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Psychotherapy and Older Adults Resource Guide Introduction Journal Articles Books Book Chapters Reports Information For Older Adults and Their Families Introduction Since about 1990, changes in the Medicare reimbursement system have allowed psychologists to provide services to older adults with Medicare coverage. These changes, in combination with managed care and market place changes have made older adult clients attractive as a client population to increasing numbers of psychologists and other mental health service providers. As the Baby Boomers become older adults over the next several years, one can expect both the need and the demand for mental health services to increase: Need is likely to change because Boomers have higher prevalence of depression and other mental disorders than do the GI Generation and Depression era cohorts; Demand may change because Boomers have typically been psychologically minded and relatively high consumers of mental health services. Key questions in thinking about working with older adults concern whether psychological interventions can be expected to work with older adults. If they work, are adaptations from work with younger adults necessary? In this resource page, research bearing on both of these questions is summarized. Does therapy work with older adults? Before turning to psychological interventions, which are the main focus of this resource guide, it should be noted that psychological assessment with older adults is more specialized than are interventions. The higher prevalence of the dementias in late life make some level of neuropsychological screening essential. The higher prevalence of medical disorders makes attention to physical causes of symptoms and to iatrogenic effects of medications as causes of symptoms highly important as well. For more on geropsychological assessment see Lichtenberg (1999). Gatz et al. (1998) reported that behavioral and environmental interventions for older adults with dementia met the standards proposed at that time for well-established empirically supported therapy. Probably efficacious therapies for the older adult included cognitive behavioral treatment of sleep disorders and psychodynamic, cognitive, and behavioral treatments for clinical depression. For nonsyndromal problems of aging, memory retraining and cognitive training are probably efficacious in slowing cognitive decline. Life review and reminiscence are probably efficacious in improvement of depressive symptoms or in producing higher life satisfaction. Scogin & McElreath (1994) reported a meta-analysis of psychological interventions for the treatment of depression in later life which showed an aggregate effect size (d = .78) roughly equal to that found in another meta-analysis for anti-depressant medications (d = .57, Schneider, 1994) and roughly equal to that found for younger adults in meta-analyses using cognitive-behavioral approaches (d = .73; Robinson, Berman, & Neimeyer, 1990; some studies overlap with those used in Scogin & McElreath, 1994). In general, then, available evidence supports the effectiveness of psychological interventions with older adults, for those interventions that have been studied. Does therapy change when working with older clients? Drawing upon life span developmental psychology, social gerontology, and clinical experience I have developed a transtheoretical framework for thinking about what changes are needed in psychological interventions with older adults: the contextual, cohort-based, maturity, specific challenge model (CCMSC; Knight, 1996). CCMSC is not a specific therapy system but a framework for thinking about the adaptation of any therapy system to work with older adults. In the model, context means that changes in therapy are often related to the social-environmental context of older adults both in the community and more especially within hospital and nursing home settings, rather than to their developmental stage. Cohort differences are based on maturing in a specific historical time period, leading to a focus on generational groups such as Depression-era generation, GI Generation, Baby Boomers, rather than on age groups. Developmental maturation leads to relatively minor changes, such as slowing down and the use of simpler language, but also to greater emotional complexity and a wealth of life experience upon which to draw. Specific challenges means that due to the high prevalence of chronic medical problems and neurological disorders, a higher percentage of psychological assessment and therapy is related to medical problems these problems. There is also a higher frequency of grief work and of attention to caregiving issues. In short, the answer to the question of whether psychotherapy needs to be adapted for work with older adults is, Yes, but (mostly) NOT because they are older. That is, the major reasons for changing therapy when working with an older client are not due to developmental differences but to context effects, cohort effects, and specific challenges common in later life. Context effects require changes for older clients living in age specific contexts such as retirement communities and long term care settings as well as for clients who are seen in de facto age contexts such as hospitals and outpatient medical settings. Cohort effects require modifications because earlier born cohorts have different skills, different values, and different life experiences than later born cohorts. The specific challenges of later life require specific knowledge and therapeutic skills because of the problems they pose for clients, not because of the client's age. How specialized does a therapist need to be to work with older adults? It will likely depend on the number and type of older adults seen in the practice. Therapists who see a small percentage of older adults, who see older adults who are physically healthy and not likely to have dementia, and whose older clients have problems similar to those of their younger clients, are not likely to need specialized training or education to work with older clients. Adapting to work with members of other cohorts is similar in difficulty and in the type of changes required to working with clients of a different gender, ethnicity, class background, or occupation-based lifestyle. It does require sensitivity to the possibility of the difference. It also requires some knowledge of history before one was born or at least the willingness to learn that history from clients. In terms of context effects, if the work with older adults is primarily in long term care settings or in acute medical settings, the work will be specialized compared to work with healthy younger adults living and working in the community. The differences are due to the specialized environmental context rather than to the age of the clients. It is likely to be somewhat similar to working with younger adults in medical care settings and rehabilitations settings. Learning these settings is likely to require some supervised experience working in them. While somewhat less different and therefore less specialized than the institutional settings, seeing clients who are living a post-retirement lifestyle, especially if