 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation, Anger, Anxiety, and Depression, Making the Connection. We're going to start out talking about trans-diagnostic and transactional theories. When I look at somebody's assessment, I personally am not necessarily looking to pigeonhole them into a particular diagnosis. What I'm looking at is what symptoms do they have. And then trying to figure out how those symptoms interact with one another to create the presenting problem that the person has come into the office with. And we'll talk about, in my opinion, why it's so important to consider all three of these and not just look at an anxiety disorder or a depressive disorder. We'll define anger and anxiety, explore types of threats and threat assessment techniques. I'll show you one that I use. It's, you know, there's obviously a lot of them out there that you can use to identify anger and anxiety triggers. We'll explore intervention techniques. What can we do once we identify what the threats are? Then we'll define depression, examine the connection between depression, anger, and anxiety. So wrapping it all up in a nice little package and talk about trans-diagnostic interventions. That is, for example, fatigue. Fatigue is pretty common in people who have generalized anxiety disorder. They feel, you know, just exhausted all the time. They become stressed but still exhausted. Fatigue is common in depression and fatigue tends to be common in people who have anger management issues. Because their threat assessment system, their threat response system is just on all the time, which impacts their sleep and or negatively impacts their sleep. Regardless of whether we're treating the depression, the anxiety, or anger issues, if we address this fatigue issue, let's look at what's causing the fatigue because then that may help people eliminate a vulnerability going back to DBT again. So they're not as reactive and it'll also start helping them feel better in multiple areas. So trans-diagnostic and transactional approaches. You know, really big obnoxious words but, you know, it sounds pretty asserts that many symptoms are common to many disorders. So trans-diagnostic means this symptom cuts across or is present in multiple disorders. Things like changes in sleeping patterns, changes in eating patterns, irritability and fatigue. So we recognize that when we hear these symptoms, our mind may go immediately to, oh, well, that sounds like depression. But we got to make sure to rule out all this other stuff over here. The transactional model asserts that there's a reciprocal interaction between everything. There's a push and a pull, if you will. And when somebody doesn't get enough sleep or will take irritability, when someone is already irritable, what is the impact on their environment? So they may be irritable, they may be cranky with other people, which tends to make people either back away or be cranky back, which creates what we consider maybe an unsupportive or a hostile environment, which may further increase their irritability. So, you know, it's back and forth. How do they impact the environment? How does the environment impact them back? And transactions can be positive or negative. So I'm giving the negative because generally that's what we're looking at when we're talking to people who come to our office. But the transaction can be positive. If you are a happy, pleasant person to be around, think about one day you're at the mall or at a store or even at work, and somebody walked by and gave you a compliment and smiled and said, you know, it's going to be a great day today. How did that impact you? I mean, you might not have turned around and been like, oh, yeah, it's going to be wonderful from being in a really awful mood. But you might have had a little perk up and been like, you know what, it probably could. You know, some people may have been like, yeah, well, it's good about it, but you know, let's work on the positive here. If we act positively, we're going to exert positive effects on our environment, on our surroundings, on our thoughts. And we will be able to create an environment that is supportive of happiness and less supportive of negativity. So what are anger and anxiety? Emotional labels or words assigned to physiological and cognitive responses to a perceived threat. Yeah, a bunch of gobbledygook. But basically, when there's a threat, for whatever reason, you know, you put your hand on a hot stove, your body says there's a threat that that's not good. You need to do something. You pull your hand back. When we encounter other threats, whether it's coming from our physical senses or cognitively, we're like, oh, yeah, I remember situations like this. This is bad. Interaction or a threat response system is turned on. And it says, high alert, high alert, danger, danger, danger. What typical threats activate our threat response system? Death. If something happens that you could have been killed, injured or severely maimed, that's going to activate the stress response system. You smell smoke. Now it could be that you forgot that you put a frozen pizza in the oven and it's burning and the fire alarm starts going off. But until you figure out what it is, your threat response system goes off and you're kind of going around going, okay, what's causing this smoke and the smoke smell? Is there really a fire? Is there danger? Rejection and isolation. As humans, we are meant to be part of a supportive group. Now that doesn't mean we have to love everybody. You know, there are different types of people and introverts, for example, prefer small groups. Extroverts like to be around large groups. But the common factor is most people want to be around or want to have companionship with other people, you know, one or two or 20. So rejection and isolation can be a threat. Think about, you know, back in the 1800s when there wasn't all of the automation, there wasn't all of the stuff. You couldn't just go down to the store and buy food. You had to rely on