Cognitive Behavior Therapyfor Depression in Older Adults"

Getting to know each other"

• Me background, biases, philosophy, etc."

• You current role, knowledge/use of CBT"

Lynn Northrop, PhD

Foundations of CBTa quick intro/review"

Lynn Northrop, PhD

•  Therapeutic relationship is essential (empathic, genuine, trustworthy, expert) "

•  Collaborative (explicit rationales, shared goals, assignments, psychoeducation, empowerment and self-responsibility, project-based learning)"

•  Requires belief in change – a few words on neuroplasticity and habits of thought and action"

•  Relation between thoughts, feelings, and behaviors (next slide)

Foundations of CBT"

Lynn Northrop, PhD

CBT Triangle is power"

Thoughts"

Behaviors" Feelings"

Feelings are not changed directly"

Distinguish thoughts and feelings"

used in"1. assessment and

treatment planning"2. patient education"3.  intervention"

Understanding healthy and unhealthy choices"

" Lynn Northrop, PhD

•  Importance of self observation, self monitoring, self awareness*"

•  Treatment plan targets observable change symptom reduction and functional improvement – why?"

•  Emphasis on goals – realistic, specific, measurable, flexible, meaningful* "

•  Past explored as a context, not a major focus of treatment – are memories in the past or the present?"

*(handouts)"

Foundations of CBT"

Lynn Northrop, PhD

Foundations of CBT"

•  Situations by themselves do not cause depression (see example)"

Lynn Northrop, PhD

Situations by themselves do not cause depression… example"

Alice and Georgia lived in the same Board and Care."

"

Alice was depressed. Georgia was not.""

Both 85 y.o., retired, widowed, chronic pain, MMP, used walkers, visual

impairment, adult children lived out of state, low SES, previous history of

depression"""

Lynn Northrop, PhD

Georgia was clinically depressed."ü Depressed/irritable/anxious/hopeless mood"ü  Anhedonic"ü  Isolative"ü Dropped many activities (self care, hobbies, social)"

ü Disturbed sleep (sleepy in day, awake at night)"

ü  Low energy"ü Diminished appetite and weight loss"ü Diminished self worth"ü  Trouble concentrating and making decisions"ü  Increased morbid thoughts"

ü  Thoughts of others deaths, Wish to die""

Alice, in similar situation was not depressed."Lynn Northrop, PhD

If situations do not cause depression, than what does?

Lynn Northrop, PhD

When Georgia was depressed..."All-or-nothing thinking"“mind reading”"

Focused on losses, negatives, morbid thougts"Past and future focused"

Unrealistic expectations of self and others"Self-focused attention - ruminating"

"

Passive"Inactive"Isolative"

Skipping meals"Did not ask for help"

Sad, hopeless, "helpless, worthless, anhedonic"

frightened by her own "negative emotions"

•  Change one and you change them all •  Goal = accurate thought and adaptive behavior

Lynn Northrop, PhD

When Georgia was well..."Seeing the grey in many situations"

Not jumping to conclusions as often, “checks it out”"More balanced focus on strengths, blessings AND losses"

Mindful and mostly present focused"More realistic expectations of self and others"

Self and other focused attention""

Assertive"active"

engaged"ask for help"

Able to tolerate negative emotions"More good days than bad"

Hopeful"More self confident"

Improved self-esteem"

Lynn Northrop, PhD

Thoughts!

Behaviors! Feelings!

•  Identify and change inaccurate thoughts"•  Reduce ruminative thought"•  Learn to worry constructively"•  Increase/improve Problems solving"•  Cognitive Diffusion"•  Self-awareness and cognitive self control"•  Acceptance"

•  Understanding one’s own emotions and their relations to thoughts and behaviors"

•  Emotions are genuine – not right or wrong"

•  Situations do not cause feelings"

•  Behavioral activation (APES)"•  Social Support Skills"•  Assertive Communication Skills"•  Relaxation training"•  Understanding the function of Bx"•  Stages of behavior change"

Interventions are flexible and tailored to the presenting problems"

Lynn Northrop, PhD

Methods and Tools of CBT"

Thoughts"

Behaviors" Feelings"

