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Block 4 Unit 3 Psychotherapy with Older Adults

1) Discuss psychotherapy in regard to older persons. Give a background of the old persons.  Discuss the various therapeutic approaches in therapy with older persons?

Psychotherapy for older persons has historically been undervalued in both old age psychiatry and psychotherapy, due to ageism and the dominance of models of psychological development that focus on childhood and younger adults. Negative stereotypes about the treatability of older people have also hindered the development of expertise and services in this area. However, many therapists have successfully applied various psychotherapies to older people.

• Background: Older people have a wide diversity of life experiences, and have matured in a world of rapid change. They are also more likely to have chronic medical conditions, functional impairments, and experience losses.
• Therapeutic Approaches: Various therapeutic approaches have been applied to older adults, including:
  • Cognitive Behavioural Therapy (CBT): This is the most frequently used therapy with older people, and has been shown to be effective for depression, anxiety, and problematic behaviours in the context of dementia.
  • Cognitive Analytic Therapy (CAT): This integrates analytic (object relations theory) and cognitive psychotherapy, and is used to provide a collaborative therapeutic journey from past trauma to present dialogue and meaning.
  • Psychodynamic Therapy: This approach focuses on developing insight into repressed unconscious material from earlier life experiences and working through this in the therapeutic relationship.
  • Interpersonal Therapy (IPT): This is a focused, brief, manual-based therapy that can be applied by a range of professionals after basic training. It focuses on disturbances in relationships.
  • Systemic (Family) Therapy: This approach looks at individuals within the context of their wider family and social system.
  • Reminiscence/Life Review Therapy: This involves recalling past events to increase self-esteem and social connection, or to rework past conflicts.

2) What is Cognitive Behavioural Therapy (CBT)?

Cognitive Behavioural Therapy (CBT) is a form of psychotherapy that focuses on identifying negative thoughts and their reinforcing behaviours. It aims to challenge unhelpful thinking, reduce negative and avoidant behaviours, and introduce positive patterns of behaviour.

• CBT techniques involve assessing the evidence behind negative thoughts, identifying 'thinking errors', evaluating the pragmatic effects of negative thoughts, and considering alternative viewpoints.
• The intensity of negative thoughts can be rated and monitored through treatment.
• Avoidant behaviours are addressed using a graded exposure model.
• CBT offers a structured, collaborative, brief, and client-centred approach.
• CBT has been shown to be effective with older adults in the treatment of depression, anxiety and problematic behaviours in the context of dementia.

3) Discuss cognitive analytic therapy and bring out the difference between cognitive behaviour and cognitive analytic therapies.

Cognitive Analytic Therapy (CAT) is an integrative approach that combines elements of analytic theory and cognitive psychotherapy. It is a brief, structured and collaborative approach which focuses on shared meaning, and the client's life story. CAT aims to link past and present by emphasising dialogue as a way of working.

• Differences between CBT and CAT:
  • CBT focuses on specific, concrete symptoms and directly challenges negative thoughts and behaviours.
  • CAT integrates object relations theory with cognitive approaches, aiming for a more comprehensive understanding of the patient's life narrative. CAT emphasizes the shared meaning of the client's life story, using dialogue and creating a narrative to link the past and present..
  • CAT tends to be more focused on the therapeutic relationship and how past patterns emerge in the present.

4) Define and describe psychodynamic therapy.

Psychodynamic therapy is an insight-oriented approach that focuses on unconscious emotions that manifest in behaviour.

• It stems from the work of Freud, Klein, and Jung.
• It is based on a highly developed and multifaceted theory of human development and interaction.
• It centers on the development of insight into repressed unconscious material from earlier life experiences, and on the working through of this material in the therapeutic relationship.
• In the treatment of couples, psychodynamic therapy works to identify emotions that manifest in behaviour, with a focus on the unique situation of each individual client, and takes into account how past relationship experiences affect current relationships.
• Psychodynamic theory has been applied to later life with emphasis on 'the third age' as each person struggles with their developmental task and related concerns about isolation, arrogance, and creativity.

5) Discuss interpersonal therapy and how is it applicable in the adults group.

Interpersonal Therapy (IPT) is a focused and brief therapy that addresses disturbances in relationships. IPT is based on the idea that mood changes relate to environmental events, and their effect on social roles.

• IPT categorizes disturbances into four domains: role transition, role dispute, abnormal grief, and interpersonal deficit.
• IPT interventions aim to improve communication, express emotions, and support renegotiated role relationships.
• It has been shown to be effective in treating depression in older people, both in the acute phase and for relapse prevention.
• IPT is applicable to the relationship and developmental issues that are relevant to people in later life.
• It can be applied by a range of professionals after a period of basic training.
• For HIV patients, IPT relates mood changes to environmental events and resulting changes in social roles. It is a treatment that addresses interpersonal problem areas, using strategies that focus on the present, and on what the patients want to achieve and what options are available.

6) What is systemic (family) therapy? Elucidate.

Systemic (family) therapy views individuals in the context of their wider family and social system.

