life on life’s terms in all contexts, so they can go to the grocery store they can get In a traffic jam, they can be in a crowded Airport and not feel like the walls are closing in on them. Clients are not responsible for all of their problems. We know this some things they had no control over are causing problems for them, but they are responsible for all of their solutions, and we’re going to talk about the four options for problem-solving in a few minutes, but they are responsible. They choose to do something and clients need to be motivated to change motivation, choosing the more rewarding option out of the available options. Well, yeah that whatever they’re doing right now is the most rewarding option they have available in their toolbox. So we’re going to give them new tools, but then we need to teach them how to make those tools effective. If you just hand me a jigsaw and say, okay go about woodworking and whatever I’m, not a woodworker, but I’m not going to know what to do with that. So I may go back to using my circular saw or whatever the case may be, which may be very clunky. We need to help clients learn how to use these new tools, so it’s more rewarding to use those than those old behaviors. They just numbed out the pain or distracted them assumptions about therapists, clarity, precision, and compassion are of the utmost importance. We need to be clear with our clients about what’s going on. Let’s not speak in generalities. We want to try to avoid some of the Socratic questions that we would normally do. We want to be clear about what we’re getting at and what we want them to look at. We need to be precise. Do we need to not say well what is it last week that caused all the problems in your relationships? Well, if they had four different fights that’s four different things we need to look at, we need to be precise to identify all of the things that trigger and we’re going to talk about behavior chains in a few minutes. So we need to be precise. We also need to be compassionate, even if we don’t agree, or we think that the reaction was disproportionate, putting ourselves in their mind in their place in their raw state. We need to be compassionate and go okay, you survived it, you did the best, you could let’s take a look at what might have caused that. Why you made the choices you did and what you might choose better next time. The therapeutic relationship is between equals, DBT or therapists can fail to achieve the desired outcome, but the client can’t fail and therapists who treat patients with pervasive emotional dysregulation needs support we need to remember that patients who are always in crisis by their very nature, it’s, exhausting because they’re always in crisis, which means we are responding in a crisis manner, not that we need to get all upset and worked up because that’s just modeling the wrong thing. But there is a lot of energy that it takes for us to use the DBT tools for us to model the DBT tools and for us to help work. The client is out of their emotional state into one where they can use their wise mind. So the first step is core mindfulness. Until they figure out what’s going on, they can’t fix it, so we want to help them integrate their rational mind they’re cognitive. This is what happened factual mind with their emotional mind. This is what it felt like in the wise mind, so you can take the facts. You can take your feelings and you can say with what I know and what I felt. What would be the best interpretation of this or the correct one for me? Interpretation of this event at this point, and what can I do about it? One of the things DBT talks about is the fact that truth is sort of subjective. What is true for one person may not be the truth for the other person, because we’ve all had different experiences, but we need to help people not underreact and stay. In that cognitive mind, if you’re a star, trek fan, think data um. He was the AI that was kind of human-robot sort of thing or, and we also don’t – want people to act in their emotional mind, acting solely based on feelings and trying to make feelings facts because feelings aren’t facts. They’re feelings, so we want to help them integrate these two things, and that is more difficult and it sounds like it takes time. Mindfulness is using effective, nonjudgmental observation and description of experiences, those thoughts, and feelings, and identifying what’s the objective evidence for and against what’s going on right here, how I’m feeling what is all the evidence. Let’s look at the big picture, not just one little aspect of it, and what are my feelings about this event? Getting in touch with what’s going on inside their mind and inside their body is going to be one of the first steps. So I talked about those four options: when there’s a problem, you have four options. You can tolerate it, grit your teeth, and Barratt there. Sometimes you just can’t do anything about it. Traffic jams probably can’t do much of anything about it. Change your beliefs about the event. Instead of seeing a traffic jam as a waste of time and just a complete pain in your butt, you can see it is a time to check voicemail and maybe return. Some phone calls are productive, make it billable, and you can solve the problem or change the situation, while you’re in a traffic jam and stopped, of course, looking at Google Maps to figure out where the next exit is so that you can get off. So you can change that situation or you can choose to just stay miserable and choosing to stay miserable is a valid choice. When clients make these decisions, we need to look at them. Why was that? Whatever their option was? Why was that option more rewarding than all the others? Why is it more rewarding sometimes to stay miserable for some people that’s what they know and they’re afraid if they feel happy, then they may get disappointed and end up feeling sadder than they already do now? Some people tolerate the problem because it’s what they know and change is hard and they would rather just tolerate it and deal with it and suck it up than have to muster up the energy to try to change whatever’s going on. So again we want to look and ask them or ask ourselves, maybe because they may not know right away the choice that you made. Why was it more rewarding? Why did you choose that over the other three options, distress, and tolerance we’re going to talk about a lot of acronyms here acronyms are really important in DBT because it helps clients have sort of a drop back and punt. There are some worksheets. There are lots of worksheets online for DBT but the acronyms we’re going to hit here are going to be some of the highlights that are going to be important for you to remember tip temperature. So you’re tipping your physiological balance now temperature. I’m not necessarily advocating for this. You don’t want to do it. If you’ve got a heart condition. You don’t want to suggest it to clients that have a history of child abuse, especially anything that involved drowning. So this one’s a little tricky one of the things I suggest to some of my clients instead of this is holding on to ice cubes. But the suggestion in the book holds your breath. Dunk your face in for as long as you can hold your breath into a sink full of ice water, then come up. Exhale, inhale and dunk, again repeat as many times as you need until you feel calmer. Well, guess what we’ve talked about combat breathing. If you are slowing your breathing, which you do, if you’re holding your breath, your heart rate is naturally going to slow. When your heart rate slows down your brain says: oh the threats going away, yippee yay, I can call off the dogs. There are other ways to slow down your breathing. Besides necessarily dunking your dunking, your head holding ice cubes is one of the reasons that that can be helpful. Instead of cutting the person’s focus, it’s a distracting technique. The person focuses on the pain because it is painful to hold on to ice cubes for a long time, instead of cutting themselves, but it also gives their body something to focus on to go. Oh, my heart rate is up because there’s a pain when the pain goes away. I can make my heart rate go down, so we’re redirecting the brain to go. Oh, this is why the heart rates are up it’s, not because there’s emotional distress, it’s because of extreme physical pain. Intense exercise increases body temperature, but it also increases the heart rate when you’re sitting still and your heart rate is 120 beats a minute because you are in a panic attack or a state of panic. It’s very, very uncomfortable and your mind is going. I don’t understand you, ‘re not moving. Why is the heart racing when you start exercising, which is why walking and getting those big muscles moving often helps? Then the body gets less confused. It’s, like Oh heart rates, beating fast, because the body is moving score, got it so when the person stops moving, the heart rate starts to go down, and this is true, even if you’re walking around. If you take a client out to walk when they’re upset – and you are talking about whatever the distressing thing is – I have found without exception.When they come back inside, they can start to calm down a little bit more and their heart rate naturally starts to go down when they stop their physical exercise and then progressive relaxation. You’re going to move from head to toe or toe to head. Whatever you prefer but head to toes, usually how we do it focusing on muscles focusing on breathing slowing, breathing relaxing muscles forcing the body to relax. So this addresses physiological arousal, so the temperature, intense exercise, and progressive relaxation. All of these serve as an ability serve the function of distracting the person from whatever cognitively or inter psychically wants to say, is going on, and all of these either explain to the brain why the heart rate is going so fast or Help reduce the heart rate, so you know there’s something to be said for them. The important thing is for you to brainstorm with your clients when you get physiologically aroused when you get upset, and you are just your hands – are shaking your palms are sweating. You’re breathing fast, and your heart rate going fast. How do you calm yourself down what works for you and we’re back to bruit again? Another acronym is accepted to distract when there’s emotional turmoil, so you can kind of let that adrenaline surge go because you have that initial fight or flight reaction and then the body kind of goes. Alright, let’s reassess and see if there’s still a threat, get involved in activities that will help you distract yourself from whatever’s going on when kids get upset. You know if they’re getting stressed out because they’re sitting in the lobby and the doctor’s office, and they know they’re going to get a chhoti. We give them something to do. We read a book, we talk we play because then they’re not focusing on the fact that they’re going to get a shot, contributing to the welfare of others. Do something nice for someone to volunteer. Do something productive that gets. If you are focused on someone else, compare yourself to others who are doing less well, that doesn’t work for everybody. You can also compare yourself in the present to your old self and focus on how much better you’re doing now compared to what you were doing six months ago, this doesn’t always work. You know these are options. Not everyone is going to work for every person, emotions do the opposite. If you’re feeling really sad get a comedian, get it to go to YouTube, and Google a comedian and watch a skit or two or ten, so you’re doing something that makes you laugh. That makes you happy to sing. Silly songs, dude silly dances go out and there’s very little. I find it more amusing than just listening to a baby laugh. If I’m having a really bad day, I will find those stupid videos of babies laughing at paper tearing if you can’t help, but laugh with them pushing away build an imaginary wall between yourself in the situation. Imagine yourself pushing away the situation with all your might or blocking the situation in your mind, and each time it comes up, tell yourself to tell it to go away. So if you start thinking about something that is particularly hurtful as soon as it comes into your mind and it comes into your awareness go no, I am NOT going to think about that right now. Thoughts counting some people count to ten, a hundred whatever it takes to get through that initial rush. Some people sing for me. I think I’ve shared before I have this irrational fear of bridges, but so, whenever I Drive over a bridge I sing, and usually, it’s, not songs on the radio. Usually, it’s songs. I used to sing to my kids. I’ll sing the ABCs something that doesn’t require a whole lot of cognitive interaction because I’m doing pretty good just to get over the bridge. And yes, I know I should be over it, but I’m not and that’s just the way it is the 10 game. I like this one think of 10 things that you like the smell of think of 10 green things. Think of 10 things you see where we’re going with this, and you can incorporate all the different senses with it. If you go through multiple iterations of it 10 things that you smelled yesterday, 10 things that you see right now, 10 things that you hear when you’re on your way to work. This helps people focus on something other than what’s going on. Here the 5 4 3 2 1 game is sort of similar to the 10 things game, identify 5 things. You see, 4 things you smell, 3, things that you can touch and follow down. Sensations like I talked about on the last slide. Sensations can help distract you from what’s going on until you have a chance to kind of get through that initial adrenaline rush, cold, holding ice, cubes, rubber band – and I don’t like this one. But some people do they put a rubber band on their arm and every time they start to perseverate on a negative thought. They snap its smells and find some good smells. Some smells bring back good memories, smells that you like. Maybe it’s roses: maybe it’s a purse-specific perfume. Maybe you just go to Walmart and start smelling all the air fresheners. Whatever makes you happy, I do suggest avoiding taste, because if you start using taste as distress tolerance, then you start moving toward emotional eating. I’ve seen it happen, so I would avoid that for most people, but if they just desperately want to go there, then you know we’re going to go there because they are choosing how to distract from their cognitive or intrapsychic. Sensations improve at the moment. Imagery goes to your happy place. Whatever your happy place is meaning find an alternate, meaning for what’s going on now. This can be Linehan refers to it as making lemonade. We all know how to do that. We don’t we’re, not necessarily the best at it, but try to make lemons. I try to look for the optimistic meaning in whatever it is prayer. Now, even if someone is not religious, they can be using radical acceptance. Accepting it is what it is and not trying to change it, just putting it out there for the universe, relaxation is always good to relax one thing at a time and this isn’t focusing on one problem at a time. This is focusing on something we’re talking about distress, tolerance, and improving the moment so focus on one thing, like your breathing: get your breath and calm down once your breathing calmed down. If you need to focus on something else, then move to. Maybe the tension in your neck. Maybe you need to lower your shoulders and release the tension in your neck, focusing on physiological things and focusing on other senses. Besides, that abstract stuff that’s in your head and your emotions can help people tolerate the distress until they can think more clearly vacation takes a timeout. Sometimes you just need to get away from it. For a few minutes, we’ve had time at work. I’m sure we all have where you’ve just been like. You know what I’m done and you lock your computer screen. You get up, you walk out of the building, and none of its clients are in there, but you walk out of the building and do a couple of laps around the campus and then you’re like okay. I can deal with this again just clear your head before you try to tackle whatever it is, an encouragement providing yourself, because you can’t necessarily rely on anyone else. Positive and calming self-talk now back to those stupid, memes and videos that I love to death there’s, one has a kitten on a laundry wire and it says: hang in there, I love having those things on screensavers. It’s, juvenile, maybe but whatever it makes me happy, and it reminds me you know even when I’m, not in a state of emotional distress. It reminds me all right keep on hanging in there. You got it and it’s got an all-factor too. So I always like anything with an all factor: the goals of emotional regulation. So once you’ve tolerated this distress, you’ve gotten through that initial surge. That initial, I cannot take this pain or upset. Then we need to move into emotional regulation, help people identify labels, understand their emotions and the functions of those emotions, decrease unwanted emotional responses and decrease emotional vulnerabilities. So what they’re going to do is identify and label emotions and their functions. I’m scared. Okay, you 39. Re scared. Tell me why what’s the function of you being scared? What do you want to do, and what do you think is causing this scared? 