Counselor Toolbox Podcast

Treating Opiate Addiction Presented by: Dr. Dawn-Elise Snipes Executive Director, AllCEUs California Drug and Alcohol Treatment Assessment's Findings ~ Treatment was cost beneficial averaging $7 returned for every dollar invested ~ Patients in MAT showed the greatest reduction in intensity of heroin use ~ Decreased healthcare use ~ Number of days of hospitalization, down  more than half during MAT Pharmacology ~ 5 Topics • Receptors • Function of opioids at receptors • Consequences of repeated administration and withdrawal of opioids • The affinity, intrinsic activity and dissociation of opioids from receptors • General characteristics of abused opioids Receptors ~ Different types in the brain ~ Mu receptor is most relevant to opioid treatment ~ Activation of the mu receptor allows opioids to exert their analgesic, euphorigenic and addictive effects Functions of Opioids at Receptors ~ Full Agonists ~ Activate receptors in the brain ~ Bind to receptors and turn them on ~ Increasing doses of full agonists produce increasing effects, until the receptor is fully activated ~ Opioids with the greatest abuse potential are full agonists ~ Examples of full agonists are morphine, heroin, methadone, oxycodone and hydromorphone Functions of Opioids at Receptors cont… ~ Antagonists ~ Bind to opioid receptors, but instead of activating receptors, they effectively block them ~ Prevent receptors from being activated by agonist compounds ~ Like a key that fits in a lock but does not open it and prevents another key from being inserted ~ Examples of opioid antagonists are naltrexone and naloxone Functions of Opioids at Receptors cont… ~ Partial Agonists ~ Bind to receptors and activate them but not to the same degree as full agonists ~ Increasing effects of partial agonists reach maximum levels and do not increase further, even if doses continue to rise—the ceiling effect ~ As higher doses are reached, partial agonists can act like antagonists by occupying receptors but not activating them and blocking full agonists from receptors ~ Buprenorphine is an example of a mu opioid partial agonist Consequences of Repeated Administration and Withdrawal ~ Repeated administration of a mu opioid agonist results in tolerance and dose-dependent physical dependence ~ Spontaneous withdrawal ~ begins 6–12 hours after the last dose ~ peaks in intensity 36–72 ~ lasts approximately 5 days ~ Precipitated withdrawal occurs when an individual physically dependent on opioids is administered an opioid antagonist or partial agonist Characteristics of Abused Drugs ~ Rate of onset of the pharmacological effects of a drug, and its abuse potential, is determined by: ~ the drug's route of administration ~ its half-life ~ Abuse Potential is related to: ~ ease of administration ~ cost of the drug ~ how fast the user experiences the desired results Naltrexone ~ Antagonist ~ Naltrexone may decrease the likelihood of relapse to drinking (vivtrol) ~ Can precipitate an opioid withdrawal syndrome in buprenorphine-maintained patients ~ Should not  be prescribed for patients being treated with buprenorphine for opioid addiction Buprenorphine ~ Because it is a partial agonist, higher doses of have fewer adverse effects ~ Slow dissociation rate (long half life) ~ Abuse of buprenorphine primarily via diverting sublingual tablets to the injection route ~ Buprenorphine's partial mu agonist properties make it mildly reinforcing thus encouraging patient compliance with regular administration ~ Suboxone is buprenorphine plus naloxone ~ Naloxone exerts antagonist properties when inject

Dialectical Behavior Therapy Skills Problem Solving Strategies Presented by: Dr. Dawn-Elise Snipes Executive Director, AllCEUs Objectives ~    Review the 4 options for problem solving ~    Go over problem solving steps ~    Review concepts such as force field analysis, root cause analysis, backward chaining Problem Solving Options ~    Stay Miserable or, Make Things Worse, by creating other, new problems for yourself ~    Tolerate The Problem this involves accepting that the problem is happening, and tolerating both the problem itself and your responses to the problem ~    Feel Better About The Problem by changing or regulating your emotional and cognitive response to the problem ~    Solve The Problem this involves changing the situation, or avoiding, leaving, or getting out of the situation for good Problem Solving Steps ~    Wise Mind What Skills ~    Observe and describe the situation ~    Check the facts ~    Identify the goal in solving the problem ~    Brainstorm solutions ~    Choose a solution that is likely to work ~    Put the solution into action ~    Evaluate the outcomes Observe and Describe Problem and Context ~    Who is involved ~    Don’t jump to who is causing the problem ~    When did this happen ~    Where did this happen ~    What ~    Is the present situation ~    Are my contributions, vulnerabilities ~    Are my current thoughts and feelings ~    Are others contributions, vulnerabilities Defining the Problem: Root Cause Analysis ~    It's amazing how much you don't know about what you don't know. ~    Get input from other people who notice the problem and who are effected by it, one at a time ~    Write down your opinions and what you've heard from others. ~    Seek advice to verify your impression of the problem. Root Cause Analysis Chain Analysis Check the Facts ~    Is this a reaction to the environment or your thoughts? ~    Are you using emotional or factual reasoning? ~    Increase mindfulness to the facts of the present situation ~    Look beyond yourself to the other person and the context (Consider the entire picture) ~    Are you using all or none reasoning? (Middle path) Check the Facts ~    Do the emotions fit the facts (Why am I feeling this way) ~    No (It is not an effective emotional response) ~    Radical Acceptance ~    Identify opposite thoughts ~    Yes (It is an effective emotional response) ~    Radical Acceptance ~    Distress Tolerance ~    Problem Solve (Wise Mind) Identify the Goal ~    Stay Miserable ~    Tolerate (Distress Tolerance, Emotion Regulation) ~    Feel Better (Change your thoughts and feelings about the situation) ~    Solve (Change the situation) Brainstorm Solutions ~    Distress Tolerance (IMPROVE and ACCEPTS) ~    Emotion Regulation: Address Vulnerabilities ~    Change Thoughts ~    Middle path ~    Focus on the negative (don’t romanticize) to force a behavior change ~    Cheerleading thoughts (SMS Message scheduler) ~    Relapse Prevention Plan/Purposeful Action ~    Identify alternate possibilities Brainstorm Solutions ~    Change Feelings ~    Focus on positive stuff to get happier ~    Attitude of gratitude ~    What makes you happy ~    Change the situation ~    Remove or eliminate the trigger ~    Use interpersonal effectiveness skills to address the situation (seek to understand and create a win/win) ~    Add something to alter the situation Force Field analysis Choose the Best Option ~    This is the best option for you that is effective at helping you move closer to your goals

