Psychological therapies should be included in psychiatric services for older people with mental illness. Despite evidence of patients requesting psychotherapy (Reference EvansEvans, 2000), few services are able to provide much in the realm of psychological treatments (Reference GarnerGarner, 1999). Quoting the National Health Service (NHS) Executive Review of Psychotherapy Services (NHS Executive, 1996), Garner highlighted the lack of evidence to suggest that older patients benefit less well than younger patients from a psychological or psychosocial approach.

Murphy (Reference Murphy2000) surveyed consultant psychotherapists in England and Wales to ascertain how many of them were treating older patients; those aged 55 and over. Few old age psychiatrists appeared to be referring their patients to psychotherapy services. Murphy (Reference Murphy2000) confirmed an anxiety about working with this age group on the part of some consultant psychotherapists, but could not explain the dearth of referrals from psychiatrists working with older patients. The majority of specialist psychotherapy departments (87%) declared no upper age limit to referrals, but admitted that they could accept older adults within their resources only because there were so few referrals of this nature.

Conditions such as depression, anxiety and dementia dominate the referrals to departments of old age psychiatry. Ageing and its challenges are about a series of adjustments, and these play a significant part in the aetiology of depression and anxiety (Reference MurphyMurphy, 1982). A psychosocial treatment in these disorders is therefore an appropriate approach. The National Service Framework for Older People highlights the need for equality of service, and to phase out discrimination on the grounds of age (Department of Health, 2001).

Aim

This survey attempts to obtain a view from the old age psychiatric perspective, and in so doing make some contribution to the question which Murphy raises: why are patients not being referred to specialist psychotherapy services by old age psychiatrists? Moreover, if they are receiving psychological treatments elsewhere, are these being provided by members of the multidisciplinary team; nurses and occupational therapists in day hospitals for older people and in-patient facilities? The level of formal support and supervision for these staff is another element requiring elucidation.

Method

The Royal College of Psychiatrists Faculty of Old Age Psychiatry list (1998) was used to conduct a postal survey. The list contained names of 365 old age psychiatrists. There were also a number of psychiatrists from other specialties on the list whose responses were not used.

Two hundred and fifty-eight usable responses were returned, giving a response rate of 71%, which was considered acceptable for this kind of survey.

Demographics

The gender ratio of responses was: 58% male to 41% female (1% of respondents did not disclose their gender). The Faculty's gender ratio is similar, suggesting that there was no gender bias in the response rate.

Personal experience of psychotherapy is not a prerequisite of psychiatric training. However, 63 of the responding psychiatrists (24%) had experience of personal therapy. The range of psychiatric experience was extremely wide – there were responses from colleagues who achieved MRCPsych or equivalent from 1971 through to 1995.

Results

Who does what?

Common to old age psychiatry services was that a great deal of ‘ psychotherapy’ of different modalities is being offered to older patients. The majority of providers are nurses and other members of the multidisciplinary team.

The psychological treatment offered in 246 of the responses (95%) was anxiety management. This is an evidence-based treatment for older users (Reference Woods, Roth, Roth and FongayWoods & Roth, 1996). The next most commonly provided treatment was cognitive–behavioural therapy (CBT), offered by 196 departments (76%). CBT was provided largely by psychologists, and by nurses supervised by the psychology team. Some departments employed art therapists and music therapists as part of occupational therapy. Treatments such as couple therapy (87; 34%) and family therapy (79%; 31%) were offered relatively commonly. They tended to be provided by the consultant and other staff members. Therapies such as grief work (9; 3%), carer's support andbereavement counselling were among the services least provided (Fig. 1).

Fig. 1. The psychological therapies offered in old age services in decreasing order of frequency offered; few services offered all while most offered only anxiety management (Anx Mx) and cognitive–behavioural therapy (CBT). Rx, therapy; CAT, cognitive–analytical therapy.

Anx Mx	CBT	Art Rx	Couple Rx	Family Rx	Dynamic Rx	CAT	Drama Rx	Group Rx	Grief Rx
246 (95%)	196 (75%)	90 (35%)	87 (34%)	79 (30%)	58 (22%)	31 (12%)	26 (10%)	8 (3%)	9 (3%)

Training and supervision

One hundred and forty-two of the psychiatrists (55%) appeared not to know of the level of psychotherapy training of the various multidisciplinary team members. Ninety-five (37%) declared that they were aware which staff were trained in the psychological therapies that they were delivering and 9 (3.5%) stated that they knew the therapists were untrained. Four and a half per cent did not respond to this question (Fig. 2).

Fig. 2. Psychiatrists’ awareness of therapists’ training.