39. No self-awareness through questioning, like that through talking it out, people will start to understand where their emotional reactions are coming from and they can choose whether or not to follow up with it a behavior. What I guess I didn’t put in a behavior train analysis is the way you can go about helping people work through that and that’s a couple more slides cop. We want to police our thoughts and check the facts. Look at doing opposite actions. If you want to hurt yourself, look at being kind to yourself, if you want to run, maybe you need to look at staying and then look at the problem. Solving reduced vulnerability through the ABC p accumulate. The positives, remember, vulnerabilities, are those situations that happen leading up to whatever the distress is. Those are the things that make you more likely to be irritable, overwhelmed angrily depressed get sad about anything. Instead of not so, we want to eliminate those vulnerabilities or reduce them. As much as possible, so we’re going to accumulate positive gratitude, journals pictures if well, everybody has things in their life that they care about. Have those on your phone in you know little picture galleries that have them as your screen. Savers have reminders around about it. Why you get up in the morning builds mastery, so you have mastery of the skills you need to deal with emotional distress and upset cope ahead of time plan for distressing situations. If you’re getting ready to go in for an annual evaluation and those things stress you out to no end rehearse, it ahead of time plan on coping ahead of time, and figure out how you’re going to react. If it goes bad figure out how you’re going to react, if it goes good figure out how you’re going to cope and physical vulnerability prevention, maintain your health, chronic pain, chemical, chemical imbalances, hormonal imbalances, those can all cause vulnerabilities or set you up. Make you predisposed to feeling like something’s at eight when it’s only two get plenty of sleep when we’re sleep deprived, is a whole lot harder to deal with life on life 39. S terms and exercise. Exercise is a great way of releasing or using up some of that stress energy that you release during the day. Behavior chain analysis. The first thing you do and a strict behaviorist will have slightly different explanations for how to do this, but just bear with me here: name the behavior reaction. What happened now, if you’re thinking back to the ABCs, this is going to be your C. Your consequence, what happened identifying the prompting event ABC is, that would be the what was the activating event now. This is where it differs a little bit. Then we want to look at the behavioral links, so you had the activating event, and then there was this reaction and in between, there were um automatic beliefs, and we have that there. We have thoughts, but there were also sensations events, and feelings between what happened and your reaction. What sensations did you feel? Did you get flushed? Did you feel nervous? Did you feel scared? Did you feel sad? Did you have a twinge of something? What feelings were there and what events happened? Did you act out in a certain way? Did you scream? Did you yell about what happened? Because these are all things that are going to go into what ultimately ended up being the behavioral reaction, then I want to look at the short-term positive and negative effects of what you did. The behavior of the reaction. If you started screaming and throwing things okay, you did what was the short-term positive effect of that? What was the benefit of that? Because that was what you chose, which means it was likely the most beneficial response you could come up with in your highly emotionally charged mind then. So what were the benefits and what? With immediate short-term negatives and then looking at the positive and negative long-term effects in the long term, if you react to this upset by screaming and throwing things what’s the impact going to be, are there any positive impacts? Are there any potential positive effects of this and a lot of times it’s? No, but we want to ask the question just in case there are because some people will have a positive and we need to address that this is sort of. If you go back to motivational interviewing what we think about when we’re talking about decisional balance, exercises address the problematic links with skills. If some sensations or actions exacerbated the distress, then we need to look at distress and tolerance. If all of a sudden you had this immediate panic reaction and you couldn’t breathe, we need to work on distress, and tolerance skills, so you don’t go to that point where you are just for lack of a better phrase in a tizzy thoughts and Feelings if your thoughts get negative and start racing and your feelings are negative and anxious and worried and all those negative words we want to look at emotional regulation. You know if you can get through it, where you get through that initial rush and you’re still having these getting stuck in the negativity. Then we want to look at emotional regulation most of the time we’re going to look at both of them and then the third component, once we’ve learned how to get through the initial flood, the initial all-hands-on-deck call, and then people Have learned to regulate their emotions and identify helpful responses, and instead of talking about good and bad, we want to talk about helpful and less helpful responses. Then we need to look at interpersonal effectiveness and how to interact with other people to make that validating environment exist. So we want to start with interpersonal and intrapersonal if you will be effective with yourself and then move to others describe what’s going on assess how you’re feeling what your reactions are, and what the best next step is asserting. Your choice reinforces the good things. Be mindful appear confident and willing to negotiate, and yes sometimes we have to negotiate with ourselves because there’s something that we want to do right now – and this is very true – with people with addictions a lot of times – they want to use. They know the long-term consequences of use are not where they want to be, so they have to negotiate with themselves to say alright. I want to do this right now, but I’m going to choose a different option in their relationship with others. We want to encourage them to give me gently instead of critically, and harshly, which a lot of times is what they’ve gotten all of their life, being gentle with other people, accepting them where they are modeling how they want to be treated, be interested in What other people have to offer, what other people have to say and what’s going on with them? A lot of people with emotional dysregulation can’t handle their own life on life’s terms. They can’t even begin to handle anybody else.’s stuff, so a lot of times they appear disinterested, validate other people and their experiences, and have an easy manner. You know sometimes we get too intense and if everything in your world is either a zero or a ten, it’s easy to be intense. About everything, as they develop emotional regulation, things will be different. You know they’ll have fours and fives in there, but practicing that not being intense and over the top about everything, and then in their relationship with the self, be fast, be fair with themselves, not judgmental just fair, avoid apologies, stick to values and be truthful. 12-step recovery step, one starts with honesty, being honest with yourself step two. We start talking about hope and faith, which is sticking with values and being fair to oneself. Being compassionate comes couple more steps down that’s not hard or not harmful. For any of our clients to teach them to be fair, to be kind to themselves, and to be honest with themselves and others. So how does treatment progress when we’re talking about dialectical, behavior therapy as an evidence-based practice stage? One is safety. We want people to move from behavioral disk control to behavioral control. We don’t want people getting a phone call, maybe a significant other has to back out on a weekend trip which was someone with behavioral disk control could send them into a state where they are self-injuring. So we want to make sure that they have the skills to not self-harm, and you know you can’t just say. Well, you can’t cut the person’s like okay, so finish, what am I going to do? Instead? If I can’t cut, if I knew how to do something else, I’d be doing it right now. We need to help them increase their self-care behaviors instead of cutting. What can you do, I’ve talked before about some of the interventions I’ve used with some of my clients that have self-harmed. It’s not ideal. It’s not where you want to end up, but moving from self-harm, too, like I said, holding ice cubes or using a ballpoint pen to draw on yourself is preferable to cutting yourself. So we want to look at small steps, not going from. You know five or six self-harm episodes a week to nothing. You’re setting yourself and your client up for failure. We want to reduce the intensity of the self-harm, so they’re not breaking the skin, so they’re not damaging themselves decrease therapy interfering behaviors what we typically call resistance and that can be showing up late that can be always coming in and trying to derail therapy sessions, it can be being bossy, it can be being reserved whatever it is that’s interfering with the therapeutic process. It’s important to understand that therapy-interfering behaviors can be exhibited on the part of the counselor too. If the client is experiencing a lot of emotional discount role, sometimes counselors will start being late to sessions and will start forgetting to review the chart before they go in and remember what homework was assigned will start forgetting to do things. So we need to make sure that both the counselor and the client are engaging in motivating therapy participatory behaviors. We want to increase the quality of life, and behaviors and decrease the quality of life-interfering behaviors. So if they’re engaging in addictions, if they’re, not sleeping if they’re, changed smoking if they are and again these are things when we look at the priority list, my main focus at first is going to be on self-harm. You know I don’t want them to be engaging in those behaviors, and then we’re going to start looking at the other things that create vulnerabilities that make them more likely to be unhappy or to be reactive in situations that would make them unhappy. We’re going to increase behavioral skills, core mindfulness, and accurate awareness, encouraging clients, not just when they’re upset, but to engage in mindfulness scans body scans, four or five times a day. So they know where they are and they know if they are starting to feel vulnerable. If they’re, it feeling exhausted all of a sudden. If they’re feeling foggy, then they know to be kind to themselves: distress, and tolerance. We talked about those skills, interpersonal effectiveness talked about those skills, emotional regulation, and active problem-solving. So these are all going to be introduced in stage one, but they’re introduced. The client has been using their old behaviors for a lot longer than stage 1 is ever going to last. So we need to remember that we have to help clients strengthen these behaviors, remember to use them if they use them at first, one out of every five times as one more time than they were using them. Last week let’s focus on the positive forward movement and not on what we think they should have done. We don’t want to set goals that are going to set them up for failure in stage two. We want to help clients, moderate emotions from excruciating and uncontrollable to modulated and emotional um. We want to feel feelings. Well, I mean, theoretically, we do so. We don’t want people to completely numb out and become robots, but we also don’t want every single emotional experience to be like debriding. For a third-degree wound, we want something in between. We need to help them decrease intrusive symptoms, like flashbacks memories, and hecklers, the things that created the situation where they feel unlovable and unacceptable for who they are. We want to decrease avoidance of emotions, and I know that sounds kind of counterintuitive to increasing emotional awareness. Again, we don’t want them to be numb. We want them to feel because if they feel, then they can choose how to act and how to react. Decreased withdrawal increases exposure to live a lot of times, clients with emotional dysregulation have withdrawn because they don’t want to be rejected so they don’t go out with friends. They don’t experience life on life’s terms. They just sit in front of the television watching Netflix. We want to decrease self-invalidation and help them understand that their experiences are their experiences and they’re not right or wrong. Their choices may be helpful or less helpful, but at any point in time that is their best as well as they can see their best options for survival. So let’s not be critical. I’m just happy you’re still here and we want to reduce mood dependency of behaviors part of this process. We’re going to teach people how to create SMART goals that are specific, measurable, achievable, realistic, and time-limited SMART goals and make sure they’re successful by validating and teaching them to self-validate, encouraging them to imagine the possibilities when you’re successful When you accomplish this goal, what’s going to be different? How awesome will it be to encourage them to take small steps, not all or nothing? You know we want to get get rid of the dichotomy’s small steps towards recovery and applaud themselves for even trying to encourage them to lighten their load and get rid of stuff that they don’t need to be stressing over right now. You know maybe now’s not the time to start remodeling the house and then sweeten the pot and encourage clients to provide themselves with rewards for the successful completion of a goal, maybe getting through an entire week or for some clients even an entire day without self-injury. I encourage you to practice these skills yourself because you’ll see how much we don’t do and how helpful these skills can be, but it also gives you more insight into two ways to help explain thanks to clients and help them apply. These tools to themselves think about which skills you’ve used that were helpful or skills you could have used. That would have been helpful in the past week for you because you’re going to ask the clients to do this. So let’s do it for ourselves, so we can put ourselves in their position and think about which skills might have been helpful for a client that you’ve worked with in the past week. Many disorders involve some amount of emotional dysregulation. That dysregulation can be caused by high sensitivity and reactivity due to innate characteristics and poor environmental fit or external traumas and lack of support, or both DBT seeks, first to help the person replace self-defeating behaviors with self-care behaviors, and then moves toward emotional regulation and Interpersonal effectiveness to help people develop the support system and learn how to feel feelings, including the good ones. A variety of tools are imparted to clients to help them set SMART goals, identify and understand, emotions and their functions, decrease, unwanted, emotional and behavioral responses, and develop a more effective, compassionate, and supportive relationship with themselves and others. Finally, remember that not every tool is going to work for every person it takes some experimentation, so prepare your clients for that. Otherwise, if they try something and it doesn’t work, they’re going to feel rejected and validated and like failures. Again, it’s a process to work together to help them figure out how they can start interfacing with life and integrate the two dichotomies of thought and emotion to make wise choices to help them live happier and healthier. .As found on YouTubeHi, My name is James Gordon 👻🗯 I’m going to share with you the system I used to permanently cure the depression that I struggled with for over 20 years. My approach is going to teach you how to get to the root of your struggle with depression, with NO drugs and NO expensive and endless therapy sessions. If you’re ready to get on the path to finally overcome your depression, I invite you to keep reading…

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…

10 Ways to Deal with Social Anxiety

 Welcome to happiness isn’t brain surgery with Dr. Snipes. This podcast was created to provide you the information and tools Doc Snipes gives her clients so that you too can start living happier. Our website DocSnipes.com has even more resources videos and handouts and even interactive sessions with Doc Snipes to help you apply what you learn. Go to DocSnipes.com to learn more. Hey everybody and Welcome to happiness isn’t brain surgery with Doc Snipes: Practical tools to improve your mood and quality of life. Tonight we’re talking about 10 ways to deal with social anxiety a lot of people have social anxiety and that’s basically having unreasonable fears that you know are kind of excessive when it comes to being in any kind of social situation some people have only social anxiety when they’ve got to do things like perform or public speaking or something like that other people have social anxiety when they have to go to work when they have to be in crowds they don’t like going to the shopping center or the mall where there are a lot of people around so depending on your level of social anxiety, some of these things may be helpful to help you work through and deal with your social anxiety the first is to minimize stimulants stimulants Reb you up anxiety Rebs you up when you take stimulants if you drink too much coffee you may feel anxious so if you’re drinking stimulants before you go into an anxiety-provoking situation you may miss attributing your anxiety about the social situation when in actuality it was the caffeine or the nicotine the other thing that you want to do is pay attention when you’re at some of these events that you’re minimizing your stimulants the other thing and I’ll you know this is not stimulant alcohol is technically a depressant but when alcohol starts to wear off about it 30 minutes after you drink your drink it starts to wear off and there’s an anxiety rebound with alcohol so if you have high anxiety if you have social anxiety drinking to quell that anxiety is probably not your best bet because in the end it’s gonna kind of backfire and bite you in the ass know your temperament not everybody likes being around big groups of people I draw energy from being around people so I love being around groups but my daughter on the other hand is much more of an introvert and she would prefer to be around you know two or three people at a time she gets exhausted when she has to be in big groups of people it doesn’t mean she’s got social anxiety so know what your preference is for being around people so when you’re developing your self-confidence when you’re developing your skills when you’re working through social anxiety you’re not putting yourself in situations that would stress you out anyway so know your temperament if you’re an introvert when you’re making your exposure hierarchy which we’re going to talk about it in a minute you’re gonna start with something like going out for coffee with a friend to Starbucks or maybe even having a friend over for coffee in your house depending on how bad your social anxiety is and then you’re gonna work up from there but if you are an introvert you’re never gonna be relaxed in a group of a large group of people so I just understanding the difference between being anxious and feeling like you’re gonna crawl out of your skin and be uncomfortable or have it be very draining to be in a large group of people who understand your temperament that’s part of it so you can say you know this is normal I am not the type of a person who likes to be in a large group of people so it’s going to take