farming. Well, what if it was a bad year and your crops didn't produce anything and you had no food? You had to rely on your neighbors. It was very interdependent back then. And a little bit of that is carried forward. Do we have to have others in our life to survive now? No, but research has shown that social support is one of the greatest buffers against stress. So rejection and isolation basically means we're taking away that buffer, which makes us more vulnerable to stress, which is a threat. Loss of control. Now there are people who really are not control freaks and there are people who really are. But in general, we like to have some sense of control over our lives. You know, you might be spontaneous. You might not need to know what you're doing every single moment of the day, but you generally like to have a concept. How many of you got up this morning and checked the weather to see what the weather was going to be like so you knew what to wear. A little bit of control, not a whole lot and definitely reasonable. You want to know whether you need a jacket or not. But we all have a desire for control and a lot of people with anger and anxiety and even depression issues have felt like so much was out of control. That sense of hopelessness and helplessness that anything that makes them feel like they're out of control can exacerbate a emotional response. The unknown. Now, again, this one isn't necessarily applicable to everybody. Some people love just going blindly into things and seeing what happens. I'm not. When I start a new job, when I move to a new place, when I go to a new place in the city, it's a little bit stressful. Now, is it horrible? No, it's kind of exciting. But my threat response system kind of kicks on and I am amped up a little bit to be alert to what's going on and, you know, I'm a little cautious. That's just the way I am. I'm also one of those people who kind of lives by a day planner. So I'm a little more rigid than some and failure. None of us likes to fail. Many people can learn to look at failure as a learning opportunity. But if someone has low self-esteem, they rely on others for external validation, or they feel like they've, you know, again, low self-esteem, they feel like they fail at everything. They may not feel like they're able to succeed at life. So again, all of these can set off our threat response system. So anger is your fight response. You know, something happens and your brain dumps all these excitatory neurochemicals and it says, all right, there's a threat. We got to do something. Fight or flee, fight or flee, fight or flee. Well, anger is your fight response. You determine that it's either a threat you can conquer. You're like, oh, no, no, I am going to make sure that goes away. Or you're trapped and you have no choice. And I always envision a cat trapped in the, in a corner, kind of lashing out. Sometimes it's something you normally would retreat from, but you feel like you have no choice. Maybe you are in a job and something happens that you perceive as threatening in some way. And normally you would retreat. You'd be like, I'm done. I'm out. But you can't just quit your job. You're trapped. So you get angry because you feel powerless. All right. So the anger response is saying, I've got to fight this one. There are different types of anger though. And a lot of times, especially newer counselors, but not necessarily, it kind of depends on your training. Think of anger in this very generic term of what makes you angry. But they forget all the different shades of anger and types of anger, rage, anger and irritation. I look at as a continuum rage, obviously being the strongest irritation being the weakest, but they're all a similar emotion. But what makes me things that make me irritated, generally are not going to provoke rage out of me. So we want to look at all of these things because if you have, think about a day you get up and, you know, you wake up late and you're driving to work. You figure out that you've got to get gas and you're not going to make it to work. You're still running late. But you get gas and you get to the office and, you know, going throughout your day, then somebody drops this big project on your desk. And you're just like, really? Compared to a day that you get up on time, get to work on time, have your coffee before they bring that project in, how's your reaction? Little stressors, irritants are additive. It's not just you can say, well, you just had irritants today. There was nothing big that happened. So why are you reacting so strongly? We need to consider irritants as additive. They take energy from us. Even if we've handled them, it sucked a little bit of our energy sucked a little bit of our energy. So having people consider that when they're thinking about, are they vulnerable to anger? But we want to make sure that we're encouraging people to pay attention to these irritants, because a lot of times irritants are things that people can find workarounds for. If you find driving into town in the morning, irritating because of the traffic, how can you work around that? If you find shopping, when there's lots of people there and long lines and you hate standing in long lines, that's an irritant. But it's probably one you can find a work around. Is it worth draining your energy, what, you know, what tank of energy you have for that day on something that you could avoid in the first place? Jealousy and envy is another type of anger. And you can kind of use these two interchangeably sometimes. But when we're talking about jealousy, if I'm jealous of somebody, I may be angry that they have something that I want. Or I may be angry at myself because I don't have something that I want that they have. So I can either be angry at them or angry at me or angry at both of us. But jealousy and envy really comes down to somebody has something you don't want and it makes you feel like you failed. It makes you feel inadequate in some way. So we want to, we'll talk about that a little