Treatment Planning for Depression
Dr. Dawn-Elise Snipes
Executive Director: AllCEUs.com
Podcast Host: Counselor Toolbox, Addiction Counselor Exam Review and Happiness Isn’t Brain Surgery
Objectives
~ Identify instruments to guide treatment planning
~ Identify the causes of depression
~ Identify behavioral interventions
~ Identify cognitive interventions
~ Identify Emotional Interventions
Effects of Depression on Treatment
~ The client with depressive symptoms may have difficulty in any or all of the following areas:
~ Ability to follow instructions and keep appointments.
~ Energy to participate in or maintain interest in program activities.
~ Motivation for change.
~ Ability to make appropriate decisions about treatment needs and goals.
~ Belief that he or she can be helped.
~ Responsiveness to reinforcements.
~ Ability to handle feelings.
~ Ability to handle relations with other clients.
~ Ability to attend to (and not disrupt) group activities.
~ Ability to avoid relapse after treatment is completed.
Placement Instruments
~ ASAM
~ Acute crisis and dangerousness
~ Biomedical conditions and complications
~ Emotional, behavioral or cognitive issues (See assessment instruments, next slide)
~ Readiness for change for EACH issue/objective
~ Improve mood
~ Address sleep hygiene
~ Improve nutrition
~ Cut out caffeine
~ Increase exercise
~ Relapse or continued problem potential
~ Recovery environment
Screening Instruments: Emotional
~ DSM V PROMIS
~ Severity Measure for Depression, Adult(Patient Health Questionnaire [PHQ-9])
~ Zung Self-Rating Depression Scale
~ Center for Epidemiologic Studies Depression Scale (CES-D), NIMH
~ Severity of Posttraumatic Stress Symptoms, Adult (National Stressful Events Survey PTSD Short Scale [NSESS])
~ Severity Measure for Generalized Anxiety Disorder, Adult
Screening Instruments: Cognitive
~ Attributional Style
~ Hardiness and Perceived Stress Scales
~ Stress Awareness/Hardiness
Causes of Depression
~ Biochemical imbalance
~ Norepinepherine (focus, motivation)
~ Serotonin (contentment, relaxation, pain, sleep, hunger, heart rate)
~ Dopamine (motivation/pleasure, memory, focus, pain)
Causes of Depression
~ What is causing the biochemical imbalance
~ Physical
~ Lack of quality sleep
~ Exhaustion/burnout
~ Poor nutrition
~ Chronic pain
~ Diabetes
~ Thyroid and sex hormone imbalances
~ Vitamin D deficiency
~ Hypocortisolism/Adrenal Fatigue
~ Anemia
~ Side effects of medications
~ Other illnesses such as MS, lupus, fibromyalgia, chronic fatigue, lyme disease, stroke…
Interventions Physical
~ Changing Behaviors
~ Identify a behavior that can be addressed:
~ Keep it simple and achievable.
~ Break big problems down into smaller, achievable components.
~ Identify the goal (outcome) the client would like to achieve:
~ Make the goal measurable so the client can know when he or she has achieved it.
~ Explore ways the client has achieved similar goals in the past.
~ Identify barriers (internal and environmental) to success and identify what parts the client can control.
~ Identify how those barriers can be overcome in specific behavioral terms. Make addressing the barrier something to do, rather than something not to do.
~ Identify supports and specific steps needed to achieve success
~ Elicit a commitment and take action to achieve the goal
Interventions: Physical
~ Get a physical to rule out hormone imbalances, physical issues causing lack of energy, fatigue, difficulty concentrating, sadness, irritability
~ Address nutrition to provide building blocks
~ Cut out caffeine 12 hours before bed
~ Stay hydrated
~ Improve sleep hygiene and sleep 7-9 hours each night without waking
~ Get moderate exercise 30 minutes a day
~ Get more sunshine 15-15
~ Review medications for side effects
~ Address chronic pain with TENS, massage, stretching, meditation, acupuncture, mild to moderate exercise, hot or cold pads, ergonomics (work, sleep, sofa)
~ Consider pharmacological interventions
Causes of Depression
~ What is causing the biochemical imbalance
~ Emotional
~ Depression
~ Lack of pleasure
~ Stress
~ Anger
~ PTSD
~ Fears activating the HPA Axis
~ Abandonment/isolation/rejection
~ Failure
~ Loss of control
~ Emotional dysregulation
Emotional Interventions
~ Keep a daily log of nutrition, sleep, things that trigger emotional distress and ways you cope, and share with your counselor to identify patterns, themes and effective interventions
~ Develop a stress management plan
~ Identify methods that help you deal with anger, anxiety and depression
~ Do things that make you happy
~ Address guilt
~ Learn distress tolerance skills to assist in tolerating emotional upset
Causes of Depression
~ What is causing the biochemical imbalance
~ Cognitive
~ Cognitive distortions
~ All or nothing
~ Availability heuristic
~ Emotional reasoning
~ Personalization
~ Overgeneralization
~ Jumping to conclusions
~ Magnification and minimization
~ Negative global, stable attributions
~ Extremely internal or external locus of control
~ Ineffective distress tolerance skills
~ Ineffective problem solving skills
Addressing Negative Self Talk & Cognitive Distortions
~ Identify the situations that make the client feel uncomfortable.
