Strengths Based Tools for Depression, Anxiety and Addiction Recovery Part 1

I'd like to welcome everybody to this presentation on strengths based tools to address mood disorders. I'm your host, Dr. Donnelly Snipes. We're going to define the transdiagnostic and transactional theories of counseling and I think it's important to look at those in turn when we're talking about strengths based, because when we start enhancing a strength, it has multiple ripple effects on people's mental and physical health. We'll define a strengths based approach. We'll explore how anger, anxiety and depression are connected, and we'll apply the strengths based model, if you will, to addressing some of the symptoms of dysphoria. We'll examine the connection between depression, anger and anxiety, explain, explore types of threats that may trigger the fight or flight reaction, the HPA axis and lead to feelings of anger and anxiety. And we'll explore strengths based diagnostic intervention techniques. So the transdiagnostic model asserts that many symptoms are common to many disorders. So changes in sleep. We know that people who have chronic pain generally have changes in their sleeping patterns. We know that in depression, in anxiety, in grief, we see changes in sleeping patterns. So it's important to kind of be aware of what different things may be contributing to any particular symptom. But we can also try, try to find one of those common threads. For example, if somebody is presenting in your office and they've got chronic pain, they've got depression and eating disturbances. If we address their sleep, that may help. And we're going to talk a lot more about that once we actually get into the meat and potatoes of this presentation. Changes in sleep, sleeping patterns, irritability and fatigue are also common to a whole lot of different physical as well as mental health issues. The transactional model asserts that there's a reciprocal interaction between everything. So if I start improving my health behaviors, improving my sleep, sleep's a big one. It's going to have multiple reciprocal effects. Wow. My tongue recognizes that. It's actually a Saturday today, I think. Sorry about that. Anyhow, so when we start getting quality sleep, it helps set the circadian rhythms. It helps the brain clear out the adenosine that builds up throughout the day so we don't feel groggy and hungover the next day. It helps set the secretion of different hormones like cortisol, estrogen, testosterone. So your circadian rhythms are really important. And when your sleep is messed up, it's going to inevitably impact your circadian rhythms. And it's important to remember that transactions can be positive or negative. And I'm really going to talk about try to talk about the positive today. What things can we do to help people move toward that rich and meaningful life that they so hope to have? Strengths based means building on what somebody already has or what they already do instead of trying to reinvent the wheel. A lot of times in counseling, people come in and we even formulate their treatment plans from a deficit based perspective, so to speak. We want to take away their depression, we want to take away their anxiety. Strengths based means what can we enhance? What can we capitalize on that's already there? The strengths based approach helps people identify how they're already trying to cope and builds on that. And I will give you a hint when we get down to the next section. There are some really interesting kind of cool inventories that are out there for free and some not for free that you can use to help people identify their strengths. But I'm getting ahead of myself. What receives attention or focus becomes what the client strives for and eventually becomes a reality. So if the client is striving to eliminate their depression, you know, that's what they're going to be focusing on. They're going to be focusing on, well, how depressed am I today? If they're striving to be happier, then they're going to be focusing on that. And I know part of that is semantics, but part of that really addresses or shapes the cognitive filter through which people are examining how they're doing. And one of the things that I just did a presentation on this week is, are our attentional networks. And we're going to talk about these attentional networks kind of as we work through the presentations today. But basically our attentional networks direct what we guess, what pay attention to. Now, when we force ourselves, if you will, to pay attention to something, when we practice becoming more mindful, when we do things that are not automatic, then we are engaging what's called the executive control network. And when we engage this network, we build new neural connections which helps our brain know, okay, when I encounter this trigger, this is what I want to do. So it helps shape and form schema and even modify old schema. Because the executive control network looks back and it says, okay, we have all these memories, we expect this to happen. But it didn't or it didn't go the way we had thought it was going to go. And the executive control network is able to inform our brains and alter those schema. Once we practice something enough where it becomes a habit, second nature, ingrained muscle memory, whatever term you want to use, then it switches over that Activity, that behavior switches over to be part