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Mental Health Awareness and DeEscalation: PACER Integrative Behavioral Health

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i’d like to welcome everybody to today’s episode of integrated behavioral health  today we’re talking about mental health awareness and de-escalation and then at  the end we’re going to talk some about mental health hygiene i am your host dr dawn elise snipes now this presentation is really designed for the average person for non-clinicians if you’re  a clinician it you know hopefully will be old hat review but a lot of people interact with  loved ones or even people that they work with um who are in crisis or who are starting to develop  some level of mental health issue so let’s talk first about some signs of distress and  these are not going to be surprising to you anger and irritability fear depression a sense  of hopelessness and helplessness guilt grief i don’t even have that one on here  difficulty concentrating and insomnia if you are dealing with somebody who is what we will call  dysphoric they are not in a happy place then it’s important to be aware that they may have something  situational going on that’s contributing to their anger or their irritability or their depression  however there are steps that we can take to help them feel acknowledged and accepted and validated  and supported and when people feel that way it often helps them to start improving the next  moment we need to recognize that dysphoric symptoms your unpleasant symptoms represent  an emotional reaction to a threat you know these symptoms are our body’s way of saying  hey something is not right in the hen house here so we need to take a look at what’s  going on and as i’ve talked before many times about this system that we have our hpa axis  mainly um is not a hundred percent accurate it’s like a smoke alarm that goes off when  you know it thinks there might be a fire it doesn’t necessarily mean there is a fire  it could be that you know you put something on the on the stovetop and it’s not catching fire it’s  just smoldering a little bit and getting getting smokey or in our house for some reason when there  are really really strong winds our fire alarms go off i don’t know why but when that happens it’s  important to check that alarm is an indication not necessarily that there is for a fact always  a problem but it’s an indication that there might be a problem and you need to check it out  either way when people are dysphoric their hpa axis their fight or flight response is  activated and it’s important to recognize that that activates in response to a perceived threat  when we feel threatened we often feel a loss of a sense of safety and control we feel unsafe  disempowered maybe unsupported so you know those are things that we really need to recognize maslow  abraham maslow many many many many years ago created this hierarchy of needs and the base of  the pyramid is our biological needs we need food we need water we need medical care the next level  is safety if we are hungry if we are sick if we are in pain if we are not getting enough sleep  um and we don’t feel safe guess what working on things like relationships and self-esteem  and all that kind of stuff that’s kind of unimportant so those the things in the base level  of maslow’s hierarchy are really important and when people feel a threat  a lot of times that threat is to at least that safety level people feel  unsafe for some reason another reason people can feel dysphoric unhappy is because of a  loss of something that was important when we feel depression when we feel grief  sometimes that’s our body saying hey that thing was really important and you’re sad it’s not  here anymore you know it’s not something that we can go go get or go do anymore so  that is an emotional reaction to a loss of control and a loss of something that was important to you what we’re really talking about today is the best way to try to interact with people  who are in crisis or who are in a uh unpleasant state of mind if somebody is irritable  and you go at them and you tell them how they should feel and what they should do or just to let  it go or whatever it’s probably going to make them feel more out of control and it’s probably going  to contribute to increased irritability so some key phrases that can trigger people to be feel  less supported and feel more threatened include things like i understand when somebody is really  upset and you tell them i understand a lot of times their response is you have no idea  or my least favorite is calm down when someone is upset  and they’re in that fight-or-flight mode they’re in their emotional mind  they want to calm down if they could calm down they would at that point in time they are feeling  oftentimes very powerless very threatened and very hyper vigilant because that threat is right there  it’s important to help them figure out how to calm down recognize that they’re safe and then overt  invalidation when i was giving birth to my son he was a micro preemie so you know we were rushed  into the hospital we were rushed into labor and i i’m sitting there you know trying to give birth  and i’m telling the doc i can’t breathe and his response to me was if you can talk you can breathe  just push and i was just like oh no you didn’t um but of course i wasn’t in a position to  fight at that point in time but my son is now 21 years old and that is still something that is  right in the forefront of my mind because that was so incredibly invalidating at that point in time  when people are in distress we want to help them regain a sense of safety that’s the first thing  help them get a safe sense of safety and that may mean also mean helping them feel  empowered to do things to get themselves safe helping them figure out what they can do to de-escalate at that point in time instead of telling somebody you need to calm down  talking with them and saying i i can see that you are really upset right now and you know you’re  breathing so fast i’m you know