 I do want to welcome you to today's presentation on Strengths-Based Biopsychosocial Approach to the Recovery from Depression. Over the next hour, we're going to define depression symptoms. We're going to learn how to ask strengths-based assessment questions. A lot of times, at least in my initial training, we asked a lot of problem-focused questions. What are you lacking? What are you missing? What are the problems instead of what are you doing right now that's helping you feel better? So we're going to look at diagnoses and symptoms from sort of a functional perspective. What is this symptom doing for the person? How can we help them achieve that same end in a healthier way? And when they've had problems in the past, what has worked to address it so we can build upon those instead of trying to reinvent the wheel? Well, identify a range of potential causes for depression. It's not just about serotonin. And we'll explore activities and interventions that can help people address some of the underlying causes. There are so many different causes for the symptoms of depression, fatigue, irritability, poor concentration, lack of pleasure. I can go on and list all those symptoms. There's no way I could possibly cover them all in an hour or even 10 hours. What I want you to do is sort of get outside of the box, get outside of our little mental health area and say, OK, what else might be causing this that we could potentially rule out? I mentioned before that there are a lot of issues with thyroid hormones, estrogen, testosterone that may contribute to depressive symptoms. So we want to look at some of the physiological causes as well as the mental health causes and the cognitive issues. Depression represents a cluster of symptoms. It's not just one. It's not just feeling blue. We're not going to diagnose somebody with clinical depression if they say, I just don't enjoy anything anymore. Now, if they're coming to us and they say that, then we're going to probably explore and say, tell me what that looks like for you or what are some of your other symptoms? We don't want people to hone in on the fact that not enjoying stuff or being bored with stuff is exclusively the criteria for depression. But diagnosis does require people to have a few symptoms. A variety of different things can cause these. Emotions like anger, anxiety, grief, guilt and shame, these are intense negative emotions that are draining. They're probably going to negatively impact sleep. They're going to make it hard to want to hang out with people. They're going to make it hard to really find a lot of pleasure if you're constantly feeling this anger or you're stressed out all the time. Life is not nearly as fun if you have all that negativity going on. Cognitive distortions, just the way you think about stuff. If you see the glass as half empty all the time. If you focus on, it's all about me. If you use extreme language, always, never. There are a lot of cognitive distortions that can make life seem a whole lot more unmanageable which can emphasize the helplessness and hopelessness. Relationships, poor self-esteem. If you don't feel good about you and you're looking out and trying to find other people to tell you you're okay, that's exhausting and if you can't find those people then you don't feel okay and if you don't feel okay, then it's depressing. Unhealthy unsupportive relationships. Some relationships are really awesome and some relationships will suck the life out of you. Having people evaluate the quality and purpose of relationships. Sometimes relationships, maybe your relationship with your biological family is not healthy or supportive but you're not wanting to break ties with them and I totally get that. So we need to look at how to handle those unhealthy unsuited relationships so they don't drain your energy. And we already talked about the need for external validation, misspelled that. Physical, neurochemical imbalances. Basically when we talk about mood disorders, when we talk about motivation, even when we talk about happiness, what we're talking about is neurochemicals because our brain is sort of the main computer, the CPU, and it's sending out all the signals and balancing all the hormones that say this is a stressful situation. You need to fight or flee. This is an awesome situation. I'm going to secrete a bunch of dopamine so you do this again. When the neurochemicals get out of whack, then those messages can't be sent. When those messages get confused, then the mood, the motivation gets wonky and like I said, it's responsible for happiness as well as sadness and anger, concentration, memory, all that stuff. And environmentally, go back to physical, poor nutrition, I said it earlier, I'll say it again. We need to have the building blocks to make the neurochemicals so we need to have decent nutrition. Now, not everybody is going to eat from every food group, but we do need to make sure that people are taking a look at what they're eating. If all they're eating is Cheetos and diet soda, my guess is they're probably not going to feel too good because their brain just can't even function without the amino acids that it needs. Exhaustion. Now, we can get exhausted or we can feel exhausted because of depression when our neurochemicals get kind of wonky, but we can also feel exhausted when hormone levels get out of balance, hypothyroid, when you've been burning the candle at both ends for way too long, when you've got something going on in your life, new baby, guess what? You're not going to sleep unless you have a au pair or a nanny. You're probably not going to sleep really well for the next 15, 16 years. Understanding that and understanding what role exhaustion plays in your feeling depressed and what role depression plays in your exhaustion is important. Exhaustion is not just related to sleep though. Exhaustion can be related to overtraining and we'll talk a little bit about adrenal fatigue in this presentation. I'm going to be doing another one in a few weeks on adrenal fatigue because it is important for people that you work with who are athletes who do train a lot and I'm not talking necessarily about marathon runners or people who are what you would call gym rats. Some people have, you know, exceed their level of training and they over train which starts causing exhaustion. We also have people who especially ones with a history of PTSD who may have a dysfunctional adrenal system. So we're going to talk about that a little bit in this presentation. And then medication side effects. Medication can make you feel depressed, guess what? If you are taking the wrong psychotropic for whatever your chemical imbalances that