Biopsychosocial Impact of Depression | Mind Body Strategies for Prevention and Intervention

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 Class I'd like to welcome everybody today's presentation the biopsychosocial impact of depression and strategies for prevention and intervention. I am your host, Dr. Donnelly Snipes. We're going to explore really quickly the symptoms of depression, the impact of depression. We will explore how to learn how to ask strengths that based assessment questions identify a range of potential causes for depression and activities and interventions that can help you help your clients address some of the underlying causes. Remember that depression represents a cluster of symptoms. Yes, everybody has to have that general malaise and apathy that has been going on for at least two weeks, more days than not, yada yada. But the rest of the symptoms it can present in. I think they did the math and it was like 142 different ways. Depression does not look the same for every single person. A variety of different things can cause depression and also be caused by depression. Let's think about emotions. If somebody is angry all the time, it can be exhausting and it can keep their HPA axis revved up, which can eventually lead to lack of energy, glucocorticoid resistance, yada yada. That is depression on the other side of the coin or whatever, depression can cause anger. When we are depressed and we are feeling sad and we are feeling low motivation and all that stuff we may feel with depression, we can get really frustrated and angry that other people have a better life, that other people don't feel this way or that we do feel this way. The same thing is true with anxiety, grief, guilt and shame. All of these things can cause us to be revved up because they're all threat sort of emotions that will trigger that HPA axis and all of them can be triggered from depression. We can feel depressed and we can feel anxious that people are going to abandon us because we're not the life of the party anymore or that we can't just don't have the energy to do the things that we used to do. We may grieve the fact that we are not feeling the way we did last year or you know, even two months ago. We may have guilt because we can't do the things that we used to do. We might may not have the energy to be making dinner and doing those sorts of things and you know, guilt and shame kind of go in there. But culturally, some people also Experience shame. Because culturally mental health issues are not as accepted, not as widely accepted as being okay. So depression can cause these feelings, but depression can also be caused by these feelings. Our thoughts can cause depression if we have cognitive distortions, if we have problems, prior learning experiences that create schema. You know, if you think back to was it Watson who first initiated schema or was it Piaget? I don't know, I don't remember my counseling 101. But we create these ideas and concepts of things like who is safe and what is okay and what looks threatening, what is our fault, what is within our control. All of those things are schema that we've created. Files that we have that tell us based on our prior learning experiences, this is what we can expect. Well, if those schema are outdated or inaccurate, then it can lead us to feel hopeless and helpless in the present. What we couldn't control when we were 10, we may very well be able to control now that we're 30. And then your old fashioned cognitive distortions, your personalization, all or nothing thinking, mind reading, yada yada, those can create a sense of hopelessness and helplessness and a sense that everything is always bad. It's really important that we recognize that our thoughts and our schema can cause depression. Likewise, when we are depressed, we tend to notice because we're depressed, we tend to notice the negative things more. So just being depressed can create more negative thoughts and those negative thoughts cause more depression. And it's this downward unfortunate cycle. Our relationships with ourselves or with other people can cause depression. If it's a unhealthy relationship in some way, it can make us feel hopeless, helpless, unlovable. Likewise, our depression can, if we're depressed, our depression can cause poor self esteem. We may feel bad about ourselves because we're feeling depressed right now. People with bipolar disorder, for example, it's something when they're, when they cycle, it's something that they struggle with. And accepting that that is a condition that they have may impact their self esteem negatively because they feel like they are broken in some way. Depression may lead to unhealthy or unsupportive relationships. When people don't know how to deal with, with our depression. So there's a lot of ways that again it can go either way. Physical issues that cause or can be caused by depression, neurochemical imbalances, when we are assuming we are have the perfect neurochemical balance. When we start and something happens, you know, there's a tragedy, we start grieving, denial, anger, bargaining, depression and Acceptance, we become depressed. There are neurochemical changes that are happening that are prompting those feeling states that are perfectly normal. However, when we feel that way, we may get stuck in that feeling or not know how to deal with that feeling. Poor nutrition can contribute to depression if we don't have the building blocks to make the neurotransmitters. Depression also contributes to poor nutrition. A lot of people lose their appetite or tend to focus on soothing foods that are high fat, high processed carbohydrates when they are depressed. Depression can cause exhaustion and be caused by exhaustion. You see where we're going here. Environmentally high stress environments can cause people to be distressed. High stress environments cause extended exposure to stress. We know that extended exposure to stress, eventually the body downregulates. It says, I can't win this one, so I'm not going to throw any more energy at it. Which means the person starts feeling more apathetic, more depressed, less energy, yada yada. We're going to talk about these more in depth, believe it or not, in the next few slides. A strengths based assessment for depression though, is really important. When somebody comes in with depression, what is one of the key characteristics of depression? Hopelessness. And hopelessness. Well, you're not going to get people to move forward very