Dialectical Behavior Therapy Skills Dialectical Strategies Presented by: Dr. Dawn-Elise Snipes CEUs are available for this series at https://www.allceus.com/member/cart/index/product/id/665/c/ Objectives ~    Define Dialectical Theory ~    Review Dialectical Strategies to help clients identify ~    Truth ~    Reality Walking the Middle Path-Dialectics ~    The universe is filled with opposing sides/forces Ex. Losses, Changes, Recovery ~    Good/Bad ~    Happy/Sad ~    Right/Wrong (Hans Dilemma) ~    There is always more than one way to see a situation and more than one way to solve a problem ~    Two things that seem opposite can be true Walking the Middle Path-Dialectics ~    What we do influences our environment and the people in it and they influence us ~    Everything is interconnected in some way (butterfly) ~    Recovery ~    Your mood ~    Changing jobs ~    Meaning and truth evolve over time ~    What is something that was meaningful to you as a child that is not as meaningful now? ~    What is something that is true now that wasn’t true 6 months ago? ~    Each moment is a new reality (beginners mind) Dialectics Checklist ~    Asked the wise mind “what am I missing” ~    Looked for a kernel of truth in the other person’s side ~    Avoided extremes such as always and never ~    Validated both myself and the other person ~    Accepted reality and tried to change it ~    Made lemonade from lemons ~    Embraced confusion ~    Played devil’s advocate ~    Used a metaphor to describe my own point of view Dialectics Checklist ~    Treated others as I want to be treated ~    Looked for similarities between us ~    Noticed the connections between all things ~    Practiced radical acceptance ~    Embraced change ~    Practiced letting go of blame ~    Remembered that change is transactional ~    Reminded myself that all things, including behaviors, are caused Keeping Your Balance ~    Use your wise mind to ask “What am I missing?” ~    Let go of extremes change either/or to both/and ~    Balance opposites by validating both sides ~    Make lemonade.  Find the silver lining ~    Treat others as you want to be treated ~    Look for similarities, not differences ~    Practice radical acceptance ~    Practice accepting change Keeping Your Balance ~    Pay attention to your impact on others and how they impact you ~    Let go of blame ~    Remember that all behaviors are caused Important Things to Balance ~    Accepting and Changing Reality ~    Validating Yourself and Acknowledging Errors ~    Working and Resting ~    Needs and Wants ~    Self Improvement and Self-Acceptance ~    Emotion Regulation and Emotion Acceptance ~    Independence and Dependence ~    Openness and Privacy ~    Trust and Suspicion ~    Focusing on Self and Focusing on Others Summary ~    Dialectics is based on the premises that ~    Truth can be found by integrating multiple points of view ~    Reality is ever changing ~    By walking the middle path with awareness of the differing forces we can ~    Radically accept reality ~    Minimize emotional turmoil

Dialectical Behavior Therapy Skills Interpersonal Effectiveness Presented by: Dr. Dawn-Elise Snipes Executive Director, AllCEUs counselor education Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery CEUs are available for this podcast at https://www.allceus.com/member/cart/index/product/id/665/c/ Objectives ~    Define interpersonal effectiveness ~    Examine the goals of interpersonal effectiveness ~    Identify barriers to interpersonal effectiveness Definition and Goals ~    Interpersonal effectiveness is the ability to ask for what you want and need, and say no to unwanted requests ~    By getting your needs met and being able to set boundaries you: ~    Will feel more respected ~    Reduce anger and resentment ~    Reduce stress ~    Free up energy to help you meet your goals Goals of Interpersonal Effectiveness ~    Goals ~    Get others to do things you want them to do ~    Get others to take you seriously ~    Effectively say no to unwanted requests ~    Strengthen current relationships ~    Find and build new relationships ~    End hopeless relationships Activity ~    For each of the following statements, give 2 examples of how this has caused a problem for you in the recent past. ~    Speculate about why you are not effective at doing these things. ~    Get others to do things you want them to do ~    Get others to take you seriously ~    Effectively say no to unwanted requests ~    Strengthen current relationships ~    Find and build new relationships Barriers ~    Lack of effective communication skills ~    Lack of clarity about what you want from others ~    Difficulty balancing your needs and the other person’s needs ~    Emotions get in the way ~    You sacrifice long term goals for short term relief/urges ~    Other people get in the way ~    Other people are more powerful than you ~    Need for external validation ~    Beliefs that you don’t deserve what you want Summary ~    Interpersonal effectiveness is more than just communication skills ~    It requires that you know what your wants and needs are ~    Helps you effectively ask for those wants and needs ~    Troubleshoot why you might not be getting your needs met ~    Take action to improve the situation ~    Develop healthy, sustainable (albeit not perfect) relationships. Dialectical Behavior Therapy Skills Interpersonal Effectiveness Presented by: Dr. Dawn-Elise Snipes Executive Director, AllCEUs counselor education Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~    Identify ways to address the barriers to interpersonal effectiveness Communication Skills DEAR MAN ~    DEAR ~    Describe in specific, objective terms ~    Clean house ~    Being supportive ~    Dressed appropriately ~    Irritable ~    What terms do you often have disagreements about? ~    Express feelings and opinions using “I” statements ~    Describe a situation and notice and correct yourself each time you don’t use an “I” statement to express feelings and opinions. Communication Skills DEAR MAN ~    DEAR ~    Assert ~    Ask for what you want ~    Don’t expect mind reading ~    Reinforce by explaining the benefits to the other person ahead of time.  (win/win) ~    If I get/you do this, the benefit to you will be… ~    Think about 3 occasions when you wanted someone to do something for you.  How could you have made it a win/win? Communication Skills DEAR MAN ~    MAN ~    Mindfulness ~    Stay focused on your goal ~    Ignore diversion techniques-blaming, magnif