can contribute to it, if you're not taking enough of a psychotropic for whatever your imbalances that may contribute to it, but also depressants like opiates and sedatives, anti-anxiety medications can also contribute to sort of a lethargic depressive feeling in some people. It's important that we understand what these side effects look like for different people. And then environmentally, high stress environments that prevent relaxation and rest are going to contribute to depression. You know, I'm thinking about certain places that I've worked that have just been extremely exhausting, that you were just constantly on edge, you were constantly going and you couldn't leave it at work. It would follow you home. And this high stress environment, this inability to take a breath, that's inability to relax for any period of time can increase a sense of hopelessness and helplessness. It's like, I just can't even get away from it until finally you just start to shut down and you're like, well, I can't do anymore. Think about the experiment that we learned in psychology 101, the dog that, and horrible experiment, they would put a shock underneath the floor and he would jump over and he would escape the shock. And then they started electrifying both sides. So no matter which side he jumped to, he couldn't escape from the shock. So eventually he just laid down and took the shock, you know, that learned helplessness. Now again, that's a horrible, horrible, horrible experiment. But it does illustrate a point. Think about people who when they're at home, it's a high stress environment. When they go to work, it's a high stress environment. When they come back home, not only is it a high stress environment, but they're getting emails and texts from work. They can't get a break. So eventually they're just going to lay down and go screw it. You know, let the phone ring. I can't handle it. I don't have the energy anymore. So when we're assessing people for depression, you know, somebody comes into my office and they say, Dr. Snipes, I'm depressed. OK, tell me what that means to you because depression has so many different symptoms and so many different presentations that that doesn't give me a whole lot to go on. So does it mean you just don't care about anything anymore? You're just like, you know, think Eeyore from Winnie the Pooh. Or that you're sad all the time. Maybe you're crying. You can't stop crying. Or you're having mood swings. Or you can't get out of bed. Or on the other side, you can't get to sleep. Tell me what makes you think you're depressed? Now, little caveat there. Most people, if they're not sleeping, if they've got insomnia, aren't going to present that as a symptom of depression because they think of depression as sleeping all the time. So I'll often sort of throw that out there when we're talking about sleeping. And I'll say, are you sleeping too much? Or are you just not able to get to sleep? One of the things that they found is people who have the poorest prognosis for recovery and the highest risk of suicidal ideation are people who end up, they go to sleep, but then they can't sleep through the night. They wake up and they can't get back to sleep. So that's just kind of a little interesting tidbit when you're assessing your clients to listen for. And then I ask them, which symptoms are most bothersome for you and why? Because where sleeping, it's huge for me. You know I love to sleep. For other people, it may be the fact they don't have the energy to go to the gym. Or they just don't have any pleasure. That means that they don't really care about hanging out with their kids and going to soccer games and that makes them feel guilty. Okay, whatever the symptoms are that are most bothersome for you, let's talk about what makes it worse and what makes it better. On these days where you felt kind of bleh and you've had to go to your kid's soccer game and you really wanna be there to support your kid, how have you motivated yourself to get there and get through it? What's made it better? So you could kind of summon the energy. And we also talk about again what makes it worse. So in these situations, are there things that have happened that have made it harder for you to get up off the couch, get out of bed, whatever the symptoms are. How is life more pleasurable prior to getting depressed? Depression doesn't, especially clinical depression, doesn't last forever, it's episodic. So when you're not in a depressive episode, what's different? What made life more pleasurable? What did you enjoy doing? And you may have to ask it two or three different ways because we all have our own idiosyncratic ways of expressing things. But I wanna know what they enjoyed doing and what they were doing that was different when they weren't depressed. Maybe they were eating more healthfully and going to the gym. Okay, so we're gonna talk about how do you think that contributed to your happiness? We wanna highlight the exceptions and this is a brief therapy intervention. Look at the times when the person's not feeling depressed. Even when we diagnose clinical depression, we say lack of interest or apathy most days, most of the time, not all the time every single day because there may be some little thing in there that you have a glimmer of hope. And it's that glimmer of hope that keeps people going. So I wanna focus on that glimmer of hope and I say, what was going on when you laughed last week? What is it that makes you happy? Right now it's hard to feel happy. So it's gonna take a lot, but if there was something that could make you happy, what would it be? And then how do you expect life to be different when your depression's gone? I wanna know what their expectations are for treatment because that's gonna help shape our ultimate goals. Maybe they're gonna be sleeping more. They're going to enjoy going to their kids soccer games. We're going to explore why each of those things is not where they want it to be right now and what they think they need to do to get it there. This is that strengths-based. What are they already doing? So neurotransmitters that have run amok, they affect your ability to feel pleasure and can lead to apathy or emotional flatness. Problems with memory, difficulty concentrating, sleep issues, lack of motivation, fatigue, pain, irritability, agitation, fight or flight, stress symptoms. Okay, so going back to the beginning. Ability to feel pleasure, apathy and emotional flatness. This could be serotonin. This could be dopamine. This could be norepinephrine. So we can't just automatically say, and the research is really starting to bear this out, that it's not always about insufficient serotonin. Sometimes