some preparation and it’s going to take a lot of energy but I can do it knowing your triggers different things trigger anxiety for different people some people have anxiety when they feel like they’re going to be evaluated so if they’re doing a presentation for their colleagues or their peers they’re more likely to be more anxious than if they’re say hanging out with five other parents at a kid’s play date or something some people have one of their triggers is authority figures I know whenever I had to present in front of the CEO or in front of my department chair or whoever gave me more anxiety than presenting even in front of a class of a hundred and fifty students so it’s kind of all about what your particular triggers are if the other trigger you might want to consider the situation you know if you feel like you are on stage if you feel like you are the center and everybody’s looking at you that’s probably going to be a lot more anxiety-provoking than if you are mixing and mingling with other people at a party so know what triggers your anxiety so thinking about how your social anxiety impacts your life what kinds of things can you not do or what kinds of things do you find are just terrifying to keep a list of all of those things starting with the things that only make you a little bit nervous about things that you would rather you know pull your eyebrows out then do and start at the beginning start with the things that only cause you a little bit of anxiety imagine them rehearsing and doing them in your mind see yourself going through them successfully for example a job interview or a first date imagine what it’s going to be like what the other a person is going to say how you’re going to respond and how it’s all going to go well just keep imagining that until you can imagine it or think about it and you don’t feel stressed than when you go in to do it it’s going to be a lot easier once you get past that first thing move on to the next thing that causes a little bit more anxiety all right start at the beginning again imagine doing it see yourself going all the way through maybe it’s doing a public speech see yourself getting dressed for it getting ready for walking out on stage and delivering the speech and seeing it go well you’re not going to see yourself tripping and falling you’re not going to see yourself stuttering and stammering or dropping all your note cards or anything those are the things the cat strophic thoughts that you have that are likely not going to happen I want you to imagine it going perfectly rehearse it in your mind until you can do it literally with your eyes closed then when you go out to do it, it’s going to be that much easier because you’ve already done it 20 times in your own head and been successful at it so just do it like you practiced keep a rational outlook a lot of times social anxiety is caused by catastrophic self-statements things that you tell yourself people are judging me they’re laughing at me people are gonna think I’m an idiot um whatever your thoughts are so keep a list what those thoughts are and write counter thoughts to the people are judging me well they may be but do you care so if people are judging me that’s on them if people are laughing at me well at least they’re laughing but in reality what other reasons could the people have had to be laughing what are three other explanations for why they might be laughing besides laughing at you so look at your catastrophic self statements like I told you before imagining that you’re going to go out on stage and you’re gonna walk out there you’re gonna trip over your own two feet and you’re gonna wipe out on the way to do this presentation and humiliate yourself well that’s pretty darn catastrophic so think about exactly what is going to happen what are you going to do and how rational how realistic how likely is it that all these things are gonna happen and you know if that is one of your fears watch the movie Miss Congeniality because she is going at as Miss America I think is who she’s trying to portray and she falls flat on her face and she just picks herself right back up and walks on and nobody thinks anything of it after that it’s not like a week later or 20 minutes later in the movie, people are still talking about her falling she did she over it and you know move past it when you make a big deal out of it when people start to think about it a little bit more practice breathing when we get stressed we tend to breathe more shallowly and more rapidly when you breathe slowly and deeply you’re triggering the relaxation response in your body it doesn’t mean you have to take those big giant deep breaths as you do at the doctor’s office or anything that’s overly dramas is it but focus on your breathing if you start feeling yourself getting an anxious breath in for a count of three hold for a count of three and breathe out for a count of three and you know again it doesn’t have to be noticeable that you’re doing it you can do it in a meeting and nobody will even know but if you can slow your breathing you’ll slow your heart rate and you’ll trigger the relaxation response to help you deal with your anxiety sometimes we’ve just got to suck it up and go through things that create a lot of anxiety for us I remember one place I worked once a month we would have to get up in front of all of our colleagues and all of the executives and give a report on how our department was doing I hated doing that I hated being up there giving this report not because of the content of the report I just hated being up there in front of everybody and it was no big deal but it would cause me a little bit of anxiety if I had to do it so distress tolerance techniques were always useful because it was an eight-hour meeting so it might be four hours of me sitting there anticipating going up and having to give my speech so what would I do during the four hours while I was waiting I would do activities I would listen to what other people were saying I would make notes I would sometimes go through clinical charts and sign off on documentation and not pay attention but you know I digress contributing so if you’re at a party you can’t do it in a meeting but if you’re at a party for example and used feeling anxious get up maybe help the hostess out or the host out in the kitchen go around pick up glasses pick up trash throw things away do something to be helpful to contribute so you’re not feeling like you’re having to sit there and be on the spot comparisons can help too you can just kind of blend back into the wall a little bit and compare how you’re doing to how other people are doing or how you’re doing to how you’ve done in the past because you’re probably doing better now than you did then trigger opposite emotions is another way of dealing with distress if you’re feeling anxious you know bring out the opposite tell a joke find something funny find a video or something that makes you laugh and share it with other people because that’ll make you start laughing and feel more relaxed and release endorphins you can also just push away some of those thoughts that keep coming into your head I’m gonna make a mistake I’m gonna say something stupid they’re judging me it’s gonna be awful just push those thoughts away and Do you know what no I can do this and I’m going to push through the final the thing you can do in this particular set of distress tolerance techniques is sensations focus on sensations some people have a rubber band that they snap on their wrists to kind of help them focus on something else some people wring their hands I don’t recommend that because you know that just kind of shows you’re anxious and keeps your anxiety going listening to loud music you can go into the bathroom and splash cold water on your face unless it’ll make your mascara run there are a variety of things you can do that you can also find go and find some coffee because coffee is hot and that focus on how the coffee feels in your hands when you’re holding the cup focus on the taste of the coffee that hot sensation will kind of distract you from other things that are going on so focus and we’re going to talk about one thing at a time in a minute another set of distress tolerance techniques that can help our imagery and we’ve talked about rehearsing it before you go to the party imagine what you’re going to do before you go to the mixer or your in-laws or wherever it is you’re going that’s potentially going to cause you anxiety imagine going through it and doing it successfully to find meaning in what you’re doing so sometimes you know maybe you’re going to your spouse’s holiday Christmas party and it’s like the last thing you want to do because you don’t like big crowds like that you don’t know anybody but find meaning in it why are you doing this is because it’s helpful to your spouse you’re providing support and you know maybe you can find somebody that has similar hobbies or something before you go if you’re going to your spouse’s Christmas party for example try to find out who might be at the party that shares similar hobbies and stuff I know my husband works with people who do organic gardening and who are kind of health-conscious I won’t say fanatical but health-conscious like I am and we like to use a lot of lentils and beans and cook in health healthy ways so identifying those people I can’t talk about what they do at work because that’s just way out of my wheelhouse and over my head but I can talk with them about these other things so I’m not just standing there looking around and feeling like I’m out of place so find meaning in what you’re doing and try to find connections and commonalities with other people before you go and then you know I can have I would have my spouse introduce me to one of the people that does organic gardening for example and then we could start talking once you get more comfortable then you’re going to feel more at ease walking up to people and going hey you know and striking up a conversation and finding out commonalities if you’ve got children a lot of other people have children so you can talk about your kids or if you’ve got pets you can talk about your pets your dog’s people love their dog’s prayer can help sometimes you just got to take a breath and say a prayer before you walk into that situation to kind of get you through and get you going practice relaxation if you’re feeling stressed just again don’t have to get out of your chair you don’t have to go anywhere but practice tensing and releasing your muscles clenching your fists and releasing your hands and feel the difference between tense and released and then tense kind of your whole upper body and you don’t have to do it like this because that’s obvious but you can kind of tense up a little bit and relax and feel the difference between stressed and relaxed and then when you do it one more time you tense and when you relaxed you feel all the stress just draining out of your body out of your fingertips so that’s a kind of guided relaxation to help you when you’re kind of on the spot one thing at a time when you’re in a the social situation there is a lot of input there is a lot of stimulus going around a lot of people focus on one thing at a time if you start getting overwhelmed if you’re at a party maybe you can go over and get something to eat and focus on talking to one person at a time or focusing on what you’re eating or you know find something that you can focus on so you’re not trying to keep up with everything that’s going on takes a mental vacation or a physical vacation sometimes you just got to excuse yourself and go to the bathroom and hide out for five minutes and that’s okay you know sometimes you need to go somewhere where you know nobody’s watching and you can take those good deep breaths and go you know I got this it’s gonna be okay I’m doing fine give yourself a pep talk look realistically over how the night’s gone and the majority of it has gone okay yeah they’re probably going to be some hiccups and Pho paws here and there and if there are that’s okay it happens to everybody nobody is perfect at their social interactions all the time and that’s okay but look over it realistically to realize that tonight is going okay it may not be going the way you had hoped it would but it’s going okay there’s nothing catastrophic ly wrong and remember that we are a lot more important in our minds than we are in anybody else’s mind so when we make a the mistake we will remember it for six months but other people probably forget it’s about sixty minutes later it’s just you know even if it’s something like you walked out of the bathroom and you had your dress tucked in the back your panties did that before trusting me not something I want to repeat but I would bet if I asked any of my staff now yes I did it at work about that incident they’d look at me and go no I don’t remember that I remember it because it was mortifying but nobody else cared they were passed it by the next day nobody thought anything about it so remember that a lot of stuff that seems huge and glaring to you is only because it happened to you and other people are so involved in their own life they probably didn’t notice or won’t remember that fear is an acronym standing for false evidence appearing real so always examine the evidence if something happens and you think it is the absolute worst thing in the world and you’re just gonna die how likely is it that that’s true is it the worst the thing in the world is people judging you so look at the evidence how do you know this is going on for certain and what are other explanations for what might be going on mentally rehearsing those stressful social situations get ready for it the job interview the first date and for some people even going to the doctor can be a stressful social situation because they get kind of a white coat syndrome where they don’t they’re afraid to speak up to their doctor, I found that if there is a certain set of things that you need to say like if you’re going in to talk to your boss or you’re going in to talk to your doctor sometimes it’s helpful to write down a list of the points that you want to cover with them or the symptoms that you’re having so you can go over it and make sure you get everything said and you don’t end up kind of getting shut down when I used to go have supervision with my boss you know I only got supervision for one hour once a week and that was if I was lucky so I would go in with a whole laundry list of things and it could be the stuff that I was upset about or having difficulty with and I could have a laundry list and just go through it and mark it off so I would make sure that I got everything said and I covered and we were on the same page by the end of the the meeting finally practice mindfulness and focus on your surroundings to know how you feel if you start feeling anxious a step back and ask yourself why am I anxious what do I need right now to feel calmer try to do this periodically so you don’t wait until your anxiety is off-the-charts focus on your surroundings look around to find places and little niches that you might feel comfortable maybe there’s somebody else sitting over in the corner and you can go sit down with them and chat maybe there’s an empty seat somewhere that you can just go sit down and take a breath or go out on if it’s a patio or a party maybe you can go out on the patio for a few minutes oftentimes there’s somebody sitting out on the patio trying to get a little peace so you can find a situation that’s less anxiety-provoking two little bonus things I’m going to tell you with social anxiety a lot of times people are afraid that they’re going to offend someone and these days it is so easy to offend people so what I tell my clients and my kids and what I try to remember myself is before I speak or when I’m talking to people if what I’m saying is true helpful important necessary and kind then you know there’s probably a good chance I won’t offend them look on your social media look at the comments people leave on other people’s posts and stuff and see if they meet these criteria true helpful important necessary and kind 90% of the time the answer is no well I won’t say that much about 50% of the time the the answer is no there are a lot of times people will just say nasty stuff that didn’t need to be said and that can be offensive but if you practice and focus on making sure what you say is true helpful important necessary and kind and if you’re following me that spells out think then the chances that you’re going to offend somebody are greatly reduced if the person still gets offended it’s probably more about them because you aren’t trying to offend them you weren’t trying to be hurtful you are trying to be helpful and kind therefore it may be more about their stuff whether they have an issue with you or they have an issue with something else that’s going on and you just happen to be kind of in the way it’s more about them you can’t control how they react to things it’s their responsibility if you’re being nice and they take it the wrong way and they get offended that’s their perception and they need to work on that the other bonus that I’ll tell you to take away is something I got from dr.Seuss and I love something he says about the judgment of those whose minds don’t matter and those who matter don’t mind so the people who matter in your life they’re going to be people judge you all the time that’s just the way humans are but those who mind what you do those who get offended those who judge you all the time they don’t matter the people who matter to you don’t mind if you make a mistake don’t mind if you’re not perfect they probably embrace all of your imperfections so before you approach a social situation remember not everybody’s gonna like you that’s just it’s not possible to have everybody like you so remember the wise words of dr. Seuss those whose minds don’t matter and those who matter don’t mind if you like this podcast subscribe to your favorite spot on your favorite podcast app join our Facebook group at docs nights comm / Facebook or join our community and access additional resources at Doc Snipes com you thanks for tuning in – happiness isn’t brain surgery with Doc’s knives our mission is to make practical tools for living the happiest life affordable and accessible to everyone we record the podcast during a Facebook live broadcast each week join us free at Doc’s 9.com slash Facebook or subscribe to the podcast on your favorite podcast player and remember Doc’s nights calm has even more resources Members Only videos handouts and workbooks to help you apply what you learn if you like this podcast and want to support the work we are doing for as little as 399 per month you can become a supporter at Doc’s nights comm slash join again thank you for joining us and let us know how we can help youAs 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…

