PIECES Method for Biopsychosocial Treatment | Essential Counselor Webinar

Foreign. Hello, everybody, and welcome to this presentation on the Pieces method. We will be getting started probably in about five minutes now. The time just changed for me, but I did want to log in early, say hi to everybody, see how your week's going. Hello, Michael. Hello, Teal Gl. Great to have you both back. Yeah, I don't have a lot to say today. Not yet. I'm really excited about this presentation. You all know this is. The Pieces method is something that I created. So it's something I'm passionate about because it's my baby. And I hope it gives people a another perspective of for differential diagnosis. Hello, phoenix. Welcome. If you have been in the classroom and Already downloaded the PowerPoint, you will know that pieces stands for physical, Interpersonal, Emotional, Cognitive, Environmental, and Spiritual. You used to be the PACER method, but affect threw people a bunch, so we switched it around in order to make a different mnemonic. And Pieces works because this really helps you see how all the pieces of your life impact all the other pieces. So it works for me. I know y' all are like, it doesn't really matter. You're going to do what you're going to do. Yeah, I am, probably, but. Hello, Lisa and Sammy and Low Lauren. Sorry. Welcome for those of you who are being shy. Welcome to all of you. I see there's a bunch of people out there in the wings, and that's okay. Not everybody wants to be, you know, chatty and on camera. I understand this. Hey, roller girl. It's been a while. I don't think I saw you the last couple, but the. I was doing more of the talking and less of the moderating since I'm teaching live now. So if I missed you, I apologize, but it's always great to see you. Oh, gosh. Hello, Robert and Dawit and. And Joelle. Sorry. Without my eyeballs, I'm struggling to read a little bit, but I'll get them back on in a minute. Hello, Mary, Gail, I'm glad to see you. Elle and Danielle, welcome, both of you. Joel, if I didn't say hi to you, hi, I think I did. But I don't want to miss anybody. If I did miss you, it was definitely not on purpose. If you have questions, remember, the Pieces model is a holistic trauma informed cognitive behavioral approach to diagnosis and treatment. So if you have questions, I encourage you to ask again. I want to try to get through everything in this hour in order that the people who need to take their CEU quiz can go ahead and do that, however, so I will Take questions at the end if you, if you do have questions. And I'm going to be posing some questions that are sort of rhetorical throughout, trying to make this as help connect the dots as much as possible. Hi Sherry. Oh, sorry, roller girl. I know working can kind of be a drag, but. Hello, Jenna. I apologize to everybody ahead of time. I may be taking a few more drink breaks than usual. I'm still getting over a sinus infection, so I'd rather take a couple of drink breaks than be having to break to cough. So we'll try to make that happen. But anyhow, I'm going to go ahead and get started. As I said, I will take questions at the end and we do have moderators in the chat room if you have just general questions as we're going through and they are very informed about the videos that I've done. So let's go ahead and get started. I'd like to welcome everybody to today's presentation on the overview of the pieces model and transdiagnostic assessment. That sounds really bloated, but it's actually really pretty, pretty. What's the word I'm looking for? Pretty simple. In this video, we're going to define the pieces model and explore how the pieces dimensions interact. So how all pieces of your life, physical, interpersonal, emotional, cognitive, environmental and spiritual, how all of them interact. And I'm going to ask you to reflect on that and not just first order thinking where you think, well, if I'm in pain, then it's going to put me into a bad mood. Okay, well that's true for most of us, but think further and then what, and what else if it, it may impact your mood? Well, if you're in a bad mood, how's that going to impact how you interact with others? How's that going to impact your pain? Because we know that stress and a bad mood actually negatively impacts our pain. It increases inflammation and makes pain worse. So we're going to continue to talk about that. But the reason I bring this up is because singular approach or a double approach to treatment just isn't working. 10% of Americans are on antidepressants for anxiety or depressive issues. Think the number's actually higher now without medication. 20 to 40% of people with clinical depression noticed symptom improvement in six to eight weeks. So that's if you want to call it spontaneous remission, that's what you can call it. It could have been depression that was brought on by a physical condition or a situational issue. We, we don't know they weren't very specific. In the study with antidepressants, 40 to 60% of people with clinical depression noticed symptom improvement in six to eight weeks. Well, that's good, but that's really not great. 40 to 60%. So four out of ten or six out of ten people noticed symptom improvement. Well, that still leaves four or six people out of every ten who are struggling. So we're not, we're not getting it. That leaves as many as 40% of people still struggling with significant symptoms after six to eight weeks. No high or moderate strength evidence for any intervention to effectively treat any phase of any type of treatment versus placebo or an active comparator has given us anything that we can say this. Use this for depression. Use this for bipolar disorder. Use this and it will help people improve their, improve their symptoms. Cognitive behavioral therapy appears to be effective in approximately 47% of cases. Well, okay, that's good. That's four, maybe five out of 10. But again, we still have five out of 10 that are going help me. Results are mixed with regarding whether cognitive behavioral therapy and antidepressants can augment treatment response. For some people it does, but for others it doesn't. And we're going to talk about why that is in a minute. Cognitive behavioral interventions for depression and anxiety prevention showed a small effect for prevention of depression, but not anxiety. And no effect. No effect at 3 to 6 months and 12 month follow up. So we can teach people all these wonderful skills that are cognitive, behavioral, and I will emphasize cognitive in nature and they're great. But it can help a little bit for depression, but it shows no help