some of their lives are spent in age-segregated environments, requires learning the social rules of those environments. Like cohort differences, these can be learned from older clients, but the therapist must be aware of the need to attend to these differences. Otherwise, judgments will be made based on the norms and folkways of young and middle-aged adults whose lives are shaped by school, work, and young families rather than by leisure time, senior community centers or meal sites, and the dispersed networks of older families. In terms of specific challenges, if the older clients are physically ill, this will pose new issues in both assessment and also in intervention with them. Sorting out physical and psychological influences on symptoms and problems is an ongoing assessment issue. Specific knowledge about the effects of different chronic illnesses as well as both the skill and emotional readiness to work with physically disabled clients become essential. Consultation and supervised experience with psychologists who have such experience is likely to needed in addition to didactic instruction. When working with clients with death and dying issues, the therapist needs to have basic skills in death counseling and in grief work. The primary problem I have observed over the years is therapists failing to recognize that clients need to talk about the death of loved ones sometimes even when this is the client's stated presenting problem. Learning to work effectively with death, dying, and grief is likely to require supervision as well as didactic instruction. Working with caregivers requires some basic understanding of the stress and coping process as it affects caregivers for frail older adults. Therapy with caregivers will usually include some need to explore relationship issues and family issues as well. This work often includes a dual focus on emotional issues for the caregiver and problem solving in order to reduce the real stress and strain of long term caregiving for a seriously disabled family member. The more of these factors that are present, the more specialized working with older adults becomes. Other things being equal, the larger the proportion of older adults in one's caseload, the more likely it is that these factors will be present, whether the therapist is immediately aware of them or not. As noted above, assessment practice with older adults requires some degree of specialized training and work in long term care or other medical settings with older adults will require specialization in learning to work effectively in that setting. In short, seeing some older adults that are much like the other adults in one's practice does not require much specialization. Seeing a lot of older adults, seeing older adults who have different problems, or seeing them in different settings requires specialized knowledge and supervised experience. Bob G. Knight, PhD University of Southern California Back to Top Journal Articles Sexual secrets of older women: Countertransference in clinical practice Altschuler, J. & Katz, A.D. (1996). Clinical Gerontologist, 17(2), 51-67. Case examples are used to demonstrate to therapists the many sexual issues associated with older female clients, and the countertransference and treatment issues for therapists working with older women. A practitioner has a responsibility to examine personal ageism, sexism, and countertransference limitations unconsciously conveyed to an older female client with sexual concerns. Otherwise the therapist's ability to be receptive to clients who want to explore their sexual secrets is hindered. Methodology for discovering and teaching countertransference toward elderly clients. Altschuler, J. & Katz, A.D. (1999) Journal of Gerontological Social Work, 32(2), 81-93. Describes a method that has been effective in helping students, paraprofessional counselors as well as mental health professionals identify countertransference reactions in themselves. The author developed a sentence completion exercise that can be used to elicit and uncover countertransference responses toward elderly people. It offers instructors and clinical supervisors a way to teach about countertransference toward elderly clients. This technique can be used in a variety of work settings such as classrooms, mental health clinics, multi-purpose centers for older adults and private practice. A randomized trial of the effectiveness of cognitive-behavioral therapy and supportive counseling for anxiety symptoms in older adults Barrowclough, C., King, P., Colville, J., Russell, E., Burns, A., & Tarrier, N. (2001). Journal of Consulting & Clinical Psychology, 69(5), 756-762. The authors used a randomized trial to compare cognitive-behavioral therapy (CBT) and supportive counseling (SC) in the treatment of anxiety symptoms in older adults who met Diagnostic and Statistical Manual of Mental Disorders criteria for anxiety disorders. Both conditions had a 6-week baseline no-treatment phase. Treatment was delivered primarily in patients' own homes and in an individual format. Outcomes were assessed at post treatment and at 3-, 6-, and 12-month follow-ups. There was no spontaneous improvement during the baseline phase. Both groups showed improvement on anxiety measures following treatment, with a better outcome for the CBT group on self-rating of anxiety and depression. Over the follow-up period, the CBT group maintained improvement and had significantly greater improvement than the SC group on anxiety and 1 depression measure. Treatment response for anxiety was also superior for the CBT group, although there was no difference between groups in endstate functioning. Presentation of depression and response to group cognitive therapy with older adults Cappeliez, P. (2001). Journal of Clinical Geropsychology, 6(3), 165-174. Examines the relationships between pretreatment components of depressive symptomatology and outcome of short-term group cognitive therapy for depression with older adults (aged 65+ yrs). Aspects of depressive symptomatology under examination were initial intensity of self-reported symptomatology, profile of melancholic depression, perceived health status, perceived social support, and intensity of negative view of self. Findings indicate that perceived social support is not related to outcome, but that a more intense depressive symptomatology, a more negative health evaluation, and a more negative view of self are variables associated with a less favorable outcome. Despite showing a sizable decrease in depressive symptoms over the course of intervention, severely depressed Ss still presented residual depressive symptoms at the conclusion of intervention. There was a tendency for Ss with a melancholic profile to show a poorer response to this intervention. Cognitive-behavioral therapy with older adults Dick-Siskin, L.P. (2002). Behavior Therapist, 25(1), 3-6. This discussion focuses on recommendations for working with older adults receiving cognitive-behavioral therapy (CBT). The following topics are addressed: is CBT effective with older adults, what brings older adults to treatment, the intake process, introducing CBT to the older adult, threats to the collaborative relationship, sensory changes in aging, suggestions