239  Treating Depressive Symptoms
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This episode was pre-recorded as part of
a live continuing education webinar. On demand CEUs are still available for this
presentation through ALLCEUs. Register at ALLCEUs.com/CounselorToolbox. Hey everybody and welcome to treatment
planning for depression. Today we’re going to identify instruments that we
need to guide treatment planning when we’re talking about working with clients
who have depressive symptoms well identify the causes of depression well
some of them we don’t know all the causes identify behavioral cognitive and
emotional interventions that we can use to help clients who are struggling with
depressive symptoms and I keep saying depressive symptoms because it’s so
important for us to address these symptoms even if they don’t meet the
criteria or the threshold for a DSM diagnosis of depression we really need
to intervene early because we know that early intervention is a lot more
successful so effects of depression on treatment so for somebody who’s in
treatment maybe they’re in treatment for anxiety or even if they’re in treatment
for depression when clients are significantly depressed they have
difficulty following instructions and keeping appointments so if we want them
to be able to do these things we need to help them with their depression if we’re
seeing them for depression we need to make sure that we keep instructions
simple keep appointments if you can at on the same day and time each day
reminder calls reminder cards anything that you can do to prompt the patient
they may have difficulty finding the energy to participate or maintain
interests in program activities if you’re doing an outpatient program for
example they may have difficulty especially in group staying focused an
individual it’s a little bit easier because you know obviously they’re on
stage and they’re having to think and talk and preferably hopefully do most of
the talking but in group they may start to kind of fade out or they may not have
energy or desire to participate in group activities during the initial phases of
depression treatment you know that may be okay we may want them to get oriented
to group and start feeling a little bit more comfortable but we also do want to
start making move having them participate in program
activities for some clients and you know the research indicates that
psychotropics only work for about 30% of the population so this isn’t the best
choice for every single person but for some clients psychotropics you know
antidepressants may help them start getting enough energy to participate in
treatment so they can start addressing the things that are keeping them
depressed they may not need to take the antidepressants for more than six months
or a year but sometimes it can be a huge help especially if they’re in early
recovery from substance abuse or addiction as well their motivation for
change is going to be low some of the hallmarks of hopelessness and
helplessness are of depression our hopelessness helplessness and apathy
well if you feel hopeless then anything’s going to get better
helpless to make a difference an apathetic that just nothing makes you
happy anyway yeah your motivation is going to be kind of low what can we do
to help people increase their motivation increase their sense of hope their in
their sense of personal empowerment that they’re not helpless they can there are
things they can do to make a difference to change the way they feel and you know
apathy help them focus on finding some things that make them at least mildly
amused there may be nothing that just really does it for them right now and
that’s okay you know we’re we want to work towards what things make you a
little bit happy or at least content you know what things before you are
depressed made you happy well let’s start bringing those things back in and
see if they can’t help a little bit alleviate some of the depression they
may have difficulty finding making appropriate decisions about treatment
needs and goals they just they don’t know they’re like you tell me what to do
I have no idea empowering them to choose you know when we’re talking about
different treatment interventions or options and ask them what’s worked for
you in the past you know let’s build off of that so
give me some direction maybe I’m the one that’s gonna have to choose what we’re
doing what we’re gonna talk about today or something but give me a little bit of
direction you know what was weighing on your mind last week okay well let’s
start there they may have difficulty believing that they can be helped
because they’ve felt depressed for so long they may not be super responsive to
reinforcements where you’re telling them great job you know you you’re you said
that you’re crying episodes are down by 50% this week that’s awesome you seem to
be feeling brighter they may not respond to that as well they may say you know
what you just you have no idea how I feel or it’ll end or however they
respond they may not have an ability to handle feelings right now
when they’re when people are depressed they’re already feeling like they’re
drowning or they’re suffocating sometimes so any other feelings that
come their way are just overwhelming anger resentment anxiety any of that
stuff so it can be completely just overwhelming they may not have the
ability to handle relations with other clients they may be irritable have low
patience that’s okay we want to work with them on you know
help normalize how they feel but then develop the skills in order to prevent
turmoil so if client Jon over here just pushes
your ever-lovin buttons and you just can’t deal with it right now
how can you function in the program where you’re not going to get into it
with Jon but you’re also you know being true to yourself because you’re on your
very last nerve maybe sharing with Jon that you know
you’re really struggling right now and on your very last nerve or you know
avoiding Jon being in different groups there a lot of things you can do you can
brainstorm how you can do that because people are going to have to generalize
the same skill when they’re depressed you know and
in treatment when they’re depressed and at work how do they keep from handling
their relationships with their co-workers you know you don’t want them
being argumentative or irritable or or whatever at work so how can they handle
that they can’t just quit their job or not go in what do they need to do they
may have a reduced ability to attend to and not disrupt group activities they
may have frequent outbursts of crying or maybe agitated where they can’t sit
still same thing is true at work so we want to help them figure out what tools
can they use in order to stay focused and engage in the task at hand
an ability to avoid relapse after treatment is completed we want to make
sure that clients who are recovering from substance abuse also have gotten
their their depression in remission because a client is not going to stay
clean very long if they are clinically depressed in most cases likely or
similarly if we have a client who’s being treated for anxiety or PTSD and
they’re also depressed we want to make sure that depression is alleviated
they’re being treated for depression they’re not going to discharge until
their depression is alleviated but we want to make sure when the person’s
treatment is completed that they are doing well you know they may not be self
actualized but they’re doing well on emotionally you know across the board
cognitively interpersonally you know etc we want to look at all those
biopsychosocial markers to make sure that they are not setting themselves up
for a relapse so the ACE am when we’re working with clients with co-occurring
disorders the ACM actually does have a co-occurring form but we want to use a
similar placement guidelines when working with clients who are depressed
