 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on strength-based biopsychosocial approaches to recovery from depression. On Tuesday, we talked about anxiety. Wednesday, we talked about panic, and we're just going to round out the mood disorders today with depression. So we're going to look at depressive symptoms and learn how to ask strength-based assessment questions instead of what do you want to get rid of? What are you hoping to move towards? Well, identify a range of potential causes for depression and different biopsychosocial interventions that can help people, and explore activities and interventions that can help people address it. So remember that depression represents a cluster of symptoms, and diagnosis with depression only requires that you have a few of these symptoms. A variety of different things can cause depression. So when we see a client, they're coming in and they've got low mood, apathy, more days than not over the course of two weeks or more. Okay, changes in eating habits, changes in sleeping habits, fatigue, difficulty concentrating, all right. So they meet the criteria for major depression. That's kind of the run-of-the-mill symptoms. But the question is, what is causing the depressive symptoms for that person? So emotions can cause depression. Being angry or anxious for too long, eventually the body just quits putting cortisol into it and says, you know what, we're not going to win this fight. And people may start feeling helpless, hopeless grief has a depressive component to it. You know, denial, anger, bargaining, depression and acceptance. Guilt and shame can also lead people to a sense of depression or a feeling of depression. So we want to look and see, you know, what things may be spurring this person's lack of apathy or lack of enthusiasm, lack of motivation, poor energy. Are they stressed out about something? What do they feel hopeless and helpless about? Thoughts can also cause depression or depressive symptoms, if you will. When people have persistent negative thoughts, they use cognitive distortions a lot. It can lead them to create a situation where they're constantly feeling angry, anxious, guilty, shameful, whatever, which again, leaves them feeling somewhat hopeless, helpless and powerless. Relationships with themselves, if they've got poor self-esteem, they may not feel lovable. They may not feel acceptable, which can lead to feelings of depression because they can't. They don't feel like they can make anybody love them. They don't feel like they can be good enough to be lovable. Unhealthy or unsupportive relationships or a need for external validation can also cause depressive symptoms. Neurochemical imbalances caused by poor nutrition, exhaustion, insufficient sleep, medication side effects, hormone fluctuations, a lot of these things can occur, Lyme disease, lupus. There are a lot of different things that can happen, some very benign, some that need medical intervention, that can cause the body to not be able to produce the neurochemicals for people to feel happy and they may start feeling depressed. They may not have enough serotonin or enough dopamine or enough norepinephrine. Environmentally, a high stress environment that prevents relaxation and rest can also keep people from resting and rebalancing and it grates on people after a while. They've shown that levels of depression tend to be somewhat higher in big cities where people have, where it's constantly noisy outside, you know, there's no quiet time. Now, I can't tell you that I've looked at the structure of how they ran those studies to look for confounding variables and stuff, but, you know, it does make sense if you're constantly worn down and you're not being allowed to rest, that eventually you're going to get tired, you're going to get exhausted, you're going to hit that wall. So when I work with clients, I start out by asking them, what does depression mean to you? If you, a lot of times clients will come in and say, Doc, I'm depressed. Okay. Well, what does that mean to you? Because what depression looks like, there are, I think, 124 different permutations. If you do the math on all the different symptom combinations of what depression can look like. So if they say they're depressed, I know that they have low mood and lack loss of interest or pleasure in things most days for at least two weeks, but what else is going along with it? Apathy, sadness, mood swings, concentration, what does depression mean to you or what does it look like for you? And which symptoms are most bothersome for you and why? Why do I ask that question? Well, if they've got fatigue, difficulty concentrating, apathy, fatigue may be contributing to their loss of pleasure in stuff because they're just too dog-on tired to really get excited about anything. So if we address fatigue, if that symptom is important to them, they want more energy so they can get more stuff done, then it's probably going to help remediate some of the other symptoms. Same thing with eating. If they're eating changes, we know that eating and the hormones that are involved in appetite regulation are linked in small part at least to the circadian rhythms. So if somebody's not getting good quality sleep and the circadian rhythms are out of whack, then they may not know when they're hungry and when they're satiated. So if eating disturbances are a problem for them, then we're going to look at what's causing those and helping them focus on that, getting good nutrition and good sleep is going to help them feel better. So we want to look at what's causing these things. And then we want to look at what, for each symptom, take fatigue, for example, what makes it worse, what makes it better, what do you do to help on the days that you feel like you have a little more energy? What was different on those days? What can you do to start helping yourself feel like you have more energy? And obviously some of it, for most patients, is going to involve some education about the mind-body connection and why it's important to take care of the body in order to have a good mood. But we want to start out by saying, what do you already do? What makes it better? And on the days when you have less energy, what happened? What was different? What made your energy levels lower? I know last night we had a horrible storm come through. So I woke up a bunch throughout the night with the storm and the thunder and that kind of stuff. Because I knew my dogs, one of my dogs has really bad thunder anxiety. And I was worried about him. So today I'm dragging a little bit. Am I depressed? No. Is my, am I fatigued? Is my energy low? Yes. So I know that if I don't get good quality sleep, my energy levels are going to be lower. So have clients start making a very practical list. Of things they do to help them deal with each symptom. Instead of looking at depression as the whole, let's look at each symptom. Because