 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody today to our presentation, Assessment Identifying the Problem. Over the next hour we're going to define screening and assessment, which you probably already know, but we're going to hit it. Define the purpose of assessment and explore the steps in a good comprehensive transactional assessment. And that's one of the keys that we're going to focus on today. We'll explain some of the steps of an ideal assessment. Identify possible screens and evaluations that could be used in alcohol and drug or mental health settings. I'm not going to ask you on the quiz about particular screening instruments. I just want you to know that there are multiple instruments out there that you can access online for free, pretty easy. We'll learn about some dos and don'ts of assessment for co-occurring disorders, learn about or review the stages of change, and learn about the first steps in moving a client toward happiness. So screening is a very quick process, which can be done by physicians, coaches, specialists and techs, counselors, pretty much anybody. A screening is basically going, do you have any of these symptoms or do you think you have any of these symptoms? And if so, if you have a certain number, then we need to refer you to a licensed professional to be evaluated. Now physicians theoretically can do the assessment, but that's not where their focus is. They're going to refer out to mental health providers most of the time. So screening is something that we really want to encourage in the co-occurring philosophy. We really want to look at helping people in multiple settings learn how to do screenings. So anywhere someone enters the system, they can get screened and maybe get referred for mental health or substance abuse treatment. So where people go to get their EBT or food stamps, where people go for any of the social services offices in the jails, obviously medical centers and places like that. Any place you can think of that a person may go who may need a screening is typically a good place to do it. One place I would really love to see them spring up, if you will, because a lot of the screenings are online. So it's not like you have to do it with another human being. I would love to see computer terminals next to all the pharmacies so people could sit down while they're waiting for their prescriptions to be filled and do a mental health screening if they think they need one. But that's just my little soapbox, my little pipe dream. Screening simply determines if there may be a need for further evaluation. The purpose of assessment, on the other hand, is to really identify and hone in on those symptoms. What does it mean when you say you're depressed? We're going to explore the course of the symptoms. So when did it start? When did it stop or has it stopped? Has it gotten better and gotten worse and gotten better and gotten worse? I guess I'm doing my up and down differently, but whatever. These are the things that we're going to talk about in an assessment. We're going to start looking for mitigating factors, things that help make it better and exacerbating factors, things that make it worse. We'll determine the impact of symptoms on the rest of the person's life. So we're not just talking about, okay, you're depressed, so you're not sleeping well, yadda, yadda, yadda, you're living in isolation. No, someone who's depressed and not sleeping well. Let's think about, real briefly, we're going to talk about it more later, how does that impact their life, their functioning at work, their happiness, their engagement and recreational activities, their social relationships. A lot of stuff is impacted by symptoms, which turns around and impacts the person back. So we really need to look at that transactional nature. Well, identify change goals that the person states. Not everybody is going to come into your office and say, I'm ready to work on these issues. Sometimes, you know, one client I had came in and he was really wanting to work on his relationship with his significant other and I'm like, great. The significant other's primary problem with the relationship was that he was using cocaine. Okay, I can see where that would be a problem. Change goals had nothing to do with stopping use. He was not in a readiness for change for addressing the addiction, but he was ready for change in this relationship. This relationship was important. The goals ended up kind of being one and the same towards the end. But by phrasing the goals as helping him enhance, improve, maintain this relationship, there was more motivation to work on it than switching gears and going, well, you know, she says that she'll stay if you just stop using cocaine, because he wasn't ready to hear that he didn't see where it was a problem. So we'll identify the client's change goals. And then we'll develop an action plan based on guess what those identified goals. One of the things I see a lot in mental health settings. And I've worked in private and I've worked in nonprofit clinics, freestanding organizations and private practice is a lot of times I see clinicians try to use the same treatment plan for every single person. So if John presents with depression. Well, here's my treatment plan for depression. And it may not have anything to do with john's identified goals. So we really want to hone in on what are your goals, because whatever john's goals are are probably going to address one or more of the symptoms he's having. And if we address those symptoms, then the overall problem is probably going to improve to. So assessment provides an awareness of snap. You know, I love acronyms strengths, what resources does the person have, you know, personal resources is intelligence creativity problem solving yada yada, but also physical resources. Can the person take time off from work in order to have a vacation can what resources do they have for relaxation for recreation for socialization. We want to know what they have access to. What skills do they have communication skills relationship skills coping skills you know there's lots and lots of skills, but we need to know what they have already so we can build on that. If you think back to dialectical behavior therapy, and you know I go back there a lot or cognitive behavioral. We talk a lot about emotion regulation skills mindfulness skills so they're awareness aware of their vulnerabilities interpersonal effectiveness skills and distress tolerance skills. Those are the ones that I usually assess kind of from the get go to see what we've got in terms of coping responses and ability