Well, good morning, I'm Dr. Jess Wright, I'm from the University of Louisville, where I'm a professor of psychiatry and director of the University of Louisville Depression Center, and I see a lot of patients with chronic illnesses, mostly mood disorders, but also anxiety disorders, other conditions in my own practice, and I've been very interested in how to address those problems, and we're going to share a bit of that with you today. Joining me to my immediate right is a senior resident, one of the terrific residents I've worked with in my career, Rena Perlin from the University of Louisville, and next we have Donna Sudak from Drexel, a very well-known cognitive behavior therapist, writer, leader in education, and then David Casey at the end, who's the chair of the Department of Psychiatry at the University of Louisville and a geriatric psychiatrist, written extensively on it, and is going to share with us at the end some insights on working with older patients. We have prepared some slides and some discussion of some common problems that we encounter in our own practice, and we'll start with that, but we wanted to save plenty of time at the end for you presenting perhaps some of your own challenging cases and for us discussing as a group how we might approach some of those problems. So keep in mind some particular cases or issues that you'd like to present to the panel or draw the whole group in here in a discussion. Unfortunately, I'm going to have to leave before the discussion because I have to catch a plane. We have an important family event back in Louisville, so I'm going to be taking off, but the rest of the panel members are well prepared to enter into the discussion. Just a few disclosures. I have some. The only ones pertaining to the talk today are royalties from my books that are published on CBT. Dr. Sudhak also is a writer and has books that I don't know if she's going to refer to those or not, but they're excellent books. I'll vouch for them. One of them we wrote together, and she has editorial honoraria from one of the publishers. So we're going to start with the topic of psychotherapy for treatment-resistant depression, which has to some extent been an ignored topic in research and perhaps in the way that many psychiatrists approach patients with treatment-resistant depression or chronic depression. In fact, we had a commentary in the American Journal of Psychiatry this year that John Markowitz from Columbia spearheaded, and I was on that article as was Donna Sudhak. The basic point was that we perhaps have ignored the value of psychotherapy when patients present with treatment-resistant depression, and it's worthwhile considering it. In order to take a deeper look at this, some of us prepared a chapter in a recent book on managing treatment-resistant depression and looked at the research that had been done on various forms of therapy, and it was a bit sobering because there weren't a whole lot of studies once you got past cognitive behavior therapy and mindfulness-based cognitive therapy, which has come on strong in the research area as far as looking at chronic illnesses, and so we just cooked up this little rating system and gave three pluses as something we thought there was really strong evidence for effectiveness, and a zero would be that there were really no published, randomized, controlled trials. That doesn't say that that therapy wouldn't be useful. It's just that it hasn't been studied, which is a real shame. It needs to be done. Of course, there are no pharmaceutical companies that are supporting these therapies, and what we mostly see now, of course, are new drugs that come on the market, and then there's an attempt to show that they're useful for an adjunctive treatment with depression, but these trials take usually an NIH grant or some other major federal grant from either the United States or some other country, and they're really hard to get and hard to do. I'll just show you just a couple examples of some outcome studies. These are about a decade or more old now, but they are fundamental, classic studies. This was the COBALT trial, and this was done in primary care, and it showed a very strong effect of CBT versus treatment as usual. The difference was quite dramatic, and that's the BDI on that thing, or the Beck Depression Inventory. Then here was another study done a little over a decade ago. This is by Watkins and another study of CBT versus treatment as usual, pre and post looking at BDI, and you can see there is another strong effect. In comparing CBT with treatment as usual, the effect size was 1.1, which is a very robust effect size. So looking at these data, I could conclude that if you want to use an evidence-based treatment, applying CBT to cases of chronic depression and mindfulness-based CBT may be useful and there needs to be a lot more work to be done. So I thought I'd drill down a bit on CBT for treatment-resistant depression and talk a bit about what we do and how we approach it. Since we're going to cover a lot of ground today, this is going to be somewhat superficial, but perhaps in the discussion you could ask Donna and Dave and Rena about how they might approach cases. I see a bunch of patients that come my way that have been on how many drugs? I'm sure you see it too. They've tried four or five, six, maybe more. They've had adjunctive therapies. Maybe they've had some psychotherapy and yet they're very discouraged, demoralized, in fact. When I was a resident, I read a book by Jerome Frank called Persuasion and Healing. I don't know if any of you ever might remember that book. It's a phenomenal book. He talked about the common operational principles in all effective psychotherapies and noted that most people that come to therapy, come for treatment, are demoralized. That means they really are at the point where they don't believe that they can manage it on their own. Part of the role of any effective psychotherapy is to essentially remoralize people or to work on generating some kind of hope or expectation that whatever you're going to do with this doctor or nurse practitioner or therapist or whatever may pay off. One of the things we face right up is looking at demoralization. I'm sure you see it in your own patients. These people are deconditioned. They're deconditioned physically because they haven't been doing much. They haven't been exercising. They haven't been walking. They've been mostly sitting. Some of them are very deconditioned. They're deconditioned interpersonally, socially, recreationally, occupationally. In a way, you almost have to be like a physical therapist. Have any of you had physical therapy? I've had it a bunch of times for like shoulder surgery. I had a ruptured patellar tendon in a skiing accident. If you've had that, you know that they start very gradually and introduce you to the things that are going to rehabilitate you. If you stick with it, sometimes you can get back. Fortunately, I'm walking well now and I can use my shoulder. I was glad that I went to physical therapy. I see some parallels between physical therapy and psychotherapy in this regard. Often there's some self-blame. People feel very badly about themselves because they've not been able to get better and perhaps they've lost a sense of meaning and purpose. There's been a sort of Viktor Frankl logo therapy element to what's going on with chronic illness. What I typically do and I think all the panelists do is we try to do a very comprehensive initial assessment, really looking under any stone for any biological features, psychological, interpersonal, spiritual, if you consider that in your formulations. Then try to collaborate with a patient and coming up with a plan that makes sense to them that gives them some idea that you could work together and get somewhere with it. My goal at the end of every first session with a patient with treatment-resistant depression is to have this sense of movement now from this abject hopelessness or demoralization toward beginning to make a little bit of progress. There might even be a behavioral assignment of some sort, an action plan, a tiny little one of engaging the patient in some step they might want to take. Donna's going to talk more about how to help patients that are stuck with behavioral methods. So I might be thinking about that as I'm ending my very first session with a patient that I'm going to follow. So I believe that clinicians with patients that have severe treatment-resistant depression may need to be a bit more active than the classic cognitive behavior therapy because the patients are having trouble doing it and they may need somebody to give them a little oomph and belief that things can happen. We directly address this demoralization and burnout. Critical emphasis, the B part of CBT can be especially important and I'm not going to cover that right now because Donna's going to talk a lot about that. One thing to point out is identifying the pessimistic attitudes of the clinician. You might be thinking of another patient walking into the office that's failed. I hate that word but that's what they say, I failed six treatments or eight treatments because then the patient may feel like they failed but it's really the treatments have failed them, it's what's going on. So anyway, the therapists may need to look at their attitudes and work on their optimism for change. And then with most of these patients, persistence of practice are really important, it's just really sticking with it, being able to go for the long haul. Here's some hopeless thoughts that I've seen in some of my patients. Maybe you've seen something similar, like I've tried everything, nothing's worked. It's my fault, I have too many problems to solve, it's just overwhelming. So if you heard that, what might you be thinking of doing as a cognitive behavior therapist, if any of you are a cognitive behavior therapist? When I hear that, I'm thinking, okay, now we need to find one or two that we can focus on instead of looking at the whole gamut because that is so overwhelming and then get a sense of being able to learn something about how to apply CBT and learn the CBT skills because if you can do that for one area, then often it can be spread to the other areas in a person's life. I'm a failure, nothing will change that fact. So these are, in a way, core beliefs or schemas that get developed, maybe they were there prior to the depression but the depression certainly hasn't helped them. So if