13 Brief Therapy Interventions for Any Person

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com Counselortoolbox you. I'd like to welcome everybody to Today's presentation on 13 useful brief interventions. I know the class you signed up for said 10, but I kind of got carried away. I know. Big surprise. I AM your host, Dr. Donnellice Snipes. Today we're going to review the benefits of brief interventions, identify the goals of brief interventions, and explore 13 interventions that can be used with most clients. There are a couple little caveats here and there, but for the most part these interventions are pretty universally applicable. The benefits to brief interventions? Well, they're brief, number one. So it's something that happens quickly and maybe I should have put goals first. But it really helps engage the client. It reduces the no show rate. When clients feel like, oh my gosh, I did something, I'm making progress, I've got momentum, they're more likely to show back up. It increases treatment engagement. When they are able to do something that actively addresses their situation, they are going to feel more empowered and more engaged in treatment. It increases compliance. If you're asking them to do something and they're actually having positive results, go figure. They're going to do it again. It increases efficacy because again, they are doing something. It's not just showing up and talking for a while and clearing out those obstacles. They're actively doing something and seeing positive changes. It can reduce aggression and isolation because when people feel frustrated, when they feel like they're at their wit's end, when they don't feel like they can want to go on like this anymore, they tend to get a little irritable. I know I do. When we provide them with hope, when we provide them with some semblance of a little bit of improvement, then aggression and isolation tends to go down more. And it also provides an interim for clients that are on waiting lists. Some clients may need residential treatment. It doesn't mean they can't get started doing something right now. So let's talk about a little bit more about what those somethings are. Brief interventions should be smart, specific, measurable, achievable in 8 to 10 weeks, relevant to the overall goal and time limited. 8 to 10 weeks is usually good for some clients. You may want to have brief interventions that are even shorter depending on their age, their cognitive capacity, etc. Some clients will need a sense of accomplishment or reinforcement sooner than other clients. You'll Just kind of want to identify those things. The thing with brief interventions is that they are very specific. Instead of saying, we're going to address this person's depression, we're going to say the brief intervention would be to address the person's sleep disruption, to help them start sleeping seven to nine hours per night. When you are mountain climbing, you put in anchors or you have legs of the trip and you can think of brief interventions as legs of the trip to their destination of recovery. Brief interventions are not huge. Again, you want to have something very, very specific that can be accomplished in a short period of time, anywhere from four to 10 weeks. But generally we think of brief therapy as being 8 to 10 weeks. The purpose is to reduce the likelihood of damage or additional problems from the current issue. We want to look at family, work, health, self esteem, guilt, anger issues. We really want to help people start feeling better so they're not damaging their relationships or having problems at work, yada yada. And we want to provide rapid, measurable change to increase hope and motivation. When people start on a diet, for example, I use that example because most people have started on a diet at some point or another if they initially drop a bunch of weight. I know my husband does, and it irritates me to no end. When he starts a diet, he can drop weight like nobody's business that first week or two. And it gets him in the groove and he gets excited. He's like, okay, I can do this. If you're doing things you know, you're already not feeling good, you're already clinically depressed and you're trying, you're being treatment compliant, you're doing whatever you're supposed to do and you're just not seeing any measurable improvement anywhere or you don't feel like it is, then it's harder to stay optimistic and motivated. When we use brief interventions, instead of having the client look at depression, which can be all encompassing, we're saying, all right, your depression is out here, but it's composed of these nine different symptoms or nine different issues. Let's look at this one issue. When I talk with clients about diagnoses in general and the transtheoretic, transtheoretical model, I suggest to them that our problems are often like a sweater or a heavy blanket. And that blanket is over top of us right now. And it feels oppressive, it's hot, can't hardly breathe, you know, it's kind of miserable. Well, how do you get that blanket off of you? Well, if you've ever had a knitted or crocheted blanket. Before, you know, you start pulling any one string and eventually that sucker is going to unravel. That's what we want to do with brief interventions. We want to identify one string, one area that the client might be willing to work on and that will start unraveling the blanket. It'll start making the blanket feel lighter, it'll start letting more air in. Same thing with their depression. They're going to feel less weighted down and may start having some more hope and optimism. Target symptoms for a variety for the majority of issues in the dsm, you know, there's going to be generally some depression, anxiety or some sort of mood issue, you know, can be grief or whatever. Muscle tension is not uncommon. By the time people come to us, they are in some level of crisis, which tends to translate to muscle tension, sleep disturbances, problems with concentration, irritability, fatigue, lethargy and psychomotor retardation. Now there's a difference for, you know, just to kind of recap, fatigue is feeling sleepy and that can come partly from not getting enough sleep. Lethargy is when. And psychomotor retardation are when it feels like your arms and legs are just weighted down and you can hardly move and it's just drudgery to do anything. And there's a sense