Abstract
Staff working in this field need to have the capacity to be aware of and to understand their own feelings and prejudices about the second half of life. For patients not offered formal therapy a psychotherapeutic approach will nevertheless enhance their psychiatric care.
Although the body of research is growing, more work needs to be done in evaluating all of the psychotherapies offered to older people.
The paradox of a medical student taking a longer life history from a 20-year-old than from an 80-year-old is paralleled by professionals’ apparent lack of interest in psychological aspects of older patients’ lives, experiences and relationships. Individual and collective ageism in the Western world deprives older adults of an acknowledged emotional life and subjects them to negative stereotypes, even in the minds of those employed to provide services [1]. Age is seen as inevitably associated with mental deterioration, which therefore rules out psychological treatments. There are changes with ageing (e.g. a slowing at some cognitive tasks so that the person may appear impaired in tasks involving speed and energy), but in others where knowledge and experience of the world can be used, older people do better. There is some evidence that working memory declines, yet despite this decrease in memory capacity, emotionrelated information is more often recalled by older than younger adults [2], which would benefit a psychotherapeutic approach to care. Many differences attributed to the ageing process are actually due to cohort effects [3]. Some of these differences may favour the older cohorts [4]. In addition there tends to be personality stability across the adult lifespan and there are positive aspects to maturation.
Not everyone is suitable for formal psychotherapy. Understanding psychosocial aspects of ageing, including our own fears and prejudices, will not only increase the provision of therapies to older people who could benefit but aid our usual psychiatric interventions and management [5, 6]. Assessment for any treatment needs to be clinical and individual not on the basis of demographics and age.
Psychodynamic psychotherapy
Freud [7] wrote of the ineducability of people over 50 and indicated that too much material would be presented by older patients to be analysed. However, psychoanalytic theory is a theory of development and contemporary analysts see development continuing throughout life. The underlying assumptions in psychoanalytic work are that there is an area of existence of which we are usually unaware; an area peopled by figures/objects from our past which nevertheless interact with our current experiences and influence our behaviour and emotional state; as our developmental pathway unfolds each stage remains with us throughout life and may be reactivated by personally potent environmental or relationship factors; our symptoms and personality difficulties have meaning which is hidden from us or unconscious; the relationship with a professional or therapist sensitive to these ideas may be diagnostic as well as therapeutic.
If these assumptions are accepted they will also be applicable to older people. Although psychoanalytic research is difficult, relying solely on randomised controlled trials ignores the wealth of information that may be gained from case studies and qualitative research, and there is evidence that older people do as well as younger in this work although dynamic therapy is less available to them [8–11]. Some analysts have been interested in treating older patients [12]. Karl Abraham [13] saw the age of the neurosis as being more pertinent to the analytic situation than the age of the patient, but even these older patients were in their thirties and forties.
Jung [14], following his split with Freud, did take on older analysands. He developed ideas about the second half of life [15], which to him presented different tasks but also different opportunities from ‘life's morning’ where the concerns were about nature, instincts, propagation of children and entrenchment in the world. In ‘life's afternoon’ the emphasis should be culture, spirituality and giving attention to the self, self illumination, a withdrawing into oneself to become oneself in a process of ‘individuation’. ‘For the ageing person it is a duty and a necessity to give serious attention to himself.’ [14]
We tend to have rather polarized views of old people, for the most part stereotyping them as diminished and inferior beings but with a few who are venerated as the ideal; generous, fearless and wise [1]. Jung himself added the description ‘wise’ to the archetype of the old man. Neither wisdom nor decline are inevitable attributes of the old. ‘Like wine some mature better than others.’ [16]
Freud's ‘structural’ model of the mind focused primarily on the internal world. The so-called Neo-Freudians restated psychoanalytic theory in sociological terms with less emphasis on the ‘individual’ and more on the external world; how people interact on and with one another, an intrapersonal model. Out of this tradition Erik Erikson, a professor of human development, supplemented Freud's ideas to describe a development continuing throughout the life cycle and involving the person's attitude to, and interaction with, the world. He paid less attention to drives, instincts and bodily needs, and emphasized cultural as well as intrapsychic factors [17–19]. He detailed different and specific tasks to be negotiated at each of the eight phases he described (see Table 1). The title of each age distinguishes a stage of psychosocial development and indicates the conflict to be negotiated at that time. Human growth is a series of alternative basic attitudes. The solution to each of these developmental crises is carried forward to the next and each is dependent upon the solution to earlier ones; this throughout life. The child is not only father to the man he is also grandfather to the old man. Although a sequence of stages, this model is also a gradual development. Although Erikson writes of ‘crises’ he considers them to be ‘decisive encounters’ with the environment. They are particular moments in psychosocial growth, turning points at tasks that may be healthily surmounted and mastered or reacted to in a self-alienating way to portend regression and retardation.