Aware of training	Don't know	Aware of no formal training	No response
95 (37%)	142 (55%)	9 (3.5%)	12 (4.5%)

With respect to supervision for the psychotherapy offered, as distinct from general clinical and management supervision, psychiatrists were asked about the provision of supervision for the therapists. Seventy-nine (30.6%) said they did not know whether supervised practice took place or not. However, prompted by the next question, 38% of these respondents wrote that they were ‘ probably supervised by a psychologist’.

Twenty-eight respondents (11%) declared that no one in their department was supervised for psychological work.

One hundred and seventy-four psychiatrists (67.5%) were aware of the levels and provenance of the supervision in their departments (five did not answer). The most common source of supervision was, in 84 cases (32.5%), from a qualified member of the existing team. Supervision from a specialist service, which could be either psychology or the local psychotherapy services was provided to 53 respondents (20.5%). Only 16 of the old age services (6%) ‘ bought in’ supervision from outside the service. The three potential sources of supervision were not mutually exclusive and some departments had all three.

Discussion

This survey generates further questions about the nature of coalitions between psychiatry and psychology services, and which model works best for psychotherapy for older people. There seems little disagreement among old age psychiatrists that older patients should have access to some kind of psychological services. What is less clear, and accords with Murphy's work, is whether people are better off being treated by old age psychiatry practitioners experienced with older patients, or whether they are better referred to specialist psychotherapists and psychologists who may have little experience in working with older adults. It may be this tension that accounts for the lack of referrals to specialist agencies.

There may exist an element of behavioural effect. Psychiatrists having learnt that some psychotherapy departments are not easily accessible to older patients may simply give up referring. Others may only refer the really ‘ difficult’ cases. It may be more acceptable to deal with patients’ psychological issues locally, with members of staff that patients already know.

The range and number of psychological treatments on offer appears to be unacceptably limited, in view of evidence of potential improvements in relapse prevention, and treatment outcomes of depression and anxiety (Reference Ong, Martineau and LloydOng et al, 1987; Reference Radley, Redston and BatesRadley et al, 1997; Reference Reynolds, Frank and PerelReynolds et al, 1999). Support for carers and people affected by dementia appeared to be particularly low.

This survey unearthed examples of excellent practice and cooperation between psychotherapy and psychological departments and old age psychiatry services. Other published examples exist (Reference TerryTerry, 1994; Reference Martindale and LindesayMartindale, 1995; Arden et al, 1998), but are taking time to filter into common practice.

With improved communication, psychotherapy, departments could provide a more accessible service to the elderly, as with younger adults (Reference HaddockHaddock, 1999). Equally, psychotherapists can support and supervise members of the multidisciplinary team in their existing work (Reference FabriciusFabricius, 1995; Reference Stern and LovestoneStern & Lovestone, 2000). Members of the specialist elderly teams could also be encouraged and perhaps funded to attend appropriate training courses of various psychological therapies.

Psychologists, psychotherapists and occupational therapists working within teams and attending ward rounds raise the awareness of psychological work. This in turn enriches the experience of the rest of the multi-disciplinary team, including psychiatrists (Reference WaddellWaddell, 2000).

The issue of training parallels an ongoing debate about the training of specialist psychotherapists. While one does not wish to de-skill practitioners or undervalue the enthusiastic amateur, there is an issue of clinical governance. Practitioners should not be offering services beyond their level of competence and should achieve some level of minimum standard of practise. Rigorous views (Reference PedderPedder, 1993) might exclude excellent nurses without formal psychotherapy qualifications, but the skills-based approach (Reference MainMain, 1990) still requires the practitioner to be well supervised in order to understand and make use of countertransference and projective mechanisms. This is important in reducing risk of harm to vulnerable patients (Reference EvansEvans, 2001).

Conclusion

The provision of psychological therapies to older NHS patients with psychiatric disorder is extremely variable across the country, and the quality of the existing services is often unknown. It is unlikely that there will be new resources to fund improvements, however some changes could begin now with small investments only. A great deal of psychological work such as support groups, anxiety management and CBT happens within old age psychiatry departments, apparently provided by non-medical professionals. If these staff were offered adequate supervision and some additional training, quality of services could improve which may have an overall benefit on service and staff morale. Trainee psychiatrists should be included; higher trainees in psychotherapy might have experience of working with older patients (Reference Bateman and HolmesBateman & Holmes, 2001). Expectations are likely to alter, as the cohort of older people changes with the next generation. This survey demonstrates that patients and their relatives are already asking for psychological treatments from a service that is traditionally more organic in its approach.

Declaration of interest

The author is a group analyst.