440 - Addiction Case Study Using the PACER Method

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. Today we're going to be doing a.

Case study on someone with an addiction using the PACER method. I am Dr. Donnelly Snipes. As they say on Law and Order. The following story is fictional and does not depict any actual person or event. What I've done with a lot of these case studies is I've taken conglomerations or bits from a couple different clients. That way we don't have any HIPAA concerns anywhere in order to create a relevant picture for you. So I do try to give you some background on who the client ish. You know the, the Frankenstein client was. Since I took multiple different parts from different clients, we'll call them a Frankenstein.

Client in this one. John is a 37 year old male.

And presents for marijuana use as required by required by his probation.

He has a wife, two kids and.

His kids are four and nine. He is not real happy to be here, which is not uncommon with a lot of clients that have addictive disorders that are referred to specifically for that addiction and clients who are on probation, parole, any of those things. It's often a condition of staying out of jail or prison that they stay clean and participate in counseling so they come to you and a lot of times they're in this pre contemplation stage. We're going to review that in a little bit and you know, not overly motivated to stay clean. But, but as a clinician my thought is okay, well I want you to stay clean, ideally forever, but you know, at least long enough to get off probation or parole. What is it that's motivating you to use the drug or drugs or activity? What benefit are you getting from using it? And how can we help you achieve that same benefit some other way that won't necessarily send you back to jail or prison?

As always, we start out with the.

Physical aspect and with a lot of clients who are involuntary or forced to be in treatment.

They're not really excited about sharing a lot.

And you will see with this client as we go through, you know, he was pretty reserved, if you will, about what was going on emotionally and cognitively. But if we're thinking about marijuana use, what does marijuana do? Marijuana helps a lot of people relax. Sometimes it helps them feel a little dissociated. But a lot of Times people use it to help them kind of chill out, maybe feel more creative, what that's doing. We want to think about what neurochemicals would make that happen. That's not likely going to be your norepinephrine and your glutamate, your stress chemicals. It's probably going to be more along the line of the dopamine, the endogenous opioids and the serotonin, which are going to be more present when somebody's relaxed and, you know, well, relaxed, their HPA axis is not going off.

So we ask him, how many hours.

Do you sleep on an average night? He says six. He doesn't have a handy dandy little.

Fitness watch, sleep tracker, so that's okay.

You know, six hours on average. How many times do you wake up during the night? He says he rarely wakes up. Well, this is good. It sounds like he's getting at least six hours of sleep. He's not waking up to have to pee or anything and the kids aren't waking him up. So that's great.

On an average, after an average night's sleep, how do you feel?

He said he feels okay. Now I'd like to hear energetic. I would like to hear ready to take on the day. Not just okay, but it's better than tired. So I'm going to file that in there for, you know, I wonder what's going on there that leaves him feeling okay, you know, is he unhappy with things in his life? Does he have some stress, some dysthymia, hormone imbalances, poor nutrition? What's going on?

When you wake up feeling refreshed, how.

Much sleep do you get? He says at least eight hours, preferably like 10. So the weekends are generally when he wakes up and he feels more refreshed if he doesn't have to get up and do something else.

As with all.

Of my clients, because I find, like I said last time, I have yet to find a client who has perfect sleep hygiene habits and is 100% aware of sleep hygiene. Most people are ignorant, you know, uneducated about the things that can impact their sleep and how important sleep is to them. So I have everybody do a sleep hygiene assessment. It can't hurt. It doesn't. It takes 15, 20 minutes tops. It's not huge commitment with involuntary clients. One nice thing about having them do these sorts of non threatening activities is it starts to get them involved in the process. It's something that they're sort of willing to talk about and it's something I can show to their probation Officer or whomever that says, hey, Jim Bob is actually participating in treatment instead of just, you know, know, winging it and going, yeah, you know, he's showing up. You know, I can show that Jim Bob has actually done something.

So that's a good thing.

When you're working with involuntary clients, another brief intervention, if you will, is to ask them, you know, and I usually couch it to them, very frankly. I say the courts are requiring you to be here for eight weeks with me, and you don't have a choice if you want to get off probation. That's just what the courts have said you have to do. How can we make the best use of this eight weeks? You know, if you don't think you have a problem with substances, which a lot of them don't, okay, so what is it that we can do together in this eight weeks that can be beneficial? What can I help you with? And a lot of times that opens the door because it puts the ball back in that person's court, so to speak, and says, okay, I'm not, surprisingly enough, you know, they come in expecting me to lecture them about the problems with using and how they need to quit and yada, yada, yada, and that ain't gonna work. You know, they know that already. And if they wanted to quit or if they felt they could quit, they would.

So when they're coming in, we want.

To join, join together on some mutually agreeable goals. We. What is it I can help you with? I know in my belief that if their life starts going better, if their body starts functioning better, if they're healthier, then they're probably going to have less craving for that particular substance or activity. So I'm not going to push that issue right now. What the this particular client wanted to do was stay out of jail. Okay?

So staying out of jail means you.