to deal with life on life's terms. And we're also going to look at mitigating factors and exceptions. You know, john presents and he's depressed. Okay, you know that it's unpleasant to be in this situation. Tell me about a time you weren't depressed, what was different. Tell me about the last time you can remember when you weren't depressed, even if it was just for like an hour or two where you actually felt kind of okay. What was different then. Too often people when they're looking for exceptions look back for the first or the most recent full remission. And we miss a lot of stuff. If we don't look for those excerpts or there's little exceptions that happen. Every so often a couple of times a week maybe. I mean they're still meeting the criteria for depression. If they have a lack of pleasure, most of the time, most days of the week, but that's not all the time all the days of the week. So, what, when was the last time you laughed, what helped you laugh. We want to encourage them to start looking for these little windows, these little windows that said you know, there's some hope. What are their needs what are their biological needs if they've got chronic pain. You know that's probably something that's going to impact their mood, and their mood is going to impact their chronic pain. Because we know that people who tend to be more depressed tend to have a lower pain tolerance and there's some speculation that has to do with this regulation of the serotonin system. That's Thursday's class though. What do they need in terms of safety and again too often we think about environmental safety. Do you have a house of your head. Okay. Is anybody being abusive to you. Okay, but we also have to ensure that they have safety from the heckler inside their own head. We talk about in the assessment. Things that happen and things they tell themselves that might contribute to their depression we start talking about thoughts here and we start talking about the internal heckler. And I have found, and you know, it was different for everybody but I found working with many of my clients when I help them envision that negative internal voice. As a heckler as a person as an entity as a something. Or you know the angel and devil that bugs bunny used to have on his shoulder. Help them envision it as some sort of separate entity. It's easier for them to start out you know we're just talking with the assessment phase here we're not 10 weeks into treatment. It's easier for them to start out talking to it and go and you know what be quiet. I don't have time to listen to you right now, or that's not true. And I encourage them to start talking back or or countering that negativity. Now if they say, for example if they're negative voices you're never going to be good enough. And you tell them well tell that person you are good enough and you're smart enough and gosh darn it people like me. But that's not necessarily going to work. And why is that it's because if they don't believe it. It's, it's not going to work. All they're doing is spouting words. So we really want to have them. If they're going to talk back to it and say something contrary or counter it with a positive statement they have to believe it. They don't believe it yet. And that's okay. I just want them to tell that voice, you know, hush, you know I don't need that kind of negativity in my life right now. One of my favorite memes is a picture of a peanut butter sandwich, and it has a bunch of peanut butter on it. And it says if you think this is too much peanut butter on this sandwich, unfriend me now because I don't need that negativity in my life. And I love my peanut butter so I kind of happen to like that meme. Anyhow, safety is not just external. It's internal safety. And then love and belonging. Who are there. Who are their supportive others. We're not necessarily and every single level of care guideline out there by the insurance says we need to involve family at least once a week. Yada yada yada if we're talking IOP treatment. But they all say we need to involve family in the recovery process. Well that's great, but most of the time I've found that either the clients don't want their family involved or the family, especially when we're talking about co occurring addiction and mental health issues the family has probably washed their hands of it, and they may not be interested in being involved at this point. So, you know we need to look at who is in your support system right now and loosely defined family, and I always say who is it that you could call or text it to in the morning, if you were really struggling. Who is it that you can count on, and there may be. Hopefully we can find one person. If not that's kind of a treatment goal I want to push up there pretty quickly. We want to help them figure out love and belonging where do they belong. Who do they fit with who's there to be supportive. And then we're going to talk about their attitudes about recovery. And this isn't just addiction. This is mental health to what does it mean to you to recover what is happiness mean what is sobriety mean what is whatever terms you're using. And what are their cultural attitudes what do we need to be aware of to be culturally sensitive to this individual. Going back to that cultural, an example I can give you when working with clients who are elderly, at least you know at this point in 2016 and my grandmother was always raised you don't take your dirty laundry and air it out for everybody to hear. So telling her for example to go to a 12 step meeting with 30 people in the room and share her story. That's not culturally sensitive at all. So we do want to be aware of when we're suggesting interventions when we're designing treatments is this culturally congruent with our clients attitudes and needs. What are your preferences. What is their learning style. If you take someone who is like me I'm a visual learner and you know, bless you for being here, because I don't think I could sit through an entire hour webinar. I'm just not wired that way to passively listen and take in things I didn't. So for example, if you've got a client who is an auditory learner, and you're constantly giving him or her books to read, they may not be picking up that much information from it. So the question is, what can you do. And for that is to get the books on tape, or to read it out loud into a tape recorder have the client read it out loud into a tape recorder and then listen to it later. Those are all things that the client can do, or go through the workbook or the book with someone and talk about it as you go because at