For clients with high physical and high intellectual functioning (Fig. 20.1, quadrant 1), James suggests that any evidence-based intervention strategy that fits both client and clinician well generally can be applied successfully. For clients with high intellectual but low physical functioning (quadrant 2), the same applies but with a special obligation for the clinician to learn about the specific physical illness in question as this may affect which therapeutic strategies are the most relevant in the given situation. Information about these illnesses should be obtained from both the clients, their physicians, and from scientific sources, as needed. For clients with low intellectual but high physical functioning (quadrant 3), behavioral techniques combined with a cue-based approach are suggested. The same is recommended for clients with both low physical and low intellectual functioning (quadrant 4), but here home visits may be a helpful or even necessary next step (James 2010).
When planning and performing CBT with older people, James (2010) recommends spending the first few sessions thoroughly assessing and evaluating the clients’ functional level with neuropsychological tests and life history information. This information, along with as much client involvement as possible, will contribute to the development of an engaging and effective treatment plan (James 2010). Client involvement and empowerment is especially important when working with older clients as this helps avoid falling into the trap of the client “drifting” into irrelevant subjects or staying on a topic to please the clinician (James 2010).
An interesting theory that may guide therapeutic work with older clients across mental disorders and therapeutic models is the theory of selective optimization with compensation (SOC) by Baltes and Baltes (1990). This framework aims to maintain a satisfying level of functioning in the areas most important to the individual when the limits of personal capacity are reached or exceeded. The SOC model guides older people with functional loss or other acquired disability to select the areas or functions that are most important to the individual because they relate to the individual identity, meaning-making, and experience of pleasure. Selection includes evaluation or reevaluation of personal goals both as a consequence to functional age-related loss and as a pro-action to deal with expected losses. Optimization is the effort to enhance the selected area and to compensate for unreachable wishes, on the intra-psychological level, for example, by reducing personal ambitions, and on the external level, for example, by simplifying the task as much as possible in a way that preserves the meaning of the selected area to the individual. Compensation involves the use of alternative means to reach the goal, for example, by taking counter steps to lessen or even prevent the potential loss (Baltes and Baltes 1990). One example of the SOC model applied can be seen with Alice, who was introduced at the beginning of this chapter.
Alice’s daughter, Sue, dies about 2 months after the MBCT course ended. It is a hard blow for Alice, and although Sue rarely is out of her mind, Alice still keeps going and is able to find joy in life. Alice used to love traveling, usually with Sue, to Australia, the Caribbean, Greenland, and other exotic places. She sees herself as a bit of a “globe-trotter” and decides to keep traveling, but she chooses closer destinations that are easier to reach (an example of “selection”). Alice is aware that traveling alone is no longer an option for her, so she arranges to go with an old friend. They plan the trip carefully to reduce the risks of unexpected challenges as much as possible. Often the trips now go to places she can reach by bus, so the hassles and challenges of international airports are avoided (an example of “optimization”). Enjoying high-quality foreign food in well-regarded local restaurants used to be an essential part of these trips. However, finding good, local restaurants takes an effort, and independent traveling outside the arranged trips is becoming too stressful for Alice. Instead, she and her friend join the rest of the travelers for the arranged meals, and she decides to enjoy the company and getting to see a bit of the world, if not the food (an example of “compensation”).
Using the SOC framework may be valuable in identifying goals for therapy for older clients and developing strategies for how to reach them.
20.5.1 Mindfulness-Based Cognitive Therapy
Mindfulness-based cognitive therapy (MBCT) and other systematic mindfulness training programs have been shown to reduce psychological distress such as depression and anxiety among both younger (Hofmann et al. 2010) and older adults (Smith et al. 2007; Splevins et al. 2009; Young and Baime 2010). MBCT is a group-based clinical intervention originally used for depressive relapse prevention that integrates elements of cognitive-behavioral therapy (Beck 1976) with systematic and extensive training in mindfulness meditations in class and as home exercises (Kabat-Zinn 2005). The aim of MBCT is to teach participants to become more aware of and relate differently to their thoughts, feelings, and bodily sensations (Segal et al. 2013). Through mindfulness exercises, the participants are taught to turn towards and accept intense emotional distress and bodily sensations in a nonjudgmental way. Specifically, the participants are taught to discover automatic reactions and thoughts as they arise, to detach their attention from the content of these reactions, and to regulate the attention back to experiences in the present moment, such as the breath or bodily sensations (Segal et al. 2013).
Our own clinical experience from MBCT-based group therapy with older people (mean age 77 years) with bereavement-related distress (O’Connor et al. 2014) is that adaptation of the physical setting of the therapy for the aging population can support the effectiveness of the intervention. For example, we provided the treatment at an optimal time (late enough for the participants to get there after breakfast, but not so late that the sessions would collide with afternoon napping), in a location with low background noise, a relatively small number of members (10–12 persons), and a short break during the session. The clinician spoke loudly and more slowly and provided clear information on the timeframe of the session and the homework. On the therapeutic level, we aimed to support intervention effectiveness by clear management of the psychological “classroom.” For example, we actively created a culture where only one person spoke at a time, presented home exercises early in the session, and double-checked several times that everyone had understood the task. We also introduced more personally relevant cues than is traditionally the case in MBCT. For example, the therapist explored the experiences of a group member in greater detail than usual and explicitly related what was being said to similar events discussed in the participant’s home exercise or to similar experiences presented by other group members. However, it is often a challenge to meet everyone’s needs when instructing a group, as can be seen in the case in the textbox below.
