Coping With Transitions Short Version Presented To Northwestern 12 08 1

Karla E.A. Steingraber, Psy.D.Licensed Clinical Psychologist

11Karla Steingraber, Psy.D. - Wolfson Psychological Services Karla Steingraber, Psy.D. - Wolfson Psychological Services

General Outline Types of Change Extreme Reactions Understanding Adjustment Disorders Identifying Contributing Factors Grief Theory Self-Esteem Assessment, Intervention, & Treatment

22Karla Steingraber, Psy.D. - Wolfson Karla Steingraber, Psy.D. - Wolfson

Psychological Services Psychological Services

Change -- A part of life

“The only constant is change.”--Unknown

A problem with this reality is that most people don’t like change, nor do we always know how to deal with it well.

Over the last centuries, life has become more complex and requires us to adapt to more things more quickly than ever before.

We are not born with all the essential life survival skills, so we have to learn them along the way.

What if we struggle to do this?



Types of Change: The Good, the Bad, & The Ugly

Loss of Employment Starting a New Job Moving Getting Married/Divorced Having a Baby Aging Loved Ones Passing Away Declining Healthy Others ?



Dealing with ChangeWhile we all struggle to deal with change to

varying degrees, sometimes our emotional resources become too taxed and overwhelmed. This can result in an adjustment disorder.

Adjustment disorders are very common and can affect anyone, regardless of gender, age, race, or lifestyle.



Adjustment Disorder:General Definition

Adjustment disorder (AD) is a stress-related, short-term, nonpsychotic

disturbance. overly intense responses to given stimuli. these responses manifest as emotional or

behavioral reactions to an identifiable stressful event

time-limited, usually beginning within 3 months of the stressful event, and symptoms lessen within 6 months upon removal of the stressor or when new adaptation occurs.



Types of Adjustment Disorders• Adjustment disorder with depressed mood. Symptoms mainly include

feeling sad, tearful and hopeless, and a lack of pleasure in the things you used to enjoy.

• Adjustment disorder with anxiety. Symptoms mainly include nervousness, worry, difficulty concentrating or remembering things, and feeling overwhelmed. Children who have adjustment disorder with anxiety may strongly fear being separated from their parents and loved ones.

• Adjustment disorder with mixed anxiety and depressed mood. Symptoms include a mix of depression and anxiety.

• Adjustment disorder with disturbance of conduct. Symptoms mainly involve behavioral problems, such as fighting, reckless driving or ignoring your bills. Youngsters may skip school or vandalize property.

• Adjustment disorder with mixed disturbance of emotions and conduct. Symptoms include a mix of depression and anxiety as well as behavioral problems.

• Adjustment disorder unspecified. Symptoms don't fit the other types of adjustment disorders but often include physical problems, problems with family or friends, or work or school problems.



Adjustment Disorder Statistics

5-20% of people in outpatient treatment have AD as principle diagnosis 0.05% (6,290) of hospital consultant episodes were for reaction to severe stress

and adjustment disorders 95% of hospital consultant episodes for reaction to severe stress and adjustment

disorders required hospital admission 50% of hospital consultant episodes for reaction to severe stress and adjustment

disorders were for men 50% of hospital consultant episodes for reaction to severe stress and adjustment

disorders were for women 80% of hospital consultant episodes for reaction to severe stress and adjustment

disorders required emergency hospital admission 18.3 days was the mean length of stay in hospitals for reaction to severe stress and

adjustment disorders 9 days was the median length of stay in hospitals for reaction to severe stress and

adjustment disorders 90% of hospital consultant episodes for reaction to severe stress and adjustment

disorders occurred in 15-59 year olds 3% of hospital consultant episodes for reaction to severe stress and adjustment

disorders occurred in people over 75

(Hospital Episode Statistics, Department of Health, England, 2002-03)



AD SymptomsEmotional Behavioral Sadness Hopelessness Lack of enjoyment Crying spells Nervousness Thoughts of suicide Anxiety Worry Desperation Trouble sleeping Difficulty concentrating Feeling overwhelmed

Withdrawing from family and Friends

Fighting Reckless driving Ignoring bills Avoiding family or friends Poor school or work

performance Skipping school Vandalism

99

Risk FactorsWhy is one person more likely than another to develop an AD?