to enhance cognitive interventions, and suggestions to enhance behavioral interventions. The case of an 82-yr-old female is offered as an example of CBT with older adults. Cognitive-behavior therapy for older adults: How does it work? Floyd, M., & Scogin, F. (1998). Psychotherapy, 35(4), 459-463. The basic premise of cognitive-behavior therapy (CBT) is that depression is mediated by depressogenic patterns of thinking. Research with a general adult population has not consistently supported the proposed mediational effect of depressogenic thinking (M. Whisman, 1993), as measured by the Dysfunctional Attitudes Scale (DAS) of A. T. Beck et al (1991). Research suggests that the mediational effect of the DAS is even weaker with an older adult population. Proposed reasons for this age difference include a greater effect of the "common factors" of psychotherapy (S. Ilardi and W. Craighead, 1994) and an increased need to specifically treat hopelessness in older adults. Comparative Effects of Cognitive-Behavioral and Brief Psychodynamic Psychotherapies for Depressed Family Caregivers Gallagher-Thompson, D., & Steffen, A.M. (1994). Journal of Consulting and Clinical Psychology, 62(3), 543-549. Clinically depressed family caregivers of frail, elderly relatives were randomly assigned to 20 sessions of either cognitive-behavioral or brief psychodynamic individual psychotherapy. At post treatment, 71% of the caregivers were no longer clinically depressed according to research diagnostic criteria, with no differences found between the two outpatient's treatments. The results suggested therapy specificity; there was an interaction between treatment modality and length of caregiving on symptom-oriented measures. Clients who had been caregivers for at least 44 months improved with CB therapy. These findings suggest that patient-specific variables should be considered when choosing treatment for clinically depressed family caregivers. Empirically Validated Psychological Treatments for Older Adults Gatz, M., Fiske, A., Fox, L., Kaskie, B., Kasl-Godley, J., & McCallum, T. (1999). Journal of Mental Health and Aging, 4(1), 9-46. Psychological treatments with older adults were evaluated against criteria developed by the Division of Clinical Psychology of the American Psychological Association for documenting effective psychosocial interventions. To be included as evidence, the studies must exclude dual or ambiguous diagnoses and must adhere to standardized treatment manuals. Demonstrated efficacy compared to waiting list control groups qualifies an intervention as "probably efficacious", whereas being categorized as "well established" requires superiority to a psychological placebo group or control treatment (or equivalence to another well-established treatment). Major findings included: use of behavioral and environmental treatments for behavior problems in dementia patients met criteria for "well established"; cognitive, behavioral, and brief psychodynamic therapy for the treatment of depression in older adults met criteria for "probably efficacious"; life review and reminiscence met the criteria for "probably efficacious" for both cognitively intact and demented individuals with symptoms of depression and those living in settings that restrict independence; cognitive behavioral treatment of sleep disorders, support groups for caregivers based on a psychoeducational model, and memory and cognitive retraining with dementia patients all met the criteria for "probably efficacious." Time's winged chariot: Short-term psychotherapy in later life Gorsuch, Nikki. (1998). Psychodynamic Counseling, 4(2), 191-202. This paper is concerned with the appropriateness of short-term psychodynamic psychotherapy with older adults, a client group, which has historically been neglected in psychotherapeutic practice. Drawing on the case study of a fourteen-session therapy with a woman in her seventies, it is argued that brief exploratory work can be of particular value to people nearing the end of their lives. The nearness of death gives a special urgency and motivation to the work and time-limited therapeutic contract mirrors the reality of having only a short time left. Making psychotherapy available to older people also represents an important valuing and validation of their experience. The management of sexualized transference and countertransference with older adult patients: Implications for practice Hillman, J., & Stricker, G. (2001). Professional Psychology - Research & Practice, 32(3), 272-277. For a variety of reasons, psychologists are beginning to see an increasing number of older adults in their practice. However, the sexualized transference and countertransference sometimes encountered with older adult patients can foster therapeutic impasse and resistance in treatment among both novice and experienced therapists. Societal taboos and therapy within the context of institutional settings (e.g., nursing homes) can make the management of these dynamics particularly challenging. Although difficult to broach, an analysis of sexualized dynamics can provide valuable information regarding an elderly patient's sense of intrinsic value, beliefs about power and agency, and difficulties with or desires for emotional intimacy. Case examples and implications for practice are presented. Treating older adults with interpersonal psychotherapy for depression Hinrichsen, G.A. (1999). Journal of Clinical Psychology, 55(8), 949-960. Interpersonal psychotherapy for depression (IPT) is a brief psychotherapy that has been found to be effective in treating major depressive disorder (MDD) and other problems in younger adults. In recent years, IPT has been used as psychotherapy for depressed elderly. With its emphasis on addressing interpersonally relevant problems, IPT appears especially well suited to the life changes that many people experience in their later years. Consistent with results of research studies, the author has found in clinical practice that IPT is effective in treating depression in older adults. In this article the author describes IPT treatment of a 74-yr-old woman who developed MDD following the onset of dementia in her husband and the challenges she faced making transitions in her role as caregiver. Psychosocial intervention for individuals with dementia: An intergration of theory, therapy, and a clinical understanding of dementia Kasl-Godley, J., & Gatz, M. (2000). Clinical Psychology Review, 20(6), 755-782. Reviewed psychosocial interventions for people with dementia using an integrated framework that views the symptoms and behaviors of demented individuals as not solely a manifestation of the underlying disease process, but also reflect the social and environmental context as well as the demented individual's perceptions and reactions. Particular attention was given to 6 interventions: (1) psychodynamic approaches, (2) reminiscence and life review therapy, (3) support groups, (4) reality orientation (RO), (5) memory training, and (6) cognitive/behavioral approaches. Interventions are described in terms of theoretical basis, how knowledge about dementia is incorporated, techniques, and empirical support. The authors found that psychodynamic approaches appear helpful for