Psychological Therapies with Older People

Developing Treatments for Effective Practice

Jason Hepple, Jane Pearce, Philip Wilkinson, Jason Hepple, Jane Pearce, Philip Wilkinson

• Publisher: Psychology Press
• Year: 2014
• Print ISBN: 9781583911365
• eBook ISBN: 9781317711018
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Sigmund Freud believed that psychoanalysis (and other forms of therapy) was not suitable for people over 50 years of age. In Psychological Therapies with Older People, the authors demonstrate the value of a range of psychological interventions with older people, showing that it is 'not too late' to help.

With an emphasis on practical application, and using a wide range of clinical examples, the authors describe the therapies most likely to be useful in a mental health service for older people, and consider the implications for service provision. Therapies covered include:

• interpersonal therapy (IPT)
• cognitive behavioural therapy (CBT)
• psychodynamic and systemic therapy
• cognitive analytical therapy (CAT)

For each treatment, the historical background and basic theoretical model is summarised before giving a description of the therapy in practice. The authors also discuss the theory of the use of evidence of efficacy and effectiveness in choosing therapeutic interventions, summarising currently available data. Psychological Therapies with Older People will be an invaluable resource for psychiatrists and psychologists working with older people, as well as to GPs, nurses and occupational therapists.

Chapter 1 Introduction

Contemporary views — a duel with the past

Laura Sutton

DOI: 10.4324/9781315783277-1

Few people in the UK receive personal therapy in old age. A recent survey of 100 departments of psychotherapy in the UK concluded that compared with younger people the provision of services to older and elderly people is woefully lacking, with only a tiny number receiving therapy (Murphy 2000). In this chapter I examine the novelty of therapy in old age. First, in the account of her therapy by a client as she is forced to encounter her life’s ending, expressing her experience of her therapy and what she gained from it, I aim to show how her therapy was shaped by a variety of tensions in the development of psychological therapies and psychotherapies, particularly in relation to how they position themselves with respect to ‘present’ and ‘past’. Implications for this when working with older people in therapy will be explored, particularly in relation to issues of authenticity and the ‘(re)historying of the self’ in society.

The novelty of therapy in old age

Britton and Woods (1999) note the roots of modern-day psychology in psychometric testing and say that we need to move on from this. They explain that one of the central ethical issues surrounding working with older and elderly people now is that of power. In the realm of psychometric testing, they note that ‘psychometric tests may similarly be the means of power: they may be used to give a diagnosis that is used to “explain” actions and behaviours that will then never be understood’ (p. 17). They go on to chart the progress of the therapies in psychology for older people, with the emergence of behavioural and cognitive therapies, the newer interest in psychodynamic and systemic approaches, as well as those therapies seen more as the province of old age such as reminiscence and Reality Orientation. They also highlight that in all this there has not been concomitant adequate theoretical development, especially in developmental theory:

The absence of the lifespan developmental perspective from mainstream psychology should be acknowledged … what is required is not simply more studies specifically on older people, or comparisons of older and younger people on yet more aspects of cognition, but rather studies that reflect the psychological functioning of people across the lifespan, and which seek to make sense of individual differences.

(Britton and Woods 1999, pp. 10, 11)

This is interesting because they suggest that we need to move on from psychometric testing, only for its attendant language — that of individual differences — to be let back in by the back door. Pilgrim and Treacher (1992) explain that in order to distinguish itself from medicine/psychoanalysis, psychology as a burgeoning discipline aligned itself with emergent notions of science so that ‘The dominant tradition associated with British psychology in its first official fifty years was to be that of studying individual differences’ (Pilgrim and Treacher 1992,p. 24).

Similarly in psychotherapy, Knight (1996, 1999) rejects what he terms the ‘loss deficit paradigm’ which he says is part of the practitioner heritage in psychotherapy, in which old age is characterised as a series of losses, with depression the typical response. He is rather in favour of integrating psychotherapy and scientific gerontology. For instance, he extends Piaget’s model of intellectual development, drawing on studies that attest to the developing emotional and cognitive complexity with age. Knight argues on these bases that old age is a time of ‘post-formal’ reasoning characterised by a dialectical understanding, that is, by a greater understanding of the nature of social change and a greater appreciation that people hold different points of view. Studies have shown that older people are generally less driven by anxiety than younger people, and are less impulsive, so have a greater capacity for tolerating ambiguities and openness (Knight 1996, 1999).

