Can the PIECES Mind-Body Approach REALLY Improve Your Mental Health?

Foreign. I'd like to welcome everybody to today's presentation on the overview of the pieces method of trans diagnostic assessment and treatment. I'm your host, Dr. Donnelly Snipes. In today's presentation, we're going to define the pieces model, which is a model that I came up with really to help my interns and my supervisees remember all of the areas that needed to be considered when making a diagnosis and when considering treatment interventions and approaches. We'll explore how the pieces dimensions interact and examine the trans diagnostic assessment prog process. Now, the first few slides are kind of introductory and then we'll get down into the meat and potatoes a little bit later. So I'm going to go quickly at the beginning. Just fair warning, 10% of Americans are on antidepressants for anxiety or depressive issues. And I dare say it's probably a lot higher than that. That. Now that data came from a study that was done a little over 10 years ago. And we know that since the pandemic there has been an epidemic of people starting to take medications. And so that that's been heart wrenching. Without medication. 20 to 40% of people with clinical depression notice symptom improvement in 6 to 8, 8 weeks. Now that doesn't mean they just sat on the couch and did nothing. It could be that it was a grief issue that they were processing. It could be that they had some sort of other acute change in their life and they moved through to acceptance and found their new normal. There's a lot of things that may have contributed to it. Maybe it was a lingering symptom of a virus that they had, for example, that caused them to feel fatigued and apathetic. We don't know. But we do know that up to 40% of people really start to feel better within six to eight weeks with antidepressants. 40 to 60% of people with clinical depression noticed symptom improvement in six to eight weeks. All right, so just think about that for a second. Now, 40% is 4 out of 10 people who take antidepressants find they're effective. That's less than half. 60% means 6 out of 10 people find they're effective. And I'm not trying to talk down to you. I'm just trying to get you to wrap your head around how ineffective these things are. 40% of people, even if you take the best estimates, 40% of people with clinical depression 20 don't notice any symptom improvement in six to eight weeks on antidepressants. That is awful. That's heartbreaking. That means as many as 60% of people are still struggling with significant symptoms after six to eight weeks. Interestingly enough, there is no high or moderate strength evidence for any intervention to effectively treat any phase of any type of bipolar disorder. So we do need to recognize that if we're talking about bipolar depression, that is slightly different in, in terms of what this research study was looking at. It was looking at unipolar depression, cognitive behavioral therapy and its branches, because we have phase one or wave one, which was your old fashioned cbt, and then we have wave two, which is your act and your DBT and some of those things. But cognitive behavioral therapy appears to be effective in approximately 47% of cases. The results are mixed. Whether CBT plus antidepressants provides a better response than CBT alone. Cognitive Behavioral interventions for depression and anxiety prevention showed a small effect for prevention of depression, but not anxiety. So we're talking prevention here. If you're going in and you're saying, hey, let me give you these tools so you don't become depressed, so you don't succumb to anxiety and it becomes a thing for you. So the. So for the depression prevention, it had a small effect. Providing people some tools was minimally effective for that, but not anxiety. But there was no effect at 3 to 6 months and at 12 months of follow up. So what does that tell us? Well, number one, even for the people who found it had some effect, we can recognize that at three to six months and possibly at 12 months, they hadn't been using those tools. They had them. They used them for a little while. It was kind of like a toy you get at Christmas. It's like, oh, this is cool, let me use this a little bit. And then it just kind of fell away to, you know, the shelf somewhere. That's my assumption. But we also need to recognize again, the things that cause depression are not always cognitive. Some of them are more behavioral. And. And we'll talk about that in a few minutes. Client outcomes are most often determined by client variables such as chronicity and severity. And I call this the pieces ripple. When you throw a stone into to smooth water, you see those ripples, right? Well, not only is it making ripples on the, on the surface, but it's also creating waves and disturbing things underneath. So we don't even know all of the ways that that rock is disrupting the micro environment. The same thing is true for people. And we need to recognize that if someone is experiencing depression and it, it lasts for a month or two months, and then they go into remission and maybe they never experience depression again. That's probably going to affect them physically, interpersonally, emotionally, cognitively, environmentally and spiritually different differently than if they have these depressive episodes. You know, two months on where they feel depressed, they have a couple of good weeks and then they're depressed again. That chronicity can be very impactful. Likewise, somebody can have one episode that is extraordinarily severe and that can have significant impacts on them physically, on their relationships, on their self esteem, on their level of anxiety, anxiety and anger and everything else. What I want you to recognize, and I think most of us know this in the back of our minds, but the mind and the body and our relationships and the environment that we're in, they all impact each other. If I'm in a good mood and I go into work and I'm like, hey, everybody, I'm smiling and able to deal with, you know, kind of whatever comes my way, at least for the first four hours, joking, that impacts my environment much differently. The people around me are going to likely be less stressed because the boss isn't all stressed out. It's like, okay, boss isn't stressed. It's gonna be a good day. So they're feeling good and they're probably going to be able to handle whatever comes their way a little easier because they don't have energy being stolen by me because they're worried about how I'm going to react. You know, so you see how that works. We've all walked into businesses or clinics or somewhere and the minute you walk in, walk in the door and it's just like this wall that hits you. Everybody there is miserable. They don't want to be there. You can tell they don't want to be there. It's not just one person. Nobody's making eye contact, nobody's smiling. And think about how that impacts everybody else in the room. If you're working with somebody, maybe both of you are working at the front desk and one person is just in a really bad mood, how likely is it the other person is going to be totally gregarious and able to maintain that if they feel that heavy presence? So we do need to recognize our impact on our environment and on the people around us. Likewise, how they impact us if you know that there are certain people that just, you know, they are negative neds and anytime you're around them, by the time you leave, you feel like, oh my gosh, you know, I'm walking with