Psychotherapy With The Elderly

Marilyn Bonjean, Ed.D.

ICF Consultants, Inc. 1524 N. Farwell Ave.

Milwaukee, WI. 53202 (414) 273-2220

www. ICFConsultants.com/programs

Demographics of Aging

Silver Tsunami

• In 2010 – 40 million over 65 -13% of total

• Baby Boomers started turning 65 in 2011

• Projected growth to 72 million or nearly 20% of US population by 2030

• Over 85 will grow rapidly after 2030 from 5.5million to 19 million by 2050

US Census Bureau 2010 summary file 1

Projected Population Distribution

Family Structure

Implications

• More older clients

• Problems and rewards of longevity

• Issues of multigenerational family

• Increased ethnic and racial diversity

Elder Developmental Tasks

• Life review – making sense of success & failure

• Accepting losses of role, decline and death

• Sharing wisdom with family, community & society

• Leaving a legacy as a mark of having lived

Family Developmental Tasks

• Grieving losses of elder’s role & functioning

• Maintaining family integrity during changes in form and function

• Coping with physical and emotional demands of care giving

• Managing resources such as assets, time, energy and human labor

Family Developmental Tasks

• Supporting individual growth and development while facing competing demands

• Providing increasing and continual emotional and physical support to elderly family members and others in the family

Is Psychotherapy with Elders Different?

• Yes and No

• Assessment is very important and requires more specialized knowledge and skills

• Treatment less specialized in terms of theoretical framework

• Issues may require more special knowledge

• Case management may be needed

Assessment

• Strengths review – competence & self-esteem

• Complex interacting variables –somatic, cognitive, affective and behavioral

• Ageism influences the experience of everyone including the elder, family, relational community, society and the therapist

• Stereotypes of aging resemble psychological problems

• Cohort effect – values and life experience

Assessment

• Social and environmental context – retirement community, nursing home

• Prevalence of medical disorders and their influence

• Medication /side effects

• Cognitive functioning screen

• Risk assessment

Lifetime prevalence of mood & other disorders

• Aging is not associated with increased rates of depression or anxiety

• Resilience is the norm

• Subjective well-being relatively high despite illness or limitations

• Meaningful activities, intimacy & sexual functioning

Depression

Depression

• Late life depression even at subclinical level is a concern due to the cascade of symptoms and consequences that can occur

• Physical health, safety and community living can be at risk

Depression

• DSM-IV criteria:

• Depression and/or anhedonia

• Cognitive symptoms: worthlessness, guilt, suicidal ideation, poor concentration, difficulty making decisions

• Physical symptoms: changes in sleep, energy and/or appetite

• Functional Impairment *Duration of 2 weeks

Depressive Symptoms in older adults

• Somatization: pain, nausea, headaches

• Alexithymia: less likely to endorse depressed mood or use psychological language

• Cognitive impairment

• Subtle psychotic symptoms, e.g. delusional guilt

Risk Factors for Depression

• Gender: women>men

• History of depression – individual & family

• Medical problems & medications

• Chronic pain, sensory changes, sleep problems

• Excessive alcohol use

• Loss of social supports

• Psychosocial stressors

Dementia and Depression

• Initial evaluation of dementia should include a screen for depression

• Personal history or family history of mood disorders

• Symptoms of depression: guilt, hopelessness, worthlessness, suicidal ideation

• Functional impairments not proportionate to cognitive symptoms

Suicide & Elders

• Account for 12% of population and 16% of suicides

• Highest suicide rate – white males > 85 yrs. old

• Attempts more often successful

• More planning and resolve

• Fewer warnings to others

• Less physical resilience

• Violent & potentially deadly means (firearms) CDCWISQARS accessed 4/13

Ethnicity, Gender & Suicide

Suicidal Ideation

Minor Depression

Comorbidity of Depression & Medical Conditions

Treatment

General Goals of Treatment

Confidence

&

Competence

Challenges to Treatment

• Long history of roles and coping behaviors within individual and family and with the larger community

• Presence of several interacting systems – multigenerational family, medical providers and community agencies

• Differences in generational, blended family and cultural expectations and customs

Challenges to Treatment

• Dire consequences of unsolved issues – cascade of symptoms can lead to rapid decline, excess disability, institutional placement and even death

Treatment for Depression

• Psychotherapy

• Medication

• ECT

Psychotherapy Research

• Majority of research focused on depression

• The consensus of the research findings is that late life major depression can be treated with psychotherapy and gains can be maintained

• Findings also support the acceptance of therapy by older adults

Psychotherapy Research

• Two types of psychotherapy have the most empiric support and are considered evidenced-based practice

• CBT -cognitive behavioral therapy

• IPT - interpersonal therapy

Psychotherapy Research

• CBT – is based on learning theory of personality and focuses on teaching new skills to cope with depression and psychosocial problems

– Lauderdale, K. & Sorocco, S. Cognitive Behavioral Therapy with Older Adults, Springer Publishing Co., 2011

Psychotherapy Research

• IPT – interpersonal therapy focuses primarily on resolution of interpersonal problems and processes through exploration of affect

• Hinrichsen,G. Clougherty,K Interpersonal Psychotherapy for Depressed Older Adults, APA, 2006

Psychotherapy Research

• Common features of these approaches

• offer structure to address symptoms

• set clear and measureable goals

• give homework to extend therapy

• are time limited

• successfully address late life depression

Practice Skills

• Collaboration – use body rhythm, restatement and correction and empathy to be perceived as not so different from the client and therefore less threatening

• Pacing – control the amount of material processed, type of material disclosed, fatigue of client an intensity of interaction

Practice Skills

• Review the session format to make interaction predictable

• Check on client’s reaction more often to increase understanding of verbal and nonverbal material

• Be sure that client can hear and see well and has time to respond

• Over-all allow more time

Practice Skills

• Clarify the client goals for the session

• Clarify the professional’s goals for the session

• Clarify the inclusion of family members and their goals

• Address the elder first and then other family members

Practice Skills

• Maintain attunement

• Repair ruptures in relationship

• Monitor for response to intensity in session hyper-arousal - fight or flight hypo-arousal - freeze or submit

• Maintain therapeutic window of arousal

Practice Skills

• Interpret body signals as safe and somatic sensations

• Observe rather than use old reaction patterns

• Try new responses

• Build new resilience

• Make healthy boundaries and have useful defensive reactions