of hopelessness and helplessness which we want to reverse to increase a sense of self efficacy. Those are your basic or individual sort of symptoms that we may look at. The meta issues that people may bring in. They may come in and they want help with relationship issues. Well, there's a lot there to deal with. You know, let's figure out one thing that we want to deal with in, in that ballpark, if you will, and we can start dealing with that because as people's mood improves, for example, they're probably going to improve their relationships. As their communication skills improve, they're probably going to improve their relationships and maybe feel less stressed and irritable. You can see where, you know, you're just doing one thing, but it's starting to unravel that blanket. Other meta issues people may present for include unhealthy habits, smoking, emotional eating, drinking, yada yada. These are behaviors we want to look at. What is that behavior communicating to us? A lot of times the behaviors are a coping skill or are communicating some sort of distress and desire to escape. Modern populations are increasingly overfed, yet malnourished, sedentary, sunlight deficient, sleep deprived and socially isolated. Okay, well, let's think about what some of these problems might be when we're overfed, we may be over fat, and if we are overweight, then that can contribute to a variety of health problems, including diabetes and heart disease and those sorts of things, not to mention, unfortunately, social stigma. But we can be overweight, overfed, yet still malnourished because we're not eating healthy foods. And you've heard me preach about it before and I'm going to preach about it again. If you're not giving your body the building blocks it needs to make the neurotransmitters and to keep the gut healthy, then you're not going to be able to experience as much happiness as you possibly could and as much health as you possibly could. Your body needs to have nourishment. When we are sedentary, we get achy. You know, if you sit still for a long time, you'll realize you get sleepy. I was on bed rest for three months with my daughter. Oh my gosh, I never knew how sleepy you could get having to stay in bed. When we are sedentary, we tend to get sleepy not only because we're not moving and we get achy, which also disrupts our sleep, but we're usually not oxygenating well enough because we're not doing anything to increase our increase our breathing. When we are sunlight deficient, it messes up our circadian rhythms and generally leads to vitamin D deficiency, which have both been linked to mood issues. When we're sleep deprived, you can be sleeping a lot, but sleep deprived or not sleeping much at all during those periods when you're not getting that restful, restorative sleep, your brain is not clearing out the adenosine, which can make it harder to focus on. You can be fatigued and sleepy all the time, which may lead to naps, yada, yada. People need good sleep. People need good sleep to rebalance the neurotransmitters, to clear out the gunk, if you will, that builds up in our brains throughout the day and to have a fresh reboot for the next day. And when we're feeling exhausted, depressed, foggy headed, irritable, we tend to not want to spend a lot of time with friends, which means we're socially isolated. However, our social supports are some of our greatest buffers against stress. So you can see where these can be a problem. Not everybody who comes to counseling is ready to start making cognitive changes right away. Sometimes we have to find alternate areas that they may be willing to work on. Additionally, a lot of the things that we talk about and we do in counseling when we're addressing cognitions and, you know, talking about feelings and situations and all that stuff. That's all well and good, but rarely is one session, one one hour session going to have the person walking out feeling empowered, hopeful and optimistic. They may feel like, oh, I got that off my chest. But oftentimes they don't have that next step, that action that we're looking for in brief interventions. So when you're doing an assessment for brief interventions and an assessment in general, identify what the resolution of the problem looks like to the person. I will not be depressed, as evidenced by how will you know when you're not depressed anymore? How will you know when you don't need to come to treatment anymore? What will that look like? Define a starting point to create one measurable change in the client's behavior. So they may say, I'm getting quality sleep. I don't cry all the time. I have more energy now. These aren't very measurable yet, but you can get there. When you're writing those goals, but you can see they're identifying multiple things. You, you're going to pick one and you're going to say, okay, let's start with one for this week and let's see where we go with it. Explore the array of causes of the behavior. Physical causes Sleep deprivation. If somebody's complaining of fatigue and foggy headedness, sleep deprivation, nutrition imbalances, dehydration, maybe they're not taking any time to relax. They're, you know, revved up all the time, which is going to prevent them from getting good sleep. Maybe they have medication that's causing that side effect or contributing to it. Even some of your SSRIs can make you feel really foggy headed and groggy. Do they have other health conditions like cardiac conditions or blood sugar issues that might be contributing to their foggy headedness and their fatigue? Do they have pain? Think about when you're in pain. If you've got a toothache or an earache, you know, how good's your mood and how good is your energy and all that stuff. Hormones can contribute to a wide variety of mood issues. When we're talking about thyroid hormones as well as sex hormones and addictive behaviors can obviously increase fatigue and confusion. Their affect. What is their affect like? If they have anxiety, depression, grief, guilt, you know, all those feeling words. Generally when people have dysphoric emotions going on, it's going to be harder for them to get energized. That is exhausting to be thinking about those, to be ruminating on those, to be trying to deal with those constantly. And that can not only just during the day make them feel fatigued and distracted, but it can keep them from sleeping well at