least if you're talking about it. They're hearing it even if you're not reading verbatim the words. What's their preference for the treatment approach. Are they wanting cognitive behavioral. Are they wanting dbt. Are they wanting just straight up rogerian psychoanalytic let's just throw that one in there. What is it that they think is going to help them the most in treatment. A lot of our clients have already done some research about the different techniques that are out there. And if they haven't that's okay. What I tell my clients is I'm going to, you know, I explained to them that I am very cognitive behavioral in in my approach and what that means. And I'm going to suggest techniques and the ones that fit great tell me that they seem to work or they sound like something doable. And then once that don't fit or they feel are a little bit out in left field. Tell me so I don't keep suggesting them. Let me know and so we'll develop our own approach to recovery as we work through treatment. But part of the assessment process is really developing rapport and having the client come to feel like they're a partner. In this process. I tell them at the beginning, because I hate assessment when we're just writing and writing or typing and typing, and the client is just sitting there and they're like, well, what's the person typing. I'm like, if you want to read this at the end you are more than welcome to. If you anything I write down that you want to read. It's your chart, you're welcome to read it. And that in mind as I am writing my assessment I make sure to use purely objective terms and with the knowledge that whether it's right now or six months from now the client has the right to read anything in their file with a few exceptions. So, that demystifies, if you will, some of the process and helps them feel like more of a partner. I also tell them that, you know what, you have lived in your body for the past 39 some odd years or however old they are. I've known you for 39 minutes, you are far more an expert on what makes you tick than I am I can provide some, you know, hints and tips that may have worked for other people, but it's going to take us working together and talking about what works to figure out what works for you. So, I stepped down off that expert role as much as I can, from the very beginning, because they walk into my office and, you know, they usually address me as Dr. Snipes or something and I'm like it's Donna lease you know it's, we're just going to sit here and we're going to chat. If I maintain I feel if I maintain that Dr. Snipes title, it distances us and puts me more in an authoritative and I want the client to take the lead. So thinking about how you approach clients how they address you and ways that you interact within the assessment session to make it more of a mutually agreeable relationship, if you will. Five principles of motivational interviewing so you got them in there you're looking for exceptions you're looking for mitigating factors, trying to figure out exactly what's going on and how to help this person. Keep the momentum going they got to your office. I wanted to keep going so they come back for the first session. What do we do. We generate a gap. That means helping them see the difference between what they view as where they want to be and their behaviors right now. How are their current behaviors, activities, emotions, thoughts affecting their journey towards that ultimate goal. Is it keeping them stuck. Is it making them go the other way, or is it helping them reach that. Rolling with resistance and I can talk forever about resistance. I view resistance as the client's way of saying you've missed the point. You don't understand or you don't hear what I'm saying, and I'm going to stay here I'm going to stay stuck until you understand. And I think about my donkeys. Whenever I think about resistance because donkeys are really really smart. And when we first got them, you know I was new to equines period never had a horse. And I get these two elderly donkeys and they're pretty set in their ways and I kept trying to get them to go in the barn and they wouldn't. And, you know, low and behold, talking with my daughter and stuff could figured out that they'd never been in a barn so when they're in the barn and the wind blows, and they hear all the creaking and the rain on the metal roof, it's really scary for them. I'm like, hey, they weren't trying to be oppositional they were telling me I was scaring the bejesus out of them. So it makes sense. So when a client seems to be resistant, take a step back and say what am I missing. In the assessment process. Don't fight it, you know, if the client says I'm not doing that I'm not going to take medication on. Okay, let's talk about what you are going to do or less. That's fine. We can table that for a different, different discussion. Avoid arguing, you're not going to get anywhere arguing with the client if they're arguing, you know arguing resistance kind of go hand in hand. Clearly you're missing the point, whatever they want, or whatever reason they're digging their heels in tells me that whatever we're suggesting is either less rewarding or scarier than what they've already got. So I need to figure out why staying the same is more rewarding than what I'm suggesting. Encourage a can do attitude. And this comes in helping them see little brief episodes where there have been exceptions to being depressed to using to fighting with their spouse, whatever the presenting issue is. Encourage them emphasize the fact that you came today, you know that took a lot of courage, you can do this and set small, very small achievable goals initially. And expressing empathy, you know that's kind of goes without saying if somebody's in your office. They don't know you from Adam's house cat. They're telling you their life story. You know that's kind of making them vulnerable that's kind of scary. And so expressing empathy, telling them you'll take it as slow as you need to and again, making sure that they understand that they're empowered to direct their own treatment. The stages of readiness for change most people have multiple issues, whether they're in our office or not, but readiness for change can be different for each issue or even each symptom of each issue. So I told you about my client before who came in and he has relationship issues. Okay. He was really ready to work on that. He also had the issues of cocaine use or cocaine addiction in that particular situation, high blood pressure and you know some generalized anxiety. That was kind of there was more of an adjustment