this, you know, albatross around my Neck because I feel so depressed. Well, we can recognize that people impact us. So it's a bi directional relationship. How I impact you, how you impact me and then how I respond to that. We need to look at the complexity of symptoms. If somebody's got one symptom, you know, they come in and they've got, well, one, one diagnosis, they've got depression that may impact their ability to work towards their rich and meaningful life and what they consider recovery more easily than if they have major depressive disorder, generalized anxiety, an autoimmune issue, sleep disruption and complex post traumatic stress. Let's just throw everything in there. And that person not saying they can't get better, they can. I truly believe they can. But they are going to have more to do because the stuff that they've got to dig through is much more, is, is much greater. The nice thing, when we consider the trans diagnostic approach again, if we have a positive change in any one area, we'll say sleep. Think about how that impacts every other area. If we can help somebody start getting better sleep, then it's going to impact how clearly they think, how their attention span, their frustration tolerance, it. And when those things are improved, it impacts their self esteem because they're like, okay, I can do this. I am, I'm not a failure. I, I'm actually doing it. Which will improve their mood. They're not going to feel hopeless and helpless. They're going to feel somewhat empowered and inspired. Maybe not, you know, miraculously, but we're going to see incremental improvements in each piece of their life as a result of a positive change in any one area. And I challenge you, I do challenge you to identify a positive change in one area that has no effect on any of the other areas and just kind of take that as a challenge. As we go through this today, their outcomes are also impacted by their acceptance of the responsibility for change. I can't fix you. You can't fix them. People have to be willing to change their thoughts, their behaviors, to evaluate their beliefs. Maybe their beliefs are spot on. It's not me for me to tell you what to believe and what not to, but it's for me to help you examine them and see if they're accurate for you based on the facts in this context at this time, people need to be motivated to take that responsibility. By the time they come to us, most people are exhausted, they're feeling defeated, maybe hopeless and helpless. So thinking about change is overwhelming. Thinking about finding the energy to do something different is exhausting. And we all know we've all changed our behavior for something at some time. And it takes effort, it takes energy. And that's where motivational interviewing is really important. Important. We want to set goals that are meaningful to the person. We want to help them figure out how to chunk those goals into steps that can be accomplished so they don't have failures. They have small successes, Small successes that build on each other. We want to highlight their successes and help them look back over last week, and yeah, there may have been some things that they didn't do the way they wanted. There may have been some backsliding in some ways, but there also may have been some really positive things. What things went well? What things did you accomplish? That helps people start feeling confident in their competence. So that's confident with an F and confidence with a P. And. And so that takes us down into motor motivation. When people. And it breaks my heart when people come to me and they start just rattling off this laundry list of mental health diagnoses they have, and I'm like, whoa, okay, let me get some paper out. I gotta write all these down. Because too often they're getting a diagnosis from their doctor and a diagnosis from this therapist and a diagnosis from that therapist and a diagnosis from the Internet, and they've smooshed them all together, and then they feel like they've got this huge mountain of diagnoses and crap to work through when one or two of those diagnoses probably explain all of their symptoms. And I sit down with people and I say, let's go. Let's look at your symptoms. Instead of looking at diagnoses, let's look at the symptoms for each one of these diagnoses and connect the dots, figure out which ones. Which diagnoses have some symptoms in common. Let's see the overlap and see if anything. Any one diagnosis or two diagnoses fully explain things. And a lot of times they do. But I like doing this activity with the client so they can say, yeah, I see how that might be true. I see basically that I might not be as broken as I thought I was. Hallelujah. Hallelujah. Clinician variables. That's us. Effective differential diagnosis. If you've got a client with major depressive disorder presenting symptoms, and they also are anemic and hypothyroid and are female going through menopause, okay, let's just, again, throw the entire bucket at it. No amount of talk therapy is going to help them reach their highest quality of life. Can we help? Certainly. Can we provide cognitive behavioral tools to help them manage what's going on in their life right now, certainly. But until the organic dysfunction is addressed in some way, the person is going to struggle. Now, not everybody is down for hormone replacement therapy. I get that. And if somebody says, no, I don't want to go on hormone replacement therapy, then that's fine. So let's figure out how you can live your highest quality of life and be post menopausal. That is your choice. That is what you're empowered to do. And living in the and which comes from acceptance and commitment therapy is such an important concept. I know I said I was going to go fast in these early ones and I'm not sorry. And we need to use appropriate treatment interventions and referrals. If I am working with somebody who has ptsd, I am very likely going to talk with them about the possibility of a referral to an EMDR therapist that we can either work together, they can do the EMDR stuff and we can continue working on depression and life skills or what have you, or they may choose to transfer totally to that person. Because I believe that EMDR is so effective in handling ptsd. Now, cptsd. I've had people report mixed results with emdr, but definitely if there are identifiable traumas in the person's life, then EMDR is high on my list. Not everybody wants to go to emdr, but I know that that's a treatment intervention that I can't provide because I haven't been certified. And it is effective and it is rapid. So why should I try to make them drag it out using treatment interventions for nutrition, for example, we're not dietitians. We're not. We can't tell people to change their eating in order to address their depression. We can educate them about what healthy nutrition looks like. We can screen for diabetes if we think somebody may be pre diabetic. More than 25% of the American population is pre diabetic and most of them are not diagnosed. So if we think they may be pre diabetic, we can screen and maybe refer out and we'll talk about why that's important in a minute. Counseled patients are significantly more likely to have recovered than non council patients. Well, this makes sense. You can take an antidepressant or a benzodiazepine and it may alter your neurotransmitters, but it is not doing anything to adjust those cognitions, those schema that get triggered, that set off your autonomic nervous system and your stress response when people go to