PSYCHOTHERAPY

Psychotherapy involves individual or group meetings with a therapist trained to use various techniques to treat psychopathology. Psychiatrists, psychologists, nurses, social workers, and counselors can provide psychotherapy interventions to older adults with psychiatric disorders. Review of the literature suggests that psychotherapy is an effective treatment intervention, either alone or in conjunction with medication, for many psychological disorders in older adults.

Advanced age can be accompanied by bereavement, relationship conflicts (either marital or with adult children), or chronic or acute illness. Although such difficulties are more common among older adults than younger adults, the development of psychiatric symptoms as a response to life stress is never normal, and most older adults remain psychologically healthy in the face of difficult circumstances.

The normal aging process does provide challenges for therapists in adapting psychotherapy to older patients. Some types of cognitive function decrease in elderly persons, although the distribution of function is widely varied. Therapists may need to proceed through material at a slower pace, or in smaller units with more repetition. Memory aids, such as tape recordings of sessions, written notes, and reminders, can help patients recall information. Clearly defined goals and strategies, plus an agenda and structure for each session, are beneficial. Also, elderly patients are more likely to have loss in visual or auditory acuity or have coexisting medical problems, requiring adaptation of standard techniques.

Many elderly persons with medical problems take multiple medications, making it difficult for a psychiatrist to prescribe and manage additional medications. This makes psychotherapy an appealing option for older adults. Though research suggests the most promising treatment for late-life psychological disorders is combined medication and psychotherapy, psychotherapy alone is also an effective treatment option. Just as there is a myriad of medications for treating psychological disorders, psychotherapy options are quite varied as well, and depend upon structure, goals, and suitability to the problem of depression, anxiety, or dementia.

Depression

Antidepressants have traditionally been regarded as a primary treatment, yet psychotherapy has been shown by several studies to be at least equally effective in treating depression in elderly persons. Psychodynamic psychotherapy, life review and reminiscence therapy, interpersonal therapy, cognitive-behavioral therapy, and group therapy are commonly used treatments of late-life depression.

Psychodynamic therapy. This therapy is rooted in psychoanalytic theory, viewing current interpersonal and emotional experience as influenced by childhood experience. According to this theory, early childhood molds a complex inner world forged by unconscious and conscious mental processes. Relationships, such as that with one's mother, are internalized and create a sense of self. A life event, such as a loss, may initiate conflict within that inner world, and unresolved conflict manifests as depressive symptoms. In therapy, these conflicts are explored and resolved.

Life review and life reminiscence therapy. These therapies are also psychodynamically oriented. Life review revisits and resolves past conflicts and reintegrates life events through a review of life experiences. Reminiscence differs from life review by focusing on social intimacy and self-esteem through past experiences, instead of directly resolving past conflicts. The process includes autobiographies, visits to childhood locations, photographs, reunions, and scrapbooks.

Interpersonal psychotherapy (IPT). This time-limited outpatient therapy focuses on four problem areas of current interpersonal issues: interpersonal disputes, role transitions, interpersonal deficits, and abnormal grief. The therapist and client decide in which direction to focus. The immediate therapeutic objective is to alleviate depressive symptoms; however, the future goal is to improve social functioning and interpersonal relationships. Role-playing, communication analysis, clarification of wants and needs, and links between affect and environmental events are some of the techniques used. Suggested adaptations of IPT to elderly patients by clinicians include flexibility of session length, focusing on long-standing role disputes, and the need to help patients with practical problems. IPT has been proven to be as effective in treating elderly patients as specific medications, with longer-lasting effects when combined with antidepressant medication.

Cognitive-behavioral therapy (CBT). The cognitive model of depression is based on the idea that, due to early learning, depressed individuals develop stable, albeit distorted, cognitive schemas that predispose them to negatively interpret life events. CBT usually consists of three components: First, the patient is pressed to increase reinforcing activities and pleasurable experiences through behavioral activation. Then, automatic dysfunctional thoughts are exposed, challenged, and substituted with more accurate cognition. Finally, the cognitive schemas driving these automatic thoughts are explored and changed to accurately fit the patient's experiences. Behavioral activation and automatic-thought modification have been shown to be effective either individually or in conjunction with each other.

Social problem-solving therapy (PST) falls within the realm of cognitive and behavioral interventions and is anchored in a model in which ineffective coping skills under stress leads to deterioration of problem-solving abilities and subsequent depression. PST approaches involve recognizing and altering maladaptive attitudes linked to ineffective problem-solving while increasing motivation to generate alternative solutions, make decisions, and assess solution utility.