Personal Components

Environmental Components

1010

Risk Factors:Personal Components Age & Gender Temperament Pre-existing Personality Disposition, Constitution Early Life Experiences History of Mental Healthy Difficulties Coping Strategies & Resilience Connectedness to others – Social



Risk Factors:Environmental/Life Experiences

Support SystemOverprotective or abusive parenting,Family disruptions and frequent moves early

in life Exposure to wars or violence without

development of PTSD Disadvantaged life circumstances Timing Form & Presentation of Stressor Recent changes, difficulties or losses at

work or in your family life



Complex Cases Most people experience multiple stressors and/or losses

simultaneously. For some, it is the accumulation of a variety of problems

which serve to overwhelm their otherwise sufficient resources.

Important to do a differential diagnosis, e.g. complicated bereavement, depression, etc.

For example:1) Declining health2) Loss of spouse3) Loss of driving privileges4) Loss of previous home

These common traumas create a very intimidating situation



Kubler-Ross Grief Stage Theory1. Denial 2. Anger3. Bargaining4. Depression5. Acceptance

Healthy grieving lessens potential for an AD



Psychosocial DevelopmentErik Erickson Trust Versus Mistrust. From ages birth to 1 year, children begin to learn the ability to trust

others based upon the consistency of their caregiver(s). Autonomy vs. Shame and Doubt. Between the ages of 1-3, children begin to assert their

independence, by walking away from their mother, picking which toy to play with, and making choices about what they like to wear, to eat, etc. (development of self-esteem)

Initiative vs. Guilt. Around age 3-6 children assert themselves more frequently. They begin to plan activities, make up games, and initiate activities with others.

Industry vs. Inferiority. From age 6 years to puberty, children begin to develop a sense of pride in their accomplishments. They initiate projects, see them through to completion, and feel good about what they have achieved.

Identity vs. Role Confusion. During adolescence, the transition from childhood to adulthood is most important. Children are becoming more independent, and begin to look at the future in terms of career, relationships, families, housing, etc.

Intimacy vs. Isolation. Occurring in Young adulthood, we begin to share ourselves more intimately with others. We explore relationships leading toward longer term commitments with someone other than a family member.

Generativity vs. Stagnation. During middle adulthood, we establish our careers, settle down within a relationship, begin our own families and develop a sense of being a part of the bigger picture. We give back to society through raising our children & being productive at work,.

Ego Integrity vs. Despair. As we grow older and become senior citizens, we tend to slow down our productivity, and explore life as a retired person. It is during this time that we contemplate our accomplishments and are able to develop integrity if we see ourselves as leading a successful life.



Defense Mechanisms Denial; an outright refusal or inability to accept some aspect of reality that is troubling. For

example: "this thing has not happened" when it actually has.

Splitting; a person cannot stand the thought that someone might have both good and bad aspects, so they polarize their view of that person as someone who is "all good" or "all bad". Any evidence to the contrary is ignored. For example: "My boss is evil", after being let go from work, when in reality, the boss had no choice in the matter and was acting under orders herself. Splitting functions by way of Dissociation, which is an ability people have in varying amounts to be able to wall off certain experiences and not think about them.

Projection; a person's thought or emotion about another person, place or thing is too troubling to admit, and so, that thought or emotion is attributed to originate from that other person, place or thing. For example: "He hates me", when it is actually the speaker who hates. A variation on the theme of Projection is known as "Externalization". In Externalization, you blame others for your problems rather than owning up to any role you may play in causing them.

