Types of Psychotherapies - Geriatric Psychiatry

8.1 Background

8.1.3 Types of Psychotherapies

In the context of emphasizing the importance of psychotherapy for mild depression in older patients, the World Health Organization defines four main psychotherapeutic treatment groups: psychodynamic therapy, interpersonal therapy (IPT), supportive counseling (Rogerian person-centered therapy), and cognitive behavioral therapy (CBT) [20]. This textbook chapter will organize the main psychotherapies based on a similar structure and listing additional variants in certain categories (see .Fig. 8.1a). While the following approaches described have been categorized based on their philosophy or focus of treatment, it is important to keep in mind that they may be used in combination, or two approaches can overlap (see .Fig. 8.1b). For instance, schema-focused therapy includes elements of CBT and psychodynamic therapy. Also, it might be challenging to make the distinction between technique and therapy (e.g., CBT can be delivered as bibliotherapy).

Supportive Therapy

This therapy constitutes the fabric, the common denominator of all approaches (see .Fig. 8.1a). It includes nonspecific factors (see .Table 8.2). Providing a safe environment, warmth, empathy, and hope is key component of this approach, like the “oxygen” of the therapeutic dyad [4]. The encouragement of an internal locus of control is another factor common to all psychotherapies.

It is important to use positive supportive statements (e.g., genuinely felt compliments when appropriate) [21]. On a nonverbal level, a handshake or a tap on the shoulder at the beginning and/or at the end of the session as well as physi- cal assistance when the patient is frail can represent a nice reassuring gesture, a gentle emotional holding to facilitate the connection if there is some sensory impairment. Grief support counseling is a subset of this approach and should be available early on. Recovery from grief means “discover- ing and completing” the unfinished emotions or elements regarding the unique lost relationship [22]. Contradictory emotions will be looked at and eventually integrated in a whole perspective of what has been and can include giving up the hope for a better or different yesterday. For some people it is accomplished through a process of forgiveness, but it is important to start with each person’s own definition, mis- conceptions, or resistance elements toward this often vague concept. A patient at one of the author’s community clinic aptly wrote during a creative writing session: “Forgiving is a word for those who don’t have to use it.”

Behavioral Therapies

These interventions share the theoretical assumption that human behavior is learned. They can employ strategies such as (1) changing how people process information from their environment (e.g., cognitive restructuring), (2) skill building (e.g., problem-solving, communication skills), and (3) mood regulation skills (e.g., mindfulness exercises, behavioral activation).

Behavioral therapy tends to focus primarily on skill building and assumes that changes in information processing are achieved via increased positive experiences with new behavior.

Mindful Awareness

Kabat-Zinn’s operational working definition of mindfulness is “the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to things as they are” [23]. Mindful awareness means attend- ing to the richness of our here-and-now experiences and is a form of intrapersonal attunement [18]. In The Mindful Brain, Daniel Siegel describes admirably mindful awareness as the following: “The role of mindful awareness is to enable the mind to “discern” the nature of the mind itself, awakening the person to the insights that preconceived ideas and emotional reactions are embedded in thinking and reflexive responses that create internal distress. With such disidentification of thoughts and emotions, by realizing that these mental activities are not the same as “self,” nor are they permanent, the individual can then enable them to arise and burst like bub- bles in a pot of boiling water” [18].

Wallin wrote that “mindfulness (like mentalizing) can allow us to be present for our experience, rather than sub- merged by or dissociated from it” [11]. It is a form of experience that seems to promote neural plasticity. It activates different areas of the brain, e.g., some that might be malfunc- tioning when there is cognitive impairment from depressive disorders, posttraumatic stress disorder, or attention deficit hyperactivity disorder. Immune response, stress reactivity, and general well-being are also improved with mindfulness.

Additionally, mindfulness-based stress reduction (MBSR) can help reduce the subjective state of suffering and accelerate healing for chronic medical conditions. Interpersonal relationships, which have been shown to promote emotional longevity, are also enhanced by its practice. Via cognitive therapy, mindfulness can prevent relapse of depressive disorder. .Table 8.5 lists some symptoms that mindfulness could alleviate.

Studies have shown that specific applications of mindful awareness improve the capacity to regulate emotions and reduce negative mindsets [11]. It helps in transitioning from one activity to the other in our busy, fast-paced existence.

Therefore, a psychotherapeutic session (individual or group) often starts with such a practice.

Mindfulness practices are therefore the foundations of many psychotherapy models. It may result in outcomes such as patience, non-reactivity, self-compassion, and wisdom [18].