it's something completely over in left field, but other times it's a different neurochemical like norepinephrine, which is an excitatory neurotransmitter that gets you motivated. It gets rid of that apathy and that emotional flatness. And the norepinephrine with dopamine says, I'm motivated and I'm enjoying it. We need to look at these different scenarios. Now, most of my clients and probably most of yours aren't gonna be real concerned about the different neurotransmitters. And if they are, I have handouts galore for them. Most of them don't care. They're just like, Doc, I wanna feel better. Okay, let's work on that. Memory issues and difficulty concentrating can come with sleep issues. Lack of motivation also can come with sleep issues. And all of these things can cause sleep issues. So chicken or the egg, it doesn't really matter. If you're having sleep issues and you're having these other symptoms, then there's a good chance if we can address the sleep issues, the memory issues, the concentration and the motivation and fatigue will probably improve somewhat. Now, I'm not saying it's a magic bullet. It's not gonna do everything. However, it's a good place to start because addressing sleep issues is probably one of the more easy interventions. Lack of motivation. Well, let's go back up to difficulty concentrating and memory. If you're having memory issues, don't test your memory. Write it down. When I had young children at home, I couldn't walk from one room to the next and remember what I was doing. I had notes written on my hand all the time. No, I wouldn't even get a piece of paper. They were written on my hand. If I was in the car sometimes, it would be written on my leg. But good thing for long skirts. Anyhow, memory issues come with a lot of different things. If you've got stress going on, if you're type A personality, if you're sleep deprived, if you're depressed, address it instead of going, well, I can't remember anything and getting frustrated about it. Figure out how to address it, fix it. You know, at least put a stop gap in place. It helps people feel more empowered. They're like, okay, I'm writing things down so I'm not forgetting things all the time. Difficulty concentrating. Yeah, sometimes it's difficult. Writing things down helps because it gets it out where you can see it and you can organize it. Also eliminating distractions. Some days when I've just got my super focus on, I can be in the middle of the dining room and have everything going on around me at the house and still write. Other days, I need to be in complete silence because it's all I can do to focus on what I've got going on right in front of me. Everybody's like that. We all have periods during the day where it's easier to concentrate but we also have days where we're just not focused. My daughter calls it her jujubes and when she writes, she'll tell me that her jujubes are going really good and on days that she's got writer's block, she's like, nope, the jujubes are on strike and I'm like, okay, let's try to figure out a way around it. So what can we do to help you concentrate? Sometimes helping people be kind to themselves is the best option. Sometimes they're just not going to be able to concentrate that day. Maybe they got horrible news the day before and their mind is somewhere else. Well, they're not going to concentrate today. So let's figure out what they can do. What else do they need to do that doesn't require that level of concentration? Encouraging people to be kind and be flexible with themselves because beating your head into the wall is not going to do any good. Sleep issues, want to address those. Create a sleep routine, reduce caffeine. Lack of motivation. I don't care about doing anything anymore. When you did care about it, what was different? Going back to that strength-based, when you enjoyed going to the gym, what was different? What helped get you motivated to go there? When you enjoyed going to your kids' games, what was different? How can you kind of recreate that? How can you increase your motivation again? What would make it enjoyable going with a friend? I know when I go to my kids' Taekwondo belt testing and everything, it's definitely more fun if I'm there with other parents who have kids that are also going through the same thing and we can share stuff and it just makes the time pass faster because there's only so long that you can watch them break boards before, you know? It's a little monotonous. So asking them, what is it that helps increase your motivation? What do you think would make it more fun, more enjoyable? Fatigue. How do we address fatigue? Well, helping people understand that our energy levels fluctuate throughout the day. Most people have a lull sometime mid-morning and a lull sometime mid-afternoon and that's normal. Most of us just super caffeinate during those periods, not that it's the best thing. If you are not sleeping well at night, that morning lull and that evening lull are going to be intensified tenfold. So it's going to feel a lot more exhausting, all the more reason to get good sleep at night so you can get through those energy. But also, arranging your day around your own rhythms. I know for me, I'm most energetic in the morning. So from 5.30, 6.00 a.m. until 1.30, I am grand, I am great. After 1.30, I can teach, I love teaching, I can write, but the thought of going to the gym or doing something that is super active just doesn't appeal to me. So I know that if I'm going to go to the gym, it needs to be first thing in the morning. Those are things that you need to look at when you're looking at motivation but also at looking at, if somebody's complaining about fatigue, maybe they're just trying to fight their normal rhythms. And then we've talked about addressing pain. Pain makes it harder to feel happy. I mean, if you're in pain, it's hard to go, woohoo, I want to go do this. It's more like, I want the pain to go away. Pain makes it hard to sleep. It tends to make people irritable. So there's a lot of stuff that goes with it that can make life a little bit harder. We also know that serotonin is involved in our pain perception. So people with low serotonin tend to feel more pain. Interesting concept. Irritability and agitation. Well, your calming chemicals, your GABA and your serotonin, if they're out of whack, then you may feel irritable and agitated. Too much serotonin can make you irritable and agitated. Too much norepinephrine can also do that. We don't want to just start and there is still no way to accurately measure the levels of neurotransmitters in the brain because they're throughout the body. So part of it is kind of ruling out and figuring