number first dimension acute crisis and dangerousness
you know are they in a place where they need to be hospitalized and under
psychiatric care 24 hours a day biomedical conditions and complications
if they’re diabetic for example and they’re depressed their insulin levels
may be in their blood sugar levels may be different and they may not be wanting
to eat or they may be gorging on high sugar foods because they’re depressed
and they’re wanting to feel better which is making their insulin levels go all
over the place so diabetes is just one example heart conditions high blood
pressure any of those things history and I guess that would go with acute crisis
and dangerousness if they have a history of suicidal or homicidal behaviors you
know that ups their risk and ups the level of care they probably need to be
in if they have emotional behavioral or cognitive issues and we’re gonna talk
about some assessments for those later on the next couple of slides but if
they’re struggling with other stuff besides depression depression is enough
if they’ve got other stuff on top of that they may need to also be at a
higher level of care and their readiness for change for each issue or objective
too many times people look at it globally like are you ready to change
your substance abuse are you ready to change your anxiety well that’s not it
there’s a lot of stuff that goes into changing that so for example if somebody
wanted to improve their mood you know get over the depression they may have to
address their sleep hygiene because maybe they’re they’ve got really poor
sleep habits and that’s contributing to their depression they may need to
improve their nutrition so their body has the building blocks to make the
neurotransmitters to help them not be depressed they may need to cut out
caffeine at least 12 hours before bed so they can sleep better and increase their
exercise in order to help relieve some stress because we know that exercise
does tend to help people sleep better so those are four interventions that that
may be suggested and they maybe totally willing to address their
sleep situation but the other three they’re like no I’m not giving up my
caffeine and exercises for the birds and I like pizza
so no I’m not what I’m not real ready to work on those yet because I don’t see
how how they’re really going to help me deal with my depression so okay you know
you’re going to use different interventions than with the sleep
hygiene we can go into problem-solving let’s educate and start doing this with
exercise for example you’re going to have to educate the client about why
exercise or how exercise can help them improve their mood by increasing the
release of serotonin as well as improving sleep which can also improve
their mood so make a case for it why is this beneficial for you and they may
still not want to do it so we want to look at why not you know
look going back to motivational interviewing 101 doing a decisional
balance what are the drawbacks to exercise you hate it you don’t want to
get sweaty it hurts you know those are the top three that I usually hear I have
no time to do it and that’s the fourth one so we can talk about that because
exercise doesn’t have to mean going to a gym and getting all sweaty and you know
exercise can mean walking around the block with your dog in the morning and
you can break it up you don’t have to do 30 minutes at a block you can do five
minutes with Fido in the morning and then you can take a walk at lunch for
ten minutes and then take another walk with the dog in the evening and you’ve
got your 30 minutes so you can talk about ways you want to look at figuring
out the reasons the person’s not motivated and making those reasons go
away to help get them a little bit more motivated to address that so you want to
address their readiness for change their relapse our continued problem potential
if their chance for staying depressed if they’re living in a
an environment that is high-stress low safety loud you know maybe they’re
living with five roommates that they really detest who are constantly arguing
and you know is an unpleasant environment that may contribute to their
depression so staying in that environment may not be conducive to
recovery the same thing is true with substances so we want to look at is this
environment going to at least not hurt their recovery a lot of times they can’t
just up and move so if they need to be in a different environment than a higher
level of care may be appropriate you may not get to the point of a residential
placement but if they’re in a clubhouse situation or an IOP program that’s four
hours a day in addition to whatever time they’re at work but they’re not in that
relapse triggering environment so it helps so how can you screen for this
stuff you know client comes in how do we know if they’re depressed and I want to
remind you and I’ve talked about depressive symptoms earlier they didn’t
meet the threshold for clinical depression we’re also talking about
depressive symptoms that are the result of substance intoxication or withdrawal
especially substance withdrawal because people who’ve been using stimulants for
a long time may probably feel depressed when they withdraw from those substances
it doesn’t matter if the person has depressive symptoms they are at a
greater risk of substance relapse then a person who is not so we want to consider
that two alcohols the same way when people withdrawal from alcohol they can
have high levels of anxiety and or high levels of depression it’s also a
life-threatening withdrawal for a lot of people so it should be medically
monitored but I digress those people also need to have their
depression treated or they’re going to be
likely to relapse on the alcohol so we can use the DEA’s dsm-5 promise which is
in all of these that I’ve linked to here are free scales freely available scales
that you can access which is helpful the severity measure for depression the
adult patient Health Questionnaire number nine and we’re going to get this
to open yet maybe maybe not so this is the dsm-5
screening measure and it gives you a quick and dirty screening
how to score it for the phq and it’s nine questions ranked on a three point
Laker scale pretty easy to administer to clients quick and dirty the song
self-rating depression scale I really like this one has a lot more questions
has 20 questions but it gives you a bigger a broader sampling of things that may be being
disrupted so you can identify depressive symptoms mornings when I feel the best
crying spells sleeping sex weight loss constipation foggy headedness I mean it
asks about a lot of different things that clients with depression often
report and each one of these things can end up serving as a treatment plan
problem that you can address and it also gives you the easy a scoring guide right
there the Center for epidemiological study depression scale was put out by
the National Institute of Mental Health the severity of post and that’s also
available for free these last two I included because symptoms of PTSD and
generalized anxiety can overlap with symptoms of depression but you can also
have them concurrently and if you don’t treat those if somebody has
post-traumatic stress disorder and depression for example you have to treat
both of them if you don’t treat the depression then the PTSD treatments
going to be good but you’re still going to have that lingering depression that
needs to be addressed so I included those it’s always good to screen since
more than half of people have been exposed to trauma not necessarily
developing PTSD but it’s always good to screen to make sure that there isn’t
PTSD and generalized anxiety when people are worried a lot and sometimes people
call it under dress or high-strung it at a certain
point your body gets exhausted and says I give up you know I’ve been fighting