counseling or engage in Self help. I'm not saying that everybody has to go to counseling, but people who go to counseling or people who start exploring their cognitions and their behaviors and making changes, find that they have a lot more luck, if you will, at recovery than people who just take the pill and keep doing the same thing. It's like taking a pill and continuing to eat three pizzas a day and expecting to lose weight. Probably not going to happen in most cases. So we need to help people recognize what can they do. There are nearly always affective, cognitive and interpersonal consequences to physical and mental health issues. Counseling helps people understand the pieces or the causes of and consequences of their problems in each of the pieces of their life. And remember that's physical, interpersonal, emotional, cognitive, environmental and spiritual. Counseling helps people understand the interaction between their behaviors, thoughts, feelings and environment. And I include people in that environment, the people that are around you if you feel supported in your environment, if you feel safe in your environment. Counseling helps people learn how to increase and maintain motivation because unfortunately, that's not something that most of us were taught when we were in school. And it is such an essential life skill. They learn effective strategies to address their problems. I'm not saying I know all the strategies to address any problem that comes along, but that's why we work with people and we say, what's worked for you in the past? Help me figure out what strategies, what approaches may have worked for you, and then we can build on those. So we use a strengths based approach to help people figure out what's going to work best for them. I'm not doing anything to them. I'm helping them examine their life, examine what's worked, examine what hasn't worked so we can more effectively tailor their treatment strategies. And counseling helps people do another thing that we should be taught in school that we are usually not. And that's how to set and achieve effective goals. Most people and even a lot of clinicians that I've worked with who've gone through graduate school struggle with setting and like writing out goals. They struggle with writing treatment plans because just breaking it down into something that's objective and measurable and stepwise is not something they ever learned. So think about chronic pain, the causes, the consequences, and the interventions. There are a lot of people these days who are experiencing chronic pain for one reason or another. And I will tell you that stress, whatever kind of stress, whether it's mental stress or physical stress, but stress triggers that autonomic nervous system triggers that stress response when that's your stress Response is activated for too long, and we've talked about this in lots of other videos. But when that stress response is activated for too long, then the receptors start becoming tolerant or resistant to things like cortisol. And cortisol, when your body's functioning well, is an anti inflammatory steroid. When you've been under chronic stress, cortisol loses its ability to suppress inflammation. So you start feeling pain. We know that pain, or I'm sorry, we know that inflammation. Systemic inflammation is associated with a host of mental health and physical health issues, not the least of which are anxiety and depression. So anyway, I digress. The causes of chronic pain, physically, injury, maybe somebody has been taking opioids so they've become extra sensitive to pain. When they're not taking those opioids, the body responds in interesting ways. So injury, illness, opioid misuse or overuse, neuroatypicality. Some people feel more pain than others. Autoimmune disorders cause inflammation. And we know inflammation is associated with pain. Fibromyalgia, Fibromyalgia does not necessarily have associated with it inflammation, but it does have pain. Think about how many people you've encountered who have one of those things. And that injury could be an injury from long ago or it could be a chronic degenerative issue like spinal stenosis. A lot of us start developing that as we get older and it causes pain and that pain keeps us from sleeping well. That pain may make us more irritable with other people and not want to go do things with other people because we didn't sleep well and we're in pain, for goodness sake. Emotionally, we're going to get frustrated because we can't sleep. We're going to get frustrated because we can't do the things we want to do because we just don't feel like it. We don't have the energy. We may feel guilty for disappointing people. Cognitively, when you're not sleeping well, it's harder to control intrusive thoughts. You have brain fog, it's harder to focus, it's harder to think clearly and quickly. It's harder to do any of those executive functioning things which can exacerbate things like ADHD for people who have adhd, but it also exacerbates a lot of those symptoms for people who don't have adhd. They just have a whole much more difficult time focusing, concentrating, problem solving, planning. And that goes back to the emotional because then they start getting frustrated that they can't remember what they walked into this room for. Environmentally. Now, environmentally Is your comfort, your safety, your security? Are you able to meet those basic needs for a roof over your head and you know, afford, you know, keep your job so you have the finances coming in to pay for a roof over your head. And, and that's really what I'm talking about with environmental. Now, I didn't put spiritual on here because that's a whole different presentation, but I do want you to recognize that something like chronic pain or frequent pain or even intense pain that seems to be, you know, four, six, eight weeks later, you're still not feeling 100% better can be really frustrating for people. Pain itself activates that stress response. That's that your body's warning that hey, something's wrong and we need to fix it. Pain is an indication that something's wrong. Now that keeps the HPA axis activated. The lack of sleep as a result of the pain keeps the HPA axis activated. And then we see that whole cascade of things that happen. Most of us have been in this position before when we've had an injury or an illness that caused pain that lasted for an extended period of time, disrupted our sleep. I want you to think about how that impacted you physically, how did that impact your self esteem and at least temporarily, your interpersonal relationships and your ability to get and seek support, your emotions, your thinking and your environment. When I'm in pain, when I'm exhausted, dusting the baseboards is the last thing on my mind. But that's one of the things that just, that's one of my pet peeves. So I'll be sitting on the couch or whatever and in pain and tired and I'm looking at the baseboards going, that's disgusting. And that puts me in a bad mood too. It is all bi. Directional. So let's think about the current counseling approaches. The humanistic approach is person centered and helps people focus on the individual, helps people identify what's going on with that person. And in the humanistic, under the humanistic umbrella are existential therapies, gestalt therapies, logotherapy and narrative therap. Humanistic approaches are great for developing a secure attachment, becoming mindfully aware of feelings, and gaining a sense of meaning in life. It helps people find the humanity in