 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. Hey everybody and welcome to treatment planning for depression. Today we're going to identify instruments that we need to guide treatment planning when we're talking about working with clients who have depressive symptoms. We'll identify the causes of depression while some of them we don't know all the causes. Identify behavioral, cognitive, and emotional interventions that we can use to help clients who are struggling with depressive symptoms. And I keep saying depressive symptoms because it's so important for us to address these symptoms even if they don't meet the criteria or the threshold for a DSM diagnosis of depression. We really need to intervene early because we know that early intervention is a lot more successful. So effects of depression on treatment. So for somebody who's in treatment, maybe they're in treatment for anxiety or even if they're in treatment for depression, when clients are significantly depressed they have difficulty following instructions and keeping appointments. So if we want them to be able to do these things, we need to help them with their depression. If we're seeing them for depression, we need to make sure that we keep instructions simple. Keep appointments if you can on the same day and time each day. Reminder calls, reminder cards, anything that you can do to prompt the patient. They may have difficulty finding the energy to participate or maintain interest in program activities. If you're doing an outpatient program, for example, they may have difficulty, especially in group, staying focused. In individual, it's a little bit easier because obviously they're on stage and they're having to think and talk and preferably hopefully do most of the talking. But in group, they may start to kind of fade out or they may not have energy or desire to participate in group activities. During the initial phases of depression treatment, that may be okay. We may want them to get oriented to group and start feeling a little bit more comfortable. But we also do want to start making movement toward having them participate in program activities. For some clients and, you know, the research indicates that psychotropics only work for about 30% of the population. So this isn't the best choice for every single person. But for some clients, psychotropics, you know, antidepressants may help them start getting enough energy to participate in treatment so they can start addressing the things that are keeping them depressed. They may not need to take the antidepressants for more than six months or a year. But sometimes it can be a huge help, especially if they're in early recovery from substance abuse or addiction as well. Their motivation for change is going to be low. Some of the hallmarks of hopelessness and hopelessness or of depression are hopelessness, helplessness and apathy. Well, if you feel hopeless, then anything's going to get better. Helpless to make a difference and apathetic that just nothing makes you happy anyway. Yeah, your motivation is going to be kind of low. What can we do to help people increase their motivation? Increase their sense of hope, their sense of personal empowerment that they're not helpless. There are things they can do to make a difference to change the way they feel. And apathy helps them focus on finding some things that make them at least mildly amused. There may be nothing that just really does it for them right now. And that's okay. We want to work towards what things make you a little bit happy or at least content. What things before you were depressed made you happy. Well, let's start bringing those things back in and see if they can't help a little bit alleviate some of the depression. They may have difficulty finding making appropriate decisions about treatment needs and goals. They just, they don't know. They're like, you tell me what to do. I have no idea. Empowering them to choose, you know, when we're talking about different treatment interventions or options and ask them what's worked for you in the past, you know, let's build off of that. So give me some direction. Maybe I'm the one that's going to have to choose what we're doing, what we're going to talk about today or something. But give me a little bit of direction, you know, what was weighing on your mind last week. Okay, well, let's start there. They may have difficulty believing that they can be helped because they felt depressed for so long. They may not be super responsive to reinforcements where you're telling them great job. You know, you say that your crying episodes are down by 50% this week. That's awesome. You seem to be feeling brighter. They may not respond to that as well. They may say, you know what, you just you have no idea how I feel or it'll end or however they respond. They may not have an ability to handle feelings right now. When people are depressed, they're already feeling like they're drowning or they're suffocating sometimes. So any other feelings that come their way are just overwhelming anger, resentment, anxiety, any of that stuff. So it can be completely just overwhelming. They may not have the ability to handle relations with other clients. They may be irritable, have low patients. That's okay. We want to work with them on, you know, help normalize how they feel, but then develop the skills in order to prevent turmoil. So if client John over here just pushes your ever loving buttons and you just can't deal with it right now, how can you function in the program where you're not going to get into it with John. But you're also, you know, being true to yourself because you're on your very last nerve, maybe sharing with John that, you know, you're really struggling right now and on your very last nerve. You know, avoiding John, being in different groups. There are a lot of things you can do. You can brainstorm how you can do that because people are going to have to generalize the same skill when they're depressed, you know, and not in treatment. When they're depressed and at work, how do they keep from handling their relationships with their coworkers? You know, you don't want them being argumentative or irritable or whatever at work. How can they handle that? They can't just quit their job or not go in. What do they need to do? They may have a reduced ability to attend to and not disrupt group activities. They may have frequent outbursts of crying or maybe agitated where they can't sit still. Same thing is true at work. So we want to help them figure out what tools can they use in order to stay focused and engage in the task at hand. An ability to avoid relapse after treatment is completed. We want to make sure that clients who are recovering from substance abuse also have gotten their depression and remission because a client is not going to stay clean very long if they are clinically depressed in most cases. Likely or similarly, if we have a client who's being treated for anxiety or PTSD and they're also depressed, we want to make sure that depression is alleviated. They're being treated for depression. They're not going to discharge till their depression is alleviated, but we want to make sure when the person's treatment is completed that they are doing well. They may not be self-actualized, but they're doing well emotionally across the board, cognitively, interpersonally, etc. We want to look at all those biopsychosocial markers to make sure that they are not setting themselves up for a relapse. So the ASAM, when we're working with clients with co-occurring disorders, the ASAM actually does have a co-occurring form, but we want to use a similar placement guidelines when working with clients who are depressed. First dimension, acute crisis and dangerousness. Are they in a place where they need to be hospitalized and under psychiatric care 24 hours a day? Biomedical conditions and complications. If they're diabetic, for example, and they're depressed, their