for people with anxiety. Well, why is that? Well, number one, when people are anxious, they're in fight or flee, they're in fight or flight. And these skills they have aren't going to come readily to mind. So they're less likely to actually implement them. But that also tells me what else, what else is going on besides their cognitions that are contributing to their mood symptoms. In a study of over 33,000 patients, that's a pretty good size. Only patients who had 18 or 20 cognitive behavioral therapy sessions showed more improvement than generic counseling. That's good. This tells us one thing that we didn't know or we hadn't talked about so far, that it's more about the therapeutic relationship and the belief in the ability to improve than it is about a particular technique. Okay. That's one of the things I run into with a lot of my supervisees who feel completely overwhelmed with all the stuff they need to know. And ultimately it boils down to, are you there? Are you present for your client? Are you able to create a safe, secure environment where they can explore? Are you able to help them see some of the things that may be contributing to their distress and brainstorm ways to fix it? Most people have some ideas about what would work. They're not relying on us, hopefully, to tell them what to do. We can give them ideas, but we can also help them evaluate what's worked in the past for you and or what's worked in the past for somebody else that you think might work for you. And let's talk about applying that. Counseled patients are significantly more likely to have recovered than non counseled patients. So people who seek help are more likely to have recovered than people who just try to wait it out. Makes sense. Counselors, social workers, therapists, whatever you want to call yourself, we are catalysts for change and we are not going to fix people. We may help them see things that are getting in their way. We may help them more efficiently and effectively clear out blockages because we have that book knowledge. The client is the expert on themselves. And when we work together, we create a good team. And we also inspire hope and confidence and provide that support and encouragement that people need. Client outcomes are most often determined by client variables such as chronicity and severity of the issue. Well, if they've been struggling with this for all of their life, or if this is a particularly intense episode, then the outcome is going to be impacted. Their beliefs about their ability to change may be impacted by the chronicity and the severity, the impact of the condition, whether it's addiction or anxiety or depression or whatever it is, the impact of that on all the other pieces of their life is going to be more significant and more severe. Someone who has been who qualifies as having a substance use disorder that is in the very early stages, that substance use disorder probably has impacted all pieces of their life, but only to a small extent, or maybe only one or two areas are significantly impacted. Once they have qualified as having a substance use disorder for two, three, five years, then the negative impacts of that problem have pain permeated and really intensified their damage in each of the pieces of their life. The complexity of symptoms also impacts client outcomes. Remember, I said before, we can do a lot of talk therapy. We can help people adjust their cognitions and look at their cognitive distortions and even do some trauma work. But if they've also got underlying autoimmune disorders, diabetes, chronic fatigue, cancer, Hepatitis, other issues going on physically, or if they are homeless, if they are malnourished. There are a lot of other things that contribute to a person's sense of well being and their symptoms. And the more things, more pieces of their life that are going poorly or have issues, the greater the complexity of the case. The wonderful thing about humans is if we start addressing one area, it generally has positive effects on all the other areas. And I say generally, we also need to remember Maslow's hierarchy. If the person's not getting their basic biological needs met, a lot of that other stuff just ain't important. So we do need to make sure that the person is at least getting their minimal biological needs met. Motivation is another thing that impacts the client's outcomes. If they are not motivated for change, then they're probably not going to do the work and we can't change them. Nobody can change another person. Only that person can change their, themselves, their own behaviors. So we want to look at that lack of motivation and ask why do they, are they feeling overwhelmed? Do they lack the skills? Do they not see a problem? Have they tried before and failed? So they don't see the point. There are a lot of things that contribute to that word. I hate so much resistance or lack of motivation that we need to address because that lack of motivation is going to sabotage the person's efforts and acceptance of responsibility for change. This is another big one. And Linehan says that we don't create our own problems, but we've got to change them, we've got to fix them a lot of times and people need to accept responsibility. Yeah, so and so did this to you and it was awful and it sucked and they may not be a safe person, they may not ever apologize. So what is, whose responsibility is it to address the resentments that are keeping you feeling distressed and untrusting of other people? Is it their responsibility? No, unfortunately, it's yours. Therapeutic change is less about talk therapy interventions and more about the patient's inability, patient's ability to maintain motivation and efficacy, a sense that they can do it, and the clinic clinical team's ability to look multi dimensionally at issues. So the Pieces method uses a transdiagnostic approach, which means many symptoms are common to multiple disorders. Think about low energy, how many things cause low energy? Just start naming them off. You've got depression, you've got grief, you've got sleep disorders, you've got thyroid problems, you've got blood sugar issues, chronic fatigue syndrome, and you know, I could go on, but we've got to move on for time's sake. If I see somebody who has depressive symptoms and I just say, oh, it's your thinking, I could be way off base. Maybe they're vitamin D deficient because it's been cloudy for three freaking weeks and they're not getting vitamin D in their diet. And I don't know. So it's important that we recognize all of the possible contributors to their symptoms and consider addressing