 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 common issues and interventions in the treatment of co-occurring disorders. What we're going to really talk about today is some of the things that we can do when people first come in or in their first couple of sessions in order to help them feel empowered and feel like they're starting to make progress and so they can start making progress. We're going to start by defining what are co-occurring disorders and which one should be treated first and that comes up still unfortunately as a discussion. So we're going to cover that real quick. Then we'll talk about awareness and mindfulness, self-esteem, sleep, nutrition and how to handle depressed or anxious mood. So co-occurring disorders are basically any physical or mental health disorder that occurs at the same time as an addiction co-occurring and I mean medical doctors have co-occurring issues that they talk about and obviously co-occurring means at the same time but what we're talking about generally are an addiction and fill in the blank. And we also do want to include physical issues because an addiction plus a pain issue is they're going to complicate the treatment picture and generally when there's a chronic pain issue there's also some chronic anxiety or depression so we really want to look at the whole spectrum of what's going on. Each one of these disorders can cause clinically significant impairment on their own and they create a hurdle in the recovery process. So the best illustration I could give, I got a map of I guess this is Waze or something and if you're on a traditional trajectory for straight addiction treatment or straight depression treatment, you know you're going up this white road right here, whatever that is and but if you have a co-occurring issue that's going to block the road you're not going to be able to continue straight on that path because there are other things that need to be attended to so you're going to need to divert a little bit and as you start to treat people with co-occurring disorders one of the things you'll see is that they'll make advances in one area and the other area will stay stable generally and you know maybe uptick a little bit or recede a little bit but generally it's kind of a give and take as their depression remits, generally their desire to use remits a little bit as their coping skills and ability to deal with their urges get stronger generally their mood and sense of self-efficacy improves so we're going to kind of make this step by step progress so look at co-occurring disorders as basically two hands trying to help somebody climb up a mountain so which do we address first, well I kind of hinted at that already you can't climb up the mountain with one hand we need to address both of them if you have someone who is depressed and not using they are not going to stay clean for very long so if they're just addressing their addiction issue but they're not addressing their mental health then that depression is not going to go away and one of the reasons, maybe not all of them but one of the reasons that they were using was probably to deal with that depression so they're not going to stay clean very long alright so let's look at the other one what if we deal with the depression will this other thing spontaneously remit no because the addictive behaviors and you know I sound like a broken record I know the addictive behaviors cause brain changes not permanent necessarily but they do cause alterations in the neurochemicals that will tend to predispose someone to feel depression and anxiety and stuff because the neurotransmitters are out of whack they're wonky so they are creating a biological venue for to breed anxiety and depression so we need to stop or squelch or reduce those addictive behaviors so the brain can balance the neurotransmitters because remember every time you engage in an addictive behavior there is a rush of whatever chemical that we're talking about it could be norepinephrine and dopamine like you see in your stimulants your cocaine, your methamphetamine your pleasure inducing drugs or it could be dopamine and some of your endogenous opioids like you see with opiate based medications whatever it is you are putting way too much into the system so the brain is turning back it's the amount that it puts into the system in order to compensate because it knows it can't run that hot for that long which can lead you to feel depressed or anxious or all of the above so assuming we're treating both at the same time some of the things that you can do in this first session when you're talking about the addiction is remind the person that the goal is progress not perfection and I hope and with all my heart that your agency embraces the concept of progress not perfection and the fact and I hate to say it but in many many most cases it's a fact that relapse is going to happen it doesn't mean that the person didn't want recovery it doesn't mean the person is being resistant it means that we missed something or we haven't strengthened the skills enough yet so we want them to come back and learn from their mistake and make continue to make progress so we want to ask them what are your triggers for use and even in the first assessment meeting that you have most people can give you a pretty good list of the things that make them want to use whatever use is for them it stresses them out makes them depressed whatever so let's start identifying those because relapse prevention planning is supposed to begin according to every level of care guideline out there relapse prevention planning is supposed to begin at assessment why is that well unfortunately with substance abuse clients we don't know that we're ever going to see them after that initial assessment we can't guarantee that they're necessarily going to come back for the second or third appointment so we want to make sure that every time they're in our office we're giving them more tools in order to make sure that they can be success and start making progress even if they don't come back we've planted that seed and enabled them to start making progress so we've identified their triggers then we ask what have you done in the past that's