managing difficult emotions - arizona living...

M a r y E l l e n B e a u r a i n , M S W S o u t h e r n A r i z o n a L e a d M e n t o r H e a l t h y L i v i n g ( C D S M P ) M a s t e r T r a i n e r K a r e n R i n g P i m a C o u n t y R e g i o n a l C o o r d i n a t o r H e a l t h y L i v i n g ( C D S M P ) M a s t e r T r a i n e r V i r g i n i a R o d r i g u e z N o r t h e r n A r i z o n a L e a d M e n t o r H e a l t h y L i v i n g ( C D S M P ) T T r a i n e r J e n n i f e r C a i n , M P H H e a l t h & W e l l n e s s C o o r d i n a t o r D E S - D i v i s i o n o n A g i n g a n d A d u l t S e r v i c e s R e v a L i t t , M P H C e n t r a l A r i z o n a R e g i o n a l C o o r d i n a t o r H e a l t h y L i v i n g ( C D S M P ) M a s t e r T r a i n e r M e l a n i e M i t r o s , P h D D i r e c t o r , A r i z o n a L i v i n g W e l l I n s t i t u t e

Managing Difficult Emotions Supporting and Enhancing Skills of Workshop Leaders

October 17, 2011

Call Etiquette

This webinar will be recorded and available on the Institute Website under Partner Login after the call.

Please remember proper conference call etiquette. Please place your phone on mute when you are not

speaking. Please do not place our call on hold. Please share comments through the CHAT function. Please ask questions by the QUESTION function

ONLY until the Q & A portion at the end of the call. Arizona Living Well Institute

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Agenda

Overview of Aging and Depression, Anxiety, Anger,

and other difficult emotions Relevant aspects of the Healthy Living Curriculum Stories and Strategies Safety Protocol Success Stories

Arizona Living Well Institute

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State of Mental Health & Aging in America

Frequent mental distress (FMD) may interfere with major

life activities, such as eating well, maintaining a household, working, or sustaining relationships.

FMD can also affect physical health. Older adults with FMD

were more likely to engage in behaviors that can contribute to poor health, such as smoking, not getting recommended amounts of exercise, or eating a diet with few fruits and vegetables.

McGuire, LC, Strine, TW, Okoro, CA, Ahluwalia, IB, & Ford, ES. Modifiable characteristics of a healthy lifestyle in U.S older adults

with or without frequent mental distress, 2003 Behavioral Risk Factor Surveillance System, Am J Geriatr Psychiatry 2007; 15(9):754-761. http://apps.nccd.cdc.gov/MAHA/IndicatorsDetails


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Presenter

Presentation Notes

The indicator for FMD was assessed through the question: “Now thinking about your mental health, which includes stress, depression and problems with emotions, for how many days during the past 30 days was your mental health not good?” People who reported 14 or more days of poor mental health were defined as having frequent mental distress (FMD). It was asked of all 50 states, District of Columbia, U.S. Virgin Islands, and Puerto Rico in 2006.

The Significance of Depression

It is estimated that 20% of people age 55 years or older

experience some type of mental health concern. Depression is the most prevalent mental health problem among older adults.

The presence of depressive disorders often adversely affects

the course, and complicates the treatment, of other chronic diseases.

Healthy Aging and Depression Action Brief 2009 University of Washington School of Public Health


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Presenter

Presentation Notes

Mental health concern - not necessarily severe or diagnosable

How Many Older Adults Are Depressed?

Majority of Older Adults are not depressed. Some

estimates of major depression in older people living in the community range from less than 1% to about 5% but rise to 13.5 % in those who require home healthcare and to 11.5% in older hospital patients.

Depression is Not a Normal Part of Growing Older www.cdc.gov/aging/mentalhealth/depression.htm

A larger number of older adults have some milder symptoms of depression.


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Presentation Notes

Major depression is severe, persistent and debilitating A larger number of older adults have some milder symptoms of depression.

http://www.cdc.gov/aging/mentalhealth/depression.htm

The Significance of Depression

Older adults with depression symptoms visit the doctor and

emergency room more often, use more medications, incur higher outpatient charges, and stay longer in the hospital than older adults without such symptoms.