Got to stay clean. And again, I didn't lecture him on the fact that you need to stay clean, you know, even after you're off probation. Da, da, da. No, I said, okay, well, my. My job, what I need to do is help you stay clean while you're on probation, which was like 18 months or something. Help you get the tools so you can stay clean while you're on probation. And then after you're off papers, which is what they call it, you can choose what you want to do. You know, I'm not. That's not my business what you do once you're off papers. What. My job is to help you stay clean while you're on probation. And Generally, that goes over really well. I spent my first two years after I got my master's working with clients that were on felony drug probation. So we went through that same spiel every single week. And I found that it worked really well, at least with my clients, because they were relieved to not have to hear the same old thing. They were relieved not to have to sit in groups every week and have somebody lecture them on why it's important not to do drugs. Instead of saying it's important not to do drugs. I looked at it from the perspective of why are you using? You're using because you're stressed. Okay, what else can you do? What skills can I teach you that can help you feel less stressed? Or what can I help you intervene in in your life that can help you feel less stressed? So anyway, that was a whole diatribe. Let's get back to physical.

For his sleep, he would like to.

Start getting eight plus hours of sleep. I want to know why he's only getting six hours during the week and that'll come out during that sleep Hygie Self assessment nutrition.

Using a free app like Spark, people.

Track your nutrition for a week. And he came back with, he doesn't get 100%. He gets 75% ish of vitamin D, calcium and potassium. Vitamin D. We have talked about this before. We talked about this with depression, but vitamin D is also associated with anxiety symptoms. If people's vitamin D levels are insufficient, then they may have mood symptoms. And I just use that term generally to encompass depression or anxiety. Calcium is necessary for the production of serotonin. When we don't have enough serotonin, then we may feel more anxious. When we have too much serotonin, we also may feel more anxious. It's a bimodal sort of thing. Calcium deficiencies are associated with anxiety symptoms. Same thing with potassium. Potassium is one of those interesting minerals that we need and potassium is really involved in, like our heart rate functioning. When people have potassium imbalances, they may start having heart palpitations which people can mistake for panic attacks or heart attacks or something else.

But potassium itself has been associated.

Potassium deficiency has been associated with anxiety. The American diet is very often deficient in D, calcium and potassium. Another interesting factor that a researcher and I can't remember what the study was called, but she did it when I was at the University of Florida. She was a dietitian and she did a research study and demonstrated that excessive protein intake contributes to osteoporosis because the bones start leaching calcium. So too Much protein can cause a calcium imbalance too, and I wish I would have thought to look that up when I was preparing this class. But for a lot of Americans, we eat too much protein. That can cause other mineral and vitamin imbalances.

Which nutrients do get? Less than 25% of the U.S. rDA.

He said none. So that's great.

When was the last time you had.

A full panel blood test done to examine your kidney and liver function, thyroid and vitamin D levels? He said, yeah, I don't know, several months ago, who knows? Describe your eating habits.

He says he eats a lot of.

Fast food and meat. He gets a lot of fried food. You know, he goes to fast food places for lunch. When he's at work, he often stops by and picks food up for dinner. He admits or says that most of the time his meals do not include vegetables or fruits. So there's a lot of grains, you know, a lot of processed white bread and a lot of meats and a lot of fried foods. Okay, well, the processed grains, at least they're vitamin enriched. You know, we'll look at the positive there. And at least he's getting enough protein. So we know his body has enough amino acids to make the neurotransmitters. We just need to get all the rest of the components in there to produce the chemical reactions necessary.

Do you eat due to stress or.

For comfort when you're upset? Yes. Most people answer yes to that question.

Do you drink at least 64 ounces.

Of non caffeinated, non alcoholic beverages each day? No.

The.

Important thing to recognize there are the fact that when we become dehydrated and if you've gotten really dehydrated, you, you may feel, you may remember feeling woozy or irritable. And that's very common when people get dehydrated. A lot of times we don't call it anxiety, but we may call it irritability.

He drinks about 300 milligrams of caffeine.

On an average day. 400 is generally what they recommend is an upper limb. So he's within that bound of, you know, safe caffeine consumption. But that is 300 milligrams of a diuretic that he's taking in addition to not getting enough water. I might look at trying to cajole him to increase the non caffeinated, non alcoholic beverages.

And I put it that way instead.

Of saying water, because a lot of times when you ask people if they drink water, they look at you and curl their lips and they're like, ew, no. So let's start small. You know, let's start with, you know, flavored, no calorie drinks. Ideally, we don't want to start at encouraging people to add a bunch of sugar drinks to their, to their list. But flavored, no calorie drinks. Then move down to lemon water or fruit water. You can get the fruit diffusers if you want to. I didn't figure that would have gone over real well with him. He wasn't a fruit diffuser kind of guy, but he was eventually he was willing to consider low calorie lemonade or just lemon water and start carrying a water bottle with him. So that was a good intervention for him that he could think about leaving that assessment. That was something that he said, okay, I understand why dehydration might be contributing to me feeling kind of blah and lethargic, making me a little bit more irritable. So it can't hurt. You know, I'm willing to at least carry around a water bottle. Can't, can't guarantee I'll drink it. And I said, okay.