as you remediate each symptom, the depression is probably going to improve. How is life more pleasurable prior to getting depressed? You know, so this is kind of a different way of asking that miracle question. You know, what was different before you were depressed? You know, what was going on? And this is how we can identify, start to identify problems in relationships, problems in stress management, things that are triggering their anxiety or consternation, maybe they're unhappy at their job or whatever. You know, they're going to start describing that. And if they can't remember a time when they weren't depressed, you know, that's okay. So let's talk about, you know, if you woke up tomorrow and you weren't depressed, what would be different? What would make life more pleasurable for you? What would it look like? How do you expect life to be different when your depression is gone? And we want to address those expectations because it's not going to be all, all roses and picnics and sunshiney days. There are going to be, you know, days where they feel okay, and there's going to be days where they feel a little sad. That's just normal human behavior. But we want to set some expectations and figure out what they're hoping to work towards. I spend a lot of time educating my clients about the importance of neurotransmitters and we can't measure those. And I will say it and I'll preach it from the hilltops. You can measure neurotransmitters in general through urine and blood levels, but that doesn't tell you the level of neurotransmitters in the brain. And the level of neurotransmitters in the brain is what's, what we're concerned about for mood. You know, how much serotonin you have in your gut is kind of irrelevant in large part to whether you're depressed or anxious. So when people want to measure their neurotransmitters, right now, we just don't have the technology to accurately do it in terms of measuring the neurotransmitters in your brain. But neurotransmitters are the way your body communicates the signals that allow you to feel pleasure, apathy, emotional flatness. So if you have too much of certain chemicals or not enough of certain chemicals, then you may, you're going to feel a certain way. And our brain chemicals need to be in a certain balance and they, they work with each other's. Some go up, others go down. And they're constantly in this ebb and flow state. And that's important. So when the neurotransmitters get out of whack is when people start feeling excessively depressed, you know, and I emphasize that feelings are normal. Anger, anxiety, guilt, all those feelings, they're normal reactions. And we don't want to get rid of feelings because then you're numb and how's life like that? It's what we do with those feelings. When you feel those feelings, do you fight with them? Do you struggle with them? Do you nurture them? Or do you figure out how to improve the next moment? You know, obviously happy feelings. We want to nurture as much as possible, but dysphoric feelings. We want to say, OK, you know, thank you, body, for telling me that I'm sad in the case of depression, that I'm, I'm sad that something that was important to me is not there anymore. What can I do to improve the next moment? Neurotransmitters affect memory, concentration, sleep, motivation, energy levels, pain tolerance, irritability, and just general stress symptoms. So when neurotransmitters are out of whack, when the body is not able to produce enough of the right neurotransmitters or when, you know, they're not getting enough rest for their brain to rebalance everything, then they can start having problems in any of these areas. But by helping the body be healthy, then it stands a better chance of rebalancing itself and helping the person start to feel better. So, yes, cognitions are almost always involved in tying up energy in holding on and nurturing dysphoric thoughts and, you know, scary thoughts and emotions. So, you know, I'm not saying that it's all about just fixing the body. But we need to fix the body too. So, to do that, people need to get quality sleep, create a sleep routine. And I said this yesterday, say it again, same three things you do before bed each night. And it doesn't have to be this long drawn out process. For me, I brush my teeth, let's see, I eat dinner. And then I come down and I brush my teeth and I get in bed and I start, I play through all my scrabble games. And my brain knows that when I'm finished with my scrabble games, I'm going to start drifting off to sleep. That's kind of my routine. And, you know, it's a good trigger now. When I start playing scrabble, I get sleepy. So, I don't do it during the day. But helping your body know that, okay, we're getting ready to do this. If you have it as a long drawn out thing, you're not likely to do it as much. So, if you have, you know, two or three things you do within like a 30 minute time span, then you can do those almost every night. Address pain and apnea. Pain will keep you awake. I had a really hard lift yesterday. And a couple of times, yes, last night when I woke up, I woke up because I had rolled over and I was just so sore that rolling over woke me up. And so, addressing pain issues so you don't wake up throughout the night is important. If people have fibromyalgia or back pain or anything else, making sure they have a good ergonomic sleeping environment is important. And to address sleep apnea, a lot of people have it. And sleep apnea is when you kind of stop breathing sporadically throughout the night. Snorers are especially guilty of having sleep apnea. So, if they think that they have it, it's important to get it checked out by the doctor. And a lot of times people with sleep apnea, their partners will say, yeah, it sounds like they're going to peel the paint off the walls when they snore. So, there's some good clues there. But even if somebody doesn't have sleep apnea, if you're sleeping with somebody who snores like a freight train, you're probably not getting great sleep. So, at least invest in some earplugs. Improve the sleep environment. Smells, you know, get rid of any stinky smells you can. Try to make it as pleasant as possible. Essential oils can help for calming, whether it's lavender or vanilla or whatever it is that you like the smell of. Make sure that the sheets are clean. You know, you don't want to be sleeping on top of dog dander and coughing all night long. Eliminate as much noise as possible and get it as dark as possible. Even nightlights can be bright enough, especially if it's a blue light. Nightlight can be bright enough to send a signal to your brain to keep it from secreting enough melatonin. So, if you're going to have a nightlight, try to have a nightlight that has a red bulb in it, just like they do in the exit signs and at the theater. So, it doesn't send the wrong cues to your brain. Make sure that if you're using a mobile