themselves. It helps people find what makes them unique, what's going on with them. The techniques that are used in humanistic approaches include exploring things that bring meaning to the person's life. And we've talked in so many videos about one of the early goals that I have for a lot of people is to have them start at least defining what's important in their rich and meaningful life because that helps them decide what to use their energy on and what to not give their energy to because they want to move forward and not backwards. Humanistic approaches explore how people interpret their experience in the present. We've talked about that a lot before. Every experience we have forms, schema or shortcuts in our brain that help help us interpret and anticipate the world. Helps me interpret what's going on now and anticipate what will come next. If my experiences and y' all know I usually use dogs, sorry, dogs. If my experiences with dogs were are good and positive and rewarding, then when I see a dog in the impress in the present, I'm going to interpret that as a non threat. I'm going going to interpret that as safe and I am going to expect that that doggy is going to come over and sit down and let me pet him and rub his belly. That's my expectation. Now that's not going to be right with all dogs, but it helps me start understanding why when I run into certain people or when I'm in certain environments, I feel afraid when maybe there's no objective need to be afraid based on the facts in this context at this time. It helps me recognize that I am interpreting the present and anticipating the future based on my past, which may or may not may or may not be accurate anymore. And it helps people see that they're separate from their problems. I am not depressed. I am a person who has depression. I am a person who has anger, anxiety, addiction. We are not our problems. Problems are behaviors or symptoms. And yes, it can indicate if the if I have the symptoms of depression, it could indicate that something's wrong within my body, but that doesn't mean that that problem is me. If that's the if that's the case, then recovery means getting rid of me. And that's not what we want to do. We want to liberate me from this problem that I have. Cognitive Behavioral Therapy As I mentioned before, we've got first wave and second wave. First wave was your reb, your cbt. Second wave has been your act, and your dbt. The benefits where humanistic approaches focus on creating meaning, understanding feelings, and seeing self as separate from problems. CBT focuses on helping people recognize the connection between their thoughts, feelings, and behaviors and identify and restructure thoughts that contribute to their distress. Like all or none. Thinking it doesn't mean that your situation didn't happen, doesn't mean your Situation wasn't awful, but is it accurate to say that your this situation happens all the time? So we want to look at that all or nothing thinking. Techniques we use in CBT include restructuring cognitive distortions, relaxation exercises and strengthening vagal tone. That's the behave one of the behavioral components, understanding the connection between thoughts, behaviors and feelings. And also I would add to that any of our health oriented behaviors to help people engage in activities that will heal their body factory so their body factory can support healthy cognition, pain management and happy feelings. Behavioral therapy, specifically behavior modification humanistic approaches focus on feelings and relationships. CBT focuses on the impact of our thoughts and our schema. Behavior modification shines in its focus on understanding triggers for behaviors and increasing and maintaining motivation to make a change. In strict behavior. Behaviorism, you're not going to discuss anything that's not observable. You're not going to talk about feelings because that's not observable. You're going to talk about behaviors and responses to stimuli in the environment. But behavioral therapy can be really useful for trigger awareness and identification, reinforcer and punishment awareness and implementation. And there's a technique that they use that's called chaining. And Linehan uses backward chaining a lot. But we can use forward chaining as well where we create a series of events that or prompts in the environment that keep us moving forward. A lot of times if somebody has a really bad day and then they finally somebody cuts them off in traffic or that straw that broke the camel's back, whatever it was, and they just lose it on somebody. With backward chaining, we can look back at how did we get here? You know what, this person did something that probably didn't warrant you unleashing a seven on them. It may have been a two that was warranted. So how did we get here? What happened, you know, right before this? All right, is that enough to push us up to a seven? No, probably not. What happened before that? What happened before that? And a lot of times we find that somebody, you know, they got up late, they were on the way to work and they spilled coffee all over themselves and they had to clean that up, which made them late for their meeting. Then they got in trouble with their boss because they were late for their meeting. And it was just one thing after another. Nothing that was super notable, but a lot of little frustrations that added up. And in addiction we see the same thing with little triggers here and there. You can ignore this one, you can, you know, suppress that one. But eventually, if you're just Continually being sort of tapped on the shoulder by these little triggers. Then you start having those urges and helping people recognize the additive nature can be really important. Now, trauma informed is not an approach per se, but in each of the emotions, in each of the aforementioned approaches, Trauma informed care recognizes the symptoms and the impact of trauma on the the person to create those symptoms and helps the person create a greater sense of safety and empowerment. In trauma informed care, the first thing that we're going to do is start out by saying how can we work together so you can feel safe, so you can feel empowered to keep yourself safe both in session and out of session. And then we're going to look at how trauma may have influenced schema and beliefs, how trauma may have impacted the person physiologically, how trauma may have altered their perceptions about other people and their ability to trust through attachment trauma, etc, and we're going to examine each one of their symptoms from the perspective of is this something that may have been caused or impacted by trauma? In trauma informed care we want to recognize the many types of trauma and their impacts on the individual as well as the family. If an individual is traumatized, an individual is a victim of a violent crime that obviously impacts the individual, but it also impacts their loved ones. Their loved ones feel guilty, their loved ones feel angry, their loved ones feel unsafe as well. And we need to recognize that. So when their loved ones are feeling overwhelmed with their own emotions, they may not be able to be as supportive and emotionally present for the identified victim. Then the identified victim starts feeling isolated and unsupported, which triggers anger and distrust. And then the people around them start feeling like they're being pushed away. We've seen this dynamic and that's where this, we need to look at it longitudinally over time. How did we get from whenever