How much nicotine you have on an average day?

And I linked to this because it was actually really hard to find the nicotine amounts in certain types of products. And cigarillos or little cigars, they're also refer to as black and mild, often have about 100 milligrams of nicotine per black and mild. And he was using about two a day. He said sometimes more. That means he was using on minimum a minimum of 200 milligrams of nicotine a day on average. There's depending on which, what you look at, it varied a little bit between 1 milligram and 8 milligrams per cigarette depending on which site I went to. But even at 8 milligrams of cigarette, if you smoke 20 a day, that would be 160 milligrams. That would be when we're thinking about cigarettes, that would be smoking a lot of cigarettes. But you know, he's getting that in two little cigars. Something to pay attention to is they are not healthier. A lot of people tend to think black and mild for some reason are healthier or have less nicotine than cigarettes. Black and mild, you know, little side note, are meant to be smoked like cigars in that there you take a puff of them and the smoke goes into your mouth and then you exhale it. You're not supposed to inhale it into your lungs like you do with cigarettes. Does that mean you don't get nicotine from it? No, not at all. Nicotine is absorbed through the mucous membranes in your mouth, which is why you can use lozenges or gums when you're trying to reduce your nicotine dependence. You can use the nicotine replacement therapies and you're told to put it between your, your gum and your cheek because the nicotine is absorbed through those membranes. Therefore, Black and Milds have way more nicotine per unit than a single cigarette. Important to be aware of because of the highly addictive nature of nicotine and the effects on the neurotransmitters.

He says he needs to currently lose about 30 pounds.

And you know, personally, you know, just kind of looking at him, that would be on the low side. He probably would be healthier if he lost about 50 pounds, but 30 is good. You know, he recognizes he needs to lose a little weight and that could be impacting his health and his energy levels some.

He hasn't had any problems with thirst.

Or hunger or hypoglycemia. Hasn't had his blood sugar tested lately. But you know, he doesn't have any signs of diabetes. You know, he's not indicating anything that would make me go, ooh, I'm really concerned about that.

He does mainly gain weight around his.

Belly, which again is a place when our HPA axis is activated, when we have high levels of cortisol. They've associated that with metabolic syndrome. And one of the symptoms of metabolic syndrome is central, as they call it, central weight gain, which means gaining it around your belly, which tells me since he gains it around there as opposed to other places, you know, it seems to be concentrated. He does tend to have high stress levels. He does tend to have more cortisol going through his system, which underscores the hypothesis that he may be using marijuana for stress relief and self medication.

We will end up referring him to his primary care physician for a physical.

To include a nutritional evaluation with. We want to make sure that his body can use the protein that he's taking in hormone evaluation to see if his testosterone levels are low. He's got a little bit of flatness, apathy, low energy and possible addition of a multivitamin.

When I asked him about the medications he was on, he said he's on a beta blocker for high blood pressure. He'd been on it for two years.

And just increased his dose. He had been. He gained a little weight. The doctor increased his dose. That again tells me there's some anxiety or something going on there. He's got high levels of norepinephrine so we may want to start looking at what's causing this stress, what's causing this HPA axis involvement.

He has Tagamet for gastric reflux.

We know that Tagamet can reduce testosterone levels. So, you know, again, something to consider.

And cannabis, when you smoke cannabis and.

Right after you smoke cannabis or right after men smoke cannabis, their testosterone levels go up. And, you know, he was smoking cannabis a fair amount. Theoretically, if his testosterone levels were low, that could correlate with high cortisol levels, because testosterone is negatively related to cortisol levels. Remember that from Monday.

So if his testosterone levels are low.

His cortisol levels may be high. Well, we've kind of established that he's got high blood pressure, which tells me that his cortisol levels are high.

He's got low energy.

You know, he's okay throughout the day. He's not, you know, raring to go. Yeah. And he's having some sleep difficulties. It could be because his nutrition is not great, so he's not able to efficiently produce the melatonin he needs to get good sleep.

Or it could be that he is.

Sort of fatigued because his testosterone is low. When he smokes cannabis, it increases his testosterone and reduces his cortisol, which. Which makes him feel better. Which tells me, again, you know, I'm interested in his. In his testosterone levels. Don't know if it's going to be anything or not.

I will educate him about the sedating.

Effects of his beta blockers and the anxiolytic effects of Tagamet and testosterone, increasing effects of cannabis and the inverse relationship between cortisol and testosterone. So. So everything I just said, we're going to talk about that. I don't just file that away and don't tell him. I'm like, okay, go get these tests and see if I'm right. I might put something out there and say, you know, after you smoke marijuana, do you feel more sexually viral? Do you feel more manly?

I don't.

You know, I'm not sure how I would put that, but pain.

He says he has no chronic pain.

So we didn't need to finish the rest of this, which is good. You know, not many people can say that.