Lynn Northrop, PhD

Common inaccurate thinking Jumping to Conclusions: Making judgments or inferences before you know

all the information.""Mind reading: Believing someone has an opinion of "you or is making judgments about you without checking it out.""Fortune Telling: Assuming that you know what the outcome of a situation

will be. Generally involves predicting that things will turn out badly.""Catastrophizing: Expecting the WORST to happen or believing "that anything bad is TERRIBLE. Using catastrophic language "to describe things that are not. Hyperbole. ""Negative Filtering: Focusing on the negative aspects of something or

someone. Spending unhealthy amount of time thinking about or talking about negative traits of self, others, or situations. Excessive complaining. "

"Lynn Northrop, PhD

Common inaccurate thinking "Minimizing the Positive: Little time is spent considering the positive aspects of self,

others, or situations. When accurate positives are presented, they may be considered unimportant or invalid. "

"Should statements: Very strict or rigid rules for self or others. Strict rules that work

against self-acceptance and accepting others. Often results in guilt, anger, and/or resentment."

"Self Blame: You see yourself as the total cause of something "bad happening when in fact you had nothing or little to do with it.""Black and White (or All-or-nothing) thinking: These thoughts usually use a language

of extremes (always, never, totally, forever, completely). Tendency to categorize things into extreme categories."

"Overgeneralization: drawing big conclusions from small "amounts of information""Labeling: Name calling or globally applying a single (usually critical) term to an

individual or situation. """ Lynn Northrop, PhD

Common inaccurate thinking Emotional Reasoning: Making decisions based on feelings rather than fact.

Assuming your feelings always match or reflect whats happening right now.""Personalization: Thinking that things people do or say is a reaction to you. "You also compare yourself to others (e.g. attractiveness, clothes, smarter, etc.)""Control Fallacy: You believe you are responsible for the distress and "happiness of others. Also, if you feel externally controlled you see "yourself as a helpless victim. ""Fallacy of Change: You expect that other people will change to suit you if you

pressure or cajole them enough. Your hopes for happiness seem to depend on others changing."

"Being Right: You believe that you are on trial to prove that "your opinions and actions are right. Being wrong is unacceptable "and you will go to great lengths to prove or demonstrate that you are right.""Heaven’s Reward Fallacy: You expect that your sacrifice and self-denial will pay off

as if there were someone keeping score. You feel bitter when the reward does not come. You may tend to be a martyr.

Lynn Northrop, PhD

Internalized myths, stereotypes and biases Depression is a normal

part of aging. Contributes to hopelessness and reluctance to fully engage in

treatment. Refuse treatment.

Can’t fix it ditto Depressed=weak If I ask for help, others will see me as weak.

If I need help I am weak. I depressed therefore I am weak. Reluctance to fully engage in tx. Generalized loss of self-efficacy. Shame

Depressed=crazy I shouldn’t tell people I am depressed. Other people think I am crazy/flawed.

Fear of discrimination or critical judgment

Avoid asking for help. Reluctant to self disclose. Defensive, aggressive, suspicious

We should save resources for the young

I am worth less. Martyrdom

Older adults/old age are scary, icky, downers

Avoid other seniors. Self-loathing Minimize problems (so as not to be perceived as old)

Lynn Northrop, PhD

Inaccurate thinking

•  More common in depression, anxiety, paranoia, passivity, anger control problems, etc.

•  Becomes automatic or habitual •  Change requires education, effort, and

repetition •  Avoiding thoughts causes problems (Erlene)

Lynn Northrop, PhD

Thought Record (side 1)

Situation (who, what, where, when):

Feelings:

Thoughts:

Behaviors: Lynn Northrop, PhD

Thought Record (side 2)"

Situation (who, what, where, when):

Feelings: What are your preferred (and realistic) feelings in this situation?

Thoughts: What are accurate, healthy and adaptive thoughts in this situation?

Behaviors: What are healthy and adaptive behaviors in this situation? Lynn Northrop, PhD

Name That Distortion* “Identify and name the common inaccurate thinking in each of the following scenarios. Underline any key words that point to a distortion.” Scenario:

Betty is about to go to her first day of volunteering at the local art museum. She feels anxious and self-conscious. She thinks, “I’m going to make a total fool out of myself. I cannot remember one single thing I learned at the volunteer training. Maybe I should just quit and let someone younger do this.”

*see handout Lynn Northrop, PhD

Name That Distortion Scenario:

Eddy wakes up and discovers that his new roommate has gone to work and left his breakfast dishes unwashed in the sink. Eddy feels offended and angry. He thinks, “He has seen how neat I keep my side of the room. He should be more considerate. He obviously doesn’t care to make a good impression. He couldn’t care less about me. If he doesn’t change, I’m going to explode!”

