Quickstart Guide to Improving Health Literacy and Mental Health and Q&A with Dr. Dawn Elise Snipes

Important decisions that they want to make about their, their life and their livelihood. So where do you find this information? Well, there are a lot of different places you can find it on the Cochrane Database, which I'm going to try to pull some of these up one by one and hopefully I will be successful at that. Let's see. Cochrane. Maybe. All right, here we go. And if you go to the Cochrane Library.com you are able to search for a variety of different issues like depression treatments. And it brings up a lot of basically what I would call meta analyses regarding different types of treatment for depression. One beef I have, if you will, with the Cochrane Database is a lot of times they present information, but their ultimate conclusions are there is no definite answer about whether this is a right, a wrong or an effective thing for any particular person, which is going to be true when we're dealing with therapy, when we're dealing with humans. But if you want somewhere to start, you can start here. And for example, we can look at acupuncture for depression. And a lot of people are put off from research because they're like, well, I don't have that statistics database and they start reading a research article and they get into the methods and the, the data and all that stuff and they start getting overwhelmed with all of these statistics. We don't want to do that. You know, you don't have to do that. That is the next level up for research evaluation. But for the general person, there are a lot of ways to be consumers of research without having to have, you know, a PhD in statistics. So let's look at this article from the Cochrane Data Pace on acupuncture for depression. I'm just going to show you the format. It starts out with a background about what we're looking at, the objectives for their meta analysis here to determine whether it's more effective than treatment, as usual, if it's more effective than control. Acupuncture for improving quality of life, yada, yada, yada. So you can read through the objectives of what they were trying to determine in this meta analysis and then they talk about the search methods, how they figured out which studies they were going to use and which studies they selected. And then they have main results and you can go through what the main results were for what they found and using the words that are here. For example, it's unclear whether data show differences between acupuncture and psychological therapy and the severity of depression biological by the end of treatment. And then they give you a bunch of numbers right here. And that is not so important if you are just being a general consumer of the research. If the article says that it's unclear, then you know, it's, it's probably unclear. You don't need to look at the data and go, well you know, maybe they're lying. If it's unclear they're giving you the numbers. So a statistic, statistician could look at it, but you don't have to. And then you have authors, conclusions here. Now if you want something even more simple, you keep scrolling down and everything that they just said up higher, they say down lower in what they call the plain language summary. And this is the one that is written for the average Joe. This is written for, for somebody who doesn't have a master's degree in counseling or, or isn't a medical doctor. So again, it restates the same thing, but it states it in very plain language and then ends with author's conclusions. So the Cochrane Database is a great place to go to start looking if you're interested. And then obviously at the end you can scroll all the way down here through all the charts and data and stuff and read more about the study. But, so that's enough. On the, on the Cochrane Database, that is a great place to start. When my mother was diagnosed with bladder cancer, this is where I started because I knew nothing about bladder cancer. So I started with the Cochrane Database to look and see what types of interventions have been set, studied. So I knew where to even start looking when I went to our next resource, which is my ultimate favorite resource of all time. And I spend way too much time there. PubMed. And if you, you probably spend a lot of time in PubMed working on your master's thesis or your doctorate. But if you aren't a counselor, if you aren't a clinician and you're not familiar with this, again, please do not be intimidated by the fact that it says PubMed and it's the National Library of Medicine. Don't be intimidated by all the statistics we're going to go through really quickly here and look at how you can use this as a tool to increase your health literacy even if you don't have, even if you never went to college. You just need to be able to get in here and figure out, all right, what do I do now? Some basic tips and tools in looking at research. We want to look at stuff generally that is less than 5 years old. Why? Because a crap ton of stuff changes in five years. Our quality of life, our air quality, the types of foods that we're eating. You know, I don't remember when they started introducing genetically modified foods, but there are a lot of things that have changed over the past two decades for certain. But five years is generally the accepted practice for looking at something that might be considered current research. So going into here, there, your, your filters are over here on the side. You can just go down. You want free full text. You want to be able to read the whole thing, not just the abstract, if you're going to be really getting into it now, the abstract, if you're not familiar, the abstract just summarizes what's in the article and it may not tell you the whys or the hows or anything like that, but it gives you the high level data. Exercise is