A Strengths Based Approach to Bipolar Disorder Treatment

 this episode was pre-recorded as part of a live continuing   education webinar on-demand, CEUs are still available for this presentation   through all CEUs register at all CEUs comm slash counselor toolbox I’d like to welcome everybody to today’s presentation on a strengths-based biopsychosocial   approach to recovery from bipolar disorder so we’re going to talk a little bit about   what bipolar is what causes it and how to mitigate it by helping people understand their   own bipolar because what triggers it for John may not trigger it for James help them identify   their warning signs because bipolar episodes just like depressive episodes and manic episodes   often don’t come from completely out of the blue if we look backward we can see where the   person was beginning to resume some unhealthy lifestyle habits that were making them   more vulnerable well look at the symptoms of depression and mania and real quickly   review bipolar one versus two and look at some co-occurring disorders and interventions another   thing I added to this presentation was a little a short piece on differential diagnosis because   I often see people who are diagnosed either only with bipolar when there’s also attention deficit   disorder present or they’re diagnosed with anxiety when it’s bipolar disorder so we’re going   to talk about how people might mistakenly diagnose one for the other and how to kind of try to ferret   that out a little bit one way is using the online assessment measures there’s another measure   we’re going to talk about in here too so we care because uncontrolled bipolar puts people at risk   for suicide addiction and addiction relapse you know even if somebody doesn’t have an addiction   when they are in a manic episode they can be more likely to engage in potentially self-injurious   behaviors, not for self-injury but just because they’re looking for even more of a   rush and when they’re in a depressive episode they can also be at risk for addictions because   they’re looking to feel better in some sort of the way so a lot of it we’re talking about well   with we’re talking about self-medication with mania we’re just talking about what they perceive   as something exciting and people are often in manic episodes engage in extreme risk-taking behavior   we don’t want our clients to go down any of these paths so we want to be aware of what might trigger   it and I don’t think I talk about it anywhere else in the presentation, it’s important to be   aware that for suicide when somebody is coming out of a depressive episode who somebody who’s   bipolar well or unipolar depression but when they’re coming out of the depressive episode   and they start having more energy is actually when they’re at greater risk of suicide than   when they’re at their absolute bottom not saying they’re safe at their absolute bottom but we don’t   want to get complacent when somebody starts feeling better and assume that they’re out   of the woods with poorly controlled bipolar disorder can leave people feeling hopeless and helpless   if they have bipolar one and they have at least a full-blown manic episode but maybe more they   may not mind that they may because it disrupts their life the depressive episodes tend to be   when patients usually present when they’ve got bipolar disorder so we want to look at what’s   going on with them and help them see how the bipolar disorder disrupts their life because   that can go a fair way to encouraging medication and treatment compliance well controlled bipolar   like well-controlled addiction helps a person feel happy optimistic motivated and energized the key   is helping them manage their vulnerabilities you now take care of their body so they have   enough energy to do things but also make sure that they get their medications right some of   the mood stabilizers can be flattened and make people feel more exhausted and it’s important   it’s vital that they openly communicate with their psychiatrist or physician about the medications if   they are if the side effects are so significant is impairing their quality of life which means   they’re likely to be medication non-compliance so we want to make sure that if they’re feeling too   flat that they talk it over with their medication provider bipolar disorder is a brain disorder you   know sometimes with like depression we can look for situational causes for anxiety we can look   for some situational causes we can look for some cognitive stuff we know in bipolar disorder something is going on in the brain that causes unusual shifts in mood energy activity levels   and the ability to carry out day-to-day tasks many very successful let me go back to that so just to   be clear and generalized anxiety panic disorder depression they also can have a brain organic   component to them but not always sometimes you can have those from a situational cause whereas in bipolar disorder we know that there’s something that’s not quite right with the balance of the   neurotransmitters for most people with bipolar okay so who has bipolar lots of people you’d be   surprised Mel Gibson demi Lovato Axl Rose, Britney Spears Jean-Claude Van Damme Marc Vonnegut and   Amy Winehouse to name just a few that I came across you know doing some internet research   Lee Lee Thompson young and Robin Williams were also, both are quite successful and revered in their   fields despite if you want to call it losing their battle with bipolar so why do I bring   that up because a lot of times people when they are given a diagnosis of bipolar disorder feel   very isolated feel very unique and I want them to realize that there are a lot of really successful   awesome people who have bipolar disorder you know it once it’s managed then people can   live a stereotypical life I work hard to avoid the word normal because what’s normal for   one person may not be for another but we want to look at they can have a very high-quality active   life bipolar disorder is caused by imbalances and neurochemicals especially dopamine serotonin and   norepinephrine the imbalances could be genetic or triggered by sex hormone changes or stress hormone   changes so they may be at you know steady state but when there’s a particular stressor some sort   of change or you know other thing and it depends on the person, it can throw those neurotransmitters   out of balance enough that it causes either a manic episode hypomanic episode or a depressive   episode more than one in 50 adults are classified as having bipolar disorder in any 12 months so I encourage people when they’re walking around the store when they’re walking around the grocery   store when they’re at church when they are sitting in a meeting at work with you know 50 other people   at least one person in that group has bipolar disorder and or will be diagnosed with it in   the year I want them to recognize how common it is I want them to start looking around and   thinking when they’re driving down the road on rush-hour traffic you know every 50th car they   pass somebody in those 50 cars probably had bipolar disorder to help them realize again   it’s not us weird diagnosis is pretty doggone common among patients seen in primary   care settings for depressive and/or anxiety symptoms twenty to thirty percent are estimated   to have bipolar disorder a lot of times primary care physicians misdiagnosed bipolar disorder as   either generalized anxiety or unipolar depression so it’s you know eighty percent of the time   seventy eighty percent of the time they’re right but the other twenty to thirty percent you’ve got   this person who is going to continue to struggle and get frustrated because the treatments   for generalized anxiety and depression are generally, SSRIs and SSRIs can trigger mania so it can make the mood lability worse bipolar the disorder is still under-recognized primarily   due to misdiagnosis as unipolar depression and that’s not just in primary care that’s also in   you know our field because if we see somebody who has unipolar depression you know they may not have   had a manic episode yet likely they have but they may not have had a manic episode yet or they may   not report it or if it’s a hypomanic episode they may not note that as something problematic and yes diagnosis of mental health conditions is out of the scope for a lot of GPS and a lot   of them will tell you that a lot of them will say If you’ve been diagnosed before I can help you   continue your medication but there are so many nuances to psychological diagnosis I want   you to get an evaluation from a psychiatrist in order to better make sure that we’re getting you   started on the right path because nothing is more frustrating to somebody who is struggling   and again generally they present in a depressive episode nobody is nothing is more troubling for   somebody who’s presenting and struggling then getting on medication and not feeling like it’s   working is one of the things they see and I’m jumping ahead of me is when somebody who has bipolar   disorder is started on an SSRI one effect could be to set off a manic episode another effect could be   to have rapid improvement and you know it takes four to six weeks for the SSRIs to get in there but they tend to have rapid improvement in days unfortunately that improvement   doesn’t last and then  they tend to go back into a depressive episode and they start to feel even   more defeated I want clients to understand us if they start talking about that pattern where   they’ve been on antidepressants and it works for a little while but then it doesn’t anymore   you know that may just be the wrong medication for them, their case is not hopeless so we know   the symptoms of depression apathy feeling down empty hopeless low energy decreased activity   sleep changes worrying difficulty concentrating forgetting things a lot of changes in eating habits   and feeling tired or slowed down how is this different than Low Energy I’ve had clients ask   me this before and what I try to the way I try to differentiate is energy is your desire to get up   and do things and feel like you can when people are feeling tired or slowed down it almost feels   like they’ve got a 50-pound rucksack on their back or their arms and legs feel like they’re just lead   and it is exhausting to even get up and walk across the room go to the kitchen go outside so   there’s a difference there’s energy to do things and then there’s just feeling like you’re filled   with cement mania people feel very up high or elated now after people come out of a depressive   episode even unipolar depression there’s a period of mild very very mild euphoria and we don’t want   to mistake that for hypomania or mania they’re just feeling good they’re like oh my gosh I see   the Sun again I see colors how awesome is this and then you know it kind of levels out but you don’t   have a crash it’s just kind of a good and then a-ok contentment people in a manic episode   have a lot of energy and increased activity levels they often feel jumpy or wired you know like they   can’t settle down they want to sometimes but they can’t they’re wide awake and they’re just looking   for something to do they have trouble sleeping may talk fast about a lot of different   things so they’re jumping around and when we talk about ADHD in a minute, we’re going to talk more   about these symptoms they may agitate irritably or touchy not everybody who’s manic is in a good   mood so they can be manic but agitated they feel like their thoughts are going fast and think they can do a lot of things at once people especially in a hypomanic episode   often find themselves taking on three four five six projects and not being able to complete them   you know when they come out of their hypomanic In the episode, they’re like oh my gosh what did I get   myself into but there’s no sense of time in a manic or hypomanic episode and they can especially   in a manic episode engage in risky and reckless behavior so mixed bipolar includes symptoms of   both manic and depressive symptoms at the same time which can be confusing to clients   they’re up they feel like they’re wired but they have no their flat they have apathy and just   that lack of pleasure and anything they may feel very sad empty and hopeless and energized bipolar   one now that big difference is bipolar one has at At least one full-blown manic episode if there hasn’t   been one full-blown manic episode then we’re going to look for bipolar 2 where you have hypomania and   major depressive disorder bipolar one can have either major depressive disorder or persistent   depressive disorder so the big difference is if there’s a manic episode there they’re number one   bipolar one patients experienced depressive symptoms more than three times as frequently   as manic or hypomanic symptoms so yeah when they hit a manic or hypomanic period it’s not a wonder   they feel pretty good and they don’t want it to go away if they experienced it three times more   often bipolar 2 patients experience depressive symptoms approximately hold your horses   39 that’s not a mistake 39 times more often than hypomanic symptoms so people with bipolar 2 can   have 39 depressives before a manic episode now unfortunately, the body is not that consistent   where we can go okay 38 39 you’re due for a manic episode but we do know that both types of bipolar   depression are experienced a lot more frequently than mania or hypomania so a common misdiagnosis is generalized anxiety disorder how do you differentiate because some people when they get   anxious get revved up and they feel like they’re wired and they can’t sleep the   goal-directed activity and generalized anxiety the disorder is often related to an anxiety theme   like if they think that there’s a problem with their finances or if they’re you know whatever   they’re worried about their activities and their thoughts generally race in that direction they’re   not all over the place they’re pretty directed in more or less and their mood is often irritable and   energetic versus elated now again just because somebody is irritable doesn’t mean it’s the anxiety   we want to look specifically at what is causing the sleep disruption and what are the themes of   the thoughts that the person is having the racing thoughts because if you know something’s going bad   at work you hear there’s going to be layoffs somebody can get anxious and go well if   I get laid off then I’m going to lose my job if If I lose my job then I’m not going to be able to   pay the house payment and I’m dead a debt a debt it and go in this rapid cycle of catastrophe and   get themselves all worked up and then not sleep then they start trying to figure out okay what I need to do to make sure I can pay the house payment what do I need to do to make   sure I can do this so anxiety disorder pretty focused ADHD approximately 60 to 70 percent of   people with bipolar disorder also have ADHD and 20% of people with ADHD have bipolar disorder   so you can draw your own Venn diagram if you want the take-home message is we don’t want to   assume that they’re mutually exclusive because if you’ve got somebody with bipolar disorder you can   get that controlled but they’ve still got the ADHD symptoms going on over here they’re going to feel   often feel frustrated now what’s the difference people with ADHD often have a hyper focus that’s   one of the hallmarks this may happen on a deadline pressure or when wrapped up in a compelling book   project or video game and so you can you can see where there’s a trigger for it hyper focus may   cause a decreased need for sleep and look like increased goal-directed activity   but is often short-lived in people with ADHD who feel exhausted when the hyper-focus fades so we   want to look for number one was there something that triggered this hyper-focus could be a video   game could be an awesome book or even a Netflix marathon whatever it is and once   that hyper-focus faded did they feel exhausted if so we’re probably looking more towards ADHD   than bipolar a manic episode is independent of external circumstances you know it’s not where   somebody gets a project and it sends them into In a manic episode, there’s a lot less control and   predictability in people with bipolar disorder and people with bipolar often want to go to sleep   or relax but describe the feeling as if they can’t wind down which can go on for a week or more so   we’re looking at duration we’re looking at what triggers it if they report let’s go back to here   sometimes having manic episodes that there was no trigger and they lasted a long time but they   also report manic goal-directed activity under deadline pressure or you know they can have all   these symptoms which means you’re looking at ADHD and mania or bipolar disorder together potentially   in ADHD people often interrupt or talk too much without noticing because they miss social cues   or because they lose focus on the threads of a conversation because their minds going six   ways till Sunday I had a friend of mine one time who had ADHD she was in graduate school with me   and she gave a presentation on it one time and we were talking and she was presenting and as she was   presenting somebody started flicking the lights on and off and all of us were looking around at each   other going this is annoying and then a little while later you know 30 seconds or a minute later   somebody turned on the radio not loud but low in the background and we’re all looking at   each other and then she started doing something else after that oh she turned on a fan so the fan   was oscillating and blowing in our faces and and finally, she’s like is this annoying and we were   like yeah that’s annoying it’s hard to concentrate and she said this is what life   is like for somebody with ADHD many times because we have difficulty filtering out what’s important   to pay attention to and what’s not so we’re paying attention to everything so that made it a lot more   understandable to me which was helpful later when my son was diagnosed with ADHD because you know   it helped me tailor his learning environment so people with ADHD kind of get lost and they’re paying attention so much that they can miss the social cues people experiencing manic   bipolar episodes are often very aware that they’re changing topics quickly and sometimes randomly but   they feel powerless to stop or understand they’re quickly moving thoughts so they’re just trying   to keep you in the loop in