11 This chapter resumes the discussion in Chapter 7 on the viability of transdiagnostic groups. It does so by outlining how depression and anxiety often coexist in elderly people. It will become apparent why it makes sense to offer a CBGT approach for both of these mental health problems and why, for elderly people, a group format is preferable to individual CBT. Depression and anxiety are common mental health problems among older adults—with prevalence from 6–9% for severe depression and 17–37% for milder (Seritan, McCloud, & Hinton, 2009) and 10–15% for anxiety disorders (Hendriks, Oude Voshaar, Keijsers, Hoogduin, & van Balkom, 2008). For all age groups, depression and anxiety often coexist, but this is especially the case among the elderly (Ames & Allen, 1991; Blazer 1997, 2002; Hinrichsen & Emery, 2005). Not only are rates of comorbidity higher than previously thought, but rates of suicide from untreated depression are also surprisingly high and increase steadily with age for both men and women. Critical risk factors for suicide include, among others, being male, elderly, and socially isolated (Seritan et al., 2009). Symptoms of depression1 (e.g., disturbance in sleep patterns, poor appetite, poor concentration, feelings of guilt, ruminating about the past, and lack of joy) and anxiety (e.g., increased heart rate, chest tightness, racing thoughts, excessive worry about ordinary things or matters beyond one’s control) are similar across the age spectrum. However, they are often overlooked or misdiagnosed in older adults. This may have to do with older adults being less likely to show emotional symptoms and more likely to present with bodily symptoms (Fiske, Wetherell, & Gatz, 2009; Seritan et al., 2009). The DSM-5 option of diagnosing major depressive disorder (MDD) with a specifier of with anxious distress (American Psychiatric Association, 2013) seems fitting for many people in the CBGT program described in the following text. There are understandable reasons why older people may be reluctant to admit to depression and a need for help. Some have survived substantial economic hardship, wars, and immigration and view mental health issues as signs of moral or personal weakness or even character flaws. Others have simply not developed an attunement to their emotional lives, growing up in times and places where communication about such matters was not encouraged. Also, many older people themselves succumb to ageism and beliefs such as “depression is an expected part of growing older” (Laidlaw, 2010). Clinicians working with older adults suggest that attending to certain issues specific to depression and anxiety in later life may be more useful for detecting psychological distress than simply reviewing symptoms (Laidlaw, 2010; Munk, 2010). Such issues include conflicts with adult children; a number of losses including of physical abilities, productivity, status, spouse, and close friends; substance or prescription drug misuse; meaning-of-life crises (including questioning whether one’s life was worthwhile); and, ultimately, unresolved fear of death. Typical CBT protocols for depression and anxiety must be adapted to address these unique stage-of-life issues. Until recently, psychotherapy for the elderly has not been easy to access. This is the case despite elderly people perceiving psychotherapy as an attractive treatment—without the side effects that medication often produces (Hanson & Scogin, 2008; Kuruvilla, Fenwick, Haque, & Vassilas, 2006). Elderly people’s responses to antidepressant medication may further be impaired by comorbid anxiety, thus pointing to the need for alternatives to pharmacotherapy (Greenlee et al., 2010). Although the problem in accessing appropriate treatment, in part, has to do with issues such as difficulty detecting psychological distress, the tradition of psychotherapy itself may until recently not have placed much value on “talking therapy” for older people. For instance, Freud was pessimistic about the prospects of elderly patients benefiting from therapy, saying, “Near or above the age of 50 the elasticity of mental processes, on which the treatment depends is as a rule lacking—old people are no longer educable” (Freud, 1905/1957). Such an attitude likely influenced generations of psychiatrists and psychotherapists. Yet, while few clinicians today are likely to agree with Freud’s opinion, professionals and laypersons alike—including elderly people themselves—do unfortunately buy into ageist myths, such as “older adults are not capable of learning new information due to limited brain plasticity.” In contrast to these beliefs, there is growing evidence that psychotherapy can greatly benefit elderly people struggling with depression and anxiety. Most of the research has focused on single-disorder therapy with an individual format. Within this context, two major psychotherapy approaches, CBT and interpersonal therapy (IPT), have been evaluated for individual treatment for either depression or anxiety (IPT, Carreira et al., 2008; Hinrichsen, 2008; Hinrichsen & Emery, 2005; CBT, Laidlaw, Thompson, Dick-Siskin, & Gallagher-Thompson, 2003; Laidlaw et al. 2008). CBT has received most research attention, with evidence suggesting it is a promising approach with elderly patients suffering from depression (Mackin & Arean, 2005; Morris & Morris, 1991) or anxiety, especially generalized anxiety disorder (GAD) (Ayers, Sorrell, Thorp, & Wetherell, 2007; Hendriks et al., 2008; Laidlaw et al., 2003; Wetherell et al., 2009). Group therapy for older adults has been available for a few decades in a variety of forms, including activity focused, reminiscence and