effective as a treatment for depression, or exercise is not effective as a treatment for depression. But you don't know exactly how they came to that conclusion. So I always check free full text. I always check publication date of 5 years or newer and you can click on additional filters. Species is another big one. I don't really care what rats do. I want to know what happens in humans because we are not rats. We operate differently than rats. We are programmed differently. Our amygdala is different than rats. I want to know how this impacts humans. Humans, go figure. If I am working with a particular person or if I'm looking for something on myself or something, I may also go down to sex. And for example, if I was looking for information to help my mother when she was dealing with bladder cancer and the depression associated with it, I would have clicked female. Because you want to look at populations that are most close, closely similar to whoever you're trying to apply this information to. So I click show and all of this stuff, when you click this happy little box here, free full text. All of this stuff is going to be free to you. So it's not like you're going to have to go somewhere and pay for it or get a subscription. That frustrates me so much when there's an article I want to read and it's behind a paywall. And the clinical paywalls are expensive. They want you to pay like $65 just to read an article. And I ain't got that kind of money. So anyhow, free full text. Five years human. And if gender makes a difference to you, then gender that will help narrow what you're looking at. And in this search, let's see, I'll do. Depression treatment, cancer. So just like you're doing a Google search, you put in your keywords here and you can scroll down and look at the studies that have been done on different approaches to helping people with, with depression or helping people with cancer deal with depression. Because most of you who are watching right now are probably either interested in mental health or your clinic. So you're interested in the mental health part, not necessarily the clinical part, but you can also do this goes through the National Library of Medicine. So maybe you were just diagnosed with a migraine or chronic migraine and you want to find out what the current research is on available treatments for migraine. And I will give you a little hint here. A lot of physicians and a lot of clinicians, I'm so sorry to say, do not stay up on current research. So there can be new practices that are out that they are not aware of yet. Not to say that they don't want to be aware of them, but if there is something that's come out in the last, you know, two to three years, you may consider printing out that article and bringing it to your physician, counselor, psychiatrist, whomever, if you want to pursue that course of treatment, because you can educate them and then you can decide together whether that's going to be an appropriate treatment for you. Now, please tell me to slow down. Ask questions as we go through here, if you have questions. Because my goal today is really, I want you to feel comfortable and maybe not rise to the level of being as excited as I am about research that's kind of difficult to do because I'm weird, but really feel confident and competent in, in directing your own health care and your own mental health care so you can find out what might help you so you don't feel stuck, so you don't feel trapped, so you don't feel at the mercy of, you know, the first professional you go to going, well, I don't know what to do. I assume, you know, don't assume. A lot of clinicians are very, very good, but a lot of clinicians are very, very good in their niche areas. So there may be something more appropriate to you that is important to consider and we're going to talk about that more in a minute. So going back to this, this is a great place to search and you can search anything in here. Mental health and correctional facilities. So this comes up. The first article is mental health of prisoners prevalence, adverse outcomes and interventions. So it gives you an idea of what might be there. So Obviously I love PubMed. You can go into this and we're going to look at some of those articles in a minute. The DOAJ is the directory of open access journals. Now you need to be a little bit careful with DOAJ because they're not all peer reviewed. However, it is a great place to go to find research and in terms of, you know, who is going to benefit from this information, you know, you're going to read through it and you are going to hopefully glean some information from it. And with. Let's just jump ahead to PubMed real quick. So this is one of the articles that I pulled out and cognitive behavioral therapy for cancer related cognitive dysfunction. So people that are having difficulty, you know, cognitively as a result of their cancer and that happens a lot, partly because of chemo and sometimes partly because of organic changes in the body that contribute to cognitive dysfunction. When people have cancer, a lot of times they don't sleep as well. That contributes to foggy headedness and problems concentrating and slower cognition. They also may have a buildup of adenosine in their brain because they're not getting quality sleep when they are sleeping, which can contribute to cognitive dysfunction. What you really want to do is you want to come in here, read the title and then read the abstract. The abstract is that high level summary that tells you what's in the article. Some people will find this is enough and they don't want to go any further. And that is totally cool. It may give you enough information to go back to your physician, your therapist and say, you know, I got a question. I read this and open that line of discussion. Because I don't expect everybody who goes through looks at