Counselor Toolbox Podcast

Pharmacology of  Opiates Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director: AllCEUs.com Counseling Continuing Education Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery Counseling and social work CEUs are available on Demand for this podcast at https://www.allceus.com/member/cart/index/search?q=opiates Objectives ~    Examine the following for opiates ~    Types of drugs ~    The short and long term effect on the person ~    Symptoms of intoxication and withdrawal ~    Detoxification issues ~    Current state of abuse ~    Recommended treatments Side Note ~    Method of administration greatly effects the intensity and duration of onset for various drugs ~    Oral (slowest) ~    Inhalation/Snorting ~    Inhalation/Smoking ~    Injection ~    Rectal suppository ~    Skin patches Opiates ~    Types of Drugs: Analgesic (pain killer); CNS Depressant How they Work ~    Body naturally produces opiate-like substance Endogenous opioids ~    Regulate pain perception ~    Hunger ~    Mood ~    “Runners High” How they Work ~    Opiates bind to the same receptors but are 50-1000 times stronger and… ~    Reduce GABA (which regulates dopamine and anxiety)  increase in Dopamine   pleasure and possible energy & focus (norepinephrine (increased arousal from decreased GABA)) ~    Increase available serotonin levels (reduced anxiety/depression, improved pain tolerance) Neurotransmitter Review ~    Dopamine ~    Pleasure ~    Energy, focus, motivation (norepinepherine) ~    Reduced GABA ~    Increased anxiety  HPA Axis activation  energy ~    Increased anxiety during detox (warming a cold bath) Opiates ~    Tolerance starts to develop in 5-7 days ~    Tolerance reversal also  starts in only a few days ~    Short term impact (up to 5 hours) ~    Depends heavily on: ~    The dose ~    The route of administration ~    Previous exposure Opiates ~    Short term impact (up to 5 hours) ~    Psychological: Euphoria, feeling of well-being, relaxation, drowsiness, sedation, disconnectedness, delirium. ~    Physiological: Analgesia, depressed heart rate and respiration depression, constipation, flushing of the skin, sweating, pupils fixed and constricted, diminished reflexes Opiates ~    Complications and Side Effects ~    Medical complications among abusers arise primarily from adulterants and in non-sterile injecting practices ~    Include skin, lung and brain abscesses, collapsed veins, endocarditis, hepatitis, HIV/AIDS, death Opiates ~    Complications and Side Effects ~    Alcohol or depressants such as benzodiazepines, hypnotics, and antihistamines increase the CNS effects of opiates ~    Sedation/drowsiness ~    Decreased motor skills. ~    Respiratory depression, hypotension Opiates ~    Potentiation: Combining 2 drugs because one intensifies the other:  Antihistamine + narcotic intensifies its effect, there by cutting down on the amount of the narcotic needed. ~    Synergism: Two drugs taken together that are similar in action  effect out of proportion to that of each drug taken separately, 1+1= 5 Opiates ~    Long term impact ~    Vein collapse ~    Depression ~    Brain changes/damage ~    Reduction of the production of natural pain killers Opiates ~    Symptoms of intoxication ~    Constricted pupils ~    Sleepiness or extreme relaxation ~    Agitation ~    Scratching and picking ~    20-25% of people get opiate itch. (remember that antihistamines potentiate opiates) Opiat

