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Rank #155 in Education category

Education
Health & Fitness

Counselor Toolbox Podcast

Updated 4 days ago

Rank #155 in Education category

Education
Health & Fitness
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Counselors, coaches and sober companions help hundreds of thousands of people affected by Addictions and Mental Health issues each year. Learn about the current research and practical counseling tools to improve your skills and provide the best possible services. Counselor Toolbox targets counselors, coaches and companions, but can also provide useful counseling self-help tools for persons struggling with these issues and their loved ones. AllCEUs is an approved counseling continuing education provider for addiction and mental health counselors in most states. Counseling CEUs are available for each episode.

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Counselors, coaches and sober companions help hundreds of thousands of people affected by Addictions and Mental Health issues each year. Learn about the current research and practical counseling tools to improve your skills and provide the best possible services. Counselor Toolbox targets counselors, coaches and companions, but can also provide useful counseling self-help tools for persons struggling with these issues and their loved ones. AllCEUs is an approved counseling continuing education provider for addiction and mental health counselors in most states. Counseling CEUs are available for each episode.

iTunes Ratings

222 Ratings
Average Ratings
187
20
10
1
4

Great podcast

By Rayshell rayshell - Apr 02 2019
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As a new counselor, these podcasts have been very helpful

Helpful podcast

By mattsasso - Aug 25 2018
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Great for review or learning for the first time.

iTunes Ratings

222 Ratings
Average Ratings
187
20
10
1
4

Great podcast

By Rayshell rayshell - Apr 02 2019
Read more
As a new counselor, these podcasts have been very helpful

Helpful podcast

By mattsasso - Aug 25 2018
Read more
Great for review or learning for the first time.

Listen to:

Cover image of Counselor Toolbox Podcast

Counselor Toolbox Podcast

Updated 4 days ago

Read more

Counselors, coaches and sober companions help hundreds of thousands of people affected by Addictions and Mental Health issues each year. Learn about the current research and practical counseling tools to improve your skills and provide the best possible services. Counselor Toolbox targets counselors, coaches and companions, but can also provide useful counseling self-help tools for persons struggling with these issues and their loved ones. AllCEUs is an approved counseling continuing education provider for addiction and mental health counselors in most states. Counseling CEUs are available for each episode.

270 -Attachment Theory and Adult Relationships

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Attachment and Impact on Adult Relationships

A direct link to the counseling CEU course based on this podcast can be found at https://allceus.com/podcastCEUs

Objectives
~ Briefly define attachment theory
~ Learn about the impact of attachment
~ Identify triggers for attachment behaviors
~ Explore the relationship between ACEs and attachment issues
~ Learn about adult attachment theory
~ Examine how attachment impacts emotional regulation and vice versa
~ Identify ways to help people become more securely attached.

What is Attachment Theory?
~ Attachment behaviors, such as crying and searching, were adaptive responses to separation from with a primary attachment figure someone who provides support, protection, and care.
~ Erikson postulated the periods of trust vs. mistrust, and autonomy vs. shame and doubt during this same time period
~ Maintaining proximity to an attachment figure via attachment behaviors increases the chance for survival
~ From this initial relationship we learn
~ How scary or safe the world is.
~ What it is like to be loved.

What is Attachment Theory?
~ The attachment system essentially “asks” the following fundamental question: Is the attachment figure nearby, accessible, and attentive?
~ If the answer is “yes,” the person feels loved, secure, and confident, and, behaviorally, is likely to explore his or her environment, interact with others.
~ If the answer is “no,” the person experiences anxiety and, is likely to exhibit attachment behaviors ranging from simple visual searching to active following and vocal signaling on the other
~ These behaviors continue until either
~ The person is able to reestablish a desirable level of physical or psychological proximity to the attachment figure
~ Until the person “wears down.”
Impact of Attachment
~ How loved or unloved we feel as children deeply affects the formation of our self-esteem and self-acceptance. It shapes how we seek love and whether we feel part of life or more like an outsider.
~ As we individuate we often again seek approval.
Does it Stop After Infancy
~ Maybe yes, maybe no.
~ Consider the child that regularly did not get needs met.
~ Persisted with attachment seeking behaviors
~ Those behaviors were eventually rewarded (so they will happen again) or not, so the child stops seeking comfort from others.
~ How does this impact
~ Self-esteem?
~ Trust in others?
~ Future relationships?
Does it Stop After Infancy
~ Maybe yes, maybe no.
~ Consider the adult who got needs met as a child, but in adult relationships regularly does not get needs met.
~ What role do significant others play in the survival of the adult human?
~ Think about Erikson’s stage of intimacy vs. isolation
~ How does not getting needs met impact
~ Self-esteem?
~ Trust in others?
~ Future relationships?
Adult Attachment Theory
~ (1987) Hazan and Shaver noted that the relationship between infants and caregivers and the relationship between adult romantic partners share the following features:
~ both feel safe when the other is nearby and responsive
~ both engage in close, intimate, bodily contact
~ both feel insecure when the other is inaccessible
~ both share discoveries with one another
~ both play with one another's facial features and exhibit a mutual fascination and preoccupation with one another
~ both engage in “baby talk”

Adult Attachment Theory
~ If adult romantic relationships are attachment relationships, then:
~ We should observe the same kinds of individual differences in adult relationships that Ainsworth observed in infant-caregiver relationships.
~ The way adult relationships “work” should be similar to the way infant-caregiver relationships work.
~ The same kinds of factors that facilitate exploration in children (i.e., Having a responsive caregiver) should facilitate exploration among adults (i.e., Having a responsive partner).
~ Whether an adult is secure or insecure in his or her adult relationships may be a partial reflection of his or her experiences with his or her primary caregivers. (During infancy or later in life)
Triggers for Attachment
~ Certain kinds of events trigger a desire of closeness and comfort from caregivers.
~ Three main sets of triggers:
~ Conditions of the person (fatigue, hunger, illness, pain, cold, etc.) (HALT)
~ Conditions involving the caregiver (absent, departing, discouraging of proximity, giving attention to another, etc.)
~ Conditions of the environment (alarming events, criticism or rejection by others)

Adverse Childhood Experiences Impacting Attachment
~ Physical, sexual and verbal abuse.
~ Physical and emotional neglect.
~ A family member who is:
~ Depressed or diagnosed with other mental illness
~ Addicted to alcohol or another substance
~ In prison
~ Witnessing a parent being abused.
~ Losing a parent to separation, divorce or other reason.

Attachment Styles
~ Avoidant infants avoid the parent—physically, visually.
~ Avoidant adults are somewhat uncomfortable being close to others. They find it difficult to trust others completely, to allow themselves to depend on others or to let anyone get too close. (What would cause this?)
~ Resistant / ambivalent infants either passively or actively show hostility toward the parent.
~ Anxious / ambivalent adults often worry that their partner doesn't really love them or won't want to stay with them and want to merge completely with another person, and this desire sometimes scares people away. (What would cause this?)

Attachment Styles
~ Secure infants often cry briefly when the parent leaves, but is consolable, greeting the parent warmly upon return.
~ Secure adults find it easy to get close to others and are comfortable depending on others and having others depend on them. They don't often worry about being abandoned or about someone getting too close to them.
~ What would cause this?
~ Consistency (emotional and physical)
~ Unconditional positive regard
~ Comfort/support/encouragement (It is okay to have feelings and it is okay to fail)

Insecure Attachment– Emotional Regulation
Avoidant Attachment –Emotional Regulation
Secure Attachment– Emotional Regulation
Question
~ Can people have different attachment styles to different people who are significant in their lives?
~ Children
~ Spouse
~ Best friend
~ Parent
Changing Your Attachment Style
~ Build self-esteem to begin seeing yourself as lovable
~ Practice acceptance of yourself and others to become less faultfinding — a tall order for codependents and distancers.
~ Take calculated risks to get outside of your comfort zone (including intimacy building) so you can learn how strong you are. (Gloria Gaynor “I Will Survive”)
~ Get healthy to nurture emotional stability and strength. (vulnerability prevention)
~ Develop emotional regulation and distress tolerance skills
~ Increase insight and understanding
~ Identify when and why you are using unhelpful relationship strategies

Changing Your Attachment Style
~ Increase mindfulness (awareness)
~ Learn to be assertive and authentic
~ Stop reacting, and learn to resolve conflict and compromise from a “we” perspective
~ Dialectics
~ Win/win
~ Challenging questions (next slide)

Changing Your Attachment Style
~ Challenging Questions
~ Attachment problems often arise out of past traumas
~ These traumas may have contributed to thinking errors
~ Questions
~ What is my belief
~ What are the facts for and against my belief in this context (i.e. this person, this situation)
~ Am I using emotional or factual reasoning (reacting from the past or the present)
~ What are other factors that may have contributed/other explanations
~ Are you using extreme words?

Summary
~ Attachment theory was first proposed by Bowlby as an adaptive survival function for helpless infants
~ Bowlby proposed that the infant-caregiver relationship was the relationship that all future relationships would be build from.
~ People’s self-esteem develops from and is impacted by how loved and secure they feel
~ Adults show similar attachment behaviors to their significant others (m/l age appropriate)
~ Attachment styles can be changed by developing self esteem, emotion regulation skills, self-awareness, interpersonal skills (boundaries, communication) and self confidence.

Jun 02 2018

1hr

Play

307 Emotion Regulation

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Dialectical Behavior Therapy Techniques
Emotion Regulation
Presented by: Dr. Dawn-Elise Snipes Executive Director, AllCEUs
Podcast Host: Counselor Toolbox & Happiness isn’t Brain Surgery with Doc Snipes
President: Recovery and Resilience International
Objectives
~ Review the basic premises of DBT
~ Learn about the HPA-Axis
~ Define emotion regulation
~ Identify why emotion regulation is important and how it can help clients
~ Explore emotion regulation techniques
Basic DBT Premises
~ Dialectical Theory
~ Everything is interconnected
~ Reality is not static
~ Constantly evolving truth can be found by synthesizing differing points of view
DBT Assumptions
~ People do their best
~ People want to get better/be happy
~ Clients need to work harder and be more motivated to make changes in their lives
~ Even if people didn’t create their problems, they still must solve them
~ The lives of suicidal [or addicted] people are unbearable
~ People need to learn how to live skillfully in all areas of their lives.
~ People cannot fail in treatment
What is Emotion Regulation
~ Emotional dysregulation results from a combination of
~ High emotional vulnerability
~ Extended time needed to return to baseline
~ Inability to regulate or modulate one’s emotions
~ Emotional vulnerability refers to [situation] in which an individual is more emotionally sensitive or reactive than others
~ Differences in the central nervous system and HPA Axis play a role in making a person more emotionally vulnerable/reactive
~ The environments of people who are more emotionally reactive are often invalidating
What is Emotion Regulation
~ According to Linehan, “Emotional regulation is the ability to control or influence which emotions you have, when you have them, and how you experience and express them.”
~ Emotion Regulation
~ Prevents unwanted emotions by reducing vulnerabilities
~ Changes painful emotions once they start
~ Teaches that:
~ Emotions in and of themselves are not good or bad
~ Suppresses emotions makes things worse

Emotion Regulation
~ Emotions are effective when:
~ Acting on the emotion is in your best interest.
~ Expressing your emotion gets you closer to your [ultimate] goals.
~ Expressing your emotions will influence others in ways that will help you.
~ Your emotions are sending you an important message.
The HPA-Axis
~ Hypothalamic Pituitary Adrenal (HPA) axis is our central stress response system
~ Hypothalamus
~ releases a compound called corticotrophin releasing factor (CRF)
~ Pituitary
~ Triggers the release of adrenocorticotrophic hormone (ACTH)
~ Adrenal
~ ACTH is released and causes the adrenal gland to release the stress hormones, particularly cortisol and adrenaline

HPA Axis
~ The Adrenals
~ Control chemical reactions over large parts of your body, including your ‘fight-or-flight’ response.
~ Produce even more hormones than the pituitary gland
~ Steroid hormones like cortisol (a glucocorticoid) increasing availability of glucose and fat
~ Sex hormones like DHEA, estrogen
~ Stress hormones like adrenaline
~ Once the perceived threat passes, cortisol levels return to normal
~ What if the threat never passes?
HPA Axis
~ The amygdala and hippocampus are intertwined with the stress response (Higgins & George, 2013)
~ The amygdala modulates anger and fear / fight or flight
~ The hippocampus helps to develop and store memories
~ The brain of a child or adolescent is particularly vulnerable because of its high state of plasticity.
~ Bad things are learned
~ Emotional upset prevents learning new, positive things to counterbalance
~ People who live in a chronically stressful environment may also have an overactive HPA-Axis

The Brain and Stress
~ What happens to the brain when there is a chronic threat to safety and a constant underlay of anxiety?
~ As it learns, people’s brains forge synaptic connections from experience and prune away connections that are not utilized.
~ People who feel a lack of control over their environment are particularly vulnerable to excessive stimulation of the HPA response.
~ Abused and neglected children
~ Abused and neglected adults
~ Adults with anxiety or depressive disorders
The Brain and Stress
~ The synaptic connections that form the foundation people’s schema of themselves and the world become skewed towards the traumatic event at the expensive of a synaptic network based on positive experiences and healthy relationships.

~ The hypervigilant state activated by the HPA response:
~ Disrupts the ability to focus and learn
~ Impairs the ability to form new memories and recall information due to the physiologic changes to the hippocampus (cannot rebalance a skewed system)
~ Is associated with emotional and behavioral dysregulation.
~ Example: A Relationship

https://campuspress.yale.edu/exploringmentalhealth/stress-and-the-hpa-axis/
Emotion Regulation
~ Transdiagnostic or useful with many different disorders
~ Increasing present focused emotion awareness
~ Increasing cognitive flexibility
~ Identifying and preventing patterns of
~ Emotion avoidance
~ Emotion-driven behaviors
~ Increasing awareness and tolerance of emotion-related physical sensations
~ Using emotion focused exposure procedures
Understanding Emotions
~ Emotional behavior is functional to the person
~ To change the behavior, it is necessary to identify the functions and reinforcers of that behavior
~ Emotions function to:
~ Communicate to others and influence and control their behaviors
~ Serve as an alert or alarm which motivate one’s own behaviors
Identifying Obstacles to Changing Emotions
~ Biological factors
~ Organic
~ Situationally caused by
~ Chronic stress
~ Addiction
~ Sleep deprivation
~ Nutritional problems +/-
~ Skills factors
~ Cognitive responses
~ Behavioral responses

Identifying Obstacles to Changing Emotions
~ Environmental Factors
~ People
~ Places
~ Things

Identifying and Labeling Emotions
~ Identifying/observe personal responses in context
~ Identify
~ The event prompting the emotion
~ Thoughts
~ Physical Sensations
~ Urges
~ Expressive behaviors associated with the emotion
~ Interpretations of that event
~ History prior to the event that increased vulnerability to emotional dysregulation
~ After effects of the emotion on other types of functioning

Changing Unwanted Emotions
~ Check the facts
~ For and Against
~ Emotional vs. Factual reasoning
~ Problem Solving
~ Changing the situation that is causing the unpleasant emotion
~ Prevent vulnerabilities
~ Reduces reactivity
~ by turning down the stress response
~ Helping the person be aware of and able to learn/remember positive experiences

Reducing Vulnerability to the Emotional Mind
~ Building mastery through
~ Activities that build self-efficacy, self-control and competence
~ Mental Rehearsal
~ Physical Body-Mind Care
~ Pain and illness treatment
~ [Laughter]
~ Eating to support mental and physical health
~ Addictive or mood altering drugs or behaviors
~ Sleep
~ Exercise

Mindfulness
~ Nonjudgmental observation and description of current emotions
~ Primary emotions are often adaptive and appropriate
~ Much emotional distress is a result of secondary responses:
~ Shame over having it
~ Anxiety about it being “wrong”
~ Rage due to feeling judged for it
~ Mindfulness serves as an exposure technique
Mindfulness
~ Exposure to intense emotions without negative consequences (Nonjudgmental acceptance) extinguishes the secondary emotional response
Summary
~ Emotional dysregulation is common in many disorders
~ People with dysregulated emotions have a stronger and longer lasting response to stimuli
~ Emotional dysregulation is often punished or invalidated, increasing hopelessness and isolation
~ Emotional regulation means
~ Using mindfulness to
~ Be aware of and reduce vulnerabilities
~ Identify the function and reinforcers for current emotions
~ Checking for facts
~ Problem solving
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Sep 08 2018

55mins

Play

260- Best Practices in Anxiety Treatment

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Best Practices for the Treatment of Anxiety
Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs
Objectives
~ Explore common causes for anxiety symptoms
~ Identify common triggers for anxiety
~ Identify current best practices for anxiety management including
~ Counseling Interventions
~ Medications
~ Physical Interventions
~ Supportive Treatments

Why I Care/How It Impacts Recovery
~ Anxiety can be debilitating
~ Low-grade chronic stress/anxiety erodes energy and ability to concentrate
~ Anxiety is a major trigger for:
~ Addiction relapse
~ Increased physical pain
~ Sleep problems
Triggers for Anxiety
~ Abandonment & Rejection
~ Low self-esteem
~ Irrational thoughts and cognitive distortions
~ Unhealthy social supports/relationships
~ Ineffective interpersonal skills  relationship turmoil and/or social anxiety
~ The unknown & Loss of control
~ Negative self talk and cognitive distortions
~ Negative others
~ Physical complaints
~ Sense of powerlessness

Triggers for Anxiety
~ Death & Loss
~ People and pets
~ Jobs and promotions
~ Safety and security
~ Dreams and hopes
~ Sickness, spiders and other phobias
~ Failure
~ Perfectionism
~ Negative self-talk

General Treatment Recommendations
~ Anxiety, depression and substance disorders as well as a range of physical disorders are often comorbid. This provides researchers key opportunities to explore pathways to mental disorders and provides clinicians key opportunities to intervene accordingly.
~ Anxiety disorders should be treated with psychological therapy, pharmacotherapy, or a combination of both.
~ Cognitive behavioral therapy can be regarded as the psychotherapy with the highest level of evidence.
~ 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.
General Treatment Recommendations
~ Current conceptualization of the etiology of anxiety disorders indicates clinicians need to explore the interaction of:
~ Psychosocial factors such as:
~ Childhood adversity or stressful events
~ Trauma related brain changes
~ Coping skills (learned or not learned)
~ Trauma issues still needing to be dealt with (domestic violence, parental absence, bullying…)
~ Current stressors
~ Current availability of social support
General Treatment Recommendations
~ Current conceptualization of the etiology of anxiety disorders includes an interaction of:
~ Genetic vulnerability
~ Medications
~ Susceptibility to effects and development of dependence
~ Which medications will be effective
~ Vulnerabilities – Which conditions are more challenging for each person
Medications
~ First-line drugs are the SSRIs and SNRIs
~ Effexor was effective according to the Hamilton Rating Scale for Anxiety
~ Zoloft, Paxil, Luvox, Lexapro, Celexa have all been found effective.
~ At least 4 different genetic variations can be correlated with development of generalized anxiety disorder. Different medications are more or less effective depending upon the genetic makeup of the person.
~ There is a higher mortality rate among benzodiazepines users compared with nonusers.
~ There is an increased risk for dependence with use for more than 6 months.
~ An increased risk of dementia was also identified in long-term (>6 months) benzodiazepine users.
~ Benzodiazepines do not treat depression, and may be associated with a higher suicide risk in comorbid anxiety and depressive disorders.
~ Other treatment options include tricyclic antidepressants, seroquel, buspirone. WebMD Health News Reviewed by Louise Chang, MD on May 06, 2008
~ After remission, medication should be continued for ~12 months.
Symptoms of Generalized Anxiety
~ Physical signs and symptoms may include:
~ Fatigue
~ Irritability
~ Muscle tension or muscle aches
~ Trembling, feeling twitchy
~ Being easily startled
~ Trouble sleeping
~ Nausea, diarrhea or irritable bowel syndrome
~ Headaches
~ Mitigate the symptoms and prevent misidentification of causation

Biological
~ Floatation-REST (Reduced Environmental Stimulation Therapy) reduces sensory input to the nervous system through the act of floating supine in a pool of water saturated with Epsom salt.
~ The float experience is calibrated so that sensory signals from visual, auditory, olfactory, gustatory, thermal, tactile, vestibular, gravitational and proprioceptive channels are minimized, as is most movement and speech.
~ 50 participants with anxiety reported significant reductions in stress, muscle tension, pain, depression and negative affect, accompanied by a significant improvement in mood characterized by increases in relaxation, happiness and well-being.
~ Tai Chi produced significant reductions in anxiety (approximately 25%) in patients with anxiety and fibromyalgia who practiced twice a week for a year.
~ Acupuncture at HT7 can attenuate anxiety-like behavior induced by withdrawal from chronic morphine treatment through the mediation of GABAA receptor system.
Biological
~ Pain
~ Anxiety about things getting worse, rejection, inability to handle pain
~ Guided imagery
~ Other-focus mindfulness
~ Physical therapy
~ Ergonomics
~ Hormones
~ Imbalances of estrogen or testosterone can contribute to anxiety
~ Rapid heart rate, sweating, palpitations are not uncommon in women in perimenopause or menopause

Biological Interventions
~ Supportive Care
~ Create a sleep routine
~ Helps the brain and body rebalance
~ Can help repair adrenal insufficiency
~ Improves energy level
~ Nutrition
~ Minimize caffeine and other stimulants
~ Try to prevent spikes (and drops) in blood sugar which can trigger the stress response
~ Drink enough water
Biological Interventions
~ Supportive Care cont…
~ Sunlight
~ Vitamin D deficiency has been implicated in some mood issues
~ Sunlight prompts the skin to tell the brain to produce neurotransmitters
~ Sunlight sets circadian rhythms which impact the release of serotonin, melatonin and GABA
~ Exercise
~ Studies have shown that exercise can have a relaxing effect. Start slowly.
Biological Interventions
~ Supportive Care cont…
~ Aromatherapy
~ Also…Clary Sage
~ https://www.davidwolfe.com/3-essential-oils-fight-chronic-anxiety/

Psychological Interventions
~ Your body thinks there is a threat. Figure out why
~ Anxiety=Threat Threat=Basic Fears
~ Failure
~ Rejection/Isolation
~ Loss of Control
~ The Unknown
~ Death/Loss (Person, Self Concept, Dreams)
~ Distress Tolerance: It isn’t always about controlling your anxiety
~ Distract don’t react
~ Use distancing techniques– “I am having the thought that…”
Cognitive Interventions
~ Functional analysis makes it possible to specify where, when, with what frequency, with what intensity, and under what circumstances the anxious response is triggered.
~ From there, psychoeducation about cognitive distortions and techniques to mitigate those circumstances can be provided.
~ Positive writing. Each day for 30 days, the experimental group engaged in 20 minutes of writing about positive emotions they felt. Long-term expressive writing of positive emotions appears to help reduce test anxiety by using insight and positive emotion words.
Cognitive
~ Mindfulness
~ In a meta-analysis, six articles about mindfulness-based stress reduction, four about mindfulness-based cognitive therapy, and three about fear of negative appraisal and emotional regulation were reviewed.
~ Mindfulness is an effective strategy for the treatment of mood and anxiety disorders and is effective in therapy protocols with different structures including virtual modalities.
~ Mindfulness & Acceptance activities
~ Observation | Acceptance | Labeling and Letting Go
~ Identify trigger thoughts

Cognitive Interventions
~ Address Unhelpful Thoughts
~ It is a dire necessity for adults to be loved by significant others for almost everything they do…
~ Concentrate on their own self-respect, on winning approval for practical purposes, and on loving rather than on being loved.
~ 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
~ Focus on the parts that are in their control and other things in life which are going well and to which they are committed
~ Misery is invariably externally caused and is forced on us by outside people and events…
~ Reactions are largely caused by the view that people take of unfortunate conditions.
Cognitive cont…
~ If something is or may be dangerous or fearsome people should be terribly upset and endlessly obsess about it (hurricane, surgery, child driving)
~ Figure out how to face it and render it harmless, and, when that is not possible, accept the inevitable.
~ It is easier to avoid than to face life difficulties and responsibilities
~ Running from fear is usually much harder in the long run.
~ People believe they should be thoroughly competent, and achieving in all possible respects or they will be isolated, rejected and failures
~ Accept themselves as imperfect with human limitations and flaws.
Cognitive cont…
~ Because something once strongly affected peoples’ lives, they should indefinitely fear it (getting lost, strangers, hurricanes)
~ Learn from past experiences but don’t be overly-attached to or prejudiced by them.
~ People must have complete control over things
~ The past and the future are largely uncontrollable. People can control their actions in the present to stay on the preferred path, and develop general skills to deal with adversity should it arise.
~ People have virtually no control over their emotions and cannot help feeling disturbed about things…
~ People have real control over our destructive emotions – if we choose to work at changing the unhelpful and inaccurate thoughts that often create them
Cognitive cont…
~ Cognitive Distortions
~ Personalization
~ What are 3 alternate explanations
~ Magnification (and minimization)
~ Focus on the facts
~ Don’t confuse high and low probability events
~ All or Nothing
~ Find the exceptions
~ Selective abstraction/filtering
~ Look for the good, the bad and the ugly (Complete the picture)
~ Remember that hindsight is 20/20.
Cognitive cont…
~ Jumping to conclusions
~ Get all the data
~ Mind reading
~ Ask. Talk. Communicate.
~ Emotional reasoning
~ Are you afraid because you feel anxious or are you afraid because there is a factual reason to be concerned?

Psychological Interventions
~ Relaxation Skills
~ What is relaxation…
~ Diaphragmatic breathing
~ Combat breathing
~ Meditation
~ Cued Progressive Muscular Relaxation
~ Self-Esteem (Fear of failure and rejection esp.)
~ Real vs. Ideal Self
~ Compassionate self talk
~ Spotlighting strengths & acceptance of imperfections

Psychological Interventions
~ Cognitive Restructuring
~ Reframe challenges in terms of current strengths (not past weaknesses)
~ Create an attitude of gratitude and optimism
~ Acceptance and Commitment Therapy (FEAR)
~ Fusion with your thoughts (Unhook)
~ Evaluations of your experience (Empower)
~ Avoidance of your experiences (Gradual exposure, Find Exceptions)
~ Reason given for your behavior (Challenging Questions)

Social Interventions
~ Improve your relationship with yourself
~ Identify your needs and wants (Mindfulness)
~ Be your own best friend
~ Internal vs. external validation
~ Develop healthy, supportive relationships
~ Learn about boundaries
~ Develop assertiveness skills (Ask for help and say no to requests)
~ Describe the ideal healthy, supportive relationship
~ Separate the ideals from the reals
~ Identify who that is, or where that could be found
~ Play the “What Does It Mean When…” game
Summary
~ 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 copings skills
~ Cognitive distortions
~ Low self-esteem/a need for external validation
~ Recovery involves
~ Improving health behaviors
~ Identifying and building on current coping strategies
~ Addressing cognitive distortions
~ Developing a healthy, supportive relationship with self and others

May 03 2018

1hr 17mins

Play

329 -Addressing Codependency and Abandonment Fears

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Addressing
Co-Dependency and Abandonment Fears
Instructor: Dr. Dawn-Elise Snipes
Executive Director: AllCEUs Counselor Education
Podcast Host: Counselor Toolbox
Objectives
~ Review attachment theory
~ Define codependency
~ Learn about core abandonment fears
~ Identify ways that codependent behaviors might be ways to cope with abandonment trauma
~ Explore tools and activities to help clients recognize their fear-related and codependent behaviors and take effective action.

What is Attachment Theory?
~ Attachment behaviors, such as crying, calling and searching, are adaptive responses to separation from with a primary attachment figure someone who provides support, protection, and care.
~ Maintaining proximity to an attachment figure via attachment behaviors increases the chance for survival
~ From our initial attachment relationship we learn
~ How scary or safe the world is.
~ How trustworthy others are
~ If we can trust our own feelings
~ What it is like to be loved.

What is Attachment Theory?
~ The attachment system essentially “asks” the following fundamental question: Is the attachment figure nearby, accessible, and attentive?
~ If the answer is “yes,” the person feels loved, secure, and confident, and, behaviorally, is likely to explore his or her environment, interact with others.
~ If the answer is “no,” the person experiences anxiety and, is likely to exhibit attachment behaviors ranging from simple visual searching to active following and vocal signaling on the other
~ These behaviors continue until either
~ The person is able to reestablish a desirable level of physical or psychological proximity to the attachment figure
~ Until the person “wears down.”
Triggers for Attachment
~ Certain kinds of events trigger a desire of closeness and comfort from caregivers.
~ Three main sets of triggers:
~ Conditions of the person (fatigue, hunger, illness, pain, cold, etc.) (HALT)
~ Conditions involving the caregiver (absent, departing, discouraging of proximity, giving attention to another, etc.)
~ Conditions of the environment (alarming events, criticism or rejection by others)

Impact of Attachment
~ How loved or unloved we feel as children deeply affects the formation of our self-esteem and self-acceptance. It shapes how we seek love and whether we feel part of life or more like an outsider.
~ As we individuate we often again seek approval.
Consequences of Abandonment
~ When biological and safety needs are not met, it can trigger anxiety at any age.
~ Fear of abandonment is a natural survival response when a person feels unlovable, ineffective/helpless
~ When people feel like they are not getting their own needs met, they often have difficulty effectively meeting the needs of others.
~ Every stressful situation becomes a crisis because they are already in “threat mode.”
~ Fear of Rejection/isolation, Loss of control/the unknown, Failure

Signs of Abandonment Issues
~ Attach to quickly
~ Move on too quickly
~ Partner pleaser
~ Settle for bad relationships
~ Constantly looking for flaws
~ Reluctant to fully invest in a relationship
~ Difficulty trusting
~ Avoid emotional intimacy
~ Feel unworthy of love
~ Jealous of virtually everyone
~ Hypervigilance and over analysis
~ Repressed Anger
~ Overly controlling
~ Self-sabotage
~ Blame yourself for breakups
Reactions to Fears of Abandonment
~ How do these supposedly prevent abandonment? What maintains them? What are the long-term consequences?
~ Fight (You don’t want to leave me because…)
~ Aggression, hostility, blaming, criticizing
~ Dominance or trying to control others
~ Recognition seeking to get attention/validation/approval
~ Manipulation and exploitation (seduction, lying, justifying)
~ Clinging and chasing
~ Shame (Self anger) about feeling needy
Reactions cont…
~ How do these supposedly prevent abandonment? What maintains them? What are the long-term consequences?
~ Flight (I don’t care if you leave)
~ Withdrawal (physical, emotional, including addiction)
~ Distraction
Co-Dependency
~ Codependency describes a type of relationship in which:
~ One partner defines his or her worth or goodness based on someone else
~ If I can save this person it means I am good
~ If this person loves me, it means I am lovable
~ The codependent person often chooses relationships in which the other person needs to be rescued, thereby making himself or herself indispensable.
~ How might this result from low self-esteem and fear of abandonment?

Characteristics of Codependency
~ In what ways do these behaviors prevent abandonment? What maintains them?
~ Avoidance confrontation/poor communication
~ Inability to identify feelings (except chronic anger)
~ Confuse pity and love
~ Neglect your needs to attend to another’s first
~ Accept verbal or physical abuse by others
~ Take responsibility for the actions of others
~ Need to control others
~ Feel shame when others make mistakes
Characteristics of Codependency
~ In what ways do these behaviors prevent abandonment? What maintains them?
~ Do more than your share at work, or at home
~ Refuse to ask for help
~ Need others’ validation to feel good about yourself (not feel hurt)
~ Think everyone’s feelings are more important than your own
~ Feel trapped in the relationship but stay to avoid feelings of abandonment
~ Enmeshment/poor boundaries
~ Overcommitment/overwhelmed
Core Abandonment Beliefs

~ Abandonment: All people leave.
~ Mistrust: People will hurt, reject, take advantage of me or just not be there when I need them.
~ Emotional Deprivation: I don’t get the love I need. Nobody understands me, cares about me or even tries to meet my needs.
~ Defectiveness: If people knew me they would reject me. (Feeling-Based Reasoning, Examine the facts, find exceptions)
~ Failure. I don’t measure up. I am not able to succeed.

*Notice the all or nothing language in these schemas.

Questions for Clients About Core Beliefs
~ Abandonment: All people leave.
~ What does it look like to be available (not abandon)?
~ Who in your past left you or was unavailable emotionally?
~ What did they do to make you feel rejected/abandoned?
~ What are alternate explanations?
~ Who in your past has been available to you emotionally?
~ Who in your present is available to you emotionally?
~ What do you do in your current relationships that causes people to leave?
~ Push them away How? Alternatives?
~ Cling How? Alternatives?

Questions for Clients About Core Beliefs
~ Mistrust: People will hurt, reject, take advantage of me or just not be there when I need them.
~ What does it look like when someone is trustworthy and safe?
~ Who in your past was untrustworthy or unsafe?
~ What did they do that taught you people were untrustworthy or dangerous?
~ What are alternate explanations?
~ Who in your past has been trustworthy and safe?
~ Who in your present is available trustworthy?
~ What do you do to yourself that is unsafe or dishonest?
~ How does your distrust impact your current relationships?
~ What could you do differently?
Questions for Clients About Core Beliefs
~ Emotional Deprivation: I don’t get the love I need. Nobody understands me, cares about me or even tries to meet my needs.
~ What does it look like when someone understands you and meets your needs?
~ How do you communicate your needs?
~ Who in the past failed to meet your needs emotionally, and how can you deal with that now?
~ Who in your past has understood you?
~ Who in your present cares about you and wants to understand?
~ How can you start better understanding yourself and taking care of you?
~ What can you do to start getting your needs met?

Questions for Clients About Core Beliefs
~ Defectiveness: If people knew me they would reject me.
~ Is this based on facts or feelings?
~ How will you know when you are accepted/acceptable?
~ Who in your past made you feel defective?
~ Are there alternate explanations?
~ How can you silence those old tapes?
~ Who in your past has been accepting and supportive?
~ Who in your present is accepting and supportive?
~ How can you start accepting yourself?

Questions for Clients About Core Beliefs
~ Failure. I don’t measure up. I am not able to succeed.
~ To what or who’s standards do you not measure up?
~ What does it look like to be successful?
~ Clients may need help with goal setting
~ What in your past made you feel like a failure?
~ What are alternate explanations/ways of viewing it?
~ What have you succeeded at in the past?
~ What are you good at in the present?
~ *Pay attention to minimization
~ What does being successful mean in terms of your relationships?
~ Who are 3 successful people you know. What makes them successful?
~ Does success = happiness?
~ What do your kids need to do to be successful in your eyes?

Behavioral Triggers
~ Abandonment/Mistrust
~ Change in someone’s behavior
~ Not getting constant reassurance
~ The other person’s relationships feel threatening
~ Hypervigilant to rejection and disconnection
~ Questions for clients
~ How has this threatened you in the past?
~ What are alternate explanations?
~ What would be a helpful reaction to these behaviors now?

Behavioral Triggers
~ Defectiveness/Failure
~ Criticism
~ Unexplained time apart
~ Absent or inconsistent reassurance
~ Failure
~ Questions for clients
~ How has this threatened you in the past?
~ What are alternate explanations?
~ What would be a helpful reaction to these behaviors now?

Envisioning Activity for Clients
~ What does a healthy relationship look like?
~ Presence vs. abandonment
~ Acceptance vs. rejection
~ Emotional support/compassion vs. emotional unavailability
~ Trustworthiness vs. untrustworthiness
~ Safe vs. harmful
~ How can you…
~ Create this relationship with yourself?
~ Create this relationship with others?

Mindfulness Questions for Clients

~ What am I feeling?
~ What is triggering it?
~ Am I safe (emotionally and physically) now? If not, what do I need to do?
~ Is this bringing up something from the past?
~ How is this situation different?
~ How am I different?
~ How can I silence my inner critic?
~ What would be a helpful reaction that…
~ Moves you more toward your goals
~ Moves you toward a positive emotional experience

Summary
~ Core beliefs about self, others and relationships are formed in early life
~ Identifying and being mindful of abandonment triggers in the present can help people choose alternate, more helpful ways of responding.
~ Codependents do not feel worthy or lovable. They need someone else to validate them
~ Recovery involves
~ Developing a sense of self-worth
~ Addressing the depression and anxiety
~ Learning about and creating a network of healthy relationships

Oct 27 2018

1hr

Play

13 Brief Interventions for Any Client

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419 -13 Useful Brief Interventions
Instructor: Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC

CEUs are available at allceus.com/counselortoolbox

Objectives
~ Review the benefits of brief interventions
~ Identify the goals of brief interventions
~ Explore 13 brief interventions that can be used with most clients
Benefits
~ Reduce no-show
~ Increase treatment engagement
~ Increase compliance
~ Increase self-efficacy
~ Reduce aggression and isolation
~ Provide an interim for clients on waiting lists
Goals of Brief Interventions
~ Goals should be…
~ Specific
~ Measurable
~ Achievable in 8-10 weeks
~ Relevant
~ Time Limited
~ Purpose:
~ Reduce the likelihood of damage/additional problems from the current issue. (i.e. family, work, health, self-esteem, guilt, anger)
~ Provide rapid measurable change to increase hope and motivation

Target Symptoms
~ General Symptoms
~ Depression/anxiety (mood)
~ Muscle tension
~ Sleep disturbances
~ Concentration
~ Irritability
~ Fatigue
~ Lethargy/psychomotor retardation
~ Hopelessness/helplessness (efficacy)
~ Meta Issues
~ Relationship issues
~ Unhealthy habits (smoking, emotional eating etc.)

~ Modern populations are increasingly overfed yet malnourished, sedentary, sunlight-deficient, sleep-deprived, and socially-isolated
Assessment for Brief Interventions
~ Identify what the resolution of the problem looks like.
~ Define a starting point to create one measurable change in the client’s behavior
~ Explore the array of causes of the behavior
~ Physical (sleep, nutrition, relaxation, medicine, health, pain, hormones, addiction…)
~ Affect (anxiety, depression, grief)
~ Cognitions (Cognitive distortions)
~ Environment and Employment
~ Social Relationships (quality, boundaries, communication)

Assessment cont…
~ Explore Current Strengths/Mitigating Factors
~ Support systems
~ Client strengths
~ Situational advantages (mitigating factors)
~ Previous treatment (What has and has not worked)
1. Backward Chaining
~ Identify triggers and mitigating factors by backward chaining.
~ Ask the client to describe a situation that triggered the problem
~ John came home late and I got angry
~ I had a bad day and came home and drank a bottle of wine
~ It was valentine’s day and I wasn’t in a relationship so I got depressed
~ I didn’t sleep well and everything seemed to make me feel overwhelmed
~ Ask the client to think of a similar situation that did not trigger the problem
~ John came home late but he called and let me know.
~ I had a bad day and decided to go out to dinner with friends from work to commiserate
~ It was valentine’s day and I wasn’t in a relationship so I went out with friends and we celebrated un-valentine’s day together
~ I didn’t sleep well, so I kept my office door closed and reminded myself that I can only do what I can do
2. Forward Chaining
~ Add in triggers for behaviors you want to start doing
~ Push notifications
~ Visual cues
~ Change buddy
~ Rewards
~ Add in obstacles to behaviors you wish to stop
~ Make it more difficult to start
~ Journal
~ Inaccessibility
~ Temporal distance
~ Aversion

3. Positive Reflection
~ Positive Affect Journaling for 20 minutes per day improves depression and anxiety , enhanced resilience, reduced medical visits
~ Alternatives for those who hate journaling
~ Tell someone about the positive things in your day for ~10-20 minutes
~ Mentally reflect on all the positive things in your day and life for ~10-20 minutes
~ Draw a picture about something incredibly awesome in your life
4. Sleep
~ Benefits: Enhances cognition, enhances immunity, reduces depression and reduces anger, anxiety, and fatigue
~ Only quality sleep within normal limits (7-9 hours) is helpful
~ Incorporation into treatment
~ Review sleep hygiene
~ Develop a sleep routine
~ Keep a log of symptom severity and sleep
5. Sunlight and Circadian Rhythms
~ The body uses sunlight to set circadian rhythms and make vitamin D
~ Vitamin D deficiency is implicated in seasonal affective disorder, behavioral withdrawal
~ Sunlight exposure related positively to job satisfaction and organizational commitment, and negatively to depressed mood and anxiety
~ Bright light therapy has been found effective for addressing eating disorders, depression, fatigue, sleep disruption
~ Incorporation
~ Sunlight exposure first thing in the morning and throughout the day
~ Light boxes
~ Full-spectrum lights (100watt or more) within 1 meter
6. Oxygenation
~ Oxygen is needed for serotonin and ATP-synthesis
~ Relaxing Deep Breathing has been shown to attenuate pain perception, tension, anger, anxiety and depression and improve sleep
~ Incorporation
~ Breathing breaks
~ Exercise improves mood, cognition and sleep
~ Even in healthy adults without clinical depression, exercise has improved depressive symptoms.
~ Exercise may modulate dopaminergic and glutamatergic neurotransmission as well as serotonin, noradrenaline, and GABA systems, which are all related to depression, anxiety, and sleep
6. Oxygenation
~ Laughter
~ Alters dopamine and serotonin activity, decreases cortisol levels and increases endorphin release
~ Impacts depression, anxiety, pain, immunity, fatigue, sleep quality, respiratory function and blood glucose
~ Significantly decreased adults' depression, anxiety, and improved their sleep quality
~ Integrating laughter into the treatment plan– 10-15 minutes per day prior to stressful situations, and at the end of the day to “reset” the system.
~ Laughter distracts from distress and “breaks the loop”
~ Laughter increases good chemicals
~ Laughter increases oxygenation

7. Hardiness
~ Hardiness
~ Commitment: Tendency to involve oneself in activities in life and as having a genuine interest in and curiosity about the surrounding world (activities, things, other people) and to recognize ones’ self as multidimensional
~ Control: Tendency to believe and act as if one can influence the events
~ Challenge: Belief that change, rather than stability, is the normal mode of life and constitutes motivating opportunities
~ Improves: Cardiovascular health, anxiety, response to bullying, insomnia, reduces neuroticism, rumination and worry

Hardiness
~ Incorporating it
~ Have clients identify all the different aspects of self which are important
~ Health
~ Housing
~ Family
~ Friends
~ Finances
~ Job
~ Other…
~ When unpleasant things happen, encourage them to identify 5 things that are going well, how this event represents a growth opportunity and what aspects of the situation they can change.

8. Cognitive Restructuring
~ Cognitive Restructuring teaches people to identify and dispute maladaptive thoughts
~ Cognitive Restructuring can assist in increasing perceived efficacy, altering negative self-concept, enhancing pain tolerance, reducing hopelessness and helplessness associated with anxiety and depression
~ Incorporating into the treatment plan
~ Worksheets (CPT, ABC-Des)
~ Identifying 3 alternatives
~ Finding meaning
~ Note: Older adults with anxiety and depression are worse at learning and benefiting from CR with a brief intervention, partially due to having poorer cognitive flexibility
9. Cognitive Dissonance
~ Create dissonance between unwanted behaviors, thoughts and emotions to encourage purposeful change– (It may be pleasurable (or “safe”), but it does not help me)
~ Resolve dissonance between helpful behaviors (exercise, sleep, nutrition)– (It’s good for me, but it is awful)
~ Cognitive dissonance has been shown to be maximized by four factors:
~ Voluntary nature
~ Absence of an external justification
~ High public accountability
~ Dissonance-inducing behaviors required a high level of effort
~ Incorporation
~ Self-talk scripts
~ Make dissonant behaviors difficult
10. Mindfulness
~ Mindfulness meditation and cognitive therapy cultivates an awareness of one’s feelings, urges, thoughts and perceptions in the present moment, without judgement and relate constructively (purposefully) to those experiences to improve the next moment
~ Mindfulness meditation improves pain perception, anxiety and depression, emotion regulation, insomnia, binge eating
~ The key is not only being aware and accepting of the present moment, but also figuring out how to relate constructively to it –Change the situation, change your reaction, let it go…
~ Incorporation
~ Mealtime/General mindfulness—Awareness and early intervention
~ Problem focused mindfulness (pain, anxiety, habits)
11. Guided Imagery
~ Guided imagery improves mood, fatigue, and quality of life, pain perception, anxiety and depression
~ Incorporating it
~ Envision success
~ Take a mental vacation
~ Envision healing
~ Altered focus (physical discomfort—pain, cravings, urges)
12. Biofeedback–HRV
~ Heart rate increases are associated with increased stress and HPA-Axis activation
~ Prolonged HPA-Axis activation contributes to fatigue, insomnia, difficulty concentrating and problem solving, irritability, anxiety and depression
~ HRV-BF is effective at reducing symptoms of depression, anxiety and “stress” as well as pain perception
~ Incorporating it
~ Fitness trackers with “stress feedback”
~ Heart rate monitors/fitness trackers can be used at point of distress to alter focus and reduce HPA-Axis activation (fight or flight response)
~ Planned relaxation breaks
13. Distress Tolerance
~ Distress tolerance significantly mitigates depression, substance misuse, negative affect, stress, intolerance of uncertainty, and anxiety sensitivity
~ Distress tolerance is related to reductions in cortisol and HRV by altering how people perceive and relate to stressors.
~ Incorporation (SPAM-IT)
~ Sensations
~ Positive focus
~ Activities
~ Mental vacation
~ Thought stopping
~ Imagery
Summary
~ Brief therapy is a cost effective technique that can:
~ Help engage clients in the preparation phase
~ Enhance treatment compliance
~ Improve outcomes
~ Increases success and client self-efficacy
~ Reduce cost-per-patient expenses
~ Be used for a variety of issues to help clients accomplish SMART goals
~ Be implemented in group or individual settings

Aug 31 2019

59mins

Play

Internal Family Systems Theory

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Internal Family Systems Theory
Dr. Dawn-Elise Snipes

Purchase CEU class for this podcast at:
https://www.allceus.com/member/cart/index/product/id/1034/c/

Objectives
~ Define Internal Family Systems Theory
~ Identify when it is used
~ Explore guiding principles

~ For more information and training programs in IFS, go to https://www.selfleadership.org/
Overview
~ IFS was developed in the 1990s by family therapist Richard Schwartz, Ph.D.,
~ It is based on the concept that an undamaged core Self is the essence of who you are, and identifies three different types of sub-personalities or “families” that reside within each person, in addition to the Self.
~ Wounded and suppressed parts called exiles (lost child)
~ Managers, that keep the exiled parts suppressed (enabler)
~ Firefighters, that distract the Self from the pain of exiled parts. (hero/mascot/scapegoat)
~ The Internal Family Systems Center for Self-Leadership conducts training programs
Basic Assumptions
~ The mind is subdivided into an indeterminate number of subpersonalities or parts.
~ Everyone has a Self which can lead the individual's internal system.
~ The non-extreme intention of each part (exile, manager and firefighter) is something positive for the individual.
~ There are no “bad” parts
~ The goal of therapy is not to eliminate parts but instead to help them find their non-extreme roles.
~ As we develop, our parts develop and form a complex system of interactions among themselves
~ When the system is reorganized, parts can change rapidly.
~ Changes in the internal system will affect changes in the external system and vice versa.
Parts
~ Subpersonalities are aspects of our personality that interact internally in sequences and styles that are similar to the ways in which people interact. (exile and the manager or the firefighter and the Self)
~ Parts may be experienced in any number of ways — thoughts, feelings, sensations, images, and more.
~ All parts want something positive for the individual and will use a variety of strategies to gain influence within the internal system.
~ Parts that become extreme are carrying “burdens” — energies that are not helpful, such as extreme beliefs, emotions, or fantasies.
~ Parts can be helped to “unburden” or recognize their role and return to their natural balance.
~ Parts that have lost trust in the leadership of the Self will “blend” with or take over the Self.
Exiles
~ Young parts that have experienced trauma and become isolated or suppressed in an effort to protect the individual from feeling the pain, terror, fear, and so on, of these parts
~ Exiles are often young parts holding extreme feelings and/or beliefs that become isolated from the rest of the system (such as “I’m worthless,” “I must be successful to be lovable,” “I am a failure”)
~ Exiles become increasingly extreme and desperate as they look for opportunities to emerge and tell their stories
~ Want to be cared for and loved and constantly seek someone to rescue and redeem them
~ Can leave the individual feeling fragile and vulnerable

Managers
~ Managers are proactive and try to avoid interactions or situations that might activate an exile’s attempts to break out or leak feelings, sensations, or memories into consciousness.
~ Different managers adopt different strategies controlling, perfectionism, co-dependency
~ The primary function of all mangers is to keep the exiles exiled….
~ Common managerial behaviors: controlling, perfectionism, high criticism, narcissism, people pleasing, avoiding risks, being pessimistic, constantly striving to achieve
~ Ask…What would trigger the exiles and how can that be prevented?
~ Common managerial symptoms: Emotional detachment, panic attacks, somatic complaints, depressive episodes, hypervigilance
Firefighters
~ Have the same goals as managers (to keep exiles away) but different strategies
~ Managers want you to look good and be approved of, FFs only care about distracting from the pain so they are often in conflict. (Shoulds)
~ Are reactive and automatically activated when an exiled part is activated (rejection, isolation, failure, traumatic memories…)
~ Their function is to eliminate the dysphoric feelings, thoughts, sensations and memories without regard for the consequences. (Autopilot/reactive/emotional mind)
~ Can do this in any number of ways, including drug or alcohol use, self-mutilation (cutting), binge-eating, compulsive sexuality

Self
~ The self is the “moderator” that the parts are talking to, that likes or dislikes, listens to, or shuts out various parts
~ When differentiated, the Self is competent, secure, self-assured, relaxed, and able to listen and respond to feedback. (afraid/wounded; should and avoidant)
~ The Self can and should lead the internal system.
~ Various levels of experience of the Self:
~ When completely differentiated from all parts (Self alone), people describe a feeling of being “centered.”
~ When the individual is “in Self” or when the Self is in the lead while interacting with others (day-to-day experience), the Self is experienced along with the non-extreme aspects of the parts.
~ An empowering aspect of the model is that everyone has a Self.