i’m afraid that you’re gonna get dizzy i’m afraid you’re gonna  pass out you know can we sit down or would it help if you took a deep breath tell explaining to them  even that when you breathe deeply and in for four hold for four out for four  it helps trigger a relaxation response so they can catch their breath you want them  to breathe you’re not telling them that they’re hyperventilating is irrational  you’re telling them you’re worried about what’s going on with them  you want to empathize and validate their current thoughts and feelings even if you don’t agree  they are in crisis that is their reality at the moment and coming in and telling them that  their reality is wrong is only going to make them feel more attacked more edgy so it’s important to  empathize and validate with what they’re going through right now what it must be like for them  and so they can feel supported once they a lot of times once people feel like  you understand and you’ve got a clear picture of what’s going on they feel  like you’ve joined with them against this threat or that you can be more supportive  so you can say things like i can see that you are feeling angry i can see that you are depressed  grieving you know i see it it doesn’t mean i feel it um but when i say that i can see  that then i am validating i am telling you i’m being responsive and saying i’m noticing  how you feel and the person will say yes or they may say you know if you say it seems like you’re  kind of upset and they may say well i’m way past kind of upset okay well at least that’s opened a  door and they’re you know communicating to try to welcome you in to help them and to support them  you can say things like this situation feels very terrifying or must feel very terrifying i remember  you know with my son the one time one and only time i’ve ridden in an ambulance it was from one  hospital to another because they had since he was so preemie they had to transfer me to a hospital  that had a higher level neonatal intensive care unit so in this 10 minute ride between  hospitals i was absolutely terrified uh about what was going on and everything else uh so just  saying to somebody you know this must feel very terrifying or it feels very terrifying for you  validates how they’re feeling even if you’re the paramedic sitting there going we got this covered  the patient probably has never been through that before you may have been through it 50 times and  you’re like yeah no biggie but the patient’s never been through it before so they may be feeling very  terrified and it’s important instead of explaining to them how they should feel and it’s not a big  deal to paraphrase how they feel and ask them what can i do to best support you you can also  say things like i can imagine how scary it feels to not have control in this situation  if you’re dealing with a parent for example who has a child that was diagnosed with cancer or even  a person who was diagnosed with cancer you know one of the things there may feel is a lot of rage  at what’s going on because they may feel like they don’t have control over what’s going on with them  i’ve created y’all know i love my acronyms or mnemonics the mnemonic craves when you’re dealing  with somebody who is in crisis calmness is very helpful and i’m not sure if that’s even actually  a word but it worked here um being calm if you get upset then they’re gonna pick up on that even if  you’re trying to hide it if you get upset they’re gonna pick up on it and go oh there must be  something to this and they may escalate further so being calm is essential being responsive to them  if they are in crisis they may be getting cold they may be hot they may want to move around not  have to sit still just asking them what can i do to best assist you to best support you right now  a stands for acceptance accepting their thoughts and feelings and  experiences as they’re experiencing them you may have a very different perception of what’s going  on but if they’re terrified right now then we need to kind of join with them and and try to  understand what it’s like in their head we’re not going to stay here forever but in order to develop  that connection and develop some rapport the first thing is to help the person feel accepted  and have their feelings validated you know i can imagine how terrifying it must be  to you know one of my friends a few years ago used to race motocross and he took a jump too high and  fell and or crashed or whatever you call it and he had compound fractures of both legs both tibias  both fibulas in both legs and you know they didn’t know if he’d ever walk again and it was absolutely  terrifying for him and his wife and it and it’s important to to validate that you know i accept  how you’re feeling right now and you know i don’t blame you i can imagine how scary this must be  e stands for empowerment once you’ve kind of joined and the person says feels like okay  this person understands what i’m going through or has a better inkling of what i’m going through  then moving to empowerment and i kind of put empowerment and safety together  remember one of the first things we want to do with people um or help people do when they  are in crisis is help them establish a sense of safety now the first steps that you did the  responsiveness and acceptance and all that that helped establish emotional safety and cognitive  safety because you’re not afraid you’re not being put off by their anger you’re not being freaked  out by their depression you are sitting there with them you’re not invalidating them so that  gives them a sense of emotional and cognitive safety that you’re not going to tell them  how they’re wrong and you’re going to be there to kind of empathize and support them then we move to  physical safety and it’s important to help people figure out you know sometimes all right what is  the next thing that you need to do for you in this situation and and how can i assist with that  so you know for example when i was in the in the ambulance on the way to the hospital  the paramedic was very