Background

Ageism, or the discrimination against people on the grounds of age alone, has been slow to gain public awareness in Western society. Although racism and sexism, for example, have been tackled in statute law in the UK, ageism is just surfacing in the collective consciousness of policy makers and clinicians. The National Service Framework for Older People (Department of Health, 2001) cites the elimination of ageism as a laudable aim, but does not go far in suggesting how this might realistically be achieved. It is interesting to consider the paradox that discrimination based on a universal experience (ageing and death) has been relatively slow to achieve public awareness compared with ‘isms’ that oppress minority groups in society. There may be many reasons for this: the prevalence of ageism among older people themselves (discouraging the formation of a ‘minority group’); our need for robust denial-based defences to protect against frightening existential uncertainties (death, meaninglessness); and the notion of the demise of ‘elderhood’ in Western society in the 20th century. For a full discussion of these factors see Reference Hepple, Hepple and SuttonHepple (2004).

Even at the age of 49 himself, Freud considered older people (the over-50s by his reckoning) ineducable (Reference Freud and StracheyFreud, 1905). This therapeutic nihilism has had a profound effect on the development of both psychotherapy theory and services for older people. Psychotherapy theory has tended to focus on childhood development and the developmental stages of infant, child and early-adult life, with later life being neglected as a developmental phase. An exception to this has been the work of Reference EriksonErikson (1966), who identified ‘eight ages of man’ in terms of dichotomies, with ‘generality v. stagnation’ and ‘ego-integrity v. despair’ describing the developmental challenges of later life. The apparent linearity of this model, however, and the lack of elaboration of the nature of psychological development in later life over the 30 years since Erikson proposed it have left old age psychotherapy detached from the mainstream and without a firm theoretical base. In addition, the dominance of the biological or organic model in old age psychiatry and neuropsychology has tended towards ‘brain-based’ rather than ‘psyche-based’ explanations for all illness and distress in later life, where the imaging and charting of deficits takes priority over any meaningful dialogue about shared existential fears between professional and patient.

Reference MurphyMurphy (2000) surveyed the prevalence and availability of psychological therapy services for older people in the UK. The respondents included a range of mental health and social care professionals, of whom 87% felt that their services failed to deliver to older people, with low expectations being reflected in the disproportionately low referral rates. For example, less than 1% of referrals involved patients over 75 years of age, although this group accounted for nearly 9% of the population. Interestingly, old age psychiatrists were less likely to refer the over-55s for psychotherapy than were general adult psychiatrists. Despite all these problems, many psychotherapists, psychologists and psychiatrists have used various psychotherapies with older people with success and enthusiasm. Of particular note is the work of Reference MartinMartin (1944) and Hildebrand (e.g. Reference Hildebrand, Bergener and FinkelHildebrand, 1990), who can be seen as pioneers in this field. Many others, who will be mentioned in the sections below covering individual psychotherapies, have been determined to apply and develop different theoretical approaches in their work with older people and to share their experience and positivity. In contrast to the pessimistic starting point that psychotherapy with older people is ‘too late’ there is hope not only that it is not too late, but that for many it can be just in time.

Cognitive–behavioural therapy

Cognitive–behavioural therapy (CBT) is the form of psychotherapy most often used with older people. In controlled clinical studies it has been shown to be efficacious in the treatment of depression, anxiety and problematic behaviours in the context of dementia (for reviews of this literature see Reference Teri, Curtis, Gallagher-Thompson, Schneider, Reynolds and LebowitzTeri et al (1994) and Reference Wilkinson, Hepple, Pearce and WilkinsonWilkinson (2002)). In a series of studies with older people in the USA by Gallagher-Thompson and colleagues (reviewed by Reference Teri, Curtis, Gallagher-Thompson, Schneider, Reynolds and LebowitzTeri et al, 1994) CBT has been shown to be highly effective with depressed patients in both hospital and community settings as well as in individual and group formats. A more recent trial (Reference Barrowclough, King and ColvilleBarrowclough et al, 2001) of the effectiveness of CBT v. supportive counselling on anxiety symptoms in older adults showed CBT to be both effective and superior to supportive counselling in terms of improvement in anxiety symptoms and self-rating of anxiety and depression over a 12-month period.