life review, and cognitive behavioral. As studies on group therapy for older adults continue to grow, we may well see stronger support for groups in treating elderly people with depression and anxiety (Kennedy & Tanenbaum, 2000; Mohlman, 2004). Considering that social isolation is a significant risk factor for onset and maintenance of depression in elderly people compared to other age groups, a group format has for decades been suggested as inherently more therapeutic (Sherbourne, Hays, & Wells, 1985). According to Leszcz (1997), it is not just the provision of social support provided by the group that is beneficial but also the opportunities to acquire and develop interpersonal skills. These skills can then be used to generate and sustain more successful social integration as a buffer against depression relapse. For elderly people with mild depression, a CBGT program consisting of eight weekly 2-hour sessions yielded promising results. Compared to a control group, the CBT group (10 clients) showed a significantly greater reduction of depressive symptoms and greater improvement of functional impairment (Hsu et al., 2010). A recent meta-analysis of CBGT for depression in the elderly based on six qualifying trials found an overall significant effect although this effect was “at best modest,” suggesting that there is room for improvement in order to make CBGT for the elderly even more effective (Krishna et al., 2010). With regard to treating anxiety among older adults, Radley and colleagues studied an 8-week CBGT program that was offered to six elderly females in the form of psychoeducation and self-help skills training. Follow-up booster sessions were held at 4 and 12 weeks. Results showed a significant drop in anxiety symptoms, with the greatest change for cognitive symptoms, for example, the interpretation of body sensations as less dangerous (Radley, Redston, Bates, Pontefract, & Lindesay, 1997). There does not seem to be any meta-analysis on group therapy for anxiety in the elderly. Although sparse, the literature encouragingly suggests that CBGT can successfully be offered to people over age 65 and with no upper limit. Any community outpatient program should thus be able to adapt a traditional CBT protocol to an elderly population. The following criteria are typically used for evaluating whether a person aged 65 and above (our oldest member was 91) may be appropriate for CBGT. It is preferable that clients meet criteria for either a depression or anxiety disorder, or both, as determined by the intake assessment and that they have only mild cognitive impairment, if any, and no substance abuse that will interfere with group attendance and homework. Further criteria for admission include an ability to set goals for treatment and an ability to commit to regular and timely attendance. During the intake assessment, it is also important to distinguish normal grief from depression. Clients are often referred for treatment after the loss of a spouse. The distinction between normal grief and depression helps clinicians to avoid pathologizing grief. Grief can be explained to the client as involving a broken heart but an intact mind, including an absence of the kind of self-denigrating thinking usually seen in depression and anxiety. In the groups I am involved with, we do not exclude people with grief only, especially not if clinical judgment indicates that the person may be at risk for their grief morphing into clinical depression. This could be the case if the bereaved has poor social support, difficulty engaging with enjoyable activities, a tendency to feel helpless and hopeless, or a proclivity to ruminate about the deceased in an angry or self-blaming way. The demographics from our CBGT for the elderly over the past several years show that 65% are women and the average age is 70 (Söchting, O’Neal, Third, Rogers, & Ogrodniczuk, 2013). The higher number of men in these groups, 35%, is encouraging and in contrast to our CBGT for depression in younger adults, where the men comprise at best only 20% of any group. In the elderly groups, the level of education tends to be high, with over 88% having completed high school. About 40% are married, 22% divorced, and 30% a widow or widower. Most are Caucasians (85%) but other ethnic groups include Asian, East Indian, people from the Middle East, African, and Hispanic. About 60% of people who successfully complete this CBGT program have had previous psychiatric treatment, 20% have experienced psychiatric hospitalization, and 9% present with passive suicidal thoughts. These elderly people who successfully complete CBGT thus have fairly significant mental health issues. Considering that many continue to have decades ahead of them, any investment in skills for managing their anxiety, depression, health issues, and social isolation is highly worthwhile. The Changeways Geriatric Participant Manual is an example of a CBT protocol for both depression and anxiety that has been adapted by several community programs for CBGT in the elderly (Geriatric Psychiatry Outreach Team, 2004; Paterson, McLean, Alden, & Koch, 1996). The Changeways Geriatric Participant Manual is especially well suited for people who are primarily depressed and whose secondary symptoms are along the lines of generalized and social anxiety. If an elderly person has a primary panic disorder with frequent, uncontrollable panic attacks and no significant symptoms of depression, a pure panic disorder protocol would be the responsible treatment and not the protocol described in the following text. The geriatric CBGT protocol is highly structured and covers specific session-by-session