insulin levels and their blood sugar levels may be different and they may not be wanting to eat or they may be gorging on high sugar foods because they're depressed and they're wanting to feel better, which is making their insulin levels go all over the place. So diabetes is just one example. Heart conditions, high blood pressure, any of those things. History, and I guess that would go with acute crisis and dangerousness. If they have a history of suicidal or homicidal behaviors, you know, that ups their risk and ups the level of care they probably need to be in. If they have emotional behavioral or cognitive issues, and we're going to talk about some assessments for those later on the next couple of slides, but if they're struggling with other stuff besides depression, depression is enough. If they've got other stuff on top of that, they may need to also be at a higher level of care. And they're readiness for change for each issue or objective. Too many times people look at it globally, like, are you ready to change your substance abuse? Are you ready to change your anxiety? Well, that's not it. There's a lot of stuff that goes into changing that. So for example, if somebody wanted to improve their mood, you know, get over the depression, they may have to address their sleep hygiene. Because maybe they've got really poor sleep habits, and that's contributing to their depression. They may need to improve their nutrition so their body has the building blocks to make the neurotransmitters to help them not be depressed. They may need to cut out caffeine at least 12 hours before bed so they can sleep better and increase their exercise in order to help relieve some stress. Because we know that exercise does tend to help people sleep better. So those are four interventions that may be suggested and they may be totally willing to address their sleep situation. But the other three, they're like, no, I'm not giving up my caffeine and exercises for the birds. And I like pizza. So no, I'm not really ready to work on those yet because I don't see how they're really going to help me deal with my depression. So okay, you know, you're going to use different interventions then with the sleep hygiene, we can go into problem solving. Let's educate and start doing this with exercise. For example, you're going to have to educate the client about why exercise or how exercise can help them improve their mood by increasing the release of serotonin as well as improving sleep, which can also improve their mood. So make a case for it. Why is this beneficial for you? And they may still not want to do it. So we want to look at why not, you know, going back to motivational interviewing 101, doing a decisional balance. What are the drawbacks to exercise? You hate it. You don't want to get sweaty. It hurts. You know, those are the top three that I usually hear. I have no time to do it. That's the fourth one. So we can talk about that because exercise doesn't have to mean going to a gym and getting all sweaty and, you know, exercise can mean walking around the block with your dog in the morning. And you can break it up. You don't have to do 30 minutes at a block. You can do five minutes with Fido in the morning and then you can take a walk at lunch for 10 minutes and then take another walk with the dog in the evening. And you've got your 30 minutes. So you can talk about ways you want to look at figuring out the reasons the person's not motivated and making those reasons go away to help get them a little bit more motivated to address that. So you want to address their readiness for change. Their relapse or continued problem potential. If their chance for staying depressed, if they're living in a, an environment that is high stress, low safety, loud, you know, maybe they're living with five roommates that they really detest who are constantly arguing and, you know, is an unpleasant environment. That may contribute to their depression. So staying in that environment may not be conducive to recovery. The same thing is true with substances. So we want to look at is this environment going to at least not hurt their recovery. You know, a lot of times they can't just up and move. So if they need to be in a different environment than a higher level of care may be appropriate, you may not get to the point of a residential placement. But if they're in a clubhouse situation or an IOP program, that's four hours a day in addition to whatever time they're at work, that they're not in that relapse triggering environment. So it helps. So how can you screen for this stuff? You know, a client comes in. How do we know if they're depressed? And I want to remind you and I talked about depressive symptoms earlier. They didn't meet the threshold for clinical depression. We're also talking about depressive symptoms that are the result of substance intoxication or withdrawal, especially substance withdrawal because people who've been using stimulants for a long time may probably feel depressed when they withdraw from those substances. It doesn't matter if the person has depressive symptoms, they are at a greater risk of substance relapse than a person who is not. So we want to consider that to alcohol is the same way when people withdraw from alcohol, they can have high levels of anxiety and or high levels of depression. It's also a life threatening withdrawal for a lot of people. So it should be medically monitored. But I digress those people also need to have their depression treated or they're going to be more likely to relapse on the alcohol. So we can use the DS DSM five promise, which is all of these that I've linked to here are free scales freely available scales that you can access, which is helpful. The severity measure for depression, the adult patient health questionnaire number nine, and we're going to get this to open it. Maybe, maybe not. So this is the DSM five screening measure. And it gives you a quick and dirty screening. How to how to score it for the PHQ. And it's nine questions ranked on a three point Laker scale. Pretty easy to administer to clients quick and dirty. The Zung self rating depression scale I really like this one has a lot more questions has 20 questions. But it gives you a bigger, a broader sampling of things that may be being disrupted so you can identify depressive symptoms. Mornings when I feel the best crying spells, sleeping sex, weight loss, constipation, foggy headedness. I mean, it asks about a lot of different things that clients with depression often report. And each one of these things can end up serving as a treatment plan problem that you can address. And it also gives you the easy scoring guide right there. The Center for Epidemiological Study depression scale was put out by the National Institute of Mental Health, the severity of post and that's also available for free. These last two I included because symptoms of PTSD and generalized anxiety can overlap with symptoms of depression, but you can also have them concurrently. And if you don't treat those, if somebody has post traumatic stress disorder and depression, for example, you have to treat both of them. If you don't treat the depression, then the PTSD treatment is going to be good, but you're still going to have that lingering depression that needs to be addressed. So I included those. It's always good to screen. Since more than half of people have been exposed to trauma. Not necessarily developing PTSD, but it's always good to screen to make sure that there isn't PTSD and generalized anxiety when people are worried a lot and sometimes people call it under stress or high strong. At a certain point, your body gets exhausted and says, I give up, you know, I've been fighting this fight for, you know, a year or three years or whatever it is, and I'm not getting anywhere. So I'm not going to devote energy to it anymore, which can feel very frustrating. And that's when the person starts to get exhausted and