CBT for Depression Treatment Week 1 of 14 | Start Addressing Depression Now

Hey there everybody and welcome to this episode of the Week by week guide to depression treatment. This is part one of 14 and I'm your host, Dr. Donnellice Snipes. In this series I'm going to explore one potential treatment path for somebody with depression. Depression looks different for each and every person, so no one treatment path with will look exactly the same. But this gives you a general idea of what treatment might look like. This particular video explores what the initial session will look like. As a helpful hint. Over the next few weeks I will be going over a lot of stuff for more in depth information about particular techniques or issues. In depth videos can be found on the YouTube channel@docsnipes.com YouTube the first thing that I do when people come into treatment is, you know, get to know them and then we start talking about what their symptoms are. I typically don't get too hung up on the DSM or the diagnostic criteria because depression may look different for every person. And there are a lot of symptoms that occur with depression that are not in the diagnostic manual. So I start by asking for each symptom the person has when it started, is it something that started a week ago or three years ago? What was different before it started? What do they think causes it, what makes it worse and what makes it better, Even if just a little bit or for a short period of time, this will give us an idea about potential causes of the symptoms, about potential things that the person already does or skills they already have that we can build on, and about things the person knows already don't work. I also encourage them to watch the video what causes that Symptom on the YouTube channel to learn more about what causes each of the symptoms that we're going to start talking about. Physically, when somebody is depressed, they may experience sleep disturbances. Likewise, people who don't sleep well often develop depression. Many of these symptoms can either cause depression or be caused by depression. And it's important to understand that and recognize the reciprocal nature. Eating disturbances are another issue that come up. Sometimes people have no appetite. Sometimes all they want to do is eat junk food. And that kind of makes sense because when we are under stress, sometimes our body says, you know what? Now's not the time to eat. We need to worry about fighting or fleeing, not resting and digesting. Other times our body is experiencing imbalances in neurotransmitters. And food we eat that are high fat, high sugar foods tend to cause the release of dopamine and serotonin and endorphins, which are feel Good chemicals. I always look at what is the behavior telling me another symptom is GI distress. Some people may experience constipation. When people get depressed, it's often a slowing of their whole system, including their gut. So we want to look at constipation and pain. Pain in the gut can be made worse because of changes in the gut bacteria, because of the depression or because of what they're eating. And generally pain can be made worse when people are depressed. Because when we're depressed, our pain tolerance actually often goes down. Things that may have been not painful or not, you know, notable before they were depressed now are painful to them. We want to recognize that that actually is a legit symptom of changes in neurochemicals in the person. When people are depressed, they often don't move a lot and they often sleep a lot more, which can also contribute to muscle imbalances and pain. So we're going to talk about pain because pain also can cause depression. Low energy can be caused by sleep disturbances, poor nutrition or chronic pain or a lot of other things. And we want to recognize that when we have low energy, it's hard to get motivated. It's hard to feel like you've got any get up and go, which can contribute to feeling depressed. You know, you just, you want to sit on the sofa all the time. Different than low energy, which is just not having the energy, not having the gas to go is slowing. And that is like Moving into a 60 mile an hour wind. When people are depressed, it often feels like it takes 10 times more energy to move, to walk, to take a shower than it did when they weren't depressed. Addiction also often comes up because when people are depressed, they often try to self medicate in some way and make it go away. This can be behavioral addictions like shopping or gaming, it can gambling, it can be chemical addictions, it can, you know, and in there we're also including nicotine. So addictions may get worse. Addictions also alter the neurochemical levels or the brain chemicals which can contribute to mood symptoms, impulsive behaviors. Some people don't have enough energy to even think about it. Other people occasionally have these little spurts of energy and they engage in risk taking behaviors or impulsive behaviors in order to feel something. You know, that's the brief moment where they have this adrenaline rush and they're like, oh my gosh, that's incredible. And immunity. When your immune system goes haywire, it can contribute to systemic inflammation. People who have autoimmune disorders are well aware of this. But anytime your immune system is triggered, it can trigger associated inflammation. That inflammation has also been associated with an increase in depressive symptoms. Likewise, depression and stress can trigger an increase in inflammatory cytokines in the body and an increase in immunity in inflammation. All of these symptoms have a back and forth affectively. Well, of course, the person is presenting