device or even watching TV right up until the time you go to bed, if you can have a red filter on and there are apps from mobile devices that put a red filter on at a certain time like at sunset, so your brain quits getting the input from the blue lights that say it's time to be awake. On my television, I've actually turned up the red and turned down the blue. So, the colors are a little bit off, but you know, that's kind of the trade-off in order to be able to watch TV up until I go to sleep for me. Other factors to consider that may impair sleep, shift work. If somebody works the overnight shift, for example, it takes about 30 days for the body to really get used to a significant change in sleep schedule. Now, jet lag, you know, moving from a couple of time zones over, you can usually adjust to in a week or so, but a significant shift in sleep schedule takes about 30 days to get used to. And it's important if you're going to get used to it to keep that sleep schedule even on your days off, so law enforcement and EMS are notorious for having one sleep schedule during the week and one sleep schedule on their days off, and so their body never gets used to when it's supposed to be awake or asleep. Daylight savings time, it's only an hour, but it can throw people for a loop for a short period of time. And if they are already kind of struggling with either seasonal effective disorder or a mood disorder, that change in an hour can increase their fatigue significantly and they can feel a little bit worse. So, encouraging people if daylight savings time is coming up to start adjusting their sleep routine about 15 minutes each week leading up to it, so for about a month ahead of time. So it's not such a shock when the time changes. Relaxation, using biofeedback or progressive muscular relaxation can help people relax so they can get better sleep and they can also reduce pain and stress and a whole bunch of other things. Not everybody likes to meditate and that's cool. You know, people need to figure out what they want to do or what they can do to relax. And as I said yesterday, biofeedback can be accomplished really easily. You can get one of those little finger pulse ox sensors, you can get a fitness watch. If you want to get, you know, fancier or whatever, you can get one of the chest straps that monitors your heart rate that they use for fitness. And you can set it so the zones, it beeps when you are either too high or too low. Too low is not usually an issue unless you're working out, but it can alert you when your heart rate is getting up there, which can alert people to stress. Address medication side effects. Psychotropics, when people are taking them, most psychotropics have some side effects. So it's important for them to make sure that, number one, the medication is doing what they need it to do. Not every SSRI works for every person. And some people, when they're depressed, SSRIs don't work at all. For some of them, they need a SNRI, which is a selective norepinephrine reuptake inhibitor. And for some people, they do better on an atypical anti-psychotic. So it depends on what neurochemical is out of whack that's causing the depression. And I emphasize this to my clients because a lot of times doctors will start out and, you know, best practice guidelines are to start out with an SSRI. But if it doesn't work to talk to their doctor and we talk about the side effects and I encourage them to chart their side effects on certain medications because certain medications can make people feel really sluggish. Certain medications can make people feel a little bit more anxious. So if they're taking a medication and they notice it's increasing what a doctor I work with calls an unacceptable side effect, you know, one that makes them want to discontinue the medication, then they need to go back and talk to the doctor and say, hey doc, this isn't working for me. And they will decide from there whether to medicate the side effect or switch medications. Most of the time, it's switching medications. And encourage people to have good nutrition. Neurotransmitters are made from the amino acids that are in the good quality proteins. So people need good quality protein. It can be vegetarian protein, but it needs to be good quality protein. And, but in order for the body to break those amino acids down and make neurotransmitters, you know, the body also has to have vitamins and minerals, a whole mess of them. So it's important that people eat a balanced diet and talk to their doctor if necessary about taking a multivitamin. Address addictive behaviors. Addictive behaviors cause the body to dump dopamine and, you know, your pleasure chemical. And it's like, woohoo, this is great. And then crash and eventually, you know, very oversimplified, but eventually the body isn't going to get enough dopamine without the addictive behaviors. So when people are not engaging in that behavior, they're going to feel flat and depressed. The great thing is the body can 99% of the time recover from that. But it takes time for the brain to go, okay, I'm not going to get flooded with dopamine anymore so I can open up some more receptors and balance things out again. It takes time six months to a year for most people. Address chronic or extreme stress. Both of these things increase the amount of neurotransmitters flooding the synapses. To protect the body from overload, the brain shuts down some of the receptors so the body doesn't overload and people get tolerant or kind of desensitized to it. When the neurotransmitters return to a normal level, the receptors are still shut down so not enough neurotransmitter gets sent out. Things that normally caused a reaction no longer are strong enough to cause a reaction. So when people are under a lot of stress, eventually the body goes, you know, I can't stay flooded with all this cortisol and stuff anymore. I got to, you know, rein it in a little bit. So it starts shutting down some receptors so the body isn't overstimulated all the time because the body can't do that. It's the brain is protecting you. It's, you know, feels kind of weird, but the brain is protecting you. But by shutting down and becoming desensitized and less bothered by stuff, that means you become less excited by things, but you also become less stressed by things, which leaves you in this gray area, the Eur area. So people start feeling kind of depressed. Hormones, thyroid hormones impact mood, libido and energy levels. Thyroid hormones are really easy to measure. So we want to make sure that people get a physical estrogen boosts neurotransmitters that affect sleep, mood, memory, libido, pain perception, learning and attention span. An increased estrogen may increase the availability of serotonin. Low testosterone may be implicated in reducing the availability of serotonin. Testosterone is manufactured in the adrenals. So, and you'll understand why