good about you know reminding me when i would have a contraction  to breathe it was one of those things i was kind of forgetting at that point in time  and he was very calm the whole time i was like totally freaking out but he was calm and and uh  empowering he was reassuring about you know the and he would tell me he’d give  me updates periodically we’re almost to the hospital it’s only a couple more minutes  so i felt like there was a light at the end of the tunnel so that was that was really good  when people are in distress let’s just say in distress because it’s not necessarily in crisis  helping them feel a sense of safety and personal power often helps get them unstuck so they can get  out of their emotional mind get out of their reactive mind and start thinking more broadly  about okay what are what’s the next thing what are the next things i need to do in order to improve  the next moment this moment sucks i don’t want to continue to have this moment over and over again  so what can i do to improve the next moment and it is important to when you’re talking with them and  you’re being responsive if you’re saying something and they’re starting to get more agitated  acknowledge that it seems like what i’m saying is upsetting to you or it doesn’t seem like you’re  feeling comforted or whatever is appropriate to say at that moment that’s fine to say and the  person can say yeah that you’re darn tootin and then you can respond by what is it that i can do  to best help you at this point in time and if they don’t know that’s okay try to have a couple  tools in your tool kit specifically the slow breathing can be very helpful  for some people they may want to hold your hand other people won’t want to be touched  ask permission before touching they are already on on edge so it’s important to  kind of step back and put them in the driver’s seat and and ask them sometimes is it okay if  i touch your hand or you know would you like to hold my hand um would you like a hug not  everybody wants a hug some people do and and go from there and their responses are perfectly  what they need at that point in time and you can tell you can get a feeling from  their especially from their nonverbals about whether they are calming down and de-escalating  or they’re not and if they’re not de-escalating you can ask them questions like what is it that  you are most fearful of right now so that helps you understand exactly what they’re focusing on  paramedics can do that after a crisis after a disaster when first responders are on scene after  a tornado or something you know asking people what is it that i can best do for you asking them  you know for example what are you most afraid of right now but also using your knowledge first  responders know that people who’ve had an extreme trauma are likely in a kind of a shocky hazy sort  of thing so it’s important to help them stay safe and you know get them get them blankets and make  sure that they’re drinking water or what have you so those are things that you can also remember  a lot of people who are who are first responders you know you don’t get a lot of training on this  but it is helpful to know that you know you’re in a position to be able to lead the person you don’t  want to do things to them if you can help it you want to lead them and say would you be willing to  can i help you buy do you think it would help if we got up and walked around for a minute  those are all things that allow the person to feel empowered and give them choice and that is the  next step they need after they feel safe then they need to feel like there’s some level of choice now i see a few questions have come in  oh and mental hygiene i did promise we would talk about that mental hygiene is a way of or a strategy for maintaining and promoting mental health and it’s  important to recognize we talk about hardiness a lot recognizing you know in the big scheme of  things all of the things that you have right now that are that you’re committed to that make your  life rich and meaningful so being grateful for what you’ve got even the stuff that’s going crappy  but recognizing that most of the time your entire life is not going crappy there are parts of it  recognizing what you can control what aspects of the situation you can control  to nurture the good and to address the bad and viewing challenges viewing problems  as challenges instead of barriers can also be very helpful heartiness was something that kobasa  proposed back in i think it was 1978 if you’re interested in looking at the wiki on it um so  that’s one step but it’s also really important and i am doing a whole series on integrative  behavioral health right now but it is really important to make sure that our body factory  is functioning optimally because when our body is physically under stress it contributes to  distress and low mood low energy difficulty concentrating lots of things that are symptoms of  anxiety disorders mood disorders or even cognitive decline so we do need to pay attention to that  on an affective note we need to add in the positive think about life if you will as a  box because we all you know want to get out of our box sometimes but think about life like a box  and if you have in that box a bunch of unpleasant stuff you know broken toys  and you want to get all those broken things out all that unpleasantness out well that’s great  but if all you do is eliminate the bad take out the broken stuff and you don’t put in the  good then when you finish eliminating the bad you’re left with an empty box and you’re like  what what’s this so it’s important to add in positive so when you get to the bottom there  are some not broken toys there are some really awesome things there the other analogy i make uh  about mental hygiene and affect is thinking about life thinking about health like a bath and anxiety  distress anger those things are hot and and when our cortisol levels are up that’s like hot  when we are doing things that we enjoy things that make us happy things that help us relax those are  like cold you