you're a cognitive behavior therapist, you may eventually want to do some core belief work. So we try to normalize depression and chronicity, shift away from self-blame, be realistic, have a problem-solving approach, use classic cognitive restructuring techniques, use classic behavioral methods, and generate some reasons to have hope. Have any of you heard of the Virtual Hope Box or used that? It's pretty nifty, it was developed by the Department of Defense in the USA, so it has high production values, it's free, and many of my patients really like that. I'm going to show you a slide with it, it's just a screen grab from the app. And what? What happened? Okay. Reena's helping me out. Okay, there it comes up. So this is a thing that you can put on your phone and you can pull up photos that are important to you that might give you a sense of optimism or hope. There are also some other things you can press to do, like you can do relaxation exercises, learn some coping tools, and so forth. So I have this on my phone, I don't show the patients what's in my Hope Box, but I show them the app and suggest to them that, you know, I carry this around and I think it's good to pull out your phone and sort of model it, that it's pretty easy to get and use. Okay, so I'm going to move along to one other treatment technique from psychotherapy that I think is particularly helpful for chronicity, and that's exposure therapy. I wonder how many in the audience do this in their treatments? Could you have a show of hands? Some people do it? Good. Well, then many of you already know about this, so if you want to discuss it later, present some of your cases, you could. But what I find in supervising residents, talking with practicing clinicians, is that lots of people talk about it a bit, but I'm not so sure how many really dig in there and can do it very well with patients and stick with it for conditions like chronic social anxiety or agoraphobia or even OCD. So I'm going to give you a few pointers from what I've learned about exposure therapy. Sometimes when I talk with a resident, I suggest that there are three or five really top things that you can draw from CBT if you wanted to look at a method or a technique, and I put exposure therapy in the top five. Would you do that also, Donna and Rena? Yeah. I put behavioral activation, which Donna's going to talk about. She ranks, you rank that number one? Okay. But I like exposure therapy. So here's the CBT model for anxiety disorders, and these abnormalities have been found in many studies of people with anxiety disorders. So people with an anxiety disorder have an increased attention to threats or danger. They're really looking for it. They're hypervigilant about it. If you had an elevator phobia and you walked into a building with an elevator, you would be watching very closely for what might be wrong with that elevator and might be looking for things posted on the walls or what the inspector has said and so forth, where most of us would just walk right in there thinking about something else. People with anxiety disorders also have an overestimate of risk in situations. They underestimate their ability to manage it or cope with it. They misinterpret their bodily stimuli. That's particularly true, of course, with panic disorder. And then the big thing here is avoidance of the feared situation. And I'm going to show you a slide next that's the basic simplified CBT model. Of course, in CBT, we're looking at multiple other factors, but the whole idea of events in our lives triggering cognitions or so-called automatic thoughts, which then influence our emotional reactions and then influence behavior, is key to working with patients. Sometimes we call a diagram like this a mini-formulation, meaning we would diagram in a session with a patient using an example from their actual life and then work with them about what could be done now at any point in this particular diagram. For example, here we have a patient with social phobia who's preparing to attend a party, and this fellow has longstanding social phobia. He has a partner who's active socially. In fact, she has a job that really requires her to go to parties and socialize, and she's been very upset with him for not going along, and so she's pressured him really badly to go on to this event with her. So he's trying to prepare to go to it, and then what kinds of thoughts does he have? Well, I won't know what to say, I look like a misfit, I'll clutch and I want to leave right away. And so what happens? He gets very anxious and tense, and he makes an excuse and he avoids the party. So every time that happens, of course, we get a deepening of the social phobia and more avoidance and more negative thoughts about being able to manage a situation, and after that's happened thousands and thousands of times, the actual skills that a person has in social situations of atrophy, or perhaps they were never developed. So we have a problem here that we need to be able to address with a treatment in CBT, and exposure therapy is one of these. So exposure therapy can be graded or rapid. Typically it's graded in most practices, meaning it's a stepwise kind of exposure. I've done some rapid desensitization, if you will. Early in my career, I actually was in research settings, and it was fairly dramatic and effective, but it was for simple phobias or more complex things. I typically do a graded exposure. You can do exposure in imagery, which is often done as a first step where a person imagines them being back in a situation, and then there's in vivo exposure. Safety behaviors are really important to target, and I'm going to talk about those in a moment. And then you can use auxiliary techniques like relaxation and breathing and so forth to help people get through some of the early stages of exposure therapy. Here's an example from my practice with a patient that did this and had success. She had essentially stopped driving, and this was very restrictive for her. A young woman, she was in her early 20s, wasn't able to work. Her friends were out in the workforce in relationships, and she was at home with her parents, and her parents were driving her around. It was a pretty bad situation. So we worked together, and by the way, this is done very collaboratively. The therapist doesn't sketch this out for the patient, but you have them begin to suggest things that would break this down into pieces that are more manageable or more difficult. And sometimes patients will put something over 100, like this person put drive three hours by herself to a city where her sister lives is 100 plus. She says, I'll never do that, Doctor, right? And of course, I'm thinking, well, if she could do that, then we really got something. Maybe then we would really have success at this exposure experience. So indeed, she did do this, and she had success. So what are safety behaviors there? Safety behaviors that allow the person to participate in the activity, so it looks like they're not avoiding it, but they really are. We go back to, for example, that patient where we had in that circle, there was a social phobia, the guy that was going to go to the party with his partner, and let's say he did go to the next party, but if you asked him in detail what happened, he walks in the door and immediately downs three glasses of wine, and he stands beside his partner and lets her do all the talking, and then he finds a way to get into the bathroom as often as possible to get away from the people. So you can see that there's sort of micro or mini avoidances that are part of the safety behaviors. Some of these can be really subtle. For example, in a person with public speaking anxiety, that we'd encourage somehow or another to come here to the APA and stand at this podium, just like I'm doing right now, but yet the person is looking at the exit sign during the entire talk instead of looking in the eyes of people engaging, whether they're responding or not. Now, fortunately, I've done enough public speaking that I can look you all in the eye, and some of you I can see you're really engaged, and you're laughing, you're sort of getting my subtle humor. Other people may be thinking of lunch, I'm not sure, or why did I get up so early to come to this talk? So that would be an example of a safety behavior that would be subtle, and it's important to learn about those things because if the person continues to do it, they have not really done full exposure, and they will not have as effective an outcome as you might otherwise. So here's some challenges in exposure therapy. These are maybe some chronic issues, people that maybe it's been tried before, you're trying it with them, it's not working so well. So you can just have a quick read of those, and then I'm going to go through them one by one, talk about what one might do if you had those difficulties, because it's not always as easy as it seems. It seems like a pretty straightforward thing. And by the way, you don't need to be a cognitive behavior therapist to do this technique, I don't think. That's a pretty straightforward thing. So I'm going to wrap up here. Glenn Gabbard, who's a friend of mine, who's obviously a psychodynamic therapist and one of the great writers on this, tells me that when he has a patient with anxiety disorder, what does he do? Exposure therapy. So here's some challenges that we run into. How about missed appointments, no-shows, avoided appointments? So here's some things that you can do. One of the things that's going on really well now is telemedicine. I don't know if it's like this in your offices, but we're having lower no-show rates with telemedicine than we did with in-person visits. So this may be a way to go about it. Sometimes you need to build in some safety behaviors in the beginning. You could argue that a safety behavior might be breathing training. I think that it can be done earlier on, but ultimately a person may need to do a public speech like this without doing a bunch of breathing beforehand or while I'm up here at the podium to be able to fully expose himself to the situation. It's always important to assess a therapeutic relationship if you're running into difficulties. What's going on here? Is there a lack of collaboration? Is that something you're doing, something you're not doing, something that can be done to improve the therapeutic relationship? Another one might be repeated non-completion. You've discussed it in the session, it seems like a