Depressive disorders are widely under-recognized and often are untreated or under-treated among older adults.

Healthy Aging and Depression Action Brief 2009 University of Washington School of Public Health


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Presenter

Presentation Notes

Untreated or under-treated because: Fear of seeking help not understanding mental illness condition not recognized by loved ones or providers Denial Huge overlap with medical illness symptoms - the great imposter (masquerade other physical illnesses)

Older adults are at increased risk. 80% of

older adults have at least one chronic health condition, and 50% have two or more. Depression is more common in people who also have other illnesses (such as heart disease or cancer) or whose function becomes limited.


How is Depression Different for Older Adults?


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How is Depression Different for Older Adults?

Older Adults are often misdiagnosed and

undertreated. Healthcare providers may mistake an older adult’s symptoms of depression as just a natural reaction to illness or the life changes that may occur as we age, and therefore not see the depression as something to be treated. Older adults themselves often share this belief and do not seek help because they don’t understand that they could feel better with appropriate treatment.



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Presenter

Presentation Notes

As a person ages, signs of depression are much more varied than at younger ages. Can appear as increased tiredness Grumpiness Irritability Confusion or attention problems

Health Information from the NIA www.nia.nih.gov/HealthInformation

Everyone feels blue now and then. It’s part of life. Being “down in the dumps” over a period of time is not a

normal part of getting older. For most people, depression will get better with treatment.

You do not need to suffer.

AgePage - Depression


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http://www.nia.nih.gov/HealthInformation

What Causes Depression?

No one cause…sometimes no clear reason

People with serious illness, such as cancer, diabetes, heart disease, stroke, or Parkinson’s disease, may become depressed.

Medications Genetics Getting used to retirement - feeling lonely Death in the family or serious illness Some - changes in the brain can affect mood and cause

depression (e.g. stroke) Pain or other disease symptoms Under a lot of stress, like caregivers

Adapted from: Health Information from the NIA www.nia.nih.gov/HealthInformation


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Presenter

Presentation Notes

Medications like sedatives, sleeping pills, etc.


A few common signs of depression (more in Session 5, Act. 4 of CDSMP)

“empty” feeling, ongoing sadness, and anxiety Tiredness, lack of energy Sleep problems Being irritable Crying too often or too much Feeling guilty, helpless, worthless, or hopeless Suicidal thoughts A hard time focusing, remembering, or making

decisions Eating more or less than usual Excerpted from: Health Information from the NIA www.nia.nih.gov/HealthInformation


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Treating Depression

Your doctor or mental health expert can often treat

your depression successfully. Support groups can provide new coping skills or

social support Talk and other therapies Medicine to treat depression can also help Excerpted from: Health Information from the NIA www.nia.nih.gov/HealthInformation

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Preventing Depression (more in Session 5, Activity 4)

Friends can help ease loneliness Develop a hobby Stay active Break jobs up into smaller jobs that are easy to finish Regular exercise Gardening, dancing, swimming Do something you like to do Being physically fit and eating a balanced diet may

help avoid illnesses that can bring on disability or depression

Excerpted from: Health Information from the NIA www.nia.nih.gov/HealthInformation


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Presenter

Presentation Notes

Brainstorm exercise: What are some things people might do to feel better when they are feeling down, blue, unhappy, or depressed?


Anxiety

Anxiety, along with depression, is among the most

prevalent mental health problems among older adults. American Association of Geriatric Psychiatry. Geriatrics and mental health - the facts. 2008. Available at

http://www.aagponline.org/prof/facts_mh.asp (accessed June 23, 2008)

Late-life anxiety is not well understood, but is believed to be as common in older adults as in younger age groups (although how and when it appears is distinctly different in older adults). Anxiety may be underestimated because older adults are less likely to report psychiatric symptoms and more likely to emphasize physical complaints.