bit more guilt. If you do something that you shouldn't have or don't do something that you should have guilt is self anger. It's me being angry at myself for what I did. So what do you feel guilty for now? I'm Catholic. I know how to feel guilty. I'm good at it. But we want to help people figure out what to do with this guilt instead of holding on to it or dwelling on it. How can you handle guilt and kind of work with it so you can grow from it and let it go. And then hate and resentment are again, sometimes interchangeable. If you really resent somebody for something they did. Sometimes you might cross over into hate. Again, it's kind of a continuum here. A lot of our clients have a lot of resentments toward people in their past and even people in their present who they feel are wronging them in some way. One of the principles of dialectical behavior therapy is the fact is the saying that you may not have created your own your problems, but you've got to solve them. And some of the things that we talk about with hate and resentment kind of center around that statement. Anxiety is the flight response. You choose not to use the energy to fight it. You're just like, you know what? I'm out. You know, okay, fine. It happened. I can't deal with this right now. So I am going to take a little mental break. It doesn't mean you have to physically run away. It doesn't mean you necessarily have to quit your job, but you could flee in some way and try to get away from it. And you don't believe you can win. You know, if it's something that you know you're not going to win, you might have a lot of stress about the fact that, you know, if I try to take this, I'm going to fail, you know, failure. So I need to figure out how to get away from it for my own safety and security. Anxiety is one of those, you know, it's a fear. It's a fear response. So of course we're going to have thoughts that center around worry and center around death and center around fear of failure and all those sorts of things. So the types of anxiety and there are probably other types that I didn't think to list here. But the types that I generally talk about are worry, fear and terror. Again, a continuum here. I can worry about something. I can be afraid of something and I can be terrified of something. Think about spiders. You know, some people, you know, worry a little bit about, well, there's a spider in here. I hope it's not poisonous. Some people are afraid of spiders and they're like, we need to make sure they don't get in here because I am afraid of them. And then some people will go to the ends of the earth to prevent spiders from getting in the house or in the building anyway, because they are just terrified of them. So, you know, spiders get a bad rap. They actually are good little bug catchers, but I digress. And then stress. Stress doesn't really fit on that other continuum, but it's one of those garbage terms that a lot of people use. I'm overwhelmed. I'm stressed. Let's talk about what are you stressed about? What are you worried you're not going to accomplish? What are you worried that is going to happen? So stress is kind of a type of worry, but the way we use it in the English language, I tend to break it out because I find that I get many different responses for that. So cumulative effects of stressors. So we have Jill and Jill wakes up in the morning and she wakes up late. All right, she wakes up late, she hurries through, she gets to the office and goes about her day. She's still got plenty of room for stressors to come in and out. It hasn't been a horrid day yet. It's just been a little irritating, little, little irritating. Now Jane, on the other hand, got up late, felt sick and she's like, oh, I'm late and I feel like crap. I'm tired. I didn't sleep well. My nose was running all night. I realized on the way to the office that I forgot to eat breakfast and now I'm hungry and my nose is running and I'm going to be late and I'm going to get in trouble. And then she gets into a fight with her significant other on the phone about what they're doing for lunch plans. So this is where Jane is when she gets to the office. She's at the top of her staircase, so to speak. That additive, each one of these kind of added a little bit of stress. So if something else happens, it may throw her into an emotional free fall. She's already had a, she's already dealt with a bunch of stuff and it's not even nine o'clock yet. Whereas Jill, on the other hand, she's only dealt with one thing. So if something else happens when she gets to the office, it's probably not going to feel as overwhelming as it does for Jane. So this threat assessment is something that I've used with my clients. They use it in group. I love group. So obviously I do as much as I can in group. I tell them to create one sheet for each emotion and the emotions are go down here and identify your triggers for that emotion. So what are your triggers for rage and anger? What triggers your irritation and I have them keep this journal for about a week. They can keep it as they go throughout the day. I think most of them do it at the end of the day or maybe before they come one day, but I'm optimistic and I think that they work on it every day. To identify what their triggers are for these different things and realize how present some, what you might consider mild irritants are in their life every single day. Because remember, you know, go back to here. You know, these are all kind of mild irritants, but when you have a bunch of them going on, it can add up. So if you're holding some hostility about something, if some traffic's bad and it irritates you, you're envious of, you know, some movie star because you were watching television today when you were eating your breakfast and you saw what a gorgeous house they had and you felt like, you know, you deserve that and why do they get that and you don't, you know, you can see how this can spiral out. So I encourage them to think about what are you jealous of? Who are you jealous of? And