Happiness Isn’t Brain Surgery: Mindfulness and Relaxation Presented by: Dr. Dawn-Elise Snipes Executive Director, AllCEUs Host: Counselor Toolbox CEUs are available for this podcast at https://www.allceus.com/member/cart/index/product/id/665/c/ Objectives ~    Review the function of mindfulness and a variety of mindfulness techniques ~    Explore the concept of relaxation ~    Identify different methods of relaxation Mindfulness ~    Being aware of your current state ~    Emotionally ~    Mentally ~    Physically ~    Spiritually ~    MindLESSness allows people to ignore “minor” stress until it adds up to a meltdown ~    What discriminative stimuli can you put in the environment to remind you to do a mindfulness scan? Mindfulness Activities ~    Body scan ~    Mindful Breathing ~    Mindful Observation ~    Specific object ~    Environmental awareness ~    Mindful awareness – Think before you act ~    Mindful appreciation: Notice 5 things in your day that usually go unappreciated. More Mindfulness Activities ~    4+4 ~    4 Senses plus 4 stimuli: Sight, Sound, Touch, Smell ~    What are 4 things that I see ~    What are 4 things I am hearing ~    What are 4 things I am feeling ~    What are 4 things I can smell ~    Tactile Mindfulness ~    Pinch or ice cube ~    Helps tune in to how you deal with pain and what emotions rise More Mindfulness Activities ~    “I” and “You” Exercise ~    Pay attention to how often you use the word I in a sentence ~    I feel ~    I am ~    I will etc… ~    Pay attention to how often you use the word “you” ~    In a blaming, directing or accusatory fashion ~    In an inquiring, compassionate fashion More Mindfulness Activities ~    Cause and effect ~    Play out the story for everything that you do for a given period of time ~    I got out of bed because…. The effect of this is… ~    Devil’s Advocate ~    Act as if you believe the opposite of what you believe about something.  Make a note of how you feel and new perspectives you gain. Relaxation ~    Relieving the mind and body of stress, tension, anxiety and restoring equilibrium ~    Emotional ~    Increase pleasant cues in your environment ~    Sound: Music, birds, silence, waterfall, ~    Sights: Pictures, colors, organization, safety ~    Feel: Temperature, texture ~    Smell: Crisp air, aromatherapy Relaxation ~    Cognitive ~    Don’t think…just be (meditation) ~    Guided Imagery ~    Reading something enjoyable/nonstressful ~    Learning a new hobby is often not relaxation in it’s truest sense because it takes a fair amount of energy, however, it does distract from other stressors Relaxation ~    Physical—Relieve pain and muscular imbalances and regulate bloodflow ~    Stretching ~    Massage ~    Hottub ~    Progressive muscular relaxation ~    Breath work Relaxation ~    Social ~    Social environments that promote calm, tranquility and happiness ~    Laughter is an excellent relaxation technique. ~    Extroverts may be more comfortable around a group of people, interruptions are welcomed ~    Introverts may find a gathering of one or two others without interruptions is optimal ~    “Judgers” do not like surprises and need to plan for the event (the unknown or unpredictable is stressful) ~    “Perceivers” love surprises and prefer not to exert the mental energy of planning everything out Relaxation ~    Environmental ~    What makes an environment relaxing for you? ~    Colors ~    Sights ~    Light level ~    Temperature

Dialectical Theory Facilitator: Dr. Dawn-Elise Snipes CEUs for this webcast can be earned through ondemand classes found at CEUs are available for this podcast at https://www.allceus.com/member/cart/index/product/id/665/c/ Objectives ~    The Basics of DBT ~    The B in DBT: What You Need to Know About Behavior ~    Mindfulness ~    Reducing Emotional Reactivity ~    Distress Tolerance Skills ~    What Clients Need to Know About Emotions ~    Regulating Painful ~    Increasing Positive ~    Helping Clients Become More Effective In Relationships The Clients ~    Emotional Vulnerability ~    React to things others wouldn’t react to ~    Reaction is more intense than others ~    Recovery time is longer than for others ~    Inability to Regulate Emotion ~    Difficulty identifying/labeling emotions ~    Difficulty understanding why they feel that way ~    Difficulty expressing the emotion in an effective way Dialectical Theory ~    Everything is interconnected (Action/reaction) ~    Examine examples of action/reaction ~    Addiction ~    Anger ~    Depression ~    Social Interactions ~    Reality is in a constant process of change ~    How you perceive something now may be different than how you perceive it in an hour? ~    What changes perceptions? ~    What does the emotional mind say? The reasonable mind? The wise mind? Dialectical Theory ~    The truth (always evolving) can be found by integrating multiple perspectives, and tolerating that two opposite things may co-exist ~    Simultaneous (understanding things differently by taking multiple people’s perspectives of the same event) ~    Example: Crime scene ~    Example: Interpersonal disagreement ~    Longitudinal (understanding things differently as knowledge is gained) ~    Example:  Mommy had no use for us and that is why she left. ~    Example: Mommy loves me, but she beats me, so I must be bad. Skills Training Groups ~    Core Mindfulness ~    Increase self-awareness of thoughts, feelings and urges ~    Develop an understanding of emotions as things that do not have to be acted upon ~    Interpersonal Effectiveness ~    Develop assertiveness skills ~    Identify the goals of relationships and skills/activities needed to achieve those goals Skills Training Groups ~    Emotion Regulation Skills ~    Label and effectively communicate feeling states ~    Understand the function of emotions and why we don’t want to eliminate them ~    Learn the connection between thoughts, feelings and behaviors and how to break the chain ~    Distress Tolerance Skills ~    Survival skills/alternatives to self-harm DBT Assumptions ~    Clients are doing their best ~    They want to get better ~    They need to work harder/smarter and be more motivated ~    Even if clients didn’t create their problems, they have to fix them ~    Clients need to learn to act skillfully in EVERY area of their lives ~    Clients cannot fail in therapy Treatment Priorities in DBT ~    Suicidal or self-harming behaviors ~    Behaviors that interfere with therapy (including clinician) ~    Suicidal or self-harm ideation and misery ~    Maintaining treatment gains ~    Other goals identified by the client Mindfulness Emotion Regulation Interpersonal Effectiveness Distress Tolerance Stages of Treatment ~    Stage 1: Attaining Basic Capacities ~    Identify behaviors that pose a direct threat to the clients (or other’s) safety ~    Monitor the frequency, intensity of behaviors using a Behavior Tracking Form ~    Address ~    Suicidal/self-harming behaviors

