 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 you to today's presentation on models and theories of mental health and addictive disorders. We're going to explore why the mental health counselor needs to understand addictive behaviors when we start out. So you can kind of figure out why we're talking about this. And we'll learn the scientific and theoretical basis of models of addiction and mental distress. I don't like the word disorders from multiple disciplines. So we're going to look at, you know, a lot of times when we went through graduate school, we did go through these different theories and talk about how they might apply to the development of mental distress or how they could be used in terms of theories of counseling, how they could be used to address mental disorders. So we're going to talk about, see I used the word disorders. We're going to talk about how these different theories educate us or inform us about different ways to intervene. We'll develop criteria for assessing models and theories. We'll look at a model and go, it's got good points, but it's got down points to instead of just looking at it and going, yeah, sounds pretty good. We'll explore the appropriate application of models and learn how to access addiction and mental health related literature from multiple disciplines. The reason we need to do this, when we're evaluating models, we need to figure out, well, where did they get this information from. If we don't really know where to find that information, then it can be a little bit more difficult. So we'll look at that. Why is this information important to the counselor? It enables us to provide more ethical and comprehensive treatment to the client. You know, remember beneficence is doing what's in the best interest of our client, but non malfeasance is above all, do no harm. So we want to make sure that we're not inadvertently causing harm. We're not necessarily addressing part of what's going on. We want to have a good idea, even if we don't treat stuff. I mean, you have clients come in, they may have physical stuff going on, thyroid issues, hormone issues, diabetes, something else. They may also have addictive disorders going on. In addition to whatever they're presenting with, we'll assume it's a mood disorder. If we just treat the mood disorder, we could inadvertently kind of be doing harm because they may not see much improvement if some of these other issues are contributing to the mood disorder. So we'll look at that. It enables clinicians to understand the influence of drugs and certain behaviors on brain chemistry, which leads to the development of additional mental health, legal health, social, economic and addiction problems. So addiction begets addiction. Most people, well, not most, a lot of people when they come to treatment are poly addicted. I don't want to say poly substance because it can be substances that can be gambling can be a variety of things. And all of these things mess with our neurochemicals, they mess with our brain chemistry and they can kind of mess with our life, which can exacerbate anxiety, depression, anger. It can also trigger schizophrenia or bipolar episodes. So it can destabilize our clients at the very best, if you want to look at it that way. Addictions and other issues can negatively impact mental health treatment progress, even if they don't cause other problems, they can keep clients from progressing as quickly as they potentially could. So we want to make sure we look at all the things that are feeding into what is causing Jane to feel the way she is. We also want to understand the influence of mental health issues on the person which can potentially lead to addictive behaviors. Does everyone start out as depressed or anxious and then develop an addiction. However, we do know that some people who have recreationally used alcohol, for example, in the past, when they hit a really hard point in their life, some, not all by any means, may start abusing alcohol as a way to escape from the pain, the mood issues that they're currently experiencing. So we want to understand that unchecked dysphoria can lead people to try to escape. That escape produces pleasure, they may be like, oh, that's good, want to keep going there. And we'll talk about that more. How common is it? Well, we want to look at something, the prevalence and incidence, and I always get these mixed up, so I'm just going to go over them here. Prevalence is the proportion of cases in the population at any time. So if we're looking at the past year in 2016, you know, what was the prevalence of depression. I believe these stats are from 2013 that 26% of the population was experiencing depression. That's a lot. That's like more than a quarter of the population. 29% of the population was experiencing clinically significant anxiety. That's one in three, basically. So I mean, think about it, when you're sitting in a restaurant, or you're sitting in church, or heck, you're sitting in a staff meeting, count how many people are there, and one in three of those may be experiencing depression or anxiety. Another study, which is in your classroom, so you can go and actually read the study, it was a meta-analysis of research, found that it was most plausible that 47% of the U.S. adult population suffers from maladaptive signs of an addictive disorder in any 12 month period. So that's almost one in two. And when we talk about maladaptive signs, it doesn't necessarily mean substance dependence, but it can mean that they're having negative consequences. So maybe somebody starts gambling a little bit too much or shopping a little bit too much to try to escape, and they start having experiencing negative consequences. So it's important to understand how prevalent this stuff is just in the general population, not to mention people who come into our clinics, they're presenting with one of these. So we know pretty much 100% of people who we see in our office are likely going to have at least one of these diagnoses. Why is this important to the