Generalities

8.1 Background

8.1.1 Generalities

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. . . I am convinced that no one therapy has a monopoly or truth for human experience. The essence of therapy¹ is the personal encounter between the client and therapist ( . . . ) I see the therapeutic encounter as an opportunity for clients to explore their experiences, learn about themselves, and learn how to cope in a safe place with someone who tries to understand them, who meets them as another human being, and who has struggled to cope and make sense of life [1].

During the French Revolution, Philippe Pinel pointed out the lack of knowledge regarding proper treatment of the psychiatrically ill. “One of the fundamental principles of conduct one must adopt toward the insane is an intelligent mixture of affability and firmness” [2]. With such a philoso- phy, Pinel was establishing the principles of individual psy- chotherapy upon which Sigmund Freud would build more than a century later [2]. The Enlightenment era that ensued shaped the development of modern psychiatry; its key influ- ence emphasized the dignity of each human being and the importance of humanism. As a result, early psychiatrists attempted to develop therapeutic techniques that included personalizing the care, using non-intrusive and compassion- ate approaches, appealing to reason when possible, and giv- ing the patient some responsibility for improving symptoms and behavior [3].

This still constitutes the standard of care for clinicians today, not only psychiatrists but all physicians, nurses, and psychotherapists. The gifts of modern science and the phi- losophy of the Enlightenment to the specialty of psychiatry included stressing the importance of careful observation in order to understand disease, mechanisms, and progression.

Other significant legacies are an emphasis on the dignity of the individual, the value of “moral treatment,”² and the integration of the “mind,” “spirit,” and “brain” rather than a dualistic understanding [3]. It is interesting and reassuring to note that such core values still seem to have their place in psychotherapy, although they might have made their way through our collective unconscious under a different name sometimes: the “not-knowing stance” necessary to observe with high level of objectivity, a patient-centered approach, trauma-informed care, and the biopsychosocial model (see .Table 8.1).

1 The words “therapy” and “psychotherapy” are considered equivalent in the context of this chapter (unless stated otherwise);

hence, both will be used interchangeably. The same applies to

“therapist” and “psychotherapist.”

2 Up until the French Revolution (late 1700s), psychiatrically ill persons were treated as criminals, shuttered away in dungeons, and chained to their cells in abominable conditions. Philippe Pinel, known to many as the first to remove chains from the “insane,” laid the groundwork for humanitarian treatment (“traitement moral”). His publications assured him the honorific title, “father of psychiatry” [2].

Learning and personal growth can take place throughout the life span, and advanced age should not be a deterrent for clinicians in initiating a psychotherapeutic journey with geri- atric patients [4]. In fact, many older adults express a prefer- ence for psychological over pharmacological treatments [5, 6].

Moreover, the geriatric population faces specific challenges, especially upon relocating to long-term care facilities, including difficulty in establishing meaningful interpersonal relationships with other residents and staff members, loss of identity and pur- pose in life, sadness and boredom, and lack of social support [7]. Suicide is largely a geriatric concern (see 7Chap. 10), with the highest rate of suicide completion in depressed older white males, particularly those who have been recently widowed or who use alcohol excessively. Hence, the centrality of the interac- tive nature of the psychotherapeutic work becomes a tremen- dously relevant factor in tackling those core issues.

Also, given the impact of side effects of medications in an aging brain and body and the risk of drug interactions with other classes of medications, such a preference for psychother- apy should be supported. When considering older patients, the open-minded therapist believes in an approach that does not generalize or distinguish on the basis of age. Discovering the relevant developmental phase for each individual (Erik Erikson listed eight stages of psychosocial crisis) can be very helpful. Even though old age is usually associated with “ego integrity versus despair,” other phases may help more with therapy planning if they are still incomplete. We can assist each patient in deter- mining at which developmental phase they are currently stuck, creating a more acceptable plan for therapy (see 7Chap. 25).

Clinicians should accept that patients will do what they are able to do. Some older adults do better than the young and others not so well, but so what? When we want to do our best, we adapt and do our best. Plus, clinicians should take every opportunity to be psychotherapeutic, bringing each patient further onto the path of self-knowledge and healing. Sometimes, the intervention is just about planting a thoughtful seed even during brief encounters.

