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Rank #136 in Education category

Education
Health & Fitness

Counselor Toolbox Podcast

Updated 3 days ago

Rank #136 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

267 Ratings
Average Ratings
225
25
10
1
6

Wonderful

By hair62 - May 31 2020
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Truly I have learned a ton. I can’t see my own counselor,so this is a big help! Thanks Erin

Great podcast

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

iTunes Ratings

267 Ratings
Average Ratings
225
25
10
1
6

Wonderful

By hair62 - May 31 2020
Read more
Truly I have learned a ton. I can’t see my own counselor,so this is a big help! Thanks Erin

Great podcast

By Rayshell rayshell - Apr 02 2019
Read more
As a new counselor, these podcasts have been very helpful
Cover image of Counselor Toolbox Podcast

Counselor Toolbox Podcast

Latest release on Oct 28, 2020

The Best Episodes Ranked Using User Listens

Updated by OwlTail 3 days ago

Rank #1: 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

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Rank #2: 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

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Rank #3: 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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Rank #4: 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

Rank #5: 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

Rank #6: Attachment Theory and Adult Relationships

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452 Attachment Theory and Adult Relationships

Attachment and Adult Relationships
Dr. Dawn-Elise Snipes
Executive Director, AllCEUs.com
Host: Counselor Toolbox Podcast, NCMHCE Exam Review Podcast
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
Attachment–CARES
• Consistency
• Attention
• Responsiveness
• Empathy
• Support
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.

Dec 24 2019

44mins

Play

Rank #7: 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

Rank #8: 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

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Rank #9: 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

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Rank #10: Cognitive Interventions for Depression

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Social Work & Case Management for Depression
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs

CEUs available for purchase at https://www.allceus.com/member/cart/index/product/id/1266/c/

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

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
• Depression indicates the loss of something important
• 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 extremal 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 depression 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 times 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

HPA-Axis
• HPA-Axis hyperactivity causes the release of inflammatory cytokines which cause symptoms of behavioral depression (lethargy, reduced locomotor activity and food intake, increased sleep) in the effort to conserve energy for physiological repair
Reduce HPA-Axis Activation
• Get quality sleep
• Sleep deprivation increases risk for major depression, which in turn increases risk for decreased sleep
• Sleep disturbances contribute inflammatory disorders and major depressive disorder
• Increased HPA-Axis activation after sleep deprivation
• Create a routine
• Eliminate blue-light
• Reduce stimulants
• Address pain and apnea (article 2)
• Improve the sleep environment (noise, allergens, light, temperature)
• Other factors: Shift work, time zones, safety/PTSD
• Antidepressants: Many antidepressants with activating effects may disrupt sleep, while those with sedative properties improve sleep, but may cause problems in long-term due to oversedation

Reduce HPA-Axis Activation
• Relaxation
• Biofeedback
• Progressive muscular relaxation
• Meditation and yoga
• Recreation
• Forest / Eco Therapy
• Address medication side effects
• Psychotropics
• Beta Blockers
• Statins
• Anticholinergic (bladder, Parkinson’s, COPD, Asthma, motion sickness)
• Opioids
• Corticosteroids
• Certain antibiotics (levofloxacin and ciprofloxacin)
• Birth control / HRT

Reduce HPA-Axis Activation
• Improve nutrition
• Access to nutrition
• Transportation
• Affordability
• Cooking
• Awareness of nutritional principles
• Macros
• Hydration
• Dehydration had negative effects on vigor, affect, short-term memory, and attention
• Aspartame
Neurotransmitters
• Addictive behaviors
• Alter dopamine, serotonin, norepinephrine levels
• Impacts of different types of neurotransmitters
• Stimulants
• Depressants
• Alcohol
• Gaming/Gambling
• Sex/Pornography

Hormones
• Thyroid
• Impact mood, libido and energy levels
• Estrogen
• Impacts neurotransmitters that affect sleep, mood, memory, libido, pain perception, learning and attention span.
• Increased estrogen may alter the availability of serotonin
• Low testosterone may alter the availability of serotonin
• 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 by impacting serotonin and norepinephrine levels
• 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

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 changes in 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

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?
• How can you address each trigger to feel safer and more empowered?
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 à apathy
• Anxiety makes it harder to sleep exhaustion  hormonal imbalances  depression

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
• 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 à exhaustion  neurotransmitter imbalances depression
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

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.