out what makes people feel better or worse. And fight or flight stress symptoms. These are hormones. They're excreting cortisol, adrenaline, saying it's time to get up and go, which means norepinephrine is going out there and you are preparing for the fight or flee. When those are going up, that means your stress level's going up. You're getting ready to defend yourself. That's counterproductive to relaxation. So again, thinking of that poor dog again, if your body is constantly in this fight or flight situation, eventually you're just gonna run out of energy and you're just gonna lay down and go, let it be what it's gonna be. We need to remember that the body needs a break. In order to keep everything in balance, the body needs a break. If there's constantly stress signals coming in, you can't relax. So we need to help people figure out how to turn those stress signals off. Not just teach them to relax, because if they're trying to relax, but they can't turn the stress signals off, it doesn't work. So guess quality sleep, create a routine. Two hours before bed. You know, lucky you, I just finished my sleep presentation. Two hours before bed. Start reducing the amount of blue toned lights. These are your daylight spectrum bulbs, the ones that tend to be a little bit harsh for cameras, your fluorescent lights, and also the lights that are on your iPads and your, any of your electronics tend to be a blue light. Those inhibit melatonin excretion. You need melatonin to start winding down. So two hours before bed, if you can, stop eating so your body's not trying to stay awake to digest food, but also so you don't have to get up in the middle of the night. Get rid of the blue lights. You know, turn it down, start winding down the lights as low as you can get them so you can, you know, focus. Use warmer colored light bulbs, your soft white bulbs. If you're gonna read or do something like that. When you go to bed, try to sleep in the darkest room possible. You don't have to go to bed at the same time every night. It's not realistic as adults. That's just not how our society operates. But if you can do kind of the same sort of thing every night, I play words with friends every night. And now my body's to the point, if I start playing that, it's like, oh, it's sleep time. So I try not to play words with friends in the middle of the day or I get sleepy. Anywho, your body is aware of certain cues that say it's time to start winding down. Address pain and apnea. Pain keeps you from getting comfortable. If you are not comfortable, you are not gonna sleep well. Physical therapy, you know, anything you can do to address pain is awesome. Using opiates as a last resort because those also kind of monkey with your sleep and your sleep quality. And then sleep apnea, if you have it, it's going to wake you up in the middle of the night and prevent you from getting good sleep. So it's important to be assessed for it if you think that that might be an issue. And if a housemate has told you that you snore, it might be worth, you know, getting assessed for it. Improve your sleep environment. Keep it as quiet as possible. Or if you can't keep it quiet, maybe you live in an apartment, try white noise or earplugs. Try to keep it smelling okay. Try to keep allergens out of the room. And I break this one all the time. You shouldn't have your dogs or cats in the bed with you. You know, three o'clock in the morning, my cat woke me up this morning, not because he was hungry. He just wanted pets. And I was just like really Milo, go away. But you should try to remove as many things that are going to wake you up as possible. Factors like shift work. Shift work really messes with your circadian rhythms. If you work shift work, if you can get to bed before it starts to get light, that helps a lot. And then when you're at work, stay in as brightly lit of an area as possible. Switching time zones. You know, I said your body has natural peaks and valleys during the day. Well, it's gonna have those peaks and valleys that it had on, you know, eastern time zone. And then if you fly out to California, you've still got those same peaks and valleys. So you're gonna be awake at all the wrong times. The cool thing is because a lot of our circadian rhythms are set by light levels, after a week or so, people's bodies tend to start catching up. Which is also why we start to feel a little bit better when time changes. After about a week or so, is it even just a change of an hour can really impact everything? Relaxation, biofeedback, helping people learn how to slow their heart rate, slow their breathing, relax their muscles. Goes a long way to reducing cortisol levels, freeing up energy, because if you're not maintaining muscle contractions, then you've got all that energy to do something else with. And people sleep better when they're not all tense. And then address medication side effects. Psychotropics have side effects. They can make you anxious, they can make you nauseous, they can give you headaches. They may also address all of those things. So I'm not saying they're bad for everybody. I'm just saying if you are having negative side effects from any medication, talk about it with your doctor. And then improve your nutrition. I'm not gonna belabor that point anymore today. Address addictive behaviors. Addictive behaviors are interesting because when we engage in them, they cause a pleasure rush for, we'll just call it that right now, a really rewarding rush of dopamine and some of your other pleasure chemicals. Well, over time, the body adjusts to that and it says I can't deal with this flood. So it shuts some of the floodgates to protect itself from too much dopamine going out. So then normal stuff, stuff that would normally make you feel happy and okay, doesn't do it for you anymore. And you start feeling flat and apathetic because you need more dopamine coming in because so many of the floodgates have been shut. We need to address the addictive behaviors. You need to rebalance that dopamine system. It takes time. And I'm not talking about a week. I'm more talking like three to six months or maybe even a year for some people who've been engaging in this for a while. Address chronic or extreme stress. Chronic and extreme stress both increase the amount of neurotransmitters flooding the synapses. So the brain shuts down some of the receptors just like with addiction. So the body doesn't overload. So if you're in a constant state of stress, your body's gonna say, we gotta shut down some of this because we've got to relax at some point. Think about your body's going, there's just not any stress out there. La, la, la, la, la, la, la, la. It