3 Goals of IFS
~ Free the parts from their extreme roles
~ Restore trust in the Self
~ Coordinate and harmonize the Self and the parts, so they can work together as a team with the Self in charge.

Beginning to Use the Model
~ Assess client's parts and sequences around the problem.
~ Check for individual's awareness of parts — ask how he or she experiences the part: thoughts, feelings, sensations, images, and so on.
~ When the manager is in control
~ When the firefighter is desperately trying to suppress the pain
~ When the exile is hurting and starting to emerge
~ Look for polarizations
~ Anorexia: Extreme Manager
~ Substance Abuse: Extreme Firefighter
~ Clinical Depression or Anxiety or PTSD: Extreme Exile
Relationship Between Internal & External Systems
~ The way you relate to your own parts parallels the way you relate to parts of others.
~ How does your exile interact with the exile of others
~ How does your manager interact with the exile of others
~ How does your firefighter interact with the exile of others
~ Individual's internal system affects and is affected by the external system of which he or she is a part.
~ Internal and external systems often parallel each other.

Beginning to Use the Model
~ When working with families, check for the family's awareness of parts in self and others.
~ Make a decision about how to begin using the model: language, direct access, imagery, and so on.
~ Assess the fears of manager parts and value the roles of the Managers; explain how the therapy can work without the manager’s feared outcomes happening.
~ Inventory dangerous Firefighter behaviors; work with managers' fears about triggering firefighters.
~ Assess client's external context and constraints to doing this work.

Working with Individuals
~ Important to assess protective parts (managers and firefighters) and work with them first. (Create safety)
~ Develop a direct relationship with the part.
~ May need to negotiate pace of work — give the part an opportunity to talk about concerns.
~ Work out a system for the part to let you know when things are moving too fast.
~ Respect the concerns of the part.
~ Eventually, identify the Exiles and start helping them tell their story and become empowered and integrated

Working with Individuals
~ Non-imaging techniques
~ Assessing internal dialogue
~ Location/sense of a part in the body
~ Diagrams — relationships among parts

Working with Individuals
~ Non-imaging techniques
~ Assessing internal dialogue
~ Journaling: What is the exile/manager/firefighter/self saying or wanting to do about this situation?
~ Direct access:
~ Therapist to parts: Let me talk to the manager for a moment.
~ Self to parts: What are the parts saying and what is the Self’s reaction
~ Part to part: What is the manager saying to the exile?

Conversation
~ Manager: “You better not do that because you know there is no way you can succeed.”
~ Exile: “I will never get Dad’s approval because I always fail at everything I do.”
~ Firefighter: “I need a drink”
~ Self: “Manager, thank you for the warning. I know it is a risk. Can you help Exile think of times she has succeeded, because it is important to me to try this? Firefighter, you don’t know that bad things are going to happen. Thank you for being at the ready. What else can I do if this doesn’t go how I want?”

Conversation
~ Manager: “I’m in control. Everything has to go as planned.”
~ Exile: “I remember when I was little and couldn’t fix [it] Mom would get really depressed. It is my fault she was so sad.”
~ Firefighter: “They aren’t listening. You better start yelling and showing them who is boss or you will feel even more out of control”
~ Self: “Manager, thank you for trying to take such good care and help me feel empowered. Exile, it did hurt to see Mom struggle so much, but it wasn’t your fault she was so sad. You were too little to do anything. What is the worst that will likely happen in this situation if I am not in control? Firefighter, yelling is one way to get my point across, but that is not how I want to interact with others. How else could I approach this situation?
Working with Individuals
~ Going back in time with a part, then “unburdening”
~ Exile: What do you wish would have happened?
~ Manager: What do you think you “should” have done to protect the Self?
~ Bringing parts into the present – “retrieval”
~ What is different about you now?
~ Future imaging
~ Exile: What do you want to happen
~ Manager: How can you deal more effectively with situations like that in the future
Working with Individuals
~ Concept of Blending: Keeping the feelings of the part from overwhelming the Self
~ Working with the Self to understand why/how not to blend
~ Working with the part to understand why/how not to blend

Strengths of the Model
~ Focuses on strengths: The undamaged core of the Self, the ability of parts to shift into positive roles
~ IFS language provides a way to look at oneself and others differently.
~ Instead of seeing someone as being self-destructive, we may see their Firefighter being triggered and trying to protect the Exile
~ There is no such thing as a bad part, just a part that has become extreme
~ Language encourages self-disclosure and taking responsibility for behavior.
~ Ecological understanding of entire therapy system, including therapist
~ Respect for individual's experience of the problem
~ Clients provide the material — the therapist doesn't have to have all the ideas.
~ Therapist looks at client's Self as “co-therapist” and trusts the wisdom of the internal system.

Summary
~ Every person has within them a Self, exile, firefighter and manager
~ Each of these parts has a survival function
~ One goal is helping parts communicate and not overwhelm each other is essential
~ Another goal is helping the Self get back into a position in which it can listen and discern feedback from the parts to determine the best course of action

May 15 2019

52mins

Play

5 Elements of Motivational Interventions & 5 Principles of Motivational Interviewing

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414 -5 Elements of Motivational Interventions & 5 Principles of Motivational Interviewing
Instructor: Dr. Dawn-Elise Snipes, PhD
Executive Director: AllCEUs.com, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
Objectives
– Learn how motivation is dynamic
– Explore reasons and methods for enhancing motivation
– Identify 3 critical elements of motivation
– Delineate the 5 elements of motivational approaches
– Review the FRAMES model
– Identify ways to deal with resistance
– Review how to use decisional balance exercises

Why Enhance Motivation-
– Inspiring change
– Preparing clients to enter treatment
– Engaging and retaining clients in treatment
– Increasing participation and involvement
– Improving treatment outcomes
– Encouraging a rapid return to treatment if symptoms recur
– Creates a therapeutic partnership
6 Characteristics of Motivation
– Motivation is positive and a key to change
– Motivation “harnesses” energy to use to accomplish a task
– What happens when you are not motivated– To clean, exercise, work
6 Characteristics of Motivation
– Motivation is multidimensional
• Emotional
• Mental
• Physical
• Social Support and Pressures
• Legal
• Financial
– Cube activity
– #1
– On a large box identify all the reasons to NOT change on each face
– Can include drawbacks to change and benefits to staying the same
– Discuss ways to eliminate those drawbacks
– #2
– Get small-ish square boxes for clients to decorate
– On each face of the cube, have them identify motivations for change
6 Characteristics of Motivation
– Motivation is multidimensional
– Scale Activity
– Get at least 10-20 regular marbles and 10 shooter marbles (bigger)
– Get (or fashion a scale) One side is labeled “change” the other side is labeled “same”
– Write on the white board 2 columns
– Benefits to Staying the Same (and drawbacks to change)
– Benefits to Change (and drawbacks to staying the same)
– Have clients complete each list
– Then talk about how some “reasons” carry more weight.
– Bring out the scale and stones.
– Have clients assign a “weight” to each reason and deposit it in the appropriate side
– Goal is to see that it is about the total weight that tips the balance

6 Characteristics
– Motivation is dynamic and fluctuating
– Is a dynamic state that can fluctuate over time and in relation to different situations rather than a static personal attribute
– Can vacillate between conflicting objectives
– Differs between objectives
– Varies in intensity, faltering in response to doubts and increasing as doubts are resolved and goals are envisioned more clearly.
– Example: Getting Healthy
– Nutrition
– Exercise
– Sleep
– What conditions would make you motivated and what conditions would undermine your motivation-
6 Characteristics
– Motivation is dynamic and fluctuating
– SMART Goals increase efficacy
– Specific
– Measurable
– Achievable
– Relevant
– Time Limited

– Examples
– Get healthy to reduce my risk of cancer
– Lose weight to get my partner to pay attention to me
Goal Setting Activities
– Out of the Hat
– Write goals on strips of paper and put them in a hat or box
– Have clients draw a strip and restate the goal in specific, measurable, Achievable, Relevant and Time limited terms
– The strip might say: Lose Weight
– The client might say: Lose 10 pounds in 2 months so I am more comfortable in my clothes
– The strip might say: Not be depressed
– The client might say: Increase my overall happiness to a rating of 4 out of 5 at least 5 days per week in the next 8 weeks.
– The strip might say: Improve my relationship
– The client might say: Reduce arguments with my partner to less than 2 per week and spend at least 1 day per week together doing something enjoyable.

6 Characteristics
– Motivation can be modified/changed
– Social Influences (Media, friends, who you are doing it for)
– Emotional
– Mental
– Physical
– Legal
– Financial
– Environmental Pressures (nonsmoking buildings, custody)
– Distress Levels (Raising the bottom)
– Critical Life Events (loved one dying of cancer)
– Activity
– Use the same goals as in the Goal Setting Exercise to identify ways to increase motivation (Weight loss, depression…)
6 Characteristics
– Motivation is influenced by clinician’s (and client’s) style
– Nonpossessive warmth & friendliness
– Genuineness
– Respect
– Validation
– Empathy
– Talk about the successes as well as the challenges
– Motivation is purposeful and intentional
Help Increase Motivation
– Counselor Techniques OARS
– Open ended questions
– Respect the client's autonomy
– Affirm their ability to succeed
– Recognize co-occurring disorders, acknowledge difficulties
– Employ client centered treatment
– Reflective listening
– Using empathy more than authority. Validate client experience
– Summarize
– Focus on client strengths, successes and personal power

CRAVE Check In
– Compassion—I am human. I am here.
– Report how the week went
– Acknowledge difficulties
– Validate
– Explain how they used their strengths and personal power to create successes (even if it is just to try again the next day)

Critical Elements of Motivation (WAR)
– Willingness involves the importance a person places on changing—how much a change is wanted or desired.
– Activity: Yes, but….
– Write a goal on the board and have clients think of as many yes, buts for getting started on that goal as possible. When you are finished, discuss ways to deal with those objections.
– Ability refers to the extent to which the person has the necessary skills, resources, and confidence to carry out a change.
– Activity: Review the SMART goals the group created (or start with new ones). Discuss what skills and resources a person needs to accomplish the goal and how to acquire those.
– Readiness represents a final step in which the person decides to change a particular behavior.

5 Principles of Motivational Interviewing
– Express empathy through reflective listening.
– Develop discrepancy between clients' goals or values and their current behavior.
– Avoid argument and direct confrontation.
– Adjust to client resistance rather than opposing it directly.
– Support self-efficacy and optimism.

Elements Of Current Motivational
Approaches
– The FRAMES approach
– Decisional balance exercises
– Discrepancies between personal goals and current behavior
– Flexible pacing
– Personal contact with clients in treatment
Help Increase Motivation
– Help clients
– Develop discrepancy between their goals and actions
– Address the drawbacks to change
– Address the benefits to staying the same
– Feel competent to change
– Developing a plan for change
– Begin to take action
– Continue to use strategies that discourage a return to the old behavior

A Note About Resistance
– Resistance and yes, buts are signs that what you are asking is
– Too threatening
– Not sufficiently rewarding
– Already known to fail

– Activity: Have clients identify activities that they resist doing.
– Dieting, ending a relationship, medication, entering treatment
FRAMES
– Feedback regarding personal risk or impairment
– Responsibility for change is placed squarely and explicitly on the client
– Advice is clearly given to the client by the clinician in a nonjudgmental manner.
– Menus of self-directed change options and treatment alternatives are offered to the client.
– Empathic counseling
– Self-efficacy is engendered in the client to encourage change.
Feedback
– Feedback should help a client
– Understand the information
– Interpret the meaning
– Gain a new perspective about the personal impact of the behavior
– Consider changing.
– Recognize a discrepancy or gap between future goals and current behavior.
Responsibility
– Give individuals the responsibility and opportunity to decide when and whether they will change their behavior
– Encourage clients to choose their treatment and be responsible for changing
– Do not impose views or goals on clients.
– When clients are free to choose whether to change, they
– Feel less need to resist or dismiss the clinician’s ideas
– Feel empowered and more invested in treatment
– May be more willing to negotiate common treatment goals with the clinician.
Advice
– The most appropriate time to give advice is when a client requests it.
– As with feedback, the manner in which the clinician advises clients determines how the advice will be used.
– Suggesting yields better results than telling clients what they should do.
– If a client requests direction, the clinician can—
– First clarify what the client wants
– Give simple advice that is matched to the client’s level of understanding and readiness, the urgency of the situation, and the client’s culture.
Menu of Options
– When clients make independent decisions, they are likely to commit to them.
– Offering a menu of options decreases dropout rates and resistance to treatment and increases overall treatment effectiveness.
– Provide accurate information about each option and a best guess about the implications of choosing one particular path
– Elicit from clients what clients think would be effective or what has worked for them in the past
– Reinforce clients’ ability to make informed choices.
Empathy
– Empathic counseling can be particularly effective with clients who are angry, resistant, or defensive.
– Explore the reasons why the client might be angry, afraid or resistant
– Allow the client to do most of the talking in a safe environment
– Allow the client’s change process to unfold, rather than directing or interrupting it
– Communicates respect for and acceptance of clients and their feelings
– Encourages a nonjudgmental, collaborative relationship
Self-Efficacy
– Clients must—
– Believe they are capable of undertaking specific tasks
– Have the skills and confidence needed to change.
– Clinicians help clients develop self-efficacy by—
– Reinforcing clients’ beliefs in their capacities and capabilities
– Believing in clients’ ability to change
– Helping clients identify how they have coped successfully with problems in the past and build on those successes
– Reinforcing small steps and positive changes
– Foster hope and optimism in clients
– Reframing past “failures” as partial successes
– Using questions beginning with “What else”
Failure Activity
– Failure is virtually inevitable sometimes.
– Look up quotes about failure.
– Create a Failure Flag
– On each stripe write a sentence that gives meaning to failure…
– Failure means…
– Discuss how this applies to
prior failures
Flexible Pacing and Personal Contact
– Pacing
– Meet clients at their levels
– Use as much time as necessary with the essential tasks of each stage of change.
– Personal Contact: letters or telephone calls
– Effective for encouraging clients to—
– Return for another clinical consultation
– Return to treatment following a missed appointment
– Stay involved in treatment
– Adhere to a plan for change.
Personal Contact Activity
– Write letters to themselves
– To remind them to reflect on how far they have come
– To reflect on what they have learned (from themselves of each other)
– To encourage them to keep going
– To remind them of all the reasons they wanted to make the change
– To congratulate them on progress

– This can also be done as a group activity in which group members write letters to each other

– Old fashioned mail is often better for this because it is more personal and the letters can be decorated.
Summary
– Motivation is dynamic, influenced by multiple types of motivation including emotional, cognitive, social, environmental
– Motivational Interviewing increases client’s hope and enhances treatment participation
– 3 critical elements of motivation: Ability, willingness and readiness
– 5 elements of motivational approaches
– The FRAMES approach
– Decisional balance exercises
– Discrepancies between personal goals and current behavior
– Flexible pacing
– Personal contact with clients in treatment

Aug 12 2019

53mins

Play

340 -Trauma Informed Interventions

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Trauma Informed Interventions
Dr. Dawn-Elise Snipes, PhD, LPC-MHSP
Podcast Host: Counselor Toolbox

CEUs/CPDs/OPDs are available for this presentation at https://www.allceus.com/member/cart/index/product/id/955/c/in the US or for clinicians in Australia at https://www.allceus.com/member/cart/index/product/id/955/c/

Objectives
~ Review the components of Trauma Informed Care
~ Identify a variety of interventions and considerations for the provision of trauma informed care
Principles of TIC
~ Safety
~ Emotional, cognitive, physical, interpersonal
~ Trustworthiness and transparency
~ Peer support and mutual self-help
~ Collaboration and mutuality
~ Sharing of power and decision-making and recognition that everyone has a role to play

Principles of TIC
~ Empowerment, voice, and choice
~ Strengths are built on and validated and new skills developed as needed.
~ Belief in resilience and individuals, organizations, and communities.
~ Building on what clients, staff, and communities have to offer, rather than responding to perceived deficits.
~ Cultural, historical, and gender issues
~ Leverages the healing value of cultural connections, and recognizes and addresses historical trauma.

Three E's of Trauma:

~ Events: Objective—What happened
~ Experiences: How the person experienced the event based upon
~ Developmental age
~ Prior history
~ Available resources

Three E's of Trauma:

~ Effects
~ Emotional
~ Mental
~ Physical
~ Social
~ Spiritual
~ Environmental
The Four R’s
~ Realization of the event
~ Recognize the experience and the effects
~ Respond to help people live a high quality of life
~ Resist re-traumatization.
Summary of the Intention of Interventions
~ Create safety and develop trust through the use of
~ Cultural resources
~ Peer support
~ Transparency
~ Collaboration and empowerment
~ To
~ Explore events, experiences and effects
~ Respond in a way to help people live a rich and meaningful life without retraumatizing them

Creating Safety
~ Develop a nurturing voice
~ Develop a crisis plan (and a post-crisis plan)
~ Mindfulness activities (Awareness of self)
~ Grounding techniques (Awareness of the present)
~ Unhooking
~ Pandora’s box
~ Boundaries
~ Physical
~ Emotional
~ Cognitive

Transparency
~ Always explain the rationale behind activities
~ Improve communication
~ Stop mindreading
~ Ask for what you need (and stop expecting mind reading)
~ Using I-statements
~ Develop an awareness of the motivations behind thoughts, feelings and urges

Collaboration and Empowerment
~ Multisensory guided imagery
~ Values identification
~ Living in the And
~ How are you different?
~ Identify and enhance strengths for coping with
~ Irritability
~ Hypervigilance
~ Sleep disturbances
~ Flashbacks
~ Numbing
~ Withdrawal

Collaboration and Empowerment
~ Creating Meaning
~ Play it out…
~ Trigger identification and modification
~ Red flags & green flags
~ Systematic Desensitization
~ Narrative therapy written or charted
~ Broken pot

Cultural and Peer Resources
~ Involve cultural supports
~ Faith healers, pastors
~ Colleagues
~ Identify peer-based resources (specialty groups)
~ Family/support therapy

Responding without Retraumatizing
~ Building resiliency and preventing vulnerabilities
~ Challenging Questions
~ Facts for and against?
~ Emotional or factual reasoning?
~ Is there a high or low probability that your belief is or will be true?
~ What else contributed to the situation?
~ Are you catastrophizing or using all or nothing thinking?

Summary
~ Create safety and develop trust through the use of
~ Cultural resources
~ Peer support
~ Transparency
~ Collaboration and empowerment
~ To
~ Explore events, experiences and effects
~ Respond in a way to help people live a rich and meaningful life without retraumatizing them
~ Ask yourself if any intervention is disempowering, nontransparent, or could be triggering in any way.
~ Inform clients before the intervention of the potential benefits and effects

Nov 23 2018

58mins

Play

352 -Attachment Issues in Counseling

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Attachment Theory: Implications for Treatment
Instructor: Dr. Dawn-Elise Snipes
Executive Director, AllCEUs Counselor Education

CEUs are available at https://www.allceus.com/member/cart/index/product/id/958/c/  

In Australia, the professional development course is located at  https://australia.allceus.com/member/cart/index/product/id/958/c/  

Objectives
~ Review Attachment Theory
~ Identify stages of distress
~ Discuss the benefits of secure attachment
~ Explore the effects of insecure attachment
~ Learn about different attachment styles and their associated problems
~ Hypothesize interventions to create secure attachment regardless of age.

Infancy and Attachment
~ Attachment
~ Attachment is the quality of the relationship with the caregiver characterized by trust, safety and security.
~ The quality of the infant-parent attachment is a powerful predictor of a child’s later social and emotional outcome
~ Determined by the caregiver’s response to the infant when the infant’s attachment system is ‘activated’
~ Beginning at six months old, infants come to anticipate caregivers’ responses to their distress and shape their own behaviors accordingly (eg, developing strategies for dealing with distress when in the presence of that caregiver)
~ Sensitive, Responsive, Loving = Secure
~ Insensitive, Rejecting or Inconsistent = Insecure
Attachment cont…
~ The primary attachment figure remains crucial for approximately the first two years of life
~ Forming this attachment is almost useless if delayed until after two and a half to three years
~ If the attachment figure is broken or disrupted between ages 1 and 5, the child may suffer irreversible long-term consequences.
~ Bifulco (1992) Women who had lost their caregiver through separation or death doubled their risk of depressive and anxiety disorders. The rate of depression was the highest in women whose caregivers had died before the child reached the age of 6.
Internal Working Model
~ Children’s attachment with their primary caregiver leads to the development of an internal working model which guides future interactions with others.
~ 3 main features of the internal working model
~ a model of others as being trustworthy
~ a model of the self as valuable
~ a model of the self as effective when interacting with others
Adult Attachment
~ Adult attachment style refers to systematic patterns of expectations, beliefs, and emotions concerning the availability and responsiveness of close others during times of distress
~ Often among multiple people with one primary attachment
~ Provide a bidirectional attachment relationship which provides adults with a secure base that they are able to depend on a daily basis.

Attachment
~ Psychological problems can increase attachment insecurity.
~ Davila et al found that late adolescent women who became less securely attached over periods of 6 to 24 months were more likely than their peers to have a history of psychopathology
~ Among soldiers with PTSD Attachment anxiety and avoidance increase over time, and the increases are predicted by the severity of PTSD symptoms

Three Progressive Stages of Distress

~ Protest: The child cries, screams and protests angrily when the caregiver leaves. They will try to cling on to the caregiver to stop them leaving.
~ Despair: The child’s protesting begins to stop, and they appear to be calmer although still upset. The child refuses others’ attempts for comfort and often seems withdrawn and uninterested in anything.
~ Detachment: If separation continues the child will start to engage with other people again. They will reject the caregiver on their return and show strong signs of anger.
Effects of Secure Attachment
~ Learn basic trust, which serves as a basis for all future emotional relationships
~ Develop fulfilling intimate relationships
~ Maintain emotional balance
~ Feel confident and good about themselves
~ Enjoy being with others
~ Rebound from disappointment and loss
~ Share their feelings and seek support
~ Explore the environment with feelings of safety and security, which leads to healthy intellectual and social development

Effects of Secure Attachment cont…
~ Develop the ability to control behavior, which results in effective management of impulses and emotions
~ Create a foundation for the development of identity, which includes a sense of capability, self-worth, and a balance between dependence and independence
~ Establish a moral framework that leads to empathy, compassion, and conscience
~ Generate a core set of beliefs
~ Provide a defense against stress and trauma

Effects of Secure Attachment in Adults
~ Securely attached adults tend to:
~ Have positive views of themselves, their partners and their relationships.
~ Feel comfortable with intimacy and independence, balancing the two.
~ Exchange support within their inner circle or secure relationships. (respect, encouragement, confiding, reassurance, sick care, talking about one's health, and things that worry or upset them)
Insecure Attachment
~ Attachment insecurity can be viewed as a general vulnerability to mental disorders, with the particular symptomatology depending on genetic, developmental, and environmental factors
~ Attachment insecurity has been linked to depression, clinically significant anxiety, obsessive-compulsive disorder post-traumatic stress disorder (PTSD), suicidal tendencies, and eating disorders
~ Lack of parental sensitivity and responsiveness contributes to disorders of the self, characterized by lack of self-cohesion, doubts about one’s internal coherence and continuity over time, unstable self-esteem, and over-dependence on other people’s approval

Effects of Insecure Attachment
~ Bowlby (1988) acknowledged that attachment patterns are difficult to change in adulthood even though it is not impossible
~ According to attachment theory, interactions with inconsistent, unreliable, or insensitive attachment figures
~ Interfere with the development of a secure, stable mental foundation
~ Reduce resilience in coping with stressful life events
~ Increases emotional dysregulation
~ Predispose a person to break down psychologically in times of crisis.
Effects
~ Insecurely attached individuals may be:
~ Less able to manage the distress associated with pain
~ More likely to use emotion-focused rather than problem-focused coping strategies
~ Less able to procure and maintain external supports
~ Less able to form therapeutic alliances
~ Less likely to adhere to treatment recommendations
~ More likely to evoke and perceive more negative responses from health professionals
Anxious Attachment
~ Occurs in relationships in which an attachment figure is sometimes responsive but unreliably so, placing the needy person on a partial reinforcement schedule that rewards persistence in proximity-seeking attempts, because they sometimes succeed.
~ Is associated with
~ Dependent, histrionic, and borderline disorders
~ Covert narcissism, characterized by self-focused attention, hypersensitivity to other people’s evaluations, an exaggerated sense of entitlement
~ Socially destructive outbursts of anger
~ Impulsive, demanding behavior toward relationship partners.

Anxious Attachment
~ People scoring high on attachment anxiety tend to rely on hyperactivating strategies to achieve proximity, support, and love combined with lack of confidence that these resources will be provided and with resentment and anger when they are not provided
~ Hyperactivating strategies represent “fight” responses to unfulfilled attachment needs. The child amplifies proximity seeking strategies to demand or force the caregiver to pay more attention to him/her. when maternal responsiveness appears inconsistent, hesitant, or unpredictable

Adult Attachment
~ Anxious-preoccupied adults
~ Seek high levels of intimacy, approval and responsiveness from partners, becoming overly dependent.
~ Tend to be less trusting
~ Have less positive views about themselves and their partners
~ May exhibit high levels of emotional expressiveness, worry and impulsiveness in their relationships.
~ Have not been able to develop sufficient defenses against separation anxiety. And will then overreact to the anticipation of separation or the actual separation from their attachment figure.
~ Look way too far into things, whether that's a text message or a face-to-face conversation.
~ They often seek a dismissive-avoidant partner.
Avoidant Attachment
~ These strategies develop in relationships with attachment figures who
~ Disapprove of and punish closeness
~ Disapprove of expressions of need or vulnerability
~ Deactivating strategies are used as “flight” reactions from a caregiver who is seen as emotionally unavailable
~ The child learns to hide or suppress the expressions of emotions that the caregiver does not tolerate (anxiety, fear, anger, or needs of consolation) and deals with threats and dangers autonomously, to avoid the frustration caused by maternal unavailability.

Avoidant Attachment
~ Avoidant attachment is associated with schizoid and avoidant disorders.
~ Avoidant attachment is associated with overt narcissism or grandiosity, which includes both self-praise and denial of weaknesses
~ Avoidant individuals often prefer to cordon off emotions from their thoughts and actions, presenting a façade of security and composure, leaving distress unresolved in ways that impair their ability to deal with life’s inevitable adversities.

Adult Attachment Styles
~ Dismissive-avoidant adults
~ Desire a high level of independence, often appearing to avoid attachment altogether.
~ View themselves as self-sufficient and not needing close relationships.
~ Passively avoid relationships when they feel as though they are becoming too close.
~ Suppress their feelings, dealing with conflict by distancing themselves from partners of whom they often have a poor opinion.
~ Have a great amount of distrust in others but a positive model of self
Adult Attachment Styles
~ Dismissive-avoidant adults
~ Cannot be convinced that other people will deliver emotional support.
~ Maintain their positive views of self, based on personal achievements and competence rather than acceptance from others.
~ Dismissive avoidance can also be explained as the result of defensive deactivation of the attachment system to avoid potential rejection, or genuine disregard for interpersonal closeness.
Adult Attachment Styles
~ Fearful-avoidant adults
~ Have mixed feelings about close relationships, both desiring and feeling uncomfortable with emotional closeness.
~ Tend to mistrust their partners
~ View themselves as unworthy.
~ Seek less intimacy
~ Suppressing their feelings.
Interventions
~ “Security priming”, includes subliminal pictures suggesting attachment-figure availability, subliminal names of people designated by participants as security-enhancing attachment figures, guided imagery highlighting the availability and supportiveness of an attachment figure, and visualization of the faces of security-enhancing attachment figures.
~ Security priming improves participants’ moods even in threatening contexts and eliminates the detrimental effects of threats on positive moods

Additional Tidbits
~ Grief and Loss:
~ Anxious attachment was associated with severe shame/guilt
~ Avoidant attachment correlated with complicated grief
~ Pain:
~ Attachment styles characterized by avoidance of emotional expression may predispose individuals to chronic pain conditions
~ Attachment deactivating and hyperactivating strategies contributing to dysregulation of the stress system within the body, and subsequently contributing to pain sensitivity

Additional Tidbits
~ PTSD
~ The relation between PTSD symptoms and attachment anxiety was stronger for individuals with current PTSD symptoms associated with early life traumas compared to individuals with PTSD symptoms linked to adulthood traumas.
~ PPD
~ Attachment style is an additional risk factor for PPD
~ Addictions and ED
~ Strong correlation with insecure attachment

Summary
~ The initial attachment relationship begins at birth
~ There is a critical period between birth and 18 months
~ Anxious attachment is associated with hyperactivating behaviors and maintained by variable reinforcement
~ Avoidant attachment is associated with deactivating behaviors
~ Both types of insecure attachment are associated with problems in mental health, physical health and relationships
~ Chronic pain or mental health issues can both cause insecure attachments and be caused by them
~ Security priming via visualization is one technique that can help clients feel safer and more secure.

Summary
~ Treatment Goals
~ Learn basic trust
~ Have positive views of themselves, their partners and relationships.
~ Maintain emotional balance
~ Feel confident and good about themselves
~ Generate a core set of beliefs and values
~ Feel comfortable with intimacy and independence, balancing the two
~ Exchange support within their inner circle or secure relationships
~ Become resilient
~ Share their feelings and seek support
~ Explore the environment with feelings of safety and security

~ Attachment theory is a lifespan approach that postulates that people are born with an innate motivational system (termed the attachment behavioral system) that becomes activated during times of actual or symbolic threat, prompting the individual to seek proximity to particular others with the goal of alleviating distress and obtaining a sense of security (bowlby, 1982). A cornerstone of the theory is that individuals build cognitive-affective representations, or “internal working models” of the self and others, based on their cumulative history of interactions with attachment figures (bowlby, 1973; bartholomew and horowitz, 1991). These models guide how information from the social world is appraised and play an essential role in the process of affect regulation throughout the lifespan (kobak and sceery, 1988; collins et al., 2004)

~ The majority of research on adult attachment has centered on attachment styles and their measurement (for a review, see mikulincer and shaver, 2007). In broad terms, attachment styles may be conceptualized in terms of security vs. Insecurity. Repeated interactions with emotionally accessible and sensitively responsive attachment figures promote the formation of a secure attachment style, characterized by positive internal working models and effective strategies for coping with distress. Conversely, repeated interactions with unresponsive or inconsistent figures result in the risk of developing insecure attachment styles, characterized by negative internal working models of the self and/or others and the use of less optimal affect regulation strategies (mikulincer and shaver, 2007).

~ Although there is a wide range of conceptualizations and measures of attachment insecurity, these are generally defined by high levels of anxiety and/or avoidance in close relationships. Attachment anxiety reflects a desire for closeness and a worry of being rejected by or separated from significant others, whereas attachment avoidance reflects a strong preference for self-reliance, as well as discomfort with closeness and intimacy with others (brennan et al., 1998; bifulco and thomas, 2013). These styles involve distinct secondary attachment strategies for regulating distress – individuals with attachment anxiety tend to use a hyperactivating (or maximizing) strategy, while individuals with attachment avoidance tend to rely on a deactivating (or minimizing) strategy (cassidy and kobak, 1988; main, 1990; mikulincer and shaver, 2003, 2008). Indeed, previous empirical studies indicate that attachment anxiety is associated with increased negative emotional responses, heightened detection of threats in the environment, and negative views of the self (griffin and bartholomew, 1994; mikulincer and orbach, 1995; fraley et al., 2006; ein-dor et al., 2011). By contrast, attachment avoidance is associated with emotional inhibition or suppression, the dismissal of threatening events, and inflation of self-conceptions (fraley and shaver, 1997; gjerde et al., 2004; mikulincer and shaver, 2007).

~ Neural basis of attachment-caregiving systems interaction: insights from neuroimaging studies.Front psychol. 2015 aug 24;6:1241
~ Bowlby (1969, 1988) proposed that caregiving is the result of an organized behavioral system, which is reciprocal to – and evolved in parallel with – the attachment system (george and solomon, 1996, 1999). The caregiving system aim is to promote proximity and comfort when the caregiver detects internal or external cues associated with situations that she perceives as stressing for the child.
~ The maternal caregiving system undergoes its greatest development during the transition to parenthood (pregnancy, birth, and the post-partum period; ammaniti et al., 2014) with striking structural and functional changes, as a result of the large amounts of hormones secreted (panksepp, 1998; mayes et al., 2005). In particular, of greatest importance is the production of oxytocin which seems to motivate and maintain caregiving behaviors, strengthening maternal sensitivity to infant affective cues (frewen and lanius, 2006; kinsley and lambert, 2006; rilling, 2013; mah et al., 2015).
~ A caregiver’s capacity to regulate her child’s emotions is crucial to his/her ultimate feeling of security (ainsworth et al., 1978; lyons-ruth and spielman, 2004). These processes are sustained by maternal sensitivity, i.e., the ability to understand the infant’s feelings in order to respond to them in an appropriate way (ainsworth, 1967, 1973; ainsworth et al., 1978).
~ When the caregiver proves not to be physically or emotionally available security is not attained and negative representations of the self and the other are formed (e.g., doubts about self-worth and worries about others’ intentions).

~ Depressed parents' attachment: effects on offspring suicidal behavior in a longitudinal family study. J clin psychiatry. 2014 aug;75(8):879-85
~ Insecure avoidant, but not anxious, attachment in depressed parents may predict offspring suicide attempt. Insecure parental attachment traits were associated with impulsivity and major depressive disorder in all offspring and with more severe suicidal behavior in offspring attempters
~ Parent-child attachment and emotion regulation. New dir child adolesc dev. 2015 summer;2015(148):31-45.
~ Insecure attachment during infancy predicts greater amygdala volumes in early adulthood
~ Genetic and environmental influences on adolescent attachment. J child psychol psychiatry. 2014 sep;55(9):1033-41
~ Twin study: Genes may play an important role in adolescent attachment and point to the potentially distinct aetiological mechanisms involved in individual differences in attachment beyond early childhood.
~ Approximately 40% heritability of attachment and negligible influence of the shared environment

~ Annual research review: attachment disorders in early childhood–clinical presentation, causes, correlates, and treatment. J child psychol psychiatry. 2015 mar;56(3):207-22.
~ Reactive attachment disorder (rad) indicating children who lack attachments despite the developmental capacity to form them.
~ Core features of rad in young children include the absence of focused attachment behaviors directed towards a preferred caregiver, failure to seek and respond to comforting when distressed, reduced social and emotional reciprocity, and disturbances of emotion regulation, including reduced positive affect and unexplained fearfulness or irritability.
~ “pathogenic care” in dsm-iv and “parental abuse, neglect or serious mishandling” in icd-10 was replaced by “insufficient care” in dsm-5 in order to emphasize that social neglect that seems the key necessary condition for the disorder to occur

~ Annual research review: attachment disorders in early childhood–clinical presentation, causes, correlates, and treatment J child psychol psychiatry. 2015 mar;56(3):207-22.
~ And disinhibited social engagement disorder(dsed) indicating children who lack developmentally appropriate reticence with unfamiliar adults and who violate socially sanctioned boundaries.
~ Inappropriate approach to unfamiliar adults and lack of wariness of strangers, and a willingness to wander off with strangers. In dsed, children also demonstrate a lack of appropriate social and physical boundaries, such as interacting with adult strangers in overly close proximity (experienced by the adult as intrusive) and by actively seeking close physical contact. By the preschool years, verbal boundaries may be violated as the child asks overly intrusive and overly familiar questions of unfamiliar adults
~ Dsed includes socially disinhibited behavior that must be distinguished from the impulsivity that accompanies adhd
~ Dsed is predictive of functional impairment, difficulties with close relationships, and more need for special education services

~ Lyons-ruth and colleagues (2009), on the other hand, showed that indiscriminate behavior was present in high-risk, family reared infants only if they had been maltreated or if their caregivers had had psychiatric hospitalizations. They also found that caregivers’ disrupted emotional interactions with the infant mediated the relationship between caregiving adversity and indiscriminate behavior
~ Although the majority of maltreated children and children raised in institutions have insecure or disorganized attachments to biological parents or institutional caregivers (carlson et al., 1989; o’connor et al., 2003; vorria et al., 2003; zeanah et al., 2005), most do not develop attachment disorders (boris et al., 2004; gleason et al., 2011; zeanah et al., 2004). This raises the question of vulnerability and perpetuating factors

~ Attachment style predicts affect, cognitive appraisals, and social functioning in daily life. Front psychol. 2015; 6: 296.
~ Participants’ momentary affective states, cognitive appraisals, and social functioning varied in meaningful ways as a function of their attachment style.
~ Those holding a secure style reported greater feelings of happiness, more positive self-appraisals, viewed their current situation more positively, felt more cared for by others, and felt closer to the people they were with individuals with an anxious attachment, as compared with securely attached individuals, endorsed experiences that were congruent with hyperactivating tendencies, such as higher negative affect, stress, and perceived social rejection. By contrast, individuals with an avoidant attachment, relative to individuals with a secure attachment, endorsed experiences that were consistent with deactivating tendencies, such as decreased positive states and a decreased desire to be with others when alone.
~ The findings support the ecological validity of the asi and the person-by-situation character of attachment theory.

~ Attachment style predicts affect, cognitive appraisals, and social functioning in daily life. Front psychol. 2015; 6: 296.
~ Anxious (or preoccupied) attachment is associated with more variability in terms of positive emotions and promotive interactions (a composite measure of disclosure and support; tidwell et al., 1996), lower self-esteem, greater feelings of anxiety and rejection, as well as perceiving more negative emotions in others (kafetsios and nezlek, 2002). In contrast, compared to secure attachment, avoidant (or dismissing) attachment has been associated with lower levels of happiness and self-disclosure (kafetsios and nezlek, 2002), lower perceived quality of interactions with romantic partners (sibley and liu, 2006), a tendency to differentiate less between close and non-close others in terms of disclosure (pietromonaco and barrett, 1997), and higher negative affect along with lower positive affect, intimacy, and enjoyment, predominantly in opposite-sex interactions (tidwell et al., 1996).

~ Infant attachment security and early childhood behavioral inhibition interact to predict adolescent social anxiety symptoms. Child dev. 2015 mar-apr;86(2):598-613
~ Insecure attachment and behavioral inhibition (bi) increase risk for internalizing problems
~ The interaction of attachment and bi significantly predicted adolescent anxiety symptoms, such that bi and anxiety were only associated among adolescents with histories of insecure attachment

~ Negative affect along with lower positive affect, intimacy, and enjoyment, predominantly in opposite-sex interactions (tidwell et al., 1996).
~ Anxious participants approached their daily person-environment transactions with amplification of distress (e.g., higher negative affect, greater fear of losing control, higher subjective stress), decreased positive affect, and greater variability in the experience of negative affect. Anxiously attached participants endorsed more negative and less positive appraisals about themselves
~ Avoidant ones endorsed a stronger preference for being alone when with others and a decreased desire to be with others when alone. Additionally, relative to their secure peers, they tended to approach their person-environment transactions with decreased happiness and less positive views of their situation, but not with amplification of negative states. Avoidant participants also felt less cared for by others and less close to the people they were with. Avoidant individuals also reported more negative views of themselves

~ Manifestation of attachment styles depends on the subjective appraisal of the closeness of social contacts, rather than on the simple presence of social interactions. The finding that it is social appraisals, not simply social contact, that interacts with attachment is compatible with the description of attachment as a “person by situation” interactionist theory
~ The affective states, situation appraisals, coping capacities, and social functioning of the anxious group worsened as closeness diminished; when in the presence of people they do not feel close to, anxious people’s preoccupation with rejection and approval is amplified and this permeates their subjective experiences.
~ Attachment styles predicted individual’s subjective experiences across the range of situations they encountered during the week, and not only those that were interaction-based, suggests that attachment styles are relevant features of personality functioning that have pervasive effects on how individuals experience their inner and outer worlds

~ Attachment classification, psychophysiology and frontal EEG asymmetry across the lifespan: a review. Front hum neuroscience 015 feb 19;9:79.
~ Insecure attachment is related to a heightened adrenocortical activity, heart rate and skin conductance in response to stress, which is consistent with the hypothesis that attachment insecurity leads to impaired emotion regulation. Research on frontal eeg asymmetry also shows a clear difference in the emotional arousal between the attachment groups evidenced by specific frontal asymmetry changes.
Addictions and Eating Disorders
~ Attachment and eating disorders: a review of current research Int j eat disord. 2014 nov;47(7):710-7. Doi: 10.1002/eat.22302. Epub 2014 may 23
~ Those with eating disorders had higher levels of attachment insecurity and disorganized mental states. Lower reflective functioning was specifically associated with anorexia nervosa. Attachment anxiety was associated with eating disorder symptom severity, and this relationship may be mediated by perfectionism and affect regulation strategies. Type of attachment insecurity had specific negative impacts on psychotherapy processes and outcomes, such that higher attachment avoidance may lead to dropping out and higher attachment anxiety may lead to poorer treatment outcomes
~ Eating disorders in adolescence: attachment issues from a developmental perspective. Front psychol. 2015 aug 10;6:1136
~ The high incidence of the unresolved attachment pattern in eating disorder samples is striking, especially for patients with anorexia nervosa. Interestingly, this predominance of the unresolved category was also found in their caregivers.

Addictions and Eating Disorders
~ A review on attachment and adolescent substance abuse: empirical evidence and implications for prevention and treatment. Subst abuse. 2015;36(3):304-13.
~ Strong evidence for a general link between sud and insecure attachment.
~ Data on connections between different patterns of attachment and sud point to disorganized and externalizing pathways.
~ Evidence suggests that fostering attachment security might improve the outcome

~ Transitions in friendship attachment during adolescence are associated with developmental trajectories of depression through adulthood. J adolesc health. 2016 mar;58(3):260-6.
~ The growth model indicated that adolescents who reported a stable-secure attachment style had lower levels of depression symptoms during adulthood than those individuals who transitioned from secure-to-insecure, from insecure-to-secure, or were in the stable-insecure group. Interestingly enough, individuals in both the attachment transition groups had a faster declining rate of depression symptoms over time compared to the two stability groups.
~ Adolescent insecure attachment as a predictor of maladaptive coping and externalizing behaviors in emerging adulthood. Attach hum dev. 2014;16(5):462-78
~ Qualities of both preoccupied and dismissing attachment organization predicted self-reported externalizing behaviors in emerging adulthood eight years later, but only preoccupation was predictive of close-peer reports of emerging adult externalizing behavior. Maladaptive coping strategies only mediated the relationship between a dismissing stance toward attachment and future self-reported externalizing behaviors.

~ Attachment and health-related physiological stress processes. Curr opin psychol. 2015 feb 1;1:34-39.
~ People who are more securely attached to close partners show health benefits, but the mechanisms underlying this link are not well specified. We focus on physiological pathways that are potential mediators of the connection between attachment in childhood and adulthood and health and disease outcomes. Growing evidence indicates that attachment insecurity (vs. Security) is associated with distinctive physiological responses to stress, including responses involving the hpa, sam and immune systems, but these responses vary with type of stressor (e.g., social/nonsocial) and contextual factors (e.g., partner's attachment style). Taking this more nuanced perspective will be important for understanding the conditions under which attachment shapes health-related physiological processes as well as downstream health and disease consequences.

Postpartum Depression
~ Adult attachment style as a risk factor for maternal postnatal depression: a systematic review. BMC Psychol. 2014 dec 18;2(1):56
~ Attachment and pnd share a common etiology and that ‘insecure adult attachment style' is an additional risk factor for pnd. Of the insecure adult attachment styles, anxious styles were found to be associated with pnd symptoms more frequently than avoidant or dismissing styles of attachment.
~ Perinatal depression and patterns of attachment: a critical risk factor? Depress res treat. 2015;2015:105012
~ Prevalence of “fearful-avoidant” attachment style in perinatal depression group
~ The severity of depression increases proportionally to attachment disorganization; therefore, we consider attachment as both an important risk factor as well as a focus for early psychotherapeutic intervention

PTSD
~ The relation between insecure attachment and posttraumatic stress: early life versus adulthood traumas. Psychol trauma. 2015 jul; 7(4): 324–332.
~ Insecure attachment may be an especially important risk factor for ptsd in older adulthood given the critical role of interpersonal relationships to well-being among older individuals
~ Results showed that higher attachment anxiety and avoidance predicted greater ptsd symptom severity after controlling for other individual difference measures associated with elevated ptsd symptoms including neuroticism and event centrality.
~ A significant interaction between the developmental timing of the trauma and attachment anxiety revealed that the relation between ptsd symptoms and attachment anxiety was stronger for individuals with current ptsd symptoms associated with early life traumas compared to individuals with ptsd symptoms linked to adulthood traumas.
~ Individuals with greater attachment anxiety reported stronger physical reactions to memories of their trauma and more frequent voluntary and involuntary rehearsal of their trauma memories. These phenomenological properties of trauma memories were in turn associated with greater ptsd symptom severity
~ Factors underlying the relation between attachment anxiety and ptsd symptoms vary according to the developmental timing of the traumatic exposure
~ Percentage of variance in ptsd symptoms explained by insecure attachment doubled among older adults with current ptsd symptoms related to early life traumas compared to those who reported symptoms linked to traumas encountered in adulthood.