Mindful awareness can promote love for oneself. But mindfulness is not “self-indulgent”; in fact, it is a set of skills that enhances the capacity for caring relationships with others. By becoming one’s best friend, we are more apt to care for others.

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Religious practices such as prayers, as long as they are not socially oppressive, should be encouraged whenever they pro- vide relief from distressing emotions, since they act similarly to mindfulness practices. Many forms of prayer in different traditions require that the individuals pause and participate in an intentional process of connecting with a state of mind or entity outside the day-to-day way of being [18]. Prayer and religious affiliation in general have been demonstrated to be associated with increased longevity and well-being.

Cognitive Behavioral Therapy (CBT)

Aaron Beck, a psychoanalytically trained therapist who wanted to implement simple effective therapies, developed the CBT. CBT focuses on dysfunctional beliefs and aims to correct the underlying dysfunctional beliefs that maintain depressive symptoms (see .Table 8.6). Our thoughts influence our behaviors, which influence our mood (and vice versa), and these three areas interplay and impact one another.

As clinically indicated, such a therapy can focus on either the cognitive component (inaccurate assumptions or dysfunctional thought patterns, by challenging them or using Socratic reasoning) or on the behavioral component (by developing more adaptive behaviors) or both. Behavioral techniques include monitoring behaviors and affect patterns, assigning pleasant events, controlling or avoiding depression- eliciting stimuli, and limiting worry and depressive rumi- nations with time limits, behavioral exposure, and skills training (through relaxation, problem-solving, and interpersonal skills). Socratic questioning is used in psychotherapy as a cognitive restructuring technique, the purpose being to help uncover the assumptions and evidence behind distressing thoughts through a dialectical perspective. .Table 8.7 gives examples of Socratic questions in cognitive therapy to deal with automatic thoughts (i.e., fleeting, primitive, tele- graphic thoughts at the deepest level of conscious thought that we feel to be true and situation-specific thoughts) that distress the patient. Careful use of Socratic questioning enables a therapist to challenge recurring or isolated instances of a person’s illogical or maladaptive thinking while maintaining an open position that respects the internal logic to even the most seemingly illogical thoughts. Ultimately, the goal is to

teach the patient a new rational way of approaching reality, in the hope that he or she will use such tools in the future and will prevent the emergence of dysfunctional thoughts and resulting unpleasant emotions.

These therapies conceptualize depression as the result of an inability to cope with life stressors, poor affect regulation skills, social isolation, and difficulty in solving problems [24].

There is sufficient evidence in the literature to support the use of CBT in the treatment of major depression and generalized anxiety disorder in the older adults [14]. Areán and Cook [25] reviewed data on the acute and long-term effects of CBT, IPT, brief dynamic therapy, and combined antidepressant medication and psychotherapy. In their literature review of psychotherapies for late-life depression, they found that CBT and most other modalities were efficacious and necessitated minor adaptations [25]. Patients who respond to CBT tend to maintain the treatment gains up to 2 years [25]. In the same review, two other studies showed that CBT delivered as bibliotherapy was more efficacious in treating mild- to- moderate depressive symptoms in older adults than attention control and no treatment. Treatment gains persisted for 2–3 years after psychotherapy ended. Based on five trials from a Cochrane study [20], cognitive behavioral therapies were more effective than controls. Three trials examined cognitive bibliotherapy compared with waiting list control. A highly significant difference between groups was found in favor of cognitive bibliotherapy.

.Table 8.5 Indications for mindfulness practices Clinical problems

Depressive disorders

Anxiety disorders (panic disorders, agoraphobia) Eating disorders

Posttraumatic stress disorder Obsessive-compulsive disorder Beginning of each therapy session

Prior to an anxiety-provoking procedure (e.g., surgery, CT scan for a patient with claustrophobia)

.Table 8.6 List of common cognitive distortions used among older adults

Dysfunctional cognitive patterns

Clinical manifestations and associated script

Black and white thinking

Depression: “If I’m not a success, I am a total failure.”

Anxiety: “If my blood pressure is higher than 140, I’ll die.”

Discounting the positive

Depression: “Nothing works, what is the point in trying another medication/therapy?”

Anxiety: “I’m doomed, I panic upon meeting new people about 90% of the time.”

Should statements

Depression: “I should go to this funeral, my religion says so, but I feel guilty because I am tired and I don’t feel like it.”

Anxiety: “I should go to this funeral otherwise my family will stop talking to me and I’m afraid of being rejected.”