everything and they may notice that you’re getting uncomfortable or   irritated or impatient but they don’t feel like they can stop racing thoughts you know all these   kind of go together but kind of not people with ADHD report racing thoughts that they can grasp   and appreciate but can’t necessarily express or record quickly enough think about the time you   got excited about something and you just had all these ideas whenever we get a new grant   that comes in I’m in charge of or I used to be in charge of writing the grant so I get the grant and   I’d read through and I start identifying all the different things that we could do to you   know get this grant and it would be hard for me to keep my pencil going fast enough to keep up with   my ideas and you know I don’t have an and you know that was perfectly normal but I was excited   and so my mind was racing people with ADHD can do this a lot you know not just because of a grant   coming in people with mania the racing thoughts flash by like a flock of birds overtaking them   so fast that their color and type are impossible to discern I loved this explanation because it’s just like you have this whole massive bird coming in and then going out and you didn’t have a chance   to even notice what they were people with with mania often feels that way they don’t can’t grab   any of those thoughts and hook on to them they’re just in and out so helping people differentiate to make sure that if they’ve got anxiety and bipolar if they’ve got anxiety and ADHD and bipolar bless   their hearts that were attending to all of their presenting symptoms and issues so what do they do   to treat bipolar well we’re going to get down into that in a minute sorry got ahead of myself things   that can trigger a bipolar episode medications antidepressants as I said can propel a patient   into mania captopril which is an ACE inhibitor something that’s used for high blood pressure can   also trigger a bipolar episode corticosteroids certain immunosuppressant medications levodopa   which increases dopamine you may see patients with schizophrenia or Parkinson’s taking web   dopa and methylphenidate or dexmethylphenidate which are ADHD medications all of these different   categories of medications can potentially trigger a bipolar so do they trigger it in every single   person no so that makes it even more difficult but it is important to be aware if somebody has   bipolar when they start taking medications that they need to be conscious and cognizant of   their symptoms so they can you know identify early onset of a depressive or a manic episode   circadian rhythm desynchronization can trigger or look like bipolar disorder hyperthyroidism can   look like a manic episode that means too much thyroid you know a lot of times we talk about   hypothyroidism and depression hyperthyroidism gets people to revved in children mania can be   misdiagnosed or look like oppositional defiant disorder and substance use both intoxication and   withdrawal but more specifically intoxication can also, look like mania or depression depending on   whether they’re taking stimulants or depressants so it’s important to make sure that the person   when they’re being assessed is substance-free Do you know what medications they’re on they’ve   had a physical to rule out any hormone causes the thyroid is a hormone and looks at their circadian   rhythms if they happen to be visually impaired that can cause problems in circadian rhythm if   they are shift workers that can cause problems with circadian rhythm so let’s make sure we don’t   label something as bipolar and start treating as such before we’ve ruled out everything else bipolar distinguishing factors and let’s see let me see if I can get that open for me right   now well anyway spontaneous hypomania premorbid affective temperament particularly hyper thymic   or cyclothymic so before somebody had an episode that they presented with do they have a history   of remembering dysthymic is feeling blue low unhappy hyper thymic is more elated and   cyclothymic is rapidly switching Moodle ability increased mental or physical energy even during   depressions family you know you know we talked about the mixed episode if there’s a   family history of bipolar disorder or a good response to lithium for unipolar depression   or bipolar that’s a risk factor or a hallmark that you might be dealing with bipolar in this   client if they have treatment-emergent hypomania mania or mixed States so as soon as they start   medication treatment generally SSRIs they have an uncharacteristically rapid response followed   by a crash again and or they have more than two failures on antidepressants now we want to look at what that means because antidepressants work differently for different people, somebody can be   on and I’m going to use the trade names here just because I don’t have all of the generics memorized   I’m not promoting any particular trade name but people could be on Lexapro or Paxil and feel like   they can’t wake up people can be on Prozac and feel like they’ve got more energy some people are   on Zoloft and don’t feel any energy change some people feel lousy but with antidepressants, we want   to look at what failure means did it fail to improve the mood or were the side effects so bad   that the person had to switch if this if it was the side effects that are not classified   as a failure because the person wasn’t able to stay on it long enough for that antidepressant   to get in their system now I do want you to see the mood disorders questionnaire, haha and that’s in this article here but there are three all of these questions that you can   have people just complete at assessment and it helps you identify if they’ve had a manic   or hypomanic episode so have there ever been a period of time when you are not your usual   self and you felt so good or hyper that people thought you are not the normal self you were so   irritable that you shouted at people or started fights you felt much more self-confident than   usual you got less sleep than usual and found you didn’t miss it you were much more   interested in sex than usual spending money got you or your family in trouble you know you can   go through all the rest of the questions and they identify yes or no to each of these once they do   that if they did check yes to more than one of the above have they ever happened during the same period if yes then again we’re probably looking at one of the bipolar and finally how much of a   problem did any of these cause for you and if it’s a minor problem then we may want to look for other   things this does not diagnose bipolar but it is an excellent screening instrument to give you an idea   about whether you need to look in that direction have clients keep a life chart ideally for three   to six months where they chart their sleep their dietary habits their exercise their life stressors   hormones for women and any bipolar symptoms that they’re having now when I have clients chart this   much I create a really simple fill in the blank a chart like for sleep number of hours did you   feel rested yes or no dietary habits I have them keep on their mobile device for exercise did you   exercise yes or no if so how much for how long you know really simple things so they can complete the   chart in under five minutes otherwise, they’re not going to do it for the bipolar symptoms I   have check blocks you know did you feel depressed did you have difficulty sleeping yada-yada so   it’s easy it’s very very simple for them to fill out and it’s also simple for me to evaluate when   I go through it encourages people to understand their bipolar because everybody’s presentation   is going to be a little bit different have them identify you know their cognitive patterns and negative thinking patterns that contribute to their depression and if so how do they handle   those in the past when they felt depressed how did they change their thinking or what they do to   help themself be a little bit more optimistic and also looking cognitively what if they got going   for them are they intelligent are they creative are they you know build on those if somebody is   creative you know I’m not so I it’s wonderful to see creative people but for somebody who’s creating one of the greatest things they can do to work with their depression is art therapy you   know it’s very therapeutic for a lot of people so find their strengths and use those to help   them resolve their current presenting symptoms physically encourage them to get adequate sleep to avoid opiate and sedative medications alcohol and any sort of over-the-counter herbs including Jen   Singh Sant Sami 5htp without talking to their the doctor first encourages them to eat a good diet   they may already be doing some of this so how much they change at one time it is gonna vary between   the person and what they’re motivated to change remind them not to change too much at once let’s   just do one or two things right now and then you can work on two more things once you have those   under underway situationally have them do a coping skills inventory to figure out how they cope when things get stressful and have them identify triggers for their bipolar that what   types of situations make you feel depressed what types of situations have you noticed might seem   to trigger a manic episode some people when they get stressed about something there’s that   anxiety it can the stress of that and having the HPA axis activated can trigger a manic episode for   them so encourage them to you know in their chart they’re going to be keeping track of what might be   contributing to triggering and mitigating bipolar symptoms so if they’re getting good sleep and eating   a decent diet their life stressors are pretty low and they’re not having any symptoms well we   know what they can do interpersonally have them identify supportive friends to help them learn about   interpersonal behaviors that trigger them and ways to deal with those interpersonal behaviors so if   when somebody tends to be in a manic episode or even in a depressive episode if they tend to be   irritable think about having them look at what behaviors trigger their irritability trigger   their anger and figure out a plan to deal with it to minimize the impact that being on   one end of the spectrum or the other mood wise might have on their relationships angers normal   irritability is normal don’t get me wrong but when somebody is in a depressive episode or a manic   episode that irritability can be intensified tenfold and people may be taken aback by it   environmentally encourage clients to look around their environments and look at what they can do to   make their environment cheerful calm and safe you know what that looks like for that particular   person those are things that they can do because it’s you know when you felt calm and safe before   what was different or what was the same what helps you feel cheerful we just recently had the inside   of the house repainted because it was time but I’ve always felt more cheerful, especially during   the winter and when there’s less sunlight when I have like a light yellow color on the walls like   straw not bright yellow and that helps me feel a little bit more cheerful which is in contrast to   all the black that I put in there but whatever it works for me and that’s how I feel comfortable in   my environment to encourage clients especially you know when they’re feeling like they’re   heading toward a depressive or manic episode to eliminate negativity from social media and television media you know if it stresses them out to watch the news do they have to watch the news   you know what will happen if they go for a month without watching the news and in their real-life environment encourage them to try to eliminate as much negativity as possible and that can   be altering how they deal with interpersonal relationships that can be looking around and   finding things that stress them out and addressing there are a lot of different things but we   want to look at it as biopsychosocial II Romania we still want to build on strengths and encourage   them to become aware of any medications they’re taking and how those medications affect them this   can include stimulants thyroid medications, Sammy and 5htp encourage them to avoid stimulants when   possible and don’t combine them with caffeine if they put ephedra for example in combination   with caffeine that used to be a common combination in pre-workout supplements that can get somebody revved up and so we want to make sure that they’re aware of the effect   not only on their body but the likelihood that could also trigger a mood episode have them identify warning signs and interventions sometimes like I said   that for people with bipolar disorder the depression and/or manic episode may seem   like it comes out of the blue and sometimes it may but 99% of the time when I’ve traced it   back with clients they weren’t taking good care of themselves they were either taking   on too much at work or they weren’t getting enough sleep or they weren’t eating well or   you know there had been something that had changed from when they were doing well and   they felt good too when they started feeling like they were heading down towards an episode some patients may try to identify triggers for manic episodes to increase those we   want to encourage them not to do that because that’s like driving your car with the RPMs up   at five indefinitely that’s not good for your the car eventually something Bad’s gonna happen   so we don’t want them to read themselves up that much we need to help them find that happy medium   where they’re content there are three or four on a scale of 1 to 5 and they’re feeling good   for some clients when they start feeling depressed they notice thinking changes and have difficulty   concentrating this is a warning sign you know they may not feel completely depressed yet but they may   be waking up in the morning going yeah not so sure I want to get out of it they may have low energy   changes in sleeping or eating irritability sadness negativity resentment withdrawal and   environmentally they may notice that they’re in the area becomes more disorganized or they may just   not be caring as much about personal hygiene as these are all things that they can identify early on and   say huh you know it looks like maybe I need to take a little bit better care of myself and it’s   hard for clients it’s hard for a lot of us to listen to our body and go okay I wanted   to do XYZ but my body is telling me that maybe I need to rest for mania warning signs can include   racing thoughts heightened creativity that’s one that for people to be aware of especially   if you’re dealing with somebody who’s naturally creative they may thrive during this period of   heightened creativity and get upset when you start suggesting that they may need to temper   that to stabilize their mood they’re gonna have to cut the top off the highs and raise   the bottom on the lows physically they may have difficulty sleeping or sitting still maybe may   feel elated excited irritable or thrill-seeking you may have some anger outbursts frustration   with others and environmentally what I’ve seen with patients especially with full-blown mania, it varies on what they do sometimes they are cleaning like crazy and other times it looks like   a whirlwind absolutely hit the room but so it’s usually extreme so treatment compliance we want   to encourage clients to do a decisional balance back exercise and I broke it down so it’s shorter   what are the benefits of eliminating depressive episodes if the person was no longer depressed how   would they feel emotionally mentally physically and how would it impact their family and friends   a lot of times that this one’s easy to fill out the drawbacks to eliminating depression are this can   be harder to fill out because they’re like well I’ll see any drawbacks okay we can leave that   for now sometimes patients come to the awareness that if they’re no longer depressed they may not   get as much attention and people may expect more of them which is anxiety provoking but this   area usually doesn’t have a whole bunch of stuff in it and then we want to ask them what are the   benefits of eliminating the mania emotionally mentally physically and socially this one’s a   little harder not as hard as the drawbacks to eliminating depression a lot of times clients   can see the benefits of eliminating the manic episodes because they don’t have the periods I   mean they have the highs and those are awesome but they don’t have the periods where they have   the lows and they don’t feel like they can do as much they don’t have the loss of time they don’t   kind of come out of it and realize that they’re completely overwhelmed because when they were in   the manic episode they took on 17 things so there are a lot of things that clients may identify as   benefits to eliminating the mania but we also want to talk about the drawbacks to eliminating   it because like I said for some people that’s when they’re their most creative and if they’re   a writer or an artist or a musician this may be the time when they are feeling like they’re uber   selves so they don’t want to get rid of it and it’s terrifying to them to think that they might   not be able to tap into what we can talk about ways to tap into their creativity when they’re   not manic and you know there are techniques that they can use it to get that focus that they   so desire but it depends on the person exactly what you’re going to use if we don’t address   all of these concerns about eliminating their mania treatment compliance is going to be lower   because people will just they’ll miss it they’ll miss it a lot and they’ll want to feel that high again so general techniques in clot ask clients how do you deal with it up until now when   you felt depressed what have you done this helped you feel better even for 10 minutes or an hour or   half a day you know maybe it didn’t work the whole time but or it helped you feel instead of feeling   just devastated you felt sad you know it helps you feel a little bit less intensely depressed   build on that ask them what they’re willing to do some clients are gonna look at you and go no I’m   not gonna do that keep your journal no not gonna do that okay so what are you   willing to do I tell my clients a lot of times I’m gonna suggest things that you may not think fit   for you or work for you or you’re not going to do well I’d rather you tell me number one that you’re   not going to do it and what I’m more concerned about is what you’re gonna do instead if   you don’t want to keep the journal okay