~ For each uncomfortable situation, make a list of the uncomfortable feelings the client experienced after the situation.
~ Ask the client to identify the first thought that comes to mind when he thinks of the uncomfortable situation. Then identify other thoughts that often arise with this situation. Try to identify a theme from the thoughts.
~ Identify how the thought(s) or theme limits the client’s options in life.
~ Help the client identify different ways of thinking about the situation and feelings that can lead to better options.
~ Once the list of reasonable responses is completed, summarize it, go back through the list of feelings generated for that situation in Step 2, and discuss the decrease in intensity of each feeling for the new list of reasonable responses compared with the feelings related to the old, negative thoughts.
~ Plan for continuing practice of this new skill.
Interventions: Cognitive
~ 5 steps to challenge beliefs that limit options for change:
~ Listen to the client’s organization of and beliefs about the problem
~ Present your understanding of the belief (“It sounds like you believe that..”); see if the client agrees or disagrees with that assessment.
~ If the client disagrees with your assessment of the belief, then ask for a more accurate statement of what he or she believes.
~ If the client agrees with your assessment of the belief, explore how holding that belief affects the client’s ability to address the problem.
~ If the client agrees with your assessment, inquire if he or she would add or change anything about the way you phrased the belief (to be as specific as possible about the belief).
~ Help the client reframe the belief from a truth (unchangeable) to a thought (changeable)
~ Help the client alter beliefs to include options for changing the problem.
Interventions: Cognitive
~ Learn about the connection between thoughts, feelings and actions
~ Identify and address/challenge cognitive distortions with
~ Daily distortions logs
~ Worksheets and videos
~ Learn about attributions and address negative global, stable attributions
~ Keep a log of negative, global, stable attributions and restructure them to be more specific and changeable.
~ Learn about locus of control and how to moderate an extremely internal or external locus of control
~ Keep a log of stressors or things that make you feel helpless and hopeless and identify what parts are within your control and what parts are not.
~ Develop effective problem solving skills based on the problems that trigger your depression (Start by reading 7 Habits)
~ Increase feelings of self-efficacy
Causes of Depression
~ What is causing the biochemical imbalance
~ Social
~ Lack of social support
~ Interpersonal conflict (Friends, family, work, social media)
~ Interpersonal losses
~ Ineffective communication skills
~ Poor self-esteem
Social Interventions
~ Learn about healthy relationships
~ Identify healthy relationships you currently have
~ Improve self esteem (your relationship with yourself)
~ Identify issues that need to be addressed in current relationships to make them healthy
~ Identify 3 people with whom you could develop a healthy support system
~ Learn skills to handle conflict
~ Learn effective communication skills
~ Learn how to ask for what you need
Causes of Depression
~ What is causing the biochemical imbalance
~ Situational
~ Losses
~ Relationships
~ Death
~ Freedom
~ Dreams
~ Sense of order in the world (control/hope)
~ Self-esteem
Causes of Depression
~ What is causing the biochemical imbalance
~ Environmental
~ People in the environment
~ Noise
~ Toxins/allergens
~ Sensory overload or deprivation
~ Depression triggers
Interventions: Environmental
~ Develop strategies to increase positive people and buffer against negative people in the environment
~ Address noise with white noise machines, ear plugs, talking to roommates
~ Eliminate toxins/allergens that may be making you feel depressed (fresh paint), or keeping you from sleeping well
~ Create a calming corner in your house and at work where there isn’t too much (or too little) stimulation, and there are triggers for happiness
Summary
~ Treatment planning needs to be individualized to address:
~ Acute crisis and dangerousness
~ Biomedical conditions and complications
~ Emotional, behavioral or cognitive issues
~ Readiness for change for EACH issue/objective
~ Strengths for addressing each issue
~ Relapse or continued problem potential
~ Stage of readiness for change
~ Recovery environment