Catastroph- izing

Depression: “If I fall and need help, no one will be there to help me because I am worthless.”

Anxiety: “If I’m late for the appointment with the doctor, it will be a disaster.”

Jumping to conclusions

Depression: “She didn’t come visit me, therefore she hates me, everyone does.”

Anxiety: “The doctor didn’t get back to me with the results, it must mean I will die soon and he’s afraid to tell me.”

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CBT along with cognitive therapy and brief dynamic therapy has positive effects 1 and 2 years after treatment [24]. There is proven efficacy of CBT and brief psychodynamic therapy for anxiety and depressive disorders. CBT and schema-focused therapy (see 7section Schema-Focused Cognitive Therapy) in particular can be useful for older adults [26].

Dialectical Behavioral Therapy (DBT)

DBT groups teach specific skills to increase mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. The modification for older adults targets cognitive/

behavioral rigidity and emotional constriction. DBT plus medication showed a faster reduction in depressive symptoms when compared with medication alone [6].

Mindfulness or stress reduction-based techniques are among the modalities to achieve better emotional regulation. The main characteristics of mindfulness include (1) observing, noticing, and bringing awareness; (2) describing, labeling, and noting; and (3) participating, all of which are done (a) nonjudgmentally with acceptance, (b) in the present moment, and (c) effectively.

Social Problem-Solving Therapy (PST)

It is based on a model in which ineffective coping under stress is hypothesized to lead to a breakdown of problem- solving abilities and subsequent depression. It mainly addresses:

5 Problem details 5 Present goals 5 Multiple solutions

5 Specific solution advantages

5 Assessment of the final solution in context

PST is more effective than reminiscence therapy or waiting list [25]. It can be delivered in a limited amount of time;

therefore, it is suitable in primary care settings. PST was associated with significantly greater improvements in depressive symptoms compared with reminiscence therapy.

Motivational Interviewing

Motivational interviewing is a method that works on facili- tating and engaging intrinsic motivation within the patient in order to change behavior. Motivational interviewing is a goal-oriented, patient-centered counseling style for eliciting behavior change by helping patients to explore and resolve ambivalence. For instance, one approach is to invite the patient to make an exhaustive list of all the pros and then the cons of a destructive behavior. One of its indications is substance- related disorders.

Interpersonal Therapy (IPT)

IPT is a short-term (12–16 sessions), manual-based treatment that was developed for treating depression in the early 1980s [13]. The treatment was derived empirically, primarily from the field of social psychology. It consists of elements of psy- chodynamically oriented therapies (exploration, clarification of affect) and CBT (behavior change techniques, reality testing of perceptions) that are used to address four areas of conflict:

(i) unresolved grief/loss, (ii) role transitions, (iii) interpersonal role disputes, and (iv) interpersonal deficits. These four areas, especially grief/loss (e.g., bereavement, loss of function or good health) and role transitions (e.g., retirement), can all be addressed in an older population (see .Table 8.8).

The IPT approach is consistent with the biopsychosocial model of disease and is fully compatible with the concomitant use of psychotropic medication. In fact, considerable effort is spent educating patients about the biopsychosocial model of depressive disorder. Interpersonal relationships are seen as the stage upon which depressive disorder is expressed. All

.Table 8.7 Examples of Socratic questioning Cognitive restructur-

ing principles Inquiry Clinical applications

(e.g., tensions with adult daughter) Revealing the issue “What evidence supports this idea? And what

evidence is against its being true?”

“Why do you think your daughter would be angry with you?

What are the elements of your relationship that do not support

Conceiving reasonable alternatives

“What might be another explanation or viewpoint of the situation? Why else did it happen?”

“If she is indeed angry, could it be that something else has happened that has nothing to do with you?”

“Other than resentment toward you, what are other factors that could explain why your daughter has not called you in a week? Could it be that she is busy with other obligations?”

Examining various potential consequences

“What are worst, best, bearable and most realistic outcomes?”

“What is the worst that could happen if she is currently upset with you? Is there anything positive that could come out of this conflict?”

Evaluate those consequences

“What is the effect of thinking or believing this? What could be the effect of thinking differently and no longer holding onto this belief?”

“How does thinking about the worst scenario affecting your mood? What would it change if your explanation were different?”

Distancing “Imagine a specific friend/family member in the same situation or if they viewed the situation this way, what would I tell them?”

“Imagine your neighbor in a similar situation with his son, what would be most helpful to tell her/him?”