Exercise, he doesn't do it.

So, you know, obviously not exercising is potentially going to contribute to some issues. Exercising, we know, releases endorphins and serotonin. So I'd like to see him get moving. That could help him feel a little bit better and actually get more energized. But, you know, he's not exercising right now, so that's sort of a non issue to file in there.

Energy levels throughout the day, he gets through the day. He hasn't had his thyroid levels tested using a pulse ox monitor.

You know, I keep one in my office. His heart rate was 75 and his O2 sats were 98. That's pretty standard. If you see O2 sats that are really low, you want to check and see if their fingers are cold or if they're Wet. If their O2 sats are below 90 and you can't figure out a reason why it might be prudent to refer them to get a professional to check it out.

Do you have high blood pressure?

He says yes, and he's medicated for it. Hence, you know, you remember he's on beta blockers and they've just been increased and. And he doesn't have any other heart conditions.

Well, that's good.

But when blood pressure goes up, when we start to see hypertension, that means the arteries may be hardening and may not be pumping blood as efficiently, which means oxygenated blood may not be moving around the body as efficiently, which can contribute to difficulty concentrating and fatigue especially.

How's your sex drive? He said it's.

It's good. It's fine.

Has there been a change in your sex drive lately?

He says yes, but, you know, nothing to really write home about.

He hasn't had his sex hormones less.

Tested and he says he engages in sexual activity one to two times per week.

I don't press him on this.

You know, given his age, that's not a unusual frequency for sexual activity. So that's, you know, all, all clear there.

He doesn't report any trauma history, any.

Hypervigilance, any autoimmune diseases? No concussions. He does have headaches that are triggered by stress, and a neck massage or ice or heat tend to help it go away. We know when our blood pressure goes up, it can cause headaches, which seem to be what may cause his.

He says he drinks two to three.

Drinks on an average week. He's not supposed to be drinking, so, you know, it was kind of one of those don't tell my P.O. but okay.

You know, two to three drinks is.

You know, nowhere near heavy drinking. It's not really a concern to me.

Does he play the gamble or play the lottery? He says he plays the lottery and.

Spends about $20 on it each week. Again, is it a potential high risk behavior? Yes. Is he using it in a high risk way? No. So I'm not really concerned about it.

For each of the following feelings, how often do you feel it? He says he feels happy three days a week.

That's, you know, he actually feels happy. It's a good day. His kids, his wife and his friends help him feel happy. He doesn't report feeling sad or depressed or stressed or overwhelmed very often, but when he does feel stressed or overwhelmed, it's because of work. His youngest kid is struggling in school and being oppositional about doing his homework. So that's causing conflict at home. He gets home, his wife's irritable, his kids throwing a temper tantrum, and, you know, it's kind of chaotic and he's had a long day, so he's not in the mood for it. Probation stresses him out because he doesn't want to go back to jail.

He was in jail for a year.

And he's just now trying to get used to being back home again and the family's trying to get used to him being back home again. And he's having to, you know, reestablish his place in that family system, if you will. Because when you have small kids and a person is removed from that system.

For a year, that's actually a really.

Huge amount of time developmentally for those kids. So now that he's back in the, in the family and actively participating on a daily basis, he needs to figure out what their rhythm is and where he fits in that rhythm. And they need to adjust a little bit to his rhythms. So there's going to be some family therapy in there to try to figure out because while he was gone or while he was in jail, his wife was taking care of the two kids by herself.

What helps you feel better?

Watching TV and smoking. So when he does get stressed out, he goes into his cave and, and turns on the TV and smokes. I didn't ask specifically what. Right now he is still testing clean, so we're going to assume it's a black and mild.

He doesn't report high levels of anxiety or worry.

And you know, I try to differentiate this from stress. Stress is that sort of overwhelmed, oppressed, you know, stressed out feeling and anxiety and worry is more like panic. And you're worried that you're not gonna have enough money to pay the bills. You're worried that you're gonna get fired. It's something that you perseverate on that's happening in the future. Sometimes it's a matter of semantics.

He doesn't report really any anger or.

Resentment towards anything or anybody right now.

But he does feel a little bit.

Guilty that he was in jail for the past year and wasn't able to be there for his. For his kid. Apparently one of the kids is his biologically and another one is his stepchild.

But he feels.

He. He does feel guilty, and that periodically passes through his mind, and he gets frustrated and down on himself. He doesn't report any losses in the past year. I mean, he was in jail and he didn't get to spend time with his kids, but, you know, there weren't any deaths or, you know, significant issues.

Stressors that are currently present.

Try not to violate probation, adjusting to being back with the family and his son's behavior.

So I follow that up with, okay.

What makes your son's behavior better? And he says, when I spend time.

With him, well, that makes sense.

You know, think about a little kid, and, you know, the little kid may have gone through some adjustment and some frustration when dad went to jail, and now dad's back and acting out could be a way of trying to get that parental attention.

What does your son like to do?

Well, he likes to play basketball at the park.

