INTRODUCTION

This chapter provides information on what is known about the commonly used strategies for psychotherapeutic treatment for older people. Some of the symptoms of the mental disorders that affect older people, such as thoughts of hopelessness and negativity, the inability to enjoy pleasurable activities, anxiety and low energy levels, can be addressed with psychotherapeutic treatments alone. However, when other symptoms such as psychotic or suicidal thoughts, appetite and sleep disturbances are evident, a combination of psychotherapeutic and pharmacological treatments may be the best course of action. Psychotherapeutic treatments are important adjunctive therapies for older people, particularly when they are required to take many medications for serious medical conditions.

SPECIAL ISSUES CONCERNING OLDER PEOPLE

When entering a therapeutic relationship with an older person, it pays to be mindful of some characteristics the older person may bring into the relationship (see also Ch 11). With the ageing process comes more physical and perhaps cognitive problems against a backdrop of vast and different life experiences. Even with a lifetime of knowledge and experience, some older people just accept whatever therapy is offered or directed at them without a thorough understanding or enthusiasm for that option. A more prudent strategy to improve engagement and hopefully achieve success with the therapy would be to present all options, including information about the pace, format and purpose, allowing the person to choose and give support for that choice. If the person has had therapy previously, it would be worthwhile to revisit any successful approaches, but older people are quite capable of learning new approaches.

Working with older people requires knowledge of what has defined their generation (e.g. wars, economic crises, dominant religions and social practices). Many older Australians experienced as children the effects of the 1930s depression and World War II, and as adults the effects of the Vietnam War and major technological advances. Social practices and beliefs of always being stoic and that personal problems or mental illness are signs of weakness and failure pervade this generation. Personal problems are often not discussed at all, or only within the family, and certainly not with strangers or therapists whose intentions may be deemed akin to brainwashing. Ageist attitudes dictate that it is normal for older people to be unhappy, cranky and inflexible to change. Normal boundaries (see Ch 11) that are set up with younger clients in regard to such issues as physical contact and acceptance of gifts may have to be rethought with some older clients (e.g. when expressing gratitude, the older person may find it insulting if you do not accept an embrace or an offer of a cup of tea). In rural areas, the mental health workers often leave older people’s houses with plant cuttings and bottles of homemade condiments. So it is a good idea to have a formal policy in place on how to deal with such circumstances.

If the therapist is younger, having credibility when the older person sees themselves as older and wiser may be an issue. This should be identified and acknowledged early in the relationship because it may interfere with continued engagement and the success of the therapy. The therapist needs to take the initiative and directly ask the older person what opinions they may hold that make it difficult for them to talk openly and easily with the therapist, and they need to establish a set of engagement rules to overcome any difficulties.

The mental health worker needs to inquire about the presence and impact of common ageing concerns, including poorer physical health, limited financial capacity, less independence, diminishing social supports, and loss of significant others and meaningful employment. Loss is a very challenging aspect of the therapeutic process in the sense that the many losses that older people experience are generally more major than what a younger person may experience, such as the loss of a lifelong partner or career. From this, the challenge for the mental health worker is to determine what a realistic level of grief reaction for the older person to these losses would be.

To overcome the barriers such as cognitive, medical and functional disabilities, the therapist may need to adjust the pace and length of the therapy sessions and where and how the therapy is delivered. For example, the content needs to match the person’s educational level, and concepts may need repeating verbally and visually with the use of a whiteboard and handouts. What the older person brings into the therapeutic relationship should be capitalised upon, such as many life experiences and accomplishments that have required a range of interactions, decisions to be made and problems to be solved. Finally, when the relationship reaches the termination phase, this can be done by gradually spacing the sessions out with occasional follow-up sessions to maintain what has been achieved and prevent relapse.

Psychotherapeutic treatments can be delivered via individual or group formats. The group format may be more economical and is particularly useful for older people who have a limited social network. In a review conducted by Pinquart et al (2007), the individual format came out slightly ahead of the group format, with it being more efficacious and experiencing less dropout rates.