easily, to get motivated, to develop momentum unless they have hope and empowerment. So we need to kind of turn the tables here. The first question is to ask people, well, the first question is, what are your symptoms? And then the second question is, you know, what do those symptoms mean to you? What, what does it mean to you to be depressed? What does it mean to you to feel sad or apathetic? Which symptoms are most bothersome for you and why? If apathy is the most bothersome, or fatigue or irritability, agitation, you know, there's the whole list of them. Which ones are the most bothersome for you? That gives me an idea from a treatment planning perspective where we probably need to start, because I want to help the person start addressing those things that are most bothersome so they can feel some relief for each symptom that they have. What makes it worse and what makes it better? If they have fatigue, what makes it worse? What makes it better? If they have difficulty sleeping? Well, first we want to know, is it difficulty falling asleep or they wake up and can't get back to sleep? What does it look like, what makes it worse and what makes it better? And most people will have some idea for them. They may not have the perfect solution or they probably wouldn't be in Your office. But they know in the past when they've had trouble sleeping or even last week, one of the things they did that helped them get back to sleep or helped them get to sleep was, you know, fill in the blank. We want to help people start identifying their inherent strengths and what they've already been doing. Right. This is where we start creating that momentum and that optimism that, hey, okay, you know, I was on the right direction because two nights last week I actually did get a little bit better sleep. Well, that is great. You know, we are looking for progress, not perfection. Two nights of a little bit better sleep is great. This week, let's shoot for three nights of a little bit better sleep and build on it from there. How was life more pleasurable prior to getting depressed? That'll give us again some more ideas about what changed and what is maintaining or potentially maintaining this depression. What is different during times when you're not depressed? Remember, the diagnosis for depression is depressed mood most of the day, most days of the week, in the preceding two weeks. So during those little glimpses when you weren't feeling just completely overwhelmed with depression, what was different before you got depressed, before this depression set in? What was different? You know, what was different with your sleep, with your activities, with your social activities? Socialization, what was going on? And that may give us some ideas about things that changed a lot of times. We'll see that when people got depressed, once that depression kicked in, they're eating and they're sleeping and their socialization, all three of those changed considerably. And we might look at ways of trying to bring in some of the things that they did before they got depressed as they're able. They may not be able to do much right now because they're so exhausted. And finally, how do you expect life to be different when your depression is gone? And this is how, when we write our treatment plans, you know, Sally will evidence remission of her depression as evidenced by. And this will give you. Give us an idea about what they're looking for. What do they want to see different when they are in recovery? This also gives them something that they can look for and they can look forward to. I will have more energy to go to my kids ball games. All right, that's an awesome goal. So let's start working on that and maybe keep a log of energy levels so you can see gradual progression. Progress, not perfection. You're not going to wake up tomorrow and suddenly feel like somebody lit a fire under your butt. It's just. Just not going to happen. Progress, not Perfection. Let's go back to some of the causes of depression and things we can do. When people have neurotransmitter imbalances, and I use that term really broadly, we're talking about dopamine, serotonin, norepinephrine, acetylcholine, gaba, glutamate. I think those are the big six that I really want to hit. When those are not in the correct balance, people are going to feel wonky. Sometimes they may feel agitated. If it's in a different proportion, they may feel depressed. If it's in a different proportion, they may feel, you know, angry, scared, whatever. There are a lot of different compositions that can happen. But what we want to help people do is figure out how to get it back into that perfect balance where they're feeling that those emotions of contentment and happiness. Yes, there are going to be times, as they say in acceptance and commitment therapy, pain in life is inevitable. There are going to be times when you feel dysphoric. It just happens. But then you can easily or relatively easily reregulate emotions and have this general steady state that you would call content or happy. That's what we're looking for now. Neurotransmitter imbalances not only affect our ability to feel pleasure, but it also can contribute to memory issues and difficulty concentrating, both of which are symptoms of depression. Sleep issues when we don't have the right neurotransmitter balance. Norepinephrine is too high, not enough serotonin, not enough melatonin. You know, there are a lot of different contributing factors will have problems with sleep. Lack of motivation. We need dopamine in order to have motivation. Motivation is one of our perseverance. Neurochemicals, fatigue, dopamine imbalances, serotonin, norepinephrine, all of them really contribute to our energy levels, our perception of pain. When those neurotransmitters are out of whack, it contributes to a higher pain perception or a lower pain tolerance, however you want to say it. We can be irritable or agitated. This is more common when serotonin is low and norepinephrine and glutamate are high. Not always, but these are things that we see. People can be depressed and irritable at the same time, and they may have fight or flight stress symptoms. These are all due to neurotransmitter imbalances. So what can we do? Well, let's start at the beginning. In order for neurotransmitters to be balanced, the body has to be healthy. We have to provide it a relatively healthy, mentally healthy and physically healthy environment. Encourage people to get quality sleep. A lot of people are