counselor? Well, we want to understand all of the factors that are going into our clients presenting issues so we can help them be as successful as possible. Patients often interpret a systemic failure as a personal failure, which causes low self-esteem, depression, guilt, and shame. So they come in, they're hoping we're going to have the answer. And when that doesn't work right away or doesn't work at all after four or six weeks, they're still not feeling any improvement. Many clients will take that very personally instead of understanding that, you know, we may not understand what is triggering your depression or anxiety or whatever right now. Or we may not have helped you experience as much remission as you had hoped because we're missing something. There's something that's contributing to this dysphoria we don't know about yet. One of the things I do in my practice is I try to take as much ownership or educate ownerships the wrong word for what's going on. And I explain to them that it's part science, part art, and what causes depression for them is going to be different than what causes depression for my nine o'clock and for my two o'clock. So it's important that we communicate about what's going on and I will help them to the best of my ability, but we're going to have to make adjustments. When we talk about addiction, you know, a lot of people try to stop on their own, whether they're in mental health treatment for something, or they're just trying to stop. Less than 30% of people who try to stop on their own or with help succeed for more than 30 days. So many of our clients may have already experienced failure at this. If they're coming in and they're trying to deal with depression or anxiety, think about smoking cessation. How many people do you know that have tried to stop smoking three, four, seven times? And it starts to get really frustrating. And less than half of patients, research has indicated that less than half of patients who begin medication psychotropic have positive results. So looking at what we're talking about here, a lot of clients come in and they see the stuff for depression, the medications for depression on TV. They're like, I want that. I need to feel better. And they start taking it and it doesn't help. And then they start feeling like, well, it must be something with me. What's going on? So they get very frustrated when the first treatment we try or even the third treatment we try doesn't seem to give them the level of remission that they're looking for. So before we get into theories, we want to talk about how do we figure out which ones are good theories, which ones are helpful and which ones not so much. Does it explain the development of the condition in some people and not others? And remember back to stats, predictive validity means the theory can predict, hey, accurately predict who will develop addiction, who will develop depression and reliable. If we use this theory and we say if all of these stars align, then this person is going to develop depression. Is that accurate or if all these stars align, they could develop depression or they could develop addiction or they could develop something else completely. So that wouldn't be very reliable if you apply that theory and couldn't reliably identify someone that was going to develop depression. So we want to make sure that it predicts what it says it's going to predict and that it can predict that across populations. Can the explanation be applied across people and situations? So if you have a Native American who is living in, you know, Southwestern Tennessee and is 35 years old, can you apply it to that person? And can you also apply it to a 20 year old who is living in upstate New York? You know, I'm just kind of throwing out there different geographic regions, different cultures, etc. Can we apply it across? Is there generalizability or not? Does this only apply to teenagers or does this only apply to the elderly? If so, wouldn't probably be a very robust theory. Can it be used to develop effective prevention and intervention strategies? Well, if it's a good theory, then it's going to say this is what causes it. So we can say, well, we look at what causes it. We try to prevent that from happening. And we're looking at what's causing it and say, all right, we have all these things going on right now. How do we fix it? So you have prevention and treatment that comes from a good theory. Does it explain the use of seemingly destructive behaviors? Now with addictions, that's kind of a no-brainer. We can look at it and go, yeah, that seems destructive when you're using cocaine and spending everything you have and hawking anything that you can to get more cocaine. And we can also look at it and go, I can see why someone might do that to escape or to experience the euphoria. When we talk about mood disorders, it's a little bit different. But when you think about it, you've got people who are clinically depressed. They can't get out of bed. They're not showering. They're not engaging with friends. So their social life is negatively impacted. They may lose their job because they can't get up out of bed and get a shower and get to work. So it's somewhat destructive. Anxiety can be the same way. If people are experiencing a lot of anxiety, it can have negative effects on their relationships, their work product, and their general health. So some theories that we'll get to would say, well, you see this destructive behavior. You don't want it to happen. You need to make it stop. You know, if it's destructive, it doesn't help. So why are they doing this despite the fact that it's destructive? The theory needs to help us understand why they're engaging in these behaviors. And are there other unaccounted four factors which may influence the development of the problem or recovery from it? So as we'll see when we start with the first one, which is the biological model, that yeah, a lot of these theories only account for a small sliver of the different variables that often feed into what can cause