Cognitive Behavioural Therapy with Older People

Interventions for Those With and Without Dementia

Ian Andrew James

• Publisher: Jessica Kingsley Publishers
• Year: 2010
• Print ISBN: 9781849857031
• eBook ISBN: 9780857002839
• Topic: Psicología
• Subtopic: Psicología cognitiva y cognición

The development of 'ageless' mental health services means that an increasing number of clinicians are now required to work with older people. Cognitive Behavioural Therapy is recognised by all recent meta-analyses as the most effective therapy, yet few clinicians are trained specifically in its usage with the elderly.

This book is a detailed guide to using CBT with older people both with and without cognitive difficulties. Reviewing its use in different settings, it covers both conceptual and practical perspectives, and details everything from causes and initial assessment to case formulation and change techniques. Case studies in both depression and dementia are used to illustrate how CBT should work and how positive effects can manifest themselves.

Suitable both for trainees and experienced therapists, this book will be essential for anybody using cognitive behavioural therapy in their work with older people, regardless of their clients' levels of cognitive ability.

Chapter 1

Introduction

1.1: INTRODUCTION

The literature on treating older people informs us that they can not only benefit from psychotherapy (Hartman-Stein 2005; Zalaquett and Stens 2006), but in some situations may show better outcomes than their younger counterparts (Walker and Clarke 2001). This book provides a review of the use of cognitive behavioural therapy (CBT) for people with and without cognitive difficulties. The book is in three parts. The first orientates the reader to the topic, examines potential adaptations, and discusses CBT from a practical and conceptual perspective. Part 2 reviews older people’s therapy in terms of the key stages of assessment, formulation and interventions. Finally, Part 3 provides practical advice, using both case examples and observations taken from trainees’ therapy to help improve therapeutic competence.

1.2: PARTITIONING – PARTS 1 TO 3

Part 1

Following this introductory chapter, the first three chapters (2–4) orientate the reader to both the topic and population. Chapter 2 is entitled ‘Patients’ Presentations and How CBT Helps’. It provides a general overview of patients’ experience of negative affect, discussing their difficulties across a range of domains (neurological, behavioural, cognitive, interpersonal, etc.). The initial section attempts to demonstrate the sorts of basic challenges that a therapist will encounter when working with someone with depression or anxiety. The next part of this chapter outlines the manner in which CBT is structured to deal with such difficulties.

Chapter 3 specifically addresses working with older people and is entitled ‘Adapting Therapy for Older People’. It criticises the tendency to discuss older people as if they are a homogenous, well-defined population. An attempt to capture the heterogeneity is made by representing older people’s issues within four distinct quadrants along the two dimensions of cognitive versus physical abilities. It is suggested that within these quadrants, one will have differing patient profiles and treatments.

The fourth chapter ‘Cognitive Changes, Executive Functioning, Working Memory and Scripts’ aims to link the first chapters with the subsequent one on ‘Assessment’. Once again the nature of mood disorders is discussed, but this time solely from a neurological and cognitive perspective. Particular emphasis is placed on the important roles that executive functioning and working memory play in patients’ abilities to engage well in therapy. Some of the typical problems associated with deficits in these areas are discussed.

Part 2

Chapters 5–7 discuss the classic stages of therapy: assessment, case formulation, and change techniques respectively. It is emphasised throughout this part of the book that it is rather artificial to make clear distinctions between these three therapy phases because they share many common structures and processes. For example, good interpersonal skills, pacing and collaborating are required throughout, and diaries, questionnaires, etc. may be used (with different functions) as both assessment and intervention tools.

The discussion sections of these chapters emphasise that the aim of therapy is to develop effective interventions to change people’s mood states. With respect to CBT, the above aims are achieved through the development of idiosyncratic formulations. Chapter 6 gives an overview of the numerous formulations that have been used with older people, examining their utility and suitability with respect to the various presentations therapists encounter when working with older people. Chapter 7 on ‘Change Techniques’ pays attention to the need for therapists to have a good understanding of the change mechanisms underpinning their change strategies. It is argued that without such awareness, there is the possibility that one might intervene inappropriately, lowering patients’ mood further and inadvertently reinforcing negative cognitions. Such scenarios are most likely to occur when therapists are operating at the level of core beliefs.

Part 3

Chapters 8–10 are practical in nature, with Chapter 8 and 10 each discussing a case. The first case study concerns a woman, Mary, with recurrent depression who is treated with a diathesis-stress formulation approach. The material used in her treatment is designed to illustrate those features discussed in the preceding chapters (Part 2) regarding assessment, conceptual work and change strategies.

Chapter 9, entitled ‘Assessing and Developing Clinical Competence’, presents an adaptation of a competency scale used to assess therapists’ abilities to use CBT. The original scale was called the Cognitive Therapy Scale-Revised (CTS-R), which I was involved in developing (Blackburn et al. 2001). The version presented here has been adapted for use with older people. It describes 12 core items associated with CBT, providing details of their rationale and practical guidance regarding their performance.

Chapter 10 presents a case of a man with dementia, Donald, who is displaying a challenging behaviour. The approach used to treat him is a form of psychotherapy used over the last ten years by a specialist team in Newcastle-upon-Tyne, UK. The approach borrows heavily from group CBT formats. The chapter shows how CBT principles can be used with care staff working in 24-hour care environments.

