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. 1
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 2
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 3
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! 4
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 5
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 6
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 7
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 8
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 9
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 10
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 11
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 12
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 13
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 14
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 15
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 16
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 17