them in a multi dimensional, multidisciplinary fashion. There are many ways to address each symptom and that's where we talk about trans theoretical. If somebody is feeling depressed, they may want to talk about their feelings, they may want to address their cognitions, they may want to start exercising and trying to eat better to feel well. There are a lot of different interventions that people can use and all of those have been shown to be helpful at improving depression. So we want to recognize that there is no one path to recovery. There is no one path to the end. We need to build on what the person believes will help them and what evidence shows will help them. As I mentioned, all the pieces physical, interpersonal, emotional, cognitive, environmental and spiritual. And when I say spiritual, I'm not talking about religion. I'm talking about their awareness of their values and their sense of connectedness to others in the world and acceptance by others and by themselves in the world based on their values. The pieces method consistently looks at bi or multi directional interactions. If I'm feeling pain or if I'm sick and I get in a bad mood because I'm sick, I wake up, I'm like, crap, another day with this sinus infection. Really, I want to get on with my life. If I get irritated, that triggers my stress response which negatively impacts my immune system or which is going to get me sicker longer. So we want to look at the bidirectional interaction. Illness causes distress, distress worsens illness. Which other directions does it go? We want to look at all of those in the pieces method. The counselor has a lot of functions. Counseling and motivational enhancement. Our job is to listen to people, hear what's going on and educate them about all the possible other things. So many people talked to me in, in sessions, so many clients, as well as people who've commented on my videos, who've said, why didn't anybody look at all these other issues to help me address my depression or anxiety when I was going to counseling? It would have helped so much. Oh my gosh. I had one client that I worked with a few years ago that was anemic in an incredible way. So much so that they put her on, you know, I an IV when she was at the doctor's office. They didn't even let her leave because she was so anemic. And once they got her anemia under control, lo and behold, her mood started going up. So yeah, we could have talked for weeks or months, but she wouldn't have reached the gains that she reached just seeing me. We want to motivate people, help them identify potential avenues to toward their rich and meaningful life. We want to help use motivational interviewing to help them see why it's worth the energy and encourage them, help them recognize small steps, not just when I get to the end. Now let's look at how much better do you feel today than you did yesterday or last week. Help them see that small progress. We want to connect people with multidisciplinary referrals. Their doctor always, if possible, get people to get a full workup with blood work to assess for some of those really basic underlying hormonal and nutritional issues. Sometimes they need a referral to a registered dietitian because their nutrition is just crap and they have no idea how to eat healthfully. Sometimes they need referral to a physical therapist and the doctor may do this. Or most insurance companies allow people to self refer for physical therapy if they're having a lot of pain, a lot of back pain, whatever. Case management is another thing. And I know you're like, we don't get paid for case management. No, we don't. But that's part of the multidisciplinary method. As the clinician using this method, you're sort of the single point of contact. So it's important for you to know which person the client's actually seeing, what their treatment plans are and making sure that you're coordinating as needed. And it's our job to improve health and mental health literacy. We don't want to tell them, oh, this is the problem, this is a problem, this is a problem. Do these things. Well, that's great, but when, what happens? When they start having more problems, they don't know how to actually figure out what's going on. We want to teach them to fish, not give them a fish, as they say. To address all pieces of a person's life, we need to identify and address what's creating or maintaining imbalances in the nervous system that cause unnecessary dysphoria. Pain is a part of life. We're going to have distress, we're going to have bad days that's okay. You know, it's the unnecessary dysphoria in acceptance, commitment, therapy, like we talked about last week, that's the dirty discomfort, the being angry over waking up depressed again, or the anger and resentment that you're holding on to for something that happened 25 years ago. So physically, what do we do? We want to rule out organic dysfunction in the system. We're not doctors, we're not nurses for the most part, so we're probably going to do a lot of referring. But we can screen and it's important to recognize that you have the ability to screen for problems. If the body cannot make or balance the neurotransmitters due to health, cognitive or behavioral issues, then those things need to be addressed. So we're going to screen for HPA axis dysregulation. Does the person go from 0 to 250 like that? Do they feel like their emotions are just completely out of control? If so, that's a good sign that their HPA axis may be dysregulated. Are they feeling most of the time kind of flat and apathetic, but when they do get upset about something, they are enraged. Okay, again, good sign that the HPA axis may be dysregulated. Do they have poor health behaviors? What's their sleep like? I've done multiple videos on the impact of sleep on ruminations, on the ability to think clearly, to problem solve, to regulate emotions, and, and just when you're sleep deprived, your stress response is in higher gear, which is not what most people with anxiety really want. So we want to screen for these poor health behaviors, which I call preventable vulnerabilities. If you've got an autoimmune disorder or chronic pain, you're not going to be able to completely prevent that. That's true, but if you've got chronic pain, we'll just go with back because a lot of people have back problems and you are sleeping on a lumpy old 25 year old mattress that, you know, you wake up and you feel like you're sleeping on the floor. Okay, that may be a preventable vulnerability. You may be able to reduce the amount of pain you're experiencing if you get an ergonomically