I'm going through this in a minute. Enhanced libido improves stamina and sleep, assists in brain function and is associated with assertive behavior and a sense of well-being. When the HPA axis is activated, when there's a threat, the threat response system goes off. It secretes cortisol and causes a whole bunch of other reactions, but we're just going to go through the simple chain. Secretes cortisol. Cortisol tells the body, you know what? We don't need estrogen. We can reduce estrogen and we can reduce serotonin. We don't need to calm down and we don't need to procreate because there's a stressor out here. Well, you see the problem with that, right? We've reduced serotonin, which is our calming chemical, and also responsible for depression in some people. And the body's reduced estrogen, which is responsible for helping serotonin be available. So we've kind of doubly reduced serotonin in order to prepare for that fight or flee. So it makes sense that if people are under chronic stress, then their serotonin levels and potentially sex hormone levels are going to be extra low. Which can contribute to depression. So I want people to see the correlation between stress and low libido and low mood, as well as understand that, you know, if they have some sort of hormone imbalance, it can also cause low mood. In response to the question, how do the receptors get turned on once they've shut down? The really cool thing is the body recognizes it. And I don't know how it recognizes it. But after a certain period of time, it realizes that things are going to be okay. And so it starts opening up, if you will, the receptor sites. And it usually takes a while. So it's a gradual process where some of those receptors are reactivated, if you will, to let more dopamine go through the system again. And I mean, it's kind of a cool process to watch in people when you start seeing them feeling happier and you're like, oh, wow, you know, things that didn't make them happy six months ago are now starting to make them, you know, at least mildly happy. One of my clients referred to it as seeing colors. He, he was a chronic relapser and, you know, we would talk and each time he came through the treatment program, we talk about what went wrong and what may have led to his relapse and yada, yada, yada. And finally, one day I remember him saying, you know what? One of the hardest things for me to stay clean is that I go out there and I do fine for the first couple of months, but there's just no color in the world. It's just gray. There's no highs. There's no lows. There's no color. And it's hard for me to go on living like that. There's just no motivation. And so I want color and that's what causes me to relapse because that brings color back. And I was like, oh, okay, well, that makes sense. Because, you know, his dopamine levels were way out of whack. So until he could start experiencing emotional variation, there was no reward. You know, dopamine is your reward chemical. He didn't have enough dopamine going through the system. So there was, wasn't enough reward to keep him doing the recovery, living the recovery lifestyle. But eventually, he figured that out and, you know, long story short, he's been clean for almost a decade now. So it is possible. It just, it takes time, but we do know that people in early recovery go through a period, often go through a period where there is significant depression and sometimes anxiety. And a lot of times that will remit after a year or two, may sometimes less for those people, even without intervention. However, we also know that if those mood issues are left unattended during the early recovery period, they are at much greater risk of relapse. So it's important to attend to the co-occurring issues. If somebody has depression or whatever, we need to make sure that they're not maintaining it with addictive behaviors. And if they have addictive behaviors, we need to make sure that we're addressing the depression, so they're not, you know, feeling this pull back towards the addictive behaviors to elevate their dopamine levels. And yeah, fake it till you make it can be one process for getting through this period until the receptors become activated again. Some people in order to deal with the depression or their anxiety is bad enough. Some people will do a short course of medication and find it helps a lot. It just depends on the person. Cortisol is also made by the adrenal glands and helps the body adapt to stress by increasing heart rate, respiration and blood pressure. Cortisol levels increase in the morning to prepare to meet the day's demands and gradually decrease throughout the day. This is your circadian rhythm. So it's important that we have enough cortisol and, you know, you don't want to eliminate cortisol. You want to make sure that you have enough because that helps you get energized. That helps you respond to threats. That helps you feel things. So cortisol is a stress hormone, but it also is important for giving you enough motivation to want to get out of bed. DHEA is also another hormone that can increase libido and sexual arousal, improve motivation, engender a sense of well-being, decrease pain, facilitate good sleep and enhance memory and immune system function. Can you take it in supplements? Yes. Is it recommended? No. The amount of DHEA that your body actually needs is minuscule compared to what they have in supplements. So is it important to be aware of? Yes. If the person's DHEA levels are low, definitely something the doctor needs to help them navigate. So encourage clients to get a physical to identify and address what might be causing any imbalances that are there. Encourage them, if appropriate, to eat a low glycemic diet so their blood sugar is not spiking and then crashing. I haven't had an example yet, an instance yet where a low glycemic diet has been contraindicated, but obviously, you know, that's between them and their physician. The less sleep you get, the higher your cortisol level will be. The more sleep you get, the lower the cortisol will be. So it's important and it's not just sleep hours. You want to have quality sleep, but that will help reduce cortisol levels, reduce stress levels, which will let testosterone and estrogen levels increase and serotonin availability increase. Final thoughts, hormone imbalances affect millions of people. Symptoms include feeling anxious, tired, irritable, gaining or losing weight, not sleeping well and noticing changes in sex drive, focus and appetite, which all sound like depressive symptoms to me. So we want to make sure we're dealing with apples or oranges. You know, we don't want to be treating depression as a cognitive issue if it's really a hormonal issue. Causes for hormonal imbalances include poor gut health, inflammation, high amounts of stress, genetic susceptibility and toxicity. Natural treatments for hormone imbalances include eating