DBT Skills to Address Vulnerabilities for Anxiety Depression Anger and Pain Relief

You. I'd like to welcome everybody to today's presentation. We're going to return to talking about vulnerabilities. And this is a topic we've covered before, but, you know, I don't seem to be able to say enough about it. So we're going to talk some more about it. We're going to define what vulnerabilities are. And, you know, I expand the definition more than what Linehan did in Dialectical Behavior Therapy because I think there are a lot of other resources or vulnerabilities out there. Sorry, I'm trying to read two things at once. Anyhow, we're going to identify some of the most common vulnerabilities as I define them. So we're going to go beyond sleep and nutrition, and we're going to look at environmental vulnerabilities, etc. Their effects and ways to present them. So why do we care? Vulnerabilities are situations or things that make it more difficult to deal with life on life's terms, leading to depression, anxiety, stress, anger, dysphoric moods. You know, we'll just kind of put it under that big old umbrella and make it easier for you to either overreact or get stuck. And when I say overreact, you know, I don't want people to take that as negatively as it sounds. It emotionally. Dysregulate might be a more clinical term to use, but it takes people and instead upset about it at a level of a one or a two. It puts them at a six. Or they start feeling something, they get angry, and they get stuck in that anger and they're just wallowing it all weekend or all week. So vulnerabilities are things we want to look at because most of them are really mitigatable, if not preventable. We can mitigate a lot of them. I mean, if you've got an infant at home, for example, you may not be able to prevent lack of sleep because that's just the way it works. But you can mitigate it. So when, you know, sleep, when the baby sleeps, or whatever the case may be, it works differently for different people. So we can look at ways to help people minimize their sleep deprivation until the child is sleeping through the night, and then they can, you know, not worry about it as much anymore. Depression occurs if people feel hopeless and helpless. So think about it. You know, if you have a loss, of course, you may feel hopeless and helpless and you go through the grieving process. Denial, anger, bargaining, depression, and acceptance. Okay, we can't prevent all losses, so we Know that we're going to feel depression occasionally, but people who feel anxious all the time, imagine just always waiting for that other shoe to drop. Imagine being in a position where you just couldn't relax, you couldn't rest, or you were angry all the time, and everywhere you looked, somebody ticked you off, and you just didn't feel like there was any hope for things getting better. You didn't have any faith in other people or the world anymore. This is where depression starts setting in. So if you think about it that way, you can see how anxiety and depression and anger and depression kind of shake hands a lot. You know, it's not uncommon to see the two of them together. Anxiety and anger, as I've said before, are representative of the fight or flight or fight or flight reaction. So when people feel threatened, then they're either going to react with fight or flee, depending on their temperament and whether they believe that it's something that they can take, you know, to fight and they'd win, or they need to get out of there. So anxiety and anger happen when people feel powerless or out of control, because generally that's what a threat means. There's something that is taking away your power and making you guess what? Vulnerable. Why am I going through all these definitions in such great detail? Because it's important for clients to understand that mood disorders and vulnerabilities kind of go hand in hand. And I want them to see how being vulnerable can lead to emotional dysphoria or dysregulation. Addictive behaviors often increase when people feel a need to escape because of stress, anxiety, depression, or physical pain. So we want to look at that. And I'm not saying everybody who uses alcohol or opiates or whatever when they're in pain, you know, emotional pain or physical pain are going to become addictive. No. You know, there are lots of people who drink socially and don't have a problem with it. There are lots of people who take opiates and, you know, three days or whatever, and then they don't. They have pills left over, and they're like, I don't know what to do with these things. So it's important to recognize that use does not translate to addiction. Addiction happens when the brain starts getting tolerant and the body starts developing a dependence on that drug. And then when the person's not using, they have difficulty feeling okay, so then they want to use again. And that's the beginning of addiction. So individual vulnerabilities, we're going to start out with the physical ones because those are the most obvious and sometimes the easiest to address. And please feel free to, you know, chime in your two cents about interventions that you've used to help patients deal with any of these things. Some of them are out of our scope of practice, so we refer out. But there are also times, like with nutrition and exercise, that we can educate patients and point them in the right direction. So let's start with pain. When people are in pain, they don't sleep well. Generally, even if they're taking opiate medication, they're probably not getting quality sleep. They may be sleeping through the night with if they take a painkiller before they go to bed, but it's probably not quality sleep. And, and without quality sleep, the brain and the neurotransmitters can't rest and rebalance and do everything they need to do. So sleep problems are going to predispose people to being more vulnerable. Think about a time when maybe you had a really bad cold and you couldn't breathe and you didn't sleep most of the night and you started getting run down. Even when you started feeling better, if you were still exhausted, how did that affect your mood? Were you irritable? Were you more likely to be impatient with people? Were you depressed? Unmotivated? I'm describing me. I know. So I don't deal well with sleep deprivation at all. So knowing that, I know that during holidays when I'm sick, you know, for whatever reason, all the time, sleep is really crucial to me in order to make sure that I'm kind of at my best. Difficulty concentrating happens when people are in pain. If you've broken an arm or, you know, had a toothache or something, or even had a migraine, how hard is it to concentrate when you're in pain? Now think about the symptoms for depression. So sleep problems, difficulty concentrating, irritable mood. Well, pain can cause all these things. So we're