how are we going to be able to notice changes and find   connections between your eating your sleeping your stress levels and your mood episodes you know   help me let’s figure out a way that we can we can do this and they may come up with something you   know I state what it is that I want to do or accomplish and why it’s important and I   say is there another way we can accomplish this when I work with clients and recovery sometimes   they don’t want to go to 12-step meetings okay if you’re not going to go then what are you gonna   do instead because you need to have some social support you need to have something to do besides sitting alone in your apartment from the time you get off work until the time you go to work the next   day because that’s a dangerous period encourage clients emotionally to practice mindfulness   because it does prevent episodes from sneaking up if they start feeling run down or tired or off you   know sometimes I hear that word I just feel off okay that’s when you need to stop and check in   with yourself and go what’s going on how do I feel what do I need and mindfulness also encourages   behaviors that prevent vulnerabilities when people check in with themselves they may say you know   what I’m really tired today I need to rest and that’s a good thing because it keeps them from   becoming vulnerable and potentially triggering an episode of stress reduction encourages clients   to identify and eliminate or mitigate stressors so what stressors do you have and they can write   them down on the list they can a lot of times if I’m doing an individual I’ll have somebody write   down on our big whiteboard all of their stressors and then we go through on one by one and say okay   can this one be eliminated if so how and the the client will start making a plan for how they’re   going to start eliminating stressors if there’s a a stressor that can’t be eliminated maybe they don’t   get along with their in-laws and periodically the in-laws come to visit or whatever okay well   you can’t eliminate that so how are you going to mitigate that stressor before your in-laws   come what can you do or may it be less stressful if you go to their house instead of them coming   to yours so we talk about different things we talk about time management because in those manic and   hypomanic episodes people can take on too much and then they feel a little overwhelmed when they’re   steady-state and they feel overwhelmed if they’re in a depressive episode I do want to   point out and I think most of us know this person don’t usually cycle from a manic to a depressive   to a manic like that they can have a depressive episode and then be asymptomatic for anything for   months and then have another depressive episode or a manic episode so it’s important to recognize   that most people who are bipolar don’t rapidly cycle and there are periods of remission or symptomatology in between cognitive processing therapy can also help people mitigate stressors   when they start feeling overwhelmed encouraging them to identify what thoughts they’re having   that are contributing to them feeling stressed or overwhelmed and then looking for the facts   for and against that thought if they’re feeling like they’ve got too much to do what are the   facts for it what are the facts against it if they do have too much to do then they need to   figure out how to address it but this helps keep people from getting stuck in emotional reasoning   where every time they feel stressed or they feel depressed or they feel anxious they think there’s   something to be dysphoric about encourage people to identify their anger management triggers they   differ for everyone they need to develop a plan for de-escalation and begin addressing their anger   triggers to maintain control of their energy they need to identify if driving in heavy traffic   stresses you out and makes you irritable and angry well ok how can you address those triggers maybe   driving a different way or maybe putting on your favorite music loud in the car or whatever   it is that you can do to mitigate that anger anger takes a lot of energy everybody everybody’s energy   is precious but people with bipolar disorder stress and excess energy drain can potentially   trigger an episode so we want to help them conserve their energy so yeah they’re gonna   get angry about some stuff but help them identify what’s worth getting angry about and using their   anger energy for and how to deal with the rest of it so they have more energy to enjoy the life   we’ve been talking about the negatives but let’s look at the positive they need to infuse happiness   have them make a list of what makes them happy and do more of it or be around it more encourage them   to schedule a belly laugh every day and there are Reddit forums there are YouTube videos there are   places they can go to get a good old belly laugh but it helps release endorphins and release some   of the calming neurotransmitters that have them keep a good things silver lining or gratitude journal   and it doesn’t have to be prose you can have them identify at the end of the day three things three   good things that happen that day or three things they’re grateful for or when things go bad they   say I got demoted at my job today alright well what’s the silver lining to that you didn’t get   fired and maybe have less responsibility now I don’t know but there are different ways you can   approach it but encouraging people to be cognizant and try to embrace the dialectics there’s going to   be bad in life but help them focus on the good to reduce dysphoria mentally address cognitive errors   all Arnon thinking focusing on only the positive or negative using feelings as facts and focusing   only on a small piece when something happens maybe you turned in a group project and your boss sent   it back and said uh no try again some people will take it very personally and focus only on the fact   that the boss sent it back with feedback instead okay it wasn’t just me participating in this   project so you know all of us need to contribute to it again and you know yes it was given back to   us but we get a second opportunity so it’s looking at a bigger piece of the puzzle encourage clients   to develop their self-esteem and view failures as lessons applaud courage and creativity   and nurture their inner child I have an inner the child my inner child comes out a lot more than   some people would like to admit or really like to see but that’s okay you know on Saturday   morning it is not uncommon for me to be watching cartoons in the living room my kids are teenagers   I can’t say I’m watching it with them anymore I like Yogi Bear I’m sorry I’m weird that way but   you know sometimes at the end of a long week of being serious and everything I just kind of need   to regress for you know half an hour two hours no encourage people to nurture their inner child and   don’t be afraid to be silly don’t be afraid to laugh or do something goofy physically increase   clients to exercise class to increase exercise it increases serotonin levels reduces stress   helps balance hormones and neurochemicals and may combat some medication side effects exercise   is anything that moves the body gardening cleaning going to the gym of course walking the dog playing   soccer with the kid anything like that so what is it that they like to do or at least they’re   willing to do nutrition provides the building blocks for the neurochemicals so people need   to have quality proteins and a nutritionist A friend of mine suggested always try to have   three colors on your plate at every meal and use a salad plate that is smaller instead of a dinner   plate because it tricks your brain into thinking that you’re getting more food as Americans we tend   to eat way more than we need and try to avoid mindless or comfort eating when people   start comfort eating a lot of times they’re not being mindful they’re eating to deal with stress   instead of acknowledging the stress and dealing with it so yeah they’re infusing themselves with   carbohydrates and fats and getting the serotonin and dopamine flowing but when all that goes away   whatever was causing the stress is probably still there so they’re either gonna have to   stress eat again or deal with it so encouraging people to be mindful of their eating sleep   helps the body repair and rebalance and sleep deprivation is known to trigger both manic and   depressive episodes too much sleep or sleeping at the wrong times can also mess up circadian   rhythms so keeping naps to a minimum of 45 minutes one time a day, if the person has to take a nap, is   important so they don’t get into that deep sleep and preferably try to avoid naps for most of a 15-minute power nap where you’re closing your eyes and you don’t ever completely   drift off has been shown to increase focus in the afternoon but naps where you’re laying down   and getting under the covers tend to mess up circadian rhythms, if people are on medication   for their bipolar which they probably will be have them work with their doctor to adjust the   dosages and dosage times to fit their schedule so if they have a medication that makes them feel sleepy maybe they take it right before dinner so it’s worn off completely by the time   they get up in the morning and it’ll be up to the person to work with their doctor I had one client   who took Seroquel and she ended up having to take it at 2:00 in the afternoon for it to be   out of her system enough where she felt alert when she woke up at 6 o’clock the next morning   so it’s gonna differ for different clients again encourage them to discuss any negative medication   side effects with their doctor and not to expect a pill to do everything you know the pill can help   stabilize the moods but if you’re taking this pill but then you’re still you know pulling the rug out   from under it by not sleeping and using cocaine or or whatever it’s likely the pill is just not going   to be able to do it all interpersonally support groups are really helpful to chat rooms if the person   is either in a rural area working shift work can’t get to an appropriate support group not all   communities have support groups that are embracing of all different types of people so it’s important   to recognize that even though there may be a support group the person that you’re working with may not   feel comfortable with the people that are in that the particular group so chat rooms can be helpful in   the know family and friends and I say in the know these are people who have to understand or have to   know that the person has bipolar disorder and be aware of their warning signs trigger their   symptoms which helps so they can be supportive and facilitative environmental clients can   explore things that improve their environment different pictures a temperature can also be   a big thing if you’re too cold or too hot it can make people irritable certain essential oils can   help increase energy such as peppermint rosemary or lemon calming essential oils if somebody tends   to have some anxiety going on lavender chamomile valerian Valerians kind of they say woody some   people think it stinks to high heaven some people love it catnip is the same way yes stuff you use   for your cats you can get it in essential oil and it’s a sedative type essential oil   for humans bergamot it’s a pretty mild smell rose is helpful rose geranium is a little bit   less expensive and frankincense is all supposed to help with calming so he’s hypomanic having   difficulty winding down anxious whatever some of these may help memory triggering include ginger   cloves cinnamon orange and jasmine which works for one person is not necessarily going to work for   another I mean there are studies out there that show certain essential oils have effectiveness at   anxiety reduction and depression improvement but it’s going to be up to that person and I   found that when a person smells something if it smells noxious to them then it’s probably not   something that they need if they smell valerian and they’re like oh my gosh that stinks okay   that’s not triggering what their brain needs their the brain knows what it needs I do the same thing with   my rescue animals you know I let them take a a good whiff of it and if they like it they’ll   stick around and they’ll sniff it some more if it’s not what they need then they’ll go somewhere   else I tried fur for our donkeys when we first got them into rescue I tried lavender because I   thought you know that’ll help them calm down they hated it they liked valerian so I learned that for   them they preferred that particular essential oil for whatever way it works in the   brain and encourage clients to visit a store that sells essential oils because they have testers and   they can sniff them to see which ones work for they and essential oils also smell different   from different manufacturers so it’s important again for them to figure out places that they can   get their essential oils and try to stick with the same company once they find one that works organization can help another thing that’s important for people with Bipolar is to   manage impulse items when they go into a manic or hypomanic episode especially and they’re prone to   engage in risk-taking behavior or less restrained behavior car keys need to be somewhere where maybe   they can’t access them if they’re known to go out and drag race or you know drive 100 miles an hour   just to see how it feels credit cards that’s a big one credit cards need to be somewhere some   of my clients will freeze their credit cards in a block of ice so they can’t get to them and they   can’t see the numbers to read them and put them in on the phone this can help prevent unrestrained spending, especially at 2:00 a.m. or something when the infomercials are on porn   sites if the client happens to have an attraction to porn sites having those blocked because it’s   really easy to get sucked into that same thing with video games and alcohol and other drugs   alcohol a lot of people have in their house so if this is a dangerous impulse item for somebody make sure they have it locked up somewhere so if they do and have a hypomanic or manic episode they   can’t drink the same thing with certain medications especially the benzos and the opiates if you can   keep it locked up somewhere all the better and during the day keep it light and bright try not   to be in an office where it’s dark some people can’t help it I mean if you’re a nurse   and you’re working in the neonatal intensive care unit it’s going to be dark most of the   time and there’s nothing you can do about that but if you can help it keep the lights on if you   don’t like fluorescent lights get lots of stand up lights that you can put around to keep it bright   so your brain knows that it’s time to be awake co-occurring disorders depression can co-occur   with bipolar I mean you can have part of bipolar is depression so when somebody is in depressive episode suicidality high-risk and addictive behaviors and self-medication we want   to shout for it just like we would for unipolar depression with mania we want to help the person   become aware and look out for explosive anger which can get them into legal trouble relationship   issues etc heightened libido which also can get them into legal trouble and relationship issues   etc and any other risk-taking that they do because when they’re in a manic episode is like they’re   this is a bad idea filter is completely turned off or it’s switched on the other way and as the let’s   try this filter so helping them understand that when they’re in that manic state it’s important to   have safeguards so that when they come out of it they haven’t done something that they’re going to end   up regretting or have to undo so bipolar is caused by neurochemical imbalances especially among   serotonin dopamine and norepinephrine the symptoms and presentation varies widely depending on the   person it’s more important to address each symptom then to address bipolar as a whole you know we   want to look at what symptoms this person presenting with and how can we help them manage   those the medication provider is going to be managing kind of the bipolar as a whole and trying   to stabilize the mood but we want to help them start addressing their symptoms so they   can feel as healthy happy healthy and productive as possible help them address each symptom identify   warning signs and eliminate or mitigate triggers and vulnerabilities remember that   treatment compliance is a huge issue because the mood stabilizers tend to flatten those highs and people   miss the most dangerous times for suicidal ideation and people with bipolar disorder are   when they’re coming out of a depressive episode or and I didn’t mention this before or during a   mixed episode remember mixed they can be depressed and have high energy both at the same time ensure   people with bipolar disorder have a crisis plan and people who interact with them daily who are   aware of their warning signs and symptoms because sometimes they’re not being mindful and most of   us are guilty of not being mindful all the time sometimes these symptoms can creep up so if they   have people they interact with daily who are in the know and can say you know John   it seems like you’re starting to destabilize a little bit then John can take a look at it people   with co-occurring addictions also need to be aware that a bipolar episode can trigger an addiction   relapse and vice versa so they need to be aware and have an extra-special relapse addiction   relapse prevention plan for when their mood symptoms arise if you haven’t already signed up   please remember that addiction and mental health counseling and Social Work continuing education   credits are available for this presentation and are accepted in most US states Canadian provinces   Great Britain Australia and South Africa go to all CEUs com counselor toolbox and click on the link counselor toolbox CEU spreadsheet to easily locate the course based on this presentation okay are there any questions now remember we’re not having class tomorrow but we’re having class on   Thursday and that is just chock-full of stuff that I’ve never actually presented   before so there is no repeat possible there oh and then next Tuesday we’re going to be   talking about enhancing social justice and why that’s important for recovery you As found on YouTubeAlzheimer’s Dementia Brain Health ➫➬ ꆛシ➫ I was losing my memory, focus – and my mind! And then… I got it all back again. Case study: Brian Thompson There’s nothing more terrifying than watching your brain health fail. You can feel it… but you can’t stop it.