an anti-inflammatory diet, consuming enough omega-3s, getting good sleep, exercising and controlling stress. So most of these are pretty easy for people to research and start implementing provided there are no contraindications. With pain, it's important to remember that our body is divided into quarters, if you will. We have the mid-sagittal or the midline, so your front and your back, or no, I'm sorry, your left and your right and the coronal or the frontal, your front and your back. So think about your muscles. You have your biceps and your triceps. They're front and back. They need to be balanced. If they're imbalanced, you're going to have pain. Think about your chest muscles or your back muscles. You know, they attach, your chest muscles attached to your sternum. If one side is stronger than the other, it could cause pain. This is especially true in your back because they kind of attach around your spine and imbalances on one side can cause pain on the other side. And I've got scoliosis, so my back looks like, you know, a speedway, not, not an actual straight up and down line. But I've always struggled with maintaining muscular balance between the right and the left. And when there is an imbalance, the weaker side spasms quite often, and it causes pain. So encouraging people to be aware of they need balance. If they're exercising, they need balance. They don't want to just do sit-ups without doing back exercises. They don't want to do just chest press without doing back exercises, etc. Same thing with stretching. You don't want to just stretch your hamstrings. You need to stretch your quads. People can exercise to help balance out muscle imbalances. They can use guided imagery and all of these things can cause pain. So exercise can reduce pain by helping reduce muscle imbalances. And also exercise can help loosen muscles. There's a method of stretching that is an active stretching. So when you are tensing one muscle, like when I'm tensing my bicep, my tricep has to relax. It has no choice. So when people have, for example, low back pain, their doctor may prescribe, obviously, doctor want to do this, not us, but their doctor may prescribe crunches, because if they're tensing their stomach, then those low back muscles have to relax. So when you, you know, when you're doing something, you know, if you strain your back, you know how it feels better. If you kind of curl up into the fetal position, well, you're tensing your abdominal muscles, which is forcing those back ones to relax. So exercise can actually help loosen things up if you do it gently. Guided imagery can help with pain. Imagine the pain going out. Imagine the pain like the color red and imagine it flowing out of your body. Muscle relaxation, obviously, will help with muscle imbalances. Alternate focus, if you focus on what hurts, it's probably going to hurt more because you're paying attention to it. If you focus on something else, then it may not hurt as much. And you can focus on something like sometimes when I'm driving, I'll get a tickle in the arch of my foot. And I hate that because I can't like reach down and scratch it. So I have to focus on something else. And I focus on driving or I focus on how the seat feels or I focus on whether I'm too hot or too cold to quit thinking about that. And eventually the feeling goes away. Same thing is true with pain. If we can get people to focus somewhere else, then their body often will forget that there's some sort of pain there. And this is especially true with non-muscle spasming pain. You know, like after you have surgery, if you have a broken bone, if you can focus somewhere else, the aching may stop a little bit more. TENS therapy, which is Transcutaneous Electronic Nerve Stimulation sounds horrible, but it really isn't. You can actually buy them over the counter now. And they're just little electrode patches you put on and it sends tiny little electric impulses and it feels like somebody is just kind of tapping on you. But it bombards the nerve endings. So the nerve endings aren't getting the pain signals anymore and you don't feel the pain for a few minutes. Physical therapy obviously can help with any muscle imbalances or whatever is causing pain, range of motion. Hydrotherapy, that's usually hot, you know, sitting in a hot tub. Most people can go to the gym or whatever and sit in a hot tub or in a hot bath. Ice or heat depending on how acute the injury is and what feels best. And hypnosis. Hypnosis has been shown to be really helpful for managing chronic pain. So any of these things can help our clients. And obviously I didn't even put opiates on here. Any of these things are non-pharmacological interventions to help clients manage pain. And pain can lead people to feel very helpless, hopeless and frustrated. If they wake up in the morning and they hurt and they hurt all day and they can't do the stuff they used to do because it hurts, it can be very frustrating and depressing. So helping them manage their pain not only helps them improve their sleep, but it can help provide them a sense of confidence and hope and empowerment. Emotions, anger, resentment, jealousy, envy and guilt. Anger, remember, is half of the fight or flight reaction and it pushes people away or asserts dominance and control. It either pushes them away or kind of pushes them down, if you will, so you're on top. Excessive anger can exhaust the stress response system, contribute to negative cognition. So people who tend to be excessively angry tend to see the world in negative terms. They look for the worst, they see the worst, they're always waiting for the other shoe to drop. It can impair relationships so that buffer against stress starts to go away and it can actually cause physical harm. They've done a lot of studies that have shown people who tend to be angrier tend to have more health problems. So in group or individual, when you're working with clients, ask them, when you're angry, what do you notice? You know, do you notice the good things? Do you notice the bad things? What are your anger triggers? And this can be a fun one to do on the board where people just start shouting out the things that irritate them. And then we go back and talk about why each one of those things makes them feel vulnerable. And they're like, wait a minute, we were talking about anger. And I said, yeah, we were, weren't we? Was how are anger and vulnerability related? Well, when you feel vulnerable, that means there's a perceived threat or there could be a threat. And so people when they feel vulnerable tend to get either angry or anxious. So why do each one of those things make you feel vulnerable or angry? And then we talk about whether it's an external threat, you know, something that could hurt them from outside or as an internal threat, something that's coming from their critical inner self that's telling them, you're not good enough or I always