Q&A with Dr. Dawn Elise Snipes

Please feel free to say hi in the chat room. You know, that way I know who's here and I would love to know what you would like to talk about. You know, I can talk about all kinds of things. I've kind of been on a rant this week about public schools, but, you know, I am happy to discuss anything that you want to know about. One thing I did find really interesting this week, I was asked by somebody to look at issues around traumatic memory and maybe not initially experiencing a lot of PTSD like symptoms as a result of a traumatic experience, but then sometime later beginning to experience some of those symptoms. And one of the issues or one of the things that may prevent someone from initially experiencing those emotional, cognitive, physical reactions to the trauma can be substance use. Alcohol is one of those substances that actually is an anti anxiety type drug when on the amygdala, at least the first part of it, as it starts to leave our system, you know, it leaves our system faster than our system can put GABA in. So people start to experience anxiety as they're sobering up or detoxing. But long term substance use can cause some changes in the amygdala that might actually prevent somebody or mitigate some of the anxiety symptoms related to a trauma until that person goes into recovery. And when they are, you know, clean and sober and their, their body has adjusted to being clean and sober, they may start experiencing a variety of different physiological reactions. So the way our brain works is, is kind of really cool in a lot of ways. Another way that alcohol or stimulants, for example, can impact our ability to encode memories is because it acts in, in some ways as a excitotoxic or chemical in our brains that can, you know, like I said, after the sedative effects, anti anxiety effects wear off, it can create an environment in our brain in which the HPA axis is very, very active. And we know when those excitatory neurotransmitters like noradrenaline are prevalent are surging through our brain, that our brain is not focused on solidifying memories. So you may end up with a bunch of memory artifacts, if you want to think about it that way, just kind of floating around that haven't been integrated because when it happened, the brain was distracted, it was flooded with all those excitotoxic chemicals. And once the HPA axis was allowed to recover some, then all of those artifacts, you know, started becoming more prevalent. Think about it like, you know, a bathtub. If you have a bunch of stuff floating around in the Bathtub, you know, you tore up pieces of paper or whatever and you put them in a bathtub full of water. You know, you might not notice them as much. You not might not be worried about them or as much. They might not be as much of an issue in a big full bathtub of water. But as the water drains out, you know, that stuff is still there. And once the water all drains out, you have to get that stuff out of the bathtub to get it truly clean. So that was, you know, probably not the best analogy I ever made, but it was. Now, I've seen a lot more people have joined in since we started, and I would like to know what you want to know about. What questions can I answer for you? What pressing issues it doesn't have to be related to Covid, by all means. Anxiety, depression, homeschooling, whatever it is that, you know, sparks your fancy or sparks your interest. If you need resources, you know, where do I find information about xyz? As long as it's related to behavioral health in some way, you know, I probably will be able to help you out. So please, you know, feel free to interact and, you know, let me know what you are thinking. Brewster, come here, boy. While I'm waiting. Good morning, Jennifer. Glad to see you here. I hope in New Hampshire. I haven't really followed the tropical storm, but I hope you are doing well and staying dry. My family is actually from a little town in New Hampshire called Laconia, so you may or may not be familiar with Laconia. Come here, Boo Boo. Came in to say hi to you guys today since, you know, it is a Saturday. Boo Boo. Okay, yes, I see you saying hi to me. I love you. Say hi to the people. You don't get that. You don't get that. But anyway, he's a good boy. So what questions? What issues? That was my little intermission, so to speak, while you guys thought about questions that you might have. What questions or issues can I be of assistance with? This is your time to pick my brain. I just did a presentation on juvenile arthritis and I learned so much about juvenile arthritis. And. And it definitely is important to recognize that there are autoimmune issues and chronic pain issues that impact children and very, very young children. So we need to ask ourselves, when children start not behaving the way we would expect, you know, what is going on? You know, a two year old, a four year old, a five year old may not be able to say, you know, my elbow hurts or my hip hurts, hurts, or. Or whatever. They may just Kind of work through it. I remember when my son was young and he would get ear infections. You really wouldn't know, except for the fact that he was a little bit more irritable. You really wouldn't know that he had, you know, bulging eardrums, which I'm a big. When it comes to ear infections. As soon as, you know, I start to get a little bit of pressure. You would think that, you know, I needed to be in the icu, the way I'm acting. But he wouldn't. And a lot of children are that way. So when children start acting withdrawn, disorganized, irritable, you know, or some other way, you know, we want to ask, what is this behavior telling us that they may not have the vocabulary to tell us? The alliance asks, what are some strategies for increasing follow through when you have depressed or anxious or otherwise un unmotivated patients? For example, with homework, exposure, CBT and other therapy strategies. All right, well, there's my thing. Resistance is one of, you know, many of my favorite topics. But it's important to look at the reasons why the person is not being compliant. You know, that will give you an idea. Because behavior communicates information. Behavior