Passive-aggression; A thought or feeling is not acceptable enough to a person to be allowed direct expression. Instead, that person behaves in an indirect manner that expresses the thought or emotion. For example: Failing to wash your hands before cooking when you normally would, and happen to be cooking for someone you don't like.

Acting out; an inability to be thoughtful about an impulse. The impulse is expressed directly without any reflection or consideration as to whether it is a good idea to do so. For example: a person attacks another person in a fit of anger without stopping to consider that this could seriously wound or disfigure that other person and/or possibly result in legal problems.



Defense Mechanisms (continued) Displacement; An unacceptable feeling or thought about a person, place or thing

is redirected towards a safer target. For example, it may feel unsafe to admit anger towards a parent, but it is perfectly safe to criticize the neighborhood he or she lives in.

Isolation/Intellectualization; Overwhelming feelings or thoughts about an event are handled by isolating their meaning from the feelings accompanying the meaning, and focusing on the meaning in isolation. For example, you cope with the recent death of a parent by reading about the grieving process.

Repression; A milder form of denial; You manage uncomfortable feelings and thoughts by avoiding thinking about them. You are able to admit that you feel a certain way (unlike in denial), but you can't think of what might have led up to that feeling, and don't really want to think about it anyway.

Reaction Formation; You react to uncomfortable, unacceptable feelings or ideas that you have (but aren't quite conscious of really), by forming the opposite opinion. For example; you unconsciously hate your parent, but your experience is to the contrary; you are only aware of loving feelings for your parent.



What Can You Do to Help Those at Risk

Prevention Strategies for

Self-Care Exercise Self-Esteem Team Unity

Education Recognition Preparation Treatment



Prevention StrategiesThe essential role of the “family” (nurses & social workers)

Develop healthy coping strategies Improve Resilience Create a good support network Seek out humor or laughter Live a healthy lifestyle & Request a healthy

lifestyle Think positively & Pass it on Prepare for change Suggest stress management Encourage checking in with health care or mental

health care provider to review healthy ways to manage stress.



Self-care: Encourage clients to:

Talk things over with caring family and friends Try to keep eating a healthy diet Stick to a regular sleep routine Get regular physical activity Engage in a hobby they enjoy Find a support group geared toward their situation Find support from a faith community : Be around those who offer encouragement to talk about feelings Offer support and understanding to others Make choices Avoid Destructive Activities. If they use these kinds of self-care steps but they don't seem to

be helping, be sure to refer them to their health care provider.



Exercise Improves symptoms of certain mental health conditions

Serotonin, dopamine, norepinephrine, and endorphins, have strong effects on mood reducie feelings of anxiety, stress (Cortisol) and depression Help to strengthen immune system. 20 types of endorphins beta-endorphins secreted during exercise reduce pain & muscle tension

Helps prevent a relapse after treatment for depression or anxiety Even small amounts - as little as 10-15 minutes at a time - can improve

mood in the short term.

Improves sleep

Increases body temperature, which may have calming effects.

If you exercise regularly but depression or anxiety symptoms still interfere with your daily living, seek professional help. Exercise isn't meant to replace medical treatment of depression or anxiety.



Self-Esteem

2222

Healthy self-esteem promotes confidence, and this can contribute to better managing difficulties, thereby lessening the potential for an AD

Karla Steingraber, Psy.D. - Wolfson Karla Steingraber, Psy.D. - Wolfson Psychological Services Psychological Services

Self-Esteem DefinedSelf-Esteem = The degree to which one values him/herself.

Self-efficacy = One’s sense of basic confidence in the face of life’s challenges.

Self-respect = Extent to which one feels “Worthy of Happiness”.The Six Pillars of Self Esteem by Nathanial Branden (1994)

1. The practice of living consciously2. The practice of self - acceptance3. The practice of self - responsibility4. The practice of self - assertiveness5. The practice of living purposefully6. The practice of personal integrity

The missing pillar: social connectedness We are social beings!