for depression, so they're depressed. They may also experience apathy or low motivation. They just, they don't really care about much of anything or what we call anhedonia. And that's feeling numb, not feeling super depressed, not feeling, you know, super happy, super anxious, just not feeling guilt. Anger and anxiety are also very prominent symptoms in people with depression. And in treatment, if somebody's experiencing these things, we talk about what's triggering them and we'll process some of those issues. But right now, we're just trying to get a picture of what depression looks like for the person cognitively or mentally. People who are depressed often have difficulty making decisions and thinking clearly. Now, this can be caused by insufficient sleep, poor nutrition, depression itself, a variety of things. But these things also make it harder to do your daily activities, which can contribute to feeling hopeless, helpless, and depressed. Pessimism can cause depression. If you've always been sort of a negative nelly, then that can contribute to feeling helpless and hopeless. A lot of times when people are depressed, though, they can start feeling more pessimistic because when they're depressed, they notice more of the negative stuff. They notice more of the stuff that's out of their control, and it can contribute to feelings of depression, ruminations. A lot of times when people are depressed, they have thoughts that bounce around in their head. And, you know, there's a lot of reasons for this. But. But what's important to recognize is those thoughts are generally critical, negative, pessimistic, and they tend to be very overwhelming and loud. That negative inner critic or those hecklers in your gallery tend to be a lot louder when you're depressed environmentally. I found that for a lot of people, their outside represents what's going on on their inside. So if they're disorganized or disheveled, that gives me a clue. That may be how they're feeling inside because of all the things that we've talked about already. People may be experiencing difficulty at school or work and resulting financial difficulties. Difficulty in these areas contributes to stress and distress and often worsens depression. Relationally, people who are depressed often withdraw from others. They can't take the input from other people. They don't have the energy to deal with their own stuff, let alone anybody else's stuff. They may withdraw from others because other people may try to cheer them up, which makes them feel rejected or misunderstood. Or other people may withdraw from them because they just can't take being around somebody who's so depressed. They may experience impatience or irritability again because they are overwhelmed. When people bring stuff to them when life happens, it can feel overwhelming and it can trigger that fight or flight response. Low self esteem is very common in depression. A lot of times because of the depression, the person is not doing the things they think they should or the way they used to, and it makes them feel bad about themselves. Now, people with low self esteem from long ago can also develop depression partly as a result of that. So yin and yang. Toxic relationships also tend to cause depression and may flourish when somebody is depressed because people, people who are depressed may tolerate toxic behavior more because they just don't have the energy to address it. Once we've identified what each symptom looks like for that person, when it started, what makes it better, what makes it worse, et cetera, then we're going to identify what recovery from each symptom looks like. And for a lot of things when we talk about psychology, we we use what's called a Likert scale. And an anchored Likert scale has words that go along with each point on the scale. So for somebody's mood, one may be miserable, two may be okay, three is happy, four is really excited, and five is unbelievably ecstatic. We don't expect them to get to five a whole lot, but that gives us an idea of where we are starting. So people can rank their moods or rank the behavior on a regular basis so we can track its progress. We will work to define goals for people's symptoms that are smart, specific, measurable, achievable, rewarding, and time limited. For example, I will have more energy as evidenced by being able to work out, go to work, and do at least 90% of my normal adulting tasks without getting completely worn out or feeling weighed down. Now this is a goal the person is setting for three months from now, not for next week. This is ultimately where they want to be. I will sleep better, as evidenced by getting at least seven solid hours of quality sleep each night. I will get motivation back as evidenced by doing the things that I need and want to do most days. It's important with goals not to set extreme goals that are 100% of the time, because generally we can't do things 100% of the time. So if you set a goal that's like that, then you're setting yourself up for failure. The next thing I do in this first session with the person is create a support plan. Change causes crisis and crisis causes change. It doesn't matter what the change is. It can be a positive change like getting healthier or bringing a new baby into the family, but that causes changes which can be stressful. It may not be like an overwhelming crisis, but it can be stressful. Change takes a lot of energy and work. And I encourage the people that I work with to to recognize that they're going to need at least 15 minutes in the morning, 15 minutes in the evening, and about 30, sometimes 60 minutes some other time during the day. So when they get up at lunchtime and before they