Triggers and Cravings CEUs are available on demand for this podcast at https://www.allceus.com/member/cart/index/product/id/19/c/ Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director, AllCEUs.com Objectives ~    Define a trigger ~    Discuss the function of triggers ~    Explore triggers for mental health symptoms ~    Explore how triggers lead to cravings and obsessive thinking ~    Explore the concept of stimulus generalization What is a trigger ~    Physical or cognitive stimulus ~    Which causes a physical or cognitive reaction ~    To either repeat (pleasure) or avoid (pain) the stimulus ~    Any pleasurable stimulus is associated with elevated dopamine levels ~    Any painful or distressing stimuli trigger the fight or flight reaction What is a Trigger ~    The same trigger can be positive or negative depending on the: ~    Frequency of the reinforcement/punishment ~    Intensity of the reinforcement/punishment Goals ~    Trigger ~    Competing response (IMPROVE, ACCEPTS) ~    Eliminate/counter condition trigger ~    Approaches ~    Continue the chain: ~     Trigger Depression  Coping Skills (competing response) ~    Break the chain ~    Eliminate the trigger (cognitive distortions, low self-esteem) ~    Eliminate the negative aspects of the trigger (bridge, Kenny, source of resentment or determination) Unconditioned triggers ~    Purpose: Generally survival ~    Sight—bright sun, something (ball, fist) headed to your face, inability to access caregiver ~    Sound—loud noise, heartbeat ~    Smell—pleasant, noxious ~    Touch— pain, temperature, hugs ~    Taste— Pleasant or noxious Conditioned Triggers ~    Conditioned triggers are things that in themselves have no meaning to the person. ~    Sight— Bottle, Snow ~    Sound—Music, Sirens ~    Smell—Smoke, Brownies ~    Touch— Hot stove, wool sweater ~    Taste— Coffee, Reeses ice cream ~    Thought– Lice, Thanksgiving Where do they come from? ~    Learned ~    Experience (Trial and error) ~    Positive/Reward: ~    Brownies  Positive feelings ~    Get good sleep  More energy, better mood ~    Negative: ~    Brownies  Blood sugar crash and upset stomach ~    Getting good sleep  Less time with friends Where do they come from? ~    Learned ~    Observation ~    Positive/Rewarding ~    Dad drinks after a hard day  gets less angry ~    Dad exercises after a hard day  gets less angry ~    Negative/Punishing ~    Dad drinks after a hard day  gets a hangover, grumpy the next day ~    Dad exercises after a hard day  cant move tomorrow and cranky Where do they come from? ~    Learned ~    Education ~    Positive: ~    Mindfulness increases awareness and reduces stress ~    Sunlight increases vitamin D and improves mood ~    Negative: ~    Mindfulness is exasperating with monkey mind ~    Sunlight increases chances of skin cancer Trigger to Obsession/Compulsion ~    Trigger ~    Pleasure—I really want to do that again because it makes me happy or eliminates pain ~    Smell brownies cant wait for them to be done ~    New relationship & cant wait to see them again ~    Gambling can’t wait to get that big win again ~    Trigger actual or memory of pain/distress hopelessness, helplessness  intensification of depression/anxiety/anger or escape Why Do I Care ~    Knowing triggers for the behavior to be eliminated will prevent the client from be

Using Groups to Address Anger, Anxiety, Depression and Addiction Presented by: Dr. Dawn-Elise Snipes  Executive Director, AllCEUs Podcast Host: Counselor Toolbox & Happiness isn’t Brain Surgery Author: Journey to Recovery (2015) & Happiness Isn’t Brain Surgery (2017) Objectives Review the benefits of groups Identify the modalities for group goals for psychoeducational and skills groups addressing anger, anxiety, addiction and depression Explore activities that can be used to enhance group engagement Benefits of Group Cost effective Peer feedback and support Development of interpersonal skills Reduce isolation and “uniqueness” Many observers Modalities for Group Face-to-face Web-meeting Video Chat Asynchronous Psychoeducational/skills video Group participation by responding to questions on a discussion board and receiving feedback from group members and the clinician HIPAA, HITECH and 42 CFR Part 2 all apply TRANSDIAGNOSTIC GROUPS Awareness Learn about anger, anxiety, depression and addiction and their symptoms Learn about the Mind-Body Connection Potential causes of symptoms Effects of symptoms Interventions for symptoms Have clients identify Their symptoms What changed which causes or worsens the symptom How they have dealt with the symptom in the past Impact of the symptom on them Awareness Negative Triggers Those things that cause or worsen the symptom Hungry Angry Lonely Tired False Evidence Appearing Real People Places Things Times (of day, anniversaries, holidays) Which ones can be avoided or prevented? Identify three ways to deal with the unavoidable ones Awareness Positive Triggers Those things that remind you to use your new tools How can you add those to your environment? Sights Sounds Smells Social Environment Awareness Vulnerabilities Explain the concept of vulnerabilities Identify the most common vulnerabilities Emotional (guilt, envy, depression, anxiety, anger) Mental (negativity, unhelpful thoughts, fogginess) Physical (pain, exhaustion, illness, medication) Social (stressful people/environments; abandonment fears) Environmental (too chaotic/quiet; disorganized, dark…) Awareness Mindfulness and Vulnerability Prevention Learn about mindfulness Purpose Benefits Methods Anchored Scan 3 minute thoughts 3 minute observations Difference from meditation Awareness Help clients brainstorm interventions and develop a plan for becoming more mindful of strengths and needs in order to: Prevent vulnerabilities (home, work, family/social gatherings) Mitigate vulnerabilities Prevent unnecessary distress Mitigate unavoidable distress Awareness Goal Identification:  What is most important to focus your energy on so you can be happy?  // What does happiness/recovery look like to you? What 5 things are important to you? What 5 relationships are important to you and what do you want them to look like? What 5 personal growth goals are important to you? What are your top 5 values that support your goals Distress Tolerance Clients with mood or addictive disorders tend to Get stuck in the unpleasant emotion Impulsively act to eliminate/escape from distress Distress tolerance skills help them learn that urges and feelings: Come in waves Do not have to be acted upon Can be tolerated Can help them practice to pause to make choices which will keep them using their energy to move toward their goals Bee metaphor Distress Tolerance Address Distress Intoler