Trauma Focused CBT Part 2 Treating Trauma and Traumatic Grief in Children & Adolescents Objectives ~    Continue learning about TF-CBT ~    Explore ~    Cognitive Triangle ~    Creating the Trauma Narrative ~    Cognitive Processing ~    Behavior Management ~    Parent-Child Sessions ~    Explore ways to use TF-CBT with adult clients Cognitive Coping ~    Recognize and understand the difference between ~    accurate and inaccurate cognitions ~    helpful and unhelpful cognitions ~    Recognize the distinction and relation among feelings, thoughts, and behavior ~    Generate alternative thoughts that are more accurate or more helpful ~    Attempt to change their feelings and behavior by thinking differently Cognitive Triangle Cognitive Triangle ~    Application ~    Differentiate between thoughts, feelings and behaviors ~    Generate scenarios to illustrate how thoughts impact feelings and behaviors ~    Explore how changing a thought impacts the feelings and behaviors ~    Apply the skill to real life ~    Not everyone will be able to differentiate between thoughts and feelings ~    Children under 8 will likely struggle identifying their personal thoughts.  Ask what someone else might think Parent Sessions During Cognitive Triangle Common Thoughts ~    I can only be happy if my child is happy. ~    I can't trust anyone anymore. ~    Being strong for my child means I should never feel upset. ~    Good parents always know the right thing to say to their children Alternate Thoughts ~    I can find things to be happy about, to show my child that happiness is possible ~    Most people are good at heart and many are trustworthy. ~    Being strong means doing what you have to do, and I am doing that. ~    Although we try our best, even the best parents sometimes don’t know the best thing to say. Creating the Trauma Narrative ~    Purpose ~    Helping to control intrusive and upsetting trauma-related imagery ~    Helping to reduce avoidance of cues, situations, and feelings associated with trauma exposure ~    Identifying unhelpful cognitions about traumatic events ~    Helping the child recognize, anticipate, and prepare for reminders of the trauma. ~    Break apart thoughts, reminders, or discussions of the trauma from overwhelming negative emotions Creating the Trauma Narrative ~    Legal issues ~    Encouraging discussion of the trauma may be perceived as “coaching,” “implanting memories,” or “tampering with testimony” ~    In TF-CBT, the therapist does not lead children by suggesting details or asking leading questions Creating the Trauma Narrative ~    Decide on the best format (poem, book, pictures) ~    Start with a general introduction of the child/person ~    Next  (3 Approaches) ~    start with what happened before the day of the trauma and work forward ~    start with the day of the trauma ~    start from the present and work backwards. ~    Encourage sharing of thoughts and feelings during the event ~    If feelings are overwhelming, start with thoughts and add emotions later ~    Present/read the narrative ~    Add the worst part of the traumatic event Creating the Trauma Narrative ~    Reading through the trauma narrative several times ~    Identifying thoughts and feelings ~    Correcting cognitive distortions and errors ~    After several “exposures” the child will typically experience progressively less extreme emotional reactions and physiological reactivity. ~    It is important to help the child ~    Create a positive and optimistic ending to the narrative ~    Realiz

Trauma Focused CBT  Part 1  Treating Trauma and Traumatic Grief in Children & Adolescents Objectives ~    Define Trauma Focused CBT ~    Explore the components of Trauma Focused CBT and their intended functions ~    Explore ways to use TF-CBT with adult clients Facts about TF-CBT ~    Works for children who have experienced any trauma, including multiple traumas. ~    Is effective with children from diverse backgrounds. ~    Works in as few as 12 treatment sessions. ~    Has been used successfully in clinics, schools, homes, foster care, residential treatment facilities, and inpatient settings. ~    Works even if there is no parent or caregiver to participate in treatment. Facts About Trauma ~    TF-CBT is intended for children with a trauma history whose primary symptoms or behavioral reactions are related to the trauma. ~    Traumatic stress reactions can be more than simply symptoms of PTSD and often present as difficulties with ~    Affect regulation ~    Relationships ~    Attention and consciousness ~    Somatization ~    Self-perception ~    Systems of meaning. ~    These effects can also interfere with adaptive functioning Components of TF-CBT ~    Psychoeducation ~    Parenting skills ~    Relaxation and stress management skills ~    Affect expression and modulation ~    Cognitive coping and processing are enhanced by illustrating the relationships among thoughts, feelings and behaviors. ~    Trauma narration ~    In-vivo mastery of trauma reminders ~    Conjoint parent-child sessions Effects of TF-CBT ~    Reduction in: ~    Intrusive and upsetting memories ~    Avoidance ~    Emotional numbing ~    Hyperarousal ~    Depression ~    Anxiety ~    Behavior problems ~    Sexualized behaviors ~    Trauma-related shame ~    Interpersonal distrust ~    Social skills deficits Inappropriate Populations ~    Primary issue is defiant or conduct disordered ~    Child is suicidal or homicidal ~    Child is severely depressed ~    Child is actively abusing substances ~    When children remain in high-risk situations with a continuing possibility of harm, such as many cases of physical abuse or exposure to domestic violence, some aspects of TF-CBT may not be appropriate. For example, attempting to desensitize children to trauma memories is contraindicated when real danger is present. Challenges ~    Potential barriers and obstacles may include the following: The parent caregiver… ~    Does not agree that the trauma occurred ~    Agrees that the trauma occurred but believes that it has not affected the child significantly or that addressing it directly will make matters worse. ~    Is overwhelmed or highly distressed by his or her own emotional reactions and is not available or able to attend to the child’s experience. ~    Is suspicious, distrustful, or does not believe in the value of therapy. ~    Is facing many concrete problems such as housing, that consume a great deal of energy. ~    Is not willing or prepared to change parenting practices even though this may be important for treatment to succeed. Interventions to Strengthen Parental Alliance ~    Specific strategies that can be undertaken include: ~    Perseverance in establishing a therapeutic alliance ~    Exploring past negative interactions with social service agencies or therapy ~    Exploring the parent/caretaker’s potential concerns that may make them feel as if they are not being understood, accepted, believed, listened to, or respected ~    Exploring/helping to overcome barriers to participating in treatment ~    Emphasizing the centrality of the caregiver’s role in the child’s recov