speaks to us. What are they saying? Are they saying what we're asking them to do is too over overwhelming and too threatening and they're terrified to do it? I've worked with clients sometimes, you know, even writing their autobiography, they wouldn't do it. And when we sat down and really talked about, you know, what is holding you back, what is keeping you from doing this, sometimes they didn't see the point. And it was, that was my fault for not articulating why I thought that would be a useful activity. So maybe they need clarification on why it's important they do it. Sometimes they were afraid that if they started writing their autobiography or started writing a narrative that they would open this Pandora's box that they would not be able to shut. And the thought of losing control was keeping them, preventing them. And makes sense, you know, they want to stay safe, was preventing them from actually doing that assignment. So you have lack of understanding of why it's important. You have fear of doing it because they don't. They're not convinced that they can handle it or that they have the coping skills to do it. And third, they may just not have the knowledge to do what we're asking them to do. Sometimes. If you were in college and you ever had a professor that had actually written the textbook you were using, a lot of times, if we know Something really well, because we've studied it for 10, 20, 30 years, depending on how long you've been in practice, we may skip over things because we, quote, assume people know, and it's important to really break it down for them so they feel like they actually understand step by step how to do it, which is really one of the reasons it's so helpful to rehearse in session what they might be doing. And a final reason why people may be resistant to engaging in, in homework activities is because they've done something like it before and they don't feel like it was helpful. And that's sort of on them. And we really want to be very open and elicit their feedback. When we start talking about interventions and ask them, do you think this is what will be helpful? Do you understand how to do it? If they've done it before, you know, ask them what the benefits and drawbacks to doing, to doing it before were. I've worked with a lot of clients, and autobiographies are huge in substance abuse treatment especially. But, you know, I've always used them in my practice because I work from a psychodynamic perspective. But if people have written autobiographies before and it's just been, yeah, I wrote this, I handed it to my therapist, and bada bing, it was done, I. Well, yeah, I can see why they might, might not be motivated to do it again. So if they've done it before, we want to understand exactly how it was implemented and maybe compare it to what you're going to do with it. Why is it that it's important to do it now? Or it could be different now, the way you approach that particular activity. And aside from looking at resistance from our part, it's really important not to provide them more homework they can handle. And it's also important to make sure that we are following up on it, checking in with them about how it's. How they're doing with it, if it's something that could be intimidating for them. And, you know, maybe you're asking them to do some type of exposure therapy every single day, and you've already rehearsed it in session. You know, it might be helpful to encourage them by following up with them each day, just having them text you after they do it to let you know how it went. You know, that might make them feel like they've got a. A lifeline, so to speak, if it feel. If they're afraid that it might be overwhelming. Another person asks, what's my advice for new counselors? Well, that's, that's an open one. So, you know, I'll, I'm going to table that for a second. And what strategies or specific activities have I found useful for heartbreak or romantic relationships? Well, you know, heartbreak there is a lot of grief that is involved and it's really important to help people explore their grief in terms of how that situation, you know, the losses they're experiencing as a result specifically of that situation, but also how, how it's triggering losses from the past, prior breakups, prior problems in relationships and, or maybe prior abandonment issues. So there's a lot of stuff that can come up in, when we're working with clients who are going through some sort of a breakups that we really need to consider. You know, what does this mean to them? It's not necessarily just oh, I'm not going to see this person anymore. It may bring up a lot of other stuff, stuff for them. We also want to look at what that relationship meant to them. If they have low self esteem or low ego strength, they may look toward a romantic relationship as a source or maybe even the single source of validation. They can't validate themselves, so they need that external validation. When that relationship ends, they don't have that source of validation. So they feel like they are floundering, they feel like they can't breathe, they feel like they don't have direction. So it may be important for, to work with the person to identify sources of self validation as self esteem development as well as what are some other people in their life that are able to provide some element of support for them. At that point, I want to get away from having them look to other people for validation, to look to other people to tell them that they're okay. I want them to get to the place where they believe that they are okay for who they are. Yet we all need support. And there's, there's a difference between validation and support. As far as new counselors, you know, can you give me a little bit more specific information about what you're thinking of? You know, work settings, interventions, best way to start sessions, you know, there, there's so much there. I don't want to just prattle on about anything. So if there's something a little more specific, you know, narrow me down a bit. In terms of identifying what to specialize in for counseling? Oh, that is going to be, you know, obviously a very personal choice. My heart tells me to find