of the default mode network. And our default mode network is really cool in its own way because it is what your brain does. It's how you respond on autopilot. So what you have learned, the way you usually respond doesn't take a lot of thinking. Think about driving to work. You know, you get in the car and you don't even probably think twice about buckling up and checking your mirrors and doing whatever you do, and even the drive to work. If you take the same route every day, then you probably don't even have to think about, oh, I need to turn here, or whatever the case may be. When you come to stoplights, you don't have to think, okay, what do I do when the stoplight turns yellow or red or what have you? It's automatic, it's ingrained. It's your default mode. And what we find with people who have anxiety, depression, anger, a lot of their default responses are unhelpful or less than helpful. So what we want to do is help them identify skills, tools, strategies that they have that they could use instead and strengthen that. So when they get angry, when they get into a disagreement with somebody, instead of lashing out or just leaving, running away, you know, they want to learn to be assertive, then we can help them rehearse those skills in session. We can encourage them to practice those skills through empty chair and cognitive rehearsal, even if they're not doing it in real life. You know, talking to somebody and practicing that skill in the moment, if you will, when they cognitively rehearse strengthens those neural connections. So when they encounter a situation that they need to use it, they've already started to gain that muscle memory, if you will. So neuroplasticity is really cool. And the strengths based means we're finding things that the person already has some connections to or has the ability to engage. And we're building on that instead of telling them, okay, you've got to learn this whole new skill. There are two types of strengths in general. Prevention and resilience. Strengths. So these are the things that people do on a daily basis to stay healthy and happy. It could be prayer, it could be eating well, it could be exercise. Whatever they do that helps them stay healthy and happy, these are their strengths. And sometimes we're going to be identifying strengths that maybe they used to work out. And they know that when they did work out in the past, it helped them feel better. Well, great. That's a strength you already know. It works for you. You know how to do it. Now we just have to reactivate it in that default mode network. So you are doing it habitually, if you will, and then you have intervention and coping strengths. In the past, when you felt this way, what has helped make it better and what has made it worse? We don't want to just focus on the positive necessarily. We also want to identify what have you tried that hasn't helped? Because that can give us some clues potentially as to what might be causing their issues. I have a client right now that I'm working with who is struggling with chronic insomnia. And one of the things for this particular person that made it worse was, was when they started antidepressants. And so recognizing for some people, antidepressants help them sleep better, but for this particular person, the antidepressants made it worse. And they have been on the antidepressants for so long. Guess what? We know that. Well, in this particular case, taking the clinical history, I know that this person's circadian rhythms are all out of whack now because they haven't been sleeping for quite some time. It's not just a week. It's been, you know, months. So it's important to recognize that only the person is already engaging in effective sleep hygiene behaviors. They're doing everything right that they know how to do. And so that's also important to recognize that sometimes the obvious things that we want people to do, they're already doing and they're not helping. And the person's starting to get frustrated. They're like, why am I doing this if it's not helping? So I do want to know what makes it worse. And in this particular client's case, they referred it directly back to the beginning of that medication, which means, guess what, let's refer you back to your doctor that's prescribing that. And you need to talk to them about what's going on. They may change the medication. They may tell them to take it at a different time of day. They may prescribe something else. I don't know to go on with it. I don't know what the doctor's response is going to be, but that gives me some indication to help the person identify. Okay, what options do we have? What resources do we have that we can pull on. When we talk about stress and distress? I mentioned earlier that a lot of things are interrelated. And if you've watched any of my videos on the integrative behavioral health or the HPA axis, a lot of this is going to seem very familiar. But it's important to recognize that anxiety and anger are part of that fight or flight response. And when that fight or flight response is engaged for too long, it can produce depression. Now, depression can also be prompted by grief, by, you know, losses, by other things. But, but we need to recognize that there's a significant portion of people out there who have concurrent anger, anxiety issues as well as depression. And that depression is a sense of exhaustion and hopelessness