5 Steps toward Improving Self-Esteem Step 1: Identify troubling conditions or situations Think about what you find troubling and deflates your

self-esteem. You may wish to change aspects of your personality or

behavior, such as a fear of giving a business presentation or frequently becoming angry

You may be struggling with depression, a disability or a change in life circumstances, such as the death of a loved one, a lost promotion or children leaving home.

Or you may wish to improve your relationship with another person, such as a spouse, family member or co-worker.



Step 2: Become aware of beliefs and thoughtsOnce you've identified troubling conditions or

situations, pay attention to your thoughts. This includes your self-talk — what you tell

yourself — as well as your interpretation of what a situation means and your beliefs about yourself, other people and events. Your thoughts and beliefs may be positive, negative or neutral. They may be rational — based on reason or facts — or irrational — based on false ideas.



Step 3: Pinpoint negative or inaccurate thinkingYour beliefs and thoughts about a condition or situation affect your

reaction to it. Inaccurate or negative thoughts and beliefs about something or someone can trigger unhealthy physical, emotional and behavioral responses, including:

Physical responses, such as a stiff neck, sore back, racing heart, stomach problems, sweating or change in sleeping patterns.

Emotional responses, such as difficulty concentrating or feeling depressed, angry, sad, nervous, guilty or worried.

Behavioral responses, such as eating when not hungry, avoiding tasks, working more than usual, spending increased time alone, obsessing about a situation or blaming others for your problems.



Step 4: Challenge negative or inaccurate thinking

Your initial thoughts may not be the only possible way to view a situation. So test the accuracy of your thoughts. Ask yourself whether your view of a situation is consistent with facts and logic or whether there might be other explanations.

You may not easily recognize inaccuracies in your thinking. Most people have automatic, long-standing ways of thinking about their lives and themselves. These long-held thoughts and beliefs feel normal and factual to you, but many are simply opinions or perceptions.



Thought patterns that erode self-esteem: All-or-nothing thinking. You see things as either all good or all bad. For

example, "If I don't succeed in this job, I'm a total failure." Mental filtering. You see only negatives and dwell on them, distorting your

view of a person or situation or your entire life. For example, "I made a mistake on that report and now everyone will realize I'm a failure."

Converting positives into negatives. You reject your achievements and other positive experiences by insisting that they don't count. For example, "My date only gave me that compliment because he knows how bad I feel." "I only did well on that test because it was so easy."

Jumping to negative conclusions. You reach a negative conclusion when little or no evidence supports it. For example, "My friend hasn't replied to my e-mail, so I must have done something to make her angry."

Mistaking feelings for facts. You confuse feelings or beliefs with facts. For example, "I feel like a failure, so I must be a failure." No matter how strong a feeling is, it isn't a fact.

Self put-downs. You undervalue yourself, put yourself down or use self-deprecating humor. This can result from overreacting to a situation, such as making a mistake. For example, "I don't deserve anything better." "I'm weak, stupid or ugly."



Step 5: Change your thoughts and beliefs The final step is to replace the negative or

inaccurate thinking you've identified with accurate thoughts and beliefs. This can enable you to find constructive ways to cope and give your self-esteem a boost.

This step can be difficult. Thoughts often occur spontaneously or automatically, without effort on your part. It can be hard to control or turn off your thoughts. Thoughts can be very powerful and aren't always based on logic. It takes time and effort to learn how to recognize and replace distressing thoughts with accurate ones.



Patient & Family EducationNurses & Social Workers are often the only point of contact for families. Teach them about what you are doing, such as…. Prevention Attention Care Individual differences AD: One instance or series of stressful events Encourage acknowledgement of the

personal significance of the stressful event. Encourage getting support



Team Unity



The Necessity of Team Unity Team Approach

ConsistencyCommunicationCommitment

Without Team Approach ….Example of team splittingGood cop, Bad cop = failed treatment

SolutionsTeam MeetingBehavior Plans



Treatment2 Treatment Options:

PsychotherapyTreatment of choice for adjustment disorders is psychotherapy, also called counseling or talk therapy. Therapy can provide emotional support, help you learn why the stressful event affected you, and healthy coping skills.