reasonable thing to do, and you set it up as an action plan between sessions, and they come back and say, well, you know, doc, I just couldn't get around to doing it, or didn't do it, I feel badly about it, or So what do you do then? This is the classic homework non-completion, and there are lots of things that can be done. One of them is to look at the case conceptualization. Is this the treatment that's being done at the right time and place? Is this something you need to back off on and come back at another time? Are assignments pitched at the ideal level? Sometimes you can make them too easy or too difficult. It doesn't work out so well. One thing that can be done is do the exposure therapy in the session. I find this particularly important with people with OCD, and if any of you do exposure therapy with OCD, I find it to be very useful treatment, and with some patients, we can do that actually in the session. I remember a patient that came to me that his big problem was counting, and when he went in, he was a churchgoer, went to a church service, he needed to count all the panes in the stained glass windows, which I said, my goodness, how could you possibly do this? Of course, you could avoid listening to the sermon because you were counting all the panes in the glass, but one thing he did was he counted books when he went into any room where there are books on a bookshelf, and my office happened to have a lot of books, and so we were able to do exposure therapy with reducing the amount of time spent on counting books, and with progressive sessions, he agreed to spend less time doing it until he winded it down to zero, which was really a successful kind of a thing. So that would be an example of an in-session exposure therapy. I think I'm going to get the hook here real soon, so I better go on and do a couple more of these and then quit. We already talked a bit about safety behaviors. I'll skip that one other than to remind you that maybe that's the reason why you're not getting success, that you haven't spotted the safety behaviors yet, and that's why the person still has the overall avoidance behavior. Family dependency. I've seen patients that the family is really playing into this by doing things with and for patients, and sometimes they need to be brought into the sessions and work on the exposure plan together. Lack of skills. Some people that have had social phobia for a long time really don't have the skills to make small talk. So what do you do then? Well, you can do skills training in sessions. You can recommend readings, online resources. There are lots of things out there that can help people with those kinds of behaviors. I'll go on to the therapeutic relationship is strained, and I'll sort of end my talk because I'm going to be going fly fishing next weekend. I'm a big fly fisher, and I sort of see working with exposure therapy with patients with anxiety disorders almost like playing a trout because if you're fortunate enough to have a trout come up and take your fly, and if you pull too hard on the line, you're going to pull it right out of the mouth, right? But if you let it go slack, then the trout gets off too. So it has to be just the right amount of pressure, and there's a certain amount of experience in this so you don't pull too hard or let the line go too slack and just play it just right until the fish comes into the net. And of course, we all do catch and release now, and you handle it in a way that works out pretty well. So you can certainly do this with exposure therapy of pressing too hard and not pressing hard enough. This is one of those therapies where the therapist, I think, sometimes does need to ask something more of the patient than in the classic collaborative empiricism mode of CBT because you can unwittingly participate in their long-term avoidance if you don't have certain expectations. Let's give it a try. Let's keep going with this. If there are barriers, we're going to work on them, and you're going to get, I think, a lot of benefit out of sticking with it. So you have to give them those kind of messages. So I think with that, I'm going to wrap up, and I think I've gone a little over, and I'm sorry. Except, oh, I have to show you my last slide here. So I like this. You must learn to let go. So I don't know if we're going to say that as a cognitive behavior therapist, but I think it's funny anyway. Thank you very much. And Dr. Perlin, Reiner Perlin, is going to come up and talk. Thank you, Dr. Wright. So I'm Reiner Perlin. I'm a PGY-4 at the University of Louisville. And we're talking about CBT and chronic mental illness today, and I'll talk to you briefly about specific applications of CBT for bipolar disorder, probably the most important of which is in relapse prevention. So I think part of our project today, I'll just speak for myself, is a little bit of myth-busting against the idea that there are certain types of people who are so severely mentally ill that CBT is no longer appropriate for them. I really would challenge that, and I think we have quite a few applications of CBT in bipolar specifically. First of all, we know that CBT for bipolar has to have in common some basic elements with CBT for general psychiatric conditions. The therapeutic alliance is paramount. And then we want to make sure that our work is patient-centered. So when I say patient-centered, I mean patient-centered as opposed to illness-centered. An illness-centered approach with bipolar patients or other patients with SMI can be very stigmatizing and can actually damage the therapeutic alliance. We also have the CBT formulation as kind of our touchstone of treatment, something that we can always come back to if we encounter barriers in the therapy. And then we'll find, kind of as we go through these next few slides, that we use some pretty basic cognitive and behavioral methods with bipolar patients when we're working with them towards the project of preventing a relapse into a mood episode. Perhaps some subtle differences would be that in CBT for bipolar, we want to really emphasize the involvement of the family, partners, and support systems. And then we do, again, have a focus on relapse prevention. And just a comment on relapse prevention here for bipolar disorder. We recognize that some common kind of forms of countertransference that might come up when we're thinking about working with a bipolar patient are stigmas that we hold as psychiatrists or that the community holds that maybe patients with bipolar disorder are not adherent or not engaged in treatment or have really poor insight. So we'll do a little bit of work on challenging some of those things today, but we do want to make sure that we take into account some of our own biases in going into this work and recognize that even though there may be non-adherence in bipolar disorder, there is non-adherence with treatment and psychiatric illnesses across the board. It's just that we recognize that the stakes may be higher and the consequences of non-adherence might be a lot more obvious for our patients with bipolar disorder when they relapse. All right, so just why would we want to make sure that family is involved? As Dr. Wright said, from the gate you're going to get a really comprehensive evaluation and making sure that the family is involved in providing a complete and accurate history to supplement the history that the patient is giving you is pretty important. We want to understand how they're functioning now. Is this their baseline? What does their baseline look like? And really critically, what have previous episodes looked like? And we'll get into that a little bit more, but the family can be very crucial in helping us understand some of the warning signs when a patient is about to go into an episode. Another thing that is beneficial with involving the family is getting everyone kind of on the same page about what are the goals of treatment, and you also have the opportunity to do some really special psychoeducation with the family. So in some family dynamics, we find that stigma coming from the family about medications, about the illness, about treatment, can actually be a barrier to engagement. So if we have the opportunity to have everyone in the same room and build some trust with both the patient and their support system, and also educate, it's a golden opportunity. We also want the family to be involved in one of our critical elements of relapse prevention for CBT, which is reducing general stress for the patient. So we consider this kind of a separate risk factor for relapse. So if there are any times in the patient's life where they can have someone maybe helping them accomplish certain things, it can be really beneficial. And then we enlist the family to aid in a more concrete treatment plan as well, and we'll look ahead towards some of that, including symptom monitoring, helping manage medications, and then everybody on board with our emergency planning. So we talk about these kind of four key components to relapse prevention. The first is addressing any modifiable or lifestyle risk factors, recognizing and monitoring any change in symptoms, planning for recurrence. So bipolar is a chronic, recurring mental illness, and it's beneficial, I think, both for the psychiatrist and the patient, as well as their family, to have an understanding that relapse is fairly likely, and to give everyone some information about what factors might make that more likely to happen. And so we plan ahead for recurrence. And then when relapse does happen, we work within the therapy context to learn from it and plan for next time. All right, so some of the modifiable risk factors for relapse. We know that medication adherence is a challenge. Stopping a mood stabilizer is one of the most common precipitants for a manic episode. And we get into a vicious cycle where symptoms of mania and depression can lead to further problems with treatment adherence. Med adherence could really be its own presentation for a CBT talk, so I'll just briefly touch on that today. But I just want to add here, when it comes to countertransference and stigma that we might bring to the therapy context, there is some evidence that medication adherence, as unlikely as it sounds in patients with bipolar disorder, may actually be higher than in patients with recurrent major depression. It's just that the consequences of med-not adherence, again, are much more obvious in our bipolar patients, so we really see