sound sleeping surface. There are over 30 hormones the body must construct to regulate the neurotransmitters. And there are over 100 neurotransmitters. No, we're not going to go over all of them. There are over 100 neurotransmitters the body must construct and balance in order to regulate your attention, your memory, your sleep, your circadian rhythms, including your hormone rhythms, feeding heart rate, respiration, energy, motivation, mood and more. Neurotransmitters have their little mitts in just about everything. So we need to make sure that the body factory is operating efficiently and effectively. Up to 95% of some neurotransmitters and hormones are made in the gut. Who knew? Well, hopefully you did. But it's important that we recognize the importance of gut health for people. This is not something we are going to prescribe. Any dietary changes or anything that's outside of our scope, we would refer to a registered dietitian. But if somebody is having GI issues, if they've got irritable bowel or chronic stomach aches or something, that's important information. If the body cannot produce or effectively regulate those hormones, people are going to have symptoms. HPA axis dysfunction and exposure to chronic or severe stress are critical components that increase the risk for developing addictions, stress related physical illnesses and more. If somebody emotionally dysregulates, if they have HPA axis dysfunction and as a result of exposure to stress, maybe it's not even stressful anymore. But their nervous system already done made those changes, so they're, they dysregulate when they get upset and they feel flat the rest of the time. How do you think that contributes to how they feel physically? How do they, how do you think that contributes to their ability to enjoy life? How do you think there that that contributes to their perception of the world or their desire to engage in relationships, their ability to trust people? Where do these breakdowns happen in the system? And this is another thing that I harp on in multiple videos. Our neurochemical system is not just as simple as hey, if you don't have enough serotonin, take an ssri. Well, that works for some people, but not for all. Why is that? Because it's a system. It's a, a factory if you will. There can be a problem in the creation of the neurotransmitter or the hormones and that can be the result of genetics or even something as simple as nutrition. If you don't give your body the building blocks it needs, it can't make the neurotransmitters, it can't make the byproducts. The release of the neurotransmitters in, into the system can also be a place where it gets hung up. The neurons just don't fire and don't secrete the dopamine, don't secrete the serotonin they just say, no, just not going to do it, or I can't do it for some reason. Okay, that could be the result of genetics or HPA axis disregulation as a result of trauma. Their nervous system may just be going, no, we're not going to respond to that. The availability of the neurotransmitters could be the result of genetics. Can the body even do something with it? And how long does it stay in the neurosynaptic space, the space between the secreting neuron and the receiving neuron? The receptor responsiveness. All right, well, it gets secreted. It's in that little space, then it needs to be picked up by a receptor. But if the receptors say, no, not going to do it, then we got a problem because it's not going to pass on the message. So. And receptor responsiveness is one of the issues we see in addiction, where people's neurotransmitters, including dopamine, but not just dopamine, have become desensitized, if you will. So when that neurotransmitters in the synaptic cleft, the receptors don't pay any attention to it. Instead of taking it up and passing on the message and then reabsorption, for some people, the neurotransmitter is released into that synaptic space, but it either sits there for too long and then they end up with too much stimulation of the receptors, or more, more often, the enzymes that are responsible for breaking it down and cleaning it out of that synaptic cleft. When it's done, they come in too quickly and they make that neurotransmitter disappear too quickly. And that's what the SSRIs do. The SSRIs say, hey, we don't want to reabsorb the serotonin quite that quickly, so we're gonna leave it in that synaptic cleft a little longer. Which is why they're called selective serotonin reuptake inhibitors. Under stress, cortisol increases norepinephrine, adrenaline, glutamate, estrogen, and I always say this wrong, ghrelin, and inhibits an availability of serotonin. And the creation of T3. Chronic stress causes resistance and tolerance. So when the body is regularly exposing those neurons to those receptors, to these hormones, to these chemicals, eventually the receptors go, yeah, you're overloading me. Can't do it. And when we talk about substance dependence and people becoming tolerant to substances, that's the same thing that's going on. The receptors are going to, oh, that's way too much dopamine coming at me. I, I need to protect myself from overload. But we do see the same thing with cortisol and that's our main stress hormone. They call it glucocorticoid resistance. But it's a very common symptom of HPA axis dysregulation and a very common symptom of people who've experienced extreme trauma or complex ongoing trauma. During relaxation. Dhea, GABA and serotonin levels increase, which reduces cortisol and norepinephrine, adrenaline, glutamate, estrogen and ghrelin. All of these hormones and neurotransmitters work together. You mess with one, it affects all of them. So if somebody is doing something to increase their serotonin, maybe they're taking it over the counter supplement. It's not just going to impact their serotonin, it's going to impact all the other neurochemicals. I see this with DHEA as well. When people start taking dhea, it for some will negatively impact their mood because it causes too much anxiety and too much stimulation. So what do we want to look at? Sleep and their circadian rhythms. Remember, circadian rhythms control the release of cortisol in the morning. So you have that awakening response and theoretically want to get out of bed. And then it declines throughout the day. It's at its lowest at night when you're getting ready to go to bed. When cortisol is at its lowest, that's when the brain says, oh, it's time to make melatonin. That's on a circadian rhythm. Your hunger and satiation hormones on a circadian rhythm. Your sex hormones are on a circadian rhythm on a hourly as well