the first symptom started to where we are right now? The Pieces method uses a trauma informed trans diagnostic and trans theoretical approach. Trans diagnostic means many symptoms are common to multiple disorders. That is true in the DSM 5TR, but it's also true with physical health. As I mentioned earlier, the symptoms of major depressive disorder and moderate to severe hypothyroid are really very similar for, for a lot of people. You can meet the criteria for major depressive disorder with hypothyroid. So we want to recognize, yes, there are things that I can do to help you. Let's also look at what else might be contributing to the symptoms you're experiencing. We get too hung up on diagnostic labels and if you're depressed, then we need to start helping you feel empowered and hopeful. Okay, well, Ducky, I don't have any energy because my thyroid is in the crapper. We need to recognize the benefits of a multidisciplinary team and how each piece may have influences. How can your supportive relationships be used as a tool to help you recover? How can your emotions be used as a tool to help you recover? Through behavioral activation? How can your cognitions be used as a tool to help you recover? Developing distress tolerant thoughts, etc? And how can we explore your environment to remove unnecessary stressors, figure out how to mitigate the inevitable ones and add triggers for safety and empowerment. We've all been in environments where I was in one the other day that the walls were kind of this. I think it used to be a seafoam green, but now it was just kind of a faded pukey green and it was dark in there and there was just kind of stuff everywhere. It was a very cluttered environment and I felt icky. I won't go as far as saying depressed, but I felt icky. And icky is definitely not how I want to feel. And the people who were living there, I'm quite sure that's not they want to feel. So I'm recognizing how the environment is impacting them and empowering them in their rooms. What can you do while you're in your room, while you're in this environment to improve it? And some people, some people's rooms were very orderly and they had meaningful things on the walls. Other people's, not so much. And, and that's one of the things that I'm working on with several of my clients right now. So recognizing that symptoms may be being caused by any piece. I'll give you one more. When my son was little, and this is common in kids, he could not go to sleep if his stuffed animals were looking at him. So before he went to sleep every night, he had to turn all of his stuffed animals so they were either looking down or looking at the wall. And that environmental modification helped him feel safer so he could sleep. Okay, you know, well, what works for you and trans theoretical means there's many ways to address each symptom. Not everybody is going to respond or even want to try cognitive behavioral therapy. Not everybody's going to respond to or even want to try emdr. There are lots of different ways to address trauma. There's lots of different ways to address pain. There's lots of different ways to address grief. And we need to communicate with the person, figure out what's worked for them or what they think might work for them now and build on that. If they believe it's going to work or if they have evidence that it may have kind of helped a little bit in the past, they're going to be more likely to implement it. We want to help them optimize each of the pieces of their quality of life. Physically we know that the body factory, if it's breaking down, it's not going to be a lot of use. So we need to help the body factory function, sleep, nutrition, pain and we're going to talk about these interpersonally. Help them optimize their relationships with others, supportive, healthy, healthy boundaries, etc and with themselves. We want to help them. Oops, I put environmental twice. Sorry. We want to help them optimize their emotions. Nobody is going to be happy all the time. That's just not reasonable. But feeling like you understand and can adequately respond to your emotions and having a blend of emotions is important. Cognitively helping people optimize their thinking. And then environmentally we already talked about, remember, consider each one of these things bi directionally or multi directionally. How I impact you I walk in, I'm in a good mood, I smile, makes you smile, puts you in a slightly better mood. So then now we're both smiling and we're probably going to engage each each other in a more positive way. So I'm going to respond back to you. If you smile back at me then I'm going to go hey, good morning. And so it is bi directional and it's not just one time, it's going to continually go bounce back and forth. So generally if I have a negative impact on you, you're going to respond defensively and then that's going to bounce back and hit me if you will. And I am going to respond defensively to that and then it's going to escalate or you know, get worse in some way. And the opposite is true with, with happiness we're going to be more relaxed, feel safer. The goals of the pieces method are to develop help people develop secure attachment with themselves as well as others and a safe place for them to explore feelings, thoughts and behaviors. Initially it'll be in the therapy room but eventually I want them to be able to explore these things on their own, in their own head without feeling afraid that they're going to be overwhelmed or bombarded by negativity. We want to empower the person to define their rich and meaningful life and use their energy to move toward that, educate them about the different issues in each Piece of their life, which can create or maintain imbalances in the nervous system that cause unnecessary distress and explore and build off techniques, tools, and triggers that have worked for them in the past. First thing, physical causes of mental illness. A lot of times it starts with that, that good old autonomic nervous system. Our stress response, the ans, can become dysregulated and the receptors can become resistant or tolerant to stress hormones. Under conditions of tron chronic stress, just like receptors become resistant to neurotransmitters that are released when al. When people consume alcohol, the same thing is true. People can develop tolerance or resistance, whatever word you want to use, in response to stress hormones as well. The body says, I can't. It's just, it's. We can't run this, this hot for this long. I've gotta back off on some of the stress. And when that happens, people start feeling sort of flat. Things that used to make them happy don't make them happy anymore. Things that used to make them irritable or frustrated, whatever. I don't have the energy for it. That's when we, that's when we know that the nervous system is starting to dysregulate. If it basically takes an act of congress to get them excited, to get them frantic, to get them furious, and there's no in between, they're flat or furious. There are over 30 hormones in the body that must be constructed to regulate the over 100 neurotransmitters. We typically only talk about six, but there's over a hundred which are made to regulate attention, memory, sleep, feeding, heart rate, respiration, energy, motivation, mood, pain management, and more. Each time our body gets out of whack, these hormones are going to be recalibrated or basically get out of whack for what we want them to be in balance for, for happiness. And it's going to impact our attention, our memory, our