Anxiety Disorders Association of America. New thinking on anciety and aging: Anciety disorders common in the elderly. (http//www.adaa.org/ADAA%20web%20fin/articles/aging.pdf)


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Presenter

Presentation Notes

Research on the overlap of symptoms in anxiety and depression has revealed that almost all depressed patients have anxiety but not all anxious patients are depressed. Depression and anxiety can result in increased social isolation, frailty, illness severity and even mortality. Tendency of older adults to emphasize somatic symptoms and deny feelings of anxiety or fear, Lenze and Wetherall (2009) recommend asking questions about stress, how often it occurs, and how the person reacts to or manages stress, as a way to approach a discussion of anxiety and methods used to control anxiety.

http://www.aagponline.org/prof/facts_mh.asp

Anger a common response to chronic illness

Loss of control over your body & loss of independence

create feelings of frustration, helplessness, and hopelessness, all of which fuel anger.

Angry with yourself, family, friends, health care providers, God, or the world in general.

Sometimes anger is not just a response to having a chronic illness, but is actually the result of the disease process itself.

Many people with chronic pain experience problems with anger.

Modified from Living a Health Life with Chronic Conditions


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Presenter

Presentation Notes

Anger is one of the most common responses to chronic illness. Angry at others including self for a variety of reasons ….for not taking better care of yourself when you were younger, family because they don’t do things the way you would like them done, angry at doctor because he or she cannot “fix” your problems Result of disease process itself - e.g. someone has suffered a stroke that affected a certain part of the brain, that person’s ability to express or suppress emotions may be affected. Pain - Unfortunately, even though anger can sometimes temporarily distract your mind from pain, it is ultimately self defeating. Learning how to communicate your anger verbally, preferably without blaming or offending others….”I” messages. Learning to change your expectations can help to change your perspective. Anger can be channeled through new activities such as exercise, writing, etc.

Unhealthy Consequences of Anger

Negative effects on your physical health. Negative effects on your emotional health.

Negative effects on your relationships with others.

Modified from ANGER AND CHRONIC PAIN by Richard W. Hanson, Ph.D.


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Presenter

Presentation Notes

Negative effects on your physical health: Whether you hold your anger inside or frequently express it outwardly, you can be causing damage to your physical health. People who have chronic problems with anger are more likely to develop high blood pressure (hypertension), coronary heart disease, digestive disorders including ulcers, headaches, skin rashes, and increased susceptibility to infection. Anger also increases muscle tension that can cause additional pain. Negative effects on your emotional health - turned inward, thereby intensifying the experience of other disease symptoms like depression. Negative Effects on your relationships: Anger and aggressive behavior can seriously damage your relationships with family and friends. Anger makes people much more rigid and defensive and destroys both trust and open communication. It triggers counter aggression in others, or others try to avoid being around the angry person. As a result, the chronically angry person is often left feeling isolated, lonely, and alienated from others.

Implications

Prevention may be the best treatment for mood and anxiety

disorders. The Prevention Intervention for Frail Elderly (PIKO) project (van’t Veer-Tazelaar et al., 2011)

Depression is one of the most successfully treated illnesses.

There are highly effective treatments for depression in late life, and most depressed older adults can improve dramatically.

Geriatric Mental Health Foundation. Depression in late life: not a natural part of aging. 2008 Available

at http;//wwwgmhfonline.org/gmhf/consumer/factsheets/depression_latelife.html


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If you are concerned about a loved one being depressed,

offer to go with him or her to see a health care provider to be diagnosed and treated.

If you or someone you care about are in crisis, please seek help immediately. Call 911 Visit a nearby emergency department or your health care provider’s

office Call the toll-free, 24 hour hotline of the National Suicide Prevention

Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to talk to a trained counselor


How Do I Find Help?