Okay, cool.

So we'll file that in and figure out how we can use that.

I asked the client, what's different when you're happy?

And he says, I can smoke as much as I want and people leave me alone. Okay, well, that's probably not something that is gonna happen at least while you're on probation, especially with smoking marijuana. But that tells me that people stress him out. And smoking, whether it's black and mild or marijuana smoking, helps him feel calmer, and being away from people helps him feel calmer. So we need to examine what it is about the interpersonal dynamics that cause him stress and other ways he can deal with stress besides nicotine and cannabis.

How long does it take for you.

To calm down after you get upset? He says 20 to 30 minutes.

Well, that's not bad. You know, most of us, it takes.

Us a little while to get back to baseline. 20 minutes really isn't that bad. If you think about urge surfing, urges usually take about 10 to 20 minutes to come in and go out. Same thing with panic attacks. They crest within 10 to 15 minutes and then go out. So somebody gets really upset and can reregulate within 20 to 30 minutes.

That's not bad. That's not horrible. What helps you calm down?

Back to smoking again and distracting myself.

So I'm hearing that he doesn't have.

A lot of coping skills. You know, he smokes and he Avoids. He smokes and he avoids.

Cognitively, his attention and concentration.

He says it's awful. Right now, he's just doesn't. He doesn't feel like he's on his game. He doesn't have a history of adhd.

And there hasn't been a change in.

His ability to concentrate. He doesn't know what's causing him to have difficulty concentrating. I mean, it's been going on for a while, and he's just not sure why.

Does it seem to be taking longer to process information?

Yes.

How's your memory?

He says it's good. Okay. You know, when people start talking about having changes in cognition and difficulty with concentration, it could be depression, it could be anxiety, it could be signs of some sort of neurocognitive thing. But the fact that it's not taking them longer to process information, that's really good.

He says his memory is good.

You know, when he concentrates, when he.

Pays attention, he can remember things.

But the rest of the time, if he's just going about not really, really trying hard to pay attention, he's having difficulty.

When you think about yourself, your life, the world, and other people, do you.

Tend to feel angry, suspicious, or hopeless? He says yes. You know, the people around him seem to be out for themselves all the time. Okay.

When I asked him about cognitions, he says, I haven't. Pay attention to his cognitions for a week and place a check by your thinking errors. He only identified three, and that's okay.

Not everybody has a lot of them.

He said he identified that he focuses.

On small aspects instead of the bigger picture of things. He focuses on what's at hand right now. Like when his son's misbehaving, he sees the small aspect. His son is misbehaving, and he must be trying to push my buttons, period. Instead of looking at the bigger picture, what are some other explanations for why your son might be misbehaving? Maybe he's having difficulty seeing and he needs to be evaluated for glasses. Maybe he's got a learning disability and he's getting frustrated with, you know, having difficulty at school. You know, there's a whole bunch of maybes we could throw out there. It's not necessarily that Junior is just trying to push your buttons.

He said he tends to focus on.

The negative and ignore the positive and recognizes that he anticipates. When he comes home, he anticipates his kid is going to be misbehaving and. And he focuses on all the things that the kid has done wrong instead of the things that he's done right. He also focuses on that with other people, you know, all the things that don't get done. And even in himself, he focuses on all the mistakes that he's made instead of the things that he has done right.

And the third distortion that he regularly.

Uses is expecting people to be able to read his mind. He expects people to know what he wants. And, you know, not only is that not real realistic when you live with somebody 24 hours a day, but since he's been gone for a year, you know, and he steps back in, it's unreasonable to expect that the kids know what he expects of them. It's unreasonable to expect that his wife knows what, what he is thinking or wanting or how he would handle a situation. So it's important to encourage him to start communicating with them and likewise, you know, not to assume that he knows what they're thinking either.

On the hardiness activity, his kids are.

Really important to him. His biological child and his stepchild. He can control the time and quality of the time he spends with them. Now, he says he wants to focus and try to remember to start praising the positive and reward Sam, his kid.

By taking him to the park to.

Play basketball once he gets his work done each day. The four year old is, you know, younger, doesn't play basketball. You know, that's a whole different issue. And we can talk about playing favorites and stuff later, but right now I just am trying to get an idea about what's important to him and what positive steps he's willing to take with.

Regard to his relationship with his spouse. He will work with Sam on his.

Homework when he gets home and back her up. Evidently, a lot of their arguments have been about him not backing her up and giving Sam excuses for not finishing his homework and, you know, not disciplining him when he mouths off to mom.

So it's important for them to get.

On the same page parenting wise.

And he needs to talk with her.

About not smoking pot around him. And I'm like, okay, whoa, that's the first time that one's come up with this particular client.

So, you know, I put that down.

But that was something I needed to put in the back of my mind.

Friend number one, figure out how to spend time together without smoking pot.

Evidently, he and his friends used to get together and they would smoke pot together and watch games or hang out or play cards or whatever they did.

But that's not something he can do.

Now, and he doesn't want to lose.

His friendships with these people.