sleep, our feeding, our heart rate, our respiration, energy, motivation, mood, pain, and even our, our motivation to engage with other people. If the body cannot make or balance the neurotransmitters due to health or behavioral issues, those issues must be addressed. We need to look at everything. Up to 95% of some neurotransmitters and hormones are made in the gut. Gut. The gut microbes. We've talked about that gut microbiome before. The gut microbes require vitamins, minerals, and amino acids to be ingested so they can, they can break down those foods, get their little component parts, and send them where they need to be sent to assemble or to be reassembled into neurotransmitters and hormones. The products produced from the foods you eat will vary depending on your stress level. Because we have a different team of microbiomes and microbes in there when we're stressed versus when we're relaxed. And whatever team of microbes is in there is they are going to create the byproducts that are needed to sustain their environment. If you've got the stress group in there, they're going to create the hormones and or byproducts needed to make the hormones and neurotransmitters for stress. And if you've got the relaxation team in there, then they're going to break down the foods into their component parts to help the body make the hormones and neurotransmitters we need for pain relief and healing and relaxation. Grossly oversimplified, but you get my point. The vagus nerve connects the gut to the brain and helps regulate the stress response. We've talked about the vagus nerve before, and that's our main downregulation nerve. We've talked about strengthening vagal tone. When our stress response is activated, the vagus nerve kind of shuts down. So if your stress response is constantly activated or nearly constantly activated, then your vagus nerve is getting no attention and it, it starts to become less active. It starts to become less us involved in things. We need to wake it up and get it to start balancing out again. Think about if you had an injury and you couldn't use your right arm for six, six weeks or six months, it would get a lot weaker because you're not using it. So your left arm would become stronger and more dominant. And when your arm gets out of the cast, you're probably still going to be using your left arm because that's what you're used to doing. And this right arm's like, hey, what about me? So we need to strengthen that vagal tone so it balances out. If the body cannot produce or effectively regulate hormones and neurotransmitters, people will experience symptoms. Now what those symptoms are very depending on the person. And if you look, a lot of the symptoms of mental health issues can be not saying they are, but can be caused by overactivation or activation of the stress response. When we have that HPA axis dysfunction and are exposed to stress, then our body can't respond effectively and people are like, I can't downregulate. I, I don't have that vagus nerve. Isn't it isn't kicking in and then they may turn to addictions to help numb that pain. They artificially turn down the intensity of the stressor some hormones and neurotransmitters increase the levels of certain other hormones and neurotransmitters while simultaneously decreasing levels of other hormones and neurotransmitters. Everything is in a balance and, and just in the kitchen when you are making different sauces, a lot of times they'll have very similar ingredients, just in different amounts and in different ratios in order to get the effect that you want. Sometimes it'll be more sugar, sometimes more butter, you know, and that's fine. You have a sauce that's appropriate for every single occasion. Examples under stress, cortisol increases norepinephrine, adrenaline, glutamate, estrogen and ghrelin and inhibits the availability of serotonin to certain receptors and the creation of T3 during relaxation, DHEA, GABA and serotonin increase, which reduces cortisol, norepinephrine, adrenaline, glutamate, estrogen and graylin. So we can see the stress group comes in and the relaxation group goes out and then they vice versa. So our physical assessment, sleep is really important. How well they're sleeping, if they are remembering their dreams, how many times they get up, how long it takes them to get to sleep. I have videos on each one of these, so I'm not going to go into huge detail, but sleep is ridiculously crucial in mental health as well as physical health. Maybe it's at least on par with nutrition. If not, maybe a little more important, I don't know, but it's right up there. Sleep and nutrition are very important. Nutrition. We need to assess their nutrition and we're not dietitians, but we can have them monitor their intake using an app like Spark People or whatever. I know there's a bunch of apps on the on in the app store that can help them figure out whether they're getting their U.S. rDA recommended daily allowance of nutrients and if not, what they might be missing. A lot of Americans don't have a really well balanced diet and just encouraging them to learn more about nutrition is important. You can also manage a lot of things by going to the doctor and getting a blood test. The doctor can test for thiamine levels, can test for D3 can test, test for B12, can test for, let's see, D thyroid hormones, oh, and iron to make sure all of those are in line. Any of those being out of whack can contribute to mood symptoms and cognitive issues. Physical assessment for weight is important and I am not weight shaming in any, by any means. But people who have more adipose tissue, more fat tissue, have higher estrogen levels. That's just a fact. And that often increase cont. Contributes to increased inflammation. People who have anorexia, who don't eat enough, who don't have enough fat tissue, their body's going to have a hard time making a lot of their gonadal hormones. And it's also going to contribute to dysfunction in the system. People who've experienced bariatric surgery don't absorb food, this and nutrients from the food the same way as people who haven't had it. It. And a lot of people who go through bariatric surgery report having significant mood and even some people say personality changes. What's their pain like? And we already talked ad nauseam about how pain can impact all pieces of a person's life. How much do they exercise versus how sedentary they are? Not everybody likes to exercise. I get that. How much do they move? Move? Are they sitting on the couch all day or sitting in front of a desk all day and then come home and sit in front of a couch? Or are they moving around doing things, getting oxygen to their brain, getting oxygen throughout their body, their energy levels, how is their energy? And a thyroid evaluation can help with this. If you think that they might have hypothyroid, a sleep test can also help measure for this. Some people have sleep apnea, don't realize it. And having a sleep study can elucidate a lot of things. And just even O2 saturation, people's libido and sex hormones. Do you have a libido? If you do great, you know, how, how do you feel about it? If somebody's libido is not good, then let's, let's talk about that. That. Are they going through andropause or menopause? Both sexes go through a pause and it contributes to a reduction in gonadal hormones which directly impacts, directly impacts the availability of serotonin. So both people can develop depressive symptoms, blood sugar and hypoglycemia. Something else we need to talk with