night. Cognitions. What are their thoughts like? What kind of cognitive distortions do they have? What is their attitude? Do they have a negative, pessimistic outlook, or are they optimistic and hopeful? What is their environment like if they are in a really stressful environment? I mean, we've all been in work situations. Unfortunately, I shouldn't say all. A lot of us have been that the organization was very dysfunctional and it was just really stressful and exhausting to be there all the time. Well, that could be contributing. I mean, as soon as Jane walks into the front door, that organization, that stress and dysfunction in the organization just starts kind of sucking her energy out. So you want to look at that, look at her employment. You know, is she happy in her job? How many hours do you spend thinking about work, getting ready for work, driving to work at work, driving home from work and ruminating about work in a 24 hour day? Most of us probably spend at least 10 to 12 hours doing that. So if you hate your job or you hate your employer, then that's going to be contributing to things. Not that Jane can necessarily quit wherever she works right now, but we do want to look at that as a potential area for intervention later, for helping her either deal with the dysfunction at the place that she works or looking at other options and social relationships. What is the quality of the social relationships the person has? Are they a buffer against stress or do they contribute to this sense of being fatigued? You know, does. Does Jane have a lot of friends that just. They are very, very needy and constantly wanting her to do things or needing her emotional support? It can be exhausting. In her social relationships, are there good boundaries? You know, when we have very, very weak boundaries, then it's easy to get enmeshed and drained by other people. And how effective is Jane's communication? Because if she's feeling a certain way and she can't communicate it, if she can't communicate to others what she needs in order to feel happy and healthy, to get her needs met, then again she's going to feel exhausted and frustrated and stuck. We don't want any of those things. So the mnemonic here is paces. It stands for evaluate the physical, affective, cognitive, environmental and social causes of the particular target behavior. Now we're just looking at the target behavior here. We're not looking at. We have depression out here. But right now we are just focusing on her fatigue and she wants to have more energy so she can focus more and work harder in therapy and explore the current strengths and mitigating factors. What is her support system like? We've already kind of talked about her support system, but who's in her support system? Who can she call on at 2 in the morning? What are her strengths? How has she solved similar problems before? I mean, she's made it until now, so clearly she's been doing something right. It may not be ideal, but she's been doing something right. What are her situational advantages and or mitigating factors? If she has six weeks of time on the books at work and she can take three weeks off, that's a situational advantage. That's a mitigating factor right there that we want to put out there as a possible thing for her to look at if she needs to take a little time off to rebalance. If her in laws live in town and they may be able to help out with the kids so she can have a weekend to herself, you know, they can go visit granny and pop for. For the weekend, that may be a situational advantage. So you want to explore different mitigating factors. She's got this fatigue and confusion going on. What's draining her energy and how can we. What resources does she have that can start eliminating some of those drains on her energy and then talk about previous treatment? No sense doing something that she knows ain't gonna work. That's. Most people are not motivated to do things that they've already tried before and it hasn't worked. So what have you tried before? What's worked? Even if for a day, even if for an hour, what's worked? And if it worked for a short period of time, then maybe we just need to modify it a little bit and build on it. And then what hasn't worked? Because I don't want. When I'm using brief interventions, I want the client to feel empowered and in control. And they're choosing from a menu of options. If you think of the frames they're choosing from a menu of options, what's going to work best for them? So let's put all the options out there. Sometimes it can be helpful to write things down on the whiteboard as you're brainstorming different things that Jane could do in order to mitigate her fatigue so she can start, you know, getting her circadian rhythms reset and getting decent sleep. So one of the first interventions is backward chaining, and you're not going to. In this presentation. You're not going to learn any of these in depth. This is just going over some 13 really good interventions that you can learn more about if it seems like something that would work for your clients. Backward chaining is used a lot in dbt, so you can learn a lot more about backward chaining if you look at DBT and we have multiple counselor toolbox episodes on each one of these things. So if you want more information, it's out there. Backward chaining is when you have a behavior. You know, Jane is just exhausted today, and she can't focus to save her life. Okay, that's where we're at. Let's look at how we got here, what led up to this point. And Jane will start identifying the things that triggered the problem, the things that triggered her to feel fatigued. Now, she may not be able to think back all the way to when she first started feeling fatigued, but why is it worse today? So have her describe a situation or things that contribute to the problem. When you're talking about, you know, make anger outbursts, the client may say, well, my partner came home late and I got angry. Okay, so the precipitating factor, the partner came home late and you got angry. That was the consequence. Then you might look back a little bit farther. What is it about your partner coming home late that made you angry? So you're going to look back to a priority example or understand a little bit more about what's causing it. Okay. Then ask the client to think of a similar situation that didn't trigger the problem. So if