Overview of the PACER Method and Transdiagnostic Assessment
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
Podcast Host: Counselor Toolbox and Case Management Toolbox
Sponsored by TherapyNotes.com
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Objectives
– Define the PACER model
– Explore how PACER dimensions interact
– Examine the transdiagnostic assessment process
Why A New Approach-
– 10% of Americans are on antidepressants for anxiety or depressive issues
– Without medication 20-40% of people with clinical depression noticed symptom improvement in 6-8 weeks
– WITH antidepressants 40-60% of people with clinical depression noticed symptom improvement in 6-8 weeks
– That leaves as many as 40% of people still struggling with significant symptoms after 6-8 weeks.
– No high- or moderate-strength evidence for any intervention to effectively treat any phase of any type of BD versus placebo or an active comparator
Why A New Approach-
– Cognitive Behavioral Therapy appears to be effective in approximately 47% of cases
– Results are mixed regarding whether CBT + antidepressants can augment treatment response
– Cognitive behavioral interventions for depression and anxiety prevention showed a small effect for prevention of depression but not anxiety and no effect at 3-6 months and at 12 months follow-up
– In a study of over 33,000 patients, only patients who had 18 or 20 CBT sessions showed more improvement than generic counseling.
Why a New Approach
– Counseled patients are significantly more likely to have recovered than non-counseled patients
– Client outcomes are most often determined by client variables such as
– Chronicity and severity
– Complexity of symptoms
– Motivation
– Acceptance of responsibility for change
– Therapeutic change is less about talk-therapy interventions and more about the patient’s ability to maintain motivation and efficacy and clinician team’s ability to look multidimensionally at issues
PACER Method
– The PACER Method uses a transdiagnostic (many symptoms are common to multiple disorders) and transtheoretical (there are many ways to address each symptom) approach to recovery to assist people in optimizing their quality of life
– Physical
– Affective
– Cognitive
– Environmental
– Relationships
– The PACER method consistently looks at bidirectional interactions
PACER Method
– The PACER Method
– Counselor Functions
– Counseling and motivational enhancement
– Connecting with multidisciplinary referrals (MD, RD, PT etc.)
– Case Management (Integrating & monitoring tx plans)
– Improving Health and Mental Health Literacy
– Goal
– To address PACER issues which create or maintain imbalances in the nervous system that cause unnecessary dysphoria.
Physical
– Rule out organic dysfunction in the system
– If the body cannot make or balance the neurotransmitters due to health or behavioral issues, those must be addressed.
– There are over 30 hormones the body must construct to regulate neurotransmitters
– There are over 100 neurotransmitters the body must construct and balance to regulate attention, memory, sleep, feeding, heart rate, respiration, energy, motivation, mood and more.
– Up to 95% of some neurotransmitters and hormones are made in the gut (Setting concrete in the rain)
– The body requires vitamins, minerals and amino acids to make hormones and neurotransmitters
Physical
– Rule out dysfunction in the system
– If the body cannot produce or effectively regulate hormones and neurotransmitters, people will have “symptoms”
– Example: HPA axis dysfunction and exposure to stress are critical components that increase risk for developing addictions
– Some hormones and neurotransmitters increase the levels of certain H & NTs while simultaneously decreasing levels of other H & NTs
– Under stress cortisol increases norepinephrine, adrenaline, glutamate, estrogen and ghrelin and inhibits and availability of serotonin and the creation of T3
– During relaxation, DHEA, GABA and serotonin levels increase which reduces cortisol and norepinephrine, adrenaline, glutamate, estrogen and ghrelin
Physical Assessment
– Sleep
– Nutrition (app & blood test*)
– Weight (obesity, anorexia)
– Bariatric surgery
– Central weight gain
– Pain
– Exercise/sedentariness
– Energy (T, T3, Sleep, O2…)*
– Libido/Sex hormones*
– Blood sugar/hypoglycemia*
Physical Assessment
– Hypervigilance/startle (Hypo- or hyper-cortisolism)
– Autoimmune issues/inflammation (RA, IBD, Diabetes Type 1, psoriasis, chron’s)
– TBI
– Headaches (stress, migraines, BP)
– Medications (beta blockers (HBP), proton pump inhibitors (GERD), Corticosteroids (RA), Parkinson’s and Antipsychotic medications, hormone altering drugs (2), stimulants, anticonvulsants (bipolar, pain), statins (cholesterol), opioids, benzodiazepines (depression/rebound anxiety)
– Substance use and potentially addictive behaviors (sex/pornography, gambling, video games)
Affective Assessment
– Helps us get an understanding of HPA-Axis functioning
– Happiness
– Sadness/Depression
– Loneliness
– Grief
– “Stress”
– Anxiety
– Anger
– Resentment
– Guilt
– Jealousy
Affective Assessment
– Dysphoric emotions typically impair sleep quality, excite the HPA-Axis, reduce pain tolerance, prompt cravings for high carbohydrate foods
– Questions
– In an average week how much time is spent on each emotion (baseline charting is helpful)-
– What triggers each emotion-
– What stressors are currently present-
– What stressors have you experienced in the past 12 months-
– What is different when you are happy-
– How long does it take for you to calm down after you get upset-
Cognitive Assessment
– Dopamine, norepinephrine, serotonin, oxytocin, estrogen imbalances can all cause cognitive dysfunction
– Cognitions can cause biological, emotional and behavioral changes which throw hormones and neurotransmitters out of balance and impact the mind, body, relationships and environment
– Negative Ned
– Positive Pete
Cognitive Assessment
– Assess Functioning
– Attention/concentration
– Memory
– Problem solving
– Assess Cognitive HPA-Axis Triggers
– Negative Attitudes/Perceptions (Learned responses)
– Hardiness (Lack of)
– Locus of control
– Cognitive distortions
– Negative self-talk
– Time management
Environmental
– Safety
– Noise
– Light
– Darkness
– Blue-light
– Smells
– Noxious
– Triggering
– Assistive (insomnia, sleep, anxiety, pain , depression, cortisol)
– Air pollution
– Carbon dioxide & nitrous oxides, Carbon monoxide (home), Volatile Organic Compounds (VOCs), tobacco smoke
– Temperature
Relationships
– Self-esteem and self-efficacy
– Relationship with self as capable, lovable and deserving
– Attachment (oxytocin, serotonin, dopamine, endogenous opioids)
– Healthy attachment without abandonment fears
– Boundaries
– Ability to set and maintain healthy emotional and physical boundaries
– Communication skills
– Ability to identify and communicate feelings and thoughts and get needs met
– Social support system
– Accessible functional and emotional support and engagement
– Animals/Pets
– Relationship with support animals
Summary
– Our current uni- or bi-dimensional approach (medication, counseling or medication+counseling) to treatment does not work for the majority of people.
– There are a myriad of underlying “causes” of distress, and most people have multiple contributing factors. (More to come)
– If your air conditioning bill was suddenly ridiculously high would you pull down all of the blinds- What impact would that have- Would it solve the whole problem-
– Would you turn up the AC so it didn’t run as often and pull down the blinds- What impact would that have- Would it solve the whole problem-
– A transdiagnostic approach works to identify all of the causes of the symptoms, understand their interrelationship and causes and develop a multidimensional treatment plan based on what the client is most motivated to address.