Describe with empirical evidence the client’s characteristics that affect therapy outcome.
Psychotherapy and Older Adults Resource Guide
Introduction
Since about 1990, changes in the Medicare reimbursement system have allowed psychologists to provide services to older adults with Medicare coverage. These changes, in combination with managed care and market place changes have made older adult clients attractive as a client population to increasing numbers of psychologists and other mental health service providers. As the Baby Boomers become older adults over the next several years, one can expect both the need and the demand for mental health services to increase: Need is likely to change because Boomers have higher prevalence of depression and other mental disorders than do the GI Generation and Depression era cohorts; Demand may change because Boomers have typically been psychologically minded and relatively high consumers of mental health services.
Key questions in thinking about working with older adults concern whether psychological interventions can be expected to work with older adults. If they work, are adaptations from work with younger adults necessary? In this resource page, research bearing on both of these questions is summarized.
Does therapy work with older adults?
Before turning to psychological interventions, which are the main focus of this resource guide, it should be noted that psychological assessment with older adults is more specialized than are interventions. The higher prevalence of the dementias in late life make some level of neuropsychological screening essential. The higher prevalence of medical disorders makes attention to physical causes of symptoms and to iatrogenic effects of medications as causes of symptoms highly important as well. For more on geropsychological assessment see Lichtenberg (1999).
Gatz et al. (1998) reported that behavioral and environmental interventions for older adults with dementia met the standards proposed at that time for well-established empirically supported therapy. Probably efficacious therapies for the older adult included cognitive behavioral treatment of sleep disorders and psychodynamic, cognitive, and behavioral treatments for clinical depression. For nonsyndromal problems of aging, memory retraining and cognitive training are probably efficacious in slowing cognitive decline. Life review and reminiscence are probably efficacious in improvement of depressive symptoms or in producing higher life satisfaction. Scogin & McElreath (1994) reported a meta-analysis of psychological interventions for the treatment of depression in later life which showed an aggregate effect size (d = .78) roughly equal to that found in another meta-analysis for anti-depressant medications (d = .57, Schneider, 1994) and roughly equal to that found for younger adults in meta-analyses using cognitive-behavioral approaches (d = .73; Robinson, Berman, & Neimeyer, 1990; some studies overlap with those used in Scogin & McElreath, 1994). In general, then, available evidence supports the effectiveness of psychological interventions with older adults, for those interventions that have been studied.
Does therapy change when working with older clients?
Drawing upon life span developmental psychology, social gerontology, and clinical experience I have developed a transtheoretical framework for thinking about what changes are needed in psychological interventions with older adults: the contextual, cohort-based, maturity, specific challenge model (CCMSC; Knight, 1996). CCMSC is not a specific therapy system but a framework for thinking about the adaptation of any therapy system to work with older adults. In the model, context means that changes in therapy are often related to the social-environmental context of older adults both in the community and more especially within hospital and nursing home settings, rather than to their developmental stage. Cohort differences are based on maturing in a specific historical time period, leading to a focus on generational groups such as Depression-era generation, GI Generation, Baby Boomers, rather than on age groups. Developmental maturation leads to relatively minor changes, such as slowing down and the use of simpler language, but also to greater emotional complexity and a wealth of life experience upon which to draw. Specific challenges means that due to the high prevalence of chronic medical problems and neurological disorders, a higher percentage of psychological assessment and therapy is related to medical problems these problems. There is also a higher frequency of grief work and of attention to caregiving issues.
In short, the answer to the question of whether psychotherapy needs to be adapted for work with older adults is, Yes, but (mostly) NOT because they are older. That is, the major reasons for changing therapy when working with an older client are not due to developmental differences but to context effects, cohort effects, and specific challenges common in later life. Context effects require changes for older clients living in age specific contexts such as retirement communities and long term care settings as well as for clients who are seen in de facto age contexts such as hospitals and outpatient medical settings. Cohort effects require modifications because earlier born cohorts have different skills, different values, and different life experiences than later born cohorts. The specific challenges of later life require specific knowledge and therapeutic skills because of the problems they pose for clients, not because of the client's age.
How specialized does a therapist need to be to work with older adults? It will likely depend on the number and type of older adults seen in the practice. Therapists who see a small percentage of older adults, who see older adults who are physically healthy and not likely to have dementia, and whose older clients have problems similar to those of their younger clients, are not likely to need specialized training or education to work with older clients.
Adapting to work with members of other cohorts is similar in difficulty and in the type of changes required to working with clients of a different gender, ethnicity, class background, or occupation-based lifestyle. It does require sensitivity to the possibility of the difference. It also requires some knowledge of history before one was born or at least the willingness to learn that history from clients.
In terms of context effects, if the work with older adults is primarily in long term care settings or in acute medical settings, the work will be specialized compared to work with healthy younger adults living and working in the community. The differences are due to the specialized environmental context rather than to the age of the clients. It is likely to be somewhat similar to working with younger adults in medical care settings and rehabilitations settings. Learning these settings is likely to require some supervised experience working in them.
While somewhat less different and therefore less specialized than the institutional settings, seeing clients who are living a post-retirement lifestyle, especially if some of their lives are spent in age-segregated environments, requires learning the social rules of those environments. Like cohort differences, these can be learned from older clients, but the therapist must be aware of the need to attend to these differences. Otherwise, judgments will be made based on the norms and folkways of young and middle-aged adults whose lives are shaped by school, work, and young families rather than by leisure time, senior community centers or meal sites, and the dispersed networks of older families.
In terms of specific challenges, if the older clients are physically ill, this will pose new issues in both assessment and also in intervention with them. Sorting out physical and psychological influences on symptoms and problems is an ongoing assessment issue. Specific knowledge about the effects of different chronic illnesses as well as both the skill and emotional readiness to work with physically disabled clients become essential. Consultation and supervised experience with psychologists who have such experience is likely to needed in addition to didactic instruction.
When working with clients with death and dying issues, the therapist needs to have basic skills in death counseling and in grief work. The primary problem I have observed over the years is therapists failing to recognize that clients need to talk about the death of loved ones sometimes even when this is the client's stated presenting problem. Learning to work effectively with death, dying, and grief is likely to require supervision as well as didactic instruction.
Working with caregivers requires some basic understanding of the stress and coping process as it affects caregivers for frail older adults. Therapy with caregivers will usually include some need to explore relationship issues and family issues as well. This work often includes a dual focus on emotional issues for the caregiver and problem solving in order to reduce the real stress and strain of long term caregiving for a seriously disabled family member.
The more of these factors that are present, the more specialized working with older adults becomes. Other things being equal, the larger the proportion of older adults in one's caseload, the more likely it is that these factors will be present, whether the therapist is immediately aware of them or not. As noted above, assessment practice with older adults requires some degree of specialized training and work in long term care or other medical settings with older adults will require specialization in learning to work effectively in that setting.
In short, seeing some older adults that are much like the other adults in one's practice does not require much specialization. Seeing a lot of older adults, seeing older adults who have different problems, or seeing them in different settings requires specialized knowledge and supervised experience.
Bob G. Knight, PhD
University of Southern California
Updated: October 2009