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When You’re Down

And Troubled:

Non-pharmacologic strategies for working with depression, anxiety, and other

behavioral health issues

By: Tom Bartol, NP

bartolnp@gmail.com

Twitter: @tombartol

Objectives

Describe strategies for integrating

behavioral health into primary care

Name some of the underlying causes of

anxiety, depression and behavioral health

issues and how these can be addressed.

Implement non-pharmacologic strategies

to help people deal with anxiety,

depression and other behavioral health

issues in a primary care visit.

Disclosures

I have no conflict of interests to report

I use all of these strategies regularly in my

primary care practice

We must open ourselves to our own issues

and fears in order to help people deal with

theirs.

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What about pharmacologic

agents? There are a lot of great medications out

there but too many are used too often

Pharmacologic agents are not a substitute

for these non-pharmacologic strategies.

They may be an adjunct

Case Study

61 y/o female with facial swelling x 1 day.

Has dental abscess

Son is a drug addict, in prison. She paid

for treatment but he didn’t complete it. He

has young children. Thinks the kids mom

is addict as well.

Father has Alzheimer's and family has een

caring or him at home. Stressful.

Case Study

48 y/o male, DM & HTN. A1c up from

6.9% 3 months ago to 8.2%.

Stress with pre-teen daughter, she is

depressed and borderline suicidal.

He is stress eating

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Case Study

46 y/o male with HTN, Obesity

On 5 antihypertensives and b/p still 160/98

Exercises and keeps active but doesn’t

lose weight

After 5 years of treating him, referrals for

b/p control (more medications), I asked

about his childhood, “It was good.”

Integrating

Behavioral Health(BH) Many people do not come in with BH

complaints, though many have BH issues

How can we “assess” BH issues?

Likely over 60% of people we see have

BH issues that affect their health

Many people are longing for someone to

share with if given the opportunity

Integrating BH is not a separate person or

clinician but what WE do

How do we integrate behavioral

health care into life? Usually only those who are “sick” enlist the

health care services

We often don’t see our struggles in life as

being “sick”

We even more often we don’t see

ourselves as having depression or anxiety

Universal health care means reaching out

in new ways, new models to reach people

that are “healthy”

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The Continuum

We all have elements psychopathology

– ADHD

– Anxiety

– Depression

The degree might vary day to day,

experience to experience

It is possible to fully function with these if

we know how to cope with them

Engaging Patients Ask, “What matters to you?” as well as

“What is the matter?”

Getting beyond blood pressure, glucose,

and cholesterol to what matters most to

the patient

From telling the patient what is wrong and

telling what to do, to listening for the

patient to tell us what is wrong and

exploring with the patient what to do

Acknowledge—pain, sadness, grief, fear

as well as joy and challenges

Questions that Engage

What could be better?

Tell me your story

What’s the hardest thing for you right now in

dealing with your (diabetes or any condition)?

If you could change one thing in your life right

now, what would you change?

How was your childhood?

…integrating behavioral health into primary care!

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Be kind

for everyone you meet

is fighting a hard battle

Underlying causes…

“Everyone is seeking to feel

good and avoid pain”

The Dalai Llama

Everyone is seeking:

Connection

Purpose

Hope

Without these, we don’t thrive,

our capacity for health is

diminished

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Past Experiences Affect Us

Childhood

Relationships

Abuse

Trauma

Tragedy

Fear

Fear & Worry Lead to:

Anxiety

Anger

Impatience

Decreased self-esteem

Less efficient functioning

Depleted self control

Overeating, addiction, antisocial behavior

The opposite of love is, not hate, but fear

We all Want to BE Liked

Liked on Facebook

Have our tweets re-tweeted

Have people view our YouTube

And to feel like those around us like us

We do what we can to feel liked

Moral Psychology: “We are obsessively

concerned about what others think of us,

although much of that concern is

unconscious and invisible to us.”

Jonathon Haidt: The Righteous Mind

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Adequacy Theory

Everyone wants to feel adequate

Our culture’s default is to point out

inadequacy

Repeated words of inadequacy lead to

feelings of inadequacy

Inadequacy comes from comparing

Feelings of Failure

Failure can lead to:

– Withdrawal

– Growth

How Can We Respond:

“A Bridge Over Troubled Waters”

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Treatment Concepts

Listen

Acknowledge: past and experiences

Affirm: who the patient is, what has been

accomplished in life

Believe in the patients and help them to

believe in themselves

Build adequacy

Share tools and strategies to use to cope

and grow

Moral psychology

The first principle of moral psychology is:

Intuitions come first, strategic reasoning

second.

Confirmation Bias: The tendency to seek

out and interpret new evidence in ways

that confirm what you already think.

We expect things to happen the way our

heart or emotion has told us they will

happen

Components of Behavior The Rider (Rational)

– Analytical

– Planner

– Problem Solver

The Elephant

(Emotional)

– Impulsive/Instant

gratification

– Irrational

– Automatic, “gut”

response

The Path (Environment)

Jonathan Haidt, The Happiness Hypothesis

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5 Motivations of Human Behavior

To be accepted

To belong

To influence (have purpose)

To protect ourselves against being hurt

To find intimacy

This is what our patients want, what they are

looking for in life.