Knight reaches a position similar to that of Britton and Woods (1999), namely that a contextual, cohort and maturity-based model for ageing is needed. He, Britton and Woods (1999) and Coleman (1999) all cite Erikson’s work (Erikson 1950, Erikson et al. 1986) as notable amongst the few to attempt a lifespan model of development. Knight explains that Erikson reinterpreted childhood development in less sexual terms than classical analysis, and extended personality development into adolescence and adulthood, and old age. Yet Knight says,

Social change which occurs before or during our childhood years may be taken for granted; that which occurs during our adult years will be truly experienced as change. These differences, while not developmental, are real.

Much of change in adulthood and old age is not so much an ontogenetic unfolding of personality development as it is the assumption and discarding of social roles which are roughly age linked, although less so in the 1990s than in earlier decades.

(Knight 1996, pp. 298 and 301)

Knight is placing development as outside real social change, and ontogeny as something which happens before ageing does. Thus, while Knight is advocating a contemporary integrating of psychotherapy and scientific gerontology to develop a maturity-based model of development over a lifetime, his words also replay a traditional view of ontological development, as though the formative years of personality development are those only of childhood.

In both texts it is as if we are seeing the voices of our forebears alongside our own, despite attempts to disassociate from them. This parallels some of the struggles in therapy with those in old age, in intergenerational issues of continuity and discontinuity, of association and dissociation or integration and disintegration (Erikson et al. 1986).

I would like to draw this out further, beginning with Lilian’s therapy.

Lilian

Lilian was in her early seventies when she was referred to her local Community Mental Health Team because of compulsive hand and face washing. She had had periods of compulsive hand and face washing since her adolescence which she had been able to cope with independently up until now, but she was feeling increasingly out of control following a diagnosis of malignant facial cancer. She had increased her rituals to forty times per day which was making her depressed and afraid to socialise. Her Community Mental Health Nurse, Moira, came to me for supervision.

Lilian had sixteen sessions with Moira, with a three-month follow-up. We drew on Salkovskis and Kirk (1989) to orientate Moira to a cognitive-behavioural approach to obsessive compulsive disorders, meantime holding the process issues (Lilian’s — and Moira’s — need for emotional containment) within supervision, especially given Lilian’s fear for her life now. This is Lilian’s account of her therapy.

For a long time I have felt unable to write this account of my illness and treatment. I believe this is because I could not bear to see the facts in cold print, although these facts are always present in my mind and cannot be dismissed in the foreseeable future.

In July 1999, following analysis of tissues taken from my face after surgery, I was found to have a serious skin cancer which is invasive and as threatening as melanoma in possible consequences. It is very aggressive and any lesion above 2 cm in length has a life expectancy for the patient of five years. Therefore I am examined by a specialist every three months for signs of a return.

At first, after receiving the diagnosis, I was numb. After I had absorbed the information I felt paralysed with fear, unable to concentrate, to sleep or eat properly and was very restless by day and night. I was prescribed Prozac daily, Valium to be taken when very shaky with sleeping tablets to be used sparingly. As the Prozac began to act I found I could eat and sleep better and I tried to wean myself off Valium. I succeeded reasonably well in this but then began to have physical symptoms in the form of a neck rash, acute acid indigestion, sore throats and a compulsion to wash my hands repeatedly resulting in damaged sore skin on my hands.

I had tried private stress therapy which had limited effect. Then was given counselling at the hospice but the symptoms continued. Every small spot sent me into panic and I became a too frequent visitor to the doctor’s surgery. After some weeks of this I was referred to the community mental health team and Moira came to my home to treat me.

I was not hopeful at first about improving my depressed state, but in response to her firm but sympathetic attitude I began to open out to my innermost fears and to face the situation more calmly and without feeling I was being selfish as I did when trying to talk to my husband when I knew I was distressing him. Without this chance to speak openly about my guilt feelings and terror of the future I believe I would have collapsed with full breakdown.