research to understand all of the nitty gritty. There's a lot of stuff in there that does take some amount of prior training, but there's also a lot of stuff that you can glean through it. So one of the things that intimidates a lot of people when they start reading the abstracts is they start seeing a lot of abbreviations. And it does frustrate me, I will give you that. It frustrates me and I read these literally every day. If you see an abbreviation that you don't know what it means, scroll back to the top of the article or do a search. You can do control F and you can do a search to find where that first came up in the article and they define it. So here CRCD is cancer related cognitive dysfunction. They just didn't want to type it out every time. Same thing with CBT and memory and attention adaptation training. They're going to call M A T throughout. It's important to know those so you don't Feel like you're totally reading a second language. But here in the summary it talks about more research with larger sample sizes. Multiple clinicians and multiple sites are needed to confirm effectiveness. But CBT approaches such as MT that address multiple psychological factors may offer a flexible non pharmacological approach to. To cancer related cognitive decline that optimizes quality of life outcomes. Okay, well that sounds really optimistic. So if I have a loved one who has cancer related cognitive decline, I might be going, hmm. Well, it sounds like there are some cognitive behavioral approaches. One is called M double A T. That might be helpful. That's enough for me to go back to my loved one social worker and say, what do you think? Now if you are a social worker and, and a lot of us who went through graduate school didn't develop a love of statistics and that's totally cool. So you want to come down. The introduction. A lot of times in these journals can be somewhat onerous for the average person because for some reason when people write these for journals, they feel like they've got to use all this big fancy flowery language. So it can get a bit mind boggling if you're willing to slow down and go through it a little bit at a time. I mean, it reads like a college textbook, but if you're willing to take the time to go through. The introduction does provide a lot of good information about the issue, about the research that has already been done on the issue, and then about why they might be looking at whatever they're trying to study. So in here, for example, just looking at this graphic, you can see that M aat includes compensatory strategies to help with daily task performance, self awareness, stress management, and education and reattribution of certain things. So that gives us a little bit more information about what kinds of cognitive behavioral strategies are being used. So when, when I'm looking through this, just scanning it, I'm getting kind of excited. I'm like, okay, you know, how might this, what might this look like in actual practice? But you know, I'm also recognizing that I'm trying to make sure that you're not put off by this. So if you can re. Can and want to read through the introduction, I think it is a great place to, to start. Um, but if it is overwhelming, you know that that's totally cool too. You can skip down that and you can look in this one. There wasn't actually a study done, but you can look at the conclusion. So read the abstract and the conclusion and that will give you the lion's share of the information that you need in order to feel like you've gotten a little bit of knowledge from this. Okay. And if we have time, I'll go through a couple of more because I don't want you to feel intimidated. There are a lot of words and there are, you know, it can feel intimidating at first, but once you get the hang of it. And remember, you can skip over the method and the results section if stats is not your thing. The abstract and the conclusion are the most important parts for for the average person to read and glean the information from. Now if you want to tear the study apart, then you're going to have to read a little bit more in depth. But if you just want to figure out what is this study trying to say, that will do you really quite well. Okay, so the dictionary, not dictionary, the directory of open access journals is another great place to go. You can just Google DOAJ and it will come up. Other places that you can get really great information that is free and it is allegedly peer reviewed are your government websites. Cdc. We all know what the CDC is and obviously that pertains more to physical health issues, but it also pertains to a lot of physical health issues that co occur with mental health issues such as autoimmune diseases and diabetes and cancer. Cancer. So the CDC is a great website. Nida, the National Institute of Drug Abuse has tons and tons of places. Let's see, let's go to nida, The National Institute on Drug Abuse. When you go to National Institute on Drug Abuse, National Institute of Mental Health, you know any of those national institutes, if they have a.gov after them, you're going to be pretty confident that the information is coming from credible sources. So.gov is one of those clues that you can look for. And then you can go in here and start with publications. That's where you get if you want to increase your health literacy. What publications have they put out? And you can search, you know, tons of stuff. You can use the search box to narrow it down more. There's a lot of stuff you can do. There are tons of free publications that you can order off NIH and NIDA. You can also download a lot of PDFs. They have a litany of resources for ranging from, you know, children and teenagers all the way up through older adults. So there's a lot of stuff out there. Same thing for the National Institute of Mental Health. That is another great place to