feel depressed. They start to feel hopeless and helpless because they've been trying to change something or trying to control their worry or trying to control everything in their life. And they're not successful at doing that because we can't control everything and they start feeling hopeless and helpless. Now a couple other instruments that I like to use to look for cognitive issues that might complicate the picture such as negative attributional style, low hardiness or high levels of stress are on this slide. Now attributional style is where you attribute things coming from. Is it internal or external? Is it whatever bad happened? Is it because of something you did or the world? So think about locus of control here. Is it global? That means, you know, whatever it is that happened makes you a horrible person or is it specific? You made a mistake or you're bad at this one thing. And that really impacts how people process the world and what they encounter throughout the world. You know, reasons for failure. You've just attended a party for a new student and have made some new friends. Then they talk about choose the reason that would best explain the outcome of it actually happened to you. So how did you make some new friends? You used the right strategy. You're good at meeting new people. You tried very hard. I have the personality traits necessary. I was in the right mood or it just, it happened. It had nothing to do with me. So that's one of those where the locus of control is very external on the last one where they said something else produced that outcome. I have no idea because it had nothing to do with me. And this can help you see and help you help clients feel better about themselves and more empowered if you can help them adjust their attributional styles. And I've got other videos on our all CEU channel that talk more about attributional styles. But you can see there's 20 questions there and then the scoring that you can look at. And then there are other reasons for success and failure, the ASAP three. It looks at the locus of control, whether people use a global or specific attributional style, whether they use a stable. That means it's forever and always or changeable. They can do something about it attributional style. So you can see as we talk how attributions can have a big effect on a person's sense of hopelessness and helplessness. So again, those three scales I've linked to you can access them. They're freely available on the Internet. There are a lot of others that you can get that are published and copyrighted, but I know budgets tend to be pretty low. So I try to be respectful of that. So you screen people and you decide that, OK, yes, they do have a depressive disorder or they've got depressive symptoms. Now what do I do? Well, we got to figure out what's causing it. Depression is a feeling. Feelings are caused by neurochemical imbalances to little dopamine, to much norepinephrine, to little norepinephrine, too much or too little serotonin. So it could be in or a combination of all those. They're just not in balance with each other. I usually use the analogy that our neurochemicals are like a really good marinara sauce. And the basil and the garlic and the fennel and the oregano and onion powder all have to be in the right balance. And if you have too much of one, then, you know, do you increase the others or do you try to scoop some of it out or what do you do with neurochemicals? Everything needs to be in the right balance in relation to everything else. So your biochemical imbalances cause depression. Norepinephrine is responsible for focus and motivation. Serotonin is your big hitter. It's responsible for feelings of contentment and relaxation, pain. It helps you sleep because melatonin is made from serotonin. It helps you regulate your hunger and your heart rate. So there's a lot with serotonin. And if that gets out of whack, you can have anxiety, you can have depression, you can feel lethargic, a whole bunch of stuff. And dopamine we know is our pleasure neurochemical. It motivates us because when we do something that's rewarding, it gives us a little jolt to dopamine and we're like, woohoo, let's do that again. It also helps with memory because we tend to remember things that produce pleasure. It helps with focus and it also helps with pain management. People who are depressed tend to have more pain, which can mean their serotonin and or dopamine levels are low in comparison to the other neurotransmitters. So we need to remember that whatever is causing this neurochemical imbalance is causing feelings of depression. So we've got to address the leak somewhere. What's causing the leak that's leading to the imbalance. So physically, there are a bunch of things lack of quality sleep. When we don't get enough sleep, our body says, you know what? We're in danger. You're not 100%, which means you're not as much on guard, which means there's a threat. So your cortisol levels tend to stay higher, which prevents you from getting quality sleep and it's this vicious cycle. So quality sleep is important for your brain to rest and rebalance and get those neurochemicals made and balanced back out. Exhaustion and burnout. Secondary burnout from being, you know, a caregiver or secondary trauma burnout at work. Any of that kind of stuff can just wear you down where you feel hopeless and helpless. You're trying and things aren't getting anywhere. Poor nutrition. If your body doesn't have the building blocks to make the neurotransmitters that it needs to make in order to help you feel happy. Then you're kind of screwed. So reasonable nutrition. I'm not talking about being a health fanatic. I'm just talking about eating colorfully, getting some vegetables in there, making sure you're getting your B vitamins, etc. Chronic pain can cause the chemical imbalance because when you're in pain, your body senses that as a threat, which keeps the threat response system, the HPA axis alerted, which keeps your cortisol levels higher, your serotonin levels lower, which means you're not going to sleep as well. And that's going to have that whole cascade effect of getting exhausted and keeping your cortisol levels high. When your HPA axis is activated, when your body believes there's a threat, it sends out cortisol. That's your stress hormone that says we got to prepare to fight or flee. Cortisol tells your body to do a bunch of things. Secret blood glucose to get ready for that initial fight or flee, which is when you have an adrenaline rush, you tend to get a little shaky because you have a bunch of sugar going through your system. And then it also tells your body, turn down the sex hormones. Now's not the time to procreate. So libido goes down. It also says turn down the serotonin because serotonins are calming chemical. If we're under a threat, now's not the time to be calm. When sex hormones go down, the availability of any serotonin in the system also goes down. So it's a double whammy to the serotonin. And we know that serotonin is implicated for a lot of people in depression, which is why our mainline antidepressants are serotonin reuptake inhibitors because it's trying to make more serotonin available. So stress directly causes the reduction in serotonin. Lower serotonin means you can't make as much melatonin, which is needed for sleep. You see where this can all happen? So we want to alleviate whatever those threats are that are keeping our threat response system alert. Diabetes can cause depression. Thyroid and sex hormone imbalances. As I just said, when your sex hormones are too low, that means the availability of serotonin and some of those other neurochemicals are lower. So, you know, that's easy enough for your doctor to measure. They can't measure neurotransmitters, but they can measure your estrogen and testosterone levels. Thyroid, hypothyroid tends to have very similar symptoms for a lot of people as depression. So rule out thyroid problems. Vitamin