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Disease

Tense Muscles

Pain

Stress/ Anxiety

Difficult Emotions

Shortness of Breath

Depression

Fatigue

Symptom Cycle

Stanford Chronic Disease Self Management, 2006 Arizona Living Well Institute 20

Presenter

Presentation Notes

Referring back to the list of problems generated earlier or the previous slide : 1) Point out that often pain and fatigue seems to be one of the most common problems experienced by people with chronic health problems. 2) As you may already have experienced, one symptom can then lead to a series of other problems, which often creates more symptoms. It becomes a symptom cycle. 3) Let me give you an example of how the symptom cycle works. Arthritis causes you pain because of inflammation or bone rubbing against bone. In response, to protect the hurting joint, you tighten the muscles in that affected area. As these are tightened for a long time, the muscles also begin to cause pain (ask them to make a fist or outstretch their hand and hold for a few minutes: as the time passes, they'll notice that it starts to ache). As your pain mounts, you become stressed and more tense, wondering if the pain will ever get better. You might even cut back on activities. This, in turn, causes weak muscles and emotions such as worry, anger, fear, frustration, and even depression. Stress, difficult emotions and lack of exercise can cause shortness of breath and fatigue, making the pain worse and completing the vicious cycle. 5) This vicious cycle can happen with any health problem, not just arthritis, and the cycle can start anywhere – depression, for example, can start the whole cycle, or fatigue. 6) How many of you have experienced aspects of this cycle (ask for a show of hands)? How many of you believe people can influence this cycle by using certain methods or techniques (ask for a show of hands)? 7) You can break this vicious cycle! There are a variety of ways to do this using physical exercises, mental exercises and more.

How does CDSMP address emotional components of chronic conditions

Lecturettes, discussions, modeling, brainstorming Difficult Emotions - Session 2, Activity 2 Pain & Fatigue - Session 3, Activity 4 Communication - Session 4, Activity 4 Depression - Session 5, Activity 4 Positive Thinking - Session 5, Activity 5

…and throughout the curriculum in skill building activities


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Stories and Strategies Learning from real workshop experiences

Very stressed client - using redirection; managed

group dynamics (Jennifer)

Content can trigger some really strong things - “When I’m in pain, I want to be left alone” (Reva)


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Presenter

Presentation Notes

Jennifer’s observations of Susan Hunter

G R O U P B R A I N S T O R M

What workshop experiences have you had related to difficult

emotions?


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Presenter

Presentation Notes

Brainstorm solutions if interested in Problem Solving Help Show of hands - if anyone heard new solutions that they might find useful in the future?

Other Concerns

What other concerns around difficult emotions could arise in a session?

Who are your resources to turn to? Co-facilitator Program coordinator Mentor AZLW Institute Leader Manual Appendices ??


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Presenter

Presentation Notes

Brainstorm ways of handling situations from the list generated.

Workshop Safety

What safety issues could arise? Leaders need to manage group dynamics, e.g.

arguments, angry outbursts

???


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Suggestions -Tips

How to stay out of the way - emotional support

comes from the group Feeling competent and helping others reduces stress Be careful to not put someone on spot - careful to be

light-footed ???


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Presenter

Presentation Notes

Could be a brainstorm exercise

Dealing with the different types of people/situations in the CDSMP workshop

CDSMP Leader’s Manual, Types of People/Situations-People, Appendix III

The “Too Talkative” Person The “Silent” Person The “Yes, but….” Person The Non-participant The “Argumentative” Person The Angry or Hostile Person The Questioner The Know-It-All Person The Chatterbox The Crying Person


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Presenter

Presentation Notes

Types of People/Situations, Appendix III, Leader Manual

Dealing with the different types of people/situations in the CDSMP workshop

CDSMP Leader’s Manual, Types of People/Situations-People, Appendix III

(People - Continued) The Suicidal Person The Abusive Person The Superior Observer The Person Who Doesn’t Make Action Plans The Person in Crisis In-class Practices


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The Suicidal Person CDSMP Leader’s Manual, Types of People/Situations, Appendix III, pg. 6

Rarely, you may encounter someone who is very

depressed and is threatening to take his/her life or expresses severe hopelessness or despair.