helped you not to use pretty simple straightforward question and they may not know but a lot of times they've tried to quit on their own they just haven't been successful for the long haul so we can start building on those and if they identify you know maybe they started going to meetings or going to church or volunteering or spending more time with their kids or working out whatever it was for them generally it's going to be a pro-social activity and generally I'm going to go okay let's do more of that let's see how can we make sure or help you do that every day because right now in early recovery downtime, idle time is generally not your friend that doesn't mean people shouldn't have time to relax that's very different if you know some people may not use it they go to the movies and the movies hopefully are very relaxing you're not exercising you're not draining your brain but it's a place where you're probably not going to be shooting up either so what is it that you can do to help yourself not use and calling a friend that's another big one or a sponsor what can you do to help yourself stay clean and not use right now because we know what worked for them in the past but not all those things are necessarily going to work in the present so we want to say you had all those things and then you had a relapse so I'm wondering either why those things are not working or why they're not workable now and if they are let's talk about how to make them work how can you do that and how can I help I also want to talk about before we get too far going into this long assessment about the mental health and physical issues what mental health MH and physical health PH issues do you have that contribute to your use so if they talk about depression if they talk about anxiety if they talk about chronic pain or rheumatoid arthritis or whatever it is maybe they got diagnosed with cancer that's a pretty devastating diagnosis even if they can get it into remission it usually scares the pants off most people so we want to ask about those things that may be triggering to their use what can you do that helps make those things less distressing we're not going to make them go away support groups reading what is it that you do and you know I could list off 50 different things and I don't know what works for that person but what helps if it's depression what helps you feel less depressed what helps you get through those times being depressed or anxious and again what can we do now we know what you've done in the past what can you do now and how can I help so I want these all written down as we're going through this assessment I usually give people a piece of paper when they walk in well it's a tablet and I ask them to take notes as we go because we're going to talk about things that I want them to do for next session but we're also going to start brainstorming relapse prevention strategies this helps keep them engaged in the process and then at the end of the assessment you can go back and review and say tell me what you wrote down because I want to make sure that we've both got the same thing and that helps make sure that they were engaged in the process they heard what you said you heard what they said yada yada yada okay so this is probably your first 20 30 minutes of your assessment now you've only got 30 minutes left to finish the other 76 pages so in early recovery and it doesn't matter whether we're talking addiction or mental health or both most people are on autopilot the powerlessness to change the situation has prompted them to disconnect emotionally mentally physically and spiritually they're just kind of there if they're depressed they're just kind of there if they're anxious you know you say what's making you anxious right now what are you stressed out about and they're just like everything you know okay you know I'm not taking that as being resistant or being vague I'm taking that as meaning I've been on autopilot because it just got so overwhelming I had to close my eyes and just kind of go with it and you know I want to validate for them that you feel really powerless right now and it seems like everything is coming down on you and it's oppressive and then we can talk about that part of the definition of addiction because remember in this particular presentation we're assuming that an addiction is one of those co-occurring disorders part of the definition of addiction is experiencing difficulties in multiple areas of life as a result of use which results in guilt resentment depression grief negative self image yada yada yada the point here it does not matter in reality in early recovery treatment the person was depressed or anxious before they started using or if they got depressed or anxious while they were using or they sobered up and they're like oh crap my life has fallen apart around me that's you know most people sober up and they have a really stern moment where they're good jumps into their throat and they're like oh I wow and that's okay what I want you to understand if you haven't worked with people with co-occurring disorders is that depression is just as real as depression that somebody has struggled with all of their life because everybody in their family has depression it's just as palpable is just as devastating and can be just as debilitating and as much of a trigger for addiction relapse okay life's about survival and avoiding intolerable pain so if you have somebody that's in pain they don't really know what's causing their pain but they're just sobering up from addiction then you know we've got some stuff to do first we're gonna have to start getting on this awareness train and figuring out what is it that's causing your distress and triggering your use so turning off the autopilot turning on mindfulness you know this is something we talk about all the time now encouraging clients to stop and and tell me how you feel right now what is it that is stressing you out right now you know we could spend three weeks going through all the stuff that just stresses you out in general but what I'm worried about right now or what I want to focus on right now is what is stressing you out or how you feel in the moment because we want to focus on