wanting to look at that. If people are having difficulty concentrating, how can we help them do that? How can we help them deal with it while they're in pain? Pain is so important. Sleep is really important, but it's important to address pain because it impacts sleep, it impacts concentration and productivity, which can make people feel frustrated, which increases their anxiety, which can increase their sense of helplessness. You see where we're going with this? Pain tends to make a lot of people irritable, especially if you've been in pain for a long time. I can deal with most types of pain for a short period of time, but if it's ongoing and I had a neck injury at one point and like six weeks and I was going to physical therapy and PT seemed to make the pain worse. And it was just frustrating as all get out and it was keeping me from sleeping, which is never a good thing. So all of those things you want to kind of take into consideration when you're talking to clients. Why is it important to do a pain assessment? If you're in a JCO accredited facility, then you're familiar with doing pain assessments. When does the pain occur? What is the quality of the pain? Is it stabbing, shooting, burning, yada, yada? You know, we do all these things initially. Well, we're not going to go into that right now. The important thing to remember is it's not just about getting medication. It's about identifying if patients have pain and helping them draw the connection between their pain, the effects of their pain and their mood. Now what can clients do for pain? They can talk to their doctor. They may, if they're on opiate medications or even some like gabapentin, it may be making them so tired that they're having difficulty functioning and they're feeling more depressed. If their pain medication is not working, their doctor may need to switch them up. It may not be an matter of increasing dose, which is not really what we typically hope is going to happen. We hope that they'll find complementary interventions. There are a lot of things, I was doing that research today, acupuncture, massage, physical therapy. There's a lot of things that physical therapy works for. Let's think about what causes pain. You know, there are things like hepatitis that causes cause pain. And yeah, physical therapy is not going to help with that. Neither is are a lot of other things so that may need medication. But if you have back pain, neck pain, migraines, what's causing that? Sometimes it's a muscle imbalance. If a patient has scoliosis, then the muscles on one side of the back are going to be tighter than the muscles on the other side. So they may spasm. If they carry their tension in their back and neck, that can cause pain and cramping, especially if they're under a lot of stress, which can contribute to migraines. So we want to find out what's causing this pain and where can we intervene. Yoga has been shown to be really helpful, especially for musculoskeletal things that are due to muscle imbalances and muscle tension. So there are ways things you can do. Hot and cold packs are also really helpful. Tens units transcutaneous electronic nerve stimulation Sounds really scary. But you put little electrode patches on and it just bombards the nerve with little impulses, which kind of busies it, if you will. So it's quit sending the pain signals. So there are a lot of non pharmacological interventions that patients can use, remembering that sometimes when patients are in pain, their mood is really bad. So we need to address it that way. But sometimes the side effects of the pain medications make the patient depressed, anxious, whatever, so we may need to deal with medication side effects. So pain and pain treatment is a tricky little thing. Poor nutrition. And I always say, don't, you know, we don't want clients to necessarily feel like they've got to become, you know, nutrition nuts. And if they do, great, but if they don't, it's not the end of the world. What we want to make sure is that they're getting a reasonable diet, which if they have three colors on every plate at every meal, probably going to get pretty close to having a reasonable diet. And that doesn't mean three shades of white and brown. So that's what I encourage them to do. Instead of getting hung up on counting number of vegetable servings and number of fruit servings, that whole food pyramid thing, because that gets tedious for a lot of people. If they can look at their plate and go, yep, there's three colors, then it's a little bit easier. Obviously, we're not going to make nutrition prescriptions for clients, but we do want to educate them about why good nutrition is important. Good nutrition gives the body the building blocks to recover from injury, keep them from getting sick and make their happy. Chemicals, make those neurotransmitters, some of your essential amino acids. Essential amino acids you have to get from your food. So some of those essential amino acids you need in order to make neurotransmitters, which means you've got to have a good diet. Serotonin, we know is implicated with stress and anxiety management, is made from tryptophan, which is an amino acid. You have to get tryptophan in your diet. Now, the good thing is it's easy to get it. You know, it's in just about every protein out there. But if clients are on like a really high fat, low protein, low carb diet, they may not be getting enough. Chances are they are. But it's important to make sure they're getting good sources of Nutrition. Water dehydration. 1% of dehydration tends to leave people feeling a Little bit foggy. 2% Dehydration actually starts to impact memory. So if you have somebody again thinking about the symptoms of depression and even anxiety, irritability, confusion, difficulty concentrating, apathy, it can happen just with significant dehydration. So encourage clients to drink water. Help them understand that just because you drink 60 ounces of water a day or 64 ounces of water a day, doesn't necessarily mean you're getting enough. Because if you're also drinking a whole pot of coffee, you know, coffee has caffeine, which is a diuretic, then you need more water in your system. And so they need to talk with their doctor and be aware of how much water they actually need. You can drink too much. That's the other thing I tell them. You can drink too much and then wash out all the vitamins and stuff that your body needs. So it's a balancing act, but it's common sense. A nutritionist friend of mine said that you drink your 64 ounces of water. That's great. And then for every eight ounces of caffeinated beverage you drink, drink another eight ounces of water, which, when I started doing that, I felt like I was going to float away. But she was right. That was a good rule to kind of think about. Oh, and with three colors on your plate at each meal, much to my father's