Nonetheless, this chapter will be an overview of the vari- ous approaches and will detail which psychotherapies were studied specifically with an older population. Reminiscence therapy has been specifically developed for older populations.

Cognitive behavioral therapy (CBT) and interpersonal ther- apy (IPT) have been developed for depressive disorders. CBT has also been developed for anxiety disorders and dialectical

.Table 8.1 Core values in psychotherapy Enlightenment era

(eighteenth century) Modern (twenty-first century) psychotherapy

Careful observation to determine pathophysiology

Being “curious and interested,”

“not-knowing stance”

Dignity Patient-centered care

Moral, nonintrusive treatment

Trauma-informed care

Integration of the mind, spirit, and brain

Integrative care, biopsychosocial conceptualizations of illness and treatments

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behavioral therapy (DBT) for personality disorders, which have been successfully modified for older patients. Both CBT and DBT can be learned, and because they have been manu- alized, there is a potential for greater consistency in clinical practice. Furthermore, stronger statistics support their appli- cation. But we are aware that this text is also only an over- view; it does not render justice to over a century of extensive work by all the founders and clinicians of different types of psychotherapy who should be better placed to speak of their own approaches. To fully appreciate each original author’s specific therapy, we invite the reader to refer to the formative research and writings.

However, it is important to keep in mind that even if evi- dence is lacking for a specific type of psychotherapy, it can remain valuable and worth trying with an older adult based on clinical judgment, the patient’s goals, and mutual agree- ment. After all, each therapist’s own set of skills is a unique tool that can catalyze the patient’s desire to change or feel bet- ter; for specific approaches to be effective and meaningful, they should incorporate such assets and embrace the use of creativity.

The concept of psychotherapy has evolved over the past decades and encompasses a highly diverse arsenal of inter- ventions to the point that finding a universally accepted uni- fying definition can be challenging. For therapists working with older patients, another one of their missions will be to help their patients identify less with their aging bodies and our culture’s view of attractiveness, shifting instead to a para- digm that values life experience and the cultivation of wis- dom and works on redefining personal goals [1].

Older adults constitute a heterogeneous group, and yet many have common features. Because of the process of psy- chotherapy itself, sometimes involving tangible activities (e.g., homework for CBT) and in other cases not so tangible elements (e.g., intuitive interventions, nonverbal and some- what unconscious interactions in psychodynamic therapy), it might be hard to pinpoint what exactly worked or made it successful. There is a significant body of research that finds common effective factors to be at the root of successful outcome of psychotherapy (see .Table 8.2) [8]. Most com- parisons of different therapies find them more alike than dif- ferent. Trust is a fundamental element; patients make rapid judgments about whether they can trust their therapist. The initial encounter is critical based on the observation that more patients prematurely terminate from therapy after the first session than at any other point. Laska et al. [9] found that 11.5% of success in psychotherapy is accounted for by collaboration and common goal consensus, and 9% is due to empathy, 7.5% to therapeutic alliance, 6.3% to positive regard and affirmation, 5.7% to congruence and genuineness, and 5% to other therapist factors. They believe that only 1% of outcome success is attributable to treatment method per se.

Alliance is the most researched common factor [9]. It can be defined as “the degree to which the therapy dyad is engaged in collaborative, purposive work.” Empathy is a complex pro- cess by which an individual can be affected by and share the emotional state of another, assess the reasons for another’s

state, and identify with the other by adopting his or her per- spective [8]. Related constructs are positive regard/affirma- tion and congruence/genuineness.

These factors are more than a set of therapeutic elements that are common to most or all psychotherapies. They col- lectively shape a theoretical model about the mechanisms of change in psychotherapy [8]. Interestingly, experience or expertise is not essential; that is to say, a positive outcome is possible even when working with a beginning therapist.