The following suggestions may help: Remember your own limits and know in advance a crisis

intervention resource to which you can immediately refer the person


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The Suicidal Person CDSMP Leader’s Manual, Types of People/Situations, Appendix III, pg. 6

Suggestions continued: Talk to the person privately. One leader can accompany

the person out of the room, and urge him/her to get help. This leader may also provide the person with the names, phone numbers and/or addresses of some specific resources in the community that can help.

If the person refuses to call the crisis center, you can call the center yourself and get suggestions on how to handle the situation.

Ask the person to call or allow you to call a family member or friend to come get them and take them to the crisis center.


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Safety/Crisis/Harm Protocol

Take participants word’s seriously and respond with compassion referring them to the professional help they need

Agency crisis protocol?

Harm/Crisis Protocol

US National Suicide Prevention Line:

1-800-273-TALK (8255)

Facilitators do not serve in capacity of providing medical advice or other professional counseling - don’t second guess the care they get - do not offer any medical or clinical advice under any circumstances


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Success Stories

What Made a Difference! Healthy Living (CDSMP) Testimonial

Healthy Living Workshop After attending the workshop for 3 weeks, I started to believe I could get back to where I was a year ago. For 9 months I have lived the entire symptom cycle. I gave into my pain. I was on morphine IV for 5 days in late December, and from then until 2 weeks ago I took Percocet 4 times a day because of the pain.

After listening to everyone talk about their exercise routine I realized I had stopped doing any. We were serious hikers for 18 years, but my feet and knees have stopped me from walking. I started thinking about what I could do vs. what I can’t do. I have been doing the first 3 exercises in Chapter 7 and they are helping me. I have signed up for aqua Tai Chi class in late August and I’m also thinking about Curves.


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Success Continued …

I always told my children that when life deals you a bad hand you have 2 choices, deal with it and become stronger or feel sorry for yourself. Our late daughter used to say “But Mom, sometimes it is hard to be strong.” It’s time that I live by my own advice. I would not be happy if they took the second choice and I know they would not be happy with me, so I’m doing several things: 1. Getting off the pain medication by focusing on something else, I am

down to 1 at bedtime. 2.Doing things we enjoy doing. 3.Getting back into a social life by spending time with friends and family.

I know it is O.K. to grieve the recent loss of 2 of our children but I will no longer let that be an excuse for feeling sorry for myself. I know my arthritis, neuropathy, and lymphoma are not going away but I will not let my pain control me, I plan to control my pain. This workshop has helped me think about what’s important and not focus on my frustration, but rather accept and be happy for what I can do.


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Presenter

Presentation Notes

After reading, invite any other stories if time.

American Association for Geriatric Psychiatry www.aagpgpa.org

American Psychological Association www.apa.org

Depression and Bipolar Support Alliance www.dbsalliance.org

National Alliance on Mental Illness www.nami.org

National Institute of Mental Health www.nimh.nih.gov

National Library of Medicine Medline Plus www.medlineplus.org

Mental Health American www.nmha.gov

Helpful Resources


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http://www.aagpgpa.org

http://www.apa.org

http://www.dbsalliance.org

http://www.nami.org

http://www.nimh.nih.gov

http://www.medlineplus.org/

http://www.nmha.gov

National Suicide Prevention Lifeline 1-800-273-8255 (toll-free/24 hours a day) 1-800-799-4889 (TTY/toll-free) National Institute on Aging Information Center 1-800-222-2225 (toll free) 1-800-222-4225 (TTY/toll-free) www.nia.nih.gov www.nia.nih.gov/Espanol NIHSenior Health www.nihseniorhealth.gov A senior-friendly website from the National Institute on Aging and the National Library of Medicine. This website has health information for older adults. Special features make it simple to use. For example, you can click on a button to have the text read out loud or to Make it simple to use.

AgePage/Depression, National Institute on Aging/National Institutes of Health…U.S. Department of Health and Human

Services/May 2008…Reprinted November 2009/Page last updated Apr. 25, 2011

More Helpful Resources


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http://www.nia.nih.gov

http://www.nia.nih.gov/Espanol

http://www.nihseniorhealth.gov

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