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important relationships are systematically explored with regard to the degree of attachment they contain for the identified patient that may indicate a causal factor in the development of a depressive disorder (such as a role dispute). This short-term treatment makes no attempt to alter personality and focuses on current problems. The therapist is a benevolent facilitator without inviting a deepened transferential relationship.

Older patients are more apt to be forthcoming and more eager to work toward goals in treatment [16]. The conver- sational style inviting the patient to tell his or her story should be comfortable and helpful. Family members often misconstrue or misattribute problem behaviors to volitional acts of defiance, when they actually are features of executive dysfunction, the least understood aspect of cognitive impairment (ci). The therapy can be adjusted for these patients (IPT-ci) and the approach includes (1) reminding the patient of abilities that remain intact that could be further developed to help compensate for the lost abilities and (2) helping the patient to foster new attachments commensurate with his or her current abilities and, when necessary, helping the patient accept increased dependency on others. It is important to adapt the interventions, especially since deficits in executive functions are associated with a poor and unstable response to antidepressant medication [24].

In one study, IPT was found to be more effective in moderate- to-severe depression [27]. Another study by Reynolds and examined by Mackin [24] found that older patients with recurrent major depressive disorder can be suc- cessfully treated with a combination of antidepressant therapy and IPT, and that older patients respond as well, albeit more slowly, as middle-aged patients. IPT may be most effective as a maintenance treatment when combined with an antidepressant medication for more severely depressed older adults [25].

Teaching Point

IPT is another psychotherapy that is suitable for primary care settings. With the anticipated worldwide shortage of psychiatrists in the foreseeable future, such an advan- tage becomes an important consideration. The basic principles can be taught to a variety of clinicians.

Psychoanalytically-Oriented Therapies Psychodynamic Psychotherapy

Relationships in early life form the basis of attachment and are internalized, assisting the formation of a sense of self.

One model holds that much psychopathology is theorized as being related to arrests in the development of the self. It reframes current interpersonal and emotional experiences in the context of past events. During therapy, patients are encouraged to develop insight into past experiences and how these experiences influence their current relationships [13].

Empathic listening, exploratory inquiry, and interpre- tation and clarification of unconscious determinants are essential parts of that approach (see Background 7Sect.

1.1 on common factors theory). Short-term psychodynamic psychotherapy is effective in treating depressive disorders in samples for older adults. This treatment is typically described as lasting less than 40 sessions [28].

Intensive short-term dynamic psychotherapy as developed by Habib Davanloo is an intensive emotion-focused psychodynamic therapy with an explicit focus on handling resistance in treatment, e.g., in somatic symptom conditions and depressive, anxiety, and personality disorders arising from adverse childhood experiences [29]. (See 7Chap. 14.) Problems arising from exposure to family dysfunction while growing up are suggested to be by-products of strong unpro- cessed emotions coupled with deficits in capacity to regulate emotions. The goal of this psychotherapy is to understand and cope better with these feelings.

Life Review and Reminiscence Psychotherapy These approaches are akin to the positive version of Socrates’

fundamental belief implying that the only life worth living is the examined life. These approaches are derived from Eriksonian developmental theory and were specifically developed for older adults. They are both based on the patient re- experiencing personal memories and significant life experiences. They are entirely patient centered, as each person knows best about her or his own life. They both assist older people in experiencing their personal value and self-identity. Reminiscence therapy uses the recall of past events, feelings, and thoughts to facilitate pleasure, better quality of life, and better adjustment. It is valu- able because it can be conducted during daily activities such as mealtime and walking around a facility. There does not seem to be reported adverse events to reminiscence therapy, and it can alleviate feelings of loneliness, anxiety, and depression [7].

Life review therapy is an advanced type of reminiscence, exploring problems through narration. The life story is an internalized and evolving myth of the self, which provides unity and purpose in the individual’s life [30]. It is an especially relevant process for older adults as they face their last opportunity to sum up their life and its meaning. Erikson emphasized that studying one’s life story enhances the individual’s sense of integ- rity, gratitude, and acceptance. It can help the patient overcome unresolved conflicts. In life review, individuals are encouraged to acknowledge past conflicts and to consider their meaning in their life as a whole. It is more structured and focused on both positive and negative life events. The life story reflects what a

.Table 8.8 The four major problem areas in interpersonal therapy

Major problem Senior specific example

Grief Death of spouse/friend/family member; loss of bodily functions

Role transition Retirement, adjusting to medical disability, ceasing to drive, self-image issues Role disputes Caregiver role disagreements, conflict

between partners, disputes with adult children

Interpersonal deficits

Difficulty reaching out for or accepting help, social isolation

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