go to get information about depression, bipolar, adhd, cognitive issues, you know, the whole kitten caboodle samsa I actually don't have on here, which I should be ashamed of myself because that is one of my. Sam. It's one of my favorite places in the world. Again, because they have a ton of free publications, posters, videos that you can use to educate clients or if you are a lay person, if you're in the general public, to educate yourself. Practitioner training is obviously designed more for people who already have some background. But you can also go over to publications, maybe website's a little slow today, but and find lots of information in here, including full treatment improvement protocols. But also, you know, it says right here, publication, primary audience, general public, and there we go. So then it narrows it down. If you're the general public and you don't want all that clinical technical stuff, it narrows it down here. But trauma, underage drinking, suicide, substance abuse, mental illness, driving while intoxicated, grief. You know, there's a lot of stuff on here if you want to educate yourself or your clients about a particular issue. Harvard Health is another one. Obviously that is a private website put on by Harvard University, but they do have a lot of great resources that I have found to be. To be very, very helpful. So I do recommend Harvard Health as one of the resources. The Surgeon General's website is another one where you can go and find really great research about a variety of topics. E cigarettes, tobacco, suicide prevention reports and publications. Again, you always want to look for that term publications. Mental health, violence, oral health, skin cancer, healthy homes, prevention of preemies. You know, the list goes on of different reports that are out there that help people understand their own health and help us as clinicians understand what people need in order to improve their own health and mental health. Another place that you can go if you have a specific issue that you're looking for is the our national associations, like the National Diabetic association or whatever it's called. So search national association and then whatever it is, diabetes, cancer, aging. And you can find a lot of good information that's generally being put out by a nonprofit organization that doesn't typically have any conflicts of interest. Other places that are not actually research but are really important to know and a lot of clinicians don't know these. So I really want you to, you know, pay attention. Drugs dot. I always, I always get the suffix messed up on these. Drugs.com has two places that are really awesome to go, the Drug Interactions checker and the Drug side Effects checker. When you have clients who are on multiple medications or they're taking a medication and maybe Some over the counter herbs. It's important to check the interactions, especially if they start having changes in their cognition, in their mood or in their health. But for most of us who are clinic, mental health clinicians, going to be paying attention to their, to their fatigue, their energy levels, their, their mood, cognition, those sorts of things. So for example, you might put in Zoloft, so we're going to add that to the list and. Buspirone and let's just throw in some oxycontin to round it out. Say the person is on Zoloft and Buspirone normally and then they have surgery and they're prescribed oxycontin for a while and they start, you know, having changes in their symptoms. So then it tells you there are two major interactions between Buspirone and Oxycontin and buspirone and sertraline, because buspirone increases serotonin. But Oxycontin and sertraline also both increase serotonin levels. So you could be looking at the beginnings of serotonin syndrome in that particular person. And then a moderate concern is oxycodone and sertraline. It is important. And whenever I have clients come in, new clients come in, I go through with them and we put all their medications that they're currently taking into this and we look at potential interactions and we talk about not only things that are prescribed because a lot of times they're going to different doctors, but also things that they're taking over the counter, like any herbs that they may be taking which could be interacting. So, for example, St. John's Wort is not recommended at all to be taken with antidepressants because they both increase serotonin, which can contribute to serotonin syndrome, which is life threatening. But this interaction thing gives you very plain language summaries of why it might be a problem. It doesn't mean it is a problem for you. And it is important not to discontinue your meds suddenly just because this website says there, that there might be a contraindication. It is important, however, to talk with your doctor about it if you have concerns. But please don't discontinue medications without physician observation. Okay? Drug side effects is also on drugs.com and then another thing that is important to recognize and to look for if you suddenly start having symptoms, drugs that can cause, and there isn't a nice database for that that I have found that I really like, that I feel is impartial. But there are a variety of medications out there that can cause symptoms that mimic Anxiety disorders that mimic depression is important to recognize if the cause of somebody's change in cognitive or mental health presentation is physiologically caused. Is it caused by something they just started taking? There are certain medications that just recently got FDA black box warnings put on them because they so significantly as one is an asthma medication because it so significantly increases the risk of depression and suicidal ideation. It is important if you start taking a medication and then you start feeling wonky that number one, you