don’t want to be in a bath that is too incredibly hot because it would burn you  and in life it’s just very unlikely that you’re going to have a bath that’s completely cold  so what you’re trying to do most of the time is regulate the temperature so it doesn’t get too hot  in acceptance and commitment therapy hayes talks about the fact that it is unreasonable to expect  life to not have pain pain is an essential part of life cognitive pain you know we lose things  that are important to us we may feel distressed we may have physical pain sometimes and that’s just  reality it’s not reasonable to expect we will have a life without pain but it is reasonable to  consider the fact that you might be able to have pain and a rich and meaningful life people who  have rheumatoid arthritis for example can have rheumatoid arthritis and still do a lot of things  they can address that as well as possible so they can have a rich and meaningful life they have  to live life a little bit differently in order to you know keep the arthritis from flaring up  but they still can have a rich and meaningful life so that’s affectively we want to do things that  encourage us to feel happy that encourage the dopamine and the serotonin cognitively we want to  address our thoughts and this is where mindfulness can come in really really handy a lot of times  we automatically fall back on negative thinking styles cognitive distortions whatever you want  to call them and that puts us in a negative frame of mind if we’re always scanning for the negative  for the threats then guess what we miss the positive so part of mental hygiene can be  being mindful of our thought patterns and practicing radical acceptance when you  see a negative in something also trying to find you know the positive it may not be in that exact  same thing but like a few few years ago it got really snowy here which you know i love snow so  that was awesome uh but we couldn’t get out of our neighborhood for almost a week and the kids and  the animals and everybody were all kind of trapped at the house and that felt a little um suffocating  at times but it was also a really amazing time because we got to go out and snowboard down the  hill in the backyard and do some other things so recognizing would i like to be able to go to the  gym right now and get to the office and do those sorts of things well heck yeah however i can’t  what what is the good i can get out of this so that can be um they sometimes people call it  cognitive restructuring sometimes they call it radical acceptance whatever you want to call it  trying to focus turn your attention to what is going well in your life what is right about this  situation instead of looking at all the things that are wrong about it another thing with mental  hygiene and we talked about this in the episode on dementia is to make sure that you’re working  your brain it’s not really a muscle but it is important to continue to regularly work your brain  to develop cognitive resources think about it as just like a pantry that you would stack up and  make sure that you had plenty of food reserves in the event of a hurricane or a blizzard or something like that the same sort of thing is true  with your brain if you build up some of those cognitive reserves then they hypothesize that  activating more aspects more areas of your brain provides you more flexibility when you  do start aging and evidencing you know inevitable cognitive decline you can stave it off if you’ve  got more resources you don’t start starving as quickly if you’ve got plenty in the pantry  environmentally mental hygiene is it’s important to evaluate your environment to make sure that  it is as relaxing and as safe feeling as possible you know no sense having extra  distress around and then interpersonally focusing on developing a few healthy supportive  relationships not everybody is going to be healthy and supportive but especially in this time of  high stress you know it’s important to think about things and ask yourself is what i’m doing  now helping me feel happier and have a more rich and meaningful life or is it contributing to my  distress i was flipping through channels the other night and it occurs to me how um awful  it is for for a lot of people right now that you know generally on the holidays  some of those hallmark christmas movies can be painful anyway because people see this  hallmark christmas and they’re like i never had that and then they start feeling like  they missed out on something like everybody else has this and i don’t so that contributes to  feelings of resentment and depression and grief when in reality you know the number of people  that actually have those hallmark christmases is probably pretty small those are idealized  but it increases people’s distress and during this particular holiday season when there’s a  lot of travel restrictions and there have been a lot of people that have gotten sick and died  there’s even more distress out there so having all of those um glorified uh holiday movies on can be really challenging so the question is if somebody  turns it on is watching this going to help me go to a happy place and imagine what life could  be like and increase my pleasure or is watching this going to make me feel grief stricken and  depressed and if it’s the second turning it off making sure you do things for your mental  fitness as well as your physical fitness because if your body is out of sync if your body is sick  in some way then your emotions are probably going to follow not too far behind but by the same token  if your body is healthy that hpa axis hpg axis hpt axis if all that stuff is healthy  or healthy-ish then your mood is probably going to follow not too far behind with the exception  of when there is some sort of situational thing that comes up you experience a loss in  your life you experience something stressful well okay when that happens if your body is  your body factory is functioning at optimal levels then it’s cranking out those hormones and  neurotransmitters and everything like