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Transcript of Geriatric Psychotherapy
Sarah Mourra MD
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
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
physical disability/ transportation limitations
moderate to severe cognitive impairment
Cognitive Behavioral Therapy
: Symptoms result from interpersonal issues
1) grief (death of spouse)
2) interpersonal disputes (conflict with adult children)
3) role transitions (retirement)
4) interpersonal deficits (lack of assertive skills)
: 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
: Patient focuses on past memories, life experiences
Encouraged with photographs, visits to childhood places
Poor evidence for treating clinical symptoms, may improve self esteem
Reasons for Seeking Therapy:
Lifelong or new onset psychiatric symptoms
Motivation to make the most of the time remaining
Sense of loneliness and need for attachment
Physical decline experienced as loss of self-sufficiency
Age-related sensory deficits
Psychodynamics of Aging
Integrity vs. Despair/Disgust:
-Acceptance of life's course as inevitable and satisfying
-Acceptance of death without fear
-Feeling that life is a failure
-Feeling that it is too late to change directions
: The "ripening of the fruit" of earlier stages is necessary for ego integrity
: 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
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
: CBT, Interpersonal, Problem Solving Therapy, Psychodynamic Psychotherapy
Reminiscence, Bibliotherapy, Dignity Therapy
Augments patients' present strategies to improve ability to handle day-to-day problems
: 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
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)
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."
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.
Pocket Talker: amplifies sound
"In short, the answer to the question of whether psychotherapy needs to be adapted for work with older adults is,
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
ability to work with new problems/ information quickly
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.
: 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.
: senior center, adult day care, hospital, post-retirement life, long term care setting (dependency) (Baltes, 1995)
"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."
Experiential Competence (family, work, relationships)
Chronic illness and disability
Grief and loss
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
(Chochinov et al 2011)
(Chochinov et al 2005)
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