CHAPTER
15
Psychotherapeutic Interventions
IN the past, mental health practitioners were taught that older patients could not participate in psychotherapy because they were too set in their ways to benefit, were unable to keep frequent appointments because of physical disability, or had cognitive impairments that prevented them from learning new skills. Research over the past few decades, however, has demonstrated that this population can indeed benefit from psychotherapy, and novel approaches, particularly for depression, have been developed specifically to accommodate the needs of older adults who may be homebound and/or have cognitive impairment (Simon et al. 2015; Wang and Blazer 2015). The importance of psychotherapy as a treatment option for older adults cannot be overstated. Because only 40%–60% of older adults experience full remission after a single antidepressant trial, practitioners should consider adjunct treatment such as psychotherapy to help their patients achieve full remission (Lenze et al. 2008; Wang and Blazer 2015). Many people do not want to take more medications or are concerned about polypharmacy; therefore, practitioners should at least be familiar with available psychotherapies so they will know how to properly refer patients. Table 15–1 lists common psychotherapies for older adults and the mental health disorders for which they are commonly used.
Type of psychotherapy | Type of mental health disorders |
Supportive psychotherapy | All types, particularly for patients with limited awareness of their mental health disorder |
Psychodynamic psychotherapy | Most commonly used for depression, anxiety, and personality disorders Also used for eating, posttraumatic stress, panic, somatic symptom, and substance use disorders |
Cognitive-behavioral therapy | Most commonly used for depression, anxiety, panic disorder, and insomnia Also used for psychotic, substance use, eating, and somatic symptom disorders |
Interpersonal therapy (including interpersonal therapy for cognitive impairment) | Used for depression, including depression with comorbid cognitive impairment |
Dialectical behavior therapy | Most commonly used for borderline personality disorder but also useful for depression with comorbid personality disorder |
Problem-solving therapy | Most commonly used for depression and anxiety, including depression with comorbid cognitive impairment, and homebound older adults |
Source. Francis and Kumar 2013; Wang and Blazer 2015. | |
Supportive Therapy
Della is a 73-year-old woman with persistent depressive disorder (dysthymia) and diabetes who has failed to respond to multiple antidepressant trials. Depression interferes with her ability to follow a diabetic diet. She tells you, “I eat sugary foods whenever I feel stressed.” She admits that she does not engage in physical activity regularly and states, “I just don’t feel like exercising.” She refuses to see a therapist because “I don’t need to be brainwashed.” You engage her in supportive therapy, making positive comments whenever she follows her diet and is physically active. After 1 year, Della’s hemoglobin A1c has improved from 10.1 to 8.6 and she is able to consistently walk 10–15 minutes each day.
Supportive therapy is probably the most commonly used type of psychotherapy because it requires neither intensive training nor a manualized approach. In supportive psychotherapy, you rarely interpret a patient’s behavior but rather provide emotional support by listening sympathetically and offering encouragement for positive behaviors. Although much of the psychotherapy research literature regarding older adults emphasizes that more subspecialized psychotherapy demonstrates higher efficacy, the utility of supportive therapy should not be underestimated, especially while practitioners are building relationships with their patients (Wang and Blazer 2015).
Psychodynamic Psychotherapy
Psychodynamic psychotherapy, also known as insight-oriented psychotherapy, is a variant of classic psychoanalysis that focuses on the understanding and interpretation of unconscious processes affecting a patient’s current behavior. The patient should be able to tolerate the emotional distress of discussing unresolved feelings and past conflicts that influence her behaviors in the present. Psychodynamic psychotherapy in older adults is similar to that for younger adults, although some modifications may need to be made for patients with physical impairment, mild neurocognitive disorder, or the early stages of major neurocognitive disorder (Morgan 2003). Modifications may include a mix of family sessions and confidential individual sessions rather than individual sessions alone, reviewing material from previous sessions and giving homework, and exploration of the loss of cognitive and physical abilities with age and loss of independence. One longitudinal study looking at psychodynamic psychotherapy in adults age 60 and older with mostly unipolar depressive and anxiety diagnoses demonstrated that they derived significant therapeutic benefit and did not need fewer sessions due to their age (Roseborough et al. 2013).
Cognitive-Behavioral Therapy
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