go to bed, possibly that's not a huge time commitment. But people who are depressed have very little energy. So this still feels like a lot. We talk about what things can you eliminate or simplify to free up time and energy for this change. And that may mean things like preparing meals ahead of time or getting pre prepared meals for a little while so you don't have the dishes and you don't have the prep time and all that stuff. So you have more time. You can focus on working your recovery plan. How can you alter your environment to stay motivated and remind you to use your new skills for change? There are a lot of new behaviors and habits that I ask people to do and those behaviors and habits can be programmed into your mobile device. You can get an app that people often use for medication and get push notifications for things like meditation. Then I ask them to think about who in your life is supportive and how can they help you and how will you let them know about plans and what you need from them. Don't expect them to read your mind and know that you need them to do extra work around the house or help you watch the kids or something else. It's important to articulate to other people what they can do to help. It's also important for the people to identify what they can do to help themselves feel safe in general. Feel safe when they're triggered and feel safe so they can work on their assignments so they're not afraid of becoming overwhelmed or spiraling. And then they're asked to identify three strategies they can use to cope when they begin to spiral. When people are experiencing depression, you don't expect them to start treatment and never have another spiraling episode. And I believe it's important to create this safety support Plan ahead of time to help people feel empowered so they have tools at their disposal that can help them endure what's going on. It's not going to necessarily make them feel wonderful, but it helps them endure it so they feel safe. They don't feel like they're going to be completely overwhelmed. The next thing we do is talk about which two or three symptoms do you want to focus on changing first? Because when you make positive changes in any area of your life, it often makes reciprocal positive changes in other areas. And you can really only effectively focus on two or three things at a time. We will talk about how we're going to measure that, whether we're going to measure the frequency, how often each occurs, how long particular episodes last, or the intensity or quality of each again on one of those Likert scales. And each time the behavior or symptom occurs, the person is also going to note what triggered it, what helped stop it, if anything, and what did not help. So we continue to get information about what is helping, what doesn't work, what triggers it, so we can address those in session. Another thing I ask them to do is a feelings awareness worksheet. Now, this is something they're going to do between sessions in order to start identifying early warning signs of distress. So they may be able to take action sooner than waiting until it's a big crisis, you know, waiting till it hits them. From quote out of the blue. I ask people to identify what particular feelings look like for them and what triggers that feeling, what thoughts, what activities, what people, and even what sensations like what sounds. The ceiling fan over my bed makes an awful humming sound, and it annoys the crap out of me. And that can trigger my irritation. So I know that that's a sound that will trigger irritability in me. And I encourage them to look at and identify what anger, anxiety, depression, and happiness look like for them and what triggers those emotions. Another thing they're going to start doing beginning tomorrow, you know, beginning the day after this session is morning and evening mindfulness. And this is the 15 minutes in the morning and 15 minutes in the even in the morning, they're asked to inhale for a count of four, envisioning energy and light filling their body. Hold it for a count of four and feel that energy spread, and then exhale for a count of four and envision fatigue, darkness, and brain fog leaving their body on their breath. You know, they can even envision their breath coming out a color that represents fatigue. Repeat this four times in the morning. This deep breathing helps increase Oxygen and get people going, so to speak. After they do this, they will do their mindfulness inventory and it seems long on these slides, but it really only takes about 10 minutes. They'll think, how do I feel physically? What are my needs physically right now? What things might make me more vulnerable to emotional distress today? What physical things do I have going on that might make me cranky or more prone to be irritable and how can I cope with them? Was it easy or hard to fall asleep? How well did I sleep? How many hours did I sleep? Do I feel rested? If I woke up a lot? Why? What will I do beginning today to address anything that is waking me up in the night? If I did not sleep well, how does that impact my energy, concentration, productivity, mood and patience with others? Affectively or emotionally and cognitively or mentally, how do I feel? Am I happy and clear headed or depressed and foggy headed or something in between? What are my needs? What might make me more vulnerable to distress today? If you wake up in the morning and you're just in a awful mood, you know that. You know that you're already kind of at your precipice and it's not going to take much to trigger irritability. So what can you do to cope during your day to so when life happens it doesn't bring on extra distress and you