problems, what can cause dysphoria in humans. So what are our theories? Biological, moral or spiritual, behavioral, environmental, sociocultural. So, you know, we're kind of switching where we're looking at. Are we looking at the body, the spirit, our actions, our environment, our social factors, or are we going to smoosh them all together in the viral bio-psycho-social model? And there are a lot of sub-theories that go under each one of these. What we're looking at is the overarching ones today. So biological and disease theories say that there's a genetic predisposition and or a brain dysfunction. So is there a genetic predisposition to substance abuse? There has been some research that has shown that, yes, there is. Doesn't mean it's causative. It means that the predisposition is there and it could be triggered. But there are also certain cultures, certain people who have a stronger genetic predisposition or a genetic predisposition have a stronger reaction to certain substances. And we know that depression and anxiety and other mental health disorders seem to be intergenerational. So there's a theory that there is a genetic component to those as well. Those genes cause some sort of a brain dysfunction, whether it means that the brain is structured differently or the neurochemicals are out of alignment for what needs to happen for the person to feel happy. We don't really know. But we do know or we're thinking that there's something going on in the brain. And I think most of us would agree that, yeah, there is something going on in the brain. Now, what's causing that is what we need to figure out. Addiction and mal-health issues are primarily a brain disorder according to this theory. In mental health, neurochemical imbalances cause the mental disorder. In addiction, the brain is disordered causing cravings for behaviors or substances to rebalance or balance the system. So some people use to self-medicate. Some people start using things get out of whack and then they need to keep using in order to feel normal. What's the evidence? Well, serotonin and norepinephrine have both been implicated in the development of depression and anxiety. So inadequate amounts of one or the other has been implicated. So that's strong evidence for disease theory there or biological. Dopamine imbalances are implicated in schizophrenia. That's biological. Dopamine pathway is involved in motivation and reward processes. So we do things that are rewarding. And the prefrontal cortex is implicated in the regulation of behavior. And they've shown through PET scans as well as through autopsy examinations that there are actual structural differences in the brains of people with addictions. Now they can't say that about every person with addiction because they don't do an autopsy on every person with addiction. But we have seen some of that. So we do know that at least in some cases there is a biological component. So two-generational twin and adoption studies have shown some correlation with trends in the type and frequency of addiction and mood disorders. Now the interesting thing to remember, the difference between correlation and causation, it's like getting a nail in your tire, that's going to cause your tire to go flat. Now driving through a construction site, that's not going to cause your tire to go flat unless you drive over a nail. So there's a correlation between how frequently you drive through construction sites and how often you get flat tires. But you can't say that the construction site caused your flat tire. You may have gotten the nail in your tire when you were at Publix. So you can't say the construction site did it. It was the nail. So what we want to look at is what is causing this situation. So what else besides genes might cause mental health or addictive issues? And you're probably already listing off like 16 things right now. Adoption studies have shown that children from addicted parents are more likely to develop addictions even if they're adopted. So that supports the genetic predisposition. But just because you're predisposed to something doesn't mean it's going to happen. Twin studies have shown that in identical twins, if one develops an addiction, the other is more likely to develop an addiction than if the children had been fraternal twins. If they're identical, they're more likely to develop both develop addictions. So, you know, if you want to read the research, there's the link to it. Addiction and mental health issues are a disease with symptoms and are incurable and progressive according to this theory. So that always gives me pause, but that's my personal bias. I don't like the thought of incurable and progressive, but the strengths of this model, it provides the hope of being treatable if it's viewed as a disease. We think diseases doctors can fix it. It often removes societal stigma because it gives people a reason for why they're depressed, why they're anxious if they have this mental health disease or this addictive disease. And it can relieve feelings of guilt and shame. If the stigma is gone, they can say, you know what, I'm built differently. You know, I was, I'm a little bit broken right now, and I'm trying to get rebalanced. The limitations, it fails to account for social or environmental influences or higher order cognitive processes. So when we're looking at those twin studies, it doesn't say, you know, let's look at the environment and see in the ones that when you have twins and they didn't actually both develop addictions. What was the difference in the environment or what caused one to become addicted and the other one not. So it doesn't account for any of that. It just says it's a brain disease. Most of the research for this theory has been done in non human species. Because you can't, we can't monitor most of the stuff in the brains of humans right yet. So a lot of it's been done in mice and rats. It removes much of the responsibility from the individual. So they can say, I've got a disease piece out, you know, just if medication doesn't work, then