the person's partner came home late, but called and let them know that they were going to be late and the person didn't get upset, it's like, voila, here's an intervention. So then we have to move to how do we get, how can we make that happen? How can we help your partner understand the benefits? And if you look at, again, DBT or any others creating win win situations, you want to help Jane figure out how can she communicate to John what she needs and why it's beneficial to him. Other examples, I had a bad day. I came home and drank a bottle of wine. Okay, so the situation, you had a bad day, which triggered the problem. Now we're just looking at the most proximal trigger. That's okay. So let's think about another time. You had a bad day and you didn't come home and drink a bottle of wine. What did you do instead? I decided to go out to dinner with friends. From work to commiserate about how awful the week's been. Okay, so there are options to your responses. Backward chaining is basically helping clients see what triggers a behavior so they can get off autopilot. It doesn't. Just because she has a bad day doesn't mean she has to come home and drink a bottle of wine. She's actually done other things before. So let's make a list of those alternatives. Forward chaining. Add in triggers for behaviors that you want to start doing. Forward. Forward chaining is basically setting up the triggers or situations that will prompt a behavior. For me to go to the gym. I need to go to the gym in the afternoon, which I don't. I hate going to the gym in the afternoon. I like going in the morning. I know if I go home, I'm not coming back out to go to the gym. So if I look backward chaining, I know I can't go home. First I need to leave from the office. What else do I need to do? I need to have my bag packed. I need to make sure I eat a good lunch. That way I'm not starving. I need to, you know, making a list of what do you need to do to help this occur. And generally, if I'm working out in the evening, I need to have a friend that I'm going to meet at the gym. Otherwise, I'm just not motivated. We want to look at those things. We want to have people add in triggers for behaviors they want to start doing. They can add in push notifications if they want to start practicing mindfulness, for example, or they want to start walking for five minutes every four hours, you can do push notifications. Those are super easy. Now you can add in visual cues that remind you for going to the gym. Having my gym bag right in the seat next to me in the car, it's kind of a visual cue. Oh yeah, I need to go to the gym. For people who are trying to get better sleep, for example, what kind of visual cues can they set up that remind them, oh, you know what, it's eight o', clock, I need to start winding down. You can have the person find a change buddy. Sometimes it's easier to to start making changes. If you've got somebody who's making a similar change, not necessarily the exact same, but a similar change. That way you can keep each other motivated and heading forward. A change buddy will call you up and say, hey, you know, it's 7:30. Have you started winding down and turned on your blue light filters on all of Your devices and you can keep each other supported. And you want to have rewards in forward chaining. If you want to prompt a behavior, you want to have a carrot out there. So the person needs to see that there's some sort of reward. Sometimes it's just feeling better, but other times, if you're doing something like starting to exercise or stopping smoking, then at the end of the week, maybe there's a reward. If you went seven out of seven days successfully. You also want to add in obstacles to behaviors you wish to stop, so you make it more difficult to start those behaviors. If somebody's an emotional eater, then maybe they need to journal before they start eating. They need to write in their food journal. Sometimes that three minutes is enough to divert them or just the hate of journaling is enough. Make it inaccessible. People who are trying to stop smoking don't keep cigarettes in the house. If you have to get out of your PJs, put your shoes on, drive down to the quartermarket to get a pack of cigarettes, then you're gonna think twice before you smoke that cigarette. So make it inaccessible. Separate it by physical distance. You can also separate it by temporal distance. Tell yourself, 15 minutes. If I'm still wanting this in 15 minutes or I'm still feeling this way in 15 minutes, then I can do something else. And then there's aversion. The most common example of aversion is Antabuse. When people drink antabuse or take ant abuse and then they drink alcohol, it makes them violently ill. Aversion therapy makes whatever you want to do completely unpleasant. Now, that's obviously not as helpful for things like crying because of depression, but if we're talking about behaviors, especially adding in positive behaviors, then that's good. If we're talking about maybe Jane doesn't get to the gym and part of the reason is because she really likes to watch tv, then you can make it easier for her to watch tv. She can watch it on her tablet at the gym and make it more difficult to start. Turn off her cable subscription and her Hulu subscription and everything else at the house. So the only way she can watch her show is to go to the gym. Positive reflection. They found that positive affect journaling for 20 minutes a day and improves depression, anxiety. It enhances resilience and reduces medical visits. Positive affect journaling is just like what it sounds like. People write or reflect for 20 minutes per day on the things that went well that day, on the things that are going well in their life at that point in time. Some people like me, I will tell you, I hate journaling. Therefore, there are options. Call somebody and tell them about the positive things in your day for 10 to 20 minutes. Mentally reflect on all the positive things in your day and life for 10 to 20 minutes. So even if you can't talk to somebody else, if you just sit there and mentally reflect, you meditate, if you want to call it that. On the positive things in your day. For people who are more artsy, draw a picture about something incredibly awesome in your life. My daughter draws pictures of her cat all the time. And, you know, that's something. It puts your mind in that positive