PTSD
~ The relationship between adult attachment style and post-traumatic stress symptoms: a meta-analysis. J anxiety disord. 2015 oct;35:103-17
~ Adult attachment plays a role in the development and perseverance of symptoms of posttraumatic stress disorder (ptsd)
~ Attachment categories comprised of high levels of anxiety most strongly related to ptsd symptoms, with fearful attachment displaying the largest association
~ Interpersonal trauma, attachment insecurity and anxiety in an inpatient psychiatric population.J anxiety disord. 2015 oct;35:82-7
~ Interpersonal trauma has an impact on insecure attachment and anxiety
~ Attachment may play a mediating role between traumatic events and psychopathology
~ Interpersonal trauma was correlated to attachment avoidance but not to attachment anxiety

Personality Disorders
~ Attachment and social cognition in borderline personality disorder: specificity in relation to antisocial and avoidant personality disorders. Personal disord. 2015 jul;6(3):207-15
~ Attachment insecurity is believed to lead to chronic problems in social relationships, attributable, in part, to impairments in social cognition, which comprise maladaptive mental representations of self, others, and self in relation to others. However, few studies have attempted to identify social-cognitive mechanisms that link attachment insecurity to bpd and to assess whether such mechanisms are specific to the disorder. For the present study, empirically derived indices of mentalization, self-other boundaries, and identity diffusion were tested as mediators between attachment style and personality disorder symptoms. In a cross-sectional structural equation model, mentalization and self-other boundaries mediated the relationship between attachment anxiety and bpd. Mentalization partially mediated the relationship between attachment anxiety and antisocial personality disorder (pd) symptoms, and self-other boundaries mediated the relationship between attachment anxiety.
Personality Disorders
~ Lower oxytocin plasma levels in borderline patients with unresolved attachment representations. Front hum neurosci. 2016 mar 30;10:125
~ BPD patients with unresolved (disorganized) attachment representations had baseline OT plasma levels which were significantly lower than in bpd patients with organized attachment representations
~ Altered OT regulation in bpd as a putative key mechanism underlying interpersonal
Personality Disorders
~ Adult attachment ratings (aar): an item response theory analysis J pers assess. 2014 jul-aug; 96(4): 417–425
~ One of the major goals in our own research on pds has been to investigate the reciprocal relationships between interpersonal attachments and emotion regulation, especially in patients with borderline personality disorder (bpd). Our general hypothesis is that many of the interpersonal behaviors of persons with bpd can be understood as frustrated (and frustrating) bids for attachment as they cope with frequent episodes of emotion dysregulation. These attempts at coping result in self-defeating efforts to secure the usual provisions of attachment—a secure base in general and a safe haven in times of acute distress, reflected in proximity-seeking to attachment figures and separation distress when apart.
~ Document the importance and specificity of problems in attachment for patients with bpd
Grief
~ The nature of attachment relationships and grief responses in older adults: an attachment path model of grief. Plos one. 2015 oct 13;10(10):e0133703.
~ Higher levels of avoidant attachment reported less emotional responses and less non-acceptance.
~ Individuals who reported higher levels of anxious attachment reported greater emotional responses and greater non-acceptance.
~ These relationships were mediated by yearning thoughts.
~ Grief therapy may be organized according to individual differences in attachment representations.

Grief
~ Attachment styles, grief responses, and the moderating role of coping strategies in parents bereaved by the sewol ferry accident Eur j psychotraumatol. 2017; 8(sup6): 1424446.
~ Anxious attachment was associated with severe shame/guilt, and avoidant attachment correlated with complicated grief. Anxious attachment was positively associated with all types of coping strategies, and avoidant attachment was negatively related to problem- and emotion-focused coping. The use of problem-focused coping strategies was a significant moderator of the relationship between the avoidant attachment dimension and shame/guilt. Avoidant attachment had a significant effect on shame/guilt in groups with a high level of problem-focused coping. In contrast, none of the coping strategies significantly moderated the relationship between anxious attachment and grief response.
~ The results suggest that people with highly avoidant attachment might be overwhelmed by shame and guilt when they try to use problem-focused coping strategies.

Chronic Pain
~ Attachment and chronic pain in children and adolescents. Children (basel). 2016 dec; 3(4): 21
~ It has been proposed that an individual’s characteristic attachment behaviors are likely to be activated as a result of an illness or threat. Illness, and arguably pain, may trigger an increased need for security and the wish for a close, caring other. This may be an adaptive response within the context of an injury or acute pain. However, in the context of chronic pain this can result in a range of complex and difficult behavioral interactions.
~ Attachment styles characterized by avoidance of emotional expression (e.g., insecure-avoidant, dismissing and fearful styles, or type a attachment strategy) may predispose individuals to chronic pain conditions [35]. Children with this attachment style may have parents who respond to expressions of negative affect, including pain, by either withdrawing from their child or responding with displeasure or anger [35]. Children learn to inhibit verbal or nonverbal signs of distress, because they have found these to serve no useful protective function [23].

Chronic Pain
~ Attachment styles that are defined by excitatory self-protective mechanisms (i.e., insecure-ambivalent, preoccupied or type c attachment strategies) are also likely to have implications for pain experiences. Children with this style may have parents who respond unpredictably. Consequently, the child may alternate between signaling various exaggerated expressions of negative affect (e.g., fear, anger, desire for comfort), with the aim of trying to get their unpredictable parent to respond [35]
~ Attachment deactivating and hyperactivating strategies contributing to dysregulation of the stress system within the body, and subsequently contributing to pain sensitivity.
~ In certain circumstances, the attachment figure in this caregiving environment may tolerate pain (owing to it being understood as a physical symptom) as an acceptable signal of distress compared to fear, anger or sadness [46]. In these circumstances, signaling of pain may elicit a caregiving response serving to reinforce the behavior for any experienced distress
Chronic Pain
~ Meredith et al.’s [53] attachment-diathesis model of chronic pain, attachment-related primary appraisals of pain interact with secondary appraisals of the self (as equipped or not to cope; worthy or not of social support [56]) and of others (as available and adequate to provide effective support [57]) [52]
~ Insecurely attached individuals may be: (1) less able to manage the distress associated with pain; (2) more likely to use emotion-focused rather than problem-focused coping strategies; (3) less able to procure and maintain external supports; (4) less able to form therapeutic alliances; (5) less likely to adhere to treatment recommendations; or (6) more likely to evoke and perceive more negative responses from health professionals [53]
~ The process of actively seeking support inherently relies on an individual’s comfort with closeness to others, the belief that the self is worthy of support and that others are available t
~ There are three possible treatment targets in attachment-based treatments with adolescents: (1) modifying the adolescent’s internal working model of self or others (especially their caregiver); (2) modifying the caregiver’s internal working model of self or others (especially their adolescent); and (3) promoting emotionally attuned communication between the caregiver and adolescent [80]o provide it [63]
~ The caregiver’s ability to maintain a cooperative partnership with an adolescent is likely to be dependent on the caregiver’s ability to monitor their own emotions, clearly asserting their own positions, while validating and supporting the adolescent’s attachment and autonomy needs [79]

Depression
~ Emotion regulation as a mediator in the relationship between attachment and depressive symptomatology: a systematic review. J affect disord. 2015 feb 1;172:428-44
~ Emotion regulation is a mediator between attachment and depression. Hyperactivating strategies, in particular, have been consistently noted as mediators for anxious attachment and depressive symptomatology, whereas evidence for deactivating strategies as mediators between avoidant
~ Attachment based treatments for adolescents: the secure cycle as a framework for assessment, treatment and evaluation. Attach hum dev. 2015;17(2):220-39
~ Cyclical processes that are required to maintain a secure attachment bond. This secure cycle incorporates three components: (1) the child or adult's iwm of the caregiver; (2) emotionally attuned communication; and (3) the caregiver's iwm of the child or adult

Jan 04 2019

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283 -Cognitive Interventions for Depression

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Based on Doc Snipes' upcoming book 100+ Practical Tools to Defeat Depression. Read the whole book for FREE with Amazon Kindle Unlimited

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Cognitive Interventions
Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs Counseling Education
Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery

Objectives
~ Define cognitive interventions
~ Explore activities to address
~ Perceptions
~ Attributions and Locus of Control
~ Cognitive Distortions
~ ABCs
~ Shoulds
~ Optimism and Cognitive Restructuring
~ Affirmations
~ Time Management
~ Goals Setting

Overview
~ Cognitive interventions are things you do to change how you think about things
~ Is the glass half full? Is it partly sunny?
~ Is this really important to having a rich and meaningful life?
~ What is the yang to this yin?
~ How can this make me stronger, or what can I learn?

Question
~ How do you help clients recognize the impact of their thoughts on their mood?

Perceptions
“Life is 10% reality and 90% what you make of it.”
~ Your past experiences created your schemas
~ Dog charging the fence barking
~ Flying
~ Angry faces
~ Creaking floorboards
~ Individual activity: Coin flip
~ Group activity:
~ On a beachball write 20 things that can be irritating or scary
~ Toss the beachball to a group member. They have to find at least one optimistic or non-threatenting way to look at whatever item they see when they look down at the ball
~ Repeat…

Attributions and Locus of Control

~ Attributions are how you perceive things
~ Internal vs. External
~ Locus of control is where you perceive that your life is controlled from.
~ Do you control your own destiny (internal locus) or does everything just happen to you (external locus)?
~ Which is better?
~ Global or specific.
~ Give examples
~ Stable or changeable
~ Give examples
~ Dialectics: There is nearly always good and bad in everything.
Attributions and Locus of Control

~ Activity
~ Apply those principles to the following statements
~ I believe that I control my own destiny
~ I blame other people for making me unhappy.
~ When I fail at something it means I am stupid
~ I am depressed
Cognitive Distortions
~ What are they?
~ Arbitrary inference: Making assumptions without all the facts
~ Selective abstraction: Only seeing what you want (or don’t want) to see
~ Over generalization: Generalizing things about one situation to all similar situations
~ Magnification and exaggeration: Blowing something out of proportion
~ Personalization: Feeling like everything is your fault or a personal attack.
~ Polarized thinking: All-or-nothing.
~ Activities
~ Individual: Examine current stressors for cognitive distortions
~ Group: Define and identify interventions; Flip chart stations; Apply the solution

Cognitive Distortions Emergency Card
~ Do I have all the facts?
~ Am I seeing the whole situation?
~ Am I using moderate words like sometimes, occasionally or often?
~ Am I making sure not to devote too much attention and energy to something that really won’t matter in a few days or weeks?
~ Have I considered possible explanations besides it being all about me?

ABCs
~ The basic structure is as follows: Fill in “A” activating event and “C” consequence first.
~ A= Activating event or the stimulus (What happened?)
~ B= Your automatic (and often unrealized unhelpful Beliefs)
~ C= The consequence of those beliefs (What was your reaction?)
~ D= Determine if your beliefs and your consequences are rational/constructive.
~ E= Evaluate whether the situation is worth the energy of continuing the reaction
~ Activity (Individual= worksheet, Group= Discussion or Belief stations)
~ Have each person share something that makes them happy or proud, and apply the ABCs
~ Have each person share something that makes them angry or afraid and apply the ABC-DEs

Who Says? Addressing Shoulds & Shouldn’ts
~ People can be miserable because they are doing, feeling and thinking the way they think they “should.”
~ When kids are about 2, they go through the “Why?” phase, and most of the time what they hear is “…because I said so!” or “That’s just the way it is.” This teaches them to not think, just to be passive receptacles of information.
~ Activities
~ Brainstorm a list of should and apply the following questions
~ Should: I should keep a clean house at all times, so people do not look down on me.
~ Who Said: My mother
~ Alternate belief (if any)? A clean house is not the ultimate priority, and needs to be balanced with other life demands.

Optimism and Cognitive Restructuring

~ Optimism is way of changing the perception of a situation.
~ Activity: Describe the day
~ Process how the person feels after being (optimistic/pessimistic) and how the GROUP feels after hearing it
~ Worry and regret are two by-products of pessimism that drain your energy, but serve no functional purpose.
~ Activity (Stations, Beach Ball, Jenga, Pass the Hat)
~ Worry
~ Restatement
~ Regret
~ Restatement
Affirmations
~ Affirmations are positive statements that encourage you to feel empowered and optimistic.
~ I am…
~ I can…
~ I will… / I choose…
~ Examples
~ I’m allowed to take up space.
~ My past is not a reflection of my future.
~ I am smart enough to make my own decisions.
~ I’m in control of how I react to others.
~ I choose peace.

Affirmations
~ Activities
~ Affirmation journal
~ Online affirmation research
~ Affirmation envelope pass (you are, you can, you will)
~ Start each group with a positive affirmation sign in… “It was a tough day, but I made it…” “I am grateful that…”

Time Management
~ Time management seems to be one of the most elusive and devastating of all the coping skills.
~ When you don’t manage your time well, it can lead to poor evaluations at work, friends getting mad at you or failing to take care of something important.
~ How does poor time management affect your life? Your relationships?
~ When you are distressed because you have too many things to do and not enough time, how does it affect you? Do you feel exhausted? Overwhelmed? Powerless?
Time Management
~ Activity
~ Describe the different time management styles and group people accordingly
~ Give them a written description of the characteristics of that style and have them brainstorm solutions
~ Type A
~ Time Juggler
~ Procrastinator
~ Perfectionist
~ Eager to Please
~ Activity
~ Eliminate, Delegate, Combine, Simplify and Prioritize
~ Have someone share their weekly to-dos
Goal Setting
~ Must be purposeful
~ Must be motivated
~ Practice using a decisional balance exercise
~ Benefits of staying the same
~ Drawbacks to change
~ Benefits of change
~ Drawbacks to staying the same
Goal Setting
~ The change I want to make is…
~ Be specific. Include goals that are positive (wanting to increase, improve, do more of something), and not just negative goals (stop, avoid).
~ My main reasons for making this change are…
~ What are the likely consequences of action or inaction?
~ Which motivations for change are most compelling?
~ The first steps I plan to take in changing are…
~ When, where, and how will the steps be taken?
~ Some things that could interfere with my plan are…
~ How will I stick with the plan despite these particular problems or setbacks?
~ Other people could help me in changing in these ways…
~ I will know that my plan is working when…

Summary
~ The way people think and perceive situations has a huge impact on how they feel
~ Helping people embrace the dialectics can help them feel more positive and empowered
~ Just like it is imperative to add happy emotions, it is imperative to add happy thoughts as well
~ By practicing optimism and addressing unhelpful thoughts people can reduce their overall stress, sleep better, gain more energy and feel less hopeless and helpless (depressed).

Jul 18 2018

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Cognitive Behavioral Interventions for PTSD

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411 -Cognitive Behavioral Interventions for PTSD
CEUs available at: https://www.allceus.com/member/cart/index/product/id/1100/c/

Dr. Dawn-Elise Snipes, PhD, LPC-MHSP
Executive Director, AllCEUs Counselor Education
Podcast Host: Counselor Toolbox Podcast, Case Management Toolbox Podcast

Objectives
– Review the symptoms of PTSD
– Explore interventions in the following areas
– Cognitive: Including ACT, DBT and CPT
– Behavioral: Including exercise, sleep, nutrition and relaxation

PTSD Symptoms
– Re-experiencing the traumatic event (Intrusion)
– Intrusive, upsetting memories of the event
– Flashbacks
– Nightmares
– Feelings of intense distress when reminded
– Intense physical (panic) reactions to reminders

– PTSD symptoms of avoidance and emotional numbing
– Avoiding reminders of the trauma
– Inability to remember important aspects of the trauma
– Loss of interest in activities and life in general
– Feeling detached from others or emotionally numb
– Sense of a limited future

PTSD Symptoms
– PTSD symptoms of increased arousal
– Difficulty falling or staying asleep
– Irritability or outbursts of anger
– Difficulty concentrating
– Hypervigilance (on constant “red alert”)
– Feeling jumpy and easily startled

– Negative alterations in cognitions and mood
– Inability to recall key features of the trauma
– Overly negative thoughts and assumptions about oneself or the world
– Exaggerated blame of self or others for causing the trauma
– Negative affect
– Decreased interest in activities
– Feeling isolated

What Happens in Trauma
– When exposed to a stressor, the HPA-Axis and amygdala are activated and cortisol is released to trigger the fight or flight response
– Sustained exposure to cortisol has an adverse impact on the hippocampus resulting in reduction of neurogenesis and dendritic branching
– Blunted response to cortisol stimulation indicate that pituitary receptors in the HPA-Axis have been downregulated in patients with PTSD
– Hypocortisolism in PTSD occurs due to increased negative feedback sensitivity of the HPA axis
Neurochemical Effects of Trauma
– Early adverse experience, including prenatal stress and stress throughout childhood, has profound and long-lasting effects on the development of neurobiological systems, thereby “programming” subsequent stress reactivity and vulnerability to develop PTSD
– The hippocampus (learning and memory) and prefrontal cortex(impulse control and higher-order thought) mediate the HPA-Axis activity…but…
– Reduced volume of the hippocampus, the major brain region inhibiting the HPA axis, is a cardinal feature of PTSD
Neurochemical Effects of Trauma
– Hypocortisolism is thought to be an autoimmune response.
– Physical and psychological stress has been implicated in the development of autoimmune disease
– Hypocortisolism may occur after a prolonged period of hyperactivity of the hypothalamic-pituitary-adrenal axis due to chronic stress
– The phenomenon of hypocortisolism has been reported not only for people with PTSD, but also for healthy individuals living under conditions of chronic stress emotional and/or physical stress.
– Hypocortisolism dysfunction at the time of exposure to psychological trauma may predict the development of PTSD.
Neurochemical Effects of Trauma
– Glucocorticoids (Cortisol) interfere with the retrieval of traumatic memories, an effect that may independently prevent or reduce symptoms of PTSD.
– Therefore, hypocortisolism might be a risk factor for maladaptive stress responses and predispose to future PTSD or stress-related bodily disorders.
– Simulation of a normal circadian Cortisol rhythm using exogenously introduced hydrocortisone is effective in the treatment of PTSD.
Neurochemical Effects of Trauma
– Core neurochemical features of PTSD include abnormal regulation of dopamine and norepinephrine, serotonin and opioid neurotransmitters, each of which is found in brain circuits that regulate/integrate stress and fear responses
– A cardinal feature of patients with PTSD is sustained hyperactivity of the autonomic nervous system, as evidenced by elevations in heart rate, blood pressure, and other psychophysiological measures
– Patients with PTSD exhibit increased heart rate, blood pressure, and NE responses to traumatic reminders sustaining the stress response even in nonthreatening situations.
Neurochemical Effects of Trauma
– Chronic exposure to stressors induces upregulation of 5HT2 and downregulation of 5HT1A receptors in animal models and downregulation of HPA-Axis response to acute stressors.
– 5HT2: Anxiety, Appetite, Cardiovascular Function, GI Motility, Alertness/sleep, Vasoconstriction (Atypical antipsychotics, sleep aids)
– 5HT transmission may contribute to symptoms of PTSD including hypervigilance, increased startle, impulsivity, and intrusive memories

Healing the Body and the Brain.
– Hypocortisolism is a key feature in PTSD
– Hypocortisolism results from an autoimmune reaction
– Autoimmune reactions are triggered or worsened by stress
– People with PTST may have excesses of dopamine, norepinephrine and insufficient serotonin at the HT1 receptor
– Cognitive behavioral treatment goals would be aimed at reducing physical and psychological stress including
– Improving nutrition
– Reducing stimulant exposure
– Improving sleep
– Addressing cognitive issues that maintain the stress response

Behavioral
– Sleep
– Nutrition
– Hydration for cellular function
– Exercise for oxygenation and increases in Serotonin 5HT1
– Eliminate unnecessary stressors
– Do things that you enjoy (relax) and laugh often.
– Laughter boosts the immune system and reducing dangerous stress hormones in the body.

Behavioral
– Environmental Grounding
– Use Feng Shui principles to eliminate unnecessary stress (feeling trapped, getting startled)
– Keep a light with a red light bulb (or yellow if red is a trigger) by the bed
– If a nightlight is needed, ensure it is no more than 5 watts and is yellow or red to minimize disruption to circadian rhythms
– Get a dog (Emotional support animal)

Cognitive
– Understanding
– When people see how their symptoms make sense, it is easier to deal with them
– Avoidance
– Hypervigilance
– Intrusion
– Negativity
– Many people who experience trauma have difficulty integrating that trauma into their schema so they get stuck in a fear (I told you so)-loop
Telling Their Story
– Clients often need to tell their story
– It is very difficult to relive that experience while looking someone else in the eye and sitting still.
– Ensure the client has something to focus on.
– Bouncing a tennis ball against the wall or a basketball with you.
– Some people prefer to swing and look at an object like a windchime
– Some prefer be doing something they enjoy like cooking, exercising
– Make sure the client feels safe
– Continually use past-tense words and reaffirm for the client they are safe in the present
– That was overwhelming for you at that age.
– When you were deployed you were constantly on edge
Then and Now
– Help clients identify how they are different/less vulnerable now.
– Help clients identify the ways the trauma changed
– How they feel about others (strangers, family, kids)
– How they feel about themselves
– Their outlook
– Help them address any cognitive distortions by
– Finding the exception
– Getting the facts
Cognitive Distortions

– Evaluate how thinking errors can play into basic fears: Rejection, isolation, the unknown, loss of control, failure
– Mindreading (F)
– I can tell that person is dangerous/wants to hurt me
– All-or-Nothing/Polarized (E)
– I will never feel safe again
– Catastrophizing (F)
– My life is over. I am ruined.
– Overgeneralization (E)
– People like that are dangerous/want to hurt me
– Shoulds (F)
– I should have known
– Recency/Availability Heuristic (F)
– It is not safe to be in parking garages/high rises/festivals….

Constructive Self-Talk
– Help clients develop survivor scripts
– Button pins, collage, ribbon tree
– I should have –> I did the best I could
– I am broken – I am changed AND lovable/stronger
– I am weak –> I survived things not everyone has to experience
– I am
Tree Metaphor
Logging

– Keeping a log of flashbacks/startle responses
– When they occurred
– What triggered it (if known)
– Intensity on a scale from 1-5
– Sleep the prior night
– Amount of caffeine/alcohol/nicotine in the preceding hours
– Prior stressors that day
– Use logging to
– Chart the reduction in frequency and/or intensity of intrusive or hypervigilant symptoms
– Identify triggers or vulnerabilities for flashbacks or startle responses
ABC-DEF
– Effective for anxiety, negativity
– Activating Event (What happened)
– Beliefs
– Obvious
– Negative self-talk/Past tapes
– Consequences
– Dispute Irrational Thoughts
– Evaluate the Most Productive Outcome
– Is this worth my energy-
– How can I best use my energy to deal with or let go of the situation-
Systematic Desensitization (Intrusion)

– Identify a feared situation (Being at home alone during the day)
– Imagine it
– Rate your anxiety on a scale from 1-5
– Use deep breathing, grounding/mindfulness skills until you can imagine it and not feel bothered
– Do something a little more anxiety provoking. (Being at home alone for 10 minutes after everyone leaves in the morning)…
– Stay home alone during the day for 30 minutes when your neighbor/friend
– Stay home alone during the day for 1 hour
– Stay home alone until it gets good and dark
– Stay home alone after dark
– Go to sleep when you are home alone
Dialectical Behavior Therapy

– Effective for anxiety, negativity, withdrawal/avoidance, intrusion
– Preventing vulnerabilities (Behavioral)
– Mindfulness
– To prevent vulnerabilities
– To prevent or mitigate triggers (i.e. grounding)
– Distress is inevitable
– Develop Distress Tolerance skills
– Urge surfing
– Activities, Comparisons, Contributing, Emotions, Pushing Away, Sensations
– Imagery, Meaning, Prayer, Relaxation, One Thing, Vacation, Encouragement
– Embracing dialectics
Acceptance and Commitment Therapy

– Effective for anxiety, negativity, withdrawal/avoidance, intrusion
– Acceptance– It is what it is
– Fusion with thoughts– I am having the thought that…
– Define goals and values
– Choose purposeful action
– Live in the And…

Cognitive Processing Therapy

– Effective for anxiety, negativity, withdrawal/avoidance
– Facts for and against
– Is your belief based in facts, emotions or habit-
– Are you using cognitive distortions*-
– Are you focusing on only one aspect of the event-
– Are you confusing high and low probability-
– Are you focusing on irrelevant factors-
– Is this thought getting you closer to what you want-
– What are the advantages/disadvantages to thinking this way-
– What difference will this make in a month/year-

Summary
– Trauma impacts the person biopsychosocially
– Behavioral interventions can help them prevent and address avoidance and hypervigilance
– Cognitive interventions can help them
– Understand the function of their symptoms to choose effective ways of dealing with them
– Address unhelpful cognitions about the trauma, themselves and the world
– Reduce chronic stress to help the HPA-Axis rebalance and recover
– Assist in integrating the trauma narrative so it is not a “loose end.”

Jul 31 2019

58mins

Play

294 -Teaching Clients How to Enhance Motivation | Journey to Recovery Series

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This podcast episode is based on Journey to Recovery: A Comprehensive Guide to Recovery from Mental Health and Addiction Issues by Dr. Dawn-Elise Snipes  Read it for free on Amazon Kindle Unlimited.

Journey to Recovery Series
Enhancing Motivation
Presented by: Dr. Dawn-Elise Snipes Executive Director, AllCEUs
CEUs are available at https://www.allceus.com/member/cart/index/product/id/924/c/
Objectives
~ Define motivation
~ Explore the various types of motivation
Definition
~ Motivation is a combination of desire, willingness and ability. It is your ability to keep your eye on the destination, and choose to do things that move you closer to that end point, instead of detouring you
~ Have you ever accomplished something you were not motivated to do?
~ What was it?
~ How did you get yourself motivated?

5 Principles of Motivation
~ Motivation is a key to change.
~ Motivation and people are multidimensional
~ Motivation is dynamic and fluctuating.
~ Motivation is influenced by social interactions.
~ Motivation can be modified.
Motivational Process
~ Motivation involves:
~ Recognizing that something needs to be done
~ Identifying the benefits to getting it done
~ Addressing the drawbacks to doing it
~ Creating a plan
~ Implementing that plan

Crisis Causes Change
~ Think about a goal you achieved, and complete the following exercise
~ What did you want to change?
~ Why did you want to change it (the crisis)
~ What was uncomfortable about the change (the other crisis)
~ Why was it worth the effort?

Types of Motivation
~ Mental Motivators: Wanting to get out of the fog, believing you can do it
~ Emotional Motivators: Depression, anxiety, panic, PTSD
~ Environmental Motivators: Reducing the tension, more money to improve my environment
~ Physical Motivators: Pain, illness, discomfort, fear of contracting a disease
~ Social Motivators: What friends and family want, what you need to do to be accepted, availability of friends, wanting to set a good example for kids
~ Occupational Motivators: Fear of losing a job, desire for a promotion, frustration at own poor work performance.

Dimensions of Motivation (MEEPS)
~ How is your “issue” impacting:
~ Your ability to think and concentrate? (Mental)
~ Your mood? (Emotional)
~ Your environment reflects how you feel inside. What is it telling you? (Environmental)
~ Your physical health (including sleep and nutrition)?
~ Your relationships? (social)
~ Your work (including your work product, desire to go to work and sick days)?

Activity
~ Part of getting motivated is to understand the benefits and drawbacks of the old behavior and the new behaviors.
~ Example:
~ I want to start eating better.
~ Benefits…
~ Drawbacks
~ Solutions to Drawbacks…
~ If I decide to NOT change my eating habits
~ Benefits…
~ Solutions/Alternative ways to meet the same needs…
~ Drawbacks…
Stages of Change
~ Precontemplation
~ Contemplation
~ Preparation
~ Action
~ Maintenance
Precontemplation
~ Reluctant precontemplators do not have sufficient knowledge or awareness about the problem, or the personal impact it is having, to think change is necessary.
~ How is your addiction and/or mental health issue impacting you and your family?
~ Rebellious precontemplators are afraid of losing control over their lives.
~ What things are making you feel forced into recovery or change?
~ How can you reframe those things, so you feel less angry/annoyed ?
~ What can you do to make the best of this situation?
~ Resigned precontemplators feel hopeless about change and overwhelmed by all of the energy required.
~ Identify all the times you have tried to change and been successful, even if only for a day.

Contemplation
~ Accept that it is normal to be ambivalent
~ “Tip the decisional balance scales” toward change by eliciting and weighing the pros and cons of substance use and change.
~ Visualizing Change
~ GOD collages
~ Drawbacks to staying the same
~ Pretend you have built this awesome community called Recovery Place. It has everything people need to be happy and healthy in its’ walls (doctors, grocery, housing, recreation, support, jobs…). You are selling houses in Recovery Place and have to convince people to buy. Why is it worth the money now? What kind of returns can people expect to see on their investment over time?

Contemplation
~ Visualizing Change cont…
~ Overcoming Obstacles
~ The three things that could take my focus off of my recovery are… I can deal with them by…
~ In the past, when I have tried to stop using, these three things have derailed my recovery. I can prevent this by…
~ The thing I am most afraid of about recovery is… I can deal with it by…
~ The part of recovery I dread the most is… I can deal with it by…

Preparation
~ Clarify goals for change.
~ Create a menu of options for change or treatment
~ Where can people find information
~ Connect with others in recovery
~ Identify and deal with barriers to change.
~ Get a commitment from those close to you to not expose you to triggers
~ Review what has worked in the past for you, or people you know.
~ Plan for handling finances, childcare, work, transportation or other potential commitments. (Why? How?)
~ Publicly announce plans to change in order to help yourself become accountable as well as aware of any inner resistance.
~ Continue to refine your vision of a RML.
~ Write a letter to yourself from the future
Points to Remember

~ Change is a gradual process. Your behaviors helped you survive until you were able to start getting other tools.
~ Focus on your strengths rather than your weaknesses.
~ Develop two or three sober, sane social supports.
~ Before you criticize yourself, ask yourself if you would be as critical of your best friend. You are likely much more critical of yourself than anyone else
~ Recognize that you are a probably addicted to many things, and when deprived of your addiction of choice, may seek out other behaviors to help you escape.
~ Recognize that you may have other coexisting mental health and physical disorders that require attention
~ Anticipate possible family, health, system, and other problems.
~ Identify high-risk situations and develop appropriate strategies to overcome these.

Energy Balance
~ Emotional/Happiness
~ Ways to improve:
~ Ways to reduce stress:
~ Mental/Creativity/ Concentration
~ Ways to improve:
~ Ways to reduce stress:
~ Physical/Pain/Sleep/Nutrition
~ Ways to improve:
~ Ways to reduce stress:
~ Social/Relationships/ Hobbies
~ Ways to improve:
~ Ways to reduce stress:
~ Environmental/Comfort/Organization/Appearance
~ Ways to improve:
~ Ways to reduce stress:

Summary
~ Motivation is Multidimensional
~ Mental
~ Emotional
~ Environmental
~ Physical
~ Social
~ Spiritual
~ It is just as important to understand why a person is motivated to do the current behavior as to understand why he wants to change
~ Part of developing motivation is addressing obstacles and creating a clear destination that is meaningful for the person.

Aug 22 2018

58mins

Play

249 Using a Strengths-Based Approach to Addressing Anxiety

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Using a Strengths-Based Biopsychosocial Approach to Addressing Anxiety
Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs
Objectives
~ Define a strengths based approach
~ Define a biopsychosocial approach

Why I Care/How It Impacts Recovery
~ Anxiety can be debilitating
~ Low-grade chronic stress/anxiety erodes your energy and ability to concentrate
~ Anxiety is a major trigger for:
~ Addiction relapse
~ Increased physical pain
~ Sleep problems
~ Depression
What Does Strengths Based Mean
~ It is easier (and more effective) to build upon something that already works to some extent.
~ Strengths-based approach helps people identify how they are already trying to cope and builds on that
~ There are two types of strengths
~ Prevention/Resilience Strengths
~ What you do on a daily basis to stay healthy and happy
~ Intervention/Coping Strengths
~ In the past when you have felt this way, what helped?
~ What made it worse?
What is a Biopsychosocial Approach
~ Bio-logical
~ Neurochemicals
~ Nutrition
~ Sleep
~ Sunlight & Circadian Rhythms
~ Psycho-logical
~ Mindfulness
~ Distress Tolerance
~ Coping Skills
~ Cognitive Restructuring
What is a Biopsychosocial Approach
~ Social
~ Improving self-esteem and your relationship with self
~ Improving relationships with healthy, supportive others
What is Anxiety
~ Anxiety is half of the “Fight or Flight Response”
~ It is an excitatory response
~ It’s function is to protect you from possible danger (Thank you!)
~ It can become a problem when it is overly intense/uncontrollable because of
~ Overgeneralization
~ Poor coping skills
~ Emotional reasoning and cognitive distortions
~ Biochemical issues (nutrition, hormones)
~ It can be caused by excess serotonin, norepinepherine or glutamate or too little GABA (est. 80% adults have neurochemical imbalance)
~ What is causing the neurochemical imbalance (water heater)

Symptoms of Generalized Anxiety
~ Generalized anxiety disorder symptoms can vary. They may include:
~ Persistent worrying or obsession about small or large concerns that's out of proportion to the impact of the event
~ Inability to set aside or let go of a worry
~ Inability to relax, restlessness, and feeling keyed up or on edge
~ Difficulty concentrating, or the feeling that your mind “goes blank”
~ Distress about making decisions for fear of making the wrong decision
~ Carrying every option in a situation all the way out to its possible negative conclusion
~ Difficulty handling uncertainty or indecisiveness

Symptoms of Generalized Anxiety
~ Generalized anxiety disorder may include:
~ Physical signs and symptoms may include:
~ Fatigue
~ Irritability
~ Muscle tension or muscle aches
~ Trembling, feeling twitchy
~ Being easily startled
~ Trouble sleeping
~ Sweating
~ Nausea, diarrhea or irritable bowel syndrome
~ Headaches

Symptoms of Generalized Anxiety (Kids)
~ Excessive worry about:
~ Performance at school or sporting events
~ Being on time (punctuality)
~ Earthquakes, nuclear war or other catastrophic events
~ A child or teen with GAD may also:
~ Feel overly anxious to fit in
~ Be a perfectionist
~ Lack confidence
~ Strive for approval
~ Require a lot of reassurance about performance

Biological Interventions
~ Your body thinks there is a threat. Figure out why
~ Supportive Care
~ Create a sleep routine
~ Helps the brain and body rebalance
~ Can help repair adrenal fatigue
~ Improves energy level
~ Nutrition
~ Minimize caffeine and other stimulants
~ Try to prevent spikes (and drops) in blood sugar
~ Drink enough water
~ Medication
~ SSRIs/SNRIs
~ Benzodiazepines
~ Buspirone
Biological Interventions
~ Supportive Care cont…
~ Sunlight
~ Vitamin D deficiency has been implicated in some mood issues
~ Sunlight prompts the skin to tell the brain to produce neurotransmitters
~ Sunlight sets circadian rhythms which impact the release of serotonin, melatonin and GABA
~ Exercise
~ Studies have shown that exercise can have a relaxing effect. Start slowly.
Psychological Interventions
~ Mindfulness & Acceptance
~ Observation | Acceptance | Labeling and Letting Go
~ Identify trigger thoughts
~ Differentiate between expectations and current reality
~ Basic Fears
~ Failure
~ Explore the dialectics
~ Encouragement
~ Rejection/Isolation
~ De-personalize
~ Explore the dialectics
~ Loss of Control & The Unknown
~ Focus on one thing in the moment
~ Think of prior experiences
Psychological Interventions
~ Distress Tolerance: It isn’t always about controlling your anxiety
~ Distract don’t react
~ Ride the wave
~ Use distancing techniques–
~ I am having the thought that….
~ Vacation
~ Thought stopping
~ Imagery
Psychological Interventions
~ Relaxation Skills
~ What is relaxation…
~ Diaphragmatic breathing
~ Combat breathing
~ Meditation
~ Cued Progressive Muscular Relaxation
~ Self-Esteem
~ Real vs. Ideal Self
~ Compassionate self talk
~ Don’t reject yourself
~ Silence the inner critic
~ Spotlighting strengths & acceptance of imperfections

Psychological Interventions
~ Cognitive Restructuring
~ Address cognitive distortions
~ Reframe challenges in terms of current strengths (not past weaknesses)
~ Create an attitude of gratitude and optimism
~ Acceptance and Commitment Therapy
~ What is truly important?
~ What are you thinking  what thoughts can help you move toward what is important
~ What are you experiencing (seeing/hearing/feeling/smelling)?  What can you do, say, listen/stop listening to etc. that can help you move closer to what is important

Psychological Interventions
~ Recreation
~ There will always be stuff you could do…
~ Sometimes a break is what you need to get a breakthrough
~ Make a list of fun things (opposite emotions)
~ Activities
~ Contributing
~ Sensations

Social Interventions
~ Improve your relationship with yourself
~ Identify your needs and wants
~ Be your own best friend
~ Internal vs. external validation
~ Be compassionate
~ Develop healthy, supportive relationships
~ Learn about boundaries
~ Develop assertiveness skills
~ Describe the ideal healthy, supportive relationship
~ Separate the ideals from the reals
~ Identify who that is, or where that could be found
Apply It Questions for the End of Group
~ Identify 3 ways you could have used this information in the past week.
~ What was the situation?
~ What did you do?
~ How effective was that for you?
~ Short term
~ Long Term
~ If you would have had this new information, what could you have done differently?
~ How would that have changed the outcome?
~ How can you start integrating this knowledge into your routine
Summary
~ 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 copings skills
~ Cognitive distortions
~ Low self-esteem/a need for external validation
~ Recovery involves
~ Improving health behaviors
~ Identifying and building on current coping strategies
~ Addressing cognitive distortions
~ Developing a healthy, supportive relationship with self and others

Resources from New Harbinger

Apr 04 2018

1hr 9mins

Play

348 -Dom-sub and Female Led Relationships: Overview for Counselors

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Dominant/submissive & Female Led Relationships
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director: AllCEUs.com

CEUs/OPD/CPD for this presentation can be found at allceus.com for clinicians in the US or Australia.allceus.com for clinicians in Australia.


Trigger Warning and Cautions
~ The following presentation involves frank discussions of kink and sexuality.
~ While not graphic, some of the content might be triggering for some people.
~ This series is meant to provide an overview to help clinicians to understand kink, BDSM and Poly, but is by no means all inclusive. It is designed to increase awareness of common issues and help clinicians identify areas where they may need further training.
Objectives
~ Explore different structures of Dom/sub relationships including:
~ Master/slave (TPE)
~ Daddy (Mommy)/little
~ Female Led Relationships
~ Identify reasons for engaging in this type of relationship
~ Review signs of abuse

~ “D/s and master and slave relationships are about a hierarchy,” says Ferrer. “They are about structure, protocol, respect. A lot of the newbies are coming in and they don’t understand the dynamics.”
D/s Structures
~ Daddy or Mommy Doms/littles
~ Daddies/Mommies take on a parental role as the Dominant.
~ They are there to protect, guide, nurture and love their little.
~ They will order or set rules for their little based on nurturing goals and what is best for their little.
~ A Daddy/Mommy should enjoy the regression that their little naturally does and appreciate the child-like attributes of their little, but they will also find their adult side attractive.
~ Daddies/Mommies are not interested in pedophilia, incest or any other paraphernalia associated with children even though their title is often misunderstood and associated with that

D/s Structures
~ Daddy or Mommy Doms/littles
~ Daddies/Mommies vs. Masters
~ Cherish their submissive's little side and encourage them to come out and play.
~ Daddies/Mommies are strict about their littles behavior to ensure they meeting their goals and needs.
~ They can be more playful than most Masters. Masters tend to have to be more rigid with their submissive or slaves.
~ Mentor and teacher, they demonstrate by example and by explicit verbal communications priorities and perspectives that help littles better understand and learn form their past and current life experiences.
~ Most Daddies/Mommies avoid the terms daughter or son
D/s Structures
~ Daddy or Mommy Doms/littles
~ Sex in a Daddy/little relationship does not stem from interest in incest or pedophilia.
~ Sex between a Daddy and his little is just like sex between any people in a relationship; as two consenting adults.
~ Provide emotional sanctuary and 100% trust
~ Don’t always live together

D/s Structures: Master/slave
~ In BDSM, Master/slave, M/s or sexual slavery is a relationship in which one individual serves another in an authority-exchange structured relationship.
~ Sometimes referred to as Total Power Exchange
~ Unlike Dominant/submissive structures found in BDSM  or Female Led Relationships in which love is often the core value, service and obedience are often the core values in Master/slave structures.
~ The relationship uses the term “slave” because of the association of the term with ownership rights of a master to the slave's body, as property.
~ Sex is not always a component of a Master/slave relationship

D/s Structures: Master/slave
~ The slave’s limits
~ Are not set by her/him in a TPE dynamic.
~ Are whatever the Master desires. A slave’s master has total control.
~ A slave doesn’t have hard and soft limits
~ Safe words are often not afforded to a slave.
~ Though the Master is dominant and the slave is the submissive, the slave can withdraw submission at anytime, which in turn would emasculate the dominance of the Master
~ Male masters are called “Master” Female Masters are called “Master” or “Mistress”

Service Oriented
~ Service-oriented refers to a relationship dynamic where the focus is on how the submissive can contribute resources to the dominant partner, and provide for some of their needs or advance their goals.
~ These relationships may also include romantic feelings or sexual activity, depending on the specific relationship dynamic chosen.
~ An expression of this relationship can be done through collaring.
~ The submissive is collared to the dominant, indicating that they are “in service” to that dominant.
~ The collar may indicate the usefulness of that submissive in specific areas.
~ Note: Some may choose pendants or other less obvious forms of representation (like wearing someone’s ring)

Service Oriented cont…
~ If those things were to change or dissipate, or either party did not want to participate in that dynamic anymore, the couple may remain romantically linked but often the collar will be removed.
~ For the submissive, the collar is seen as a status symbol signifying the approval and acknowledgement of a person they wish to serve.
~ For the dominant, the benefits are practical as well as emotional. Many take great pleasure in being ‘served' in this manner, and having the additional resources available is of immense utility.

TPE Contract
~ Slave's Role
~ Slave's Veto
~ Master's Role
~ Punishment
~ Rules of Punishment: Punishment of the Slave is subject to certain rules designed to protect the Slave from intentional abuse or permanent bodily harm
~ Permanent Bodily Harm: Since the body of the Slave now belongs to the Master, it is the Master's responsibility to protect that body from permanent bodily harm
~ Others
~ Alteration of Contract
~ Termination of Contract
~ Signatures
~ Example on Scribd
Female Led Relationships
~ A form of a D/s relationship in which the woman takes on the dominant role
~ Generally lifestyle relationships
~ Can take 2 forms:
~ A relationship that revolves around controlling the sub and is generally dictated by the sexual pleasures of the sub (FemDom)
~ A relationship that revolves around empowering the woman
~ Subs who take to this lifestyle tend to fall into two diverse categories:
~ Those who have always been submissive
~ Those who are alphas in the public/vanilla world, but want to relinquish all of that control when they get home.

A Female Led Relationship does not necessarily include kink or BDSM

  • Women in FLRs recognize that their subs benefit them by providing emotional, mental and financial support.
  • In FLRs a subs needs are recognized.  After all people will not continue to do things that have no benefit to them.
  • Women in FLRs honor the subs who are completely dedicated to their relationship.
  • Women in FLRs respect and support their subs to become better, and subs are devoted to ensuring their woman has all the resources and support to achieve her goals

Common Issue in FLR
~ Men are often seeking a FemDom relationship that is about her using her power to satisfy is desires to be dominated and humiliated, cuckolded, punished.
~ FLR is about empowering the woman to:
~ Identify her needs and wants
~ Be able to explicitly state those needs and wants
~ Get those needs and wants met to help her achieve her goals.

Why FLR
~ Some subs feel it relieves pressure both in and out of the bedroom
~ Some say that women are often more proactive at resolving problems…calling a professional when needed
~ Mindreading expectations are eliminated. In a FLR she says what needs to be done
~ Power struggles are eliminated
~ Just like any BDSM or D/s relationship, both partners enter into the agreement willingly, there are often contracts and negotiations and either partner can terminate the contract at anytime.

informed by Lianne Choo,  Elise Sutton, Femdommed and LovingFLR

4 Levels of a FLR
Exploration: One partner has hinted at or directly brought up the idea, but the other partner is hesitant/ambivalent.
~ The sub begins taking on more tasks and chores and is permitted (expected) to serve or pamper her in a variety of ways
~ Women in Level 1 FLRs aren’t exactly comfortable with connecting to their dominant side, nor will they be able to congruently lead their man in any kind of direction beyond those which he has given to her as examples
4 Levels of a FLR
Beginning: The woman identifies some of the genuine benefits and is motivated to explore a bit.
~ Characterized more as an ongoing roleplay than an acceptance of the lifestyle
~ Woman in this level of FLR care deeply about their man, but have their limits.
~ She may begin worrying about what will happen to the overall dynamic of the relationship (and her feelings towards her sub) if she explores the path further with him/her.
4 Levels of a FLR
Engaged: This woman enjoys being in control and has a deeper understanding of her sub’s desires.
~ She exercises control in some of the 5 Fs:
~ Finances
~ Feeding
~ Fornication
~ Free-time
~ Friends
~ Higher levels of kink may be entertained here.
4 Levels of a FLR
Immersed: The woman occupies a position of genuine and total power over her sub/subs.
~ The sub is now a willing servant as opposed to playing a role
~ The dynamic has fully permeated every aspect of their relationship and the woman has full control of the big 5.

Signs of Abuse
~ The Dominant refusing to let the submissive have private conversations especially with treatment staff
~ The submissive seeming withdrawn, reluctant or afraid to talk in front of the Dom
~ Does the relationship dynamic erode the wellbeing of the sub or enhance it?
~ Does the sub look forward to interactions with the Dom?
~ Is the Dom’s behavior uncontrollably violent (i.e. punching walls, breaking things)
~ Abusive episodes are out of control situations. In healthy BDSM, a Dominant never acts spontaneously out of anger. Scenes are pre-planned with care.
~ Abusive situations usually end with negative emotions. A BDSM scene is designed to leave the participants feeling good and satisfied.
~ Does the sub feel he or she can leave the relationship at any time?
~ Consent is the cornerstone of all BDSM activity, and it’s one of the major factors that differentiates it from abuse
Signs of Abuse
~ Does your partner ever hit, choke, or otherwise physically hurt or restrained you outside of a scene?
~ Are you confused about when a scene begins and ends?
~ Has she or he ever violated your limits?
~ Do you feel trapped in a specific role as either the top or bottom?
~ Does your partner constantly criticize your performance, withhold sex as a means of control, or ridicule you for the limits you set?
~ Does your partner use sex to make up after a violent incident?
~ Does your partner isolate you from friends, family, or groups?
~ Does your relationship swing back and forth between a lot of emotional distance and being very close?
~ Does your partner use scenes to express/cover up anger and frustration?
~ Do you feel that you can't discuss with your partner what is bothering you?

Questions for the Counselor to Ask
~ What interests you about D/s relationships?
~ What do you know about D/s relationships?
~ What needs or desires do you think will be fulfilled in this type of relationship?
~ Do you want a bedroom power exchange or a lifestyle?
~ What would it look like?
~ Is your ideal Dom controlling and task oriented or nurturing and devoted to helping you enhance yourself?
~ Is your ideal sub totally submissive in every way or more child-like in their presentation?
~ Describe your ideal D/s relationship

Summary
~ D/s relationships can take many forms
~ They can be bedroom relationships or 24/7 TPEs
~ There are very significant differences between the different types of relationships which should be explored prior to entering into a contract.
~ While we discussed the levels or relationships in relation to FLR, they can apply to most lifestyle D/s structures and can be a treatment issue when one or more partners is not at the same “level.”
~ As noted in other presentations, long term TPEs should be undertaken with extreme caution, especially in people with a history of mental illness

Dec 26 2018

54mins

Play

257 -Supporting the Person Without Enabling

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Supporting the Person Without Enabling
Instructor: Dr. Dawn-Elise Snipes
Executive Director: AllCEUs Counselor Continuing Education
Podcast host: Counselor Toolbox and Happiness Isn’t Brain Surgery
Objectives
~ Explore how a person becomes an enabler
~ Define enabling
~ Examine the consequences of enabling
~ Learn about the connection between enabling and co-dependency
~ Define characteristics of codependency and how they may develop from being in an enabling relationship
~ Examine practical strategies to provide support and encouragement to the loved one without enabling.