Lynn Northrop, PhD

Clinical example

Helping the client use the triangle. Volunteer?

Lynn Northrop, PhD

Strategies to increase accurate thinking •  What are the alternative explanations?

•  Look at the evidence for and against your conclusion.

•  Check it out. Clarify with the person what they were thinking. •  Substitute catastrophic language such as “terrible” and “horrible” with

more accurate language such as “it is inconvenient.” What are the odds? Make an honest and realistic assessment of the situation in terms of odds and percentages. What is the worst thing that could happen? Could I live with that? What is the best thing that could happen? What is the most likely?

•  Make a list of positives that apply to the person or situation. If need be, ask

someone else to help you come up with positives. Refer to this list when you catch yourself complaining or minimizing positive. Is there something you can do to improve the situation? Consider problem solving or assertive communication.

•  Substitute “it would be nice” or “I would like” statements for “should,” “must,” and “have to” statements for both yourself and others. Think about the rules you apply to yourself and others. Are there ways you can make them more flexible? Lynn Northrop, PhD

•  Use percentages and pie charts to allocate realistic responsibility. How much are you responsible for and how much are others responsible for?

•  What would it mean if the thought were true?

•  There are no absolutes. Look for the grey. Think in percentages.

•  Look for evidence to support the more balanced view.

•  Say “I’m not going to draw a general conclusion from this one situation.” Be specific and quantify what it is you are referring to.

•  Instead of using global labels, use specific and quantifiable language such as “I made a mistake” instead of “I’m a stupid idiot.”

•  Feeling is not fact.

•  How much is in your control and how much is in the control of others?

•  Serenity Prayer

Strategies to increase accurate thinking

Lynn Northrop, PhD

Acceptance of inaccurate thoughts

Goal is not always to make thoughts go away

•  Sometimes unrealistic (memories, triggers, habits)

•  The struggle can be more harmful than the thought

Acknowledge and objectify thought and

recognize that you can carry it with you.

Lynn Northrop, PhD

Foundations of CBT"

Thoughts"

Behaviors" Feelings"

Lynn Northrop, PhD

Downward Spiral"

Feel Bad"""

Do Less"""

Feel Worse"""

Do Even Less"

Feel Even Better""

Do More"""

Feel a Little Better""

Do Something"

Lynn Northrop, PhD

Pleasant Events Model: Depression occurs when

the stressful, negative, unpleasant aspects (and views) of life out weigh the pleasant, positive aspects of life.

Negative events"

What are 3 ways to shift the balance?!

Wellness = balance"

Lynn Northrop, PhD

Daily APES*

•  Accomplishment •  Pleasure •  Exercise •  Socialization

*handout, next 3 slides Lynn Northrop, PhD

o  Listen to favorite music o  Enjoy a relaxing nap o  Enjoy a long, warm bubble bath o  Visit a museum or art gallery o  Go for a walk o  Practice yoga o  Share a hug with a loved one o  Relax in a whirlpool or sauna o  Relax outside o  Enjoy a cool, refreshing glass of water o  Physical activity (of my choice) o  Count my blessings, “I am thankful

for…” o  Say or read a spiritual prayer o  Enjoy the beauty of nature o  Attend a caring support group o  Play as I did as a child o  Practice deep breathing o  Star gaze o  Do stretching exercises o  Cloud gaze o  Reflect on positive qualities “I am…” o  Window shop o  Laugh o  Daydream o  Write my thoughts and feelings in

personal journal o  Tell myself the loving words I want to

hear from others o  Concentrate on a relaxing scene o  Tell someone what you appreciate

about them. Lynn Northrop, PhD

o Create a collage representing the “real me”

o Go paddle boating or watch others paddle boating

o Receive a massage o Buy myself a gift I can afford o Give someone a massage o Create with clay or pottery o Reflect on “I appreciate…” o Play cards – solitaire or other o Watch the sunrise or sunset o Practice positive affirmations o Attend an athletic event o Pet an animal o Do something adventurous o Watch my favorite TV show o Read a special book or magazine o Reflect of my strengths or successes o Sing, hum, whistle a happy tune o Write a poem o Go dancing o Read a poem o Play a musical instrument o Make a bouquet of flowers o Meditate o Have a cup of tea o Garden and work with plants o Make something nice for myself or

someone else o Learn a new skill o Visit a park, woods, forest o See a special play, movie or concert o Call an old friend and tell them what you