Common Issues & Interventions in the Treatment of Co-Occurring Disorders Objectives ~ What are Co-occurring Disorders ~ Chicken and Egg Dilemma ~ Awareness and Mindfulness ~ Self-Esteem ~ Sleep ~ Nutrition ~ Depressed and/or Anxious Mood What are Co-Occurring Disorders ~ Any physical or mental health disorder that ~ Occurs at the same time as an addiction ~ Can cause clinically significant impairment on its own ~ Creates a hurdle in the recovery process Chicken and the Egg ~ Which to address first—Mental Health or Addiction ~ Both! (assuming motivation) ~ Addiction (Goal is progress not perfection) ~ What are your triggers for use? ~ What have you done in the past that has helped you not use? ~ What can you do to help yourself stay clean/not use now? ~ How can you do that? / How can I help? ~ Mental and/or Physical Health Issues ~ What MH/PH issues do you have that contribute to your use? ~ What can you do that helps make those things less distressing? ~ How can you do that? / How can I help? Awareness ~ Most people in early recovery are on autopilot ~ The powerlessness to change the situation often prompts disconnection emotionally, mentally, physically and spiritually ~ Part of the definition of addiction is experiencing difficulties in multiple areas of life as a result of use which often results in guilt, resentment, depression, grief, negative self-image ~ Life is about survival  avoiding the intolerable pain Awareness –Interventions ~ Turn off Autopilot ~ Mindfulness ~ How I feel right now ~ Meeting my needs ~ Thoughts Feelings, Urges and Behaviors that keep me unhappy ~ Thoughts Feelings, Urges and Behaviors that will help me start changing Awareness –Interventions ~ Purposeful Action Continuum Awareness –Interventions ~ Deal with thoughts and feelings that prevent self awareness ~ Guilt (I need to ignore my needs and make up for…) ~ Fear (If I tune in, I might get overwhelmed) ~ Apathy (What’s the point?) ~ Self-Hatred/Negative Internal Voice (Suck it up!) Self-Esteem ~ Low Self Esteem ~ Powerless ~ Walk the middle path, identifying what you do and do not have control over ~ Learn from prior failures ~ Create a Success Mantra Quotes About Success and Failure ~ “Failure isn't fatal, but failure to change might be” – John Wooden ~ “I have not failed. I've just found 10,000 ways that won't work.” – Thomas A. Edison ~ “Success is stumbling from failure to failure with no loss of enthusiasm.” – Winston Churchill ~ The only real mistake is the one from which we learn nothing.” – Henry Ford ~ “Success is the result of perfection, hard work, learning from failure, loyalty, and persistence.” Colin Powell Self-Esteem ~ Low Self Esteem ~ If people do not feel worthy of recovery/happiness, they will not stay motivated for it ~ Change the Dialogue ~ Undeserving of happiness (refusal to forgive self) ~ What would it mean if you forgave yourself? ~ What are you afraid will happen? ~ What makes someone deserving of happiness? Self-Esteem ~ Low Self Esteem ~ If people do not feel worthy of recovery/happiness, they will not stay motivated for it ~ Change the Dialogue ~ Unlovable or fallible? ~ What makes someone lovable? ~ Useless/purposeless or undirected? ~ What skills/qualities/attributes do you have? ~ How can you use those? Sleep ~ Sleep is disrupted by ~ Addictions ~ Stress/Depression/Anxiety ~ Physical Pain ~ Poor Nutrition ~ Sufficient quality sleep improves ~ Focus/C