it doesn't have to be people in their actual life. What things did you feel guilty for today? Even small guilt. You know, oops, I screwed up and I forgot to. That's guilt. Let's add it to the, let's add it to the pile and figure out what you're dealing with just so we can get an idea. And this also helps normalize people's reactions because they may go, you know, I don't know what I'm so worried about or I don't know why I feel so stressed out all the time. Well, let's take a look at it. Okay, so then we go on. And one way you can do this is to kind of categorize and I do this in group. I put a big, I have a big whiteboard. And I say, okay, of the things that cause you to feel angry or enraged, which of those made you feel like there was a threat of death, you know, you could have been killed, hurt or maimed. Maybe you got cut off in traffic, you know, technically, if you spun off, flip the car, you could have been killed, hurt or maimed. All right, so what else, what other triggers do you have that make you angry that relate to fearing rejection or isolation? And when you get cut off in traffic, you know, it feels like somebody's disrespecting you, which is a form of rejection. So, all right, we might put that there too. And we go through this whole list of the things that cause you rage or anger, which of them trigger a sense of loss of control. And getting cut off in traffic again is a great example. This one hits in so many different categories that I usually use it as my example. Because when somebody cuts you off in traffic, you didn't have any control over that. You're just driving along being a good safe driver and all of a sudden right in front of you with no warning. So you didn't have control. You could have gotten into an accident, and it was not respectful of you as a human being. So it can trigger people's anger and rage issues if they're already feeling forgotten and disrespected and isolated. Then we go down, obviously we go down each one of these and across the row. If you're doing it in group, you can put different stressors in each category. So things that trigger anger that are brought on by a threat of rejection or isolation, you might have 15 things in here from your group. And that's okay. It just gives you some stuff to talk about, about where all this anger comes from. Another way to look at it would be to use it on a single stressor, like a breakup. So you had a breakup and how'd you feel about it? Well, felt angry. Okay? Why did you feel angry? Was there a threat of death? No. Did you feel rejected and that made you angry? Well, could have put that one there. Loss of control. That would make you angry. When somebody just like comes up and says, you know what? This isn't working for me anymore. Toodles, I can see where somebody would get angry. The unknown and failure, you know, when a relationship ends, you may fear that you failed in the relationship. You might not be able to ever get in another relationship. Now that can either trigger rage and anger or worry. But what I want them to do is see the depth and the complexity of their reactions to something as, quote, simple as a breakup. They may feel jealous of the new significant other. They may hate their ex for dumping them for the new significant other. You know, let's talk about all these feelings and address them and figure out what to do with them and how to deal with them if we need to. And that's a whole different issue about whether it's something that you're going to deal with or whether you can look at this and go, you know what? Yep, we're broken up and it just ain't worth my effort to use my energy on that. What I want to do is take either the chart or the list that, you know, each page that has their list of triggers for irritation and anger. How many anger and anxiety triggers is the person experiencing on a typical day? Which ones of them can be eliminated? Is there a relationship between a number of triggers and the intensity of their reaction? Remember those stair steps? I want people to start bringing that home by looking and going, yeah, you know, when I, when I had this whole cascade of negative things, I tended to dysregulate more emotionally than if I was having a pretty good day and something happened. Is there a particular threat those triggers relate to? People have lots of emotions or really strong emotions around one of those threats, like rejection or failure. So we want to look and see if there's a theme. Is there a theme to what makes you angry or what just freaks you the freak out? What are your automatic beliefs supporting that threat? And yes, I capitalized beliefs because in cognitive behavioral, the ABCs were thinking about our automatic beliefs that are leading to the reaction. So what thoughts did you have that prompted that anger or anxiety reaction? And what are some alternate beliefs that the person could use to dispute the unhelpful ones? So if they say, you know, everybody abandons me all the time, I'm worried that I'm going to be alone forever and be living by myself with 23 cats. Okay, that is a worry. What other beliefs do you have that could counter that? Have there been good relationships? You know, what is it that you see in your future? How can you change what may be coming? What is the impact of the emotional or behavioral reaction on the person and his or her environment? So I put behavioral there because when people get angry, they don't just generally get angry and like sit there and see it on it. A lot of times they lash out physically or verbally. Same thing with anxiety. When somebody is anxious, when they're really worked up, when they're really worried, they tend to pace. They may get anxious. They may be irritable with people. They may cut people off in sentences. So there are behavioral reactions. So we want to say when you get wound up, whatever that word would be for you, angry, anxious, stressed out. What is the impact of that on your emotions? Does it, you know, keep you from feeling happy? Does it take