chagrin, condiments don't count. He thought ketchup was a vegetable. And try to eat smaller meals every few hours. If you can't eat a big meal, depending on the person, any medical conditions they have that might not work for them, but what we just want to do is make sure they're getting a variety of foods. Encourage them to keep a food diary so they can show their physician or they can bring it in. Because if they keep a food diary, even though we're not making prescriptions about what to eat, they're going to be more cognizant of what they're eating. Sufficient quality sleep. We want to make sure that people realize, you know, we talked about pain on the first slide. Well, let's talk about sleep in general, because there's lots of things that cause bad sleep. Drug and alcohol induced sleep is rarely good quality. And this includes antihistamines, which, if you look at most of the over the counter sleep aids. Diphenhydramine, which is Benadryl, is the ingredient in an over the counter sleep aid. Well, that helps you get to sleep faster. But when you look at, or when scientists look at the actual brain waves and the deep sleep, there's less deep sleep. You Stay in lighter sleep when that antihistamine is in your system. They've also started to link antihistamine with the development of Alzheimer's late and dementia later in life. So that's another cause for concern if you're. If somebody's taking antihistamines on a regular basis, especially like diphenhydramine and the sedating antihistamines. But anyhow, back to sleep. Lack of sleep can produce fogginess, difficulty concentrating, irritability, and overeating. When we're circadian rhythms are in whack. And when we sleep, we help our circadian rhythms get set. That also sets those hormones in our brain that are responsible for hunger and satiation. So if we're not getting enough sleep, if our circadian rhythms are not in balance or in rhythm, then we may tend to overeat. My husband was on patrol for, oh, golly, 10, 12 years of his career, and for a lot of it, he was on midnight shift because that's what he loved. But he would get home and he'd work 7pm to 7 a. He'd get home, and on his days off, he wouldn't go to sleep. He'd stay up so he could be with the family on his two days off, and then he'd go back to work. So his body never knew, do we sleep when it's dark? Do we sleep when it's light? And he always had just kind of this permanent stage of jet lag, and he never really knew if he was hungry or not. The body can't figure out when it's hungry, when it's sleepy at a certain point. So helping people understand that, that it's really important for maintaining your weight, for maintaining your immunity, as well as maintaining your mood to get good sleep. So encourage people to develop a sleep routine and any suggestions you want to throw in here. They have blue light filters that you can get for your digital devices, so it won't prohibit your brain from starting to make melatonin if you're still playing on your iPhone and doing Candy Crush or Scrabble or whatever you do up until you go to bed. But TVs also emit blue light, which trick your brain. And your brain doesn't know if it's supposed to be awake or asleep. So anytime you can, if you can go into the color settings in the TV in my bedroom, I have the red color settings turned way up and the blue color settings turned way down to help a little bit because I'm bad about watching TV until late at Night, but that can help. Don't take a hot shower right before bath. Most people think hot shower relaxation, that'll help me get sleepy. The body needs to cool down in order to get sleepy. Now my house tends to be really cool. So if I take a hot shower and I get out, I get cold really fast. So maybe I kind of undo that. But encourage people to sleep when it's cool. Make sure they've got a good sleep environment. Kick the dogs out, kick the cat out. Get rid of any allergens that you can have, a comfortable mattress and a comfortable pillow. There are lots of articles people can find online on how to develop an ergonomic sleep situation so your neck is not all cranked up and you can actually rest more peacefully. Those things can be important. Cut back on caffeine 12 hours before bed. Caffeine stays in your body. What you drink at noon is still going to impact your sleep quality at midnight. Now, after I drink caffeine, well, I don't drink it anymore. But when I used to, an hour or two later, I was starting to feel groggy again, so it was time for another hit. But that was just building up more and more in my body, so it was harder for it to get rid of all the stimulant effects so I could get to sleep. And I go to sleep usually around 8, get up around 4. So when I went to bed at 8, the stuff that the caffeine that I had had at three was still full bore in my system. So try to cut back on caffeine 12 hours before your bedtime, but definitely six hours before bedtime. Cutting back on caffeine can cause headaches, irritability, a whole bunch of other stuff. Again, advise clients to do it mindfully, talk with their doctor, yada yada. But you know, wean down is generally, if it's not clinically contraindicated, what a lot of clients prefer to do. So they go to 3/4 caffeine for a month and then half caf for a month, and then, you know, so on and so forth. I drink decaf like it's going out of style. But I don't drink caffeine anymore. So I still have that, you know, drink that I like, but I'm not suffering. Develop a sleep routine, same three things. Each night you go to bed or you get home, you eat dinner, then you do something, whatever it is you do, and then you do something else, whatever it is you do, and then you go to sleep. That sets your brain up just like you used to do with your children. They'd come home from school, play, eat dinner, take a bath, read a story, go to bed. Their brain kind of knew what to expect. And as soon as they came home and ate dinner, the brain would start going, okay, we're going to be going into that melatonin zone pretty soon. It helps us even if you don't go to sleep at exactly the same time each night, if you can go to sleep close to the same time and definitely do those three things. So don't make them super involved. For me, I come home, I make dinner, we put all the animals up. I live on a farm, so we got to put everybody to bed. I come home, I play Scrabble, and then I go to sleep. And as soon as I start playing Scrabble, I can feel myself kind of nodding off. So those are things to be aware of and help clients figure out what. What can they do that fits in with their lifestyle? I don't want to try to have them upset the apple cart. What can you do that's easy to integrate into your lifestyle with sleep? You can also have them keep a sleep journal and note how they feel in the morning when they wake up and then throughout the day on days they think they