and helplessness from being unable to move that anxiety. Boulder so when we talk about the HPA axis and all of these emotions, when the threat response system is triggered, the person attempts to fight or flee, but may be unsuccessful. Now, some of that could be that they are fighting, if you will, a stressor or a threat that's in their own mind. They are fighting with their inner critic, they are fighting with their cognitions. And however you know, it's still something that may be causing them continued distress. The threat response system stays activated to continue to protect the person. If they are feeling anxious, if they have fears of abandonment, for example, maybe they have an internal critic that's telling them they're awful, nobody's going to love them, they're going to be alone forever. Hearing that regularly is really devastating. So that is going to continue to keep feelings of anxiety and anger activated. When that happens, when our HPA axis, our threat response system stays activated, it prevents us from getting quality sleep. We are not going to be able to get into that good deep sleep where adenosine gets cleared out of our brain and we feel awake and refreshed the next morning. This will lead to circadian rhythms being impaired because people are going to potentially start drinking more caffeine, they are going to potentially start taking lots of naps during the day, and then the body doesn't know when am I supposed to secrete that cortisol again? And melatonin, when are we supposed to do that? Now, the interesting thing we'll get down to when we start talking about strengths is these are areas that we can explore. When you were able to sleep well, when you were didn't have insomnia, what was different? And we can start probing each of the symptoms for what the person does or doesn't do that can help. When the circadian rhythms are impaired, hormones regulating sleep and feeding are impaired. So your melatonin, your ghrelin, your leptin, all of those start getting secreted at the wrong times. Irritability increases as the stress load increases. I don't know about you, but for me When I start to get tired, especially if I get tired and foggy headed because I'm not getting good quality sleep, I tend to have a much lower stress tolerance. So I tend to be more irritable and exhaustion sets in. Lack of quality sleep, poor nutrition, and continuation of the stress response causes neurotransmitters and hormones to get out of balance. We know that chronic stress or chronic distress, if you want to think about it that way, can lead to alterations in dopamine, norepinephrine, serotonin levels, as well as thyroid levels, estrogen and testosterone levels. And all of those hormones and neurotransmitters interact with one another. So when one becomes less available, it may make certain other neurotransmitters more available and others less available. So it's kind of interesting how they interact with one another. Excitatory neurotransmitters may, over time, go into conservation or tolerance mode. And people who have been anxious for a long time, if they have generalized anxiety disorder, if they have ptsd, if they have chronic anger and irritability, the brain can only tolerate that high level of excitatory neurotransmitters for a short period of time before it becomes neurotoxic. And, and when it becomes neurotoxic, what we see is the hippocampus, which is where a lot of our emotion processing and emotion regulation happens, starts to shrink. And the strength of the connections in the amygdala with the default mode network start to get much, much stronger. So when the amygdala responds, when the person feels anxious, it kicks off with great fervor, that HPA axis. And that encourages the person to try to fight or flee. They have high levels of anxiety, which further increases the amygdala activation. But over time, the body recognizes, I can't do this. I can't tolerate being this amount of excitatory neurotransmitters. And it's kind of like what we see with people with addictions. When the tissues become exposed to excessive levels of toxins or excitatory neurotransmitters for too long, eventually the receptors become tolerant. They don't even respond anymore. So cortisol, norepinephrine, adrenaline. They're knocking on that door, trying to get through, and nobody's opening it. So they start feeling flat. We need norepinephrine, adrenaline, all those things to feel happy, to feel elated, as well as to feel anxious. Concentration becomes difficult, motivation wanes, apathy, lack of pleasure, because you see dopamine as well as norepinephrine going down and hopelessness and helplessness may set in. So you can see how these things can ultimately lead to depression. So let's think, where can strengths be capitalized on to interrupt this cascade? When we think of people's strengths, we may not be able to, to prevent them from experiencing a trigger. You know, there's triggers everywhere. We can potentially help them identify in their environment, you know, what things are triggering, and is there any way to replace them with things that trigger positive, empowered thoughts and feelings so you feel safe and empowered? And it may not just be things, it may be developing resources that they can use that they can connect with things that they do, like mindfulness in the morning in order to mitigate or prevent distress. If the person