that coming up more often. So when it comes to medication adherence, in our early sessions with bipolar patients, we really have an opportunity to assess what are some factors that have led to non-adherence in the past and get a comprehensive history of medication treatment specifically, so that we make sure that we're taking a patient-centered approach and not starting someone on something that they're unlikely to take, not reinforcing some of their mistrust in the psychiatric system. And so there's a difference between the issues with acceptance of medication and trouble with management of medication. Some barriers to acceptance of medication might involve trouble accepting the diagnosis. I think this is where CBT can come into some pretty important play, because what do we consider full, perfect insight or full acceptance of a diagnosis? We have acceptance of the label of bipolar disorder, and then do we have acceptance that this is a chronic relapsing condition where maintenance medication might be necessary? And if there isn't that acceptance, which we find in a lot of our bipolar patients, or at least I have in training, does that pretty much wipe away anything that we can do in CBT to help with adherence? Or are there some kernels of insight that we can play on, some things that a person might understand about their illness that might help us work with them to work on medication adherence? And then basic issues with medication management, of course, with cost and organizational skills, and this is where the family can be pretty beneficial. The circadian rhythm factors are also a pretty important risk factor to help manage, making sure that people maintain a good sleep routine and a good balance of activity between things that are stimulating enough without being excessively stimulating, especially in a period of vulnerability for entering a manic episode. Stress management we talked about a little bit, and then avoiding some predictable triggers, or at least being aware that they're coming up. Some patients have real obvious seasonal circadian triggers for episodes, work or shift hour changes, and then travel can be a big trigger. And then obviously substance abuse, which I won't spend too much time on here. So one of the things that we do in helping patients to prevent relapse using CBT is kind of fostering a recognition of what symptoms actually look like and teaching patients and families and working kind of as a team to monitor those symptoms over time. So again, family needs to be involved, record review, as much information as we can get from the outset on what episodes look like for the individual person, and then we kind of start from the perspective of what have things looked like for you in the past or what have things looked like for your family member so that we can make sure that we're really working on this individual's level rather than imposing maybe some external ideas of what manic and depressive symptoms look like. And then once we have an idea of what the individual's episodes have looked like in the past, we can do some education and bring into the therapy some things that patient and family might not have realized represented symptoms of mania or depression. So we have an opportunity for education there. So I'll go through the next few slides and show just a couple of charts that can be really helpful. CBT has a stereotype of being very chart heavy, very worksheet heavy, and these are a couple of such worksheets, but I think they're pretty beneficial. So we'll look at the symptom summary worksheet and the mood log, and we'll start with this chart that kind of helps folks gather some history about severity of symptoms, severity of mood symptoms, and creating that kind of gradient that can help people recognize when they're maybe in an early phase of a manic episode, maybe things are progressing over time. So we can see that we have our chart on top for the symptoms of mania and then below the symptoms of depression, and we have this kind of gradient from mild to moderate to severe. So for example, as far as their mood, their affect, they might be happier than usual if it's just a mild symptom, a mild change from baseline, maybe increased laughter and joking on the moderate level, and then when things are severe, they're just euphoric, they're on top of the world, they could conquer everything. And I won't belabor this slide, but we will, I think our slides are not uploaded to this workshop yet, but I will work with the conference organizers to make sure that everybody has them so that it's not too big of a deal that we just click through. So this is a symptom summary worksheet, and this is borrowed from BASCO's bipolar workbook, which I think is a wonderful resource. And this is something that we can kind of go through, again, during a period of euthymia, and we have some insight and we can reflect back on previous episodes to say, you know, what did your mood look like, what did your sleep look like when you were manic, when you were depressed, and during euthymia, and this can be another kind of signal to people that things may be changing if those things are different over time. And how do we change over time? Something like a mood log can be really helpful. So we have zero as kind of the set point baseline of euthymia, and then the positive numbers indicate possible manic symptoms, and negative numbers indicate depressive symptoms. And you can see that it's a weekly calendar, and you can just place a checkbox in the box that reflects kind of where mood is at on any given day. And I think encouraging folks to do this can really grant actually some sense of power and some sense of autonomy over, you know, their sense of being able to prevent some of these episodes, being able to recognize some symptoms when things typically can tend to feel pretty out of control. So planning for recurrence is a critical part of this process, and working in therapy to address any early signs and symptoms, not kind of letting those things go, expecting that they're going to get better, but intervening as early as possible. So again, we do this work when the patient is euthymic, when the person is euthymic, so that they have, you know, the best possible insight into previous episodes and current functioning to work ahead, you know, when things change. And we want to identify and address any possible exacerbating stimuli, things that might tend to trigger an episode, whether it's, again, you know, shift work changes, vacation, a really stressful event, anything that might interfere and potentially trigger an episode that has in the past. And then we want to take a close look at any cognitions that have occurred in the past around episodes or any that are going on right now that might interfere with engagement and treatment. And a lot of those are things, you know, some of those are things that Dr. Wright addressed earlier, just thoughts and beliefs that interfere in engagement and treatment. But some other thoughts that might come up would be permissive thoughts. When mania sets in, you know, you can talk to your patient and see, was there ever a time where you were becoming manic and you started being a little bit more impulsive, maybe with your spending, and you notice some thoughts like, this is fine, you know, I've been doing well, I can spend a little bit of money. At what point does that come in? And is there some utility? And I'd argue that there is, using some cognitive methods before those things come up to develop a plan to challenge them as a part of the overall treatment plan. And then, again, behavioral temptations, are there opportunities for the patient or family to remove those things if mania or depression begin to set in? For example, you know, if I'm becoming depressed and I have this temptation to spend all day in bed, kind of becoming more deconditioned, can I or my family intervene in that pretty early on, get me back out, walking around, and again, with the understanding that obviously, you know, pharmacotherapy is ongoing at the same time. And then, you know, conversely, is there an opportunity for maybe access to a car to be removed or access to credit cards if somebody has a history of erratic driving or excessive spending during a manic episode? Stabilizing sleep and routine, fairly self-explanatory, but you can also involve the family in that. For example, if there are childcare responsibilities at night, shifting some of those to the other partner can be pretty beneficial. Managing emotions, so being able to recognize the connection between shifting emotions, beliefs about the illness, and making a plan to kind of intervene in those things ahead of time. And then making emergency plans. So this obviously includes emergency medication plans, which again, can be very empowering for the patient and can actually enhance medication adherence. So this idea that you make a plan with the patient that if you start noticing some of these symptoms, you're going to call me or you're going to call, you know, whatever resource we've put on your crisis plan, but, you know, I may also empower you to change the dose of your medication on your own, which can be a bit controversial, but I've seen it done pretty efficiently and it increases trust and can be done quite safely. So that can be part of an emergency plan, but then obviously making a list of, you know, people to call and engaging family and activating that plan if the patient themselves is not prepared to do so. And then we want to be able to enhance insight and specifically being able to enhance some acknowledgement that symptoms are happening as they're happening. So using some of these basic CBT methods to plan ahead and say, well, you know, when you became manic, you very strongly believed this. You began to behave in this way and we've got this, you know, in our notebook here. We've got this in your chart. So can I call your attention back to this if you come to session and I believe that you're, you know, becoming manic? So that's some of the ways that we plan for recurrence. And then critically, anytime a relapse happens, it's a learning opportunity. We really have the opportunity to, in our education, the patient and family that this is a, you know, a chronic episodic illness, the opportunity to normalize relapse and say that a relapse is not a treatment failure, but maybe an expected outcome that we now have the opportunity to plan a little bit differently for and