While no therapy models are seen as much more effec- tive than others, there is no evidence of harmful results from using already well-learned therapies that incorporate the com- mon factors described previously. To adapt to specific needs or limitations of older patients, the most valuable therapist will be flexible, eclectic, and adjusting to frequent changes in situation or medical status. He or she will use approaches that are the most helpful at any given moment. Integrative therapists have the ability to combine various approaches, e.g., to bring a gestalt perspective to CBT and/or a cognitive perspective to gestalt therapy [10]. All therapies with structure, given by empathic and caring therapists, and which facilitate the patient’s engage- ment in behaviors that are salubrious, have approximately equal effects [8]. Conversely, there is evidence that rigid adherence to a therapy protocol can attenuate the alliance and increase resis- tance to the treatment, whereas flexibility in adherence is related to better outcomes. Studies have shown that effective therapists are able to form stronger alliances across a range of patients, have a greater level of facilitative interpersonal skills, express more professional self-doubt, and engage in more time outside of the actual therapy practicing various therapy skills [8].

One of the outcomes of a process where many common factors are actualized is attachment. Attachment is now well accepted as beneficial at all ages [11]. When attachment is deficient in childhood, there are greater challenges, but it is never too late to address and work on them. Hence, the patient’s connection with a therapist, supportive friendships (that flourish when fairness skills are high enough), and par- ticipation in good groups are effective therapies.

.Table 8.2 Examples of common factors in psychotherapy Patient factors Therapist

factors Relationship factors (factors common to patient and therapist) Motivation/

desire to change cognitive/behav- ioral/emotional patterns

Empathy/

respectful listening Positive regard/

affirmation

Common goal Therapeutic alliance

Facing and exposure

Congruence/

genuineness

Expectation of treatment effectiveness Mastery and

control

Confronting Consistency Availability Flexibility and open-mindedness

Belief in the internal locus of control Appropriate silences for reflection Psychotherapy in Late Life

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PSYCHOTHERAPIES a

Psychodynamic Systemic/

family CBT

Experiential / Existential

Psycho- analysis

Life review/

Reminiscence

therapy IPT Cognitive Behavioral PST

DBT MBSR

ACT SFT

Motivational interviewing Logotherapy

Gestalt

Art therapy

Dreamwork

Grief MBT counseling

SUPPORTIVE THERAPY

.Fig. 8.1 a Types of psychotherapy Teaching Point

Common or nonspecific factors in psychotherapy mean that the main elements (such as empathy and work- ing toward a common goal) contributing to a thera- peutic success are often found in most of the various approaches. The inherent qualities and skills of the thera- pist and the commitment of both patient and therapist are more important than the technical skills.

The various overlaps and internal variations of some forms of therapies make the process of classification daunting and arbitrary at best (see .Fig. 8.1a, b). Do we have another indication that psychotherapies might have more similarities than differences? After all, the therapy can be a complex inter- play of subjective, multilayered, overlapping elements. In any case, it is important to keep in mind that just like languages, medical treatments or educational methods, psychotherapies

are likely to change to adapt to the specific cohorts of peo- ple that also evolve throughout time. Just like each person’s development, the process of co-creation between therapist and patient is inherently dynamic and unique.

In a case study, Rothe suggested that “impending death may force the individual to undergo a hurried and com- prehensive process of self-analysis and to engage in urgent corrective actions” [12]. Realizing that urgency may be coun- terproductive allows more deliberate and accurate planning and negotiation of therapy.

Psychotherapy is often overlooked as a treatment modality despite being an effective treatment method for a number of psychiatric disorders seen in older adults. Therapy especially helps with many stressors including family, relationship, and health changes and even the role transitions involved in mov- ing to long-term care settings [13]. Unfortunately, there is a paucity of publicly funded psychotherapy services for older adults. As well, some medical practitioners may be reluctant to refer geriatric patients for psychotherapy [14]. Because of

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the cost and limited availability of psychotherapy in certain settings, we suggest assessing a patient’s “readiness” for change in psychotherapy. The first step is for both the therapist and the patient to recognize and accept that a problem serious enough to justify the work and cost of psychotherapy exists.

It is a choice that an informed individual makes rather than a prescription that another believes will be corrective therapy.

Therapy is ideal when it is sought by a person who is ready for it. The therapist does the negotiating with the patient at the earliest part of therapy. When there is no negotiation but therapy is presented as “take it or leave it,” the risk of “leaving it” (not really being “onboard” for the project, etc. even as clear defiance) is much higher. The negotiations are part of the respect building between parties. For agencies that can provide funded therapy, triage principles are often practi- cal and needed. Some cases are trivial, and others are more difficult that almost no amount of resources could be effec- tive. Efficiencies like group therapy can also provide equal or better results for some patients with common problems.