What Makes an Enabler
~ A person that you love who is in trouble or experiencing pain
~ An addicted person
~ A person with mental health issue
~ A person with chronic pain
~ A child
~ A sense of responsibility for the problem (If I would have been more aware…, If I had…)
~ Denial that there is a problem requiring professional help (initially)
~ Once you have “helped” once it is hard to stop
~ Emotional manipulation to maintain the behavior

What is Enabling
~ Enabling behavior:
~ Protects the person from the natural consequences of his behavior
~ Keeps secrets about the person’s behavior from others in order to keep peace
~ Makes excuses for the person’s behavior (with teachers, friends, legal authorities, employers, and other family members)
~ Bails the person out of trouble (pays debts, fixes tickets, hires lawyers, and provides jobs)
~ Blames others for the person's behaviors (friends, teachers, employers, family, and self)
~ Sees “the problem” as the result of something else (shyness, adolescence, loneliness, broken home, ADHD, or another illness)
~ Avoids the person in order to keep peace (out of sight, out of mind)
~ Gives help that is undeserved, unearned or unappreciated

What is Enabling
~ Enabling behavior:
~ Attempts to control the other person by planning activities, choosing friends, and getting them jobs and doctor appointments
~ Makes threats that have no follow-through or consistency
~ “Care takes” the person by doing what she/he is expected to do for herself/himself
~ Ignoring the person’s negative or potentially dangerous behavior
~ Difficulty expressing emotions –especially if there are negative repercussions for doing so
~ Prioritizing the needs of the person with the addiction before their own
~ Acting out of fear – Since addiction can cause frightening events, the enabler will do whatever it takes to avoid such situations
~ Resenting the person with the addiction

What Does Enabling Look Like
~ “He’s so irresponsible with money, he could never make it on his own. If I kicked him out, he would be homeless. What else can I do?”
~ “Every time I’ve tried to talk to her about her addiction, she’s gone on an even worse binge, and I’m afraid she will overdose.”
~ “I know I shouldn’t have paid for his lawyer after the third DUI, but if he went to jail, he would lose his job, and we rely on his income.”
~ “Every time she and her boyfriend fight, she crashes here. I let her because I know he can be violent, and I don’t want her to be hurt.”
~ “If I don’t get the emails, he will miss them and lose his scholarship.”
~ “It is my fault she is in pain, so I must do whatever she wants.”
~ “If I can’t change what he did, at least I can limit the damage.”
~ “Maybe he will wake up and come to his senses.”
~ “Maybe I just need to find the right treatment for him.”

Consequences of Enabling
~ Enablers detest the behaviors of the enabled, but fear the consequences of those behaviors even more.
~ They are locked into a lose-lose position in the family. Setting boundaries feels like a punishment or abandonment of the person they love.
~ Enablers may struggle with the guilt they would feel if the person they’re enabling were hurt by the real consequences of their actions.
~ Enablers are also protecting themselves and/or children from those consequences
~ Enabling means that someone else will always fix, solve, or make the consequences go away.
Consequences of Enabling
~ Enabled persons will come to expect that their behaviors have no consequences or negative outcomes.
~ Enablers may become “emotional hostages” as the person learns to manipulate them in order to ensure that the help and support keep coming.
~ The enabler is desperate to prevent one enormous crisis, but winds up experiencing a constant state of stress
~ The enabled person becomes stuck in a role in which he or she feels incompetent, incapable, disempowered, dependent, and ineffectual.
~ He or she may gradually accept a self-concept that includes these negative traits, destroying self-esteem and leading to co-dependency
Characteristics of the Co-Dependent Person
~ The person had someone they loved and…
~ Failed to “fix” them. The loved one “chose” another behavior over the relationship—impacting self-esteem, self-efficacy and abandonment anxiety.
~ Believes it is his or her responsibility to care-take the other person
~ An exaggerated sense of responsibility for the actions of others
~ A tendency to confuse love and pity, with the tendency to “love” people they can pity and rescue
~ A willingness do anything to hold on to a relationship; to avoid the feeling of abandonment
~ An extreme need for approval and recognition
~ A sense of guilt when asserting themselves/setting boundaries
~ A tendency to do more than their share and become hurt when people don’t recognize their efforts

Characteristics of the Co-Dependent Person
~ A compelling need to control others
~ Lack of trust in self and/or others
~ Difficulty identifying feelings
~ Rigidity/difficulty adjusting to change
~ Problems with intimacy/boundaries
~ Chronic anger
~ Lying/dishonesty
~ Poor communications
~ Difficulty making decisions (Don’t talk, don’t trust, don’t feel)

What to Do
~ Learn about addiction and any co-occurring issues the person may have.
~ Get help and support from others.
~ Calmly let your loved one know that you are aware of their problem, that you will not tolerate that continued behavior, and that you are willing and able to support them on the road to full recovery.
~ This should include explaining that you will be withdrawing financial and other support should they choose to refuse your help–which means that you will not enable them, but only support them on the path to recovery.

What to Do
~ Healthy help involves providing information, encouragement, and coaching to your loved one.
~ Give the person contact information for doctors, counselors, lawyers, or rehabilitation programs, without feeling the need to force him or her to accept this help.
~ Discuss with the person what the possible consequences of actions might be, without feeling as if you must make sure they make the choice you want them to make.
~ Foster hope, for you and the person.
~ Sometimes people refuse to get help, only to turn around and ask for help a short time later. (control)
~ By refusing to tolerate or enable the addiction related behavior, but being willing to fully support their recovery, you can foster hope that can grow and catch on.

Practical Strategies
~ Take care of yourself
~ Sleep
~ Nutrition
~ Exercise
~ Emotions
~ Social relationships and activities
~ Awareness of what is truly important to you
~ When you’re together, remember not to helicopter
~ Don’t obsess or worry about him or her.

Practical Strategies
~ Example thoughts
~ I have to….or he will…
~ If I truly loved her, I would…
~ If she chooses that behavior, it means I am a failure and unlovable
~ Handing thoughts
~ Unhook from thoughts.
~ I am having the thought that…
~ Challenging Questions
~ What is the evidence for and against this?
~ What parts of this are my responsibility?
~ Play it through to the end… If I do this it will…
~ Which important things does this help me move toward? Away from?
~ Which values does doing this support? Undermine?

Practical Strategies
~ Don’t judge them. (It is what it is.)
~ Don’t have expectations of others; instead, meet expectations of yourself.
~ Remember that you didn’t cause someone else’s behavior. You are only responsible for yours.
~ You cannot change or “fix” someone else.
~ Before engaging in enabling behavior, weigh your options for short-term and long-term pain
~ Write about your feelings in a journal.
~ Pursue your own interests and have fun.

Practical Strategies
~ Set Boundaries
~ Part of your recovery is to get very clear about your boundaries.
~ What do you expect from your partner?
~ What behaviors are acceptable and what will you no longer tolerate.
~ What will happen if there is a relapse?
~ What do you need to feel safe and secure?
~ Learn how to say no and mean it.
~ Learn how to ask for help and get it.
Practical Strategies
~ Take a time out when you get emotional. Practice distress tolerance and get into your wise mind.
~ Each day, identify 3 things you did well or like about yourself, and write them in your awesomeness journal.
~ Take the labels off (good/bad, should). When it comes to expectations, assumptions and excuses, ask yourself how you would treat the other person if he or she wasn’t your loved one.
~ When you’re tempted to think or worry about someone else, turn your attention back to you.
~ Pay attention to how you talk to and treat yourself. Silence the inner critic. Be compassionate.
Practical Strategies
~ Have some fun. Pursue hobbies and interests.
~ Spend time alone with yourself.
~ Start looking for the positive in your life and add to your gratitude list each day
~ Stand-up for yourself if someone criticizes, undermines, or tries to control you.
~ Practice mindfulness and radical acceptance to deal with worry
~ Let go of control and the need to manage other people. Remember the saying, “Live and let live.”
~ Accept yourself. You don’t have to be perfect.

Practical Strategies
~ Get in touch with your feelings. Don’t judge them. Feelings just are. They’re not logical or right or wrong.
~ Express yourself honestly with everyone. Say what you think and what you feel. Ask for what you need.
~ Reach out for help when you feel bad. Don’t fall into the trap of thinking you should be able to manage alone. That’s a symptom of codependency, too.

Practical Strategies
~ Encourage and Support Recovery Activities (Avoiding the dry drunk)
~ You can’t be your partner’s only support.
~ You can encourage and support by helping to arrange time in the family schedule and budget and providing emotional support or transportation.
~ Encouraging doesn’t mean forcing, manipulating, making ultimatums, or nagging.
~ Engage in your own recovery activities
Practical Strategies
~ Restore Balance
~ Stop making excuses, minimizing or avoiding problems, and simply doing things that s/he can do for him/herself.
~ Leave the person to clean up the messes she makes while engaging in the destructive behavior.
~ Don’t allow the person to put you in situations which may endanger yourself or others
~ Follow through with plans even if the person refuses to participate

Summary
~ Enabling behaviors can occur with anyone, not just people who are addicted.
~ Most of the time people do not start out enabling, they often feel responsible in some way and are trying to make things better

Apr 21 2018

1hr 2mins

Play

Treating Addictions and Borderline Personality Disorder Symptoms

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Treating Addictions and Borderline Personality Disorder Symptoms
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs
Host: Counselor Toolbox Podcast

CEUs are available for this presentation at AllCEUs https://www.allceus.com/member/cart/index/product/id/1002/c/

Objectives
~ Review the characteristics of BPD and Addictions
~ Explore the functions of these symptoms
~ Identify interventions to help the person more effectively manage emotions and relationships

Internal Reality
~ Lack of a sense of self—If they aren’t someone’s something, then they are nothing
~ Unlovable for who they are
~ Constant fear of abandonment

Consequences
~ Lack of emotional boundaries
~ Anger is used to control others and is rewarded
~ Emotional dyscontrol
~ Inability to self-soothe/Impulsivity
~ Lack of coping skills
~ Relationship problems
~ Physical health problems and complaints
~ Cognitive distortions are reinforced
First
~ Identify the most salient symptoms
~ Their function (and alternate ways to meet that need)
~ Identify what it looks like for that person
~ When X happens, how do you feel? What do you think? What are your urges? What do you do?
~ How that behavior is being maintained (what are the benefits and other ways to get the same benefit)
Frantic efforts to avoid real or imagined abandonment

~ Function: The person only knows how to exist as a role, such as being someone else’s spouse/parent etc. (Co-dependency)
~ Preventing abandonment means preventing death or dissolution
~ What does it look like (Benefits/Drawbacks)
~ Hypervigilant/hypersensitive to rejection/criticism
~ Anger at/belittling others to control them
~ Acting out to control through guilt, manipulation
~ Emotional dyscontrol
Abandonment cont…
~ Origins
~ Failure to develop a sense of self due to constantly trying to appease the caregivers
~ Addict –Don’t Talk, Don’t Trust, Don’t Feel
~ Borderline –Do as I say or else…
~ History of abandonment/rejection/CPR
~ If they are something to someone then they are filling a need and are less likely to be abandoned
~ History of neglect/abuse (You (as a person) are not worthy of love)

Abandonment Cont…
~ Interventions
~ Develop a sense of self and self-esteem
~ Differentiate between who you are and what you do
~ Explore what makes someone/something “lovable”
~ Dogs/horses
~ Children
~ Others
~ Which of those characteristics do you have in yourself?
~ Identify and address messages/events in the past that communicated unlovability

Abandonment Cont…
~ Interventions
~ Explore the notion of responsibility (Who and what are you responsible for)
~ Not responsible for the parent
~ Responsible for you
~ Nobody else can make you…
~ Explore and address abandonment/rejection triggers
~ Is it about you? What are alternate explanations?
~ Explore faulty thinking

Relationships are Unstable
~ Function: Controlling others provides a feeling of safety and predictability
~ What does it look like (Benefits/Drawbacks)
~ Intense and unpredictable interactions
~ If you do what I want, I love you
~ If you do not, you are rejecting me and I hate you
~ Everyone walks on eggshells
~ Jekyll/Hyde

Relationships are Unstable
~ Origins
~ Children were rejected (or the caregiver was unavailable) at an age in which they were still thinking in concrete, all-or-nothing terms
~ The A/B expects rejection and has never experienced an authentic relationship with self-or others
~ Inability to self-soothe is terrifying and the A/B fears they cannot cope on their own
~ Repeated rejections become most salient and support all-or-nothing thinking

Relationships are Unstable cont…
~ Interventions
~ Use CBT to explore and address perceived rejection
~ From others in real life
~ From the gallery/hecklers
~ From yourself
~ Use contextual approaches to separate REactions to the present
~ Differentiate dislike of actions/ideas from dislike of person (People can disagree or dislike something you do but that doesn’t mean they don’t like you

Relationships are Unstable cont…
~ Interventions
~ Learn to identify and assertively communicate needs and wants
~ Explore characteristics of healthy relationships and address parts that feel scary
~ Honesty
~ Trust
~ Hope
~ Faith

Self-Damaging Impulsivity
~ Function: Distraction/Escape
~ What it looks like (Benefits/Drawbacks)
~ Self-harm
~ Spending
~ Addictive behaviors
~ Violence toward self or others
~ Overly sexualized behavior
~ Origins
~ Lack of coping skills in the face of overwhelming emotions
~ Inability to self-soothe

Self-Damaging Impulsivity
~ Interventions
~ De-escalation/Distress tolerance
~ Self-soothing
~ Mindfulness
~ Coping skill development
~ Vulnerability prevention

Transdiagnostic Interventions
~ A/B both have high levels of HPA-Axis overactivation and corresponding physical, emotional and interpersonal issues
~ Vulnerability Prevention
~ Sleep
~ Nutrition
~ Pain management
~ Temperament
~ E/I
~ J/P
Transdiagnostic Interventions
~ Acceptance & Tolerance / Serenity
~ Urge surfing/Don’t swat the bee
~ Distress Tolerance

Transdiagnostic Interventions
~ Mindfulness/Honesty/Wisdom
~ Increases awareness of
~ The present moment wants, needs, sensations, thoughts, feelings in the present moment
~ Picture test
~ 5-4-3-2-1
~ Picture memories and sensations
~ Scent memories and sensations
~ Sound memories and sensations
~ Current: Sensations, physical cues, emotions, thoughts, urges, needs

Transdiagnostic Interventions
~ Mindfulness/Honesty/Wisdom
~ Increases awareness of
~ The influence of the past on the present

Similar situations in the past The present situation (objective)
What I learned about myself, How I am different now
others and the world What my current needs are
What I did to protect myself/survive The best use of my energy
Transdiagnostic Interventions
~ Psychological Flexibility
~ The serenity to accept the things I cannot change
~ The courage to change the things I can
~ The wisdom to know the difference

Reactive behaviors Active behaviors
(What I want to do) (What I could to do toward a RML)

Reactive thoughts/feelings Reactive thoughts/feelings
(What I want to do) (What I could to think toward a RML)

Summary
~ People with BPD first need to learn how to safely deal with intense feelings
~ Specific Issues which may trigger intense feelings and interventions include:
~ Poorly developed, or unstable self-image, often associated with excessive self-criticism and feelings of inadequacy
~ Development of self-concept
~ Differentiation of whats from whos

Summary
~ Interpersonal hypersensitivity (i.e., prone to feel slighted or insulted)
~ Desensitization
~ Self-Soothing
~ CBT Interventions
~ Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, fear of abandonment, and difficulty trusting people due to alternations between feeling appreciated and condemned
~ Learn how to be honest with yourself about wants/needs/fears
~ Develop the ability to trust self
~ Learn what it means to trust others
~ Learn how to set healthy boundaries

Apr 06 2019

1hr 1min

Play

304 -Behavior Modification | Journey to Recovery Series

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Journey to Recovery:  Behavior Modification Basics
Presented by: Dr. Dawn-Elise Snipes
Executive Director, AllCEUs
Host: Counselor Toolbox
Objectives
~ Define behavior modification
~ Explore how behavior modification can be useful in practice
~ Learn basic behavior modification terms:
~ Unconditioned stimulus and response
~ Conditioned stimulus and response
~ Discriminitive stimuli
~ Learned helplessness
~ Reinforcement
~ Punishment
~ Extinction Burst
~ Premack Principle

Why Do I Care
~ Behavior modification principles will help you understand some of the reasons people act/react the way they do
~ By understanding what rewards(causes and motivates) people’s behavior or discourages (punishes/Strains) their behavior, we can better address their issues
~ The focus on observable, measurable conditions to the exclusion of cognitive interpretation underscores the mind-body connection
How can this be useful in practice
~ Traditional (strict) behavior modification can be quite useful in simplifying stimulus/reaction
~ Integrating the cognitive interpretations (labels) can help people in identifying and addressing what is causing their “distress” (Behaviorists would refer to excitatory response)
~ Understanding what causes feelings can also give people a greater sense of empowerment.
Example
~ Organisms learn behavior through direct and observational reinforcement and correction
~ Puppy 1 tackles puppy 2  threat
~ Puppy 2 responds by tackling puppy 1  counter threat
~ Both puppies get a surge of adrenaline
~ The puppy that dominates receives a dopamine surge that reinforces the prior behaviors — do that again.

~ If Puppy 1 plays too rough, then puppy 2 will either become more aggressive or leave.
~ Either way, puppy 1s behavior is punished.
Example 2
~ In addition to direct and observational learning, humans learn to label certain internal experiences with feeling words (angry, scared, happy)
~ Sally goes to a pet store.
~ A puppy comes out, sits in her lap and puts is head on her leg. This contact (we know from studies) usually causes the release of dopamine and oxytocin –both reward chemicals. Sally calls this “happy”
~ If Sally had previously had a threatening experience with a dog, when she saw it, her body would likely respond by secreting adrenaline, kicking off the fight or flight reaction. Sally would label this as “fear”
Points
~ People with dysphoria or unhelpful behaviors may need to:
~ Recondition X is not actually a threat (anymore)
~ Relabel the state
~ Stressed vs. hungry vs. bored vs. tired
~ Explore the dialectics: Excitement/Fear
~ Unhook– X is causing me to have the feeling that…
Basic Terms
~ Unconditioned stimulus and response
~ Something that evokes an unconditioned/automatic response in an infant and adult
~ Loud noises
~ Pain
~ Excessive cold/heat
~ Contact
Basic Terms
~ Conditioned Stimulus
~ Something that in itself has no meaning to the person (yellow light)
~ Conditioned Response
~ The person’s reaction to the stimulus (slow down or floor it)
~ Stimuli and responses can be traced back to survival: Fight-Flee-Forget-Repeat
Basic Terms
~ Discriminitive stimulus
~ The stimulus which triggers the reaction. (Includes vulnerabilities)
~ Going to work
~ Good day
~ Bad day
~ Learned Helplessness “Damned if I do, damned if I don’t”
~ A response which occurs when people have tried and failed. Giving up.

Fight or Flee
~ Stimuli that present a threat of pain or death can trigger the excitatory fight or flight response
~ A useful intervention is to identify
~ The threat
~ If it is actually a threat
~ Break down parts of the situation into controllable and uncontrollable
Conditioning
~ Mindfulness can help people identify
~ Positive stimuli  dopamine  “happy”
~ Negative stimuli  adrenaline  fight or flee
~ Little things build up and lead to a big reaction. (Pressure cooker)
~ Stimuli that trigger a negative reaction can be reconditioned as neutral by
~ Embracing the dialectics: Find the positive (snowy day)
~ Being psychologically flexible: Not worth the energy (rainy day)
Conditioning: Repeat
~ Adding and noticing positive stimuli in the environment is vital
~ Happiness Triggers
~ Smells (pumpkin spice…lol)
~ Sights (wildlife, my kids)
~ Sounds (babbling brook)
~ Feel (crisp autumn breeze)

Putting it Together
~ How can you use discriminative stimuli to:
~ Increase a feeling of control and “self-efficacy” (Remind them to have a can-do attitude)
~ Increase “self-esteem” (Remind them they are lovable)
~ Decrease angry responses (Remind them to use coping or distress tolerance skills)

New Terms
~ Positive Reinforcement
~ Providing something positive in order to increase the likelihood a behavior will occur again
~ Examples
~ Touch
~ Gifts (Food, Money (Paycheck))
~ Words of Affirmation
~ Acts of Service
~ Power (Choosing activities, promotion)
~ Quality Time
~ What can be added that is rewarding AND helpful for the person
New Terms
~ Negative Reinforcement
~ Removing something negative in order to increase the likelihood a behavior will occur again
~ Examples
~ Reducing nagging and fighting
~ Dropping restitution or additional charges upon completion of counseling
~ Can leave the table once vegetables are eaten
~ What can be eliminated that would be considered rewarding AND helpful for the person

New Terms
~ Positive Punishment
~ Adding something negative to decrease the likelihood that a behavior will recur
~ Examples
~ Antabuse
~ Additional Chores
~ Additional sessions
~ Rubber band snaps
~ What can be added that would be considered unpleasant for the person

New Terms
~ Negative Punishment
~ Removing something positive to decrease the likelihood that a behavior will recur
~ Examples
~ Freedom/privileges
~ Money (Fines)
~ Relationship/Setting boundaries to stop a behavior
~ Control/power
~ What can be eliminated that would be considered desirable?

~ You cannot just eliminate a behavior. You must put something in its place.

Types of Rewards and Punishments
~ Rewards and Punishments can be:
~ Emotional (Happiness)
~ Mental (Improved decision making, cognitive clarity)
~ Physical (Appearance, health, pain, energy, sleep, relaxation)
~ Social (Acceptance, admiration, support)
~ Spiritual/Karmic
~ Financial
~ Environmental (freedom, pleasant conditions)

Apply It
~ The more rewards that can be gained the stronger the motivation to repeat the behavior

Apply It
~ Behavior 1: Social Withdrawal
~ Social withdrawal is rewarding mainly due to negative reinforcement (elimination of the unpleasant)

Apply It
~ Behavior 2: Emotional Eating
New Term
~ Behavior Strain
~ The point at which the reinforcement or punishment is no longer effective
~ Effected by:
~ Age
~ Cognitive development
~ Strength of the reinforcement or punishment
~ Smaller, more frequent rewards for completion of smaller goals:
~ Provide rapid benefits
~ Maintain momentum
New Term
~ Extinction Burst
~ A temporary increase in a behavior when rewards are absent or insufficient
~ Child in the store
~ Pigeon wanting food
~ “Acting Out”
~ The behavior ceases when the demands/costs of the behavior exceed the potential reward
~ What the person is doing for a promotion
~ What the person is doing to feel better/get his way
New Term
~ Premack Principle
~ Concurrently pairing something undesirable with something desirable
~ Examples
~ Laundry folding with watching television
~ Exercise with socialization/puppy time/nature
~ Studying with peer support
~ Cleaning with music/tv/aromatherapy
~ Work with coffee
New Term
~ Shaping
~ Rewarding the successive approximations of the target behavior
~ Punishing or ignoring non-target behaviors
~ Ignore if negative attention is better than no attention
~ Solidify gains
~ Withhold reward for a higher level of target behavior
~ Goal: Brewster meet me at the door quietly and sitting
~ Target behavior 1: Not jumping
~ Target behavior 2: Sitting on command
~ Target behavior 3: Sitting when I walk in without command

Apply It
~ Shaping
~ Cutting Behavior
~ Target Behavior #1: Ice cube or ink pen
~ Target Behavior #2: Alternate self-soothing behavior
~ Stress Eating
~ Target behavior #1 Fruit on a plate + mindfulness exercise (premack)
~ Target behavior #2 Drink + mindfulness exercise
~ Target behavior #3 Mindfulness exercise

New Term
~ Chaining
~ A cascade effect leading to a behavior
~ Behaviors, stimuli, reinforcements and punishments that lead up to a positive or negative result
Apply It
~ Example 1: Car problems
~ Slept well
~ Get up on time (Monday morning)
~ Get ready for work
~ Eat breakfast
~ Start driving to work and the car breaks down
~ “Get Irritated”
~ Call for assistance

~ Example 1a: Car problems (dysregulation)
~ Didn’t sleep well
~ Get up late(Monday morning)
~ Get ready for work
~ Eat breakfast and spill coffee on your shirt
~ Start driving to work and the car breaks down
~ “Get Angry”
~ Cannot think straight

Apply It
~ Example 2: Stress Eating
~ Bad day at work
~ Come home
~ Start eating
~ Feel better
~ Example 3: Panic Attack
~ Didn’t sleep well
~ Get up
~ Drink 2 cups of coffee
~ Get stuck in traffic driving to work
~ Panic attack

Summary
~ If you eliminate a behavior, you must replace it with at least one, preferably 3 new ones
~ People are “motivated” for rewards and to avoid punishment.
~ Decisional balance exercises can help people make new behaviors rewarding and old behaviors…less rewarding
~ Reinforcers must be reinforcing to the person
Summary/In Practice
~ When a client is trying to change a behavior
~ Analyze exceptions (chaining—what was different when you did not …)
~ Behavior chains can help identify antecedents/triggers and vulnerabilities
~ Remember that every behavior is maintained by rewards (getting up, going to work, eating)
~ Eliminating a behavior means
~ Making that behavior LESS rewarding than the alternative
~ Making the new behavior MORE rewarding than the alternative

Aug 29 2018

1hr 1min

Play

327 -Finding Meaning with Acceptance and Commitment Therapy

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Acceptance and Commitment Therapy Skills
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs
Objectives
~ The Goal of ACT
~ What is Mindfulness?
~ How Does ACT Differ from Other Mindfulness-based Approaches?
~ What is Unique to Act?
~ Destructive Normality
~ Experiential Avoidance
~ Therapeutic Interventions
~ Confronting the Agenda
~ Control is the Problem, Not the Solution
~ Six Core Principles of ACT

Why I Care/How It Impacts Recovery
~ “You can't stop the waves, but you can learn to surf” Kabat-Zinn 2004

~ Distracting oneself from distress is akin to constantly running away from one’s shadow. In the attempt to control the negative thoughts and feelings, one is at a loss for control in other life situations.

ACT Acronym
~ Accept your reactions and be present
~ Choose a valued direction
~ Take action

Overview
~ ACT is based on relational frame theory (RFT)
~ a psychological theory of human language.
~ developed largely through the efforts of Steven C. Hayes of University of Nevada, Reno and Dermot Barnes-Holmes of National University of Ireland, Maynooth.
~ Relational frame theory argues that the building block of higher cognition (reasoning) is ‘relating', i.e. the human ability to create links between things.
Overview
~ Contextualists seek to understand the complexity and richness of a whole event through appreciation of its participants and features.
~ Functional contextualism emphasizes:
~ Humans learn language (i.e., communication) through interactions with the environment
~ We must focus on changeable variables in the context in which these events occur in order create general rules to predict and influence psychological events such as thoughts, feelings, and behaviors.
The Goal of ACT

~ The goal of ACT is to create a rich and meaningful life, while accepting the pain that inevitably goes with it.
~ Who is important?
~ What is important to me? (Values, things, experiences)
~ How can I move toward those goals?
~ “ACT” is a good abbreviation, because this therapy is about taking effective action guided by our deepest values and in which we are fully present and engaged.
What is Mindfulness?

~ “Consciously bringing awareness to your here-and-now experience with openness, interest and receptiveness.
~ Facets to mindfulness
~ Living in the present moment
~ Engaging fully in what you are doing rather than “getting lost” in your thoughts
~ Allowing your feelings to be as they are, rather than trying to control them
~ Mindfulness does not require meditation

What is Mindfulness?

~ Mindfulness skills are “divided” into four subsets:
~ Acceptance
~ Cognitive diffusion
~ Contact with the present moment
~ The Observing Self

How Does ACT Differ
~ ACT can be used in a wide range of clinical populations and settings
~ Not manualized
~ ACT allows the therapist to create and individualize their own mindfulness techniques, or even to co-create them with clients.
What is Unique to Act?

~ ACT does not have symptom reduction as a goal.
~ The ongoing attempt to get rid of “symptoms” actually creates a clinical disorder
~ Private experience is labeled a symptom  a struggle with the symptom
~ A “symptom” is by definition something “pathological” and something we should try to get rid of.
~ In ACT, the aim is to transform our relationship with our difficult thoughts and feelings, learn to perceive them as harmless, even if uncomfortable, transient psychological events.
Destructive Normality

~ ACT assumes that the psychological processes of a normal human mind are often destructive, and create psychological suffering for us all, sooner or later.
~ ACT postulates that the root of this suffering is human language itself.
~ Memories/perceptions/schemas are created through analyzing, comparing, evaluating, planning, remembering, visualizing—and all of these processes rely on human language.
~ I am stupid vs. I have the thought that I am stupid
~ I cannot go on vs. I am feeling like I cannot go on
Experiential Avoidance

~ ACT asserts that human language naturally creates psychological suffering by setting us up for a struggle with our thoughts and feelings, through experiential avoidance.
~ Problem = something we don't want.
~ Solution = figure out how to get rid of it, or avoid it.
~ The more time and energy we spend trying to avoid or get rid of unwanted private experiences, the more we are likely to suffer “Quicksand”
~ Addiction
~ Anxiety
~ Depression
Experiential Avoidance

~ The ACT interventions focus around two main processes:
~ Developing acceptance of unwanted private experiences which are out of personal control.
~ Commitment and action toward living a valued life.
First Step: Confronting the Agenda

~ The client's agenda of emotional control is gently and respectfully undermined
~ Clients identify the ways they have tried to get rid of or avoid unwanted private experiences. (Creative hopelessness)
~ They are then asked to assess for each method:
~ “Did this reduce your symptoms in the long term?
~ What did this strategy cost you in terms of time, energy, health, vitality, relationships?
~ Did it bring you closer to the life you want?”

Confronting the Agenda
~ Control is the Problem, Not the Solution
~ Clean Discomfort: When emotions and reactions are accepted, it leads to a natural level of physical and emotional discomfort
~ Dirty Discomfort: Once we start struggling with it, your “struggle switch is turned on” and discomfort increases rapidly.
~ Struggle switch is like an emotional amplifier—switch it on, and we can have anger about our anxiety, anxiety about our anger, depression about our depression, or guilt about our guilt.

Six Core Principles of ACT
~ Once the emotional control agenda is undermined, we then introduce the six core principles of ACT to help clients develop psychological flexibility:
~ Diffusion
~ Acceptance
~ Contact with the present moment
~ The Observing Self
~ Values
~ Committed action

Cognitive Diffusion
~ Learning to perceive thoughts, images, and memories as bits of language, and pictures—as opposed to what they can appear to be—threatening events, objective truths
~ Cognitive diffusion means “stepping back” and recognizing that thoughts are just transient private (subjective) events
~ DARE-ing to separate yourself from your thoughts and FEARs

Unhooking/Diffusion
~ FEARs
~ F = Fusion
~ E = Excessive goals (your goal is too big, or you lack the skills or resources)
~ A = Avoidance of discomfort (unwillingness to make room for the discomfort)
~ R = Remoteness from values
Unhooking/Diffusion
~ The antidote to F.E.A.R. is D.A.R.E.
~ D = Diffusion
~ I am having the thought that…
~ I am having feelings of…
~ My behaviors were…
~ A = Acceptance of discomfort
~ R = Realistic goals
~ E = Embracing values

Diffusion Activity
~ Here’s a simple exercise in cognitive diffusion for yourself:
~ Think of a negative self-judgment that takes the form “I am X” such as “I’m stupid.” Think about it. Believe it as much as you can. Notice how it affects you.
~ Now insert the phrase “I’m having the thought that….” in front of “I am X.” Think about it. Notice what happens.
~ In step 2, most people notice a “distance” from the thought, such that it has much less impact. Notice there has been no effort to get rid of the thought, nor to change it. Instead the relationship with the thought has changed—it can be seen as just words.

Other Diffusion Techniques
~ ‘The Mind” Treat “the mind” as an external event; almost as a separate person
~ Thoughts are not causes “Is it possible to think that thought, as a thought, AND do x?”
~ Who is in charge here? Treat thoughts as bullies
~ OK, you are right. Now what?
Acceptance
~ Make room for unpleasant feelings, sensations, urges, and other private experiences
~ Allow them to come and go without struggling with them, or giving them undue attention.
~ Thoughts/feelings don’t always lead to action
~ Identify the problem: When we battle with our inner experience, it distracts and derails us.
~ Explore effects of avoidance. Has it worked in your life?
~ Define the problem. What you struggle against = barriers toward heading in the direction of your goals
~ The Serenity Prayer: Change what you can, accept what you can’t.
Contact with the Present Moment
~ Bringing full awareness to your here-and-now experience, with openness, interest, and receptiveness; focusing on, and engaging fully in whatever you are doing.
~ How do I feel
~ What am I thinking
~ What physical sensations am I experiencing
~ Describe the environment—smell, temperature, colors, objects, people, sounds, etc…
~ I (see, hear, smell) ______ It reminds me of _____
Contact with the Present Moment
~ The Observing Self
~ Accessing a continuity of consciousness that is unchanging, ever-present, and impervious to harm.
~ From this perspective, it is possible to experience directly that you are not your thoughts, feelings, memories, urges, sensations, images, roles, or physical body.
~ These phenomena change constantly and are peripheral aspects of you, but they are not the essence of who you are.
Values
~ Clarifying
~ What is most important, deep in your heart
~ What sort of person you want to be
~ What is significant and meaningful to you
~ What you want to stand for in this life
~ A lack of values or a confusion of goals with values can underlie the inability to be psychologically flexible.

Values
~ The next step in the ACT process is
~ Choose a direction
~ Identifying motivating values
~ Establish a willingness to regain control of life, not necessarily just to control thoughts and feelings.
Committed Action
~ Setting goals, guided by your values, and taking effective action to achieve them.

Summary
~ The goal of ACT is to create a rich and meaningful life, while accepting the pain that inevitably goes with it
~ Being aware and present in the moment
~ Destructive Normality the psychological processes of a normal human mind are often destructive, and create psychological suffering. “This is depressing. I am helpless”
~ Actions designed to avoid the experience in the present
~ Therapeutic Interventions focus around two main processes:
~ Developing acceptance of unwanted private experiences which are out of personal control.
~ Commitment and action toward living a valued life.

Summary
~ Confronting the Agenda (to eliminate distress)
~ Explore sources of distress
~ Explore prior attempts at removing distress
~ Explore effectiveness
~ In the short and long term
~ Specific to the problem and other areas of life
~ Six Core Principles of ACT
~ Diffusion– Separate self from feelings/experience
~ Acceptance—Accept what is
~ Contact with the present moment– Mindfulness
~ The Observing Self– Fly on the wall
~ Values Identification
~ Committed Action

Oct 20 2018

58mins

Play

Developing Positive Self-Talk in People of All Ages

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Building Positive Self Talk for Confidence and Self-Esteem
Dr. Dawn-Elise Snipes
Executive Director: AllCEUs Counselor Education
Host: Counselor Toolbox Podcast

CEUs for this podcast are available at: https://www.allceus.com/member/cart/index/product/id/1030/c/

Objectives
~ Identify the function of negative self talk
~ Explain the benefits of positive self talk
~ Describe 15 methods for teaching positive self talk to people of all ages
Function of Negative Self Talk
~ Protection from threats and failure
~ I can’t do this.
~ I’m not smart enough to…
~ I cannot find a decent partner
~ Nobody wants to be my friend
~ I am ugly
~ I could lost my job at any moment
~ Attention (See UFD Game…)
Ugly, Fat and Dumb Game
~ The ugly, fat, and dumb game is a method of attaining attention by the individual in any given group whom needs the most attention (not necessarily the individual with the lowest self-esteem).
~ An individual draws attention to their own (perceived or real) flaws in order to get others to announce their own in an attempt to make the first person feel better and subsequently, lowering their own self-esteem

~ For example:
~ While eating dinner, Sally announces her weight to the table and calls herself fat causing all the other girls at the table (who nearly all clearly weigh more) to announce their weight in an attempt to make Sally feel better about herself.
~ If someone at the table isn’t of lower weight, they find another deprecating thing to say about themselves– “But you are so pretty. I would kill to have your hair. Mine is like a rats nest.”

Benefits of Positive Self Talk
~ Reduced cortisol and HPA-Axis activation
~ Reduced pain
~ Improved physical health (Less stress-related disease)
~ Increased energy
~ Greater life satisfaction
~ Improved immunity
Unconditional Positive Regard
~ From attachment figures who teach positive talk
~ From self
~ Encourage the use of the phrase
~ “I love you even if…”

Self Awareness
~ Who you are
~ I have the ability to… (things you do)
~ I am… (inner qualities)
~ Keep a daily journal or account of your successes, good qualities and accomplishments
~ What you say to yourself
~ Journaling

Mantras
~ Don’t wait until you are stressed. Practice positive self talk throughout the day—Every day (Positive Thinking Apps)
~ Mantras
~ I am capable.
~ I am lovable.
~ Today is going to be an awesome day.
~ I choose to be present in all that I do.
~ I feel energetic and alive.
~ I can achieve my goals.
~ I love challenges and what I learn from overcoming them.
~ I’ve got this

Visualization
~ Visualization helps people’s brains “see” how they can succeed (or fail)
~ Negative self talk “teaches” the brain that negative things will happen which increases anxiety and distress, reduces concentration and increases a sense of helplessness.
~ Positive self-talk helps people’s brains “see” that
~ Success is possible
~ Happiness is possible
~ The person has power

Visualization
~ Visualizations combined with desensitization help reduce anxiety and distress around…
~ Public speaking
~ Tryouts or job interviews
~ Driving
~ Starting a new school/job
~ Taking a test
~ …
~ Have people watch others who are successful and/or role play then use that data to visualize.
Environments
~ Surround yourself with positivity
~ Parents model positivity
~ Listen to positive songs

~ Have family members bring a positive quote or song (lyrics) with them to dinner once a week and put it on the fridge.
~ Give yourself a pep talk every morning.
~ Keep a success wall/scrapbook

Personalizing
~ When you take things personally you are often assuming you have control over how other people feel or react or the way things happen.
~ Sally didn’t text me today. She must be mad at me.
~ I didn’t get that job/role/position they must have hated me.
~ I don’t know what I did, but Dad was in an awful mood all day today.
~ Encourage people to
~ Look for 3 alternate (nonpersonal) explanations
~ Examine the facts. Did it have anything to do with you?

Catastrophizing
~ Expecting the worst
~ Encourage people to
~ Evaluate probability
~ Make a plan B
~ Examples
~ If I ask him out, he will laugh in my face
~ I am sure I am going to bomb that audition/try out
~ There is no way I can win this election/promotion
~ Any day now I could lose my job then be homeless
~ I have a pain in my side, so it must be cancer

Magnification
~ Focusing on the negative aspects of an event
~ Change the negative to a neutral, a positive or a challenge
~ I can’t run today because I sprained my ankle
~ I guess I get a recovery day since my ankle is sprained
~ What else could I do for cardio that doesn’t put weight on my ankle
~ Jake said no when I asked him out. I am mortified
~ I can ask someone else out
~ He will never know what he is missing out on. I have a lot to offer.
~ I didn’t get that job
~ There are better things in store for me
~ There is probably a different job that is a better fit
Self-Other Comparisons
~ Coming to the understanding that it is likely there will always be someone other there better than you are at some things is vital to mental health
~ Focus on being the best person you can be that day, and better than the day before.
~ What do you do well?
~ What did you do well yesterday?
~ What could you do better on today?
Global Statements
~ Global negative statements generally start with
~ I am…
~ I must…
~ Focus on your language.
~ How different does it feel to say
~ “I am stupid” vs. “I am stupid at math.”
~ “I am ugly” vs. “I look bad in this outfit”
~ “I am useless” vs. “I am not sure how I contribute to this situation”
~ “I must be the best” vs. “I must be the best that I can be”
Locus of Control
~ Too internal means you try to control EVERYTHING
~ Identify parts of the situation you did NOT have control over
~ I should be able to achieve anything I try to do
~ It is my fault that my mother got sick
~ To external means you feel you have NO control
~ Identify parts of the situation you had control over
~ I only did well because of luck
~ It was bad luck that I fumbled the pass
~ Just my luck the teacher collected homework today
~ I got demoted because my boss has it in for me
~ Instead of saying I can’t, say I won’t or I choose not to.
~ Focus on the present and improving the next moment

Minimization of the Positive
~ Too often people focus on what went wrong or what they don’t have. (evaluations, money, relationships)
~ Encourage people to
~ Spend 10 minutes each day focusing on what went right
~ Find the silver lining in the bad
~ Remember all the other things that are okay, even when one thing goes awry.
All or Nothing Thinking
~ These self statements usually contain the words always, never, every, nobody, etc.
~ Encourage people to
~ Look for exceptions and what is different
~ I will never be happy again
~ I am always depressed
~ Find ways to remedy the issue
~ Nobody ever calls me to go out on the weekend
~ I never can seem to lose weight

Emotional Reasoning
~ I feel scared to give a speech, therefore it must be something scary.
~ I am scared to start driving, so it must be dangerous.
~ I am angry that people are always mean and rude.
~ Encourage people to
~ Find 3 alternate explanations
~ Evaluate the facts of the situation
~ Check for all or nothing thinking
~ See if they are confusing high and low probability events
Fear of Failure / Inner Critic
~ This voice heckles people from the back of their mind telling them they are inadequate or incapable.
~ Encourage people to change self limiting statements to challenging questions
~ I’ll never get this!
~ How can I get this? (Where there’s a will there’s a way)
~ You know if you try that you are just going to fail.
~ I want to try, so how can I increase my chances of success?
~ I failed but what can I learn from this experience to become better or stronger?
~ Do you really think that you, of all people, will get that job?
~ Why should I, of all people, get that job/lead role/position?

For Kids
~ Put positive notes in their coats, lunch boxes etc.
~ Give them kudos (or even stars) for being the best that they can be.
~ Keep a good things jar for each person in the family. Each time they do something well or helpful they get to put a penny in the jar.
~ Reinforces that even if they do not succeed, if they did the best that they could do there will be benefits
Summary
~ Positive self talk helps you feel empowered and good about being the best you that you can be.
~ Feelings of empowerment reduce feelings of helplessness and hopelessness and can protect against depression, anxiety and a host of stress related illnesses.
~ Positive self-talk does not mean ignoring the negative it means
~ Embracing the good with the bad
~ Learning to evaluate situations objectively
~ Seeing failure (or the potential for failure) as a learning opportunity
~ Fully recognizing your strengths and capabilities

May 03 2019

Play

251 Using a Strengths-Based Approach to Addressing Depression

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Strengths Based Biopsychosocial Approach to Recovery from Depression
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs
Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery
Objectives
~ Define depression (symptoms)
~ Learn how to ask strengths-based assessment questions
~ Identify a range of potential causes for depression
~ Explore activities and interventions that can help people address some of the underlying causes

Depression
~ Depression represents a cluster of symptoms
~ Diagnosis with depression only requires people to have a few of the symptoms
~ A variety of different things can cause depression
~ Emotions: Anger, anxiety, grief, guilt, shame
~ Thoughts: Cognitive distortions
~ Relationships: Poor self-esteem, unhealthy/unsupportive relationships, need for external validation
~ Physical: Neurochemical imbalances, poor nutrition, exhaustion, insufficient sleep, medication side effects
~ Environmental: High stress environments that prevent relaxation/rest and increase hopelessness/helplessness

Depression Assessment
~ What does this mean to you? (apathy, sadness, mood swings)
~ Which symptoms are most bothersome for you and why?
~ For each symptom
~ What makes depression worse?
~ What makes depression better?
~ How was life more pleasurable prior to getting depressed?
~ What is different during when you are NOT depressed?
~ How do you expect life to be different when your depression is gone?
Neurotransmitters
~ Ability to feel pleasure/Apathy/Emotional Flatness
~ Memory issues
~ Difficulty concentrating
~ Sleep issues
~ Lack of motivation
~ Fatigue
~ Pain
~ Irritability/Agitation
~ Fight or flight stress symptoms

Neurotransmitters
~ Get quality sleep
~ Create a routine
~ Address pain and apnea
~ Improve the sleep environment
~ Other factors: Shift work, time zones, daylight savings time
~ Relaxation
~ Biofeedback
~ Progressive muscular relaxation
~ Address medication side effects
~ Psychotropics
~ Opiates
~ Improve nutrition
Neurotransmitters
~ Address addictive behaviors
~ Address chronic or extreme stress
~ Refresher
~ Both of these increase the amount of neurotransmitters flooding the synapses.
~ To protect the body from overload, the brain shuts down some of the receptors so the body does not overload (tolerance/desensitization)
~ When the neurotransmitters return to a normal level, the receptors are still shut down, so not enough neurotransmitter gets sent out.
~ Things that normally caused a reaction, no longer are strong enough to cause a reaction
Hormones
~ Thyroid
~ Impact mood, libido and energy levels
~ Estrogen
~ Boosts neurotransmitters that affect sleep, mood, memory, libido, pain perception, learning and attention span.
~ Increased estrogen may increase the availability of serotonin Behavioral and Cognitive Neuroscience Reviews Volume 4 Number 1, March 2005 43-58
~ Low testosterone may be implicated in reducing the availability of serotonin
~ Testosterone is manufactured by the adrenal glands,
~ Enhances libido, improves stamina and sleep, assists brain function, and is associated with assertive behavior and a sense of well-being.