willing to start thinking about this because most, not all, but most people with depression have been having problems with sleep and they would be so grateful for a few good nights of quality sleep. And when you propose this as an intervention, instead of starting out with, well, let's just talk about your family history for a while. This is something tangible. This is something they can do right now. What can they do in order to improve their quality of sleep? Create a sleep routine. Three things. I like the number three. For whatever reason, three things they do every night that cues their body in that it's time to go to bed. With our kids, we did, you know, they came home from school, they played for a while, they ate dinner, they took a bath, they got read a story, they went to bed. So as soon as you started eating dinner, it started cueing the body to make melatonin or secrete melatonin, because before long it was going to be bedtime. And it takes our body a little while to, you know, kick into gear for getting to sleep. So creating a routine, does it mean they have to go to bed the same exact time every night? No. Ideally within an hour or two. You don't want to be going to bed at, you know, 7 o' clock Monday through Friday and then staying up until 1 in the morning on the weekends. You want to keep it kind of close. But if you have a night out on Saturday or something, you still want to be able to have fun. However, those doing those same three things when they get home can help them fall asleep. One of the things that's not in here that I should have added is avoid alcohol with within two or three, well within two or three hours of bedtime. Ideally, you should have a blood alcohol level of zero when you go to sleep because alcohol may initially they actually found it does initially shorten the time to fall asleep and improve sleep in the first half of the night. But as the alcohol wears off, as the person sobers up, sleep gets dramatically worse. Depending on what point that person starts to sober up their sleep, their sleep quality is going to kind of go into the toilet. I recommend to people, I'm not going to tell them, unless they're in substance recovery, that they should not drink at all. However, with people that are struggling with depression, ideal if they're going to drink, if their blood alcohol is zero or close to zero when they go to sleep, alcohol Actually also slows respiration. So if they've got sleep apnea, it will make the sleep apnea worse, which will worsen their sleep and increase their cortisol levels and make their depression worse. All kinds of reasons not to drink right before bed. We want to help people address pain. If they have chronic pain, then it's going to keep them from sleeping as well at night. I lifted yesterday and I'm not putting that in chronic pain, but I was sore last night and when the thunderstorm woke me up, it was harder for me to get back to sleep because my quads were kind of killing me. If we've got somebody who's depressed and they are in pain for some reason and think about when you sit on the sit on the sofa binging on Netflix with your neck all kinked up or whatever, or just sit still for a long time as people tend to do when they're depressed because they have very little energy and they have a lot of motor slowing going on. They're not moving as much. They may have more aches and pains. We want to help them figure out how to address that. May need a doctor's referral, may need a physical therapy referral. They may just need to move and maybe stretch, maybe yoga, something gent that they can do to loosen some of those muscles. And as I said, obstructive sleep apnea contributes to depression and poor cognitive functioning. Therefore, it is important when people have sleep apnea to get evaluated for it. They found that using a CPAP machine, the continuous positive airway pressure CPAP machines actually do have a significant effect on people's mood as well as their cognitive functioning when people are depressed. And Renee raises a good point. When people are depressed, especially if they're depressed because their serotonin is low, they tend to have a lower pain tolerance so they feel more pain and that can be problematic. Other problems that they may need to look at for getting quality sleep shift work can be a real bugger. If somebody is struggling with major depressive disorder, if they can get off of shift work for a while until they can get everything squared away, that's good. If not, they need to maintain the same shift. If they're working midnight shift. I have a friend right now who works 5pm to 5am and then on the days in between when he's not working, he switches his schedule so he can spend time with his son, which is great. It's very admirable. But that is horrible for his sleep quality and his circadian rhythms. Time zones can also Affect quality sleep. If somebody is going between different time zones, then it can be significantly problematic to them and daylight savings time. Some of the things that they found for quality sleep and adjusting to time zones and daylight savings time have been using light boxes in order to most effectively set circadian rhythms. Other things with getting quality sleep like y' all are mentioning, limit blue light exposure within two hours of bed. Get a blue light filter for your television and every single digital device that you have. Ideally log off of any stressful devices within two hours of sleep. And that will help significantly cue your brain in that it's time to start going to sleep. Relaxation can help balance neurotransmitters because when we relax, it triggers that rest and digest, which triggers the release of serotonin and GABA into our system. Biofeedback can be really helpful and you don't have to have anything super fancy. You can lay down or sit down in a chair and put your hands on your abdomen and you'll feel yourself breathe in and breathe out. And you may also feel your heartbeat. You want to feel that slow down. If you want to get a little bit more high tech, you can use a fitness tracker and you can practice deep breathing to reduce your heart rate. And a lot of the fitness trackers now actually monitor heart rate variability and will clue you in. If the heart rate tracker thinks that you're too stressed and will provide you with some biofeedback activities, then progressive muscular relaxation, you can search for that online and find plenty of videos on YouTube. How to do progressive muscular