don't spiral environmentally, what are three positive things in my environment right now? What things might come into my environment today that cause me distress and how can I best deal with them? Planning ahead for any obstacles that you might encounter relationally, how do I feel about myself? What relationships do I have that enhance my life? And this can include your pets. What can I do to nurture them? What relationships might trigger or make me more vulnerable to distress today and how can I best cope with them? So if you know you've got to interact with a person at work that typically gets on your very last nerve, how can you best cope with this so it doesn't cause extra distress? In the evening, you're going to do deep breathing again, but this time inhale for a count of four. Envisioning cool blue entering your body and helping you relax. Hold for a count of four and feel that soothing feeling spread. Then exhale for a count of four. Envisioning stress, darkness and irritability leaving your body on your breath. If you've got kids in the house, this can be a fun activity to do with them. And everybody gets bubble stuff and you try to see who can blow the biggest bubble in order to blow a single big bubble, you have to exhale a lot of breath very, very slowly in the evening. The questions are a little bit different again. Physically, how do I feel and what are my needs? What things made me more vulnerable to distress today? So you're doing a look back. How well did I cope with them? Is there something I will do differently next time? Affectively and cognitively, how do I feel emotionally and mentally, what are my needs? What would make me happy right now? How well did I cope with my feelings today? How good was my concentration? And is there something different I will do tomorrow to improve the moment? Environmentally, what are three positive things in my environment right now? What things came into my environment today that caused me distress? How well did I cope with them? There something different I will do next time. And finally, relationally, what are three things I did well today? This plays on your relationship with self or your self esteem. What relationships do I have that enhance my life? Remember those pets again? And what can I do to nurture them? I also ask people to get a physical because there are a lot of physiological things like low testosterone, estrogen imbalances, hypothyroid anemia, low vitamin D. There are a lot of things that have relatively simple fixes that can contribute to depressive symptoms and no amount of talk therapy is going to address those things. I ask people to schedule their physical as soon as possible so that we will have the results, including the blood work, back by week six. I encourage them to make sure that they get their blood pressure and their oxygen saturation evaluated, vitamin D and B12 levels, liver and kidney functioning, their sex hormones, gonadal hormones and thyroid hormones. So like testosterone, estrogen and thyroid hormones, assess for anemia and if there might be a chance that they have an undiagnosed autoimmune disorder, do to also ask the doctor if it would be appropriate to look for those autoimmune markers. Finally, I ask people to think about their housing and their finances. When you don't feel like you've got stable housing, it adds stress, it adds distress, which makes it harder to recover and contributes to feeling helpless and hopeless. I encourage people over the next 12 weeks to start thinking about what they need to do in order to make sure that they feel as safe as possible in their own four walls so they can relax. And what do they need to do, if anything, to ensure the stability of their housing so they know that they've got a home. I asked them to do the same thing with their finances because we need to have enough Money to pay the rent, to keep the lights on, to get medication, to get food, all those. And without those things, we are at much greater risk of experiencing distress and depression. So I encourage people over the week to evaluate their housing and their finances to identify if there's anything that needs to be addressed. In this first session, people have identified their symptoms and the causes. They've defined the overall overall what recovery looks like for them. We've worked together in session to develop a support and safety plan. Now, throughout the week, they're going to use worksheets to gather baseline data on their two or three symptoms that they're going to start addressing. They're going to do the Feelings worksheet to identify what feelings look like for them. Begin practicing morning and evening mindfulness and bring those mindfulness worksheets to session, because we'll process them in session. We'll look for themes, we'll look for trends, we'll look for triggers, and we'll look for improvement. As you start keeping these mindfulness journals, it will provide a whole lot of information. And then they're going to schedule a physical and assess their financial and housing stability. So that's a lot to do in the first week. But when you really look at it, there is the feelings activity, assessing finances and housing and scheduling that physical. So none of those should take too terribly long. Beginning practicing morning and evening mindfulness. So that's your 15 minutes in the morning and 15 minutes in the evening. This show was produced by Mr. Charles Snipes and presented by Dr. Donnelly Snipes. You can learn more about depression treatment, boundaries and mental health@docsnipes.com YouTube they can be reached at 1633 West Main Street, Suite 902, Lebanon, Tennessee 37087 or by email at supportocsnipes.com.