living in the moment and improving the next moment instead of getting too far back here because we are out here so I want to ask them what are your thoughts, feelings, urges and behaviors that are currently keeping you unhappy and what are thoughts, feelings, urges and behaviors that you might be able to have that could help you start changing so I want them to figure out where they are right now you know what can I think you know if they're having this moment where they're doubting whether they can feel any better they're in your office because they have to be but they don't think it's going to work you know you have a lot of disempowerment hopelessness, helplessness so we want to look at empowerment and self-efficacy and can-do attitude and confidence and all that happy stuff but I need them to come to it on their own I can be a cheerleader I can be obnoxiously optimistic but if they don't believe it it doesn't do any good so having them identify things that they've done and things that they've told themselves in the past that helped them will help them develop a sense of self-efficacy and motivation so I have my purposeful action continuum and you can do it in multiple different ways you can either have thoughts, feelings, urges and behaviors that are keeping me unhappy and thoughts, feelings, urges and behaviors that will help me start changing and hopefully that's kind of right on point with what we're talking about but sometimes it's hard for people to figure out I don't know what's going to make me happy okay so let's step out of that role because I don't want people to get frustrated and go I don't know how to think happy or I don't tell me what a happy person thinks like so you know they have all those books out there like eat like a thin person and whatever well I want you to tell me if in your estimation think about somebody you think of as being happy and tell me what they would put in that column um and the other way you can approach it which is even a little bit more abstract I don't like this way but it's there is do opposites you know pretend the grumpiest most unhappy miserable curmudgeonous person in the world and the most obnoxiously happy Mary Poppins type type person that you can think of and create that and then you'll find somewhere in the middle about kind of what where they want to be and what can help this is a great activity to do in group um if you want to have one side be the curmudgeon and one side be Mary Poppins um it can be fun and it can encourage people to really start even if they go to the extreme in their mind they're thinking a little bit more realistically um deal with thoughts and feelings that prevent self-awareness well what can prevent self-awareness guilt a lot of people in early recovery if they've been depressed for a long time and haven't been able to go to their kids games and just haven't been able to get out of bed now that they start having a little bit more energy they may feel like they need to ignore their needs and be aware of what they need because they need to make up for all the stuff with addiction fear if I tune in and become aware of how I'm feeling right now and what my thoughts are I might get overwhelmed and not be able to stop and that is a very realistic fear so we want to say how can we help you deal with this how can we help you put the stops on what can you do if you start to feel overwhelmed um part of that would be when they do their mindfulness because I mean we're not asking them to do a whole bunch of in-depth retrospective stuff I'm asking you how you feel right now um but if they start to feel like they're going off the rails have an action plan in place you can call so and so you can go out for a walk you can whatever it is that can help them interrupt that behavior and kind of change direction um oh and back to guilt ignoring their needs ultimately is going to put them back in the same position that they are or were so pointing out to them that you can't continue to be there for your kids or your family or your boss if you let yourself get run down and completely relapse so it's important to pay attention to your needs so you can be there for them um now jumping down to apathy what's the point in being aware I've been aware before it's done no good I've been in treatment before it's done no good what's the point and to that I ask them well what is the point what are you hoping is going to be different this time and have you tried mindfulness have you tried something like this um and if you did what was the impact and if you didn't are you willing to give it a shot and let's talk about ways to make it work like the term mindfulness because it sounds too much like meditation to them they're not comfortable there but if you can find a way to make it objective talk about an inventory whatever you want to call it and help them see how mindfulness will help them prevent unnecessary stress so they can maintain as much energy as possible for the future and anything that life throws at them the final thing that may get in the way of awareness and mindfulness and beginning on this journey is self-hatred and that negative internal voice that tells them to just suck it up quit being depressed get off your butt and do the next right thing or what's the big deal why can't you just not use why can't you just stop after one drink so becoming aware they may be torn because they have this voice in their head that says why are you needing to do all this touchy-feely awareness stuff just suck it up and deal with it and we know that that's not possible we know that there are things that are underlying most of this stuff that's going on that we need to help them figure out but we need to help them figure hear that voice in their head and deal with it telling it to be quiet and handle their negative internal voice is going to be important because that voice is also the one that tells them your needs aren't important right now you need to focus on and that person's not helpful so low self-esteem I have yet to meet a client that's come into my office who's had high self-esteem so this is a good place to start as any a lot of times when people have low self-esteem they feel powerless so