Transcript Psychotherapies in Later Life

Psychotherapies
in Later Life
Dr Annette Downey
Consultant Psychiatrist, Exeter
& cognitive analytic therapist
MRCPsych Course, Derriford
June 2011
Therapy is BOTH the Same and
Different
Therapy challenges the double
pessimism of Old age and mental
disorder
How is it Different?
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Narcissistic & borderline traits can re-emerge in later life
Self harm
Bereavement & loss
Withdrawal states of pseudo-dementia
Severe disability
Treatment resistant depression
Dementia
Lifelong consequences of early trauma
• These can all adversely affect the thoughts, feelings and
behaviour of older people, their families and carers.
Old Dilemmas, Reciprocal roles
and idealisations resurface
As can the terror of the threat of
illness and the prospect of death
threaten the integrity of self
Cultural and Historical Influences
are important
• Adding to the gulf in understanding
between the patient and the therapist
which is to be bridged through relationship
• With the use of jointly shared language –
an example - the state of criticising is
understood as ‘chiding’.
Erik Erikson’s Psychosocial
developmental tasks of later life
• Emphasized reciprocity across the life course
• BOTH young & old need each other if they are to
flourish
• The struggle is not just
about life and death
but also about all the
previous life stages too!
The Seven Ages of Women
Hans Baldung Grien
Museum der Bildenden Kunste Leipzig
Ageism
• Psychotherapy for
older people
challenges negative
attitudes and low
expectations &
prevents collusion.
• The age of ‘decline’
• The demographic
timebomb
Therapy Classification
• Specific for older people – usually
dementia – Reminiscence therapy,
Validation therapy, Reality
Orientation
• Generic for all ages –
psychodynamic, systemic, cognitive
behavioural, interpersonal.
Psychological Treatments used
with Older Adults
• Psychoanalytic and psychodynamic – understanding the clinicians
reaction
• Systemic – family factors influencing depression
• Cognitive behavioural therapy
• Interpersonal therapy
• Validation therapy
• Reminiscence therapy
• Cognitive analytic therapy
• Problem solving therapy
• Dialectical behaviour therapy
• Cognitive therapy – aimed at carers improving care skills &
attending to the carers own emotions & reactions
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• Wilkinson, P: Psychological treatments
Oxford textbook of Old Age Psychiatry 2008 p241
Common Therapeutic factors
Jerome Frank 1961
Persuasion and Healing Baltimore :
John Hopkins University Press
• Effect of morale of being attended to by a recognized
expert offering a new perspective
• Therapeutic alliance - collaborative
• Targeted goals
• Guided practice
• Specific feedback
• Roth & Fonaghy 1996 reviewed 25 years of
psychotherapy research and showed that no one model
of therapy works any better than any other.
Roth A & Fonaghy P: 1996 What works for Whom?
A critical review of psychotherapy research
NY: Guildford Press
Combination Therapies
• Individual therapy for caregiver and family
meetings
• Integrative psychotherapy models
• Cognitive analytic therapy – Hepple 2002
• Dialectical behaviour therapy – Lynch et al 2007
Indications for psychotherapy
• Patient preference
• Augmenting biological treatments
• To avoid the useful of harmful medications –
dementia where there is challenging behaviour
• Caregiver distress
• Psychological problems related to ageing – to
achieve contentment or to resolve family
disputes that have happened due to illness of an
older family member
• To provide the clinician with a psychological
reformulation of the patients problems.
Must take account of Sensory and
cognitive changes
• Use technical aids & audiotaping
• Memory aids and other strategies to retain
information & skills acquired through
therapy
• CBT is being used in the management of
patients with established dementia
Unfortunately the provision of
psychotherapy for older people is rare and
referral rates are low in the UK –
especially in the old older population
Murphy S: (2000)
Provision of psychotherapy services
for older people.
Psychiatric bulletin 24 184-187
Cognitive Behaviour Therapy
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Emotional states depend upon how the person processes information about
themselves and the world.
Beliefs that have been functional for years cause problems with negative life
events & impoverished social environments – ‘my place is my family’ or
lifelong negative attitudes to ageing – ‘growing older is growing weaker’ or
‘old people must not be a burden on the family’.