headspace and gives your whole body sort of a break from distress, so those cortisol levels can go down. Sleep. Adequate quality sleep enhances cognition, enhances immunity, reduces depression, anger, anxiety, and fatigue. And each one of these hyperlinks goes to different articles that are in referee journals that support these. I'm not just pulling this out of thin air, but it's important to recognize that only quality sleep, not just any sleep, but quality sleep within normal limits, which is about seven to nine hours for adults. Helpful. When people sleep too little or they sleep too much, it can negatively impact their circadian rhythms as well as their mood. In order to incorporate sleep into treatment, you can review sleep hygiene with people, give them a checklist, and you can find sleep hygiene checklists online or, you know, in the other presentations that we did on sleep for Counselor Schulbachs, you can develop. Encourage them to develop a sleep routine. Just like with little kids. Do the same three or four things every single day, and that will start cueing your body when you start doing that, that it's time to start making melatonin and getting ready for bed. And encourage people to keep a log of symptom severity and sleep. If we're working with Jane and her fatigue and her confusion. Okay, so let's keep a log of how much you slept, how well you slept, and the intensity on, you know, like a Likert scale of your confusion and fatigue that day. Hopefully, she can start seeing a connection. How do you monitor quality of sleep? Well, you can do it by how many times somebody wakes up. You can also do it. A lot of the fitness trackers now have sleep monitoring. It's not exact, you know, it's a real rough estimate, but it gives you an idea about how much you tossed and turned, how much you move during the night, and they guesstimate your deep sleep versus light sleep. That can be really helpful for people to identify. And then if they See that they're not sleeping well, then they can do backward chaining and go, okay, what did I do yesterday that may have prevented me from sleeping well? Sunlight and circadian rhythms is another intervention that is really very easy, and most people are not going to balk about it. The body uses sunlight to set our circadian rhythms. Our circadian rhythms are responsible for regulating when our cortisol goes up and down. They're responsible for our hormones that help us to feel hungry and satiated. They're responsible for a whole bunch of things. So when your circadian rhythms get out of whack, you tend to see mood and behavioral disruption. The body also uses sunlight to make vitamin D. The vitamin D that your body makes is way more bioavailable and effective than the stuff that you take in a pill. Vitamin D deficiency is implicated in seasonal affective disorder and behavioral withdrawal. Sunlight exposure relates positively to job satisfaction and organizational commitment. When people are able to see the sunlight at work, Go figure. They tend to be happier in their workplace. It relates negatively to depressed mood and anxiety. Again, remember, when we talk about correlations, that means that when sunlight exposure goes up, depression and anxiety go down. That's a negative correlation. Bright light therapy has been found to be effective for addressing eating disorders, depression, fatigue, and sleep disruption. Not everybody can get sunlight. Not everybody is in a place. When my son and my daughter were in the nicu, the neonatal intensive care unit, they keep the lights really low in there so the babies can sleep, which means the nurses who are in there for 12 hours a day are in really low light levels, so their brain isn't registering it's daytime, and they're not getting the benefit of actual sunlight. So they found that bright light therapy can help with setting the circadian rhythms, improving sleep patterns and improving mood and some behavioral issues. How do you incorporate it? Encourage people to get sunlight exposure first thing in the morning and throughout the day. It doesn't have to be consistent for eight solid hours. They found that, you know, five or 10 minutes here or there throughout the day is just about as effective. So first thing in the morning when they're driving to work, well, you're like, well, they drive to work when it's dark. Okay, well, take your first break when the sun comes up and go outside to drink your coffee or walk around the building or do whatever to get a little bit of actual daylight light. Boxes can be used, and these are. I don't think they're prescription anymore, but they are really, really bright lights that can be used for a Prescribed amount of time to help set those circadian rhythms. Some people find that full spectrum lights, not the soft whites, you have to get the ones with the clear bulbs. Yes, it's a harsh light, I know, but you, you want it to be as bright as possible, 100 watts or more. With the invention of LEDs, you can actually get some really bright freaking lights and not sweat to death while you're sitting in front of them. And you want to keep them within about one meter, about three feet of you. So if you're sitting at a desk, a desk lamp, if you're sitting in a recliner, you can have one of those chairs that has the book lamp that comes over your head. You want it to be kind of close to your head. I mean, ideally you want to do it in a relatively well lit area. You don't want to be sitting in the dark with this like glowing thing because that just messes with your head. But light, light therapy has been found to be extremely effective for a lot of people. Oxygenation. Oxygen is needed for serotonin and ATP synthesis. Who knew you need oxygen to make serotonin from the foods that you eat? So if you're not getting enough, if you're not well oxygenated, if you are anemic for some reason, then your body may have difficulty keeping up with the serotonin demand. We know serotonin is responsible for heart rate, sleep, hunger, pain, perception, depression, anxiety, the list goes on. ATP, basically your body's energy factory. So in order for your body to make energy, it has to have oxygen to make ATP. Without oxygen, you're going to feel fatigued. The reason most people yawn, they've found, is not because you're actually sleepy, but because you are poorly oxygenated. Your body is going, I need some more of