you down this whole spiral of negativity? Where you start, first you're worried and then you start feeling angry and resentful and then, you know, depressed and you just keep compounding those negative emotions and then guilty. Can't forget guilty for feeling all those feelings. Is that what happens? So what is the effect of your emotional reaction? How does it impact your thoughts? You know, if you are in a anger state, what happens to your thought processes? Are you going towards your impulsive? I've got to make this stop. I've got to lash out. Or are you going to something more mindful? What does it do to your physical comfort and energy? I don't know about you, but when I get stressed out or angry or, you know, any of those dysphoric emotions, my neck gets tight, my back gets tight, my head starts to hurt and my belly gets upset. I somaticize like crazy. So I want to know what happens to the clients. And is this something that you really want to keep doing? What we're doing by examining the impact, obviously, is helping them see why they want to change, helping them increase their motivation for unhooking from their emotions a little bit and maybe choosing a different reaction. And relationships. When you are stressed out all the time, when you're angry all the time, how does that affect your relationships with your significant other, with your kids, with yourself? I mean, I don't even like being around myself when I'm in a crappy old mood. So I don't think anybody else likes being around me. Encourage them to look at all these things because it'll increase their motivation to say, all right, let me figure out what I can do differently. One of the challenges that I find with a lot of clients when I'm dealing with anger and anxiety and threat is a lot of times they'll feel like they're giving up control. If they say, you know what, that's not worth my energy, not going to deal with it, or I'm going to let that go. I encourage them to have a paradigm shift. And instead of saying you're giving up addressing this, you're giving up, whatever, you are choosing to not devote your energy over there. You were choosing not to give your energy away to something that is not going to help you achieve your long term goals. So empower them to make the choice about, all right, what's really worth dealing with, you know, going back to that breakup is getting angry about it. What are you going to do, going to solve anything? And how is it impacting you? How could you, how else could you use that energy to further your goals? Depression, bringing it, you know, like I said, we'd bring it full circle, a sense of hopelessness and hopelessness. Most people with depression have currently or have had high levels of anxiety and anger. The stress response system has been amped up. Very rarely do I run into clients who report that, you know what, everything was going great. And one morning I just woke up and I was depressed. Generally, there's a trigger. It could be a physical trigger, you know, maybe an illness they've had, maybe they haven't been sleeping well, maybe they've been eating really poorly. And it's kind of extreme to think just poor nutrition is going to make somebody depressed. But we want to look at what contributed to it. But most of the time there's also underlying anxiety or anger. So they were revved up. If you've ever sat in a car, and I don't know why you would do this, but you know, in the driveway, in park, with your foot on the gas, and that's kind of how we are when our stress response system is activated. We're just driven that engine, ready to go, ready to get the heck out of there. But you rev the engine. You don't keep it floored because what happens if you keep it floored? That engine block overheats and it cracks on you. We don't want that to happen, but that's what your body kind of goes through when you're stressed for too long. Your brain goes, I cannot maintain this level of excitation for this long. I need to store some energy for, you know, real true emergencies. And I just can't run this hot for this long. So I am going to turn down the sensitivity of the stress response system. What does that mean? Well, unfortunately, our stress response system stress, if you remember, there's you stress and distress. You stress is good stress, like going to an amusement park or seeing somebody that you haven't seen in a long time, things that make you happy and get you excited. Distress is stuff that makes you angry and gets you, you know, wound up. Both of them require your brain to secrete excitatory neurotransmitters. But if your brain has turned down the sensitivity and said, no, we're not going to get excited about much. That means you're not getting excited about the bad stuff. So you're not getting as upset all the time. But it also means you're not able to get excited about the good stuff either. So kind of like this guy pushing a boulder up the hill at a certain point, he's just tired and he feels like nothing's going to change. He's helpless. He's hopeless. And he just kind of sits down and gets squished by the boulder, which is kind of an ugly metaphor. When we're helping working with somebody with depression, we need to help them understand that there is a correlation between being too stressed out and too revved up for too long and not being able to feel what they would consider to be happy. So transactional analysis, the threat response system is triggered, warning, warning, warning, the person attempts to fight or flee. So that, you know, he's trying to push this boulder up the hill so it doesn't squish him. The attempts are unsuccessful. And he's stuck right there. Can't move. The threat response system continues in order to protect him, that your threat response system is going, you can't quit pushing on this boulder or you're going to get squished. And he's getting more and more tired and more and more exhausted. When your threat response system is on, it's not going to let you get that deep restorative sleep, because if you're