prepare a little bit differently for. And also something that we can manage. You know, it's not the end of the world if an episode happens, but that we have a plan together as therapist and patient and support system to manage these things. And then discussing the details, obviously, reviewing any records, getting a new history for recurrent episodes, and then modifying any of those checklists that we made to make sure that things are updated based on the most recent episode. And then I think this is a pretty important final point and something that we don't tend to do a lot for our bipolar patients, at least not in my experience, is to screen for any heightened anxiety or even post-traumatic symptoms following an episode, specifically manic episode. We have pretty good evidence at this point that bipolar patients are more vulnerable to the development of post-traumatic symptoms and a pretty hefty load of cases in the literature of people who develop post-traumatic symptoms related to traumatic incidents that happened while they were manic, as you can imagine. All right, these are some of my references and recommended readings, but again, I'll upload this slide so everyone can take a look at it. I do recommend Dr. Wright's book on CBT for Severe Mental Illness and Dr. Vasco's bipolar workbook. Thank you. And I'll hand it over to Dr. Sudhak. Thank you. Thanks, Rena. And I just wanted to say this is my safety behavior right here, my notes, because I'm an anxious public speaker. You caught me. What I loved about Jess's talk about physical therapy, and if you've, like me, are an athletic person in midlife, you've had a lot of it, is that when somebody's stuck, I kind of think about the mindset of every physical therapist I've ever had, which is incredibly optimistic and also incredibly relentless. And relentless optimism, I think, is very important when you're managing persistent behavior patterns in someone that feels stuck to you. The first thing to think about when we think about patients who are stuck in persistent behavior patterns, I think, is that change is fundamentally hard. I give all of my residents in their second year a project called the Change Project, where they have to change something about themselves over 12 weeks. And they have to do it sort of with data about finding out what things would help. And at the end of the project, I no longer hear about the terribly resistant patient who doesn't want to change. Because, in fact, change is hard. And change is hard when we're doing well and we really want to change something about ourselves. But frequently, when patients come to us, they come to us in a tremendous amount of pain. They're struggling with something. Their lives are very, very difficult. And they just want to feel better. And what we're translating that into our minds are all the things about this person that have to be different. And it's no wonder that that translation sometimes goes awry, that the things that we're asking someone to do are to change behavior patterns that have gotten them to this particular place. But what they're feeling is a lot of ouch. And so we have to consistently juggle the tending to the ouch, but also asking for something to be different. And often, when we think about difficult patients, I think one thing that we have to do is to stop being global about it. You know, the patient is resistant. The patient doesn't want to change. The patient has too many problems. And to get more specific about exactly what is going wrong. How do I think about what this person is doing or not doing that's keeping things stuck? What is the person doing that is or isn't a problem between the sessions, in the session? Are they not paying attention? How do I understand that? Are they not thinking about therapy outside of therapy? How do I understand that? Are they not doing tasks outside of the session that might be helpful to them? And how do I understand what keeps this going? Everything that happens with our patients happens for a reason. What's going on is serving some purpose, or it wouldn't continue to exist. And so how I conceptualize the problem becomes quite important. So I'm doing the David Letterman approach about this. I'm going to do the top six reasons that I think we might have problems with being stuck. And I'm going to talk about this mostly in reference to behavioral activation as a paradigm. But I think if you look at this, you can look at this about any particular stuck point. And the first stuck point is that this alliance has problems. Because the alliance, when the bottom line is, if you don't have a good alliance, you're not getting anywhere. That the person really has to trust you and have a sense of you and the person working together in order to have the courage to do things that are hard or different. And so if the person and you don't have a good empathic connection, you should be thinking about how to shore that up. And also, if the person doesn't understand the rationale for what it is that you're doing, it doesn't make sense to them, or you haven't said it in a way that resonates or that they believe, then it's a nonstarter. So with behavioral activation, for example, you need to explain clearly to the person that, in fact, the natural tendency of being depressed is to pull the covers over your head, get into bed, put on Netflix, and eat Ben and Jerry's. We've all been there, or at least some of us have been there. But when you're depressed, that happens day after day after day. And eventually, your life gets to be a mess. And your friends stop calling. And you lose your job. And you might get kicked out of your apartment because you're not paying your rent. And so what we have to explain to the person is that it's very natural to want to withdraw from activity. But if you put up this cycle, how would you expect to get out of this? And most people will say, well, I have to get moving. And then what becomes the connection is, let's see how I can help you get there. And so they have to understand that. So the other piece is that you can be wrong, right? You can understand the patient's problems incorrectly. So if you're really stuck, a good thing to do is to go over the conceptualization with the patient. Here's what we came about as the understanding of your problems. And what am I missing? Is there something that we've left out here? I'm recalling someone who I treated many years ago. And I was just really stuck. And it turned out that what I was missing was that this person had been hospitalized as an adolescent and gotten ECT and hadn't told me about it because they were so ashamed. And they had carried the burden of the shame of that throughout life. And so you have to really be able to think about, you might be missing something. That's problem one. Problem two, it's too big. For many people who are starting this work, particularly work in CBT, their ambition is that they're going to cover six things or 10 things on the agenda. And the assignments that the patient leaves with are like my kid's backpack in high school. There's just too many things on the list. And so one of the things to think about is not misjudging how much someone can do and setting up success. Get the person to find at least their initial assignment to be something that could be something that makes sense and feels good and is of the right size. Like, can you think of one or two things that you could do this week that might just lift your mood even a little bit? And what would those be? And so you're really trying to right size this and not overwhelm the person and also set them up with the idea that doing something is better than doing nothing and that planned activity and exposing yourself to planned activity, particularly when we're doing behavioral activation, has a real potential in terms of giving your mood a boost. So we want to help the person by asking them, is this too much? Is this too little? It's kind of a Goldilocks approach, right? We also want to make sure this is an assignment that might be meaningful to them as well. And sometimes when things that are too big, one of the things we can do in behavioral activation or in any other task is think about all of the different steps that it would take to actually be able to manage this task. I've had more than one patient over the years, particularly with treatment-resistant depression, who have come to see me saying, I am wearing my last clean t-shirt. I've also had a daughter in college who I think brought home everything except her last clean t-shirt. So I know this is like the labors of Hercules and the Aegean stables, right? So when you think about having this pile of laundry that is so enormous and you're depressed and you look at that pile of laundry, the conclusions that you're going to draw about yourself are, what a worthless pig I am. I don't even have any more clean clothes. And it's staring you in the face. But it also feels like, how am I ever going to manage to get this done? So that one thing we can do when a task is that big is to sit with the person and say, well, why don't we think about all the steps that would be involved and break this down? If I'm going to write a book, if I'm going to make bagels, if I'm going to do something that has a lot of steps, I've got to think about what all of those are and figure out, how can I plan for each one of those steps in order to get a big job done? And this looks like a really big job. And so one thing this does is it helps me to understand, does the patient have the capacity to plan out the steps? Do they know what's involved in a task? And it helps them to learn to do that. And then it might help us to put a sense of the pieces that are involved so that they could do one piece at a time. So maybe this week, you could sort the clothes on one day and go down to the change machine and get some change for the laundry machine and get some detergent. Maybe another day, you can take the laundry down and begin to get it done. The other thing that works really well in BA about this is to time limit things. Because frequently, if you're like me, you think, I've got two minutes. I don't have time to do anything. But if you actually do something during the time that the microwave is going for two minutes, you can find it's a lot of time. So if somebody has a big pile of dishes in the sink, a good thing to do is to say, well, how long do you think you could wash those dishes for? Five minutes? Could you try