this fight for you know a year three years or whatever it is and I’m not
getting anywhere so I’m not going to devote energy to it anymore
which can feel very frustrating and that’s when the person starts to get
exhausted and and feel depressed they start to feel hopeless and helpless
because they’ve been trying to change something or trying to control their
worry or trying to control everything in their life and they’re not successful at
doing that because we can’t control everything and they start feeling
hopeless and helpless now a couple other instruments that I like to use to look
for cognitive issues that might complicate the picture such as negative
attributional style low hardiness or high levels of stress are on this slide
now attributional style is where you attribute things coming from is it
internal or external is it whatever bad happened is it because of something you
did or the world so think about locus of control here is it global that means you
know whatever it is that happened makes you a horrible person or is it specific
you made a mistake or you’re bad at this one thing and that really impacts how
people process the world and what they encounter throughout the world
you know reasons for failure you’ve just attended a party for a new
student and have made some new friends then they talk about choose the reason
that would best explain the outcome if it actually happened to you so how did
you make some new friends use the right strategy you’re good at meeting new
people you tried very hard I have the personality traits necessary I was in
the right mood or it does it happened it had nothing to do with me
so that’s one of those where the locus of control is very external on the last
one where they said something else produced that outcome I have no idea
because it had nothing to do with me and this can help you see and help you
help clients feel better about themselves and more empowered if you can
help them adjust their attributional styles and I’ve got other videos on our
LC e use channel that talk more about attributional styles but you can see
there’s 20 questions there and then the scoring that you can look at and then
there are other reasons for success and failure the ACE at three it looks at the
locus of control whether it people use a global or specific attributional style
whether they use a stable that means it’s forever and always or changeable
they they have they can do something about it
attributional style so you can see as we talk how attributions can have a big
effect on a person’s sense of hopelessness and helplessness so again
those three scales I’ve linked to you can access them they’re freely available
on the internet there are a lot of others that you can get that are
published and copyrighted but I know budgets tend to be pretty low so I try
to be respectful of that so you screen people and you decide that
okay yes they do have a depressive disorder or they’ve got depressive
symptoms now what do I do well we got to figure out what’s causing it depression
is a feeling feelings are caused by neuro chemical imbalances too little
dopamine too much norepinephrine too little norepinephrine too much or too
little serotonin so it could be in or a combination of all those they’re just
not imbalanced with each other I usually use the analogy that our neuro chemicals
are like a read good marinara sauce and the basil and
the garlic and the fennel and the oregano and onion powder all have to be
in the right balance and if you have too much of one then you know do you
increase the others or do you try to scoop some of it out or what do you do
with there Oh chemicals you everything needs to be in the right balance in
relation to everything else so your biochemical imbalances cause depression
norepinephrine is responsible for focus and motivation serotonin is your big
hitter it’s responsible for feelings of contentment and relaxation pain it helps
you sleep because melatonin is made from serotonin it helps you regulate your
hunger and your heart rate so there’s a lot with serotonin and if that gets out
of whack you can have anxiety you can have depression you can feel the Thar
jek a whole bunch of stuff and dopamine we know is our pleasure neuro chemical
it motivates us because when we do something that’s rewarding it gives us a
little jolt to dopamine and we’re like whoohoo let’s do that again it also
helps with memory because we tend to remember things that produce pleasure it
helps with focus and it also helps with pain management people who are depressed
tend to have more pain which can mean their serotonin and/or dopamine levels
are low in comparison to the other neurotransmitters so we need to remember
that whatever’s causing this neurochemical imbalance is causing
feelings of depression so we’ve got to address the leak somewhere what’s
causing the leak that’s leading to to the imbalance so physically there are a
bunch of things lack of quality sleep when we don’t get enough sleep our body
says you know what we’re in danger you’re not a hundred percent which means
you’re not as much on guard which means there’s a threat so your cortisol levels
tend to stay higher which prevents you from getting quality sleep
and it’s this vicious cycle so quality sleep is important for your brain to
rest and rebalance and get those neuro chemicals made and balanced back out exhaustion and burnout secondary burnout
from being you know a caregiver or secondary trauma burnout at work any of
that kind of stuff can just wear you down where you feel hopeless and
helpless you’re trying and things aren’t getting anywhere poor nutrition if your
body doesn’t have the building blocks to make the neurotransmitters that it needs
to make in order to help you feel happy then you’re kind of screwed so
reasonable nutrition I’m not talking about being a health health fanatic I’m
just talking about eating colorfully getting some vegetables in there making
sure you’re getting some your B vitamins etc chronic pain can cause the chemical
imbalance because when you’re in pain your body senses that as a threat which
keeps the threat response system the HPA axis alerted which keeps your cortisol
levels higher your serotonin levels lower which means you’re not gonna sleep
as well and that’s going to have that whole cascade effect of getting
exhausted and keeping your Sarah um cortisol levels high when when your HPA
axis is activated when your body believes there’s a threat it sends out
cortisol that’s your your stress hormone that says we got to prepare to fight or
flee cortisol tells your body to do a bunch of things secrete blood glucose to
get ready for that initial fight or flee which is when you have an adrenaline
rush you tend to get a little shaky because you have a bunch of sugar going
through your system and then it also tells your body turn down the sex
hormones now’s not the time to procreate so libido goes down it also says turn
down the serotonin because serotonin is our calming chemical if were under a
threat now time to become when sex hormones go down
the availability of any serotonin in the system also goes down so it’s a double
whammy to the serotonin we know that serotonin is implicated for a lot of
people in depression which is why our mainline antidepressants are serotonin
reuptake inhibitors because it’s trying to make more serotonin available so
stress directly causes the reduction in serotonin lower serotonin means you
can’t make as much melatonin which is needed for sleep you see where this can
all happen so we want to alleviate whatever those threats are that are
keeping our threat response system alert diabetes can cause depression thyroid
and sex hormone imbalances as I just said when your sex hormones are too low
that means the availability of serotonin and some of those other neuro chemicals
are lower so you know that’s easy enough for your doctor to measure they can’t