Because they've grown up together. But you know, he also doesn't want to go back to jail.

He doesn't identify any other friends that.

Are really important to him. Okay.

With regard to his job, he's going to keep going to work and doing.

The next right thing so he doesn't violate his probation. A lot of times with people who are on probation, another condition besides staying clean and is maintaining gainful employment. It's important for him, even though he hates this job, to continue to go. He's been out of the workforce for over a year and that's contributed to some difficulties on his resume. You know, you have gaps on your resume now.

Plus he was in jail for a.

Felony, which makes him a high risk employee.

As a side note, People who are.

Considered high risk and there's a lot of conditions besides just having a felony on your record that make you hard to employ. There is a special bond program that you can get through the workforce development agency in your county or in your state that bonds puts a bond on people so employers don't take a risk. If they hire somebody with a felony history, they get a bond for six months that basically the state guarantees or the feds, I don't remember who it is, guarantees that, okay, for six months we will protect you if this person does something wrong. You've got $100,000 bond or whatever. Just like contractors are licensed and bonded and everything. Same thing with him.

And.

You can go to workforce development and look up bonds for jobs or bonds for, I can't remember what it is, bonds for felons. We can look that up at the end of class. But it is a great program that.

They just go down to the local.

Workforce development place and you know, talk to them, find a job and then the case manager there will help them get a, help them get a bond in order to protect the employer from any liability.

Okay, so remind me to look that.

Up at the end of class.

He also, as far as money, money is important to him.

He doesn't like where they live right now. They live in an area that is, has a lot of drugs and you know, people, places and things that are triggers for him. He wants to move to a different place. In order to do that, he needs more money. He recognizes he has to re establish his work history so he can get a higher paying job. Now he has two reasons to deal with this job that he really doesn't like right now and stay there for 18 months and really establish a steady work history.

And health wise, he wants to Lose.

Some weight to reduce his blood pressure medication. He's not happy that he had to increase it. He doesn't feel as good when he's on it, which makes sense.

We will talk about psychological flexibility and.

Discuss how, how much and how often he intends on doing each of these things and, and make a schedule or a checklist, same thing as we've done in the other case studies, helping him see and envision. What does recovery look like, what does an ideal life look like? Whatever you want to call it, depending on the client.

And how does each one of these.

Things fit in there? Now what are you going to do in order to best use your energy to move towards that ultimate goal that you have in mind?

He says he's good at managing his.

Time, but like most of us, when there's something we don't want to do, we can get irritable. When it's like looming over our heads, we know it's got to be done, but we don't want to do it. And then doing it at the last minute, we feel rushed. We can also get irritable. That's, you know, that's common for most people.

I'll encourage him to develop a schedule.

That includes his must do's and delegates and simplifies when possible. What is it that he might be procrastinating right now and what can he get off of his plate so he doesn't have that hanging over his head, causing him extra stress?

Environmentally, he says he feels safe most of the time.

He lives in, you know, a neighborhood that he's lived in all of his life. You know, there are drugs there, but he feels safe there. He knows everybody and he has a couple of dogs that are, you know, big old, big old things.

Are you able to have peace and quiet when you want and when you sleep?

He says no, not with two kids around the house. And evidently in their neighborhood there's always dogs barking and sirens here and there and it's just noisy. So one thing that he can do to reduce unwanted noise, he can wear noise canceling headphones. And that's what he does when he goes. When he comes home after work and he just wants to decompress and go into his man cave and watch tv, he can put on his noise canceling headphones that have the Bluetooth and listen to his TV and not hear all the commotion going on in the rest of his house.

During the day. Are you able to access natural light.

Or at least a really bright working area? Yes. He works outside.

When you're Asleep.

Are you able to make your room totally dark or block out the light? He says yes.

Do you eliminate blue light from television.

And electronic devices at least two hours before bed? He says no. He watches TV right up until the time he goes to bed. So that might be an area that comes up in that sleep hygiene assessment.

He says he's regularly exposed to asphalt.

And roofing tar smells, which are noxious and unpleasant, but, you know, you get used to them.

Musty smells.

When he smells them, he goes into old buildings, they remind him of jail, and that's triggering for him because it reminds him of mistakes he's made and he starts beating himself up.

Happy, relaxing, energizing smells.

Barbecue, home cooking. Anything that reminds him of family get togethers, especially with his extended family.

Are you able to keep your environment at a temperature you find comfortable? He says no for finance reasons.

He's trying to keep utility bills down so they usually don't run the air conditioning at all, and they keep the heat as low as absolutely possible.

In relationships, do you feel you. You are capable, loving and deserving?

Yes.

He thinks his relationships are healthy.

Overall, he can effectively identify and communicate feelings, thoughts, and get. Get his needs met.

He says yes. Other things that he said during the.

Assessment make me think, maybe not going back to those cognitive distortions, but, you know, overall he doesn't feel like he's unheard or being used as a doormat.

Do you have a social support system that can provide practical assistance and emotional support? He says, practical assistance, yes.