it for five minutes and just see? What generally happens is it's like activation energy. Once the person gets started, they just kind of keep going. And it didn't take as long as they thought. One of the things that happens with behavior when you're depressed is that you often think it's going to take much, much longer than it actually is. So what we can do is to say, let's try it. Set a kitchen timer for this much time. And that will be the accomplishment. And then generally, you can get things done. Problem number three. And this is a critical problem. You didn't write down the assignment. The patient didn't write down the assignment. Or you didn't write down the assignment. And set up reminders. If it's not written, if there are not reminders, it's not going to happen. It's not going to happen. And frequently, when people have been depressed or demoralized or they don't have a lot of organization in their life, it's very difficult to remember to do things. So that when someone's in therapy and they're anxious and there's lots that's going on in a therapy session, they might leave the session and forget completely what it is that you've set up. And I will say, it's also the case that you need to write it down. Because you might forget completely what you've asked the patient to do. Because you've got six other patients in the course of the day and six emergencies and God knows what else. So by the time the next week comes around, you don't ask the patient about what you asked them to do. And if you don't ask and the assignment doesn't seem important to you, it's a non-starter. It's not going to happen. So you need to have a record of what it is that you've asked about. And the patient needs to have some sort of record of what it is they're going to be doing. Now, if you get stuck, there are a couple of things to think about. One thing is to ask the patient where they put the record and what they did with it when they left the office. If it's in the same briefcase or bag that they bring to therapy and they never took it out of the bag, that's a problem. Because if you don't see what you've written down, it's not going to be the stimulus to remind you to do what you were going to do. I love using the cell phone for this. So when you make a behavioral assignment, you actually put in the patient's phone a time when this is going to happen, label it, and set an alarm. So that there's a stimulus that's going to occur that reminds the patient, hey, this was the time you said you were going to go sit in the park and see if that made your mood feel better. Now, a really important thing that I've found out is that you've got to put a label on it. Because I've had patients come in and say, you know, my phone went off this week and I didn't know what that was for. And so you've got to make sure that the stimulus is connected to what it is that you were going to do. No reminders, not written down, not going to happen. Now, when you're using activity scheduling, and Dave is going to talk about that more extensively when he talks about working with older adults, activity scheduling is really just a way of getting the person to engage in activity, using things that help them to remember and to size the activity and problem solve about the activity so that it actually occurs. And when I'm doing a homework assignment, and one thing that we don't do these days often is call it homework, even though in my mind I think of it that way. We don't call it homework in CBT any longer because people hate homework. Often they've had a really bad experience at school. So we might call it action plans. That's a little too corporate for me. So I usually call it practicing or finding out or something good you can do for yourself, whatever it is that you call it. It has to be written down. And I like thinking about W's when I write down my ideas for what the person's going to do that week. What are you going to be doing? When are you going to do it? Where are you going to do it? And with whom are you going to do it? I want to get that granular. And it's got to be something that can actually happen. If I said, what I thought I'd do this afternoon is to, in my half hour break, walk to the Golden Gate Bridge, walk across the bridge, walk around in Sausalito and come back, that's an assignment that would be too big for that half hour. So it's got to be actually something that could happen. And structured initially and particularly so that success is nearly guaranteed. I want the person to feel like this is something they can do and that will benefit them. I want to make sure that I ask the person, it says three minutes. All right, I'm good. What kinds of things could get in the way of the assignment? I want to make sure that they have reminder systems. Problem number four, there's not sufficient reinforcement. We are primates. Why do we eat the chocolate cake? Because it tastes good. And if we want to avoid eating the chocolate cake, we want to make sure that we do things to counter that. We want to help the person to understand that change is hard. We want to look at how immediate rewards are always going to look more tempting and have plans to manage that. Thinking about negative consequences in the future, setting goals, thinking about establishing alternative rewards or delay. This is when whatever the patient's engaging in is pleasurable to them in a particular way. And we want to replace that with a different kind of behavior. But sometimes when someone's really depressed, there's not a lot of reinforcement that happens in the new activity. They might go to the movies and they'll say, well gosh, I don't feel as good as I did when I used to go to the movies. I don't know why I bothered being here. And so it's important to think through the idea that when you're really depressed, getting even a little bit of movement, a little bit of relief. If your mood goes from a one to a three, that's a win. That you don't go from a one to a 10. And so helping the person to look at even small increments as a positive thing. And we also need to look at what thoughts might occur that deactivate pleasure. When we're really stuck, getting someone, a person who might do things with them can be very helpful or potentially helping family to be engaged with the person to increase activity. When someone's doing some activity and what's assigned doesn't have a lot of oomph, we might need to plan unusual rewards. This isn't so much for depression, but it might be for someone who's studying for a big exam. If you're really doing something that isn't very rewarding as your activity, you wanna think about an unusual reward that might be helpful. I'm gonna speed through the last couple, but it's important to look at the thoughts and beliefs that the person has that are increasing when they try to do activity and it really derails them. So we have to look at our own thoughts in terms of being persistent and optimism and having optimism about the patient. But we also need to think about setting some reasonable goals for them. If the person says, I don't feel like it, and that's the natural default when someone is depressed, we need to think about number one, validating that. That makes total sense because it does. To the depressed patient, not feeling like doing something is totally how they perceive things. But the second thing is, if you act from the outside in when you're depressed, if you act because you have a plan, then because you feel a particular way, it's much more likely that you'll get better and feel better. And most people have had an experience where they've done something where they didn't feel motivated. Like being here this morning, you might have rather be outside seeing in San Francisco, but you told yourself, gosh, it might be a good talk and I'm a professional and I'm getting CME credits, but here you are. Or you don't feel like going to work. I'm sure there were one or two people that have had that experience. And most people have gone anyway. And so we have to give the person the example that this is something that they can do in the service of getting better. It's an action prescription. The other thing that we have to look at is potentially other beliefs that interfere with change. Like I'll fail if I try to do something different or maybe it's beliefs about me. I'm in control if the patient does what it is that I've asked them to do. Last but not least, it's motivation. It's possible that the person has a lot to lose in the process of change. So we need to think about what is the person, if they change, going to lose in their environment or in their family system or in their day-to-day life. They might need to take on new responsibilities or take risks or there may be people in their life who aren't gonna like it very much if they get to be more assertive. Everything that someone engages in has a reason. And if we understand and empathize with that and problem solve about it, we're much more likely to get where we want to go. Thanks very much. Thank you. Good morning, everybody. So we're coming to the end. I hope that you're still with us this morning. It's hard for me to pay attention to a lot of talks in a row. So maybe that's because I'm getting old and that's what I'm gonna talk about today. So I'm a geriatric psychiatrist. Any other geriatric psychiatrists in the group? One or two. So a few kindred spirits here. And I'm gonna talk a little bit about the issues of depression in older adults, issues of chronicity and treatment resistance and how we can address them, including carrying on some of the discussion about behavioral activation that Donna was talking about earlier. So to begin with, some very important basic points. Depression is not a normal part of aging. When older people become depressed, then that's an issue that deserves assessment and treatment. Incidence and prevalence of major depression is similar with older patients as in the other group, although some at-risk groups, people in nursing homes, for example, have higher rates. But depressive symptoms that may not meet the criteria for major depression are fairly common. In older people. When I first got interested in geriatric psychiatry, I sort of started in internal medicine and switched over to psychiatry. I imagined that the medical model would be the most important aspect of treating older people who have the effects of aging and many medical issues. And that certainly is true. It's foundational. But I also