material. They include goal setting, understanding the nature of stress, the role of one’s social life, introduction to assertiveness, worry control, and identifying and overcoming distorted thinking and faulty assumptions, such as “I’m worthwhile only so long as I’m doing something for someone else” or “I can change people.” Final sessions include education about planning for the future and how to deal with minor (and major) setbacks in symptom recurrence. Our CBGT program further adapted the Changeways protocol by inviting professional guest speakers on topics relevant to older adults, such as nutrition (dietician), medication (pharmacist), and spiritual/religious (hospital chaplain). Other topics such as falls prevention, exercise and leisure, and chronic disease management are addressed by offering clients information about community resources. Goal setting and homework are assigned in each session. All sessions begin with a go-round, where group members take turns reporting on how their week was and how they did with their homework. CBGT for the elderly typically involves 12–14 weekly group sessions each lasting 2 hours. The following outline shows common session themes for CBGT for the elderly in a 13-session group. The major treatment components in this geriatric protocol are reviewed in the following text. As highlighted in italics above, CBGT for the elderly has the option of expanding the three-part model of CBT to include physical health. Facilitators may introduce this expanded CBT model by saying (Figure 11.1): Thoughts, emotions, physical health and behavior are powerfully connected to one another. In fact, we can picture our personal lives as a square. The four sides of the square represent four aspects of our lives. The sides of the square are connected. These connections are critical factors in personal change. Figure 11.1 Interconnection between thoughts, feelings, behavior, and physical health. This square is illustrated with the following example from the Changeways Geriatric Participant Manual (Geriatric Psychiatry Outreach Team, 2004): Doris is a 66-year-old, retired woman who has weekend plans to go shopping with a friend. Unfortunately, she wakes up feeling ill on Saturday morning (physical health) and isn’t able to go shopping (behaviour). She thinks: “My friend will think that I really don’t want to go shopping. She’ll never invite me to go shopping again (thought). This belief raises her anxiety (emotion) as well as her frustration about not feeling up to par. This makes it even harder for Doris to figure out how to face the day, and consequently, she stays in bed (behaviour), which in turn only serves to raise her anxiety (emotions) and strengthens her negative thoughts about her friend’s reaction (pp. 12–21). The two goal-setting modules start with group members first writing a problem list, from which they then pick just one problem at a time for turning into a goal. For example, 81-year-old Heather’s problem list was the following: Within the framework of picking one problem at a time and breaking it down to manageable chunks, Heather decided to start her goals with calling a friend from whom for months she had refused phone calls. Other later goals included having a conversation with my son about money and contact the local Parkinson’s Disease Support Group. The module on the Role of Leisure expands on goal setting by first offering education on the importance of making time for enjoyable and fun activities. The facilitators explain that when we have mood problems, our energy reserves are low. Removing things we normally enjoy can feel like a way of conserving energy for more important tasks, but giving up enjoyable activities actually reduces energy in the long run. What would happen if we asked someone who is not depressed to do as little as many depressed individuals do—to have few social contacts, to get out rarely, and to give up many pleasant activities. This person would likely begin to show signs of depression! Michael, age 75, found this resonated with him: (Geriatric Psychiatry Outreach Team, 2004, p. 47) The Thinking about Thinking modules follow a modified Thought Record. The 7-column Thought Record was illustrated in Chapter 5. The modified approach involves a 4-column Thought Record, which if often preferred by clinicians dealing with older people. Although older people can manage working with seven columns, this comprehensive approach does require sustained focus and attention for quite some time. Sustaining concentration can be a challenge in this group in which fatigue due to medication and physical health complications is more present compared to groups of younger adults. Another reason for choosing a shorter record has to do with its better applicability to both depressive and anxious thoughts. The usefulness of a 4-column Thought Record for groups where problems with depression and anxiety are combined is illustrated in two examples. Alice, a primarily depressed 78-year-old woman, wrote this answer in column 1 to the question Where and When Were You? “I was waiting in a restaurant for Shirley and she did not show.” In column 2, she answered “sad and rejected” to the question What Was I Feeling? In response to the third column, which asks the question, What Was I thinking? Alice wrote, “Shirley didn’t want to spend time with me. She doesn’t like me. No one likes me. I’ll always be alone.” Lastly, the fourth column challenges clients to determine if their thinking may contain Thinking Errors, such as jumping to conclusions, personalization, or catastrophizing (Appendix F offers a handout of common Biases in Thinking for