Fetal Alcohol Spectrum Disorders in Mental Health and Criminal Justice Instructor: Dr. Dawn-Elise Snipes Executive Director AllCEUs.com, Counseling Continuing Education Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery CEUs are available for this podcast at https://www.allceus.com/member/cart/index/product/id/127/c/ Objectives ~    Where to begin… ~    Explore the scope of the problem ~    Identify the impact of the impairments across life domains ~    Discuss specific issues for adolescents ~ Identify special issues for suicide intervention ~ Explore techniques to modify the treatment environment to accommodate the needs of a person with an FASD Stats ~    National Institute on Alcohol Abuse and Alcoholism, the prevalence of FAS in the general population ranges from 2% to 5% for the entire continuum of FASD. ~    94% of individuals with an FASD also have a mental illness ~    73-80% of children with full-blown FAS are in foster or adoptive placement ~    61% of adolescents with an FASD experienced significant school disruptions Stats cont… ~    The prevalence of FASD in the child welfare system is approximately 17 to 19 times higher than that in the general population in North America (meta-analysis published online September 9 in Pediatrics). ~    12.8 is the average age children with an FASD begin having trouble with the law. (https://www.mofas.org/2014/05/fasd-and-the-criminal-justice-system/) ~    60% of people with an FASD have a history of trouble with the law What is FASD ~    FASD is not a diagnostic term, but is an umbrella term encompassing four categorical diagnostic entities: ~    Fetal alcohol syndrome (FAS) ~    Partial FAS ~    Alcohol-related neurodevelopmental disorder ~    Alcohol-related birth defects Impact of Functional Impairment ~    Problems in multiple domains interferes with treatment success, including inability to: ~    Remember program rules or follow multiple instructions. ~    Remember and keep appointments, or to get lost on the way there. ~    Independently make appropriate decisions about treatment needs/goals. ~    Appropriately interpret social cues ~    Observe appropriate boundaries, either with staff or other clients. ~    Attend to (and not disrupt) group activities. ~    Process information readily or accurately. ~    ‘Act one's age.’ ~    When indicators occur in any these domains (and particularly when they occur across multiple domains), it is worthwhile to apply the FASD 4-Digit Code Caregiver Interview Checklist (Astley, 2004b) Special Considerations for Adolescents ~    Evidence shows that adolescents will commonly exhibit learning and behavior challenges, especially in ~    Adaptive function/getting along from day to day ~    Remaining organized and regulated ~    Learning information slowly (especially what is said to them) ~    Tending to forget things they have recently learned ~    Making the same mistakes over and over. ~    Impulsivity/finding it hard to inhibit responses ~    Social communication (leaving out important details/being vague). ~    Suggestibility (and therefore easily influenced by others) ~    Immature social skills. (too friendly/trusting,/difficulty recognizing dangerous situations. Differential Dx ~    There is some evidence for distinguishing between children with FASD and children with ADHD. Using the four-factor model of attention it has been shown that: ~    children with FASD have difficulties with encoding (taking in and processing information) and shift (shifting attention (hyperfocus)) ~    children with ADHD have problems with focus a

Screening and Motivational Enhancement Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC CEUs are available for this presentation at https://www.allceus.com/member/cart/index/product/id/40/c/ Objectives ~    Compare and contrast MET with other approaches to therapy ~    Briefly review the FRAMES approach ~    Describe the stages of change ~    Define EE-DD-AA-RR-SS ~    Define OARS ~    Explore strategies for increasing motivation MET Unique Characteristics ~    Emphasis on personal choice regarding future behavior ~    Objective evaluation focused on eliciting the CLIENT’s OWN concerns ~    Resistance is an interpersonal behavior pattern indicating failure to accurately empathize ~    Resistance is met with reflection Motivational Enhancement Therapists Do NOT ~    Argue with clients ~    Impose diagnostic labels ~    Tell clients what they “must” do ~    Seek to “break down” denial through direct confrontation ~    Imply client’s powerlessness OARS ~    Open Ended Questions ~    Affirmations ~    Reflective Listening ~    Summaries Stages of Change ~    Motivation needs to be enhanced and maintained in all stages of change ~    Stages ~    Precontemplation ~    Contemplation ~    Preparation ~    Action ~    Maintenance Basic Principles: EE-DD-AA-RR-SS ~    Express Empathy ~    Reflective listening (accurate empathy) is a key skill ~    Develop Discrepancy ~    Perceive a discrepancy between where they are and where they want to be ~    Raise clients’ awareness of the personal consequences of their drinking in order to precipitate a crisis increasing motivation for change ~    Avoid Arguing ~    No attempt is made to have the client accept or “admit” a problem Basic Principles cont… ~    Roll with resistance ~    New ways of thinking about problems are invited but not imposed. ~    Ambivalence is viewed as normal, not pathological, and is explored openly. ~    Solutions are usually evoked from the client rather than provided by the therapist ~    Support self-efficacy ~    People will not try to change unless they believe there is HOPE for success Hardiness ~    Control ~    Self-efficacy ~    Hope and Faith ~    Commitment ~    Courage and Discipline ~    Challenge CBT vs. MET Cognitive Behavioral ~    Assumes client is motivated ~    Identify and modify maladaptive cognitions ~    Prescribes change strategies Motivational Enhancement ~    Builds client motivation ~    Explores and reflects client perception without correcting ~    Elicits change strategies from the client Nondirective vs. MET Nondirective ~    Client determines content and direction ~    Avoids injecting counselor’s advice and feedback ~    Empathy is used noncontingently MET ~    Directs client toward motivation ~    Offers advice and feedback ~    Empathic reflection used selectively to reinforce certain points Building Motivation ~    Since you are here, I assume you have been having some concerns or difficulties related to your use. Tell me about them. ~    Tell me a little about your drinking. What do you like about it? What’s positive about drinking for you? And what’s the other side? What are your worries about drinking? ~    How has your drinking has changed over time? What things do you think could be problems, or might become problems? ~    What have others said about your drinking? What are they worried about? ~    What makes you think that perhaps you need to make a change in your drinking?