measure neurotransmitters but they can measure your estrogen and testosterone
levels thyroid hypothyroid tends to have very similar symptoms for a lot of
people as depression so rule out thyroid problems
vitamin D deficiency vitamin D is the vitamin that your body makes when is
exposed to sunlight we also get it from milk and stuff that has vitamin D put in
it but by far the most useful form of vitamin D is the kind your body makes
from sun exposure so if it’s been cloudy if you live in an area where you’ve got
six months of darkness or if you just haven’t been outside even if it has been
sunny then you may have a vitamin D deficiency they’re not sure how it works
but they know in those areas of the brain responsible for mood and
depression there are an abundance of vitamin D receptors so they know that
it’s connected somehow and they also know that people with seasonal affective
disorder tend to have lower levels of vitamin D
and when that vitamin D is brought up they tend to start feeling better so
vitamin D is important if you live in one of those places where there’s not a
lot of sunlight or it’s been really rainy and your client is struggling with
with depression have them talk to their doctor about even light therapy can help
increase vitamin D levels reset circadian rhythms to get them normalized
again so they get better sleep etc hypo cortisol ism or adrenal fatigue is
another thing when your body has been trying to or your brain or whatever you
want to say has been trying to solve a problem or deal with something for a
long enough time and not been successful eventually somewhere in your little
primitive brain it says you know what we’re not gonna waste energy on that
anymore because it’s not doing any good we need
to conserve energy for when there’s a real threat oh that means that things
that would normally cause you to get stressed out you just don’t even care
about anymore you’ve got that sense of apathy but things that used to make you
excited you also don’t care about anymore it’s
just like look you know I don’t have that get up and go anymore
a lot of people will self-medicate this with caffeine stimulants of some sort at
a certain point you know hypo cortisol ISM cortisol is the stress chemical that
tells your body to release adrenaline and all that kind of stuff well here we
go adrenal fatigue that’s your body going I’m I can’t be stressed I can’t do
this anymore I don’t have any more adrenaline to give and that’s not
exactly a hundred percent medically accurate but you get the idea when
you’ve been stressed for so long sometimes your body can’t recoup and so
you keep getting more and more tired and depressed anemia can cause feelings of
depression because enough oxygen isn’t getting throughout your brain when you
get iron it gives helps the red blood cells carry
oxygen throughout your body iron can be toxic don’t just assume that you’re
anemic and start taking huge levels of iron supplements not a good idea always
have your doctor checked your blood levels medication side effects can cause
depression side effects of opiates for example opiates or depressants and they
can cause you to feel depressed for some people that causes them to feel euphoric
but for some people it can cause depression and there are other
medications that can be taken for heart disease or a variety of other conditions
that may cause symptoms of depression so ask clients you know when did the
depression start and did you start taking a new medication or change your
dose on a medication within three weeks of it starting and other illnesses such
as multiple sclerosis lupus fibromyalgia chronic fatigue lyme disease stroke and
the list goes on can also cause symptoms of depression and I don’t read off this
litany to clients because it would freak them out although they can find it if
they go on google I do encourage them to make sure that they’ve gotten a complete
physical within the last three months two that included a blood panel and
everything to rule out any physiological causes because if there’s something
broken in the body no matter how much talking they do to me I am NOT going to
help them feel as good as they could so it’s going to be really important to
have them get get a physical changing behaviors identify behaviors that can be
addressed keep it simple and achievable and break big problems or changes down
into smaller achievable components when we’re talking about physical
interventions a lot of times we’re talking about behavior changes so for
example if you are talking about somebody starting to exercise I’m not
gonna have them start going to the gym three days a week or five days a week or
whatever from jump I’m gonna say okay first you need to figure out what you
like doing to exercise so this week you know why don’t you try two
different things to exercise or learn about different exercises or maybe try
starting out by just walking your dog or stretching hmm obviously with medical
approval the idea and then we’ll build on that just you know you don’t start
training for a marathon by running 14 miles the first day you start by
training for a marathon by walking a mile and then jogging a mile and then
running a mile and then working up from there
so we want to do the same thing for our clients if they’re trying to change
their nutrition you know they don’t need to turn everything out in their in their
kitchen overnight say all right this week I just want you to work on drinking
more water next week we’ll talk about making one more change so happen to make
one small change each week that gets them closer to that goal so it’s simple
it’s achievable it’s something that they can say I did that
all right this wasn’t so hard identify the goal or the outcome the client would
like to achieve so we want them to be happy for example well that that’s great
but you know what does that mean to them what is it that the client is wanting to
do and how will he or she know that they’ve achieved it so what does
happiness look like to you and how will you know when you’re happy explore ways
the client has achieved similar goals in the past so when you’ve been depressed
in the past what’s helped you feel a little bit happier now this next step is really important
identify internal and environmental barriers to success and what parts the
client can control so if we’re talking about dealing with depression we’ll
continue to talk about that because that’s what this class is on we’re going
to talk about you know on days where it’s raining we’ve recently gone through
a spell here in Tennessee where it’s been raining for days I mean every
morning I get up and there’s an aerial flood watch it’s just it’s raining and
it’s dreary and it’s cold and it’s miserable and so people with seasonal
affective disorder are starting to get a little bit antsy they can’t control that
they can’t control the weather and make a spontaneously sunny what can we do we
can encourage them to use light therapy we can encourage them to stay in rooms
that are brightly lit any other interventions that has worked for them
in the past when it’s been kind of gray outside with their doctor’s approval
they may take some vitamin D supplements on those days to help boost their
vitamin D there are a variety of interventions but you need to ask them
what works for them what helps them stay in a better mood identify how barriers can be overcome in
specific behavioral terms make addressing the barrier something to do
rather than something not to do so instead of saying well you don’t want to
dwell on it you don’t want to let it you’re gonna say alright what are you
going to do this is happening so what are you going to do to overcome it and
have it be really specific such as you’re going to get up at your by seven
o’clock and get dressed and then when you go into the office you’re going to