understanding intrapsychic concerns of demented individuals. Support groups and cognitive/behavioral therapy assist early stage individuals to build coping strategies and reduce distress. Reminiscence and life review provide mild to moderate stage individuals with interpersonal connections. Behavioral approaches and memory training target specific cognitive and behavioral impairments and help to optimize remaining abilities. RO is similar but is more useful for its interpersonal functions. Cognitive behavioral psychotherapy with older adults Knight, B. & Satre, D.D. (1999). Clinical Psychology-Science & Practice, 62(2), 188-203. This review integrates discussion of cognitive and behavioral intervention techniques with recent research and clinical observation sin the field of gerontology. Cognitive changes with aging, personality and emotional development, cohort effects, and the social environment of older adults are discussed in reaction to psychotherapy. Applications of cognitive behavior therapy to specific late-life problems such as chronic illness and disability, depression, alcoholism, and insomnia are presented. The effectiveness of cognitive and behavioral techniques in treating these disorders in older adults is discussed. The scientific basis for psychotherapeutic interventions with older adults: An overview Knight, B.G. (1999). Journal of Clinical Psychology, 55(8), 927-934. Findings from reviews of outcome studies indicate that therapy is effective with older adults. The contextual, cohort-based, maturity, specific-challenge model (CCMSC) is used to organize an overview of findings from scientific gerontology. These findings suggest that some adaptations are needed when working with older adults, but that these changes are more often due to cohort-differences, context effects, and presenting problems rather than to the age of the client. Adapting psychotherapeutic practice for older clients: Implications of the contextual, cohort-based, maturity, specific challenge model Knight, B.G., & McCallum, T.J. (1998). Professional Psychology - Research & Practice. 29(1), 15-22. The contextual, cohort-based, maturity, specific challenge model integrates concepts from gerontology with psychotherapy to apply those ideas in psychotherapy with older adults. The model suggests that older adults display greater maturity than younger adults but may also be facing some of the most difficult challenges of adulthood. The model further asserts that the social context of older adults and the fact that they are members of earlier-born cohorts should be recognized and incorporated into the psychotherapeutic process. Although the model outlines important differences between older and younger adults in therapy, similarities often outweigh differences between the groups as the process of psychotherapy unfolds. Pretherapy training for group cognitive therapy with depressed older adults Latour, D., & Cappeliez, P. (1994). Canadian Journal on Aging, 13(2), 221-235. Explored the effectiveness of a pre-therapy training procedure in enhancing group cognitive therapy for depressed older adults. 29 depressed Ss (aged 65-79 yrs) were randomly assigned to a pre-therapy training condition or an attention-placebo control condition. The pre-therapy training procedure was based on social cognitive theory and included verbal persuasion, vicarious experience, and performance accomplishment. The pre-therapy training improved knowledge about psychotherapy and promoted the development of a problem-oriented focus in therapy. However, it was unsuccessful in significantly reducing dropouts, increasing attendance, modifying role expectancies in the expected direction, and differentially affecting the outcome of cognitive therapy. For both conditions, 53.7% of the Ss demonstrated clinically significant improvement at the end of therapy. A brief cognitive behavioural therapy group for the elderly: Who benefits? Leung, S.N., & Orrell, M.W. (1993). International Journal of Geriatric Psychiatry, 8(7), 593-598. Examined the efficacy of brief focused cognitive-behavioral group intervention in the treatment of mood disorders in older adults in different diagnostic groups. At 1-yr follow-up, out of a total of 27 patients (aged 61-82 yrs), 70% required no input from the mental health services and reported that they were recovered and functioning well. When separated into 2 groups according to diagnoses on the Mental Disorders-III-Revised (DSM-III-R), 92% of Ss with major depressive episode were discharged and functioning well. Only 50% of Ss with other disorders (e.g., dysthymia and cyclothymia) were discharged and functioning well. Psychological assessment and psychotherapy in long-term care Lichtenberg, P.A., & Duffy, M. (2000). Clinical Psychology-Science & Practice, 7(3), 317-328. The continued growth of the older adult population, combined with the inclusion of psychologists in Medicare, is leading to psychological services increasingly being delivered in long-term care settings. This article reviews some basic concepts in psychological assessment and psychotherapy with older adults in long-term care settings. A guide is provided for the assessment of dementia, delirium, and depression. The use of validated empirical instruments, the collection of multiple sources of historical data, and the incorporation of assessment results in treatment planning is emphasized. Psychotherapy with persons having a dementia and psychotherapy with persons having a personality disorder is the focus of the treatment section of this article. The authors argue that these have been neglected areas of practice, and yet treatment can produce significant benefits to these patients. A general approach to assessment and a guide for integrating the assessment results into the plan of care are outlined. How effective are psychotherapeutic and other psychosocial interventions with older adults? A meta analysis Pinquart, M. & Soerensen, S. (2001). Journal of Mental Health and Aging, 7(2), 207-243. Meta-analysis was used to synthesize the effects of 122 psychosocial and psychotherapeutic intervention studies with older adults. Three research questions were explored: (1) what is the effectiveness of psychotherapeutic and psychosocial treatments (cognitive-behavioral therapy, reminiscence, psychodynamic approaches, relaxation, supportive interventions, control enhancement, psychoeducational treatments, activity treatments and training of cognitive abilities) on self-ratings of depression, clinician-rated depression, and other measures of subjective well-being in older adults; (2) the influences of moderator variables, and (3) whether the effects of psychosocial and psychotherapeutic interventions vary by age. Psychotherapeutic interventions changed self-rated depression and other measures of psychological well-being by about one half standard deviation and clinician-rated depression by more than one standard deviation. Psychotherapy with suicidal older adults Richman, J. (1994). Death Studies, 18(4), 391-407. Presents general principles for psychotherapy with suicidal older adults (OAs). Many psychotherapists do not realize how much potential OAs possess for overcoming their depressed state, but a thorough evaluation can