Cognitive–behavioural therapy focuses on negative thoughts and their reinforcing behaviours, attempting to identify dysfunctional cycles and to intervene with challenges to unhelpful thinking, the reduction of negative and avoidant behaviours and the introduction of positive behaviour patterns. Negative thoughts can be challenged by techniques that assess the evidence behind the thought, the ‘thinking errors’ that are present, the pragmatic effect of negative thoughts on overall well-being and the consideration of alternative viewpoints. The intensity with which thoughts are held can be rated and monitored through treatment, and the reinforcing avoidant behaviours can be tackled using a graded exposure model. In work with older people, writers in the field suggest some adaptations to CBT technique, including increased emphasis on maintaining the focus on the work, acknowledgement of feelings of guilt and helplessness following the onset of disability and other life events and an awareness of the interaction of somatisation and the physical symptoms of organic disease. Cognitive–behavioural therapy offers a structured, collaborative, brief and client-centred approach. The wide availability of this therapy for younger people in the UK makes it well positioned for further expansion into later-life work.

Cognitive analytic therapy

Cognitive analytic therapy (CAT) represents a modern integration of analytic (object relations theory) and cognitive psychotherapy traditions to provide a brief, structured and collaborative therapeutic journey from past trauma into reconnection with dialogue and meaning. In existence for less than 20 years, the evidence base, although in progress, is yet to be established, but there is interest in applying the model to older people and potential for the development of a therapy that truly speaks to later life through its emphasis on shared meaning in the context of the client's life story and the recognised importance of the ‘dialogue’, both cathartic and reparative, in the therapeutic relationship (Reference Hepple, Hepple, Pearce and WilkinsonHepple, 2002). Traditional concepts from psychoanalytic theory and psychiatry (such as narcissism, borderline personality traits and post-traumatic syndromes) have recently been applied to later life from a CAT perspective (Reference Hepple and SuttonHepple & Sutton, 2004).

Later life can be a time when coping mechanisms are challenged by losses, disability and changes in social role. It is then that pre-existing trauma and low self-esteem can resurface to produce anxiety, depression and self-destructive behaviours, which need to be understood in terms of the person's whole life story. Cognitive analytic therapy can offer a coherent way of linking past and present, and may be well suited to work in later life because of its emphasis on the interpersonal and the need to find shared meaning and understanding in therapy across generational and cultural boundaries. Anthony Ryle, the originator of CAT, writes:

The following case vignette demonstrates the CAT approach in treating re-emergent trauma in late life.

Psychodynamic therapy

This broad range of therapies, stemming largely from the work of Freud, Klein and Jung, has been discussed widely in relation to later life (for reviews see Reference GarnerGarner (2002) and Reference Arden, Hepple, Pearce and WilkinsonArden (2002)). Some empirical evidence exists to suggest that psychodynamic work with older people is at least as effective as CBT in dealing with depression (Reference Thompson, Gallagher and BreckenridgeThompson et al, 1987).

Psychodynamic approaches often centre on the development of insight into repressed unconscious material from earlier life experience and on the working through of this material in the therapeutic relationship. Experience has shown that the client's age can be an important factor in the nature of the transference and countertransference aspects of the therapy. Therapists may be reluctant to acknowledge the infantile needs of an elderly client because of a subconscious fear of the perceived dependence and helplessness that they might themselves experience in old age. Erotic transference may be ignored or ridiculed in the countertransference, and the client's situation may elicit in the therapist idealised care fantasies resulting from the therapist's unconscious fears and concerns about their own older family members. The psychodynamic model, however, is likely to be well suited to working with material derived from the client's ‘feelings of abandonment and despair, intimacy and isolation, arrogance and disdain, stagnation and creativity as each of us struggles with the developmental task of “the third age”’ (Hildebrand, quoted in Reference HunterHunter, 1989: p. 250).

Interpersonal therapy

Interpersonal therapy is a practical, focused, brief, manual-based therapy that can be applied by a range of professionals after a period of basic training. Its accessibility has generated considerable interest in its use with older people, and a reasonable evidence base exists to support its efficacy in the treatment of depression in older people, both in the acute phase and in relapse prevention (Reference Reynolds, Frank and PerelReynolds et al, 1999).