disorder than like full full blown generalized anxiety disorder, but there was a lot of stuff there that we were talking about. When we started talking about what are you ready to work on. You know his most crucial thing was this relationship with his significant other. He was ready to work on that. Now, in dealing with that, we had to start looking at okay what's causing the problem so there are multiple issues with communication and trust and, you know, collaboration around the house and those sorts of things I mean there were a lot there that came up that we needed to talk about addressing his cocaine use wasn't something he was willing to work on quite yet. Why. Well, I hypothesize that he was waiting to see if there was going to be any positive progress before he gave up the cocaine, but that's just my hypothesis. We started working on the things he was ready to work on. So stages pre contemplation. The question comes in any thought thoughts on how age differences impact readiness for change and or on the assessment process and being aware that people of different age groups, whether it be generation X or millennials or elderly or you know, or even people from different religions or backgrounds. We may have differences in the way we communicate. You know I've got two teenagers at home, and they have a whole different way of communicating, but understanding what your process is and understanding what your limitations are, as far as communicating with this particular generation, or a particular group of people can help you see where you might need to do some multicultural continuing education if you will, if that is a population that you work with a lot. If it's a population that you don't work with a lot. And you know I don't know if it's the rightest thing, but I let the person know that you know I recognize that there are some differences between us, whether it be age or background or whatever. And I want them to let me know if anything I say is offensive or if I don't seem to be making sense or anything I say seems to be irrelevant. So let's talk about that because there's no sense them being in my office and kind of rolling their eyes going oh this is like listening to my mother. So I tell them ahead of time that I understand that you know I'm not 100% perfect with communication either. So let me know and we'll try to overcome any communication obstacles. The stages of change pre contemplation. I don't have a problem can't tell me I have a problem, not not a problem contemplation. Okay, maybe I use a little bit too much, but still not a problem I got it I can stop anytime I want preparation and determination. Yeah, yeah this is a problem I don't. I'm not quite ready to go into therapy, but I recognize it's a problem and I'm going to start learning about different ways to address it. Action is when they show up in your office. They're at least in the action stage for one of those problems if they're a voluntary client and maintenance we forget about maintenance a lot because remember people have multiple issues. So if we help, you know, Jim Bob comes in and he's got anxiety issues and major depressive disorder and marijuana addiction. Okay, so we help him become abstinent from marijuana. Well, he still has those mood disorders over here. Do we just switch gears and start addressing the mood disorders to the exclusion of the marijuana because he's not using anymore. The answer is no, we need to make sure that we're touching base with that goal to help make sure he's in maintenance, at least for the first year, and hopefully he's not going to be with us for a year or more. That he'll reach a plateau, take a break and then enter another episode of care later. So we need to remember that they're not going to be ready to necessarily learn about everything or address all their problems. If they're in the preparation determination stage they acknowledge it's a problem but they're not ready to they don't really want to focus on it right now. Point them in the direction of education of literature of videos of something. And then let it go at that for now. So empower them, give them some options to learn and then start focusing on what they want to focus on so they don't feel like they're being manipulated or forced to work on something when that's not really where they're where their heart is at that moment. Addiction basically means tolerance in terms of needing more to get the same rush high or feeling and this can be behavioral or chemical. Now needing more can be needing more of the same substance or needing something more intense. If you think of Internet porn, you know, some people start with the mild stuff. When that doesn't work for them anymore, even though there's constant novelty, they move up to something that's a little bit more shocking. And this is how we see people progress with pornography addiction into some of the grayer areas of bestiality and bondage and those sorts of things. So they start with the sort more mundane stuff that doesn't do it anymore. They progress withdrawal psychological withdrawal is just as important to pay attention to as physical withdrawal. So anxiety and irritability when you can't access your substance or when you're coming down off your substance or behavior. Shake, sweats, nausea and depression when unable to access the addiction and I use that real generally so we're thinking about gambling, sex, pornography shopping. If it's something a person does in order to help them escape and they can't access it. It's one of those things helps them deal with their overwhelming anxiety or anger. If they can't access it, then they're going to be like, I'm going to explode. So we start seeing the psychological withdrawal symptoms. Negative consequences continued use even though there have been negative consequences in multiple areas of their life. So is it causing relationship issues, financial issues, legal issues, neglected or postponed activities because of use. They just skip your kids soccer game so you could gamble a little bit more or you could go to the track. Yeah, that's just one example. Significant time or energy spent and this is important obtaining using concealing planning or recovering from you so it's not just use. It's that whole lead up and recovery from included in the use period. And when we're talking with people with addictive behaviors we find there's a lot of obsessive thinking a lot of planning. Even when we're talking about people with eating disorders. You know they spend a lot of time thinking about what they're going to eat how they're going to prepare it. When