knew you would screw up. Then we move on to talking about how they can address each trigger to feel safer and more empowered. Now an individual, I usually do this in a series of homework assignments, you know, we talk about in session when you're angry, what do you notice? Homework for the first session is what are your anger triggers? Make a list of them over the next week. And then when they come back in, we talk about why the anger triggers make them feel vulnerable. And then their homework for the second week is to figure out three ways they can address each trigger to help them feel safer and more empowered. So for example, if something causes their internal critic to start telling them that they're not good enough and nobody will ever love them, how can they address that internal critic in order to basically shut it up? Jealousy. Now we think of anger and anxiety, those are easy. Resentment, you can see is anger, but what about jealousy and envy? Well, jealousy, if you think of it as really anger at somebody or envy is really anger at somebody for having something you want or anger at yourself for not having something somebody else has, but it's anger. If you're jealous about something, you want to look at what does whatever they have represent to you? Why does it make you feel vulnerable or less than or disempowered? So have people make a list of the things that they envy or they're jealous of and identify why they're jealous of them? What is it about, you know, such and so celebrity that makes you feel jealous of them? In what ways are they better or better off than you because of those things? So let's talk, let's get down to it. Let's be honest. How does this envy or jealousy affect you? So, you know, people who live in mansions and have millions of dollars and don't have to worry about, you know, finances at all. Yeah, you know, in a way, they may be better off. But, you know, there's lots of other things that I have that they don't. So, but that's not in this exercise. So we say, okay, you know, they don't have the stress of worrying about finances. That's true. How does this envy or jealousy affect you? Well, generally it's not in a good way. So we want to look at is being angry at them for not having to worry about their finances. Is that helping you move towards a rich and meaningful life? Is that helping you in your life in any way? And if not, what is a more productive way to use this energy? Guilt can be thought of as shame, embarrassment or self-anger for something that you did or you should have done. So you can see how these are all kind of coming together. When somebody passes away, many times people will feel guilty because they're like, well, I should have told them how much I love them or I shouldn't have had our last discussion be a fight or, you know, whatever. There's lots of shoulds and shouldn'ts that contribute to guilt. So it's anger at yourself most of the time. Some people have difficulty letting go of guilt because they think they deserve to suffer. You know, I should have been a better friend to them and I should have noticed this. So I deserve to suffer for it. So I'm going to hold on to this guilt or they fear that if they forgive themselves, they might do it again. So we talk about the difference between forgiving and forgiving and forgetting versus forgiving and learning because forgiving is a power play. Forgiving is me saying, you know what? I am not going to leave my energy stuck and tied up in this. I'm going to accept that it happened. I'm going to learn from it and I'm going to move on. Have people make a list of things they feel guilty about, which sometimes is thought of as a fearless moral inventory and then have them think about, okay, how can I make amends, learn from it and then ultimately forgive myself? You know, it's always going to be there. You know, I'm always going to have that memory. I'm not going to forget it, but how can I move past it? So I'm not, pardon me, is not stuck back there. The second activity for guilt is to have people really start talking about what forgiveness means. A lot, a lot of people who, especially those who have been traumatized or abused, have difficulty with the concept of forgiveness because they don't want to tell, feel like they're telling somebody, it's okay, you did this. Forgiveness doesn't have to mean that. Forgiveness can be letting go of the hurt. Great, great concept, Carl. And it's also a way of saying, you know what? It happened. I can't change it, but I am not willing to stay miserable for something that you did. So we talk about, before we go into all that, we talk about how the concept of forgiveness makes people feel and usually I get a whole bunch of negative reactions because they're like, oh, I ain't going to forgive that. You know, okay, you know, let's talk about that. And what is the phrase, forgiveness is not for them, it's for you, mean. And I let them sit with that for a while and we talk about what that might mean. And then we start talking about ways they might be able to move towards forgiveness to anything that's, they're stuck on. Anxiety is the other half of fight or flight. And chronic anxiety, worry and stress, also exhaust the stress response system, causing those neurochemical imbalances and hormone imbalances. So just like too much anger can be bad, too much anxiety can be bad. Anxiety makes it harder to sleep, which leads to exhaustion, hormone, excess cortisol, hormone imbalances, which can eventually lead to depressive symptoms. So for half people write down three situations in which they experience the common fears, if you will, three things that trigger their fear of rejection and isolation, three fears that trigger their fear of, three things that trigger their fear of failure, loss of control and the unknown. And then we talk about why those situations trigger anxiety and brainstorm ways to deal with them. And you can actually turn this into a four group series. So one group or sometimes three groups, one group, you talk about rejection and isolation. Another group, you talk about things that trigger failure and how to deal with them. And the third group, you talk about loss of control and the unknown and how to deal with that, because we don't know what's going to happen in 30 minutes, let alone what's going to happen a week from now. So we, in life, we have to accept that there's certain amount of things that are unknown and there are certain things we can't control. Grief is sadness or depression and is experienced as the result of a loss of something important. And grief is our body's way, depression is our body's way of saying you lost something that was important to you. Well, things, if we didn't feel that, you know, we wouldn't be able to know when there was something truly important that was gone, so to speak. So grief involves often anger at yourself for whatever happened at the other