I am going to have this disability. And that's, that's it. Which can also leave people to feel disempowered, which I don't like that thought provides hope for recovery in a pill with the biological theory. We're saying that, you know, something's wrong with the functioning of your body. It's a disease. We tend to think that there's some medication to fix every disease. It can provide excuses for relapse or to avoid treatment. People will fall back into old ways of thinking or doing and not take responsibility for living a different lifestyle, living a recovery lifestyle. It assumes recovery upon the achievement of abstinence when we're talking about substances. And it's also important to recognize that there are no consistently useful pharmacological interventions, SSRIs or medication assisted therapy that have emerged that work for the majority of people, let alone every person. They don't work for the majority. There are a couple of nicotine replacement drugs that do seem to have greater efficacy, but that's it. So we're still really shooting in the dark with a lot of these. So biological disease theory really doesn't hold a lot of water for predictive validity. Implications for prevention and treatment. It recognizes that changes within the brain are present in the majority of persons with symptoms of addictions or mental health issues. Clients can address those biological issues through pharmacological interventions and nutritional and health interventions to rebalance or restore functioning within the brain. So pretty much we're left to fixing the body. It's not addressing the brain. It's not addressing other things. And support groups are also usually implemented to help the person deal with the disease that they have. The moral model. Addiction and mood disorders are caused by a lack of willpower and moral degradation. So gluttony, sloth, all of those, you know, seven deadly sins, think about it. Depression. People are lazy and won't get out of bed and just don't have the motivation to shake it off and do the next right thing, according to this model. Addiction. People engage in overly pleasurable activities, their gluttoness, and they don't have the desire to do all the hard work to find recovery. And it's not just gluttony and sloth. Those are just the two easy ones to hit on. According to this model, if you have willpower, motivation and determination to live by spiritual and moral principles, you will find recovery. That's sufficient. Addiction. You don't need to change your environment. You know, you just need to pull yourself up by your bootstraps. The strengths. It emphasizes personal responsibility for choices and recovery. So, I mean, we do require our clients to really have some motivation and determination to live by a treatment plan. Now, spiritual and moral principles, you know, maybe that's part of it, maybe not. There is a certain amount of personal responsibility that clients do have to take in their own recovery. The limitations. This doesn't account for biological, environmental or social factors that are contributing to the person's emotional and physical state right now. So, you know, it's not always a matter of choice. It's not that somebody wakes up in the morning goes, you know what, I want to screw up my life today. Or I think I don't want to get out of bed, you know, so I can get fired. People don't do that for the most part, unless there is some other overarching reason. So, we want to look at, you know, what's causing it. Treatment implications in the moral model are pretty straightforward. Clarify your values, what's important to you, and use cognitive therapeutic interventions to figure out how to make the right and moral choice. Very thought oriented. Behavioral theory says that addictions and mental health issues are learned. Through direct experience, you do something, it gets rewarded, you're going to do it again. So, if you're depressed and you stay in bed and people are, you know, calling to check on you and you get a lot of attention and you get out of having to do things you don't want to do. Well, that might be rewarding. So, you might choose to do it again. If you use substances, that's probably rewarding. So, you may choose to do that again if it helps the distress go away. Social learning, if you remember back to Psych 101, is seeing others experience benefits from having this condition or doing this behavior. And vicarious learning is also, you know, seeing what other people are doing. Social learning also can apply to peer pressure. If your friends are doing it, then you're going to want to do it too. So, types of ways it's reinforcing and creating this behavior. It can reinforce negative thinking styles, anxiety, depression, anger, resentment. It can reinforce helpless behavior, you know, so the person is getting a lot of assistance. It can force pleasurable or escape behaviors, especially when pleasure is lacking. So, if somebody engages in something, whether it's substances or gambling or porn, and it produces an escape and some pleasure, that's reinforcing. It gives them a break. Lack of effective responses to deal with stressors can also contribute to the development of these behaviors. If you don't have any appropriate responses in your repertoire, then you might choose ones that are less than helpful. And lack of reinforcers in the environment to do the things that are recovery oriented or, you know, that would make you happy. So, we want to look at what's maintaining this behavior and for whatever it is, however you define recovery or happiness, what are the benefits to that? What are the rewards? In this theory, learning is influenced by biology. So, what's rewarding and punishing to that individual? They're cognitions and as, you know, a pseudo-behaviorist, it kind of made me go, ugh, because behaviorists only believe in what's observable. Cognitive behaviorists do think about, you know, how your thoughts are impacting. If you're having positive thoughts about something, it's going to be rewarding. Past