The developmental task in late life is to negotiate between the polarities of ego-integrity and ego-despair. The person who possesses integrity in old age is one who accepts that his life is the only one he could have had at that time in history; he accepts his family of origin as it was, his position in world affairs and history to be as it had to be and his personal life as his own responsibility. The person without integration does not accept their life cycle as the only possible way for them; they despair that life is too short, death is too near and regret that now there is no possibility of a different route for them; rather than valuing ‘having been’ they fear ‘not being’. This despair may be presented as rage, contempt, disgust and misanthropy. The therapist needs to offer containment and space for these difficult and painful feelings; to help the patient acknowledge and accept the failures, the missed opportunities, the losses and disappointments while also holding on to the worthwhile aspects of life of having loved and been loved [20].
Other analysts have later taken up the theme of adult development. Colarusso and Nemiroff [21] present a series of seven hypotheses as a theoretic foundation for this (see Table 2). Hildebrand [22], drawing on the work of Erikson [17, 19] and of King [23, 24] has delineated particular tasks and difficulties (see Table 3) that need to be addressed for a content later life. Earlier developmental issues, dormant but with one throughout life, may re-emerge with force in later years.
Seven hypotheses for adult development ‘Colarusso and Nemiroff, 1981’ [21]
Developmental tasks and difficulties in later life ‘Hildebrand, 1982’ [22]
Increasing dependency, or anticipation and fear of dependency, bring the capacity for trust once more to the fore [25, 26]. This, in Erikson's scheme, is the first task for the infant. If in old age one has disabilities such that personal care tasks need to be done or assisted by others the fear is of being hated, of disgusting the carer and perhaps it is intolerable to be literally in someone else's hands. Good enough experiences of dependency in early life can be transferred onto current care givers with trust that they, the old person, can be tolerated and treated benignly. Referrals may be received of people with anxiety and depression related to fear of dependency. The pseudo-independent person who despite major and obvious difficulties refuses all attempts at help, as well as the one who eats up staff making more and more unrealistic demands for assistance not overtly needed are both wellknown to staff in old age psychiatry [20]. Dependent and therefore in need of discharge is a criticism often levied at older patients but the ability to accept appropriate help in the light of increasing frailty is a strength.
The most common theme in work with older people is loss. Inevitably, over the years and particularly in advanced age one loses many things. Actual losses [27] of spouse, friends, employment, financial status, physical strength and health, independence, home, etc. may occur alongside the fear of anticipated future losses and the loss of possibilities – all those things which in younger life one might do or be in the future, which now will never happen. However, loss is specific. Recognition that there are many losses does not by itself do justice to the particular nature of the losses [3].
Pollack [28] writes of mourning-liberation being the focus of work in later life. Ageing well depends on the ability to mourn for the self, which opens up possibilities and freedoms in the years that are to come. Ageing with its inevitable losses and traumata may in itself, for those with sufficient internal resources, be a spur to positive development, courage and strengthening of the personality [29, 30].