call your doctor. But you know, if it's 2 in the morning and you don't want to, you don't feel it's bad enough to go to the emergency room. You can look at drugs that can cause and you know, for example, when I take one of the. I can't remember which one it is. One of the over count over the counter antihistamines. When my allergies get really bad, I feel super, super groggy all day long. And it's one that's not supposed to make you groggy, but it does. I think it's Zyrtec but I can't remember but that's just how it impacts me. So I know and I went and I looked and one of the side effects is, is fatigue on for some people even though they say it's not. It's supposed to be a non drowsy. Well that's not always true. Those are things that, those are places that you can go to find information. Now I'm really briefly and I've kind of gotten away from myself today but I really briefly want to talk about how to evaluate research because all research is not created equally. The first thing, without getting too deep into it and overwhelming correlation versus causation. When we are working with humans 99% of the time all we can show is a correlation because we can't control for enough of the other variables to say for certain that X causes Y, that stress causes cancer, that this causes this. We can't say, we, we can't necessarily address that. So we want to remember that most studies are correlational. That means they indicate that there is a relationship between e.g. stress and cancer or smoking and cancer. But whether it's causational or not is, you know, that's kind of a touchy thing. So do recognize that because there could be other things that are causing it. When we look at for example studies of depression or anxiety or pretty much anything mental health, you can have twins that grew up in the same household and experienced nearly the same things, have very different mental Health profiles. And so we can't say that there is any one thing that necessarily caused it. It's trying to figure out why one twin that grew up in the same household developed addiction and major depressive disorder and the other one didn't. You know, that is a bit of a quandary. So, you know, recognize that it's almost impossible to prove 100% causation. A lot of times you can look at meta analyses. And so researchers have already looked through hundreds of studies and found information and, and kind of synthesized all the information and said, okay, here's what you need to know. They already do that on the Cochrane Database. But you'll find a lot of a meta. Meta analyses on, on PubMed. I like meta analyses because it gives me a place to start. They've already pulled together the most current, usually studies on the topic that I'm interested in. So I read the meta analysis and then I look in the references list and I go and look up each one of those individual studies if I want to know more. You do want to consider the inclusion criteria. And there's one here that I want to point out. So for this one, it looked at the effect of probiotics on depression. All right, so read through the abstract. It said that they had a positive effect on some people, but had no effect on people over the age of 65. Now that's a pretty strong comment. And I'm like, well, if they had a effect on both the healthy population and people with major depressive disorder who were under 60 but not over 65, what's the difference? And you scroll down, you can read the introduction. But one thing I did find when I was looking at the studies that were included, the only study that looked at people over the age of 65 was done in Japan. The other studies were done in other countries. None of them were done in the US which, and we know that what we eat and our lifestyle significantly impacts our gut microbiome. So it's very possible. And that the microbiome of the people who were in the study in Japan who were over 65 was significantly different enough that the probiotics weren't helpful. So this one really doesn't provide us a whole lot of information. They have different dosages, they have different age, age ranges, and they also have different bacteria that they were giving people. So there are a lot of confounds in this that make it unclear as to exactly what would be effective. So I have a hard time drawing many conclusions from the meta analysis. I'd want to go and look at for example, this one in Iran, 20 to 55 years old patients with major depressive disorder. Okay, well, you know, that's a population I work with pretty frequently in the U.S. so let me look at this population in Iran. And, and you know, in Iran they have higher stress levels in some ways. They have much different diets. So probiotics are going to probably affect them differently. So these are the things that go through my mind when I'm researching because I tend to be the devil's advocate. You want to look at the sample size, sample size of 30 or greater. That's. That is, if it doesn't have a sample size of at least 30, then you're really going to have a hard time extrapolating and applying it to other people. You want to look at the sample similarity like I was just pointing out, you know, something that is done on a study of elderly men in the correctional system is not going to apply to my teenage clients in, in high school. You know, they're just completely different populations. So you need to make sure that you're trying to compare as closely as you can, apples to apples, the age of the study, as I said earlier, less than five years is better publication resource. Make sure it is a legitimate resource, preferably peer reviewed. PubMed is a great place to go to ensure that you're getting good quality research as well as those government institutions that I mentioned earlier. And you want to look for conflict of interest. And this is especially true if you are looking at just