Feb 19 2020

55mins

Play

Rank #11: 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

Rank #12: 357 – Thinking Errors (Re-Release)

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To all my loyal listeners, I apologize for recycling podcasts, however, my mother suddenly passed away Saturday and we are a bit off schedule.  I will release new podcasts beginning the first week in February.  CEUs are available for this podcast at https://www.allceus.com/member/cart/index/product/id/497/c/

In Australia, the professional development course is located at  https://australia.allceus.com/member/cart/index/product/id/497/c/  

~Dr. Snipes

Jan 23 2019

59mins

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Rank #13: Supporting Families Without Enabling

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424 -Supporting the Person Without Enabling

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

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 and the enabler become stuck in a role in which they feel incompetent, incapable, disempowered and ineffectual.
– They 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
– Handling 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
– Supporting without enabling means
– Getting clear about your wants and needs
– Setting boundaries (emotional, physical, financial…)
– Learning how to say “no”
– Being willing to encourage and support healthy behaviors

Sep 21 2019

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Rank #14: Complicated Grief and Attachment

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Complicated Grief and Attachment
Dr. Dawn-Elise Snipes PhD, LPC-MHSP
Podcast Host: Counselor Toolbox

CEUs are available for this presentation at AllCEUs https://www.allceus.com/member/cart/index/product/id/995/c/

Objectives
~ Define Complicated Grief
~ Identify how loss of or lack of an attachment relationship may represent a loss that needs to be grieved.
~ Explore the overlap between complicated grief and trauma
~ Identify risk factors for CG
~ Explore tasks for successful grief resolution
Definitions:
~ Loss: Change that includes being without someone or something—in this case the primary attachment relationship
~ Secondary loss: Other losses as a result of a primary loss. Example, loss of security when rejected by primary caregiver
~ Grief: Reaction or response to loss; includes physical, social, emotional, cognitive and spiritual dimensions.
~ Trauma: Any situation that causes the individual to experience extreme distress

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 and toddler when the child’s attachment system is ‘activated’
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 (what is the loss here?)
~ a model of the self as valuable (what is the loss here?)
~ a model of the self as effective when interacting with others. (what is the loss here?)
~ Secure attachments also help children
~ Feel loved and accepted
~ Learn to manage their emotions
~ Address dichotomous thinking and cognitive distortions

Bowlby on Attachment and Grief
~ Attachment Relationships Help Regulate Psychological And Biological Functions Including:
~ Mastery and performance success
~ Learning and performing
~ Relationships with others (and future attachment)
~ Cognitive functioning
~ Coping and problem solving skills
~ Self-esteem
~ Emotion regulation
~ Sleep quality
~ Pain intensity (physical and emotional)

Bowlby
~ Attachment and safety stimulate a desire to learn, grow and explore
~ Caregivers provide support and reassurance (Safe haven)
~ Encouragement and pleasure (secure base)
Feeney J Pers Soc Psych 631 -648 2004

Bowlby
~ Loss of an attachment relationship
~ Disrupts attachment, caregiving and exploratory systems
~ Attachment: Activates separation response and impacts restorative emotional, social and biological processes
~ Exploratory system: Inhibits exploration with a loss of a sense of confidence and agency.
~ Caregiving: Produces a sense of failure and can include self blame and survivor guilt