The final chapter of the book, Chapter 11, briefly considers important topics that could not be discussed in detail in the main sections of the text. The three main topics are ‘Working with carers’, ‘Alternative models to CBT in the treatment of depression’ and ‘Improving access to psychological therapies: provision of mental health services of older people’. This chapter ends with some reflections on the book and on my personal journey over the last 20 years as a clinician using and adapting CBT.

The book ends with two appendices. In Appendix I a number of the disorder-specific conceptual frameworks are discussed in relation to the anxiety disorders (panic, generalised anxiety disorder, obsessive compulsive disorder and social phobia). They have been included in support of Chapters 3 and 6 (adapting therapy and case formulation respectively). The material provides the reader with an overview of how generic formulations need to be changed to accommodate the features of each diagnosis. Appendix II presents an unpublished manuscript designed to aid teaching of the CST-R. The content enhances the material presented in Chapter 9, providing the reader with specific examples of good and poor practice taken from my clinical and supervisory work over the last ten years.

PART I

Chapter 2

Patients’ Presentations and How CBT Helps

2.1: INTRODUCTION

In this chapter the reader is first provided with a description of mood disorders as experienced by patients and is then given a summary of standard CBT. The former aims to highlight the difficulties faced by both patients and therapists during treatment. The latter describes how CBT is designed to deal with such problems.

This chapter aims to illustrate the following:

1.Mood disorders can be conceptualised from many different perspectives (neuropsychological, chemical, behavioural, cognitive, etc.).

2.People suffering from mood disorders experience their distress within many of the above domains.

3.When patients attend therapy, they bring their amotivation, avoidance, poor memory, concentration and attention with them. Hence, therapy must factor these features in, requiring the therapeutic framework to be simple and conducted very slowly.

4.CBT is a therapy that attempts to impose simple structures around people’s experiences, making their difficulties less overwhelming and more manageable.

5.The acronym KISS (Keep It Simple and Slow…very slow) can be used as a reminder for clinicians, regarding their therapeutic approach.

6.The principles of CBT can be used in non-standard forms in numerous other settings (e.g. working with people with dementia and their carers).

2.2: NATURE OF THE MOOD DISORDERS

The nature of depression and anxiety may be conceptualised in terms of a number of domains. For example, they can be described in terms of: the actions of neurotransmitters, brain changes, hormones, information processing biases, intrapsychic features, and interpersonal changes. Neurotransmitters are generally the targets of psychotropic medication, and will not be discussed in detail in this text. Structural alterations to the brain are associated with low mood, with some form of late-onset depression linked to arteriosclerotic, inflammatory and immune changes (Alexopoulos 2005). A great deal of debate has occurred about whether such changes indicate that this type of depression is ‘untreatable’ via medication. In contrast to this hotly debated issue, less attention has been paid to the changes frequently found in brain functioning as observed by scanning techniques (Drevets and Raichle 1995). Of particular interest to therapists (James, Reichelt, Carlsson and McAnaney 2008) are the changes occurring within the frontal lobes because these have a direct influence on therapeutic processes (see Chapter 4). Psychometric studies of people experiencing low mood also reveal marked information processing deficits. Some of these deficits can be related directly to frontal lobe dysfunction, but others, such as marked memory problems, demonstrate the more diffuse impact of the psychiatric disorders (Cassens, Wolfe and Zola 1990; Williams 1992). Behavioural changes are also common when someone is experiencing poor mood. Indeed, depending on the nature of the difficulties, the person may become either more agitated or increasingly withdrawn. Further, low mood often leads to changes in people’s self image, and both their view of the world and their future. Beck has described the latter in terms of the triadic model (aka the content specificity model, Beck 1976, Figure 2.1). As outlined in the diagram, when all three self-views are negative, the belief formed is associated with a negative mood state. The specific views and themes associated with these mood states are outlined in the table.

The belief systems become the engine room of negative patterns of thinking, and a positive feedback loop is set up with the thinking reinforcing the person’s belief systems. Thus over time, dysfunctional cycles become established, resulting in a reduction in the threshold of activation of the belief systems. This leads to negative styles of thinking becoming the default way of interpreting the world for the individual. Beck labelled the products of this style of thinking ‘negative automatic thoughts’ (NATs). Cognitive therapists are particularly interested in NATs as they are the verbalised form of patients’ experiences. However, it is important to note that the thoughts are merely the tip of the iceberg in relation to the person’s difficulties, and if one solely dealt with them it is unlikely that one would obtain lasting benefits (James, Southam and Blackburn 2004). Indeed, below the level of the NATs is an inter-connected, symbiotic network of chemical, neurological, behavioural, intrapsychic processes. And because these processes reinforce each other, their collective actions work to maintain the negative homeostasis. For example, consider a depressed person who h...

Table of contents

• Cover
• Of Related Interest
• Title Page
• Copyright
• Contents
• List of figures and tables
• Chapter 1 Introduction
• PART I
• PART 2
• PART 3
• Appendix I Disorder-Specific Conceptual Models
• Appendix II Cts-R Training Manual For Promoting Therapeutic Competence
• References
• Subject Index
• Author Index