• It focuses on the interactional patterns between people, as well as their intra-psychic processes.
• It seeks to improve the functioning of the family as a unit, or its subsystems, and/or the functioning of individual members of the family.
• It recognises that presenting symptoms in a patient may result from dysfunctional dynamics in the wider matrix of relationships surrounding the individual.
• Techniques include circular questioning, positive connotation, paradoxical intervention, reframing, and exploring the shared genogram.
• It may be particularly helpful in the context of communicating and processing a diagnosis of dementia in a family setting.
• It can also be helpful in unravelling the reinforcing factors in dysfunctional somatizing and sick role behaviour in older adults.
• Family therapy is not about creating or maintaining traditional nuclear families, but is about recognising the diversity of family configurations.

7) Put forward the reminiscence life review therapy

Reminiscence Therapy (RT) involves recalling the past to increase self-esteem and social connection.

• It is often conducted in a group setting, using artifacts, newspapers, and music to stimulate memories.
• The sessions are usually structured with the therapist picking the topics.
• It is used to help elderly people gain perspective on their lives, and is often popular in senior centers and retirement communities.

Life Review Therapy (LRT) is a more intense type of RT that involves reworking past conflicts to gain a better understanding and acceptance of the past.

• It is based on Erikson’s model of psychosocial development and aims to help older adults resolve the conflict between ego integrity and despair.
• LRT seeks to help older adults formulate and accept personalised answers to existential questions such as 'Who am I?' and 'How did I live my life?'

8) Discuss the therapies suited to the following specific problems

a) Dementia

• Behavioural and environmental treatments for behaviour problems may be effective.
• Memory and cognitive retraining for some forms of late-life cognitive impairment may be effective.
• Support groups and CBT can help with coping strategies and reducing distress in early-stage dementia.
• Reminiscence Therapy (RT) may provide connections for those with mild to moderate dementia.
• Family and systemic approaches can be useful in exploring a diagnosis of early dementia.
• Psychodynamic theory and CAT can contribute to understanding the role-play between caregiver and person with dementia.
• A general approach based on validation therapy, with time for reminiscence, is likely to provide a humane backdrop to dementia care.

b) Uncomplicated depressive illness Cognitive behavioural therapy (CBT) or interpersonal therapy (IPT) may be offered, with or without pharmacological treatment. Both therapies are useful in relapse prevention. IPT may be preferred where there are tensions in current relationships, whereas CBT may suit a more cognitively-minded patient.

c) Depressive illness with borderline or narcissistic personality traits Cognitive analytic therapy (CAT) or psychodynamic therapy are the treatments of choice.

d) Depression in dysfunctional family systems Systemic (family) therapy is indicated if at least some of the family can engage in it.

9) Write about psychotherapy in dementia?

Psychotherapy in dementia is an area in need of further investigation.

• People with dementia may experience cognitive impairments such as memory loss, decreased capacity for judgment and problem solving, and co-morbid emotional distress.
• Their symptoms and behaviours should not be seen as only biological manifestations, but as being affected by social, psychological, and environmental contexts.
• Various CBT, environmental, and supportive interventions can help reduce disruptive behaviours and disabilities, maintain positive behaviours, improve memory or learn coping skills, and increase quality of life.
• Support groups and CBT can help people with early stage dementia to develop coping strategies and reduce distress.
• Behavioural approaches and memory training target specific impairments and optimise remaining abilities.

10) “It is often necessary to adapt therapies to address special considerations unique to older adults”. Discuss?

Adapting therapies for older adults is often necessary due to several factors.

• Older adults have at least one chronic medical illness and some degree of functional impairment.
• They experience increasing losses and decreasing controllability of these losses.
• Psychotherapy may occur at a slower pace due to sensory problems and slower learning rates.
• Repetition is important in the learning process.
• Information should be presented in both verbal and visual formats.
• Older clients should be encouraged to take notes.
• Therapy with older adults often requires a collaborative style, fewer clearly outlined goals, and a more active or task-focused approach.
• The goals of therapy should be continually highlighted to reinforce the direction of treatment.
• Therapists may need to lead older adults to conclusions, rather than expecting them to infer the answers, due to a normal age decline in fluid intelligence.

11) What modifications or adaptations do we make in treatment of adults?

Modifications and adaptations to treatment for older adults include:

• Using multimodal teaching (visual and verbal).
• Maintaining interdisciplinary awareness of any physical health issues.
• Presenting information more clearly and at a slower pace.
• Developing knowledge of aging challenges and strengths.

• Offering flexibility in scheduling and location.
• Being flexible in terms of treatment setting.
• Adapting the therapy sessions with aids for hearing or vision impairments.
• Engaging the caregiver in aspects of the treatment when appropriate.
• Spreading out the ending of sessions, or offering booster sessions.
• Providing an introductory orientation or socialisation into psychotherapy to challenge negative stereotypes about mental health.
• Separating the effects of maturation (developmentally common changes in older adulthood) from the effects of cohort (specific to a birth-year group).
• Being aware of cohort differences in the expression and treatment of psychological problems.
• Learning about chronic illness and its psychosocial impact.
• Being aware of management of chronic pain, adherence to medical treatment, and negative medication effects.
• Recognising that older adults often have a greater chance of hospitalisation, reduced mobility, and caring responsibilities, and may need missed therapy sessions to be accommodated with phone calls or letters.
• Being flexible in relation to treatment duration.