D deficiency. Vitamin D is the vitamin that your body makes when it's exposed to sunlight. We also get it from milk and stuff that has vitamin D put in it, but by far the most useful form of vitamin D is the kind your body makes from sun exposure. So if it's been cloudy, if you live in an area where you've got six months of darkness, or if you just haven't been outside, even if it has been sunny, then you may have a vitamin D deficiency. They're not sure how it works, but they know in those areas of the brain responsible for mood and depression, there are an abundance of vitamin D receptors. So they know that it's connected somehow. And they also know that people with seasonal effective disorder tend to have lower levels of vitamin D. And when that vitamin D is brought up, they tend to start feeling better. So vitamin D is important. If you live in one of those places where there's not a lot of sunlight or it's been really rainy and your client is struggling with depression, have them talk to their doctor about even light therapy can help increase vitamin D levels, reset circadian rhythms to get them normalized again so they get better sleep, etc. Hypocortisolism or adrenal fatigue is another thing. When your body has been trying to, or your brain or whatever you want to say, has been trying to solve a problem or deal with something for a long enough time and not been successful. Eventually somewhere in your little primitive brain, it says, you know what, we're not going to waste energy on that anymore because it's not doing any good. We need to conserve energy for when there's a real threat. Well, that means that things that would normally cause you to get stressed out, you just don't even care about anymore. You got that sense of apathy, but things that used to make you excited. You also don't care about anymore. It's just like, you know, I don't have that get up and go anymore. A lot of people will self medicate this with caffeine stimulants of some sort. At a certain point, you know, hypocortisolism, cortisol is the stress chemical that tells your body to release adrenaline and all that kind of stuff. Well, here we go. Adrenal fatigue. That's your body going, I'm, I can't be stressed. I can't do this anymore. I don't have any more adrenaline to give. And that's not exactly 100% medically accurate. But you get the idea when you've been stressed for so long, sometimes your body can't recoup and so you keep getting more and more tired and depressed. Anemia can cause feelings of depression because enough oxygen isn't getting throughout your brain. When you get iron, it gives helps the red blood cells carry oxygen throughout your body. Iron can be toxic. Don't just assume that you're anemic and start taking huge levels of iron supplements. Not a good idea. Always have your doctor check your blood levels. Medication side effects can cause depression. The side effects of opiates, for example, opiates or depressants, and they can cause you to feel depressed. For some people it causes them to feel euphoric, but for some people it can cause depression. And there are other medications that can be taken for heart disease or a variety of other conditions that may cause symptoms of depression. So ask clients, you know, when did the depression start and did you start taking a new medication or change your dose on a medication within three weeks of it starting? And other illnesses such as multiple sclerosis, lupus, fibromyalgia, chronic fatigue, Lyme disease, stroke, and the list goes on can also cause symptoms of depression. And I don't read off this litany to clients because it would freak them out, although they can find it if they go on Google. I do encourage them to make sure that they've gotten a complete physical within the last three months that included a blood panel and everything to rule out any physiological causes. Because if there's something broken in the body, no matter how much talking they do to me, I am not going to help them feel as good as they could. So it's going to be really important to have them get a physical. Changing behaviors, identify behaviors that can be addressed, keep it simple and achievable and break big problems or changes down into smaller achievable components. When we're talking about physical interventions, a lot of times we're talking about behavior changes. So for example, if you are talking about somebody starting to exercise, I'm not going to have them start going to the gym three days a week or five days a week or whatever from jump. I'm going to say, okay, first you need to figure out what you like doing to exercise. So this week, you know, why don't you try two different things to exercise or learn about different exercises? Or maybe try starting out by just walking your dog or stretching, obviously with medical approval. And then we'll build on that. Just, you know, you don't start training for a marathon by running 14 miles the first day. You start by training for a marathon by walking a mile and then jogging a mile and then running a mile and then working up from there. So we want to do the same thing for our clients. If they're trying to change their nutrition, you know, they don't need to turn everything out in their kitchen overnight. Say, all right, this week I just want you to work on drinking more water. Next week we'll talk about making one more change. So having to make one small change each week that gets them closer to that goal. So it's simple. It's achievable. It's something that they can say, I did that. All right, this wasn't so hard. Identify the goal or the outcome the client would like to achieve. So we want them to be happy, for example. Well, that's great. But, you know, what does that mean to them? What is it that the client is wanting to do? And how will he or she know that they've achieved it? So what does happiness look like to you? And how will you know when you're happy? Explore ways the client has achieved similar goals in the past. So when you've been depressed in the past, what's helped you feel a little bit happier? Now this next step is really important. Identify internal and environmental barriers to success and what parts the client can control. So if we're talking about dealing with depression, we'll continue to talk about that because that's what this class is on. We're going to talk about, you know, on days where it's raining, we've recently gone through a spell here in Tennessee where it's been raining for days. I mean, every morning I get up and there's an aerial flood watch. It's just, it's raining and it's dreary and it's cold and it's miserable. And so people with seasonal affective disorder are starting to get a little bit antsy. They can't control that. They can't control the weather and make it spontaneously sunny. What can we do? We can encourage them to use light therapy. We can encourage them to stay in rooms that are brightly lit. Any other interventions that has worked for them in the past when it's been kind of gray outside with their doctor's approval, they may take some vitamin D supplements on those days to help boost their vitamin D. There are a variety of interventions, but you need to ask them what works for them. What helps them stay in a better mood? Identify how barriers can be overcome in specific behavioral terms. Make addressing the barrier something to do rather than something not to do. So instead of saying, well, you don't want to dwell on it. You don't want to, you're going to say, all right, what are you going to do? This is happening. So what are you going to do to overcome it? And how that be really specific, such as you're going to get up at your, by seven o'clock and get dressed. And then when you go into the office, you're going to make sure that all the lights are on. So it's a brighter environment. You're going to play cheerful music on the radio. Whatever helps them feel happier, you're going to identify specific steps they're going