they need to get the food yada yada yada and then you know they eat if and then there's a time to recover from it if they're binging and purging or whatever the case is. And unsuccessful attempts to cut down or control use you tried to stop you found you couldn't and you find that bothersome. So these are the criteria that we generally use to determine if somebody has crossed over from recreational use into addiction and depending on the person. More or fewer of these symptoms may be present before they go yeah this is this is a big problem. Mental health depression hopelessness and apathy. We want to start kind of figuring out what is the person have going on mood wise anxiety and worry you know tell me about the how much you worry how much anxiety you have what are your stress triggers. Do you have difficulty concentrating tell me what that's like irritability agitation fatigue changes in sleep duration or quality and changes in eating. So let's think about this. If you're depressed. You're feeling hopeless. Nothing really doesn't for you anymore you know think your. How is that going to impact your productivity at work your desire to get out of bed the cleanliness of your house you know even caring whether you're going to dust today or not. Your relationship with other people I mean are you really you know a barrel of monkeys to be with or not. And so we'll assume that this depression and hopelessness is having an effect on your relationship with other people. What's that effect is it going to be a positive effect is it going to strengthen your relationships is it going to increase your happiness probably not you may have. Some positive feedback from others initially where they're trying to help you get unstuck and develop hope and all that stuff again. But generally people don't want to hang out with a negative Nellie all the time. So they may start backing off as the social support goes away the depression tends to increase because the person feels more isolated rejected yada yada. Same thing with anxiety and worry have you ever been around somebody who worries about everything or is just really just a little stress ball. And I know I can be at times and my kids are like mom you just need to go outside and work in the garden or do something go to the gym. Because you're just using stress and it's not pleasant to be around. And I'm yeah you're right. Difficulty concentrating now that's not generally as negatively impactful on relationships so to speak. But think about how it works at work if you're having difficulty concentrating and focusing and even like kind of getting through the day. How do you feel about your work product how does it impact your self esteem when you walk into a room and you get there and can't remember why you got why you went even went there in the first place. That happens to me a lot. Or you can't remember what you're supposed to do or you started task, and you read the same page like six times, and just aren't even processing it. I personally get really frustrated when that happens, which tends to make me a little bit more irritable, which tends to make me a little bit less pleasant to be around. You can see how this is all transactional, because then people are going to back off. And, well, I might actually get more work done then we want to ask them what the effects are. So the first steps in the assessment are really to identify the problem, have the patient identify it. What exactly do you see as the problem. What is the solution when this problem is gone. What's it going to look like what's going to be different. What do you hope for, and start ferreting that out in terms of as evidenced by. So I will be happier. Okay, what does that look like how will I know that you're happy. What's the evidence going to be is it going to be how you how many times you laugh lack of lack of crying episodes what is it that you're hoping is going to be different. And if they can't identify something specific, then I dropped back to my friendly neighborhood Likert scale on a scale of one, just miserably depressed to five as happy as you've ever been. So where are you on a general day, and if we're working towards a happiness goal we might look for a three five out of every seven days. You know that's content to moderately happy. I'm good with a three, you know, this is our initial goal it's not our endpoint, but where do we want to go where's what are we working towards right now that's realistic. And it's not going to be every day, every day is not going to be a three four or five. We don't want to tell our clients that that's going to be the case so we want to say on a scale of one to five and give them anchors so they know what each number means in words. On a scale of one to five, your, maybe you'd be a three, that's, you know, moderately happy, not terribly upset five out of every seven days does that sound like a something that's achievable. Okay, we can put that down. So while we may not have anything specifically measurable crying episodes or a number of hours of sleeping. This gives us something to kind of start working towards. We want to learn about what causes the problem in general, and educate the client about these are all the potential causes for depression. And that can get into pretty lengthy stuff but as I'm asking the different questions about, you know, tell me about how you've been sleeping. And then I tell them why I asked that question, because lack of quality sleep can contribute to depression. Or when I ask about pain, because pain does tend to make a lot of people more irritable and it can keep you from getting quality sleep, which can impact your depression. So every time I ask them a question, I give them I'm asking this because follow up. Learn about what causes the problem for that person. So what causes it for you we've talked about all these different things as we've gone through the assessment. Now that with end of the assessment, what do you think are some of the contributing factors to your depression or anxiety right now. Let's talk about possible solutions. So you've identified these four things as potentially contributing to your depression. What do you think you'd be willing to try to do this week to start working on at least one of those things. And let's identify solutions that will work for that person and I always said it in terms of what do you think you can do this week. And we don't usually hit all four goals. You know we'll hit one or two I just want you to focus on one thing or two things and do it really well and see how that works. And then we'll develop a plan to