slept well versus not well. With the new sleep trackers on a lot of our fitness devices, they are not really accurate. Basically, they measure tossing and turning versus not tossing and turning. Not so much deep and light sleep. But it does give you an idea about how much you tossed and turned all night long. When you look at the sleep trackers to figure out I was asleep for nine hours, but was it restful sleep? Have them compare how they feel on days when they had restful sleep versus days that they didn't have restful sleep. Okay. Illness is another vulnerability. I'm not pleasant to be around when I'm sick. My son is even more unpleasant. When you can't breathe or you have something, you know, you're nauseous or whatever it is, your sleep gets disrupted. So we're back to that whole sleep thing again. You feel exhausted, your body is trying to help you recoup, so you're not going to have that get up and go to go to the office and, you know, work on three different projects. You may have a foggy head, difficulty concentrating, either from like a sinus infection from lack of sleep or side effects of the medication. I know for me, whenever I take Sudafed, I'm loopy as can be. So knowing how medication affects you, you can't necessarily Prevent getting sick, but make sure that you have, you know, do your best to prevent it. None of us wants to get sick. But make sure clients have ways to mitigate this stuff so they don't get as frustrated when they are experiencing illness and so that they're aware, they draw the connection again, between, okay, when I am sick or when I'm not feeling well or when my allergies are acting up. This is how I tend to feel. And, you know, I'm not on my A game or I tend to be more irritable and impatient with people. So maybe that's not the time to be volunteering for the PTA or whatever. So helping them make those connections is the big thing with vulnerabilities and then figuring out ways that you can minimize the time you're sick. And when you are sick, how can you make the best out of it? You know, interventions. Compassion. Have compassion for yourself instead of saying, I need to get up and push through it. Sometimes you just need to sit your happy little butt in bed and watch TV and, you know, drink chicken soup or whatever you do. Let your body have a chance to recoup. You also want to have compassion for other people when you're sick. Number one, if you tend to be irritable, it's not going to do well for your relationships. If you walk in and you're like, snotting all over the place, and then you're also being snotty, nobody's going to want to really be around you. But you also don't want to get them sick. So be kind to others. And, you know, part of being kind to others not only is not getting them sick, but but also not being around them or forcing them to be around you when you're in a really crappy mood. Good nutrition can help keep illness away. We know if we keep our body charged with the vitamins it needs, the B vitamins and the D vitamins and all that stuff, it does help stave off illnesses. Wash hands a lot. Helping people, especially during this flu season, making sure my kids understand how viruses and stuff are transmitted and all that sort of stuff has been really important, but help people realize, where do you get some of these things from? And there are articles that show that our cell phones are actually have more germs on them for a lot of people than toilet seats. And I'm like, okay, really? That's disgusting. So I'm like disinfecting my phone constantly now. But those are things that they can think about in order to prevent vulnerabilities Some people have a lower immune system than other people. I tend to have a really strong one because I've got kids at home. And, you know, kids are little germ factories. But, you know, my mother, for example, not nearly as immune to the stuff as the stuff as she used to be because she's not around children, and she's. She's around other people who aren't around a lot of children and mutant bugabuggas, as we call them in our household. So I'm aware of that, and I am cognizant of that fact. And she is too. So she doesn't put herself in situations like if we're getting over a cold, she doesn't like, say, oh, hey, I'll come down and help. She's like, oh, give me a call when you get better, okay? So brain changes. Brain changes can be hereditary. They can be from an accident, or they can be the result of addictive behaviors. But anything that makes your brain not optimally functioning, if you will, can predispose you to depression, anxiety, addiction. You know, we know that for a lot of people with mood disorders and other disorders, there's a organic component to it. There is a brain change. There's a brain issue in there. So we want to make sure that people are aware of this. Changes in the structure of the brain have all kinds of effects, including memory, concentration, and mood. Helping people recognize what causes these brain changes. If they've had an accident or if they've, you know, even if they've had some sort of trauma that is going to cause some, at least temporary changes in their brain structure. They've shown in soldiers that sometimes trauma can cause permanent changes in brain structure, similar to concussive brain injury. Being aware of this, being aware that brain changes can happen, we want to prevent it when at all possible. So preventing addiction, preventing accidents. But if people do have that, helping them understand that, okay, you know, you injured this part of your brain, so your impulse control may not be where it used to be. So let's talk about how to deal with that so it doesn't cause you further problems. For a lot of people, brain changes is a matter of keeping their neurochemicals at optimal levels, which also means taking good care of themselves, getting a good diet, getting enough sleep, and taking medication as they need to to help stabilize those neurochemical levels. Emotional vulnerabilities. You wake up in the morning and for whatever reason, you get up on the wrong side of the bed and you are just a big old cranky pants so think about that. How is that going to impact the rest of your day, especially if you don't get it in check? But when people are angry, then if they're already starting at like level three on anger and something happens that normally would have only mildly irritated them, they're already at a level three. So whatever that is is going to take them up to a level four or level five. So they're going to be more likely to be overly angry. They're going to be more likely to act more, react more strongly to something than they probably normally would have if they're already starting out angry. Same thing with anxiety. When people have a lot of anxiety, they tend to be more irritable. Think fight or flight. You have a person who is already