relaxation. But that can help the body relax physiologically and it can also help the person relax cognitively because they're focusing on noticing the difference between tense and relaxed, which means they're not focused on monkey mind. You know, that really helps people become more mindful, at least for a minute. And we need to encourage people to address medication side effects like psychotropics. Even any of your medications that you take. Psychotropics, opioids may have side effects that alter neurotransmitters. Opioids, for example, have a depressant effect. Other psychotropics people may take may increase sedation. Some of your antidepressants are serotonin reuptake inhibitors. Some of them are norepinephrine, others are dopamine, and yet others are serotonin, norepinephrine and dopamine reuptake inhibitors. When people take psychotropic medication, they are altering the balance of those neurotransmitters. Other things people can do for neurotransmitter balance is improve their nutrition, address and address addictive behaviors. When we engage in addictive behaviors, and these are the things that produce that rush of endogenous opioids and dopamine and a lot of times norepinephrine too. So you get that euphoria that can be toxic to the brain. After a while, the brain adjusts in order to protect itself from that toxicity, which is what we call tolerance. We want to address those addictive behaviors because every time we do that, we are flooding the system with certain chemicals and altering that neurochemical balance. Encourage people to address chronic or extreme stress. As a brief refresher, both chronic stress, you know, low grade ongoing stress, or acute extreme stress increase the amount of neurotransmitters flooding the synapses to protect the body from overload. The brain shuts down some of the receptors in order to prevent, you know, burnout. Basically, when the neurotransmitters return to a normal level, the receptors are often still shut down. So not enough neurotransmitter gets sent out. When things are back to normal, so to speak, the dopamine receptors may still be shut down. Therefore, not enough dopamine gets through compared to what is being secreted. Tolerance and withdrawal are very interesting things to look at, and we need to remember it can happen in response to stress, not only in response to addiction. What we see with stress and the HPA axis is the body starts protecting itself from having too much cortisol and glutamate in the system, as opposed to addiction, where we're talking about dopamine and norepinephrine. Thyroid hormones are altered in response to chronic stress. And depression is a form of chronic stress, especially again, because it alters our relationships and how we perceive the world. Thyroid hormone alterations impact mood, libido and energy levels. Our gonadal hormones, estrogen and testosterone also impact our mood. Estrogen boosts neurotransmitters that affect sleep, mood, memory, libido, pain, perception, learning, and attention. Spanish, all of which are symptoms of or problems in any of those are symptoms of depression. Go figure. Increased estrogen may also increase the availability of serotonin. Now you may be going, well, that's great because more serotonin means less depression. Not necessarily. They found that too much serotonin can also contribute to anxiety disorders and development of anxiety related depression. Everything's about moderation and balance. Testosterone may be implicated in reducing the availability of serotonin when it's too low. Low testosterone, low serotonin testosterone is manufactured in your adrenals and it enhances libido, improves stamina and sleep, assists in brain function, and is associated with assertive behavior and a sense of well being. So you can see how low levels of testosterone could also contribute to depression. Why am I bringing this up? Because all the talk therapy in the world may not alter the levels of thyroid, estrogen or testosterone, unless the imbalances in thyroid, estrogen or testosterone levels, because a lot of times those are caused by something physiological. We need to make sure that we're not looking at every problem, every episode of depression as a cognitive issue and continuing to hammer it with just that tool. Cortisol is our stress hormone. And it, like testosterone, is made in the adrenal glands and helps the body adapt to stress by increasing heart rate, respiration and blood pressure. Cortisol goes up, we tend to feel fight or flight anxiety or anger. Cortisol goes down too low, we tend to feel depression. Cortisol is necessary for life. It helps us get out of bed in the morning and meet the demands of the day, and it gradually decreases throughout the day. This is called our circadian rhythm. Circadian rhythms are not just about sleep. It's about our cortisol levels and our feeding hormones and other things. Insufficient cortisol, as a result of a variety of things, but especially glucocorticoid resistance, can lead to heart rate and blood pressure reductions, as well as reductions in energy and motivation, which can leave people feeling depressed. And DHEA is yet another hormone in our body that can go wonky and contribute to symptoms of depression. DHEA levels decrease as we age, just normally, like some of our gonadal hormones. It's important that we encourage people to get a physical to rule out any physiological causes of their depression. Adequate levels of DHEA can increase libido and sexual arousal, improve motivation, engender a sense of well being, decreased pain, facilitate rapid eye movement, sleep, and enhance memory and the immune system. We want people to have appropriate levels by all means. Not recommending to go out and get supplements to start trying to regulate these on themselves, because the amount of DHEA in supplements is like hundreds of times greater than what we would normally have in our body. And too much DHEA can contribute to anxiety and heart palpitations and all kinds of other bad mojo. What do we need to do? We need to have people get a physical to identify and address what might be causing these symptom imbalances. Encourage them as long as it's physiologically sound, based on doctor Recommendations to eat a low glycemic diet. Does that mean they can't have cake? Of course not. Unless they have diabetes and it's not okay. What it means is trying to eat relatively healthfully most of the time. And remember that the less sleep you get, the higher your cortisol. The more