that O2 stuff. So you've got to breathe deeply. It makes you breathe deeply. Relaxing deep breathing has been shown to attenuate pain perception, tension, anger, anxiety and depression and improve sleep. You can call it belly breathing, you can call it whatever you want it to be. A relaxing experience for the person where they're breathing in for a count of four or so and breathing out. This also helps set the rest and digest system in people's bodies. So when you start slowing your breathing, your brain goes, oh, it's time to relax. This is a cool thing. And it starts sending out all of the relaxation chemicals, including GABA and other things. Deep breathing can be really helpful. Incorporate it into the day with breathing breaks. I know it sounds weird breathing, but it is really helpful, and it helps clear your mind a little bit. If people take breathing breaks and it's not the old take 10 deep breaths. Because most people I know when they're told to take 10 deep breaths, they're like, that's not it. You want to breathe in, feel your stomach expand, breathe out, take those breathing breaks throughout the day. When you take a breathing break, typically you improve your posture, too, which also helps get that oxygen where it needs to be. If you don't like breathing breaks or you won't do them, or even if you will, exercise also helps improve oxygenation and improves mood, cognition, and sleep. Even in healthy adults without clinical depression, exercise improves depressive symptoms. So even if they don't qualify for major depressive disorder, exercise can help. Exercise, they found, modulates dopaminergic and glutamatergic neurotransmission. Dopamine is our pursuit chemical. Basically, dopamine says, I want that again. I want to go after it. I want to go back and get. Get some more, which is our motivation chemical. It's involved in energy, too. If we don't have enough dopamine, we're going to be exhausted. Glutamine is our main excitatory neurotransmitter. If we don't have enough glutamine, then we're going to feel fatigued and lethargic. Interestingly, ketamine works on your glutamine receptors, so they found a distinct relationship between depression and glutamine. So exercise enhances dopamine and glutamine, which both of them have been associated with depression and anxiety. So that's a great thing. Exercise also increases serotonin, noradrenaline, and GABA systems, which are all related to depression, anxiety and sleep. So when you exercise, your main neurotransmitters, pretty much they're all. There are getting rebalanced and reactivated, and that helps people feel better. Exercise doesn't have to be exhausting. I'm not talking about going out and running five miles. Gentle walking can be enough for a lot of people. Another way to oxygenate is laughter. Laughter alters dopamine and serotonin activity, decreases cortisol levels, and increases endorphin release. Endorphins work with dopamine to create that pleasure principle. When we do something that is pleasurable, we get an endorphin release, which raises our dopamine levels and our body goes, I want to do that again. Cortisol is our main stress chemical. So if laughter is reducing cortisol, then That's a good thing. That also means that we're calming down the HPA axis or your threat response system. Laughter impacts depression, anxiety, pain, immunity, fatigue, sleep quality, respiratory function and blood glucose. Wow. Who knew that laughter could help? There is something to be said for watching those cat videos on YouTube. I tell you what, laughter significantly decreases adults depression, anxiety, and improves their sleep quality in several studies. Well, that's great. Now finding somebody who's clinically depressed and going, okay, you need to laugh, you know, five times a day, that's a little bit harder. So we need to help people figure out how to integrate that. If they can plan 10 to 15 minutes per day prior to stressful situations and at the end of the day to reset the system. So if they're getting ready to go into a stressful meeting, even taking five minutes out to listen to a comedian or watch a video that's going to make them laugh can help set that system so they're not going in with a bunch of cortisol and anxiety and stuff. Then at the end of the day, when you're trying to relax so you can go to sleep, you want to decrease cortisol levels, you want to increase serotonin and melatonin. Laughing can help. That helps kind of rejuvenate the system. Laughter distracts from distress and breaks the loop. If you're laughing, if you're focusing on something funny, you're not perseverating on something unpleasant. Laughter increases good chemicals. And if it's a good belly laugh, which it really needs to be, it increases oxygenation. So you're getting that oxygen in and helping the body out. Make serotonin and ATP and everything else we've been talking about. Hardiness is defined as commitment, control and challenge. If we can help people develop hardiness, this is more of a cognitive intervention. Hardiness commitment represents the tendency to involve oneself in activities in life and having a genuine interest in and curiosity about the surrounding world and recognizing oneself as multidimensional. Recognizing that, okay, this aspect of my life right now may not be going so well, but all these other things are going. When my mother passed, you know, that aspect of my life was going not so well right then, but my kids were healthy, work was going okay. Recognizing that I had a lot of things that were important to me that were going well. So I didn't just focus on this one thing and think, oh, my life is over. Control means a tendency to believe and act if one can influence the events, Sometimes that means changing our response. Other times that means actually Changing what's going on, but recognizing what we can and can't control. And challenge means believing that change, rather than stability, is the normal mode of life and constitutes motivating opportunities. Okay, you know, I got fired from my job. Well, I could get really upset about it, or I could view it as a challenge. All right, this is a change. Didn't necessarily want it, but it's a change. So how can I view it as an opportunity to grow or a motivating opportunity? Hardiness has been linked with cardiovascular health, reduced anxiety, an improved response to bullying, insomnia