can't deal with it anymore. So then the person is just exhausted. Not enough neurotransmitters are getting sent in there to get you motivated anymore because the brain has protected itself and it shut down some of the floodgates. So now you're not, you're kind of apathetic. You're like, whatever, you know, I just don't care. As the brain recovers, motivation will go back up. So motivation and pleasure are both attenuated when they're exposed to extreme levels of stress or pleasure. So we need to make sure people understand that too much of anything is bad. Hormones, the thyroid impacts mood, libido and energy levels. So people with hyper or hypothyroid may have depression, anxiety, poor libido, low energy levels. Estrogen boosts neurotransmitters that affects sleep, mood, memory, libido, pain perception, learning and attention span. So estrogen's kind of important no matter how much we want to hate it. One of the things that estrogen really increases a lot is serotonin. Increased estrogen may increase the availability of serotonin. Some people when they go, women obviously, when they go into menopause, if they start to experience depressive symptoms, the first line is, oh, hey, let's give you an extra estrogen supplement. That's not always what's gonna work. Sometimes if they start taking hormone supplements, the anxiety gets a whole lot worse because they already had too much estrogen. It was a different neurochemical that was out of whack. So we need to pay attention to what the patient's reaction is to different interventions and different cycles in their own body, their own rhythms. Low testosterone may be implicated in reducing the availability of serotonin. So increased estrogen and increased testosterone can both of those can increase serotonin availability. Reduced estrogen, reduced testosterone can also reduce serotonin availability. They've really looked at serotonin a whole lot more than most of the other neurochemicals like norepinephrine, which is why I refer to those all the time. But it is important to understand the interaction between other hormone hormones and neurochemicals. Testosterone is manufactured by the adrenal glands. It enhances libido, improves stamina, and sleep. So estrogen improves sleep, testosterone improves sleep, insists in brain function, both estrogen and testosterone, and is associated with assertive behavior and a sense of well-being. We want these chemicals to be in balance, or to be in balance, I-N. Cortisol is also made by the adrenal glands and helps the body adapt to stress by increasing heart rate, respiration, and blood pressure. This is your long-haul fight-or-flight chemical. This is what tends to be a lot higher in people who don't sleep, or don't sleep enough, or don't have good sleep, and who are under a lot of stress. This is the hormone that also negatively impacts kind of the way we look, if you will. High cortisol levels contribute to more rapid aging. Cortisol levels increase early in the morning. It says, hey, get up, we got a day to prepare for, and gradually decrease throughout the day as part of your circadian rhythms. Now, again, if you're under constant stress, and you're bringing that stress home, and you're still checking your email 15 minutes before you go to bed, that cortisol is not going away. And if that cortisol doesn't go down, then you're not going to get the restful sleep that you need. DHAA can also increase libido and sexual arousal, improve motivation, and engenders the sense of well-being. Decreases pain, facilitates rapid eye movement sleep, enhances memory, and enhances the immune system. So all of these are chemicals within your body, hormones within your body that are responsible in some way for affecting your mood. So we're not just talking about what we think of as your brain chemicals, your serotonin levels, and your norepinephrine levels. We're talking about a lot of stuff, and it all operates in synchrony in order to help you feel calm, cool, and collected, but also respond to stressors when they present. Have clients get a physical to identify and address what may be causing any imbalances. This is the first step in a real good assessment of clients to find out if there's anything physical going on. Encourage them to eat a low glycemic diet. If they're having blood sugar spikes and crashes, it's going to not only impact their mood, but it's probably gonna contribute to fatigue. And it is important to understand that the less sleep you get, the higher the cortisol will be. The more sleep you get, the lower your cortisol will be. So if you want to feel refreshed and rejuvenated, and you wanna fight the aging process as an extra bonus, we wanna make sure we're getting good sleep, and we're trying to reduce our cortisol and stress levels as much as possible. Final thoughts, hormonal imbalances affect millions of people. Symptoms include anxiousness, irritability, weight changes, not sleeping well, and noticing changes in your sex drive, focus, and appetite. Hello, those are also symptoms of depression. Causeful hormonal imbalances include poor gut health, inflammation, high amounts of stress, genetic susceptibility, and toxicity, among other things. Which is why differential diagnosis is so important. Are we dealing with estrogen imbalances or are we dealing with serotonin imbalances or what do we need to do to tweak the system so it works better for this particular individual? Natural treatments for hormone imbalances may include eating an anti-inflammatory diet, consuming enough omega-3s, getting good sleep, exercising, and controlling stress. Exercise helps burn off and reduce some of those cortisol levels and also raises serotonin, which can also improve mood. Gotta love it. Pain. And I finally found a little picture to illustrate what I talk about with exercise. Most of the time, or a lot of the time, when we have pain, when we have stress, it's because there's, again, an imbalance. We have balance between the right and the left side. Think about your spine going down the middle. Yeah, mine goes more like this. But when one side of your back is tight, then the other side is probably going to try to counteract it, which may cause spasming, which may cause pain. So it's important to have the right and the left be relatively balanced, and the front and the back be relatively balanced. Your hamstrings are your quadriceps. If one is a lot stronger than the other, you're setting yourself up for a muscle tear. You're setting yourself up for spasming. Try to pay attention to that. If you do a lot of things, you know, I do a lot of ab work when I'm at the gym, but I don't do back as much as I should. So then when I go