attempts to fight or flee but is unsuccessful, it's important to, for them to have some sort of, okay, what do I do now? And we talk about this a lot when we talk about secure attachments. People who have secure attachments do have a safe home base, if you will, that they can respond to. It's important that we help people recognize that they're not always going to be able to address stressors all by themselves. Sometimes they may need some support, and at that point they can start identifying, okay, when I start feeling overwhelmed or unable to handle something myself, what options, what resources do I have? Sleep and circadian rhythms, when they start to become impaired, you know, we can look at it and we can identify in the past, when you've been able to sleep well before you started having this restless sleep, what was different. And they may identify a variety of things. Now, one thing that's interesting to note is that chronic stress can lead to hypothyroidism, which can also impair circadian rhythms. So sometimes it is helpful. I find most of the time it is helpful at the beginning of treatment or if there's been a marked change in presentation for people to get evaluated by their primary care. Because if they've had an alteration in some level of hormone or vitamin D levels or something that's contributing to their symptoms, you know, that is something that's a resource we can call on that they can use in order to feel more empowered and feel like, okay, it wasn't just me, you know, there really was something physiologically going on. Irritability increases as the stress load increases. So here we can look at helping people with time management and delegation and, and down regulation. A lot of times when people are irritable, they recognize it and they don't want to be irritable, so they start feeling guilty about being irritable. We can help them address that dirty discomfort. But we also want to pull on their, on their strengths here and say, okay, you're exhausted. You know, what is it that you have to get done and what resources can you call on to help you get them done? Nutrition is helpful. And as people's bodies start to recover or get in balance, then we'll see a lot of these symptoms remit. We can help people address their cognitions if they know that they have a critical inner voice that is just screaming at them. That will be something that we can help them work on by identifying what works in order to help them feel safe in their own heads. So when I talk about strength space, I really talk about a very biopsychosocial approach. And so starting with bio physically, you know, what's going on with the person that might be contributing to their symptoms right now. Now, these physiological changes could be the result of stress or grief or trauma, and often are. But sometimes it goes in the other direction where the physiological issues started. And then they started getting frustrated and developing insomnia. Either way, it's transactional. So if we notice that people seem to have a sense of apathy or, or low energy indications that there may be a disruption in their neurotransmitters, you know, we can't measure the neurotransmitters in the brain, but a physician, as I mentioned earlier, can do blood work to measure the functioning of a lot of other things that affect the level of neurotransmitters in the brain. So that's one of the things that we can look at. We can also help people identify things that help them hack, if you will. That's the new term, hack their neurochemicals. So what things can they do naturally that may help increase their levels of dopamine? Dopamine is a favorite of a lot of people because they've heard it and they think of it as the pleasure chemical, which is not really. It's your motivation chemical. And when you do things that are positive, you want to do it again, but you also get a hit from the endorphin system and that's where you feel pleasure. But regardless, that's kind of splitting hairs. We want to help them figure out, you know, what can help you increase your feelings of motivation and enjoyment. What has worked in the past, and it may not work to the same extent right now because the system is kind of needs to be recalibrated. But what has worked in the past for me. Going on a hike, watching the birds, even sometimes going to the gym, those can help me feel better. But that's not for everybody. For some people, it's playing their guitar or, you know, playing with their dog or going riding on their Harley. What is it that tends to help you feel less depressed? But typically we want to say happier because we want to focus on helping them move towards that goal of happiness. And as things like dopamine go up, they automatically raise levels of things like serotonin, norepinephrine, endorphins, and endocannabinoids. So it's a win win. We don't have to get into all the specifics with people, but basically, in order to help people balance their neurochemicals, we want to say what things help you feel happier or have in the past. Nutrition. And with neurochemicals, we'll talk about scaling later. But it is important to help people, to encourage people to keep a log, a baseline, if you will, each day of how am I feeling? Because our goal is to reduce the frequency, intensity, and or duration of the dysphoria. So they may not see every day as an improvement. They may have three days of