learning, did you do it before and it was good? Probably want to do it again. Situational antecedents. So, what triggers it? You know, maybe you have a fight with your spouse and you get really angry and that triggers a depressive episode. And reinforcement contingencies. So, what is, again, what is maintaining the symptoms, the dysphoric behavior, the symptoms of depression, the inability to get out of bed, the crying? We want to look at, you know, is there something maintaining it? And, you know, I find myself thinking with these that, you know, a lot of times there's, you're kind of left going, I don't know. I can't see what's maintaining some of this behavior, especially with the mood disorders. So, we want to continue to expand our focus a little bit, recognizing that learning does play a big factor, but it's not the only factor. The strengths of this theory are that behaviors are easily observed. So, if the person's crying all day or crying six hours out of the day, we can observe that and see incremental changes. We can see triggers for, identify and monitor triggers for it. We can help clients increase awareness of triggers and antecedents for their behaviors. What things happen that tend to prompt an anxiety reaction? My daughter's dog came up the other morning and she was kind of hunched over and she's an old dog. So, of course, I freaked out right away because if this dog passes away or when this dog passes away, my daughter is going to be devastated. And she's kind of hunching over and my past experience when animals do that is kidney failure. So, of course, that's where my brain went and I had this like instant panic reaction. And then I reined it in, but it's important to understand that that was a trigger for an anxiety reaction. I'd like freaked out. I was like, okay, what do I need to do with this dog? Helping clients become aware of their triggers. What triggers their anxiety is helpful. Treatment goals are easily defined for changing the behavior by modifying the triggers or consequences for the behavior. So, you know, if there are positive consequences to a behavior you don't want, you got to remove those. Think about anti-abuse with alcohol. When people drink and if they're on anti-abuse, they get violently ill. So that removes the benefit. Limitations of behavioral theory. It may not encourage the involvement of the family and the larger social system because we're just looking at the person right there. Reinforcement contingencies or pressures implemented by the family to maintain current behaviors are not directly addressed. A lot of times the family, you know, if you think family systems indirectly contributes to the maintenance of certain behaviors. So, you know, if they're constantly waiting on John hand and foot when John's depressed. Well, if they're continuing to do that, then what motivation does he have? When my son was little, he was like 20 months old and he still wasn't speaking in full sentences and I was freaked out. And I told the pediatrician and he looks at me and this man had like eight kids and he's like, is he getting his needs met? He said, of course. And then he just looked back at me said, well, he has no reason to speak. When he has a reason to speak, he will speak. And so looking at, I was giving him, I was allowing him to communicate through verb nonverbal interactions and stuff. He didn't have a reason as soon as he started preschool. He hasn't shut up since. The rewards that are encouraged and behavioral theory need to be in non-destructive. But unfortunately, often they have the, they don't have the reinforcement strength of the addictive behavior. So when we're talking about addictions, having somebody go to a meeting to a 12 step meeting just pales in comparison to doing a line of cocaine. You know, let's just be frank, there is a very different qualitative response. So we have to encourage them to expand how they define reinforcing and look towards the larger goals instead of just the immediate relief. Treatment and prevention implications. In behavioral theory, we enhance triggers and reinforcement frequency for positive behaviors. So getting out of bed, taking a shower, not using, using distress tolerance skills when someone gets stressed out, increasing those identify and reduce reinforcing properties of undesired behaviors. So when you get depressed and you don't want to get out of bed, remove the reinforcing properties. You know, get out of bed and or maybe, you know, if you're in a dark room, turn on bright lights because it's really hard to sleep with bright lights. Make it a little bit more unpleasant to continue that behavior and reduce the punishing properties of new behaviors. If somebody doesn't like the alternative that you gave them, they're not likely to continue to do it for very long. So make sure that what you're offering them is all as an alternative is rewarding. And, you know, if it has some downsides to it, which most alternatives will make it as unpunishing as possible. So getting out of bed for somebody who's clinically depressed is really freaking hard sometimes. We know that it's probably a good step in the right direction. So we want to make sure that they have something when they get out of bed, what are they going to do that's reinforcing instead of just getting out of bed and going like, okay, I'm up. And for me, I hate making my bed. So getting out of bed and going, oh crap, now I got to make the stupid thing. Not rewarding. So helping people remove any of the negative aspects of the new behaviors. Sociocultural theories, environmental and social pressures contribute to the development of addiction and mental health issues, including unemployment, single parenting, poverty, the attitudes of family, peers and society. You know, if you live in an environment that is kind of wrought with stress and distress, are you probably going to be happy as a clam? Probably not. I don't know why clams are happy. I don't know where that's saying came from, but whatever I digress. If you're an environment