make sure that all the lights are on so it’s a brighter environment you’re going
to play cheerful music on the radio your whatever helps them feel happier you’re
going to identify specific steps they’re going to take in order to help them
achieve their goal of dealing with the the raine enos identify supports and
specific steps needed to achieve success and elicit a commitment and take action
to achieve the goal have them commit to it you know next time it’s rainy I’m
gonna do these sorts of things so it doesn’t you know drag me down encourage
clients to get a physical to rule out hormone imbalances physical issues
causing a lack of energy fatigue difficulty concentrating sadness and
irritability you know there are a lot of things that can do that so let’s take a
look at what some of those might be you know have them take a look at it with
their doctor just to rule out stuff that we can’t even begin to help with address
nutrition to provide building blocks now I will say unless you are a registered
dietician you cannot give nutritional prescriptions you can’t say you need to
start taking more vitamin D supplements or you need to eat this meal plan can’t
do that you can’t educate them about why good nutrition is important for building
neurotransmitters and recovering from depression and refer them to a dietician
and or any self-help books that might be useful encourage people to cut out
caffeine 12 hours or bed because it stays in your body for
12 hours so what you drink at noon is going to impair your sleep up until
midnight I know you know within three hours you feel like it’s already done
worn off and you’re like I need another cup of coffee but you’re just building
it up stay hydrated dehydration in increases confusion it reduces memory it
reduces energy level and it can contribute to feelings of foggy
headedness all of which are symptoms of depression drinking water is not that
hard have people carry a water bottle around with them I always keep a spare
in my car in case I forget my true water bottle I just have one you know that I
got when I got a Powerade or something and I keep it in my car so I’ve got
something to put water in improve your sleep hygiene and get seven to nine
hours of sleep each night without waking this can be a huge goal for a lot of
people mmm they may maybe they wake up three four or five times a night or
maybe they aren’t used to sleeping for six or seven hours that are shot for
whatever reason so we need to help them this is so important to improving a
variety of issues including depression there I do have another video on sleep
hygiene or why sleep is important and ways to improve sleep so you can talk
about that you can watch that if you want the big ones are cutting out
caffeine not taking a hot shower before bed because your body needs to cool in
order to sleep having a economically comfortable sleeping area getting rid of
rid of any allergens that may be keeping you awake and creating a sleep routine
where you do roughly the same three things every night just like you do with
kids you know with kids it’s dinner and then bath and then storytime then bed
that’s probably not what you’re gonna do but you know you begin with eating
dinner and then do something and then you know whatever yada yada yada so as
soon as you eat dinner your brain start saying all right I need
to start making melatonin because it’s calling me time to go to sleep in a
couple hours get moderate exercise for at least 30
minutes a day clients are often not going to be able to do this from the
beginning so have them start out doing something for 30 minutes even if it’s
dancing around their house like a crazy person while they clean 30 minutes a day
some kind of movement and then move from some kind of movement to something
that’s a little bit more intense get more sunshine and I use the 1515
principle you don’t have to bask in the sunshine if you can get 15 minutes in
the morning and that includes when you’re driving to work that Sun shines
coming in through the through the car windows and 15 minutes in the evening so
when you’re driving home or if you take Fido out for a walk for 15 minutes in
the morning and 15 minutes in the evening that can help set your circadian
rhythms and that’s generally enough to get you the vitamin D do you need it
might not be enough to really get you in a happy place but that’s more
psychological than it is physiological review medications for side effects to
make sure you’re not taking something that you know is causing you to feel
hungover I know when I take melatonin the next morning I wake up and I feel
really chipper for about three hours and then I hit a wall and I crash hard
melatonin doesn’t work for me like it works for other people so I know that
and I can be aware of how it affects me address chronic pain so you’re gonna get
better sleep and you’re gonna be less irritable and all that other stuff that
goes with chronic pain preferably by methods other than opiates tends
machines trans electronic nerve stimulation can help you
it basically bombard the nerves with little tiny electrical currents that
feels like somebody’s just tapping on you but it confuses the nerve endings so
it stops sending the pain signals I’ve used TENS units on my back before great
things massage if you can afford it or you’ve
got a spouse who will do it stretching with doctor’s approval meditation can
help and there are a lot of guided meditations and guided imagery scripts
that you can use for pain acupuncture or acupressure has been shown to be really
helpful with pain conditions mild to moderate exercise with dr. approval may
help a lot of pain conditions by balancing out those muscles relieving
stress related muscle tension and helping to stop some muscle spasm a hot
or cold pads depending on your injury and your preferences when my jaw acts up
my TMJ I’ll put ice packs on my jaw and it
makes them feel a whole lot better ergonomics if somebody has pain you know
they may tend to sit and favor one side or something paying attention to your
economics where you work you know your desk chair you know that you spent eight
hours in your sofa that you sit on to watch TV you spend a couple hours
sitting there and your bed making sure that you’ve got a economically sound
sleeping setup and you don’t want your neck cranked out of whack
etc you can find different articles on sleep ergonomics online to help clients
figure out how big of a pillow they need and other things and finally consider
pharmacological interventions it works for about 30% of the people to help them
get a little bit more energy and start feeling better some people stay on it
indefinitely some people stop after six months or a year once they’ve developed
some other tools and they don’t need the boost in their energy when we look at
emotional causes of depression it can be depression causing depression lack of
pleasure you know just not it’s not so much that things are going bad it’s just
nothing’s good it’s just blah which can cause people to feel depressed
if they feel like they’re in a rut stress too much stress that HPA axis
eventually is going to say I’m tired I can’t do it anymore and person may start
feeling fatigued hopeless and helpless not sleeping as well anger is exhausting
and people who are angry a lot will start to feel exhausted than hopeless
and helpless PTSD can cause feelings of depression any fear that activates that
HPA axis including abandonment isolation rejection failure or loss of control and
then people who are emotionally disregulated which means when something
happens they go from 0 to 250 in 2.3 seconds
yeah that’s exhausting and sometimes it’s a biochemical thing sometimes it’s
the way they’re wired sometimes it’s because of traumas they encountered when
they were younger whatever if you know you’re one of those people if you are