we want to encourage them to walk that middle path yes you are powerless over some stuff you are powerless over how other people act and react you are in control of how you choose to react to your feelings you are not in control of other people's thoughts and opinions but you are in control of whether you love yourself your behaviors if you want to say it that way so we want to help them start walking that middle path stop relying on external validation and focusing on what they do have control over in order for them to feel empowered we want them to learn from prior failures and create a success mantra because failures don't mean powerlessness failures are an opportunity to learn you wouldn't tell a little child who made a mistake well you are a failure you are never going to do any better no you wouldn't you would say alright get up dust yourself off and let's figure out what to do next if your kids ever played t-ball or anything like that you know exactly what I am talking about so I found a few quotes about success and failure which I found to be meaningful but I would encourage people to start and find their own mantra and when I say mantra it's one or two little sayings that they find that when they start feeling like a failure or when they make a mistake they can repeat to themselves to remind themselves that failure isn't fatal but a failure to change maybe yeah nice little segue there anyhow and this is true especially for people with addictions but people with clinical depression can also become suicidal so we want them to understand that you know failure to achieve your recovery goals isn't fatal right now but failure to change and start doing something differently might be I've not failed I've just found 10,000 ways that won't work this is one of my favorite success is stumbling from failure to failure with no loss of enthusiasm and I've worked with these clients before and I really enjoy working with these clients who I don't enjoy their relapse but I do enjoy the fact that they come back and they've dusted themselves off they're like well crap that didn't go well so let's figure out how to do it better next time the only real mistake is the one from which we learn nothing and this is one I tell clients when they come back with their tail between their legs because they're expecting judgment they're expecting me to say well if you would have if you would have and unfortunately they hear this a lot in 12-step programs and in treatment programs I'm not just pointing the finger at 12-step programs I'm pointing the finger at treatment to where they'll go to treatment and treatment will discharge them because they relapsed and I'm like okay how does that make sense they're here because they have they're not able to not use they have an addiction so if they relapse that tells me that we haven't given them the right tools or strong enough tools to deal with that problem in 12-step programs they hear something like the program has never failed someone who has honestly worked the program which communicates you didn't honestly work the program so it's your fault and I don't believe personal editorial I don't believe that any one program can work for every person so I really want people to learn from their mistakes figure out what needs to be changed and move on success is the result of perfection hard work learning from failure loyalty and persistence and loyalty to themselves is something we don't see in a lot of our clients so encouraging them to thine own self be true you know yeah it's gonna sting a little bit to go back and admit you relapsed but you're being true and loyal to yourself to do what's best for you and you're being persistent so we're still on self-esteem if people don't feel worthy of recovery or happiness they're not gonna stay motivated for it if they don't feel like they're worthy of love they're not going to stay motivated so we want to change the dialogue if they're undeserving of happiness I want to know why why don't you deserve to be happy many times it comes back to a refusal to forgive themselves for what they did in their addiction for what they've done in their past so we want to ask them questions to ponder what would it mean if you forgave yourself what are you afraid will happen if you forgive yourself you know those are two that they can kind of ponder on for a week or a month or six and keep coming back to whenever they don't feel worthy of happiness they can ask themselves this question another question I asked them is you know how many times how much longer are you gonna keep lashing yourself with a wet noodle because it's not serving any purpose at this point and what makes someone deserving of happiness so not only what makes you undeserving but how are you gonna know when you're deserving what makes someone deserving of happiness they may feel unlovable so again I want to change the dialogue why are you unlovable and you know a lot of times it comes down to they've made a lot of mistakes in their life and they've hurt a lot of people so does that make you unlovable or fallible you made some mistakes but I've made mistakes too so again what makes you unlovable but what makes someone lovable and I refer again to the little girl in the corner is she did she make a mistake or is she unlovable and you can imagine what it would feel like to a child to say you're unlovable you're useless and some of our clients heard that when they were growing up and that stuck in their head the other one is useless purpose or purposeless and some of our clients don't have conventional skills and that's just the way life is not everybody has the same skills so they may feel like a square peg trying to be put into a round hole so we want to help them see what skills, qualities and attributes they have and the fact that those are really actually awesome skills and tools and stuff how can we direct them how can you use them up until this point you've had them but they haven't been properly directed and you know case in point some of my clients with addictions are some of the best salespeople who are writers on this earth and I just want them to use that talent for good you know they become great sales salespeople if they