Trauma
~ Trauma is any event that is distressing or disturbing
~ How do we know what is distressing or disturbing
~ Erodes a sense of safety (Triggers fight or flight)
~ Emotional (including dysregulation)
~ Mental (interpretations and schemas)
~ Physical (object permanence, darkness, pain, prior experiences)
~ Adverse Childhood Experiences that may disrupt primary attachment
~ Immediate family member with a mental health or addiction issue
~ Immediate family member who is incarcerated
~ Divorce
~ Abuse (child or DV)
~ Neglect

How Can Disrupted Attachment  Trauma
~ The primary attachment figure remains crucial for approximately the first 5 years of life
~ Trust/mistrust (Ages 0-2)
~ Object Permanence
~ Autonomy/shame (Ages 2-7)
~ Egocentrism: children assume that other people see, hear, and feel exactly the same as they do
~ Children’s moral sense in this phase of development is rigid and believe that a punishment is invariable, irrespective of the circumstances.
~ They regard bad things that happen as a consequence for misdeeds and a punishment for misbehavior.
http://www.childhealth-explanation.com/cognitive-development.html
Attachment and “Supposed Tos” Discussion
~ What is a child supposed to have from a caregiver?
~ Emotionally
~ What happens when this doesn’t occur?
~ How is that traumatic?
~ Cognitively
~ What happens when this doesn’t occur?
~ How is that traumatic?
~ Physically
~ What happens when this doesn’t occur?
~ How is that traumatic?
~ What is a caregiver supposed to be like?
~ What happens when this doesn’t occur?
~ How is that traumatic?
~ How might these traumas also represent a loss?—Let’s look

Complicated Grief
~ Symptoms
~ Separation distress involving intrusive, distressing preoccupation with the loss
~ Traumatic stress reflecting specific ways the person was traumatized by the loss
~ Avoidance of reminders
~ Intrusive painful thoughts
~ Emotional numbing
~ Irritability
~ Feelings of hopelessness and purposelessness
~ Shattered self identity
Risk Factors for Complicated Grief Related to Attachment
~ Child
~ Age
~ Physical issues
~ Emotional issues (pre-existing)
~ Cognitive understanding
~ Personality and character traits
~ Nature of the loss
~ Number of losses
~ Circumstances of the loss
~ Resources available
~ Nature of the relationship
~ Length/duration
~ Importance
~ Culture/Roles
~ Quality
~ Dependence
~ Hopes and Dreams (retrospectively)
~ Amount of Daily Change (foster care, relative placement)

Emotional Effects of Trauma and Complicated Grief
~ Dysregulation
~ Anxiety
~ Separation anxiety
~ Reactive Attachment
~ Angry/Irritable/Oppositional
~ Depressed
~ Lonely/Isolated
~ Guilty/Regretful
Physical Effects of Trauma and Complicated Grief
~ Appetite (eating) disturbances
~ Energy, fatigue, lethargy
~ Sleep disturbance
~ Anxiety
~ Gastrointestinal disturbance
~ Compromised immune response; increased illness

Intellectual Effects of Trauma and Complicated Grief
~ Confusion; “What is real?”
~ Difficulty concentrating; ex. Read the same page several times
~ Short attention span; ex. Can’t finish a 30 minute TV program
~ Difficulty learning new material; short term memory loss; ex. Income taxes
~ Difficulty making decisions
~ Lack of a sense of purpose
~ Inability to find meaning in the events and life itself

Social Effects of Trauma and Complicated Grief
~ Withdrawal
~ Isolation
~ Searching
~ Avoidance
~ Self absorption
~ Clinging/dependence
Reconciliation Tasks
~ To help adults or adolescents who never formed that attachment
~ Acknowledge the reality of the loss.
~ Move toward the pain of the loss while being nurtured physically, emotionally, and spiritually.
~ Develop a new self identity based on a life without that relationship.
~ Experience a continued supportive presence in future years
Reconciliation
~ Learn basic trust, which serves as a basis for all future emotional relationships
~ Learn how to develop fulfilling intimate relationships
~ Develop strategies to maintain emotional balance and resiliency
~ Develop the ability to control behavior, which results in effective management of impulses and emotions
~ Enhance confidence and self-esteem
~ Learn how to share feelings and seek support