general websites that provide medical information and I'm not going to call them out by name or if you're listening to talking heads on tv, what do they have a conflict of interest? Do they have a financial or other stake in what they're saying? For example, if you are a stockholder, a shareholder in a particular pharmaceutical company that makes antidepressants and you want that stock to go up, then you want to say as much positive and find as many ways to tout the positives of your drug. There's going to be drawbacks to it. There's drawbacks to every drug. But, but that person is probably going to emphasize the positives and probably forget or fail to mention the downside. So we do want to look at conflict of interest when we are considering the source of the information. Okay, going really quickly through confounding variables, then I'll get to the question up here that Sarah had conf. Founding. Variables can be things that are occurring that alter the, alter the results. You know, gender for Example, when we look at the effect of certain medications, women sometimes have a different reaction to medications than men because of our hormones. Estrogen affects serotonin availability and a lot of other stuff. Testosterone does, too, but in different ways. Pre menopausal versus postmenopausal women, we have different types of estrogen that are prominent, also are going to have different reactions. So gender, for example, can have an effect, especially with medications, but also with things like cognitive behavioral therapy based on cultural norms. And, you know, if you're doing certain types of expressive therapies, the cultural norm may discourage males in that culture from being expressive and encourage it in females. So you do want to look for confounds. You want to look at the species. As I said, we are not rats. Look for things that were done on humans. Consider other diagnoses. If they come to a conclusion that this works or this doesn't work, ask yourself, why is it necessarily that treatment that they did? Or are there other things going on that may be contributing to it? For example, depression can be exacerbated by thyroid problems, imbalances in sex hormones, high blood pressure and cholesterol medications. So if somebody is taking statins, for example, they may feel. Some people feel symptoms of anxiety, some people feel symptoms of depression. But it is important to recognize that there are a lot of physical conditions and medications people may be taking that might contribute. So if you're looking at a population, you want to figure out, I've never seen a study where 100% of the people have responded or 100% of the people have not responded. So my question always is, all right, 60% of the people responded positively to this treatment, but 40% didn't. What's different between those two groups of people? Why would this group over here benefit? You know, I want to know that so I can, you know, tailor my treatment. And what about the 40% that it didn't work for? You know, what's different about them? What else might be going on with them that would keep this treatment from being effective? You also want to look at the unaffected within the population I talked earlier. You can have a family that grew up. You know, you can even have identical twins that grew up in the same family. One develops a wicked addiction problem and the other one doesn't. What's the difference? We want to look at race, ethnicity, and genetics. Some people are genetically predisposed to certain medical conditions, certain mental health conditions. We want to look at what's going on with them. People of certain ethnicities, for example, are more susceptible to lung cancer than others. People of certain ethnicities respond differently to alcohol than people of other ethnicities. There is an element of genetics that affects our physiological reaction to stress as well as to toxins. And we want to look at environmental variables. If you're comparing, you know, a group of people and half of them are living in poverty or don't have adequate nutrition or not getting enough sleep, and the other half, you know, don't have those problems, you know, those are significant compounds because all three of those things are strongly correlated with mood issues. And you want to look, you know, if you're a clinician especially, you want to consider possible underlying neurochemical issues. Our feelings, our reactions, our symptoms are prompted by changes in the neurochemical balance within our body. What is causing that? Is it disturbance of our gut microbiota? Is it lack of sleep? Is it poor nutrition? Is it stress? Is it an overactive HPA axis? There are a lot of things that alter our neurochemical balance that we want to conceive, consider. And you know, I point all this stuff out and I really am excited about it because it's so important for people to recognize that, for example, depression, oh my gosh, there are at least, at least 50 things that I can name right off the top of my head that might cause depression. And all of them have slightly different best practices for treatment. You know, if somebody comes into your office and they've got major depressive disorder and it's because they've got poor nutrition, well, no amount of talk therapy is going to do any good if they don't have the building blocks to make the serotonin. If they come into you, if they're not getting adequate sleep, you know, no amount of nutritional counseling and cognitive behavioral is going to do any good. So we want to look at what might be causing it. If they've got thyroid problems, you know, if that those their thyroid levels are low or if their sex hormone levels are low, there's only so much that talk therapy can do. And antidepressants probably also won't touch it because antidepressants are not going to significantly increase thyroid or