to take in order to help them. Achieve their goal of dealing with the, the raininess. Identify supports and specific steps needed to achieve success and elicit a commitment and take action to achieve the goal. So have them commit to it. You know, next time it's rainy, I'm going to do these sorts of things so it doesn't, you know, drag me down. Encourage clients to get a physical to rule out hormone imbalances, physical issues causing a lack of energy, fatigue, difficulty concentrating, sadness and irritability. There are a lot of things that can do that. So let's take a look at what some of those might be, you know, have them take a look at it with their doctor just to rule out stuff that we can't even begin to help with. Address nutrition to provide building blocks. As people say, unless you are a registered dietitian, you cannot give nutritional prescriptions. You can't say you need to start taking more vitamin D supplements or you need to eat this meal plan. Can't do that. You can't educate them about why good nutrition is important for building neurotransmitters and recovering from depression and refer them to a dietitian and or any self-help books that might be useful. Encourage people to cut out caffeine 12 hours before bed because it stays in your body for 12 hours. So what you drink at noon is going to impair your sleep up until midnight. I know, you know, within three hours you feel like it's already done worn off and you're like, I need another cup of coffee, but you're just building it up. Stay hydrated. Dehydration increases confusion. It reduces memory. It reduces energy level and it can contribute to feelings of foggy headedness, all of which are symptoms of depression. Drinking water is not that hard. Have people carry a water bottle around with them? I always keep a spare in my car in case I forget my true water bottle. I just have one, you know, that I got when I got a power eight or something and I keep it in my car. So I've got something to put water in. Improve your sleep hygiene and get seven to nine hours of sleep each night without waking. This can be a huge goal for a lot of people. They may maybe they wake up three, four, five times a night or maybe they aren't used to sleeping for six or seven hours at a shot for whatever reason. So we need to help them. This is so important to improving a variety of issues, including depression. I do have another video on sleep hygiene or why sleep is important and ways to improve sleep. So you can talk about that. You can watch that if you want. The big ones are cutting out caffeine, not taking a hot shower before bed because your body needs to cool in order to sleep. Having a ergonomically comfortable sleeping area. Getting ready, rid of any allergens that may be keeping you awake and creating a sleep routine where you do roughly the same three things every night. Just like you do with kids, you know, with kids, it's dinner and then bath and then story time and then bed. That's probably not what you're going to do. But, you know, you begin with eating dinner and then do something and then, you know, whatever, yada, yada, yada. So as soon as you eat dinner, your brain starts saying, All right, I need to start making melatonin because it's going to be time to go to sleep in a couple hours. Get moderate exercise for at least 30 minutes a day. Clients are often not going to be able to do this from the beginning. So have them start out doing something for 30 minutes, even if it's dancing around their house like a crazy person while they clean 30 minutes a day, some kind of movement and then move from some kind of movement to something that's a little bit more intense. Get more sunshine. And I use the 1515 principle. You don't have to bask in the sunshine. If you can get 15 minutes in the morning. And that includes when you're driving to work that sunshine's coming in through the, through the car windows and 15 minutes in the evening. So when you're driving home, or if you take Fido out for a walk for 15 minutes in the morning and 15 minutes in the evening, that can help set your circadian rhythms and that's generally enough to get you the vitamin D you need. It might not be enough to really get you in a happy place, but that's more psychological than it is physiological. Review medications for side effects to make sure you're not taking something that, you know, is causing you to feel hungover. I know when I take melatonin the next morning I wake up and I feel really chipper for about three hours. And then I hit a wall and I crash hard melatonin doesn't work for me like it works for other people. So I know that and I can be aware of how it affects me. Address chronic pain. So you're going to get better sleep and you're going to be less irritable and all that other stuff that goes with chronic pain, preferably by methods other than opiates, TENS machines, trans electronic nerve stimulation can help you. It basically bombards the nerves with little tiny electrical currents that feels like somebody's just tapping on you. But it confuses the nerve endings so it stops sending the pain signals. I've used TENS units on my back before, great things. Massage, if you can afford it, or you've got a spouse who will do it. Stretching with doctor's approval. Meditation can help and there are a lot of guided meditations and guided imagery scripts that you can use for pain. Acupuncture or acupressure has been shown to be really helpful with pain conditions. Mild to moderate exercise with doctor approval may help a lot of pain conditions by balancing out those muscles, relieving stress related muscle tension and helping to stop some muscle spasming. Hot or cold pads depending on your injury and your preferences. When my jaw acts up, my TMJ, I'll put ice packs on my jaw and it makes them feel a whole lot better. Ergonomics. If somebody has pain, you know, they may tend to sit and favor one side or something. Paying attention to your ergonomics where you work. You know, your desk chair that you spend eight hours in. Your sofa that you sit on to watch TV. You spend a couple hours sitting there and your bed making sure that you've got an ergonomically sound sleeping setup. And you don't want your neck cranked out of whack, etc. You can find different articles on sleep ergonomics online to help clients figure out how big of a pillow they need and other things. And finally, consider pharmacological interventions. It works for about 30% of the people to help them get a little bit more energy and start feeling better. Some people stay on it indefinitely. Some people stop after six months or a year once they've developed some other tools and they don't need the boost in their energy. When we look at emotional causes of depression, it can be depression causing depression. Lack of pleasure, you know, just not. It's not so much that things are going bad. It's just nothing's good. It's just blah, blah, which can cause people to feel depressed if they feel like they're in a rut. Stress, too much stress that HPA axis eventually is going to say, I'm tired. I can't do it anymore. And person may start feeling fatigued, hopeless and helpless, not sleeping as well. Anger is exhausting and people who are angry a lot will start to feel exhausted, then hopeless and helpless. PTSD can cause feelings of depression. Any fear that activates that HPA axis, including abandonment, isolation, rejection, failure or loss of control. And then people who are emotionally dysregulated, which means when something happens, they go from zero to 250 in 2.3 seconds. Yeah, that's exhausting. And sometimes it's a biochemical thing. Sometimes it's the way they're wired. Sometimes it's because of traumas they encountered when they were younger. Whatever, if you know you're one of those people, if you are doing that zero to 250, you know, two, three, four times a day or more. It's exhausting and you may start to feel very out of control and depressed and helpless. So