out to the farm, and I'm throwing hay bales around, and at the end of the day, I'm going, oh my gosh, I feel like I'm 80. There's a reason for that. It's because I don't have muscle balance. So a lot of times physical therapy will help people work on developing muscle balance so they're not having the muscle spasms. Your body wants to retain balance. The right side and the left side are going to compete. The front and the back are going to compete. So they need to be in balance. So they're not struggling. Guided imagery. I worked with one therapist who suggested a guided imagery of having angels rubbing certain spasms in somebody's back or when they had a migraine, giving them a head massage. Whatever guided imagery works for your clients, have them go to their happy place, whatever it is, great. Muscle relaxation. A lot of times, tense muscles contribute to or exacerbate pain. So if you've already got pain, you can have muscle tension that makes it worse. So muscle relaxation techniques. Alternate focus. I like this one. So if you've got something that's really hurting, say you've got a migraine, focusing on something else that's not hurting. Focus on your hand. Focus on something else. Sometimes I'll pinch the area like right between my thumb and my index finger when I've got a really bad headache. And yeah, it hurts a little bit, but I'm focusing on that. I'm not focusing on my head for a second. And then I tend to stop focusing on any of it when I let go of my finger. I'm like, whatever. It works. It sounds weird. And obviously you can read much more in-depth explanations for how to use the alternate focus technique online. TENS Therapy stands for Transcutaneous Electronic Nerve Stimulation. Little tiny electric impulses basically give you a constant massage, if you will, but it helps kind of dull the nerve sensation so it's not going, there's pain, there's pain, there's pain. It's like there's, I don't know what there is. The pain signals don't get sent out so the person feels less pain. Like I said, physical therapy will help balance some of the muscle imbalances. Hydrotherapy, you know, whirlpools, hot tubs, those sorts of things work for some people. Ice or heat packs and hypnosis. All of those, and you notice none of those is medication. All of those can help address chronic pain issues. Medication may be in there somewhere for some people. But there are a myriad, and I didn't even put in acupressure and acupuncture. Emotions, anger, resentment, jealousy, envy, and guilt. Anger is half of the fight or flight reaction. When you get angry, that's the fight. That's the, I'm gonna beat this threat. Fear is the other half. Anger pushes people away or asserts dominance and control. When you get angry, a lot of times it's because you feel out of control, you feel a threat of some sort and you want to regain your power. Excessive anger can exhaust the stress response system, contribute to negative cognitions, impair relationships, and cause physical harm. I mean everything from, you know, putting your fist through the wall to stress-related gastrointestinal stuff and migraines. One of the things that we talk about in group, when you're angry, what do you notice? What do you notice about your body? What do you notice around you? A lot of times when people are angry, they notice angry stuff. They notice negative stuff. They're not gonna see the cute little bunny rabbit over on the side of the road. They're gonna see either nothing or something that irritates them. So understanding that when you're angry, you're going to see angry things or you're probably going to be more likely to perceive threats is an important concept. Helping them identify anger triggers and, you know, whiteboards are great for this. Let's just start writing up what triggers anger for everybody. Once we get through anger, I'll twist it a little bit and say, okay, let's talk about resentment because anger, resentment, jealousy, envy, and guilt are all really kind of forms of anger. Then we look back at these triggers and go, why do those triggers make you feel vulnerable, feel threatened? Is it an external threat? Is it something that's gonna harm your person? Well, we need to figure out how to address it. Or is it an internal threat? The tapes that you're playing over and over again, the memories that you have being unkind to yourself. What's going on that is making this whatever it is, cause you to feel anger. And it's important to remember and help our clients understand that all of our emotions are very, very necessary. What we do with them is not necessarily always necessary. Nurturing anger, not gonna do a whole lot of good. Anger is designed to help us fight. Fear and anxiety are designed to help us flee, not sit there and rock back and forth and worry. Pull out our hair, pick at our fingernails, whatever we do. Jealousy and envy can be thought of as anger at somebody else for having something you want. We need to look at where that's coming from. Self-anger for not having it. When you're jealous, when you're envious of somebody, there's this, you know, the green-eyed monster, whatever you want to call it, what is motivating that? Or existential anger at the universe for not being fair. Think about a time when you've been jealous or envious of someone and how have you felt towards them? You know, it's like, well, fine. Or have you been happy for them and use that as a motivation to try to do something so you can have the same thing? That's not jealousy, that's motivation. So really kind of fine-tuning our definition of what those look like. Another activity you can use is to have people make a list of people that they envy or are jealous of. Because these people we run into every day or we see on TV. How much good does it do to be jealous, envious and angry at some actor out in California for something they don't even know that they did or have that you want? No good. So we wanna make a list of all these people that bring out all that negativity. Identify why you're jealous of them. Identify in what way they are better. How are they a better person because they have a 10,000 square foot mansion? In what way are they better or better off than you because of those things? And obviously we're gonna bring this back around to, they're probably not. How does envy and jealousy affect you? Like I said, being envious of some famous person probably isn't going to be an efficient or effective use of your energy because it doesn't change anything, it just robs you of your energy and gives them power. So then we ask what's a more productive way to use this energy? So you are envious of them because they have a 10,000 square foot