feeling threatened for whatever reason, who is already feeling anxious for whatever reason, then something else comes along and it's going to intensify that fight or flight reaction. So they may be irritable, they may push other stuff away. I can't deal with one more thing, depression. People who are depressed have more difficulty dealing with life on life's terms. So again, we want to ask clients, when you are feeling this way, what can you do to help yourself improve the next moment and prevent yourself from encountering things that are going to make it worse? When I am under stress at work for some reason, normally I have my door open unless I am recording and people can come in and, you know, whatever, I am happy for people to stop by and say hi. Same thing when I worked at the treatment center. But on days where I was feeling irritable or stressed out for some reason, I knew that my patient's fuse was about this long. So I would close the door. And everybody was respectful of the fact that when my door was closed, you really probably only wanted to knock on it if you absolutely needed something. Because there was probably a reason my door was closed, which there was. So that's one of the ways I mitigated my vulnerabilities. When I'm anxious, when I'm stressed, and order to prevent me from being rude to somebody or making a rash decision, I keep my door closed. So then, you know, I'm not getting interrupted. And it doesn't bother me as much when you're grieving, when you're feeling guilty, when you're feeling jealous, resentful. Any of these things can make you more likely to react more strongly to adversity. That happens. And adversity, we want to really think about this. There's adversity, like your boss comes in and writes you up for something that's unpleasant. But then there's also adversity in terms of being in a situation that is counter to your temperament and thinking about the Kircy temperament sorter or the Myers Briggs. I tend to be, like, pegged out on the J. I love my structure, and I don't deal well with interruptions or alterations to my day. I can handle interruptions if I'm planning for them, but if I'm in a situation where I am stressed and I have a lot of interruptions or things get changed at the last minute, it's much harder for me to deal with it than times when I have more energy and I'm not trying to deal with six other things. So helping clients recognize that when they are feeling less than on their A game, trying to keep their environment and trying to keep their day flowing in a way that is conducive to their personality and temperament is going to be really important. You know, extroverts tend to talk things out while they're thinking and draw energy from being around other people. So extroverts may want to go out to lunch with a friend, whereas an introvert is going to be even more exhausted by having to be on socially when they're already dealing with whatever is bothering them. So they may need some time to just sit out in the park and feed the pigeons or whatever they do. Encouraging people to know what it is that they need when they're feeling dysphoric to at least not make it worse. When people are having negative motions, it keeps the brain in that fight or flight phase, which takes energy. I mean, your brain is constantly surveilling for anything that might happen. That could potentially be another thing. You know, you're already dealing with this threat here. So it's saying, all right, you deal with that, and I'll keep a lookout for all the rest of the stuff. Well, that's exhausting. And it also keeps you from being able to wind down. It keeps you from being able to get that quality sleep. If you're constantly stressed or amped up, it can prevent your calming neurotransmitters, your GABA and your serotonin from being excreted. If you're on alert, then your body's not going to say, hey, let's give you some chillax kind of neurotransmitters. It's going to say, we need to keep the norepinephrine going so we have more focus and more alertness, and we can keep an eye on everything that's going on, the glutamate, all those things are going to be up your excitatory neurotransmitters. So when people are having negative emotions, have them develop a list that they keep with them of five things they can do to deal with those negative emotions. Sometimes you can't fix them. You know, when you're angry, sometimes there's nothing you can do about it. So what distress tolerance skills can the person use? Insert positive and rewarding experiences. I'm working with a client right now who's just going through some devastating stuff. And I asked her when was the last time that you can remember laughing? And she couldn't. And I was like, okay, so here's what we're going to do this week. You're going to start trying to find something that you can do that can help you feel a little bit happier and at least for an hour. And I gave her some movie recommendations that she might be able to watch with her family. That may not do it for her. But encouraging people to do things that make them happy, because if they're happy, you know, if they start laughing, if that's triggered, their body is going to be releasing endorphins, dopamine, and more of the relaxing either GABA or serotonin. So that's what we want. So we can artificially kind of force it to happen. Just like you can artificially force somebody to excrete stress hormones by scaring them. You can artificially cause yourself to start secreting some happy hormones by doing things that typically make you happy. And you know, what you would normally feel is probably like a 10. What you're going to feel when you're kind of forcing yourself to do it may only raise to the level of a six, but that's still a whole lot better than feeling like you're at a 1. Encourage people to get plenty of rest, eat a healthy diet and exercise. Exercise helps get rid of, well, it helps increase serotonin levels, which reduces anxiety and reduces depression. Both of those are really awesome. Exercise also helps people take some of that pent up nervous energy, anxiety, anger, and move that energy out. So the body has adrenaline circulating and cortisol circulating in it and it's going well. What do I do with all this energy? Well, exercise can help them sort of diffuse some of that, which can help them relax. It can also help release muscle tension that may be keeping them from sleeping. So there's a lot of benefits to exercise. It doesn't have to be super intense. You know, Dripping sweat. Exercise. It can be walking the dog around the block, but any exercise for about 30 minutes is going to help raise serotonin levels and help people feel a little bit better. Attributional styles can also be vulnerabilities. And sometimes, I mean, we have our typical attributional style and hopefully it's a positive one, but sometimes something can