Trauma Among Older People

Issues and Treatment

Leon Albert Hyer, Steven Sohnle

• Publisher: Routledge
• Year: 2014
• eBook ISBN:
  9781317722328
• Print ISBN:
  9781583910818
• Subtopic: Developmental Psychology

Trauma Among Older Adults presents an integrative model of treatment that considers current theories of treatment in light of special considerations relating to elderly patients. The book provides case studies, vignettes, and discussions, and demonstrates the importance of considering the personality, memory, and familial history of an elderly individual who has suffered a trauma.

1
CHAPTER

Aging and Trauma

“After the first death, there is no other.”
Dylan Thomas

Trauma has been labeled as the “soul” of psychiatry (van der Kolk & McFarlane, 1996). During the past decade it has become the most intriguing and studied construct to evolve in mental health. Trauma is ubiquitous. To expect victims of trauma, any trauma, to walk away from the experience as whole people would be unreasonable (Hyer, 1994a). They stand intruded upon with aspects of their personhood eroded. Perhaps the biggest problem of trauma is that it upsets the illusion of a purposeful life. Trauma symptoms are sufficiently prevalent and intrusive as to become a major concern for mental health practitioners, giving rise to myriad pathologies, ranging from subclinical symptoms to full-blown psychiatric disorders.

The study of trauma in older people, especially the diagnostic syndrome posttraumatic stress disorder (PTSD), is fraught with problems related to developmental issues and lifespan patterns, rendering uncontaminated facts hard to come by. Complications are present, related to the nature of trauma and aging decline, to cohort issues, and to the natural transition from an acute to chronic status (of trauma). Often in an almost imperceptible way older people downwardly adapt to meet the needs of life changes. The intimate relationship between symptoms and the unique and complex experience of the individual is lost (van der Kolk, 1996).

There have been major alterations over the 20+ year history of PTSD. In the beginning, for example, the fact of a trauma was considered the principle component in the understanding of psychopathology. Now there is a virtual smorgesboard of elements that cause, moderate, mediate, and influence the experience. The components of the trauma have actually become less important and, in some circles, irrelevant. The fact of trauma has now been found mooring in the role of meaning attached by the person to the traumatic event. It is conventional now to argue (Green, 1991) that the trauma response is a function of: the individual (personality variables), considerations of the trauma itself, and the mediating influences of the recovery process.

In all of this however, the predicament of older people has been wanting or absent altogether. When the aging process is added to the mix, the trauma response is not so easily separated. Where the influence of trauma on aging is concerned, disruptions in lifespan transitions result and alter the acquisition and integration of developmental competencies (Pynoos, Sternberg, & Goenjian, 1996). Like a deathbed confession, trauma needs to be heard and is not very poetic in its expression. If listened to, the voice of trauma can be heard in every part of a person’s life and echoes throughout the lifespan. Influencing development, disrupting expectancies and competencies, juggling transition points, and disturbing biological maturation, trauma has much to say in how a life unfolds. The very soul of the person is affected.

It is at the interface of aging and trauma that we seek more clarity. We juggle both issues. If there is simplicity, it is that we believe the operative concerns of trauma are more a function of factors relevant to the variables related to trauma (PTSD) when we consider treatment and more about aging when we consider assessment and the context of care. Regarding treatment, most issues affecting younger trauma groups play similar roles in the experience of the elderly when we address the trauma memory. In this way, we argue then for the “continuity position” as far as the influence of aging is concerned. However, when we address the issues of care in the broader sense, we talk about aging. An understanding of the needs of an older trauma victim rests to some extent then on chronological status and to some extent on a practical knowledge of psychiatric disorders or disordered responses to life (trauma responses). As in any therapy where the more the person knows about the therapy, the better the chances for success, so too the therapist well-versed in the concatenations of aging and trauma is more likely to succeed. It is important to note here too at the outset that this understanding of trauma at older ages is in its infancy (Gurian & Miner, 1991).