as a monthly circadian rhythm. We need to acknowledge this. We also need to recognize that nutrition is going to directly impact people's health and well being. It's going to impact their gut health and it's going to impact their ability to make neurotransmitters. I will say about gut health, though, stress and illness and medications all impact generally negatively the gut and the gut microbiome. So even if somebody's eating really well, if they're under a lot of stress, that microbiome changes in order to make more of the stress hormones, if you will. People ought to be advised to track their nutrition for a week or so using any old app that they can download from the app store so they can show you or their physician what they're eating and get an idea about if there are any nutrients that they're getting way too much of or way not enough of. A blood test is also really helpful and part of a general physical to assess for iron deficiencies, vitamin D deficiencies, VI vitamin B12 deficiencies, and any blood sugar issues that may be going on. Weight is another issue. And I know some people are going, we can't talk about that. Well, I'm sorry. It's just a fact of life. People who have excess adipose tissue, excess fat, tend to have higher levels of estrogen, male or female, which tends to increase inflammation throughout the body. Now, what excess is for an individual person varies quite a bit. And whether somebody makes the decision that, hey, I don't care, that's up to them. But we do know that people who are overly fat, you know, have too much adipose tissue or not enough, they're anorexic, tend to have cognitive as well as inflammatory responses. Bariatric surgery, not knocking it, but there are people who, after bariatric surgery either don't follow their treatment regimen to a T and they're not absorbing all of the nutrients that they need, or in, in some cases, they do follow it to a T, but they still aren't getting enough thiamine. And we can start to see things like, we're Nicky Corsic cough syndrome in people who have anorexia or who have undergone bariatric surgery. Now, that's not true for everybody, but it's something to be aware of. Not everybody who drinks alcohol is an alcoholic. Not everybody who has bariatric surgery is going to have problems from it. But if they're in your office and they're presenting with symptoms, it doesn't hurt to ask and refer them back to their treating physician. Central weight gain is another sign of stress in a lot of people. And diagnostic feature. I know a lot of people who are very, very thin because when they get stressed, they don't eat. So it's not diagnostic, but it is a clue, especially if they tend to have a lot, like right here and they don't drink, which, you know, this could also be caused by hepatitis. But I digress. If they have pain, how is that pain impacting them? Anxiety, anger, stress, all of those things increase pain. Depression is known to be associated with increased inflammation. So people who have pain tend to have poor mood. People who have have poor mood tend to have more pain and a reduced pain threshold. We need to understand that, help people use that as a motivating factor, but also help people figure out, okay, it's a fact of life right now. So how can I best be empowered to live with this pain? How can I minimize unnecessary pain? Exercise and sedentariness are also things that we want to look at. You know, they say sitting is the new smoking. Not everybody wants to exercise. I get it. But we do know that sitting for too long and not being active tends to increase pain, increase achiness, and, you know, stiffness. And it reduces oxygenation in the blood, which directly impacts mood and cognition. People's energy levels can be measured by thyroid tests and imbalances. And thyroid hormones can impact our energy levels. Poor sleep as a result of, you know, crappy sleep habits or sleep apnea or something else, all of those things can negatively impact energy. O2 lack of sufficient oxygen getting into the system can also negatively impact energy. People who have cardiovascular diseases that have low oxygenation levels tend to have more cognitive and mood issues. Libido and sex hormones. When you're stressed, your body says, hey, not the time to reproduce. So if libido has gone down, then it may be an indication of stress. But it's also important to recognize as we age. After about the age 35, our sex hormones start naturally declining. I love that word, naturally declining. I'm like, really? And as a result, people may have more difficulty concentrating. They have, may have less energy, they may have lower libido and all of those things. I mean, think about it. If I can't concentrate, I'm tired, and I have no sex drive, what's that going to do to my mood and my relationships? I mean, really. So we want to have that assessed for people and they can decide what to do about it. There are a lot of different approaches other than hormone replacement therapy. But also just educating them if they don't want to address it, educating them that it's kind of natural to. For your brain to take a few more minutes to engage as you get older, partly because some of your hormones have decreased. It doesn't mean you're getting dementia. It's just a fact of aging. And that can be a relief from a lot of people and actually relieve some of their anxiety. And then blood sugar issues issues and hypoglycemia can also contribute to mood and cognitive issues. And think about times when you've gotten hangry. Are you really pleasant and patient with other people? How does it impact your relationships? How does it impact your mood? How does it impact your. Your stress level or even your pain level? We want to assess hyper vigilance and startle as a result of cortisol resistance. If somebody is hypervigilant, if they're constantly on guard, if they're constantly stressed, that is exhausting. That's exhausting. And it's going to make it harder for them to get good quality sleep. It's going to make it harder for them to relax. It's going to increase their pain, it's probably going to make them feel. Feel unsafe more most of the time, which is going to negatively impact their mood. We want to evaluate their hypervigilance and startle responses and start educating them or having them educate themselves and become more aware of their triggers and ways to deal with those triggers and heal their nervous system. Autoimmune issues and inflammation, including rheumatoid arthritis, irritable bowel syndrome, diabetes, psoriasis, and crohn's disease. Yes, diabetes is actually now considered