Group Therapy (TIP 41) Chapter 6&7 Leadership Skills & Common Errors Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC, NCC Executive Director, AllCEUs Module 6 Objectives Objectives: ~ Discuss the characteristics of group leaders. ~ Describe concepts and techniques for conducting substance abuse treatment group therapy. Leaders Choose ~ How much leadership to exercise ~ How to structure the group ~ When to intervene ~ How to effect a successful intervention ~ How to manage the group’s collective anxiety ~ How to resolve other issues Personal Qualities of Leaders ~ Constancy ~ Active listening ~ Firm identity ~ Confidence ~ Spontaneity ~ Integrity ~ Trust ~ Humor ~ Empathy ◦ Communicates respect and acceptance ◦ Encourages ◦ Is knowledgeable ◦ Compliments ◦ Tells less; listens more ◦ Gently persuades ◦ Provides support Leading Groups ~ Leaders vary therapeutic styles to meet the needs of clients. ~ Leaders model behavior. ~ Leaders are sensitive to ethical issues: •Overriding group agreement •Informing clients of options •Preventing enmeshment •Acting in each client’s best interest Leading Groups (cont.) ~ Leaders improve motivation when: ◦ Members are engaged at the appropriate stage of change. ◦ Members receive support for change efforts. ◦ The leader explores choices and consequences with members. ◦ The leader communicates care and concern for members. ◦ The leader points out members’ competencies. ◦ Positive changes are noted in and encouraged by the group. Leading Groups (cont.) ~ Leaders work with, not against, resistance. ~ Leaders protect against boundary violations. ~ Leaders maintain a safe, therapeutic setting: •Emotional aspects of safety •Substance use •Boundaries and physical contact ~ Leaders help cool down affect. ~ Leaders encourage communication within the group. Interventions ~ Connect with other people. ~ Discover connections between substance use and thoughts and feelings. ~ Understand attempts to regulate feelings and relationships. ~ Build coping skills. ~ Perceive the effect of substance use on life. ~ Notice inconsistencies among thoughts, feelings, and behavior. ~ Perceive discrepancies. Avoid a Leader-Centered Group ~ Build skills in members; avoid doing for the group what it can do for itself. ~ Encourage group members to learn the skills necessary to support and encourage one another. ~ Refrain from overresponsibility for clients. Clients should be allowed to struggle with what is facing them. Confrontation ~ Can have an adverse effect on the therapeutic alliance and process. ~ Can point out inconsistencies such as disconnects between behaviors and stated goals. ~ Can help clients see and accept reality, so they can change accordingly. Transference & Countertransference ~ Transference. Clients project parts of important past relationships into present relationships. ~ Countertransference. The other person projects emotional response to a group member’s transference: ◦ Feelings of having been there ◦ Feelings of helplessness when the leader/other person is more invested in the treatment than the client is are ◦ Feelings of incompetence because of unfamiliarity with culture and jargon Resistance ~ Resistance arises to protect the client from the pain of change. ~ Resistance is an opportunity to understand something important for the client or the group. ~ Resistance indicates the proposed solutions are less rewarding/appealing than the old behaviors or there is a fear that they w

Group Therapy (TIP 41) Chapters 3-5 Stages of Treatment and Process Issues Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC, NCC Executive Director, AllCEUs Module 3 Goal and Objectives Goal: Provide an overview of how to match clients with groups, depending on clients’ readiness to change and their ethnic and cultural experiences. Objectives: ~ Match clients with substance abuse treatment groups. ~ Assess clients’ readiness to participate in group therapy. ~ Determine clients’ needs for specialized groups. Matching Clients With Groups ~ The client’s characteristics, needs, preferences, and stage of recovery ~ The program’s resources ~ The client’s ethnic and cultural experiences Clients Who May Be Inappropriate ~ Clients who refuse to participate ~ Clients who cannot honor group agreements ~ Clients in the throes of a life crisis ~ Clients who cannot control impulses ~ Clients whose defenses would clash with the dynamics of the group ~ Clients who experience severe internal discomfort in groups Primary Placement Considerations ~ Women ~ Adolescents ~ Level of interpersonal functioning ~ Motivation to abstain (if an addiction group) ~ Stage of recovery ~ Expectation of success Preparing the Group for New Members ~ Integrate new clients into the group slowly, letting them set their own pace. ~ Be aware of signs of transference and countertransference between ◦ Clinician and clients ◦ Clients and other clients ~ Watch for signs of increased participation and comfort Module 4 Goal and Objectives Objectives: ~ Distinguish the differences between fixed and revolving membership groups. ~ Prepare clients for groups. ~ Describe the tasks for each of the three phases of group development. Fixed Membership Groups ~ Members are prepared and stay together for a long time. ~ Membership is stable. ~ Groups are either: ◦ Time limited. Members participate in a specified number of sessions and start and finish together. ◦ Ongoing. New members fill vacancies in a group that continues over a long period. Revolving Membership Groups ~ New members enter a group when they become ready for its services. ~ Groups must adjust to frequent, unpredictable changes. ~ Groups are either: ◦ Time limited. Member attends a specified number of sessions, starting and finishing at his or her own pace. ◦ Ongoing. Member remains until he or she has accomplished his or her specified goals. Pregroup Interviews ~ Begin as early as the initial contact between the client and the program. ~ Strive to: •Form a therapeutic alliance between the leader  and the client. •Reach consensus on what is to be accomplished  in therapy. •Educate the client about group therapy. •Allay anxiety related to joining a group. •Explain the group agreement. Preparation Meetings ~ Explain how group interactions compare with those in self-help groups. ~ Emphasize that each person may be at a slightly different place in recovery ~ Let new members know they may be tempted to leave the group at times. ~ Recognize and address clients’ therapeutic hopes. Group Agreements ~ Establish the expectations that group members have for one another, the leader, and the group. ~ Require that group members entering a long-term fixed membership group commit to the group. ~ Inspire clients to accept the basic rules and increase their determination and ability to succeed. Elements in a Group Agreement ~ Communicating grounds for exclusion ~ Confidentiality ~ Physical contact ~ Use of mood-altering substances ~ Contact outside the group ~