depression and anxiety). With support from the group, Alice came to see that she was indeed jumping to the conclusion that Shirley did not like her, without putting any effort into “checking the facts.” It turned out that the facts offered a whole other interpretation. Shirley had waited for Alice in a different restaurant, where she and Alice usually meet, and had completely forgotten that Alice suggested they try to mix up their routine by trying a new place. The group chuckled at how we can learn from younger people in terms of getting comfortable with cell phones. Bruce, an 81-year-old divorced man with GAD and occasional panic attacks, worked on an episode in which, after 2 weeks of intense worrying, he had cancelled an invitation to his daughter’s choir performance. In column 1, he wrote: “I was at home calling my ex-wife saying I was not well enough to attend, and that she should not come and pick me up.” As to the question What was I Feeling? Bruce wrote “anxious and pathetic.” In terms of what he was thinking, he wrote: “What if I feel some shortness of breath, become dizzy? What if I start to panic? It will be too embarrassing to get up from my seat with everyone noticing that I’m leaving.” With help from the group, Bruce realized he was doing a lot of catastrophizing with all the “what ifs.” He became able to decatastrophize and began to prepare himself for not cancelling when the next opportunity to attend a social function with his daughter came up. He became able to counter his anxious anticipation with adaptive statements like “So what if I get anxious? It’s no big deal to get up and step outside for a few minutes to do some deep breathing. So what if people notice I look anxious? The main thing is that I’m there for my daughter and not what other people may think.” The Role of Your Social Life module helps clients make an inventory of close friends, intimates, other friends, acquaintances, and familiar faces. Group members may discover that they have no close friends with whom they feel they can share their vulnerability but have many acquaintances; or they may realize that their main social support revolves around only one person. Suggestions for ways to broaden or deepening friendships are presented and discussed. The Sustaining Lifestyle module helps clients evaluate how they spend their time and energy and take care of their bodies and minds. A number of topics are included ranging from diet, sleep, alcohol, prescription medication, sexuality, and spirituality. Guest speakers such as a pastoral counselor, dietician, or pharmacist can offer helpful presentations that stimulate group discussions. The following case shows a common client presentation in CBGT for the elderly and how the group format offers unique opportunities for therapeutic gains. John is an 80-year-old retired business man whose spouse of 52 years passed away 1 year earlier. His diagnoses include MDD and GAD. A World War II veteran, he spent his adult life as a sales executive with several large corporations before retiring at age 70. John is becoming increasingly socially withdrawn to the point of avoiding family functions. His somatic complaints are accumulating and now include weight loss and difficulty sleeping. Despite his adult children’s encouragement, he refuses to accept help with meals and other daily activities. He is preoccupied with the loss of his wife and has abandoned his former social and leisure activities, including reading, watching the History Channel, and walking. John admits to an increase in worries about smaller issues, for example, paying bills on time, as well as larger issues related to his difficulty with daily functioning and increased loneliness. In the group, members encouraged John to set goals related to meeting people who shared his interests. He did begin to meet regularly over coffee with a man from his neighborhood after they had attended the same European history lecture at the local library. From the Role of Your Social Life module, John realized he no longer had friends he considered close. Initially, in the group, he was reluctant to speak to “strangers” and held some beliefs about how talking about it would only make his pain worse. Over the first 5 weeks of the program, a shift began and he came to see that sharing personal information about his wife actually made him feel closer to others in the group and better about himself and his ability to cope. The following dialogue illustrates how John began to realize that, despite missing the company of his wife, he needed and wanted to work on getting closer with others. Therapist:
Later Life Depression and Anxiety
Depression and Anxiety in the Elderly
Psychotherapy for the Elderly
Group therapy
CBGT for the elderly
CBGT Protocol for the Elderly
Psychoeducation in CBGT for the elderly
Goal setting in CBGT for the elderly
I used to think that if I was struggling, straining and sweating I must be doing the right thing, and that anything easy, fun, or just leisure was ‘shallow’ and not worthwhile. When I look back on it I think this idea was guaranteed to make my life miserable. Now I make sure I include fun as part of my life.
Challenging unhelpful thinking in CBGT for the elderly
Capitalizing on the Group for the Elderly
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Later Life Depression and Anxiety
Let’s complete the work on your Thought Record, John. It’s an interesting example because it’s actually about our here and now group. So far you have noted that your situation was [therapist writes on the board]: “I was in my therapy group and there was pressure on me to talk.” What were your feelings?