Hormones
~ Cortisol
~ Cortisol is made by the adrenal glands.
~ Helps the body adapt to stress by increasing heart rate, respiration, and blood pressure.
~ Cortisol levels increase early in the morning to prepare to meet the demands of the day, and gradually decrease throughout the day (“circadian rhythm”).
~ DHEA
~ DHEA can also increase libido and sexual arousal. It improves motivation, engenders a sense of well-being, decreases pain, facilitates the rapid eye movement (REM) phase of sleep, enhances memory and enhances immune system function. Dr. Elise Schroder http://womeninbalance.org/about-hormone-imbalance/hormones-101/

Hormones
~ Get a physical to identify and address what may be causing any imbalances
~ Eat a low-glycemic diet
~ “The less sleep you get, the higher your cortisol will be; the more sleep you get, the lower your cortisol will be.” John Romaniello, co-author of Man 2.0 Engineering the Alpha: A Real World Guide to an Unreal Life.
Hormones
~ Final Thoughts on Hormonal Imbalances:
~ Hormonal imbalances affect many millions of people
~ Symptoms include feeling anxious, tired, irritable, gaining or losing weight, not sleeping well and noticing changes in your sex drive, focus and appetite
~ Causes for hormonal imbalances include poor gut health, inflammation, high amounts of stress, genetic susceptibility, and toxicity
~ Natural treatments include eating an anti-inflammatory diet, consuming enough omega-3s, getting good sleep, exercising and controlling stress

http://draxe.com/10-ways-balance-hormones-naturally/

Pain
~ Exercise
~ Guided imagery
~ Muscle Relaxation
~ Alternate focus
~ TENS therapy
~ Physical therapy
~ Hydrotherapy
~ Ice/Heat
~ Hypnosis
Emotions
~ Anger/Resentment/Jealousy/Envy/Guilt
~ Anger is half of the fight or flight
~ It pushes people away and/or asserts dominance/control
~ Excessive anger can
~ Exhaust the stress-response system
~ Contribute to negative cognitions
~ Impair relationships
~ Cause physical harm
Emotions
~ Anger/Resentment/Jealousy/Envy/Guilt
~ Activity (Group or Individual)
~ When you are angry, what do you notice?
~ What are your anger triggers?
~ Why do those triggers make you feel vulnerable?
~ Is it an external threat?
~ Is it an internal threat?
~ How can you address each trigger to feel safer and more empowered?
Emotions
~ Anger/Resentment/Jealousy/Envy/Guilt
~ Jealousy and envy can be thought of as:
~ Anger at someone else for having something you want
~ Self anger for not having it
~ Existential anger for the universe not being fair
~ Activity
~ Make a list of people you envy or are jealous of?
~ Identify why you are jealous of them?
~ In what way are they better or better off than you because of those things?
~ How does envy/jealousy affect you?
~ What is a more productive way to use this energy
Emotions
~ Anger/Resentment/Jealousy/Envy/Guilt
~ Guilt can be thought of as shame, embarrassment or self-anger for something you did or should have done
~ Some people have difficulty letting go of guilt because they think
~ They deserve to suffer
~ If they forgive themselves they might do it again

Emotions
~ Anger/Resentment/Jealousy/Envy/Guilt
~ Activity: Guilt
~ Make a list of things you feel guilty about (aka fearless moral inventory)
~ How can you:
~ Make amends?
~ Learn from it?
~ Forgive yourself?
~ Activity 2: Forgiveness
~ What does forgiveness mean to you?
~ How does the concept of forgiveness make you feel
~ What does the phrase “Forgiveness is for you” mean?
Emotions
~ Anxiety
~ Anxiety is the other half of fight or flight
~ Chronic anxiety/worry/stress will also exhaust the stress response system causing neurochemical and hormonal imbalances and increasing muscle tension and pain
~ This causes the body to adapt to excessive stress chemicals by shutting down the receptors y

Emotions
~ Anxiety
~ Activity
~ For each of the following fears, identify three situations in which you experience it
~ Rejection/Isolation
~ Failure
~ Loss of control
~ The Unknown
~ Explore why those situations trigger anxiety
~ Brainstorm ways to deal with them
Emotions
~ Grief
~ Grief is sadness/depression experienced as a result of loss
~ The grief process involves
~ Anger (at self, other, existential)
~ Depression
~ Helplessness to change the situation
~ Hopelessness that you will move on
~ Losses are not just about death

Emotions
~ Grief
~ Activity Part 1: Loss Identification
~ Identify your losses
~ Existential (dreams, hope, faith, safety, independence, innocence…)
~ Social (moves, death (people & pets), relationships ending)
~ Physical (abilities, health, appearance)
~ Property (houses, favorite bike, grandmother’s broach)
~ Explore what about each of those losses makes you angry or fearful
~ Develop an action plan to deal with that anger and fear
~ Give yourself permission to grieve

Emotions
~ Grief
~ Activity Part 2: Acceptance
~ True losses cannot be reacquired.
~ The final step in the grief resolution process is acceptance.
~ What does acceptance mean to you?
~ For each of your losses, describe what acceptance means
Emotions
~ Happiness… (Duh!)
~ You cannot be happy and depressed at the same time
~ Happiness chemicals reduce stress and depression chemicals (I know, real clinical explanation there!)
~ Increase the happy times
~ Comedians
~ Children (even youtube videos of babies laughing)
~ Animal Videos
~ https://www.youtube.com/watch?v=Ln2Xq8fCNI8
~ https://www.youtube.com/watch?v=FMBchZmPlXA

Cognitive
~ Negative thinking styles
~ Contribute to exhaustion
~ Highlight what is out of your control
~ Heighten a sense of helplessness/hopelessness (depression)
~ Cognitive distortions
~ All-or-Nothing (Nobody ever)
~ Self-fulfilling prophesies

Relationships
~ Poor self-esteem
~ Contributes to self-loathing, shame and a feeling of unlovability
~ Negatively impacts relationships (loneliness/rejection)
~ Often causes a person to seek external validation
~ Activity:
~ Complete a self-esteem inventory
~ For all the characteristics you don’t have, answer the question:
~ If your child/best friend had this flaw, would I still love them?
Relationships
~ Unhealthy/unsupportive relationships
~ Negative relationships can take a toll on self esteem
~ Fears of abandonment can maintain high levels of stress and feelings of helplessness
~ Fail to buffer people against stress
Environmental
~ High stress environments
~ prevent relaxation/rest
~ increase hopelessness/helplessness
~ Increase stress hormones / decrease relaxation hormones
~ Activity
~ Design a low stress area in
~ Your home (bedrooms are good)
~ At work/school
~ Identify ways to reduce the stress in your environment in both places (noise, interruptions, poor lighting, negativity)
~ Identify ways to turn the negative into a positive

Why I Care/How It Impacts Recovery
~ We experience emotions through neurochemical signals
~ Imbalances in the neurochemical system
~ Depressive symptoms are huge triggers for relapse
~ Identifying what causes these neurochemical imbalances for each individual and addressing them is crucial to recovery
~ What helps?
~ What makes it worse?
~ What is different when the problem doesn’t exist?
Apply It
~ Identify 3 ways you could have used this information in the past week.
~ What intensified your depression over the last week
~ What made you happy or helped you feel better
~ If you would have had this new information, what could you have done differently?
~ How would that have helped you feel less depressed?
~ How can you start integrating this knowledge into your routine
Summary
~ Depression is the cluster of symptoms created when there is a neurochemical imbalance in the brain.
~ What causes the imbalance can be emotional, cognitive, physical, interpersonal, environmental or some combination of the above.
~ Part of the strengths based approach means helping people see what they already are doing to prevent or deal with the symptoms
~ Biopsychosocial means
~ Examining all causative factors
~ Recognizing that all factors are reciprocal in nature.

Apr 11 2018

1hr

Play

449 – Happiness Habits

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449 – Happiness Habits
Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director: AllCEUs Counseling CEUs and Specialty Certificates
Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery

Objectives
~ Learn why these habits contribute to recovery from addiction and mood issues and techniques to help clients implement them
~ Habit: Awareness and Authenticity
~ Habit: Acceptance
~ Habit: Gratitude
~ Habit: Compassion
~ Habit: Breathing
~ Habit: Purposeful action and Long-Term Goals
~ Habit: Back-Talk
~ Habit: Thought Conditioning
~ Habit: Be Sense-sational

Biological Impact of Happiness
~ Reduced risk of diabetes (41% – 100%), autoimmune issues, cardiovascular disease (anxiety, depression 80%)
~ Reduced activation of the HPA-Axis
~ Improved hormone balance
~ Improved sleep
~ Reduced pain
~ Slowed aging process
~ More energy
~ Releases endorphins
Emotional & Cognitive Impacts of Happiness
~ Difficulty to be simultaneously happy and unhappy
~ Changes the lens through with the world is viewed
~ Increases cognitive flexibility
Social Impacts of Happiness
~ Happy people tend to attract happy people
~ Happy people often have more energy to devote to relationships
~ Improved social relationships increase happiness
Awareness and Authenticity
~ To get your wants and needs met, you first need to be aware of them
~ Practice Mindfulness
~ What do you need
~ What vulnerabilities do you currently have
~ How can you mitigate them
~ How can you prevent them
~ Why is it important to prevent them?
Awareness and Authenticity
~ Living authentically means living in a way that is true to yourself.
~ Define what happiness means to you:
~ What makes you happy?
~ How will your thoughts and outlook change when you are happy?
~ What is the impact of happiness on your health and body (energy, sleep, weight, pain, illness…)?
~ When you are happy, who do you see in your support system and what will your relationships be like?
~ What will be different in your day to day life, hobbies and activities when you are happy?
~ How can you start making these things happen? (Principle of Reciprocity)
Acceptance
~ Fighting against things that are unchangeable (or not realistically changeable by you) wastes a TON of energy.
~ Feelings
~ Other people
~ Certain situations
~ Accept the situation by saying “Okay, what now?”
~ Decide whether you will…
~ Change part of the situation to make it more tolerable
~ How can you do this?
~ Change your reaction to the situation
~ How can you do this?

Gratitude
~ It can be easy to focus on all of the things you don’t have or what is not going right
~ An attitude of gratitude helps you
~ refocus on the positive
~ appreciate the simple things
~ Let go of envy and jealousy
~ Even if one area of your life is a mess, it is likely that you have other things to be grateful for.
~ Activities
~ Keep a gratitude list. Add at least one thing that went well each day
~ Look around and compare yourself to others who are not doing as well and/or the you in the past
Compassion
~ Compassion means sympathetic awareness of others' distress and a desire to alleviate it
~ People may have compassion for others but not for themselves
~ Many of us were raised to think that if we are compassionate with ourselves it means we are lazy, weak or a failure.
~ Activity
~ Think of three times you have been compassionate in the past week. To whom? Why? How did it impact them?
~ How are you compassionate to yourself? How could you be?
Breathing (and Laughter)
~ Deep breaths help oxygenate blood and reduce fatigue
~ Slow deep breaths also help lower heart rate and trigger the relaxation response.
~ Laughter not only makes you breathe deeper, but it also releases endorphins.
~ Activity
~ Practice deep breathing after each meal
~ When you are stressed, take a few deep breaths
~ Schedule in 10 minutes to laugh every day.
Purposeful Action and Long-Term Goals
~ When you see that you are moving closer to your long term goals it inspires hope.
~ Each small step toward a rich and meaningful life can make you feel happier.
~ Purposeful action means
~ Using your energy to do things to achieve your goals
~ Focusing on things you can control
~ Activity
~ Define what a rich and meaningful life means to you
~ Identify 3 small changes you can make today to move closer to that life.
Back Talk
~ Your internal critic and ingrained habits can cause you a lot of distress.
~ Choosing happiness habits means quieting the negativity and changing behaviors
~ Back talk means
~ Telling the critic to be quiet and pushing away negative thoughts.
~ Telling yourself “No” when you start to engage in unhelpful habits (Stress eating, smoking, engaging in unnecessary conflict)
Thought Conditioning
~ Most of us are not in the habit of always seeing the bright side or the silver lining.
~ Just like conditioner softens your hair, thought conditioning softens your thoughts by helping you:
~ Look for the positive
~ Walk the middle path
~ Eliminate cognitive distortions
Be Sense-ational
~ Your moods are largely impacted by your environment.
~ What smells make you happy? (Essential oils, memory-related smells)
~ What sights make you happy? (Pictures, colors, organization)
~ What sounds make you happy? (birds, music, water)
~ What feelings/touch makes you happy? (warm fireplace, thick angora sweater, cool silk…)
~ How can you integrate these into your:
~ Home
~ Car
~ Work space
Peer Pressure
~ Surround yourself with positive people
~ Positive people can often help you condition your thoughts, provide support and are more encouraging
~ Negative people tend to drain energy and enhance a feeling of helplessness and hopelessness.
~ Energy in conversations and relationships is contagious.
~ Think of a person you know who is extremely negative.
~ How do you feel when you see they are calling?
~ How do you feel after spending time together?
~ Think of a person you know who is extremely positive.
~ How do you feel when you see they are calling?
~ How do you feel after spending time together?

Forgive
~ Resentment, regret and guilt are natural responses to a threat
~ Holding on to these feelings drains your energy.
~ The feeling is telling you
~ Something bad happened
~ You need to fix it and/or protect yourself
~ Activity
~ Think about something you are resentful about.
~ How does holding on to the resentment help protect you?
~ What would happen if you let go of the resentment?
~ How can you forgive the person, or yourself, so it stops draining your energy

Project Happiness (Fake It ‘Til You Make It)
~ When you walk hunched over, looking at the ground you
~ Feel more depressed
~ Miss some of the simple pleasures
~ Miss opportunities to positively engage with people
~ Sit and walk sitting up
~ Look up from your phone
~ Make eye contact and smile
~ How else can you project happiness so others can tell you are happy?
Summary
~ Happiness doesn’t magically happen.
~ By choosing habits that promote happiness, you can start feeling happier.
~ Your thoughts, emotions, physical sensations and environment all contribute to your mood. Choose happy!

Dec 14 2019

53mins

Play

Post Stroke Psychosocial Issues

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448 – Post Stroke Psychosocial Issues
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director: AllCEUs
Podcast Host: Counselor Toolbox, Case Management Toolbox, NCMHCE Exam Review

Objectives
• Examine the prevalence of and risk factors for stroke
• Identify Post-Stroke Psychosocial Issues
Intro
• Many of our clients are at high risk of stroke
• People with anxiety disorders have a 33% higher risk of stroke partly due to HBP and lifestyle factors such as smoking
• Mood stabilizers were collectively associated with a significantly increased risk for stroke in participants with bipolar disorder
• Benzodiazepine use is associated with a 20% higher risk of stroke
• Almost 40% received 1 or a combination of drugs hypothesized to impair recovery during the first 30 days after stroke.(e.g. clonidine which reduces NE levels, atypical antipsychotics, benzodiazepines)
Risk for Stroke
• Smokers are 2-4x as likely to have a stroke
• Make blood sticky and more likely to clot, which can block blood flow to the heart and brain
• Damage cells that line the blood vessels
• Increase the buildup of plaque (fat, cholesterol, calcium, and other substances) in blood vessels
• Cause thickening and narrowing of blood vessels
• Alcohol increases stroke risk by 38%
• Causing A-Fib
• Development of atherosclerosis, or the hardening and narrowing of arteries
• Liver damage impairing blood clotting
• HBP during detoxification
Risk for Stroke
• Stimulant abuse increasing blood pressure
• High blood pressure
• Sleep apnea
• Non-sleep-apnea sleep disorders
• Age
• Diabetes doubles the risk of stroke
• Use of nonsteroidal anti-inflammatory drugs (NSAIDs), but not aspirin, may increase the risk of heart attack or stroke, particularly in patients who have had a heart attack
Mini-Strokes
• The signs and symptoms of a TIA resemble those found early in a stroke and may include sudden onset of:
• Weakness, numbness or paralysis in your face, arm or leg, typically on one side of your body
• Slurred or garbled speech or difficulty understanding others
• Blindness in one or both eyes or double vision
• Dizziness or loss of balance or coordination
• Sudden, severe headache with no known cause
• 70% reported that their TIA had long-term effects including memory loss, poor mobility, problems with speech and difficulty in understanding. 60% of people stated that their TIA had affected them emotionally

Assessments
• When
• Just before discharge
• One month after stroke
• Three months after stroke
• Six months after discharge
• What to look for
• Cognitive functioning
• Depression
• Anxiety
• Social withdrawal
• Changes in physical presentation
Impacts of Stroke
• General Physical Issues
• Reduced mobility / independence
• Vision problems
• Difficulty with ADLs
• Difficulty swallowing
• Sleep problems (36%)
• Chronic headaches
• Pneumonia
• Pain

Impacts of Stroke
• Difficulty understanding or expressing emotions
• Post-stroke depression (PSD) (67%)
• Post-stroke depression may remit as the person regains function
• Correlated with hospitalization, functional loss and particular areas of the brain being damaged
• Post-stroke anxiety (25%)
• Post-stroke emotional incontinence (PSEI) uncontrollable outbursts of involuntary laughing or crying for no apparent reason (34%)
• Functional status, serotonin polymorphisms, and low social support were related to PSEI at three months post-stroke
• SSRIs are often effective

Impact
• Post-stroke anger proneness (PSAP)
• serotonergic dysfunction seems to play a role in the development of PSAP
• Post-stroke fatigue (PSF) (50%-86%)
• Depression
• Neurological deficits
• Antidepressants
• Sleep disturbances
• Post-stroke pain
• Changes to thinking, memory and perception after stroke can impact how the person sees, hears and feels the world. This can affect how they feel about themselves and others

Impact
• Cognitive skills can be affected by emotional state or tiredness, but brain damage caused by stroke can also cause difficulties with
• Ability to learn new skills
• Ability to plan
• Ability to problem solve
• Attention – being able to concentrate and focus
• Orientation – knowing the day and time
• Short-term memory – knowing what happened recently
• Changes in working memory
• Intellectual fulfillment

Attention and Memory Intervention
• Minimum of 1 hour a day of actively listening to music showed recovery in both verbal memory and focused attention, as early as 3 months after a stroke
Impact
• Personality changes
• Repetitive behavior
• Disinhibition – tendency to say and do things that are socially inappropriate
• Impulsivity including sudden and socially inappropriate actions.

Impact
• Perception is the term that describes how you see, hear and feel the world. After a stroke, your perception can include changes to:
• Feeling contact, pain, heat or cold on the side of your body affected by stroke
• Judging distance
• Performing certain movements even without physical disability (apraxia)
• Recognising shapes and objects, or even your own body
• Seeing or feeling things only on one side – which can cause you to bump into things
• Watching TV or reading – can become difficult
• Vision – some people lose half their vision in each eye (hemianopia).

Impact
• Communication after stroke
• Difficulty in finding the right words or understanding what others are saying (aphasia or dysphasia)
• Weakness in the muscles that help speech (dysarthria)
• Dysfunction of the nerve connection between your brain and mouth, making speaking difficult (dyspraxia)
• Reading and writing problems caused by a weak writing hand or problems thinking or seeing.

Impact
• Physical changes after stroke
• Difficulty with gripping or holding things
• Fatigue or tiredness
• Incontinence – many types of incontinence can occur, but it can be caused by medication, muscle weakness, changes in sensations, thinking and memory
• Pain – can be caused by actual or potential damage to tissues (nociceptive pain) or by damage to nerves that then send incorrect messages to the brain (neuropathic pain)
• Restricted ability to perform physical activities or exercise
• Swallowing issues
• Vision problems
• Weakness or paralysis of limbs on one side of the body.

Impact
• Aphasia
• Affects about one third of the stroke population and 40% continues to have significant language impairment at 18 months post-stroke
• Persons with aphasia (PWA) are especially prone to psychosocial problems, such as
• Anxiety and depression
• Threatened identity
• Changes in interpersonal relationships
• Reduced social networks
• Unemployment
• Abandonment of leisure activities
Post Stroke Grief
• Losses
• Independence
• Function/hobbies/employment
• Home (if moved to an ALC)
• Self-Esteem
• Appearance
Post-Stroke Guilt
• Not being able to do things with kids/family/friends that they used to
• Needing assistance from caregivers/feeling like a burden

Post-Stroke Interpersonal Issues
• Social life
• Personality changes, anger, depression, fatigue may inhibit relationships
• Emotional Incontinence may cause social withdrawal
• Financial challenges
• Loss of employment
• Need for an ALC
• Need for PT/OT
Post-Stroke Caregiver Needs
• Caregivers should be assessed for their ability to provide care
• Regularly assess caregiver wellbeing
• Caregiver Strain Index
• Caregiver Burden Scale
• Support caregivers in balancing personal needs and caregiving responsibilities by providing community programs, respite care, and educational opportunities
Summary
• Stroke impacts people physically, affectively, cognitively, and interpersonally.
• It is important to explore the causes of mood or cognitive issues to identify the best interventions
• Brain damage
• Sleep dysfunction
• Cognitive issues
• Life changes

Dec 11 2019

59mins

Play

Gut Health and Mental Health (Re-Release)

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447 – Gut Health & Mental Health: The Impact of the Second Brain
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, Executive Director: AllCEUs.com

CEUs are available at allceus.com/counselortoolbox Get two free months of Therapy Notes by using the promocode CEU when you sign up for a free trial at TherapyNotes.com

Between writing notes, filing insurance claims, and scheduling with clients, it can be hard to stay organized. That’s why I recommend TherapyNotes. Their easy-to-use platform lets you manage your practice securely and efficiently. Visit TherapyNotes.com to get two free months of TherapyNotes by just using the promo code CEU when you sign up for a free trial at TherapyNotes.com.

Disclaimer
~ This is for educational purposes only and not intended to replace medical advice. Always have clients discuss any nutritional changes or supplements with a Registered Dietician or their primary care physician.
Objectives
~ BREIFLY review the findings from the research identifying the connection between the brain and the gut
~ Differentiate gut health from proper nutrition
~ Identify signs and consequences of poor gut health
~ Explore the bidirectional relationship between the brain and the gut (second brain)
~ Identify promising alternative approaches to treating mood (and other) disorders.
Overview
~ Depression is the leading cause of disability in the world according to the World Health Organization. The effectiveness of the available antidepressant therapies is limited.
~ Data from the literature suggest that some subtypes of depression may be associated with chronic low grade inflammation.
~ The uncovering of the role of intestinal microbiota in the development of the immune system and its bidirectional communication with the brain have led to growing interest on reciprocal interactions between inflammation, microbiota and depression.
~ The intestinal microbiota: A new player in depression? Encephale. 2018 Feb;44(1):67-74
Overview
~ Gut microbiota appear to influence the development of emotional behavior, stress- and pain-modulation systems, and brain neurotransmitter systems
~ Microbiota changes caused by illness, dietary changes, probiotics and antibiotics impact endocrine and neurocrine pathways (bottom up)
~ The brain can in turn alter microbial composition and behavior via the autonomic nervous system (“stress”) (top down)
~ Even mild stress can change the microbial balance in the gut, making the host more vulnerable to infectious disease and triggering a cascade of molecular reactions that feed back to the central nervous system

Overview
~ Exposure to chronic stress decreased the relative abundance of Bacteroides species and increased the Clostridium species in the caecum; and caused activation of the immune system (i.e. inflammation)
~ Children with Autism Spectrum Disorder treated with oral vancomycin —antibiotic to reduce Colostridium– had significant improvement in behavioral, cognitive and GI symptoms
~ Acute and chronic stress increase GI and BBB permeability through activation of mast cells (MCs)
Gut Inflammation and Mood
~ Inflammation of the GI Tract places stress on the microbiome through the release of cytokines and neurotransmitters.
~ Coupled with the increase in intestinal permeability, these molecules then travel systemically.
~ Elevated blood levels of cytokines TNF-a and MCP (monocyte chemoattractant protein) increase the permeability of the blood-brain barrier, enhancing the effects of rogue molecules from the permeable gut.
~ Their release influences brain function, leading to anxiety, depression, and memory loss.
Gut-Brain Connection
~ The vagus nerve is one of the biggest nerves connecting your gut and brain. It sends signals in both directions
~ In mice it was found that feeding them a probiotic reduced the amount of cortisol in their blood. However, when their vagus nerve was cut, the probiotic had no effect
~ Ingestion of Lactobacillus strain regulates emotional behavior and central GABA receptor expression in a mouse via the vagus nerve. Proc Natl Acad Sci U S A. 2011 Sep 20;108(38):16050-5
Overview
~ Alterations in the gut microbial community have been implicated in multiple host diseases such as obesity, diabetes, and inflammation, while recent evidence suggests a potential role of the microbiota-gut-brain axis in neuropsychiatric disorders, such as depression and anxiety.
~ Research has found that tweaking the balance of gut bacteria can alter animal’s brain chemistry and lead it to become either more bold, anxious or depressed.
Overview
~ A healthy gut absorbs nutrients sufficiently to support brain health.
~ A healthy gut prevents bacteria and inflammation causing agents to “leak” into the bloodstream
~ A healthy gut can adequately produce neurotransmitters
~ Gut bacteria manufacture about 95 percent of the body's supply of serotonin

Gut and Neurotransmitters
~ Lactobacillus and Bifidobacterium synthesize gamma-aminobutyric acid (GABA) from monosodium glutamate
~ E. coli, Bacillus and Saccharomyces produce norepinephrine
~ Candida, Streptococcus, Escherichia and Enterococcus produce serotonin
~ Bacillus and Serratia produce dopamine.
Gut and Neurotransmitters
~ Mucosal 5-HT (serotonin precursor) plays a direct role in the regulation of intestinal permeability
~ Norepinephrine (NE), epinephrine (E), dopamine (DA), and serotonin are able to regulate and control not only blood flow, but also affect gut motility, nutrient absorption, gastrointestinal innate immune system, and the microbiome
What is Leaky Gut
~ Leaky gut is when the cells lining your gut aren’t stuck together as tightly as they could be, allowing proteins, viruses, bacteria, and more to leak out of the gastrointestinal tract and into the bloodstream.
~ ‘Leaky gut' syndrome, is often described as an increase in the permeability of the intestinal mucosa, which could allow bacteria, toxic digestive metabolites, bacterial toxins, and small molecules to ‘leak' into the bloodstream.

Leaky Gut
~ Lipopolysaccharide (LPS) is an inflammatory toxin made by certain bacteria.
~ TNF-alpha is an inflammatory cytokinine also made in the gut, which has been linked with depression and a reduction in serotonin production Inflammation and high LPS in the blood have been associated with a number of brain disorders including severe depression, dementia and schizophrenia
~ These molecules increase inflammation and which trigger the HPA-Axis
~ The HPA-Axis releases cortisol and suppresses serotonin and sex hormones.
Leaky Gut
~ When inflammatory agents “leak” into the bloodstream it also increases the permeability of the Blood-Brain-Barrier letting potential inflammatory molecules into the brain.
~ Inflammation is associated with major depressive disorder (MDD) and suicidal behavior.
~ Those with MDD and a recent suicide attempt had higher levels of gut permeability markers. Leaky gut biomarkers in depression and suicidal behavior. Acta Psychiatr Scand. 2018 Oct 22

Gut-Brain Connection
Interventions
~ “Psychobiotics”, which are live organisms, when ingested may produce health benefits in patients suffering from mood disorders
~ In a study of 124 healthy volunteers (mean age 61.8 years), those who consumed a mix of specific psychobiotics (Lactobacillus helveticus and bifidobacterium longum) exhibited less anxiety and depression
~ Children with ADHD were substantially improved on either an AFC-free diet, or by dietary supplementations with polyunsaturated fatty acids (PUFA), iron and zinc

Interventions
~ Nutrition activates hormonal, neurotransmitter and signaling pathways in the gut which modulate brain functions like appetite, sleep, energy intake, reward mechanisms, cognitive function and mood.
~ In a study of older adults it was found that healthy nutrition can reduce the incidence of depression from 40-50%
~ Healthy foods such as olive oil, fish, fruits, vegetables, nuts, legumes, poultry, dairy and unprocessed meat (no nitrates or nitrites, hormone and steroid free) have been inversely associated with depression risk
Interventions
~ Magnesium, calcium, iron and zinc are inversely associated with depression
~ Chromium leads to a secondary synthesis of serotonin, norepinephrine and melatonin and have been associated with reductions in depression
~ Vitamin C was also found to have an equivalent effect as amitriptyline (antidepressant)
~ Folate, B12 and B6 combine to enhance cognitive performance and reduces the risk of depression
~ Vitamin D is also associated with reduced depression
~ Calcium and copper
Interventions
~ Several medications (metformin, gram-negative antibiotics), showed a certain potential to treat depression
~ Lactobacillus acidophilus induced the expression of the cannabinoid 2 and μ-opioid 1 receptors in the colonic epithelium
~ Lactobacillus farciminis inhibited stress-induced visceral hypersensitivity
~ Ingestion of Lactobacillus casei Shirota, Lactobacillus and B. Longum reduced anxiety and depressive symptoms and cortisol levels
~ Prebiotics result in lower cortisol levels and improved attention to positive stimuli (lactose, fiber)

Interventions
~ Lactobacillus helveticus is a type of lactic acid bacteria that’s naturally found in the gut. It’s also found naturally in certain foods, like:
~ Italian and Swiss cheeses (e.g., Parmesan, cheddar, and Gruyère)
~ Milk, kefir, and buttermilk
~ Fermented foods (e.g., Kombucha, Kimchi, pickles, olives, and sauerkraut)

Interventions
~ Elevated hypothalamic-pituitary-adrenal (HPA) axis response and depression in GF rats can be reversed by administering a single bacterium, Bifidobacterium infantis
Interventions
~ Increase Bifidobacteria
~ Take probiotics esp. Lactobacillus and Bifidobacteria
~ Eat high-fiber foods such as apples, artichokes, blueberries, almonds and pistachios to feed the good bacteria
~ Eat prebiotic foods (carbs that help healthy bacteria grow). Onions, garlic, bananas and chickory root
~ Eat polyphenols from foods such as cocoa, green tea and red wine
~ Eat whole grains such as oats and barley
~ Eat fermented foods such as yogurt and kimchi
~ Exercise
Summary
~ How does anxiety or depression perpetuate itself via the gut-brain axis?
~ How do gut disorders like IBS or Chron’s impact mood?
~ How do autoimmune disorders contribute to depression and anxiety?
~ How does HPA-Axis dysregulation contribute to leaky gut?
Insulin Resistance
~ Insulin resistance is when cells in your muscles, fat, and liver don’t respond well to insulin and can’t easily take up glucose from your blood.
~ This can eventually lead to higher than normal blood glucose levels or “prediabetes”
~ obesity, especially too much fat in the abdomen and around the organs, called visceral fat, is a main cause of insulin resistance
~ belly fat makes hormones and other substances that can contribute to chronic, or long-lasting, inflammation in the body.
~ Risk factors
~ Obesity
~ Sedentary lifestyle
~ Sleep issues

~ Neuroimmune imbalances have been found as potential biomarkers of stress, anxiety, depression, systemic inflammation and leaky gut, which may result in the imbalance between regulatory and proinflammatory T cells
~ Methods Mol Biol. 2018;1781:77-85. Neuroimmune Imbalances and Yin-Yang Dynamics in Stress, Anxiety, and Depression

~ Chapter Fifteen – The Importance of Diet and Gut Health to the Treatment and Prevention of Mental Disorders International Review of Neurobiology Volume 131, 2016, Pages 325-346
~ Perturbations of the gut microbial community have already been implicated in multiple host diseases such as obesity, diabetes, and inflammation, while recent evidence suggests a potential role of the microbiota-gut-brain axis in neuropsychiatric disorders, such as depression and anxiety. Microbes and mental health: A review. Brain Behav Immun. 2017 Nov;66:9-17

~ Inflammation is associated with major depressive disorder (MDD) and suicidal behavior. According to the ‘leaky gut hypothesis', increased intestinal permeability may contribute to this relationship via bacterial translocation across enterocytes. gut Those with MDD and a recent suicide attempt had higher levels of gut permeability markers. Leaky gut biomarkers in depression and suicidal behavior. Acta Psychiatr Scand. 2018 Oct 22

~ —Various afferent or efferent pathways are involved in the MGB axis. Antibiotics, environmental and infectious agents, intestinal neurotransmitters/neuromodulators, sensory vagal fibers, cytokines, essential metabolites, all convey information about the intestinal state to the CNS. Conversely, the HPA axis, the CNS regulatory areas of satiety and neuropeptides released from sensory nerve fibers affect the gut microbiota composition directly or through nutrient availability. Such interactions appear to influence the pathogenesis of a number of disorders in which inflammation is implicated such as mood disorder, autism-spectrum disorders (ASDs), attention-deficit hypersensitivity disorder (ADHD), multiple sclerosis (MS) and obesity.

~ Neuro/immune-active substances derived from the intestinal lumen can penetrate the gut mucosa, be transported by blood, cross the blood-brain-barrier (BBB) and affect the CNS
~ Gut microbiota can influence CNS function through their ability to synthesize or mimic a range of host-signaling neuroactive molecules s, such as acetylcholine (Ach) gamma-aminobutyric acid (GABA), histamine, melatonin and 5-hydroxytryptamine (5-HT, serotonin)16.

~ “Psychobiotics”, which are live organisms, when ingested may produce health benefits in patients suffering from mood disorders. In a study of 124 healthy volunteers (mean age 61.8 years), those who consumed a mix of specific psychobiotics (Lactobacillus helveticus and bifidobacterium longum) exhibited less anxiety and depression
~ Children with ADHD were substantially improved on either an AFC-free diet67, or by dietary supplementations with polyunsaturated fatty acids (PUFA), iron and zinc68

~ Recent studies revealed new mediators of both energy homeostasis and mood changes (i.e. IGF-1, NPY, BDNF, ghrelin,leptin, CCK, GLP-1, AGE, glucose metabolism and microbiota)
~ CCK
~ is a gut hormone that is released in the small intestine when fats and proteins are eaten.
~ One of the most powerful panic inducers
~ Ghrelin
~ Increased by the consumption of carbohydrates
~ Regulates CNS development
~ Exerts an antidepressant effect
~ Displays dopaminergic properties

~ Leptin
~ Triggered by a high concentration fructose diet
~ Highly associated with depressive symptoms, sleep disturbances and decreases in feeding-stimulated dopamine release
~ Triggers increased food intake
~ Seems to regulate response to psychiatric medications
~ Intranasal IGF (Insulin growth factor-1) administration has been shown to have comparable effects to SSRIs
~ Insulin resistance has been linked to PI3K signaling which is central in the development of depressive symptoms

~ The animal-based diet increased the abundance of bile-tolerant microorganisms (Alistipes, Bilophila and Bacteroides) and decreased the levels of Firmicutes that metabolize dietary plant polysaccharides (Roseburia, Eubacterium rectale and Ruminococcus bromii). Diet rapidly and reproducibly alters the human gut microbiome Nature volume505, pages559–563 (23 January 2014)

Dec 07 2019

57mins

Play

Relationship Insecurities: Causes, Consequences and Interventions

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446 – Relationship Insecurities
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC, NCC
Executive Director, AllCEUs
*Based in part on Love Me Don’t Leave Me by Michelle Skeen, PsyD.

Objectives
• Identify signs of relationship insecurities
• Explore causes of relationship insecurities
• Identify at least 5 interventions to address relationship insecurities

Signs of Relationship Insecurities
• Difficulty trusting your partner
• Comparing yourself to your partner’s exes or random people in the community
• Requiring frequent reassurance that you are enough
• Anxiety when separated
• Internalizing negative thoughts creating self-fulfilling prophesies
• A feeling of distance or detachment
• Reading negative into everything your partner says

Relationship Bricks
• Often past relationships cause us to build a wall around our heart
• Have clients write the name of people from prior relationships on bricks and put them in a backpack
• Have them put on the backpack and go on a nature walk for 15 minutes.
• When you get back, ask about all of the things they noticed on the walk and how carrying that heavy backpack kept them from being mindful

Causes of Relationship Insecurities
• Insecurities indicates anxiety or fear of being hurt or abandoned
• Prior learning (Unpack those bags—1 bag/person/session)
• Create paper “bags” for each past relationship brick
• Write a pros and cons list of that relationship
• Write a goodbye letter to that person/relationship detailing what happened, how you felt and how it impacted you
• In sharing what is in the bag, take back your power.
• Instead of saying “You made me feel” say “I felt”
• Instead of a narrative of abandonment and betrayal because of personal inadequacies, explore other reasons the other person to left the relationship
• Explore forgiveness in terms of choosing not to allow that person to continue to hurt you

Causes of Relationship Insecurities
• Insecurities indicates anxiety or fear of being hurt or abandoned
• Prior learning (Unpack those bags—1 bag/person/session)
• When you are ready to let go of that anger and hurt, take the brick out of the backpack.
• Each week notice how much lighter the backpack feels and how much less energy it takes to tote around

Causes of Relationship Insecurities
• Insecurities indicates anxiety or fear of being hurt or abandoned
• Trying to master a prior failed relationship
• Make a Venn diagram

Causes of Relationship Insecurities
• Insecurities indicates anxiety or fear of being hurt or abandoned
• Low self-esteem (Self-validation)
• Collage
• Best friend activity
• Values activity
• Sell yourself
• People may have difficulty developing self-esteem based on a pathological inner critic
• Thought stopping
• Handling hecklers
• Validate in the present / check for accuracy
• Embrace imperfection and synergy

Causes of Relationship Insecurities
• Insecurities indicates anxiety or fear of being hurt or abandoned
• Poor communication
• Stop assuming you know and expecting mind reading
• Mindfulness
• Lack of Connection
• Intentional activity—Make a list of all of the things you like to do. Intentionally spend time with each other each day.

Causes of Relationship Insecurities
• Insecurities indicates anxiety or fear of being hurt or abandoned
• Imbalance in power (She does everything… If he leaves, I will not be able to survive.)
• Address anxieties about dependency or helplessness
• Develop support systems and strategies and disaster plans

Causes of Relationship Insecurities
• Insecurities indicates anxiety or fear of being hurt or abandoned
• Jumping to conclusions/Personalization
• Relationship Assumptions “Family Feud”— We surveyed a bunch of people. What are the top 3 explanations for this…Smells like perfume, is late, doesn’t text back right away, doesn’t want to do anything lately, lost interest in sex

Interventions
• Address emotional vs. factual reasoning
• Grieve past losses
• Partners
• Friends
• Parents
• Heart-Break Pot (break into large pieces)
• Using paint pens and markers write on the inside of the broken pieces their feelings about the loss
• On the outside of the pieces name or draw their sources of support.
• Glue back together

Interventions
• Love yourself and believe you deserve love
• Love languages know yours and your partners
• Touch
• Quality time
• Acts of service
• Words of affirmation
• Gifts

Core Principles of Relationships
• Uniqueness of the relationship from others
• Celebrate the uniqueness—How is this time different?
• Integration of beliefs, behaviors and motivations
• Relationships are about synergy
• What beliefs, motivations and behaviors do you share?
• What beliefs, motivations and behaviors do you each have that compliment each other?
• Temperament
• Tendencies
• Values
Core Principles of Relationships
• Mutually envisioned trajectory
• Relationship goals
• Relationship activities
• Relationship pace
• Positive and negative evaluation
• Emphasize the positives
• Mitigate the negatives
• Responsiveness
• Pay attention and be responsive to your needs
• Pay attention, ask about and be responsive to your partner’s needs

Core Principles of Relationships
• Communication and challenge resolution
• Develop rules for discussing and resolving challenges
• Maintenance
• Ensure both partners are engaging in self and relationship maintenance activities
• Recognize the importance of self-maintenance
Core Principles of Relationships
• Shared goals and needs
• Discuss shared goals and needs
• Compromise on differing goals and needs (i.e. money, sex, activities)
• Knowing and exceeding relationship expectations/standards
• Know what a “good” relationship looks like to you and your partner and strive to exceed expectations
Mindfulness Questions for Clients

• What am I feeling?
• What is triggering it?
• Am I safe (emotionally and physically) now? If not, what do I need to do?
• Is this bringing up something from the past?
• How is this situation different?
• How am I different?
• How can I silence my inner critic?
• What would be a helpful reaction that…
• Moves you more toward your goals
• Moves you toward a positive emotional experience

Summary
• Low self esteem and failed prior relationships can cause problems in future relationships
• Transference, cognitive distortions, low self esteem and poor relationship maintenance can all contribute to relationship insecurities
Excellent Resources for Clients

I absolutely love both of these books. Google previews are available on the New Harbinger website: https://NewHarbinger.com
Remember to use promocode 1168SNIPES to get 25% off your entire order. (Clients can use the code too)

Dec 01 2019

50mins

Play

Biopsychosocial Impact of Malnutrition and Strategies for Intervention and Prevention

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445 – Malnutrition Impact and Intervention
Presented by: Dr. Dawn-Elise Snipes Executive Director, AllCEUs
Podcast Host: Counselor Toolbox & NCMHCE Exam Review Podcast
Objectives
• Review the nutritional building blocks for health and wellness
• Examine how these nutrients (or lack thereof) contribute to neurotransmitter balance
• Identify several nutrient dense foods that you can include in your diet
• Note: Nutritional changes should always be made under the supervision of a registered dietician or your primary physician. This presentation is for general informational purposes only.
Why I Care/How It Impacts Recovery
• In early recovery, nearly every person’s neurotransmitters are out of balance.
• This causes feelings of depression, apathy, anxiety, and/or exhaustion.
• Understanding why you feel the way you do is the first step
• Figuring out how to help yourself feel better is the next
What are Neurotransmitters
• The human brain is composed of roughly 86 billion neurons.
• These cells communicate with each other via chemical messengers called neurotransmitters.
• Neurotransmitters regulate
• Mood
• Cravings, addictions
• Energy
• Libido
• Sleep
• Attention and concentration
• Memory
• Pain Sensitivity

Neurotransmitters Cont…
• About 86% of Americans have suboptimal neurotransmitter levels — our unhealthy modern lifestyle being largely to blame.
• Chronic stress, poor diet, environmental toxins, drugs (prescription and recreational), alcohol, nicotine, and caffeine can cause neurotransmitter imbalances.

Think about it
• How do you feel when you are not getting enough oxygen? (Hint: You yawn)
• What effect might a low carb diet have on mood?
• What effect might a low protein diet have on mood? (Most non-vegan Americans get plenty of protein)
• Why do doctors test for vitamin-D levels in patients with depressive symptoms?

Effect of Nutrition on Brain Function

• Early-life malnutrition is highly correlated with neurodevelopment and adulthood neuropsychiatric disorders
• Improvements in nutrition are known to bring tangible benefits and many diseases and conditions can be prevented, modulated or ameliorated by good nutrition
• Iodine is necessary for energy metabolism in the brain cells.
• Vitamin B1 is necessary for the utilization of glucose in the brain.
• Vitamins B6 and B12, among others, are directly involved in the creation of neurotransmitters.
• Nerve endings contain the highest concentrations of vitamin C in the human body.
• Vitamin E is necessary for effective transmission of neurological signals
Effect of Nutrition on Brain Function

• Eating foods with a low glycemic index improves the quality and duration of intellectual performance http://www.glycemicindex.com/
• Dietary proteins contribute to good brain function
• Tryptophan is necessary for the creation of serotonin and melatonin
• Brain cell functioning requires omega-3 fatty acids.
• Omega-3s have also been found to help prevent and/or treat mood disorders, particularly depression
• Iron is necessary to ensure oxygenation and for the synthesis of neurotransmitters.
Effect of Nutrition on the Person
• Reduced libido
• Low energy
• Impaired relationships
• Impaired concentration/attention
• Sleep disturbances

Amino Acids (Protein Building Blocks)
Essential Amino Acids
• Must be acquired from diet:
• Valine
• Isoleucine
• Leucine
• Lysine
• Methionine
• Phenylalanine
• Threonine
• Tryptophan
Complete vs. Incomplete Proteins
• Complete proteins are those that contain all essential amino acids:
• Meat
• Fish
• Dairy products (milk, yogurt, whey)
• Eggs
• Quinoa*
• Buckwheat*
• Chia seed*
• Spirulina*
Complete vs. Incomplete Proteins
• Incomplete proteins are those that don’t contain all 9 essential aminos
• Nuts & seeds
• Legumes
• Grains
• Vegetables
Tryptophan
• Food Sources: Egg whites, chia seeds, sesame seeds, wheat germ, turkey
• Needs Iron, magnesium, B6 and Vitamin C to convert tryptophan to serotonin
• More readily absorbed when eaten with high carbohydrate meal.
• Insulin causes competing amino acids to be absorbed into the tissues
• Only precursor to serotonin

• Focus on Tryptophan by John W. Crayton, MD, Professor of Psychiatry at Loyola University Medical School, Maywood, Illinois. NOHA* NEWS, Winter 2001
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908021/ L-Tryptophan: Basic Metabolic Functions, Behavioral Research and Therapeutic Indications Int J Tryptophan Res. 2009; 2: 45–60.

Important Non-Essential Amino Acids
• Arginine helps with insomnia
• Glutamine àGlutamateàGABA
• Theanine: Increases GABA and serotonin levels (Green Tea)
• Tyrosine: Used to make dopamine and norepinepherine and thyroid hormones.
• Parmesan, mozzarella, swiss cheeses, lean beef, pork or salmon, tuna or mackerel, chicken breast, pumpkin seeds, peanuts, sunflower seeds, dairy, beans

B Vitamins
• Low levels of B vitamins may be linked to depression.
• Vitamin B3 (Niacin)
• Food sources: Poultry, fish, meat, whole grains, and fortified cereals
• What it does:
• Helps with digestion and changing food into energy
• Helps body conserve tryptophan and convert it into serotonin
B Vitamins
• Vitamin B 5 Pantothenic Acid
• Food sources include: beef, mushrooms, eggs, vegetables, legumes, nuts, pork, saltwater fish, whole rye flour, whole wheat
• What it does
• Help control the secretion of cortisol
• Help with migraines and chronic fatigue syndrome
• Supplementation in very high doses can increase in panic attacks
B Vitamins
• Vitamin B6
• Food sources include: Fortified cereals, fortified soy-based meat substitutes, baked potatoes with skin, bananas, light-meat poultry, eggs, peas, spinach
• What it does: Supports your nervous system by helping the body break down proteins.
• Vitamin B9- Folate
• What it does: May reduce depression when taken in conjunction with vitamin B12.
• Food sources include: Spinach, kale, lentils, asparagus, black eyed peas, broccoli, avocado, French bread

B Vitamins
• Vitamin B12
• Food sources include: Beef, eggs, shellfish, salmon, poultry, soybeans, yogurt, tuna and fortified foods
• What it does:
• Helps with cell division and helps make red blood cells.
• Deficiency can lead to mood problems, including depression, anxiety, poor memory, difficulty concentrating

http://www.mayoclinic.org/diseases-conditions/depression/expert-answers/vitamin-b12-and-depression/faq-20058077
http://www.calmclinic.com/blog/calm-clinic-review-b-vitamins
Fava M, Borus JS, Alpert JE, Nierenberg AA, Rosenbaum JF, Bottiglieri T. Folate, vitamin B12, and homocysteine in major depressive disorder. Am J Psychiatry. 1997;154:426-428.
Alpert JE, Mischoulon D, Nierenberg AA, Fava M. Nutrition and depression: focus on folate. Nutrition. 2000;16:544-546

Vitamin C
• Food sources include: Citrus, berries, tomatoes, potatoes, broccoli, cauliflower, brussels sprouts, bell peppers, cabbage, spinach
• What it does:
• Promotes a healthy immune system
• Helps make collagen.
• It's also needed to regulate norepinepherine, dopamine and serotonin
• Associated with significant reductions in anxiety.

Pak J Biol Sci. 2015 Jan;18(1):11-8. Effects of Oral Vitamin C Supplementation on Anxiety in Students: A Double-Blind, Randomized, Placebo-Controlled Trial
Wang Y, Liu XJ, Robitaille L, Eintracht S, MacNamara E, Hoffer LJ. Effects of vitamin C and vitamin D administration on mood and distress in acutely hospitalized patients. Am J Clin Nutr. 2013 Sep;98(3):705-11.
Mazloom Z, Ekramzadeh M, Hejazi N. Efficacy of supplementary vitamins C and E on anxiety, depression and stress in type 2 diabetic patients: a randomized, single-blind, placebo-controlled trial. Pak J Biol Sci. 2013 Nov 15;16(22):1597-600.
http://www.livestrong.com/article/525632-link-between-vitamin-c-deficiency-anxiety/
J Neurochem. 2013 Feb;124(3):363-75. Behavioral and monoamine changes following severe vitamin C deficiency.
Vitamin D-3 (Sunlight Vitamin)
• Food sources include: Fortified milk, cheese, and cereals; egg yolks; salmon, cod liver oil
• What it does:
• Maintains bone health and helps the body process calcium;
• Important for immune system function
• Related to a reduction in depression as it affects the amount of chemicals called monoamines, such as serotonin, and how they work in the brain

J Intern Med. 2008 Dec;264(6):599-609. Effects of vitamin D supplementation on symptoms of depression in overweight and obese subjects: randomized double blind trial.
J Chem Neuroanat. 2005 Jan;29(1):21-30. Distribution of the vitamin D receptor and 1 alpha-hydroxylase in human brain.
Am J Geriatric Psychiatry 2006Dec; 14(12): 1032-1040 Vitamin D Deficiency Is Associated With Low Mood and Worse Cognitive Performance in Older Adults

Calcium
• Food sources include: Dairy products, broccoli, dark leafy greens, and fortified dairy, grains and juices
• What it does:
• Helps build and maintain strong bones and teeth.
• Helps muscles work.
• Supports cell communication.
• Deficiency causes nerve sensitivity, palpitations, irritability, anxiety, depression and insomnia
• Excess can cause depression and difficulty concentrating

A Beneficial Effect of Calcium Intake on Mood Kamyar Arasteh, Ph.D. Journal of Orthomolecular Medicine
Chromium
• Food sources include: Some cereals, beef, turkey, fish, broccoli, and grape juice
• What it does:
• Helps maintain normal blood sugar (glucose) levels
• Influences the release of norepinepherine and serotonin
• Researchers at Duke University have found that a daily dose of 600 mcg of chromium led to a significant decrease in symptoms among those with atypical depression especially their tendency to overeat

Davidson JR, Abraham K, Connor KM, McLeod MN. Effectiveness of chromium in atypical depression: a placebo-controlled trial. Biol Psychiatry. 2003;53:261-264. Abstract
Copper
• Food sources include: Seafood, cashews, sunflower seeds, wheat bran cereals, whole-grain products, avocados, and cocoa products
• What it does:
• Helps break down iron
• Make red blood cells
• Helps produce energy for cells
• Helps maintain bones, connective tissue, and blood vessels.
• High copper and low zinc can contribute to depression

Indian J Physiol Pharmacol. 1991 Oct;35(4):272-4. Levels of copper and zinc in depression.