an autoimmune issue, especially type one. But they're looking at type two and going, huh, There's a really strong inflammatory component to this one too. So autoimmune issues are associated with inflammation. That is their defining, one of their defining features. When we have inflammation, how does that impact everything? How does that impact your sleep, what you eat, your mood, your desire to go out and hang out with people, your desire to go to the gym and exercise, Traumatic brain injury, headaches, which can come from stress or migraines or even high blood pressure. If somebody's complaining of headaches, we don't want to just say, okay, well, that sucks. Let's talk a little bit more about when do they come and what's the quality of them. To, to screen for whether we need to refer out blood pressure will be taken at the doctor's office. Medications like beta blockers, proton pump inhibitors that people take for reflux, corticosteroids, Parkinson's and antipsychotic medications, hormone altering drugs, stimulants, anticonvulsants, statins, opioids, benzodiazepines and more impact mood, impact your hormones. Now, you're not going to remember all these. That's okay. If you have a person who is coming to see you, get a list of all the medications and all the herbs they're taking. And there are databases online you can go to to find out what the side effects are or you can search for, you know, is taking this particular proton pump inhibitor associated with increased depression? Statins have been associated with increased depression. So doing your due diligence can also be helpful. Doesn't mean the person's going to come off the medications, but it can be, again, a relief and empowering for them to go, okay, well now I know what's causing it and I can make a plan. Telling people about potential side effects of their medications can be helpful, but we also need to emphasize do not under any circumstances discontinue your medication without talking to your doctor. Just don't do it. We also want to ask them if they started taking medications and they started having symptoms. Let's talk about the timeline. Did this did you have the symptoms before you started the medication? And once you started the medication, did the symptoms get worse? If so, something you ought to talk to your doctor about? Or did you always have the symptoms and you just started taking the medication and it had no effect? There's a lot of people out there who take statins and other medications that it doesn't impact their mood or their energy at all. So we do want to look at the timeline, whether the symptoms started after the medication started and and if so, encourage the person to advocate for themselves with their doctor. We also want to check out substance use and potentially addictive behaviors like sex, pornography, gambling and video games. Addictions increase inflammation Addictions are extremely draining on the system and addictions tend to keep the stress response that HPA axis hyper engaged. Most of the time it's when you start using, you're overwhelming the system, that's stressful. And then when you're detoxing, if you will, then you don't have enough and that's stressful. So your stress response is triggered. Coming and going. Interpersonal self esteem and self efficacy. We need to see, does the person see themselves as capable, lovable and deserving? If you don't see yourself that way, how does that impact your mood? How does that impact your relationships? How does that impact your belief that you can change or that you even deserve to be happy? You know, there's a lot of things that can go into it. Attachment do are they securely attached or do they have this fear of abandonment? Healthy attachment increases oxytocin, our bonding hormone, which also increases serotonin, dopamine and our endogenous opioids, our internal painkillers. When people feel secure in their relationships, they feel less anxious. But they also have a higher pain tolerance and tend to have an improved mood as a result of increasing these neurotransmitters. And yes, attachment can involve a pet. And not that we want people to just me and my dog, but for some people who have been just terribly traumatized by other human beings, starting out with a pet may be a Safe place to venture before they're willing to even try to connect with a human. Boundaries the ability to set, maintain and respect healthy emotional and physical boundaries. We talked about the different types of boundaries. We have them in all pieces of our life. Physical, you know, don't hurt me, but also don't glare at me. Not, not just physically violating my boundaries, but non physically through looking at me too much or getting too close. Those non verbals if you will. Emotional and cognitive boundaries, don't violate them. I feel how I feel and I think what I think and that's my right. And you feel what you feel and you think what you think and that's your right. We may not agree, but it's important that people are able to say this is my belief and I don't have to change in order to please you. When people don't have good boundaries, if their boundaries are too rigid or too weak, it tends to negatively impact their relationships, which negatively impacts their ability to experience. Positive attachment may negatively impact their self esteem, their mood, their sense of safety. You know, it's, it's a cascade. And communication skills. People's ability to identify and communicate their feelings and thoughts and get their needs met. We all have needs. If you're unable or if your client is unable to communicate those needs, then they may feel unloved, they may feel ignored. When that may not be what's going on, it may be other people just don't realize. Likewise, some people may over communicate their their needs and they demand it instead of assertively asking for it. So we need to help people learn how to identify, become mindful of their thoughts, wants and needs and effectively communicate them without expecting mind reading. Their social support system. We want to assess whether it's accessible, functional, and whether the people are providing emotional support and engagement. Do they get together, do they do things or is it just There is this theoretical support system that I can call on if I need help, but other than that I'm out here flapping in the wind. You can see how that could feel very isolating. We also want to recognize the bi directional impact between ourselves and others. We want to help clients see how when I'm in a good mood and I act nicely towards others, they act nicely back