start implementing those solutions. So maybe if one of the things they say is I need to become more mindful of how I'm feeling. Because I'll just get up and go to work and I'll be doing my thing and somebody'll say something to me and I'll bite their head off and just out of the clear blue. Okay, but mindfulness is one of those things that takes some practice. So how is this person going to implement new mindfulness skills. When they leave the assessment. Please try to give them something, even if it's just collecting baseline data or journaling. Give them something to do so they feel like they're making forward progress it empowers them to start taking control of their thoughts emotions and behaviors. So we asked them about their presenting problem. What are your symptoms as evidenced by and I'll go through each of, if we're talking about depression, for example. How many days last week. Did you just not care about much of anything. Then I'll ask about sleep and eating and all that other stuff. How long has each one been going on. You know let's get an idea is this been going on for a week since your mother died, or is it been going on for a month. And there was no particular precipitating trigger, you know we want to rule it out from grief. What makes it worse what makes it better and what are the consequences as evidenced by so you know when you're in a bad mood. How does that impact everything the rest of the day, how you interact with your kids what you eat, how you feel how you sleep. Yada yada, you'll find that people who are having an emotional upset day, emotionally dysphoric day, typically report that they don't sleep as well. Either they have nightmares they wake up a lot or they just wake up the next day and they feel like they got hit by a truck. So I want to know that, because that's something for them to be aware of and to go oh yeah I can see how why it might be really important to start addressing this because it really is having a reverberating impact. And we asked them what their goal is. Remember I said we want to start with Mr like it scale. But we can also ask them what would be different emotionally, you know, obviously I'm going to be happier. Okay, you know that's usually a pretty easy one. Mentally, and if they have other emotions I'll be more curious all inquisitive. I'll be more patient. Yeah, those are all great things to mentally. Do you tend to be more negative or more positive. Do you think you'd be more positive and see the silver lining if you will, when you're happier. Basically what will be different and go back over the sleeping the eating the drinking alcohol the energy to just get up and face the day energy to go out and exercise. Socially, what will be different. Now I put self esteem here, because a lot of times we forget to evaluate our relationship with ourselves we jump on to relationship with significant others. Well before we can have a good relationship with significant others, we have to have a decent enough relationship with ourselves. So if you're happier. How do you think that's going to reflect on how you feel about yourself. And how do you think it will affect your recreation, you know, things you do to have fun and go out and hang out, whether it's one person or 20 people and environmentally, what will be different. I know for me and I had a supervisor one time, who we were staffing at the at the boys facility. And we had 16 teenage boys for six months, and we would staff each case each week. And we brought in this one kid, and he just looked awful. You know he was all disheveled. And he used to be, you know, leading up to that week, you know, premium proper and, you know, just all cleaned up and, you know, great. And Paul looks at him he's like, you know, call him john, john, you'll look awful. And what I know is that generally, this is not normal for you. And a lot of times, the way we feel on the inside is reflected on the outside. So tell me what this is all about. And, you know, this client was getting ready to discharge he was terrified about discharge and you know there were a lot of there was a lot of stuff and anxiety that was coming up. He was sort of trying to self sabotage, because he quit following some of the hygiene rules. So, environmentally, you know, think about when you've been really depressed, grieving exhausted deal at the house go a little bit, or, you know, some people, when they get really really stressed out clean, like, you know, nobody's business and they're down there with it with a toothbrush. And that's how you react and what your environment does when you're happy versus when you are dysphoric. And then I also asked them, you know what, what's going to be the same. And they usually look at me quizzically for this because something is going right for you right now. What is in your life right now that you hope is going to be the same that you hope you will continue maybe you have a job you, you know, are okay with. Maybe you have a car that that's running, you know, it may not be a Lexus or one of them fast fancy cars, but it runs and it gets you from place to place. Those are the good things. So we want to look at what do you have going for you right now, in addition to what are you hoping to have. And the transactional model basically says the way you feel emotionally or physically impacts how you interact with others, and how they interact with you, your stress response, and how stress affects you. So if I am already really stressed out and I lash out, then generally that's going to boomerang back at me, and I'm going to get increasingly stressed out. I have the ability to concentrate and your attitude. So, again, if I can't concentrate, and I'm getting frustrated and yada yada. My attitude tends to get a little bit icky, which makes it harder to concentrate and, you know, circ, circular cyclical and impacts your environment. I don't know about you. When I get dysphoric. My environment go a little bit. And it just drives me crazy. I am, I am not fastidious by any means, but I do not like to have stuff piled up on flat surfaces, and I don't like lots of dust. And I'm a freak about floors. I am a freak about floors. Other than that, you know, if everything is relatively in its place. I'm cool. I don't go around with white gloves and check the top of door jams and stuff. When I am not feeling so hot, I tend to not put the effort or decide to clean and being stuck in squalor makes me feel worse. And I just kind of want to pull the cover over my head because I'm looking around going, oh, that's overwhelming to even think about cleaning at this