that deep into sleep, then you're vulnerable. So sleep becomes impaired. When sleep is impaired, hormones that regulate sleep and eating become impaired. So now you see where we're getting into the depressive symptoms of sleep changes, eating changes and fatigue. Irritability increases as the stress load increases. So again, think that you're holding that boulder, try not to get squished. And somebody comes by and says, hey, John, look at this and you're like, really? I have, no, I'm barely keeping this boulder from moving right now. I don't have time to look at whatever YouTube video you want to show me. Exhaustion sets in. Lack of quality sleep and continuation of the stress response cause a neurotransmitter imbalance. You're not resting and restoring. The excitatory neurotransmitters go into conservation mode. That's what I was talking about with the brain going, we can't stay this hot for this long. Concentration becomes difficult. One of your main excitatory neurotransmitters, norepinephrine, is also one of your main focus neurotransmitters. So if you don't have it, not only are you not getting excited, but you're not able to concentrate as well. Motivation wanes. You start just not caring apathy. There's a lack of pleasure. You have to have the excitatory neurotransmitters to have pleasure. And I mean dopamine comes in there too. But you need to be able to get excited. Hopelessness and helplessness sets in because you don't feel like anything's ever going to change. He's stuck. He's holding that boulder, can't move up, can't let it go, doesn't know what to do. And we've got depression. So you can see how all of these things sort of feed in on each other. And one of the more visual activities that you can do with clients is to put a boulder, you know, make one out of paper mache and put it in the middle of your group room and have each one of them, each of your clients start writing down their worries and their stresses on it. Just to kind of get an idea. And I've done it on a smaller scale with a beach ball. And we'll pass the beach ball around and you get the beach ball and whatever you end up looking at when you look down on the beach ball is the stressor that you're going to talk about and how you would deal with it. So we kind of brainstorm some different ways to deal with stress and anxiety and those sorts of things. And it makes it a little bit more fun than just writing on a blackboard. So where to intervene. You know, my favorite one is sleep. If we're not allowing the brain to rest and restore your body wants to restore homeostasis, it wants to recover. So if we can help it do that, we're going to help our clients along the way. We're going to help them reset their sleep, eat, wake cycle, and get that cortisol where it's supposed to be. Now cortisol is your stress hormone. Yes, but it's also remember you stress and distress. One of the things cortisol does is it helps you get up in the morning. There's a surge of cortisol kind of first thing in the morning right around 8am, which like that's midday for me, but whatever. There's a slight surge of cortisol, which is generally what makes us want to get up, get out of bed, get to work. We're like, okay, gotta face the day. And then there's another surge later in the day, but it peaks and rises and falls throughout the day. And that's normal. It falls when it's time to go to sleep. If your cortisol is out of whack, if your circadian rhythms are out of whack, then your cortisol levels may not go down at night or may not rise in the morning. So you may not be sending the right cues to your body. So we want to help people set their circadian rhythms. It will also help regulate their feeding hormones, garolin and leptin, so they know when they're hungry. They know when they're satiated. It'll help balance neurotransmitters and other hormones, thyroid hormones, sex hormones. We know libido is affected when people are depressed, angry or stressed. So we want to help them balance those out too. So they start feeling something close to normal. It'll help with eating disturbances, exhaustion, irritability and low libido. Most clients are not going to turn this intervention away because it's one of the easy ones. It's not like having to lay on a couch and talk about your deepest darkest secrets. Interventions to start out with help the person create a sleep routine. An hour to an hour and a half before bed, they should do about the same thing. Now they may go to bed at 10 o'clock one night and midnight another night, and that's okay. You know, let's not be unrealistic here. But they need to have the same routine just like we did with our kids when they were little. Eat dinner, take a bath, read a story, go to bed. That cued their brain into, hey, it's time to start producing melatonin so we can go to sleep. And also have them examine their sleep hygiene to identify reasons sleep is difficult. With people with high anxiety, a lot of times their brains won't shut off. So how can you deal with that? And there are a lot of guided imagery, meditation. I also encourage people to keep a notepad by their bed so they can jot down anything they need to remember for the next day so it's not just bouncing around up there. Nutrition provides the building blocks for mood and health. So good nutrition. It doesn't have to be perfect. You know, pizza has lots of vegetables and dairy and grains and protein. I mean, you have most every food group on pizza. So I'm a big fan of pizza. But we want to encourage people to eat things that are somewhat healthy, not just chips and soda. So blood sugar issues, irritable bowel syndrome, Crohn's and excessive use of caffeine can all intensify or prolong the stress response and negatively impact sleep and hormone balance. If you've ever had low blood sugar, you know, you start to get shaky and a little bit irritable. Well, if you're shaky and irritable, then it can come out as irritability and anger transactional. You make the environment unpleasant for others. They tend to