happen or you can get up on the wrong side of the bed and you can be in that mood. We all know what that mood is where everything is always negative and you see the worst in everything and you expect the worst and everything. And it's just you're seeing the glasses half empty and you're seeing it as a partly cloudy day instead of partly sunny. I mean, everything is the negative side. All right, well, when everything is always, it adds stress. And when you're looking through the day and all you're seeing is negative stuff that day, it's probably going to be impactful on your mood and how you react and your. How you act, interact with other people and your desire to interact with other people. When you have an internal attributional style, when you're assuming that anything that happens is a reflection on me as a person, then that's also going to add extra stress. So helping people recognize, you know, sometimes when we are in a bad mood, we can be more sensitive and to other people's moods and stuff and sometimes take things a little bit more personally. And you can speculate about all the reasons that people do that. And, you know, there are a lot of theories that. And it depends on the person. But regardless if somebody is taking everything personally and carrying the weight of the world's on their shoulders, it's going to carry extra stress. So encourage clients to focus on things as being specific and alterable. You know, looking outside today, it's raining again. And I could be negative about that feeling like it's been raining forever and it's never going to stop. Well, that's kind of doom saying, might as well build an ark. But in reality, it's been raining for a couple of days and supposed to stop tomorrow. So focusing on it as being this has been a really bad week for the weather, or this has been a really bad week at work instead of my job really sucks. All right, maybe it was a bad week. So let's look at the big picture and try to make whatever's bad specific so you can figure out, number one, how to avoid it in the future. But number two, how to fix it. Because specific and alterable what parts of this can you fix? Normally, I don't turn all the lights on in the office. I mean like in the hallway and everything else, because it wastes electricity. But on days when it's this dark outside, oh yeah, I turn on all the lights to make it as bright and cheery as possible. So that's how I alter, you know, I can't control the weather, but that's how I alter my environment to be more cheerful and explore the difference between what makes you a good person versus your skills. So if somebody's in a bad mood and you know something bad happens, they get written up at work and they say, I'm a failure. All right, well, you failed to get do your job, get your reports in on time, and you got written up. That is unfortunate. That stinks. However, does that mean that you as a human being are a failure, or does that mean you failed at accomplishing this particular task? So encouraging clients again to take negative stuff and make it specific, Identify what they can change of the stuff they can't change. How are they going to deal with it? Extremely internal or external locus of control can add extra distress. If you think that destiny controls everything and you've got no chance of changing anything, that's stressful, especially when bad things are happening. You're like, I just got to have to sit here and take it because nothing I do is going to help. Very disempowering. On the other hand, if you have an extremely internal locus of control, then you think you should be able to change absolutely everything. That means you can control other people, you can control the weather, and when they don't behave the way you want them to, then it makes you angry. Well, neither one is really healthy or realistic. So helping clients look at the middle, but helping them recognize when they're in that mindset that they're feeling extremely powerless, or they're in that mindset that they're trying to control, everything can help them recognize, all right, I need to change my way of thinking or I'm going to set myself up for increasing my own distress. Low self esteem is another vulnerability. And again, this isn't necessarily perpetual. People don't necessarily have low self esteem from the time they're born. You know, sometimes something happens and somebody's self esteem takes a nosedive. They lose a job, they get divorced, something happens. But when your self esteem is low, it can predispose you to being more vulnerable to depression, anxiety and stress. Low self esteem can cause people to feel helpless, not deserving of love or Success. So those are things we can work on with people in counseling. But we do want to help them see the connection between how they feel about themselves and how they feel. Explore what characteristics the client thinks he or she should have, but don't. And decide if they're important. You know, I would love to be much better at math, but it's not important enough for me to really work at it. You know, I let my husband do all the math with the kids and that's okay. So it's not important to me to work on that thing. So I mark that off, you know, as far as how I feel about myself. Yeah, I struggle with math. I can muddle my way through and that's about it. But that's okay. I don't feel like I'm, you know, any less good of a person because that's not a good, a strong skill for me. If you decide that it's important, you know, it's something that you really need. Like, I would like to be compassionate, but I'm not. Well, how can you work on developing compassion then? So encouraging people to look at their self esteem, identify who it is they really want to be and start making steps towards that negative perceptions and cognitive style. If they see the world as a negative, depressing, out of control or scary place, it makes everything seem negative and makes people not want to take chances. People who've been through trauma can sometimes get stuck in this area where they're experiencing life in terms of avoidance of threat instead of, you know, life is good and threats gonna happen, I'll have to deal with it. They live their life each day just trying to protect themselves. When people see everything as negative and not rewarding, they don't want to do anything. So if they get a promotion and instead of seeing it as, oh, that's wonderful, I'm gonna get so much more money every month and I've got a little more responsibility and that shows people's confidence. Instead they see it as, lord, now I've got more responsibility and I'm going to end up, you know, having to deal with more headaches. And I'm, you know, where we go from this. I have a difficult time being negative. But you can see where people might not want to get a promotion if they see all the negatives to something. Using