Post on 05-Feb-2018
transcript
Psychotherapy With The Elderly
Marilyn Bonjean, Ed.D.
ICF Consultants, Inc. 1524 N. Farwell Ave.
Milwaukee, WI. 53202 (414) 273-2220
www. ICFConsultants.com/programs
Demographics of Aging
Silver Tsunami
• In 2010 – 40 million over 65 -13% of total
• Baby Boomers started turning 65 in 2011
• Projected growth to 72 million or nearly 20% of US population by 2030
• Over 85 will grow rapidly after 2030 from 5.5million to 19 million by 2050
US Census Bureau 2010 summary file 1
Projected Population Distribution
Family Structure
Implications
• More older clients
• Problems and rewards of longevity
• Issues of multigenerational family
• Increased ethnic and racial diversity
Elder Developmental Tasks
• Life review – making sense of success & failure
• Accepting losses of role, decline and death
• Sharing wisdom with family, community & society
• Leaving a legacy as a mark of having lived
Family Developmental Tasks
• Grieving losses of elder’s role & functioning
• Maintaining family integrity during changes in form and function
• Coping with physical and emotional demands of care giving
• Managing resources such as assets, time, energy and human labor
Family Developmental Tasks
• Supporting individual growth and development while facing competing demands
• Providing increasing and continual emotional and physical support to elderly family members and others in the family
Is Psychotherapy with Elders Different?
• Yes and No
• Assessment is very important and requires more specialized knowledge and skills
• Treatment less specialized in terms of theoretical framework
• Issues may require more special knowledge
• Case management may be needed
Assessment
• Strengths review – competence & self-esteem
• Complex interacting variables –somatic, cognitive, affective and behavioral
• Ageism influences the experience of everyone including the elder, family, relational community, society and the therapist
• Stereotypes of aging resemble psychological problems
• Cohort effect – values and life experience
Assessment
• Social and environmental context – retirement community, nursing home
• Prevalence of medical disorders and their influence
• Medication /side effects
• Cognitive functioning screen
• Risk assessment
Lifetime prevalence of mood & other disorders
• Aging is not associated with increased rates of depression or anxiety
• Resilience is the norm
• Subjective well-being relatively high despite illness or limitations
• Meaningful activities, intimacy & sexual functioning
Depression
Depression
• Late life depression even at subclinical level is a concern due to the cascade of symptoms and consequences that can occur
• Physical health, safety and community living can be at risk
Depression
• DSM-IV criteria:
• Depression and/or anhedonia
• Cognitive symptoms: worthlessness, guilt, suicidal ideation, poor concentration, difficulty making decisions
• Physical symptoms: changes in sleep, energy and/or appetite
• Functional Impairment *Duration of 2 weeks
Depressive Symptoms in older adults
• Somatization: pain, nausea, headaches
• Alexithymia: less likely to endorse depressed mood or use psychological language
• Cognitive impairment
• Subtle psychotic symptoms, e.g. delusional guilt
Risk Factors for Depression
• Gender: women>men
• History of depression – individual & family
• Medical problems & medications
• Chronic pain, sensory changes, sleep problems
• Excessive alcohol use
• Loss of social supports
• Psychosocial stressors
Dementia and Depression
• Initial evaluation of dementia should include a screen for depression
• Personal history or family history of mood disorders
• Symptoms of depression: guilt, hopelessness, worthlessness, suicidal ideation
• Functional impairments not proportionate to cognitive symptoms
Suicide & Elders
• Account for 12% of population and 16% of suicides
• Highest suicide rate – white males > 85 yrs. old
• Attempts more often successful
• More planning and resolve
• Fewer warnings to others
• Less physical resilience
• Violent & potentially deadly means (firearms) CDCWISQARS accessed 4/13
Ethnicity, Gender & Suicide
Suicidal Ideation
Minor Depression
Comorbidity of Depression & Medical Conditions
Treatment
General Goals of Treatment
Confidence
&
Competence
Challenges to Treatment
• Long history of roles and coping behaviors within individual and family and with the larger community
• Presence of several interacting systems – multigenerational family, medical providers and community agencies
• Differences in generational, blended family and cultural expectations and customs
Challenges to Treatment
• Dire consequences of unsolved issues – cascade of symptoms can lead to rapid decline, excess disability, institutional placement and even death
Treatment for Depression
• Psychotherapy
• Medication
• ECT
Psychotherapy Research
• Majority of research focused on depression
• The consensus of the research findings is that late life major depression can be treated with psychotherapy and gains can be maintained
• Findings also support the acceptance of therapy by older adults
Psychotherapy Research
• Two types of psychotherapy have the most empiric support and are considered evidenced-based practice
• CBT -cognitive behavioral therapy
• IPT - interpersonal therapy
Psychotherapy Research
• CBT – is based on learning theory of personality and focuses on teaching new skills to cope with depression and psychosocial problems
– Lauderdale, K. & Sorocco, S. Cognitive Behavioral Therapy with Older Adults, Springer Publishing Co., 2011
Psychotherapy Research
• IPT – interpersonal therapy focuses primarily on resolution of interpersonal problems and processes through exploration of affect
• Hinrichsen,G. Clougherty,K Interpersonal Psychotherapy for Depressed Older Adults, APA, 2006
Psychotherapy Research
• Common features of these approaches
• offer structure to address symptoms
• set clear and measureable goals
• give homework to extend therapy
• are time limited
• successfully address late life depression
Practice Skills
• Collaboration – use body rhythm, restatement and correction and empathy to be perceived as not so different from the client and therefore less threatening
• Pacing – control the amount of material processed, type of material disclosed, fatigue of client an intensity of interaction
Practice Skills
• Review the session format to make interaction predictable
• Check on client’s reaction more often to increase understanding of verbal and nonverbal material
• Be sure that client can hear and see well and has time to respond
• Over-all allow more time
Practice Skills
• Clarify the client goals for the session
• Clarify the professional’s goals for the session
• Clarify the inclusion of family members and their goals
• Address the elder first and then other family members
Practice Skills
• Maintain attunement
• Repair ruptures in relationship
• Monitor for response to intensity in session hyper-arousal - fight or flight hypo-arousal - freeze or submit
• Maintain therapeutic window of arousal
Practice Skills
• Interpret body signals as safe and somatic sensations
• Observe rather than use old reaction patterns
• Try new responses
• Build new resilience
• Make healthy boundaries and have useful defensive reactions