choose to go into that they can be great managers because they're actually very in tune to hearing and being sensitive sometimes hypersensitive to other people so it's interesting to take whatever skills somebody has and say okay if we put it in a different environment how could this be useful in a work setting sleep my favorite topic not only do they have low self-esteem but most of our clients are not getting good sleep if they're depressed they may be sleeping all the time but we know that if you're sleeping all the time your circadian rhythms get out of whack and you're not getting quality sleep so no matter how much you sleep you don't wake up feeling rested sleep is disrupted by addictions which you know mess up the neurochemicals melatonin gets out of whack circadian rhythms out of whack stress, depression and anxiety keep your cortisol levels high so again your melatonin levels and your circadian rhythms get out of whack physical pain even if it doesn't wake you up at night it may keep you on high enough alert because your body is like okay you're vulnerable right now so you need to stay awake like a soldier in a foxhole and poor nutrition if you don't give your body the building blocks it needs to make serotonin which is broken down to melatonin and that building block is triptophan you are not going to get quality sleep sufficient quality sleep improves focus and concentration what's a symptom of depression lack of focus and concentration it's going to give you more energy symptom of depression fatigue and lack of energy it's going to regulate balance out hormone levels and your hormone levels play a big role in how much serotonin is available which plays a big role in anxiety levels appetite and mood are also both affected by sleep so you know we want to make sure that they understand that part of the recovery process regardless of whether they're just simply depressed or they've got addiction and depression or whatever that they need to start taking care of their body so their body can take care of them interventions they need to create a three step sleep routine it can be a 30 minute routine or a three hour routine I would suggest 30 minutes because it's easier to keep do every night take a bath or if you don't want to take a bath do something like stretch read a book and say your rosary or whatever it is that you do we eat dinner I go down and watch TV for a little bit and then I generally play a couple of games at checkers on my mobile device and then I'm out like a light so whatever it is for your sleep routine but it's important because it cues your brain as soon as you start doing that it's about time to go to sleep so I need to start making melatonin eliminate caffeine nicotine and alcohol before bed caffeine stays in your system 12 hours so anything that's caffeinated that you're drinking right now look whatever time it is in your time zone is going to be in your system at that time tonight so either 12 30 in the morning or 1 30 in the morning for most of you which means those first few hours of sleep are not going to be as restful as they could be nicotine doesn't stay in your system near as long but it's still a stimulant and alcohol is a system depressant which will exacerbate sleep apnea because it reduces people's breathing as far as melatonin question came in about melatonin before bed that is something that some people need to talk with their doctor about because we don't necessarily know whether it's because there's not enough melatonin that they're not getting to sleep there could be another problem that's keeping them from getting good sleep like pain that is keeping their cortisol levels up so their body is not letting them get that restful sleep so if they're taking melatonin that's just kind of going into a pit and a lot of people who take melatonin who don't have a melatonin deficiency that feeling extremely lethargic and sluggish the entire next day almost like people who take prescription sleep aids so I can't say whether I know for some people it works great let me back up and say that but that's going to be something that the person needs to talk over with their physician and based on what other medications they're on it could negatively interact with some of your psychotropic meds try guided imagery or at least thinking about something non-stressful for me I think about my garden I think about where plants are going to go because that takes a lot of my mental energy and it keeps it occupies me enough that I can't think about whatever other stuff was irritating me or weighing on my mind throughout the day and it's something that makes me happy so you know it's a little bit more calming and address pain allergy and apnea issues that would wake you up if you need to get Fido out of the room do so if it's just a matter of making sure he doesn't sleep on your pillow consider changing keeping your pillow in a cabinet during the day and or changing your pillowcase every night that's one of the things I do because I refuse to order my dog off the bed I have no boundaries nutrition more than half of the population is meeting or exceeding total grain and total protein food recommendations but grains that they're eating are refined and not whole which greatly reduces the nutrient value fortified grains don't provide vitamins and minerals in the same natural bio available ratio the way they make fortified cereals is they make they strip everything down they make the mush they make the great flakes and then they go by and basically spray it with a multivitamin spray so all you're doing is basically eating multivitamins about three fourths of the population has an eating pattern that's low in vegetables fruits dairy and oils well most a lot of things you can get from grains and meats but vitamin C calcium and magnesium are much more available if not exclusively available from vegetables fruits dairy and oils depending on what we're talking about here so it's important to have some of those incorporated in your diet especially if you're bad about eating fruits and vegetables at every meal tryptophan I know we've gone through this before you need iron, magnesium, calcium B6 and folic acid to convert tryptophan to 