people about, we're not going to measure, but constant stress leads to constant inflows of blood sugar into the system to prepare you for fight or flee. So people who are under chronic stress are much higher risk of developing diabetes, especially type 2 and traumatic brain injury. Hypervigilance and their startle response lets us know if they're reacting. If they feel unsafe when People feel safe. They don't have an exaggerated startle, they're not hyper vigilant, scanning for threats all the time. If they are, that tells me you feel unsafe. So there's this undercurrent of stress that you may not even notice anymore. We want to ask about autoimmune issues and inflammation because that contributes to pain. Autoimmune issues flare under stress and autoimmune issues cause stress, which makes the autoimmune issues flare even more. Diabetes type 1 is thought to be an autoimmune disorder, as are rheumatoid arthritis, psoriasis, Crohn's disease, and much more. Headaches. Whether they're stress headaches or migraines or headaches that are induced by high blood pressure, those can all indicate or cause mood symptoms or be caused by mood symptoms. If I'm, you know, a little ball of stress, I'm probably going to increase my blood pressure and contribute to stress headaches. Medications like beta blockers, proton pump inhibitors for gastric reflux, corticosteroids like for rheumatoid arthritis, Parkinson's and antipsychotic medications, and hormonal altering drugs, stimulants, anticonvulsants, statins like anti cholesterol medications, opioids, benzodiazepines, your anti anxiety meds, all of those things have mood symptoms. And I gave you a link at the beginning of class today. That's drugs.coms as in SAM FX. So and that stands for side effects and that is a great database of side effects for and common medications and substance use and potentially addictive behaviors including sex or pornography, gambling, video games. These can all contribute to stress which can dysregulate the autonomic nervous system and contribute to mood symptoms. Many people turn to substance use or medications or our little stress balls and have stress headaches because of prior trauma. So we do need to recognize and look at the full scope of things interpersonally, self esteem and self efficacy. If somebody doesn't think they're a good person, if they don't think they're a capable person, that's going to add a lot of stress. It's going to impact their relationships, it's likely going to add stress to physiological stress, is likely going to impact the way they view the world and and think about things. If they don't think they're conf competent or capable of doing things. Attachment is important. And so many people have attachment trauma that it's important to recognize if people had adverse childhood experiences, if they never formed a secure attachment or if they had their attachment disrupted later in life, that will impact the levels of oxytocin, serotonin, dopamine and their endogenous opioids. They're natural painkillers. So yeah, having attachment disruption can actually cause mood symptoms and pain and boundaries. We want to help people set and maintain healthy emotional and physical boundaries so they feel safe. If I feel safe knowing that you're not going to invade my boundaries and tell me what to think and how to feel, if you're not going to go through my stuff and if I feel safe around you, then that's going to reduce my stress. If I feel that I've got the ability to keep myself safe and maintain those boundaries in a healthy way, I'm going to feel empowered to adjust those boundaries as appropriate. We want to assess communication skills because too many people expect mind reading and do a lot of mind reading, which leads to a lot of miscommunication. So helping people learn how to identify how they feel, how to be mindful and assertively communicate their thoughts, wants and needs is important. Helping people develop a social support system is more important than ever. As we've kind of dropped back into video land and Internet land and a lot of people don't even know how to develop a social support system in real life anymore. So that may be an important intervention. And then animals and pets, I have that under interpersonal because they've got little personalities, they increase oxytocin. They can help some people who still are apprehensive about other humans. They can help those people feel safe, feel loved, feel acknowledged, emotional causes of mental and physical illness. And I know I'm running over, if you need to go to your client, next client, or you want to go take your quiz, that's fine, but I'm going to keep going through. So we're able to finish this entire series, but in terms of emotional causes of stress or mental and physical illness, we want to look at people's happiness. How often are they happy? Happiness is reflects a neurochemical situation that is promoting rest, relaxation, etc. Sadness and depression indicate a sense of hopelessness and helplessness. So thinking about how feeling hopeless, helpless, apathetic, how does that impact my energy? How does that impact my mood? And when we start experiencing that sense of hopelessness and helplessness, that's stressful and that stress turns into physiological reactions, our nervous system will actually kick in and we need to understand what is going on physiologically with people when they are experiencing a lot of these psychological symptoms. We also need to recognize people's emotional intelligence. And that's not their smarts, that's how well are they. How, how able are they to identify what emotion they're feeling, the function of that emotion and what triggered that emotion right now? So how able are they to identify those things? How able are they to down regulate into their wise mind so they can activate that prefrontal cortex and think logically about what's going on instead of reacting from the fight or flight or the emotional mind? How able are they to effectively evaluate their options for responding to this situation in a way that helps them move toward their rich and meaningful life? Life. And then how able are they to take action based on what they decide some people will identify? Yeah, I could do this. And then they don't do it. So IDEA stands for identification down, regulation, evaluation and action thinking of all of these emotions. And I want you to consider how each one of these emotions is, impacts each area, each piece of a person's functioning. Dysphoric emotions typically impair sleep quality, excite the stress response or the HPA axis, reduce pain tolerance, prompt cravings for high carb, carbohydrate or high fat foods, or even addictive behaviors. Questions we can ask clients sense in an average week how much time is spent on each emotion, and you can have them for a week, keep a chart or keep a log of what emotion they feel, how much. Or you can just do a pie chart in the office and figure out what part of the pie is anger and what part of the pie is depression. What does this emotion look like for you in each piece of your life when you're depressed? What does that look like for you physically? What, how does that impact your relationships? What does that look like for you emotionally? How does it impact you cognitively and in your environment? Do that for each of the emotions they're experiencing. What triggers each emotion for that person? What triggers anger for me may not trigger anger for you. So we need to know what triggers it for them. What stressors are currently