improvement and then one day that's really crappy, and then two days and then another crappy day. But what we want to do is see the crappy days get fewer and further between and less intense. That's something I work on a lot with people who are in early recovery from addiction because we have something called post acute withdrawal syndrome, as well as people who are grieving. And I tend to do it with everything. But it's helpful to be able to look at something that is quantitative, if you will. As quantitative as you can get with a Likert scale. So they can see that. Okay, you know, last week I did have four, four good days. The bad day was really freaking bad. But I did have four really good days. So what was different? We want to explore nutrition. And we are not dietitians, we are not registered nutritionists, whatever. So we can't prescribe, obviously, nutritional changes. That is outside of our scope of practice. But we can help them understand that our body makes our neurotransmitters and our hormones and repairs our tissues and everything else from the foods that we eat, encouraging them to be aware of their nutrition. Keep a nutrition log. Some people are super sensitive to sugar, to processed foods, to gluten, to certain dyes. And it's important for them to become aware of that. You know, that's A strength. As they start to become more mindful and aware of their own body, then they can make informed decisions. We're not asking them to change their nutrition, we're just asking them to increase their awareness. And obviously we can make a referral to the physician or registered dietitian or something. If they say, yeah, you know, sometimes when I'm eating better, I feel better. Or maybe they saw a program online because there's lots of them and they say, well, if I do this eating program, it tells me that I'll feel better instantly. Or if I take all these supplements. Whenever people start talking about upheaving, that's a word. Their nutrition or taking a bunch of supplements, I always default to. It's important to check that out with your doctor or your nutritionist before you start making huge changes and or throwing a whole bunch of money away. I don't know if it'll work or not, but it's at least worth having a consult because a lot of times supplements and things can get really expensive really quickly. So nutrition is important and part of nutrition is hydration. Helping people figure out in the past when, when I have been drinking enough water, how did I do it? And I know for me that means carrying a water bottle with me and I don't have a water bottle in sight right now. And I've been really bad about drinking enough actual clear water. So I know that's something that I could choose to start doing. Same thing we want to ask about sleep. If people are not getting enough sleep, they are going to be in a persistent state of HPA axis activation. It's just the way it is. When we don't get enough sleep. When we're tired, the brain actually secretes extra cortisol to try to give us energy. It's trying to give us natural caffeine, if you will. So the HPA axis stays activated. And our sunlight and our circadian rhythms are so important now you don't have to go out and bask in the sun. Being in a room where there is direct sunlight coming in is very helpful to triggering the pineal gland to know, hey, it's time to be awake. And when it's dark, hey, it's time to be asleep. During those short, short days of winter, it's important that we explore with people. You know, what can you do that can help you maintain your circadian rhythm so you don't feel like you need to go to bed at 4:30 here in Tennessee, you know, when we get down to like December, it is dark like pitch dark at 4:30 in the afternoon. I put the chickens up at, you know, 3:34 o'. Clock. And our circadian rhythms are partially set based on not only sunlight levels but also what we're doing and social interactions. So for me, since we put our. Typically it's come home, eat dinner, relax for a little bit, then go down and put the chickens up, then come up and get ready for bed. So when I start putting the chickens up at 3:34 o' clock in the afternoon, I come up and my body says, hey, we're going to bed in 30 minutes. And I have to fight like mad to try to reprogram that. So it's interesting how our brain picks up on sleep routines. And we can ask people, you know, what can you do in order to regulate that? Because we don't want people going to bed at 4 because a lot of times they're gonna. That would mean they'd be getting up at like one in the morning or something. Circadian rhythms affect nearly every system in our body. From immunity, which can impact autoimmune disorders, which can impact systemic inflammation, which can impact depression, to gonadal hormones, to our thyroid hormones. It's got its little pause in just about everything. So circadian rhythms are important to look at. And that's one of those things that's tangible. A lot of times what we do as counselors, as clinicians, helping people process trauma, helping people, you know, adjust the way they perceive things or process things, it's very abstract or it can be very abstract. So when people have something tangible that they can look at and they can make a voluntary choice, am I going to change this or not? Then a lot of times they feel more empowered. Affective and cognitively, we do want to help people