highlight these strengths. OAs often exhibit more danger signs than younger persons. Ego-weakening factors, social factors, psychodynamic factors, and clinical signs are discussed. The importance of dealing with family reactions to the client is stressed. Criteria for hospitalization are considered, and the necessity for a small caseload, continuity of treatment, and the preferred treatment modality are discussed. The best counselor for the suicidal OA is seen as one who is aware of the client's assets (no matter how buried), who respects the person's wisdom and experience, and who realizes how much that person still has to offer. Efficacy of psychosocial treatments for geriatric depression: A quantitative review Scogin, F. & McElreath, L. (1994). Journal of Consulting and Clinical Psychology, 62(1) 69-74. A meta-analysis of 17 studies examined the efficacy of psychosocial treatments for depression among older adults. Psychosocial treatment was defined as an intervention, the primary mode of action which was through psychological or social mechanisms such as psychotherapy, bibliotherapy, or behavior therapy. Studies were included only if a comparison was made to a control condition (no treatment, delayed treatment, or placebo treatment) or another psychosocial intervention. Results indicated that treatments were reliably more effective than no treatment on self-rated and clinician-rated measures of depression. Effect sizes for studies involving participants with major depression disorder were also reliably different from zero, as were effect sizes from studies involving participants with less severe levels of depression. These findings compare favorably with several other quantitative reviews of treatments for depression. Results suggest more balanced presentations of the potential benefits of psychosocial interventions are warranted. Residual geriatric depression symptoms: A place for psychotherapy Scogin, F., Shackelford, J., Rohen, N., Stump, J., Floyd, M., McKendree-Smith, N., & Jamison, C.(2001). Journal of Clinical Geropsychology, 7(4), 271-283. Geriatric depression is a relatively commonly occurring mental disorder. A subpopulation of depressed older adults are those who have engaged in or completed pharmacotherapy, yet continue to experience depressive symptoms. The authors review the prevalence, psychosocial effects, and treatment of residual symptoms of depression in older adults. Data from previous studies conducted by our group are presented to support our contention that residual symptoms of geriatric depression are treatable through psychosocial means. Treatment of generalized anxiety in older adults: A preliminary comparison of cognitive-behavioral and supportive approaches Stanley, M.A., Beck, J.G., & Glassco, J.D. (1996). Behavior Therapy, 27(4), 565-581. Compared the efficacy of cognitive behavior therapy vs. nondirective, supportive psychotherapy for 31 older adults (aged 55+ yrs) with well-diagnosed Generalized Anxiety Disorder (GAD). Treatments were administered in small groups that met for 14 weekly half-hour sessions. Treatment effects were assessed at post treatment and over a 6-mo follow-up period. Two composite indexes of treatment response were derived to identify treatment responder status and high end-state functioning. Results show significant improvements on outcome variables measuring worry, anxiety, and depression in both treatment conditions. Effect sizes generally were large, and treatment gains were maintained or improved over the 6-mo follow-up phase. Examination of treatment responder status and end-state functioning revealed no significant differences between groups. Behavioral treatment of depression in dementia patients: A controlled clinical trial Teri, L. (1997). Journals of Gerontology Series B-Psychological Sciences & Social Sciences, 52B(4), 159-166. The current study is a controlled clinical investigation of 2 nonpharmacological treatments of depression in patients with Alzheimer's disease (AD). Two active behavioral treatments, one emphasizing patient pleasant events and one emphasizing caregiver problem solving, were compared to an equal-duration typical care condition and a wait list control. 72 patient-caregiver dyads were randomly assigned to 1 of 4 conditions and assessed pre- and post-treatment, and at 6-mo follow-up. Patients in both behavioral treatment conditions showed significant improvement in depression symptoms and diagnosis as compared with the 2 other conditions. These gains were maintained at follow-up. Caregivers in each behavioral condition also showed significant improvement in their own depressive symptoms, while caregivers in the 2 other conditions did not. Results indicate the importance and effectiveness of behavioral interventions for treatment of depression in AD patients and their caregivers. Comparison of desipramine and cognitive/behavioral therapy in the treatment of elderly outpatients with mild-to-moderate depression. Thompson, L., Coon, D.W., Gallagher-Thompson, D., Sommer, B.R., & Koin, D. (2001). American Journal of Geriatric Psychiatry, 9(3) 225-240. This study evaluated the efficacy of desipramine alone vs. cognitive/behavioral therapy alone (CBT) vs. a combination of the two, for the treatment of depression in older adult outpatients. 102 patients (mean age 66.8 yrs) meeting criteria for major depressive disorder were randomly assigned to one of the three treatments for 16-20 therapy sessions. All treatments resulted in substantial improvement. In general, the CBT only and combined groups had similar levels of improvement. In most analyses, the combined group showed greater improvement than the desipramine alone group, whereas the CBT alone group showed only marginally better improvement. The combined therapies were most effective in patients who were more severely depressed, particularly when desipramine was at or above recommended stable dosage levels. Cognitive behavioral psychotherapy: A comparison between younger and older adults in two inner city mental health teams Walker, D.A., & Clarke, M. (2001). Aging & Mental Health, 5(2), 197-199. To assess the feasibility of establishing a new cognitive behavior therapy (CBT) service specifically for older adults (aged 66-80 yrs), the authors decided to compare an older adult mental health service with a younger adult service in terms of range of referrals, outcomes, attendance rates and length of time in therapy. Assessments were conducted using a behavioral interview. 