it needs to so you have the resources  to deal with distress when it happens you have the extra in the bank so to speak whereas if you  weren’t practicing mental hygiene if you weren’t taking care of your mental health leading up to it  then your pantry was empty and a lot of times you don’t have the resources to cope as well and you’re right nick many um helping professionals do lack a bedside manner especially  um well i’m not going to call out particular professions but there are some professions  and in the helping field that tend to be more uh tend to be less focused on the warm and fuzzy and  more focused on the facts so it is important to recognize how important and how that can really  help with understanding what’s going on with the person and this is true not just of health  professionals but of firefighters of paramedics of law enforcement it doesn’t take a lot of time but  a lot of times it actually speeds up the process if you can go in there and quickly establish  rapport if you spend the first 10 minutes kind of struggling to see who’s going to have power  in the relationship uh you’re wasting a lot of time if you get in there and you know help the  person feel heard and understood and safe you’re going to be able to gain a whole lot more traction  more quickly regardless of what your profession is or where you’re at and this is true for  supervisors too this isn’t just first responders if you’ve got a staff member who is  starting to show signs of dysphoria you know it’s not just today john is in a bad mood but for the  last three weeks john has been you know on a tear then these skills can also be super helpful to  initiating a discussion that may end up in for example a referral to the employee assistance program and it is important you’re right nick to  try to be as careful as possible responding to people based on  their age their gender their cognitive ability their culture they may respond differently to to different people and to different situations so you can’t assume that any two people are going to  respond exactly the same way and and that’s a really good point that you want to just  let them come in some people may come in like like my friend who had the two broken legs some people  may come in and you know they’ve broken lots of bones before and this isn’t a huge big deal i mean  it’s stressful don’t get me wrong but they’re not like super freaked out about it um other people  may come in with something that seems pretty minor and they are in terror about it for example  my mother um unfortunately had uh kidney we’re not sure where it started but kidney cancer and  you know she had low back pain and that was the first sign that she had kidney cancer  she put off going to the doctor because she thought she just heard herself working out low  and behold she goes in she’s stage four so what do you think my reaction was for the first year after  mother got her diagnosis whenever i would get low back pain you know my first thought would be  oh my gosh and then i would have to kind of talk myself down and be like okay realistically you  were you know squatting with 150 pounds yesterday so not surprising your low back sore today  and it was important for me to be able to back up and look at that but having a  professional a caregiver um of some sort of doctor say oh  you know there is no chance that you have this and and dismissing my concerns uh could have  been very invalidating and not comforting at all if i didn’t feel like i was taken seriously and yes i would love to do a future lecture on the effects cognitive effects on the hippocampus and  amygdala due to abuse and chronic stress if you have not read it already um the body keeps the  score by uh bessel van der kulk is a is an amazing book um i believe it’s by bessel vander kulk um  let me see if i can pull it up here for you guys um yep uh so evidently it’s on audible on amazon but the body keeps the score is one of those  foundational readings if you deal with people who experience trauma and i have another  article that i can share with you guys i will put it in the comments section  after we finish today’s presentation that you can look at if you’re interested in some of the wide-ranging changes that occur as the result of ptsd and trauma in the brain in the body so  it’s it’s not just a thinking thing there are a lot of physiological alterations that happen  as a result of trauma so i’ll pull up that article it’s one of my favorites  and i can share that with you you can also actually find it i’ve done a couple of videos on the youtube channel on the neurological impact of trauma are there any other questions as i said i’ve been working on a series on  integrative behavioral health and i’m just learning so much about how things like  testosterone levels and estrogen levels impact thyroid levels and neurotransmitters and how  sleep and nutrition and you know actually lack of enough fat or lack of enough carbohydrates  can add stress to the body and you know obviously the the the whole gut brain axis  thing and talking about leaky gut and how an unhealthy gut can also contribute to  distress and how distress how cognitive distress and emotional distress and  unhelpful thinking styles can trigger that hpa axis and actually make the body sick  so you know i think it’s a really fascinating system that our body has although imperfect alrighty everybody thank you so much for being here with me today i appreciate you taking time  out of your day to join me as always if you have further questions after i sign off the  chat quits pretty quickly so i can’t respond to a whole bunch of stuff so if i haven’t responded  to something that you’ve put in the live chat after i end the stream you can also put comments  below the video and we do respond to those comments as quickly as we can  so thank you for being here i look forward to seeing you on monday have a fabulous weekend  figure out some awesome things to put in that box not just unpleasant things to take out

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