Group therapy. Group therapy consists of a group of patients meeting regularly with a therapist or therapist team that leads the discussion. Some group therapy emphasizes the teaching of coping skills or social skills, while other groups may focus on supportive and expressive resolution of individual difficulties in a group setting. Older patients may prefer group therapy because it can provide a social network of support, as well as decrease the cost of care.

Anxiety disorders

There are three central cognitive-behavioral techniques in the treatment of anxiety: relaxation training, cognitive restructuring, and exposure. Relaxation training consists of tension-relaxation exercises involving different muscle groups and adaptations of the progressive relaxation techniques of Bernstein and Berkovec. Cognitive restructuring involves identifying cognitions associated with fear and modifying them into alternative, less distressing cognitions, as well as teaching coping strategies. Patients are also required to monitor thoughts and practice strategies outside therapy sessions. Exposure helps to manage phobias and consists of gradual real-life exposure or imagined exposure to the phobic situation. For example, a person with a phobia of the dentist, will, gradually and with therapist support, look at pictures of dentists, be in an examination room with a dentist and patient, and then have dental work performed. The patient is thus safely exposed to her or his fear.

There is virtually no research on psychotherapeutic treatment effectiveness in elderly anxious patients. However, Sheikh and Cassidy recommend that treatment strategies can be based on the research with younger populations and modified for older patients. The literature has demonstrated effectiveness of CBT for different anxiety disorders in adults, including generalized anxiety disorder (GAD), panic disorder, phobias, and obsessive-compulsive disorder. CBT interventions have been found successful, either alone or with medication for all of these disorders. Also, research suggests that post-traumatic stress disorder (PTSD) can be chronic, continuing into old age from an earlier event. Snell and Padin-Rivera have reported that group psychotherapy is effective in treating elderly veterans with PTSD.

Dementia

Patients with dementia have worsening memory impairment in addition to compromised functioning in at least one other cognitive domain. Alzheimer's disease constitutes the most frequent cause of late-life dementia. Psychotherapy with clients with dementia is made difficult by the loss of language, which complicates communication between client and therapist. The relative success of psychotherapy correlates with the level of connection and communication achieved between the therapist and client. When that client suffers from dementia, the therapist's job becomes more challenging. Subtler subvocal and paralinguistic cues of communication must be utilized in an effort to avoid clinical detachment.

Considerable debate exists on the prospect of memory interventions and the proposed success for patients with Alzheimer's disease. However, techniques using environmental adaptations and external memory aids have been used to help patients with dementia. Reality orientation programs have implemented the use of signs, diaries, memory wallets, and recordings to help patients recall personal information. Cognitive stimulation programs have also been increasingly advocated. Validation therapy acknowledges the truth of feelings behind acting-out behaviors in an effort to decrease these behaviors.

Barriers to treatment

The present body of research in geropsychology supports psychotherapy as a treatment option for older persons with psychological disorders. However, several limitations curb its effectiveness. Older adults are less likely to report psychological problems and to seek help from mental health professionals or physicians than are younger adults. This may be due to social stigma associated with treatment for psychological problems. Psychological problems in elderly persons may also be underdiagnosed because they may pass off psychiatric symptoms as signs of physical illness. The responsibility for the diagnosis of psychiatric disorders in older adults is often left to primary care physicians, who have a limited amount of time with their patients. Also, mental health professionals with expertise in geriatric psychology are quite few, and therefore may not be available for referral.

Even when diagnosed, not all late-life psychological problems are treated adequately. Ageism still pervades American health policy and the minds of many health care providers. Research by Ford and Sbordone found that psychiatrists viewed elderly patients as less likely to respond to treatment than their younger counterparts. Only since 1989 has Medicare covered outpatient mental health care, and it still only covers 50 percent of the cost, compared with 80 percent coverage of physical health care costs.

Despite these barriers, there is convincing evidence that older adults respond as well to psychotherapy as do younger adults. It is important to begin to address the individual, physician, and policy barriers that prevent older adults with psychiatric disorders from receiving aggressive treatment.

Christine M. Vitt Autumn Edenfield Thomas R. Lynch

See also Anxiety; Cognitive-Behavioral Therapy; Dementia; Depression; Geriatric Psychiatry; Interpersonal Therapy; Life Review; Problem Solving Therapy; Psychological Assessment.

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