This is really a book about therapy that attempts to manage a person of the trauma victim who is older. In this process we attempt to apply what is known about the elderly and trauma. We are interested most in the interface of these two: How/where/why do aging and trauma play together? In this chapter we are interested in aging first, as it relates to trauma, especially PTSD, and the synergistic shadow cast by the interaction of the two. In Chapter 2 we address PTSD first, with aging as the context. Naturally we are carving nature at its joints too finely. The first section isolates key elements of aging, given trauma. Next, we address the key trauma elements of trauma that are intimately related to aging. We then address key moderating variables of trauma and then issues of aging and treatment. Hopefully this will set the stage for later chapters on aging, trauma, and its assessment and treatment.

□ Good Enough Understanding of Aging

Our culture is reforming by the revolution of the rising demographic tide. The annoying issue, who is old, aside, in due time the crest of the baby boomers will constitute 20% of the population of the United States (Albetes et al. 1997). The fastest growing age group in the United States is the aged, especially those individuals age 85 and older. Neugarten and Neugarten (1994) described the changing age distribution of the population, in which the proportion of old to young is rapidly increasing. At the turn of this century, 1 out of 25 persons in the United States was age 65 or older. Today it is about 1 in every 8. By 2020, when the baby boom will have become the senior boom, it is expected to be 1 in every 6, or even 1 in every 5. By 1985, approximately 70% survived until age 65 and 30% lived to be 80 or more. Now half of all deaths occur after age 80. This trend marks a revolutionary change in human history. There are more older persons and they are older than in previous generations (Siegler, 1994). Box 1-1 is an effort to downsize “our” components of aging. It is a short summary of relevant facts of aging, loosely related to trauma. Perhaps Einstein’s question of life is most relevant to many of the items. He wanted to know the answer to this important question: “Is the universe a friendly place or not?” Most older people have an answer here: It is. Older people are happy, varied, and in possession of considerable experience. They are also not, by and large, passive in the pursuit of tasks. Aging is more an opportunity than a “crisis in slow motion” (Weinberg, 1970).

The developmental process is basically the same in adults as in children: adult development is an ongoing, dynamic process, that there is a continuous and vital interaction between childhood and adulthood; developmental processes are influenced by a person’s adult past as well as his or her childhood; and physical processes and the awareness of death are central phases that affect psychological expression in adulthood (Colarusso & Nemiroff, 1981; Nemiroff & Colarusso, 1990). In this regard, aging is a highly individualized process. More variability is found at later life on just about every dimension than at other age periods. Because the aged are a heterogeneous group, generalizations should be made cautiously. Along the way people struggle to make sense out of what happens to them, to provide themselves with a sense of continuity and order. People also age at different rates and in various ways. An ipsative lifespan course of unique events and stressors occurs for each person (Lazarus & DeLongis, 1983). Multiple causation—the accumulation of stressors and the concurrent weakening of the person due to age—is considered a basic rule of living. It is also a basic rule in trying to understand the life course.

Box 1-1
Age-Related “Facts”

1. Most older people rate life satisfaction high. Even though health-related difficulties increase with advancing age, of persons aged 65 to 74, over 80% report no limitations in carrying out these daily activities; of those 75 to 84, more than 70% report no such limitations; and of those over age 85, half report no limitations.

2. Life-span perspective has multiple interactions (social, biological, and psychological aspects of development). It is frequently pointed out that these issues may have greater interactive consequences with advancing age.

3. In contrast with early development, where knowledge of age provides developmental benchmarks, in later life age itself contains relatively less information. A major difference between theories of child development and adult development is that the former generally try to account for well-known phenomena, and the latter try to point out phenomena to be explained. Whereas childhood development is focused on formation of psychic structure, adult development is concerned with the continuing evolution of existing psychic structure.

4. Interindividual variability is maximal at later life. Pick an attribute (e.g., intelligence, income), the distribution of scores for older adults will overlap to some extent the distribution of scores for younger adults and show more variability.

5. Cohort is as important as age. Cohort refers to the generation into which the person was growing up and growing older in a particular time in history. All we know about stress at later life, we learned from this current older group.

6. The older individual is not simply the passive recipient of events and changes. The individual is an actor in his or her own life, coping and managing.

7. The older the organism, the longer it will take to return to baseline. Not all physiological functions decline with age and not all age related physiological changes result in disease.