Iodine
• Food sources include: Iodized salt, some seafood, kelp, and seaweed
• What it does: Works to make thyroid hormones.
• Deficiency: Weight gain, fatigue, difficulty concentrating, depression

Philip NS, et al. “Pharmacologic Approaches to Treatment Resistant Depression: A Re-examination for the Modern Era,” Expert Opinions in Pharmacotherapy (April 2010): Vol. 11, No. 5, pp. 709–22
Iron
• Food sources include: Leafy green vegetables, beans, shellfish, red meat, eggs, poultry, soy foods, and some fortified foods
• What it does: Carries oxygen to all parts of the body through red blood cells, synthesis of neurotransmitters. (Helps fight fatigue and brain fog)

• Indian J Psychiatry. 2008 Apr-Jun; 50(2): 77–82. Understanding nutrition, depression and mental illnesses

Magnesium
• Food sources include: Whole grains, leafy green vegetables, almonds, Brazil nuts, soybeans, halibut, peanuts, hazelnuts, lima beans, black-eyed peas, avocados, bananas, cocoa
• What it does:
• Helps muscles and nerves work
• Optimizes thyroid function
• Steadies heart rhythm
• Maintains bone strength
• Helps the body create energy

http://kellybroganmd.com/magnesium-most-important-female-supplement/
Pharmacol Rep. 2013;65(3):547-54. Magnesium in depression.
Rapid recovery from major depression using magnesium treatment Eby, George A. et al. Medical Hypotheses , Volume 67 , Issue 2 , 362 – 370

Omega 3 Fatty Acids
• Food sources include: Walnuts 1/3c., chia seeds 4t., 2/3 cup mackerel, 9 ounces tuna, 1 T salmon fish oil
• Use canola, olive and flaxseed oil to increase omega-3s
• Flax Seeds are not nearly as efficient at producing positive effects because the ALA needs to be converted to EPA and DHA to be useful
• What it does:
• Helps your body transmit nerve signals
• Maintain serotonin balance
• Reduce inflammation
Omega 3s and Omega 6s
• “The ideal ratio is one to one or two to one, omega-6 to omega-3.”
• The American diet has been flooded with omega-6 fatty acids, mostly in the form of vegetable oils such as corn oil and safflower oil.”

Artemis Simopolous, MD, who directs the Center for Genetics, Nutrition and Health, in Washington, D.C http://www.webmd.com/diet/healthy-kitchen-11/omega-fatty-acids?page=3
J Clin Psychiatry. 2009 Dec; 70(12): 1636–1644. A Double-Blind Randomized Controlled Trial of Ethyl-Eicosapentaenoate (EPA-E) for Major Depressive Disorder
Nemets B, Stahl Z, Belmaker RH. Addition of omega-3 fatty acid to maintenance medication treatment for recurrent unipolar depressive disorder. Am J Psychiatry. 2002;159:477-479.
Cott JM. Omega-3 essential acids and psychiatric disorders. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Symposium 19B.
http://www.health.harvard.edu/staying-healthy/why-not-flaxseed-oil
http://www.doctoroz.com/article/daily-dose-omega-3

Lycopene
• What it does: Antioxidant, prevents brain degradation with age
• Food sources include (Reds): Watermelons, pink grapefruits, apricots, tomatoes (cooked is better)

• J Affect Disord. 2013 Jan 10;144(1-2):165-70. A tomato-rich diet is related to depressive symptoms among an elderly population aged 70 years and over: a population-based, cross-sectional analysis.
https://draxe.com/lycopene/

Potassium
• Food sources include: Broccoli, potatoes with the skin, prune juice, orange juice, leafy green vegetables, bananas, raisins, and tomatoes
• What it does: Required to activate neurons; helps maintain a healthy balance of water
• “Without the electrical charge sparked by potassium, neurotransmitters like serotonin cannot be utilized to make us feel better.”

• Br J Nutr. 2008 Nov;100(5):1038-45. doi: 10.1017/S0007114508959201. Epub 2008 May 9. Dietary electrolytes are related to mood.
• Nat Neurosci. 2006 Sep;9(9):1134-41. Epub 2006 Aug 13. Deletion of the background potassium channel TREK-1 results in a depression-resistant phenotype.
• McCleane, G. J. and Watters, C. H. (1990), Pre-operative anxiety and serum potassium. Anaesthesia, 45: 583–585.

Selenium
• Food sources include: Brazil nuts, Brown rice, turkey, Chicken, Spinach, sunflower seeds
• What it does:
• Antioxidant
• Regulates thyroid hormone
• Helps regulate circadian rhythm
• Caution toxicity is easy. Upper limits are only 55-60mcg for adult females

• The Importance of Selenium to Human Health. Margaret P. Rayman Centre for Nutrition and Food Safety, School of Biological Sciences, University of Surrey, Guildford GU2 5XH

Zinc
• Food sources include: Red meat, fortified cereals, oysters, almonds, peanuts, chickpeas, soy foods, and dairy products
• What it does:
• Supports immune, reproductive and nervous systems,
• Balances with copper.
• Deficiency: Anxiety

• The Neuropsychotherapist. Kim Uildriks (2016); 4(12): 16-17. Clinical Implications of Zinc Deficiency for Anxiety.
Helpful Notes
• When you get nutrients from real foods
• There is much less danger of toxicity
• It is more bioavailable in most instances because it is in a useful ratio
• Nature is all about balance—increases in one may decrease others
• Buy/grow organic fruits and vegetables to maximize nutrient value
• Download an app such as Spark People or MyFitnessPal to track your nutrition.
• Small changes are longer lasting. Try to add more of one type of food that has multiple vitamins.

Summary
• Deficiencies of nutrients such as calcium, magnesium, zinc, omega-3 fatty acids, and vitamins A, B-complex, C, D3 and E are common, especially if you eat refined foods.
• There are a variety of different vitamins and minerals involved in addiction and mental health disorders
• It is not always about increasing a vitamin or mineral. Sometimes you need to decrease it.
• Human brains try to maintain homeostasis and too much or too little can be bad
• A balanced diet will provide the brain the necessary nutrients in synergystic combinations
Nutrient Summary
Other Resources
• An overlooked connection: serotonergic mediation of estrogen-related physiology and pathology Leszek A RybaczykEmail author, Meredith J Bashaw, Dorothy R Pathak, Scott M Moody, Roger M Gilders and Donald L Holzschu. BMC Women's Health BMC series open, inclusive and trusted 2005 5:12
• Isr Med Assoc J. 2003 Sep;5(9):653-8. Aggression: the testosterone-serotonin link. Birger M1, Swartz M, Cohen D, Alesh Y, Grishpan C, Kotelr M.
• Phytother Res. 2011 Nov;25(11):1636-9.
• Nutr Neurosci. 2013 Jul 23.

Nov 30 2019

52mins

Play

Case Study: PTSD Assessment and Intervention with the PACER Method

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444 – PTSD Case Study
Using the PACER Method
Counselor Toolbox Podcast Episode 444
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
Podcast Host: Counselor Toolbox and Case Management Toolbox
Objectives
• Review a case study using the transdiagnostic, transtheoretical PACER approach

• As they say on Law and Order…
• The following story is fictional and does not depict any actual person or event.”
Case
• John is 48 years old. When he was 24 his house caught on fire due to faulty Christmas lights which were accidentally left on when the family went to bed. His wife and 2 children died in the fire. He has remarried and had 3 more children (14, 12, 9) since the event and continues to experience PTSD related symptoms. His wife insisted he come to counseling after he was caught having another affair.

Summary
• PTSD causes a variety of physical, cognitive, emotional and interpersonal alterations to protect the person from future trauma.
• Until the trauma is integrated the HPA-Axis will often stay activated and have exaggerated responses to reminders of the trauma.
• Persistent activation can lead to sleep deprivation, irritability, anger and hypocortisolism altering the levels of testosterone, thyroid hormones and neurotransmitters.
• Sexual activity and risk taking both increase dopamine
• It is important to explore all behaviors and symptoms through the lens of how they might be a reaction to the trauma, to hypocortisolism or something totally different.

Nov 27 2019

48mins

Play

Sleep Disturbances- Impact and Intervention

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443 – Sleep Disturbances:
Impact and Intervention
Presented by: Dr. Dawn-Elise Snipes Executive Director, AllCEUs
Podcast Host: Counselor Toolbox & NCMHCE Exam Review

Objectives
• Learn about sleep
• The function of sleep
• Sleep cycles
• How much is enough
• How lack of sleep contributes to feelings of depression, anxiety and irritability
• Understand the connection between sleep and circadian rhythms
• Learn techniques for sleep hygiene

Impact of Sleep Disturbance
• People whose circadian rhythms are off
• Have a difficult time getting restful sleep
• Usually have higher cortisol levels
• Often report being tired at all the wrong times
• Have difficulty concentrating
• Confuse sleep and hunger cues
What is the Function of Sleep
• Sleep is time to rest and restore
• Adequate sleep improves memory and learning, increases attention and creativity, and aids in concentration and decision making.
• Toxins that accumulate in the brain are thought to be cleared out during sleep
• Healing and repair of cells takes place during sleep
• Sleep helps to maintain the balance of hormones in the body:
• Ghrelin and leptin, which regulate feelings of hunger and fullness
• Insulin, which is responsible for the regulation of glucose in the blood

Functions cont…
• Sleep deficiency is also linked to a higher risk of
• Cardiovascular disease
• Stroke
• Diabetes
• Kidney disease
• Sleep deprivation is correlated to
• Difficulty concentrating
• Irritability
• Fatigue/Loss of energy

Understanding Sleep Cycles
• Stage 1 NREM sleep is when you drift in and out of light sleep and can easily be awakened.
• Stage 2 NREM brainwaves slow with intermittent bursts of rapid brain waves, the eyes stop moving, the body temperature drops and the heart rate begins to slow down. 
• This stage usually lasts for approximately 20 minutes
• Stage 3 NREM sleep, also known as deep sleep or delta sleep, is marked by very slow delta brainwaves. There is no voluntary movement. You are very difficult to wake.
• This stage usually lasts for approximately 30 minutes
• The largest percentage of Deep Sleep comes in the early part of the total night's sleep pattern
Understanding Sleep Cycles
• REM Sleep (Rapid Eye Movement) is characterized by temporary paralysis of the voluntary muscles and fast, irregular breathing, inability to regulate body temperature, faster brain waves resembling the activity of a person that is awake.
• Most dreams occur during REM sleep

How Much is Enough?
Sleep and Hormones
• Estrogen usually improves the quality of sleep, reduces time to fall asleep, and increases the amount of REM sleep
• Too little or too much testosterone may affect overall sleep quality
• Cortisol is your stress hormone and prevents restful sleep
• Thyroid hormones which are too high can cause insomnia and too low can cause fatigue and lethargy

Nutrition and Sleep
• Tryptophan is used to make serotonin
• Serotonin is used to make melatonin
• Melatonin functions to help you feel sleepy
• Caffeine is a stimulant with a 6-hour half life
• Nicotine is a stimulant with a 2-hour half life
• Decongestants are stimulants with a 2-hour half life
• Antihistamines make you drowsy but contribute to poor quality sleep
• Alcohol blocks REM sleep and can cause sleep apnea
Nutrition cont…
• Eat a high protein dinner to ensure you have enough tryptophan in the body
• Make sure you are getting enough
• Selenium
• Vitamin D
• Calcium
• Vitamin A
• Magnesium
• Zinc

Function of Sleep
• Allows the brain to focus on rebuilding and repairing
• Animals deprived entirely of sleep lose all immune function and die in just a matter of weeks.
• Prisoners deprived of sleep entirely often develop psychotic symptoms
• New parents deprived of sleep have difficulty with memory and concentration
• Muscle growth, tissue repair, protein synthesis, and growth hormone release occur mostly, or in some cases only, during sleep.
• Other rejuvenating aspects of sleep are specific to the brain and cognitive function.
• While we are awake, neurons in the brain produce adenosine.
• The build-up of adenosine in the brain may lead to our perception of being tired.

Circadian Rhythms
• Internal Body Clock
• patterns of brain wave activity, hormone production, cell regeneration, and other biological activities linked to this 24-hour cycle.
• normal circadian clock is set by the light-dark cycle over 24 hours.
• Circadian rhythms allow organisms to anticipate and prepare for precise and regular environmental changes. They thus enable organisms to best capitalize on environmental resources (e.g. light and food)
Circadian Rhythms
• Circadian rhythm disorders can be caused by many factors, including:
• Shift work
• Pregnancy
• Time zone changes
• Medications
• Changes in routine such as staying up late or sleeping in
• Medical problems including Alzheimer's or Parkinson disease
• Mental health problems

Impact of too much/too little sleep
• Explore the effects of:
• Insufficient sleep
• Energy Allocation
• Disrupts normal hormonal rhythms
• Excessive sleep
• Disrupts normal hormonal rhythms
• Can make you sleepier due to lack of movement and light.

Serotonin Connection
• Serotonin and sleep
• L-Tryptophan is used to make serotonin
• Serotonin is used to make melatonin
• When serotonin and/or melatonin levels rise, other hormones like norepinephrine go down
• Depression & Anxiety
• Too much or too little serotonin impacts mood
• Symptoms of depression and sleep deprivation are very similar: Altered feeding and sleeping habits, fatigue, difficulty concentrating

Sleep Hurdles
• Drugs
• Stimulants (caffeine, pseudoephedrine, diet pills, preworkout supplements, nicotine, ADHD medications)
• Sedatives (Anti-anxiety medications, barbiturates)
• Diphenhydramine (Benadryl ®)
• Pain medications (Opiates)
• Alcohol

Sleep Hurdles
• Physical Conditions
• Pain
• Pregnancy / PMS / Postpartum
• Temperature regulation
• Changes in estrogen levels impact serotonin levels
• General discomfort
• Apnea
• Allergies
• Sinus congestion
• Coughing
• Restless leg syndrome
• Head Injury especially to the front part of the brain

Sleep Hurdles cont…
• Hormones
• Stress hormones (Cortisol, Thyroxine)
• High levels of cortisol can create agitation, insomnia and sugar cravings.
• Low levels can be associated with inability to handle stress, extreme fatigue, low libido and mood instability.
• Estrogen
• Increases norepinephrine and serotonin
• Decreases dopamine
• Testosterone
• Progesterone: balance estrogen, promote sleep and has a natural calming effect. Abnormal levels of progesterone cause insomnia and contribute to irritability.
Sleep Hurdles cont…
• Light levels
• As light increases, so do our motivating chemicals (norepinephrine)
• As light decreases the body secretes serotonin that is converted to melatonin
• Physical cues
• Alarm clock
• Eating meals
• Coming home from work
• Certain routines

Sleep Hurdles cont…
• Lack of Exercise
• Exercise helps reduce cortisol levels
• Increases serotonin levels
• Can help in reducing aches and pains which keep people awake
• “Stress”
• Racing thoughts
• Ruminations
• High levels of “fight or flight” (excitatory) hormones

Sleep Hygiene
• Create a wind-down ritual
• Reduce or eliminate exposure to blue-light 1 hour before bed (TV, Computer, Phone, some light bulbs)
• Go to bed at roughly the same time every night
• Eliminate as much light as possible (Sleep mask)
• Eliminate as much noise as possible (Ear plugs)
• Do not exercise or take a hot bath within 2 hours of bed.
• Keep the room cool (72 is ideal)
• Consider a cooling pillow and mattress topper
• Avoid anything that might get you upset (Social media)

Sleep Hygiene
• Reduce or eliminate caffeine at least 6 (preferably 12) hours before bed
• Drink the majority of fluids during the day
• Keep an air purifier in the room if you have allergies
• Keep animals off the bed
• Make the bedroom a place of relaxation and sleep
• Keep a red-light and a notepad by your bed to write down anything that pops into your head
• Weighted blankets help some people get to sleep easier

Sleep Hygiene
• Keep daytime naps to under 45 minutes
• Consider diffusing essential oils
• Lavender
• Chamomile
• Patchouli
• Catnip (Yep…catnip…just don’t let the cats in the bedroom)
• Select the right pillow

Summary
• Insufficient quality sleep contributes to
• Fatigue
• Difficulty concentrating
• Reduced reaction time
• Apathy
• During deep sleep is when researchers think the brain rests and rebalances.
• Over time sleep deprivation can cause changes in
• Neurotransmitter levels
• Immune functioning
Summary cont…
• Most people could benefit from auditing their sleep quality
• Reduce light
• Reduce noises
• Reduce bathroom trips
• Reduce wake-ups because of allergies or being too hot
• Stop caffeine 6 (preferably 12) hours before bed
• If you are only willing to change one thing this month to start being happier, more energetic and clearer headed, sleep might be a great place to start.
Additional Resources
http://www.news-medical.net/health/Function-of-Sleep.aspx
http://staging.aesnet.org/files/dmfile/Saper1.pdf
http://www.sleepdex.org/stages.htm
http://psychcentral.com/lib/stages-of-sleep/
https://sleepfoundation.org/how-sleep-works/what-happens-when-you-sleep
http://www.ncbi.nlm.nih.gov/books/NBK10996/
https://www.drmarinajohnson.com/articles/chronic-insomnia-and-hormones/
• The Relationship Between Testosterone and Sleep Disorders https://www.ncbi.nlm.nih.gov/pubmed/24435056
https://www.bcm.edu/news/sleep-disorders/experts-warn-against-antihistmaines-sleep-aid
https://sleepfoundation.org/sleep-topics/how-alcohol-affects-sleep
http://www.webmd.com/sleep-disorders/news/20130118/alcohol-sleep#1
• The Effect of Melatonin, Magnesium and Zinc on Insomnia https://www.ncbi.nlm.nih.gov/pubmed/21226679

Nov 23 2019

53mins

Play

Adjustment Disorder Case Study

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442 – Adjustment Disorder Case Study
Using the PACER Method
Counselor Toolbox Podcast Episode 442
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
Podcast Host: Counselor Toolbox and Case Management Toolbox
Objectives
• Review a case study using the transdiagnostic, transtheoretical PACER approach

• As they say on Law and Order…
• The following story is fictional and does not depict any actual person or event.”
Case
• Dana is a 18 year old freshman attending the University of Gallifray. This is the first time she has been away from home for any length of time. She did not get a bid at the sorority she wanted to join, does not like her roommates in the dorm and is finding it difficult to attend classes and keep up with her work.
Physical
• Sleep
• On an average night how much sleep do you get? REM _1__ Deep _.5__ Light _3___ Just can seem to sleep.
• On an average night how many times do you wake up? __1-2 (When roommates come home)
• After an average night’s sleep how do you feel? Tired _x__ Okay ___ Energetic ____
• When you wake up feeling refreshed, how much sleep do you get? REM __3_ Deep __2+_ Light __3+__
• Sleep hygiene self assessment.

Physical
• Nutrition
• Using a free app like SparkPeople, track your nutrition for a week.
• Which nutrients do you get less than 75% the full RDA? Selenium
• Which nutrients do you get less than 25% of the RDA? None
• When was the last time you had a full panel blood test to examine your kidney and liver function, thyroid and vitamin D levels? Unknown
• Describe your eating habits: I have been eating a lot of pizza and Jimmy Johns lately
• Do you eat due to stress or for comfort when you are upset? yes
• Do you drink at least 64 ounces of noncaffeinated, nonalcoholic beverages each day? yes
• How much caffeine do you have on an average day? (100-150 mg/8oz of regular coffee; 35-50 mg/8oz of soda) ~600mg

Physical
• Nutrition
• How much nicotine do you have on an average day? (1mg/1 cigarette; 6-24mg/vaping cartridges) __0___
• Are you currently over or under fat? (Note: People can have a lot of muscle and not be unhealthy) _no____
• Have you recently had any problems with excessive thirst or hunger? __no
• Do you have problems with hypoglycemia (your blood sugar dropping)? _no
• Have you recently gained or lost a lot of weight? No
• Has your doctor tested your blood sugar lately (fasting blood test)? __no
• Do you mainly gain weight around your belly? __no__
Physical
Physical
• Pain
• Do you have any chronic pain? __no__
• If so what causes it?_____ How long have you had it? ___
• What makes it worse? ___________
• What makes it better? _How has it impacted your mood/relationships/energy/sleep/self-esteem? N/A

Physical
• Exercise/sedentariness
• Do you exercise? ____yes______ If yes, how often and for how long? ____daily 60-90 minutes_____
• How is your energy, mood and appetite after you exercise? ___good________________
• Do you sleep better on days you exercise? __yes___ Does muscle soreness make it harder to sleep? __No___

Physical
• Energy
• Which best describes your average energy level Low__x_ I can get through the day___ Great! ___
• Have you had your thyroid levels tested lately? __N__ If so were they in normal range? __?__
• Using a pulse ox monitor: What is your resting heart rate? __70_ What is your O2 saturation? __98___
• Do you have high blood pressure? _N__ Heart conditions? _N____ if so, what

Physical
• Libido/Sex hormones
• How is your sex drive? Low __x___ Good _____ Incredible______
• Has there been any change in your sex drive? __N___ If so when and what caused it? ____?__ Been low for a couple years
• If you are over 45 have you had your sex hormone levels tested in the past year? ___N/A___
• How often do you engage in sexual activity? ___celibate
Physical
• Do you tend to feel on edge and startle easily? ___N___
• Do you have a history of trauma? ____N___
• Do you have any autoimmune issues/inflammatory conditions like psoriasis, rheumatoid arthritis, Chron’s disease, lupus etc.? ___N_
• Have you ever had a concussion or other traumatic brain injury? ___N_____
• How often do you have headaches? ____N__ What triggers them? __
• What helps them go away? _________
• Do you ever see spots or floaties when you get a headache? __
• Do you get migraines? ___N_____
• How often do you drink alcohol? _daily_ What do you drink? Beer/wine _none_
• Do you gamble or play the lottery? __N___ How much money do you spend on it each week? _______

Affective
• For each of the following feelings, identify how often you feel it each week, what triggers it and what makes it better.
• I feel happy 0-3 days a week __x__ 4 or 5 days a week __ More than 5 days a week __
• What 5 things help you feel happy? _going home__
• * What things used to make you happy or did you enjoy: My dog, working out, my friends, planning for college, photography, hiking
• I feel sad or depressed 0-3 days a week __0__ 4 or 5 days a week _x___ More than 5 days a week ____
• What triggers it? I’m just always “blah”
• What helps you feel better? Nothing
• I feel stressed or overwhelmed 0-3 days a week ____ 4 or 5 days a week ____ More than 5 days a week _x____
• What triggers it? _Class assignments, grades, scholarship
• What helps you feel better? __nothing. Even when I get them done, there will be more…they never stop
Affective
• I feel anxious or worried 0-3 days a week _x_ 4-5 days a week _ >5 days a week __(see stressed)__
• What triggers it? __
• What helps you feel better? ______?____
• I feel angry, resentful 0-3 days a week ___ 4 or 5 days a week _X_ >5 days a week
• What triggers it? My rude roommates, seeing girls from the sorority I rushed, having to sit through class while the professor drones on
• What helps you feel better? Nothing
• I feel guilty 0-3 days a week __0_ 4 or 5 days a week __ >5 days a week
• What triggers it? ___
• What helps you feel better? _______

Affective
• In the past year, I have experienced the following losses which caused me to feel grief: Not getting into the sorority. Breaking up with my HS boyfriend. Moving to college.
• What stressors are currently present? __school assignments, roommates, no social support (Nobody at school. Parents not understanding. Feels like a failure (sed to be big fish in a little pond))
• What is different when you are happy? I can focus. I am more responsible.
• How long does it take for you to calm down after you get upset? _+/- 1hr
• What helps you calm down? __I watch TV or go on a run___
Educate about HPA-Axis activation, biofeedback and relaxation techniques.
Discuss affective issues in counseling

Cognitive
• How is your attention/concentration? ___awful___
• Have you ever been diagnosed with ADHD? _N____
• Has there been a change in your ability to concentrate lately? _Y__ How long? ___3 months___
• If so, what is causing it? __lack of sleep? Depression? I don’t know.
• Does it seem to be taking longer to process information? _Y_
• How is your memory? __awful______ Have you been more forgetful than usual? ___y_____
• If so, when did your forgetfulness start? A couple weeks after I got here.
• When you think about yourself, your life, the world, other people, do you tend to feel angry, suspicious or hopeless? ___Y___
• If yes, have you always felt this way or did something happen to change your feelings? __Came to college…It is not what I thought it would be. My friends got into sororities and I didn’t. I don’t think I did well on my midterms.

Cognitive
• Negative self-talk
• Do you frequently judge or criticize yourself? ___Yes
• Do you hold yourself to a higher standard than you hold other people? ____N______
• Do you think you are lovable/likeable only if you are perfect (or almost perfect)? ___N*____
• Where did you learn your negative self talk? __My family is very successful. My parents always achieved anything they put their mind to. When I fail I disappoint them

Cognitive
• Pay attention to your thoughts for a week. Place a check by the thinking errors which are most common for you and contribute to your unhappiness.
• All or none thinking Find Exceptions
• Focusing on a small aspect instead of the bigger picture Consider alternate explanations
• Expecting life to be fair Explore living in the AND
• Taking things too personally Consider alternate explanations
• Focusing on the negative and ignoring the positive Learn about radical acceptance
• Taking something bad and blowing it out of proportion (catastrophizing)
• Expecting people to be able to read your mind Evaluate how you communicated what you wanted and practice assertive communication
• Assuming/Jumping to conclusions without all the facts Get the facts
• Assuming you know what others are thinking. Evaluate your evidence. Get the facts.
Educate about cognitive distortions and interventions. Provide worksheets to address CDs.

Cognitive: Hardiness
Cognitive
• Time management
• How effective are you at managing your time? Bad. I used to do 4th period homework in 3rd period
• Do you often take on too much and feel overwhelmed or rushed? Yes
• Are you a perfectionist? __Y___ If yes, how does that impact your mood, sleep and relationships? I tend to get irritable
• Do you procrastinate? __Y__ I just don’t have the desire to do homework and laundry and stuff so I put it off until it is a crisis.
• If yes, how does that impact your mood, sleep and relationships? __When I am procrastinating I’m okay, but then I have to pull all nighters to get my assignments done.
Develop a schedule that includes the “must dos” delegates and simplifies when possible.

Environmental
• Do you feel safe most of the time? _____Y___ If no, where do you not feel safe and why?
• What helps you feel safe? __Campus feels safe
• Are you able to have peace and quiet when you want it and when you sleep? ___no If no, what can you do to reduce unwanted noise? Move. Ear plugs/headphones.
• During the day are you able to access natural light, or at least a really bright working area? ___Yes walking to class
• When you sleep, are you able to make your room totally dark or block out the light? _N—Roommates in and out at all hours_
• Do you eliminate blue light from television and electronic devices at least 2 hours before bed? __N I play on my phone until I fall asleep
Environmental
• What smells are you regularly exposed to?
• Noxious/unpleasant/irritating __nothing.
• Triggering (reminds you of something unpleasant) _nothing_
• Happy/relaxing/energizing __coffee. The gym. Air fresheners
• Are you able to keep your environments at a temperature you find comfortable? __Yes
Relationships
• Do you feel you are capable, lovable and deserving? _not sure____ If not, why not? __I used to be really confident. Since I got here—well it is all just so different. Not what I expected._
• Do you have healthy relationships or regularly fear abandonment? ____My parents won’t abandon me, they will just be disappointed if Idon’t continue to be the best (valedictorian)______
• Can you effectively identify and communicate feelings and thoughts and get your needs met? ___apparently not_____
• Do you have a social support system that can provide practical assistance and emotional support? __No

Summary
• Dana is struggling to adjust to college. In high school she was the valedictorian, on the dance team and very popular.
• The study habits she had in high school are not helpful in college. She has difficulty budgeting her time to study and do her assignments and experiences a great deal of anxiety over her grades being comprised of just a couple tests/papers.
• She anticipated college classes to be enthralling and college to be an adventure. She is disillusioned to find that her freshman classes feel like a re-hash of high school. Part of her feels the work is so easy she can get it done at the last minute and she has difficulty getting motivated to get started. Then she ends up pulling all nighters to get the work done and turning in less than her best work.
• She identifies that her mood and desire to do anything changed significantly when she was rejected from the sorority. Her friends from HS are all in one. She doesn’t really know where she fits in.
• She has 2 roommates. 1 is rushing a sorority. The other just stays out until all hours. They wake her up when they come and go and she has very little in common with them.
• She tried to talk to her parents, but they told her that everyone goes through an adjustment period and blew her off. She is worried that they will be disappointed if she doesn’t get straight As
• Her BF went to another college, so they broke up before the school year started. She thought she would be so busy with stuff she wouldn’t care, but she cant stop thinking about it.
• Currently she is not sleeping much, and when she does it is not well. She reports feeling exhausted, “foggy” and generally apathetic.

Tx. Plan Goals
• Dana will figure out where she fits in and develop social support
• Dana will complete a compare and contrast of HS and college to figure out what was different in HS that made her happier and work toward recreating some of that.
• Dana will enhance her social circle at college by exploring volunteering (humane society?) and getting a job teaching spin
• Dana will make a plan for moving out of the dorm next semester so she can have her dog at school with her and go to the dog park
• Dana will start texting her BFF from HS at least twice a week

Tx. Plan Goals
• Dana will develop better study habits, rekindle her enthusiasm for college and reduce her anxiety about her grades.
• Dana will make a master study schedule and post it over her desk
• Dana will learn about and practice “chinking”
• Dana will sign up to start getting paid to take notes so she can save money to get an apartment off campus (and it will encourage her to go to class)
• Dana will get involved in the undergraduate honor society for her major to explore what upper division has to offer
• Dana will find a study buddy to help her get motivated to do work in a timely manner.
• Dana will make use of her professor’s office hours to get feedback on projects or papers before turning them in

Tx. Plan Goals
• Dana will improve her sleep
• Dana will get ear plugs or noise cancelling headphones and a sleep mask to help her stay asleep despite the noise in the dorm to improve her energy and focus throughout the day
• Dana will add a blue light filter to her phone to help with sleep
• Dana will reduce her anxiety and depression
• Dana will address cognitive distortions especially catastrophic thinking, personalization and focusing on only a couple aspects of a situation
• Dana will start doing one thing each day that makes her happy
• Dana will begin each day with positive forecasting and end each day with positive reflection and radical acceptance
• (Note: Family session is not currently a consideration due to parents being in another state)

Tx. Plan Goals
• Dana will work through her grief issues in counseling
• Breakup
• Not getting a sorority bid
• Not being a “big fish”

Reassessment
• Dana made the school schedule and started “chunking” She found that it helped her to get her work done if she made herself go to the library instead of going back to the dorm
• Dana has started using her professor’s office hours and feels more confident in her ability to do her work.
• Getting paid to take notes has significantly increased her motivation to go to class and pay attention. She is not sure if it will help with her grades, but she is not falling nearly as far behind and hasn’t pulled an all nighter in 2 months.
• Dana still hates the dorm, but she talked with her parents and they have agreed to help her move off campus next semester and bring her dog to school. This improved her outlook.
• When comparing to high school, Dana realized that there she felt noticed and appreciated. Dana has found a couple extracurricular groups that she enjoys going to. She hasn’t met any real “friends” yet, but she does feel a little more connected.

Reassessment
• Dana reports that she still hates her classes but she now sees them as a way to pad her GPA before upper division.
• Dana still holds some bitterness toward the sorority, but realizes that holding on to that anger is not going to change anything. She does her best to avoid those women right now and focus her attention on her new activities.
• She has worked through some of the grief related to her breakup. She recognized that it represented another rejection (in addition to the sorority) and was focusing on that because she thought it was something she might be able to change.
• Dana has found positive forecasting and reflection and radical acceptance helps her to focus on the bigger picture which has also reduced her catastrophizing.

Summary
• Unlike depression and anxiety disorders which generally have no identifiable trigger, adjustment disorders typically have a clear “cause”
• When life changes (even for the better) it throws our world out of balance and we have to adjust.
• Dana recognized how college was more than just a different school and identified ways to bring her “world” back into balance.

Nov 20 2019

Play

Biopsychosocial Aspects of HPA-Axis Dysfunction

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441 – Biopsychosocial Aspects of HPA-Axis Dysfunction
Objectives
– Define and explain the HPA-Axis
– Identify the impact of trauma on the HPA Axis
– Identify the impact of chronic stress/cumulative trauma on the HPA-Axis
– Identify symptoms of HPA-Axis dysfunction
– Identify interventions useful for this population
Based on
– Post-traumatic stress disorder: the neurobiological impact of psychological trauma
Dialogues Clin Neurosci. 2011 Sep; 13(3): 263–278.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182008/
– Lifestyle Factors Contributing to HPA-Axis Activation and Chronic Illness in Americans
Archives of Neurology and Neuroscience. 2019 Oct.; 5(2) ANN.MS.ID.000608. DOI:10.33552/ANN.2019.05.000608
https://irispublishers.com/ann/pdf/ANN.MS.ID.000608.pdf

What is the HPA Axis
– Hypothalamic-Pituitary-Adrenal Axis
– Controls reactions to stress and regulates digestion, the immune system, mood and emotions, sexuality, and energy storage and expenditure
– The signs and symptoms of HPA-Axis dysfunction reflect a persistent, abnormal adaptation of neurobiological systems to trauma or chronic stress.
– In addition to trauma, multiple lifestyle factors have been associated with HPA-Axis dysregulation including
– Noise
– Stimulant use (caffeine, nicotine, ADHD medications)
– Insufficient quality sleep
– Media exposure

Consequences of HPA-Axis Dysfunction
– More than 50% of Americans suffer from one or more chronic conditions associated with disturbances of the HPA-Axis with an estimated cost of $3.3 trillion annually including:
– Major depressive disorder (20%)
– Generalized anxiety disorder (18.1%)
– Sex hormone imbalances (25%)
– Diabetes (9.2%)
– Autoimmune disorders (23%)
– Chronic pain
– Metabolic syndrome (30%)
– Cardiovascular disease (44%)
– Hypothyroid (4.6%)
– IBS symptoms such as constipation and diarrhea
– Reduced tolerance to physical and mental stresses (including pain)

Overview of Healthy HPA-Axis Function
– When exposed to a physical, environmental or social stressor, the HPA-Axis is activated and prompts the “fight or flight” reaction.
– Glutamate and Norepinephrine are released
– The hypothalamus releases corticotropin releasing factor (CRF) and arginine vasopressin (AVP) to stimulate the anterior pituitary to produce and secrete adrenocorticotropic hormone (ACTH).
– ACTH causes glucocorticoid (cortisol) synthesis and release from the adrenal glands

Overview of Healthy HPA-Axis Function
– Cortisol’s primary function is to
– Increase blood glucose and modify fat and protein metabolism to fuel the fight or flight reaction
– Modulate immune and brain function to effectively manage stressors.
– Cortisol initially causes a potent anti-inflammatory response which allows the organism to react to the stressor without being pain or fatigue.
– Glucocorticoids interfere with the retrieval of traumatic memories
– As cues of the threat wane, the body increases inflammation by releasing proinflammatory cytokines to accelerate wound healing
Stress Response
– The response of an individual to stress depends not only on stressor characteristics, but also on factors specific to the individual.
– Perception of stressor
– Proximity to safe zones
– Similarity to victim
– Degree of helplessness
– Prior traumatic experiences
– Amount of stress in the preceding months
– Current mental health or addiction issues
– Availability of social support
– Compared to positive events, negative events, or “stress” causes greater awareness and recall of event details leading to stronger encoding of negative or stressful events.

Emotional Valence
– The NEVER (Negative Emotional Valence Enhances Recapitulation ) model of emotional valence, asserts that the greater the number of stimuli related to the unpleasant event that are remembered, the greater the likelihood that the person will encounter reminders of the event leading to increased recapituation.
– According to Dr. Aaron Ben-Zeev, people tend to perseverate on negative information and events five times more than positive ones.
– Recapitulation initially leads to repeated HPA-Axis activation, but over time the continued stress prolongs the inflammatory response via continued activation of the HPA-Axis leading to glucocorticoid resistance causing cells to become less sensitive to cortisol to protect them from the persistent secretion.
Glucocorticoids
– Low cortisol levels (glucocorticoid resistance) at the time of exposure to psychological trauma may predict the development of PTSD. (Prior trauma or chronic stress exposure may predispose to PTSD)

Physiological Changes Due to Hypocortisolism
– Sustained HPA-Axis activation causes persistently high levels of CRH which eventually causes a blunting of the ACTH response to CRH stimulation
– Disinhibition of corticotropin releasing hormone (CRH) and norepinephrine which lead to an exaggerated response to acute stressors and corresponding increase in cortisol.
– Exposure to additional stressors produces stronger trauma-related symptoms in part due to the exaggerated HPA-Axis response causing the stressor to have a stronger negative emotional valence
– Exaggerated elevation of cortisol during exposure to acute stressors increases the sensitivity of NMDA receptors, which makes the brain generally more vulnerable to excitoxic effects of stress

Physiological Changes Due to Hypocortisolism
– The volume of the hippocampus which controls not only the HPA-Axis and stress responses, but also declarative memory is reduced due to the excitotoxic environment.
– Amygdala activity increases and promotes hypervigilance and impairs threat discrimination
– Reduced prefrontal cortex volume impairs executive functioning and impulse control
– Reduced anterior cingulate volume impairs the extinction of fear responses
– Thyroid hormones become imbalanced leading to abnormal T3:T4 ratio and increases in anxiety

Neurochemical Factors
– GABA (inhibitory) activity is decreased, and glutamate (excitatory) activity is increased
– GABA has profound anxiolytic effects in part by inhibiting the CRH/NE circuits
– Patients with PTSD exhibit decreased peripheral benzodiazepine binding sites.
– May indicate the usefulness of emotion regulation and distress tolerance skills due to potential emotional dysregulation
– We need to reduce excitotoxicity in order to reduce distress, improve stress tolerance and enable the acquisition of new skills

Physiological Changes Due to Hypocortisolism
– Increased dopamine and norepinephrine levels increase arousal, startle response, fear memory encoding and increased HPA-Axis activation in response to recapitulation.
– Changes to the ratios of estrogen, testosterone and progesterone occur which impact the body’s ability to modulate cortisol levels
– Prolonged psychological stress suppresses estrogen causing amenorrhea which has profound effects on cardiac, skeletal, psychological and reproductive systems
– Serotonin levels are simultaneously decreased in parts of the brain disrupting communication between the amygdala and the hippocampus which leads to increased vigilance, startle, impulsivity, and memory intrusions, hostility, aggression, depression, and suicidally

Serotonin Receptors (Soap Box)
5-HT1A
• Addiction
• Aggression
• Anxiety
• Appetite
• Blood Pressure
• Heart Rate
• Impulsivity
• Memory
• Mood
• Respiration
• Sexual Behavior
• Sleep
• Sociability

5-HT1B
• Addiction
• Aggression
• Anxiety
• Learning/Memory
• Mood

5-HT1D
• Anxiety

5-HT2A
• Addiction
• Anxiety
• Appetite
• Cognition
• Imagination
• Learning
• Memory
• Mood
• Perception
• Sexual Behavior
• Sleep

5-HT2B
• Anxiety
• Appetite
• GI Motility
• Sleep

5-HT2C
• Addiction
• Anxiety
• Appetite
• Mood
• Sexual Behavior
• Sleep

5-HT3
• Addiction
• Anxiety
• GI Motility
• Learning
• Memory
• Nausea

5-HT4
• Anxiety
• Appetite
• Learning
• Memory
• Mood
5-HT5A
• Sleep

5-HT6
• Anxiety
• Cognition
• Learning
• Memory
• Mood

5-HT7
• Anxiety
• Autoreceptor
• Memory
• Mood
• Respiration
• Sleep

https://en.wikipedia.org/wiki/5-HT_receptor

Modifiable Factors
– To help people benefit as much as possible from treatment, we need to help them reduce the assaults on their HPA-Axis

Cognitive Factors
– Instruction in skills to handle emotional dysregulation
– Mindfulness
– Vulnerability prevention and awareness
– Emotion Regulation
– Distress Tolerance
– Problem Solving
– Of those exposed to trauma, education about and normalization of heightened emotional reactivity and susceptibility to PTSD in the future may be helpful
Media
– According to the social signal transduction theory of depression, perception of social threat by exposure social, symbolic, or imagined threats and adversity up-regulate the HPA-Axis.
– Modern media recasts social, cultural and political events and highlights our current vulnerabilities to terrorism and dystopia 24 hours a day
– Chronic HPA-Axis activation can trigger depressed mood, anhedonia, fatigue, psychomotor retardation, and behavioral withdrawal
– Exposure to predominantly negative stories in the news results in increased negative emotional responses thus increasing HPA-Axis activation
Media
– These messages are of increased concern regarding youth who, depending on their developmental level, may not be able to discern something that is being recast from something that is still occurring, setting the stage for generalized anxiety
– HPA-Axis activation in children is also of great concern, because youth and adolescence is a time of rapid brain development making the brain more susceptible to injury.
Social Media
– In 2016, 98% of young adults used approximately 7.6 different social media regularly
– Individuals who spent more than 120 minutes on social media per day or who visited social media sites more than 9 times per day had significantly increased odds of depression
– Increased time online is associated with
– Decline in communication with family members
– Reduction of the internet user’s social circle
– Reduction in sleep
– Increased feelings of depression and loneliness
– There is a strong positive correlation between amount of social media usage and perceptions of isolation
Sleep
– According to the CDC, 1 in 3 adults does not get enough sleep
– There are many causes of sleep deprivation in American culture
– Sleep disruption or deprivation can impair lead to hyperactivation of the HPA-Axis and circadian rhythm disruption
– Significant increases of plasma cortisol levels
– Reduction in serotonin and melatonin
– Increases in norepinephrine
Sleep and Nutrition
– A recent study of the 2007-2008 National Health and Nutrition Examination Survey (NHANES) found inadequate intake of vitamin A, calcium, selenium, carbohydrates, vitamin D, and lycopene to be associated with “poor sleep”
– low levels of zinc and magnesium are implicated in the development of depression through overactivity of the HPA-Axis
– A significant negative correlation was found between sleep quality and low quality carbohydrate intake from processed foods
– Skipping breakfast and eating irregularly were strongly associated with hypoglycemia which can cause chronic HPA-Axis activation and poor sleep quality
Light & Snoring
– Lack of access to natural light, shift work and overnight work which prohibits the body from receiving cues from the environment which would regulate a 24-hour circadian rhythm.
– Insomnia at night causes frustration
– Daytime drowsiness causes people to use stimulants contributing to even more HPA-Axis activation
– Blue light from digital devices and televisions
– 26% of adults have sleep apnea which is associated with HPA axis activation
– Nighttime noise causes frequent awakening, less deep sleep, increased subjective disturbance and is correlated with an increased risk of HPA-Axis activation, cardiovascular disease, depression, anxiety.

Alcohol
– Twenty percent (20%) of Americans are heavy drinkers
– Within the USA, it is estimated that societal costs of alcohol-related sleep disorders exceeds $18 billion
– Alcohol decreases the time it takes for people to fall asleep (sleep latency), and increases the quality and quantity of NREM sleep during the first half of the night, but disrupts it during the second half of the night sleep
– Alcohol stimulates HPA-axis and repeated alcohol exposure leads to a blunted HPA-Axis response which is associated with depressive symptoms such as anhedonia, fatigue and behavioral withdrawal as well as widespread inflammation
Nicotine
– Recent nicotine use and lower dependence is associated with increased activation of the HPA-Axis, but as dependence goes up (persistent exposure), response of the HPA-Axis decreases (glucocorticoid resistance)
– Significant reciprocal, relationships between smoking and sleep disturbances.
Caffeine
– Caffeine is found not only in coffee, but also soda, chocolate, over the counter migraine medications, decongestants and some diet and workout supplements.
– When caffeine was paired with a mental or physical stressor, cortisol and adrenaline levels exceeded levels seen when caffeine or stressors were encountered independently
Nutrition
– A healthy gut microbiome has over 1000 species of bacteria and can decrease depression and anxiety, regulate sleep, appetite and improve cognition [61]. An unhealthy gut microbiome contributes to an exaggerated HPA-Axis response [61,62].
– Insufficient levels of tryptophan with the help of iron, magnesium, vitamin B6, folic acid, vitamin C and zinc
– Frequent intake of caffeine or other stimulants can cause serotonin levels to become depleted
Sedentariness
– Exercise has been shown to moderate both inflammatory cytokines and oxidative stress.
– Low intensity exercise (at 40% VO2max) has even been shown to reduce cortisol levels and increase serotonin contributing to the relaxation response
– 220-age-RHR* (HR%) + RHR
– 220-50= 170
– 170-50=120
– 120*.4= 48
– 48+50= 98 BPM
Summary
– Some level of activation of the HPA-Axis is necessary for motivation and energy.
– When the HPA axis is activated in response to stress it
– Impacts the balance of
– Dopamine, serotonin, norepinephrine, GABA, and glutamate
– T3:T4 thyroid hormones
– Modulates the release of
– Inflammatory cytokines
– Estrogen and testosterone
– Impacts insulin sensitivity and the balance
– Sustained activation of this bidirectional system results in brain changes which alter hormones and monoamines (neurotransmitters) leading to further HPA-Axis activation
Summary
– Pre-existing issues causing hypocortisolism set the stage for the Flat and the Furious –> toxic levels of glutamate upon exposure to stressors – Increased stimuli encoding – Enhanced recapitulation
– This points to the importance of prevention and early intervention of adverse childhood experiences as well as chronic stress

Additional Information
– The Neurobiological Impact of Psychological Trauma: The HPA-Axis
– Gut Health and Mental Health
– Adrenal Fatigue and How It Impacts Recovery

Nov 16 2019

Play

Addiction Case Study Using the PACER Method

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440 – Addiction Case Study
Using the PACER Method
Counselor Toolbox Podcast Episode 440
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
Podcast Host: Counselor Toolbox and Case Management Toolbox

Sponsored by TherapyNotes.com
Manage your practice securely and efficiently. Two free weeks of TherapyNotes with coupon code “CEU”

Objectives
– Review a case study using the transdiagnostic, transtheoretical PACER approach

– As they say on Law and Order…
– The following story is fictional and does not depict any actual person or event.”
Case
– John is 37 years old and presents for marijuana use as a requirement of his probation. He has a wife and 2 kids, 4 and 9.
Physical
– Sleep
– On an average night how much sleep do you get- 6 hours
– On an average night how many times do you wake up- __not often
– After an average night’s sleep how do you feel- Tired ___ Okay __x_ Energetic ____
– When you wake up feeling refreshed, how much sleep do you get- 8+
– Sleep hygiene self assessment.
Physical
– Nutrition
– Using a free app like SparkPeople, track your nutrition for a week.
– Which nutrients do you get less than 75% the full RDA- D, Calcium, potassium
– Which nutrients do you get less than 25% of the RDA- None
– When was the last time you had a full panel blood test to examine your kidney and liver function, thyroid and vitamin D levels- ___- months
– Describe your eating habits: I eat a lot of fast food and meat
– Do you eat due to stress or for comfort when you are upset- yes
– Do you drink at least 64 ounces of noncaffeinated, nonalcoholic beverages each day- No
– How much caffeine do you have on an average day- (100-150 mg/8oz of regular coffee; 35-50 mg/8oz of soda) 300 mg

Physical
– Nutrition
– How much nicotine do you have on an average day- (1 mg/1 cigarette; 6-24mg/vaping cartridges, 100mg/cigarillo) __200mg___
– Are you currently over or under fat- (Note: People can have a lot of muscle and not be unhealthy) _yes I need to lose about 30#____
– Have you recently had any problems with excessive thirst or hunger- __no
– Do you have problems with hypoglycemia (your blood sugar dropping)- _no
– Has your doctor tested your blood sugar lately (fasting blood test)- __no
– Do you mainly gain weight around your belly- __yes__
– Referral to PCP for physical to include nutritional evaluation, hormone evaluation and possible addition of multivitamin to address nutritional deficiencies.
Physical
Physical
– Pain
– Do you have any chronic pain- __no__
– If so what causes it-________________ How long have you had it- ____
– What makes it worse- ___________
– What makes it better- _____________________
– How has it impacted your mood/relationships/energy/sleep/self-esteem-

Physical
– Exercise/sedentariness
– Do you exercise- ____no______ If yes, how often and for how long- _________
– How is your energy, mood and appetite after you exercise- ___N/A________________
– Do you sleep better on days you exercise- __N/A___ Does muscle soreness make it harder to sleep- __N/A___

Physical
– Energy
– Which best describes your average energy level Low___ I can get through the day_x__ Great! ___
– Have you had your thyroid levels tested lately- __N__ If so were they in normal range- __-__
– Using a pulse ox monitor: What is your resting heart rate- __75_ What is your O2 saturation- __98___
– Do you have high blood pressure- _Y__ (medicated) Heart conditions- _N____ if so, what

Physical
– Libido/Sex hormones
– How is your sex drive- Low __ Good _x__ Incredible__
– Has there been any change in your sex drive- __Y___ If so when and what caused it- ____-__
– If you are over 45 have you had your sex hormone levels tested in the past year- ___N___
– How often do you engage in sexual activity- ___1-2x / week

Physical
– Do you tend to feel on edge and startle easily- ___N___
– Do you have a history of trauma- ____N___
– Do you have any autoimmune issues/inflammatory conditions like psoriasis, rheumatoid arthritis, Chron’s disease, lupus etc.- ___N_
– Have you ever had a concussion or other traumatic brain injury- ___N_____
– How often do you have headaches- ____Y__ What triggers them- _stress_
– What helps them go away- ______neck massage or ice/heat___
– Do you ever see spots or floaties when you get a headache- Y__
– Do you get migraines- ___N_____
– How often do you drink alcohol- _daily_ What do you drink- Beer/wine _X_
– How many drinks do you have in an average week- __2-3/wk
– Do you gamble or play the lottery- __Lottery___ How much money do you spend on it each week- ___$20____

Affective
– For each of the following feelings, identify how often you feel it each week, what triggers it and what makes it better.
– I feel happy 0-3 days a week __3__ 4 or 5 days a week __ More than 5 days a week __
– What 5 things help you feel happy- ___my kids, my wife, friends_
– I feel sad or depressed 0-3 days a week __0__ 4 or 5 days a week ____ More than 5 days a week ____
– What triggers it- NA
– What helps you feel better- NA
– I feel stressed or overwhelmed 0-3 days a week __X__ 4 or 5 days a week ____ More than 5 days a week _____
– What triggers it- ___Work, my kid struggling in school and being [oppositional] about doing his homework, probation, getting used to being “out”
– What helps you feel better- __Watching TV and smoking
Affective
– I feel anxious or worried 0-3 days a week _0_ 4-5 days a week _ >5 days a week ____
– What triggers it- __
– What helps you feel better- ______
– I feel angry, resentful 0-3 days a week __0_ 4 or 5 days a week __ >5 days a week
– What triggers it-
– What helps you feel better-
– I feel guilty 0-3 days a week _1_ 4 or 5 days a week __ >5 days a week
– What triggers it- ___I feel guilty that I was in jail for the past year and wasn’t able to be there for my kid.
– What helps you feel better- ___-_____

Affective
– In the past year, I have experienced the following losses which caused me to feel grief: None
– What stressors are currently present- __Trying to not violate probation, adjusting to being back with the family, son’s behavior
– What makes son’s behavior better- When I spend time with him
– What does he like to do- Play basketball at the park
– What is different when you are happy- I can smoke as much as I want and people leave me alone
– How long does it take for you to calm down after you get upset- _20-30min.
– What helps you calm down- __smoking, distracting myself___

Cognitive
– How is your attention/concentration- ___awful___
– Have you ever been diagnosed with ADHD- _N____
– Has there been a change in your ability to concentrate lately- _N__ How long- ___6 months___
– If so, what is causing it- __lack of sleep- Stress- I don’t know.
– Does it seem to be taking longer to process information- _Y_
– How is your memory- __Good______ Have you been more forgetful than usual- ___N_____
– If so, when did your forgetfulness start- NA What is causing it-
– When you think about yourself, your life, the world, other people, do you tend to feel angry, suspicious or hopeless- ___Y___
– If yes, have you always felt this way or did something happen to change your feelings- __Started watching the news and spending time around people__

Cognitive
– Negative self-talk
– Do you frequently judge or criticize yourself- _N_______
– Do you hold yourself to a higher standard than you hold other people- ____N______
– Do you think you are lovable/likeable only if you are perfect (or almost perfect)- ___N_______
– Where did you learn your negative self talk- __N/A

Cognitive
– Pay attention to your thoughts for a week. Place a check by the thinking errors which are most common for you and contribute to your unhappiness.
– All or none thinking Find Exceptions
– Assuming/Jumping to conclusions without all the facts Get the facts
– Focusing on a small aspect instead of the bigger picture Consider alternate explanations
– Expecting life to be fair
– Taking things too personally Consider alternate explanations
– Taking something bad and blowing it out of proportion (catastrophizing)
– Focusing on the negative and ignoring the positive
– Expecting people to be able to read your mind Evaluate how you communicated what you wanted and practice assertive communication
– Assuming you know what others are thinking. Evaluate your evidence and get the facts.