learn about mindfulness because it becomes very, very important. Athletes have used mindfulness for decades in order to improve their performance. They cognitively rehearse new skills, new plays in order to help when they actually are implementing those, do them more effectively. Law enforcement pilots also practice mindfulness. They rehearse or what they need to do in particular situations. So when they're in those situations, especially situations that are high stress, that that set of behaviors is in the default mode network, they don't have to think, they just do. And when we are, when that fight or flight system is triggered, when our HPA access is triggered, we, we're pretty much stuck in that default mode network. We've got tunnel vision coursing with adrenaline. We're not in our wise mind. As Lynnehan would say, and so we need to have resources in that default mode network that we can pull upon. Mindfulness helps create those resources, helps create that neural memory, distress tolerance skills. There are a lot of them out there, you know, activities that you can do that help you feel happier. And it's important to help people understand that distress tolerance does not mean pretending it doesn't exist or ignoring the pain. It means saying, okay, I can't think clearly about this right now, so I'm going to set this issue aside and until I can get into my wise mind and then I'll come back to it. For some people, it's important to learn how to sit with their distress. And that's another distress tolerance skill. Being able to, as Hayes would say, live in the and understand, recognize that I am going to feel anxious when I do this, but I can do it or and I can do it when I go and do public speaking, for example, for somebody who's afraid to do public speaking, recognizing that the anxiety will not overcome them and practicing those distress tolerance skills and all that stuff. Coping skills and cognitive restructuring are also strategies that we can examine. So then we move over and a lot of the affective, cognitive, that counseling 101. So I'm not spending a whole lot of time on that right now. We move over to environmental. When people are homeless, even if they've got a roof over their head, if they're couch surfing or you know, sleeping on some at somebody else's house because they don't have a home of their own, when they've got housing instability, it creates an extreme amount of stress for a lot of people. You know, think of Maslow's hierarchy. What's that bottom line, safety or not safety, but housing, medical care, you know, being able to meet your basic needs. It's important to identify what resources people have for housing. When they are leaving residential treatment for addiction, for example, a lot of people are automatically default to going back to that same place and those same people that they were hanging around with when they used. And you know, a lot of times that can be very counterproductive. Now sometimes it's inevitable, it just can't be avoided. But it's important to start exploring early in the treatment process. What options do you have? Where else could you go? What might be a safer option for you? If they are seeing you for something like depression or anxiety and they happen to be not in a permanent housing situation, helping them get that so they have a sense of physical, not only cognitive, but physical grounding this Is home can be huge in helping people be able to relax and down regulate that HPA axis. We need to be aware of resources in our community that are available to help people with housing. And you can call United Way information and referral if you don't have a case manager on staff. But there are often a lot of options that you may not even realize. If you're working with somebody with substance abuse and you don't happen to be working at that community behavioral health agency in your local area, contact them. They may have grants. I know when I worked at Meridian in Florida, we had lots of grants for transitional housing order to help people not have to go back to the same people, places and things. So it's worth reaching out and developing connections and brainstorm other options. Not that it was a psychological issue, but I have a friend right now who is working at a place where he works 10 days on, 10 days off. And it didn't make sense for him to continue to have a pay rent on an apartment. It was just as expensive or just as cheap, however you want to look at it, to stay in an Airbnb for 10 days and then go home to be with his family for 10 days and come back. So having a stable roof over your head is not necessarily the ideal for everybody. But we do want to help them feel confident and comfortable that they are going to have a roof over their head and they're not in an environment where they feel like they're imposing on somebody. We want to look at sensory information and our senses are some of our strongest memory triggers. They trigger that default mode network because we smell something, we taste something, we feel something and we remember and our brain pulls out those schemas. It's not like we're trying to actively process what's going on. It just poof, kind of happens. And that's the default mode network going back and pulling out those schema. So it's important for people to recognize sensory triggers for them and triggers can be positive or negative. We want to help them