Trauma Focused Cognitive Behavioral Interventions: Trauma Informed Care

 this episode was pre-recorded as part of a live continuing   education webinar on-demand, CEUs are still available for this presentation   through all CEUs register at allceus.com/counselortoolbox I’d like to welcome everybody to today’s presentation on trauma-focused cognitive   behavioral therapy part 1 treating trauma and traumatic grief in children and adolescents   in this first part we’re going to define trauma-focused CBT and talk about what   we’re dealing with here because trauma-focused CBT is a best practice and it is a manualized   best practice so you’re going to learn about it today but you’re not going to have enough skills   where you can say you are certified in TF CBT however I will provide your resources should   you want to go out and pursue those so we are going to talk about TF CBT as a best practice   and implementing fidelity but I’m going to also take a few detours and as I always   do and talk about how this might be able be useful with adults who have a history of trauma   in childhood we’ll explore the components of trauma-focused CBT and their intended   functions, we’re not going to get through all of those today but we’re going to start and we’re   going to explore ways to use TF CBT with adult clients so TF CBT works for children who have   experienced any trauma including multiple traumas so what we’re talking about is children who   come to your office who are presenting with trauma-related issues it’s effective with   children from diverse backgrounds and works in as few as 12 treatment sessions so a lot   can be accomplished in 12 sessions they’re not necessarily weekly sessions they can be spaced   out a little bit part of it depends on the age level of the child how long ago the trauma was   any concurrent developmental or mental health issues that might be present yada yada yada so   it may be a little bit longer it may be a little a bit shorter in terms of calendar time but you   can also extend the number of sessions because some of these things for example when they start   talking about cognitive coping differentiating between thoughts and feelings, some children take a while to get the hang of the the nuance between the difference between thoughts   and feelings so you might have to do two or three sessions helped them to identify   feelings and use the feelings thermometer this has been used successfully in clinics schools   homes foster care residential treatment facilities and inpatient settings so there’s not an environment in which it can’t be used provided that there is a supportive caregiver that can be   of assistance obviously if you’re working with a 10 or 11-year-old or a little bit younger or   an older adolescent but you know any child who may need some support outside of session we don’t want   to be creating a crisis and then leaving them kind of defend for themselves between sessions   without some sort of emotional and cognitive support so there must be a relationship that there is a bond if you will a the rapport between the clinician and the caregiver who may not be the biological parent or the caregiver and the child it does work even if there is no   parent or caregiver to participate in treatment however again we need to be selective about how we’re using that so if you have a child and you’re going to use this particular approach and   there’s no parent or caregiver to participate it may be safer to use it in a residential   setting or an inpatient setting where there is a clinician somewhere where they can get emotional   support because as you’ll see when we get into the trauma narrative gets intense TF   CBT is intended for children with a trauma history whose primary symptoms or behavioral reactions are   related to the trauma so if you’ve got someone who has an unfortunate childhood but you think   their behaviors may be more related to the peer group maybe more related to conducting disorder or FASD   or something else that may not be appropriate because what we’re going to look at with TF CBT   is reducing the PTSD symptoms the hyper-vigilance avoidance behaviors etc as well as improving   social skills and helping the person identify and communicate their feelings and needs traumatic   stress reactions can be more than simply symptoms of PTSD and also present as difficulties with   affect regulation we’ve talked before about how people who are experienced who have experienced   trauma may develop a situation where they are more likely to experience emotional dysregulation the HPA axis kind of tightens up and holds on to the stress hormones hold on to the stress reaction   but then when it does perceive a stressor it goes from 0 to 250 there’s no I’m going to get a little   bit upset it is either nothing or it is a huge mountain there’s no mole hills there so there   may be problems with affect regulation there may be problems in relationships because of difficulty   trusting other people because of difficulties with their self-perception and systems of meaning which   you know we’re getting to in a few minutes but the way they conceptualize the world because all   of a sudden their world was turned upside down somatization feelings coming out as physical   symptoms so headaches body aches more illnesses more days where they just don’t feel well and you   know sometimes they just really don’t feel well however, is it because of a bacteria or a virus   or is it because of a stress reaction that is kicking off all kinds of imbalances in hormones   and neurotransmitters so we want to look at what the effect are these traumas having on this youth or   person and if we address this trauma and if we help help them come to some sort of resolution   or acceptance of the trauma and integration into their world view of why this trauma happened   and making meaning from it will help improve these areas will help them reduce their hyper-vigilance etc and for many clients the answer is yes and I talked earlier about the fact that this   may be useful now it was designed for children and adolescents but many of the adults I’ve worked   with are very Alex thymic they are very unable to identify their emotions their very unable to   express their feelings sometimes they don’t even know where their fear is coming from they’re just   sort of paralyzed with fear and don’t trust the world and they’re angry at everybody and if it   comes from a traumatic experience then helping them explore how that trauma is impacting   them in the present can be useful in their recovery process so these issues that TF CBT may   help improve aren’t just limited to children and adolescents they can present in adults who were   traumatized as children and who didn’t develop the skill to effectively deal with the trauma   components of CBT TF CBT psychoeducation we’re going to start by teaching them what they need   to know about the trauma we’re going to talk about in depth about these so I’m not going to detail them   very much here parenting skills and if you’re dealing with an adult oftentimes I will provide   what I call reap Aron ting skills if your parent were here or if your parent would have responded   how you would have wanted how would they have responded how can you do that for yourself   now because sometimes you don’t have a significant other or a caregiver with an adult client either   but we want to help them figure out how to self nurture if needed relaxation and stress management   skills because some of the stuff we’re fixing to talk about is going to be extremely distressful so   you have some wiggle room if you will in terms of what skills do you teach here they prescribe some but   as far as relaxation and stress management affect expression and modulation DBT skills seem to fit well into this framework for helping people tolerate the distress not act on their   impulses understand where the emotions are coming from and preventing vulnerabilities and all that   other stuff that can help them function outside of session and when they’re not doing their homework   help them feel like they’re able to focus on something besides the trauma because we’re   just kind of ripping the band-aid off that wound at a certain point and they may have difficulty   focusing on anything else likewise some children and adolescents will come to you when that trauma   is still relatively present and all they can think about is that trauma or it regularly comes up for   them and so we can help them learn skills so they can start living more of what they might   consider a meaningful life that’s not dominated by memories of this trauma while we’re working   through the process we want to give them a little hope that there’s relief in sight cognitive coping and   processing are provided next and enhanced by illustrating the relationships among thoughts   feelings and behaviors so initially cognitive coping skills are taught and then all of this   is going to be applied later as soon as we get into the trauma narration helping the   youth work through narrating the trauma and cope with the feelings and thoughts that come up in   vivo mastery of trauma reminders so any of those triggers that are triggering flashbacks that are   kicking off hyper-vigilant situations we’re going to address as they come up in the trauma narration   we’re going to help the person identify what it is about certain situations that bring up this particular memory and how we master how to do we deal with it and then finally conjoint Parent   Child sessions and these don’t come till the end all along the parents or the caregivers are   participating in the process assuming there is a parent or caregiver and understand learning a   little bit more about what’s going on but we’ll talk about what the clinician does in the parent   sessions as well as what the clinician does in the child sessions as we go through each stage effects of TF CBT reduction in intrusive and upsetting memory so that’s awesome and you know   if you think about what’s the function of these intrusive memories a lot of times it is because   either they haven’t been integrated into the person’s schema of the world and well-being and or   they still feel unsafe they have some cognitions that is telling them they need to be alert they   need to be aware they’re not safe so helping them identify any cognitions and triggers that may be   causing intrusive and upsetting memories and addressing those again in the in vivo desensitization avoidance helping people reduce their avoidance of certain situations and certain   activities so they don’t feel like they are confined basically to their prison it helps   reduce the emotional numbing of a lot of people when they go through trauma it’s so overwhelming and they’re   so afraid if they feel they won’t be able to stop feeling so they numb emotionally it’s protective   it makes sense and as they develop the skills to handle this and as they learn they can tolerate   the distress of the memories of the trauma it empowers a lot of clients there’s a reduction in   hyperarousal depression and anxiety behavior problems when you’re dealing with adolescents   or children, especially ones who don’t have the ability to articulate their feelings and their   thoughts that are underlying these feelings and how they relate to the trauma   I don’t know many adults that can do that so children typically act out physically to either protect themselves or try to get some sort of protection comfort attention so they   feel more secure so it’ll help reduce some of that as we empower the child to identify what’s   going on and articulate their needs more effectively communicate with their parent and also deal with   some of the stuff that’s making them still feel threatened or afraid reductions in sexualized   behaviors trauma-related shame interpersonal distrust and again social skills deficits if   a youth has been dealing with this trauma issue for a while, they may have avoided other people   because they don’t trust other people they’re afraid of other people haven’t made sense of it   so they may not have developed the social skills that other youth have developed because they have   been avoidant situations that might trigger the trauma memories so who is is inappropriate   for if the primary issue is defiant or conduct disordered it if you don’t believe from a   clinical standpoint that this is coming from a the root of trauma history and addressing trauma   is probably not going to do it now do these children who are oppositional defiant conduct   disordered have traumas in their history sure probably they do but are those traumas causing   the behavior or are those traumas sort of irrelevant and one thing that you’ll find   is a lot of we’ll talk about it more in a minute a lot of people have multiple traumas but they   may have resolved certain ones and be okay with they but others are still open wounds don’t use   it if the child is suicidal homicidal or severely depressed if a child is in that particular state   we don’t want to start poking the bear especially in an outpatient setting but even in   residential and even residential with adults I was always extraordinarily cautious and hesitant   to do any sort of trauma work in the first 30 to 60 days I had a client in residential substance   abuse treatment I mean the first 30 days they’re still kind of sobering up there are a lot of impulse   issues and in the next 30 days there’s usually a a lot of mood issues so I want them to feel like   they’ve got a handle on things before we start ripping band-aids off open wounds if possible   and if you’re obviously if you’re dealing with a a child the safety and ethics would just tell you   when this might not be appropriate additionally when children remain in high-risk situations with   a continuing possibility of harm such as in many cases of physical abuse or exposure to   domestic violence some aspects of TF CBT may not be appropriate for example attempting to   desensitize to trauma memories is contraindicated when real danger is present I took that   verbatim from the TF CBT training or one of them that is cited in your booklet or your class   it is important to understand that not all of these children are coming or existing living   in an environment that is healthy and you may have a parent who is court-ordered or ordered   by child welfare to bring the youth to counseling to address trauma issues but that child is going   back to a chaotic situation so again it’s going to be an ethical decision on your part once you have   all of the training and you’ve become certified and TF CBT it would be an ethical   decision at that point whether or not to implement the program to fidelity and you know we   want to make sure that the child is cognizant of any real and present dangerous challenges, they   always come up, especially when you’re dealing with families if the carrot parent or caregiver does   not agree that the trauma occurred and we’ve all dealt with this whether you deal with adults who   were traumatized as children and they say nobody believed me when I was a child and I tried to   get somebody to here or whether you’re dealing with a child right now who is with a caregiver   or removed from a caregiver it doesn’t matter but the caregiver was present at the time and   the caregiver doesn’t believe the trauma occurred it can be a huge barrier because that caregiver is   not going to be able to be as supportive if the The caregiver agrees the trauma occurred but believes that it is not affecting the child significantly or thinks that addressing it will make matters   worse then we can do some education here we can identify symptoms that are coming out that are   present which may be caused by the trauma and we can show the research of TF CBT as well as other   methods if you choose not to use TF CBT but you can show the caregiver how addressing this trauma   can mediate or mitigate some of those symptoms if the parent is overwhelmed or highly distressed by   his or her emotional reactions and is not able to attend to the child’s experience so if   the parent feels guilty for what happened or you know such as in the cases of domestic violence the   parent is dealing with their trauma because they are surviving domestic violence they   may not be able to attend to the issues of the child at that point and it’s not a judgment it’s   just how much energy you have and if you’re trying to survive yourself you’re probably not   going to be able to devote your full attention to jr. Over here so we need to look at timing if the   parent is suspicious distrustful or doesn’t believe in the value of therapy again we can   do some education here rapport building and go slow if the client and I my experience has been   this occurs when the client is court-ordered or ordered by child welfare the parent does not trust   the system and by the fact the system referred them to you you’re part of the system   so start low go slow try to be as compassionate open and honest as possible I try with all of my   clients but especially with my clients who are involuntary I am very open about what’s in my   records and what I write down because that could go to the court which could you know potentially   reflect upon them you know we talked about what’s going in into the chart I don’t use subjective   judgment everything’s objective unless we talk about something and they say yeah I’ve made   progress here or I feel like I’m backsliding here and then we talk about how to how that’s going to   be put in the notes I don’t lie I don’t cover-up but I do want to make them feel more comfortable   with what’s being written in that magic file that gets stored away that nobody can see if the parent   is facing many concrete problems such as housing but consume a great deal of energy again if it’s   a domestic violence issue and they’ve moved out and they’re living in a homeless shelter or a   domestic violence shelter the parents may be exhausted and just not able to fully attend to   the increased emotional and psychological demands of the child during this therapy you know they’re   going to be doing good to help junior through the present crisis let alone anything else or   if the parent is not willing or prepared to change parenting practices even though this   may be important for treatment to succeed and there are few and far between situations where   this may happen one of the situations would be if you have a parent who is the biological parent and you have a boyfriend or girlfriend who is abusing the child and you know that comes   out and there needs to be some change in the the way that children are introduced to new people   or there may need to be some change in another situation and how to indiscipline there are a lot   of variations that may come up but ultimately we need the parent’s full buy-in we need them   to be willing to work with children on emotions identification and cognitive coping and all this   other stuff which ultimately ends up helping them most of the time anyway because I don’t believe   any of these skills can be harmful to a person at At least the initial skills of the trauma narrative if   it’s done inappropriately or incorrectly can be very very harmful but we’ll get there specific   strategies that can be undertaken through perseverance in establishing the therapeutic alliance reach   out to contact and try not to serve as the all-knowing omniscient person but asking them what they need asking them what changed with jr. Asking them for feedback and suggestions about what helps when   jr. gets like this and so you can brainstorm put the parent in the expert role of being the parent imagines that explore past negative interactions with social service agencies or therapy not that   we can undo that but we can make sure not to repeat it and if they start acting disengaged   we can evaluate the situation and come back and say is this reminding you of that prior situation   or you know are you feeling disempowered again or whatever the case may be being fully aware that n   TF CBT you have two very distinct clients plus a the third one is the family so you’ve got a lot   of different things to juggle if you want to explore the parent’s concerns that may make them feel as if they’re not being understood or accepted the lead listens to or is respected and that gets a   little dicey sometimes especially when we start talking about cultural sensitivity about belief about why the trauma occurred or a variety of other things that we’ll talk about   it’s important to be able to hear the parent and come from a culturally sensitive and culturally   informed perspective it’s also important if the parent feels guilty for some reason you   know and sometimes they will be cognizant of any nonverbals or any statements that you make   that might make them feel that way and if it comes out or if there’s no other way to say it you know   talk about any feelings they may have that about being not believed or not respected and how can   you best facilitate making them feel respected and accepted and all that stuff explore and help   them to come overcome barriers to participating in treatment, if it’s transportation if it’s a   job if it’s something else there may be some brainstorming that’s required and a little bit   of case management and I recognize that most of us when we work in private practice or agency   work don’t get any credit for billable hours for case management but it has to be done in the best   interest of the client and emphasize the centrality of the caregiver’s role in the child’s recovery   making sure that they understand that this can’t succeed without their help by using parent sessions   to reduce parent caregiver distress and guide them through structured activities that empower them in   interactions with the child so you’re going to bring them in each week and you’re going to talk   to the parent independently about what’s going on what you’re covering how juniors behaving how you can help them help jr. Etc sometimes you need to delay joint sessions until the parent or caregiver   can offer the child support and sometimes that means not even starting treatment really until   the parent and caregiver parent or caregiver can be on board now you can get started with   psychoeducation emotions identification feelings identification and stress management and coping   skills you know there were not really poking a bunch of bears so you can probably   safely get started on that if it’s sometimes it’s court-ordered and they have to start treatment by   April 1st or something so there are things you can do but you may need to delay the actual beginning   of the trauma narrative until the parent is able to be available to educate everybody on how   therapy works and instill in everyone not just the parent optima optimist that well optimism   about the child’s potential for recovery you know sometimes they’ve been dealing with this   child’s acting out behaviors for so long they’re just like you know we’ve already been to three   other therapists I don’t know what’s going to fix it or I’ve done everything I