sleep you get, the lower your cortisol will be. In general, encouraging people to get sleep within the normal recommendations for their age range, which, remember, for us adults is still eight to nine hours or seven to nine hours a night. And that does not decrease as we age. Final thoughts on hormonal imbalances. They affect millions of people. Symptoms include feeling anxious, tired, irritable, gaining or losing weight, not sleeping well, changes in sex drive, focus and appetite. Causes may include poor gut health, inflammation, high amounts of stress and depression, genetic susceptibility and toxicity. And regardless of where it starts, if we start having these hormone imbalances, we very well could develop symptoms of depression. Which again is why we want to look back not just one step to what's out of whack, but we want to look back one more step to what is causing that to be out of whack. Natural treatments Four hormonal imbalances include eating an anti inflammatory diet, consuming enough omega 3s, getting good sleep, exercising, and controlling stress. You know, go figure. That's really not a surprise. We talked about pain earlier. Low serotonin is associated with increased pain perception. In addition, depression contributes to muscle tension as well as stiffness and achiness. You know, when we're depressed, sometimes, especially if you have concurrent anxiety, you might have jaw tension, neck tension, what have you. Encourage people to remember that their body is three dimensional. They have a front and a back, they have a right and a left, and all of these things need to be imbalanced. If your front is tight, then your back is going to have to compensate and your back has to be loose. We want them to be equal in their tension and relaxation. If your front is exceptionally tight and your back is weak, I see this a lot in the gym. People will go in and they will do all kinds of chest exercises and that's great, but then their chest muscles get really tight and bulky and their shoulders start to hunch over like this because they're not doing anything on their back and their back muscles just can't compete. And then they start having all kinds of pain because of poor posture. Anyhow, exercise can help with balance, guided imagery can help with pain. And I have an entire video on LCEU's education that you can look at on non pharmacological interventions for pain. We're not going to go deep into them right now, for time's sake. Muscle relaxation can help. When people start to become more mindful of their muscle tension, then they can intervene in order to release it. If they start noticing that they're grinding their teeth, then they can become more mindful and do something different. Alternate focus is another way of addressing pain. Instead of focusing on the fact that oh my gosh, my knee hurts, it hurts so bad it's aching. Or oh my gosh, my tooth hurts, it hurts so bad it's aching. I can't focus on anything else. Forcing yourself to focus on something else. It can mean for some people, if the pain is bad enough, maybe it means initially holding ice cubes or putting their hands in warm water, you know, that's less aversive. So they're focusing on what that feels like. Or aromatherapy. They've actually found that essential oil of bergamot is super helpful at reducing anxiety and anxiety and pain in people. TENS therapy can be really useful. You can get tens units over the counter now. Transcutaneous electronic nerve stimulation. Sounds horrible. Really not. You put little electrode patches on and you turn it on and it sends a little electric signal that feels like somebody tapping at you. What it does is it bombards the nerve ending so the nerve ending quits, sending pain signals to the brain for a little point in time, which allows the muscles around it to relax. Physical therapy, hydrotherapy, ice and heat and hypnosis are also helpful. And the essential oil I mentioned. Recent research has indicated that essential oil of bergamot is actually helpful for pain as well as anxiety. Emotions can contribute to or be caused by depression. Remember that anger is half of the fight and flight reaction. It pushes people away and asserts control and dominance. Excessive anger can lead to depression when it exhausts our stress response system. When you are just angry all the time and, and you are irritable, think about how much energy it takes to basically be that pot. Sitting on the stove, stewing. You know you're trying to keep. When you're holding anger, it's like trying to keep a pot boiling. How much energy does that take to just keep that pot boiling indefinitely? A lot. It contributes to negative cognitions. When we're angry, we typically see the unpleasant side of things, the stressful side of things. We typically see things, people as being more malevolent in their actions and their beliefs. And excessive anger can also lead to depression when it impairs relationships. When People are angry a lot. Other people often don't want to be around them. When people are angry a lot and they perceive other people as malevolent, they, they may make accusations that are unfounded. They may have ruptures in their trust. There's lots of ways that relationships can be impaired when somebody is excessively or chronically angry. Jealousy and envy are types of anger and they can be thought of anger at someone else for having something you want, self anger for not having it, or existential anger for the universe just not being fair. It's not fair that so and so won the lottery and I didn't. Jealousy and envy may contribute to feelings of hopelessness and helplessness. Because when people feel jealous or envious a lot of times they're looking at that other person saying they don't deserve it any more than I do and I can't get it. So I feel hopeless and helpless. I will never be able to have the happy life that they have. Well, so we need to intervene, help people make a list of the things and people that they envy or are jealous of and why they're jealous of them. Let's start just breaking it down. Why are you jealous of this influencer or this celebrity or this person at work or, or you know, your sister in law, whoever it is, in what way are they better or better off than you because of those things? And this is one of those questions that people may take a little offense to. You know, why are they better than me? What does it mean they're better than me? I don't know. If you're jealous of them, it may indicate that you think that