person or the situation for whatever happened and sometimes at the higher power for what happened. So going through grief, you need to deal with your anger and when you lose something, you know, let's go back to those basic fears. When you lose something, you know, somebody dies, for example, or you break up from a relationship, you may be experiencing rejection, isolation, loss of control, the unknown and failure all at once from one death or relationship break up or whatever. So yeah, it makes sense that it's going to trigger your fight or flight response. So either anger or anxiety. Once you feel that for a while and you start realizing, well, there's nothing I can do to change it, then that sense of helplessness to change the situation may sit in set in and hopelessness that you're going to be able to move on. Can kick in, not always, but a lot of times people go through a period of helplessness and hopelessness and, you know, life will never be the same without this person in it, yada, yada, and they need to work through that. But do remember that losses are not just about death. It can be loss of dreams, loss of hopes, loss of the way you thought your life should have been when you were growing up, loss of, you know, the idea that somebody would ever behave the way you wanted them to. So we need to look at all of these losses which often represent a loss of control. And yes, most emotional pain, most things that cause us anger or anxiety represent some sort of loss of control or failure or rejection and things that cause depression also involve losses. So losses are involved in a lot. So we want to help clients recognize that there is a grief process. Does it have, does every loss take two years to grieve? No. You know, some things will take a little while. Some things you can get through in a day depending on how important that loss was to you. You know, if you get rejected, you apply for a job and you don't get it. Yeah, it may sting for a minute. You make it angry for a second, then get depressed and then you move on to acceptance. You're like, okay, well, let's figure out what to do next. That's a loss that may not be super significant so you can go through it a little bit faster. A loss of a pet or a loved one or a friend or a relationship can take a lot longer. So, you know, helping people see that it's a process and understand the function of the process. So have people, if they're dealing with a lot of grief that is maintaining their depression, identify their losses. And I have a lot of them listed here, dreams, hope, faith, safety, independence, innocence. You know, there's a lot of those existential type things that people can lose, but they hang on to. And they're angry that somebody took it away or somebody didn't give it to them. Socially, they can have losses because they moved. You know, just when you move, when we moved to Tennessee, you know, my best friend is still down in Florida. We're still friends. You know, we can still talk online, but we're not going over to each other's houses, you know, three, four times a week. You can lose people and pets due to deaths or relationships ending. Physical losses can include loss of abilities. So, you know, as you get older and you lose your ability to see as well, or when people get Parkinson's and they can't do some of the things they used to do because they're shaking too much. You can lose your health. You can lose your appearance. As people get older, their appearances change, and some people have to grieve that. Some people don't move into an acceptance with that very well. So it underscores a lot of their depression because they don't feel like they can fight the hands of time, which again, is a loss of control. You can't control time. And you can lose property. You can lose stuff. Houses, your favorite bike, your grandmother's brooch, these things may be more or less significant. However, it's important for the client to look at the loss and come to some understanding of it, figure out whether it's important and deal with it. They need to identify what about each of these losses makes them angry or fearful. Develop an action plan to deal with that anger or fear and give them self-permission to grieve, not to say, well, it's stupid to be upset over that. You are upset over that. It was important to you. So go ahead. People often have different reactions to when their pets die. When our pets die, they're parts of our family and it's devastating for us. So I give myself permission to grieve. And even when we live on a farm and when one of our chickens passes away, it's not devastating. I'm not gonna be upset for days on end about it, but it's sad for a few minutes and we always give it a little funeral and whatever, but that's how we deal with it because each life is precious to us, even if it's not a human. Part two is acceptance. True losses can't be reacquired. Once they're gone, they're gone. The final step in grief resolution, the grief resolution process is moving towards acceptance, but first clients have to know what acceptance means to them. So for each loss, that may be something different. And I encourage them to think about writing their own story. They're a character in their own narrative. So how would you end this part of the storyline? How would you end this part of the storyline? Sometimes it's closing an entire chapter. Sometimes it's just ending a tangential storyline somewhere, but how do they tie that up so they can move on and start to have new experiences in their story? Happiness. Well, you can't be happy and depressed at the same time. So we've talked about eliminating a lot of stuff, but we wanna increase happiness. We wanna bring more of it. Happiness chemicals reduce stress and depression. So increase the happy times by finding some comedians that you like. Children can often make you laugh. Even YouTube videos of babies laughing. If you listen to a long enough, you can't help but laugh. Or silly animal videos or knock, knock jokes. Whatever it is that makes you laugh, preferably with a belly laugh, will help release endorphins and improve happiness chemicals. Cognitively, address negative thinking styles because these contribute to exhaustion. If you're always looking at the world as a dark, scary, unpleasant place, you're gonna keep that threat response system more active and or contribute to your sense of hopelessness and helplessness. You're looking around at this bleak landscape. If you have a more positive thinking style and you focus on some of the good stuff, then it kinda normalizes things. It's important to encourage clients to highlight what is out of their control and figure out how to come to acceptance of that. I can't control the weather. I can't control other people, for example. So identify those things and figure out how to deal with the fact that you just ain't ever gonna be able to control it. So you might as