5-HTP and then you need vitamin C vitamin B6, zinc and magnesium to convert 5-HTP to serotonin and that's the long version of eat a reasonably healthy diet I'm not saying go completely crazy about it but try to eat something from each food group at each meal and we know serotonin is broken down to make melatonin which prevents sleep problems but serotonin is also involved in gut and heart problems fibromyalgia and other pain conditions and cravings for carbohydrates alcohol and certain drugs so serotonin is kind of important even though it's not necessarily responsible for depression we do know that it has links to a lot of other things water aids in digestion which makes minerals and nutrients more accessible to the body so it carries the good stuff throughout your body and it picks up the sludge and takes it out even better because any system that's built up with sludge, think about the pipes in your house it's not going to run as efficiently the brain is approximately 85% water water gives the brain the electrical energy for all the brain functions including thought and memory processes think about water conduction through electricity conduction through water a lot of the things that go on in the brain are electrical signals so we need to make sure that the transmission can actually happen if you're 1% dehydrated and I learned this during this presentation 1% dehydration leads to a 5% decrease in cognitive function so your memory your focus and your concentration 5% out the window 2% dehydration leads to fuzzy short-term memory and problems with focusing so next time you start having difficulty focusing and you have a fuzzy memory and stuff, think whether you've had enough water that day and remember that for every cup of caffeine or caffeinated beverage you have to have at least one other cup of water to replenish since caffeine is a deretic and I used to drink a lot of caffeine a lot of water depression hopelessness, helplessness and apathy most of our clients when they come in for their assessment are feeling a sense of hopelessness, helplessness and apathy to some extent so we want to have them figure out kind of what's underlying some of that and I will have them complete the sentence I don't think there's any hope that if hopelessness seems to be a theme that's coming up and we go through those for each sentence I have them identify why they believe there's no hope and then what would have to change to give him or her hope now this can be done in a homework assignment depending on the stability of the client during the assessment I've often given it as a homework assignment for the next session so they can start thinking about these things but if I think it's going to trigger them into a deeper depression then obviously it's something you'll want to do either in individual session or group the hope chest and this is just a shoebox and if they want to decorate it great if they don't that's totally fine too but each day add a card with something that indicates that things are starting to go better you know maybe it's just that they only cried three times today or they got through the entire day without binging whatever it is that's showing little improvements and put it in that chest so they can go back and review those things to see improvements as they go helplessness nothing I can do will change it hmm well hopefully they don't actually truly believe that or at least there's a little bit of ambivalence there they wouldn't be in our office so I might approach it with the question of what have other people done who've had depression or have had addiction and who've recovered or found recovery or gotten sobriety or whatever however you say it because I want them to see that there is a way for some people and then we'll talk about why that's not working for them or why it wouldn't work for them then we'll get there to okay what would work for you you're telling me this doesn't work and this is why so let's brainstorm some options about things that are similar that might work we want to ask them what's worked in the past for them they've tried to change the situation and likely they've changed it before maybe for an hour maybe for two hours that's okay that's a change so when you didn't use for two hours you were able to get up and go to the mall with your kids what did you do differently that enabled you to do that and how can you do that now we want to validate steps that they've already taken nothing I can do will change it you're here so what I'm sensing is that you have hope that I might have something that you've never heard of or you haven't tried before that's going to help you start and you're hoping that I can help you change it and then we'll identify the next steps together what is it what's the next step you need to take in order to start feeling better and that'll change for each person you know whatever is the most salient symptom for them is probably what they're going to identify and we'll work together to identify goals so we can create successes to increase self-efficacy and empowerment so again I'm not going to say well you'll go an entire week without using I'm going to say well so you'll go the rest of the day or until our meeting tomorrow without using and if you feel you're going to use this is you'll go to a meeting or you'll do this that at the other so we want to set small reasonable attainable goals and for some clients it's four hours for other clients it's 24 hours in early recovery when they usually let it go on longer than a week but I usually try to put a couple in there even if they have to self-reinforce and my behavior mod teacher would be cringing right now even if they have to reinforce their own behaviors it's important for them to see that they're making progress apathy they're sick and tired of being sick and tired and they just they're done they just they don't care anymore whatever and this always reminds me of the Seligman experiment and I hated this one in college he had a dog and on either side of this wall is an electrified floor so the dog would be on this side and they would electrify the floor and shock the dog the dog would yelp jump over to the other side to escape the pain where there's