mansion. Okay, so if you really think that makes them a better person and you really want a 10,000 square foot mansion, how are you gonna do it? Or how are you going to get somewhere where you feel less envious? A lot of times we can also go back to what does having a 10,000 square foot mansion mean to you? Does it mean success? Okay, so let's talk about how you're successful or what do you feel you need to change so you can feel successful? Ha, those underlying meanings, gotta love them. Guilt can be thought of as shame or embarrassment or self-anger for something you did or should have done. In addictions treatment, we deal with this a lot. Some people think, some people have difficulty letting go of guilt because they think they deserve to suffer. I did this and I need to hold on to it because I'm a horrible person. There are just so many treatment issues in that statement, I just can't even begin to deal with them. Understanding that guilt is difficult to let go of. People are not gonna say, here, take my guilt. I don't want it anymore. They're holding on to it for a reason. What is that reason? And then how can we address it? What happens if you forgive yourself? Some of my clients have said, if I forgive myself, I'm afraid that I'll do it again. Or again, I'm not worthy of forgiveness so I can't forgive myself. We talk about this a lot in terms of forgiveness of other people as well, which is forgiveness is just a huge, huge hornet's nest when you get into treatment, especially with people with addictions I've found. And then, so for guilt, make a list of things you feel guilty about. In 12-step recovery, there's a step that encourages people to take a fearless moral inventory. These are all the things that you did that you're like, oh yeah, I know, I shouldn't have done that. Then we need to look at how can you make amends? How can you learn from it or how can you forgive yourself? Because those are your three options. Holding on to it and stewing on it is doing nobody any good. A lot of times clients will put these issues on index cards and address one a day. What does forgiveness mean to you? How does the concept of forgiveness make you feel? This is usually a good one for a pretty heated conversation. And what is the phrase forgiveness is for you, not them, mean to you? If you forgive your abuser, if you forgive yourself, what does that mean to you? Anxiety is the other half of fight or flight. We already talked about anger and fighting. Now we're talking about fear and fleeing. You've decided that you cannot handle, you cannot conquer this, so you need to get the heck out of there for your own survival. Makes sense. Chronic anxiety, worry or stress will exhaust the stress response system, cause a neurochemical imbalance, increase muscle tension, increase pain, reduce sleep, and increase depression. This causes the body to adapt to excessive stress, which leads to apathy. We already covered that. So it's important for people to understand that depression very rarely just occurs on its own. We need to look at all the other stuff that is sucking your energy, contributing to your sleep problems and your sense of hopelessness and helplessness. What anger issues are there? What anxiety issues are there? What self-esteem issues are there? So for each of the following fears, identify three situations in which you experience it. So when people experience anxiety, let's talk about what are three times their experiences, situations that make you feel rejected or isolated. When do you feel failure? Loss of control and the unknown. What things make you feel out of control and what things make you feel like you just can't predict what's gonna happen, the unknown. And then explore why those situations trigger anxiety. For some, they can rephrase rejection as well. You don't like me, that's your loss. They see failure as a learning opportunity. They see loss of control as being kind of a relief. It's like, cool, we can be spontaneous. And the same thing for the unknown. Whereas people who have high anxiety tend to see rejection as the end of the world. Failure as a personal comment. And loss of control and the unknown as completely unbearable. And then we wanna brainstorm ways to deal with this. Again, to help them switch to sort of a different perception of these situations because they're going to happen. You're going to be rejected. You're going to experience failure and loss of control. So how can you deal with them in a way that doesn't exhaust you and make you feel depressed, anxious, however it makes you feel? Grief is sadness or depression is experienced as a result of the loss. Remember, denial, anger, bargaining, depression and acceptance. Anger is part of the grief process. Anger is exhausting. People need to deal with that anger. If they hold on to it, then they are just burning up a crap ton of energy holding on to this anger and trying to keep it contained. Depression, hopelessness to change the situation and hopelessness that you will move on. You know, when there's death involved, you know, you can't change it. They're done. The thought that it won't get any easier can be very depressing, very exhausting. There's a whole lot of stuff that goes into grief. It's vital that we help people understand that grief is not just about death. Grief can be about moves. If you move from one place to another, grief can be about life changes, graduating high school, graduating college. There's a lot of sort of existential things that we can grieve. So we want to talk about what losses people have experienced because of this grief we find or I find that a lot of people who present with depression have a lot of grief. Existential grief, dreams, loss of hope, loss of faith, safety, independence and innocence. We can go on for hours about these. A lot of people are very upset that they didn't have the life that they thought they should have. So we need to deal with that. If they had a loss of safety, my grandmother was recently put into an assisted living facility. So she's been going through a lot of grief about losing her independence. She lived in the same house for 35 years. So there's a whole lot of grief, their loss of memories, loss of that house and her husband passed away in that house. So they're compounded, a lot of stuff going on. Social losses because of moves, death and this includes pets. Now, some of you may disagree but for a lot of us, our pets are family and it's experienced differently obviously than losing a brother or losing a child or a parent but it's still a loss and relationships ending. Maybe not because they died but it just ended and it's hard. There's a transition period. Loss of