Building a Relationship of Hope

Believe in others

Suspend negative judgement

Listen and acknowledge, rather than trying to

solve the problem

Affirm them for who they are

This will do more healing than any medication

or treatment we have!

Perspective

Woman without her man is helpless

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Perspective

Woman, without her man, is helpless

Perspective

Woman, without her, man is helpless

Perspectives:

Depression and Anxiety The result of a very narrow or limited view

or perspective of the situation

Based on past experiences not future

hopes

Based on fears and inadequacies

Perspectives are reality for each person

We can’t change what happens, only our

perspective of it, our attitude, how we

choose to see it

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Changing Perspectives

We don’t have to internalize what others

say to us

What others say to/about us is often their

issue, their projection or insecurity

Find compassion for those who say things

that may hurt and try not to justify,

rationalize, defend, blame or compare

Changing Thinking

Our thoughts create our reality. Practice

positive thoughts

Gratitude/Appreciation

Vision what you want and the cognitive

unconscious will take over

See challenges as “opportunities” to grow

Embrace your failures

Believe that the universe has good in store

for you

We Create Our Own Reality

What is happening to me right now is the

best thing that could be happening.

– It may not be easy

– It can bring what I need…if I let it

Our thoughts become a vortex and create

more of what we think

The more we think and speak positive, the

more positive will happen around us

Our words are our world

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Practice Appreciation

Sharing appreciation for others helps us

feel better about ourselves

More than a “thank you,” say to someone

something you appreciate they did

Start at check-out from the clinic today

Dealing with Past Traumas

Fear of being hurt, always protecting self

Messages of self-blame

Messages of inadequacy

“You are an amazing person!”

Beyond blame to acknowledging

Affirm the good and gifts that have

happened

Recognize Triggers

Relationships/Conflict

Do you want to be “right” or solve the

problem?

“Help me to understand what you are

saying.”

Compassion is an openness to other

perspectives

It’s not the “what” but the “why” of the

message

Choose compassion over blaming

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Responding to Conflict

Listen to Understand (not to respond)

Hear the other’s perspective and acknowledge

Don’t justify, rationalize, compare, defend or

blame

Conflict needs 2 sides, you can control one

Leave the other a way out

Respond to the “why” not the “what” of a

statement

Leave room for dialogue

Resentment

Resentment must be repeated again and

again, it takes a lot of energy

Resentment does not help the resented or

the resenter

Forgiveness need be done once

Forgiveness helps heal resentment... in us

as well as the one we are forgiving

Fundamental Attribution Error

When someone else does something

wrong, it is because of who they are

– “Non-compliant”

– Lazy

When we do something wrong, it is

because of what is happening around us

– External circumstances caused it

– What others did

It is an ego protection mechanism

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The Victim Syndrome Everyone else is responsible for the

unhappiness

– Blaming

– Criticizing

– Negativity

– Doesn’t trust

Logic won’t work, listen, don’t solve

We can’t change the victim, only our

response.

Respond with compassion, as to a

disability

Meditation

or

Medication

Beginner Meditation Tips

Start with 2 minutes daily (set a timer or

use an app)

Sit in a comfortable, relaxed position

Breathe through the nose, focus on the

breath moving in and out of the nostrils

If your mind wanders, acknowledge and

return to the breath…each return to the

breath is part of the exercise

After 2 minutes, finish, don’t judge it

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Looking at your Meditation

Say, “I did it and it is good.”

Success is doing it

Be kind and patient, viewing your mind

wandering as an opportunity to practice

awareness and redirecting your attention.

Notice the infusion of calm, in the moment.

Recommend Meditation

Try it before you recommend it…have

some experience with it yourself

The key is how you approach it.

Ask, “Have you ever done meditation?”

Listen to the response, acknowledge

something said to you, and offer an

opportunity to learn.

Announce that your are Happy!

“It is a modern tragedy that despair has so many spokesmen, and hope so few.” Oscar Hammerstien II

Find and share enjoyment in your work/life – It doesn’t mean we won’t experience setbacks,

disappointment, sadness or pain

– Amidst challenges are many more positive things.

– On what do you choose to focus?

Embrace imperfections, see them as opportunities rather than as faults

Embrace the moment

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Some simple strategies:

Write down 2 things you are thankful for

each day

Journal…and re-read it in a month, a year

Don’t defend, blame, justify, rationalize or

compare

Hear what is said, acknowledge it, even if

you don’t agree

Vision what you want and allow the

cognitive unconscious to take over

We’ve been wrong about what our

job is in medicine. We think or job

is to ensure health and

survival. But really it is larger than

that. It is to enable well-being.

Atul Gawande from

Being Mortal

Take Home Points

Listen with your heart. The greatest gift

we can give is to listen and hear another

Acknowledge and affirm (that is being

“liked”)

Work on the “why” not the “what” (the

elephant not the rider)

Everyone deserves to be happy and loved

Daily Gratitude

Nurture yourself

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Your thoughts and

questions…

Tom Bartol, NP

bartolnp@gmail.com

Twitter: @tombartol

We’ve been wrong about what our job is in

medicine. We think or job is to ensure

health and survival. But really it is larger

than that. It is to enable well-being. And

well-being is about the reasons one wishes

to be alive. Those reasons matter not just at

the end of life, or when disability comes, but

all along the way.

Atul Gawande from

Being Mortal