Interpersonal therapy focuses on disturbances in current relationships, categorised into four domains: role transition, role dispute, abnormal grief and interpersonal deficit. A range of therapeutic interventions aim to improve communication, express affect and support renegotiated role relationships, with the effect of symptom reduction and improvement in functionality. Experience in applying interpersonal therapy to work with older people has suggested that it is directly applicable to the relationship and developmental issues relevant to people in later life. For a review of this area see Reference Miller, Reynolds, Hepple, Pearce and WilkinsonMiller & Reynolds (2002).

Systemic (family) therapy

Although the evidence base for the use of systemic approaches in work with older people is sparse, a model that looks at individuals in the context of their wider family and social system seems to have wide applicability (Reference Pearce, Hepple, Pearce and WilkinsonPearce, 2002). A systemic approach may be particularly helpful in the context of communicating and processing the diagnosis of dementia in a family setting and also in unravelling the reinforcing factors in dysfunctional somatising and sick-role behaviour in older adults (Reference QuallsQualls, 2000). Systemic approaches can be used pragmatically both in one-off therapeutic assessments and in more formal therapy sessions following an established family therapy model.

The systemic approach recognises that presenting symptoms in the index patient may result from dysfunctional dynamics in the wider matrix of relationships surrounding the individual. By using techniques such as circular questioning (e.g. ‘What do you think X would say to that?’), positive connotation (e.g. ‘You are such a close family that sometimes you care too much’), paradoxical intervention (e.g. ‘So it seems that you have solved all your difficulties and don't need our help any longer’), reframing (e.g. ‘It seems as if X is flagging up the distress on behalf of the whole family’) and exploration of the shared genogram (family tree), therapy may tip the system into positive change. The availability of professionals skilled in system approaches is likely to be highly beneficial as a consultative tool for those working directly with clients in old age psychiatry, who are well aware of the challenging family dynamics often uncovered by mental illness in late life.

Psychotherapy in dementia

For a detailed review of non-pharmacological treatments in dementia I recommend a recent APT article by Reference Douglas, James and BallardDouglas et al(2004). They discuss the evidence supporting behavioural approaches in improving the behavioural and psychological symptoms of dementia (BPSD), reviewing some of the alternative therapy approaches and the evidence base for the more ‘traditional’ approaches on which I comment below. Rather than duplicate their review, I will comment from a more psychodynamic and CAT perspective.

Owing to the presence of often severe memory deficits in people with dementia, one-to-one psychotherapy is usually avoided. From an interpersonal and systemic point of view, however, the organic pathology itself is but one aspect of the individual's situation, and disability and distress can often be understood clearly in terms of psychological models rather than as neurological symptoms such as disinhibition or apathy. Laura Sutton has recently restated Tom Kitwood's ‘malignant social psychology’ of dementia care in the reciprocal-role terminology of CAT (Reference Sutton, Hepple, Pearce and WilkinsonSutton, 2004). Maintaining a view of the person's pre-dementia personality structure and attending to the repetition of unhelpful role-play in the professional–client relationship is a promising way of processing the challenging dynamics of dementia care.

Over the years, various fairly superficial approaches have been used in dementia care, often using a group approach. Reminiscence therapy, reviewed by Reference Thornton and BrotchieThornton & Brotchie (1987), is undergoing something of a resurgence in the UK. The idea of improving communication and self-esteem through reminiscence is undoubtedly helpful. However, there is a tendency for group reminiscence (remembering the sights and sounds of the Second World War, for example) to lump individuals into a ‘cohort’ more imagined by the younger carers than remembered by the older people themselves. At its worst, this behaviour verges on the ageist.