reflect it back on you. You see where we're going here. And it's just also not good for our mood to be going like this all the time. Irritable bowel syndrome and Crohn's disease are painful, but they also inhibit the guts ability to absorb nutrients. So we want to help people control that so they are getting the benefit of the food they're eating, as well as not being in pain and losing sleep because they're doubled up in the fetal position. You know that caffeine stays in your body for 12 hours. So if you are having a triple latte at noon, it ain't going to be anywhere near out of your system until at least nine to 12 o'clock. Dehydration contributes to difficulty concentrating and fatigue. And most of the water bottles we find now are 20 ounce water bottles. I encourage people to carry one with them. Just keep it filled and sip on it. Generally, you'll get more than your 64 ounces if you just do that throughout the day instead of getting really hung up on it. Limit caffeine, especially eight hours before bed. I'm being realistic. Most people aren't going to cut out caffeine at 10 in the morning. But have people be cognizant of what has caffeine. Coke, Pepsi, Mountain Dew, Dr. Pepper, pretty much any of those non clear sodas and Mountain Dew have caffeine in them. Chocolate has caffeine in it. So be aware of what you're eating. Try to minimize simple sugars. It's going to happen, but try not to be downing a bunch of it all day long. And aim to have a dairy, a protein, a whole grain and a fruit or vegetable at each meal. You know, it's really easy to get fruits in at breakfast. I wouldn't think of eating a vegetable at breakfast. And you can get fruits or vegetables at lunch and vegetables at dinner and then your golden sample foods. Interestingly, and I know we're kind of running out out of time here. Lime beans, peas, sweet peppers, pumpkins, squash, tomatoes, all of these are actually fruits because they are the derivatives of the flowers of the plant. So, you know, whatever. I don't get too particular about splitting fruits and vegetables at our house. You know, I'm pretty happy if my kids are eating one or the other at each meal. Grains, oats, rice, amaranth are gluten-free grains. So be aware that some of your clients obviously aren't going to be able to tolerate gluten, but there are grains that they can have. Grains are important for your B vitamins, which support serotonin conversion. Proteins, you know, there's a whole bunch of proteins out there. Soy, tofu and tempeh are all soy derivatives, but they are a complete vegetable protein. And if you put nuts, lentils or beans with rice or oats, you create a complete protein. So, you know, there are lots of vegetarian, complete proteins. And then we all know the dairy sources. So eating healthfully, you don't have to get too crazy. Just pick one from every column for each meal and you're good. Thoughts are another place we can intervene. Your memories alert the brain to threats. So something you've interpreted as a threat before, you're probably going to interpret as a threat again. So encouraging people to identify things that they perceive as threats or stressors and address those thoughts. The more often a memory is triggered, the stronger it is. So if you've gone to a family gathering 15 times and 12 out of the 15 times, it was just a miserable experience. It's time to go to that family gathering again. What memory, what is your first reaction when you hear, oh, it's time to go to this family gathering? It's probably one of anxiety, dreads, something like that. Because your memory pathway to the negative memories is stronger because it's gone there more times. So we want to help people strengthen their memory pathways to positive things. Repeatedly failing, threat of failure, or to successfully control, threat of loss of control, a threat can intensify hopelessness and helplessness. So when you've been in a situation and you haven't been able to conquer it, you haven't been able to defeat it or, you know, come to terms with it in some way. It can intensify feelings of depression because you're just like, I, this keeps coming up and I just, I can't fix it. Being aware of this and helping people figure out what they can do to either accept, accept it as it is or change the situation or change their reaction. Interventions identify the thoughts maintaining the threat. So what is it about this family gathering that you anticipate being so miserable? You know, what's the reality? What's the evidence for and against that? And is this based on emotional reasoning or logical reasoning? So we want to look at, are we looking at facts or just your gut reaction? Examine the possible responses. Okay, you've got to go to this family gathering. What could you do in order to make it so you're not stressed out about it for the next two weeks and dreading it? And then choose a course of action. I encourage my clients to write these things down, you know, write down their possible responses and then write down in order to prepare for this family gathering or whatever. I will, da-da-da-da-da-da, and when I start to get stressed about it, I will, da-da-da-da-da-da. That way, when they start to get stressed, they can look, it's already written down and they know what they're going to do in order to prevent distress. So we want to help them. They can sort it out this way. Your goals are over here. This is where you want to go. Anything that doesn't get you where you want to go may be a, may help you feel better for the moment, but it's not going to help you get to your ultimate goals. So we want to get past the urges and look more towards the long-term goals so they can sort out their helpful or wise behaviors and mindful thoughts and emotions that can help them be happy and have more energy despite this whatever event is. And they can be aware of their impulsive behaviors. What do they want to do? What's their knee-jerk reaction? What are the thoughts and emotions that are making them want to escape? And then we