Reconciliation
~ 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 core set of beliefs that leads to empathy, compassion, and conscience
~ Begin exploring the environment with feelings of safety and security, which leads to healthy intellectual and social development

AVOIDANCE
~ Recognize the loss
~ Acknowledge the loss of or lack of establishment of the attachment relationship
~ Understand the losses as a result of the lack of attachment

CONFRONTATION
~ React to the realization of the loss
~ Experience the pain
~ Feel, identify, accept, and give some form of expression to all the emotional, cognitive and physical reactions to the lack of or loss of the attachment figure
~ Identify and mourn secondary losses
~ Loss of safety
~ Loss of happiness (distress)
~ Loss of the childhood I “should” have had
~ Loss of self esteem
~ Loss of success

CONFRONTATION
~ Recollect and re-experience the relationship
~ Review and remember realistically
~ Revive and re-experience the feelings
~ Relinquish the old attachments to the old assumptive world

ACCOMMODATION
~ Readjust to move adaptively into the new world without forgetting the old
~ Revise the assumptive world
~ Develop a new relationship with the self
~ Adopt new ways of being in the world
~ Form a new identity
~ Reinvest

Summary
~ Failure to develop a primary attachment relationship can be viewed as a loss (or something that was needed that was never achieved)
~ When examining the behaviors of adult or adolescent clients whose primary attachment was disrupted, the traumatic impact can be seen.
~ In order to help people reconcile the trauma it is essential to help them
~ Identify and grieve the losses
~ Review and remember realistically what happened (to combat inaccurate schema)
~ Review the assumptive world (if I just…then she will be love me)
~ Develop a new loving relationship with the self
~ Learn how to trust the self and others to form meaningful and supportive relationships

Mar 13 2019

58mins

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Rank #15: 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

Rank #16: 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
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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

Rank #17: 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

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Rank #18: Contextual Cognitive Behavioral Therapy

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Mindfulness & Acceptance of Addictive Behaviors
Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director: AllCEUs Counselor Education
Host: Counselor Toolbox Podcast

CEUs are available for this presentation at AllCEUs https://www.allceus.com/member/cart/index/product/id/1001/c/

Objectives
~ Define and review the concepts of contextual cognitive behavioral therapy
~ Explore the impact of context on people’s phenomenological reality
~ Explore how addiction and mental health issues can be influenced by context
~ Explore how acceptance, awareness, mindfulness and psychological flexibility can be used transdiagnostically.

Why Contextual
~ Addiction and mental health issues are often intergenerational
~ Addiction and Mental Health issues are strongly correlated with:
~ Each other
~ Adverse childhood experiences (history of and children with)
~ Impaired occupational and social functioning
~ Health problems
Contextual Approaches
~ Encourage mindfulness in the present moment
~ Accept each person’s “truth” is constructed from their schema and the resulting interpretation of the current moment
~ The goal is to consider the context and function of the past and present issue and empower the person to make a conscious choice toward their valued goals
~ Remember that the prefix RE means to do again
~ REpeat
~ REdo
~ REgress
~ RElapse
~ REaction

Childhood Context and Development
~ The family context can be a preventative or risk factor for the development of issues
~ Children develop schema about themselves, others and the world through these early interactions
~ In later life people continue to develop schema influenced by their past learning.