8. Disease is most often chronic. The average older person has 3.5 diseases and fills 13 prescriptions annually (Albert, 1989). Common diseases in later life do not start there; thus a life span developmental perspective may be helpful.

9. Chronological age is not the most important factor of adjustment: It may be more important to consider the age of the disease. This applies to chronic diseases as well as psychological stress.

But older people do poorly relative to younger groups. Three hypotheses have been offered as explanations of aging (Salthouse, 1994). None appear apt. First is the speed. Speed slows with age. This a fact. Peripheral or motor processes decline with age and thereby a decline in cognitive status occurs. However the cause of the decline is not speed by itself as the time on task and signal detection tasks (where central and peripheral tasks are differentiated) show that time required to reach a solution is not just a function of a perceptual motor process deficit. Second, the disuse hypothesis holds that tasks are not exercised enough. If so, then tasks that are continually performed should show small or no declines; however, data show that adults forget meaningful stories systematically with age. In addition, tests high in ecological validity have been found to decrease with age, even when prompted. Additionally, older adults do worse than younger adults remembering familiar sayings, the source of acquired information, and in overlearned actions. In fact, even people in mentally demanding occupations (e.g., faculty professors) perform less well than younger matched participants. Third, the changing environment hypothesis holds that, because with each generation the environment changes, the older cohort is “punished” in tasks because they are less familiar with the tasks or at least its context. This is the cohort effect. These are people with the same environmental and sociocultural influences. But again, data (from the Schaie Seattle Longitudinal Study in 1983) are persuasive. Cohort factors are not responsible for many of the age-related changes on mental abilities tests seen in cross sectional studies because equivalent age-related differences also occur in comparison within the same birth cohort.

The life span implies continuity. On the whole, modifications follow directly from integrating knowledge of life-span development, normative life events, and normal age-related changes with what the astute clinician already knows and practices. To the extent that there are adaptations to be made, they have their basis more in the particular client and the particular attribute inspiring the adaptation (from visual impairment to lack of familiarity with psychotherapy) than in chronological age per se. As implied, discontinuity or a greater respect for issues of aging applies more to assessment than interventions of care (e.g., Knight, 1986; Zarit, Eiler, & Hassinger, 1985).

Of course, the question about aging and health is critical: When a person’s age is known, what does one know about that person? Disease exists. Problems at later life are likely to be chronic (rather than acute). This also applies to trauma. Trauma is likely at earlier ages and its residuals are likely to be carried over extended periods of time. Stress is chronic because it represents an accumulation of daily insults (hassles) or negative life events whose effects remain beyond their time (usually one year). Past them is prologue, that is, past psychiatric symptoms are crucial to the understanding of current problems; past problems account for the majority of the variance of a “now understanding.”

What we have discovered simplistically is that what distinguishes people who develop trauma problems from people who are acutely stressed and recover is that they start organizing their lives around trauma. A qualitatively different type of reaction ensues in which the primary concern is to survive in order to preserve resources. This is modal “PTSD at later life” and often is a chronic and subclinical form. The variations of a given disorder are very individual and intrinsically idiosyncratic. This is especially true at older ages.

A difficult problem facing advocates of adult development theories is simply d...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Preface
• Table of Contents
• Chapter 1 Aging and Trauma
• Chapter 2 PTSD in the Context of Aging
• Chapter 3 Life Story of the Aging Person
• Chapter 4 Person and Memory
• Chapter 5 Treatment: PTSD and Beyond
• Chapter 6 Key Ingredients to Psychotherapy
• Chapter 7 Treatment Model: Early Stages
• Chapter 8 Personality
• Chapter 9 Core Memory: The “Good” Memory
• Chapter 10 The Trauma Memory: The “Bad” Memory
• Chapter 11 Grief Work and Forgiveness in the Context of PTSD
• Chapter 12 Using Assessment Data to Inform the Treatment Plan
• References
• Appendix A: Cognitive Behavioral Therapy: Application
• Appendix B: Treatment Rules for Axis II
• Appendix C: EMDR Relaxation Procedure
• Appendix D: Relaxation
• Index
• About the Authors