to me. And when people act nicely to me, I act nicely back to them. And you can see how the interaction works. If I'm in a crappy mood and I bite somebody's head off, it's likely they're going to get defensive or go off in a huff and then I'm going to get even more irritable probably, and it's going to spiral in the wrong direction. We need to understand that. We also need to recognize that as I said, not all of us is going to have an A day, every day. So it's important that we acknowledge. Hey Sam, Judy, whomever, whoever's in your office or whatever, I'm having a bad day today. I'm in a God awful mood, I apologize. I'm gonna go to my office so I don't spread my nastiness everywhere. But you know, just letting you know, that's why I've got my door shut. That helps a lot of people because then they're not thinking, well, why is this person in their office with the door shut? Are they angry at me? Are they this because as humans we do tend to speculate and do some of our own mind reading, which isn't healthy. But that's a whole other thing, recognizing how much relief it provides to people if you just let them know ahead of time. I'm mindful of the fact that I'm not having a good day today. So not apology ahead of time, but letting you know this so you understand why I'm being standoffish. People are often happy to hear that. Not happy that you're in a bad mood. But then they, they're, they have the ability to reach out and go, oh, is there anything I can do to help? Or don't worry about it, we've got all this out here. You just go do your thing. And as I said, animals and pets, a lot of people have emotional support animals and they are very important to them. And you don't have to have a diagnosis with a sheet saying this is an emotional support animal. If you engage with your four legged companion, well and two legged and well, snakes don't have many legs with your companions and they're meaningful to you. That actually increases oxytocin. So we don't want to minimize the impact of an animal's health or an animal's passing on and human's mental health. Emotional assessment helps us get an understanding of their HPA axis functioning. If their HPA axis is dysregulated, it's generally flat or frantic or furious. There's not much in between. If they feel happy, sometimes that's good. Sadness, depression, loneliness, grief, stress, overwhelmed anxiety or anger in all of its permutations, resentment, guilt, shame and jealousy. Remember, guilt is anger at myself for something I did that I shouldn't or something that I didn't do. That I shoulda and shame. I don't like putting shame under anger because shame is just a feeling that I'm not good enough, I'm broken, I'm not okay. And that's different than guilt. And a lot of people use the word interchangeably. But we do need to address all of these feelings and identify what what triggers these for you. Help people develop that emotional intelligence. Dysphoric emotions typically impair sleep quality, excite the stress response, that HPA axis reduce pain tolerance, prompt cravings for high carbohydrate foods, disrupt relationships and impact self esteem. And I think most of us can look back on a time where we've been really depressed or had a period where we were just like super super stressed out and recognize how it impacts all pieces of our life. We want to evaluate people's distress tolerance skills. Pain is inevitable. Are you able to tolerate distress when it happens? We want to evaluate their degree and frequency of dysregulation. Know how, how often do you lose it or spiral just in general, let's get get a feel. What is their level of emotional intelligence? Do they understand the purpose and function of each emotion? You know anger and anxiety protect us from a threat. Do they understand what their triggers are for each emotion that we listed on the last slide? Do they know what the symptoms of each emotion are from for them? What does anger look like for you? What are your early warning signs of anger? What does depression look like for you? What are your early warning signs? Do they have strategies to tolerate and respond to each emotion? And are they good at problem solving when you get anxious or angry or whatever, how do you solve that problem? It's you're feeling that way about something. So what steps do you take? Dopamine, norepinephrine, serotonin, oxytocin, estrogen and estrogen imbalances can all cause cognitive dysfunction. When any of the neurotransmitters or hormones get gets out of whack, it can cause difficulty thinking clearly and brain fog. Cognitions or thoughts that are based on inaccurate or outdated schema often contribute to feeling unsafe and powerless and result in trauma based responding. Schema are formed based on our prior experiences to help us anticipate in similar situations in the future what's going to happen. But those situations are not always and usually aren't exactly the same. So the schema aren't 100% accurate. And sometimes your interpretation of what happened may not be the same way you would interpret it now as a 20 year old versus as a 10 year old cognitions can cause biological, emotional and behavioral changes which throw hormones and neurotransmitters out of balance and impact all pieces of your life. And I alluded this to this before, when you have negative net, think about what his life is like, his relationships, his mood, his pain, his immune system, his ability to get good sleep. You know, he, he's cranky all the time. He may drink a few beers to help him calm down enough to get to sleep. Negative Ned really struggles to get through the day. Positive Pete, on the other hand, and I'm not talking about just toxically positive, but positive Pete that uses good cognitive skills tends to feel safe and empowered. How does that impact all of the pieces of his life? Cognitively? We want to assess functioning and contributing factors. How are people's attention, concentration and memory. Just because it's crappy doesn't mean they've got dementia. It could mean they're not sleeping well. Poor sleep leaves adenosine in the brain, which leads to brain fog. When you've got a new baby at home, you're not going to get good sleep, which means you're going to have brain fog. If you're going through chemotherapy, it causes brain fog. So we do want to evaluate other things that may be contributing to it. And what are people's skills in terms of problem solving? Some people are great at it, some people have no idea. They're like, I got this problem, I don't know what to do. I, I've never developed those skills. We want to assess their cognitive