In the second session of this MBCT with women with chronic pain (mean age 58 years), the participants were presented with the cognitive ABC model of connections between triggers, thoughts, and feelings and subsequently worked with identifying triggers for both positive and negative emotional experiences and how mood may affect the experience of a situation (Segal et al. 2013). Karen aged 79 and Nora aged 75 really feel they learned something from these exercises and the class in general. Now, in week 6 of MBCT, the participants are asked to identify the first signs of relapse into depression or negative mood: the participants are asked to consider the types of events that may typically trigger negative moods for them, thoughts that run through their minds when there is a mood drop, and the emotions and bodily sensations that arise. The participants are paired up to discuss these questions, and most of the younger participants start talking vigorously and writing on their worksheets. Karen and Nora just sit there looking at each other with their hands in their laps. The instructor comes over and asks if they have any questions. “We don’t know what we are supposed to do” they say. The instructor explains: “Nora, remember last week when we had that meditation where we introduced a difficult experience and you told the class about that you noticed that sinking feeling in your stomach, and that you know that feeling very well from other bad times in your life?” “Yes” Nora says. “Well, today we are trying to identify and write down bodily sensations, feelings, and thoughts that we often have when we are feeling down, just like you often have a sinking feeling in your stomach at bad times. If we become good at noticing these signs of negative mood, it will make it easier for us to do something about it before the bad mood takes over in the future. This is what I would like you to do now.” Nora nods, turns to Karen, and starts talking.
20.6 Advice to Clinicians Working with Older People with PTSD Symptoms
To date, no evidence-based protocol for treating PTSD symptoms in older people is available. However, the clinical literature indicates that minor adaptations of current protocols, mindful of the special needs of older adults, are likely to provide effective treatment. Clinicians must draw on their own clinical experience and evidence from treatment of PTSD symptoms in other adult populations. Part III of this volume outlines a number of evidence-based psychological treatments for trauma-related disorders that are likely to apply to older clients as well as they do for younger people. This gives room for the clinician to select a treatment method that fits with his or her experience and preferences and with the preferences and motivation of the client. Several observations and recommendations are provided below to guide the clinician in providing effective psychotherapy with older adults.
First, evidence-based psychotherapy protocols for depression in older people are available. Much can be gained from studying and incorporating knowledge from this work into the selected protocol or framework for treating adults for PTSD symptoms. Relevant suggestions on how to do this can be found in the work by James (2010) in advance of selecting the therapeutic strategies for the following course of treatment.
Second, a key aspect of therapy with older populations is empowerment of the client, an experience that is relevant and applicable across different evidence-based treatment protocols. The SOC model may support empowerment and help the clinician stay in tune with and focused on areas of functioning that are most important to the individual older client.
Third, supervision and training from clinicians with experience in working with older clients are strongly recommended for therapists who are not used to working with this population (James 2010). This may be particularly important in relation to handling the therapist’s own impatience and irritation when working with older clients with especially pronounced tendency to progress and develop slowly in therapy.
Lastly, we will summarize strategies for responding to some of the special challenges of treating older clients, particularly individuals with PTSD symptoms. Certainly, there is an increasing frequency of intellectual disabilities beyond expected age-related changes resulting in dementia (Oliver et al. 2008), and many older people worry that the memory problems they are experiencing are signs of dementia. Since both expected age-related changes and PTSD symptoms often result in reduced memory function, this type of worry is based on actual experiences of memory problems, but may not be related to dementia. Intellectual functioning must be assessed before treatment begins, and if changes in cognitive functioning are detected during the course of treatment, assessment must be reapplied to identify their source. If there is a mild degree of dementia (e.g., Alzheimer’s disease) present at the start of therapy, further cognitive decline can often be expected, and the treatment must be adapted accordingly during the course of treatment. New losses sometimes come thick and fast in old age, and it can be a challenge for the clinician and client to determine which issue is more important and should be dealt with first. Clinician and client will need to explicitly collaborate and agree on goals and process repeatedly throughout the course of treatment. The older client will present with somatic complaints, and it may be difficult to identify their source. Careful assessment of physical complaints, including review of health history and contact with health provider, is often necessary. This is particularly important because old people typically have several and constantly develop more somatic disorders that, if overlooked, can be detrimental for the client. Finally, the potential risk of cohort or generational effects between clients and clinicians should also be mentioned as a challenge. We have a tendency to be somewhat blind to our own cultural heritage, and it can be difficult to discover when cohort effects create a potentially destructive gap between client and clinician. Some of the assumptions clinicians make about aging may be cultural artifacts rather than true, age-related differences. Keeping a watch out for and an open mind to cohort effects is therefore important when doing psychotherapy with older people.
Related posts:
EMDR Therapy for Trauma-Related Disorders
Psychological and Social Theories of PTSD
Considerations in the Treatment of Veterans with Posttraumatic Stress Disorder
Trauma as a Public Health Issue: Epidemiology of Trauma and Trauma-Related Disorders
What Works for Whom?
Neurobiological Findings in Post-traumatic Stress Disorder
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