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Geriatric Psychotherapy

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Transcript of Geriatric Psychotherapy

Psychotherapy and the Older Adult


Sarah Mourra MD
Clinical Instructor
UCLA Geriatric Psychiatry

"Psychotherapy is not possible near or above the
age of 50
, the elasticity of the mental processes, on which treatment depends, is as a rule lacking-
old people are not educable
- and on the other hand, the mass of material to be dealt with would prolong the duration of treatment indefinitely."
- 'On Psychotherapy,' 1905
Why Psychotherapy?
50-75 percent of older adults prefer counseling over medications

Psychotherapy can be as effective as medication, avoiding side effects

Mild cognitive impairments do not have a significant impact on response
Obstacles:
stigma
physical disability/ transportation limitations
moderate to severe cognitive impairment
Psychotherapies
Cognitive Behavioral Therapy
Problem Solving
Therapy (PST)
Interpersonal Therapy
Theory
: Symptoms result from interpersonal issues

Focus On:
1) grief (death of spouse)
2) interpersonal disputes (conflict with adult children)
3) role transitions (retirement)
4) interpersonal deficits (lack of assertive skills)
Psychodynamic Psychotherapy
Theory
: current experience influenced by early childhood experiences Focus on how relationships are internalized into a sense of self and how unresolved conflicts may be activated by present events (ie loss)

Patients develop insight into past experiences and their bearing on the present

Short term psychodynamic psychotherapy equally effective as CBT for depression (12-24mos f/u)



Life Review/ Reminiscence Therapy
Theory
: Patient focuses on past memories, life experiences

Encouraged with photographs, visits to childhood places

Poor evidence for treating clinical symptoms, may improve self esteem
P
Reasons for Seeking Therapy:
Lifelong or new onset psychiatric symptoms
Crisis events
Life Transitions
Motivation to make the most of the time remaining
Sense of loneliness and need for attachment
Physical decline experienced as loss of self-sufficiency



Unique Considerations:

Age-related sensory deficits

Cognitive Impairment
Unique Considerations
Unique Considerations
Chronic Illness
Unique Considerations
Family involvement
Psychodynamics of Aging
Eriksonian
Integrity vs. Despair/Disgust:

-Ego Integration/Wisdom
-Acceptance of life's course as inevitable and satisfying
-Acceptance of death without fear
vs.
-Feeling that life is a failure
-Feeling that it is too late to change directions
Erikson
: The "ripening of the fruit" of earlier stages is necessary for ego integrity

Vaillant
: Career consolidation and "keeper of meaning" role

Shift from "taking care of one's children to preserving one's culture"- passing knowledge down and investing in meaning that persists beyond the self

Most evidence to date in late life depression, anxiety disorders

Theory
:

patient lacks coping skills to manage challenges of aging pessimistic view of self and world
less active socially

Telephone and primary care versions

Best results when combined with medication



Most evidence
: CBT, Interpersonal, Problem Solving Therapy, Psychodynamic Psychotherapy

Less Evidence:
Reminiscence, Bibliotherapy, Dignity Therapy
Augments patients' present strategies to improve ability to handle day-to-day problems

Theory
: Symptoms result from repeated failed attempts to solve problems hopelessness and helplessness

Most effective when used in combination with medication

Ideal for patients with executive deficits
As effective as nortriptyline for depression, best in combination
Bibliotherapy
Theory:
Patients can acquire skills via selected readings

Readings have a CBT focus (ie. David Burns' Feeling Good)

At 3 month follow up, no significant differences between bibliotherapy and CBT (Floyd et al 2004)
Vignette 2:

A 67 year old former ballet dancer with no previous psychiatric history comes to your office seeking assistance with symptoms of depression, anxiety following a serious car accident one year prior. She has developed a phobia of driving anywhere, leading to social isolation.

She describes feelings of sadness since her partner died of cancer 5 years ago, describes worries about dating again due to feeling disgusted with her body "because it is an old woman's body now."


References


Baltes, MM. Dependency in Old Age: Gains and Losses. Current Directions in Psychological Science 4: 14-18, 1995

Chochinov et al. The effect of dignity therapy on distress and end-of-life experience in terminally ill patients: a randomised controlled trial. Lancet Oncology; 12(8): 753–762, 2011

Floyd M, Scogin F, Mc-Kendree-Smith NL, et al: Cognitive therapy for depression: a comparison of individual psychotherapy and bibliotherapy for depressed older adults. Behav Modif 28:297–318, 2004

Knight, B. et al. Adapting Psychotherapeutic Practice for Older Clients: Implications for the Contextual, Cohort Based Maturity Specific Challenge Model. Professional Psychology: Research and Practice; 29(1): 15-22, 1998.