The form and type of psychotherapy will vary upon the clinician, and the personality features of the patient. This therapy often takes the form of solution-focused, to help the individual deal more effectively with the specific life problem.

A focus on guiding the client toward finding new coping mechanisms, or finding a better understanding of issues in their lives.

MedicationsIn some cases, medications may help, too. Medications can help with such symptoms as depression, anxiety and suicidal thoughts.



Therapeutic Options Individual psychotherapy Crisis intervention Family and group therapies



Treatment OverviewTreatment of ADs entails psychotherapeutic counseling aimed at: reducing the stressor, improving coping ability with stressors that cannot be reduced or

removed, and formatting an emotional state and support systems to

enhance adaptation and coping.

Goals of psychotherapy should include: Analyze the stressors that are affecting the patient, and

determine whether they can be eliminated or minimized. Clarify and interpret the meaning of the stressor for the patient. Reframe the meaning of the stressor. Illuminate the concerns and conflicts the patient experiences. Identify a means to reduce the stressor. Maximize the patient's coping skills. Assist patients to gain perspective on the stressor, establish

relationships, attend support groups, and manage themselves and the stressor.



‘Goodness of Fit’ TheoryGoodness of Fit results when the properties of the

environment and its expectations and demands are in accord with the individual’s own capacities, characteristics, and style of behaving.

(Apply to ADHD-work=Minimal distractions Spouse=organized, Patient

Interactionism - A combined function of inherent and environmental influences. An expression of continuous organism-environment interaction.

Individualization – Uniqueness. One’s variability in his/her physiological, psychological, cognitive, and perceptual attributes.

Chess, Stella & Thomas, Alexander (1999).



Medication Classes & Problems with Typical Use in Special Populations Stimulants/ADHD (e.g. Ritalin, Concerta, Focalin); Alternatives

(Strattera, Wellbutrin)

Antidepressants/Depression or anxiety (e.g. Prozac, Zoloft, Effexor, Cymbalta)

Antipsychotics/Psychosis or PTSD (e.g. Resperidone, Seroquel, Geodone, Abilify)

Mood stabilizers/Bipolar Disorder (e.g. Trileptal, Abilify, Depakote)

Difficulties Social stigma Team disagreements



Challenging the notion of “Toughing it out”

An adjustment disorder is a severe emotional reaction to a difficult event.

It impacts daily routines and gaining satisfaction out of life.

No one should have to tough it out alone.

Nurses and Social Workers, who see the these clients very regularly, are in the best position to impact these clients Because they are liked and admired Because they are available



Bibliography Kaplan, Harold & Sadock, Benjamin (1988) Synopsis of Psychiatry 5th

edition. Williams & Wilkins, Baltimore, MD DSM-IV-TR American Psychiatric Association, Washington DC Branden, Nathaniel (1994) The Six Pillars of Self-Esteem. Bantam

Books, New York, N.Y. Chess, Stella & Thomas, Alexander (1999). Goodness of Fit.

Brunner/Mazel, Philadelphia, PA Faulkner, Terry (2008). Personal communication. Kubler-Ross, Elisabeth (1969) On Death And Dying. Macmillan Publishing Co., New York, N.Y. MayoClinic.com eMedicine.com PsyWeb.com wrongdiagnosis.com absolutefitness.co.uk appliedsportpsych.org

3939Karla Steingraber, Psy.D. - Wolfson Psychological Services Karla Steingraber, Psy.D. - Wolfson Psychological Services

Coping With Transitions Short Version Presented To Northwestern 12 08 1

Health & Medicine

Transcript of Coping With Transitions Short Version Presented To Northwestern 12 08 1