reduction, and reductions in neuroticism, rumination, and worry. To incorporate it, have clients identify all the different aspects of themselves or which are important to them, including their health, their housing, their family, their friends, their finances, their job, anything else they want to add to the list so they can see that life is multidimensional. When unpleasant things happen, encourage them to identify five things that are going well, how this event represents a growth opportunity, and what aspects of the situation they can change. Give them a worksheet. They're going to need the worksheet. They're not going to remember this when they're under stress, but that way they can start changing their perception. Cognitive restructuring teaches people to identify and dispute maladaptive thoughts. It can assist in increasing perceived efficacy, altering negative self concept, enhancing pain tolerance, reducing hopelessness and helplessness associated with anxiety and depression. You probably already learned a ton about cognitive restructuring in school. Talk about incorporating it into the treatment plan. Give people worksheets. They think a lot, and they're going to think a lot between your session and the next session you have with them. So it's important for them to start changing those cognitions regularly. So give them worksheets to complete at home. That way, they are regularly evaluating their thought patterns. A shorter thing that they can do when they start getting anxious about something, they feel like, you know, bad things are going to happen. Identifying three alternatives. You know, my daughter's late coming home from wherever she was, so, you know, she must have gotten into a car wreck and she's in the emergency room. Okay, that's one possibility. What are three other alternatives that are at least equally as likely? You know, identifying those, her phone's off, she lost track of time, whatever. And encourage people to find meaning even in unpleasant events. You can see unpleasant events that happen to you as awful and horrible and whatever. Or you can say, all right, this is the hand that I've been dealt. How can I find meaning in this? What is this going to teach me how is it going to make me stronger? Now, as I said, there are some caveats here. Older adults with anxiety and depression tend to be worse at learning and benefiting from cognitive restructuring, partially due to having poorer cognitive flexibility. When you're using cognitive restructuring, you know, people who are psychotic or who are having difficulty with cognitive flexibility may not benefit from this one. Cognitive dissonance. Create dissonance or dispute between unwanted behaviors, thoughts and emotions to encourage purposeful change. Things that we're doing right now may be pleasurable or safe, but it doesn't help me. Smoking, I may be doing it and I like it and it has some benefits for me, but it doesn't help me achieve my goals of not getting cancer. So that's creating dissonance, creating a conflict, being depressed. And you think, well, nobody'd want to do that. If you've been depressed for a while, sometimes that's what you know and you figured out how to deal with it. It may not be pleasant, but it's what you know when it's safe. Safe, so to speak. Creating dissonance between that and somebody's goals and helping them see how shedding that behavior or set of behaviors may be helpful. Resolve dissonance between helpful behaviors. Sometimes people see helpful behaviors and they're like, yeah, I know it's good for me, but it's awful, like eating Brussels sprouts. So how can you resolve that dissonance so they can start seeing the benefit? Sleep is one of those. Sometimes people don't want to do sleep interventions because they work all day long and they come home and they want to catch up on their TV and whatever else, and they just can't figure out a way to get to bed before 12 or 1 in the morning. Helping them resolve that dissonance. They're like, I need to do this, but I really don't want to. How can we help them want to do it? How can we help them see that it will encourage them and enable them to better achieve their goals? Cognitive dissonance is maximized by four factors. It has to be voluntary. If people feel forced, then they are most likely not going to maintain that change. Just like when somebody goes into involuntary treatment, they'll do it as long as they're not being. As long as they're being forced. But as soon as somebody takes the pressure off, they will revert. There needs to be an absence of external justification. They need to be doing it for them. Not to please you, not to. For something else. But for them, there needs to Be high public accountability. So if they stop doing what they're supposed to be doing, or start doing something they're not supposed to be doing, that they are held accountable in group therapy, with their therapist, with their significant other, whomever. And dissonance inducing behaviors need to require a high level of effort. So if somebody is trying to quit smoking, like I suggested earlier, making sure that it requires a whole lot of effort to be able to access cigarettes, you can incorporate cognitive dissonance through self talk scripts, where people, you know, talk themselves through things, going, this is not really where I want to be right now, and then obviously making dissonant behaviors more difficult. Mindfulness Mindfulness meditation and cognitive therapy cultivates an awareness of one's feelings, urges, thoughts and perceptions in the present moment without judgment, and helps them relate constructively and purposefully to those experiences to improve the next moment. You don't want to just become aware and stop there. That's not helpful. If you become aware of how miserable you are, well, okay, that's an awareness. But then you got to do something about it. Improving the next moment, you don't have to fight with it. It's not, I shouldn't feel that way. It's okay. This is how it is. What's the next step? Mindfulness meditation improves pain perception, anxiety and depression, emotion regulation, insomnia, and binge eating, to name a few. The key is not only being aware and accepting of the present moment, but also figuring out how to relate constructively to it. Figuring out how you can either change the situation, change your reaction to the situation, or