COGNITIVE BEHAVIOUR THERAPY

Cognitive behaviour therapy (CBT) has been shown to be successful in treating a wide variety of disorders that affect older people, such as depression, anxiety, panic attacks and sleep disturbance (Hill & Brettle 2006, Knight 2004, Laidlaw et al 2003, Pinquart et al 2007, Wilson et al 2009). The basic premise of CBT is determining how the older person perceives themselves and how they judge the effect certain experiences have had on their lives. The CBT therapist questions and challenges strongly held beliefs that may be reinforcing negative self-concepts. Through the therapeutic process, the older person is made aware of how they distort and misinterpret certain events in their lives, and then positive thoughts and behaviours are activated by altering these erroneous thought patterns. The therapy is usually time limited to 10 or so sessions. CBT is effective in the acute phase of treatment and also in the longer term by helping reduce the risk of recurrence. The usual protocols for CBT are behavioural strategies drawn from Lewinsohn’s (1974) operant model and cognitive strategies from Beck et al’s (1979) cognitive model.

Initially, to get a clear picture of what may be distressing the older person, baseline information is gathered about the situation(s) in which the symptoms occur, accompanying thoughts, the physiological response and behaviour patterns. An example would be:

This information is obtained through direct questioning (e.g. ‘What was happening when the panic attacks started?’), standardised self-report scales and a self-monitoring log of symptoms relating to feelings of sadness and/or anxiety. As well as this information, it is important to identify what activities have a positive influence of giving pleasure or a sense of achievement, and what barriers exist and ways to overcome these. Goals can be set to increase these activities.

Following the identification of thoughts, physical symptoms and behaviour pattern, how these factors interact with each other is examined. Next, a suitable intervention strategy is chosen from a range of CBT techniques. Some techniques work well with some problems and not with others. There may be some trial and error in these initial stages. A daily log is an integral part of the treatment process. It brings objective awareness of the symptoms the person is experiencing and how the treatment is progressing. The older person logs what the troubling situation is and the concurrent thoughts, physical symptoms and behaviour. This record then enables the therapist and the older person to identify the antecedents and consequences, as well as the effect of any intervention strategy. Physical responses such as rapid breathing, sweating and increased heart rate are easy to identify. Simple strategies such as breathing techniques, progressive muscle relaxation and antianxiety medications are effective in countering adverse physical responses.

With CBT, erroneous thoughts are challenged and the older person is taught how to reframe these thoughts as hypotheses so that their thinking processes are trained to be more rational. This is done by identifying the troubling thought, assembling the evidence that supports and does not support this thought, using skills to challenge the erroneous thoughts and developing alternative ways of thinking. Examples of questions would be: ‘How do you know that your family thinks you are a burden?’ and ‘Does a person’s age mean they have to behave in a certain manner?’ The responses to the reframed questions can then be converted into simple, coping statements that are reflective of a more realistic situation, such as: ‘My family is an important part of my support network. I do not know if I am a burden to them.’ Realistic statements help to reduce anxious or depressive feelings. Brief, affirmative statements can be used by the person when they feel the onset of anxious or depressive feelings.

BEHAVIOUR THERAPY

Behaviour therapy (BT) that is suitable for older people includes techniques such as relaxation and exposure therapy, including systematic desensitisation (see Ch 23). It is effective generally with disorders such as depression and anxiety and dealing with specific symptoms such as insomnia (Engels & Vermey 1997).

BT has the goal of changing or positively influencing behaviour that is contributing negatively to the disorder. For example, a disorder such as depression can be almost self-perpetuating by negative behaviours reinforcing each other. A clinical feature of depression is loss of pleasure in previously enjoyed social activities. In this situation, the older person may not be inclined to participate in social activities, thereby decreasing such positive benefits of interpersonal relationships and physical exercise. The lack of both of these activities exacerbates the depressive illness. This behaviour can become so ingrained that it is difficult to change and the older person will require much direction and support to break the destructive cycle. The direction may be as specific as identifying pleasurable events, scheduling them and going with the older person so that their thoughts and perceptions during the experience can be explored and adapted. In addition to improving interpersonal skills and increasing physical activity, BT can be used to enhance activities of daily living and to manage incontinence. It can also be used to help manage problems related to the behavioural symptoms of dementia such as wandering and agitation.

A major task of BT is detailed and ongoing recording of observations of the behaviour, in particular:

Related posts:

Consumers and carers Clinical cognitive assessment Functional assessment Community management of acutely ill older people Palliative and end-of-life care Management of behaviour in dementia

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