Academic journal article American Journal of Psychotherapy

Psychotherapy with Older Adults

Academic journal article American Journal of Psychotherapy

Psychotherapy with Older Adults

Article excerpt

The scope of need and possible benefit of psychosocial interventions in late life far exceeds the scientific evidence of efficacy. Most studies have been conducted in academic settings with self-selected, relatively independent older adults for whom measures of benefit were narrowly defined. In reviewing the existing literature concerning individual, group, and couples therapies in the geriatric population, we find that with appropriate adaptations for medical comorbidity, cognitive and sensory impairment, caregiver inclusion, and realistic modification of treatment goals, psychotherapeutic endeavors with the senior patient can prove to be highly successful.

INTRODUCTION

All therapies share common themes of establishing a supportive optimistic relationship, examining distortions, addressing conflict and ambivalence, repairing interpersonal or intrapsychic deficits, and restructuring defenses. The goal of each is to change expressed behavior through individualized treatment (1, 2). While advanced age is not in itself an obstacle to therapy, age-relevant adaptations with special attention given to medical comorbidity, cognitive capacity, and the role of family members and caregivers are often necessary to make the endeavor effective. In addition, modifications of the therapeutic goals to include increased self-reliance, reduction in primary-care-service needs, improved social or family functioning, and long-term health care planning can further optimize treatment outcomes.

Older adults are particularly receptive to the short-term, focused psychotherapies developed in recent years. These therapies have in common an emphasis upon clinical problems and treatment goals. Following an initial assessment of the clinical issues, including cognitive abilities, capacity for change, and structure of care giving to name only a few, one may select the therapeutic modality best suited to the needs of the individual. In the following paper we will summarize various brief, group, family, and caregiver therapies, emphasizing adaptations suited to the needs of the older adult (See table I).

BRIEF PSYCHODYNAMIC THERAPY

Short-term psychodynamic therapy is indicated for older persons with adjustment disorders, grief reactions, and recent onset of traumatic stress disorders (3). An essential component of treatment is to help the patient reestablish a positive sense of self and mastery while avoiding excessive dependency. Setting a time limit of 15 sessions is often useful. While support is an integral feature of the therapy and is often sought to resolve problems of survivor guilt, and/or negative attitudes toward the self and aging, most patients can achieve insight and successfully terminate treatment without requiring long-term, supportive care. However, for those patients unable to meet these goals, ongoing supportive therapy may be indicated in order to control symptoms and maintain present levels of functioning.

Although transference may not be interpreted in short-term psychotherapy, an awareness of transference and countertransference is an important element in any therapeutic relationship. Transference in late life evolves out of childhood relationships as well as significant adult ties, and is often evoked by stress or conflict. Certain transferences arise more frequently in late life as the older adult confronts the loss of goals and ideals, changes in family and intimate relationships, illness, disability, and mortality. In reviewing the available literature on transference, Lazarus and Sadavoy (3) noted that in older patients, transference may appear as an inability to engage in an alliance with a younger (in their eyes inexperienced) therapist, therefore doubting the therapist's capacity to understand or help senior citizens. However this "reverse transference" often hides deeper fears of decline, inferiority, and dependence (4). Retired persons seeking to adjust to the loss of self-esteem and the rewards and recognition in the workplace may experience the (successfully employed) therapist as a domineering, rival sibling. …

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