that is hopeful and positive and less stressful, I don't think any environment stress free, you're probably going to feel differently and react differently. So we want to look at the larger culture and what sort of factors are impending or are looming on this person that might be contributing to their dysphoria or to their choice of behaviors. It can also be something that, you know, everybody's doing it. I had one client who bless her heart. She was not able to drive herself. She had schizophrenia and couldn't drive, never learned to drive. And she lived in a not so great neighborhood, section of town where we were at. And I remember her one day, I was asking her what was keeping her, she kept relaxing and what was continuing to keep her relaxing. She said, Miss Dawn, they just come to my door like the Avon lady selling crack. I don't know what to do. And I'm like, okay, well, that's something definitely doable if somebody, because not only did she not have the social skills to say no, and you know the boundaries and all that kind of stuff. But they were just like constantly there because they knew she would purchase from her from them. Environment can predispose people to dysphoria or addiction because it creates emotional stress. People may just not have education about coping skills. You know, we don't, we're not born with them. So if you don't learn them growing up, you may not ever develop them. So if you're in an impoverished environment, mom and dad don't have any coping skills. Neighbors don't have any coping skills. You don't learn coping skills. Physically, poor nutrition, safety and health can all contribute to dysphoria, anxiety and neurochemical imbalances. Socially, peer pressure to use or peer pressure to act or feel a certain way. And we've seen how people get in clicks in high school and stuff, and they can be very negative. It's not necessarily a positive thing. So peer pressure to act or react a certain way can also contribute to people's emotional or behavioral reactions. Observational learning, you know, seeing if if Johnny does this, then he gets a reward. So I guess I'm going to do that. Spiritually, the environment can lead to an absence of hope or love and compassion. So we want to look at the environment and say, you know, if the person doesn't have hope. I mean, that's, wow. Yeah, I can see that's depressing to even think about. And environmentally, there can be advertising that is contributing to emotional distress, advertising where you've got people who are perfect looking, and maybe like a size less than zero can contribute to negative self images of young people who develop eating disorders and notice I didn't say women, the prepon the number of eating disorders in men is just skyrocketing. So advertising, whether it's billboards or in on TV or in magazines and laws, you know, this is more towards substances, but laws that are more permissive of substances, in effectively enforced laws and laws that are more permissive of things like bullying can also contribute to dysphoria. Strengths of this theory, it views issues within the context of the larger environment, it recognizes that we do not operate in a vacuum and acknowledges the impact of social and environmental pressures in the development of mental health and addictive issues. So score for that. But it doesn't pay attention what we'll get there. It largely ignores biological and genetic aspects of mental health and addiction. So it doesn't consistently explain why in similar cultural environments, one person develops issues. Well, another one does not. So if you have two people and they're living in the same neighborhood in the same cultural environment, why is why does one develop depression, the other one doesn't. According to this theory, treatment should involve changing the social environment of the person to improve family functioning and enhance cultural sensitivity, get them into a place where they fit better. Well, that's not real practical. But ideally, this is what we would do. So we would want to look at how can we make a more culturally sensitive and sensitive environment, recognizing that people are probably not going to say, oh, OK, I'll just move. Not going to happen. So what can they do? And unhelpful behaviors need to be replaced with helpful behaviors and triggers for those behaviors. The Enviro-Bio-Psychosocial Model. This is kind of everything in the kitchen sink. And it's the one that's more prominent right now because we've recognized that something from every one of those theories, for the most part, contributes to the development of mental health and addictive issues. Mood and addictive behaviors often result from an interaction of multiple factors. Environmental influences include things that trigger dysphoria, trigger anxiety and depression, or the desire to use. Seeing a billboard for some kind of vodka could trigger somebody to want to use. Even if they're not an addict, even if they're not an alcoholic, they may look at it and go, I really need a drink right now because that's our society kind of programs that in us. When you're stressed out, having a drink will make you feel so much better. Social pressures can also trigger use, you know, drinking, substance use, as well as, you know, dysphoric feelings. And the availability in the case of substances or addictive behaviors, whether it's food or pornography, which is never-ending, and drugs, etc. So how available is it? Since we recognize that a lot of people have access to things that can become addictive, we do want to kind of screen for that when we're doing our initial assessment to see if there are any behaviors that they're using. To cope with the distress right now, you know, the best they can, because they want to survive, got it. They're doing the best they can with the tools they have. But is there anything that, even if it's not problematic right now, might become problematic? We kind of want to keep an eye on it, not that we need to make it necessarily the main treatment issue. Social learning