something that you enjoy doing, finding, find groups that you really, you love working with. So that means going and Trying out just like in, in the United States, I see you're in the Philippines. In the United States, doctors and, you know, depending on the program, sometimes clinicians are required to do internships or residencies in various different settings in order to try things out. See whether you like working with substance abuse or mental health issues or, you know, people who are acutely suicidal, people who have schizophrenia, or severe and persistent mental illnesses. Those just those four right there are very, very different in their approaches. It's also going to be important to identify, you know, the approaches that you want to use, whether you use cognitive, behavioral or existential or whatever approach it is that you use, and find a group or find an area in which that approach works really, really well. So those, those are two things to start with. Go where your heart draws you to because you will really flourish most of the time working with that population. And a lot of times when you go through your internship or your residency, you're going to identify places where, when you're working with clients, you feel like it clicks. You feel like you have those aha. Moments in session more often. And I would say, you know, go with your strengths instead of being a fish swimming upstream. The third consideration is less emotional and more practical. Look in your area, what is the need? If you are doing this as a job, which you probably are, identify what you know, types of clinicians are needed in your area so you know that you can get a job. You know, for example, in certain parts of the United States, school counselors are in super, super high demand. In other parts of the United States, substance abuse counselors. Well, in most of the United States, substance abuse counselors are in high demand. But in the US Especially in some of our rural areas, you know, there isn't so much of a demand for somebody who specializes in one thing. They're looking for somebody who can address pretty much everything in the dsm. And I know that's not a direct answer to, you know, what to choose, but you know, you're going to be doing this 40 plus hours a day for, you know, several years at, at the very least. So it's important to do something that you at least have a somewhat of a heart connection to, but also to make sure that you are specializing or getting trained in something that will have earning potential. Are there other questions? Another thing for new counselors is to identify the type of setting you want to work in here. You know, I kind of went off on a, on a soapbox this morning because they are defunding police departments and talking about sending counselors and social workers instead of law enforcement to certain calls. And we just aren't trained for that with law enforcement. Now I can see where that might be beneficial. But law enforcement works differently than behavioral health. Law enforcement is about getting to a call, you know, resolving it as quickly as possible and moving to the next one. Mental health is different. So it would be ideal if there were some sort of a handoff option. And I know one county or one agency they actually serve, 13 counties in Florida is actually doing something like this where they have behavioral health professionals ride along. But if they don't have a person that can ride along, they have a. The ability to connect people via virtual video meeting, you know, via zoom or something else, with the crisis stabilization unit or with a crisis counselor. So that person has a warm handoff from law enforcement to a behavioral health professional who may not be physically there, but is at least available via video. So there are some options. Do you want to work in residential? Do you want to work in private practice? Do you want to work with kids? I personally was not trained to work with small children, so that's not a setting that I would gravitate toward. How does CBT help wean off antidepressants? Well, it's. They're two different things. Weaning when you wean off antidepressants, you are altering or you are causing your body to alter the levels of certain neurotransmitters in your brain, which is going to increase potentially certain symptoms. The medication is no longer going to be bolstering the amount of serotonin or norepinephrine or whatever in your system. So ideally, cognitive behavioral therapy can help you cope with the increases in distress that you're experiencing as a result of not having as much of those neurochemical in your brain at that point in time. The goal in treatment, or at least with the people that I work with, is to not necessarily use it as a one to one replacement. What I want people to do is to develop the skills and tools, you know, maybe while they're on antidepressants, if they're taking medications, to be able to live a health, happy, healthy lifestyle, to help them get to the place where their HPA axis is not constantly disregulated. So when they start to wean off of their, you know, psychotropic medications, that they are starting with as much resilience and as many physiological and cognitive resources as possible to deal with life on life's terms. CBT is a method of coping with distress and antidepressants may for some people. Now remember, antidepressants and psychotropics only work for about 30% of the population when we're talking about mood disorders. But antidepressants sort of artificially increase your calming or your modulating neurotransmitters. In terms of strategies to wean off antidepressants, it's going to be important to work with your prescribing physician to identify ways to do that, because as you do it, you know it. When you quit taking certain medications, it generally takes your body a while to realize that it's not going to get that artificial bolus anymore and it needs to start doing more on its own. So that's the first thing. It needs to be a very slow process, very slow process for most people. You know, if, if you're having medical complications because the antidepressants, obviously it speeds up quite a bit, but