choosing to just let it go. Sometimes things will happen and there's nothing you can do about it, so you just say, you know what? Not worth my energy. You can incorporate mindfulness in general by doing mealtime mindfulness, encouraging people to do a mindfulness scan at breakfast, lunch, and dinner. This helps people become aware of how they're feeling and what their needs, thoughts and urges are, and intervene early. You know, if they notice they're starting to get irritable, then they can do something about it. Problem focused mindfulness can be used with things like chronic pain, where people may envision heat. You know, they may use guided imagery or they may focus their attention somewhere else. So if their back is hurting, they may focus on their hands or their feet or somewhere else besides where the pain is. Guided imagery improves mood, fatigue and quality of life, pain perception and anxiety and depression. Guided imagery, you can do a lot of different things. You can envision success if you're stressed out about Doing a presentation, envision yourself doing it successfully. Take a mental vacation. Sometimes life is just unpleasant. So you need to go to your happy place and use as many senses as possible with guided imagery. You know, what do you see, hear, smell, feel, taste, touch, whatever. If there's an injury or an illness like cancer or they've actually shown with guided imagery in people with hiv, they can actually increase their T helper cell count with guided imagery. So envision the healing process and then altered focus. Kind of like what I was talking about with mindfulness. If there's physical discomfort or if somebody has cravings, they can focus on that craving or they can intentionally move their focus somewhere else and focus on a thought or a feeling. Biofeedback and this is hrv. Heart rate variability. Heart rate increases are associated with increased stress and, and HPA axis activation. Remember, HPA axis is your threat response system. Prolonged HPA axis activation contributes to fatigue, insomnia, difficulty concentrating and problem solving, irritability, anxiety and depression. Heart rate variability. Biofeedback is effective at reducing symptoms of depression, anxiety and stress as well as pain perception. Well, that's great. When we get stressed out, when we're in pain, when we're anxious, when we're angry, when we're, you know, whatever, our heart rate generally goes up. That HPA axis is activated by calming the heart rate. We trigger that rest and digest system and all of the relaxation chemicals. We have fitness trackers now that have stress feedback and it will alert people when there's too much heart rate variability and the tracker thinks that you're too stressed, guide them through some meditation or deep breathing exercises. Heart rate monitors with a strap or fitness trackers can be used at a point of distress to alter focus and reduce HPA axis activation. So if you're stressed out, then you can use the heart rate monitor either on your fitness tracker or if you have a strap on and you can watch your heart rate and you can practice breathing until you get your heart rate back down to wherever you want it to be. And you can also use heart rate variability and heart rate monitoring for planned relaxation breaks. So you know that you're going to go sit and for five minutes you're going to practice getting your heart rate down to a certain level. Distress tolerance significantly mitigates depression, substance misuse, negative affect, stress, intolerance of uncertainty and anxiety sensitivity. It's also related to reductions in cortisol and heart rate variability by altering how people perceive and relate to stressors. Now, if you go back to dbt, you've got the accepts and improves and mnemonics that you can use. The ones that seem to be most ubiquitous. For my clients, I've kind of mushed into an acronym spam. It sensations, you know, holding ice cubes or having a heating pad, something that they can focus on that will distract them. Positive focus. Finding something positive that they can focus on in their life or something positive right in that moment. They can focus on their dog or their child activities doing something instead of sitting there ruminating, get up and do something for me. I do yard work. If I go outside and I'm using power tools, my kids know just to give me a little bit of space. Take a mental vacation. Go to that happy place that goes back to that guided imagery. Sometimes we just need to break the cycle and and go to, you know, the Bahamas. In your mind, use thought stopping and it can be as simple as having the person you know tell those thoughts to talk to the hand. You know, I'm not going to think about that right now. Or you know, if they start having those ruminative thoughts. Sing a song. You know, it's hard to sing a song and ruminate at the same time. And using imagery like we discussed earlier to envision successfully dealing with a situation can also help people tolerate distress. Brief therapy is a cost effective technique that can help engage clients in the preparation phase, enhance treatment compliance, improve outcomes, increase successes and client self efficacy, reduce cost per patient expenses because they're engaged and they're actively working. It can be used for a variety of issues to help clients accomplish smart goals. Remember specific, measurable, achievable, relevant and time limited. And it can be implemented in group or individual settings. To answer your question about migraines, I didn't look for anything specifically on guided imagery and migraines, but I can certainly look that up and I will put the information in your additional resources section of your class. Now remember, today was not designed to teach you how to do any of these. It was just to highlight that there are techniques out there that you can learn more about to implement. Most of the techniques there are covered in different counselor Toolbox podcast episodes. So you can just go to the podcast or you can go to our YouTube channel@allce.com it's the easiest way to get it and you can watch the video. So I hope you all have an amazing Labor Day and I will see you on the flip side. Between writing notes, filing insurance claims and scheduling with clients, it can be hard to stay organized. 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