present? What stressors have you experienced in the past 12 months? Because the more stressors we have, it's cumulative. We start getting worn down and then it's harder to deal with life on life's terms. What's different when you're happy and how long does it take for you to calm down after you get upset? People whose nervous system is dysregulated, takes them a lot longer to get back to baseline than people who, whose nervous system is functioning as it should. It takes them a lot longer to down regulate. That's not a criticism, that's a symptom. Dopamine? No. Norepinephrine, serotonin, oxytocin and estrogen imbalances can all cause difficulty concentrating, brain fog, memory problems and difficulty with problem solving thing thoughts can cause physical, emotional and behavioral changes which throw hormones and neurotransmitters out of balance and impact the mind, body, relationships and environment. And, and we've talked before about negative Ned and how he impacts his environment and the people around him and how that impacts him physically, emotionally, cognitively and then positive peace. And I think we all know one of each type of person in our lives cognitively. We want to assess people's cognitive functioning, their attention and concentration, their memory, their problem solving, maybe their frustration tolerance to get an idea about what they where they're at right now. Because we're going to use this as one of the things that we look at for improvement. If their attention and concentrations in the crapper. Okay, what's causing that? Is it, does the person have adhd? Is the person hyper vigilant because of trauma? Is the person having difficulty concentrating because they're not sleeping because of pain? I don't know. We need to find out. We want to assess cognitive stress triggers like negative attitudes and perceptions, negative schema they formed from traumatic or stressful incidents in their past. A lack of hardiness or resilience, a locus of control that's either too internal, they feel like they should be able to control everything or too external, they feel like they have control over absolutely nothing. Both of those are extremely stressful. The cognitive distortions they have have their, the negative self talk if they engage any and their time management and organizational skills. Now that's one of those executive functioning things. However, if people's organizational skills and time management are not good, that's going to add stress to their life which is going to set off a cascade of multi directional effects. Environmental causes of distress if somebody doesn't feel safe or if they're objectively not safe, if they're sleeping in their car, that's going to cause distress. Noise is going to cause distress. If you're living in an apartment and your neighbor is stomping around over top of your head at 2 o' clock in the morning and waking you up, that's going to cause distress. Been there, done that. So different noises and hums. For example, if you're in an office where a ballast is getting ready to go out on a fluorescent light and it has that awful Humming that can be really stressful. For some people, encouraging them to identify noises in their environment that they find irritating or stressful is important. So then they can figure out how to address it it and what noises do they like? Some people prefer all silence. Some people, even people with adhd, may actually feel more grounded and centered if they've got noise going on. Some people prefer to have the TV on in the background while they're studying because it makes them feel safer or less lonely. Okay, whatever works for that person. But assessing what noises causes the cause them distress is important. Light is another cause of distress. That harsh blue light coming off of your mobile devices, your computers, etc can disrupt your circadian rhythms. Likewise, if it's the middle of the day and it's really dark or dim where you're at, that will also mess with your circadian rhythms and that impacts your hormones, your, your, your sex hormones, your eating hormones, your neurotransmitters, everything. When your circadian rhythms get out of whack, smells can also cause distress. You have noxious smells. I burned popcorn last night and I could still smell it this morning when I came upstairs to try to make coffee. I opened the microwave and it hit me like a wave, and it was just awful. And it's kind of a noxious smell. Well, but there are other noxious smells that we need to be aware of and try to mitigate as much as possible. When my dog starts getting a little stanky, he gets a bath and everything's fine. Other noxious smells, like the smell of gas. It's noxious for a reason. Your body's going, that ain't right. You need to do something. We want to address triggering smells. Maybe somebody that you work with wears the same aftershave that your abusive ex used to wear. That can be a triggering smell. Now, you're probably not going to tell them not to wear it, but you got to figure out how to mitigate that so it's not triggering in the current context. And then there are assistive smells like aromatherapy that can help with insomnia, sleep, anxiety, pain management, depression, and even regulating cortisol levels. I have an entire video on aromatherapy, so I won't belabor that. And then air pollution, Carbon dioxide and nitrous oxides. Yep. Some people abuse nitrous oxides, but they're not good for you. Carbon monoxide in the home, volatile organic compounds, those things that come out of paint that make it stink so bad, tobacco smoke, all of those things are unhealthy and will trigger the stress response in the body and are found more or less distressful depending on the individual and then temperature. The temperature that you are experiencing in your life or in your environment is going to cause distress. If you're too cold or you're too hot, it triggers the stress response. Spiritually means identifying whether a person has a sense of purpose for themselves, for their lives, for what's going on in their life, even if it's horrible. Some people find it's easier to cope with if they can find meaning or purpose in it. And a lack of a sense of connection can also contribute to distress For a lot of people. Our current uni or bi dimensional approach to mental health and physical health doesn't work for the majority of people. There are a myriad of underlying causes of distress and most people have multiple contributing factors. If your air conditioning bill was suddenly ridiculously high, would you pull down on the blinds? Well, probably. What impact would that have? It would help, but would it solve the whole problem? Probably not. Would you turn up the AC so it didn't run as often and pull down the blinds? Okay, you're doing a couple of things now. How much would that help? And again, would it solve the whole problem or do you still need to address those windows and doors that are just letting the drafts in like crazy? Same thing's true for our mental health. A lot of times we need a multi dimensional approach to address any one symptom. A trans diagnostic approach works to identify all of the causes of the symptoms, understand their interrelationship and causes, and develop a treatment plan based on what works and the person is most motivated to address in a manner that works best for them. I appreciate those of you who hung with me through the rest of it and I, I know that was a little longer, but, you know, I could only talk so fast and I hope to see you next week.