so work with your physician on weaning off of those when you're ready. It is highly, highly recommended that when you begin that wean off process, if you can plan it, if you can time it, to make sure that you've got at least six months to a year where there is probably not going to be any major stressors going on. You know, if you're one of your loved ones was just diagnosed with cancer, you know, that's probably not the time to start thinking about trying to wean off medication. If you just started a new job, if you, you know, just had a new baby or whatever, you know, major life changes cause stress in the middle of COVID lockdowns, financial stresses, social unrest, everything that's going on right now. I would strongly discourage my clients from trying to necessarily wean off the anti depressants or psychotropic medications right now. You know, wait till they're in a place where they're not stressed out all the time. You know, wait till they're at a place where, you know, they can go most days feeling pretty dagum good and then start again slowly working with their physician to slowly wean off. Some people will say that there are alternatives, there are herbs, there are, you know, complementary therapies that can take the place of antidepressants. And for some people, that does work. Again, I can't emphasize enough how important it is to work with your prescribing physician so you don't precipitate a, a crisis. And you know, there is, there are, is whatever the verb, verb conjugation should be. There are multiple different things that you can do to Ease that transition. And that can be anything from yoga to massage to acupuncture to acupressure. Let me show you, let me see if I can get it to come up right now. Here we go. Cochrane.org Cochrane database. They have already gone through and looked at a lot of the research that's on PubMed and they kind of summarize what the research says. Unfortunately, most of the stuff for, for humans and behavioral health is inconclusive. But you can start here. So you go to cochrane.org and. I typed in depression and it's talking about, you know, music therapy for depression. Look, and this report will tell you what they found in terms of what do the studies say about the usefulness of music therapy, acupuncture, relaxation, family therapy, exercise, nutritional interventions? You know, there's lots of different things that people have tried. So if you're thinking about, you know, I wonder what acupuncture, how effective acupuncture is for depression, you can look on the Cochrane database and see what the research has shown thus far. Combating compassion, fatigue and burnout is really important. And I actually have several videos, well, a couple of videos on burnout prevention on the YouTube channel. So, you know, make sure to check those out when this is over. But it is important to recognize when you're starting to get stressed out, to be very mindful and understand, you know, how you're feeling, what's going on. Sometimes things that clients bring up will be triggering for you and it's going to be important to be mindful enough to notice that and address it for yourself. Physical health is so important. Making sure you're getting enough sleep, making sure you're eating well, you're not abusing substances. Obviously that is crucial. Getting exercise, recreation is so important. You know, it's really just like any other job. You know, whether you're a nurse or you're a doctor or a lawyer or a counselor. Part of burnout prevention is that ever elusive work, life, balance. And it's really important to identify in your mind, you know, ask yourself what does a rich and meaningful life look like to me? And working 80 hours a week is probably not it. So what does it look like to you? And then every time you start to do something, take on another patient or, you know, whatever it is, ask yourself if that is going to help you achieve that rich and meaningful life or you know, work against it. And I have a couple of videos on psychological flexibility you can do, you can watch that are on the YouTube channel. But you know, just briefly, you Know, get a poster board, you know, just a big old plain old poster board and draw on it, you know, several circles. And in each circle identify things that are important in your rich and meaningful life. Like on mine, I have family, I have friends, I have health, I have my job, I do love my job. And, you know, I have my pets. I have a variety of other things on there that helps you see what's important. And then on top of each one of those circles that you've labeled, take a sticky note and write down things that you need to start doing or you would like to start doing to nurture those. You know, what do you want that relationship with your kids to be like, with your friends to be like? What do you want work to look like? You know, for me, one of the things I put on there that I strive for, don't think I done it yet, but I strive for, is to work a 40 hour week and, you know, leave it at home. So it is important to be able to visualize what's important and recognize that, yes, you can take on, you know, a bunch more clients or, you know, whatever and spend more time doing work and that will give you more money potentially. However, does that give you, you help you work towards that rich and meaningful life Broadly, does that help or hinder your relationship with your friends, with your family? Does that help or hinder your health to be working 60, 70, 80 hours a week? And that's what it keeps coming down to, is figuring out, you know, every time you do something, every decision that you make is using my energy toward this, helping me move toward my rich and meaningful life, or is it keeping me stuck, or worse yet, taking energy away from things that are important to me? Are there any other questions? I really appreciate you guys being here today and asking your questions. For channel members, I do this every single week. For people who are not members of the channel, I do it once a month. And so you can always tune in at the very least once a month and pick my brain as much as you'd like. Okay, everybody, have an amazing day and I will see you later.