discovered that it only takes you so far. That understanding these people as individual human beings who have their own life experiences, their own family and cultural backgrounds and traumatic history and so on is as important, in many cases perhaps more important, than simply applying the medical model. In my practice, my average patient approaches 80, that's typical, and probably the bulk of the people that are referred to me have some kind of treatment-resistant depression, and often it's an acute on chronic situation where the person's been depressed for a period of time, often they've had many, many forms of treatment, and then there's a flare that causes them to be sent to me or someone like me for further treatment. So the category of elders in the United States is a constructed or artificial category. There's nothing magic about age 65 that makes a person, once they turn that age, different than they were at 64. And so there are historical reasons why we often use that age, but the approach that we use in geriatric psychiatry begins to shift for patients that have chronic medical problems, often multiple medical problems, issues with mobility and special senses, cognitive problems, and sort of an accumulation of those things, particularly in extreme old age, people 80, 85 or plus, who have frailty, sometimes failure to thrive, issues of dependency and autonomy. Those categorize a group of patients that often require a more specialized approach. We see all kinds of losses, grief, loss of a spouse or family member, multiple life transitions moving from home to a care facility, for example, issues with financing, not whether the person's able to drive or not, and all these things are accompanied by the potential for a loss of pleasurable activities, a loss of a sense of mastery, and a loss of companionship. So one thing that I like to keep in mind is that every clinical interaction, whether it's labeled as psychotherapy or not, has a psychotherapeutic element. That is, we're always communicating to people something about the illness, something about the treatment, something we want them to know about how those things can be managed, communicate to them a sense of realistic hopefulness, and sort of combat the sense of hopelessness and helplessness that is likely to occur in a situation like this. Donna talked about positivism, so I find that it's necessary to guard against a sense of therapeutic nihilism. If you're sitting with depressed patients who have multiple problems all day long, every day, it's possible to find yourself slipping into that kind of thinking process, and you have to guard against that. And so I'm looking for a realistic and yet relentless sense of hopefulness that I'm going to communicate to folks. One thing I've learned is that I'm not going to cure very many of the people that I see. And so I'm interested in trying to enhance and sustain quality of life for them and often for their caregivers and families and for the people around them. And so I have to set realistic goals, goals that can actually be achieved, and then measure the progress and measure my own progress against realistic goals that often include accepting a degree of granicity that may be impossible to completely resolve. The sessions have to be tailored to the individual patient's energy and cognitive level. So one size does not fit all. Depression in old age is a very heterogeneous problem. There are patients that have had chronic depression or depressive episodes all through life and continue to do so in old age. There are also people that develop depression for the first time in old age, and those people may have a unique set of problems, perhaps some incipient cognitive disorder or the effects of medical problems, maybe a cerebrovascular disease or cardiovascular disease, multiple medications and the like. Sometimes people who come to me are suffering from the effects of overtreatment, that is, they have excessive treatment in a perhaps excessive or a well-meaning but misguided attempt to improve the person by just adding on more and more medications. And so assessing the medications and often discontinuing medications that are no longer helpful is an important part of what we're doing. I don't always rely on sort of off-the-shelf kinds of tools, things like scales or monitoring systems or so on. For many of my patients, it's necessary for me to work with them to create a simple system that they can use. If I'm asking somebody to do an action plan that may include, for instance, activity monitoring, then it has to be inherently doable and pleasurable for them in some sense to do it, or they won't do it. And so enhancing pleasure begins in the therapy session and enhancing mastery and communicating the sense of mastery starts in the therapy session and the action plan that we provide for people. I like to start with the most comprehensive sort of evaluation that I can, not only the medical aspects of the treatment, but getting to know the individual as a person and asking them about their biography, about their family, their cultural background, previous treatment, traumatic experiences that they've had. And often people will disclose to me things in a situation like that they've never told anybody. It's fairly common for a person to say that they were sexually assaulted, for instance, in childhood, never having told anybody about it, and those things turn out to be useful. And so that's the beginning of therapy for me. And so I always like to begin by doing that, but when the session is beginning to conclude, I'm moving into a psychotherapeutic mode and beginning to think about an action plan beginning from the first session. Behavioral activation, which Donna talked about, is one of the most powerful tools available to therapists dealing with chronic depression in old age. Behavioral activation is a form of operant conditioning. It's the idea that depression in part is occurring because there's a lack of positive reinforcement for healthy behaviors and perhaps, I hesitate to use the word, but some kind of punishment for behaviors that might be helpful. But also sometimes a reward for behaviors that are unhelpful, for instance, excessive dependency would be an example. And so what I'm always doing is thinking about an action plan that will identify things this person has done in the past that are still open to them that might enhance a sense of mastery and pleasure and try to minimize things that would else be unhelpful. Easier said than done because passivity and inaction are inherently very rewarding for people. Withdrawal behaviors may be very rewarding in the short run, and so we have to figure out a way to substitute other kinds of behaviors that are more helpful as time goes on. Interestingly, you can think about a conceptualized behavioral activation as a treatment of its own, but the cognitive work often flows from the discussion about behavior. As you go on, you are beginning to talk to people about the kinds of activities that they find to be useful, and you begin to deal with things like values. You have an 80-year-old and you're thinking about this person may not have an unlimited lifespan. What do they want to accomplish with their life? What's still important to them to do? So a discussion of values, goals. So you may find yourself, even though you're starting with a behavioral action plan, in a fairly philosophical and existential discussion with a person that flows out of the sense of activity. Activity scheduling is a fundamental technique. So again, by simply asking the person to list in a way that's doable for them the things that they're currently doing, I'll usually start with the question, how do you spend your day? What's a typical day like for you? And then go from there. Here's kind of an aside. I'm reading a book right now called Metazoa. Anybody reading this book? It's pretty cool. It's about the evolution of consciousness and intelligence. One of the things that's discussed is the idea that physical activity, that is the need to move, control movement, have proprioception about movement, and sensations that help the creature deal with motion are inherent in developing a sense of self, a sense of limits, self versus others. And I read an article about AI the other day that made the point that machines, as close to human thinking as they can get, still don't have self-controlled ability to monitor their boundaries to move and then have proprioception about what effect the movement have. In other words, action and activity are part of what makes us us. And that's part of what's lost in the kinds of depression that we're talking about. You got to write things down. A simple written plan is necessary. When somebody leaves my office, they ought to have a written plan for what we're going to do. And I really want to delve into this, whether when the person leaves the office, are they really going to do this? Is this doable for them? Are they just trying to please me by saying they're going to do it? Or do they know as they're walking out the door they're not going to do it? And so I need to meet people where they are. That is, construct an action plan for them that's doable. If you give a plan, you have to discuss the plan. When the person comes back to you, then you need to go over the action plan with them and see what worked, what didn't work. In my view, there's no such thing as failure. If there's an action plan that was maybe incorrectly formulated, when the person didn't carry it out, it's simply an opportunity to review the action plan and once again to try to revise it so we're meeting people where they are. In this kind of work, you have to involve caregivers, and the caregiver often is responsible for many aspects of the action plan. For instance, they may have to drive the person from place to place, and so you have to understand whether the caregiver is going to be on board with those things. But you also have to decide who is the patient. Who is the patient? Because the caregiver and the caregiver's wishes or desires or goals for this person might be at odds with the patient themselves. And so I find myself in a situation where I have to think about the patient's own desires, the patient's own ideas about themselves and be respectful of their limits and not just substitute the caregiver or caregiving kind of situations, desires for them, and let that override their sense of self-efficacy and autonomy. When you're working