Reality orientation is widely used in dementia care and it works on the premise that people with dementia will benefit from environmental and interpersonal intervention that reorients them in terms of person, place and time and that corrects their misperceptions and forgotten reality. This approach has been manualised in an ambitiously titled publication The Way to Reality (American Hospital Association, 1976). Many working in dementia care, however, find that constant reality orientation can cause distress and the cyclical remembering and forgetting of losses and disabilities. Reference Sutton, Hepple, Pearce and WilkinsonSutton (2004) calls this interaction ‘outpacing to unbearably outpaced’, remarking that it can recreate the most distressing aspects of cognitive impairment repeatedly in the care setting. An opposite approach, which gained many devotees in the 1970s, is Naimo Feil's validation therapy (Reference FeilFeil, 1982). The symbolic content of dialogue and interpersonal interaction is explored and, where possible, shared and validated by the carer, with no attempt to re-establish orientation in reality. This approach can be cathartic and reconnecting, although it requires a very active therapist to maintain engagement. In its broader applications, this approach has permeated many dementia care settings.

What for whom?

The choice of psychological approach will largely depend on availability of expertise, which is often sadly lacking because psychotherapies are still regarded as being unnecessary or ineffective for older people. In an ideal world, however, a range of therapies would be available, and given that some require considerably more time and resources than others, the following is a guide to deciding what might be best for whom.

Developing services

A psychological perspective is a key part of the biological, psychological and social triad underpinning good psychiatric treatment. However, it is probably unreasonable to expect a large input of resources for specialist training and the appointment of dedicated therapists to work with older people. A gradually increasing awareness of, and skills in, psychotherapies among ‘front-line’ workers will probably deliver the most overall benefit.

Where services exist for adults of working age then age barriers to referral should be removed and old age service professionals should work in collaboration with colleagues in general adult psychiatry. One way of doing this is to set up ‘psychological therapies networks’ within trusts or institutions. Box 1 outlines the procedure for establishing such a network, which my colleagues and I have described in greater detail elsewhere (Reference Hepple, Wilkinson, Pearce, Hepple, Pearce and WilkinsonHepple et al, 2002b ).

The community psychiatric nurses, social workers, occupational therapists and in-patient and day patient staff engaged in psychotherapeutic work with patients and clients should be supervised by experienced therapists. A consultation model of supervision rather than a formal therapy model can be helpful to both patients and staff (Reference Sutton, Hepple, Pearce and WilkinsonSutton, 2004).

Moving forward

A range of psychological therapies have proved themselves effective in the management of older people with mental health problems, both in controlled trials and the growing body of clinical experience and case material in the literature. There is little prospect of funding for large-scale controlled studies involving older people, and if a therapy is shown to be effective in treating younger people, then there seems no reason why older people should be excluded from the benefits it may offer. The growing movement for old age psychiatry to become primarily a ‘brain specialty’ can only be countered by individual clinicians taking the initiative to gain experience and supervision in psychological therapies as a core part of their professional work. It is now mandatatory for psychiatric trainees to gain experience in a range of psychological therapies. Specific training in psychological work with older people for specialist registrars in old age psychiatry would be a positive move towards equipping old age psychiatrists with the full complement of skills they need to help their patients. Psychiatrists will always play a key role in assessment and in encouraging other staff's understanding of each patient in their biological, psychological and social context. To honour this role, we must ensure that the psychological dimension does not continue to take a back seat to biological and social-care models.

MCQs

1. 1 Ageism:

   1. a is a psychological defence

   2. b creates negative stereotypes of older people

   3. c is mainly found among the young

   4. d is an inevitable response to ageing

   5. e is an NSF target.

2. 2 Psychological therapy services for older people:

   1. a are widespread

   2. b attract low referral rates

   3. c are disconnected from general psychotherapy services

   4. d are a low priority in the NHS

   5. e can sometimes be offered ‘just in time’.

3. 3 CBT with older people:

   1. a is an effective treatment for depression

   2. b is an effective treatment for anxiety disorders

   3. c is an effective treatment for bipolar disorder

   4. d challenges negative thoughts

   5. e challenges avoidant behaviours.

4. 4 The following are focuses for interpersonal therapy with older people:

   1. a role transition

   2. b normal grief

   3. c interpersonal deficit

   4. d reciprocal roles

   5. e the ‘wise old man’.

5. 5 The following have been used in dementia care:

   1. a cognitive analytic therapy

   2. b personal construct therapy

   3. c behavioural therapy

   4. d social role valorisation

   5. e validation therapy.