Caregiver Requirements for Secure Attachment and Healthy Development
~ Consistent Age-Appropriate Responsiveness
~ Trust
~ Autonomy
~ Industry
~ Identity
~ Empathy
~ Compassion
~ Effective Communication Skills
~ Unconditional Love

Think About It
~ What is it like for a child growing up in a house in which one or both parents has:
~ An addiction
~ A mental health issue
Common Addicted Characteristics
~ Difficulty dealing with life on life’s terms
~ Difficulty dealing with distress (poor coping)
~ Impulsivity / lack of patience and distress tolerance
~ Neglectfulness
~ Hostility
~ Defensiveness
~ Blaming
~ Manipulation
~ Withdrawal
~ From others/disconnected
~ No pleasure in other activities
~ Justification/minimization/denial
~ Low self-esteem
~ Guilt and shame

Common Characteristics in People with Mental Health Issues
~ Difficulty dealing with life on life’s terms
~ Difficulty dealing with distress (poor coping)
~ Impulsivity / lack of patience and distress tolerance
~ Neglectfulness
~ Hostility
~ Irritability

~ Withdrawal
~ From others/disconnected
~ Apathy
~ Low self-esteem
~ Guilt and shame
~ Fatigue
~ Sense of hopelessness or helplessness

The End Product
~ People’s REactions to things are based on prior learning + present moment.
~ Bridges
~ Stress
~ Depression
~ Self-esteem

Core Concepts in Contextual CBT
Mindfulness
~ Improves people’s ability to be present in the present
~ Shift from automatically reacting to thoughts and feelings based on schema to being aware of ALL experiences in the present to provide more flexibility

Encouraging Acceptance of Internal Experiences
~ Accepting thoughts, feelings, sensations without having to act on them
~ Radical Acceptance
~ Unhooking
~ Dialectics
~ I can be a good person AND be divorced
~ I can be happy AND grieving
~ I can stay sober AND be stressed
Acceptance of Internal Experiences
~ Accepting thoughts, feelings, sensations without having to act on them
~ Distress Tolerance
~ ACCEPTS
~ Activities
~ Contributing
~ Comparisons
~ Emotions (opposite)
~ Push Away
~ Thoughts
~ Sensations
Focus on Adding vs. Eliminating
~ Help the person define a rich and meaningful life and make choices based on that vs. eliminating a problem
~ Depression
~ What do we do to eliminate depression?
~ What are we left with when we eliminate depression?
~ How do you prove the absence of depression?
~ Addiction
~ What do we do to eliminate addiction?
~ What are we left with when we eliminate addiction?
~ How do you prove the absence of addiction?
~ Accepting feelings thoughts and reactions and changing your relationship with them

Creating a Rich and Meaningful Life
~ Increasing Awareness
~ For each of the following areas identify which are important in your RML and what that looks like now and what you want it to look like

Changing Your Relationship
~ Radically accept feelings, thoughts and urges
~ Think of them like road signs
~ You can take them under advisement and decide what to do.
~ Speed limit/Anger
~ Construction/Giving up
~ No passing/Addiction
~ Rest stop/Depression
Motivational Enhancement (Functional)
~ Understanding motivation for change as well as no change in the context of the person’s RML in order to motivate purposeful action

Use a Broad Functional Approach
~ Transdiagnostic
~ Common mechanisms underlying an array of difficulties: Depression, Low Self-Esteem, Addiction
~ Shoulds and Shouldn’ts (Acceptance)
~ I should feel
~ I shouldn’t think
~ I should be
~ Lack of Awareness of Needs/Wants (Mindfulness)
~ Vulnerabilities
~ Autopilot or Rigid Thinking (Psychological Flexibility)
~ A willingness to accept all aspects of ones experience without unnecessary avoidance—Emotional, Cognitive, Behavioral, Physical
~ The ability to ponder multiple possible actions and thoughts and consciously choose
Difficulties with Self-Processes
~ Difficulty with self esteem or self efficacy may cause or maintain problems
~ Self-as-content – Narrative about one’s self and attributes
~ Being overly attached to the conceptualized self can prohibit flexibility
~ Ex. Being a good worker in a bad job
~ Ex. Being a good daughter but getting a divorce