physical abilities, loss of health, loss of appearance. As people get older, there is a period of depression, midlife crisis, whatever you wanna call it that some people experience and even things like loss of property. Maybe you had your grandmother's favorite brooch and you lost it and your grandmother has passed away and you feel guilty about the fact that you lost the one thing that you had from her. Dealing with those things, letting them go because even those little things add up over time. Explore what about each of those losses makes you angry or fearful? What's going on? We need to go through the denial, anger, bargaining, depression and acceptance. I usually just jump right into anger and depression so we can get on to acceptance. I wanna look at the whole grief process with each one of those and have people really accept the fact that it's impactful. Develop an action plan to deal with that anger and fear and give yourself permission to grieve. Acceptance is the last part of the grief process. True losses can't be reacquired. So the final step and a loss can be a loss of trust too. So sometimes we're dealing with that in treatment. The final step in the grief resolution process is acceptance. So what does that mean to your clients? When you've accepted this loss, what's gonna be different? What does it mean to you? And how is that going to impact you? And happiness, duh. You can't be happy and depressed at the same time. So that's really awesome. If we increase happiness, we reduce depression. Happiness, chemicals reduce stress and depression. They're just, they don't go in the same time. So we want to increase happy times. And I did have some links here, but in the interest of time, I'm going to spare you, except for this one, maybe. Find things that make you laugh. And then, there is this one, one of my favorites. Night time, day time, night time, day time, night time. You can see it doesn't take much to humor me. Find videos online that make you laugh, bookmark them, put them in a playlist, save them to your phone, whatever, so you can find them. When you're having a blue moment or a flat moment, find something that makes you laugh. Laughing reduces stress and depression. And then, there's this one, one of my favorites. Laughing releases your natural endorphins. Address negative thinking styles. This is kind of what we're trained in from the get-go, so this part is kind of most intuitive for us. Because negative thinking styles contribute to exhaustion. Highlight what is out of people's control. And heighten the sense of helplessness and hopelessness. If you see everything as scary and working against you and out of your control, it's gonna be exhausting, and it's not gonna be very fun to go out and try to do anything because it doesn't feel like it's going to have a positive effect. Address cognitive distortions and self-fulfilling prophecies. If you expect things to go wrong, guess what? You're probably only gonna see the parts of it that do go wrong, because you're going to create that situation. Poor self-esteem. You need to have a good relationship with yourself in order to have a good relationship with others. Poor self-esteem contributes to self-loathing, shame, and a feeling of unlovelability, which can contribute to, guess what, depression. It negatively impacts relationships. Do you really want to be around somebody who's like, I suck, everybody sucks and I suck? No, it's not fun to be around those people. So eventually, other people are gonna start backing away. Positive attracts positive, and this is not how magnets work, it's how people work. Poor self-esteem makes people look for external validation. Guess what? Most of the time, people who are going to provide you a fusive external validation are extremely codependent. So you're just bringing in a whole other hornet's nest of stuff to deal with. Have people complete a self-esteem inventory? Who they want to be versus who they are? And then identify, for all the characteristics they don't have that they think they want to, ask them, if your child or best friend had this flaw, would you still love them? Most of the time, the answer's gonna be, yeah. So encourage people to really take a more objective point of view instead of being so hard on themselves and holding themselves to such a high standard that they wouldn't hold anybody else to. Unhealthy, unsupported relationships can take a toll on self-esteem. Fears of abandonment can maintain high levels of stress and feelings of helplessness. If you fear abandonment, you're not gonna connect. If you don't connect, then you're lacking that whole buffer against stress that social relationships provide. Sense of isolation, it's exhausting to deal with everything all the time by yourself. High stress environments, increased stress hormones and decreased relaxation hormones. Have people design a low stress area in their home. Bedrooms are good because that'll help with sleep too. But sometimes it's the only place you can call your own because everywhere else you've got kids papers and dogs and everything else. But also at work or at school and it could be in your car. It could be at your desk. It could be a cubby hole somewhere. But have somewhere where you can go that's relaxing. Identify ways to reduce the stress in your environment in at home and at work, such as noise, interruptions, poor lighting and negativity. If you have an office mate who is just always negative, how do you tune that out? What can you do to deal with that ongoing stress? And then identify ways to turn the negative into a positive. Why do we care? Because stress, hormone imbalances, lack of sleep, poor nutrition, all of that can contribute to depression or cause feelings of depression, cause symptoms of depression. And we have those symptoms and we can't figure out how to get rid of them. We can start feeling helpless and hopeless. That contributes to emotional feelings of depression. And then, voila, we've got a problem here. Depression is a cluster of symptoms created when there's a neurochemical imbalance in the brain. Whether it's caused by nutrition, lack of sleep, all those other things we talked about. There's a neurochemical imbalance. Part of the strengths-based approach means helping people see what they're already doing to prevent or deal with the symptoms and build on those. Biopsychosocial means examining all the causative factors and then recognizing that all things are reciprocal in nature. So if you improve one area, every other area is probably gonna show some improvement. Likewise, if you are just destroying one area, it's probably gonna impact everything else. Are there any questions?