can help them sort through those and figure out how to deal with them. So back to the breakup again because that's one that comes up a lot. You are here, right in the middle. You have a choice to move towards your goals or away from your goals. So if you yell, drink, smoke, hit something, sleep, or eat, you know, those are all kind of escape behaviors or anger lashing out behaviors. It may make you feel better in the moment, but it's probably not going to help you be happy in the long run. So after you do those things, do you feel better? Do you feel awesome? And generally the answer is no. So what are the thoughts that are going through your head that are prompting you to want to do these things? This is awful. I may be alone. I can't believe that person dumped me. I am so angry. I feel depressed and helpless to change the situation. You know, they may be helpless to change the situation, so we've got to figure out what to do with that. And there's going to be grief over the loss. Those are natural emotional reactions. I'm not saying they're wrong. However, we've got to figure out how we're going to deal with them. So, you know, this is awful grieving over the loss. Positive thoughts they could have, this too shall pass. I can focus on the people that are in my life. I can remember that getting angry about it's not going to do any good because I can't change another person or make this person come back. I can use the energy to do something to make myself happy. Take a mental vacation, take, you know, maybe a weekend vacation. Behaviors I can do. Mindfulness. Practicing, being aware of when I start feeling angry or stressed or what I'm needing. Prevent vulnerabilities. So, try to get enough sleep. Try to eat a healthy diet so I'm not making it more likely that I'm going to stay anxious and depressed. Work on some distress tolerance skills. And there's a whole list of those that people can work on because they are feeling pretty awful right now. And, you know, that's just how it is. But whoops, what can they do instead? And help them find the middle path, you know, looking at the positives and the negatives. Find the balance, make lemonade, find the silver lining, whatever you want to talk about. So there are a lot of different options they have. What are they going to choose? I validate what people put in each one of these quadrants and ask how each thought or behavior helps the person move towards his or her ultimate goals. So, thinking this is awful. I'll validate that. You're right. It's awful. And it's going to hurt for a while. However, is this somewhere, do you want to unpack and stay here? Depression and helplessness. You know, again, I'm going to validate it and say, that's, I can see where you would be feeling that. When you've been depressed or felt this way before, what things have you done or what thoughts have you had that have helped you survive it? And help them start working towards building this list up over here for alternate responses to the current situation. Ultimate goals identify what are their goals? We want to help them get past this hopelessness. So if we want to help them have hope, we've got to give them to have something to hope for. So what are your goals? What is the best resolution you can think that would happen out of this? Empower our clients to identify unhelpful thoughts and behaviors, maintaining their stress response, you know, we talked about on the last slide, and make more effective choices so they don't feel so helpless. They realize that there are things they can do to start feeling better. Prevent vulnerabilities, I know I sound like a broken record, including poor sleep, poor nutrition and excessive use of stimulants. Anxiety and anger are responses to a perceived threat. It is what it is. It's a natural response, and it's not wrong. It's just the response the person has based on the information they have at that time. So help them identify what they perceive as the threat. Identify and examine the thoughts maintaining that perception. So, you know, examine the reality of it, if you will. Cognitive Processing Therapy has a worksheet that's called Challenging Questions Worksheet. So if you Google Cognitive Processing Therapy and Challenging Questions Worksheet all together, you'll come up with it. But it is a nice step-by-step guide that walks you through examining some of these thoughts. We'll explore alternative thoughts and reactions that would help people get towards their goals instead of stay stuck in unhappiness or just temporary relief revisited by unhappiness and temporary relief. And we'll encourage them to choose a response. Remind them when they're vulnerable, they're more reactive to threats. So again, we're going to go over sometimes ad nauseam, identifying vulnerabilities, eliminating the ones they can, and accommodating to the ones that they can't. So sometimes things just can't be eliminated. If you've got an infinite home, you're not going to get good sleep. So how can you accommodate to that and make room for it and realize that you're just not going to be 100% today? Depression is a state of hopelessness and helplessness that occurs generally after the stress response system is exhausted. In order to adequately treat depression, we need to obviously address the depressive symptoms, but also look at the underlying threats which may have caused the stress response system to overload in the first place. And identify and address vulnerabilities, which are preventing the person from rebalancing and restoring. Okay, went a little bit longer than 45 minutes, but I think we're, you know, we're still well within our hour. Do you have any questions? If you need to go and get ready for your next client or whatever you have planned, that's awesome. No problem. If you want to stick around and chat, that is awesome as well. You can log in, take your quiz and get your certificate anytime now. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. 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