Addressing Self as Content
~ Who do you want to be?
~ Explain why each of those is important?
~ In what ways does the current situation prevent you from being who you want to be?
~ What areas in your life are going as you want them to? (addressing global attributions)
~ Are there other ways to achieve or conceptualize the same end?
~ Examples
~ A size 3 (attractive/lovable)
~ A doctor (successful)
~ Not divorced (not a failure)
~ Loyal/dependable (not a quitter)

Difficulties with Self-Processes cont…
~ Difficulty with self esteem or self efficacy may cause or maintain problems
~ Self-as-process
~ Awareness of internal experience
~ Many people have difficulty attending to their internal experience in a flexible way
~ Handling urges, feelings
~ Identifying thoughts, feelings, urges, sensations etc.
Addressing Self-As-Process
~ Mindfulness journals/logs
~ Meditation to increase awareness
~ CBT Exposure-Noticing / In-Vivo Logs
~ Anger
~ Fear
~ Craving
~ Relapse prevention plans to handle internal processes
~ Make a committed action worksheet for each thing that is important to you.

Difficulties with Self-Processes
~ Difficulty with self esteem or self efficacy may cause or maintain problems
~ Self-as-context
~ Adopting the perspective of the self in the past, present and future—Who you were-are-want to be
~ Ability to take the perspective of others
~ Rigid self as context—or inability to take perspective may inhibit effective problem solving.
~ I am and always will be a failure/an addict/depressed
Addressing Self-As-Context
~ Increasing Perspective
~ Looking at your definition of a RML, what does your…
~ Past self tell you about your current situation? (schema)
~ What might your future self tell you about your current situation? (Flexibility)
~ What might you tell someone else in a similar situation?
~ How do your current thoughts, feelings, behaviors help you move toward what is important to you?

Summary
~ Contextual CBT involves understanding people’s phenomenological truth
~ Problems can arise when people
~ Thinks/feels that they are not who they should be or things are not as they should be
~ Are unaware of their internal feelings, thoughts, urges
~ Are unaware of the motivation (in context) of their feelings, thoughts, urges
~ Use rigid problem solving and conceptualization without considering context or perspective
~ Contextual CBT uses awareness, mindfulness, radical acceptance and psychological flexibility activities to help people move toward a rich and meaningful life instead of trying to escape or avoid discomfort.

Apr 03 2019

1hr 1min

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Rank #19: Developing Self-Esteem and Self-Efficacy

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466 – Developing Self-Esteem and Self-Efficacy

Developing Self-Esteem and Self-Efficacy
Presented by: Dr. Dawn-Elise Snipes
Executive Director, AllCEUs Counseling Continuing Education
Podcast Host: Counselor Toolbox, Case Management Toolbox

https://www.allceus.com/member/cart/index/product/id/1030/c/

Sponsored by TherapyNotes.com
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Objectives
• Understand what self esteem and self-efficacy are, why they are important and how to develop them

The Nature of Self-Esteem
• How people feel about theirself in contrast to who people think people “should” be
• The more rejecting people are of theirself, the more
• Distress people experience
• people seek external validation or withdraw
• In order to develop healthy relationships people need to
• Feel good about theirself
• Get in touch with theirself and their true values
• Believe people are a lovable and worthwhile person
• Choose actions in harmony with their true self

The Gift of Mindfulness
• Teaches people to live in the moment
• Not stuck in guilt or resentment of the past
• Not paralyzed by fear of the future
• Putting one foot in front of the other
• Cornerstone of mindfulness is acceptance
• Nonjudgmental
• Letting be
• Patient
• Mindfulness teaches that when people trust theirself and act with awareness and purpose people become more self reliant

Note: The book will give people access to online, recorded versions of several meditations

Impact of Mindlessness
• Ignoring or invalidating how people feel
• Failing to integrate feelings, thoughts, sensations and urges
• Running on autopilot and not making time for the things that are important (getting us closer to our ideal selves)
• Blindly adopting mainstream messages of who/what we should be
• Not in harmony with who we really want to be
• Not achievable or realistic
Developing a Self-Concept and Efficacy
• You are more than your accomplishments or your bank account.
• What do you want to stand for (values)?
• Download a values list and circle the ones that are important to you.
• Identify how you CURRENTLY demonstrate those.
• Identify other ways you could demonstrate those.
• What things do you do that go against your values? (i.e. impatience)
• What could you start doing today to address one of those?