stress triggers, their negative attitudes and perceptions. These are generally based in prior experiences that were traumatic. Their hardiness, their ability to be resilient and bounce back, or their lack of do they feel safe and empowered or unsafe and powerless? Their locus of control. Too much or too little, Both are problematic. Some people believe they can control everything, which we know ain't the case, which leads them to feeling disillusioned and like a failure when they can't control everything. Some people feel like they can control nothing, which again leaves them feeling very powerless and unsafe in their current situation because they're just a victim of circumstance. We want to address their cognitive distortions. We have entire videos on that for a reason. Because people's unhelpful thinking styles tends to contribute to distress. We want to assess their negative self talk and their time management skills. Oh my gosh, how much stress are you under if you have poor time management skills? Environmentally, we want to look at do they feel safe? Pretty straightforward thing. We also want to look at the amount of light and when that light is present, when it's supposed to be dark, is it dark? When it's supposed to be light, is it light? There's a lot of information that's coming out now about blue light from televisions, from computer screens, from mobile devices that indicates that it increases inflammation and increases stress on the body. So what can we do about that? Well, we can encourage them to consider filters and other interventions. Smells. Noxious smells tend to make people irritable and may well tend to make them irritable, triggering smells. If you smell something, maybe you were in a house fire when you were younger and now when you smell wood burning, it triggers that memory, okay, well you're not going to be able to get rid of that smell all the time. But being aware of it is half the battle. And then having a strategy to deal with it, when you do smell, it is the other half. And then what I call assistive smells. There are essential oils and other things that you can diffuse in your environment that help with insomnia, sleep, anxiety, pain, depression and cortisol levels. And these are all if you download the PDF from your class when you go in to take your quiz, these are all evidence based articles from PubMed. It's not me just saying, hey, try this. Air pollution, carbon dioxide and nitrous oxides, carbon monoxide and volatile organic compounds all can contribute to headaches, brain fog, difficulty thinking clearly, and sometimes even negative mood and temperature. If you're too hot or too cold, it tends to affect your energy levels and your mood. When you get too cold, you tend to go into this sleepy state. When you get too, and you may be shivering but you tend to be sleepy. When you get too hot. A lot of people get irritable because they can't cool themselves down anymore. So let's look at that. You know, is your environment contributing to it? And for people who are on medications, there are a lot of medications that impact the body's ability to regulate its own temperature. And for people who are on some medications like antipsychotics, if they get too hot and they start to get dehydrated, or if they just start to get dehydrated because they're not drinking enough, it impacts the blood levels of their medication and, and it can contribute to a upsurgence in symptoms. It's important to understand that because in the summer we may see people who need to have their medications adjusted, especially if they're homeless or they work outside or something where they're sweating a lot. Spiritually is the person's values and the dissonance between their values and behaviors. These are my values here. Now, the way I'm acting right now, how does that feel to me? Am I feeling like I have to do things that go against my values, which results in moral injury? And what is my sense of connection and belonging? Do I feel like I am out here on an island all by myself and nobody gets me? Or do I have a sense of connection to some people somewhere? Our current uni or bi dimensional approach to treating mental health issues just doesn't work for the majority of people. So medication works for some, medication plus counseling works for some. But we need to expand, get past this very simplistic thinking and say, what else? 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 all the blinds? Well, probably. What impact would that have? Might cool off the house a little bit. But would it solve the whole problem? No. Would you turn up the AC so it didn't run as often, so now it's hotter in there, which is probably going to make you cranky and pull down the blinds? Okay, yeah, that'll save me some money. What impact would that have? And again, would it solve the whole problem? No. I mean, generally we're going to need to look at, you know, dealing with drafts and gaps and maybe increasing insulation. And there are other things that we would need to look at to solve the underlying problem of why the air conditioning bill suddenly spiked. A transdiagnostic approach works to identify all of the causes of the symptoms, understand their interrelationship and causes, and develop a multi dimensional treatment plan based on what the person is most motivated to address. And that's really important. If they're not motivated to talk about their feelings. Well, what else can we do? What are you willing to do? What's one thing that you're willing to do to start addressing some of these issues that are contributing to your distress? And let's make it happen. Thanks for being with me today. Are there any questions? Well, Phoenix, I'm glad it was a really productive session for you. And I do have a lot of other videos that go granularly into some of these things, like addressing inflammation, hormone issues, sleep, nutrition. So I'm not sure what issues you're specifically saying that I've touched on, but there are a lot of shorter videos that may be useful for you. Alrighty everybody. Well, thank you for being here today. I see we still have 66 people in the chat room. So I don't want to leave too quickly, but we are coming to the end of this. And yes, I agree for a lot of people, we have to sort of reverse engineer the process. If they have been betrayed before, we need to look at how that happened and what can you do in the future to prevent that from happening? Alrighty, everybody. I'm not seeing any questions, so I am going to log off for today and I will see you next Wednesday at the very latest and we'll do it again.