what can you do about it? Emotional interventions are not super numerous because all you're doing is addressing the feeling, but anything can help. Keep a daily log of nutrition, sleep, things that trigger your emotional distress and ways you cope. That's four things. But they're important because you might find connections between your poor nutrition or drinking too much caffeine and your emotionality or poor sleep and your emotionality. Things that trigger your emotional distress as you identify those, then you can start figuring out how to deal with them or prevent them. And ways you cope is important to keep track of because we want to build on those. Those are obviously working for you at least a little bit right now. They may need to be strengthened or tuned up, but at least that gives us an idea about where we can start building instead of having to start from scratch. So as a clinician, I take these logs and I help people look at them, try to identify patterns. And for women also keep track of your hormone cycles to see if there is a correlation because you also may have premenstrual dysphoric disorder. Develop a stress management plan. High levels of stress, anxiety and anger exhaust the system, then you start feeling depressed. So if you manage stress, then you may prevent some of the depression. Identify methods that help you deal with anger, anxiety and depression. Make a list. What helps you? If it helps you for 10 minutes or if it helps you for 10 days, I don't care. I want to find out what helps you feel better and we can build off those. Some of them we may try to eliminate if they're unhealthy. But we and it also gives me a better idea about what might causing your depression or what neurotransmitters might be out of whack. If I see that you consistently reach for alcohol, for example, when you're feeling depressed, you know, that might tell me that you've got high levels of anxiety and you're trying to use the alcohol to depress that. It may not be exactly right, but it gives me some ideas to spitball and talk up, talk about it with with my clients. Do things that make you happy. You can't be happy and sad at the same time. So I have clients do 15 minutes of something that makes them happy every day. And it may, like I said, it may not make them deliriously happy. But if at least we get up to content, you know, funny animal videos, listening to a comedian, taking a bubble bath, going fishing, whatever it is, do it for 15 minutes, at least every day. Address guilt because guilt can keep people feeling really stuck and learn to stress tolerance skills to assist in tolerating emotional upset. Those people that go from zero to 250, that feels really overwhelming and out of control. So learning to stress tolerance skills can help feel empowered, which takes away some of that helplessness. Distress tolerance skills also help us not get stuck in an emotion where we're fighting with it and saying I shouldn't feel this way or dwelling on it. Distress tolerance skills help us see that emotions come in and go out just like the ebb and flow of the tides. Cognitive causes of depression, cognitive distortions such as all or nothing thinking. When you think every time I try to be nice, I get bit in the butt or I never succeed at anything I do, those extreme words. Very rarely does anything always or never happen. So encourage clients to think about exceptions. When are some exceptions to this never thing that happens? The availability heuristic. This is when clients see something on the news, for example, and they think it's more frequent than it really is because they saw it and that's kind of prominent in their mind or something that recently happened. So if you're in a relationship with somebody and you've been in a relationship for 10 years and maybe the last month or so, they've just been a real bugger and a half. The availability heuristic might lead you to focus on that last month and a half and go, you are such a jerk. I don't know why I ever got into a relationship with you because that's what's available. That's in your kind of shorter term memory. You're getting the other, you know, 10 years leading up to that. So encouraging clients to broaden and get all the facts and look at the big picture. Emotional reasoning is reasoning based on purely feelings. If I'm afraid to do something, it must be scary. If I feel like I can't do something that I must be powerless to do it. Emotional reasoning can be countered by looking at the facts. What are the facts that support you being unable to do it? And what are the facts that support you being able to do it? Personalization means taking everything personally. So if somebody's in a bad mood, it's my fault. If something bad happens, it's my fault. If, you know, something bad happens, everybody's going to blame me, which can lead people to feel overwhelmed. Overgeneralization is taking one bad thing or one good thing, but taking one thing and generalizing it. So, you know, if Sam, if I can't even think of an example right now, but overgeneralization means taking something that happens once and assuming that it's going to happen all the time. Or one person that you met that, you know, was a certain way. You were in a relationship with a person and they were just an idiot and they were abusive and it was awful and you broke up the relationship. And then because of that one relationship, you say all men are bad. Well, that's not true. All men aren't bad. You had one bad apple, but all men aren't bad. And jumping to conclusions, Sam comes home and he's got lipstick on his collar. So you can jump to conclusions and assume that he's having an affair or you can find out the facts that there was a holiday party or a going away party for somebody who was leaving the firm. And, you know, he got a hug from the woman who was leaving and she got lipstick on his collar. It's purely innocent, you know, so, but you can jump to conclusions, which increases stress and increase can increase depression and fears of abandonment and anxiety and magnification of bad things. So when one bad thing happens or might happen, blowing it out of proportion, you know, if you get in trouble at work, I'm going to get fired and then I'm going to lose my job. Or then I'm going to lose my house and then my wife's going to leave me and that I will be homeless and penniless and yada yada. Wow. How did we get there from you getting written up once and minimization is kind of the opposite because people who are depressed often minimize their accomplishments and the good things. Something good happens and they're like, that was just a fluke or it won't last. So they're waiting for the other shoe to drop. So we want to look at those cognitive distortions and help people get a better, more balanced view of the way things are so they don't feel hopeless and helpless. Negative global stable attributions and we talked about that earlier. Global means it's about all of me or all the world, you know, the world is just evil. Well, that's a global attribution. It means everybody in the world is evil. A stable or a specific attribution would be to say there are certain people in the world who are evil. Stable means it can't be changed. You know, the world is evil and there's nothing that can be changed. It's just, it's inherent. Changeable means people could be, you know, people in the world are doing evil things right now, but there is hope. You know, we can educate and we can pull together as a community and there are good people that can help spread goodness. Extremely internal or external locus of controls. You know, that's also kind of with the attributions. If you believe that nothing in the world is in your control, you have a completely external locus of control, then yeah, you're going to feel helpless because it says destiny is going to control everything. So you might as well just sit back for the ride. On the other hand, if you have an