they are better than you, that they deserved it more than you or somebody thought they deserved it more than you. So let's take a look at that. Is there, what's the difference? How does envy or jealousy affect your ability to live a rich and meaningful life? How does being jealous that this influencer has a 10,000 square foot house or this person makes? I don't know. I saw yesterday some number about how much Jeff Bezos made on a daily basis. You know, I see that and I'm like, well that must be nice. But how would being envious or jealous of him impact my ability to live a rich and meaningful life? I'm never going to run Amazon. That's just the way it is. Those are the cards I was dealt. So being angry about it doesn't do anything but drain my energy as I try to keep that pot boiling and use the energy that I could use to to focus on the things that are important in my life. Which takes us to what's a more productive way to use this energy than just boiling a pot of water all the time? Guilt can be thought of as shame, embarrassment or self anger for something you did or should have done. Some people have difficulty letting go of guilt because they think they deserve to suffer. I should have known better. I should hold myself responsible for this henceforth and forevermore. And if they forgive themselves, they might do it again. When I worked in residential treatment, I worked with a lot of people who had co occurring disorders and they felt guilty about what they did in their addiction and were afraid to let go of that guilt because they were afraid if they did that they might go do it again if they forgave themselves. And it was important for them to understand the other option, that if they continue to hold on to that guilt and feel bad and beat themselves up, that also might lead to a relapse with guilt. Have people make a list of things they feel guilty about and recovery. We call this a fearless moral inventory and explore. Have them explore how they can make amends for it. You know, it's done. It is what it is. You can't change the past. How can you make amends for it? How can you learn from it so you don't do it again? How can you forgive yourself instead of continuing to boil that pot of water or lash yourself with a wet noodle? How can you forgive yourself for this so you can free up that energy? And then sometimes we feel guilty for things that there's no reason to feel guilty for. So how can you let it go? You can encourage clients to make a guilt bill of rights for those things that they feel guilty for. That really they may not need to feel guilty for. I'm trying real hard not to say the word should, like sleeping in or, you know, going out to dinner or buying a new outfit or whatever it is that they feel guilty for that is a justified something that's justified something they, that other people might not feel guilty for. Give themselves permission, that guilt bill of rights and then encourage people to look at forgiveness. What does forgiveness mean to them? How does the concept of forgiveness make you feel? A lot of people, most people that I work with, as soon as we start talking about forgiveness, their hackles go up. Because that feels like powerlessness, that feels like turning over power and telling somebody what they did was okay. We talk a lot about what the phrase forgiveness is for you means. Because forgiveness, we talk about it as a power play when I forgive. I am choosing not to leave my energy tied up in holding on to that resentment or anger anymore. I am choosing to accept that it happened. I may not like it. I'm choosing to accept it happened, but not continue to lock my energy there because I want to use my energy for other things. I like the forgiveness fire activity. I don't use a lot of fire activities, but this one I really do like, where people take their things that they feel guilty for, things that they need to forgive, others for, whatever they need to forgive, and they write them on notes, cards, slips of paper, however you want to do it. They put them in a trash bin, little tiny one, so you can control the fire, and they burn it. Would it be nice to do it with balloons and let them fly up into the air? Yes, but that is very bad for the environment. Burning is not great for the environment, but it's a little bit better. A forgiveness fire is something that we used to do at my treatment center about once a month, and the clients generally really enjoyed it. When you are angry, another activity you can do is have people figure out, be mindful. When you are angry, what do you notice? What do you pay attention to? It helps people recognize that when they are angry, they tend to notice the negative and dismiss the positive. What are your triggers? Why do those triggers make you feel vulnerable? If one of your triggers for anger and is somebody sneaking up behind you and scaring you. I hate it when people do that. Why does that make you feel vulnerable? Is it an external threat? In that case? Yes, it is. Is it a current threat or something from your past? Well, where I live now, you know, with my kids and my dogs and my husband, and, you know, it's a safe environment. So, you know, probably not a current threat. Now we are ingrained. You know, even little kids, even infants, can get startled. And that's just one of our protective mechanisms. So that could be, if you want to say something from your past. You know, getting startled can be something that is not actually a current threat, but it's your body's way of saying, hey, pay attention. Does this threat keep you from living a rich and meaningful life and figuring out how those things go? When my son was little. And then I'll move on to the next slide. This was when Star wars was big and he would go to bed and his father would put on the Darth Vader helmet and walk down the hall making the Darth Vader noises. And you could hear him stomping and doing that, huffing that Darth Vader did. And Shawn would shriek, daddy, stop doing that. And he would get so angry. And I sat him down one day, and I'm like, son, your father does it because he thinks it's funny when he gets you upset. If you quit reacting to it, he won't do it anymore. And from that point on, he didn't get angry about it. He was just like daddy. And he would ignore it, but it was helping him understand that dynamic. But he got angry. Was it an external threat at that point in time? It was. Is it something in the present? Yeah, he was afraid of that, even though we know it