Developing a Self-Concept
• What things are you good at, and what are your accomplishments?
• What traits/values do those accomplishments and strengths represent? Success, courage, determination, creativity, compassion
• How would your friends describe you?
• Loyal, compassionate, caring, honest…
• How do you demonstrate those?
• Self Esteem Acronym (THINK)

Breathing and the Body
• The constant noise often keeps people from addressing the underlying issues of emotional turmoil
• Life becomes focused on treading water
• Forward goals are exchanged for just surviving
• This reduces self-efficacy
• Mindfulness and self-awareness help people quiet their thoughts
• By making contact with the present moment people can:
• Find their strength
• Learn to grow
• Choose how people wish to respond
Activities
• A Deep Full Breath
• Abdominal breathing signals the brain to slow down and relax. “Rest and digest”
• Simply paying attention to breath often causes it to slow down
• Feel the loving touch (their Breath)
• Life begins and ends with breath
• Breathing helps relax the body and move Qi
• Add visual and auditory breathing reminders
Activities cont…
• In and Out
• Do a body scan and yay attention to what their body is trying to tell them
• Inhale and take in positive affirmations
• Make a list of 1-3 affirmations
• Exhale and let go of stress and negative energy
• Envision stress leaving like a wave/cloud/balloon
• Note: This can also be done with bubbles
• Practice noticing points of tension/tightness/heaviness and feel them relax or loosen as they exhale
• Develop confidence that they can feel feelings and not have to impulsively act.

Thinking and the Mind
• An Impartial Witness (Fly on the wall)
• Stop Sorting (into good and bad)
• See the Whole Room, Not Just the Elephant
• The issue
• The strengths
• Everything/everyone involved
• Check the Hecklers
• Identify self talk
• Examine its source and reliability.
• No Blame
Emotions and the Heart
• Spaciousness
• Recognize all the emotions contained within their heart
• Cultivate warm heartedness
• Plant your garden (What are you going to use your energy to cultivate?)
• Tend and befriend
• Count your Blessings
• Delight for Others
Being in the World
• Claim Emotional Baggage
• Don’t let it stay on the conveyor
• Don’t give it to someone else
• Listen—Just Listen
• Listen to hear and understand (self and others)
• Speak with Compassion (To self and others)
• Write a Job Description
• Goals
• Duties

Mindfulness to Increase Self-Efficacy
• Reflect daily on how they embodied the values most important to them
• Value progress over perfection
• Develop self compassion
• Use backward chaining to identify vulnerabilities which may have contributed to mindless behavior
Summary
• Self esteem begins in childhood
• Being aware of self helps people identify their strengths and develop their “me” identity.
• Part of self esteem development includes
• Values identification
• Understanding wants vs. needs
• Addressing cognitive distortions
• Being aware of sensations, feelings and thoughts
• Helps choose behaviors which are in unison with values
• Helps support people through the difficult moments
• Silences the critics
• Clarifies who people are and what people want

Feb 08 2020

42mins

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Rank #20: Motivational Enhancement & Stages of Readiness for Change

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484 – Motivational Enhancement & Stages of Readiness for Change

Sponsored by TherapyNotes.com
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CEUs available at: http://allceus.com/member/cart/index/product/id/1275/c/

Types of Motivation

* Motivation is essential for change

* Motivation helps you identify why it is worth the effort to make a
change

* Motivation helps you keep going when the going gets tough
* Change can be hard and uncomfortable

* Motivation is different for different goals

» Changing people, places and things

« Motivation may decrease over time unless you actively maintain it

* Going to meetings or counseling

* Placing a priority on adequate quality sleep and stress management

Apr 08 2020

54mins

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