and modeling from peers, family, culture, attitudes, and behavior can also contribute. If a person grows up in an environment that is, you know, parents are clinically depressed or there's a lot of hostility and anger, it has an effect on their emotional state. So there is a lot of influence on that. And which behaviors are rewarded by the social system? Are you rewarded for being happy? Are you rewarded for being motivated and getting out there and taking risks? Or are you rewarded for not? Are you rewarded when you use because you have more people around you and you feel like you're more social after you drink? You know, we want to look at that. Psychological influences. Addictive behavior produces positive feeling states and or numbing in response to dysphoric states. Lack of effective coping skills can lead to mood or addictive disorders. So when people are using substances to cope, you know, that can contribute to the development of addictive disorders. And sometimes motivation to escape can be another reason people use substances or engage in addictive behaviors. It's just too much. They need a break. And like I said at the beginning, just because John goes to play poker with his friends on Friday and to forget all the stress of the week, that doesn't mean he has a gambling addiction. That means he went to play poker. Now, if he does it Friday, Saturday, Sunday, oh, and Monday and Tuesday starts neglecting his sleep and has lost all of his money in his savings account, then we might want to start talking about whether it's a problem. But there are a lot of people who socially gamble, a lot of people who socially drink. So I want to make sure that we differentiate that. Biological influences to the development of any of these problems brain changes, the brain wants to maintain balance homeostasis it gets a certain level and it goes okay I'm going to maintain this. Now for some people that level is down here in depression for other people that level is up here and kind of revved and anxious all the time. And then for other people is at this normal level, but because of any of these factors, it may get out of whack and the brain wants to rebalance itself. But the people who normally have, you know, a setting, if you will their brain is set to be more anxious or their brain is set to be more depressed, because they don't make as much of certain neurotransmitters. Those people theoretically medication might be useful for other things we want to look at genetic predispositions. Is this something that you've kind of grown up with doesn't mean we can fix it just gives us an idea nutritional is your body getting the building blocks it needs. Are you getting enough sleep. Are you managing pain because pain tends to cause higher levels of anxiety and depression. And are there any medication side effects, including vitamins and workout supplements that you're taking that might be contributing to the development of your symptoms. So when we talk about assessing models and theories, I think most of us went through each one of those, even the moral spiritual model, because the fact that it emphasizes personal responsibility, that's what I take out of that model. But the dedication but the rest of it I personally kind of leave behind because I feel like it is far too accusatory and disempowering to people in that way because it's too much finger pointing and shaming. I don't like that, but that's me. We all have our own theories of how things develop, but we do want to really look at how each factor contributes. A lot of times, and you know I'll say even today when I do assessments, but definitely when I first got out of college and I was a new counselor, and I would do assessments, I wouldn't look for substance abuse, I wouldn't look for compulsive use, I wouldn't really evaluate the environment to see what's going on besides in like the nuclear family, what might be going on that's contributing or maintaining this person's mental health status or addictive behaviors. You know so I look and in today's culture, I guess, where we're all online so much. One of the things when I do assessments now is I encourage people to share with me, you know, if they spend a lot of time social networking on Instagram or Pinterest or what's that other one, Snapchat. You know, what is that like? Is it an adversarial thing? Is it a competitive thing? It can get pretty nasty. I mean there are some people who keep it nice and on the positive side. But that all influences people's mood so it's important to look at, you know, your circle of friends, not just the ones that you go to school with or go to work with necessarily, but more globally those people that you interact with on a daily basis. How do they influence your moods, your choice of behaviors, your choice of reactions, and is that helping you move towards what you define as health and recovery. So there are a variety of theories of the development of addiction and mental health issues. Research has indicated that people with addictions just like those with mental health issues have differences in brain structure or the amount or ratio of neurochemicals available. So I think I've made the analogy in here before about a plumbing problem. And when I explain how medications work to my clients, this is kind of how I do it. When somebody's feeling depressed, that means that in that system of the antidepressant chemicals, there's a leak in one of those pipes. So we have the option of starting medication which will increase the amount of happy chemical, the amount of antidepressant chemicals going through that pipe. It's kind of like turning up the water pressure, but the leak is still there. So eventually that leak is probably that crack in the pipe is probably going to grow unless we figure out what's causing it and where it is and patch it up. So when I explain it to my clients that way, they kind of see how if medications work for them, it's likely that it won't be 100% successful on its own. Now I'm not saying it won't be, but I do let them know