Educate about cognitive distortions and interventions. Provide worksheets to address CDs.

Cognitive: Hardiness
Cognitive
– Time management
– How effective are you at managing your time- ___Good __
– Do you often take on too much and feel overwhelmed or rushed- No
– Are you a perfectionist- __N___ If yes, how does that impact your mood, sleep and relationships-
– Do you procrastinate- __Y__ If yes, how does that impact your mood, sleep and relationships- __I tend to get irritable when I have something to do that I am procrastinating then irritable when I feel rushed.
Develop a schedule that includes the “must dos” delegates and simplifies when possible.

Environmental
– Do you feel safe most of the time- _____y___ If no, where do you not feel safe and why-
– What helps you feel safe- __My dogs. My neighborhood.__
– Are you able to have peace and quiet when you want it and when you sleep- ___No_____ If no, what can you do to reduce unwanted noise- Headphones
– During the day are you able to access natural light, or at least a really bright working area- ___Yes_
– When you sleep, are you able to make your room totally dark or block out the light- _Y_
– Do you eliminate blue light from television and electronic devices at least 2 hours before bed- ___N__
Environmental
– What smells are you regularly exposed to-
– Noxious/unpleasant/irritating _asphalt and roofing tar__
– Triggering (reminds you of something unpleasant) __musty smells (old buildings) remind me of jail
– Happy/relaxing/energizing __barbecue, home cooking
– Are you able to keep your environments at a temperature you find comfortable- __No, trying to keep utility bills down___
Relationships
– Do you feel you are capable, lovable and deserving- _y____ If not, why not- ___
– Do you have healthy relationships or regularly fear abandonment- ____Healthy overall______
– Can you effectively identify and communicate feelings and thoughts and get your needs met- ___y_____
– Do you have a social support system that can provide practical assistance and emotional support- __practical assistance, yes…emotional support not as much___

Addiction Specific Questions
– Acute Intoxication and/or withdrawal: Can be managed in outpatient
– Biomedical complications impacting recovery: None
– Emotional, behavioral and cognitive conditions: Stress and anxiety that is self-medicated with cannabis and nicotine
– Readiness to change: Action due to wanting to stay out of prison
– Relapse/continued use potential: High
– Recovery Environment: Significant other smokes pot, friends smoke pot. Won’t smoke in front of kids
Addiction Specific Questions
– Relapse Prevention
– When you are not using what is different
– Kids are around
– I am at work
– I am in jail
– How do you deal with stress and cravings in those situations-
Addiction Specific Questions
– Emotional: Relief to be off probation
– Obstacle: Anxiety/stress
– Mental: Belief that I can stay clean until I get off papers. I will probably be able to concentrate a little more
– Obstacle: Knowledge of ways to defeat drug tests
– Physical: More energy/less fatigue
– More anxiety
– Social: Be able to be there for my kids.
– Obstacle: Friends use
– Environmental: May be able to move into a better place once I’m off probation
– Obstacle: Lots of drugs in the neighborhood
Initial Tx Plan goals
– Referral to PCP for hormone evaluation and nutritional assessment
– Tagamet lowers T. which can increase cortisol and anxiety. Cannabis increases T which lowers cortisol and anxiety.
– Vitamin D deficiency can lead to or worsen anxiety and hypertension
– Calcium deficiency inhibits production of serotonin
– Potassium helps regulate serotonin
– Remove all cannabis from the house
– Begin helping Sam with his homework each night and taking him to play basketball after dinner if he does his homework
– Learn about cognitive distortions and start addressing one each week.
– Learn distress tolerance skills to teach your son
– Make a list of things to do when you are feeling stressed besides smoke

Initial Tx Plan goals
– Specific Worries for Discussion (Beginning Week 1)
– Getting through probation without violating
– One day at a time
– View it as a challenge
– Psychological flexibility
– Getting my son’s behavior under control
– Positive reinforcement
– Potential LD assessment
– Not smoking pot even though my wife is smoking
– Finding other “rewards” for not using
– Talking with her about not using at the house
– Dealing with having to stay at this crappy job for the next 18 months
– Mindful focus
– Positive review and forecasting

Reassessment
– PCP assessed hormone levels and determined levels to be on the extreme low end of the normal range. No intervention
– Has lost 12# since starting to play basketball with his son in the evenings, reduced blood pressure medication.
– Arguing less with his wife since his son is behaving better, although she is still smoking, just not at the house.
– Has not used, but is still not intrinsically motivated to quit.

Summary
– Substances are often used to self medicate
– Helping him identify previous coping strategies and learn new distress tolerance skills (to teach his son) is helping with his stress at home and at work
– Engaging in activity with his son leaves less time to use
– Marijuana alters not only brain chemicals, but also hormones.
– Marijuana can stay in the body for a long time since THC is stored in the fat.

Nov 13 2019

53mins

Play

Biopsychosocial Impact of Hormone Imbalances and Strategies for Prevention

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439 – Biopsychosocial Impact of Hormone Imbalances
Objectives
– Review the sex hormones and their functions
– Review the impact of sex hormones in the HPA-Axis
– Review causes and consequences of imbalances in
– Estrogen
– Progesterone
– Testosterone

Estrogen
– Multiple forms
– Estradiol is predominant prior to menopause
– Estrone is the primary form postmenopausally
– Synthesized by fatty tissue
– Estrogen works synergistically with many biological systems to promote physical, cognitive and affective function
– Estrogens can modulate neuronal excitability, through serotonin, norepinephrine, dopamine, and endorphin regulation
– Estrogen supplementation can decreased both systolic and diastolic blood pressures and reduced norepinephrine levels

Estrogen
– Estrogen modulates mood via the serotonergic system
– Estrogen also contributes to the
– Downregulation of 5-HT-2 (stimulating) receptors and monoamine oxidase (think MAOIs)
– Downregulation of 5HT1A receptors presynaptically
– Upregulation of postsynaptic serotonin 5-HT1A (calming) receptors
– In one study, 80% of women given estradiol reported significantly decreased mood symptoms after three or six weeks, compared to only 22% of women on placebo
– Similarly, estradiol resulted in improved mood in 68% of peri-menopausal women with depressive disorders, whereas only 20% of women on placebo experienced similar benefit

Estrogen
– Estrogen also regulates glucose metabolism and energy production
– Declines in these processes are characteristic of neurodegenerative diseases
– Estrogens exert neuroprotective actions to maintain cerebrovasculature health including prevention glutamate-induced excitotoxicity and hippocampal shrinkage
– Estrogens exert some anti-inflammatory effects
– Naturally occurring higher levels of estrone were associated with poorer cognition, specifically working memory performance
– Estradiol acts in part through nitric oxide (arginine)to increase extracellular dopamine levels.

The Sex Hormones
– Estrogen
– Premenopausal females have a better response than males to serotonergic antidepressants, indicating female hormones may improve the efficacy of SSRIs
– Depressed postmenopausal females on supplemental estrogen plus SSRIs showed improved response compared with depressed postmenopausal females without estrogen
– Estrogen alone did not relieve depression
– Largest clinical trials of HT ever conducted revealed an increased risk of cancer, dementia and cognitive decline with prolonged administration of conjugated equine estrogen (CEE)

Estrogen and the HPA-Axis
– Higher levels of Estradiol produced a stronger HPA axis response during non-threatening situations and during and after stressors
– Under conditions of anxiety and stress, women attend to threat differently depending on endogenous estradiol levels, being avoidant when estradiol is lower, and vigilant when estradiol is higher
– Estradiol increases the activation of Corticotropin Releasing Hormone and base levels of ACTH
– Chronic stress produces a hyporesponsive HPA axis that is hypersensitive to the modulating effects of estrogen
– Changes in 5-HT1A receptor binding in the hippocampus and hypothalamus are restored by estrogen replacement.
Estrogen and the HPA-Axis
– Treatment with estradiol could inhibit the negative feedback effects of cortisol increasing cortisol levels
– Estradiol treatment has been shown to increase corticosteroid binding globulin (CBG ) which inactivates cortisol in males
– Crosstalk between the hypothalamic–pituitary–gonadal (HPG) and HPA axes could lead to abnormalities of stress responses, and as a result exacerbate peripheral pathologies i.e.:
– Low estrogen –> blunted HPA-Axis response (depression)
– High estrogen – exacerbated HPA-Axis response and sustained higher levels of ACTH – anxiety, inflammation, autoimmune…
Estrogen and Cognition
– Estrogen
– HT administered at or around the time of menopause may improve cognition, but HT initiated five years or more after menopause shows no cognitive benefit but may produce cognitive decline
– Shorter time between menopause and initiation of HT was associated with larger hippocampal volume
– HT utilizing Estradiol more effectively recalibrates the estradiol/estrone ratio to approximate pre-menopausal levels.
Estrogen and Allergy
– Estrogen
– Estrogen's actions skew immune responses toward allergy and autoimmune responses
– Not only do endogenous estrogens appear to play a role, but environmental estrogens have also been implicated including bisphenol A (BPA) and phthalates enhance allergic sensitization and may enhance asthma in humans.
– Increased estrogen induced by exposure to essential oils of geranium and rose compared to control odor.
Progesterone
– Progestins regulate cognitive functions as well as social behavior and mood
– Some of the progestins currently used in clinical practice exert neuroprotective and anti-inflammatory effects in the nervous system
– Synthesized by the ovaries and adrenal glands, it has widely distributed receptors and is antagonistic to estrogen.
– The progestogenic component in combined hormone therapy was found to potentially counteract the beneficial influence of estrogens on mood and to even induce negative mood symptoms
Progesterone
– Women with higher average progesterone levels across their cycles reported higher levels of anxiety
– Progesterone has also been shown to decrease gastric emptying, which has the potential to modify an antidepressant's pharmacokinetics
– Use of combined HT in the previous month was associated with worse depression and anxiety among 6000 peri- and postmenopausal women

Testosterone
– Testosterone is essential for maintaining virilization and muscle mass and may also affect libido, mood regulation, bone health and cardiac disease
– Hypogonadal men exhibit a significantly higher prevalence of anxiety disorders and major depressive disorder
– Certain chemotherapies can reduce testosterone and increase anxiety
– testosterone can enhance dopamine and serotonin release in the mesolimbic system
Testosterone
– Testosterone can enhance GABA
– Gonadal dysfunction appears to impair dopamine release but not synthesis (important esp for transgender individuals)
– Testosterone acting in the hippocampus has a number of anxiolytic, antidepressant, and protective cellular actions
– Testosterone can influence the degree of amygdala activation in relation to fear, with a positive correlation observed between testosterone levels and amygdala activation in men and a negative correlation in women

Testosterone
– Gonadal steroids impact HPA axis reactivity differentially.
– Testosterone replacement blunts the CORT and ACTH response to stress.
– Estradiol treatment increases the reactivity of the HPA axis
– To maintain homeostasis, the neuroendocrine system continuously monitors the levels of gonadal steroids using estrogen and androgen receptors in the hypothalamus.
– Dysregulation of either or both of these axes can result in compromised responses to stressful life events.
– Testosterone is suppressed with long term opioid use
Testosterone
– Testosterone treatment in hypogonadal men has beneficial effects on depressed mood.
– The highest prevalence for maternal depression was typically during the first 3 postpartum months; whereas paternal depression seemed to peak somewhat later, between 3 and 6 months postpartum
– 30% lower testosterone levels in the postpartum period. Interaction with the infant lowers Testosterone levels even more.
– Testosterone levels increase in a reproductive context (i.e., mating) and decrease in long-term bonds and paternal care settings
HPA Axis
– Chronic activation of the HPA-Axis, has an inhibitory effect upon estrogen and testosterone secretion
– Stress in adulthood continues to mediate HPG activity in females through activation of a sympathetic neural pathway originating in the hypothalamus and releasing norepinephrine (NE) into the ovary, which produces a non-cyclic anovulatory ovary that develops cysts. (PCOS)
– Chronic social stress in females may lead to low estradiol and a hypersensitivity in Estradiol-replacement
– The ability to modulate the HPA-Axis is significantly reduced in ovariectomized females suggesting a hyporesponsive HPA phenotype resembling that observed in several human psychopathologies, including post-traumatic stress disorder.

– Depression and anxiety commonly associated with dysregulation of the mesolimbic system, the hypothalamic-pituitary-adrenal (HPA) axis, hypothalamic areas, hippocampus, and medial prefrontal cortex
– Dysfunction in hormone synthesis, release or reuptake can disrupt the hormone balance and impact the HPA axis via the HPG axis
– Variance in body fat, hormone levels, and liver metabolism between sexes have been shown to affect the pharmacokinetics of antidepressants and oral hormone replacement.

Biopsychosocial Impact
– Physical
– HPA-Axis Activation
– Autoimmune disorders
– Blood pressure dysregulation
– Insomnia
– Fatigue
– Hypervigilance
– Altered libido
– Psychological
– Irritability
– Anxiety
– Depression
– Increased risk for addiction
– Social
– Social withdrawal (depression/anxiety/fatigue)
– Impaired relationships due to irritability
– Work impairment

Potential “Hidden” Culprits
– Triclosan (antibacterial agent) disrupts estrogen, testosterone and thyroid hormones according to the Natural Resources Defense Council.
– Estrogen Increasers
– BPA and Pthyalates (water bottles, PVC, food wraps, canned foods and plastics)
– PFAS/PFOAs (Teflon)
– Certain essential oils
– Phytoestrogens (plant estrogens)
– Testosterone Lowering
– Opioids
– Cimetidine (Tagamet for GERD)
– Antidepressants
– Statins (lower cholesterol)
– Diabetes
– Child birth

Summary
– To treat depression or anxiety by increasing serotonin, norepinephrine and/or dopamine is overly simplistic.
– Mood and physical symptoms may result from impaired reuptake of one or more of the monoamines or sex hormones.
– It should be noted that when sex hormones or monoamines are artificially replaced, it impacts the balance of the whole system.
– Estrogen and testosterone have neuroprotective effects, but excess can also cause problems with monoamine balance
– Too much testosterone: Mood swings, irritability, anxiety, impaired judgment
– Too much estrogen: Anxiety, insomnia, fatigue, cognitive decline, mood swings, weight gain
– Too little estrogen: Mood swings, hot flashes, depression, fatigue, difficulty concentrating
– Too little testosterone: depression, cognitive decline, fatigue, weakness

Nov 09 2019

Play

Case Study: Depression

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438 Depression Case Study
Using the PACER Method
Counselor Toolbox Podcast Episode 438
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
Podcast Host: Counselor Toolbox and Case Management Toolbox

Objectives
– Review a case study using the transdiagnostic, transtheoretical PACER approach
– As they say on Law and Order…
– The following story is fictional and does not depict any actual person or event.”
Case
– Tom is a 36 year old male and has been struggling with depression on and off for years, but the past 2 months it has gotten intolerable. He recently lost 85 pounds to try to help get his diabetes under control and improve his sleep apnea and blood pressure. He was thrilled with his weight loss progress, but he hit a plateau and feels like he is going backwards.
Physical
– Sleep
– On an average night how much sleep do you get- REM _1__ Deep _.5__ Light _6___
– On an average night how many times do you wake up- __3-4 but has sleep apnea___ Has not been waking up as much since he lost weight and started on the CPAP
– After an average night’s sleep how do you feel- Tired _x__ Okay ___ Energetic ____
– When you wake up feeling refreshed, how much sleep do you get- REM __3_ Deep __2+_ Light __3+__
– Sleep hygiene self assessment.

Physical
– Nutrition
– Using a free app like SparkPeople, track your nutrition for a week.
– Which nutrients do you get less than 75% the full RDA- Zinc
– Which nutrients do you get less than 25% of the RDA- None
– When was the last time you had a full panel blood test to examine your kidney and liver function, thyroid and vitamin D levels- 6 months
– Describe your eating habits: I have been eating healthier on my diet and try not to get too crazy because of diabetes
– Do you eat due to stress or for comfort when you are upset- yes
– Do you drink at least 64 ounces of noncaffeinated, nonalcoholic beverages each day- yes
– How much caffeine do you have on an average day- (100-150 mg/8oz of regular coffee; 35-50 mg/8oz of soda) ~600mg

Physical
– Nutrition
– How much nicotine do you have on an average day- (1mg/1 cigarette; 6-24mg/vaping cartridges) __0___
– Are you currently over or under fat- (Note: People can have a lot of muscle and not be unhealthy) _no____
– Have you recently had any problems with excessive thirst or hunger- __no
– Do you have problems with hypoglycemia (your blood sugar dropping)- _yes (diabetic)
– Have you recently gained or lost a lot of weight- Yes
– Has your doctor tested your blood sugar lately (fasting blood test)- __yes
– Do you mainly gain weight around your belly- __yes__
– Referral to PCP

Physical
– Pain
– Do you have any chronic pain- __Yes__
– If so what causes it-__bad knees___ How long have you had it- _since college___
– What makes it worse- __standing, walking_________
– What makes it better- _heat, ice, elevation
– How has it impacted your mood/relationships/energy/sleep/self-esteem- Knee pain is annoying and keeps me from playing tennis with my daughter

Physical
– Exercise/sedentariness
– Do you exercise- ____not anymore ______ If yes, how often and for how long- ____daily 45 minutes_____
– How is your energy, mood and appetite after you exercise- ___I’m exhausted________________
– Do you sleep better on days you exercise- __-___ Does muscle soreness make it harder to sleep- __No___

Physical
– Energy
– Which best describes your average energy level Low__x_ I can get through the day___ Great! ___
– Have you had your thyroid levels tested lately- __N__ If so were they in normal range- __-__
– Using a pulse ox monitor: What is your resting heart rate- __85_ What is your O2 saturation- __98___
– Do you have high blood pressure- _Y__ (managed with medication) Heart conditions- _N____ if so, what

Physical
– Libido/Sex hormones
– How is your sex drive- Low __x___ Good _____ Incredible______
– Has there been any change in your sex drive- __N___ If so when and what caused it- ____-__ Been low for a couple years
– If you are over 45 have you had your sex hormone levels tested in the past year- ___N___
– How often do you masturbate or have sex- ___<1_____/ week Physical - Do you tend to feel on edge and startle easily- ___N___ - Do you have a history of trauma- ____N___ - Do you have any autoimmune issues/inflammatory conditions like psoriasis, rheumatoid arthritis, Chron’s disease, lupus etc.- ___N_ - Have you ever had a concussion or other traumatic brain injury- ___N_____ - How often do you have headaches- ____N__ What triggers them- __ - What helps them go away- _________ - Do you ever see spots or floaties when you get a headache- __ - Do you get migraines- ___N_____ - How often do you drink alcohol- _daily_ What do you drink- Beer/wine _X_ - How many drinks do you have in an average week- __2-3/day - Do you gamble or play the lottery- __N___ How much money do you spend on it each week- _______ Affective - For each of the following feelings, identify how often you feel it each week, what triggers it and what makes it better. - I feel happy 0-3 days a week __x__ 4 or 5 days a week __ More than 5 days a week __ - What 5 things help you feel happy- ___ - * What things used to make you happy or did you enjoy - I feel sad or depressed 0-3 days a week __0__ 4 or 5 days a week ____ More than 5 days a week __x__ - What triggers it- Breathing - What helps you feel better- Nothing - I feel stressed or overwhelmed 0-3 days a week __x__ 4 or 5 days a week ____ More than 5 days a week _____ - What triggers it- ___ - What helps you feel better- __ Affective - I feel anxious or worried 0-3 days a week _0_ 4-5 days a week _ >5 days a week ____
– What triggers it- __
– What helps you feel better- ______-____
– I feel angry, resentful 0-3 days a week ___ 4 or 5 days a week _X_ >5 days a week
– What triggers it- The news, my depression, messages about “toxic masculinity” and white male privilege.
– What helps you feel better- Nothing
– I feel guilty 0-3 days a week __0_ 4 or 5 days a week __ >5 days a week
– What triggers it- ___
– What helps you feel better- _______

Affective
– In the past year, I have experienced the following losses which caused me to feel grief: None
– What stressors are currently present- __Lost a promotion to someone who was less qualified and had less seniority but was not a white male. I am still [bitter] about that, my diabetes, kids getting ready for college which will be expensive. So many people get paid a crap ton of money for “jobs” that don’t contribute to society (anchors, actors, athletes).
– What is different when you are happy- I am not tired all the time. I am able to workout. People don’t [annoy] me as much
– How long does it take for you to calm down after you get upset- _+/- 1hr
– What helps you calm down- __I vent about it to my wife___
Educate about HPA-Axis activation, biofeedback and relaxation techniques.
Discuss affective issues in counseling

Cognitive
– How is your attention/concentration- ___awful___
– Have you ever been diagnosed with ADHD- _N____
– Has there been a change in your ability to concentrate lately- _Y__ How long- ___6 months___
– If so, what is causing it- __lack of sleep- Depression- I don’t know.
– Does it seem to be taking longer to process information- _Y_
– How is your memory- __awful______ Have you been more forgetful than usual- ___y_____
– If so, when did your forgetfulness start- A few months ago What is causing it- I don’t know
– When you think about yourself, your life, the world, other people, do you tend to feel angry, suspicious or hopeless- ___Y___
– If yes, have you always felt this way or did something happen to change your feelings- __Started watching the news and spending time around people__

Cognitive
– Negative self-talk
– Do you frequently judge or criticize yourself- ___Not really_______
– Do you hold yourself to a higher standard than you hold other people- ____N______
– Do you think you are lovable/likeable only if you are perfect (or almost perfect)- ___N_______
– Where did you learn your negative self talk- __

Cognitive
– Pay attention to your thoughts for a week. Place a check by the thinking errors which are most common for you and contribute to your unhappiness.
X All or none thinking Find Exceptions
X Assuming/Jumping to conclusions without all the facts Get the facts
X Focusing on a small aspect instead of the bigger picture Consider alternate explanations
X Expecting life to be fair Explore living in the AND
X Taking things too personally Consider alternate explanations
X Focusing on the negative and ignoring the positive Learn about radical acceptance
– Taking something bad and blowing it out of proportion (catastrophizing)
– Expecting people to be able to read your mind Evaluate how you communicated what you wanted and practice assertive communication
– Assuming you know what others are thinking. Evaluate your evidence. Get the facts.
Educate about cognitive distortions and interventions. Provide worksheets to address CDs.

Cognitive: Hardiness
Cognitive
– Time management
– How effective are you at managing your time- Good when I am not depressed
– Do you often take on too much and feel overwhelmed or rushed- No
– Are you a perfectionist- __N___ If yes, how does that impact your mood, sleep and relationships-
– Do you procrastinate- __Y__ I just don’t have the energy to do anything so I put it off until it is a crisis.
– If yes, how does that impact your mood, sleep and relationships- __I tend to get irritable when I have something to do that I am procrastinating then irritable when I feel rushed.
Develop a schedule that includes the “must dos” delegates and simplifies when possible.

Environmental
– Do you feel safe most of the time- _____Y___ If no, where do you not feel safe and why-
– What helps you feel safe- __My dogs. My neighborhood. My guns (Former Reserves. No deployments)
– Are you able to have peace and quiet when you want it and when you sleep- ___Yes___I wear earplugs to block out the sound of the CPAP__ If no, what can you do to reduce unwanted noise-
– During the day are you able to access natural light, or at least a really bright working area- ___Yes_but I don’t
– When you sleep, are you able to make your room totally dark or block out the light- _Y_
– Do you eliminate blue light from television and electronic devices at least 2 hours before bed- __N I watch television until I drift off__
Environmental
– What smells are you regularly exposed to-
– Noxious/unpleasant/irritating __nothing. My allergies keep me from smelling much__
– Triggering (reminds you of something unpleasant) __
– Happy/relaxing/energizing __
– Are you able to keep your environments at a temperature you find comfortable- __No. My wife keeps it hot in the summer and cold in the winter.
Relationships
– Do you feel you are capable, lovable and deserving- _y____ If not, why not- ___
– Do you have healthy relationships or regularly fear abandonment- ____Healthy overall______
– Can you effectively identify and communicate feelings and thoughts and get your needs met- ___y_____
– Do you have a social support system that can provide practical assistance and emotional support- __Practical assistance, yes…Emotional support from my parents, not so much my wife.

Initial Tx Plan goals
– Referral to PCP for hormone evaluation and to check blood pressure medication levels due to rapid weight loss. Discuss antihistamines and allergies Get feedback from physician visit.(Week 0)
– Sleep duration and quality–Sleep hygiene assessment handout (Week 0)
– Make a sleep hygiene enhancement plan based on handout data. (Review progress and impact weekly through week 8)

Initial Tx Plan goals
– Emotional Dysregulation and Psychological Flexibility Matrix
– Week 0: Define a rich and meaningful life—People, activities, thoughts, behaviors to achieve it
– Week 1: Identify autopilot thoughts and behaviors in response to distress and discuss radical acceptance
– Week 2: Develop a list of distress tolerance skills and empowerment oriented self-talk to add to the matrix. Provide matrix handout (complete at least one each day)
– Weeks 3-8: Practice applying the matrix at home and in session

Initial Tx Plan goals
– Cognitive distortions worksheet/log. Focus on one distortion each week. (due weeks 3-8)
– Hardiness Enhancement to increase positive chemicals (Week 3-8). Create a schedule to help better use time to focus on the important things.
– Specific Stressors for Discussion (Beginning Week 1)
– Unfairness in the world
– Discrimination due to being a white male and feelings of rejection due to society’s stance on “toxic masculinity”
– Financial stress of kids getting ready to leave for college

Reassessment
– Tom went to his PCP and had a physical. The doctor was pleased with his weight loss and reduced his blood pressure medications. Tom’s thyroid hormones were on the low end of normal range and testosterone levels were low so he was put on a low dose testosterone replacement gel. He discussed his allergies with his doctor who switched him to an antihistamine nasal spray. Tom is still not being totally open with his doctor about alcohol and caffeine use.
– Sleep hygiene assessment identified issues with allergies, blue light exposure, caffeine intake, daytime napping, and staying in the dark. Tom ordered a blue light filter for his TV and now sets a sleep timer. He also ordered noise cancelling ear buds and wears those at night when he watches television and they help block out CPAP noise the rest of the night. He stopped drinking alcohol after 7pm and has cut out caffeine after 3pm.
– Tom’s energy seems to be improving. He rated his energy “good” or “okay” 6 out of 7 days for the last 3 weeks.
Reassessment
– Tom’s persistent frustration with “life” seems to be contributing to learned helplessness and hypocortisolism which is also impacting his blood pressure, diabetes and mood.
– Tom is becoming more aware that a sense of disempowerment is contributing to his depression and is practicing using the matrix each day.
– Tom has been consistent with sticking to his hardiness enhancement plan which has left him less time to perseverate on the news and is getting him out of the house more
– He has removed all news apps from his phone and only allows himself to watch the news when he is on the stationary bike at the gym. He says he can work out his frustrations easier that way.

Reassessment
– Tom is still struggling with some cognitive distortions because he feels like if he doesn’t focus on the injustices in the world, “they” are winning. We are continuing to work on identifying what parts are within his control, which irritants are worth his energy and refocusing attention on what is going right in his life instead of what he perceives as wrong with the world.
– Tom has stopped looking for a new job as he likes his current job and believes he will experience the same injustices elsewhere.

Summary
– Depression can be the result of low serotonin, dopamine, norepinephrine or glutamate; excessive anxiety or trauma causing hypocortisolism; buildup of adenosine as a result of poor quality sleep.
– Sleep can be disrupted by alcohol, caffeine, sleep apnea, blue light exposure, circadian rhythm disruption,
– Fatigue can be caused by poor sleep, some antihistamines, blood pressure medication, diabetes, excessive stimulant use, poor nutrition, low testosterone.
– Social and behavioral withdrawal can be caused by anhedonia, fatigue and irritability.

Nov 02 2019

55mins

Play

Social Work Considerations for Addressing Chronic Conditions (Re-Release)

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437 -Social Work Considerations for Addressing Chronic Conditions
Dr. Dawn-Elise Snipes
Counselor Toolbox Podcast

CEUs can be earned for this presentation at https://www.allceus.com/member/cart/index/product/id/1078/c/

~ Chronic conditions such as diabetes, arthritis, chron's disease, and depression
Introduction
~ 60% of people in the US have a chronic illness
~ Many serious illnesses have a much longer course with episodes of exacerbations and remissions
~ Chronic Illness can be highly stressful for patients and families
~ Care for people with chronic illnesses is increasingly done by family in the home.
~ Untreated mood disorders in individuals with co-morbid chronic health conditions increases morbidity and mortality rates and reduces the capacity for self-management

Biopsychosocial Impact of Chronic Conditions
~ Sleep
~ Pain
~ Medication side effects
~ Fatigue
~ Circadian rhythm disruption
~ Physical changes (weight changes, ports, pumps, hair loss)
~ Loss of mobility
~ Depression
~ Anxiety
~ Anger
~ Grief/Adjustment
~ Jealousy or resentment
~ Irritability
~ Withdrawal
~ Self Esteem changes
~ Loss of social support
~ Smothering social support
~ Inability to engage in prior important activities
~ Loss of independence
~ Vocational problems
~ Financial hardships (Medical expenses, job loss, environmental modifications)
~ Access to nutritious food
~ Physical, sexual and emotional relationship problems

Goals of Chronic Care Models
~ Shift from acute, episodic treatment to one of ongoing proactive care
~ Emphasizes
~ Prevention (getting worse, developing other conditions)
~ Patient’s role in managing health with mutual goal setting and action planning (self-management)
~ The goal of self-management interventions are to:
~ Improve knowledge about the condition and intervention options
~ Increase confidence in the ability to change
~ Leverage what he or she can do to promote personal health (prevention)

Goals of Chronic Care Models
~ The goal of self-management interventions are to
~ Improve motivation and problem solving rather than simple compliance with a caregiver’s advice
~ Help the participants’ master six fundamental self-management tasks:
~ Solving problems
~ Making decisions
~ Using resources
~ Forming a patient -provider partnership
~ Making action plans for health behavior change
~ Self-tailoring
Categories of Interventions (FRAMES)
~ Self Management Support
~ Feedback
~ Develop collaborative relationships
~ Use an ask-tell-ask framework with clients and caregivers
~ Responsibility
~ Ability and motivation for self-management fluctuates. Tailor interventions appropriately (symptom exacerbations, med changes, life changes…)
~ Advice
~ Use education and scaffolding to empower clients to adjust their behaviors and take control of health self-management
~ Menu of Options depends on individual circumstances, and resource availability
~ Empathy and Encouragement
~ Self-Efficacy

“5 A’s” of Behavioral Change
~ Assess
~ Advise/engage
~ Agree/collaborate
~ Assist/identify obstacles and interventions (treatment)
~ Arrange for follow up (evaluate/review)

Categories of Interventions
~ Assess
~ Regular assessment and enhancement of motivation and readiness for self-management
~ Ongoing Biopsychosocial Assessment (including quality of life and a Health Risk Appraisal (HRA)
~ An HRA is a systematic approach to
~ Collecting information about risk factors
~ Providing individualized feedback
~ Linking the person with at least one intervention to promote health, sustain function and/or prevent disease

Categories of Interventions
~ Advise:
~ Multimodal education about the condition and treatment options
~ Teach self-monitoring for clients and caregivers
~ Families and clients are educated about
~ The illness
~ What to expect from a family member who has the illness
~ How they can best help
~ How to take care of themselves

Categories of Interventions
~ Agree and Assist (Collaborate)
~ Engage through goal directed counseling and conferences with patients, families, and support networks to
~ Motivate and empower them to take an active part in the recovery process
~ Teach them how to monitor and improve their motivation and commitment to tasks
~ Set goals, collaboratively, with clients, using templates that can be modified based on the client’s context
~ Develop tools that the client can use in the future

Categories of Interventions
~ Agree and Assist (Collaborate)
~ Engage through goal directed counseling and conferences with patients, families, and support networks to
~ Encourage the use of specific tools and templates that can be modified based on the client’s context (home, work, vacation)
~ Teach how to break down goals and tasks into small steps
~ Help clients and families integrate feelings and attitudes regarding their condition and life with a focus on issues and concerns that they have experienced since first developing signs of the problem, and how to address those problems

Categories of Interventions
~ Agree and Assist (Collaborate)
~ Crisis intervention
~ Social support facilitation
~ Interdisciplinary care planning, collaboration, referrals (i.e. Church-based support groups, local community health programs, clinic and internet based support groups)
~ Advocacy on patients’ behalf including addressing problems related to treatment options and setting transfers
~ Assistance with decision making with regard to advance directives
~ Personalized feedback and help the client learn how to ask for, receive and use feedback

Categories of Interventions
~ Arrange for Follow-Up and Step-Down
~ Build in evaluation processes to help clients measure their progress
~ Service plan reassessments
~ Discharge planning

Additional Interventions
~ Additional services
~ Assertive community treatment (ACT) programs to monitor medication and treatment plan compliance in clients with low motivation and/or low functioning
~ Assist clients in using
~ Information from self-monitoring techniques
~ Clinician extenders like mindfulness, CBT or pain management apps
~ Linkage with community support programs

Change Process
Qualities of Good Action Plans
~ Something the person wants to do
~ Avoid having to take insulin
~ Feel less pain
~ Specific and positive
~ Improve my weight, nutrition, exercise and stress levels
~ Be able to comfortably sleep and engage in meaningful activities
~ Measurable: What? How much? When? How often?
~ Reduce my weight by 5%, follow the prescribed diet, get 30 minutes of exercise 5 days a week, reduce daily stress levels from a 7/10 to a 4/10
~ Reduce my daily pain rating from a 4/5 to a 2/5, get at least 7 hours of quality sleep, be able to take my dog on 2 30-minute walks a day
~ Achievable with a high probability of success
~ Relevant
~ Time limited (3 months)—Break it down further…

Summary
~ Treatment for persons with chronic conditions requires use of many strategies outside of traditional emotion or cognition focused counseling to educate, motivate and empower clients to take charge of their condition.
~ It is beneficial to educate the client as well as the family/support system about the condition, effects of the condition, expectations for improvement and benefits and drawbacks of possible interventions.
~ Using the FRAMES approach empowers the client to take charge of self-management, provides a menu of options and support to help the client enhance self efficacy

Nov 02 2019

49mins

Play

Case Study Anxiety Assessment and Intervention with the PACER Method

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436- Anxiety Case Study
Using the PACER Method
Counselor Toolbox Podcast Episode 436
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com

Sponsored by TherapyNotes.com
Manage your practice securely and efficiently. Two free weeks of TherapyNotes with coupon code “CEU”

Podcast Host: Counselor Toolbox and Case Management Toolbox
Objectives
– Review a case study using the transdiagnostic, transtheoretical PACER approach

– As they say on Law and Order…
– The following story is fictional and does not depict any actual person or event.”
Case
– Sally is a 49 year old female with one child in college and a second child who is a senior in high school. She has started having anxiety, difficulty sleeping and panic attacks over the last 6 months.
– Her doctor prescribed her Xanax to take as needed to prevent panic attacks and help her sleep. She says the rebound anxiety from that is terrible and won’t take it anymore. She cannot identify any particular precipitating factor. She says the anxiety came on kind of gradually over the past few months and the panic attacks only started in the past few weeks.
– She reports that she was in counseling for a month with someone else but it wasn’t helping very much. Things are getting worse and her doctor
Physical
– Sleep
– On an average night how much sleep do you get- REM _2__ Deep _.5__ Light _6___
– On an average night how many times do you wake up- __3-4___
– After an average night’s sleep how do you feel- Tired _x__ Okay ___ Energetic ____
– When you wake up feeling refreshed, how much sleep do you get- REM __3_ Deep __2+_ Light __3+__
– (Sleep has worsened significantly in the last 4 months.)
– Sleep hygiene self assessment. (This will also address caffeine after noon and alcohol) 

Physical
– Nutrition
– Using a free app like SparkPeople, track your nutrition for a week.
– Which nutrients do you get less than 75% the full RDA- Mg, Zn, Fe
– Which nutrients do you get less than 25% of the RDA- None
– When was the last time you had a full panel blood test to examine your kidney and liver function, thyroid and vitamin D levels- ___18 months
– Describe your eating habits: I eat pretty healthy but tend to be a stress eater and have cut out all processed foods (breads, cereals) and red meat
– Do you eat due to stress or for comfort when you are upset- yes
– Do you drink at least 64 ounces of noncaffeinated, nonalcoholic beverages each day- yes
– How much caffeine do you have on an average day- (100-150 mg/8oz of regular coffee; 35-50 mg/8oz of soda) 1200 (one pot)

Physical
– Nutrition
– How much nicotine do you have on an average day- (1mg/1 cigarette; 6-24mg/vaping cartridges) __0___
– Are you currently over or under fat- (Note: People can have a lot of muscle and not be unhealthy) _no____
– Have you recently had any problems with excessive thirst or hunger- __no
– Do you have problems with hypoglycemia (your blood sugar dropping)- _yes
– Has your doctor tested your blood sugar lately (fasting blood test)- __no
– Do you mainly gain weight around your belly- __yes__
– Referral to PCP for physical to include nutritional evaluation, hormone evaluation and possible addition of multivitamin to address nutritional deficiencies. Discuss with PCP sleep problems with onset ~beginning of Mirapex and the possibility of iron deficiency anemia causing RLS. Discuss with PCP the frequent headaches with floaters. Discuss with PCP chronic pain issues and possibility of a physical therapy referral.

Physical
Physical
– Pain
– Do you have any chronic pain- __Yes__
– If so what causes it-____Back injury_______________ How long have you had it- _18 months___
– What makes it worse- __Bending, sitting_________
– What makes it better- _heat, ice, muscle relaxants____________________
– How has it impacted your mood/relationships/energy/sleep/self-esteem- Frustrating to be in pain and tired all the time and not able to do my gardening_

Educate about ergonomics. Ergonomic self study.

Physical
– Exercise/sedentariness
– Do you exercise- ____yes______ If yes, how often and for how long- ____daily 45 minutes_____
– How is your energy, mood and appetite after you exercise- ___good________________
– Do you sleep better on days you exercise- __Y___ Does muscle soreness make it harder to sleep- __Y___
Discuss methods for reducing muscle soreness to improve sleep

Physical
– Energy
– Which best describes your average energy level Low___ I can get through the day_x__ Great! ___
– Have you had your thyroid levels tested lately- __N__ If so were they in normal range- __-__
– Using a pulse ox monitor: What is your resting heart rate- __65_ What is your O2 saturation- __98___
– Do you have high blood pressure- _Y__ (managed with diet) Heart conditions- _N____ if so, what

Physical
– Libido/Sex hormones
– How is your sex drive- Low __x___ Good _____ Incredible______
– Has there been any change in your sex drive- __Y___ If so when and what caused it- ____-__
– If you are over 45 have you had your sex hormone levels tested in the past year- ___N___
– How often do you masturbate or have sex- ___<1_____/ week Physical - Do you tend to feel on edge and startle easily- ___N___ - Do you have a history of trauma- ____N___ - Do you have any autoimmune issues/inflammatory conditions like psoriasis, rheumatoid arthritis, Chron’s disease, lupus etc.- ___N_ - Have you ever had a concussion or other traumatic brain injury- ___N_____ - How often do you have headaches- ____Y__ What triggers them- _stress_ - What helps them go away- ______neck massage or ice/heat___ - Do you ever see spots or floaties when you get a headache- Y__ - Do you get migraines- ___N_____ - How often do you drink alcohol- _daily_ What do you drink- Beer/wine _X_ - How many drinks do you have in an average week- __2-3/night to relax__ 14-21/wk - Do you gamble or play the lottery- __N___ How much money do you spend on it each week- _______ Affective - For each of the following feelings, identify how often you feel it each week, what triggers it and what makes it better. - I feel happy 0-3 days a week __3__ 4 or 5 days a week __ More than 5 days a week __ - What 5 things help you feel happy- ___my kids, dogs, shopping, watching funny movies, hiking___ - I feel sad or depressed 0-3 days a week __0__ 4 or 5 days a week ____ More than 5 days a week ____ - What triggers it- NA - What helps you feel better- NA - I feel stressed or overwhelmed 0-3 days a week ____ 4 or 5 days a week _x___ More than 5 days a week _____ - What triggers it- ___Work, finances, not being able to workout like I want, too much to do around the house__ - What helps you feel better- __focusing on my kids, cooking Affective - I feel anxious or worried 0-3 days a week __ 4-5 days a week _ >5 days a week __7__
– What triggers it- __kids happiness, whether I was a good parent, finances, my health, family hx of cancer (Dad died when he was my age)__
– What helps you feel better- ______-____
– I feel angry, resentful 0-3 days a week __0_ 4 or 5 days a week __ >5 days a week
– What triggers it-
– What helps you feel better-
– I feel guilty 0-3 days a week __3_ 4 or 5 days a week __ >5 days a week
– What triggers it- ___I regret not doing more with my kids when they were younger. I feel bad for not being as good of a friend as I should.
– What helps you feel better- ___-_____

Affective
– In the past year, I have experienced the following losses which caused me to feel grief: My dog died. My mother died. My grandmother died. My oldest child moved out and started college. My best friend barely has time to talk to me anymore. (NOTE: Youngest child is a senior —preparing for empty nest)
– What stressors are currently present- __So much misery and hate in the world. Trying to save for retirement. Work regularly has layoffs. Back injury. Worried about kids’ choosing a path that will help them be successful and happy.
– What is different when you are happy- I am spending time with my family and animals, have time and energy to exercise and go hiking. I am 15 pounds lighter and the house is clean.
– How long does it take for you to calm down after you get upset- _+/- 1hr
– What helps you calm down- __distracting myself or solving the problem___
Educate about HPA-Axis activation, biofeedback and relaxation techniques. Have her use her fitness tracker to practice a variety of relaxation techniques when she starts to feel stressed and/or starts getting a stress headache to reduce her heart rate by 5 or more bpm
Discuss affective issues in counseling

Cognitive
– How is your attention/concentration- ___awful___
– Have you ever been diagnosed with ADHD- _N____
– Has there been a change in your ability to concentrate lately- _Y__ How long- ___6 months___
– If so, what is causing it- __lack of sleep- Stress- I don’t know.
– Does it seem to be taking longer to process information- _Y_
– How is your memory- __Good______ Have you been more forgetful than usual- ___N_____
– If so, when did your forgetfulness start- NA What is causing it-
– When you think about yourself, your life, the world, other people, do you tend to feel angry, suspicious or hopeless- ___Y___
– If yes, have you always felt this way or did something happen to change your feelings- __Started watching the news and spending time around people__

Cognitive
– Negative self-talk
– Do you frequently judge or criticize yourself- ___Y_______
– Do you hold yourself to a higher standard than you hold other people- ____N______
– Do you think you are lovable/likeable only if you are perfect (or almost perfect)- ___N_______
– Where did you learn your negative self talk- __my family, teen media__

Cognitive
– Pay attention to your thoughts for a week. Place a check by the thinking errors which are most common for you and contribute to your unhappiness.
X All or none thinking Find Exceptions
X Assuming/Jumping to conclusions without all the facts Get the facts
X Focusing on a small aspect instead of the bigger picture Consider alternate explanations
– Expecting life to be fair
X Taking things too personally Consider alternate explanations
– Taking something bad and blowing it out of proportion (catastrophizing)
– Focusing on the negative and ignoring the positive
X Expecting people to be able to read your mind Evaluate how you communicated what you wanted and practice assertive communication
X Assuming you know what others are thinking. Evaluate your evidence and get the facts.
Educate about cognitive distortions and interventions. Provide worksheets to address CDs.