no shock but as soon as he'd settle down guess what they'd shock him on this side and that would go on for a little while and then eventually they turned on the entire floor so it didn't matter which side he was on he was just continually getting shocked and eventually he just laid down and took it because he's like I give up nothing I do is going to change the situation and I feel like for many of our clients sometimes by the time they get to treatment that's what they're feeling like so we want to say okay you know and I don't usually share the puppy experiment because I find that one devastating to even think about but what bad events happened in your past what bad events are keeping you from feeling like you are hopeless you're helpless they're keeping you feeling depressed what's going on because generally those events were generalized and they started feeling like they had control over everything at all or nothing at all so it's important to help them identify those events in the past there's nothing we can do about them now what do you have control of in the present and how can that empower you and make you less helpless so identify the bad events determine which parts were uncontrollable sometimes that helps with guilt and then again determine which parts in the present are controllable I don't want to look back and go what should I could because that's just going to make them feel worse what I want to do is look in the present and say all right we can't change the past but what can we do to help you move forward anxiety and worry loss of control and inability to cope two prominent things that people present with are really most about being out of control of and why I had one woman who I worked with generalized anxiety but really had a phobia of driving and what I asked her was what is it about driving that freaks you out the most and she told me not being not being able to control what other drivers do and I'm like well yeah that part really sucks because people can drive like maniacs this was up in Washington DC and if you've ever driven up there you know what I'm talking about anyhow what parts of the situation are in your control you know she can control which roads she goes on she doesn't have to go on the interstate she can take back roads she can there's things she can do not drive during high traffic times those are things that she can do in order to feel like she's more in control because she had gotten to the point where she couldn't drive period and then we also talked about in the past when you've been driving and you've lost control that means you know somebody cut you off it wasn't even like you lost control of your car but you were not 100% in control of the situation what happened and how did you deal with it because there were times when people would cut her off or whatever and we were able to reflect from there on what she could do once she tried to make it the best situation possible if another driver was just being a jerk how to protect herself so she wouldn't get into a full scale panic attack which takes us to inability to cope she was afraid that if something happened she would have a panic attack and wouldn't be able to function so we talked about what are some things you can do to cope with situations like that and what are some of the most difficult things you've coped with in your life not necessarily even related to traffic and how did you cope with them and my goal was to highlight the fact that she has a lot of strengths and she was a very strong woman this particular situation had gotten over generalized to see how much resilience and how much strength she'd shown in other situations to empower her to feel confident that she could develop the skills in this one emotional dysregulation is the inability to tolerate or handle any more stress now our clients with depression have generally gotten down to the point where they just don't even have the energy to get dysregulated they're just barely functioning but a lot of our other clients where they're holding on by a thread and it's like a pressure cooker and not one of those neat ones now that can't blow its top off but one of the old fashioned ones that it was ready to blow its top off if you would have turned the heat up just a little bit you would have not had upper cabinets well with a lot of our clients that's kind of how they feel they're just holding on there's so much stress they can't hardly stand life and if somebody looks cock-eyed at them it's going to turn up that heat enough even though it wasn't a huge issue all they needed was a little bit more heat to send their skills out of control they just had nothing left to deal with the stress so we want to talk about alright I hear you are at your wits end what stressors can you eliminate you know is there anything you can just get rid of for right now to be steam cleaned but does it have to be steam cleaned right now who can handle other stressors like paying bills that stresses a lot of people out maybe your spouse can do that picking up kids maybe the neighbor who has kids at the same school can pick yours up so you don't have to wait in that ugh so hated pick up line what can you do to try to be good to yourself for the next month you know give a prescribed time like well I don't want to rely on everybody else forever let's talk about a month what can you do for a month what are your current stressors you are dealing with put each on an index card and prioritize them I have them sort into three piles urgent has to be done like right now or something bad is going to happen bills lights are going to get turned off something like that things that need to be done but you know the world will not end today and then things I'd like to get done but they can get put off and I have them sort things into those piles as they come up they start out you know I'll probably spend 30 minutes or an hour creating cards and then tomorrow if something else comes up add a card figure out what pilot goes in and then work on the piles in order of urgency ideally address one to three each week and try to get rid of as many things that are not repetitive stressors one thing I do I don't like doing laundry well I hate