You know, his mom and dad are close by, his wife is willing to, you know, pitch in, but he doesn't feel like people really are there to hear him when he's frustrated or provide that emotional support.

Addiction specific questions. What are his motivations for staying clean.

And for staying compliant with treatment? It'll be a relief to be off probation. So great. One hurdle to staying clean would be anxiety and stress. We need to figure out how to help him or he needs to figure out how to help himself deal with anxiety and stress and minimize unnecessary stress. Mentally motivators to stay clean and, you.

Know, do the next right thing.

Belief that he can stay clean until he gets off papers, and the belief that he'll probably be able to concentrate and remember things a little bit better, which will help help him do better at work and reduce some arguments and stuff at the house. An obstacle, mental obstacle to motivation is his knowledge of ways to defeat drug tests. He is very open about the fact that it's not that hard to defeat a drug test Physical.

He feels that if he's compliant and.

He doesn't use, he will have more energy and less fatigue. However, if he stops using marijuana, stops smoking, he's worried he's going to have more anxiety than even just the nicotine he feels helps him with his anxiety socially.

Motivation to stay clean, stay out of jail. He'll be there for his kids.

An obstacle is his friends and his spouse all use marijuana. So we need to talk about, okay, how can you create a safe environment environmentally?

Motivation to continue with treatment and do.

This is that he may be able to move into a better place once he's off probation. The obstacle is, like I said, in this neighborhood that he's in now, he can get drugs any time of day, any day of the week that he wants, and it's a temptation for him constantly.

Those are going to be things that.

We'Re going to address in his relapse prevention plan.

So his initial treatment plan goals refer to his primary care physician for hormone.

Evaluation and nutritional assessment. Tagament for gastric reflux lowers testosterone, which can increase cortisol and anxiety. Cannabis increases testosterone, which lowers cortisol and anxiety.

Typically, vitamin D deficiency can lead to.

Or worsen anxiety and hypertension, not just depression.

Calcium deficiency inhibits production of serotonin and potassium.

Also, I didn't mention this earlier. Potassium does help regulate serotonin. So not only is it involved in heart rhythm and other things. Muscles, you know, we get muscle cramps when we don't have enough potassium, but it also helps regulate serotonin and all of the activities that serotonin does.

Another goal is to remove.

Remove all cannabis from the house.

If his PO shows up at his.

House and there's cannabis there, he's going to be violated. It's important for him to get the cannabis out of the house now.

He's not going to get it out of the neighborhood.

And, you know, he may not be able to get his wife to stop using, but if she's not keeping it in the house and she's not using in the house, that's one step towards creating a safe environment.

He's going to begin helping Sam with his homework each night and taking him.

To play basketball after dinner. If he does his homework, he will learn about cognitive distortions and start addressing one each week. So we're going to start working on some of those issues that I talked about.

He'll learn distress tolerance skills to teach his son. He.

One way I help people learn tools sometimes is by helping them learn them so they can teach their Children, and his child gets frustrated doing his homework and gets irritable and just wants to walk away. Helping the child learn distress tolerance skills by teaching them. He's also probably modeling them. So it's, I'm going to get a twofer here, and I'm all about them.

Have him make a list of things to do when he's feeling stressed.

Besides smoke. What else can he do? Can he go on a walk? Can he mow the yard? Can he. I don't know what works for him.

Specific worries for discussion beginning week one.

Get through probation without violating. So we're going to talk about taking it one day at a time. You know, he can think about, you know, I have to do this for 18 months. And that can feel overwhelming. Just like, well, not just like, but something that many of us can relate to. If we go on a diet and we say, oh, I can't. You know, if you take a food out, which I'm not recommending, but a lot of us do, we say, oh, I can't have that for a month. It's like, oh my gosh, I don't know if I can go a month without chocolate or I don't know if I can go a month without caffeine.

Well, for him it's 18 months.

Think about how overwhelming that is.

So with him, we're going to think.

About one day at a time. Just get through today without smoking and we can talk about tomorrow.

Have him view his probation requirements as a challenge.

You know, he's capable of doing anything he puts his mind to. So have him view it as a personal challenge to show his strength and courage and encourage him to use psychological flexibility when he starts having the urge to use or quit his job or do something that might violate his probation. Encouraging him to envision that future goal that he wants, that happy life that he's hoping to create when he gets off probation and ask himself, is doing this, whatever I want to do right now, worth it? Is it going to help me achieve that goal or is it going to potentially hinder me or sabotage me?

Another worry for discussion is his son's behavior.

So we're going to talk about different ways to provide positive reinforcement when the child is doing things well. And also look at the possibility for a learning disability assessment if it appears that the child may be having difficulty understanding the information or might have adhd. I need to probe a little bit more before I figure out what to do there or I figure out what to suggest.

Not smoking pot even though his wife.