wasn't real. And he knew that his father wasn't actually Darth Vader, you know, it was a threat. So it was important for him to figure out whether it was actually a threat. And turns out it wasn't. You know, he just had to figure out how to deal with it and how to deal with it from there. So how can you address each trigger to feel safer and more empowered? Anxiety is the other half of fight or flight. Chronic anxiety, worry, or stress will also exhaust our stress response system that HPA axis, causing neurochemical and hormonal imbalances and increasing muscle tension and pain. This causes the body to adapt to excessive stress by shutting down those receptors, leading to feelings of apathy. And remember that anxiety makes it harder for sleep. And when we don't get enough sleep, we tend to get exhausted. When we're anxious, we're in that fight or flight, so we're not able to relax and get sleep. That leads to exhaustion, which leads to hormone imbalances, which can lead to depression. When we're working with people with concurrent anxiety, help them identify the threats that they experience in their life threatening that make them feel threatened for rejection, isolation, failure, loss of control, and the unknown. And explore why those situations trigger anxiety. For example, I'm getting ready to go next week to Chicago. And, you know, it is very stressful for me. I don't do big cities. Y' all know, I don't do big cities and I don't travel. So putting those two things together feels very overwhelming because it's kind of the unknown. I haven't been to Chicago since I was in sixth grade. And, you know, there's a lot that I just. I can't even begin to plan for how things are going to work. So that is stressful. Explore why those situations trigger your anxiety and then brainstorm ways to deal with them, such as fact checking, guided imagery and dialectics. Fact checking, you know, what Are the chances I'm going to miss my flight or something bad is going to happen? Probably none. What are the chances I'm going to get lost from the airport to my Airbnb? Probably none. You know, going through and looking logically at it. Guided imagery. I can envision myself getting on the plane and getting to my Airbnb and getting to my conference with no problems. That's something I can start training my mind to just see it happening because it's very possible that it will. And I want to envision the positive outcome and then dialectics. Instead of seeing it as something threatening and scary, I can say, okay, this is a learning opportunity. Let me see it as a challenge. I haven't done this before, so let's try something new and step outside my comfort zone. Those are just some ways that people can start addressing anxiety instead of feeling suffocated by it. Grief is sadness or depression experienced as the result of loss. Remember, it involves anger. Depression and denial. Anger, bargaining, depression and acceptance. When people are depressed during that grief process, they're helpless to change the situation. Whatever it is is gone and it's probably not coming back. And they may feel hopeless that they will be able to move on. And it's important for us to identify what they have the power to change. When you experience a loss, you may not be able to get it back, but you do have the memories from whatever it was. You do have the past that will still continue to influence who you are and what you do henceforth and forevermore. And remember that losses are not just about death. We can lose hope, we can lose dreams. We can lose friends. There are a lot of things that we can lose. We want to help people identify these losses. Existential losses, Dreams, hope, faith, safety. Some people after trauma have their sense of safety obliterated. They've lost that sense of safety. They may lose their independence if they are in an accident or they start developing Alzheimer's disease or whatever it is, they may lose innocence. Social losses can include loss of your neighborhood because you move, or your friends because you move. Death of people and pets or relationships ending. Physical losses include loss of physical abilities. And it can be, you know, you lose the ability to use your arm or your sight. Or it can even be, for some people, when. For some women, for example, when they go through menopause, there is a grieving process because they lost the ability to have children. Property losses. These are things. Houses, your favorite bike, your grandmother's brooch. Sometimes when we lose things, it is devastating to us because it was something that had emotional meaning to it. Explore what about each of those losses makes you angry, fearful, or hopeless. And develop an action plan to deal with those unpleasant feelings, giving yourself permission to grieve. Remember that true losses cannot be acquired. The final step in grief resolution is acceptance. Talk with people about what acceptance means. You know, accepting it is what it is, we can't change it. But also accepting what we can change or what we can do. Other activities that people can do. Narrative therapy. They can write. We've talked about this many times before. Writing a little mini novel that describes the person and the events leading up to the loss. And then the loss. And the loss is the close of a chapter or the close of a series and the next chapter or the next season. That person or thing is not there anymore. And we need to see how it influences the main character henceforth and forevermore. And people can write and forecast ways that that loss can positively influence them, even though it's not there anymore. Like the memories of a loved one that passed on even in television series, people will occasionally reappear as flashbacks or memories. And people can also write letters to things and even concepts that they lost to the loss of my innocence. This is what I'm going to write. And figure out how to communicate with that. You can create wind chimes, so every time they jingle, it reminds you of the positive things about that person or thing that you lost. Or one of my favorites are sun catchers or light catchers. You can do them with Shrinky Dinks or even plastic lids from, like, yogurt tubs and color them with transparent paints, hang them in the light, hang them in a window or in front of a string of, like, LED Christmas lights. So when the light shines through, it illuminates the beauty of whatever it was you're trying to remember. Happiness. Happiness chemicals reduce stress