Complex Trauma in Children and Adolescents CEUs can be earned for this presentation at https://www.allceus.com/member/cart/index/product/id/158/c/ Resources ~ This presentation is based, in part, upon ~ a white paper from the National Child Traumatic Stress Network: “Complex Trauma in Children and Adolescents” 2003 ~ Child-Witnessed Domestic Violence and its Adverse Effects on Brain Development https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193214/ ~ The Adverse Childhood Experiences Study https://www.cdc.gov/violenceprevention/acestudy/ Objectives ~ Define complex trauma ~ Define and explore Adverse Childhood Experiences ~ Highlight the cost of complex trauma ~ Examine the impact and diagnostic issues of complex trauma What is Complex Trauma ~ Exposure to traumatic events plus the short and long term impact of exposure resulting in: ~ Emotional dysregulation ~ Loss of safety ~ Inability to detect or respond to danger cues ~ Inability to detect or respond to internal cues ~ Generalization of cues More About Complex Trauma ~ Complex Trauma is most likely to develop if the danger is unpredictable and uncontrollable (p.8) ~ The greatest source of danger, unpredictability and uncontrollability is the absence of a caregiver who reliably and responsively nurtures and protects the child. Adverse Childhood Experiences ~ ACEs measured in the study include: ~ Physical, sexual, emotional abuse ~ Physical or emotional neglect ~ Mother treated violently ~ Substance misuse within household ~ Household mental illness ~ Parental separation or divorce ~ Incarcerated household member *Could happen anytime prior to 18th birthday *Two thirds of the 17,000 people in the ACE Study had at least one ACE Effects of ACEs ~ Psychosocially induced biological alterations (in the brain and the HPA-Axis) related to maladaptation (especially post-traumatic stress disorder) in the context of child-witnessed DV ~ Child-Witnessed Domestic Violence and its Adverse Effects on Brain Development https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193214/ Effects of ACEs ~ Nearly 60% of women and 35% of men with 4 or more ACEs reported chronic depression ~ The risk of perpetrating violence increased dramatically with the ACE score was over 5 ~ Those with at least 4 ACEs had nearly double the chance of being raped later in life. ~ 18% of those with at least 4 ACEs attempted suicide. National Incidence Study of Child Abuse and Neglect ~ NIS-3 (1996) ~ Harm Standard: 1,553,800 ~ Endangerment Standard  2,815,600 ~ Emotional (584,100) ~ NIS-4 (2006) ~ Harm Standard: 1,256,600 million (1:58) ~ Endangerment Standard: 2,905,800 (1:25) ~ Significant finding: Emotional (1,173,800) 7 Domains of Impairment ~ Attachment ~ Biology ~ Affect Regulation ~ Dissociation ~ Behavioral Regulation ~ Cognition ~ Self-Concept As defined by the NCTSN Complex Trauma Taskforce Attachment ~ Secure attachment ~ Internalize regulation strategies ~ Identify internal and external cues ~ Learn to use support systems in the face of overwhelming experience Attachment ~ Insecure attachment (80% maltreated children) ~ 3 types ~ Avoidant ~ Rejecting caregiving—What does this look like ~ Disregard and distrust self and others Attachment ~ Ambivalent ~ Parents alternate between validation and invalidation/detachment and enmeshment (Borderline-esque) ~ Children become hypersensitive to cues and overgeneralize ~

Relapse Prevention CEUs can be earned for this presentation at https://www.allceus.com/member/cart/index/product/id/574/c/ Dr. Dawn-Elise Snipes PhD, LMHC, LPC Objectives ~    Define Relapse ~    Identify Relapse Warning Signs ~    Identify Strengths ~    Learn about how your issue developed Relapse Definition ~    Relapse is the return to something that has been previously stopped ~    Relapse is multidimensional ~    Emotional ~    Mental ~    Physical ~    Social ~    A relapse is when you start returning to any of these people, places, things, behaviors or feeling states. Activity: Distress vs. Happiness Worksheet In your Unhappiness ~    Emotionally ~    Mentally ~    Physically ~    Socially When you are Happy ~    Emotionally ~    Mentally ~    Physically ~    Socially Triggers ~    Triggers are stimuli that set off an event. ~    Triggers can prompt positive or negative event as ~    Triggers can be ~    Visual ~    Auditory ~    Tactile ~    Olfactory ~    Cognitive ~    Temporal (Time or location) Emotional Relapse ~    In emotional relapse, your emotions and behaviors become negative and unpleasant. ~    You start finding it difficult to experience pleasure ~    What triggers your negative emotions (Anger/resentment/jealousy/guilt; anxiety/fear/stress; depression) ~    Things/Media ~    People ~    Places ~    Events Emotional Relapse ~    Negative emotions make us uncomfortable ~    Identify the emotion, explore why you are feeling that way and take steps to fix the problem ~    You can become stuck in the emotion, sometimes ~    Nurturing and blowing it out of proportion ~    Compounding it with other emotions like anger and guilt ~    Personalizing it ~    Trying to escape from it ~    Remember that emotions are just cues like a stoplight. ~    You feel how you feel in the moment ~    You can choose to change or improve the next moment Preventing Emotional Relapse ~    Practice mindfulness ~    Increase positive experiences (real and guided imagery) ~    Keep a gratitude journal ~    Avoid personalizing something that may not be about you ~    Remember that… ~    Negative emotions are the mind’s way of telling us to get off our butts and do something—Like our car’s idiot light or hunger pangs ~    Dwelling on, nurturing, avoiding or hiding from negative emotions never makes anything better ~    You can *choose* to feel and fix, or relapse and repeat ~    Identify and put in place triggers for positive emotions Activity ~    List 10 things that you chose to get anxious or angry about over the last week ~    Why did you get upset?  (What was your mind telling you needed to be fixed) ~    Did holding on to the upsetness do any good? ~    What was your initial reaction, and was it helpful? ~    What could you do differently next time to either ~    Change/fix the situation (Improve the next moment) ~    Change how you feel about the situation  (Walk the middle path) ~    Let it go (Radical Acceptance) Mental Relapse ~    In mental relapse there's a war going on in your mind. ~    Part of you wants to stay positive, but part of you is struggling with tolerating the distress. ~    The signs of mental relapse are: ~    Focusing on the negative ~    Having a pessimistic/helpless/hopeless attitude ~    If you had an addiction, you may also be: ~    Thinking about people, places, and things you used with ~    Glamorizing your past use ~    Lying