doing that 0 to 250 you know 2 3 4 times a day or more it’s exhausting and you
may start to feel very out of control and depressed and helpless so what can
you do about it emotional interventions are not super
numerous because all you’re doing is addressing the feeling but anything can
help keep a daily log of nutrition sleep things that trigger your emotional
distress and ways to cope that’s four things but they’re important because you
might find connections between your poor nutrition or drinking too much caffeine
and your emotionality or poor sleep and your emotionality things that trigger
your emotional distress as you identify those then you can start figuring out
how to deal with them or prevent them and ways you cope is important to keep
track of because we want to build on those those are obviously working for
you at least a little bit right now they may need to be strengthened or tuned up
but least that gives us an idea about where
we can start building instead of having to start from scratch so as a clinician
I take these logs and I help people look at them try to identify patterns and for
women also keep track of your hormone cycles to see if there is a correlation
because you also may have premenstrual dysphoric disorder develop a stress
management plan high levels of stress anxiety and anger exhaust the system
then you start feeling depressed so if you manage stress then you may prevent
some of the depression identify methods that help you deal with anger anxiety
and depression make a list what helps you if it helps you for 10 minutes or if
it helps you for 10 days I don’t care I want to find out what helps you feel
better and we can build off those some of them we may try to eliminate if
they’re unhealthy but weak and it also gives me a better idea about what might
causing your depression or what neurotransmitters might be out of whack
if I see that you you consistently reach for alcohol for example when you’re
feeling depressed you know that might tell me that you’ve got high levels and
anxiety and you’re trying to use the alcohol to depress that it may not be
exactly right but it gives me some ideas to spit ball and talk talk about with
with my clients do things that make you happy you can’t be happy and sad at the
same time so I have clients do 15 minutes of something that makes them
happy every day and it may like I said it may not make them deliriously happy
but if at least that we get up to content you know funny animal videos
listening to a comedian taking a bubble bath going fishing whatever it is do it
for 15 minutes at least every day address guilt because guilt can keep
people feeling really stuck and learn to stress tolerance skills to assist in
tolerating emotional upset those people that go from zero to 250
that feels really overwhelming and out of control so learning to stress
tolerance skills can help feel empowered which takes away some of that
helplessness distress tolerance skills also help us not get stuck in an emotion
where we’re fighting with it and saying I shouldn’t feel this way or dwelling on
it distress tolerance skills help us see that emotions come in and go out just
like the ebb and flow of the tides cognitive causes of depression cognitive
distortions such as all-or-nothing thinking when you think every time I try
to be nice I get bit in the butt or I never succeed at anything I do those
extreme words very rarely does anything always or never happen so encourage
clients to think about exceptions when when are some exceptions to this never
thing that happens the availability heuristic this is when clients see
something on the news for example and they think it’s more frequent than it
really is because they saw it and that’s kind of
prominent in their mind or something that recently happened so if you’re in a
relationship with somebody and you’ve been in a relationship for 10 years and
maybe the last month or so they’ve just been a real bugger and 1/2 the
availability heuristic might lead you to focus on that last month and a half and
go you are such a jerk I don’t know why I ever got into a relationship with you
because that’s what’s available that’s in your kind of shorter term memory
you’re forgetting the other you know 10 years leading up to that so encouraging
clients to broaden and get all the facts and look at the big picture emotional
reasoning is reasoning based on purely feelings if I’m afraid to do something
it must be scary if I feel like I can’t do something that
I must be powerless to do it emotional reasoning can be countered
looking at the facts what are the facts that support you being unable to do it
and what are the facts that support you being able to do it
personalization means taking everything personally so if somebody’s in a bad
mood is my fault if something bad happens it’s my fault
if you know something bad happens everybody’s gonna blame me which can
lead people to feel overwhelmed over generalization is taking one bad thing
or one good thing but taking one thing and generalizing it so you know if Sam if I can’t even think of an example
right now but over over generalizations means
taking something that happens once and assuming that it’s going to happen all
the time or one person that you met that you know was a certain way but you were
in a relationship with a person and they were just an idiot and they were abusive
and it was awful and you broke up the relationship and then because of that
one relationship you say all men are bad well that’s not true
all men aren’t bad you had one bad apple but all men aren’t bad and jumping to
conclusions sam comes home and he’s got lipstick on
his collar whoo so you can jump to conclusions and
assume that he’s having an affair or you can find out the facts that there was a
holiday party or a going-away party for somebody who was leaving the firm and
you know he got a hug from the woman who was leaving and and she got lipstick on
his collar purely innocent you know so but you can jump to conclusions which
increases stress and increase can increase depression and fears of
abandonment and anxiety and magnification of bad things so when one
bad thing happens or might happen blowing it out of proportion you know if
you get in trouble at work I’m gonna get fired and then I’m gonna lose my job I’m
then I’m gonna lose my house and then my wife’s gonna leave me and that I will be
homeless and penniless and yadda yet Wow how did we get there from you getting
written up once and minimization is kind of the opposite because people who are
depressed often minimize their accomplishments and the good things
something good happens and they’re like that was just a fluke or it won’t last
so they’re waiting for the other shoe to drop so we want to look at those
cognitive distortions and help people get a better more balanced view of the
way things are so they don’t feel hopeless and helpless
negative global stable attributions and we talked about that earlier global
means it’s about all of me or all the world you know the world is just evil
well that’s a global attribution it means everybody in the world is evil a
stable or a specific attribution would be to say there are certain people in
the world who are evil stable means it can’t be changed you know the world is
evil and there’s nothing that can be changed it’s just its inherent
changeable means people could be you know people in the world are doing evil
things right now but there is hope you know we can educate and we can pull
together as a community and there are good people that can help spread
goodness extremely internal or external locus of control you know that’s also
kind of with the attributions if you believe that nothing in the world is in
your control you have a completely external locus of control then yeah
you’re gonna feel helpless because it says destiny is going to control
everything so you might as well just sit back for the ride on the other hand if