well figure out a way to be okay with that. And negative thinking styles heighten the sense of helplessness and hopelessness, cause it's just yucky. So encourage people to look at cognitive distortions such as all or nothing thinking and avoid creating self-fulfilling prophecies. When you're expecting something bad to happen, usually you can find the bad in whatever does happen. So encourage them to try to balance things and embrace the dialectics. Yes, the bad stuff happened and it's unfortunate. What else is there? And the same thing with hardiness, remember commitment, control and challenge. Things may be going really poorly in one aspect, but in eight other aspects of your life, they're going really well. So you're committed to those eight aspects. And yeah, this one over here we're gonna address, but those eight other aspects give you a reason to continue getting out of bed in the morning. Poor self-esteem contributes to self-loathing, shame and a feeling of unlovability. Negative and it negatively impacts relationships because people with poor self-esteem generally are constantly seeking external validation and can have very poor boundaries. Encourage people to complete a self-esteem inventory for all the characteristics that are important to them in their self-esteem inventory who they really want to be that they don't already have. Encourage them to answer their following questions. If your child or best friend had this flaw, would you still love them? And most of the time they're like, well, yeah, okay. So yeah, you're not perfect. However, are you still lovable? Unhealthy and unsupportive relationships also take a toll on self-esteem and enhance fears of abandonment, which maintains high levels of stress and feelings of helplessness because we know we can't control other people. And if we're constantly worried that they're going to leave us and we're going to be unable to cope, then we're constantly on edge. We're constantly hyper-vigilant, looking for signs or symptoms that that person might abandon us. Unhealthy relationships also fail to buffer against stress, which can lead to exhaustion, neurotransmitter imbalances and depression. Environmentally, high stress environments prevent relaxation and rest, increase hopelessness and helplessness and increase stress hormones and decrease relaxation hormones. Think about soldiers that are on the battlefield in a foxhole. That is a high stress environment and they're not going to be able to get good rest. You know, you watch the old mass shows and stuff and I'm like, how did they ever even sleep in those tents? I don't think they ever got good sleep. So when you're in a high stress environment, obviously most of us are not deployed, but even if your home life is highly stressful because of financial concerns or relationship issues, the person may be having difficulty getting good rest and may feel trapped and stuck, which leads to feelings of hopelessness and helplessness. Have people design a low stress area in their home? Bedrooms are good. I have, you know, my bedroom is a low stress area, but I also have an area in the living room. That's my little corner. I've got a tapestry of the serenity prayer and my chair and stuff, but a place where they can go where they can sit and just be. You know, it's got happy triggers in it. It's got happy things to see. It's got things that make them feel calm. If it smells good, even all the better. Have them identify ways to reduce the stress in their environment in most places that they are, in the car, at home and at work, such as noise. If they don't like certain noises, how can they drown it out with white noise or try to eliminate it? Interruptions, if they really bother you, how can you control for that? Poor lighting can put a lot of stress on people. It can increase eye strain, headaches, pain, all kinds of stuff. And negativity, you know, if you're in an environment where there's a lot of negativity, even if you're not the negative one, it can be really stressful. So figuring out how to deal with that negativity to create sort of a force field so it doesn't permeate and make you depressed and negative is really important for clients to do. And have clients identify ways to turn the negative into a positive because crap happens. So when stuff happens, how can you make it work for you? You know, if your kid's playing in the house and he breaks a window, well, that's a negative. It's a stressor, but, you know, the good news is now you can get a new double-pane insulated window or something. So try to find ways to embrace both, you know, the negative that happened, but what can be the positive outcome? So remember or remind clients that they experience emotions through neurochemical signals. Inbalances in the neurochemical system leads to problems in mood, concentration, energy, libido, sleep, and eating behaviors, AKA depression, which leads to more imbalances in the neurochemical system. It's sort of this negative spiral. Depression symptoms are a huge trigger for relapse into addictions. And addiction symptoms are huge triggers for relapse into depression. So we need to make sure we treat both of them. When we're talking about recovery for people and depression, it's important for them to identify what causes the neurochemical imbalances for them, not for their person sitting next to them and address those causes. That's crucial to recovery. They can start doing this by just looking at what helps when I'm feeling blue, when I'm feeling depressed, what helps and what makes it worse. So we know what to do and what not to do and then we can start building on that. Depression is the cluster of symptoms created when there's a neurochemical imbalance in the brain. What causes the imbalance can be emotional, cognitive, physical, interpersonal, environmental, or some combination of the above. And it's usually a combination. Part of the strengths-based approach means helping people see what they already are doing to prevent or deal with those symptoms and build on that, because they can start doing that right now. And biopsychosocial means remembering to examine all of the cognitive factors, not just relationships and thought patterns, but also the biological stuff and the environment and recognize that all these factors are reciprocal in nature. When one starts getting better, it'll have a positive impact on the rest. When one starts going wonky, it could have a negative impact on the rest. So we need to pay attention to the person holistically. Are there any questions? Do your clients need a little help staying on track between sessions? Are you looking for a great aftercare resource? Look no further than docsnipes.com. For as little as $15 per week, Dr. Snipes provides concierge coaching services to clients through online weekly groups, chat availability seven days a week, and members-only resources. Learn more at docsnipes.com.