Psychotherapy involves loss [31] – giving up previous maladaptive, erroneous, infantile wishes and behaviour. In the same way that to move through the phases of life things need to be given up. Everything lost leaves its indelible mark and plays its part in moulding the personality, also through adulthood.
Other themes and modifications in work with older people
The 25-year-old in therapy may feel he has all the time in the world to alter his life. For the 75-year-old thoughts of the brief remaining time left to him may accelerate psychological change [10]. Other older patients, perhaps linking the idea of discharge with thoughts of death, may need to feel that the therapist is available for the rest of their lives. It may be appropriate not to discharge the patient absolutely but to indicate that he may come back if he wishes. Knowing this may be sufficient for the patient and the need to return may not arise.
The biological and social realities of the lives of people in advanced years may be very different from in their younger days. Ill health and disability may affect multiple physical systems and may be chronic. Mobility problems may exacerbate isolation and financial constraints may further curtail activity. These realities need to be acknowledged in therapy. It may be that seeing an older patient requires some adaptation to the therapy and to the room. Perhaps they need to be seen on the ground floor or given a helping arm out of the chair [32]. Not to do these things may be cruel and insensitive but if modifications are made it should be discussed and be part of the work done between therapist and patient.
The body–mind relationship is emphasized in psychodynamic and other theories of child development but tends to be ignored in work with adults. The patient may avoid examining this because of the narcissistic injury involved in ageing, as one may lose good looks, physical attractiveness and health. However, the therapist needs to continually return to this [33] as adults are profoundly influenced by the body, its function and appearance. The physical pain and disability from accumulating handicaps will not be alleviated by the exploratory approach of psychotherapy but the negative effect on the patient and his relationships may be ameliorated. Psychological mindedness may be a mitigating factor in dealing with adverse circumstances [34].
Ideas of therapeutic change may need to be refocused [16] and different goals set. Change may be purely internal and not be reflected in lifestyle or behaviour as it may be in younger patients. Older people, because of the constraints of their external world, have less opportunity for choice and for taking a different path. The wished for outcome may need to be acceptance of and equanimity about what cannot now change. In therapy a focus for work could be chosen. A complete reconstruction of a lifetime of history may not be needed. People take into old age the difficulties and problems they have internally and externally, as well as the character strengths and coping skills that have helped them previously; with age comes an increased capacity for delayed gratification and for getting on with things that need to be done [35].
Some people in middle life come to terms with their own mortality and negotiating death is not a particular task for later years [36]. For other older people, however, death is viewed as a persecutory or depressive anxiety [37] and patients are seen whose dread is of ‘not being’. An exploration of the patient's anticipated ‘life after death’ may be clinically significant. Even those with no religious conviction may find it difficult to conceive of themselves/their minds/the unconscious as being anything but timeless and eternal so death is not a real possibility [26]. More pressing concerns can be about how one may cope with the anticipated increasing disability, dependence, pain and disintegration.
Working in this area the patient will inevitably be older, possibly much older, than the therapist. Although in part the patient may envy the therapist his youth, health, sexuality and holidays, within the relationship the therapist may also be seen as spanning generations [27]; child, sibling, parent, grandparent. Not only the early years but also the adult past is a source of transference [21]. For the therapist this relationship with an older person, possibly with physical problems or a dementing illness, may evoke particular feelings. The patient idealized or denigrated may be seen as grandparent, parent or themselves in old age. The relationship is ostensibly unequal and seeing themselves in the more powerful position may evoke unhelpful feelings of pity or sadism in the therapist [35]. Treating a life in decline is a blow to our medical narcissism [38]. We may feel compelled to act and do rather than to be with the patient or wish to quickly discharge the one whose apparent helplessness has been projected into us and is unwelcome. Good supervision to explore these countertransferential feelings is essential in psychotherapeutic but also any work with older patients. Gabbard [39] reminds us that concepts such as therapeutic alliance, doctor/patient collaboration, transference and countertransference apply in all our interactions with patients.