Cognitive: Hardiness
Cognitive
– Time management
– How effective are you at managing your time- ___Good if I give up sleep_____
– Do you often take on too much and feel overwhelmed or rushed- Yes
– Are you a perfectionist- __N___ If yes, how does that impact your mood, sleep and relationships-
– Do you procrastinate- __Y__ If yes, how does that impact your mood, sleep and relationships- __I tend to get irritable when I have something to do that I am procrastinating then irritable when I feel rushed.
Develop a schedule that includes the “must dos” delegates and simplifies when possible.

Environmental
– Do you feel safe most of the time- _____y___ If no, where do you not feel safe and why-
– What helps you feel safe- __My dogs. My neighborhood.______
– Are you able to have peace and quiet when you want it and when you sleep- ___Yes_____ If no, what can you do to reduce unwanted noise-
– During the day are you able to access natural light, or at least a really bright working area- ___Yes_
– When you sleep, are you able to make your room totally dark or block out the light- _Y_
– Do you eliminate blue light from television and electronic devices at least 2 hours before bed- ___Y__
Environmental
– What smells are you regularly exposed to-
– Noxious/unpleasant/irritating __Dog poop, burned food__
– Triggering (reminds you of something unpleasant) __musty smells (old buildings)___
– Happy/relaxing/energizing __rosemary, basil, roses, caramel, wax tarts___
– Are you able to keep your environments at a temperature you find comfortable- __Yes except during hot flashes___
Relationships
– Do you feel you are capable, lovable and deserving- _y____ If not, why not- ___
– Do you have healthy relationships or regularly fear abandonment- ____Healthy overall______
– Can you effectively identify and communicate feelings and thoughts and get your needs met- ___y_____
– Do you have a social support system that can provide practical assistance and emotional support- __practical assistance, yes…emotional support not as much___

Initial Tx Plan goals
– Referral to PCP for nutritional and hormone evaluation, medication side effects, headaches. and chronic pain—PT referral (due week 1) Get feedback from physician visit.
– Sleep duration and quality–Sleep hygiene assessment handout (Due week 1) Make a sleep hygiene enhancement plan based on handout data. (Review progress and impact weekly through week 8)
– Emotional dysregulation and biofeedback (Weeks 0-8. Week 1 belly breathing and object focus) Keep a log of when you do it and the results. (Repeat each week with different relaxation and distress tolerance activities)
– Pain frequency, intensity, impact and interventions including ergonomic assessment (due week 2)
– Cognitive distortions worksheet/log (due week 2-8)
– Hardiness Enhancement with Psychological Flexibility to increase positive chemicals (Week 3-8)

Initial Tx Plan goals
– Specific Worries for Discussion (Beginning Week 1)
– Kids' happiness
– Whether she was a good parent
– Finances
– Personal health and anxiety related to family hx of cancer and the possibility of current pain being permanent
– Guilt for not being the parent she thinks she should have been and the friend she things she should be
– Grief over empty nest, deaths

Reassessment
– PCP provided PT referral which seems to be reducing pain. Hormone levels indicated early stages of menopause. Normalized heart palpitations associated with hot flashes. Blood pressure is stable. Started taking a multivitamin and eating more grains and green leafy vegetables to improve nutritional profile. D/cd Mirapex and started taking iron and magnesium supplements.
– Reports sleeping somewhat better. Still waking up occasionally, but getting more deep sleep. Energy seems to be improving.**
– Still drinking a full pot of coffee each day, but is drinking half caf. and stopping caffeine after 3pm. Working toward no caffeine after noon.
– Has cut back on alcohol at night, but still drinks occasionally. Started taking (per MD 1mg Melatonin to help her get sleepy)
– Biofeedback seems to be helping. She got a new fitness tracker that monitors her heart rate variability and prompts her to use belly breathing when it detects she is “stressed” Stress episodes have decreased from an average of 5 times per day to 3.5 times per day.

Reassessment
– Pain is improving with physical therapy. She got a stability ball to sit on at her desk to prevent leaning and poor posture and got a knee pillow to help keep her back in better alignment when she sleeps.
– She is becoming more aware of her cognitive distortions which she credits with reducing her “stress episodes” In session she quickly corrects herself when she makes a distorted statement and is effectively identifying 85% of the distorted statements she makes. (I keep a tally sheet as we talk)
– Hardiness Enhancement with Psychological Flexibility activity has been her favorite. She reports that she feels she is making much better use of her time instead of just feeling stuck and confused.

Reassessment
– Specific Worries for Discussion
– Kids' happiness—She reports realizing that she cannot make anyone else happy and is focusing now on helping her children start to use the psychological flexibility tools she learned in counseling.
– Whether she was a good parent– Reports she has stopped focusing on what she should have done to be a good parent and is more objectively looking at her kids’ overall success and mood compared to other adolescents.
– Finances—She recognizes that most of her stress about finances comes from cognitive distortions of catastrophizing and has made an objective budget and set savings goals which she is adhering to. She also consulted with a financial planner to get reassurance that she will have enough money to retire and not have to work until she is 80.

Reassessment
– Specific Worries for Discussion
– Personal health and anxiety related to family hx of cancer and the possibility of current pain being permanent. She assessed her lifestyle and risk factors for cancer and came to the conclusion that, while it is possible, her main risk factors are alcohol use and stress, both of which she is working to reduce. Regarding her pain, the physical therapist assured her that it is muscular and not nerve or spine related so she should recover fully in 3-6 months. She also recognized that catastrophizing was increasing her stress about her injury.

Reassessment
– Specific Worries for Discussion
– Guilt for not being the parent she thinks she should have been and the friend she things she should be. She is still working on radically accepting that she cannot change the past and she is not happy about some of her choices, but she can start making choices more congruent with her values starting now.
– Grief over empty nest, deaths. It has not been a year since her mother’s death and less than 2 years since her grandmother’s death. They were the last “family” she had besides her kids and spouse. She is still working through the bereavement process for those losses and has recognized that her daughter getting ready to go to college is triggering a lot of feelings of isolation and loss.

Summary
– By understanding that “anxiety” is an excitatory response brought on by activation of the HPA-Axis we were better able to understand the impact of medications, alcohol use, nutritional deficiencies, grief and chronic stress on HPA-Axis functioning and resultant anxiety
– Anxiety is the result of stimulation of the HPA axis.
– Panic attacks may be the result of HPA-Axis dysregulation due to chronic “stress” over the past year
– RLS medications typically increase dopamine causing insomnia
– Insomnia leads to fatigue, hypocortisolism and excessive caffeine consumption
– Addressing the problem from the standpoint of identifying and addressing the causes of HPA-Axis dysfunction instead of simply addressing symptoms with talk therapy can prove much more beneficial in the long-term.

Case Study Review
– Assessment Sheet

Oct 27 2019

57mins

Play

Biopsychosocial Impact of Pain and Strategies for Prevention and Intervention

Podcast cover
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435 – Biopsychosocial Impact and Strategies for Prevention and Intervention
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs
Podcast Host: Counselor Toolbox and Case Management Toolbox

Sponsored by TherapyNotes.com
Manage your practice securely and efficiently. Two free weeks of TherapyNotes with coupon code “CEU”

Objectives
– Review the following effects of pain
– Depression
– Anxiety
– Circadian Rhythm Disruption
– Grief
– Self Esteem problems
– Explore mitigating and exacerbating factors
– Identify primary, secondary and tertiary prevention activities
Characteristics of Pain
– Everyone has pain sometimes
– Our bodies are incredibly resilient
– Knowing your pain can help your care team.
– Acute or Chronic
– Stabbing, aching, throbbing, burning…
– Constant or intermittent
– Stationary or radiating
– Any numbness

Prevention
– Primary –Prevent the pain from happening
– Secondary –Prevent the pain from getting worse
– Tertiary –Prevent the pain from causing other problems like depression, anxiety, addiction
Primary Prevention
– Proper ergonomics/form at work, home, in bed and at the gym
– Exercise bilaterally
– Stretch frequently
– Don’t overtrain
– Gradually increase activity by time not quantity
– Eat a healthy diet with omega3s, anthocyanins

Secondary Prevention
Managing Pain
– Pain interferes with enjoyment of life
– Pain management can improve quality of life
– The first step is diagnosis
– Assessing your pain
– Keeping track
– Descriptive language
– Numerical Scales
– Verbal Scales
– Visual Scales
Understanding Your Pain

– Exacerbating factors—Makes it worse
– Emotional
– Mental
– Physical
– Environmental
– Social
– Mitigating factors – Helps You Feel Better
– Emotional
– Mental
– Physical
– Environmental
– Social

Mapping a Treatment Plan
– Complex equation
– Some treatment might involve a team of professionals
– Pain therapy goals
– Multimodal approach
– Treatment interference
– Holistic/complementary care
– Treat the cause
Mapping a Treatment Plan (Cont’d)
– Available treatment options include:
– Pharmacotherapy
– Psychosocial Interventions
– Rehabilitation Techniques
– Complementary & Alternative Medicine (CAM)
– Injection/Infusion
– Implantable Devices and Surgical Interventions

Pharmacotherapy
– Using medicine to control pain
– OTC or Prescription
– Special programs available to assist people who cannot afford their medication
– 3 Classes of Analgesics
– Non-Opiods
– Opiods
– Adjuvant Analgesics

Medical Interventions for Pain
– Tylenol and NSAIDS (Over the counter)
– Opiates
– Provide relief by attaching to opioid receptors
– Body stops making natural (endogenous) opioids when flooded with prescription opiates
– Over time body reduces amount of opiate being let through (tolerance) (after only several days)
– When you stop taking prescription opioids the body takes a few days to start making natural opioids again so pain threshold is markedly decreased

Adjuvant Analgesics
– Corticosteroids
– Muscle Relaxants
– Topical Analgesics
– Local Anesthetics
– Drugs for Anxiety, Depression (Serotonin) and Sleep (cortisol, GABA and Serotonin)
Complimentary Therapies
– Mind-Body Interventions
– Prayer, Guided Imagery, Pilates
– Biologically Based Therapies
– Aromatherapy, Dietary Supplements/Nutrition
– Manipulative and Body-Based Methods
– Chiropractic Care, Massage, TENS, Dry Needling, PT
– Energy Therapies
– Qigong, Healing Touch, Reiki, Therapeutic Touch, Accupuncture
Complimentary Therapies cont…
– Guided Imagery
– Color Imagery: Think of a color that you associate with pain, such as red, and picture the painful area of your body as red. Imagine shrinking, fading or dispersing the red.
– Symbol Imagery: Think about how the pain feels. Does it feel like a knife sticking in your joint- If so, imagine you are pulling the knife out of your joint and throwing it away
– Scenic Imagery: Imagine a place that is calming to you using all of your senses
Tertiary Interventions
Effects of Pain and Chronic Illness

– Depression
– Fatigue
– Sleep Disturbances
– Hopelessness/Helplessness
– Negative thoughts -> Stress -> Serotonin -> Pain
– Interventions
– Mindfulness
– Good sleep habits
– Circadian rhythm maintenance
– Identify the things you CAN control and that are GOOD
– Eat healthfully to support Serotonin functioning

Emotional Effects of Pain

– Anxiety
– Things won’t get better
– It is getting worse
– Consequences of pain (lost job, relationships, fitness…)
– Interventions
– Avoid caffeine and nicotine
– Educate yourself about the disorder and the PROBABILITY things will get worse
– Keep a log of the good and bad days
– Practice distress tolerance skills
– Use the Challenging Questions Worksheet to address anxiety provoking thoughts

Effects of Pain

– Guilt
– Self anger for not being able to…
– Can cause you to lash out at others—push them away so you don’t disappoint them like you disappointed yourself
– Interventions
– Think about how you would want your child or best friend to feel if they were in your position
– Get rid of the shoulds
– Focus on the things that you CAN do
– Decide whether it is worth using your energy to be mad at yourself (and the world)

Effects of Pain

– Grief
– Stages: Denial, Anger, Bargaining, Depression, Acceptance
– Interventions
– Work through the stages of grief for each of the losses because of the pain (Physical, self-concept, job, freedom (driving/mobility), dreams…)

Mood Interventions for Pain

– Mindfulness
– Alternate focus: Stop thinking about the pain and how to relieve it
– Deep relaxation breathing through the pain
– Distractions
– One moment at a time
– Radical Acceptance
– Life can be worth living even with painful events. Live in the And.
– Rejecting reality does not change reality.
– Changing reality requires first accepting reality.
– Pain can’t be avoided
– Refusing to accept reality can keep you stuck in unhappiness, bitterness, anger, sadness, shame, or other painful emotions.

Mood Interventions cont…

– Stress Management
– Stress causes
– Digestive upset/pain
– Back pain
– Migraines/headaches
– Jaw pain
– Interventions
– Meditation
– Distract Don’t React
– Identify your most important values, decide whether stressing over [this] gets you closer to or further away from your goals/values

Effects of Pain
– Social Support Loss
– Changes in activities (pain, exhaustion, med. side effects)
– Withdrawal
– Supports who don’t understand
– Pushing away supports through helplessness and complaining
– Interventions
– Modify activities or develop new mutually enjoyable activities
– Join a support group and address mood issues
– Address cognitive distortions
– Practice radical acceptance and living in the And
Effects of Pain

– Self-Esteem
– How you feel about the difference between who you want to be and who you are
– Interventions
– Make a list of the positive things about you
– Identify 1 or 2 goals you can work toward
– Celebrate small things
– Silence the inner critic

Physical Effects of Pain
– Problems
– Sedentariness
– Weight gain
– Reduced libido (HPA-Axis, exhaustion, pain itself)
– Interventions
– Work with your doc to identify ways to move (PT)
– Work with a nutritionist to eat an anti-inflammatory diet that will not pack on the pounds
– Address emotional eating

Physical Effects of Pain cont…

– Circadian Rhythm Disruption
– Not getting out of bed
– Staying inside in the dark
– Sleeping too much
– Interventions
– Get out of bed at roughly the same time each morning
– Get dressed in “day-clothes”
– Turn on lights and sit in front of a window or get outside to get your “day-clock” started
– If you must take a nap, keep it under 45 minutes to avoid messing up your sleep schedule
Summary
– Pain is inevitable
– Many people struggle with chronic conditions including TMJ, migraines, depression, fibromyalgia and pain.
– It impacts your
– Mood
– Thoughts
– Behaviors
– Relationships
– Addressing pain will help reduce related
– Anxiety
– Depression
– Anger
Summary
– Pain Management
– Medical
– Nonmedical
– Pain management requires a comprehensive approach addressing
– Physical causes of pain
– Mood
– Social supports
– Sleep

Oct 24 2019

58mins

Play

Impact of Social Media on Mental Health

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434- Impact of Social Media on Mental Health

Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director: AllCEUs.com
Podcast Host: Counselor Toolbox Podcast, Case Management Toolbox

Sponsored by TherapyNotes.com
Manage your practice securely and efficiently. Two free weeks of TherapyNotes with coupon code “CEU”

Objectives
– Examine the extent of social media use
– Explore the positive and negative impacts of social media on mental and physical health
– Identify resiliency factors
What Research Tells Us
– The number of social media accounts is moderately correlated inattention, hyperactivity/impulsivity, ODD, anxiety, and depressive symptoms, as well as fear of missing out (FoMO) and loneliness.
– Chicken/Egg-
What Research Tells Us
– Internet use in general significantly affects participation in IRL experiences.
– Increased time spent online is related to
– A decline in communication with family members (or inadequate support to begin with)
– Reduction of the internet user's social circle
– Reduction in sleep
– Increased feelings of depression and loneliness
– Chicken or egg
– Internet cause or ancillary behaviors cause-
What Research Tells Us
– People spend the majority of their time on SNS looking at peers’ profiles and photos, rather than posting or updating their own profiles
– Computer-mediated communication may lead to the mistaken impressions about physical appearance, educational level, success, intelligence, moral integrity, and happiness of other people, thus increasing depression.
– Constant self-evaluation and competition with other users, incorrectly perceiving characteristics of others and feelings of jealousy may positively or negatively influence self-esteem.

What Research Tells Us
– Technology-based Social Comparison and Feedback-Seeking (SCFS) was found to be associated with depressive symptoms when comparing people with similar levels of overall frequencies of technology use, offline Excessive Reassurance-Seeking (ERS), and prior depressive symptoms
– Stronger associations between technology-based SCFS and depressive symptoms for unpopular individuals
– May increase FoMo
– Allows for unhealthy perseveration

What Research Tells Us
– Higher psychological distress was associated with displaying depression language on Facebook and with less satisfaction with friend’s responses
– Depression was negatively correlated with how much social support participants thought they received from their Facebook networks
– Sudden cessation of online social networking (i.e., lack of Internet connection) may in some chronic users cause signs and symptoms of psychological withdrawal
– Some researchers identify that due to the wide array of activities available on SNS, it is difficult to conclude which parts contribute to preoccupation and withdrawal (gaming, FoMo, attention etc…)
Benefits
– Easily reach millions of people with information to improve their health literacy
– Increase health-related behaviors through gamification and social support (Garmin, Bodybuilding.com, SparkPeople)
– Allows for potential screening and early identification of problems #bigbrother
– May bring to light conversations and behaviors that existed all along IRL
– Increases communication with IRL friends at a distance

Resiliency Factors
– IRL support
– Self esteem
– A sense of belonging
– Self-awareness
– Effective communication skills
– Psychological flexibility
– Alternate sources of validation
– Understanding of the algorithms on SNS
– Fewer stranger connections
Question
– What social media factors influence depression/anxiety in people
– Number of likes
– Whether it appears other people are happier, more successful or more popular
– Check-ins during extended absences
– Comments (support, flaming, disinhibition)
– Public presentation vs. reality
– Other factors contributing factors
– Pre-existing mood disorders
– Insufficient/ineffective IRL supports

Summary
– Social media itself is not necessarily harmful
– Social media can provide opportunities for positive interactions
– People’s reaction to social media
– May mirror their IRL activities like excessive attention seeking
– May be the opposite of RL presenting an idealized self which then makes them feel even more isolated

Oct 22 2019

45mins

Play

Mind-Body Connection How Health, Thoughts, Feelings and Behaviors Interact

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Mind-Body Connection: How Health, Thoughts, Feelings
and Behaviors Interact
Counselor Toolbox Podcast Episode 433
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
Podcast Host: Counselor Toolbox, Case Management Toolbox

Sponsored by TherapyNotes.com
Manage your practice securely and efficiently. Two free weeks of TherapyNotes with coupon code “CEU”

Objectives
– A healthy body is essential to health and happiness.
– Explore…
– How emotions are created
– How physical symptoms including pain, fatigue are created
– How is this done (general overview)
– ANS/PNS
– HPA Axis
– Circadian Rhythms
– Gut-Brain Axis and the Vagus Nerve
– The bidirectional relationship between the mind and body
How are Emotions Created (Simplified)
– Born with the capacity for anger (fight), fear (flee/freeze), depression (f-It)
– Emotional responses are regulated by the autonomic nervous system (ANS)
– SNS- Sympathetic (Fight or Flee)
– PSNS- Parasympathetic (Rest and Relax)
– The limbic system helps control the ANS and PNS
– Hippocampus (memory consolidation, learning, attention, olfaction)
– Amygdala (fight or flee/survival)
– Hypothalamus (hormone regulation (HPA-Axis))
How are Emotions Created
– Unconditioned emotional responses are reactions to stimuli which did not need to be learned– i.e. present from birth
– Startle (puppy)
– Pain-Cry (shots)
– “Love”/ “contentment” (kangaroo care)
How are Emotions Created
– Conditioned emotional responses are learned emotional reactions to stimuli
– What things get conditioned and how can they cause or reduce stress-
– Dogs/Fire/Police/Guns
– Phone Calls
– Being Alone (child vs. adult)
– Transference
– Failure
– Rejection
– Loss of Control
HPA –Axis (Threat Response System)
– Secretion of adrenaline, norepinephrine and corticotropin releasing hormone (CRH)
– Cortisol is released
– Glutamate is released and GABA is inhibited
– Blood pressure increases
– Blood glucose is elevated
– Some 5HT receptors are activated, others are inhibited

Neurobiology of Attachment
– Hormones including dopamine, norepinephrine, cortisol, oxytocin and the serotonergic system modulate attachment
– Opioids may inhibit oxytocin and reduce feelings of social connection
How Physical Sensations Are Created
– Nociception can occur in the absence of awareness of pain, and pain can occur in the absence of measurably noxious stimuli
– CNS receives a pain signal from the PNS (peripheral nervous system)
– This triggers the Autonomic Nervous System and HPA-Axis
– All pain “information” is transmitted via glutamate
– An “inflammatory soup” is created which results in signals to the CNS as well as initiating inflammation which releases substance P and causes vasodilation, leakage of proteins and fluids into the extracellular space near the terminal end of the nociceptor (swelling), and stimulation of immune cells
– Substance P is associated with depression and anxiety symptoms
Neurotransmitters Pain & Fatigue
– Serotonin
– 5-HT2A receptor produces anxiety, pain, insomnia
– 5HT1A receptors reduce anxiety, pain, insomnia
– Serotonin directly and indirectly regulates dopaminergic neurons
– GABA may decrease the perception of pain.
– Dopamine
– Helps relieve pain
– Increases energy
– Norepinephrine
– Activated during pain (emotional and physical) and causes decreased sensitivity to painful stimuli (hypoalgesia) and pain relief (analgesia).
– Mobilizes the brain and body for action

Gut-Brain Axis
– Up to 95% of some neurotransmitters are made in the gut
– The gut communicates with the brain via the vagus nerve, the enteric nervous system
– Lactobacillus produces acetylcholine
– Controls voluntary movement, memory, learning, and sleeping patterns. Excess can cause depression whereas deficiencies cause Dementia
– Candida, streptococcus, E. Coli and enterococcus produce 5HT
– Serratia (gram neg. bacteria) produces dopamine
– Lactobacillus, Bifidbacterium, candida and streptococcus secrete GABA and regulate endocannabinoid expression
– A healthy gut microbiome can decrease depression and anxiety, regulate sleep, appetite and improve cognition (1000 species)
– An unhealthy gut microbiome contributes to an exaggerated HPA-Axis response
Gut-Brain Axis
– The effect of acute stress is limited due to microbiota's long time relative stable state, but chronic stress can disturb this balance
– The structure of intestinal microbiota is strongly influenced by diet and environmental stressors
– Corticotrophin-releasing factor (CRF) plays an important role in changing intestinal permeability
– Research suggests that gut-brain axis dysfunction may be involved in the development of mood disorders, schizophrenia, addiction, and neurodevelopmental and neurodegenerative diseases as well as age-related cognitive decline*
– The treatment of these conditions may adversely affect the composition of intestinal microbiota since antipsychotics and antidepressants are antibacterial agents
Endocannabinoid System
– Clinical studies revealed altered endocannabinoid signaling in patients with chronic pain and depression
– Dysregulation is associated with
– Schizophrenia and depression
– (CB1) plays a crucial role in preventing the neurotoxicity caused by activation of glutamate N-methyl-D-aspartate receptors (NMDARs).
– “Inadequate endocannabinoid control may produce excess or insufficient dampening of NMDAR activity, thus promoting dopamine signaling, such as in schizophrenia, or diminishing serotonergic activity, as observed in depression”
– Problems in neurotransmission, neuroendocrine, and inflammatory processes
– Omega3s have a neuroprotective function and can modulate activity in the endocannabinoid system

Circadian Rhythms (Sleep!)
– Cortisol helps regulate our circadian rhythms, and circadian rhythms regulate cortisol levels.
– Circadian disruption is a stressor
Recap
– Perception of and response to internal and external stimuli shape how we interact with the world and the world interacts with us.
– Stimuli interpreted by the limbic system as threatening based on past experiences to similar situations
– Triggers ANS and HPA-Axis activation (stress response)
– Increased norepinephrine, glutamate, adrenaline
– Reduced GABA
– Alterations in the 5HT system (increased 5-HT2CR receptor activity & reduced 5HT 1A) and sex hormones
Recap What Causes Stress
– Physical pain (injury, inflammation, Intense exercise and overtraining)
– Physical illness or dysregulation (hormones, brain health, sickness)
– Nutrient availability & medications
– Gut Health (microbiome homeostasis)
– Nutrition
– Deficiencies due to lack of nutrient consumption or malabsorption
– Hypo/hyperglycemia/insulin resistance
– Lack of sleep
– Prior learning experiences (schemas/PTSD)
– Physical environment
– Social environment

Consequences of Chronic Stress
– In a state of chronic stress, the body does everything it can to survive leading to one of two situations:
– Hypercortisolism—The negative feedback mechanism doesn’t kick in to protect against ever present danger (Fight, Flee, Freeze)
– Hypocortisolism – The negative feedback mechanism kicks in too much to conserve energy for only the most severe emergencies (F-It)
– Base cortisol levels are reduced after exposure to chronic uncontrollable stressors.
– Chronic stress causes inflammatory cytokines to be released which interfere with H & P function
– H & P are responsible for producing precursors to thyroid hormones producing hypothyroid
– Suppress the sensitivity of thyroid hormone receptors to thyroid hormones.
Consequences cont…
– Emotional impact of a stressor is determined by our allostatic load
– Social Environment
– Physical Environment
– Physical Health
– Cognitive Perception of the Problem
– Behavioral Reactions

Consequences of HPA-Axis Activation
– Until the person feels safe…
– Irritability (physiological, behavioral emotional)*
– Perseveration*
– Hypervigilance*
– Sleep disruption*
– Increased pain (long term)
– Increased GI motility*
– Changes in gut microbiome*
– Reduced libido

– Hypothyroid
– Social withdrawal*
– Eating changes (ghrelin alterations)
– Inflammation*
– Decreased latency to immobility and increased duration of immobility after exposure to stressors*

Summary
– The mind helps the body interpret signals based on stimulus input and prior learning
– The body sends out messages in the form of hormones and neurochemicals which produce physiological reactions we label with “emotions”
– Positive emotions promote HPA-Axis downregulation which improves attachment and sleep, reduces cortisol, increases 5HT1A, GABA, dopamine and reduces pain
– The mind-body system is bidirectional and complex therefore it is essential to explore all causes of “symptoms” and enhance factors that promote positive changes.

Oct 17 2019

57mins

Play

Animal Assisted Therapy

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432 -Animal Assisted Therapy
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
Podcast Host: Counselor Toolbox, Case Management Toolbox

Sponsored by TherapyNotes.com
Manage your practice securely and efficiently. Two free weeks of TherapyNotes with coupon code “CEU”

Objectives
– Define Animal Assisted Therapy
– Explore the research around animal assisted therapy
– Review some general cautions

Definitions
– Animal Assisted Activities/Pet-Therapy
– Integration of animals into activities to facilitate motivation, education and recreation, encouraging casual interaction without following a specific set of criteria or goals
– Animal Assisted Therapy
– Intentional and therapeutic, whereby the animal’s role is integral in assisting with mental health, speech, occupational therapy or physical therapy goals, and augments cognitive, physical, social and/or emotional well-being
General Benefits
– Reduced blood pressure
– Release of oxytocin
– Increase in understanding of UPR (3 legged dog, one eyed cat, blind horse)
– Increase ability to take multiple perspectives
– Enhance empathy and compassion
– Biofeedback/Mindfulness
– Stress reduction and laughter
– Increased physical activity
– Consistency and clear communication
– Decrease learned helplessness behaviors and increase a sense of control over self and environment

General Benefits
– Act as a bridge by which therapists can reach patients who are withdrawn, uncooperative, and uncommunicative
– Participants interacting with the animals were more inclined to smile and demonstrate pleasure, and were more sociable and relaxed with other participants
– More sensitive issues can be rendered less incendiary when an animal is involved
– A multisensory aspect is also available when an animal is involved; increasing the level of attention and interest of the client who is active or struggles with focus or concentration

Which Animals Can Be used
– Any Animals…
– Fish (AAA)
– Guinea Pigs (AAA)
– Dogs (AAA, AAT)
– Cats (AAA, AAT)
– Rabbits (AAA)
– Horses (AAA, AAT)
– Dolphin (AAA, AAT)

Hippotherapy (Equine)
– Using horse movement to compliment therapy
– Self-awareness
– Developing trust and respect
– Meeting/Join Up (understanding the prey/predator relationship)
– Petting
– Feeding
– Addressing personalization/exploring dialectics
– Going into a barn or trailer
– Bonding/relaxation
– Confidence
– Acceptance (despite being different)
– Choosing animals with differences
– Highlighting unique animal pairs (donkey and goat)
Farm Animals
– The diversity of a farm experience offers much stimulation, and provides the basis for creative and varied interventions, such as providing the client with opportunities to practice
– Nurturing activities
– Organizational skills
– Perspective taking (no 2 animals are exactly alike)
– Problem solving

Dogs
– A “dog’s social life is organized around dominance-subordinance relationships”
– Dogs are expected to obey commands and offer clients what is often referred to as “unconditional acceptance” (Brewster vs. Duke)
– Difference in the children’s response during sessions, including more laughing, increased eye contact, communication with the dog, and a desire to connect through feeding the animal dog treats
– Teaching people positive dog training techniques could help them understand
– Clear communication
– Relationship development (trust, respect, nurturance and termination)
– Empathy
– Perspective-taking
– Delayed gratification
– The connection between behaviors and consequences in a non-threatening manner

Dogs
– Teaching people positive dog training techniques could help them
– Learn patience and consistency
– Develop clear communication
– Learn about relationship development (trust, respect, nurturance and termination)
– Develop empathy and compassion
– Enhance perspective-taking to understand behavior/reactions
– Delay gratification
– Understand the connection between behaviors and consequences in a non-threatening manner
– Increase confidence and self-efficacy

Dogs
– More benefits
– Helps separate bad behaviors from bad organisms
– Improves awareness of cognitive distortions esp personalization, all or nothing thinking, mind reading
– Teaches the appropriate way to treat themselves and others
– Helps the person get out of their own head (depression, addiction)
– Serves as a biofeedback monitor (dogs mirror owner reactions)
– Models unconditional positive regard
– Reward/de-escalation/reduced anxiety and depression via enhancing relaxation and oxytocin (doctors office, studying, flying…)
– Reduces hypervigilance (PTSD, panic attacks, seizures)
– Increases physical activity
– Helps set circadian rhythms

Cats
– “Cat socialization toward is based on
– “Give and take”
– Mutuality/reciprocity
– Respect for their independent nature
– In contrast to human-horse or human-dog relationships. Chandler (2005) listed the following attributes for felines in therapy:
– Quietness and calmness
– Level of comfort with being touched
– Motivation to be around people
– Playful cats offer lighthearted moments which can act as an “icebreaker”
– Distraction/distress tolerance when discussing stressful events

Techniques
– Teach the client how to direct the animal, and then collaboratively problem-solve when confronted with an obstacle to promote self-monitoring, mindfulness, and to empower the client and encourage generalization to daily life situations, among other things.
– Parenting (consistency and clear communication)
– Communicating with a spouse or boss
– Giving and receiving affection
– Being aware of emotions and nonverbal communications
– Understanding the reciprocal nature of interactions
– Greeting Brew at the door
Techniques
– The client and counselor could collaboratively develop behavioral experiments to involve animals.
– If a client believes she cannot be assertive. A behavioral task may be as simple as calling for the animals to come in, or placing her in charge of directing the animal to accomplish a task.
– The counselor could question client to encourage mindfulness of her actions and experience to help expose cognitive distortions.
– Cognitive rehearsal could be facilitated is assertiveness is a problem she has encountered in the past.
– Have the client try to walk a donkey into a barn, or get a dog into a crate.
– Discuss her thoughts as the animal resists (gives up, gets angry etc)
– Discuss reasons why the animal may not be complying.
– Work through the exercise to increase assertiveness. (win/win)

Techniques
– Activities designed to draw attention to existing dynamics encourage the family to acknowledge current behaviors and interrelationships, and reflect on healthier interactions.
– One scenario may be asking that family work together to maneuver a horse or dog from point A to point B without talking to each other or to the animal.
– Parent and child concretely exploring the metaphor of feeling ‘reined in’ through horse or dog work. The family can discover the animal is more compliant and responsive with a looser rein or leash.
– When held tight, the animal may fight to gain control, or will become passive and stubborn, much like a child on a tight rein

Techniques
– Clients with less-developed verbal skills can experience a sense of success when interacting with an animal.
– Asking a dog to sit, or offering food to an animal provides positive interaction without the need for language
– Individuals with lowered self-esteem and confidence can experience acceptance
– People with social anxiety can walk a dog in a public place

Multisensory Activities
– Photographing or videotaping the animals
– “What was it thinking-”
– Scrapbooking
– Learning about special animals especially at a rescue
– She was abused, blind, starved and had broken bones in her back. She was also  understandably afraid of people.  There is no telling what kind of horror she had survived!  She immediately received the medical care she needed.
– Unique friendships
– Story writing
– Animals can provide an entity onto which the client may project or identify (Reichert, 1998), i.e. storytelling from the animal’s point of view as a means for the client to raise metaphorical, or even factual, details of a topic otherwise difficult to talk about
Multisensory Activities
– Journaling
– Their training progress (consistency and efficacy)
– The use of metaphors and symbolism can be very effective as well
– What animal are you most like and why-
Other Activities
– Memory/Cognitive:
– Remembering dog’s name, breed or history
– Remembering handler’s name
– Activities with dog’s picture book
– Giving commands
– Remembering colors, shapes, directions
– Problem Solving:
– Choosing type of toy or treat
– Deciding where to go during a walk and how to get there
– Giving dog appropriate commands
– Positive redirection
– Choosing type of activity to do with the dog
– Deciding where to hide treats for the dog to find

Cautions
– Client’s physical and emotional response to a particular species of animal as being based on “previous direct and indirect experiences with as well as their beliefs, desires, and fears about specific species”.
– The role of animals in the client’s life outside the therapy session is another cultural consideration (Farmers, hunters, pet owners)
– sanitation and the potential for disease must be addressed.
– Animal inoculations and parasite control must be current (Delta Society, 1996)
– Clients must also be screened for potential allergies or sensitivities
– Environmental distractions, combined with the predictability of the client’s behavior, can present challenges to the counselor, particularly in an outdoor setting
– Elderly and small children often report feeling safer around smaller animals because they were afraid of being knocked over by a larger, more rambunctious dog

Summary
– There are a variety of techniques that can be used to incorporate animals into counseling practice
– Animals help develop
– Self esteem
– Confidence
– Assertiveness
– Empathy
– Mindfulness
– Distress Tolerance
– Effective Communication Skills
– Animals can also serve to relieve anxiety

Oct 12 2019

59mins

Play

Overview of the PACER Method

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Overview of the PACER Method and Transdiagnostic Assessment
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
Podcast Host: Counselor Toolbox and Case Management Toolbox

Sponsored by TherapyNotes.com
Manage your practice securely and efficiently. Two free weeks of TherapyNotes with coupon code “CEU”

Objectives
– Define the PACER model
– Explore how PACER dimensions interact
– Examine the transdiagnostic assessment process
Why A New Approach-
– 10% of Americans are on antidepressants for anxiety or depressive issues
– Without medication 20-40% of people with clinical depression noticed symptom improvement in 6-8 weeks
– WITH antidepressants 40-60% of people with clinical depression noticed symptom improvement in 6-8 weeks
– That leaves as many as 40% of people still struggling with significant symptoms after 6-8 weeks.
– No high- or moderate-strength evidence for any intervention to effectively treat any phase of any type of BD versus placebo or an active comparator
Why A New Approach-
– Cognitive Behavioral Therapy appears to be effective in approximately 47% of cases
– Results are mixed regarding whether CBT + antidepressants can augment treatment response
– Cognitive behavioral interventions for depression and anxiety prevention showed a small effect for prevention of depression but not anxiety and no effect at 3-6 months and at 12 months follow-up
– In a study of over 33,000 patients, only patients who had 18 or 20 CBT sessions showed more improvement than generic counseling.
Why a New Approach
– Counseled patients are significantly more likely to have recovered than non-counseled patients
– Client outcomes are most often determined by client variables such as
– Chronicity and severity
– Complexity of symptoms
– Motivation
– Acceptance of responsibility for change
– Therapeutic change is less about talk-therapy interventions and more about the patient’s ability to maintain motivation and efficacy and clinician team’s ability to look multidimensionally at issues

PACER Method
– The PACER Method uses a transdiagnostic (many symptoms are common to multiple disorders) and transtheoretical (there are many ways to address each symptom) approach to recovery to assist people in optimizing their quality of life
– Physical
– Affective
– Cognitive
– Environmental
– Relationships
– The PACER method consistently looks at bidirectional interactions
PACER Method
– The PACER Method
– Counselor Functions
– Counseling and motivational enhancement
– Connecting with multidisciplinary referrals (MD, RD, PT etc.)
– Case Management (Integrating & monitoring tx plans)
– Improving Health and Mental Health Literacy
– Goal
– To address PACER issues which create or maintain imbalances in the nervous system that cause unnecessary dysphoria.

Physical
– Rule out organic dysfunction in the system
– If the body cannot make or balance the neurotransmitters due to health or behavioral issues, those must be addressed.
– There are over 30 hormones the body must construct to regulate neurotransmitters
– There are over 100 neurotransmitters the body must construct and balance to regulate attention, memory, sleep, feeding, heart rate, respiration, energy, motivation, mood and more.
– Up to 95% of some neurotransmitters and hormones are made in the gut (Setting concrete in the rain)
– The body requires vitamins, minerals and amino acids to make hormones and neurotransmitters

Physical
– Rule out dysfunction in the system
– If the body cannot produce or effectively regulate hormones and neurotransmitters, people will have “symptoms”
– Example: HPA axis dysfunction and exposure to stress are critical components that increase risk for developing addictions
– Some hormones and neurotransmitters increase the levels of certain H & NTs while simultaneously decreasing levels of other H & NTs
– Under stress cortisol increases norepinephrine, adrenaline, glutamate, estrogen and ghrelin and inhibits and availability of serotonin and the creation of T3
– During relaxation, DHEA, GABA and serotonin levels increase which reduces cortisol and norepinephrine, adrenaline, glutamate, estrogen and ghrelin

Physical Assessment
– Sleep
– Nutrition (app & blood test*)
– Weight (obesity, anorexia)
– Bariatric surgery
– Central weight gain
– Pain
– Exercise/sedentariness
– Energy (T, T3, Sleep, O2…)*
– Libido/Sex hormones*
– Blood sugar/hypoglycemia*

Physical Assessment
– Hypervigilance/startle (Hypo- or hyper-cortisolism)
– Autoimmune issues/inflammation (RA, IBD, Diabetes Type 1, psoriasis, chron’s)
– TBI
– Headaches (stress, migraines, BP)
– Medications (beta blockers (HBP), proton pump inhibitors (GERD), Corticosteroids (RA), Parkinson’s and Antipsychotic medications, hormone altering drugs (2), stimulants, anticonvulsants (bipolar, pain), statins (cholesterol), opioids, benzodiazepines (depression/rebound anxiety)
– Substance use and potentially addictive behaviors (sex/pornography, gambling, video games)

Affective Assessment
– Helps us get an understanding of HPA-Axis functioning
– Happiness
– Sadness/Depression
– Loneliness
– Grief
– “Stress”
– Anxiety
– Anger
– Resentment
– Guilt
– Jealousy
Affective Assessment
– Dysphoric emotions typically impair sleep quality, excite the HPA-Axis, reduce pain tolerance, prompt cravings for high carbohydrate foods
– Questions
– In an average week how much time is spent on each emotion (baseline charting is helpful)-
– What triggers each emotion-
– What stressors are currently present-
– What stressors have you experienced in the past 12 months-
– What is different when you are happy-
– How long does it take for you to calm down after you get upset-

Cognitive Assessment
– Dopamine, norepinephrine, serotonin, oxytocin, estrogen imbalances can all cause cognitive dysfunction
– Cognitions can cause biological, emotional and behavioral changes which throw hormones and neurotransmitters out of balance and impact the mind, body, relationships and environment
– Negative Ned
– Positive Pete

Cognitive Assessment
– Assess Functioning
– Attention/concentration
– Memory
– Problem solving
– Assess Cognitive HPA-Axis Triggers
– Negative Attitudes/Perceptions (Learned responses)
– Hardiness (Lack of)
– Locus of control
– Cognitive distortions
– Negative self-talk
– Time management

Environmental
– Safety
– Noise
– Light
– Darkness
– Blue-light
– Smells
– Noxious
– Triggering
– Assistive (insomnia, sleep, anxiety, pain , depression, cortisol)
– Air pollution
– Carbon dioxide & nitrous oxides, Carbon monoxide (home), Volatile Organic Compounds (VOCs), tobacco smoke
– Temperature

Relationships
– Self-esteem and self-efficacy
– Relationship with self as capable, lovable and deserving
– Attachment (oxytocin, serotonin, dopamine, endogenous opioids)
– Healthy attachment without abandonment fears
– Boundaries
– Ability to set and maintain healthy emotional and physical boundaries
– Communication skills
– Ability to identify and communicate feelings and thoughts and get needs met
– Social support system
– Accessible functional and emotional support and engagement
– Animals/Pets
– Relationship with support animals

Summary
– Our current uni- or bi-dimensional approach (medication, counseling or medication+counseling) to treatment does not work for the majority of people.
– There are a myriad of underlying “causes” of distress, and most people have multiple contributing factors. (More to come)
– If your air conditioning bill was suddenly ridiculously high would you pull down all of the blinds- What impact would that have- Would it solve the whole problem-
– Would you turn up the AC so it didn’t run as often and pull down the blinds- What impact would that have- Would it solve the whole problem-
– A transdiagnostic approach works to identify all of the causes of the symptoms, understand their interrelationship and causes and develop a multidimensional treatment plan based on what the client is most motivated to address.

Oct 11 2019

53mins

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Intuitive Eating Basics and Benefits

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429 -Intuitive Eating Basics and Benefits
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs Counselor Education

Sponsored by TherapyNotes.com
Manage your practice securely and efficiently. Two free weeks of TherapyNotes with coupon code “CEU”

Podcast Host: Counselor Toolbox and NCMHCE Exam Review
Objectives
– Identify the 10 + 1 principles of intuitive eating
– Describe the interaction between mood, health and eating
– Begin identifying tools to help people get off the dieting rollercoaster
Basic Principles
– From IntuitiveEating.Org
– Reject the diet mentality
– Honor your hunger
– Make peace with food (Forbid forbidding)
– Challenge the food police in your head
– Respect your fullness
– Discover the satisfaction factor (Mindfulness)
– Use food for physical nourishment not in response to feelings
– Respect your body
– Exercise
– Honor your body with good nutrition
Reject the Diet Mentality
– Develop a lasting way of eating
– Yo-yo dieting wreaks havoc on your body and leads to weight gain and low self esteem
– Recurring attempts to diet signals the body that the food supply is often insufficient and leads to greater fat storage than if food was always abundant
– Dieting is correlated with the development of metabolic syndrome characterized by central obesity, insulin resistance and hypertension that increase risk of type 2 diabetes and cardiovascular disease.
– Puts additional stress on the cardiovascular system
Reject the Diet Mentality
– Identify what you do differently when you are on a diet that can be helpful
– Set small goals
– Pay attention to what you are eating
– Only eat when you are sitting down and not distracted
– Eat from dishes not the box
– Carry a water bottle
Reject the Diet Mentality
– Remain aware of hidden forms of dieting
– Low carb
– Low fat
– Grain free
– Intermittent fasting
– Taking supplements to lose weight
– Excessive exercise
Honor Your Hunger
– Become aware of your body cues
– Hunger
– Thirst
– Type of food
– Eat when you are physically hungry, not because
– The clock says so or says not so
– You are tired
– You are bored, upset, happy
– You are with people or alone
– It is a habit
– You want more

Make Peace with Food
– Forbid forbidding (unless medically contraindicated)
– Disinhibition and self-efficacy
– Address your food phobias

Challenge the Food Police
– What do the voices in your head say about:
– Which foods to eat or not eat-
– How much to eat-
– How much to weigh-
– When to eat-
– The clean plate club-
– Who is judging you-
– What you should or shouldn’t have eaten-
– Where did those voices come from-
– Media, family, comments from others, personal knowledge
– Make fact-based choices
– Don’t insist on 100% compliance

Make Peace with Fullness
– It takes 20 min. for your body to cue your brain that you are full
– Your empty belly is about the size of your fist
– Learn the difference between full and stuffed
– Savor what you are eating when you eat it
– Left hand
– Mini bites
– Fork down
– Remember that leftovers will be there to enjoy tomorrow
– Stay hydrated
– Learn about foods and eating patterns that promote fullness

Eat for Satisfaction
– Make sure you are not dehydrated
– Cravings tell you something
– Salty, sweet, sour…
– Red meat or spinach (Iron)
– Cheese (Tryptophan)
– Chocolate (Theobromine, magnesium)
– Soda (Calcium)
– Fatty foods
– Eat colorfully and flavorfully
– Eat mindfully and reflect on how the food nourishes your body, gives you energy, improves your mood
Use Food for Hunger not Emotions
– Make a list of your feelings and ways to cope with or celebrate them without food
– Pause before getting food to notice if you are hungry or something else (journals, checklists, dishes)
– Reconceptualize “food addiction” and reclaim power
– Addictions are a coping response to dysphoria
– Addictive behaviors alter neurotransmitter levels
– Core reasons for compulsive food consumption
– Reward-driven eating as opposed to physiological hunger)
– Psychological preoccupation with food
– Perceived lack of self-control around food (autopilot/hooked to thoughts)
– Frequent food cravings

Respect Your Body
– Embrace body positivity
– Stop comparing
– Explore you as a person
– Discover what size means to you and why
– Wear comfortable clothes
– Throw out the scale
– If you have difficulty maintaining a healthy weight get screened for*
– Diabetes
– PCOS/Hormone imbalances
– Depression
– Sleep disturbances
Prevent Vulnerabilities
– Exercise intuitively
– Increases energy and oxygenation
– Improves sleep
– Reduces cortisol (Low intensity 40-50% VO2max)
– Increases serotonin which impacts hunger and depression
– May reduce “stress” via distress tolerance
– Sleep*
– Sleep deprivation significantly increases ghrelin levels and is associated with higher consumption of calories
– Stress, shift work, pain, medication, alcohol, apnea, poor sleep hygiene, infants

Honor Your Body with Good Nutrition
– When you are depressed, exhausted, angry, stressed you will often crave comfort foods which are low in nutritional value
– Poor sleep is associated with depression and anxiety as well as disrupted ghrelin levels
– When you have poor nutrition it contributes to depression, exhaustion and irritability
– Dopamine (Tyrosine, B6, iron)
– Serotonin (Calcium, B6, Mg, iron, folic acid, zinc, C)
– Norepinephrine (Tyrosine, B6, C, iron)
– Glutamate (Glutamine, 107 regulators,31 enzymes)

Good Nutrition–Gently
– Make a list of foods you LOVE
– Try a new recipe each week
– Notice how you feel after you eat certain things
– Eat colorfully
– Take what you want and put half back
– Use a smaller plate
– Keep binge foods out of the house but not out of your life
– Avoid buffets if you have to “get your money’s worth”
– Keep a nutrition log to learn what YOUR body needs
– Plan your menu of options and prepare ahead
– Close the kitchen
– Keep a water bottle with you

Summary
– Significant evidence indicates episodic “dieting” and yo-yo weight loss is physically and psychologically harmful
– Intuitive eating teaches people to
– Pay attention to the signals their body sends them
– Learn to differentiate between hunger, exhaustion, emotional states and compulsive thinking
– Address the underlying issues of cravings and excessive hunger

Learn More
– Books by New Harbinger
– Save 25% off your entire order at NewHarbinger.com with promocode 1168 SNIPES

Oct 05 2019

54mins

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