23 older adults (aged 66-80 yrs) were referred. The range of disorders referred was a wide mix of anxiety disorders and depression. There were no significant differences in therapy outcomes apart from home adjustment measures where older adults showed greater improvement. Younger adults showed significantly higher rates of non-attendance and had higher dropout rates. Possible reasons for this are discussed. CBT appeared effective in both age groups, however older adults were treated more quickly due to a higher attendance rate. Treatment of anxiety in older adults Wetherell, J.L. (1998). Psychotherapy, 35(4), 444-458. This article is a broad review of psychological literature that addresses the prevalence, consequences, and psychological treatment of anxiety in older adults. Psychological treatments, including relaxation, cognitive-behavioral therapy, psychodynamic therapy, and life review, are explored as alternatives to pharmacological approaches to treatment of anxiety. Several anxiety-associated conditions are discussed: dementia, depression, phobias, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. Case histories illustrate the effectiveness of psychological intervention for treatment of anxiety in the elderly. Included is a comprehensive list of manuals for anxiety treatment procedures. Overcoming obstacles in providing mental health treatment to older adults: Getting in the door Yang, Janet A., & Jackson, C.L. (1998). Psychotherapy, 35(4), 498-505. Older adults significantly underutilize mental health services relative to their numbers in the population. Barriers that impede their access include physical, financial, cognitive, emotional, and attitudinal issues. This article discuss strategies for overcoming these barriers including physical adaptations such as in-home psychotherapy and telephone sessions, use of support groups, strong community outreach, and liaisons with other professionals. Adaptations that help to increase older adults' use of mental health services are discussed, including education about treatment, nontraditional "pursuit" of clients, and use of alternative terminology. Informed consent is discussed as a special issue. Back to Top Books Guiding Autobiography Group for Older Adults: Exploring the Future of Life Birren, J., & Deutchman, D. (Eds.), (1990). Baltimore: Johns Hopkins University Press. Describes Birren's guided autobiography groups, a structured and powerful method for exploring the meaning of one's life. Useful comments are included for the leaders of such groups. Handbook of counseling and psychotherapy with older adults Duffy, M. (Ed.), (1999). New York: John Wiley & Sons, Inc. This handbook provides a much-needed resource in treatment approaches for mental health professionals who provide counseling and psychotherapy to older clients. Part I focuses on a series of treatment modalities, including the use of psychotherapy process, group and expressive approaches, family and intergenerational interventions, and social and community interventions. Part II provides conceptual and best practice interventions for a series of specific problems. This volume will be useful to a variety of interested persons, including experienced geropsychologists and geropsychiatrists, geropsychiatric nurses and social workers, and counselors who focus on mental health and aging. It will also be an important resource for experienced general therapists who wish to develop greater proficiency in working with older adults. Countertransference and older clients. Genevay, B., Katz, R.S. (Eds.), (1990). CA: Sage Publications, Inc. This is a book about how our feelings about aging and loss, and about disability and death affect our work with older people. It is addressed to all who work with old and dying people, and to those who work with younger people who have become "instantly old" due to disability. Innovative behavioral healthcare for older adults: A guidebook for changing times Hartman-Stein, P.E. (Ed.) (1998). San Francisco: Jossey-Bass, Inc. This book makes a case for the cost-cutting advantages of offering mental health programs to the fastest-growing segment of our population. The authors outline clinical and political guidelines for organizing and delivering behavioral healthcare to older adults. They present the most current research, techniques, and model programs for cost-effective and quality assessment and psychotherapy. The book also describes innovative roles and services that offer creative opportunities for clinicians. Clinical perspectives on elderly sexuality Hillman, J.L. (2000). Dordrecht, Netherlands: Kluwer Academic Publishers This book features a combination of research findings, clinical case studies, and specific guidelines for assessment and intervention. A variety of topics typically neglected in this population, such as body image and eating disorders, HIV, the long term impact of sexual trauma in late life, sexuality in institutional settings, sexuality for partners of older adults with dementia and other chronic illnesses, traditional and nontraditional relationships, and information about medications that can cause sexual dysfunction, are reviewed in detailed. In addition, practitioners are given practical suggestions for interviewing older adults about sexual issues, working with character-disordered older adults, managing sexualized transference in the therapeutic relationship, mediating conflict between professionals on interdisciplinary teams, and assessing HIV and HIV-induced dementia. Assessing and treating late-life depression: A casebook and resource guide Karel, M.J., Ogland-Hand, S., Gatz, M., & Unuetzer, J. (2002). New York: Basic Books, Inc. This practice-oriented, research-based casebook draws on extensive clinical and academic data on late-life depression and its treatment as a resource for practitioners and researchers. The authors--a practicing psychologist and two clinical geropsychologists among them--provide an interdisciplinary framework for understanding and treating late-life depressive symptoms. The authors elucidate the problems and principles of late-life depression with fourteen extended case studies. Explicating the range of syndromes and strategies for assessing and treating them, they conclude with a guide to medications, screening tools, innovative models, and supplementary resources. Psychotherapy with older adults (2nd ed.) Knight, B.G. (1996). Thousand Oaks, CA: Sage Publications. Provides a practical account of the knowledge, technique, and skills necessary to work with older adults in a therapeutic relationship. This volume considers the essentials of gerontology as well as the nature of therapy, including special content areas and common themes. It presents a comprehensive discussion of assessment and options for intervention. Numerous case examples illustrate the dynamics of the therapeutic task and issues covered in therapy and stress the human element in working with older adults On Death and Dying Kubler-Ross, E. (1993). New York: Macmillian. A classic work on working with dying people and the need for professionals to be comfortable discussing death. Moving case material, sensitively presented. Professional psychology in long term care: A comprehensive guide. Molinari, V. (Ed.), (2000). New York: Hatherleigh Press. This book provides therapists with the tools and skill sets they will need to face the challenges of administering optimal care to this growing population. The book is divided into three major sections: Assessment of Psychopathology, Treatment (including individual, family and group therapies, behavioural interventions for patients with dementia and counseling elderly dying patients), and Professional Issues such as training, private/group practice, ethics, clinical research and public policy related to the delivery of mental health care to older adults The race against time: Psychoanalysis and psychotherapy in the second half of life Nemiroff, R.A. & Colarusso, C.A. (Eds.), (1985). New