point. Transactional. So we want to evaluate potential causes of any of the symptoms that the people are having sleep. It could be depression. Sure, it could be a serotonin imbalance because we know serotonin is broken down to make melatonin, which helps us sleep. And when that gets out of whack. We have sleep problems. And when serotonin is out of whack, we may emphasis on may have some depressive issues. But there are a lot of other things that cause sleep disturbances, other than depression, pain, for example, drinking too much caffeine too close to bedtime. For example, have the person make a list of what keeps them up and just poor sleep hygiene, which most of us have nutrition. If they are eating more for comfort than for nutritional value. Okay, no judgment here, but let's look at what is the purpose when you're eating and are you craving things do you have food cravings. What does that mean. When was your last physical educate them about how important nutrition is yada yada dehydration can cause difficulty concentrating confusion and lack of energy and fatigue. So have you been drinking enough water. I mean, water generally doesn't make somebody go oh I'm not depressed anymore, but it helps. Do you have pain or chronic illness that is constantly sort of plaguing you, whether it's accepting the chronic illness you know maybe you're recently diagnosed with diabetes, or you've got some sort of chronic pain that you're constantly just kind of fighting. How is that impacting you it's probably well, we know that that tells your body that there's a threat that you're under stress. So you don't sleep as well when you're in pain. You know that sleep is is not as good as it could be. But how else is it impacting you. Are you feeling guilty because you can't go play ball with your kid. Are you feeling, you know, let's talk about the impact. Sunlight helps set your circadian rhythms. It helps you know when you're supposed to be awake when you're supposed to eat when you're supposed to sleep. And it also helps with vitamin D vitamin D has been associated with deficiency has been associated with depression. They're not exactly sure how, but they do know that there's lots of vitamin D receptors in the emotion regulation parts of the brain. Are they getting enough sunlight do they actually get up and open the blinds don't encourage them to try not to sit in the house with the blinds drawn all day long. Are they getting some exercise and this just means movement. I'm not talking going to the gym and doing a yoga class or a power anything class. I'm talking about walking the dog, or just going out and walking around the yard a couple of times. Are there addiction issues alcohol. If they're drinking alcohol, even if it's not to an addiction standpoint or addiction threshold. When somebody first drinks is a depressant. So it depresses the respiration it generally makes people as a disinhibitor so it makes them a little bit more loose lipped makes them feel a little bit better. As it wears off there's a rebound anxiety and also hypertension. If you're talking about somebody who is an alcoholic. This is why alcohol detox can be life threatening because that rebound anxiety and hypertension can lead to stroke. And alcohol can also give you tremors. So if somebody is experiencing depression and anxiety. We want to look at is it increased or made worse. When you drink alcohol or if you drink drink alcohol the day before. If they're using amphetamines cocaine or other stimulants including caffeine, if they have anxiety and panic. Depression which is a withdrawal symptom from your stimulants your body's kind of crashing if you will. And again tremors tremors come up a lot. And when I get shaky. I kind of attribute that to panic attacks or stress or stress reactions. So tremors can actually make somebody think that there's something to be worried about when there isn't necessarily. But if they're experiencing anxiety depression or tremors, we want to talk about are you using stimulants. You know I kind of joke that I'm, I've given up my four pot a day habit of coffee. Well I've switched to decaf. I think I still drink four pots a day but it's decaf now so that's all the better. But yeah, you know I used to kind of push that whole toxic level to the nth degree. And I tended to be a little bit more shaky and jittery and I'd get headaches and fatigue and foggy head when I didn't have it. So encourage clients to be aware of that marijuana since it's been legalized felt I needed to add it can trigger anxiety apathy lack of motivation impaired concentration. All of those are kind of in there with that depression anxiety diagnosis. So if they're using marijuana, you know let's start by talking about well what happens when you're not using is this mood disorder caused by the substance. Or are you self medicating the mood disorder with the substance. And it can also cause paranoid delusions and hallucinations if you have a bad trip so being aware of that. And opiates their depressants they slow breathing they tend to help people feel less anxious to which is why a lot of people abuse them. They're associated with decreased pain tolerance when you quit taking the opiates you are more sensitive to pain for a little while until your body kicks back in and starts producing its own natural pain killers. And opiates tend to make you really sleepy because they're depressants so people on opiates tend to sleep more, but they don't get quality sleep. And when they're sleeping more it tends to mess up their circadian rhythms, in addition to not getting quality sleep so you know let's look at if you're taking opiates and maybe they're prescribed and if they are. Let's look at how we can create a multidisciplinary treatment plan to help address any of the concurrent depression. Age, many physiological changes take place as a result of age, taking this into account can assist in determining that some of the possible causes of the symptoms. So, you know, menopause, hate to bring it up but sometimes estrogen and progesterone both have very significant effects on the availability of serotonin. So, there are some mood impacts when hormones start to change. Men's testosterone levels start dropping between 25 and 30. And their estrogen levels start going up. Yes, they have estrogen too. So, we can see that there may be some mood impacts here. We're going to talk about that on Thursday. People have fewer experiences against which to judge current experiences. So what seems like the end of the world to a 12 year old may not seem like a big deal to a 32 year old. But if you're dealing with