know how to   do good luck so we can talk about you know a different approach or we can talk about what   they’ve done that’s worked for a short period of time and build on those strengths to instill optimism and hope and empowerment so initially, when we talk about psycho-education   it’s important to provide accurate information about the trauma when children are traumatized   they can be confused and not completely understand what happened they may blame themselves and they   may hold on to myths because they’ve been misled and/or deliberately given incorrect information so   one of the best ways we can help is to correct that information provides information about how   often this happens and whether you know it’s okay to do this that or the other psychoeducation   clarifies inappropriate information children may have obtained directly from the perpetrator or   on their own so the perpetrator may have told them that this is how I express love or this is how you   need to be disciplined because you don’t learn this is how I was disciplined whatever it is or   they could have gotten it on their own they could have gotten it from school from the internet or   just come up with it in their little heads trying to make sense of what happened psychoeducation   also helps them identify safety issues the difference between safe situations and dangerous   situations and as we get through this I really want you to get away from the notion that TF CBT   and childhood trauma are only physical and sexual abuse there are so many other traumas as evidenced   by the adverse childhood experiences survey that I want you to wrap your head around that and there   are things they didn’t cover in the aces such as bullying and natural disasters so we want to help   children whatever the trauma is the trauma made they feel unsafe so we want to identify safety   issues if the trauma was a hurricane then we want to talk about what hurricanes are how often they   hit what to safety plan etc so every time a the thunderstorm comes they don’t freak out and we   want to use psychoeducation to provide another way to target faulty or maladaptive beliefs by   helping to normalize thoughts and feelings about the traumatic experience you know it makes sense   that that was scary and makes sense that you’re angry it makes sense that you feel   this way and we can talk about why that makes sense and why it makes you feel that way through   cycle education you’re getting the child to start talking about the specific trauma that he or she   experienced in a less anxiety-provoking way by talking in Jen wrong about the type of trauma   so you’re talking about natural disasters you’re talking about plane crashes you’re talking about   domestic violence so they start learning about it and then eventually you’re going to move down   to their experience with it so like I said there are a ton of different traumas and the ACE study   even acknowledges that these are just the ten most common ones that they heard however there are many   many many different traumas and types of trauma some of the biggest ones are physical   and sexual abuse physical neglect emotional abuse and neglect and the Aces identified mother treated   violently I would say anyone in the household treated violently it’s not just the mother’s substance misuse within the household and that can be by the parents or by siblings household   mental illness parental separation or divorce and an incarcerated household member so those were   aces but then like I said there’s also bullying the death of a parent or sibling is extremely   traumatic hurricane tornado natural disaster and then I put the fire out separately because sometimes   fire can be man-made sometimes it can be a wiring problem but sometimes it can be Jr was playing with matches now even if jr. Accidentally started the fire does that make it any less traumatic no   it probably makes it more traumatic because then there’s a whole sense of guilt and responsibility   but it’s still a trauma that has to be dealt with so I put a link to the adverse childhood   experiences website if you want to go look more about that but we’re going to move on psycho-education involves specific information about the traumatic events the child has experienced   not the child’s event we’re not going to go into police records or something, we’re just   going to talk about specific information about domestic violence or whatever body awareness   and sex education in cases of physical or sexual maltreatment and there are caveats for getting   parental consent and permission and all that other stuff and Risk Reduction skills to decrease the   risk of future traumatization now going back to those other things it’s not just about physical   or sexual abuse so we want to look at what was the the risk created by you know how can you reduce your   risk of being bullied how can you reduce your risk of being traumatized in a tornado you   know you can’t stop the tornado from coming and they’re everywhere so what do you do and talk about a safety plan the same thing with fire information needs to be tailored to fit a child’s   particularly particular experiences and level of knowledge obviously, you’re going to provide   different information to a seven-year-old than you are to a 17-year-old provide caregivers with   handout materials to reinforce the information discussed in session so this may help educate   the parents about some of it but it lets them know what you talked about and it gets us all   on the literal same page you’re providing them a handout of everything you went over with Junior   and we want to encourage caregivers to discuss this information at home reinforces accurate   information about how safe or unsafe they are and obviously, we’re going towards safe   and reinforced accurate information and develop a safety plan so they feel confident that at   home they’re going to be taken care of when you start psychoeducation you do want to get a sense   of what the child already knows and you can use a question-and-answer game format in which the   child gets points for answering questions which I love this suggestion so you can ask them if you know   what is a hurricane or is a tornado and see if they know and see if they know how much time and much-advanced warning we have for a tornado versus a hurricane or you know whatever situation   you’re talking about you see I did a lot of posts Hurricane Katrina counseling in northern Florida   so that’s one of those things that comes up for I am talking with children about how likely is   it that a category 5 hurricane is going to hit again but encouraging them to give your aunt’s   give answers and if they give the wrong answer you know it’s great to try now you know try to coach them   into a correct answer or provide them the correct one but give them credit for at least making an   effort sample questions might include what is you know and put in the type of trauma what is   bullying how often do you think bullying happens and why does bullying happen you know those are   some questions you can ask to just open a dialogue about bullying, if this child has been a victim of   bullying and is and is traumatized so cultural considerations meet the child and family where   they are by presenting information in a way which they can relate it to their belief system and   you may need to consult with their spiritual guidance guides leaders whether it be a pastor   or you know whatever to get some guidance on how to handle certain aspects of whether it was   the will of God and in the case of sexual abuse how to handle the concept of virginity and how to   handle the concept of bad things happening to bad people and whatever else they think is coming   from or their parents are instilling in them in a belief system we want to make sure that we’re not   necessarily contradicting it and going oh mom dad and the church is wrong but we also want to help   them try to integrate this in a way that can help they have strong self-esteem so reaching out to   those spiritual leaders and the family asking what their belief system about certain things can   be very helpful assess the general beliefs about the trauma if something happened or when something   happens ask the parent or the family that’s there not necessarily the child but you want to get a   sense of what the family stance is on why this happened what it means how it’s going to impact   life hence foreign henceforth and forever more focus on the events they perceive as traumatic to the family but most especially the child if the child’s going back to the Aces you know maybe   the parents got divorced but the child doesn’t see that as traumatic because there was domestic   violence ahead of time the domestic violence was traumatic the divorce was a relief so wherever the   child is with each trauma we want to be respectful of what they perceive is traumatic   and tailor the information so the family can be more receptive to it as supportive as possible and   sometimes you need to make sure that the language you know make sure the language is not jargony about general views of mental health and mental health treatment should also be assessed and addressed in   the psychoeducation piece not only with the child but also with the family, if they are suspicious   of it don’t understand it think that you’re just going to magically fix Junior we want to demystify   the process and talk about what is the purpose of the assessment what is the purpose of each one of   these activities and why am I doing this or why are we doing this as a team and how can it help   and then we also want to provide information to D stigmatize and normalize mental health issues   and seeking treatment some cultures are still resistant to seeking treatment and I use the term   cultures broadly because there’s a stigma associated with it so normalizing for   them how many people go to treatment how common PTSD is or whatever the situation you’re dealing   with it doesn’t mean they have to like it but at At least it will give them a little bit of a nugget   to understand that they’re not the only ones if they are from a cultural group a minority cultural   group of some sort you might want to provide information about how common this particular   issue is in their group I’ve done a lot of work with law enforcement and emergency responders   and they’re kind of their little group so we talk about how common depression is among law   enforcement and emergent emergency responders specifically, because they face so much so many   different stressors than you know Joe Schmo over here so it D stigmatizes and normalizes a little   bit now they still may not talk about it and go well hey you know 37% of us have clinical   depression no that’s probably not going to happen but at least in the back of their mind, they can go   you know what I’m looking around this room and I can bet that at least one other person’s on   antidepressants or something and feel a little less unique and isolated in parent sessions you   want to provide a rationale and overview of the treatment model educates parents about the trauma and talks about the child’s trauma-related symptoms so we’re going to go over what is hyper-vigilance   what is the function it why people become hypervigilant after trauma and what might it   look like in a child because it presents very differently for different children so we might   want to give some ideas and say does this sound like Johnny or does this sound like Johnny and   help them understand why these behaviors may be coming out we want to talk about how early   treatment helps prevent long-term problems okay maybe the trauma happened three years ago but   still, it’s better than waiting ten more years and you know Johnny’s still not having any Ellucian   will want to talk about the importance of talking directly about the trauma to help the children   cope with their experiences and not hedging and this will be on a case-by-case basis but the manual   walks you through handling this discussion with the parents about exactly how much detail do I go   into if Johnny brings it up at home reassure parents that children will first be taught   skills to help them cope with their discomfort and that talking about the trauma will be done   slowly with a great deal of support so we’re not just going to plop them down and go okay and tell   me about the day that all this happened which is what the child has experienced already if   it was reported to law enforcement and/or the child welfare they’ve probably had somebody sit down   and say get right to the nitty-gritty at least once or twice and it’s completely dehumanizing   so we want to reassure parents that we’re not going to do that to the child again will help the   caregiver understand their role in the child’s treatment since this modified since this model   emphasizes working together as a team so I’m not just going to be educating you it’s not going to   be a parallel thing where I go in and I work with Johnny and then I tell you what I did and then I   work with Johnny I’m going to work with Johnny and then we’re going to discuss what Johnny and   I did in session and I’m going to get input from you and we’re going to talk about how you feel   about it and then I’m going to provide you with tools so you can help Johnny outside of the session because   you’re going to be with them for six-and-a-half other days that I’m not and this can’t work   if it’s just one hour once a week and we want to elicit parent input questions and suggestions as   much as possible because they’ve been living with their kid for you know however many years so they   probably have an idea about what works and what doesn’t so we’ll start with both parents and   children in their respective sessions helping them understand what control breathing is and how   it helps slow the heart rate and trigger the wrist and digest sort of reaction in your body   when your breathing slows your heart naturally slows because the stress reaction tells your   brain you’ve got to breathe fast and the heart rates got to go fast well when you override that   then you’re kind of overriding the whole system and we’ll also talk about thought stopping and   this is especially helpful if the trauma is recent or and/or ever-present in the mind of the youth so they   can say I am NOT going to talk about that right now I’m not going to think about that right talk about distraction techniques go back to your DBT stuff talks about improving the moment   and accepts to help the child develop skills to handle and work through when those thoughts pop   up replace unthawed unwanted thoughts with a pleasant one so talk about it in session   when thoughts like that come up what would you prefer to think about and then really get into   the Nitty Gritty the five senses what do you see smell hear taste you know help me get into   that situation or that thought this teaches that thoughts even unexpected and intrusive ones can be   controlled so that gives them hope and again we’re not exacerbating the thoughts right now we’re not bringing up their particular trauma and having them get into detail we are just helping   them deal with what’s happening normally on a day-to-day basis so they feel like they have   more control for the older kids you can have them people log about when this technique is used what   they were thinking about and how effective the thought stopping was and then review it and help   them tune it up if it’s not really effective and give them praise for when they use it effectively   relaxation training persons of Asian or Hispanic origin tend to express stress in more somatic or   physical terms so just be aware of that but that doesn’t mean that Caucasians don’t relaxation   training is good for anyone and the medical school of South Carolina training recommended that relaxation is stress-free and workbook by Davis Schulman and McKay so and   it is still in publication when deciding how to present relaxation techniques are creative have   the child help you to integrate the elements into the technique that makes it more relevant   to them so, what are you thinking about when you relax you know I know I like to go to the woods   but maybe this kid likes to think about a video game or play with their dog whatever it is but helps them make it relevant to them and then have they identify other things they do to relax like   drawing listening to music walking and making a list of those things so they can refer to it when   you’re teaching relaxation training especially if you’re doing something like progressive muscular   relaxation be sensitive to the child’s wishes if they don’t wish to close their eyes or lie down which could trigger memories of the trauma we’re not going there yet so if they feel vulnerable   lying down or taking orders like that because you can imagine how being told to lie down and   close their eyes might be a trigger for certain abuse survivors you know be cognizant of that   and say you know get into a comfortable position or how where would you like to sit while we talk   about this like I said parents can often benefit from the relaxation training as well   so because they’re dealing with their issues about the trauma but they’re also dealing with   trying to figure out how to help Johnny and any of them deal with any of Johnny’s misbehaviors   or problematic behaviors then they move on to feelings identification so it helps the therapist   judge the child’s ability to articulate feelings if you can tell me what makes you happy that’s   great but if you can’t then you know we need to work on figuring out what makes you happy you   also want to help the child rate the intensity of the emotion don’t let them stick with happy   mad sad glad and afraid you know let’s talk about different emotions and use the emotion chart with little faces on it or you can use the emotion thermometer so is it a hot emotion or is   it a cool emotion and helps the child learn how to express feelings appropriately   in different situations I mean sometimes they’re going to be angry but it might not be appropriate   to you know get up and stomp out of the room or whatever however they communicate it so help them   figure out how to articulate that so they can be heard and supported some children have difficulty   discussing or identifying their feelings so you might try stepping back and discussing the   feelings of other children or characters from books or stories so you know think about Puff   the Magic Dragon if they’ve read that you know that dates me a little bit there but you know how   did the little boy feel and talking about things different characters and different stories where there are elements of anger and shame and loss and all of that stuff helps children identify   how they experience emotions if they seem detached from the experience because sometimes they just   they’ve shut it off it was just too overwhelming so we want to talk about you know when you’re   happy what does that feel like or when you’re angry what happens what does your body feel   like when you’re angry and they might be able to tell you they hear their heartbeat in their   ears or everything gets all fuzzy or whatever but help them start tuning in to how they react   and connecting that with an emotional word and then after all, that’s done they can identify feelings   they can identify feeling intensity now we want to differentiate between thoughts and feelings many   children describe thoughts when they’ve been asked about a feeling so if you ask them how they feel they may say I want to run away so you want to say okay well I hear that you want to   run away so I’m wondering if you are bored and you you’re bored and want to get away from it or if   you’re scared can you tell me a little bit more about what it means to you to want to run away during feelings identification the parent sessions normalize what is going on with their   child and help the parent understand that some children may be seemingly in constant distress   or detached from the trauma and that’s okay we all react differently to traumas so again   we’re going to share with the parents what we’re Do let them know any specific difficulties if   any juniors have encouraged the parent to praise the child for appropriate management of difficult motions and I put in parenthesis successive approximations because they’re not going to get   it a hundred percent right every time so if they try to effectively manage their emotions even a   little bit let’s give them praise for that and then help them figure out how to do it a little   bit better the next time so instead of having a complete meltdown maybe they got up and stomped   out of the room well that’s an improvement so then we want to talk about how to shape that   behavior so it’s a more appropriate communication if parents have difficulty identifying their   own emotions provide them with examples so continually ask them questions about how you feel when it’s a rainy day outside and how to do you feel when somebody’s supposed to call you and they   don’t how do you feel when and have about 15 or 20 examples and you can have them on a piece of paper   and even give it to the parent to take home for their homework if parents are overcome with   their own emotions about the trauma validate their feelings and explain how children need to see that their parents can handle talking about the trauma so there the children need to see   the strength and the parents which is what you’re going to work on in parent sessions to make sure   that the parents have the resolve and the skills handle talking about this topic with junior TFC BT can be an effective intervention for children or adolescents whose primary   presenting issue is trauma-related emotional or behavioral dysregulation TF CBT is not appropriate   for clients who are actively suicidal and severely depressed or currently abusing substances we want to make sure they’re clean and sober as much as possible TF CBT starts   with psychoeducation and then teaches stress management and coping skills to aid in the   management of distressing feelings psycho IDI helps to clarify the inappropriate information   children may have and start getting them a little a bit more comfortable talking about the topic in   general before we start going deeper and feelings identification helps participants start   effectively labeling and communicating their feelings so they can receive the support and   nurturance they need from their caregivers and their support system if you enjoy this   podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with dr. Snipes by subscribing to 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 to counselors therapists and nurses   since 2006 use coupon code consular toolbox to get a 20% discount on your order this month.As found on YouTubeAlzheimer’s Dementia Brain Health ➫➬ ꆛシ➫ I was losing my memory, focus – and mind! And then… I got it all back again. Case study: Brian Thompson There’s nothing more terrifying than watching your brain health fail. You can feel it… but you can’t stop it.