and depression. It's possible to be depressed about one aspect of your life, but happy about five others. You can hate your job, but you can love your kids and you can love your gym and other things. Generally, you're not going to be happy and depressed at the exact same moment. So let's increase the happy times. Listen to comedians. Focus on what's going right. Congratulate yourself for progress, not perfection. I don't have to be happy all the time. I'm happier today than I was yesterday. Exercise we know that releases positive neurochemicals and put triggers in the environment for happiness. Pictures that make you smile, sounds that are calming, smells that bring back positive memories, negative Thinking styles also contribute to exhaustion. Encourage people to highlight what is out of their control and what is in their control. Heightened negative thinking styles heighten a sense of helplessness and hopelessness. So we want to encourage people to acknowledge the negative but also turn their attention and notice the positive. Cognitive distortions also contribute to depression. All or nothing thinking. Encourage them to find the exceptions. Very rarely does anything happen, all the time or never. If they're creating self fulfilling prophecies, they expect something to be bad so it ends up being bad. Encourage them to use positive mental imagery and envision it going well. And if they personalize things, encourage them to find three alternate explanations why somebody may have been grumpy with them today instead of assuming it was about them and people hate them and they're unlovable. Poor self esteem contributes to self loathing, shame and a feeling of unlovability and also negatively impacts our relationships. When we don't feel good about ourselves, it's hard to encourage people to want to engage with us because we're presenting ourselves as not lovable, not likable. Poor self esteem, however, often causes a person to seek external validation. Have people complete a self esteem inventory and for all the characteristics they don't have, answer the question for themselves. If my best friend had this flaw, would I still love them? Another activity if you're doing group is to use snowflakes. Have cut out paper snowflakes like we used to do when we were kids. Every person gets a snowflake and each snowflake is different than every other snowflake in the room. Have people pass their snowflakes around and everyone in the group writes on everybody else's snowflake something positive about that person so they get their snowflake back and they have 10 or 12 comments of positive things about themselves. A final activity you can do for self esteem is encourage people to sell themselves. Tell them to pretend that they're a marketer and they need to convince some big conglomeration to hire them or to whatever so they need to sell themselves. Why are they awesome? Why would they make a great contribution to that team? Unhealthy and unsupportive relationships can take a toll on self esteem. Fears of abandonment can maintain high levels of stress and feelings of helplessness. When people have poor relationships, then it fails. They don't have the relationships there to buffer against stress, which can lead to exhaustion, neurotransmitter imbalances and depression. Interventions for these relationships encourage people to enhance their adult attachment with people. Who cares? I know that's horrible English. But CARES stands for consistency, attention, responsiveness, empathy and solution generation. Encourage them to find people in their lives who are consistent, attentive, responsive, empathetic and can help them generate solutions and also to use those same principles for themselves. Be consistent with themselves and be mindful. Pay attention to themselves and responsive to what they need. Address prior abandonment experiences and enhance mindfulness. Finally, environmentally high stress environments prevent relaxation and rest and increase hopelessness and helplessness. Stress hormones and decrease relaxation hormones. Encourage people to brainstorm how they can design low stress areas in their home. Maybe not the whole house, but their private corner that is their oasis. And at work or at school, where can they go? That is a low stress area where they can regroup and encourage them to turn the negative into a positive. In our house we have a lot of animals and fosters and there's dog hair everywhere. I saw a meme once that said having dogs is like brushing your teeth while eating Oreos at the same time. It just is. Yes, there's dog hair everywhere and it's annoying. But I love the dog hair everywhere because it means I've got dogs and I wouldn't want life without dogs, noisy families the same way. You know, I've got a lot of noise and chaos in my house, but I wouldn't have it any other way because that means I've got a house full of very happy, enthusiastic people. Depression is the cluster of symptoms created when there's a neurochemical imbalance in the brain or what causes the imbalance can be emotional, cognitive, physical, interpersonal, environmental, or a combination of all of the above. Parts of the strength based approach means helping people see what they already are doing to prevent or deal with the symptoms. And biopsychosocial means remembering to examine all the causative factors, including the biological ones, and recognize that all factors are reciprocal in nature. Are there any questions? I appreciate everybody's activity in group today. That made it a lot more fun for me. And for the wind chimes activity, if you go online and you search, as much as I hate to say it, search Pinterest, there are a lot of different activities. And when you make wind chimes, for example, grief wind chimes, you can use things that remind you of that person. Not only just things that go clinkety clank, like, you know, you can get bottle caps or even plastic caps like off peanut butter jars and use that as a frame and then cut out the picture of whatever it is you want to remember, paste it inside the cap from the peanut butter jar and you can hang that. So yes, it's not going to make a pretty jingling clanking, but it will make a rattling when the wind blows CARES stands for Consistency, Attention, Responsiveness, empathy, and solution generation. Alrighty everybody, have a great couple of days and I will see you on Thursday. 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. 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