decisional balance exercises can always help people see the positive, but helping them see a balanced view, encourage them to look for the silver lining. When they start to see something as negative, find the positive. You know, maybe somebody broke up from a relationship well, yeah, that's devastating. However, it gives them the opportunity to find somebody who's a better fit. That's not what they're going to want to hear right then, but hopefully we can help nudge them in that direction and encourage them to look for exceptions. If they say everything is, you know, the world is against me, everything is horrible, you know what in your life is going good right now? This one thing, work or your relationship or your health, you know, there may be this one thing that's going really poorly, but are there other things in your life that are going pretty positively poor? Organization and time management can also make people vulnerable. We've all been there where we've had too many things to do. Hopefully we haven't double booked ourselves, but we feel like we're being pulled in 16 different directions. I don't know about you, but I know for me, when I feel that way, I tend to again, be more irritable, impatient, react more strongly. And when bad things happen, I tend to feel more powerless because I'm just like, I can't do one more thing, I give up. So we want to help people work on organization and time management. Poor time management can lead to people feeling over committed, feeling rushed or harried, or cause them to forget to do things, which leads to conflict, which also increases negative moods, preventing vulnerabilities. I mean, if we're helping people create a recovery lifestyle that manages to set the groundwork for giving them as much energy and happiness as possible, yeah, stuff's gonna happen. But we want them to be as well prepared and have as much reserve, energy and extra that they can use in a crisis as possible. So this is why we're talking about pain management, sleep, nutrition, time management, all those things in order to help people be at their very best. Poor communication skills can be a vulnerability. It can impede you from stating your needs, may cause misunderstandings, or can hurt your relationships. And you may have really good communication skills with some people, but then not be able to communicate effectively with your boss or your spouse. And that can make you more vulnerable to feeling like nobody's hearing you. It can make you more vulnerable to getting impatient and angry because you're not getting your point across. So helping clients develop communication skills, weak emotional boundaries may leave people feeling overburdened because they're taking on everybody else's bad mood if they walk in. And a lot of times this happens in addicted families. But sometimes in families where they've got someone with a severe and persistent mental illness, the person it may not have been safe to be happy. If they were happy, they had to check in with the identified patient, so to speak, to see how are they doing today, because that tells me what I can do. And they're walking around on eggshells. So we want to help people examine times when it's safe for them to feel how they feel and when they don't feel safe, what's going on, because we want them to be able to develop emotional boundaries so they can be in situations and always feel safe to get their needs met. We want them to start paying attention to their wants, needs, and feelings instead of just deferring and going, whatever makes the least waves, I'll do it. Because then they're not getting their needs met, and eventually they're going to feel potentially feel resentful, hopeless, and helpless. When people need external validation, and sometimes we need it, you know, sometimes you're having a really bad moment and you need somebody to go, you know what? You're awesome. And you're just like, oh, thank you. I needed to hear that today. But that need for external validation can make people feel more vulnerable. If they're feeling down, if they're feeling bad about themselves, or maybe they turned in a project and their boss didn't like it and sent it back and said, this is awful, redo it, and they're feeling down, a word of encouragement can help, but it can also mean that they're feeling helpless, they're feeling inadequate, and they're feeling. May feel a little bit depressed. So this is when they may need a little external validation. So help clients, number one, be able to give it to themselves and take a time out and go, all right, why am I okay? I'm okay as a person. This other thing over here, I didn't do so well, but I'll get better at it and look at why you need other people to validate you and kind of work on that. If you feel like you need other people to tell you you're okay a lot, then you're probably going to be a lot more emotional. If you're not getting that validation and security, you're going to feel anxious. If you feel anxious, then you're going to be more likely to emotionally dysregulate. So encouraging people to look for that and to have people in their circle who do provide emotional support, I mean, we're not saying somebody that's always there going, you know what? You're good enough, you're smart enough, and gosh darn it, I like you. But. And that Comes from Saturday Night Live for those of you who are way too young to remember it. But anyway, the. We do want to have those people in our life. We don't want to have to have them telling us that all the time. But, you know, every once in a blue moon, it doesn't hurt to let them know. So these are all things that we need to consider when we're helping patients gather their resources and think about getting ready to go out for battle, if you will. You know, the military trains and they do practice drills. Well, in counseling, we do role playing, which is kind of like practice drills. The military identifies any potential obstacles, barriers, or things that they may encounter. Well, we try to do that in counseling, too. We say, what is it that you may encounter that you're going to have to overcome? And let's work on some coping skills and strategies to deal with that. But the military also wants their troops to be healthy, well fed, if you can consider an mre, well fed. But they want their troops to be at 100% in order to be able to go out there and be effective. And that's what vulnerability prevention is all about. We want our clients to be able to figure out how to make themselves 100% so they're ready to go out and take on the battlefield of life. And they've got the energy, the resources, the concentration, everything they need. And so if something happens, not saying it will, but if something happens, they have the resources to deal with it. So think about just for you, and we talk a lot about clients, but think about for