This document provides an overview of cognitive behavioral therapy (CBT) techniques for treating depression in older adults. It discusses the foundations of CBT including the importance of the therapeutic relationship and collaborative approach. It explains the CBT triangle model relating thoughts, feelings and behaviors. Several common types of inaccurate thinking are outlined. Methods are described for helping clients identify inaccurate thoughts and replace them with more balanced perspectives using tools like thought records. Strategies like behavioral activation are presented for shifting out of downward spirals and maintaining wellness.

1. Cognitive Behavior Therapy
for Depression
in Older Adults"

2. Getting to know
each other"
• Me background, biases, philosophy, etc."
• You current role, knowledge/use of CBT"
Lynn Northrop, PhD

3. Foundations of CBT
a quick intro/review"
Lynn Northrop, PhD

4. Foundations of CBT
"
• Therapeutic relationship is essential
(empathic, genuine, trustworthy, expert) "
• Collaborative (explicit rationales, shared goals,
assignments, psychoeducation, empowerment and self-
"
responsibility, project-based learning)
• Requires belief in change – a few words on
neuroplasticity and habits of thought and action"
• Relation between thoughts, feelings, and
behaviors (next slide)
Lynn Northrop, PhD

5. CBT Triangle is power"
used in"
Distinguish thoughts 1. assessment and
and feelings" treatment planning"
Thoughts"
2. patient education"
3. intervention"
Behaviors"
Feelings"
Understanding healthy and Feelings are not
unhealthy choices" changed directly"
" Lynn Northrop, PhD

6. Foundations of CBT
"
• Importance of self observation, self
monitoring, self awareness*"
• Treatment plan targets observable change
symptom reduction and functional improvement – why?"
• Emphasis on goals – realistic, specific,
measurable, flexible, meaningful* "
• Past explored as a context, not a major
focus of treatment – are memories in the past or
the present?"
Lynn Northrop, PhD *(handouts)"

7. Foundations of CBT"
• Situations by themselves do not
cause depression (see example)"
Lynn Northrop, PhD

8. Situations by themselves do not
cause depression… example"
Alice and Georgia lived in the same
Board and Care."
"
Alice was depressed. Georgia was not."
"
Both 85 y.o., retired, widowed, chronic
pain, MMP, used walkers, visual
impairment, adult children lived out of
state, low SES, previous history of
depression"
Lynn Northrop, PhD
"

9. Georgia was clinically depressed."
ü Depressed/irritable/anxious/hopeless mood"
ü Anhedonic"
ü Isolative"
ü Dropped many activities (self care, hobbies, social)"
ü Disturbed sleep (sleepy in day, awake at night)"
ü Low energy"
ü Diminished appetite and weight loss"
ü Diminished self worth"
ü Trouble concentrating and making decisions"
ü Increased morbid thoughts"
ü Thoughts of others deaths, Wish to die"
"
Alice, in similar situation was not depressed."
Lynn Northrop, PhD

10. If situations do not cause depression,
than what does?
Lynn Northrop, PhD

11. When Georgia was depressed..."
All-or-nothing thinking"
mind reading "
Focused on losses, negatives, morbid thougts"
Past and future focused"
Unrealistic expectations of self and others"
Self-focused attention - ruminating"
"
Passive"
Inactive" Sad, hopeless, "
Isolative" helpless, worthless, anhedonic"
Skipping meals" frightened by her own "
Did not ask for help" negative emotions"
• Change one and you change them all
• Goal = accurate thought and adaptive behavior
Lynn Northrop, PhD

12. When Georgia was well..."
Seeing the grey in many situations"
Not jumping to conclusions as often, checks it out "
More balanced focus on strengths, blessings AND losses"
Mindful and mostly present focused"
More realistic expectations of self and others"
Self and other focused attention"
"
Assertive" Able to tolerate negative emotions"
active" More good days than bad"
engaged" Hopeful"
ask for help" More self confident"
Improved self-esteem"
Lynn Northrop, PhD

13. • Identify and change inaccurate thoughts"
Interventions • Reduce ruminative thought"
are flexible • Learn to worry constructively"
• Increase/improve Problems solving"
and tailored • Cognitive Diffusion"
to the •
Thoughts! Self-awareness and cognitive self control"
• Acceptance"
presenting
problems"
Behaviors! Feelings!
• Behavioral activation (APES)" • Understanding one s own
• Social Support Skills" emotions and their relations to
• Assertive Communication Skills" thoughts and behaviors"
• Relaxation training" • Emotions are genuine – not
• Understanding the function of Bx" right or wrong"
• Stages of behavior change" • Situations do not cause feelings"
Lynn Northrop, PhD