you have an extremely internal locus of control you feel like you should be able
to control absolutely everything and then when that doesn’t happen you feel
like you’ve failed so a locus of control that’s to external or to internal can be
problematic ineffective distress tolerant skills can lead you to feel
stressed and exhausted a lot and ineffective problem-solving skills can
do the same thing so helping clients identify and address cognitive
distortions develop problem-solving skills and distress tolerance skills
identify the situations that make the client feel uncomfortable and that’s you
know kind of where we want to start with with negative self-talk and cognitive
distortions what situations make you feel depressed and
angry for each of those situations make a list of the feelings that you
experienced after the situation mmm so if you’ve had a feeling of anger and
resentment and guilt and whatever just write them all down identify the first
thought that comes to mind when you think of the uncomfortable situation so
if I’m talking about you know going in for a job interview and my first thought
about going in for a job interview is fear you know I’m not going to get hired
a sense of helplessness when my first thought when I think about going in for
an interview if somebody asked me what my first thought that comes to mind is
my first thought is I’m not going to get the job
I’m there’s no way it’s going to happen other thoughts that often arise with
this situation I have no business applying for this job or you know I’m
not going to know what to say in the interview and I start identifying
all those thoughts and identify a theme from the thoughts and in the scenario I
just gave you it would be one of powerlessness or loss of control you
know I don’t feel like I’m in control of this situation identify how the thoughts
or the theme limits the clients options in life by being constantly afraid of
rejection or loss of control how does that keep you from trying new things and
maybe interviewing for jobs that you might actually get help the client
identify different ways of thinking about the situation and feelings that
can lead to better options so when thinking about a job interview for
example think of it as a learning experience and a challenge and how can
you feel empowered to go in there and and try and see what happens and if it
doesn’t pan out the way you hope how can you learn from it maybe contacting the
hiring supervisor back and finding out what you could have done differently
once a list of reasonable responses is completed summarize it go back through
the list of feelings and discuss the decrease in intensity of each feeling
for the new list of reasonable responses so one of my one of my thoughts about
going in for an interview is there’s no point because I’m not going to get the
job anyway with some of the new responses I could
say well you know maybe I can maybe I’m not gonna get this job but by going in
for this interview I’m gonna be better prepared for the next interview because
I’ll know what kind of questions they’re gonna ask so I’m looking at it as a
stepping stone or a learning opportunity and then continue to practice the new
skill so each situation that makes the person feel use negative self-talk or
feel bad or angry or depressed they can look at it and identify the types of
thoughts they’re telling themself about the situation and then identify
alternate ways of thinking about the situation five steps to challenge
beliefs that limit options for change listen to the clients organization of
and beliefs about the problems present your understanding of the belief that’s
you know what we were talking about with helping the client identify themes that
might be coming through ask the client if you’re on point if the client
disagrees with your assessment then ask for a more accurate statement of what he
or she believes if they agree with your assessment then explore how holding that
belief affects their ability to address the problem so if you hold on to this
belief that you’re powerless and it’s pointless for you to go interview for
this job how does that keep you from addressing your fears about the
interview if the client agrees with your assessment inquire if he or she would
add or change anything about the way you phrased the belief so did I hit it right
on the nail or would you change it help the client reframe the belief from a
truth you know I’m not going to get the job
to a thought I’m having the thought or the fear that I might not get the job
because the truth is unchangeable but a thought is just something that comes and
goes it’s like when you know somebody’s trying to quit smoking and if they say I
have to have a cigarette that’s a truth that’s what has to happen if they say
I’m having the thought that I need to have a cigarette it’s a thought and
thoughts go I I can tell you you know any of us who’ve had children can
remember it can tell you that thoughts come and go really fast and sometimes
you can’t remember why you walked in a room help the client ULTRA beliefs to
include options for changing the problem so you’re gonna brainstorm options for
changing the problem options for changing their perception or looking at
it in a different way help clients learn about the connection between thoughts
feelings and actions you know what you think affects how you feel and how you
react to situations how you feel if you’re in a battle battle mood that day
it’s going to affect how you perceive and think about situations and what you
do what you do is going to affect you know if you’re eating well and taking
care of yourself and you know being kind to others you’re probably going to think
and feel differently about things then if you’re not taking care of yourself
and you don’t have the resources to deal with it identify and address cognitive
distortions with daily distortion logs have clients keep a list of things that
triggered their depression and the thoughts they had I usually give clients
a list of the cognitive distortions and have them put a hash mark next to each
Distortion each time they they use it that way we can see which ones they use
more often and then I provide them worksheets and videos to start
challenging those distortions learn about attributions and address negative
global stable attributions again have them keep a log of negative
global stable attributions and restructure them to be more specific and
sense tape and changeable so if they’re thinking things are always one way and
everything is always one way then we want to help them see that some things
are sometimes this way learn about locus of control and how moderate to an
extremely internal or external locus of control can cause depression like we
said if you feel like destiny is going to do everything and you have no way of
improving your situation or if you feel like you should have control over
absolutely everything and we know you don’t either one of those can cause
feelings of helplessness and hopelessness so we want to help people
see what they can change and learn how to accept what they cannot change
develop effective problem-solving skills based on the problems that trigger that
client’s depression because what triggers depression for me doesn’t
trigger depression for my best friend you know
we’re very different people so we each would need different problem-solving
skills and different plans I encourage clients to start by reading
the seven Habits of Highly Effective People because this is a great way to
start figuring out how to be happier and more empowered and step number one or
habit number one is begin with the end in mind as you begin what are you
working towards what does it look like to be happy you know if when you’re
happy you’re not having all these negative thoughts all the time well then