Groups
There are numerous accounts of the value of group therapy with older people [40–43]. Therapeutic factors in groups, as detailed by Yalom [44], remain active also when the group members are older, some with particular relevance [45]; ‘universality’ and finding that problems are common and shared is significant for those who are isolated; older people often suffer a poor self image and feel useless to others, the group therapeutic factor of ‘altruism’ gives a sense of being of value and can indirectly reduce self-preoccupation.
Foulkes [46], in developing a theory of group analysis, derived ideas from social theory as well as from psychoanalysis. In addition to personal pathology the phenomenon of ageing – personal, group, cohort experience and prejudice – can be explored in this setting. Evans [47] extends Zinkin's idea of malignant mirroring [48] to include an older population and what prevents them going out to social clubs – ‘it's full of old people’. In the group setting these projections can be elaborated, examined and taken back, and the positive and negative images of age explored.
Sexuality
Negative sociocultural stereotypes and attitudes to sexuality in old age are reflected by professionals who rarely take a sexual history from older patients [49–51]. They in turn are unlikely to spontaneously complain of problems if they sense the doctor's reluctance to hear. Compared with the weight of literature on sexuality in younger people little has been written about later life; what there is tends to be about mechanics and frequency rather than qualitative aspects of sexuality.
There is some evidence of a loss of sexual functioning in old age [52] but it is difficult to separate the effects of age itself from the effects of disease and treatment, which are likely to accumulate with the years. Pain and disability may decrease sexual pleasure and functioning, also through their effects on self image. There is a view that sexuality positively promotes health in later life [53] and there is a continuing human need for intimacy and connectedness whatever the age.
Little has been written from a psychodynamic perspective about sexuality in older people [54]. Despite resistances from the therapist [55] and the patient, sexuality is always present in psychodynamic work, whatever the age. If the unconscious is seen as timeless so too are impulses and wishes [56].
Some authors [22, 57, 58] see men and women becoming more alike physically and psychologically with advancing age. Marriages may suffer as the husband becomes more sensual and affiliative and the wife more autonomous and assertive or the two may appreciate this coming together.
Both men and women may mourn their loss of youthful looks or strength and stamina. Changes in body image may provoke depressive feelings or hypochondriacal preoccupations. A continuing overt sexual life may heal some of the narcissistic wounds of old age [59]. Older people as a reflection of cultural stereotypes may adopt a negative view of their own sexuality and avoid functioning. This can add to feelings of deterioration, helplessness and hopelessness [56]. The couple who in younger days acted out their battles in bed may continue to do so with additional conflicts as a consequence of the ageing process [60].
Homosexual people and couples, while perhaps being subject to even more unfavourable prejudice, have similar preoccupations as heterosexual people – health and the quality of relationships [61].
Close and empathic couples able to communicate directly or intuitively are likely to successfully adapt to the changing sexuality of old age, which may remain an enduring source of pleasure. There is no reason why a couple needing help for relationship [62] and sexual problems should not be taken on for therapeutic work because they are in the senium.
Dementia
A dementing illness is not inevitable in old age. 75% of people over 80 do not have a dementia, but it is a fear associated with ageing; anxiety at the idea that one loses basic skills and abilities, loses memories and loses the person one was [63]. Loss of the self may occasion an existential terror, even so the main thrust of services has been biological and social rather than attempting psychological understanding and containment of this disintegration. Dementia is an illness with a biological aetiology but not all the symptoms we see are organically determined [64]. The dementia sufferer will become more coherent albeit to protest or swear if they are angry. Emotion temporarily integrating memory will also occur if the patient is touched by a therapeutic understanding.