First, I had to learn that I could not escape my problems. Acknowledgement. Second, to realise that should the cancer return I would not be shunned like a leper by those I loved. I was not unclean as I had thought, but unfortunate like many millions of others with the disease throughout the world. In short Acceptance. A long lesson this and it was tough to grapple with those destructive thoughts that crept like rats through any quiet moment to start their ceaseless scratching. I was asked to keep a written record of my stress levels in various situations, for example when resisting an impulse to wash my hands as a response to inner turmoil. Throughout this long phase I also unearthed and revealed to Moira earlier distressing life events which had affected me, I now knew, at a subconscious level. I was aware that absolute honesty was vital despite the pain of re-living things I had felt were well buried. From Moira, I understood that cognitive-behavioural therapy was a method of making me aware of how undisciplined destructive thought will weaken reasoning ability and result in obsessive attitudes and actions. These in turn nurture panic attacks and physical symptoms arising from strain.

The final step was Adjustment. A difficult but rewarding period. I learned by painful repetition to control panic attacks by breathing techniques and a gradually forming ability to talk myself calm whatever my fears. Not the least of the benefits was a new evaluation of myself and a belief that I can and will cope should the cancer return, now that I realise that I am not unclean and do not deserve to suffer.

The whole process took from February to July. I was glad to receive this treatment in my own home as it made me feel less of a ‘case’. I remain as co-ordinator of a riding school, a volunteer at a training bureau, and go to an art class. My Christian faith has helped me in ways impossible to quantify and remains a strong factor in recovery of my spiritual health.

In relation to Lilian’s words about her illness and treatment, it was clearly important to her that she felt less of a ‘case’. It is as if she is speaking out against the internalisation of a powerful medical discourse framing distress, in part a depersonalising discourse. To pathologise her further, we believe, would have replayed the dissociations she had lived out of so far. As her story unfolded it became clearer how she had become the way she had within the dynamics of her family, society and the culture surrounding her over time, present and past.

What to do with all that

Lilian was in shock, with her fear and panic, and despair in the face of the threat to her life, all the while carrying a fear of full breakdown. Moira was an experienced practitioner close in age to Lilian — both, as Moira put it, with a ‘degree from the university of life’. Yet she was daunted by the prospect of conducting Lilian’s therapy. She couldn’t see how she was going to keep to the CBT model to help Lilian with her obsessional rituals while she was so distraught about her cancer. Reading the CBT text didn’t help Moira with this. It spoke largely of cognitions and behaviours, with techniques for accessing cognitions and devising behavioural experiments to challenge such cognitions. It is a peculiarly abstracted language which gives little or no sense of what people’s struggles are over their lives.

This predicament reminds me of debates within the cognitive psychology of memory between the ‘purists’ and ‘ecologists’ of memory (Sutton 1995). In the early 1900s with experimental psychology came the experimental approach to memory. This is predicated on the ‘mind body’ split of classic Cartesian dualism (Still and Costall 1991). ‘Memory’ is taken as one of the cognitive faculties — in other words, a faculty of the mind. Experiments are then designed to try and measure aspects of pure memory (rather than ‘remembering’ which they regard as affected by all sorts of extraneous factors, such as ‘emotion’ — that is, ‘body’). Ebbing-haus’s early experiments on the recall of nonsense syllables are often used as a historical marker of the beginnings of the experimental approach to memory.

By the 1970s frustration had grown. In 1978 Ulric Neisser addressed the first conference on the practical aspects of memory in Cardiff, UK (Gruneberg and Morris 1992). He said that whilst we know a lot about remembering nonsense syllables, lists of words and so on in the context of the laboratory, we have ended up not knowing very much about remembering other things in everyday contexts (Neisser 1978). Neisser’s address, in turn, is taken as one of the historical markers of the developing interest in the practical aspects of memory.

I suspect that similar philosophical problems were at work in Moira’s dilemma, in that the abstract language of cognitions and behaviours made it hard for her to connect to real things. Moira was encouraged, though, by Lilian’s bringing a CBT book with her to her f...

Table of contents

• Cover Page
• Frontispiece
• Half Title Page
• Title Page
• Copyright Page
• Table of Contents
• List of figures and boxes
• Notes on contributors
• Foreword by Mike Hobbs
• Preface
• Acknowledgements
• 1 Introduction: contemporary views — a duel with the past
• 2 Psychodynamic therapy
• 3 Cognitive behaviour therapy
• 4 Systemic therapy
• 5 Interpersonal psychotherapy
• 6 Cognitive analytic therapy
• 7 Psychological therapies with older people: an overview
• Index