Collaborative, active therapist, diary, behavioural experiments: counting
thoughts, distraction techniques, activity scheduling, identifying thinking,
challenging assumptions, preparing for the future.
Includes psycho-education
Individual or group based
Treats depression, anxiety, health anxiety,
Also helps dementia caregivers
Chronic sleep problems
Depression & anxiety
– associated with memory problems
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Psychotic symptoms – applied but not evaluated
Interpersonal Therapy
• Examines the persons distress within an interpersonal
context –overlaps with the work of Kitwood (1997) &
Stokes (2000)
• Early experiences and unmet attachment needs are
seen as important
• Interpersonal inventory of social network & key
relationships
• Relevant for late life depression
• Distress is conceptualised through:
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Interpersonal disputes (role disputes)
Interpersonal/personality difficulties
Bereavement
Transitions/life events (role transitions)
Systemic Family Therapy
• Aims to foster better relationships between
family members within and across
generations and to achieve more
appropriate support and independence for
older family members. Richardson et al
1994
Types of Family Therapy
• Structural – Minuchin et al 1967 – the family=the site of the
presenting problems. Families function well with particular
structures.
• Strategic Systemic – reframing – the symptom is being maintained
by the apparent solution – example: the anxious older man elicits
over-protectiveness in the daughter.
• Milan Systemic – Boscolo et al 1987 – multigenerational family
patterns; examines the struggles of different family members over
several generations; circular questioning
• Contextual – healing of relationships with growth of commitment,
trust, & development of loyalty,fairness & reciprocity
• Psycho-educational – especially with carers, reducing expressed
emotion, critical comments & hostility
Iveson,C 1990 Whose Life? Community care of
Older people & their families
• Three main issues in family therapy with older people –
– ‘belongingness’ (being full members of society)
– Responsibility for their actions
– Capacity to make choices
Therapists need help to empower older adults rather than to over
protect them
If we protect older people from themselves we end up making key
decisions for them
If we protect older people from their families or neighbours we can
be in danger of undermining them.
Yet if we don’t , we may put them at risk
What did Sigmund Freud think of psychotherapy for older people?
Psychodynamic Psychotherapy
– ‘Near or above the age of 50 the elasticity of the mental
processes, on which the treatment depends, is as a rule lacking
– old people are no longer educable – and on the other hand the
mass of material to be dealt with would prolong the duration of
the treatment indefinitely’ Freud 1905
– Which he wrote when he was 49!
– Offered significantly less often to older people – BUT the
outcomes are often comparable & sometimes better than, for
younger patients.
Psycho-dynamically informed mental health services for older
people are particular opportunities for containment & reflection
Psychological Interventions in Care
homes
• Dementia challenging behaviour –
delusions/hallucinations/anxiety/
• depression/apathy/ agitation/aggression/
• wandering/ disinhibition
• These are common – 60-90% of people with dementia
especially in the later phases of their life.
• Psychotropics are associated with stroke, weight gain &
increasing cognitive decline.
• The behaviour is often understandable – eg banging the
door because she wants to go home or he calls out
frequently in the night – because he wishes to go to the
toilet and to get attention of the night nurses.
Non-pharmacological strategies
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Reality orientation – rehearsal & physical prompts to improve cognition
related to personal orientation – 6 RCTs, positive cochrane review
Reminiscence therapy – discussion of past experiences – photos, familiar
experiences, sensory items to prompt recall, life story work, increases
wellbeing & pleasure - popular-5 RCTs good results but poor quality
Validation therapy -acceptance of the reality of the person & his/her
experience – 3 studies – 2 positive but insufficient evidence for
effectiveness – the emotional content of what is being said is important
Psychomotor therapy – walking/ballgames/dance/ drama 1 trial
Multisensory stimulation – 2 RCTs – insufficent evidence
Cognitive stimulation therapy – 2 cochrane reviews insufficient evidence
Aromatherapy – favourable outcome – 2 RCTs
Music therapy – 5 studies poor quality
Art therapy – self expression, communication,self esteem, new skills
Environment manipulation – cues, signage, building layout, colour, lighting
Animal visitors, dolls, teddy bears,
Behavioural management – functional analysis: antecedants, behaviour,
consequences – 23 studies but poor quality