A psychodynamic approach with its emphasis on the uniqueness of an individual can move us away from warehousing patients in their final days. Miesen [65] maintains we metaphorically ‘decapitate’ dementia sufferers by not taking their needs seriously and by having very little life history information about patients in longterm care. We rather primitively divide conditions into the psychogenic and organic, it is either a disease of the mind or of the brain [66, 67]. However, advances in neuroscience may suggest this boundary is permeable [68, 69].
Psychological work with someone suffering from dementia aims to support acceptance and bearing of what cannot be changed [34] but also to explore what possibilities for change there may be.
Being able to reiterate an autobiography is not necessary for psychotherapeutic work [70]. Freud [71] was 542 PSYCHOTHERAPIES AND OLDER ADULTS clear that what the patient does not remember is repeated in the transference and is therefore available in some form to the therapist. In taking on a patient for this type of work modifications will be needed [72, 73] (e.g. shorter more frequent sessions may be appropriate, it could be helpful to use photographs and objects as cues, life review techniques may be incorporated, the therapist will be acting as an auxilary ego [74] and taking on the role of that part of the ego which observes [75]). Communication takes place at many different levels and may continue without language [76]. Supervision is necessary to help prevent the therapist being overwhelmed by ordinary human feelings [77] of helplessness, guilt at not providing a cure, aggression and sadism with consequent depression and reparative wishes. Therapy outcomes are modified; if the patient feels contained, terror may diminish and he ends his days in some peace.
Many different analytic theories provide a suitable framework for work with older patients [78] and other psychotherapeutic models have now been developed that add to the range of therapies available to people of older age.
Cognitive–behavioural therapy
Cognitive–behavioural therapy (CBT) arose out of Aaron Beck's [79, 80] theories of depression with emphasis on changing dysfunctional thoughts rather than attempting to alter feelings directly. Cognitions are of fundamental importance in determining mood; an individual's mood state is determined by his view of himself, the future and the outside world; mood at any moment in time is determined by ‘automatic thoughts’; underlying the cognition are personal schemata or silent assumptions, which in depression are maladaptive; errors of logic characteristic of the cognitive style of depressed patients include arbitrary inference, selective abstraction, maximization and minimization, over-generalization, personalization and dichotomous thinking. The purpose of therapy that is directive, time-limited and structured is to change maladaptive beliefs and to develop adaptive thinking and behaviour. A wide range of techniques are used, such as self-monitoring, challenging negative thoughts and assumptions that maintain problematic behaviour, developing problem-solving abilities, reengaging in activities the individual enjoys and increasing the number of positive experiences. Cognitive– behavioural therapy has been shown to be effective in work with younger and older patients [11, 36, 81]. In a large scale meta-analysis [82] of psychosocial and psychotherapeutic interventions with older adults CBT had above average effects on depression and subjective wellbeing. The effect was greater if the therapist had not only high general qualifications but if they also had specialized training in work with older adults. Effects of interventions were weaker on depression in the old-old group (median age greater than 77 years) but nevertheless were still significant. No age-associated decline in intervention effects were found on other measures of subjective wellbeing, for example life-satisfaction and morale.
From both a review of literature and their own experience Koder et al. [83] suggest a number of adaptations that may be helpful when treating older patients; more emphasis on rationale of the treatment at the beginning with thoughts such as ‘I am too old to change’ challenged early on; selection of realistic concrete goals emphasing activity and behaviour rather than cognitive restructuring; reinforcement strategies with written materials and repetition of issues; particular attention given to common themes of ageing; incorporating life review; later in therapy involving significant others; gradually terminating therapy and offering later followup sessions. Chronological age is not a good indication of how much adaptation may be needed [84] and some changes may be required to respond to the strength of older adults (e.g. using life experience as a potential resource). Some of these modifications are also useful in psychodynamic work, and as in all work with patients the quality of the collaborative therapeutic relationship is vital for supporting a successful treatment [85].