Group Therapy (TIP 41) Chapter 1 Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director, AllCEUsTraining Objectives ~ Goal: ◦ Provide an overview of group therapy used in substance abuse treatment. ~ Objectives: ◦ Discuss the use of group therapy in substance abuse treatment. ◦ Define five group therapy models used in substance abuse treatment. ◦ Explain the advantages of group therapy. ◦ Modify group therapy to treat substance abuse Group Therapy in Treatment ~ Supports members in times of pain and trouble. ~ Enriches members with insight and guidance. ~ Is a natural ally with addiction treatment. ~ Has trained leaders. ~ Produces healing or recovery from substance abuse Group Therapy in Treatment cont… ~ Can address factors associated with addiction ◦ Depression ◦ Anxiety ◦ Anger ◦ Shame ◦ Temporary cognitive impairment ◦ Character pathology ◦ Medication Management ◦ Pain Management Advantages of Groups ~ Provide positive peer support for abstinence and positive action ~ Reduce isolation ~ Enable members to witness the recovery of others. ~ Allow members to see how others deal with similar problems. Advantages of Groups (cont.) ~ Provide information to clients who are new to recovery. ~ Provide feedback on group members’ values and abilities. ~ Offer family-like experiences. ~ Encourage, coach, support, and reinforce. Advantages of Groups (cont.) ~ Allow a single treatment professional to help a number of clients at the same time ~ Can add needed structure and discipline ~ Instill hope, a sense that “If he can make it, so can I.” ~ Support and provide encouragement to one another outside the group setting. Summary ~ Group therapy is not individual therapy done with an audience ~ Group therapy is not a mutual support group ~ Group therapy is designed to help people develop and practice knowledge and skills in a microcosm ~ Group therapy also aids patients in learning how to develop healthy, supportive relationships Module 2 Goal and Objectives Goal: Provide details about the group therapy models used in substance abuse treatment. Objectives: ~ Explain the stages of change. ~ Discuss the three specialized group therapy models used in substance abuse treatment. Training Stages of Change ~ Precontemplation ~ Contemplation ~ Preparation ~ Action ~ Maintenance ~ Recurrence Variable Factors for Groups ~ Group or leader focus ~ Specificity of the group agenda ~ Heterogeneity or homogeneity of group members ~ Open-ended or determinate duration of treatment ~ Level of leader activity ~ Duration of treatment and length of each session ~ Arrangement of room ~ Characteristics of the individuals Psychoeducational Groups ~ Assist individuals in every stage of change ~ Help clients learn about ◦ Their disorders ◦ Treatment options ◦ Other resources ~ Provide family members with an understanding of the person in recovery. Psychoeducational Groups ~ Educate about a disorder or teach a skill or tool ~ Work to engage clients in the discussion ~ Prompt clients to relate what they learn to their own issues (disorders, goals, challenges, successes) ~ Are highly structured and often follow a manual or curriculum.  Teach  Apply  Practice Basic Teaching Skills ~ Components of Learning ◦ Capture (acquire knowledge)  Auditory/Kinesthetic/Visual  Global/Sequential ◦ Conceptualization (Relating to building blocks) ◦ Caring (Motivation) Psychoeducational  Tec

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, magnification,

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 ~    Realize th

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 recovery

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/Conce