Gum AM, Areán PA, Hunkeler E, et al: Depression treatment preferences in older primary care patients. Gerontologist 46:14–22, 2006

Lavretsky, H. "Psychotherapy" Late Life Mood Disorders, Oxford University Press 2013

Lynch, T, Smoski, M. "Individual and Group Psychotherapy," The American Psychiatric Publishing Textbook of Geriatric Psychiatry, 4th Edition

Morgan, A. "Practical Geriatrics: Psychodynamic Psychotherapy with Older Adults" Psychiatric Services, 2003

Schaie, KW. Intellectual Development in Adulthood: Seattle Longitudinal Study, New York 1995. Cambridge University Press.

Thompson LW, Gallagher D, Breckenridge JS: Comparative effectiveness of psychotherapies for depressed elders. J Consult Clin Psychol 55:385–390, 1987





Everybody Rides the Carousel: John and Faith Hubley, 1975
A 90 year old musician with a medical history of glaucoma and hearing loss presents to your office. Prior to the appointment he contacts you to say that he felt the front desk staff was "cold" and too focused on his co-pay for the visit. He comes for the consultation, and states that since turning 90 he has wanted to die. He states that this is because "everyone treats me differently now" and "nobody cares about me except my wife." His wife is an actress who is 20 years younger. He discusses feeling as though others do not take him seriously in his industry when they hear his age, and also struggles with his legacy and what he leaves behind.

He mentions that he fathered a child 18 years ago via sperm donation to a couple with whom he and his wife were close friends. Since that time he has distanced himself from this couple, as he feels like "they only call me when they need something." He feels hurt by their daughter's refusal to have a relationship with him. He has been unable to sleep due to ruminating about their reluctance to allow him to tell mutual friends about his status as their daughter's biological father, stating "they must see me as someone they are ashamed of, who they look down on." He describes a lifelong pattern of feeling "unloved" by others, with a sense that other people are only using him.
Vignette 1:
Pocket Talker: amplifies sound

Context
Cohort
Maturity
Specific Challenges

CCSMC Model
"In short, the answer to the question of whether psychotherapy needs to be adapted for work with older adults is,
Yes
,
but 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."
-
-Robert Knight, PhD
Normal Cognitive Changes in Aging
Fluid intelligence:
ability to work with new problems/ information quickly

Crystallized intelligence:
general fund of information and experience
Membership in a birth-year defined group that is socialized into abilities, beliefs, attitudes and personality dimensions that stay stable as they age.
Cohort:
Example
: Extroversion and threat reactivity increasing in successive cohorts across the century, education (Schaie 1995)
The social ecology of the settings in which older adults live, seek healthcare, spend leisure time can affect the individual's self concept and shape options for behavior.

Example
: senior center, adult day care, hospital, post-retirement life, long term care setting (dependency) (Baltes, 1995)
Context
:
"At 80, one can take a long view and have a vivid, lived sense of history not possible at an earlier age. I can imagine, feel in my bones, what a century is like, which I could not do when I was 40 or 60.
I do not think of old age as an ever grimmer time that one must somehow endure and make the best of, but as a time of leisure and freedom, freed from the factitious urgencies of earlier days, free to explore whatever I wish, and to bind the thoughts and feelings of a lifetime together."
-Oliver Sacks
Cognitive complexity
Emotional Maturity
Experiential Competence (family, work, relationships)
Maturity
Specific Challenges
Chronic illness and disability
Grief and loss
Ethnic issues
Dignity Therapy

Theory:
Near end of life loss of dignity/ meaning

depression and anxiety, hopelessness, burden

Helpful for patients with terminal illness or nearing end of life




"When you face death, it's like facing a wall, and it forces you to turn around and look at the life that you've lived."

"The prevailing mythology is that you die the way you live, and you can't change yourself in any way. The fact is that the last few months of life — because of the awareness of death — create an urgency that facilitates growth and change."

-William Breitbart MD
Sloan Kettering Cancer Ctr
On Dignity Therapy
Specific Challenges:
Caregiving
(Chochinov et al 2011)
(Chochinov et al 2005)
Vignette 1:
Social history is significant for a son in his 60s with whom the patient has never felt connected or close. He was raised in the Jewish faith, and grew up very poor. He described his mother as "very crude, uncivilized, self-centered and vain." He was raised primarily by his older sister who he described as beautiful, refined and generous, who became a famous costume designer but never married due to concerns about taking care of their mother, though she never got along with their mother and "my mother never said a word of thank you." His sister passed away in 1999 which was a huge loss for him.
What more information would you need to know?
What approach would you use?
Are there important context, cohort, maturational and special challenges that are at play?
Strauss, W and Howe, N. Generations: The History of America's Future 1584-2069. Quill Publishing, 1992
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