a 12 year old, we have to kind of get into their frame of reference. And the culture and environment changes for people of different ages. So we just need to be aware of what they bring to the table. What are your social potential causes? Is your immediate family there or are they an addition of chaos and drama? Do you have social supports? They're great buffers against stress, but you have to have them. What are your social stressors? Do you have social anxiety? And how do you feel about yourself? What is your self-esteem like? What do you bring to the table in these relationships? Finally, environmentally. Are there things in your environment that are contributing to your anxiety or your depression? Do you like environments that are active and you don't mind interruptions or do you prefer calm and peaceful? So if you don't like interruptions or loud noises, if you have a kind of an exaggerated startle response, you might be more stressed out in environments where there's frequent loud noises like in a house with four dogs. Is your environment supportive of sleep? Is it conducive? And supportive of relaxation? Or do you have three toddlers and four dogs and two cats running around screaming and going crazy and tracking mud through the house? Not real supportive of relaxation. So how can you find somewhere, even if it's the bathroom, that is supportive of relaxation where you can escape for 15, 20 minutes? And emotional causes. Do you have anger, anxiety, or depression issues that are kind of feeding into each other? Remember, anger and anxiety are flip sides of the same coin. And a lot of times when people get really anxious about stuff, they start to get irritable and angry and because they can't control it. So we want to talk about thought triggers for each of these emotions and how they might be contributing to the presenting problem. All right, I know we're running a little short on time so I'm going to pick up the pace a little bit. The symptom assessment, I use this chart with my clients. I have them take it home after we've talked because then they can digest what we've talked about and fill this in. Filled out a sample one on Lenny. Lenny is what I lovingly refer to, I guess, as is a tightness in my chest. I had a cardiac episode, I guess it's been two years ago now. And really tight chest, couldn't breathe. And whenever I start to feel that again, I can kind of precipitate a panic attack in myself going, oh, here we go again. So Lenny, let's talk about him. What makes the symptom worse? What behaviors do I do? Well, working out really hard for several days in a row, not getting enough sleep or drinking too much caffeine. Those all increase that chest tightness. Thoughts that I have that make the symptom worse. I'm having another episode, I can't breathe. I have to make this stop. I'm completely overwhelmed and I can't deal with it. And you can run through these with your clients. What environments make the symptom worse? For me, if I'm already stressed out for some reason, chaotic environments can tend to make the symptom a little bit worse. And negative people. I don't like being around environments where everybody just seems to hate everybody else. I want to kind of escape from there. So then you go through the same thing with what can you do? What behaviors make the symptom better? What makes Lenny go away? What thoughts can I have that make Lenny go away? What positive self-talk can I do so I don't go into a full-blown panic attack? What can I do in my environment to make it so I don't feel as, you know, lenified? And then we talk about the impact of the symptom. When Lenny is showing his ugly head, how do I feel? Well, I'm afraid to work out because I'm afraid I'm going to have another episode and end up back in the emergency room. And I also tend to get kind of lethargic. You know, I just don't want to do anything because I'm afraid that I'm going to trigger him. Increased sense of helplessness and I tend to withdraw from other people. I'm just like, you know, whatever. So it's not a good, you know, Lenny is not beneficial to overall health and wellness. If the client brings this back to me and then we would go through how to address those things that make the symptom worse, you know, either not do them or mitigate them. How to increase the things that make the symptom better and just being aware of how much this symptom really impacts multiple areas of his or her life. So we want to increase people to become mindful of their symptom triggers emotionally, mentally and physically. I encourage them from the minute they walk out of my office at every meal. Do a mindfulness scan and ask, ask yourself, how do I feel emotionally, mentally and physically just to start getting used to being self aware. The assessment is really the beginning point. It helps clients get a clear idea of what may be causing their symptoms or making them worse. Proper nutrition, adequate quality sleep and pain management are all necessary for happiness and recovery. At this stage in the assessment clients are just starting to envision what happiness or recovery looks like for them. So we want to help them identify their strengths and what things would be good uses of their energy. We'll help them identify which presenting symptoms they're most willing to work on and develop a treatment plan from there. From the perspective of the transactional model, we recognize that improving any area will likely improve the person's overall happiness. And if you use the symptom assessment chart, you can help clients identify current strengths and possible contributors to each one of their symptoms. Now, the one thing that we didn't go over in this class is that addictive behaviors and you know, I don't usually quiz you on numbers or percentages, but this one is important. 47% of people in the United States have addictive suffer from addictive behaviors in any 12 month period. So it's important to understand that when we talk about assessment and understand that when we're doing an assessment, even if we're just mental health, we are going to interact with people with substance abuse issues. So it's important to at least be aware that they're there and screen for them and refer out as necessary if it's not something that you feel comfortable handling. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com slash counselor toolbox. This episode has been brought to you in part by allceus.com providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists and nurses since 2006. Use coupon code, counselor toolbox to get a 20% discount off your order this month.