sex hormone levels. Antidepressants are not going to be able to compensate for crappy nutrition or lack of sleep. So we do want to look at what are the other things that could be causing this problem. Okay, so that is the end of what I intended to be a short little introduction on research for improving health literacy. Now to answer a couple of questions up here, what are some ways to handle the anger Toward a parent who infected chronic disease to their child, which they died for when they were a child. So what I'm, what I'm thinking is the question is understanding, dealing with anger towards a parent who transmitted a chronic disease to the, to the child, which eventually caused the child's demise. And there is a significant grief process in that and figuring out, I mean, part of it depends on who we're talking about. Is it the parents self anger? Is it the family's anger at the parent? But one thing we do want to recognize is, is that anger indicates a sense of threat, indicates a sense of fight or flee. Resentment can also indicate anger at a person for not protecting someone else or for, you know, doing something against us. We want to look at what the roots of that anger are and remember that that anger indicates the person is still in a constant state of fight or flee in a current state of emotional turmoil over that situation. Help them figure out how they can move through that grief process. Because anger is a part of that grief process. And it sounds like they're stuck in the, you know, denial, anger, bargaining, depression and acceptance. As Kubler Ross pointed out, it sounds like they're still stuck in that anger. So we want to look at what function the anger is serving, how they might be able to accomplish that some other way, what benefit the anger is serving for them right now. Because anger nurtured really rarely serves any benefit. It actually has a lot of negatives associated with it. By ramping up the HPA axis, increasing systemic inflammation, contributing to depression. There's a lot of stuff anger is, is pretty noxious in and of itself. If we nurture it as a feeling when we have it, it's our body's way of saying there's a problem or there might be a problem, take a look. You need to protect yourself. But we got to help this person figure out how they can protect themselves. What again, what function the anger is serving, how the anger is helpful right now, you know, what is it doing positive for them? Ways they might be able to work through that grief process can't bring the kid back, unfortunately. You know, just being very blunt, that ain't going to happen. And holding on to anger at that person is giving them power. You know, it's giving them power to keep you feeling stressed out and it's sucking your energy. Is that something that you want to do? And exploring why they're afraid to let go of that anger? What does it mean to them if they let go of that anger? In this case, I might think that if the person let go of that anger, they might be afraid that they are being disloyal to the child that died. They might feel like they are not honoring that child's memory and working through that with the parent or the person that is embracing that anger is going to be really important. Remember, behavior is communication. What is this person's behavior communicating and how can we help them communicate that in another way? How can we help them grieve that loss? Because it doesn't sound like they've grieved the loss of that child and honor the memory of that child in a way that is healthy. And when they think of that child, it can bring a smile to their face instead of pain to their heart. That's an excellent question. Are there any other questions? Well, gosh, everybody, thank you for being here today. If you're not already subscribed, please remember to click the button below and subscribe so you are notified before we go live. I go live for the general public the first Saturday of every month at 10am CST 11am EST. And for members, I go live every single Saturday at 10am Or I'm sorry, yeah, at 10am CST. I hate time zones. Resources for the Beginner to Know more about Motivational Interviewing There are two primary places I would send you to. Can't type motivational interviewing samhsa has an entire. Section dedicated to motivational interviewing so you can learn. There are a ton of resources. The Motivational Interviewing Reminder Card Am I doing this right? You can also Enhancing Motivation for Change in Service Training or the tip. It is a really easy read. So it's not one you're going to feel overwhelmed. It's kind of long, but it is a really easy read and a great primer for motivational enhancement. You can also go on the YouTube channel. Oops, nope. Just do motivational. I have what about 15 different videos that go over different aspects of motivational enhancement. So you just go to the all CEU's education channel and type in the keyword motivational and they will start popping up like popcorn. And a lot of these videos are based at least in part on those SAMSA resources. So if you prefer to watch a video instead of read the manual, a lot of people are more auditory than I am. Then you know, by all means you can get the lion share of what's in that tip from these different videos. The same thing, Sarah. You can also search on our website for with the keyword grief and that will bring up a lot of videos that may per help with that person that is struggling with the, with the death, the child, specifically the complicated, complicated grief video. But helping clients deal with grief is another one that goes through a lot of activities that can be useful. All righty. Thank you so much for the questions and for being here with me on this Saturday morning. Have a wonderful day. I hope it is beautiful where you guys are at. And I will see you hopefully next Saturday. It.