identify distress triggers that they can mitigate or eliminate. But we also want to help them identify positive triggers that they can add to their environment. We want to help them recognize sensory issues, if you will, that add stress to their life. If they are already anxious about something, but they are living in an environment that has, you know, lots of noise and trains going by at all hours of the night and they can't get any good sleep or it's just for whatever reason they are in sensory overload, then they're going to have a hard time dealing with their anxiety because their body regularly triggering their sensory overload is regularly triggering that HPA axis. People with sensory differences may be more sensitive or less sensitive, but often more sensitive to environmental stimuli, noises, smells, light levels, etc. And that's not just people who are on the autism spectrum. Sensory gating is what they call it. And people who have sensory gating issues, they have difficulty filtering out stimuli or stimuli may feel way more intense to them. And that is present for a significant portion of people with ADHD score, schizophrenia and a lot of other issues. So it's important to recognize that a lot of people with mental health issues also might fall in that area or that categorization of being neuroatypical. And by that I mean that sensory stimuli can be super intrusive and overwhelming. Once people realize this, they recognize, oh, that might be contributing to it and I have the ability to affect it, then they feel more empowered. And that's really from a trauma informed, strength based perspective. We want people to feel safe and empowered. We want to help them look at their safety. And I talked earlier about safety within their own head because safety, a lot of times we think, you know, can you, are you worried about getting injured or whatever in your environment? Well, physical safety is one, but we also want emotional and cognitive safety. Are they safe living authentically? Are they able to, you know, communicate their thoughts, feelings, wants, needs? Are they safe in their own head or do they have a really aggressive inner critic? And I know that's not typically what you think of as environmental, but I didn't know where to stick it financially and that I put under environmental. Because if people have a low ses they tend to have higher levels of stress because they're trying to figure out how to pay the bills to keep the housing and pay enough and have enough money to get good nutrition and all those other things. And they spend so much time working that they don't have any time to decompress and relax and restore. And finally, we want to look at the community. Are people able to tap into resources in their community? And a good case manager can help you a lot with this, but a lot of us don't have that kind of luxury to have a case manager on staff. United Way 211 can be a lifeline for you to identify community resources that can help with some of these things. And finally, relationally helping people explore their self esteem and their relationship with their self and figure out how that's a strength or could be a Strength as well as relationships with healthy, supportive others. So applying this to anger, anxiety, depression, you know, mood issues we talked about, Physically, we can help people identify what things can they do physically that help them feel better. I mean, that's really what it comes down to. Exercise, sunlight, nutrition, hydration, physical. I can't say that enough because so often I just had a client, we'd been working together for quite a while and he had hit a plateau and lo and behold, long story short, his thyroid meds took a nosedive and suddenly needed to be way adjusted up compared to what they had been. And that helped him feel better physically, a lot. And the hypothyroid was contributing to his feelings of anhedonia and depression. Affectively, cognitively, we can help people identify strengths that help them cope with life. What can you tell yourself that helps you cope? When you've encountered this problem before, what problem solving skills have you used? All of that, we want to pull on what's worked in the past. And then environmentally, we want to look at housing, stimuli, those sorts of things. Relationally, we want to help them identify social supports. Oxytocin is huge, a lot bigger than you might think, given the fact that we rarely talk about it. But oxytocin, our bonding hormone, is hugely implicated in anxiety and depression, as well as certain types of schizoaffective issues. And spiritually, now, I didn't talk about this one a lot yet. At all yet. But for some people, they consider put spiritual and in terms of their connection with the world and how the world impacts them. So we want to help them identify. Are there aspects of your spiritual life that help you feel safer, more empowered, less depressed? A strengths based approach helps people recognize and capitalize on their resources and build on those neural networks that already exist. We're not reinventing the wheels or finding something that may have a weak connection and strengthening that neural connection so it becomes more automatic. A strengths based approach helps recognize the transactional nature of emotions, thoughts and behaviors and seeks to help the person become more authentic. Are there any questions?