Brief cognitive–behavioural group therapy for depression has also been found to be effective in those with chronic disabling physical conditions [86] and CBT has been used to treat depressive symptoms in older medical inpatients [87]. For the frail and elderly the basic CBT technique of breaking the problem into its basic components to prevent a feeling of being overwhelmed should be applied to the therapy itself [88]. Considering other mood disorders, people with dysthymia and cyclothymia seem to do less well than patients with a major depressive disorder [89]. It has been used in combination with antidepressants to better effect than medication alone in moderately depressed patients [90]. Perhaps because of higher attendance and lower dropout rates older patients have been shown to respond more quickly than younger ones and to have a better home adjustment outcome [91]. The therapy has been used successfully in non-healthcare settings (e.g. a cognitive telephone group therapy with physically disabled elderly [92] and a non-patient community study for minor depressive symptoms in elderly Chinese Americans [93]).
Not only depression is amenable to this approach to treatment. Patients with panic disorder achieve a decrease in symptoms and in physiological arousal [94]. Cognitive– behavioural therapy and supportive psychotherapy administered in small groups were both therapeutically effective for older patients with generalized anxiety disorder [95], although a later study showed more effect with CBT than supportive counselling [96]. Cognitive– behavioural therapy used to reduce anxiety in cognitively impaired elders also increases self-esteem and independence [97]. Supportive psychotherapy based on cognitive behavioural principles has been considered useful for patients with cognitive impairment who are coming to terms with illness and diminished autonomy [88].
As a treatment approach for older problem drinkers there is some evidence of the superiority of CBT over the 12-step and social support models [3, 98]. Cognitive– behavioural approaches have worked well for older veterans with significant medical, social and drug-use problems [99]. As a model it has been successfully used in the management of chronic pain for nursing home residents [100] and when used for the treatment of obsessive–compulsive disorder, older patients experienced improvement comparable to younger ones [101]. In single case studies CBT has been found effective in pathological grief [102] and with delusional disorder [103]. In late life insomnia it has been effective in reducing sleep latency, waking in the night and early morning wakening and therefore in increasing sleep efficiency [104]. Previously, behavioural procedures were found to be more beneficial than cognitive ones for sleep maintenance problems [105].
Bizzini [106] describes a psychotherapeutic treatment of personality disorder in elderly people termed ‘cognitive therapy with decentreing strategies’ (CTDS) that helps the patient develop personal plans that increase the probability of re-constructing more adaptive versions of self, the world and the future.
Reminiscence therapy
Spending time and talking about the past has been equated with living in the past and seen as a negative aspect of old age; an unhealthy one not to be encouraged and from which older people should be distracted. It was simplistically associated with the idea of mental deterioration and that older people cannot deal with current times. However, an element of ‘Life Review’ [107] as a precursor of developmental change is involved in several models of psychotherapy and is essential for successful ‘individuation’ [14] and ‘integration [17] in later life and is a modification suggested for CBT with older patients [83, 108]. Spontaneous reminiscence is adaptive for many people. Others, perhaps because of experiencing major dissatisfaction with either previous or current life, do not see the purpose of reminiscence or they find it depressing [109].
In the apparently simple act of taking a psychiatric history one may begin to help the patient shape a narrative of their life. Winnicott [110] writes of therapeutic consultation. His work was with children but similar principles apply in work with adults who may be assisted to understand successes and regrets in their life, not what happened to them in a passive sense but the role they played in their own history. At the same time attention can be paid to the affective quality of the memories presented. Creative reminiscing is not the same as brooding on the past [111] or obsessive recounting but can be a platform from which to constructively re-evaluate relationships, achievements and failures and to engage in fantasy conversation with people/objects from the past.
In a comparison of a life review group and a cognitive therapy group both treatments were as effective with treatment gains measured on the Beck Depression Inventory and Life Satisfaction in the Elderly Scale. The same was true for the old-old age group as well as for the old [112].