14. Methods and Tools of CBT
"
Thoughts"
Behaviors" Feelings"
Lynn Northrop, PhD

15. Common inaccurate thinking
Jumping to Conclusions: Making judgments or inferences before you know
all the information."
"
Mind reading: Believing someone has an opinion of "
you or is making judgments about you without checking it out."
"
Fortune Telling: Assuming that you know what the outcome of a situation
will be. Generally involves predicting that things will turn out badly."
"
Catastrophizing: Expecting the WORST to happen or believing "
that anything bad is TERRIBLE. Using catastrophic language "
to describe things that are not. Hyperbole. "
"
Negative Filtering: Focusing on the negative aspects of something or
someone. Spending unhealthy amount of time thinking about or talking
about negative traits of self, others, or situations. Excessive
complaining. "
"
Lynn Northrop, PhD

16. Common inaccurate thinking
"
Minimizing the Positive: Little time is spent considering the positive aspects of self,
others, or situations. When accurate positives are presented, they may be
considered unimportant or invalid. "
"
Should statements: Very strict or rigid rules for self or others. Strict rules that work
against self-acceptance and accepting others. Often results in guilt, anger, and/or
resentment."
"
Self Blame: You see yourself as the total cause of something "
bad happening when in fact you had nothing or little to do with it."
"
Black and White (or All-or-nothing) thinking: These thoughts usually use a language
of extremes (always, never, totally, forever, completely). Tendency to categorize
things into extreme categories."
"
Overgeneralization: drawing big conclusions from small "
amounts of information"
"
Labeling: Name calling or globally applying a single (usually critical) term to an
individual or situation. "
"
Lynn Northrop, PhD
"

17. Common inaccurate thinking
Emotional Reasoning: Making decisions based on feelings rather than fact.
Assuming your feelings always match or reflect whats happening right now."
"
Personalization: Thinking that things people do or say is a reaction to you. "
You also compare yourself to others (e.g. attractiveness, clothes, smarter, etc.)"
"
Control Fallacy: You believe you are responsible for the distress and "
happiness of others. Also, if you feel externally controlled you see "
yourself as a helpless victim. "
"
Fallacy of Change: You expect that other people will change to suit you if you
pressure or cajole them enough. Your hopes for happiness seem to depend on
others changing."
"
Being Right: You believe that you are on trial to prove that "
your opinions and actions are right. Being wrong is unacceptable "
and you will go to great lengths to prove or demonstrate that you are right."
"
Heaven s Reward Fallacy: You expect that your sacrifice and self-denial will pay off
as if there were someone keeping score. You feel bitter when the reward does
not come. You may tend to be a martyr.
Lynn Northrop, PhD

18. Internalized myths, stereotypes and biases
Depression is a normal Contributes to hopelessness and reluctance to fully engage in
part of aging. treatment.
Refuse treatment.
Can t fix it ditto
Depressed=weak If I ask for help, others will see me as weak.
If I need help I am weak.
I depressed therefore I am weak.
Reluctance to fully engage in tx.
Generalized loss of self-efficacy.
Shame
Depressed=crazy I shouldn t tell people I am depressed.
Other people think I am crazy/flawed.
Fear of discrimination or Avoid asking for help.
critical judgment Reluctant to self disclose.
Defensive, aggressive, suspicious
We should save resources I am worth less.
for the young Martyrdom
Older adults/old age are Avoid other seniors. Lynn Northrop, PhD
scary, icky, downers Self-loathing
Minimize problems (so as not to be perceived as old)

19. Inaccurate thinking
• More common in depression, anxiety,
paranoia, passivity, anger control
problems, etc.
• Becomes automatic or habitual
• Change requires education, effort, and
repetition
• Avoiding thoughts causes problems (Erlene)
Lynn Northrop, PhD

20. Thought Record (side 1)
Situation (who, what, where, when):
Thoughts:
Behaviors: Feelings:
Lynn Northrop, PhD

21. Thought Record (side 2)"
Situation (who, what, where, when):
Thoughts: What are accurate, healthy and adaptive thoughts in
this situation?
Behaviors: What are healthy and Feelings: What are your preferred
adaptive behaviors in this (and realistic) feelings in this
situation? situation?
Lynn Northrop, PhD

22. Name That Distortion*
Identify and name the common inaccurate thinking in each of the
following scenarios. Underline any key words that point to a distortion.
Scenario:
Betty is about to go to her first day of volunteering
at the local art museum. She feels anxious and
self-conscious. She thinks, I m going to make a
total fool out of myself. I cannot remember one
single thing I learned at the volunteer training.
Maybe I should just quit and let someone younger
do this.
*see handout
Lynn Northrop, PhD