There are twice as many women as men in the age group of 65–85 years [15]. This fact can put women at higher risk of isolation, which can lead to a higher prevalence of depressive

symptoms [15]. Psychotherapeutic interventions such as groups often help increase socialization and ability to cope with losses (see .Table 8.3). Being in a group with others who experience similar problems helps correct self- esteem issues by establishing a better perspective. A poorly developed sense of self will make the patients more fragile and sensitive to losses. On the other hand, a healthy sense of self or “flex- ible narcissism” (developed through mirroring, idealization [16], good-enough parenting, and some early experiences of frustration with validation during childhood and in group therapy) helps a person to process losses more adaptively.

Age can make one more resilient to stressors [15]. The frequent age difference between the patient and the thera- pist may lead the patient to relate to the therapist as a son or daughter, a phenomenon called reverse transference [15]. Romantic transference can be a source of humilia- tion for the patient. Conversely, the therapist’s fear of aging and emotional memories of parents and grandparents are another common area of interference [15]. Careful attention to the realities of therapy rather than friendship is extremely important for beginning therapists. Being objective requires healthy boundaries that recognize that the bulk of hard work

b Exploration

of past

Behavioral modification Mind/Body

awareness

Psychoanalysis Psychodynamic Life review

Yoga Meditation Relaxation

Breathing exercises

Exposure CBT, PST, MI, exercise LogoTx

Experi- ential

IPT , SFT

DBT ACT 12-step MBSR Systemic Common

factors

.Fig. 8.1 (continued) b Overlap of therapeutic approaches. ACT Acceptance and Commitment therapy, CBT Cognitive-behavioral therapy, DBT Dialectical-behavioral therapy, IPT Interpersonal therapy,

LogoTx Logotherapy and existential analysis, MBSR Mindfulness-based stress reduction, MBT Mentalization-based therapy, MI Motivational interviewing, PST Problem-solving therapy, SFT Schema-focused therapy Psychotherapy in Late Life

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really does belong to the patient, and when therapists take too much responsibility for the outcome, blurred boundaries result in ineffective therapy.

Although some believe that short-term psychoanalytic therapy and cognitive psychotherapy are less suitable for older adults because they make considerable demands of the individual’s capacity for introspection or abstract thinking, their features are important and contribute to effectiveness in mentalizing, or theory of mind. There is good evidence supporting the new therapy of mentalizing [17]. Mentalizing includes the common effective factors listed previously, and it focuses on learning to think about thinking, one’s own thinking and that of others, as a focus for finding fairness and consensus between therapist and patient.

As a practical approach for those wishing to provide effec- tive psychotherapy who have not had extensive training, we suggest that the most powerful component of therapy is the relationship one develops with the patient. Various authors believe that such a relationship as lived rather than analyzed is the primary therapeutic intervention [11]. We believe that

this is best accomplished through being rather than doing.

There is a rich heritage for this idea in eastern philosophy (Buddhist especially), and mindfulness emphasizes it as an overall goal. Being in the moment is a constant goal for medi- tation. Mindfulness has been developed and widely accepted therapy in the world as a foundation for emotion manage- ment and well-being. In our daily life, it means being aware, each moment, of what we are doing as we are doing it [18], as opposed to being on automatic pilot.

Participating in psychotherapy appears to be a form of remoralization [8]. From a philosophical perspective, since older adults are a vulnerable population and are often victims of oppression or abuse, and also due to ageism, one could conceptualize the framework of therapy as one enhancing social justice [19]. All patients possess inner strengths, and it is the therapist’s role to invite them to unearth such riches.

Seeing our patients as capable beings (and also teachers to the therapist interested in the breadth of human experience) rebalances perspective and is thus empowering.

The list of specific therapies below is not for practitioners to follow. At best, it suggests techniques and concepts that we could incorporate leading to creative eclectic therapies of our own. Those who have been trained (or choose to be) in any of the specific therapies already have or will gain a solid framework to meet the patients where they are. In sharing that with patients, they are meeting one of the most impor- tant components of common factors theory.