you, what vulnerabilities did you have in the last week, and what impact did that have on you? Because clients aren't going to be motivated to work on this stuff, work on sleep or nutrition, unless they can see a direct benefit to them. You know, why is it that I keep harping on good nutrition or getting enough sunlight? Well, this is why. This is how it connects to your mood. This is how it connects. You know, you said to have a rich and meaningful life, you wanted to have a good relationship with your spouse, you wanted to have a good relationship with your kids, you wanted to have a good job and good relationships with your peers and whatever else, and that would help you have a rich and meaningful life, which would help you be happy. Okay, that's great. However, if you are a grump, if you are anxious and angry all the time, it's going to be difficult to have those good relationships. So what do we need to do to help you not have that emotional dysphoria? Well, let's look at some of the things that might cause it, and let's look at some of the things that might make it worse and figure out how we can eliminate those things so you can have those healthy, fulfilling relationships and that awesome career and whatever else. So encouraging clients to buy into it, asking them, you know, if you would have had this new information, what could you have done differently? So if they look back and go, you know what? I did get up on the wrong side of the bed that morning, and if I would have really thought about it, I could have done something to help myself get into a better headspace before I went into my meeting with my boss. Okay, cool. Well, you didn't do it then, but you can do it the next time. So encouraging them to look at, how does mindfulness and self awareness of their own vulnerabilities, how can that be used to help them, again, not get depressed or anxious? But if they are in a bad mind space, not make things worse, and if they would have checked their mind space before they went into the meeting with their boss, how would that have changed the outcome? You know, would it have gone a little bit more smoothly or not? And then encourage clients to think about how they can start integrating this knowledge into their routine. And I typically break the vulnerabilities group up into four different groups. We do nutrition one day, sleep one day, you know, and specific things so it's easier to kind of chunk. And then we talk about small changes. For example, with nutrition, encouraging them to start trying to get three colors on their plate every day, that's one thing that they may be able to consider doing. When we talk about sleep, you know, I don't give them that whole litany of stuff and go, okay, now go home and change everything. You know, I say start out by developing a sleep routine. Let's talk about what that's going to look like for you. Try it for a week, and then let's talk about it. After they have a sleep routine, then we talk about maybe putting on the blue light filters on their electronic devices if they need a little bit more help. So gradual changes, they're going to be a lot more enduring than trying to change everything all at once. And it's also a lot easier for clients to integrate stuff into their routine. Think about when you do counseling. If you've done counseling this way for 20 years or even for two years, you have a rhythm, you know what your responses are. And then you go to a workshop and you learn all these new tools and you're like, oh, those are so awesome. And you go back to your office and you start doing counseling. And for a lot of us, we don't use those new tools because we have all these new tools, but we haven't thought about how to integrate them into our practice. So what I suggest and what works for me at least, is when I go to a conference or something and I learn a new tool, I pick one tool that I learned and I try to focus on using that with clients and, you know, with my family and any other way I can use it for two weeks. And then once I'm in the habit of using that, once it actually comes to mind when there's an opportunity to use it, then I add another skill and then another skill. So I'm not trying to go, well, I need to use some sort of motivational interviewing skill each client session. No, I would say I need to use decisional balance exercises at least once every single day for the next two weeks. And that helps integrate the knowledge into the routine slowly and incrementally. Addressing vulnerabilities frees up energy so clients can deal with other stuff that comes their way. Eliminating vulnerabilities, like making sure you get plenty of sleep to begin with, can help people feel less stressed, exhausted, and overwhelmed because they're fully recharged. Persistent vulnerabilities can be the first relapse warning sign. So if people are persistently not getting enough sleep, not eating well, and in a negative frame of mind, for example, those can all be very early warning signs of a depression relapse. Encourage clients to look back over, you know, when they've had episodes before. If they've had an episode of clinical depression the three months before that, you know what was going on. Were there any signs that you might be starting to get depressed? They'll probably be able to identify some vulnerabilities and you can say, okay, that's where we're going to start. You know, let's try to prevent those. But then if you do see those creeping in, you see yourself waking up in a negative mood. More often than not, you know that you're potentially headed down the road for a depression relapse. So then they can take steps early on to keep it from getting to a full blown clinical depressive episode. Be mindful. Encourage clients to be mindful of when they're vulnerable and take positive steps to address it in order to ensure recovery success. It may happen in the middle of the day that they get some bad news or they start getting sleepy and they tend to start getting impatient or whatever. It's important for them to be aware of that and know that alright feeling tired or I'm hungry. Hungry is another one. My husband has hypoglycemia and when his blood sugar gets really low the only time he ever drew a complaint when he was on patrol was when his blood sugar was low and he's the same way around the house. If his blood sugar is fine he tends to be really scary level sometimes but if his blood sugar is low he can be a little bit more irritable which is notable because he's so level most of the time but he became aware of that and he started carrying stuff in his car so if he wasn't able to go on his meal break he could keep his blood sugar up and that kind of solved the problem. So we need to help clients brainstorm solutions like that and be aware of how other things, not just their mood, impacts their mood. If you enjoy this podcast.