with a caregiver, the things that the caregiver is doing for the patient, which may be necessary, also may come fraught with a lot of interactions that are potentially negative, reinforcing dependency or adding a kind of a negative or punishment like aspect of caring. And you also have to be respectful of the caregiver because they're typically overwhelmed and stress themselves. As a matter of fact, many caregivers end up being patients because they are also dealing often with an overwhelming situation. Avoidance behaviors, avoiding is sort of a natural part of many aspects of aging and depression may be driven by lots of things. Fear of falling would be one, fear of failure, many other things. So difficulty initiating, negativism, lack of opportunity to perform pleasurable activities are often present and we have to address those in the action plan and incorporate the caregiver. Persistence in the face of high levels of negativism may be a problem for the therapist, as I mentioned, but persistence often yields benefits, improved quality of life rather than cures an appropriate goal. And with that, we'll wrap up and I guess it's time for questions. I think we have about 10 minutes left, which is we're very passionate about these topics, so we went a little bit over. But if anybody has any cases that they'd like to bring up or any specific questions about CBT for chronic mental illness, we'd love to hear them. Dr. Perlin, could you give a little clinical story of one of your patients whose relapse led to PTSD and what you did with that? So I've been fortunate enough to not have any of my therapy patients have an episode that led to a traumatic event that they disclosed any post-traumatic symptoms related to that. And I think my approach would generally be kind of a straightforward approach, a therapeutic approach to post-traumatic symptoms that I would use for any type of patient. And taking also those experiences into account, not in a stigmatizing way when planning for the next episode. So I would really be cautious to avoid any sense of blame for the traumatic event that happened when the patient was manic or depressed, but incorporating that into a sense of urgency and preventing future episodes as possible, I think, without being stigmatizing. I just, I'll add that I think that sometimes people's shame about actions that happened during a manic episode is often really overwhelming and often keeps them from treatment or returning to treatment. And it's important to navigate those waters empathically. Additionally, when Reena was talking about PTSD, it's also the case that about 50% of folks who have bipolar disorder have a concomitant anxiety disorder, irrespective, not related to PTSD. And we know that those people do far better if they have psychotherapy in addition to pharmacological treatment. So it's important for us to keep our eye open for that. Thank you so much for this talk. It was very educational, very informative, super appreciated. I was wondering how often, for any of the three of you, how often in your experience have you come across patients that have essentially adopted their mental illness as their identity and thus kind of are resistant to any kind of improvement or don't notice improvement if they're experiencing it? How have you addressed that in your therapy? I think the short answer to that is yes. But it's possible to put too much of a pejorative slant on that. You know, people cope with the things that are available to them to cope with. So if a person feels overwhelmed, they may seek whatever means of coping that's available. So there are people that feel overmatched by the problems of life and they take refuge in the sick world. And that's true not only in psychiatry, it's true in other aspects of fields of medicine also. And so it's possible to become maybe impatient with a patient like that. But I think that's simply a part of the illness that they have. It's a complicating aspect of their presentation. And perhaps we can help them to work through that. There is a new wrinkle that's being introduced to this, that is social media, which has shifted the conversation amongst, you know, a group of particularly younger people who see it as virtuous to have a diagnosis or may see a professional standing in the way of a diagnosis sometimes. And so I don't know that we've quite wrapped our minds around that and how to deal with it, but for the phenomenon itself is not anything really new. Particularly for bipolar disorder, I would say, that often people volunteer to me that they have bipolar disorder in a way that they might have been reluctant to do in the past. And after I talked to them, I'm not so sure they actually do have bipolar disorder, but for them it's an explanatory model for the problems they've had in life. I'm just curious. If you've come across autism in your practice yet, young people with cluster B traits, self-diagnosing with autism, because that's something that's pretty popular on social media nowadays. If you have, how have you addressed it? I haven't. I've certainly heard about it from other psychiatrists, but being a geriatric psychiatrist, I haven't seen it. I will say that I have people who come to see me in their 80s and they tell me they believe that they're autistic, or more commonly, they believe they have ADHD. And it's very difficult. I mean, there's some, but not very much literature on the question of how you approach the issue of diagnosis of ADHD in a person of that age, but distinguishing it from cognitive disorders or from cognitive effects of medical disorders and medications is very different. But sometimes for them, it provides an explanatory model for problems they've had. I think that it would be a question of staying on the same side of the table and saying, well, what problems does this bring you that we want to try to work on? We may learn more about whether or not this diagnosis fits. Here's what I see. Here's what you see. What problems are you having now? Thanks for that question, Dr. Reske. I think we have time for maybe one, maybe two more. I have one. Thanks for this presentation. I want to ask about your thoughts about the use of adjunctive medications in helping people over anxiety. I have one woman, whenever she drives, she has to take propranolol. I have another woman, whenever she flies, she has to take Klonopin. The first woman continues to take propranolol. The second woman just stopped taking Klonopin, and she did fine. But my approach to them was more or less the same. I don't know why one of them continued and one of them stopped. I'm never quite sure what's the right way to approach that problem, and I would appreciate your thoughts about that. So I find myself wondering if the person who stopped the Klonopin still carries it with her. Yes. So those are just variations of safety-seeking behaviors, right? They're my notes when I give a talk, that people can sometimes gradually relinquish those things. The problem with having them is that you're always at risk for the problem returning, that it's a way of making you think, well, just in case this is really terrible, I'll have this. And many people who have anxiety disorders keep some variation of those and sometimes gradually relinquish them, sometimes relinquish them by accident. So, for example, the person who uses the Klonopin on the airplane and keeps it in their pocket might forget it on one flight, and they find out that they're really okay, which is exposure, right? And so what I generally do in those circumstances when it does not involve chronically using benzodiazepines, which is another story in my mind, is to let the person know that they're still vulnerable if they continue to have this. How could they gradually relinquish that as a step in their recovery? It might take a long period of time. It might not be when I'm seeing them, but the fact is that they should know it's just this in-case way is keeping in their mind the idea that this could really be dangerous to them. Can you comment please on, in terms of older adults, what would be the suitability for patients that are referred? I'm a geriatric psychiatrist. I didn't practice psychotherapy myself, but we have a limited resource in terms of CBT. Which patient that you would choose to refer as an older adult to the psychotherapist? I had a little trouble hearing you asking about who should be referred to a psychotherapist. That's right. Who is the suitable patient to be referred to the CBT? In our clinic, we have many people who I believe would benefit from therapy and not very many therapists. A good example is we have a couple of our residents here today who have been through our geriatric clinic. It's primarily a diagnosis of psychopharmacology treatment. We bring in a fairly large number of people and manage them. Then we refer them out for psychotherapy. That's not always true, but it's often true. We have to pick and choose because there simply is not a cadre of trained therapists who are capable of dealing with this kind of patient. Or in some cases, any therapist readily available to them who can perform these duties. I don't have a good handle on how to solve that problem, but I would say many people express an interest in therapy. They have some psychological mindedness. They come in the door hoping to be referred for therapy. We often will try to accommodate that need. As I said earlier, in my view, every interaction that we have with a patient, whether we designate it to be psychotherapy or not, is in fact psychotherapy. We're giving people a sense of encouragement and hope. We're educating about the illness. We're learning about them as a person and what they expect of us. Those are the elements of therapy, so I view it that way. It's also the case that you can use adjunctive other kinds of interventions. There's a wonderful self-help book on behavioral activation called Overcoming Depression One Step at a Time. It's fairly easy, even in briefer sessions, to get an action prescription on board. If you have that mindset, you can incorporate that even in a shorter session. Thank you very much for your questions and thank you for attending. Thank you.

psychotherapy

cognitive-behavioral therapy

treatment-resistant depression

bipolar disorder

depression in older adults

cognitive restructuring

behavioral techniques

Virtual Hope Box

therapeutic alliance

relapse prevention

behavioral activation

activity scheduling

individualized therapy