23. Name That Distortion
Scenario:
Eddy wakes up and discovers that his new
roommate has gone to work and left his
breakfast dishes unwashed in the sink. Eddy
feels offended and angry. He thinks, He
has seen how neat I keep my side of the
room. He should be more considerate. He
obviously doesn t care to make a good
impression. He couldn t care less about me.
If he doesn t change, I m going to
explode! Lynn Northrop, PhD

24. Clinical example
Helping the client use the triangle.
Volunteer?
Lynn Northrop, PhD

25. Strategies to increase accurate thinking
• What are the alternative explanations?
• Look at the evidence for and against your conclusion.
• Check it out. Clarify with the person what they were thinking.
• Substitute catastrophic language such as terrible and horrible with
more accurate language such as it is inconvenient. What are the odds?
Make an honest and realistic assessment of the situation in terms of odds
and percentages. What is the worst thing that could happen? Could I live
with that? What is the best thing that could happen? What is the most
likely?
• Make a list of positives that apply to the person or situation. If need be, ask
someone else to help you come up with positives. Refer to this list when
you catch yourself complaining or minimizing positive. Is there something
you can do to improve the situation? Consider problem solving or assertive
communication.
• Substitute it would be nice or I would like statements for should,
must, and have to statements for both yourself and others. Think about
the rules you apply to yourself and others. Are there ways you can make
them more flexible? Lynn Northrop, PhD

26. Strategies to increase accurate thinking
• Use percentages and pie charts to allocate realistic responsibility. How
much are you responsible for and how much are others responsible
for?
• What would it mean if the thought were true?
• There are no absolutes. Look for the grey. Think in percentages.
• Look for evidence to support the more balanced view.
• Say I m not going to draw a general conclusion from this one
situation. Be specific and quantify what it is you are referring to.
• Instead of using global labels, use specific and quantifiable language
such as I made a mistake instead of I m a stupid idiot.
• Feeling is not fact.
• How much is in your control and how much is in the control of others?
• Serenity Prayer
Lynn Northrop, PhD

27. Acceptance of inaccurate thoughts
Goal is not always to make thoughts go
away
• Sometimes unrealistic (memories, triggers, habits)
• The struggle can be more harmful than the
thought
Acknowledge and objectify thought and
recognize that you can carry it with you.
Lynn Northrop, PhD

28. Foundations of CBT
"
Thoughts"
Behaviors" Feelings"
Lynn Northrop, PhD

29. Downward Spiral"
Feel Bad" Feel Even
" Better"
" "
Do Less" Do More "
" "
" "
Feel Worse " Feel a Little
" Better"
" "
Do Even Do
Less" Something "
Lynn Northrop, PhD

30. Pleasant Events Model: Depression occurs when
the stressful, negative, unpleasant aspects (and
views) of life out weigh the pleasant, positive
aspects of life.
Negative
events"
Wellness = balance"
What are 3 ways to shift the balance?!
Lynn Northrop, PhD

31. Daily APES*
• Accomplishment
• Pleasure
• Exercise
• Socialization
Lynn Northrop, PhD *handout, next 3 slides

32. o Listen to favorite music o Enjoy a relaxing nap
o Enjoy a long, warm bubble bath o Visit a museum or art gallery
o Go for a walk o Practice yoga
o Share a hug with a loved one o Relax in a whirlpool or sauna
o Relax outside o Enjoy a cool, refreshing glass of water
o Physical activity (of my choice) o Count my blessings, I am thankful
for…
o Say or read a spiritual prayer o Enjoy the beauty of nature
o Attend a caring support group o Play as I did as a child
o Practice deep breathing o Star gaze
o Do stretching exercises o Cloud gaze
o Reflect on positive qualities I am… o Window shop
o Laugh o Daydream
o Write my thoughts and feelings in o Tell myself the loving words I want to
personal journal hear from others
o Concentrate on a relaxing scene o Tell someone what you appreciate
about them.
Lynn Northrop, PhD

33. o Create a collage representing the real o Go paddle boating or watch others
me paddle boating
o Receive a massage o Buy myself a gift I can afford
o Give someone a massage o Create with clay or pottery
o Reflect on I appreciate… o Play cards – solitaire or other
o Watch the sunrise or sunset o Practice positive affirmations
o Attend an athletic event o Pet an animal
o Do something adventurous o Watch my favorite TV show
o Read a special book or magazine o Reflect of my strengths or successes
o Sing, hum, whistle a happy tune o Write a poem
o Go dancing o Read a poem
o Play a musical instrument o Make a bouquet of flowers
o Meditate o Have a cup of tea
o Garden and work with plants o Make something nice for myself or
someone else
o Learn a new skill o Visit a park, woods, forest
o See a special play, movie or concert o Call an old friend and tell them what you
like about them
Lynn Northrop, PhD