York : Plenum. The editors argue that the nearness of death accelerates change in therapy with older adults. Several provocative observations about psychodynamic processes occurring in midlife and later life as well as illustrations of childhood issues that are still affecting later life relationships. Probing discussions of transference and counter transference issues. Clinical Geropsychology Nordhus, I.H. & VandenBos, G. (Eds.), (1998). Washington, DC: American Psychological Association. Written for practicing clinicians, graduate students in training, and other scientifically informed mental health professionals, this book provides guidance for individuals working with aging populations. Part I presents a theoretical anchoring across perspectives on psychological, cognitive, and biological aspects of aging. Part II provides brief introductions to an array of practical issues and life challenges in the lives of aging individuals. Part III provides practical advice on clinical assessment and intervention approaches to assisting older individuals and their families. This last section provides the reader with an introduction to various psychological interventions, clinical issues that typically arise and how best to address them, and topics that the therapist should consider in the clinical treatment of older adults. Psychology and the aging revolution: How we adapt to longer life Qualls, S.H., & Abeles, N. (Eds.), (2000). Washington, DC: American Psychological Association. Examines the latest theories and research on how aging affects cognition, memory, social relationships, emotion, physical and mental health, and responses to psychotherapy. The findings presented show that although later life brings inevitable decline and losses, aging also fosters positive characteristics such as wisdom, emotional maturity, and the ability to engage in proactive strategies for shaping one's life in meaningful ways. Sections include: neuropsychology and cognitive aging, memory, emotion, social relationships in later life, health psychology, aging research and health, depression, and psychotherapy. Personality disorders in older adults: Emerging issues in diagnosis and treatment Rosowsky, E., Abrams, R.C., Zweig, R.A. (Eds.), (1999). Mahwah: Lawrence Erlbaum Associates, Inc. This book focuses on the prevalence of personality disorders in older people and the pivotal roles they play in the onset, diagnosis, course and treatment outcomes of other emotional and cognitive problems and physical problems as well. The various authors use many different theoretical perspectives (intrapsychic, interpersonal, neuropsychological, and systems), summarize the empirical literature, present phenomenological case reports, and review psychodynamic, cognitive-behavioral, and pharmacological treatment approaches. The first session with seniors: A step-by-step guide Scogin, F. (2000). New Jersey: John Wiley & Sons, Inc. This book offers practical, concrete advice for psychologists, psychiatrists, social workers, counselors, and psychiatric nurses who work with older adults. Step-by-step, the book reveals how clinicians can structure the first-and often the only-fifty-minute session to meet the special psychological needs of older adult clients. Placing particular emphasis on the skills needed to recognize the often hidden problems of senior clients, this important resource offers behavioral health care professionals clear-cut suggestions for the quick, informal evaluation of both the cognitive and medical condition of older adults. Aging and mental health Smyer, M.A. & Qualls, S.H. (Eds.), (1999). Malden, MA: Blackwell Publishers Inc. Provides an introduction to and overview of aging and mental health. The book offers a detailed and comprehensive discussion of the reigning theoretical models of mental health and their application to later life. These discussions are supplemented by case material. The authors have also included the most recent information on effective therapeutic techniques for working with older adults. Psychopathology in later adulthood Whitbourne, S.K. (Ed.), (2000). New York: John Wiley & Sons, Inc. This book provides a comprehensive review of psychopathology in older adults, combining theory, research, and practice. The ways in which psychological disorders manifest in later years of life create special challenges for professionals working with older clients. This book addresses the assessment, diagnosis, and treatment issues health professionals encounter in late adulthood. Combining theory, research, and case examples, this book explores both the physical and cognitive changes that occur as adults age. Each chapter focuses on a specific disorder (i.e. personality, anxiety, mood, sexual dysfunction, schizophrenia, dementia, suicide, substance abuse and insomnia), and includes a relevant clinical case study, which is integrated into the substantive content. This book provides the reader with the insight needed to understand and successfully treat the complex aspects of aging. Mental disorders in older adults: Fundamentals of assessment and treatment Zarit, S., & Zarit, J.M. (Eds.), (1998). New York: The Guilford Press. In this book, the authors begin by describing the normal processes of growing older, showing how healthy individuals learn adaptive coping skills to compensate for mild cognitive decline. The book then details the assessment and treatment of the disorders most commonly experienced by older adults, including Alzheimer's disease, depression, anxiety, delirium, and paranoia. The authors delineate psychological evaluation methods with particular relevance to for elderly clients, including techniques to assess mental competence and to differentiate dementia from other disorders. For each common disorder, a variety of therapeutic approaches are examined--including behavioral, cognitive-behavioral, and interpersonal psychotherapies. As the authors demonstrate, even degenerative conditions often contain treatable components. The volume also provides important information on frequently prescribed medications, facilitating more effective collaboration between mental health and medical professionals. This book is intended for all mental health clinicians who work with older adults and serves as a text for courses in psychology and aging, gerontology, and geriatric psychiatry. A guide to psychotherapy and aging: Effective clinical interventions in a life-stage context Zarit, S.H. & Knight, B.G. (Eds.), (1996). Washington: American Psychological Association. A Guide to Psychotherapy and Aging dispels the common belief that older people respond poorly to psychotherapy. A comprehensive overview of clinical interventions with older adults, backed by research and illustrated with case examples, this volume explores the challenges as well as the rewards of working with the growing elderly population. Experienced clinicians describe how to adapt traditional psychotherapeutic approaches and apply them to later-life problems. The chapters of this edited volume combine theory and research with case examples, emphasizing the practical clinical decisions faced when working with older people in either individual or institutional settings. Back to Top Book