extremely internal locus of control, you feel like you should be able to control absolutely everything. And then when that doesn't happen, you feel like you failed. So a locus of control that's too external or too internal can be problematic. Ineffective distress tolerance skills can lead you to feel stressed and exhausted a lot. And ineffective problem solving skills can do the same thing. So helping clients identify and address cognitive distortions, develop problem solving skills and distress tolerance skills. Identify the situations that make the client feel uncomfortable. And that's, you know, kind of where we want to start with with negative self talk and cognitive distortions. What situations make you feel depressed, anxious, angry. For each of those situations, make a list of the feelings that you experienced after the situation. So if you've had a feeling of anger and resentment and guilt and whatever, just write them all down. Identify the first thought that comes to mind when you think of the uncomfortable situation. So if I'm talking about, you know, going in for a job interview, and my first thought about going in for a job interview is fear. You know, I'm not going to get hired a sense of helplessness. When my first thought when I think about going in for an interview, if somebody asks me what my first thought that comes to mind is my first thought is I'm not going to get the job. I'm there's no way it's going to happen. Other thoughts that often arise with this situation. I have no business applying for this job or, you know, I'm not going to know what to say in the interview. And I start identifying all those thoughts and identify a theme from the thoughts and in the scenario I just gave you it would be one of powerlessness or loss of control. You know, I don't feel like I'm in control of this situation. Identify how the thoughts or the theme limits the client's options in life by being constantly afraid of rejection or loss of control. How does that keep you from trying new things and maybe interviewing for jobs that you might actually get help the client identify different ways of thinking about the situation and feelings that can lead to better options. So when thinking about a job interview, for example, think of it as a learning experience and a challenge. And how can you feel empowered to go in there and try and see what happens. And if it doesn't pan out the way you hope, how can you learn from it, maybe contacting the hiring supervisor back and finding out what you could have done differently. Once a list of reasonable responses is completed, summarize it, go back through the list of feelings and discuss the decrease in intensity of each feeling for the new list of reasonable responses. So one of my one of my thoughts about going in for an interview is there's no point because I'm not going to get the job anyway. With some of the new responses, I could say, well, you know, maybe I can, maybe I'm not going to get this job. But by going in for this interview, I'm going to be better prepared for the next interview because I'll know what kind of questions they're going to ask. So I'm looking at it as a stepping stone or a learning opportunity. And then continue to practice the new skill. So each situation that makes the person feel use negative self-talk or feel bad or angry or depressed. They can look at it and identify the types of thoughts they're telling themselves about the situation and then identify alternate ways of thinking about the situation. Five steps to challenge beliefs that limit options for change. Listen to the client's organization of and beliefs about the problems. Present your understanding of the belief. That's what we were talking about with helping the client identify themes that might be coming through. Ask the client if you're on point. If the client disagrees with your assessment, then ask for a more accurate statement of what he or she believes. If they agree with your assessment, then explore how holding that belief affects their ability to address the problem. So if you hold on to this belief that you're powerless and it's pointless for you to go interview for this job, how does that keep you from addressing your fears about the interview? If the client agrees with your assessment, inquire if he or she would add or change anything about the way you phrased the belief. So did I hit it right on the nail or would you change it? Help the client reframe the belief from a truth, you know, I'm not going to get the job to a thought. I'm having the thought or the fear that I might not get the job because the truth is unchangeable, but a thought is just something that comes and goes. It's like when, you know, somebody's trying to quit smoking and if they say I have to have a cigarette, that's a truth. That's what has to happen. If they say I'm having the thought that I need to have a cigarette, it's a thought and thoughts go. I can tell you, you know, any of us who've had children can remember, can tell you that thoughts come and go really fast and sometimes you can't remember why you walked in a room. Help the client alter beliefs to include options for changing the problem. So you're going to brainstorm options for changing the problem, options for changing their perception or looking at it in a different way. Help clients learn about the connection between thoughts, feelings and actions. You know, what you think affects how you feel and how you react to situations, how you feel. If you're in a bad out battle mood that day, it's going to affect how you perceive and think about situations and what you do. What you do is going to affect, you know, if you're eating well and taking care of yourself and, you know, being kind to others. You're probably going to think and feel differently about things than if you're not taking care of yourself and you don't have the resources to deal with it. Identify and address cognitive distortions with daily distortion logs. Have clients keep a list of things that triggered their depression and the thoughts they had. I usually give clients a list of the cognitive distortions and have them put a hash mark next to each distortion each time they use it. That way we can see which ones they use more often. And then I provide them worksheets and videos to start challenging those distortions. Learn about attributions and address negative, global, stable attributions. Again, have them keep a log of negative, global, stable attributions and restructure them to be more specific and changeable. So if they're thinking things are always one way and everything is always one way, then we want to help them see that some things are sometimes this way. Learn about locus of control and how moderate to an extremely internal or external locus of control can cause depression. Like we said, if you feel like destiny is going to do everything and you have no way of improving your situation, or if you feel like you should have control over absolutely everything and we know you don't, either one of those can cause feelings of helplessness and hopelessness. So we want to help people see what they can change and learn how to accept what they cannot change. Develop effective problem solving skills based on the problems that trigger that client's depression because what triggers depression for me doesn't trigger depression for my best friend. You know, we're very different people. So we each would need different problem solving skills and different plans. I encourage clients to start by reading the seven habits of highly effective people because this is a great way to start figuring out how to be happier and more empowered. And step number one or habit number one is begin with the end in mind. As you begin, what are you working towards? What does it look like to be happy? You know, if when you're happy, you're not having all these negative thoughts all the time. Well, then you know that's something you need to