ahead of time that you don't want to expect you're going to take a pill and tomorrow morning you're going to wake up and feel like a different person. Because we want to rebalance those levels of neurochemicals, but we need to figure out the underlying issue. If there's too much stress in that person's environment and they're just constantly drained and exhausted. Well, no amount of positive thinking and medication is probably going to help them feel better until they eliminate some of those energy drains. So we do want to help people look at what's causing your symptoms. No singular theory has been developed to date, which can reliably explain or predict why some people develop addiction or mental health issues and others do not. Now we can retro retrospectively look and go, yeah, it makes sense why this person developed this issue, but predictively now we're out. Research has indicated that biology environment culture social relationships and cognitions are all involved in the development and maintenance of mental health or addictive issues. It's unknown which factors are causative remember like the nail in the tire and which factors, which things occur as the result of pre existing issues. So, you know, we don't know what causes it we don't know it's correlated to it. You know, we're just still kind of guessing treatment involves assessing the enviro biopsychosocial condition of the individual try saying that six times fast and defining what will help him or her manage the presenting symptoms in a way that's meaningful to him or her. You know what we define or what I define as recovery or happiness is going to be different than than what my clients may. So helping them figure out what is a rich and meaningful life look like to them places you can go to find more information about what do they know about what's causing depression, for example, one article I read when I was doing a class on opiates indicated that actually several articles that they're now experimenting with opiates in the treatment of intractable depression, they found that the dopamine that is secreted when people take opiates does help a proportion of the population who hasn't responded to SSRIs or SNRIs starts helping them feel better. So that helps us understand where the disorder or problems may be coming from but also keep up to date on some of the research. Open access journals are is also a good another good peer review area, the British Medical Journal, National Institute of Mental Health publications. Now you can find research here, but I put these two links in your class because you can find booklets that are already pre prepared that help explain to clients what is depression and what do we think causes it. And then SAMHSA also has a bunch of publications, but they also do a lot of research to try to figure out where is some of the stuff coming from depression anxiety PTSD and co occurring disorders specifically. So you can find great free literature at these last three places that are appropriate for clients and in many cases they are in multiple languages so a lot of them are in in Spanish there are some that are in Korean. Can't remember if I saw Chinese in there. But so if you're working with a culturally diverse population you can potentially find stuff that's pre printed and you can order them for free they're beautiful glossy little things so save your organization a lot of money. And now the National Library of Medicine. And I'm just going to walk you through this really quick. You go to this website and I googled causes of depression. Then I can look at article attributes I don't really care publication date within the last five years. And then show additional filters. Article attributes open access open access means it's free so you don't have to have a subscription or pay $50 to read an article. So go through and look at any articles that you want you can print them out download them. So this one looks at the role of social cognition on major depressive disorder. If you're like me and this is how you spend your free time. It's a really cool site because you can find a lot of information that can help some clients that seem to not be responding with what we typically our first line of suggestions and treatments. Your open access journals. So we can look for depression. And these are all open access so they're the articles are free. Now obviously I didn't narrow it enough but there are seven journals that it came up with. So if you want to go peruse those journals you can obviously that one's not in English. The nice thing with this one again you can narrow it down by subject and publisher if you really want to full text language to make sure it's in English and the date added so you can make sure it's less than five years old or whatever. We'll go to National Institute of Mental Health Publications. You can browse by disorder down here or browse by type booklets brochures fact sheets posters these are all free your tax dollars have already paid for them. We'll just go to anxiety disorders. Now of course this one is not in multiple languages but a lot of if your agency is accredited by car for Jacob. They often require that you have informational pamphlets available to your patients. Again this is a really easy way to get it for free and save your organization some money. And the last one we'll look at really quick is SAMHSA go to publications. So all of these have an aversion that is written for Spanish speakers. So you can order those and have them available. You can also print them out if you want to. But like I said if you order them they come in these pretty little glossy professionally printed things. Alrighty well thank you for being here today I appreciate it if you want to stick around for the discussion and application of the case studies to kind of see how these models fit great. And if you are ready to go and get on with your day that is awesome to and I will see you on Tuesday today's Thursday. Alrighty everybody. 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