like about them Lynn Northrop, PhD

o Work out with weights or small hand weights

o Go on a picnic

o Make myself a nutritious meal o Practice relaxation exercise

o Draw or paint a picture o Hold a sleeping baby

o Swim and relax at the beach or pool o Take a class or attend a lecture

o Do aerobic activity to fun music o Practice the art of forgiveness

o Visit a special place I enjoy o Treat myself to a nutritious meal or snack at a local restaurant or coffee shop

o Take time to smell the flowers o Enjoy my favorite hobby

o Sit in front of a fireplace and watch the fire

o Walk in the rain or watch the rain

o Read a cartoon or joke book o Feed the birds

o Reflect on “My most enjoyable memories”

o Listen to bird song

o Look at old photos o Create my own list of self nurturing activities

Lynn Northrop, PhD

Creating Your “Top Ten List” of

Pleasurable Activities •  Deciding whether an activity makes the Top Ten:"

•  Is it realistic? "–  A trip around the world may not be realistic. However, a day-trip, a

travel video, a lecture about a foreign culture, looking through photos from a previous trip, or planning a small trip for the future may be realistic. "

•  Is it pleasurable?"–  Sometimes we are inclined to fill our Top Ten List with “have to”

activities (clean the kitchen, pay the bills, etc.) Although you may experience relief when you accomplish a necessary task, that’s not enough to qualify for the Top Ten. You are looking for activities that are intrinsically pleasurable (or have been in the past). "

•  Is there room to do more?"–  At least some of the items on your Top Ten List should be activities that

you could do more often than you are. (high pleasure, low frequency)"

Lynn Northrop, PhD

APES Top Ten List" Day:" Day:" Day:" Day:" Day:" Day:" Day:"Date:" Date:" Date:" Date:" Date:" Date:" Date:"

Lynn Northrop, PhD

Barriers to Daily APES"Low motivation, Limited interest"Not feeling well physically"Not feeling well emotionally (e.g. depressed, anxious, upset)"

Pain"Low energy"Really can’t do what I used to do / used to like to do (e.g., fishing)"Negative/distorted self-talk"Transportation problem"Scheduling Conflict"Too little time"Not enough $$"Weather (e.g., rain, heat, sun)"Can’t think of anything to do (81 ideas for self nurturing)"Nobody to do anything with."Physical mobility problem (e.g., trouble walking)"

Lynn Northrop, PhD

Social Support Education regarding sources and types of support

emotional, informational, tangible, companionship, motivational, spiritual, reciprocal

Where does the problem lie? expanding network, eliciting support, maintaining support

Setting specific support goals join club, tell husband how he can help, say thank you

Thoughts that get in the way of support (handout) Conjoint session – educating family, helping pt negotiate

support, assessing caregiver burden, gathering data so you can help pt set realistic goals

Lynn Northrop, PhD

Thoughts!

Behaviors! Feelings!

•  Identify and change inaccurate thoughts"•  Reduce ruminative thought"•  Learn to worry constructively"•  Increase/improve Problems solving"•  Cognitive Diffusion"•  Self-awareness and cognitive self control"•  Acceptance"

•  Understanding one’s own emotions and their relations to thoughts and behaviors"

•  Emotions are genuine – not right or wrong"

•  Situations do not cause feelings"

•  Behavioral activation (APES)"•  Social Support Skills"•  Assertive Communication Skills"•  Relaxation training"•  Understanding the function of Bx"•  Stages of behavior change"

Interventions are flexible and tailored to the presenting problems"

Lynn Northrop, PhD

Challenges in treating older adults?"

•  Sensory deficits"•  Cognitive changes"•  Fatigue"•  Physical frailty or disability"•  Co-morbid medical "•  Transportation limitations"•  Internalized stigma"

Lynn Northrop, PhD

How is CBT modified for use with older adults?"

•  Same theoretical model, many of the same techniques"

•  Pace of treatment"•  Multimodal presentation of information"•  Repetition"•  Accommodate for Sensory deficits

(amplifier, large print)"•  Accommodate Memory difficulties"

Lynn Northrop, PhD

How is CBT modified for use with older adults?"

•  Sometimes more directive approach"•  I am a consultant, teacher, this is a class,

they are learners"•  More family involvement - sometimes"•  Scheduling considerations"•  Physical environment (lighting, chairs,

accessibility)"

Lynn Northrop, PhD

Questions or comments?

Please feel free to contact me. Lynn Northrop, PhD lynn.northrop@gmail.com

Lynn Northrop, PhD