work on. And finally, increase feelings of self-efficacy or that can do attitude in your clients by making sure to help them set small achievable goals. So each week they're having some successes and they're going, okay, it's not huge progress, but it's progress. Social causes of depression include lack of social support, interpersonal conflicts, which can include conflicts with friends and family conflicts at work, or conflicts on social media with people you've never even met. Interpersonal losses, ineffective communication skills and poor self-esteem. Why do I have self-esteem under social? Because self-esteem is your relationship with yourself. It's how you feel about yourself and whether you're accepting and loving of who you are. So what do you do? Learn about healthy relationships. What do they look like? What are their characteristics? What do you want in a healthy relationship? And then, oh my gosh, start doing that for yourself. Be your own best friend. Be your own best healthy relationship. If you are, then it's going to make everything else easier because you're getting ready to get into a relationship with somebody else. If you're your own best friend, you're going to say, best friend self, is this a good idea for me? And best friend self may say, heck no. If you're not your own best friend, if you're constantly needing validation from other people, then you don't have anybody to go to to say, is this really a good idea? So you're going to tend to go into other relationships just to get that validation. Identify healthy relationships you currently have, if any. And generally, we have one or two that are at least semi-healthy. Let's build on those. Improve your self-esteem, your relationship with yourself. And there are tons of self-esteem workbooks out there, so I'm not even going to delve into all the different ways to do that. Identify issues that need to be addressed in current relationships to make them healthy. It was like I said, most of our relationships are pretty healthy or semi-healthy, but not all they could be. And one thing you can encourage clients to do is read the five love languages. That helps them understand how to improve connection with other people. And that's the first step in understanding what makes people tick a little bit better. Identify three people with whom you could develop a healthy support system. So look around and go out. I might like to be friends with that person or start going to meetups like hiking meetups or coffee or canoeing or whatever it is that you do. And meet new people to add to your support system and set a goal of three. You know, that's not hard to find three people that you might want to start including. Learn skills to handle conflict. There are videos on that. There are online classes to help. Learn effective communication skills, books, videos, online classes, workshops. And learn how to ask for what you need. Sometimes we're afraid to ask because we're afraid of rejection. But when people are feeling depressed, it means they feel exhausted and fatigued and hopeless and helpless. So this is when we need to be able to ask for help and get that support in order to bolster us up. And situational causes of depression can include losses such as relationships, death, loss of freedom, loss of dreams, a loss of sense of order in the world, a sense of control and hope. I mean, I know when I look around and I watch the media and the news which I try not to do for more than 30 minutes a day, it can feel really overwhelming because there's so much that's out of my control. But I know I can control my little slice of the world. And people may experience a loss of self-esteem, which can cause them to feel depressed if their significant other leaves them, if they get fired from a job. There are things that can happen that can injure self-esteem. Environmental causes of depression include people in the environment, toxic people in the environment, negative people in the environment. You want to try to have an environment that builds you up. And you have control in many cases over your environment, maybe not the whole house. I mean, I can't control my kid's rooms. I've kind of thrown my hands up, but I can control the common areas. If you live with roommates, you may only be able to control your room, but you can control that little slice of your world. Noise, think about how to deal with noise, toxins and allergens that keep you from sleeping well. And some toxins can also cause you to feel depressed. Paint, for example, paint fumes, paint is actually a depressant. People huff paint and it like liquefies brain cells, but it causes also causes depression and depressant effects, slowed respiration, etc. Some people are extremely sensitive to paint. I know I am. I'm a sensitive to a lot of really strong odors and they'll give me a headache, which can make it harder for me to sleep and just kind of put me in a grumpy or mood. So eliminate toxins and allergens. Eliminate or minimize sensory overload. So if there's, you know, I have difficulty in environments where there's stuff going on behind me and next to my side and there's noise and there's clutter and there's people walking by and it's just too much when I'm trying to focus on something. So avoid sensory overload when possible. Or, and the same thing is true for sensory deprivation. Don't sit in a dark room with no sunlight, no windows, no stimulation at all for too terribly long because you'll probably start getting depressed. We need to have input and depression triggers can be in your environment. So if you have a picture on your bedside table of you and your significant other who just left you, that's probably going to be a depression trigger. If you have a picture of somebody who's passed away and it's still a raw nerve, it may be a depression trigger. So look around and see if there's anything that you look at in your environment or shows that you watch on TV that trigger your depression and avoid those or do something so you're not encountering them right now. Environmental interventions include developing strategies to increase positive people and buffer against negative people in the environment. You may not be able to get rid of them, but you can buffer against them. If you go to a family reunion and, you know, Aunt Sally's there and oh, she drives you up a wall. You can figure out what positive people can you hang around or maybe at the family reunion, I know I do this. I stay in the kitchen and I try to help out whoever's cooking or preparing and I do what I can to help. So I stay busy and then I'm less likely to, you know, interact with Dear Aunt Sally. Address noise with white noise machines, earplugs or just talk to your roommates and say, you know what? I really need to go to sleep by XYZ time or whatever part of the noise bothers you and see if you can come to a compromise so it's not so noisy. Eliminate the toxins and allergens and create a calming corner in your house and at work because you spend a lot of time there too, where there isn't too much or too little stimulation and there are triggers for happiness, pictures that you look at and make you smile, pictures that you look at or songs that you play, you know, you can put on your headphones and songs that you play that make you happy. Treatment planning needs to be individualized to address acute crisis and dangerousness, biomedical conditions and complications, emotional behavioral and cognitive issues, relapse prevention and the recovery environment. Each treatment plan that you write is going to be unique to that person. Each person with depression is going to have different things that trigger that depression. So make sure that you look at it from a biopsychosocial perspective so you're providing them comprehensive treatment to make sure that you're addressing all the things that are causing their neurochemical imbalance. 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.