you know that’s something you need to work on and finally increased feelings
of self-efficacy or that can-do attitude in your clients by making sure to help
them set small achievable goals so each week they’re having some successes and
they’re going okay it’s not huge progress but it’s progress
social causes of depression include lack of social support interpersonal
conflicts which can include conflicts with friends and family
conflicts at work or conflicts on social media with people you never even met
interpersonal losses ineffective communication skills and poor
self-esteem why do I have self-esteem under social because self-esteem is your
relationship with yourself it’s how you feel about yourself and whether you’re
accepting and loving of who you are so what do you do learn about healthy
relationships what do they look like what are their characteristics what do
you want in a healthy relationship and then oh my gosh start doing that for
yourself be your own best friend be your own best healthy relationship if you are
then it’s going to make everything else easier because you’re getting ready to
get into a relationship with somebody else
you’re your own best friend you’re gonna say best friend self is this a good idea
for me and best friend self may say heck no if you’re not your own best friend if
you’re constantly needing validation from other people then you don’t have
anybody to go to to say is this really a good idea so you’re gonna tend to go
into other relationships just to get that validation identify healthy
relationships you currently have if any and generally we have one or two there
at least semi healthy let’s build on those improve your self esteem your
relationship with yourself and there are tons of self esteem workbooks out there
so I’m not even going to delve into all the different ways to do that identify
issues that need to be addressed in current relationships to make them
healthy it was like I said most of our relationships are pretty healthy or semi
healthy but not all they could be and one thing you can encourage clients to
do is read the five love languages that helps them understand how to improve
connection with other people and that’s the first step in understanding what
makes people tick a little bit better identify three people with whom you
could develop a healthy support system so look around
I might like to be friends with that person or start going to meetups like
hiking meetups or coffee or canoeing or whatever it is that you do and meet new
people to add to your support system and set a
goal of three you know that’s not hard to find three people that you might want
to start including learn skills to handle conflict there are videos on that
there are online classes to help learn effective communication skills books
videos online classes workshops and learn how to ask for what you need
sometimes we’re afraid to ask because we’re afraid of rejection but when
people are feeling depressed it means they feel exhausted and fatigued and
hopeless and helpless so this is when we need to be able to ask for help and get
that support in order to bolster us up and situational causes of depression can
include losses such as relationships death loss of freedom loss of dreams a
loss of sense of order in the world a sense of control and hope I mean I know
when I look around and I watch the media and the news which I try not to do for
more than 30 minutes a day it can feel really overwhelming because there’s so
much that’s out of my control but I know I can control my little slice of the
world and people may experience a loss of self-esteem which can cause them to
feel depressed if their significant other leaves them if they get fired from
a job you know there are things that can happen that can injure self-esteem environmental causes of depression
include people in the environment toxic people in the environment negative
people in the environment you know you want to try to have an environment that
builds you up and you have control in many cases over your environment maybe
not the whole house I mean I can’t control my kids rooms I’ve kind of
thrown my hands up but I can control the common areas if you live with roommates
you may only be able to control your but you can control that little slice of
your world noise think about how to deal with noise toxins and allergens that
keep you from sleeping well and some toxins can also cause you to feel
depressed paint for example paint fumes paint is actually a depressant people
Huff paint and it like liquefies brain cells but it causes also causes
depression and depressant effects slowed respiration etc some people are
extremely sensitive to paint I know I am I’m except sensitive to a lot of really
strong odors and they’ll give me a headache which can make it harder for me
to sleep and just kind of put me in a grumpy mood so eliminate toxins and
allergens eliminate or minimize sensory overload so if there’s you know I have
difficulty in environments where there’s stuff going on or behind me and next to
my side and there’s noise and there’s clutter and there’s people walking by
and it’s just too much when I’m trying to focus on something so avoid sensory
overload when possible or and the same thing is true for sensory deprivation
don’t sit in a dark room with no sunlight no windows no stimulation at
all for too terribly long because you’ll probably start getting depressed we need
to have input and depression triggers can be in your environment so if you
have a picture on your bedside table of you and your significant other who just
left you that’s probably going to be a depression trigger if you have a picture
of somebody who’s passed away and it’s still a raw nerve it may be a depression
trigger so look around and see if there’s anything that you look at in
your environment or shows that you watch on TV that trigger your depression and
avoid those or do something so you’re not encountering them right now
environmental interventions include developing strategies to increase
positive people and buffer against negative people in the environment you
may not be able to get rid of them but you can buffer against them if you go to
a family reunion and you know aunt sally’s there and all
she drives you up a wall you can figure out what positive people can you hang
around or maybe at the family reunion I know I do this I stay in the kitchen and
I try to help out whoever’s cooking or preparing and I do what I can to help so
I stay busy and then I’m less likely to you know interact with dear Aunt Sally
address noise with white noise machines earplugs or just talk to your roommates
and say you know what I really need to go to sleep by XYZ time or whatever part
of the noise bothers you and see if you can come to a compromise so it’s not so
noisy eliminate the toxins and out allergens and create a calming corner in
your house and at work because you spend a lot of time there too where there
isn’t too much or too little stimulus steam hmm stimulation and there are
triggers for happiness pictures that you look at and make you
smile pictures that you look at or songs that you play you know you can put on
your headphones and songs that you play that make you happy
treatment planning needs to be individualized to address acute crisis
and dangerousness biomedical conditions and complications emotional behavioral
and cognitive issues relapse prevention and the recovery environment each
treatment plan that you write is going to be unique to that person each person
with depression is going to have different things that trigger that
depression so make sure that you look at it from a biopsychosocial perspective
so you’re providing them comprehensive treatment to make sure that you’re
addressing all the things that are causing their neurochemical imbalance if you enjoy this podcast please like
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