Reminiscence techniques can be used therapeutically, not only with patients with depression but also those with dementia. The aims and details may be different depending on the diagnosis but also on the individual concerned. Reminiscence therapy can usefully be added to a programme in a unit for patients with a dementing illness. As a recreation reminiscing is an enjoyable activity for people of all ages. It can help the patient to make sense of his life, its value, purpose, accomplishments and disappointments. As previous successes are recalled self esteem may be improved. Talking about events in the past often helps communication, interaction and socialization and along with that may be improvement in mood. Cognitive functioning has been shown to improve on the Raven standard progressive matrices [113]. Patients may be helped to resolve unfinished business or conflicts [36]. The more staff understand the patient's previous life, experiences and relationships the more they may be able to make sense of the patient's current behaviour and talk. Staff are also able to take account of life long preferences in tailoring future care [114]. Patients may be indirectly helped by the positive effect on care staff feeling more involved with the lives of the people suffering from dementia. Staff behaviour is altered at least during groups by increasing interactions directed towards patients and reducing those with other staff [115].
Life review with reminiscence may be under-utilized in systemic family therapy. Reflection on past events could help develop a positive understanding of the role of experience that may assist in avoiding the repetition of past mistakes and in creating future successes [116, 117]. It may also help the older family member in the role of giver or sharer of resources and knowledge 544 PSYCHOTHERAPIES AND OLDER ADULTS rather than one who is needy and takes from the younger members.
Systemic family therapy
Family therapy theory and practice developed from the idea that although we are individuals we are not isolated. We act and react as a member of a social group. Therapy is an interactional process and does not regard the identified patient as the unique site of problems [118]. Rather, it takes a contextual view of pathology. Family therapy has been the main approach for most child psychiatry departments and within general psychiatry, work with families has been seen as a potential approach to assist in the management of mental illness. Including older adults within this framework is the ‘logical extension of the principles of family therapy’ [119]. Family therapy clinics that specialize in seeing families where the identified patient is an older adult are rare, but many old age psychiatry departments regard work with families as integral to a comprehensive service for elderly people [120] including those with a diagnosis of dementia [121].
Systems theory was developed in the physical sciences in an attempt to formulate basic principles applicable to all systems. It is a theory of parts being organized to make a whole. Each system (e.g. the family) has properties of its own greater than the sum of constituent parts. There is a boundary around the system but within it other, more or less, permeable boundaries delineate subsystems. A change in one element of the system will change the system. A systemic approach is concerned with patterns of reciprocal relationships. Changes and development for one family member means change for all (e.g. retirement of an older adult may alter his relationship with his wife and also with his son). If he is no longer the professional or the breadwinner his role within the family may be different from both his and from others’ perspectives.
Professionals also need an understanding of the development of the family over the years through a series of stages [120]. A longitudinal view of family development is known as its life cycle. In the same way that a life cycle developmental model of individual psychology suggests that there are psychosocial tasks to be negotiated at each phase, so too with the family. Subsequent development depends at least in part on the outcome of earlier phases. Families may run into difficulties at significant transition points in the life cycle. Transitional changes are normal. Family strengths could be reinforced so that these changes may be seen as an opportunity rather than a loss [122].
Key family therapy concepts [121, 123–125] and strategies are used in multigenerational work, behaviour and mental states being passed down the generations; the reconstruction of genograms; transmission of family history and myths; transgenerational analyses of patterns; circular patterns of interaction and causality; neutrality on the part of the therapist; the generation of hypotheses; understanding paradox and prescribing symptoms; role play and role reversal; structural moves; using an empty chair; understanding secrets; challenging cultural beliefs (e.g. ageism; positive reframing); and task setting. Communication patterns are noted as are interactions also involving affect, nurturing and control. Loyalties, alliances and boundaries are explored.