34. o Work out with weights or small hand o Go on a picnic
weights
o Make myself a nutritious meal o Practice relaxation exercise
o Draw or paint a picture o Hold a sleeping baby
o Swim and relax at the beach or pool o Take a class or attend a lecture
o Do aerobic activity to fun music o Practice the art of forgiveness
o Visit a special place I enjoy o Treat myself to a nutritious meal or
snack at a local restaurant or coffee shop
o Take time to smell the flowers o Enjoy my favorite hobby
o Sit in front of a fireplace and watch the o Walk in the rain or watch the rain
fire
o Read a cartoon or joke book o Feed the birds
o Reflect on My most enjoyable o Listen to bird song
memories
o Look at old photos o Create my own list of self nurturing
activities
Lynn Northrop, PhD

35. Creating Your Top Ten List of
Pleasurable Activities
• Deciding whether an activity makes the Top Ten:"
• Is it realistic? "
– A trip around the world may not be realistic. However, a day-trip, a
travel video, a lecture about a foreign culture, looking through photos
from a previous trip, or planning a small trip for the future may be
realistic. "
• Is it pleasurable?"
– Sometimes we are inclined to fill our Top Ten List with have to
activities (clean the kitchen, pay the bills, etc.) Although you may
experience relief when you accomplish a necessary task, that s not
enough to qualify for the Top Ten. You are looking for activities that are
intrinsically pleasurable (or have been in the past). "
• Is there room to do more?"
– At least some of the items on your Top Ten List should be activities that
you could do more often than you are. (high pleasure, low frequency)"
Lynn Northrop, PhD

36. APES Top Ten List" Day:" Day:" Day:" Day:" Day:" Day:" Day:"
Date:" Date:" Date:" Date:" Date:" Date:" Date:"
Lynn Northrop, PhD

37. Lynn Northrop, PhD
Barriers to Daily APES"
Low motivation, Limited interest"
Not feeling well physically"
Not feeling well emotionally (e.g. depressed, anxious, upset)"
Pain"
Low energy"
Really can t do what I used to do / used to like to do (e.g., fishing)"
Negative/distorted self-talk"
Transportation problem"
Scheduling Conflict"
Too little time"
Not enough $$"
Weather (e.g., rain, heat, sun)"
Can t think of anything to do (81 ideas for self nurturing)"
Nobody to do anything with."
Physical mobility problem (e.g., trouble walking)"

38. Social Support
Education regarding sources and types of support
emotional, informational, tangible, companionship,
motivational, spiritual, reciprocal
Where does the problem lie?
expanding network, eliciting support, maintaining support
Setting specific support goals
join club, tell husband how he can help, say thank you
Thoughts that get in the way of support (handout)
Conjoint session – educating family, helping pt negotiate
support, assessing caregiver burden, gathering data so
you can help pt set realistic goals
Lynn Northrop, PhD

39. • Identify and change inaccurate thoughts"
Interventions • Reduce ruminative thought"
are flexible • Learn to worry constructively"
• Increase/improve Problems solving"
and tailored • Cognitive Diffusion"
to the Thoughts! • Self-awareness and cognitive self control"
• Acceptance"
presenting
problems"
Behaviors! Feelings!
• Behavioral activation (APES)"
• Understanding one s own
• Social Support Skills" emotions and their relations to
• Assertive Communication Skills" thoughts and behaviors"
• Relaxation training" • Emotions are genuine – not
• Understanding the function of Bx" right or wrong"
• Stages of behavior change" • Situations do not cause feelings"
Lynn Northrop, PhD

40. Challenges in treating older adults?"
• Sensory deficits"
• Cognitive changes"
• Fatigue"
• Physical frailty or disability"
• Co-morbid medical "
• Transportation limitations"
• Internalized stigma"
Lynn Northrop, PhD

41. How is CBT modified for use with
older adults?"
• Same theoretical model, many of the
same techniques"
• Pace of treatment"
• Multimodal presentation of information"
• Repetition"
• Accommodate for Sensory deficits
(amplifier, large print)"
• Accommodate Memory difficulties"
Lynn Northrop, PhD

42. How is CBT modified for use with
older adults?"
• Sometimes more directive approach"
• I am a consultant, teacher, this is a class,
they are learners"
• More family involvement - sometimes"
• Scheduling considerations"
• Physical environment (lighting, chairs,
accessibility)"
Lynn Northrop, PhD

43. Questions or comments?
Please feel free to contact me.
Lynn Northrop, PhD
lynn.northrop@gmail.com
Lynn Northrop, PhD