PTSD Exploring the Functional Nature of Symptoms Instructor: Dr. Dawn-Elise Snipes LPC-MHSP, LMHC, CCDRC Executive Director: AllCEUs Host: Counselor Toolbox and Happiness Isn’t Brain Surgery Podcasts Continuing education Credits for this podcast are available at https://www.allceus.com/member/cart/index/product/id/59/c/ Objectives ~    Review PTSD Symptoms and explore their functional nature Purpose ~    By understanding the function of symptoms we can ~    Normalize the behavior ~    Identify alternate ways to meet that same need or address the issue ~    Re-Experiencing ~    Trying to replay it to figure out how to integrate into your schema (like fitting a puzzle piece) ~    Reminding the person of similar situations to “protect” them Purpose ~    Avoidance ~    The system is already over taxed.  Avoiding upsetting stimuli by blocking out most stimuli, memories of the event. ~    Avoiding unnecessary use of energy by not getting “excited.” ~    Changes in Beliefs ~    Protects against future “surprises” ~    Tries to assimilate the experience into schema ~    Increased Arousal ~    Protects the individual Re-Experiencing ~    You re-experience things every day ~    Access schema that guide your actions ~    When you go to work ~    When you encounter a particularly volatile client ~    When you approach a stop light ~    Re-Experiencing in PTSD ~    The context is often overgeneralized ~    The precipitating factors are often unknown ~    In many cases the resolution was not one of empowerment, resulting in trying to continually figure out how to not be disempowered Re-Experiencing: Assimilation or Accommodation ~    Intrusive distressing memories of the traumatic events ~    In children repetitive play may occur in which themes or aspects of the traumatic events are expressed. ~    Recurrent distressing dreams in which the content or feeling of the dream is related to the events ~    In children there may be frightening dreams without recognizable content. ~    Flashbacks or other dissociative reactions in which the individual feels or acts as if the traumatic events are recurring ~    In children trauma-specific reenactment may occur in play. Re-Experiencing ~    Intense or prolonged psychological or physiological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic events ~    The event represents a time in which the person experienced or witnessed something horrifying ~    The brain is trying to help the client ~    Avoid future similar situations ~    Learn how to protect during future similar situations Avoidance ~    Purpose: Avoidance of Recurrence of Pain or Arousal of Stress Response System ~    Emotional numbness and avoidance of places, people, and activities that are reminders of the trauma. ~    Inability to remember an important aspect of the traumatic events (not due to head injury, alcohol, or drugs) ~    Purpose: An exhausted system conserves energy in case there is another threat ~    Markedly diminished interest or participation in significant activities ~    Feelings of detachment or estrangement from others ~    Persistent inability to experience positive emotions Hypocortisolism ~    Cortisol is the stress chemical ~    After extreme stress and/or under chronic stress the brain may reduce the responsiveness of the stress response system by reducing the cortisol ~    This is protective, it keeps the organism from using precious resources by getting “excited” about anything (including pleasure) ~    Due to fear conditioning

Medication-Assisted Therapies for Addiction Presented by: Dr. Dawn-Elise Snipes, Ph.D, LMHC, LPC-MHSP Executive Director of AllCEUs.com An on-demand course based on this product is available for CEUs at https://www.allceus.com/member/cart/index/product/id/16/c/ Objectives ~    Discuss the purpose of long-term pharmacotherapy ~    Identify pharmacotherapies for ~    Smoking ~    Alcohol ~    Opioids ~    Methadone ~    Buprenorphine ~    Cases Why Medication Assisted Therapy ~    Early Recovery ~    Reduces cravings ~    Provides increased self-efficacy and a greater sense of control ~    Anxiety Reduction due to: ~    May alleviate some of the anxiety/fear about relapsing ~    Pharmacological effects of certain MATs ~    May improve depressive symptoms by ~    Enhancing hope and an sense of empowerment ~    Pharmacological effects of certain MATs What is our Goal in Early Recovery ~    Reduce Co-Occurring issues ~    Identify and address vulnerabilities ~    Improve overall health ~    Sleep ~    Nutrition ~    Energy (exercise) ~    Maintain abstinence ~    Increase time to relapse ~    Reduce intensity of binge if relapse occurs Clinical Use of Pharmacotherapy ~    Part of comprehensive plan that addresses the following issues or problems: ~    Emotional ~    Cognitive ~    Physical ~    Social ~    Occupational ~    Environmental ~    Not a substitute for counseling ~    Works best in combination with psychosocial support Co-Occurring Model of Addiction ~    Co-Occurring Disorders are the Expectation ~    Mood issues must be addressed to prevent relapse ~    Relapse begins when thoughts/urges or behaviors return to “addicted” mindset ~    Addictive behaviors were “learned” as a way to stop distress. ~    Learned behaviors cannot be unlearned. ~    Alternate behaviors and their consequences must be more rewarding than addictive behaviors and the consequences. (LT vs. ST) Drugs or No Drugs     No pharmacotherapy for most abused drugs ◦    Stimulants ◦    Hallucinogens (LSD, PCP, Ketamine, Dextromethorphan, Benadryl, Dramamine) ◦    Inhalants ◦    Marijuana     What is the function of… ◦    Stimulants ◦    Hallucinogens ◦    Psychedelics (5HT2A); “state of empathetic wellbeing” ◦    Dissociatives (reduces glutamate); altered pain perception, depressant; Ketamine, Dextromethorphan ◦    Deliriants (reduces acetylcholine) Benadryl, Dramamine ◦    Inhalants (Depressants) ◦    Marijuana (increases dopamine); generally “relaxing,” pain relieving Drugs or No Drugs     Factors to consider ◦    Cost ◦    Availability ◦    Side effects ◦    Barriers     Workplace drug testing     Other meds taken     Incarceration ◦    Motivation Barriers ~    Stimatization ~    Science vs. dogma ~    Evidence-based treatment vs. “drugs for drug addicts” ~    12-Step groups ~    Becoming more progressive ~    Methadone Anonymous is alternative ~    Counselors ~    Different experiences and biases ~    Payors ~    Most payors require medication assisted therapy be “considered when available.” What is the endpoint? ~    Duration of most pharmacotherapy is not indefinite ~    Months to years ~    Goal is stabilization ~    Flexibility ~    Individualized ~    Allow for relapse Smoking Cessation Pharmacotherapy ~    Replacement ~    nicotine patches ~    nicotine gum ~    nicotine lozenges ~    nic