putting it away I don't mind doing it and my family used to just bring down dirty clothes constantly and just set it in the laundry room so I was doing laundry every day and it kind of graded on my nerves a little bit not a huge thing but I decided that you know what no everybody brings their clothes down on Sunday and I will do laundry on Sunday if your clothes are not in the laundry room on Sunday they're not going to get washed and you can wash them yourself or you're going to have to wait a week and that released my stress because then I wasn't constantly having to worry about do I have to stay up until the dryer's done or can I go to bed and all that other stuff so identify things even if it's something that happens every single week identify ways you can minimize the impact of the stress in order to turn down the heat practice four things you can do when you get stressed out and angry practice the pause stopping before you act you get upset some people take a breath some people walk around in circles some people say a serenity prayer whatever it is you do practice the pause distract don't react find a way to distract yourself loud music holding onto ice cubes watching a funny movie whatever it is improve the moment improve the next moment so you feel angry, upset, depressed right now what can you do for the next moment to make it a little less unpleasant and then turn your attention by focusing on something in the room and you know my favorite is four things you can see three things you can smell two things you can hear and one thing you can feel is that you're not solving skills so once they've kind of de-escalated and gotten out of that emotional mind what are three things that they can do to help them create a win-win sometimes they just need to brainstorm because they don't know what to do with the problem so write down all your options and then once you have it where you can see it pick from those options and I encourage them to focus on the parts that are in their control because if they are focusing on the stuff in their control they're just using up a lot of excess energy and turning up that heat by adding frustration interpersonally we need strong interpersonal relationships so ask them what their relationships have been like and what they think a healthy relationship looks like you may explore what caused prior relationships to end because I know in my assessment we talk about what social supports that you have and you may not be able to get through but it could be something to cover in the first or second session to start learning about their social support system and I ask them what do you need most in a best friend and why what do you look for and then I turn it back around on them and I go okay how do you bring each one of those things to the table how are you your own best friend how can you be compassionate to yourself and how can you be whatever they stated to yourself not saying that they don't need other people but they also need to be able to kind of be their own best friend I share with them that healthy relationships are kind of like chocolate chip cookies one person is a sugar cookie sugar cookies are great on their own they don't need anything else they're stand alone stand up desserts chocolate chips stand alone you know I can eat chocolate chips straight out of the bag great dessert great by themselves together they make something totally fabulous and what you're looking for in a healthy relationship is not someone to complete you like flour completes a sugar cookie or a sugar cookie recipe you don't want flour you want someone that can stand on their own remind them that psychotropics are available for depression and anxiety sometimes short term sometimes long term that's between them and their doc also relaxants or medications like gabapentin which are non-narcotic for pain can be really helpful obviously sometimes their doc is going to want to put them on their narcotic and that's there between the two of them and there are antagonist and partial agonist medications for addiction including nicotine antagonist means whatever drug that they take will either if they take it while they're taking this medication it will either make them sick or it will have no effect which is kind of a bummer a partial agonist is a medication that gives them a controlled dose of the substance that has a ceiling so it doesn't get them high it just takes the edge off if you will antagonists and partial agonists are used in medication assisted therapy like I said they're really highly successful with smoking, nicotine and also with alcohol there's a lot of debate on the ones for opiates people with addiction should be expected to have mood issues addiction isn't diagnosed until there are multiple problems which will cause mood issues there are many common themes that can be identified and addressed in early recovery to help our clients enhance their self-esteem empower them to start taking control of their recovery and begin creating a resiliency narrative are there any questions? and for the people who sent me private messages about, you know, getting here a little bit late or whatever totally fine, no big deal thank you for checking in so you are logged in as being you know, participatory at the beginning-ish of class I don't think any board is going to be too persnickety if you have no further questions you are free to go if you have anything you want to add feel free to do so again, if you were late and you had questions about the difference between autism and FASD and how to diagnose both of them if you scroll up to the very beginning of the chat I gave you three links that answer your questions let me see I may still have the Mophis article up open and I do not everyone have an absolutely fabulous weekend I hope it is warm and sunny wherever you are and I will see you on Tuesday if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com slash counselor toolbox this episode has been brought to you in part by allceus.com providing 24-7 multimedia continuing education and pre-certification training to counselors therapists and nurses since 2006 use coupon code counselor toolbox to get a 20% discount off your order this month