Chapters Psychotherapy with older adults: Theoretical issues, empirical findings, and clinical applications Bortz, J.J., & O'Brien, K.P. (1997). In P.D. Nussbaum, (Ed.), Handbook of neuropsychology and aging. Critical issues in neuropsychology (pp. 431-451). New York: Plenum Press. An overview of key issues relevant to psychotherapy with older adults, including accessibility and utilization of mental health services and relevant clinical, empirical, and theoretical issues in the diagnostic categories of late-life depression, anxiety, obsessive-compulsive disorder, alcoholism and substance abuse. Concludes with a discussion of suggested guidelines for therapeutic interventions with both cognitively intact and impaired older adults, with particular attention to psychiatric disability in individuals with neurological disorders. Psychotherapy with older people Culverwell, A., & Martin, Carol. (2000). In G. Corley, (Ed.), Older people and their needs: A multi-disciplinary perspective (pp. 92-106). London, England: Whurr Publishers, Ltd. Addresses the issues relevant to therapy with older people with the aim that it would prove useful not only for those readers who are involved in the provision of psychological services but also for those who are interested in the challenges and concerns faced by older people. There is a burgeoning literature covering the use and effectiveness of a range of therapeutic approaches with older people. The chapter explores the different psychoanalytical models, which are useful for considering the experience of older people, whose lives are increasingly permeated by an awareness of mortality, necessity and limitation. Aims of therapeutic work with older people and the difficulties for therapists who work with this group are addressed. Age and interpersonal issues are explored to show there importance in the psychotherapeutic relationship with older people. The role of families, institutions and services are also explored. Psychotherapy with older adults Gallagher-Thompson, D., McKibbin, C., Koonce-Volwiler, D., Menendez, A., Stewart, D., & Thompson, L.W. (2000). In C.R. Snyder & R.E. Ingram, (Eds). Handbook of psychological change: Psychotherapy processes & practices for the 21st century (pp. 614-637). New York: John Wiley & Sons, Inc. The purpose of this chapter is to review what is currently understood about effective mental health care for older adults. Specifically, the authors review patterns of mental health access Issues pertaining to assessment of older adults presenting with physical and psychological symptomatology, preparation of older adults for psychotherapy (including barriers to treatment access or engagement), efficacy of different forms or models of psychotherapy with older adults, and limitations of the authors current knowledge so that future clinicians and researchers may begin to address these gaps and ultimately enhance quality of care for the coming wave of older Americans. Treatments for depression and anxiety in the aged Niederehe, G. & Schneider, L. (1998). In Nathan, P.E. & Gorman, J.M. (Eds.). A guide to treatments that work (pp. 270-287). London: Oxford University Press. Antidepressant medications, ECT, and selected psychosocial interventions have all been shown to be efficacious treatment approaches for depression in the elderly. Most studies have used drug and psychotherapy protocols specifically tailored for use with older patients. This chapter evaluates the efficacy evidence for these treatments, emphasizing randomized clinical trials with elderly samples in which depression or anxiety have been objectively characterized. Depression in later life: Epidemiology, assessment, impact, and treatment Powers, D. V, Thompson, L., Futterman, A., Gallagher-Thompson, D. (2002). In Gotlib, I.H. & Hammen, C.L. (Eds.). Handbook of depression (pp. 560-580). New York: Guilford Press. The goal of this chapter is twofold: (1) to reinforce the importance of the diverse nature of depression in older adults and (2) to review key advances in research on the epidemiology, assessment, impact, and treatment of late-life depression. A review of the current literature has led the authors to focus on 5 questions that are important for both researchers and clinicians: (1) How big is the issue of late-life depression? (2) Is depression the same for older adults as for younger adults? (3) How is depression assessed? (4) What is the health impact of depression? and (5) How is depression treated and how well do the treatments work? Family therapy with aging families Qualls, S. H. (1996). In Zarit, S.H. & Knight, B.G. (Eds.), A guide to psychotherapy and aging: Effective clinical interventions in a life-stage context (pp. 121-137). Washington: American Psychological Association. Family therapy addresses the mental disorders and behavior problems of older adults within their primary interpersonal context, the family / provide a rationale for conducting family therapy with later-life families, examine the history of family therapy with later-life families, suggest benefits and disadvantages of this particular therapeutic approach, and describe the theory and basic techniques used in family therapy with aging families. Back to Top Reports The Surgeon General's Report on Mental Health (1999) Department of Health and Human Services. U.S. Public Health Service. Washington DC. http://www.mentalhealth.org/features/surgeongeneralreport/chapter5/sec1.asp Chapter 5, Older Adults and Mental Health, first reviews the normal developmental milestones of aging, highlighting the adaptive capacities that enable many older people to change, cope with loss, and pursue productive and fulfilling activities. The chapter then considers mental disorders in older people, including their diagnosis and treatment, and the various risk factors that may complicate the course or outcome of treatment. Gains that have been realized in making appropriate mental health services available to older people and the challenges associated with the delivery of services to this population are discussed. The chapter concludes with a review of the supports available for older persons that extent beyond traditional, formal treatment settings. Older Adults and Mental Health: Issues and Opportunities (2001) Department of Health and Human Services. Administration on Aging, Washington DC. http://www.aoa.dhhs.gov/mh/report2001/default.htm This report focuses on community-based services that can be utilized by a wide range of elders, including older persons in good mental health, for whom outreach and education might be helpful; older persons who are experiencing acute stress or crisis and those with severe mental disorders. While substance misuse and abuse are closely intertwined with mental health and merit full discussion, the primary focus of this report is on mental health and aging and the services and systems are designated to deal with these areas of concern. Back to Top ***Information for Older Adults and Their Families*** http://www.nia.nih.gov/health/agepages/depresti.htm The National Institute on Aging website has Age Pages on various topics. "Depression: A Serious but Treatable Illness" discusses its causes, symptoms, treatment and helpful resources. Back to Top