On the whole, families feel that cooperation is preferable to deadlock but they can become stuck in their usual ways of interacting and need assistance in transforming this helplessness [126]. Some indications for family therapy are noted in Table 4 [127]. The families seen are as diverse as families are; it may be a number of generations living in close proximity, or apart – with increasing social mobility physical distance does not imply lack of emotional cohesion [119]; siblings who may have lived together unmarried throughout life or come back together in widowhood; couples who have lived well together but now need assistance in adjusting to retirement or illness; couples who have lived uncomfortably together joined in mutual difficulties and alienation now not coping with ageing; adults divorcing with consequent disturbance to their children but also to their parents; referral may be in the context of an older person needing to move accommodation or developing a functional or dementing illness with an upset to the balance of power and dependence. Working from a systems theory perspective an alteration for one family member is also a change for others in the system. The therapist and family are ‘cocreating alternative ways of understanding the situation’ [128].
Indications for family therapy ‘Mouratoglou, 1997’ [127]
Research evaluating systemic work with older adults is rare [129], but clinicians and authors see family therapy as offering important conceptual and strategic advantages with the elderly and their systems [130]. Improved communication generally with families (with the agreement of the identified patient) particularly over actual transitions such as moving from hospital to home can aid adaptation and the success of the plan [131]. Family therapists with a systemic perspective may help bridge the gap between the counterpointing realities of someone with Alzheimer's disease, the family and society in general [132]. It has also been used where the older person has been admitted to a nursing home – seeing the family and the staff as a system [133, 134] extending beyond the family to include professional and informal carers. A systems perspective has been used even when the only family member available was the older patient [135]. Other relationships can be brought into the therapeutic conversation by systemic interviewing involving two therapists. This is a common and useful way of approaching families. The choice of therapists should be such that they will not be members of staff who also see the patient in a different setting within the unit. Receiving family secrets from one member seen separately is not helpful and can make the therapist fearful of breaking expectations of confidentiality [136]. It is practical for two or more clinical teams to cooperate in providing a family therapy service across the old age psychiatry department. Co-therapy may be useful training for less experienced staff working with the more experienced. Conflicts between the two are not necessarily unhelpful if it is seen and understood as reflecting family dynamics. Some suggest these conflicts should be discussed in front of the family [136].
Co-therapists will probably be from different disciplines, or ‘transdisciplinary’ [137], providing an opportunity for thinking about relationships within the clinical team. Whatever their experience therapists need to use language that has meaning for the people involved (e.g. some families are able to understand and use abstract ideas or metaphors, others need more concrete communication). Apparent resistance by the family may be the therapists failing to adapt their interventions to the family and its capabilities.
In addition as in all work with older people staff need to recognize [138] and work on their own preoccupations, preconceptions, prejudices and misbeliefs about old age.
Conclusion
Increasing the psychological treatments available to older patients (including many therapeutic models not mentioned here) does not detract from the value of biological and social approaches but adds a further dimension to management in what should be a holistic, flexible multidisciplinary approach. Negative stereotyping and generalizations have limited older people's access to the psychotherapies and because, to a large extent, older adults share societal prejudices they have not complained.
Any generalizing about older people is probably unhelpful. As individuals they are as diverse as younger people with perhaps even greater variability after a lifetime of experience and development. A psychological approach needs to begin by looking at the uniqueness of the patient, their history, experiences and current mental state. All psychotherapies benefit from an aspect of life review. If older people do not process information as quickly as younger ones this may be accommodated by minor modifications to technique such as leaving longer latencies between interventions [108] and between sessions. Despite leaving more time between sessions to process material it can feel that therapy is progressing as rapidly as it may with younger patients [36]. The core principles of the therapies are the same whatever the age of the adult. The therapeutic efficacy of psychotherapeutic treatments has been established in older patients.
Older adults experience much from the external world to disturb happiness, contentment and equanimity. The aim in treatment is neither youth nor happiness, but coming to an acceptance of what is, or changing what internally may be changed in order that the highest quality of life possible may be achieved in whatever circumstances the patient finds himself.