Is smoking well, he needs to find other rewards for not using. If he's not using, he needs to be able to pat himself on the back and go, atta boy, you're doing what's right to do right by your son, your kids, stay out of jail, yada yada. And talk with her about not using it at the house, you know, if she's not willing to give it up completely. Talking with her about, you know, can you just not keep it or use it in the house? Because, you know, that could directly contribute to me going back to jail and.

Dealing with having to stay at this.

Quote, crappy job for the next 18 months. All right, so we might use techniques like mindful focus, helping him focus on each day. What do I got going for me today? What's good about today? What am I planning for today? Where can I get help today? So he can see this forward momentum and then positive review and forecasting at the end of the day, looking back over it and identifying the positive things, it's easy to remember the negative things, but identifying the positive things that happen that day. And positive forecasting is, you know, like driving to work, envisioning having a good day. You know, forecasting how things are going to go well for you that day because you're rested or. And you're getting to work on time and whatever else.

In his reassessment, his doctor assessed his.

Hormone levels, determined them to be on the extreme low end of the normal range. So there was no intervention. Okay, well, you all know how I feel about those ranges. Since he's symptomatic and he's on the low end of the range, there may be something to it, but I'm not a doctor. I'm not going to contradict the doctor, so I'm going to bite my tongue on that one.

He's lost 12 pounds since starting to.

Play basketball with his son in the evenings and reduced his blood pressure medication again, which is good. You know, not only is he. If they're going to play basketball, that means the kid is doing his homework. So score there and he's getting out and moving. And if he's with his kid, he's not smoking. So that's another score. We know he's staying clean during that period of time, and he's getting up and moving, which is theoretically getting some serotonin and endorphins going. So yet another score.

And what was the other thing? Oh, he's not sitting at home and.

Eating or doing other things that are increasing his weight gain.

So there's a lot of benefits to.

Him engaging with his kids. And one of the reasons I focused on that with this particular client is because when I asked him, when you're not using, what's different? He said, my kids are around. And I said, okay, well, let's keep those little ankle biters around as much as possible.

He's arguing less with his wife since.

His son is behaving better. Although she's still smoking, she's not doing it at the house, so that was good. She obviously wants to help him stay out of jail. And he has not used but is still not intrinsically motivated to quit. That's just an assessment. It's not a judgment. It's where we are right now. And he was always perfectly open about the fact that, you know what? I don't have any intention of never smoking again, but I will stay clean while I'm on probation. And you know, theoretically, if you can stay clean for 18 months, that means you can stay clean for however long you want to. So maybe he'll change his mind.

Substances are often used to self medicate, Helping him identify previous coping strategies and.

Learn new distress tolerance skills. To teach his son is helping with his stress at home and at work.

Engaging in activity with his son leaves.

Less time to use and gets those happy chemicals going.

Remember that marijuana alters not only brain.

Chemicals but also hormones that alters those testosterone levels, which we know alter the brain chemicals. And marijuana can stay in the body for a long time since THC is stored in the fat.

So especially since this person happened to.

Have more fat tissue, means it had.

More pockets to store that thc.

So as he loses weight, he may have some recurrences of cravings that we want to talk with him about or prepare him for, I guess is a better word. Now let me look up that website for the bonds. Here we go.

The federal bonding program.

It's at bonds the number four jobs.com and whoopsies.

There we go. The U.S. department of labor established the.

Federal Bonding Program in 1966 to provide fidelity bonds for at risk, hard to place job seekers.

The bonds cover the first six months.

Of employment at no cost to the job applicant or the employer.

Who does it serve. Thousands of justice involved citizens return home.

To restart their lives to ridicule, discrimination and hostility. But it's not just for people who have been incarcerated for some reason. It's also for people who, for example, have never had a job. They've been homemakers all their life. They have a very spotty work history. There are a lot of different reasons. And it says that somewhere on the website. It's been a while since I've been there, but control C there we go. Bonds4jobs.com the other you know, I mentioned it earlier. The little kind of gotcha with this one is the person has to go out and find a job and an employer that is willing to hire them and then they apply for the bond. So you don't go to an employer and go, hi, I'm interviewing here. I've got this bond. It's hi, I'm interviewing. Will you hire me if I can get a bond that covers me? And the employer says yes. And then the caseworker says, all right, Directory of State Bonding coordinators. You can go here and you can find your state and figure out who is coordinating that in there in your area.

So anyway, the site is really easy.

To navigate once you get in there. I'm just trying to do it really quickly, but I have used it before and it has been helpful.

Are there any questions? So, oh my gosh. Like I said, Monday's a holiday for most of you.

I hope some of you were able to take Friday off as well and you're going to have an extra long weekend. Have an awesome weekend and I will see you Tuesday. Between writing notes, filing insurance claims and scheduling with clients, it can be hard to stay organized. That's why I recommend TherapyNotes. Their easy to use platform lets you manage your practice securely and efficiently. Visit therapynotes.com to get two free months of therapy notes by just using the promo code CEU when you sign up for a free trial at therapynotes.com you.

If this podcast helps you help your.

Clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com podcastceus that's allce.com podcastce to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week. Go to allce.com Sponsor thank you.